2018 Formulary Drug List - Home | GlobalHealth...labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg...

MSTDF18 Lists Updated 11/2017

2018 Formulary Drug List

For State, Education, and Local Government Employees

GlobalHealth, Inc.701 NE 10th Street, Suite 300

Oklahoma City, OK 73104-5403 www.GlobalHealth.com/state

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HELPFUL NUMBERS Plan Issuer: GlobalHealth, Inc. PO Box 2393 Oklahoma City, OK 73101-2393

GlobalHealth Customer Care, Language Assistance, and Disease Management: [email protected] 405.280.5600 (local) 1.877.280.5600 (toll-free) 711 (TTY) Monday – Friday, 9 a.m. – 5 p.m. Central www.GlobalHealth.com/state

Behavioral Health and Substance Use: [email protected] 405.280.5600 (local) 1.877.280.5600 (toll-free) 711 (TTY) Monday – Friday, 9 a.m. – 5 p.m. Central www.GlobalHealth.com/state

Pharmacy Benefits Manager: Magellan Rx Management, LLC Customer Service 1.800.424.1789 (toll-free) 711 (TTY)

Medication Prior Authorizations: [email protected] 918.878.7361

Mail Claims to: Magellan Rx Management, LLC PO Box 85042 Richmond, VA 23261-5042

Mail Order Pharmacy: Magellan Rx Management, LLC 1.800.424.1789 (toll-free) 711 (TTY) P.O. Box 620968 Orlando, FL 32862

24/7 Nurse Help Line: Information Line 1.877.280.2993 (toll-free)

GlobalHealth Compliance Officer: 1.877.280.5852 (toll-free) 405.280.5852 [email protected]

GlobalHealth Privacy Officer: 405.280.5524 [email protected]

mailto:[email protected]

http://www.globalhealth.com/state


http://www.globalhealth.com/state



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IMPORTANT INFORMATION This formulary applies to Members who enrolled through the State, Education, and Local Government employees Plan.

Member Materials Your comprehensive Member handbook has three booklets. Each one has a different purpose. These documents are important legal documents. Keep them in a safe place.

Booklet Purpose

Member Handbook for State, Education, and Local Government Employees (“Member

Handbook”)

Tells you about your benefits.o What benefits are covered and how much you will pay.o How they are covered (including limitations and exclusions).o How to use them.

Physicians and Health Providers Directory (“Provider Directory”)

Lists our Network of doctors, Facilities, and pharmacies.

Tells you if a Facility is preferred or not.

Formulary Drug List for State, Education, and Local Government Employees (“Drug Formulary” or “Formulary”)

Lists drugs we cover.

Tells you what Tier a drug is in.

Tells you if there are any rules to getting a drug.

Member materials are available on our website. Contact Customer Care for printed copies at no charge. But, be aware that the most current Drug Formulary and Provider Directory lists are on the website.

This is an important legal document. Please keep it in a safe place.

When this document says “we”, “us”, or “our”, it means GlobalHealth, Inc. Words or phrases that start with a capital letter are defined in the Member Handbook glossary.

For specific questions about your coverage, please call the phone number printed on your Member ID card.

Preferred Drugs Preferred drugs are listed in this Drug Formulary. Drugs on the list are selected based on quality (effectiveness and safety) as well as cost-effectiveness. Doctors and pharmacists have worked together to develop the Formulary, which includes generics and brand name drugs that are approved by the U. S. Food and Drug Administration (“FDA”).

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For the Member: Generic drugs contain the same active ingredients in the same amounts as brand name products. However, they may be a different color, shape, or size.

For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.

THIS DOCUMENT LIST IS EFFECTIVE AS OF THE DATE ON THE COVER. THIS LIST IS SUBJECT TO CHANGE. You may find the most current list, including any

Utilization Management requirements, on our website. Contact Customer Care for printed copies.

TIER DESCRIPTION

0 Health Care Reform

1 Generics

2 Preferred Brands

3 Non-Preferred Brands

4 Specialty Drug

TYPE DESCRIPTION

QL Quantity LimitThere is a limit on the amount of this drug that is covered perprescription, or within a specific time frame.

PA Prior AuthorizationYour provider is required to get prior authorization before you fillyour prescription, which ensures appropriate use of the selecteddrug. Without prior approval, we may not cover this drug.

ST Step TherapyIn some cases, you may be required to first try certain drugs to treatyour medical condition before you move up a “step” to other drugoptions.

GL Gender Limit This prescription drug is restricted for a single gender. .

AL Age LimitThis prescription drug may only be covered if you meet theminimum or maximum age limit.

C Custom This drug has unique restrictions.

S Specialty DrugSpecialty drugs are high-cost drugs used to treat complex or rareconditions. Some examples of the diseases include; multiplesclerosis, rheumatoid arthritis, hepatitis C, and hemophilia.

MED Medical DrugThis medication is not on our drug list. Click on the THERAPEUTICCLASS or sub class to find covered alternative medications. If youhave questions, please contact member services.

HCR Health Care Reform ProductsThe Affordable Care Act (ACA) requires certain preventive genericproducts to be covered at zero dollar copay. This does not includeplans that are grandfathered.

PAGE 1 LAST UPDATED 11/2017

PS Preferred Specialty Preferred Specialty.

HCG High Cost Generic High Cost Generic.

LCG Low Cost Generic

Generic drugs available at the lowest cost. Please note the specificstrengths and dosage forms; other strengths and/or dosage formsof these products would be subject to the standard generic Cost-share.


LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ADRENERGIC AGENTS

ALPHA AND BETA ADRENERGIC AGONIST(RESPR)

epinephrine (0.1 mg/ml syringe, 1 mg/ml vial, 1 mg/ml(1)ampul) 1

epinephrine (0.15/0.15 auto injct, 0.15mg/0.3 auto injct,0.3mg/0.3 auto injct) 1 QL 2 / fill

epinephrine hcl/pf 1

epinephrine/pf 1

SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR)

ADVAIR DISKUS 2 QL 2 / day

ADVAIR HFA 2 QL 0.4 / day

albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2mg/5 ml syrup, 4 mg tab er 12h, 8 mg tab er 12h) 1

albuterol sulfate (2 mg tablet, 2.5 mg/0.5 vial-neb, 2.5 mg/3mlvial-neb, 4 mg tablet, 5 mg/ml solution) 1 LCG

ANORO ELLIPTA 2 QL 2 / day

BREO ELLIPTA 2 QL 2 / day

COMBIVENT RESPIMAT 2 QL 0.267 / day

fluticasone propionate/salmeterol xinafoate 1QL 0.04 / day

AL At least 12 yrs old

ipratropium bromide/albuterol sulfate 1

levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial-neb,1.25mg/0.5 vial-neb, 1.25mg/3ml vial-neb) 3 HCG

metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mgtablet) 1

PROAIR HFA 2 QL .8 / day

PROAIR RESPICLICK 2QL 0.07 / day



PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SEREVENT DISKUS 2 QL 2 / day

STRIVERDI RESPIMAT 2QL .144 / day

ST

SYMBICORT 2 QL 0.4 / day

terbutaline sulfate (2.5 mg tablet, 5 mg tablet) 1 LCG

terbutaline sulfate 1 mg/ml vial 1

VENTOLIN HFA 2 QL 1.5 / day

ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)

NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS

doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg tablet, 8 mgtablet) 1

prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule) 1

terazosin hcl 1

NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS

dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial) 1

dihydroergotamine mesylate 0.5mg/spry spray/pump 3QL 8 / 30 days

HCG

ergoloid mesylates 1 mg tablet 1

ergotamine tartrate/caffeine 1

phenoxybenzamine hcl 10 mg capsule 1

phentolamine mesylate 5 mg vial 1

phentolamine mesylate/alprostadil in bacteriostatic water 1

SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT

alfuzosin hcl 1QL 1 / day

GL Male

carvedilol 1



dutasteride/tamsulosin hcl 1QL 1 / day

GL Male

labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1

RAPAFLO 2QL 1 / day

GL Male

tamsulosin hcl 1 QL 2 / day

ANALGESICS AND ANTIPYRETICS

ANALGESICS AND ANTIPYRETICS, MISC.

acetaminophen with codeine phosphate (120-12mg/5 solution,300mg/12.5 solution) 1

QL 139 / day


acetaminophen with codeine 300mg-15mg tablet 1QL 22 / day






acetaminophen/caff/dihydrocod 320.5-30mg capsule 1QL 10 / day


acetaminophen/caff/dihydrocod 325-30-16 tablet 1 QL 10 / day

butalbital/acetaminophen/caffeine(butalb/acetaminophen/caffeine 50-300-40 capsule,butalb/acetaminophen/caffeine 50-325-40 capsule,butalb/acetaminophen/caffeine 50-325-40 tablet)

1 QL 6 / day

butalbital/acetaminophen/caffeine/codeine phosphate 1 QL 6 / day

CAPACET 1 QL 6 / day

ENDOCET 1QL 12 / day




ESGIC CAPSULE 1 QL 6 / day

gabapentin (100 mg capsule, 300 mg capsule, 400 mg capsule) 1 QL 9 / day

gabapentin (250 mg/5ml solution, 300 mg/6ml solution) 1 QL 72 / day

gabapentin 600 mg tablet 1 QL 6 / day

gabapentin 800 mg tablet 1 QL 5 / day

hydrocodone bitartrate/acetaminophen(hydrocodone/acetaminophen 2.5-108/5 solution,hydrocodone/acetaminophen 5-217mg/10 solution,hydrocodone/acetaminophen 7.5-325/15 solution)

1QL 140 / day


hydrocodone/acetaminophen 2.5-167/5 solution 1QL 100 / day


hydrocodone bitartrate/acetaminophen(hydrocodone/acetaminophen 5 mg-300mg tablet,hydrocodone/acetaminophen 7.5-300 mg tablet,hydrocodone/acetaminophen 10mg-300mg tablet)

1QL 13 / day


hydrocodone bitartrate/acetaminophen(hydrocodone/acetaminophen 5 mg-325mg tablet,hydrocodone/acetaminophen 10mg-325mg tablet)

1QL 12 / day


hydrocodone/acetaminophen 2.5-325 mg tablet 1QL 20 / day


hydrocodone/acetaminophen 7.5-325 mg tablet 1QL 8 / day


isometheptene mucate/caffeine/acetaminophen 1

isometheptene mucate/dichloralphenazone/acetaminophen 1

LORCET 1QL 12 / day


LORCET HD 1QL 12 / day


LORCET PLUS 1QL 6 / day




LORTAB (5-325 MG TABLET, 7.5-325 MG TABLET, 10-325 MGTABLET) 1

QL 8 / day


MARGESIC 1 QL 6 / day

MARTEN-TAB 1 QL 6 / day

NODOLOR 1

NORCO 5-325 TABLET 1QL 12 / day


oxycodone hcl/acetaminophen 5-325/5 ml solution 1QL 62 / day


oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5-325 mgtablet, hcl/acetaminophen 5 mg-325mg tablet,hcl/acetaminophen 7.5-325 mg tablet, hcl/acetaminophen10mg-325mg tablet)

1QL 12 / day


oxycodone hcl/acetaminophen 10mg-300mg tablet 1QL 3 / day


oxycodone hcl/acetaminophen 5 mg-300mg tablet 1QL 7 / day


oxycodone hcl/acetaminophen 7.5-300 mg tablet 1QL 4 / day


TENCON 1 QL 6 / day

tramadol hcl/acetaminophen 1QL 8 / day


VERDROCET 1QL 20 / day


VICODIN 1QL 8 / day


VICODIN ES 1QL 13 / day




VICODIN HP 1QL 13 / day


ZEBUTAL 1 QL 6 / day

OPIATE AGONISTS

alfentanil hcl 1

ASCOMP WITH CODEINE 1QL 6 / day


ASTRAMORPH-PF (1 MG/ML AMPUL, 10 MG/10 ML VIAL) 1 QL 50 / day

ASTRAMORPH-PF (1 MG/2 ML AMPULE, 5 MG/10 ML VIAL) 1 QL 100 / day

carisoprodol/aspirin/codeine 200-325-16 tablet 1 QL 21 / day

codeine/butalbital/asa/caffein 30-50-325 capsule 1QL 6 / day


codeine sulfate 1QL 6 / day


DURAMORPH 10 MG/10 ML AMPUL 1 QL 5 / day

DURAMORPH 5 MG/10 ML AMPUL 1 QL 10 / day

EMBEDA 2QL 2 / day

PA

fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72,37.5mcg/hr patch td72, 50mcg/hr patch td72, 62.5mcg/hrpatch td72, 75mcg/hr patch td72, 87.5mcg/hr patch td72, 100mcg/hr patch td72)

1QL 0.5 / day

PA

fentanyl citrate (200 mcg lozenge hd, 400 mcg lozenge hd, 600mcg lozenge hd, 800 mcg lozenge hd, 1200 mcg lozenge hd,1600 mcg lozenge hd)

3

QL 4 / day

PA


HCG

fentanyl citrate-0.9 % nacl/pf 600mcg/30 pca vial 1 QL 19 / day



fentanyl/bupivacaine/ns/pf 2-1250mcg plast. bag 1 QL 192 / day

fentanyl/bupivacaine/ns/pf 4mcg/ml-.1 plast. bag 1 QL 96 / day

fentanyl/bupivacaine/ns/pf 2-625mcg/1 pump resvr 1 QL 192 / day

fentanyl citrate/pf 50 mcg/ml ampul 1 MED Medical Drug

fentanyl citrate/pf 50 mcg/ml vial 1 MED Medical Drug

fentanyl citrate/ropivacaine hcl/sodium chloride 0.9%/pf(fentanyl/ropivacaine/ns/pf 2-1500mcg pump resvr,fentanyl/ropivacaine/ns/pf 2mcg/ml-.1 pump resvr)

1 QL 192 / day

hydrocodone bitart/chlorpheniraminemaleate/pseudoephedrine 1

QL 20 / day


hydrocodone/ibuprofen (hydrocodone/ibuprofen 2.5-200mgtablet, hydrocodone/ibuprofen 7.5-200 mg tablet,hydrocodone/ibuprofen 10mg-200mg tablet)

1QL 5 / day


hydrocodone/ibuprofen 5mg-200mg tablet 1QL 6 / day


hydromorphone hcl 1 mg/ml ampul 1 QL 13 / day

hydromorphone hcl 1 mg/ml liquid 1QL 13 / day


hydromorphone hcl 3 mg supp.rect 1 QL 4 / day

hydromorphone hcl 0.5mg/.5ml syringe 1QL 50 / day


hydromorphone hcl 1 mg/ml syringe 1QL 13 / day


hydromorphone hcl 2 mg/ml syringe 1

QL 6 / day


MED Medical Drug

hydromorphone hcl 4 mg/ml syringe 1QL 3 / day




hydromorphone hcl (8 mg tab er 24h, 12 mg tab er 24h, 16 mgtab er 24h, 32 mg tab er 24h) 3

QL 2 / day

PA

HCG

hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg tablet) 1QL 6 / day


hydromorphone hcl (2 mg/ml ampul, 2 mg/ml vial) 1 QL 6 / day

hydromorphone hcl/pf 10 mg/ml ampul 1QL 1 / day


hydromorphone hcl/pf 10 mg/ml vial 1 QL 1 / day

IBUDONE 5-200 MG TABLET 1QL 6 / day


ibuprofen/oxycodone hcl 1QL 4 / day


levorphanol tartrate 2 mg tablet 1QL 4 / day


meperidine hcl 10 mg/ml cartridge 1QL 50 / day


meperidine hcl 50 mg/5 ml solution 1QL 50 / day


meperidine hcl 100 mg tablet 1QL 5 / day


meperidine hcl 50 mg tablet 1QL 10 / day


meperidine hcl/pf 100 mg/ml vial 1QL 5 / day








methadone hcl 10 mg/5 ml solution 1QL 8 / day

PA

methadone hcl 5 mg/5 ml solution 1QL 18 / day

PA

methadone hcl (10 mg tablet, 10 mg/ml oral conc) 1QL 2 / day

PA

methadone hcl 5 mg tablet 1QL 3 / day

PA

methadone hcl 10 mg/ml vial 1 QL 2 / day

METHADONE INTENSOL 1QL 2 / day

PA

morphine sulfate (10 mg cap er pel, 20 mg cap er pel, 50 mg caper pel, 100 mg cap er pel) 1

QL 2 / day

PA

morphine sulfate (30 mg cap er pel, 30 mg cpmp 24hr, 45 mgcpmp 24hr, 60 mg cap er pel, 60 mg cpmp 24hr, 75 mg cpmp24hr, 80 mg cap er pel, 90 mg cpmp 24hr, 120 mg cpmp 24hr)

1QL 1 / day

PA

morphine sulfate (10mg/0.7ml pen injctr, 15 mg/ml vial) 1QL 3 / day

PA

morphine sulfate (20 mg supp.rect, 100 mg/5ml solution) 1 QL 3 / day

morphine sulfate 10 mg/5 ml solution 1 QL 25 / day

morphine sulfate 20 mg/5 ml solution 1 QL 13 / day

morphine sulfate 10 mg supp.rect 1 QL 5 / day





morphine sulfate 5 mg/ml syringe 1QL 10 / day

PA

morphine sulfate 15 mg tablet 1QL 3 / day


morphine sulfate 30 mg tablet 1QL 2 / day


morphine sulfate (15 mg tablet er, 30 mg tablet er, 60 mg tableter, 100 mg tablet er, 200 mg tablet er) 1

QL 3 / day

PA

morphine sulfate 8 mg/ml vial 1

QL 6 / day

PA

MED Medical Drug

morphine sulfate/pf 0.5 mg/ml vial 1QL 100 / day

PA

morphine sulfate/pf 1 mg/ml vial 1QL 50 / day

PA

opium/belladonna alkaloids 30-16.2 mg supp.rect 1 QL 2 / day

opium/belladonna alkaloids 60-16.2 mg supp.rect 1 QL 1 / day

oxycodone hcl 20 mg/ml oral conc 1 QL 2 / day

oxycodone hcl 5 mg/5 ml solution 1 QL 33 / day

oxycodone hcl 10mg/0.5ml syringe 1 QL 4 / day

oxycodone hcl (10 mg tab er 12h, 15 mg tab er 12h, 20 mg taber 12h, 30 mg tab er 12h, 40 mg tab er 12h, 60 mg tab er 12h,80 mg tab er 12h)

1QL 3 / day

PA

oxycodone hcl (5 mg capsule, 5 mg tablet, 15 mg tablet, 20 mgtablet, 30 mg tablet) 1

QL 8 / day


oxycodone hcl 10 mg tablet 1 QL 8 / day



oxycodone hcl/aspirin 1QL 7 / day


oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mgtab er 12h, 15 mg tab er 12h, 20 mg tab er 12h, 30 mg tab er12h, 40 mg tab er 12h)

3

QL 2 / day

PA


HCG

oxymorphone hcl (5 mg tablet, 10 mg tablet) 3

QL 12 / day


HCG

promethazine/phenyleph/codeine 6.25-5-10 syrup 1QL 30 / day


REPREXAIN 10-200 MG TABLET 1QL 5 / day


tramadol hcl (100 mg cpbp 25-75, 150 mg cpbp 25-75, 200 mgcpbp 25-75, 300 mg cpbp 17-83) 1

QL 1 / day

PA


tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, 200 mgtab er 24h, 200 mg tbmp 24hr, 300 mg tab er 24h, 300 mgtbmp 24hr)

3

QL 1 / day

PA


HCG

tramadol hcl 50 mg tablet 1QL 8 / day


XYLON 10 1

OPIATE PARTIAL AGONISTS

buprenorphine hcl (0.3 mg/ml syringe, 0.3 mg/ml vial) 1 QL 17 / day

buprenorphine hcl (2 mg tab subl, 8 mg tab subl) 1QL 3 / day

PA



buprenorphine hcl/naloxone hcl 3

QL 3 / day

PA

HCG

butorphanol tartrate 10 mg/ml spray 1QL 0.3 / day


butorphanol tartrate 1 mg/ml vial 1QL 7 / day


butorphanol tartrate 2 mg/ml vial 1QL 4 / day


nalbuphine hcl (10 mg/ml ampul, 10 mg/ml vial) 1 QL 5 / day

nalbuphine hcl (20 mg/ml ampul, 20 mg/ml vial) 1 QL 3 / day

pentazocine hcl/naloxone hcl 1QL 12 / day


SUBOXONE (2 MG-0.5 MG FILM, 8 MG-2 MG FILM) 2QL 3 / day

PA

SUBOXONE (4 MG-1 MG FILM, 12 MG-3 MG FILM) 2QL 2 / day

PA

ANOREXIGENIC AGENTS

AMPHETAMINE DERIVATIVES

diethylpropion hcl 25 mg tablet 1

QL 3 / day

PA


diethylpropion hcl 75 mg tablet er 1QL 1 / day

PA

LOMAIRA 1

QL 3 / day

PA




phendimetrazine tartrate 105 mg capsule er 1QL 1 / day

PA

phendimetrazine tartrate 35 mg tablet 1QL 3 / day

PA

phentermine hcl (15 mg capsule, 30 mg capsule) 1QL 1 / day

PA

phentermine hcl (37.5 mg capsule, 37.5 mg tablet) 1

QL 2 / day

PA


ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS

AMPHETAMINES

benzphetamine hcl 25 mg tablet 1

QL 3 / day

PA


benzphetamine hcl 50 mg tablet 1QL 3 / day

PA

DEXEDRINE 10 MG TABLET 1 QL 6 / day

DEXEDRINE 5 MG TABLET 1 QL 2 / day



dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mg cap er 24h,dextroamphetamine/amphetamine 5 mg tablet,dextroamphetamine/amphetamine 7.5 mg tablet,dextroamphetamine/amphetamine 10 mg cap er 24h,dextroamphetamine/amphetamine 10 mg tablet,dextroamphetamine/amphetamine 12.5 mg tablet,dextroamphetamine/amphetamine 15 mg cap er 24h,dextroamphetamine/amphetamine 15 mg tablet,dextroamphetamine/amphetamine 20 mg cap er 24h,dextroamphetamine/amphetamine 20 mg tablet,dextroamphetamine/amphetamine 25 mg cap er 24h,dextroamphetamine/amphetamine 30 mg cap er 24h,dextroamphetamine/amphetamine 30 mg tablet)

1 QL 2 / day

dextroamphetamine sulfate 10 mg capsule er 3QL 5 / day

HCG

dextroamphetamine sulfate 15 mg capsule er 3QL 4 / day

HCG

dextroamphetamine sulfate 5 mg/5 ml solution 3QL 60 / day

HCG

dextroamphetamine sulfate (5 mg capsule er, 5 mg tablet) 3QL 2 / day

HCG

dextroamphetamine sulfate 10 mg tablet 3QL 6 / day

HCG

methamphetamine hcl 1 QL 5 / day

VYVANSE (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE,40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE, 70 MGCAPSULE)

2 QL 1 / day

VYVANSE (10 MG TABLET, 20 MG TABLET, 30 MG TABLET, 40MG TABLET, 50 MG TABLET, 60 MG TABLET) 2 QL 1 / day

ZENZEDI 10 MG TABLET 1 QL 6 / day

ZENZEDI 5 MG TABLET 1 QL 2 / day



RESPIRATORY AND CNS STIMULANTS

caffeine citrate 60 mg/3 ml solution 1

caffeine/sodium benzoate 1

dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50,15 mg cpbp 50-50, 25 mg cpbp 50-50, 30 mg cpbp 50-50, 35mg cpbp 50-50, 40 mg cpbp 50-50)

3QL 1 / day

HCG

dexmethylphenidate hcl 20 mg cpbp 50-50 3QL 2 / day

HCG

dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet) 1 QL 3 / day

dexmethylphenidate hcl 10 mg tablet 1 QL 2 / day

METADATE ER 1QL 3 / day

LCG

methylphenidate hcl (10 mg cpbp 30-70, 20 mg cpbp 30-70, 20mg cpbp 50-50, 40 mg cpbp 30-70, 40 mg cpbp 50-50, 50 mgcpbp 30-70, 60 mg cpbp 30-70)

3QL 1 / day

HCG

methylphenidate hcl (30 mg cpbp 30-70, 30 mg cpbp 50-50) 3QL 2 / day

HCG

methylphenidate hcl (54 mg tab er 24, 60 mg cpbp 50-50) 1 QL 1 / day

methylphenidate hcl 10 mg/5 ml solution 1 QL 30 / day

methylphenidate hcl 5 mg/5 ml solution 1 QL 60 / day

methylphenidate hcl 2.5 mg tab chew 1

methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24, 36 mgtab er 24) 1 QL 2 / day

methylphenidate hcl (5 mg tab chew, 10 mg tab chew, 20 mgtablet, 20 mg tablet er) 1 QL 3 / day

methylphenidate hcl 10 mg tablet 1QL 5 / day

LCG

methylphenidate hcl 5 mg tablet 1QL 3 / day

LCG



methylphenidate hcl 10 mg tablet er 1 QL 5 / day

WAKEFULNESS-PROMOTING AGENTS

armodafinil 3

QL 1 / day

PA

HCG

modafinil 1QL 1 / day

PA

ANTI-INFECTIVE AGENTS

ANTHELMINTICS

ivermectin 3 mg tablet 1 PA

URINARY ANTI-INFECTIVES

AZUPHEN MB 1

HYOPHEN 1

INDIOMIN MB 1

methenamine hippurate 1

methenamine mandelate (1 g tablet, 500 mg tablet) 1

methenamine/sod phosph,monobasic/methyleneblue/hyoscyamine 1

nitrofurantoin 25 mg/5 ml oral susp 1

nitrofurantoin macrocrystal (25 mg capsule, 50 mg capsule,100 mg capsule) 1

nitrofurantoin monohydrate/macrocrystals 1

PHOSPHASAL 1

trimethoprim 100 mg tablet 1

UR N-C 1

URELLE 1

URETRON D-S 1



URIBEL 1 QL 4 / day

URIMAR-T 1

URIN D.S. 1

URO-458 1

URO-BLUE 1

URO-L 1

UROPHEN MB 1

URYL 1

USTELL 1

UTA 1

UTIRA-C 1

ANTI-INFECTIVES (EENT)

ANTIBACTERIALS (EENT)

AK-POLY-BAC 1 QL 0.434 / day

bacitracin 500 unit/g oint. (g) 1 QL 0.434 / day

bacitracin/polymyxin b sulfate 1 QL 0.434 / day

BACTROBAN NASAL 2

CIPRODEX 2 QL 0.257 / day

ciprofloxacin hcl 0.2 % droperette 1 QL 0.567 / day

ciprofloxacin hcl 0.3 % drops 1 QL 0.767 / day

doxycycline hyclate 20 mg tablet 1

erythromycin base 5 mg/gram oint. (g) 1 QL 0.54 / day

gatifloxacin 0.5 % drops 1 QL 0.36/day

GENTAK 1 QL 0.54 / day

gentamicin sulfate 0.3 % drops 1 QL 2.143 / day



gentamicin sulfate 0.3 % oint. (g) 1 QL 0.54 / day

ILOTYCIN 1 QL 0.54 / day

levofloxacin 0.5 % drops 1 QL 0.767 / day

MOXEZA 2 QL 0.434 / day

moxifloxacin hcl 0.5 % drops 1 QL 0.434 / day

NEO-POLYCIN 1 QL 0.124 / day

NEO-POLYCIN HC 1 QL 4 / fill

neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone 1 QL 4 / fill

neomycin sulfate/bacitracin/polymyxin b 1 QL 0.124 / day

neomycin sulfate/polymyxin b sulfate/gramicidin d 1 QL 1.47 / day

neomycin sulfate/polymyxin b sulfate/hydrocortisone(neomycin/polymyxin b/hydrocort 3.5-10k-1 drops susp,neomycin/polymyxin b/hydrocort 3.5-10k-1 solution)

1 QL 10 / fill

neomycin/polymyxin b/hydrocort 3.5-10k-10 drops susp 1 QL 10/ fill

neomycin/polymyxin b/dexametha 0.1 % drops susp 1 QL 5 / fill

neomycin/polymyxin b/dexametha 3.5-10k-.1 oint. (g) 1 QL 4 / fill

ofloxacin 0.3 % drops 1 QL 1.47 / day

POLYCIN 1 QL 0.434 / day

polymyxin b sulfate/trimethoprim 1 QL 1.47 / day

sulfacetamide sodium 10 % drops 1 QL 5 / fill

sulfacetamide sodium 10 % oint. (g) 1 QL 4 / fill

sulfacetamide sodium/prednisolone sodium phosphate 1 QL 5 / fill

tobramycin 0.3 % drops 1 QL 2.143 / day

tobramycin/dexamethasone 1 QL 5 / fill



VIGAMOX 2 QL 0.434 / day

ANTIVIRALS (EENT)

trifluridine 1 % drops 1

EENT ANTI-INFECTIVES, MISCELLANEOUS

ACETASOL HC 1

acetic acid 2 % solution 1

acetic acid/aluminum acetate 1

chlorhexidine gluconate 0.12 % mouthwash 1

hydrocortisone/acetic acid 1

PAROEX 1

PERIOGARD 1

povidone-iodine 5 % solution 1

ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)

ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)

CLEOCIN 100 MG VAGINAL OVULE 2

CLINDACIN ETZ 1% PLEDGET 1

CLINDACIN P 1

clindamycin phosphate 1 % foam 1 QL 1.667 / day

clindamycin phosphate 1 % gel (gram) 1 QL 75 / 30 days

clindamycin phosphate (1 % lotion, 1 % med. swab, 1 %solution, 2 % cream/appl) 1

clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) 3QL 1.5 / day

HCG

clindamycin phosphate/benzoyl peroxide (phos/benzoyl 1 % gel(gram), phos/benzoyl 1 % gel w/pump) 3

QL 1.667 / day

HCG

clindamycin phosphate/tretinoin 3QL 2 / day

HCG



ERY 1

erythromycin base/benzoyl peroxide 3QL 1.60 / day

HCG

erythromycin base/ethanol 2 % gel (gram) 1 QL 1 / day

erythromycin base/ethyl alcohol (base/ethanol 2 % med. swab,base/ethanol 2 % solution) 1

gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g)) 1

metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 %lotion, 1 % gel (gram)) 3 HCG

metronidazole (0.75 % gel w/appl, 1 % gel w/pump) 1

mupirocin 2 % oint. (g) 1

mupirocin calcium 1

NEUAC GEL 1 QL 1.5 / day

ROSADAN (CREAM, GEL) 1

VANDAZOLE 1

ANTIVIRALS (SKIN AND MUCOUS MEMBRANE)

acyclovir 5 % oint. (g) 3 HCG

ZOVIRAX 5% CREAM 2

QL 0.167 / day

PA


LOCAL ANTI-INFECTIVES, MISCELLANEOUS

AVAR CLEANSER 1

AVAR-E 1

AVAR-E GREEN 1

BP 10-1 1

CLEANSING WASH 1

DERMAZENE 1



guaiacol 1

hydrocortisone acetate/iodoquinol/aloe vera 1

hydrocortisone/iodoquinol 1

LUGOL'S STRONG IODINE SOLUTION 1

phenol liquid 1

ROSANIL 1

SEB-PREV 3QL 12 / day

HCG

selenium sulfide (2.25 % shampoo, 2.5 % lotion) 1

silver nitrate (0.5 % solution, 10 % oint. (g), 25 % solution, 50% solution) 1

silver sulfadiazine 1 % cream (g) 1

SSD 1

SSS 10-5 (10-5 CREAM, 10-5 FOAM) 1

sulfacetamide sodium (10 % cleanser, 10 % clnsr gel) 3QL 12 / day

HCG

sulfacetamide sodium 10 % shampoo 1 QL 8 / day

sulfacetamide sodium 10 % suspension 1 QL 4 / day



sulfacetamide sodium/sulfur (sodium/sulfur 8 %-4 %suspension, sodium/sulfur 9 %-4 % cleanser, sodium/sulfur 9%-4.5 % cleanser, sodium/sulfur 9.8%-4.8% cleanser,sodium/sulfur 10 %-2 % cleanser, sodium/sulfur 10 %-2 %cream (g), sodium/sulfur 10 %-4 % med. pad, sodium/sulfur 10%-5 % foam, sodium/sulfur 10-5%(w/v) lotion, sodium/sulfur10-5%(w/w) cream (g), sodium/sulfur 10-5%(w/w) lotion,sodium/sulfur 10-5%(w/w) suspension)

1

sulfacetamide sodium/sulfur 10-5%(w/w) cleanser 1

sulfacetamide sodium/sulfur/skin cleanser comb no.23 1

sulfacetamide sodium/sulfur/urea 1

SULFACLEANSE 8-4 3 HCG

THERMAZENE 1

ZENCIA 1

SCABICIDES AND PEDICULICIDES

lindane (1 % lotion, 1 % shampoo) 1

malathion 3 HCG

permethrin 5 % cream (g) 1

spinosad 3 HCG

ANTI-INFLAMMATORY AGENTS (EENT)

CORTICOSTEROIDS (EENT)

budesonide 32mcg spray/pump 1 QL 0.574 / day

dexamethasone sod phosphate 0.1 % drops 1 QL 10 / fill

flunisolide 25 mcg spray 1 QL .834 / day

fluocinolone acetonide oil 3 HCG

fluorometholone 1 QL 10 / fill

fluticasone propionate 50 mcg spray susp 1 QL 0.6 / day

mometasone furoate 50 mcg spray/pump 1 QL 0.567 / day



prednisolone acetate 1 QL 21 / fill

prednisolone sod phosphate 1 % drops 1

triamcinolone acetonide 55 mcg spray 1 QL 0.55 / day

EENT ANTI-INFLAMMATORY AGENTS, MISC.

RESTASIS 2 PA

RESTASIS MULTIDOSE 2 PA

EENT NONSTEROIDAL ANTI-INFLAM. AGENTS

ACUVAIL 2 QL 1 / day

bromfenac sodium 0.09% drops 1 QL 8 / rx

diclofenac sodium 0.1 % drops 1 QL 5 / fill

flurbiprofen sodium 1 QL 3/ fill

ketorolac tromethamine 0.4 % drops 1 QL 5 / fill

ketorolac tromethamine 0.5 % drops 1 QL 15 / 30 days

ANTI-INFLAMMATORY AGENTS (RESPIRATORY)

LEUKOTRIENE MODIFIERS

montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tabchew, 10 mg tablet) 1 QL 1 / day

zafirlukast 1 QL 2 / day

MAST-CELL STABILIZERS

cromolyn sodium 20 mg/2 ml ampul-neb 1

cromolyn sodium 4 % drops 1 QL 10 / fill

cromolyn sodium 20 mg/ml oral conc 1



ANTIANEMIA DRUGS

IRON PREPARATIONS

FEROCON 1

FEROTRINSIC 1

FERROCITE PLUS 1

HEMATINIC PLUS 1

HEMATINIC WITH FOLIC ACID 1

HEMAX 1

HEMOCYTE-F 1

INFED 4 S

OBSTETRIX ONE 1 GL Female

pediatric multivitamin no.45/sodium fluoride/ferrous sulfate 1

POLYSACCHARIDE IRON FORTE 1

TRIFERIC 272 MG POWDER PACKET 4 S

VYNATAL-FA 1 GL Female

ANTIARRHYTHMIC AGENTS

ANTIARRHYTHMICS, MISCELLANEOUS

DIGITEK 1

DIGOX 1

digoxin (250 mcg/ml ampul, 250 mcg/ml syringe) 1

digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) 1

LANOXIN 500 MCG/2 ML AMPULE 2

LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5 MCGTABLET, 250 MCG TABLET) 2

LANOXIN PEDIATRIC 2

magnesium sulfate (4 meq/ml syringe, 4 meq/ml vial) 1



CLASS IA ANTIARRHYTHMICS

disopyramide phosphate 1

NORPACE CR 100 MG CAPSULE 2

procainamide hcl 500 mg/ml vial 1

quinidine gluconate 324 mg tablet er 1

quinidine gluconate 80 mg/ml vial 1

quinidine sulfate (200 mg tablet, 300 mg tablet, 300 mg tableter) 1

CLASS IB ANTIARRHYTHMICS

DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG CAPSULE) 2

DILANTIN-125 2

lidocaine hcl (20 mg/ml vial, 30 mg/3 ml syringe, 100mg/10mlsyringe) 1

lidocaine hcl/pf (hcl/pf 20 mg/ml ampul, hcl/pf 20 mg/ml vial) 1 MED Medical Drug

lidocaine hcl/pf 100mg/10ml syringe 1

mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mgcapsule) 1

PHENYTEK 2

phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5mloral susp) 1

phenytoin sodium extended 1

CLASS IC ANTIARRHYTHMICS

flecainide acetate 1

propafenone hcl (225 mg cap er 12h, 325 mg cap er 12h, 425mg cap er 12h) 3 HCG

propafenone hcl (150 mg tablet, 225 mg tablet, 300 mg tablet) 1

CLASS II ANTIARRHYTHMICS

acebutolol hcl (200 mg capsule, 400 mg capsule) 1

atenolol (25 mg tablet, 50 mg tablet) 1 LCG



atenolol 100 mg tablet 1

atenolol/chlorthalidone 1

betaxolol hcl (10 mg tablet, 20 mg tablet) 1

bisoprolol fumarate 1

bisoprolol fumarate/hydrochlorothiazide 1 LCG

HEMANGEOL 4 S

metoprolol succinate 1

metoprolol tartrate (25 mg tablet, 50 mg tablet) 1 LCG

metoprolol tartrate (37.5 mg tablet, 75 mg tablet) 1

metoprolol tartrate 100 mg tablet 1

metoprolol tartrate/hydrochlorothiazide 1

nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet) 1

nadolol/bendroflumethiazide 1

pindolol 1

propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 mlsolution, 40 mg tablet, 40mg/5ml solution, 60 mg cap sa 24h,60 mg tablet, 80 mg cap sa 24h, 80 mg tablet, 120 mg cap sa24h, 160 mg cap sa 24h)

1

propranolol hcl/hydrochlorothiazide 1

SORINE 1

sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mgtablet) 1

timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1

CLASS III ANTIARRHYTHMICS

amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1

CORDARONE 2

dofetilide 4 S

PACERONE 1



TIKOSYN 4 S

CLASS IV ANTIARRHYTHMICS

CARTIA XT 1 QL 1 / day

DILT XR 120 MG CAPSULE 1 QL 1 / day

DILT-XR (180 MG CAPSULE, 240 MG CAPSULE) 1

diltiazem hcl (60 mg cap er 12h, 90 mg cap er 12h, 90 mgtablet, 120 mg cap er 12h, 240 mg cap er 24h, 240 mg cap erdeg, 240 mg cap sa 24h, 300 mg cap er 24h, 300 mg cap sa24h, 360 mg cap er 24h, 360 mg cap sa 24h, 420 mg cap sa24h)

1

diltiazem hcl 180 mg cap er 24h 1 QL 1 / day

diltiazem hcl (120 mg cap er 24h, 120 mg cap er deg, 120 mgcap sa 24h, 180 mg cap er deg, 180 mg cap sa 24h, 300 mg taber 24h, 360 mg tab er 24h, 420 mg tab er 24h)

1 QL 1 / day

diltiazem hcl 180 mg tab er 24h 1 QL 3 / day

diltiazem hcl 240 mg tab er 24h 1 QL 2 / day

diltiazem hcl (30 mg tablet, 60 mg tablet, 120 mg tablet) 1 QL 4 / day

MATZIM LA (300 MG TABLET, 360 MG TABLET, 420 MG TABLET) 1 QL 1 / day

MATZIM LA 180 MG TABLET 1 QL 3 / day

MATZIM LA 240 MG TABLET 1 QL 2 / day

TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE) 1 QL 1 / day

TAZTIA XT (240 MG CAPSULE, 300 MG CAPSULE, 360 MGCAPSULE) 1

verapamil hcl (100 mg cap24h pct, 120 mg cap24h pel, 120 mgtablet er, 180 mg cap24h pel, 180 mg tablet er, 200 mg cap24hpct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct,360 mg cap24h pel)

1 QL 1 / day

verapamil hcl (80 mg tablet, 120 mg tablet) 1 QL 3 / day

verapamil hcl 40 mg tablet 1



ANTIBACTERIALS

AMINOGLYCOSIDES

amikacin sulfate 1

BETHKIS 4

PA

S

PS

gentamicin sulfate (20 mg/2 ml vial, 40 mg/ml vial) 1

gentamicin sulfate/pf 20 mg/2 ml vial 1

KITABIS PAK 4PA

S

neomycin sulfate 500 mg tablet 1

paromomycin sulfate 250 mg capsule 1

streptomycin sulfate 1 g vial 1

TOBI 4PA

S

TOBI PODHALER 4PA

S

tobramycin in 0.225 % sodium chloride 4PA

S

tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial) 1

tobramycin/nebulizer 4PA

S

MACROLIDES

ERYPED 200 2

erythromycin base 250 mg capsule dr 1

erythromycin base (250 mg tablet, 500 mg tablet) 3 HCG



erythromycin ethylsuccinate 200 mg/5ml susp recon 1

erythromycin ethylsuccinate 400 mg tablet 3 HCG

QUINOLONES

ciprofloxacin 250 mg/5ml sus mc rec 1 QL 7 / day

ciprofloxacin 500 mg/5ml sus mc rec 1 QL 10 / day

ciprofloxacin hcl (100 mg tablet, 250 mg tablet, 750 mg tablet) 1 QL 2 / day

ciprofloxacin hcl 500 mg tablet 1QL 2 / day

LCG

ciprofloxacin/ciprofloxa hcl 1000 mg tbmp 24hr 1 QL 14 / 1 rx

ciprofloxacin/ciprofloxa hcl 500 mg tbmp 24hr 1 QL 28 / fill

levofloxacin (250mg/10ml solution, 500mg/20ml solution) 1

levofloxacin (250 mg tablet, 500 mg tablet, 750 mg tablet) 1 QL 30 / fill

moxifloxacin hcl 400 mg tablet 1 QL 21 / fill

ofloxacin (300 mg tablet, 400 mg tablet) 1 QL 56 / fill

SULFONAMIDES (SYSTEMIC)

sulfadiazine 500 mg tablet 1

sulfamethoxazole/trimethoprim(sulfamethoxazole/trimethoprim 200-40mg/5 oral susp,sulfamethoxazole/trimethoprim 400mg-80mg tablet,sulfamethoxazole/trimethoprim 800-160/20 oral susp)

1

sulfamethoxazole/trimethoprim 800-160 mg tablet 1 LCG

sulfasalazine (500 mg tablet, 500 mg tablet dr) 1

SULFATRIM 1

TETRACYCLINES

AVIDOXY 1

demeclocycline hcl 1



doxycycline hyclate (50 mg capsule, 100 mg capsule, 100 mgtablet) 1

doxycycline hyclate (50 mg tablet dr, 75 mg tablet dr, 100 mgtablet dr, 150 mg tablet dr) 3 HCG

doxycycline hyclate 200 mg tablet dr 3QL 7/ rx

HCG

doxycycline monohydrate 40 mg cap ir dr 1 QL 1 / day

doxycycline monohydrate 150 mg capsule 1 QL 30 / fill

doxycycline monohydrate (25 mg/5 ml susp recon, 50 mgcapsule, 50 mg tablet, 75 mg capsule, 75 mg tablet, 100 mgcapsule, 100 mg tablet, 150 mg tablet)

1

minocycline hcl (90 mg tab er 24h, 135 mg tab er 24h) 3QL 1 / day

HCG

minocycline hcl 45 mg tab er 24h 3QL 3 / day

HCG

minocycline hcl (50 mg capsule, 50 mg tablet, 75 mg capsule,75 mg tablet, 100 mg capsule, 100 mg tablet) 1

MONDOXYNE NL 1

MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1

PYLERA 2 QL 120 / 365 days

tetracycline hcl (250 mg capsule, 500 mg capsule) 3 HCG

ANTIBACTERIALS, MISCELLANEOUS

BACITRACINS

BACIIM 1

bacitracin 50000 unit vial 1

GLYCOPEPTIDES

vancomycin hcl (125 mg capsule, 250 mg capsule) 3 HCG

vancomycin hcl 125mg/2.5 syringe 1



LINCOMYCINS

clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mgcapsule) 1 QL 4 / day

clindamycin palmitate hcl 75 mg/5 ml soln recon 1 QL 70/ day

clindamycin phosphate 150 mg/ml vial 1

lincomycin hcl 1 QL 10 / day

OXAZOLIDINONES

linezolid 100 mg/5ml susp recon 1 QL 900 / rx

linezolid 600 mg tablet 1 QL 2 / day

POLYMYXINS

colistin (colistimethate na) 150 mg vial 1

polymyxin b sulfate 1

RIFAMYCINS

rifabutin 1

rifampin (150 mg capsule, 300 mg capsule) 1

ANTICHOLINERGIC AGENTS

ANTIMUSCARINICS/ANTISPASMODICS

atropine sulfate (0.05 mg/ml syringe, 0.1 mg/ml disp syrin, 0.1mg/ml syringe, 0.4 mg/ml vial, 1 mg/ml vial) 1

B-DONNA 1

chlordiazepoxide/clidinium bromide 1

dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mgtablet) 1 LCG

dicyclomine hcl 10 mg/ml vial 1

diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025/5liquid, hcl/atropine 2.5-.025mg tablet) 1

ED-SPAZ 1



glycopyrrolate (1 mg tablet, 2 mg tablet) 1

hydrocodone bit/homatrop me-br 5-1.5 mg/5 syrup 1QL 30 / day


hydrocodone bit/homatrop me-br 5 mg-1.5mg tablet 1QL 6 / day


HYDROMET 1QL 30 / day


hyoscyamine sulfate (0.125 mg tab rapdis, 0.125 mg tab subl,0.125 mg tablet, 0.125mg/ml drops, 0.375 mg tab er 12h,125mcg/5ml elixir)

1

HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML ELIXIR) 1

INCRUSE ELLIPTA 2 QL 1 / day

ipratropium bromide 0.2 mg/ml solution 1 QL 12.5 / day

methscopolamine bromide (2.5 mg tablet, 5 mg tablet) 1

NULEV 1

OSCIMIN (0.125 MG ODT, 0.125 MG TABLET) 1

OSCIMIN SL 1

OSCIMIN SR 1

phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb 1

PHENOHYTRO 1

propantheline bromide 15 mg tablet 1

scopolamine hydrobromide 0.4 mg/ml vial 1

SPIRIVA 2 QL 1 / day

SPIRIVA RESPIMAT 2 QL 1 / day

STIOLTO RESPIMAT 2 QL 0.134 / day

SYMAX 1

SYMAX-SL 1



SYMAX-SR 1

TUSSIGON 1QL 6 / day


ANTIPARKINSONIAN AGENTS

benztropine mesylate (2 mg/2 ml ampul, 2 mg/2 ml vial) 1

benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1

trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elixir, 5 mg tablet) 1

ANTICOAGULANTS

ANTICOAGULANTS, MISCELLANEOUS

sodium citrate 4 % (3 ml) syringe 1

COUMARIN DERIVATIVES

COUMADIN 2

JANTOVEN (1 MG TABLET, 2.5 MG TABLET, 3 MG TABLET, 4 MGTABLET, 5 MG TABLET) 1 LCG

JANTOVEN (2 MG TABLET, 6 MG TABLET, 7.5 MG TABLET, 10 MGTABLET) 1

warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mgtablet, 4 mg tablet, 5 mg tablet) 1 LCG

warfarin sodium (6 mg tablet, 7.5 mg tablet, 10 mg tablet) 1

DIRECT FACTOR XA INHIBITORS

ARIXTRA (2.5 MG/0.5 ML SYRINGE, 5 MG/0.4 ML SYRINGE) 4 S

ARIXTRA (7.5 MG/0.6 ML SYRINGE, 10 MG/0.8 ML SYRINGE) 4 S

fondaparinux sodium (2.5 mg/0.5 syringe, 7.5mg/0.6 syringe,10mg/0.8ml syringe) 4 S

fondaparinux sodium 5mg/0.4ml syringe 4 S

XARELTO STARTER PACK 2

XARELTO (10 MG TABLET, 20 MG TABLET) 2 QL 1 / day



XARELTO 15 MG TABLET 2 QL 2 / day

DIRECT THROMBIN INHIBITORS

IPRIVASK 4 S

PRADAXA 2 QL 2 / day

HEPARINS

enoxaparin sodium (30mg/0.3ml syringe, 40mg/0.4ml syringe,60mg/0.6ml syringe, 80mg/0.8ml syringe, 100 mg/ml syringe,120mg/.8ml syringe, 150 mg/ml syringe, 300mg/3ml vial)

4 S

FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR,7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML,95,000 UNITS/3.8 ML VL)

4 S

heparin sodium,porcine (5000/ml(1) cartridge, 20000/ml vial) 1

heparin sodium,porcine 10000/ml vial 1 MED Medical Drug

heparin sodium,porcine/pf (sodium,porcine/pf 5000/0.5mlsyringe, sodium,porcine/pf 5000/0.5ml vial) 1

heparin sodium,porcine/pf 1000/ml vial 1

LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 60MG/0.6 ML SYRINGE, 80 MG/0.8 ML SYRINGE, 100 MG/MLSYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE, 300MG/3 ML VIAL)

4 S

ANTICONVULSANTS

ANTICONVULSANTS, MISCELLANEOUS

carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tablet, 300 mgcpmp 12hr)

1

carbamazepine (100 mg tab er 12h, 200 mg tab er 12h, 400 mgtab er 12h) 3 HCG

CARBATROL 2

DEPAKOTE ER 2

DEPAKOTE SPRINKLE 2



divalproex sodium (125 mg cap dr spr, 125 mg tablet dr, 250mg tab er 24h, 250 mg tablet dr, 500 mg tab er 24h, 500 mgtablet dr)

1

EPITOL 1

felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oralsusp) 1

GABITRIL (12 MG TABLET, 16 MG TABLET) 2

lamotrigine (25 mg tab er 24, 50 mg tab er 24, 100 mg tab er24, 200 mg tab er 24, 250 mg tab er 24, 300 mg tab er 24) 3 HCG

lamotrigine (5 mg tb chw dsp, 25 mg tab rapdis, 25 mg tablet,25 mg tb chw dsp, 25(21)-50 tb rd dspk, 25(42)-100 tab ds pk,25(84)-100 tab ds pk, 25-50-100 tb rd dspk, 25mg (35) tab dspk, 50 mg tab rapdis, 50(42)-100 tb rd dspk, 100 mg tab rapdis,100 mg tablet, 150 mg tablet, 200 mg tab rapdis, 200 mgtablet)

1

levetiracetam 500 mg/5ml solution 1 QL 946 / 30 days

levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg taber 24h, 500 mg tablet, 750 mg tab er 24h, 750 mg tablet, 1000mg tablet)

1

magnesium chloride 200 mg/ml vial 1

oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oralsusp, 600 mg tablet) 1

ROWEEPRA 1

SABRIL (500 MG POWDER PACKET, 500 MG TABLET) 4

QL 6 / day

PA

S

TEGRETOL XR 2

tiagabine hcl 1

TOPAMAX (15 MG SPRINKLE CAP, 25 MG SPRINKLE CAP, 25 MGTABLET, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET) 2

topiramate (25 mg cap spr 24, 50 mg cap spr 24, 100 mg capspr 24, 150 mg cap spr 24, 200 mg cap spr 24) 3 HCG

topiramate 15 mg cap sprink 1 LCG



topiramate (25 mg cap sprink, 25 mg tablet, 50 mg tablet, 100mg tablet, 200 mg tablet) 1

valproic acid 250 mg capsule 1

valproic acid (as sodium salt) (valproate sodium) (250 mg/5mlsolution, 500mg/10ml solution) 1

vigabatrin 4

QL 6 / day

PA

S

ZONEGRAN 2

zonisamide (25 mg capsule, 100 mg capsule) 1

zonisamide 50 mg capsule 1 LCG

BARBITURATES (ANTICONVULSANTS)

phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir,30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet,97.2mg tablet, 100 mg tablet)

1

phenobarbital sodium 1

primidone (50 mg tablet, 250 mg tablet) 1

BENZODIAZEPINES (ANTICONVULSANTS)

ATIVAN 4 MG/ML VIAL 1

clonazepam (2 mg tab rapdis, 2 mg tablet) 1 QL 10 / day

clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mgtab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet) 1 QL 3 / day

clorazepate dipotassium 15 mg tablet 1 QL 6 / day

clorazepate dipotassium 3.75 mg tablet 1 QL 24 / day

clorazepate dipotassium 7.5 mg tablet 1 QL 12 / day

diazepam (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) 1 QL 0.07 / day

diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5mg/ml oral conc, 5 mg/ml syringe, 5 mg/ml vial, 10 mg tablet) 1



lorazepam (2 mg tablet, 2 mg/ml oral conc) 1 QL 5 / day

lorazepam (0.5 mg tablet, 1 mg tablet) 1 QL 3 / day

lorazepam (2 mg/ml syringe, 2 mg/ml vial, 4 mg/ml syringe, 4mg/ml vial) 1

LORAZEPAM INTENSOL 1 QL 5 / day

ONFI (2.5 MG/ML SUSPENSION, 10 MG TABLET, 20 MG TABLET) 4PA

S

SUCCINIMIDES

ethosuximide (250 mg capsule, 250 mg/5ml solution) 1

ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 2

ANTIDEPRESSANTS

ANTIDEPRESSANTS, MISCELLANEOUS

BUPROBAN 0QL 2 / day

HCR

bupropion hcl (200 mg tab er 12h, 200 mg tablet er) 1 QL 2 / day

bupropion hcl 150 mg tab er 24h 1 QL 3 / day

bupropion hcl 300 mg tab er 24h 1 QL 1 / day

bupropion hcl 100 mg tablet 1 QL 5 / day

bupropion hcl 75 mg tablet 1 QL 6 / day

bupropion hcl (100 mg tab er 12h, 100 mg tablet er) 1 QL 4 / day

bupropion hcl (150 mg tab er 12h, 150 mg tablet er) 1QL 2 / day

HCR

mirtazapine (15 mg tab rapdis, 15 mg tablet, 30 mg tab rapdis,30 mg tablet, 45 mg tab rapdis, 45 mg tablet) 1 QL 1 / day

mirtazapine 7.5 mg tablet 1 QL 2 / day



MONOAMINE OXIDASE INHIBITORS

phenelzine sulfate 15 mg tablet 1 QL 6 / day

rasagiline mesylate (0.5 mg tablet, 1 mg tablet) 1

selegiline hcl (5 mg capsule, 5 mg tablet) 1

tranylcypromine sulfate 1 QL 6 / day

SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR

desvenlafaxine (50 mg tab er 24, 50 mg tab er 24h, 100 mg taber 24, 100 mg tab er 24h) 3

QL 1 / day

HCG

desvenlafaxine fumarate 3QL 1 / day

HCG

desvenlafaxine succinate 3QL 1 / day

HCG

duloxetine hcl (20 mg capsule dr, 30 mg capsule dr) 1 QL 1 / day

duloxetine hcl (40 mg capsule dr, 60 mg capsule dr) 1 QL 2 / day

venlafaxine hcl 75 mg cap er 24h 1 QL 3 / day

venlafaxine hcl (37.5 mg cap er 24h, 37.5 mg tab er 24, 75 mgtab er 24, 150 mg cap er 24h, 150 mg tab er 24, 225 mg tab er24)

1 QL 1 / day

venlafaxine hcl (37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100mg tablet) 1

venlafaxine hcl 25 mg tablet 1 LCG

SELECTIVE-SEROTONIN REUPTAKE INHIBITORS

citalopram hydrobromide 10 mg/5 ml solution 1 QL 20 / day

citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 mgtablet) 1

QL 1 / day

LCG

escitalopram oxalate 5 mg/5 ml solution 1 QL 20 / day



escitalopram oxalate (5 mg tablet, 10 mg tablet) 1 QL 1.5 / day

escitalopram oxalate 20 mg tablet 1 QL 1 / day

fluoxetine hcl 10 mg capsule 1QL 1 / day

LCG

fluoxetine hcl 20 mg capsule 1QL 4 / day

LCG

fluoxetine hcl 40 mg capsule 1 QL 2 / day

fluoxetine hcl 90 mg capsule dr 1 QL 0.142 / day

fluoxetine hcl 20 mg/5 ml solution 1 QL 20 / day

fluoxetine hcl 10 mg tablet 1QL 1.5 / day

LCG

fluoxetine hcl 20 mg tablet 1 QL 4 / day

fluoxetine hcl 60 mg tablet 1 QL 1.5 / day

fluvoxamine maleate (100 mg cap er 24h, 150 mg cap er 24h) 3QL 2 / day

HCG

fluvoxamine maleate (25 mg tablet, 50 mg tablet) 1 QL 1 / day

fluvoxamine maleate 100 mg tablet 1 QL 3 / day

olanzapine/fluoxetine hcl 3

QL 1 / day


HCG

paroxetine hcl (25 mg tab er 24h, 30 mg tablet, 37.5 mg tab er24h) 1 QL 2 / day

paroxetine hcl (12.5 mg tab er 24h, 40 mg tablet) 1 QL 1 / day

paroxetine hcl 10 mg tablet 1QL 1.5 / day

LCG



paroxetine hcl 20 mg tablet 1QL 1 / day

LCG

paroxetine mesylate 1 QL 1 / day

sertraline hcl 20 mg/ml oral conc 1 QL 10 / day

sertraline hcl (25 mg tablet, 50 mg tablet) 1QL 1.5 / day

LCG

sertraline hcl 100 mg tablet 1QL 2 / day

LCG

SEROTONIN MODULATORS

nefazodone hcl 100 mg tablet 1 QL 6 / day



nefazodone hcl 250 mg tablet 1 QL 2.5 / day


trazodone hcl 100 mg tablet 1QL 4 / day

LCG


LCG

trazodone hcl 300 mg tablet 1 QL 1 / day


LCG

TRICYCLICS, OTHER NOREPI-RU INHIBITORS

amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75mg tablet, 100 mg tablet, 150 mg tablet) 1 LCG

amitriptyline hcl/chlordiazepoxide 1



amoxapine 1

clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mgcapsule) 3 HCG

desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75mg tablet, 100 mg tablet, 150 mg tablet) 3 HCG

doxepin hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 100mg capsule) 1 LCG

doxepin hcl (10 mg/ml oral conc, 75 mg capsule, 150 mgcapsule) 1

imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) 1 LCG

imipramine pamoate 3 HCG

maprotiline hcl 1

nortriptyline hcl (10 mg capsule, 10 mg/5 ml solution, 25 mgcapsule, 50 mg capsule, 75 mg capsule) 1

perphenazine/amitriptyline hcl 1

protriptyline hcl 1

trimipramine maleate 1

ANTIDIABETIC AGENTS

ALPHA-GLUCOSIDASE INHIBITORS

acarbose 100 mg tablet 1 QL 3 / day



miglitol 1 QL 3 / day

AMYLINOMIMETICS

SYMLINPEN 120 2 QL 0.4 / day

SYMLINPEN 60 2 QL 0.2 / day



ANTIDIABETIC AGENTS, MISCELLANEOUS

KORLYM 4PA

S

WELCHOL 3.75G PACKET 2 QL 1 / day

WELCHOL 625 MG TABLET 2 QL 6 / day

BIGUANIDES

ACTOPLUS MET XR 15-1,000 MG TB 2QL 3 / day

ST

ACTOPLUS MET XR 30-1,000 MG TB 2QL 1 / day

ST

AVANDAMET 2QL 2 / day

PA

glipizide/metformin hcl (glipizide/metformin 2.5-500 mg tablet,glipizide/metformin 5 mg-500mg tablet) 1 QL 4 / day

glipizide/metformin hcl 2.5-250 mg tablet 1 QL 8 / day

glyburide/metformin hcl (glyburide/metformin 2.5-500 mgtablet, glyburide/metformin 5 mg-500mg tablet) 1 QL 4 / day

glyburide/metformin hcl 1.25-250mg tablet 1QL 8 / day

LCG

INVOKAMET 2QL 2 / day

ST

INVOKAMET XR 2QL 2 / day

ST

JANUMET 2QL 2 / day

ST

JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET) 2QL 2 / day

ST



JANUMET XR 100-1,000 MG TABLET 2QL 1 / day

ST

JENTADUETO 2QL 2 / day

ST

JENTADUETO XR 2QL 1 / day

ST

metformin hcl 500 mg tab er 24h 1

QL 5 / day

C Only Glucophage ERgeneric covered

LCG

metformin hcl 750 mg tab er 24h 1QL 3 / day

C Only Glucophage ERgeneric covered

metformin hcl 1000 mg tablet 1QL 2.5 / day

LCG

metformin hcl 500 mg tablet 1QL 5 / day

LCG

metformin hcl 850 mg tablet 1QL 3 / day

LCG

pioglitazone hcl/metformin hcl 3QL 3 / day

HCG

repaglinide/metformin hcl 1 QL 5 / day

SYNJARDY 2QL 2 / day

ST

SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET, 12.5-1,000 MG TAB) 2

QL 2 / day

ST

SYNJARDY XR 25-1,000 MG TABLET 2QL 1 / day

ST



DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

JANUVIA 2QL 1 / day

ST

TRADJENTA 2QL 1 / day

ST

INCRETIN MIMETICS

BYDUREON 2QL 0.15 / day

ST

BYDUREON PEN 2QL .15 / day

ST

BYETTA 10 MCG DOSE PEN INJ 2QL 0.8 / day

ST

BYETTA 5 MCG DOSE PEN INJ 2QL 0.04 / day

ST

SOLIQUA 100-33 2QL 0.6 / day

PA

TRULICITY 2QL 0.08 / day

ST

VICTOZA 2-PAK 2QL 0.3 / day

ST

VICTOZA 3-PAK 2QL 0.3 / day

ST

INSULINS

HUMALOG (100 UNITS/ML CARTRIDGE, 100 UNITS/ML VIAL) 2

HUMALOG KWIKPEN U-100 2




HUMALOG MIX 50-50 2

HUMALOG MIX 50-50 KWIKPEN 2

HUMALOG MIX 75-25 2


HUMULIN R U-500 2

HUMULIN R U-500 KWIKPEN 2

LANTUS 2

LANTUS SOLOSTAR 2

TOUJEO SOLOSTAR 2

MEGLITINIDES

nateglinide 1 QL 3 / day

repaglinide (0.5 mg tablet, 1 mg tablet) 1 QL 4 / day

repaglinide 2 mg tablet 1 QL 8 / day

SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

INVOKANA 2QL 1 / day

ST

JARDIANCE 2QL 1 / day

ST

SULFONYLUREAS

chlorpropamide 100 mg tablet 1

chlorpropamide 250 mg tablet 1 QL 3 / day

glimepiride 1 LCG

glipizide (2.5 mg tab er 24, 5 mg tab er 24, 10 mg tab er 24) 1 LCG

glipizide (5 mg tablet, 10 mg tablet) 1 LCG

glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mg tablet) 1 LCG



glyburide,micronized 1 LCG

pioglitazone hcl/glimepiride 1 QL 1 / day

tolazamide 250 mg tablet 1 QL 4 / day

tolazamide 500 mg tablet 1 QL 2 / day

tolbutamide 1 QL 6 / day

THIAZOLIDINEDIONES

AVANDIA 2 MG TABLET 2QL 3 / day

PA


PA


PA

pioglitazone hcl 1 QL 1 / day

ANTIEMETICS

5-HT3 RECEPTOR ANTAGONISTS

AKYNZEO 4

QL 0.15 / day

PA

S

granisetron hcl 1 mg tablet 1 QL 6 / 30 days

ondansetron 1

QL 24 / 30 days

CMax allowable- 3/daywith max of 24 / 30days

ondansetron hcl 4 mg/5 ml solution 1 QL 20 / day

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

QL 24 / 30 days

CMax allowable- 3/daywith max of 24 / 30days



ondansetron hcl 24 mg tablet 1 QL 3 days

ondansetron hcl/pf (hcl/pf 4 mg/2 ml ampul, hcl/pf 4 mg/2 mlvial) 4 S

ondansetron hcl/pf 4 mg/2 ml syringe 4 S

SANCUSO 4QL 0.144 / day

S

ANTIEMETICS, MISCELLANEOUS

aprepitant 125mg-80mg cap ds pk 1 QL 3/ fill

aprepitant (40 mg capsule, 125 mg capsule) 1 QL 0.08 / day

aprepitant 80 mg capsule 1 QL 0.15 / day

CESAMET 4

QL 0.67 / day

PA

S

dronabinol 3QL 5 / day

HCG

scopolamine 1

TRANSDERM-SCOP 2

VARUBI 90 MG TABLET 4

QL 0.15 / day

PA

S

ANTIHISTAMINES (GI DRUGS)

COMPAZINE 25 MG SUPPOSITORY 1

COMPRO 1

dimenhydrinate 50 mg/ml vial 1

meclizine hcl (12.5 mg tablet, 25 mg tablet) 1

prochlorperazine 1



prochlorperazine edisylate (5 mg/ml vial, 10 mg/2 ml vial) 1

prochlorperazine maleate (5 mg tablet, 10 mg tablet) 1

trimethobenzamide hcl 300 mg capsule 1

ANTIFUNGAL (SYSTEMIC)

ALLYLAMINES

terbinafine hcl 250 mg tablet 1

ANTIFUNGALS, MISCELLANEOUS

griseofulvin ultramicrosize 1

griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) 3 HCG

LUGOL'S SOLUTION 1

potassium iodide/iodine 1

triacetin 1

AZOLES

fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mgtablet, 100 mg tablet, 200 mg tablet) 1

fluconazole 150 mg tablet 1QL 0.4 / day

LCG

itraconazole 100 mg capsule 1

ketoconazole 200 mg tablet 1

voriconazole 200 mg/5ml susp recon 3QL 20 / day

HCG

voriconazole (50 mg tablet, 200 mg tablet) 3QL 4 / day

HCG

POLYENES

amphotericin b 50 mg vial 1

nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500kunit tablet, 500mm unit powder(ea), 100000/ml oral susp) 1



PYRIMIDINES

flucytosine (250 mg capsule, 500 mg capsule) 1

ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)

ALLYLAMINES (SKIN AND MUCOUS MEMBRANE)

naftifine hcl 1

ANTIFULGALS (SKIN, MUCOUS MEMBRANE),MISC

EXODERM 1

AZOLES (SKIN AND MUCOUS MEMBRANE)

clotrimazole (1 % cream (g), 1 % solution, 10 mg troche) 1

clotrimazole/betamethasone dipropionate(clotrimazole/betamethasone 1 % cream (g),clotrimazole/betamethasone 1 % lotion)

1

econazole nitrate 1 % cream (g) 3 HCG

ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo) 1

oxiconazole nitrate 3 HCG

terconazole 1QL 1.5 / day

GL Female

HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)

CICLODAN 0.77% CREAM 1

CICLODAN 8% SOLUTION 1 QL 0.22 / day

ciclopirox (0.77 % gel (gram), 1 % shampoo) 1

ciclopirox 8 % solution 1 QL 0.22 / day

ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) 1

POLYENES (SKIN AND MUCOUS MEMBRANE)

NYAMYC 1

NYATA 100,000 UNIT/GM POWDER 1



nystatin (100000/g cream (g), 100000/g oint. (g), 100000/gpowder) 1

nystatin/triamcinolone acetonide (nystatin/triamcin 100000-0.1 cream (g), nystatin/triamcin 100000-0.1 oint. (g)) 3 HCG

NYSTOP 1

ANTIGLAUCOMA AGENTS

ALPHA-ADRENERGIC AGONISTS (EENT)

ALPHAGAN P 0.1% DROPS 2 QL 0.4 / day

brimonidine tartrate (0.15 % drops, 0.2 % drops) 1 QL 0.4 / day

COMBIGAN 2 QL 0.334 / day

BETA-ADRENERGIC BLOCKING AGENTS (EENT)

betaxolol hcl 0.5 % drops 1 QL 0.54 / day

carteolol hcl 1 QL 0.334 / day

dorzolamide hcl/timolol maleate 1 QL 0.334 / day

levobunolol hcl 1 QL 0.4 / day

metipranolol 1 QL 0.334 / day

timolol maleate 0.5 % drops 1 QL 0.334 / day

timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % sol-gel) 1 QL 0.286 / day

CARBONIC ANHYDRASE INHIBITORS (EENT)

acetazolamide 500 mg capsule er 3 HCG

acetazolamide (125 mg tablet, 250 mg tablet) 1

acetazolamide sodium 1

AZOPT 2 QL 0.334 / day

dorzolamide hcl 1 QL 0.4 / day

methazolamide (25 mg tablet, 50 mg tablet) 1



MIOTICS

pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) 1 QL 0.54 / day

PROSTAGLANDIN ANALOGS

bimatoprost 0.03 % drops 1 QL 0.13 / day

bimatoprost 0.03 % drop w/app 1

latanoprost 0.005 % drops 1 QL 0.13 / day

LUMIGAN 2 QL 0.13 / day

TRAVATAN Z 2 QL 0.167 / day

travoprost (benzalkonium) 1 QL 0.167 / day

ANTIHEMORRHAGIC AGENTS

HEMOSTATICS

desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2mg tablet, 10/spray spray/pump) 1

desmopressin acetate (4 mcg/ml ampul, 4 mcg/ml vial) 1

RECOTHROM (5,000 UNIT VIAL, 20,000 UNIT VIAL) 4 S

STIMATE 4 S

tranexamic acid 650 mg tablet 1QL 6 / day

GL Female

ANTIHISTAMINE DRUGS

FIRST GENERATION ANTIHISTAMINES

ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) 1 AL At least 2 yrs old

carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid) 1 AL At least 2 yrs old

clemastine fumarate 2.68 mg tablet 1 AL At least 2 yrs old

cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4 mg/10 mlsyrup) 1 AL At least 2 yrs old



diphenhydramine hcl 12.5mg/5ml elixir 1

diphenhydramine hcl (50 mg/ml syringe, 50 mg/ml vial) 1

SECOND GENERATION ANTIHISTAMINES

cetirizine hcl 1 mg/ml solution 1 QL 10 / day

desloratadine (2.5 mg tab rapdis, 5 mg tab rapdis, 5 mg tablet) 1 QL 1 / day

fexofenadine hcl 180 mg tablet 1 QL 1 / day

fexofenadine hcl 30 mg tablet 1

fexofenadine hcl 60 mg tablet 1 QL 2 / day

levocetirizine dihydrochloride 2.5 mg/5ml solution 1 QL 30 / day

levocetirizine dihydrochloride 5 mg tablet 1 QL 1 / day

ANTIHISTAMINES (RESPIRATORY TRACT AGNTS)

FIRST GENERATION ANTIHIST.(RESPIR TRACT)

BROMFED DM 1 AL At least 2 yrs old

brompheniramine maleate/pseudoephedrinehcl/dextromethorphan 1 AL At least 2 yrs old

CENTERGY 1

CENTERGY DM 1

hydrocodone polistirex/chlorpheniramine polistirex 1QL 10 / day


phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup 1

promethazine hcl (25 mg/ml ampul, 25 mg/ml syringe, 25mg/ml vial, 50 mg/ml ampul, 50 mg/ml vial) 1 AL At least 2 yrs old

promethazine hcl (6.25mg/5ml syrup, 12.5 mg tablet, 50 mgtablet) 1 AL At least 2 yrs old

promethazine hcl 25 mg tablet 1AL At least 2 yrs old

LCG

promethazine hcl/codeine 1



promethazine/dextromethorphan 6.25-15/5 syrup 1AL At least 2 yrs old

LCG

SECOND GENERATION ANTIHIST(RESPIR TRACT)

DYMISTA 2 QL 0.8 / day

ANTIHYPOGLYCEMIC AGENTS

GLYCOGENOLYTIC AGENTS

GLUCAGEN 2

GLUCAGON EMERGENCY KIT 2

glucagon hcl 1

ANTILIPEMIC AGENTS

ANTILIPEMIC AGENTS, MISCELLANEOUS

JUXTAPID (20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE,60 MG CAPSULE) 4

QL 1 / day

PA

S

JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE) 4

QL 2 / day

PA

S

KYNAMRO 4

QL 0.15 / day

PA

S

niacin (750 mg tab er 24h, 1000 mg tab er 24h) 1 QL 2 / day

niacin 500 mg tab er 24h 1 QL 3 / day

omega-3 acid ethyl esters 3QL 4 / day

HCG

TRIKLO 3QL 4 / day

HCG



BILE ACID SEQUESTRANTS

cholestyramine (with sugar) 4 g powder 1 QL 24 / day

cholestyramine (with sugar) 4 g powd pack 1 QL 4 / day

cholestyramine/aspartame 4 g powder 3QL 24 / day

HCG

cholestyramine/aspartame 4 g powd pack 3QL 4 / day

HCG

colestipol hcl (5 g granules, 5 g packet) 1 QL 6 / day

colestipol hcl 1 g tablet 1 QL 4 / day

PREVALITE POWDER 3QL 24 / day

HCG

PREVALITE PACKET 3QL 4 / day

HCG

CHOLESTEROL ABSORPTION INHIBITORS

ezetimibe 1 QL 1 / day

ezetimibe/simvastatin 1 QL 1 / day

FIBRIC ACID DERIVATIVES

fenofibrate (40 mg tablet, 50 mg capsule) 1 QL 2 / day

fenofibrate (150 mg capsule, 160 mg tablet) 1 QL 1 / day

fenofibrate 120 mg tablet 1 QL 1 / day

fenofibrate 54 mg tablet 1 QL 2 / day

fenofibrate nanocrystallized 145mg tablet 1 QL 1 / day

fenofibrate nanocrystallized 48 mg tablet 1 QL 2 / day

fenofibrate,micronized (67 mg capsule, 130 mg capsule, 134mg capsule, 200 mg capsule) 1 QL 1 / day



fenofibrate,micronized 43 mg capsule 1 QL 2 / day

fenofibric acid 105 mg tablet 1 QL 1 / day

fenofibric acid 35 mg tablet 1 QL 2 / day

fenofibric acid (choline) 135 mg capsule dr 1 QL 1 / day

fenofibric acid (choline) 45 mg capsule dr 1 QL 2 / day

gemfibrozil 600 mg tablet 1 QL 2 / day

HMG-COA REDUCTASE INHIBITORS

amlodipine besylate/atorvastatin calcium 3QL 1 / day

HCG

atorvastatin calcium 1 QL 1 / day

fluvastatin sodium 40 mg capsule 1 QL 2 / day

fluvastatin sodium (20 mg capsule, 80 mg tab er 24h) 1 QL 1 / day

lovastatin (10 mg tablet, 20 mg tablet) 1 QL 1 / day

lovastatin 40 mg tablet 1 QL 2 / day

pravastatin sodium (10 mg tablet, 20 mg tablet, 40 mg tablet) 1QL 1 / day

LCG

pravastatin sodium 80 mg tablet 1

rosuvastatin calcium 1 QL 1 / day

simvastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) 1QL 1.5 / day

LCG

simvastatin 5 mg tablet 1QL 1 / day

LCG

simvastatin 80 mg tablet 1QL 1 / day

PA



PCSK9 INHIBITORS

PRALUENT PEN 4

QL 0.08 / day

PA

S

PS

PRALUENT SYRINGE 4

QL 0.08 / day

PA

S

PS

REPATHA PUSHTRONEX 4

QL 0.13 / day

PA

S

PS

REPATHA SURECLICK 4

QL 0.08 / day

PA

S

PS

REPATHA SYRINGE 4

QL 0.08 / day

PA

S

PS

ANTIMIGRAINE AGENTS

SELECTIVE SEROTONIN AGONISTS

almotriptan malate 3QL 0.4 / day

HCG

eletriptan hbr 3QL 0.4 / day

HCG



frovatriptan succinate 3QL 0.6 / day

HCG

naratriptan hcl (1 mg tablet, 2.5 mg tablet) 1 QL 0.6 / day

rizatriptan benzoate (5 mg tab rapdis, 5 mg tablet, 10 mg tabrapdis, 10 mg tablet) 1 QL 0.6 / day

sumatriptan (5 mg spray, 20 mg spray) 3QL 6 / 30 days

HCG

sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml peninjctr, 6 mg/0.5ml cartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5mlvial)

3QL 0.167 / day

HCG

sumatriptan succinate 6 mg/0.5ml syringe 1 QL 0.167 / day

sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mgtablet) 1 QL 0.3 / day

zolmitriptan (2.5 mg tablet, 5 mg tablet) 1 QL 0.2 / day

zolmitriptan (2.5 mg tab rapdis, 5 mg tab rapdis) 3QL 0.2 / day

HCG

ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 2 QL 0.2 / day

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, MISCELLANEOUS

dapsone (25 mg tablet, 100 mg tablet) 1

ANTITUBERCULOSIS AGENTS

clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250mg/5ml susp recon, 500 mg tab er 24h, 500 mg tablet) 1

cycloserine 250 mg capsule 1

ethambutol hcl 1

isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) 1

isoniazid 100 mg/ml vial 1

pyrazinamide 500 mg tablet 1



ANTIPARKINSONIAN AGENTS (CNS)

ADAMANTANES (CNS)

amantadine hcl (50 mg/5 ml solution, 100 mg capsule, 100 mgtablet) 1

CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.

carbidopa/levodopa/entacapone 1

entacapone 1

tolcapone 1

DOPAMINE PRECURSORS

carbidopa/levodopa (carbidopa/levodopa 10mg-100mg tabrapdis, carbidopa/levodopa 10mg-100mg tablet,carbidopa/levodopa 25mg-100mg tab rapdis,carbidopa/levodopa 25mg-100mg tablet, carbidopa/levodopa25mg-100mg tablet er, carbidopa/levodopa 25mg-250mg tabrapdis, carbidopa/levodopa 25mg-250mg tablet,carbidopa/levodopa 50mg-200mg tablet er)

1

DUOPA 4

QL 1 / day

PA

S

ANTIPROTOZOALS

AMEBICIDES

metronidazole (250 mg tablet, 375 mg capsule, 500 mg tablet) 1

ANTIMALARIALS

atovaquone/proguanil hcl 1 PA

chloroquine phosphate (250 mg tablet, 500 mg tablet) 1

hydroxychloroquine sulfate 200 mg tablet 1

mefloquine hcl 1

primaquine phosphate 1

quinine sulfate 324 mg capsule 1QL 42 / 365 days

PA



ANTIPROTOZOALS, MISCELLANEOUS

atovaquone 1 PA

IMPAVIDO 4 S

tinidazole (250 mg tablet, 500 mg tablet) 1

ANTIPSYCHOTIC AGENTS

ANTIPSYCHOTICS, MISCELLANEOUS

loxapine succinate 1 AL At least 18 yrs old

molindone hcl 1

pimozide 1

ATYPICAL ANTIPSYCHOTICS

aripiprazole 1 mg/ml solution 1QL 30 / day


aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tab rapdis, 10 mgtablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 30 mgtablet)

1QL 1 / day


clozapine 200 mg tablet 1QL 4 / day


clozapine 25 mg tablet 1QL 18 / day


clozapine (100 mg tab rapdis, 100 mg tablet) 1QL 9 / day


clozapine (12.5 mg tab rapdis, 25 mg tab rapdis, 50 mg tablet) 1QL 3 / day


clozapine (150 mg tab rapdis, 200 mg tab rapdis) 1 AL At least 18 yrs old

NUPLAZID 4

QL 2 / day

PA

S



olanzapine (2.5 mg tablet, 5 mg tablet) 1 QL 6 / day

olanzapine 10 mg tablet 1 QL 3 / day



olanzapine 7.5 mg tablet 1 QL 4 / day

olanzapine 10 mg tab rapdis 3QL 3 / day

HCG


HCG


HCG


HCG

olanzapine 10 mg vial 1

paliperidone 3AL At least 12 yrs old

HCG

quetiapine fumarate (300 mg tab er 24h, 400 mg tab er 24h) 3

QL 2 / day


HCG

quetiapine fumarate 150 mg tab er 24h 3

QL 5 / day


HCG


QL 4 / day


HCG


QL 6 / day


HCG



quetiapine fumarate (25 mg tablet, 50 mg tablet) 1QL 6 / day


quetiapine fumarate 100 mg tablet 1QL 3 / day


quetiapine fumarate 200 mg tablet 1QL 1.5 / day






risperidone 1 mg/ml solution 1QL 16/day


risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mgtablet) 1

QL 8 / day


risperidone 3 mg tablet 1QL 5 / day


risperidone 4 mg tablet 1QL 4 / day


risperidone (0.25 mg tab rapdis, 0.5 mg tab rapdis, 1 mg tabrapdis, 2 mg tab rapdis) 3

QL 8 / day


HCG

risperidone 3 mg tab rapdis 3

QL 5 / day


HCG

risperidone 4 mg tab rapdis 3

QL 4 / day


HCG



SEROQUEL XR SAMPLE KIT 2 AL At least 10 yrs old

SEROQUEL XR (300 MG TABLET, 400 MG TABLET) 2QL 2 / day


SEROQUEL XR 150 MG TABLET 2QL 5 / day






ziprasidone hcl 1QL 2 / day


BUTYROPHENONES

haloperidol (0.5 mg tablet, 2 mg tablet, 5 mg tablet, 10 mgtablet, 20 mg tablet) 1

haloperidol 1 mg tablet 1 LCG

haloperidol decanoate 50 mg/ml ampul 1

haloperidol decanoate (50 mg/ml vial, 100 mg/ml ampul, 100mg/ml vial) 1

haloperidol lactate 5 mg/ml ampul 1

haloperidol lactate 2 mg/ml oral conc 1

haloperidol lactate 5 mg/ml vial 1

PHENOTHIAZINES

chlorpromazine hcl 25 mg/ml ampul 1

chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet,100 mg tablet, 200 mg tablet) 3 HCG

fluphenazine decanoate 25 mg/ml vial 1

fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5ml elixir,5 mg tablet, 5 mg/ml oral conc, 10 mg tablet) 1



fluphenazine hcl 2.5 mg/ml vial 1

perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16 mgtablet) 1 AL At least 18 yrs old

thioridazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100mg tablet) 1

trifluoperazine hcl 1

THIOXANTHENES

thiothixene 1

ANTIRETROVIRALS

HIV ENTRY AND FUSION INHIBITORS

FUZEON 4QL 2 / day

S

SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75 MGTABLET, 150 MG TABLET, 300 MG TABLET) 4

S

PS

HIV INTEGRASE INHIBITORS

GENVOYA 4 S

ISENTRESS 100 MG POWDER PACKET 4S

PS

ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW, 400MG TABLET) 4

S

PS

ISENTRESS HD 4S

PS

STRIBILD 4 S

TIVICAY 4 S

TRIUMEQ 4 S



HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.

ATRIPLA 4S

PS

COMPLERA 4S

PS

EDURANT 4S

PS

INTELENCE 4S

PS

nevirapine (50 mg/5 ml oral susp, 100 mg tab er 24h, 200 mgtablet, 400 mg tab er 24h) 4 S

ODEFSEY 4 S

RESCRIPTOR (100 MG TABLET, 200 MG TABLET) 4 S

SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG TABLET) 4 S

VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 4 S

VIRAMUNE XR 4 S

HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS

abacavir sulfate (20 mg/ml solution, 300 mg tablet) 4 S

abacavir sulfate/lamivudine 4 S

abacavir sulfate/lamivudine/zidovudine 4 S

COMBIVIR 4 S

DESCOVY 4QL 1 / day

S

didanosine 4 S

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 4S

PS



EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MGTABLET) 4 S

EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 4 S

EPZICOM 4 S

lamivudine 10 mg/ml solution 4 S

lamivudine (150 mg tablet, 300 mg tablet) 4 S

lamivudine 100 mg tablet 4 S

lamivudine/zidovudine 4 S

RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 4 S

stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule,30 mg capsule, 40 mg capsule) 4 S

TRIZIVIR 4 S

TRUVADA 4S

PS

VIDEX 4S

PS

VIDEX EC 4 S

VIREAD POWDER 4 S

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300MG TABLET) 4

S

PS

ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20 MG CAPSULE,30 MG CAPSULE, 40 MG CAPSULE) 4 S

ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 4 S

zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) 4 S



HIV PROTEASE INHIBITORS

APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 4S

PS

CRIXIVAN 4S

PS

EVOTAZ 4 S

fosamprenavir calcium 4 S

INVIRASE (200 MG CAPSULE, 500 MG TABLET) 4S

PS

KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET, 200-50MG TABLET) 4 S

LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 4 S

lopinavir/ritonavir 4S

PS

NORVIR (80 MG/ML SOLUTION, 100 MG SOFTGEL CAP, 100 MGTABLET) 4 S

PREZCOBIX 4 S

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MGTABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) 4

S

PS

REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 MGCAPSULE) 4

S

PS

REYATAZ 50 MG POWDER PACKET 4S

PS

TECHNIVIE 4

QL 2 / day

PA

S

VIEKIRA PAK 4

QL 4 / day

PA

S



VIEKIRA XR 4

QL 3 / day

PA

S

VIRACEPT 4S

PS

ANTITHROMBOTIC AGENTS

PLATELET-AGGREGATION INHIBITORS

aspirin/caffeine/dihydrocodeine bitartrate 1QL 10 / day


aspirin/dipyridamole 3QL 2 / day

HCG

BRILINTA 2 QL 2 / day

butalbital/aspirin/caffeine 50-325-40 capsule 1 QL 6 / day

cilostazol 1 QL 2 / day

clopidogrel bisulfate (75 mg tablet, 300 mg tablet) 1 QL 1 / day

dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1 QL 4 / day

prasugrel hcl 1 QL 1 / day

ticlopidine hcl 1 QL 2 / day

PLATELET-REDUCING AGENTS

anagrelide hcl 1 QL 4 / day

THROMBOLYTIC AGENTS

CATHFLO ACTIVASE 4 S



ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES

ANTITOXINS AND IMMUNE GLOBULINS

antivenin,latrodectus mactans 1

antivenin,micrurus fulvius 1

CUVITRU 4PA

S

GAMMAGARD LIQUID 4PA

S

GAMMAKED 4PA

S

GAMUNEX-C 4PA

S

HIZENTRA 4PA

S

HYPERHEP B S-D (NEONATAL SYRIN., SYRINGE, VIAL) 4 S

HYPERRAB S-D 4 S

HYPERTET S-D 4 S

HYQVIA 4PA

S

HYQVIA IG COMPONENT 4PA

S

IMOGAM RABIES-HT 4 S

NABI-HB 4 S

VARIZIG (125 UNIT VIAL, 125 UNIT/1.2 ML VIAL) 4 S



TOXOIDS

ADACEL TDAP (SYRINGE, VIAL) 0 HCR

BOOSTRIX TDAP (SYRINGE, VIAL) 0 HCR

DAPTACEL DTAP 0 HCR

INFANRIX DTAP (SYRINGE, VIAL) 2

PEDIARIX 2

TENIVAC (SYRINGE, VIAL) 0 HCR

tetanus and diphtheria toxoids, adult 0 HCR

tetanus,diphtheria toxoid ped/pf 1

VACCINES

ACTHIB VACCINE WITH DILUENT 2

AFLURIA 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR

AFLURIA QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017VIAL) 0 HCR

BEXSERO 2

BIOTHRAX 2

CERVARIX 0 HCR

ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) 0 HCR

ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5 ML PED VL,PEDI 10 MCG/0.5 SYRN) 0 HCR

EZ FLU 16-17 (FLUZON QUAD PED) 0 HCR

EZ FLU 2016-2017 (AFLURIA) 0 HCR

EZ FLU 2016-2017 (FLUVIRIN) 0 HCR

FLUAD 2016-2017 0 HCR

FLUARIX QUAD 2016-2017 0 HCR



FLUBLOK 2016-2017 0 HCR

FLUCELVAX QUAD 2016-2017 0 HCR

FLULAVAL QUAD 2016-2017 (2016-2017 SYR, 2016-2017VIAL) 0 HCR

FLUVIRIN 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR

FLUZONE HIGH-DOSE 2016-2017 0 HCR

FLUZONE INTRADERM QUAD 2016-17 0 HCR

FLUZONE QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017VIAL) 0 HCR

FLUZONE QUAD PEDI 2016-2017 0 HCR

GARDASIL (SYRINGE, VIAL) 0 HCR

GARDASIL 9 (9 SYRINGE, 9 VIAL) 0 HCR

HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5 ML VIAL,1,440 UNITS/ML SYRINGE, 1,440 UNITS/ML VIAL) 0 HCR

HIBERIX VACCINE WITH DILUENT 2

IMOVAX RABIES VACCINE 2

IPOL VIAL 2

IXIARO 2

KINRIX (TIP-LOK SYRINGE, VIAL) 2

M-M-R II VACCINE 0 HCR

MENACTRA 0 HCR

MENHIBRIX 2

MENOMUNE-A-C-Y-W-135 0 HCR

MENVEO A-C-Y-W-135-DIP 0 HCR

MENVEO MENA COMPONENT 2

MENVEO MENCYW-135 COMPONENT 2



PEDVAXHIB 2

PENTACEL 2

PENTACEL DTAP-IPV COMPONENT 2

PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 0 HCR

PREVNAR 13 0 HCR

PROQUAD 2

QUADRACEL DTAP-IPV 2

RABAVERT 2

RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, 10MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML VIAL) 0 HCR

ROTARIX 2

ROTATEQ 2

STAMARIL 2

THERACYS 4 S

TWINRIX (SYRINGE, VIAL) 0 HCR

TYPHIM VI (25 MCG/0.5 ML AL, 25 MCG/0.5 ML SYRNG) 2

VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 ML VIAL, 50UNITS/ML SYRINGE, 50 UNITS/ML VIAL) 0 HCR

VARIVAX VACCINE 0 HCR

VAXCHORA ACTIVE COMPONENT 2

VAXCHORA VACCINE 2

VIVOTIF 2

VIVOTIF BERNA 2

YF-VAX 2

ZOSTAVAX 0 HCR



ANTIULCER AGENTS AND ACID SUPPRESSANTS

HISTAMINE H2-ANTAGONISTS

cimetidine (200 mg tablet, 300 mg tablet, 400 mg tablet, 800mg tablet) 1

cimetidine hcl 1

famotidine (20 mg tablet, 40 mg tablet, 40mg/5ml oral susp) 1

nizatidine 150 mg capsule 1 QL 2 / day

nizatidine (150mg/10ml solution, 300 mg capsule) 1

ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet,300 mg capsule, 300 mg tablet) 1

ranitidine hcl (25 mg/ml vial, 50 mg/2 ml vial) 1

PROSTAGLANDINS

diclofenac sodium/misoprostol (sodium/misoprostol 50 tab irdr, sodium/misoprostol 75 tab ir dr) 1

misoprostol (100 mcg tablet, 200 mcg tablet) 1

PROTECTANTS

CARAFATE 1 GM/10 ML SUSP 2

sucralfate 1 g tablet 1

PROTON-PUMP INHIBITORS

esomeprazole magnesium 20 mg capsule dr 1 QL 1 / day

esomeprazole magnesium 40 mg capsule dr 3QL 1 / day

HCG

esomeprazole strontium 1 QL 1 / day

lansoprazole 15 mg capsule dr 1

lansoprazole 30 mg capsule dr 1 QL 1 / day

lansoprazole/amoxicillin trihydrate/clarithromycin 3QL 112 / 365 days

HCG



omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsuledr) 1 QL 1 / day

omeprazole/sodium bicarbonate 40mg-1.1g capsule 3 HCG

omeprazole/sodium bicarbonate (omeprazole/sodium 20-1680mg packet, omeprazole/sodium 20mg-1.1g capsule,omeprazole/sodium 40-1680mg packet)

1

pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) 1QL 1 / day

LCG

rabeprazole sodium 1 QL 2 / day

ANTIVIRALS (SYSTEMIC)

ADAMANTANES

rimantadine hcl 1

INTERFERONS

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITSVIL)

4PA

S

PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) 4PA

S

PEGASYS PROCLICK 4PA

S

PEGINTRON 4

PA

S

PS

PEGINTRON REDIPEN 4

PA

S

PS

SYLATRON 4PA

S



NEURAMINIDASE INHIBITORS

oseltamivir phosphate (30 mg capsule, 45 mg capsule, 75 mgcapsule) 1 QL 20 / 365 days

NUCLEOSIDES AND NUCLEOTIDES

acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mgtablet, 800 mg tablet) 1

adefovir dipivoxil 4 S

BARACLUDE 0.05 MG/ML SOLUTION 4

QL 20 / day

PA

S

BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 4

QL 1 / day

PA

S

COPEGUS 4

QL 6 / day

PA

S

entecavir 4QL 1 / day

S

famciclovir 1

HEPSERA 4

QL 1 / day

PA

S

MODERIBA (200-400 MG DOSEPACK, 400-400 MG DOSEPACK,600-400 MG DOSEPACK, 600-600 MG DOSEPACK) 4

QL 2 / day

PA

S

MODERIBA 200 MG TABLET 4

QL 6 / day

PA

S



REBETOL 200 MG CAPSULE 4

QL 6 / day

PA

S

REBETOL 40 MG/ML SOLUTION 4

QL 30 / day

PA

S

RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 4

QL 6 / day

PA

S

RIBASPHERE 400 MG TABLET 4

QL 3 / day

PA

S

RIBASPHERE 600 MG TABLET 4

QL 2 / day

PA

S

RIBASPHERE RIBAPAK 4

QL 2 / day

PA

S

RIBATAB 4

QL 2 / day

PA

S

ribavirin (200 mg capsule, 200 mg tablet) 4

QL 6 / day

PA

S

ribavirin 6 g vial-neb 1

TYZEKA 4

QL 1 / day

PA

S



valacyclovir hcl (500 mg tablet, 1000 mg tablet) 3 HCG

valganciclovir hcl 50 mg/ml soln recon 1

valganciclovir hcl 450 mg tablet 1 QL 4 / day

VEMLIDY 4

QL 1 / day

PA


S

ANXIOLYTICS, SEDATIVES AND HYPNOTICS

ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC

buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mgtablet, 30 mg tablet) 1

droperidol (2.5 mg/ml ampul, 2.5 mg/ml vial) 1

eszopiclone (1 mg tablet, 2 mg tablet) 1 QL 1 / day

eszopiclone 3 mg tablet 1QL 1 / day

AL Up to 65 yrs old

HETLIOZ 4

QL 1 / day

PA

S

hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mgtablet, 50 mg tablet, 50 mg/25ml solution) 1 AL At least 2 yrs old

hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial) 1 AL At least 2 yrs old

hydroxyzine pamoate (25 mg capsule, 50 mg capsule) 1 AL At least 2 yrs old

hydroxyzine pamoate 100 mg capsule 1

meprobamate 1

PHENADOZ 1 AL At least 2 yrs old

PHENERGAN (12.5 MG, 25 MG, 50 MG) 1 AL At least 2 yrs old

promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect, 50 mgsupp.rect) 1 AL At least 2 yrs old



PROMETHEGAN 1 AL At least 2 yrs old

zaleplon 1 QL 1 / day

zolpidem tartrate (1.75 mg tab subl, 3.5 mg tab subl, 5 mgtablet, 6.25 mg tab mphase, 10 mg tablet, 12.5 mg tab mphase) 1 QL 1 / day

BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)

pentobarbital sodium 50 mg/ml vial 1

BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

alprazolam (0.5 mg tab er 24h, 1 mg tab er 24h) 1 QL 1 / day

alprazolam (2 mg tab er 24h, 2 mg tab rapdis, 2 mg tablet) 1 QL 5 / day

alprazolam 3 mg tab er 24h 1 QL 3 / day

alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tabrapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet) 1 QL 4 / day

chlordiazepoxide hcl 10 mg capsule 1 QL 30 / day



estazolam 1 QL 1 / day

flurazepam hcl 1 QL 1 / day

midazolam hcl 2 mg/ml syrup 1

midazolam hcl (2 mg/2 ml vial, 5 mg/5 ml vial, 5 mg/ml vial, 5mg/ml(1) vial, 10 mg/10ml vial, 10 mg/2 ml vial) 1

midazolam hcl/pf (hcl/pf 2 mg/2 ml vial, hcl/pf 5 mg/5 ml vial,hcl/pf 5 mg/ml syringe, hcl/pf 5 mg/ml(1) vial, hcl/pf 10 mg/2ml vial)

1

oxazepam 1 QL 4 / day

quazepam 1 QL 1 / day

temazepam 1 QL 1 / day

triazolam 0.125 mg tablet 1 QL 1 / day



triazolam 0.25 mg tablet 1 QL 2 / day

AUTONOMIC DRUGS

AUTONOMIC DRUGS, MISCELLANEOUS

CHANTIX STARTING MONTH BOX 0 HCR

CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MGTABLET) 0

QL 2 / day

HCR

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)

bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet,50 mg tablet) 1

cevimeline hcl 3 HCG

donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tab rapdis,10 mg tablet, 23 mg tablet) 1 AL At least 40 yrs old

galantamine hbr (8 mg cap24h pel, 16 mg cap24h pel, 24 mgcap24h pel) 3 HCG

galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg tablet, 12mg tablet) 1

guanidine hcl 1

MESTINON 60 MG/5 ML SYRUP 2

physostigmine salicylate 1

pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1

pyridostigmine bromide (60 mg tablet, 180 mg tablet er) 1

rivastigmine 1 AL At least 40 yrs old

rivastigmine tartrate 1 AL At least 40 yrs old

BETA-3-ADRENERGIC AGONISTS

SELECTIVE BETA-3-ADRENERGIC AGONISTS

MYRBETRIQ 2 QL 1 / day



BETA-ADRENERGIC BLOCKING AGENTS(SYMPATH)

NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS

BYSTOLIC (5 MG TABLET, 10 MG TABLET) 2 QL 3 / day

BYSTOLIC 2.5 MG TABLET 2 QL 1 / day

BYSTOLIC 20 MG TABLET 2 QL 2 / day

BYVALSON 2 QL 1 / day

BLOOD FORMATION, COAGULATION, THROMBOSIS

HEMATOPOIETIC AGENTS

ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING,25 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 40 MCG/ML VIAL,60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 MLSYRINGE, 100 MCG/ML VIAL, 150 MCG/0.3 ML SYRINGE, 150MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/MLVIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500MCG/1 ML SYRINGE)

4

PA

S

PS

EPOGEN 4PA

S

GRANIX 4PA

S

LEUKINE 4PA

S

MIRCERA 4PA

S

MOZOBIL 4PA

S

NEULASTA (6 MG/0.6 ML SYRINGE, ONPRO 6 MG/0.6 ML KIT) 4

PA

S

PS



NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) 4

PA

S

PS

PROCRIT 4

PA

S

PS

PROMACTA 4PA

S

ZARXIO 4

QL 90 / 30 days

PA

S

HEMORRHEOLOGIC AGENTS

pentoxifylline 400 mg tablet er 1

BRONCHODILATORS

XANTHINE DERIVATIVES

THEOCHRON 1

theophylline anhydrous (80 mg/15ml elixir, 80 mg/15mlsolution, 100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er12h, 400 mg tab er 24h, 450 mg tab er 12h, 600 mg tab er 24h)

1

CALCIUM-CHANNEL BLOCKING AGENTS

DIHYDROPYRIDINES

felodipine 1 QL 1 / day

isradipine 1 QL 2 / day

nisoldipine 3QL 1 / day

HCG



CALCIUM-CHANNEL BLOCKING AGENTS(HYPOTEN)

CALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN)

trandolapril/verapamil hcl 1

DIHYDROPYRIDINES (HYPOTENSIVE AGENTS)

AFEDITAB CR 30 MG TABLET 1 QL 1 / day

AFEDITAB CR 60 MG TABLET 1 QL 2 / day

amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1 QL 1 / day

amlodipine besylate/benazepril hcl 1 QL 1 / day

amlodipine besylate/olmesartan medoxomil 3QL 1 / day

HCG

amlodipine besylate/valsartan (besylate/valsartan 5 mg-320mgtablet, besylate/valsartan 10mg-160mg tablet,besylate/valsartan 10mg-320mg tablet)

1 QL 1 / day

amlodipine besylate/valsartan 5 mg-160mg tablet 1 QL 2 / day

amlodipine besylate/valsartan/hydrochlorothiazide 3QL 1 / day

HCG

nicardipine hcl (20 mg capsule, 30 mg capsule) 3 HCG

NIFEDICAL XL 1 QL 1 / day

nifedipine (10 mg capsule, 20 mg capsule) 1 QL 4 / day

nifedipine (30 mg tab er 24, 30 mg tablet er, 90 mg tab er 24,90 mg tablet er) 1 QL 1 / day

nifedipine (60 mg tab er 24, 60 mg tablet er) 1 QL 2 / day

nimodipine 30 mg capsule 1



CARDIAC DRUGS

CARDIAC DRUGS, MISCELLANEOUS

CORLANOR 2QL 2 / day

ST

RANEXA 2 QL 2 / day

CARDIOVASCULAR DRUGS

CALCIUM-CHANNEL BLOCKING AGENTS

telmisartan/amlodipine besylate 1 QL 1 / day

CENTRAL NERVOUS SYSTEM AGENTS

ANTIMANIC AGENTS

lithium carbonate (150 mg capsule, 300 mg capsule, 300 mgtablet, 300 mg tablet er, 450 mg tablet er, 600 mg capsule) 1

lithium citrate 1

CENTRAL NERVOUS SYSTEM AGENTS, MISC.

acamprosate calcium 3 HCG

atomoxetine hcl 1QL 2 / day


AUSTEDO 4

QL 4 / day

PA


S

carbidopa 25 mg tablet 1

guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er24h, 4 mg tab er 24h) 1

guanfacine hcl (1 mg tablet, 2 mg tablet) 1

INGREZZA 40 MG CAPSULE 4

QL 2 / day

PA


S



memantine hcl 2 mg/ml solution 1QL 360 / 30 days


memantine hcl 5 mg-10 mg tab ds pk 1 AL At least 40 yrs old

memantine hcl 10 mg tablet 1QL 2 / day


memantine hcl 5 mg tablet 1QL 3 / day


NUEDEXTA 2 PA

riluzole 1

tetrabenazine 4PA

S

XENAZINE 4PA

S

XYREM 4

QL 18 / day

PA

S

OPIATE ANTAGONISTS

DEPADE 1

naloxone hcl (0.4 mg/ml syringe, 0.4 mg/ml vial, 1 mg/mlsyringe) 1

naltrexone hcl 50 mg tablet 1

VIVITROL 380 MG VIAL 4PA

S

CEPHALOSPORINS

FIRST GENERATION CEPHALOSPORINS

cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule,500 mg/5ml susp recon) 1



cefazolin sodium (10 g vial, 20 g vial, 100 g bulkbaginj, 300gbulkbaginj, 500 mg vial) 1

cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mgtablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg tablet,750 mg capsule)

1

FOURTH GENERATION CEPHALOSPORINS

cefepime hcl 1

SECOND GENERATION CEPHALOSPORINS

cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5mlsusp recon, 375 mg/5ml susp recon, 500 mg capsule) 1

cefaclor 500 mg tab er 12h 1 QL 20 / 30 days

cefotetan disodium (1 g vial, 2 g vial) 1

cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5mlsusp recon, 500 mg tablet) 1

CEFTIN (125 MG/5 ML ORAL SUSP, 250 MG/5 ML ORAL SUSP) 2

cefuroxime axetil 1

cefuroxime sodium 750 mg vial 1

THIRD GENERATION CEPHALOSPORINS

cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300mg capsule) 1

cefditoren pivoxil 1

cefixime 3QL 1200 / 90 days

HCG

cefotaxime sodium 1

cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet,100 mg/5ml susp recon, 200 mg tablet) 1

ceftazidime (1 g vial, 2 g vial, 6 g vial) 1

ceftibuten (180 mg/5ml susp recon, 400 mg capsule) 3 HCG

ceftriaxone sodium (1 g vial, 2 g vial, 10 g vial, 100 gbulkbaginj, 250 mg vial, 500 mg vial) 1



TAZICEF (1 VIAL, 2 VIAL, 6 VIAL) 1

CORTICOSTEROIDS (RESPIRATORY TRACT)

ORALLY INHALED PREPARATIONS (STEROIDS)

AEROSPAN 2 QL 0.334 / day

ARNUITY ELLIPTA 100 MCG INH 2 QL 2 / day

ARNUITY ELLIPTA 200 MCG INH 2 QL 1 / day

budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1mg/2 ml ampul-neb) 1

FLOVENT 250 MCG DISKUS 2 QL 8 / day

FLOVENT DISKUS (50 MCG, 100 MCG) 2 QL 4 / day

FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 MCG INHALER) 2 QL 0.8 / day

FLOVENT HFA 44 MCG INHALER 2 QL 0.767 / day

PULMICORT FLEXHALER 2 QL 0.07 / day

CYSTIC FIBROSIS (CFTR) MODULATORS

CYSTIC FIBROSIS (CFTR) CORRECTORS

ORKAMBI 4

QL 4 / day

PA

S

CYSTIC FIBROSIS (CFTR) POTENTIATORS

KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULESPACKET, 150 MG TABLET) 4

QL 2 / day

PA

S



DEPIGMENTING AND PIGMENTING AGENTS

DEPIGMENTING AGENTS

ALPHAQUIN HP 1

BLANCHE 1

hydroquinone 4 % cream (g) 1

hydroquinone microspheres 1

MELPAQUE HP 1

PIGMENTING AGENTS

methoxsalen 10 mg cap lq rap 1

UVADEX 4 S

DIAGNOSTIC AGENTS

ADRENOCORTICAL INSUFFICIENCY

cosyntropin 0.25 mg vial 1

H.P. ACTHAR 4PA

S

CARDIAC FUNCTION

indocyanine green 1

KIDNEY FUNCTION

INDIGO CARMINE 1

indigotindisulfonate sodium in water for injection,sterile 1

OCULAR DISORDERS

BIOGLO 1

FLUCAINE 1

FLUOR-I-STRIP AT 1

FUL-GLO 1 MG OPTH STRIPS 1

proparacaine hcl/fluorescein sodium 1



ROENTGENOGRAPHY

MD-GASTROVIEW 1

DIURETICS

LOOP DIURETICS

bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1

bumetanide 0.25 mg/ml vial 1

ethacrynic acid 1

furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet,40mg/5ml solution, 80 mg tablet) 1

furosemide (10 mg/ml syringe, 10 mg/ml vial) 1

torsemide 1

OSMOTIC DIURETICS

mannitol/sorbitol solution 1

POTASSIUM-SPARING DIURETICS

amiloride hcl 1

amiloride hcl/hydrochlorothiazide 1

triamterene/hydrochlorothiazide(triamterene/hydrochlorothiazid 37.5-25 mg capsule,triamterene/hydrochlorothiazid 37.5-25 mg tablet,triamterene/hydrochlorothiazid 50 mg-25mg capsule,triamterene/hydrochlorothiazid 75 mg-50mg tablet)

1

THIAZIDE DIURETICS

chlorothiazide 1

hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 50 mgtablet) 1

hydrochlorothiazide 25 mg tablet 1 LCG

methyclothiazide 1



THIAZIDE-LIKE DIURETICS

chlorthalidone 1

indapamide 1

metolazone 1

VASOPRESSIN ANTAGONISTS

SAMSCA 15 MG TABLET 4

QL 1 / day

PA

S

SAMSCA 30 MG TABLET 4

QL 2 / day

PA

S

DIURETICS (HYPOTENSIVE AGENTS)

POTASSIUM-SPARING DIURETICS (HYPOTEN)

eplerenone 3 HCG

spironolactone (25 mg tablet, 50 mg tablet, 100 mg tablet) 1

spironolactone/hydrochlorothiazide 1

THIAZIDE DIURETICS(HYPOTENSIVE AGENTS)

benazepril hcl/hydrochlorothiazide 1 QL 1 / day

candesartan cilexetil/hydrochlorothiazide(candesartan/hydrochlorothiazid 32-12.5mg tablet,candesartan/hydrochlorothiazid 32mg-25mg tablet)

1 QL 1 / day

candesartan/hydrochlorothiazid 16-12.5mg tablet 1 QL 2 / day

captopril/hydrochlorothiazide 1 QL 2 / day

enalapril/hydrochlorothiazide 10 mg-25mg tablet 1 QL 2 / day

enalapril/hydrochlorothiazide 5mg-12.5mg tablet 1

fosinopril sodium/hydrochlorothiazide 1 QL 2 / day



irbesartan/hydrochlorothiazide 150-12.5mg tablet 1 QL 2 / day

irbesartan/hydrochlorothiazide 300-12.5mg tablet 1 QL 1 / day

lisinopril/hydrochlorothiazide (lisinopril/hydrochlorothiazide10-12.5mg tablet, lisinopril/hydrochlorothiazide 20-12.5 mgtablet)

1 QL 2 / day

lisinopril/hydrochlorothiazide (lisinopril/hydrochlorothiazide20 mg-25mg tablet, lisinopril/hydrochlorothiazide 20-25mgtablet)

1QL 2 / day

LCG

losartan potassium/hydrochlorothiazide(losartan/hydrochlorothiazide 100-12.5mg tablet,losartan/hydrochlorothiazide 100mg-25mg tablet)

1 QL 1 / day

losartan/hydrochlorothiazide 50-12.5 mg tablet 1 QL 2 / day

methyldopa/hydrochlorothiazide 1

moexipril hcl/hydrochlorothiazide 1 QL 2 / day

olmesartan medoxomil/amlodipinebesylate/hydrochlorothiazide 3

QL 1 / day

HCG

olmesartan medoxomil/hydrochlorothiazide 1 QL 1 / day

quinapril hcl/hydrochlorothiazide(quinapril/hydrochlorothiazide 10-12.5mg tablet,quinapril/hydrochlorothiazide 20-12.5 mg tablet)

1 QL 2 / day

quinapril/hydrochlorothiazide 20 mg-25mg tablet 1 QL 1 / day

telmisartan/hydrochlorothiazid 80-12.5mg tablet 3QL 2 / day

HCG

telmisartan/hydrochlorothiazide(telmisartan/hydrochlorothiazid 40-12.5 mg tablet,telmisartan/hydrochlorothiazid 80 mg-25mg tablet)

3QL 1 / day

HCG

valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide320-12.5mg tablet, valsartan/hydrochlorothiazide 320mg-25mg tablet)

1 QL 1 / day



valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide80-12.5mg tablet, valsartan/hydrochlorothiazide 160-12.5mgtablet, valsartan/hydrochlorothiazide 160-25mg tablet)

1 QL 2 / day

DOPAMINE RECEPTOR AGONISTS

ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS

bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) 1

cabergoline 1

NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST

APOKYN 4PA

S

pramipexole di-hcl (0.375 mg tab er 24h, 0.75 mg tab er 24h,1.5 mg tab er 24h, 2.25 mg tab er 24h, 3 mg tab er 24h, 3.75 mgtab er 24h, 4.5 mg tab er 24h)

3 HCG

pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mgtablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) 1

ropinirole hcl (2 mg tab er 24h, 4 mg tab er 24h, 6 mg tab er24h, 8 mg tab er 24h, 12 mg tab er 24h) 1 QL 1 / day

ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mgtablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) 1

ELECTROLYTIC, CALORIC, AND WATER BALANCE

ACIDIFYING AGENTS

PHOSPHA 250 NEUTRAL 1

VIRT-PHOS 250 NEUTRAL 1

ALKALINIZING AGENTS

citric acid/sodium citrate 1

CYTRA-2 1

CYTRA-K (CRYSTALS PACKET, ORAL SOLUTION) 1

potassium citrate 1

potassium citrate/citric acid 1100-334/5 solution 1



sodium/potassium/potassium citrate/sodium citrate/cit ac 1

TARON-CRYSTALS 1

TRICITRATES 1

VIRTRATE-2 1

VIRTRATE-3 1

VIRTRATE-K 1

AMMONIA DETOXICANTS

BUPHENYL (500 MG TABLET, POWDER) 4 S

CARBAGLU 4 S

CONSTULOSE 1

ENULOSE 1

GENERLAC 1

KRISTALOSE 1

lactulose 1

RAVICTI 4

QL 20 / day

PA

S

sodium phenylbutyrate (0.94 g/g powder, 500 mg tablet) 4 S

CALORIC AGENTS

ACD 1

LYSIPLEX PLUS 1

REPLACEMENT PREPARATIONS

0.9 % sodium chloride 0.9 % syringe 1

0.9 % sodium chloride 0.9 % vial 1

bacteriostatic sodium chloride 1

cardioplegic solution no.1 1



EFFER-K 25 MEQ TABLET EFF 1

K EFFERVESCENT 1

K-SOL 1

KLOR-CON 20 MEQ PACKET 1

KLOR-CON 10 1

KLOR-CON 8 1

KLOR-CON M10 1

KLOR-CON M15 1

KLOR-CON M20 1

KLOR-CON SPRINKLE 1

KLOR-CON-EF 1

MONOJECT 0.9% SODIUM CHLORIDE 1

MONOJECT PREFILL 0.9% FLUSH 1

MONOJECT PREFILL ADVANCED 1

NEBUSAL 3% VIAL 1

potassium bicarbonate/citric acid 1

potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meqcapsule er, 10 meq tab er prt, 10 meq tablet er, 20 meq packet,20 meq tab er prt, 20 meq tablet er, 20meq/15ml liquid,40meq/15ml liquid)

1

potassium chloride/potassium bicarbonate/citric acid 1

PULMOSAL 1

sodium chloride for inhalation 1

SYREX 1

SALT AND SUGAR SUBSTITUTES

saccharin 1

URICOSURIC AGENTS

probenecid 1 QL 4 / day



probenecid/colchicine 1 QL 2 / day

EMOLLIENTS, DEMULCENTS, AND PROTECTANTS

BASIC LOTIONS AND LINIMENTS

ammonium lactate 12 % lotion 1

lactic acid 10 % lotion 1

BASIC OILS AND OTHER SOLVENTS

LUXAMEND 1

BASIC OINTMENTS AND PROTECTANTS

ammonium lactate 12 % cream (g) 1

lactic acid 10 % cream (g) 1

ESTROGENS AND ANTIESTROGENS

ESTROGEN AGONIST-ANTAGONISTS

clomiphene citrate 50 mg tablet 1 GL Female

DUAVEE 2

raloxifene hcl 0 HCR

SEROPHENE 1 GL Female

ESTROGENS

AMABELZ 1QL 1 / day

GL Female

CLIMARA PRO 2QL 0.15 / day

GL Female

COVARYX 1 GL Female

COVARYX H.S. 1 GL Female

DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 1 MG GELPACKET) 2 GL Female



EEMT 1 GL Female

EEMT H.S. 1 GL Female

ENJUVIA 2QL 1 / day

GL Female

ESTRACE 0.01% CREAM 2 GL Female

estradiol (.025mg/24h patch tdsw, .0375mg/24 patch tdsw,0.05mg/24h patch tdsw, .075mg/24h patch tdsw, 0.1mg/24hrpatch tdsw)

1QL 0.29 / day

GL Female

estradiol (.025mg/24h patch tdwk, 0.05mg/24h patch tdwk,0.1mg/24hr patch tdwk) 1

QL 0.15 / day

GL Female

estradiol (.0375mg/24 patch tdwk, 0.06mg/24h patch tdwk,.075mg/24h patch tdwk) 1

QL 0.15 / day

GL Female

estradiol (0.5 mg tablet, 1 mg tablet) 1

QL 1 / day

GL Female

LCG

estradiol 10 mcg tablet 1 GL Female

estradiol 2 mg tablet 1QL 1 / day

GL Female

estradiol valerate (20 mg/ml vial, 40 mg/ml vial) 1 GL Female

estradiol/norethindrone acetate 1QL 1 / day

GL Female

ESTRING 2QL 90 days

GL Female

estrogens,esterified/methyltestosterone 1 GL Female

estropipate 1

QL 1 / day

GL Female

LCG



FYAVOLV 1 GL Female

JINTELI 0

QL 1 / day

GL Female

HCR

LOPREEZA 1QL 1 / day

GL Female

MENEST 0.3 MG TABLET 2QL 1 / day

GL Female

MIMVEY 1QL 1 / day

GL Female

MIMVEY LO 1

norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet, 1mg-5mcg tablet) 0 HCR

PREMARIN VAGINAL CREAM-APPL 2 GL Female

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET,0.9 MG TABLET, 1.25 MG TABLET) 2

QL 1 / day

GL Female

PREMARIN 25 MG VIAL 2

PREMPHASE 2QL 1 / day

GL Female

PREMPRO 2QL 1 / day

GL Female

YUVAFEM 1 GL Female

EYE, EAR, NOSE AND THROAT (EENT) PREPS.

ANTIALLERGIC AGENTS

azelastine hcl 0.05 % drops 1 QL 0.267 / day

azelastine hcl (137 mcg spray/pump, 205.5 mcg spray/pump) 1 QL 2 / day



epinastine hcl 1 QL 0.286 / day

olopatadine hcl (0.1 % drops, 0.2 % drops) 1 QL 0.286 / day

olopatadine hcl 0.6 % spray/pump 3QL 31 / 30 days

HCG

EENT DRUGS, MISCELLANEOUS

acetylcysteine in sterile water/pf 1 QL 10 / 30 days

apraclonidine hcl 1 QL 0.8 / day

balanced salt irrig soln no.2 1

BSS 1

CYSTARAN 4PA

S

ipratropium bromide (21 mcg spray, 42 mcg spray) 1 QL 2 / day

LUCENTIS (0.3 MG/0.05 ML VIAL, 0.5 MG/0.05 ML SYRING, 0.5MG/0.05 ML VIAL) 4

QL 0.04 / day

PA

S

OCUCOAT 1

LOCAL ANESTHETICS (EENT)

ALTACAINE 1

ALTAFLUOR 1

benoxinate hcl/fluorescein sodium 1

cocaine hcl 4 % solution 1

cyclopentolate hcl/lidocaine hcl/phenylephrine/tropicamide 1

FLUROX 1

GLYDO 1

lidocaine hcl (2 % jel/pf app, 2 % jelly(ml), 2 % solution, 40mg/ml solution) 1



proparacaine hcl 0.5 % drops 1

TETCAINE 1

tetracaine hcl 0.5 % drops 1

tetracaine hcl/pf 0.5 % drops 1

TETRAVISC 1

TETRAVISC FORTE 1

MYDRIATICS

atropine sulfate (1 % drops, 1 % oint. (g)) 1

cyclopentolate hcl (0.5 % drops, 1 % drops, 2 % drops) 1

cyclopentolate hcl/tropicamide/phenylephrine hcl in water 1

HOMATROPAIRE 1

homatropine hbr 1

tropicamide (0.5 % drops, 1 % drops) 1

VASOCONSTRICTORS

naphazoline hcl 1

phenylephrine hcl (2.5 % drops, 10 % drops) 1

GASTROINTESTINAL DRUGS

ANTI-INFLAMMATORY AGENTS (GI DRUGS)

alosetron hcl 1GL Female


APRISO 2

balsalazide disodium 1

CANASA 2

LIALDA 2

mesalamine 4 g/60 ml enema 1

mesalamine 1.2 g tablet dr 3 HCG

mesalamine with cleansing wipes 1



ANTIDIARRHEA AGENTS

FULYZAQ 4 S

loperamide hcl 2 mg capsule 1

MYTESI 4 S

opium tincture 1 QL 5 / day

paregoric 1

XERMELO 4

PA


S

CATHARTICS AND LAXATIVES

AMITIZA 2QL 2 / day


GAVILYTE-C 0 HCR

GAVILYTE-G 0 HCR

GAVILYTE-N 0 HCR

GOLYTELY PACKET 0 HCR

MOVIPREP 0 HCR

peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride 0 HCR

PEG-PREP 1

polyethylene glycol 3350 (3350 17g powd pack, 335017g/dose powder) 0 HCR

sodium chloride/nahco3/kcl/peg 420g soln recon 0 HCR

sorbitol solution 70 % solution 1

TRILYTE WITH FLAVOR PACKETS 0 HCR



CHOLELITHOLYTIC AGENTS

CHENODAL 4 S

ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1

DIGESTANTS

CREON 2

ZENPEP 2

GI DRUGS, MISCELLANEOUS

CHOLBAM 250 MG CAPSULE 4

QL 7 / day

PA

S

CHOLBAM 50 MG CAPSULE 4

QL 4 / day

PA

S

CIMZIA (200 MG VIAL KIT, 200 MG/ML SYRINGE KIT) 4

QL 0.08 / day

PA

S

CIMZIA 200 MG/ML STARTER KIT 4

QL 3/ fill

PA

S

GATTEX 4PA

S

HUMIRA (20 MG/0.4 ML SYRINGE, 40 MG/0.8 ML SYRINGE) 4

QL 0.22 / day

PA

S

PS

HUMIRA 10 MG/0.2 ML SYRINGE 4

QL 0.15 / day

PA

S

PS



HUMIRA PEDIATRIC CROHN'S 4

QL 0.22 / day

PA

S

PS

HUMIRA PEN 4

QL 0.22 / day

PA

S

PS

HUMIRA PEN CROHN-UC-HS STARTER 4

QL 0.22 / day

PA

S

PS

HUMIRA PEN PSORIASIS-UVEITIS 4

QL 0.22 / day

PA

S

PS

LINZESS 2QL 1 / day

ST

OCALIVA 4

QL 1 / day

PA

S

VIBERZI 2QL 2 / day

PA

PROKINETIC AGENTS

metoclopramide hcl 10 mg/2 ml syringe 1

metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mgtablet, 10 mg/10ml solution) 1 LCG

metoclopramide hcl (5 mg tab rapdis, 10 mg tab rapdis) 1



metoclopramide hcl 5 mg/ml vial 1 LCG

GENERAL ANESTHETICS

GENERAL ANESTHETICS, MISCELLANEOUS

ketamine hcl (10 mg/ml vial, 50 mg/ml vial, 100 mg/ml vial) 1

INHALATION ANESTHETICS

COMPOUND 347 1

isoflurane 1

sevoflurane 1

SOJOURN 1

TERRELL 1

GENITOURINARY SMOOTH MUSCLE RELAXANTS

ANTIMUSCARINICS

darifenacin hydrobromide 3QL 1 / day

HCG

flavoxate hcl 1

oxybutynin chloride 5 mg/5 ml syrup 1 QL 20 / day

oxybutynin chloride (10 mg tab er 24, 15 mg tab er 24) 1 QL 2 / day

oxybutynin chloride 5 mg tab er 24 1 QL 1 / day

oxybutynin chloride 5 mg tablet 1 QL 4 / day

tolterodine tartrate (2 mg cap er 24h, 4 mg cap er 24h) 3QL 1 / day

HCG

tolterodine tartrate (1 mg tablet, 2 mg tablet) 1 QL 2 / day

trospium chloride 60 mg cap er 24h 3QL 1 / day

HCG

trospium chloride 20 mg tablet 3QL 2 / day

HCG



VESICARE 2 QL 1 / day

HCV ANTIVIRALS

HCV POLYMERASE INHIBITORS

EPCLUSA 4

QL 1 / day

PA

S

PS

HARVONI 4

QL 1 / day

PA

S

PS

SOVALDI 4

QL 1 / day

PA

S

PS

HCV PROTEASE INHIBITORS

OLYSIO 4

QL 1 / day

PA

S

ZEPATIER 4

QL 1 / day

PA

S

HCV REPLICATION COMPLEX INHIBITORS

DAKLINZA 4

QL 1 / day

PA

S



HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

A-METHAPRED 1

betamethasone acetate/betamethasone sodium phosphate 1

budesonide 3 mg capdr - er 3 HCG

cortisone acetate 25 mg tablet 1

DELTASONE 1

dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5mlsolution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet,4 mg tablet, 6 mg tablet)

1

DEXAMETHASONE INTENSOL 2

EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORALSUSP, 30 MG TABLET, 36 MG TABLET) 4

PA


S

fludrocortisone acetate 0.1 mg tablet 1

hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1

MEDROL 2 MG TABLET 2

methylprednisolone (4 mg tab ds pk, 4 mg tablet, 8 mg tablet,16 mg tablet, 32 mg tablet) 1

methylprednisolone acetate 1

methylprednisolone sodium succinate (40 mg vial, 125 mg vial) 1

prednisolone 1

prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tabrapdis, 10 mg/5 ml solution, 15 mg tab rapdis, 15 mg/5 mlsolution, 20 mg/5 ml solution, 25 mg/5 ml solution, 30 mg tabrapdis)

1

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mgtablet, 5 mg/5 ml solution, 10 mg tab ds pk, 10 mg tablet, 20mg tablet, 50 mg tablet)

1

PREDNISONE INTENSOL 2



triamcinolone acetonide (10 mg/ml vial, 40 mg/ml vial) 1

ANDROGENS

ANDRODERM 2

QL 1 / day

PA

GL Male

ANDROGEL (1.62% GEL PUMP, 1.62%(1.25G) GEL PCKT,1.62%(2.5G) GEL PCKT) 2

QL 5 / day

PA

GL Male

danazol (50 mg capsule, 100 mg capsule, 200 mg capsule) 1

methyltestosterone 10 mg capsule 1

oxandrolone (2.5 mg tablet, 10 mg tablet) 1PA

GL Male

testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) 1 GL Male

testosterone enanthate 1PA

GL Male

CONTRACEPTIVES

ALTAVERA 0

QL 1 / day

GL Female

HCR

ALYACEN 0GL Female

HCR

AMETHIA 0

QL 91 days

GL Female

HCR

AMETHIA LO 0

QL 91 days

GL Female

HCR



AMETHYST 0

QL 1 / day

GL Female

HCR

APRI 0GL Female

HCR

ARANELLE 0GL Female

HCR

ASHLYNA 0GL Female

HCR

AUBRA 0

QL 1 / day

GL Female

HCR

AVIANE 0

QL 1 / day

GL Female

HCR

AZURETTE 0GL Female

HCR

BALZIVA 0GL Female

HCR

BEKYREE 0GL Female

HCR

BLISOVI 24 FE 0GL Female

HCR

BLISOVI FE 0GL Female

HCR

BRIELLYN 0GL Female

HCR



CAMILA 0GL Female

HCR

CAMRESE 0

QL 91 days

GL Female

HCR

CAMRESE LO 0

QL 91 days

GL Female

HCR

CAZIANT 0GL Female

HCR

CHATEAL 0

QL 1 / day

GL Female

HCR

CRYSELLE 0GL Female

HCR

CYCLAFEM 0GL Female

HCR

CYRED 0GL Female

HCR

DASETTA 0GL Female

HCR

DAYSEE 0

QL 91 days

GL Female

HCR

DEBLITANE 0GL Female

HCR

DELYLA 0

QL 1 / day

GL Female

HCR



desogestrel-ethinyl estradiol 0.15-0.03 tablet 0GL Female

HCR

desogestrel-ethinyl estradiol/ethinyl estradiol 0GL Female

HCR

drospirenone/ethinyl estradiol/levomefolate calcium 0GL Female

HCR

ELINEST 0GL Female

HCR

ELLA 0

QL 1 / day

GL Female

HCR

EMOQUETTE 0GL Female

HCR

ENPRESSE 0GL Female

HCR

ENSKYCE 0GL Female

HCR

ERRIN 0GL Female

HCR

ESTARYLLA 0GL Female

HCR

ethinyl estradiol/drospirenone 0GL Female

HCR

ethynodiol diacetate-ethinyl estradiol 0GL Female

HCR

FALMINA 0

QL 1 / day

GL Female

HCR



FAYOSIM 0

QL 91 days

GL Female

HCR

FEMYNOR 0GL Female

HCR

GIANVI 0GL Female

HCR

GILDAGIA 0GL Female

HCR

GILDESS 0GL Female

HCR

GILDESS 24 FE 0GL Female

HCR

GILDESS FE 0GL Female

HCR

HEATHER 0GL Female

HCR

INTROVALE 0

QL 91 days

GL Female

HCR

ISIBLOOM 0GL Female

HCR

JENCYCLA 0GL Female

HCR

JOLESSA 0

QL 91 days

GL Female

HCR



JOLIVETTE 0GL Female

HCR

JULEBER 0GL Female

HCR

JUNEL 0GL Female

HCR

JUNEL FE 0GL Female

HCR

JUNEL FE 24 0GL Female

HCR

KAITLIB FE 0GL Female

HCR

KARIVA 0GL Female

HCR

KELNOR 1-35 0GL Female

HCR

KIMIDESS 0GL Female

HCR

KURVELO 0

QL 1 / day

GL Female

HCR

LARIN 0GL Female

HCR

LARIN 24 FE 0GL Female

HCR

LARIN FE 0GL Female

HCR



LARISSIA 0

QL 1 / day

GL Female

HCR

LAYOLIS FE 0GL Female

HCR

LEENA 0GL Female

HCR

LESSINA 0

QL 1 / day

GL Female

HCR

LEVONEST 0GL Female

HCR

levonorgestrel 0

QL 0.07 / day

GL Female

HCR

levonorgestrel-ethin estradiol 0.15-0.03 tablet 0

QL 91 days

GL Female

HCR

levonorgestrel-ethin estradiol 6-5-10 tablet 0GL Female

HCR

levonorgestrel-ethinyl estradiol (0.1-0.02 tablet, 90-20 mcgtablet) 0

QL 1 / day

GL Female

HCR

levonorgestrel-ethin estradiol 0.15-0.03 tbdspk 3mo 0

QL 91 days

GL Female

HCR

l-norgest/e.estradiol-e.estrad 150-30(84) tbdspk 3mo 0GL Female

HCR



levonorgestrel/ethinyl estradiol and ethinyl estradiol (l-norgest/e.estradiol-e.estrad 0.15mg(84) tbdspk 3mo, l-norgest/e.estradiol-e.estrad 100-20(84) tbdspk 3mo)

0

QL 91 days

GL Female

HCR

LEVORA-28 0

QL 1 / day

GL Female

HCR

LILLOW 0

QL 1 / day

GL Female

HCR

LO LOESTRIN FE 0GL Female

HCR

LOESTRIN FE 1.5-30 TABLET 0GL Female

HCR

LOMEDIA 24 FE 0GL Female

HCR

LORYNA 0GL Female

HCR

LOW-OGESTREL 0GL Female

HCR

LUTERA 0

QL 1 / day

GL Female

HCR

LYZA 0GL Female

HCR

MARLISSA 0

QL 1 / day

GL Female

HCR



MELODETTA 24 FE 0GL Female

HCR

MIBELAS 24 FE 0GL Female

HCR

MICROGESTIN 0GL Female

HCR

MICROGESTIN 24 FE 0GL Female

HCR

MICROGESTIN FE 0GL Female

HCR

MONO-LINYAH 0GL Female

HCR

MONONESSA 0GL Female

HCR

MYZILRA 0GL Female

HCR

NATAZIA 2 GL Female

NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 1-50-28 TABLET,10-11-28 TABLET) 0

GL Female

HCR

NECON 7-7-7-28 TABLET 1

QL 1 / day

GL Female

HCR

NIKKI 0GL Female

HCR

NORA-BE 0GL Female

HCR



norethindrone 0.35 mg tablet 0GL Female

HCR

norethindrone ac-eth estradiol 1mg-20mcg tablet 0GL Female

HCR

norethindrone acetate-ethinyl estradiol/ferrous fumarate (1mg-20(21) tablet, 1mg-20(24) tab chew, 1mg-20(24) tablet) 0

GL Female

HCR

norethindrone-ethinyl estradiol/ferrous fumarate 0GL Female

HCR

norgestimate-ethinyl estradiol 0GL Female

HCR

NORINYL 1+50 0GL Female

HCR

NORLYDA 0GL Female

HCR

NORLYROC 0GL Female

HCR

NORTREL 0GL Female

HCR

NUVARING 0GL Female

HCR

OCELLA 0GL Female

HCR

OGESTREL 0

QL 1 / day

GL Female

HCR

ORSYTHIA 0

QL 1 / day

GL Female

HCR



PHILITH 0GL Female

HCR

PIMTREA 0GL Female

HCR

PIRMELLA 0GL Female

HCR

PORTIA 0

QL 1 / day

GL Female

HCR

PREVIFEM 0GL Female

HCR

QUASENSE 0

QL 91 days

GL Female

HCR

RAJANI 0GL Female

HCR

RECLIPSEN 0GL Female

HCR

RIVELSA 0

QL 91 days

GL Female

HCR

SETLAKIN 0

QL 91 days

GL Female

HCR

SHAROBEL 0GL Female

HCR

SPRINTEC 0GL Female

HCR



SRONYX 0

QL 1 / day

GL Female

HCR

SYEDA 0GL Female

HCR

TARINA FE 0GL Female

HCR

TAYTULLA 0GL Female

HCR

TILIA FE 0GL Female

HCR

TRI FEMYNOR 0GL Female

HCR

TRI-ESTARYLLA 0GL Female

HCR

TRI-LEGEST FE 0GL Female

HCR

TRI-LINYAH 0GL Female

HCR

TRI-LO-ESTARYLLA 0GL Female

HCR

TRI-LO-MARZIA 0GL Female

HCR

TRI-LO-SPRINTEC 0GL Female

HCR

TRI-PREVIFEM 0GL Female

HCR



TRI-SPRINTEC 0GL Female

HCR

TRINESSA 0GL Female

HCR

TRINESSA LO 0GL Female

HCR

TRIVORA-28 0GL Female

HCR

VELIVET 0GL Female

HCR

VESTURA 0GL Female

HCR

VIENVA 0

QL 1 / day

GL Female

HCR

VIORELE 0GL Female

HCR

VYFEMLA 0GL Female

HCR

WERA 0GL Female

HCR

WYMZYA FE 0GL Female

HCR

XULANE 0

QL 0.12 / day

GL Female

HCR



ZARAH 0GL Female

HCR

ZENCHENT 0GL Female

HCR

ZENCHENT FE 0GL Female

HCR

ZEOSA 0GL Female

HCR

ZOVIA 1-35E 0GL Female

HCR

ZOVIA 1-50E 0GL Female

HCR

GONADOTROPINS

BRAVELLE 4

PA

GL Female

S

PS

chorionic gonadotropin, human (1mm unit powder(ea), 2mmunit powder(ea), 5mm unit powder(ea), 10mm unit powder(ea),10000 unit vial)

4 S

ELIGARD 4PA

S

FOLLISTIM AQ (75 UNIT VIAL, 300 UNIT CARTRIDG, 600 UNITCARTRIDG, 900 UNIT CARTRIDG) 4

PA

S

GONAL-F 4

PA

S

PS



GONAL-F RFF 4

PA

GL Female

S

PS

GONAL-F RFF REDI-JECT 4

PA

GL Female

S

PS

leuprolide acetate (1 mg/0.2ml kit, 1 mg/0.2ml vial) 4PA

S

LUPANETA PACK 4 S

LUPRON DEPOT (DEPOT-4 MONTH KIT, DEPOT 7.5 MG KIT,DEPOT 11.25 MG 3MO KIT, DEPOT 22.5 MG 3MO KIT, DEPOT 45MG 6MO KIT)

4PA

S

LUPRON DEPOT 3.75 MG KIT 4PA

S

LUPRON DEPO 11.25MG (LUPANETA) 4PA

S

LUPRON DEPOT 3.75MG (LUPANETA) 4PA

S

LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25 MGKIT, 15 MG KIT, 30 MG 3MO KIT) 4

PA

S

MENOPUR 4

PA

GL Female

S

PS

NOVAREL 10,000 UNITS VIAL 4PA

S



OVIDREL 4

PA

S

PS

PREGNYL 4PA

S

SYNAREL 4PA

S

LEPTINS

MYALEPT 4PA

S

PARATHYROID

calcitonin,salmon,synthetic 1 QL 0.13 / day

FORTEO 4PA

S

MIACALCIN 400 UNIT/2 ML VIAL 4 S

NATPARA 4PA

S

TYMLOS 4

QL 1.60 / day

PA


S

PITUITARY

desmopressin acetate (non-refrigerated) 1



GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG,MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG,MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG,MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MGCARTRIDGE)

4PA

S

HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG CARTRIDGE,24 MG CARTRIDGE) 4

PA

S

NORDITROPIN FLEXPRO 4

PA

S

PS

NUTROPIN AQ 4PA

S

NUTROPIN AQ NUSPIN 4PA

S

OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 MLCRTG) 4

PA

S

SAIZEN (5 MG VIAL, 8.8 MG CLICK.EASY CARTG, 8.8 MG VIAL) 4PA

S

SAIZEN-SAIZENPREP 4PA

S

SEROSTIM 4

QL 1 / day

PA

S

vasopressin 1

ZOMACTON 4PA

S

ZORBTIVE 4

QL 1 / day

PA

S



PROGESTINS

DEPO-SUBQ PROVERA 104 0

QL 90 days

GL Female

HCR

ENDOMETRIN 4

GL Female

S

PS

hydroxyprogesterone caproate 250 mg/ml vial 4

PA

GL Female

S

MAKENA (250 MG/ML VIAL, 1,250 MG/5 ML VIAL) 4

PA

GL Female

S

PS

medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10mg tablet) 1

GL Female

LCG

medroxyprogesterone acetate (150 mg/ml syringe, 150 mg/mlvial) 0

QL 0.04 / day

GL Female

HCR

norethindrone acetate 1 GL Female

progesterone 50 mg/ml vial 1 GL Female

progesterone, micronized (100 mg capsule, 200 mg capsule) 1 GL Female

HYPOTENSIVE AGENTS

CENTRAL ALPHA-AGONISTS

clonidine (0.2mg/24hr patch tdwk, 0.3mg/24hr patch tdwk) 3QL 0.29 / day

HCG



clonidine 0.1mg/24hr patch tdwk 3QL 0.15 / day

HCG

clonidine hcl 0.1 mg tab er 12h 3QL 4 / day

HCG

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1 LCG

methyldopa 1

DIRECT VASODILATORS

hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100mg tablet) 1

hydralazine hcl 20 mg/ml vial 1

minoxidil (2.5 mg tablet, 10 mg tablet) 1

HYPOTENSIVE AGENTS, MISCELLANEOUS

VECAMYL 4PA

S

PERIPHERAL ADRENERGIC INHIBITORS

reserpine (0.1 mg tablet, 0.25 mg tablet) 1

ION-REMOVING AGENTS

PHOSPHATE-REMOVING AGENTS

calcium acetate 1

FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW,1,000 MG TABLET CHEW) 2

lanthanum carbonate 1

RENVELA 800 MG TABLET 2

sevelamer carbonate (0.8 g powd pack, 2.4 g powd pack, 800mg tablet) 3 HCG

POTASSIUM-REMOVING AGENTS

KIONEX (15 GM/60 ML SUSPENSION, POWDER) 1



sodium polystyrene sulfonate (15 g/60 ml oral susp, 30g/120ml enema, 50 g/200ml enema, powder) 1

SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMA) 1

MACROLIDES

OTHER MACROLIDES

azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5mlsusp recon, 500 mg tablet, 600 mg tablet) 1

azithromycin 250 mg tablet 1 QL 6 / 5 days

ZMAX 2 QL 60 / fill

MISCELLANEOUS B-LACTAM ANTIBIOTICS

MONOBACTAMS

aztreonam 1

CAYSTON 4PA

S

MISCELLANEOUS THERAPEUTIC AGENTS

5-ALPHA-REDUCTASE INHIBITORS

dutasteride 3

QL 1 / day

GL Male

HCG

finasteride 5 mg tablet 1QL 1 / day

GL Male

ALCOHOL DETERRENTS

disulfiram (250 mg tablet, 500 mg tablet) 1

ANTIDOTES

amyl nitrite 1

deferoxamine mesylate 1



edetate calcium disodium 200 mg/ml ampul 1

leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25mg tablet) 1

leucovorin calcium (50 mg vial, 100 mg vial, 200 mg vial, 350mg vial, 500 mg vial) 4 S

MEPHYTON 2

phytonadione (vit k1) (1mg/0.5ml ampul, 1mg/0.5ml syringe,10 mg/ml ampul) 1

pralidoxime chloride 600 mg/2ml pen injctr 1

VISTOGARD 4 S

ANTIGOUT AGENTS

allopurinol 100 mg tablet 1QL 3 / day

LCG

allopurinol 300 mg tablet 1QL 2 / day

LCG

colchicine 0.6 mg capsule 1 QL 2 / day

colchicine 0.6 mg tablet 1 QL 4 / day

COLCRYS 2 QL 4 / day

indomethacin (50 mg capsule, 75 mg capsule er) 1

indomethacin 25 mg capsule 1 LCG

naproxen (125 mg/5ml oral susp, 375 mg tablet, 500 mg tablet) 1 LCG

naproxen (250 mg tablet, 375 mg tablet dr, 500 mg tablet dr) 1

naproxen sodium (275 mg tablet, 550 mg tablet) 1

naproxen sodium (375 mg tbmp 24hr, 500 mg tbmp 24hr) 3 HCG

ULORIC 2QL 1 / day

ST



BONE RESORPTION INHIBITORS

alendronate sodium (35 mg tablet, 40 mg tablet, 70 mg tablet,70 mg/75ml solution) 1 QL .15 / day

alendronate sodium (5 mg tablet, 10 mg tablet) 1 QL 1 / day

etidronate disodium 1

ibandronate sodium 150 mg tablet 1 QL 0.04 / day

risedronate sodium 150 mg tablet 3QL 0.04 / day

HCG

risedronate sodium 30 mg tablet 3 HCG

risedronate sodium 35 mg tablet 3QL 0.15 / day

HCG

risedronate sodium 5 mg tablet 3QL 1 / day

HCG

risedronate sodium 35 mg tablet dr 1

CARIOSTATIC AGENTS

CLINPRO 5000 1

DENTA 5000 PLUS 1

DENTAGEL 1

FLUOR-A-DAY 2.5 MG/ML DROPS 0 HCR

fluoride (sodium) 0.2 % solution 1

fluoride (sodium) (0.25(0.55) tab chew, 0.5 mg/ml drops,0.5(1.1)mg tab chew, 1mg(2.2mg) tab chew) 0 HCR

FLUORIDEX 1

FLUORIDEX DAILY DEFENSE 1

FLUORIDEX SENSITIVITY RELIEF 1

FLUORITAB (0.125 MG/DRP DROPS, 0.5 MG TABLET CHEW, 1MG TABLET CHEW) 0 HCR



FLURA-DROPS 0 HCR

LUDENT FLUORIDE 0 HCR

pediatric multivitamin no.150 with sodium fluoride 1

pediatric multivitamin no.2/sodium fluoride 1

SF 1

SF 5000 PLUS 1

COMPLEMENT INHIBITORS

FIRAZYR 4PA

S

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

ACTEMRA 162 MG/0.9 ML SYRINGE 4

QL 0.15 / day

PA

S

azathioprine 50 mg tablet 1

azathioprine sodium 1

cyclosporine (25 mg capsule, 100 mg capsule) 4 S

cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mgcapsule, 100 mg/ml solution) 4 S

DEPEN 2

ENBREL 50 MG/ML SURECLICK SYR 4

QL 0.15 / day

PA

S

PS

ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/MLSYRINGE) 4

QL 0.29 / day

PA

S

PS



GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE,100 MG/ML SOLUTION) 4 S

KEVZARA 4

QL 0.1 / day

PA


S

leflunomide 1

methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) 1

methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25mg/ml vial) 1

NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATIN CAPSULE,100 MG/ML SOLUTION) 4 S

ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 ML SYRINGE,125 MG/ML SYRINGE) 4

QL 0.15 / day

PA

S

ORENCIA CLICKJECT 4

QL 0.15 / day

PA

S

OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTERPACK) 4

QL 2 / day

PA

S

RIDAURA 2

SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE) 4 S

SANDIMMUNE 100 MG/ML SOLN 4S

PS

SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML SYRINGE,100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE) 4

QL 0.04 / day

PA

S



STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL, 90MG/ML SYRINGE) 4

QL 0.08 / day

PA

S

TREXALL 2

XELJANZ 4

QL 2 / day

PA

S

XELJANZ XR 4

QL 1 / day

PA

S

GONADOTROPIN-RELEASING HORMONE ANTAGNTS

CETROTIDE 4

PA

GL Female

S

PS

FIRMAGON 120 MG VIAL 4PA

S

ganirelix acetate 4GL Female

S

IMMUNOMODULATORY AGENTS

ACTIMMUNE 4 S

AUBAGIO 4

QL 1 / day

PA

S

PS

AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG, PREFILLEDSYR 30 MCG KT) 4

QL 0.15 / day

PA

S

PS



AVONEX PEN (PEN 30 MCG/0.5 ML, PEN 30 MCG/0.5 ML KIT) 4

QL 0.15 / day

PA

S

PS

BETASERON (0.3 MG KIT, 0.3 MG VIAL) 4

QL 0.5 / day

PA

S

COPAXONE 4

QL 1 / day

PA

S

PS

EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) 4

QL 0.5 / day

PA

S

GILENYA 4

QL 1 / day

PA

S

PS

GLATOPA 4

QL 1 / day

PA

S

PLEGRIDY 125 MCG/0.5 ML SYRING 4

QL 0.04 / day

PA

S

PS

PLEGRIDY SYRINGE STARTER PACK 4

QL 1 / lifetime

PA

S

PS



PLEGRIDY 125 MCG/0.5 ML PEN 4

QL 0.04 / day

PA

S

PS

PLEGRIDY PEN INJ STARTER PACK 4

QL 1 / lifetime

PA

S

PS

POMALYST 4

QL 1 / day

PA

S

REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE) 4

QL 0.22 / day

PA

S

REBIF TITRATION PACK 4

QL 4.2 / 365 days

PA

S

REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 4

QL 0.22 / day

PA

S

REBIF REBIDOSE TITRATION PACK 4

QL 4.2 / 365 days

PA

S

REVLIMID 4

QL 1 / day

PA

S

TECFIDERA 4

QL 2 / day

PA

S

PS



THALOMID (150 MG CAPSULE, 200 MG CAPSULE) 4

QL 2 / day

PA

S

THALOMID (50 MG CAPSULE, 100 MG CAPSULE) 4

QL 1 / day

PA

S

ZINBRYTA 4

QL 1 / day

PA

S

IMMUNOSUPPRESSIVE AGENTS

ASTAGRAF XL 0.5 MG CAPSULE 4

QL 15 / day

PA

S

ASTAGRAF XL 1 MG CAPSULE 4

QL 30 / day

PA

S

ASTAGRAF XL 5 MG CAPSULE 4

QL 6 / day

PA

S

CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 MGTABLET) 4 S

cyclophosphamide (25 mg capsule, 50 mg capsule) 1 PA

ELIDEL 2

QL 2.5 / day

ST


ENVARSUS XR 4

QL 1 / day

PA

S



mercaptopurine 50 mg tablet 1

mycophenolate mofetil 200 mg/ml susp recon 4 S

mycophenolate mofetil (250 mg capsule, 500 mg tablet) 4 S

mycophenolate sodium 4 S

MYFORTIC 4 S

PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 4 S

PURIXAN 4PA

S

RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORALSOLN, 2 MG TABLET) 4 S

sirolimus (1 mg tablet, 2 mg tablet) 4 S

sirolimus 0.5 mg tablet 4 S

tacrolimus 0.5 mg capsule 4QL 2 / day

S

tacrolimus 1 mg capsule 4QL 8 / day

S

tacrolimus 5 mg capsule 4QL 4 / day

S

ZORTRESS 4PA

S

OTHER MISCELLANEOUS THERAPEUTIC AGENTS

acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1

AMPYRA 4

QL 2 / day

PA

S

PS



ARCALYST 4PA

S

BOTOX COSMETIC 4PA

S

CERDELGA 4

QL 2 / day

PA

S

CYSTADANE 4 S

CYSTAGON 4 S

ethyl alcohol (98 % ampul, 98 % vial) 1

ILARIS 150 MG/ML VIAL 4

QL 0.04 / day

PA

S

KEVEYIS 4

QL 4 / day

PA

S

KUVAN (100 MG POWDER PACKET, 100 MG TABLET, 500 MGPOWDER PACKET) 4

PA

S

levocarnitine 330 mg tablet 1

levocarnitine (with sugar) 1

ORALAIR (100-300 IR CHILD SAMPL, 300 IR ADULT SAMPLE KT,300 IR STARTER PACK, 300 IR SUBLINGUAL TAB) 4

PA

S

ORALAIR 100 IR STARTER PACK 4 S

ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MGCAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) 4

PA

S

PROCYSBI 4 S



SENSIPAR (30 MG TABLET, 60 MG TABLET) 4

QL 2 / day

PA

S

SENSIPAR 90 MG TABLET 4

QL 4 / day

PA

S

TYBOST 4S

PS

XURIDEN 4 S

ZAVESCA 4PA

S

PROTECTIVE AGENTS

MESNEX 400 MG TABLET 4 S

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

CYCLOOXYGENASE-2 (COX-2) INHIBITORS

celecoxib (50 mg capsule, 200 mg capsule) 1 QL 2 / day

celecoxib 100 mg capsule 1 QL 3 / day

celecoxib 400 mg capsule 1 QL 1 / day

OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS

diclofenac potassium 1

diclofenac sodium 1.5 % drops 3 HCG

diclofenac sodium 1 % gel (gram) 3QL 1000/ 30 days

HCG

diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75 mgtablet dr, 100 mg tab er 24h) 1

diflunisal 1



etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h,400 mg tablet, 500 mg tab er 24h, 500 mg tablet, 600 mg tab er24h)

1

fenoprofen calcium (200 mg capsule, 400 mg capsule, 600 mgtablet) 1

flurbiprofen (50 mg tablet, 100 mg tablet) 1

ibuprofen 100 mg/5ml oral susp 1

ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1 LCG

ketoprofen 200 mg cap24h pel 3 HCG

ketoprofen 50 mg capsule 1 LCG

ketoprofen 75 mg capsule 1

ketorolac tromethamine 30 mg/ml cartridge 1QL 20 / 30 days

LCG

ketorolac tromethamine 30 mg/ml syringe 1 QL 20 / 23 days

ketorolac tromethamine 10 mg tablet 1QL 21 / fill

LCG

ketorolac tromethamine (15 mg/ml cartridge, 15 mg/ml vial) 1 QL 40 / 23 days

ketorolac tromethamine (30 mg/ml vial, 60 mg/2 ml syringe) 1 QL 20 / 30 days

ketorolac tromethamine (60 mg/2 ml cartridge, 60 mg/2 mlvial) 1

QL 20 / 30 days

LCG

ketorolac tromethamine 30mg/ml(1) vial 1QL 20 / 23 days

LCG

KLOFENSAID II 3 HCG

meclofenamate sodium (50 mg capsule, 100 mg capsule) 1

mefenamic acid 250 mg capsule 3QL 5 / day

HCG

meloxicam 7.5 mg/5ml oral susp 1 QL 10 / day



meloxicam (7.5 mg tablet, 15 mg tablet) 1QL 1 / day

LCG

nabumetone (500 mg tablet, 750 mg tablet) 1

oxaprozin 600 mg tablet 3 HCG

piroxicam (10 mg capsule, 20 mg capsule) 1 AL Up to 75 yrs old

sulindac (150 mg tablet, 200 mg tablet) 1

tolmetin sodium (200 mg tablet, 400 mg capsule, 600 mgtablet) 1

SALICYLATES

carisoprodol/aspirin 200-325 mg tablet 1

choline salicyl/mag salicylate 500 mg/5ml liquid 1

salsalate (500 mg tablet, 750 mg tablet) 1

PENICILLINS

AMINOPENICILLINS

amoxicillin (125 mg/5ml susp recon, 200 mg/5ml susp recon,250 mg capsule, 400 mg/5ml susp recon, 875 mg tablet) 1 LCG

amoxicillin (125 mg tab chew, 250 mg tab chew, 250 mg/5mlsusp recon, 500 mg capsule, 500 mg tablet, 775 mg tbmp 24hr) 1

amoxicillin/potassium clav 1000-62.5 tab er 12h 3 HCG



amoxicillin/potassium clavulanate (amoxicillin/potassium 200-28.5/5 susp recon, amoxicillin/potassium 200-28.5mg tabchew, amoxicillin/potassium 250-125 mg tablet,amoxicillin/potassium 250-62.5/5 susp recon,amoxicillin/potassium 400-57mg tab chew,amoxicillin/potassium 400-57mg/5 susp recon,amoxicillin/potassium 500-125 mg tablet,amoxicillin/potassium 600-42.9/5 susp recon,amoxicillin/potassium 875-125 mg tablet)

1

ampicillin sodium (1 g vial, 2 g vial, 10 g vial, 125 mg vial, 250mg vial, 500 mg vial) 1

ampicillin sodium/sulbactam sodium (sodium/sulbactam 1.5 gvial, sodium/sulbactam 3 g vial, sodium/sulbactam 15 g vial) 1

ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule,250 mg/5ml susp recon, 500 mg capsule) 1

AUGMENTIN 125-31.25 MG/5 ML 2

NATURAL PENICILLINS

penicillin g potassium 1

penicillin g procaine 1

penicillin g sodium 1

penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet,250 mg/5ml soln recon, 500 mg tablet) 1 LCG

PENICILLINASE-RESISTANT PENICILLINS

dicloxacillin sodium 250 mg capsule 1

dicloxacillin sodium 500 mg capsule 1 LCG

nafcillin sodium (1 g vial, 2 g vial, 10 g vial) 1

oxacillin sodium (1 g vial, 2 g vial, 10 g vial) 1

RENIN-ANGIOTENSIN-ALDOSTER.INHIB(HYPOTN)

ANGIOTENSIN II RECEPTOR ANTAGON.(HYPOTN)

candesartan cilexetil 1 QL 1 / day

eprosartan mesylate 1 QL 1 / day



irbesartan 1 QL 1 / day

losartan potassium (25 mg tablet, 50 mg tablet) 1QL 2 / day

LCG

losartan potassium 100 mg tablet 1QL 1 / day

LCG

olmesartan medoxomil 1 QL 3 / day

telmisartan 1 QL 1 / day

valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet) 1 QL 2 / day

valsartan 320 mg tablet 1 QL 1 / day

ANGIOTENSIN-CONVERT.ENZYME INHIB(HYPOTN)

benazepril hcl (10 mg tablet, 40 mg tablet) 1 QL 2 / day

benazepril hcl 20 mg tablet 1 QL 4 / day

benazepril hcl 5 mg tablet 1 QL 3 / day

captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mgtablet) 1 QL 4 / day

enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20mg tablet) 1 QL 2 / day

fosinopril sodium 1 QL 2 / day

lisinopril (2.5 mg tablet, 10 mg tablet, 20 mg tablet) 1QL 1 / day

LCG

lisinopril (5 mg tablet, 30 mg tablet) 1 QL 1 / day

lisinopril 40 mg tablet 1 QL 2 / day

moexipril hcl 1 QL 1 / day

perindopril erbumine 1 QL 1 / day

quinapril hcl 1 QL 2 / day



ramipril 1 QL 2 / day

trandolapril 1 QL 2 / day

RESPIRATORY TRACT AGENTS

ANTIFIBROTIC AGENTS

ESBRIET (267 MG CAPSULE, 267 MG TABLET) 4

QL 9 / day

PA

S

ESBRIET 801 MG TABLET 4

QL 3 / day

PA

S

OFEV 4

QL 2 / day

PA

S

ANTITUSSIVES

benzonatate 1 AL At least 11 yrs old

MUCOLYTIC AGENTS

PULMOZYME 4

QL 5 / day

PA

S

VASODILATING AGENTS (RESPIRATORY TRACT)

ADCIRCA 4

QL 2 / day

PA

S

ADEMPAS 4

QL 3 / day

PA

S



LETAIRIS 4

QL 1 / day

PA

S

PS

OPSUMIT 4

QL 1 / day

PA

S

ORENITRAM ER 4

QL 3 / day

PA

S

REMODULIN 4PA

S

REVATIO 10 MG/ML ORAL SUSP 4

QL 6 / day

PA


S

REVATIO 20 MG TABLET 4

QL 3 / day

PA


S

sildenafil citrate 20 mg tablet 4

QL 3 / day

PA

S

TRACLEER 4

QL 2 / day

PA

S

PS

TYVASO 4

QL 1 / day

PA

S



TYVASO INSTITUTIONAL START KIT 4

QL 1 / day

PA

S

TYVASO REFILL KIT 4

QL 1 / day

PA

S

TYVASO STARTER KIT 4

QL 1 / day

PA

S

UPTRAVI 200-800 TITRATION PACK 4

PA


S

UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCGTABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCGTABLET, 1,400 MCG TABLET, 1,600 MCG TABLET)

4

QL 2 / day

PA


S

SKELETAL MUSCLE RELAXANTS

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT

carisoprodol (250 mg tablet, 350 mg tablet) 1

chlorzoxazone 500 mg tablet 1

cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet) 1

cyclobenzaprine hcl 10 mg tablet 1 LCG

LORZONE 750 MG TABLET 1

METAXALL 1

metaxalone 3 HCG

methocarbamol (500 mg tablet, 750 mg tablet) 1

methocarbamol 100 mg/ml vial 1



tizanidine hcl (2 mg capsule, 2 mg tablet, 4 mg capsule, 4 mgtablet, 6 mg capsule) 1

DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

dantrolene sodium (25 mg capsule, 50 mg capsule, 100 mgcapsule) 1

GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT

baclofen (10 mg tablet, 20 mg tablet) 1

SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS

orphenadrine citrate 100 mg tablet er 1

orphenadrine citrate (30 mg/ml ampul, 30 mg/ml vial) 1

SKIN AND MUCOUS MEMBRANE AGENTS

ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)

ALA-CORT 1

alclometasone dipropionate (0.05 % cream (g), 0.05 % oint.(g)) 1

amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) 1

ANUCORT-HC 1

ANUSOL-HC 25 MG SUPPOSITORY 1

betamethasone dipropionate (0.05 % cream (g), 0.05 % gel(gram), 0.05 % lotion, 0.05 % oint. (g)) 1

betamethasone dipropionate/propylene glycol(betamethasone/propylene 0.05 % cream (g),betamethasone/propylene 0.05 % lotion,betamethasone/propylene 0.05 % oint. (g))

1

betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 %oint. (g), 0.12 % foam) 1

calcipotriene/betamethasone dipropionate 1 QL 3 / day

clobetasol propionate (0.05 % cream (g), 0.05 % foam, 0.05 %gel (gram), 0.05 % lotion, 0.05 % oint. (g), 0.05 % shampoo,0.05 % solution, 0.05 % spray)

1



clobetasol propionate/emollient base (propionate/emoll 0.05 %cream (g), propionate/emoll 0.05 % foam) 1

clocortolone pivalate 0.1 % cream (g) 1

CLODAN 0.05% SHAMPOO 1

COLOCORT 1

CORMAX 1

desonide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 3 HCG

desoximetasone (0.05 % cream (g), 0.05 % gel (gram), 0.05 %oint. (g), 0.25 % cream (g), 0.25 % oint. (g)) 3 HCG

diflorasone diacetate (0.05 % cream (g), 0.05 % oint. (g)) 1

EUCRISA 2

QL 2.143 / day

ST


fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.025 %cream (g), 0.025 % oint. (g)) 3 HCG

fluocinolone acetonide 0.01 % solution 1

fluocinolone acetonide/shower cap 3 HCG

fluocinonide (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint.(g), 0.05 % solution, 0.1 % cream (g)) 1

fluocinonide/emollient base 1

fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g),0.05 % lotion) 1

halobetasol propionate (0.05 % cream (g), 0.05 % oint. (g)) 3 HCG

HEMMOREX-HC 1

hydrocortisone (1 % cream (g), 1 % crm/pe app, 1 % oint. (g),2.5 % cream (g), 2.5 % crm/pe app, 2.5 % lotion, 2.5 % oint.(g), 100mg/60ml enema)

1

hydrocortisone acetate (25 mg supp.rect, 30 mg supp.rect) 1

hydrocortisone/lidocaine/aloe 0.55%-2.8% gel w/appl 1



hydrocortisone acetate/pramoxine hcl(hydrocortisone/pramoxine 1 %-1 % cream/appl,hydrocortisone/pramoxine 2.5 %-1 % cream (g),hydrocortisone/pramoxine 2.5 %-1 % cream/appl,hydrocortisone/pramoxine 2.5-1%(4g) cream/appl)

1

hydrocortisone butyrate (0.1 % cream (g), 0.1 % oint. (g), 0.1 %solution) 1

hydrocortisone butyrate/emoll 0.1 % cream (g) 1

hydrocortisone valerate (0.2 % cream (g), 0.2 % oint. (g)) 1

hydrocortisone/mineral oil/petrolatum,white 1

lidocaine/hydrocortisone ac 3 %-0.5 % cream (g) 3 HCG

lidocaine hcl/hydrocortisone acetate (lidocaine/hydrocortisone3 %-0.5 % cream/appl, lidocaine/hydrocortisone 3-2.5%(7g)gel w/appl)

1

mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 %solution) 1

ORALONE 1

PRAMCORT 1

prednicarbate (0.1 % cream (g), 0.1 % oint. (g)) 1

PROCTO-MED HC 1

PROCTO-PAK 1

PROCTOFOAM-HC 2

PROCTOSOL-HC 1

PROCTOZONE-HC 1

SANADERMRX 1

SCALACORT 1

triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion,0.025 % oint. (g), 0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g),0.1 % paste (g), 0.147mg/g aerosol, 0.5 % cream (g), 0.5 %oint. (g))

1

TRIANEX 1

TRIDERM 1



ANTIPRURITICS AND LOCAL ANESTHETICS

CIDALEAZE 1

doxepin hcl 5 % cream (g) 1

ethyl chloride 1

lidocaine 5 % adh. patch 3QL 3 / day

HCG

lidocaine 5 % oint. (g) 1

lidocaine hcl (3 % cream (g), 3 % lotion, 4 % solution) 1

lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g),lidocaine/prilocaine 2.5 kit) 1

lidocaine/tetracaine 1

LIDOPIN 3% CREAM 1

LIDOPRIL 1

LIDORX 2QL 1 / day

PA

LP LITE PAK 1

phenazopyridine hcl (100 mg tablet, 200 mg tablet) 1

CELL STIMULANTS AND PROLIFERANTS

AVITA (CREAM, GEL) 1

tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.025 % gel(gram), 0.05 % cream (g), 0.05 % gel (gram), 0.1 % cream (g)) 1

tretinoin microspheres (0.04 % gel (gram), 0.04 % gel w/pump,0.1 % gel (gram), 0.1 % gel w/pump) 3

QL 1.667 / day

HCG

tretinoin/emollient base 1

KERATOLYTIC AGENTS

BENZEPRO (6% FOAMING CLOTHS, 7% CREAMY WASH) 1

benzoyl peroxide 7 % cleanser 1



BP-50% UREA 1

BPO 6% FOAMING CLOTHS 1 QL 2 / day

LATRIX 1

PACNEX 1

potassium hydroxide 5 % solution 1

PR BENZOYL PEROXIDE 1

REA LO 40 (40 CM, 40 TION) 1

REMEVEN 1

SALACYN (CREAM, LOTION) 1

salicylic acid (6 % cream (g), 6 % crm er (g), 6 % foam, 6 % gel(gram), 6 % lotion, 6 % lotion er, 6 % shampoo, 26 % liquid,27.5 % liq-film, 28.5 % sol-filmer)

1

salicylic acid/ammonium lactate/aloe vera 1

silver nitrate 10 % solution 1

silver nitrate/potassium nitrate 1

UMECTA 40% MOUSSE 1

URE-K 1

urea (35 % foam, 39 % cream (g), 40 % cream (g), 40 % gel(ml), 40 % lotion, 40 % nl fm susp, 45 % cream (g), 45 % gel(ml), 45 % lotion, 47 % cream (g), 50 % cream (g))

1

KERATOPLASTIC AGENTS

coal tar 20 % solution 1

SKIN AND MUCOUS MEMBRANE AGENTS, MISC.

acitretin (17.5 mg capsule, 25 mg capsule) 3QL 2 / day

HCG

acitretin 10 mg capsule 3QL 4 / day

HCG

adapalene (0.1 % cream (g), 0.3 % gel (gram), 0.3 % gelw/pump) 3

QL 1.5 / day

HCG



adapalene 0.1 % gel (gram) 1 QL 1.5 / day

adapalene 0.1 % lotion 1 QL 2 / day

AMNESTEEM 3PA

HCG

calcipotriene (0.005 % cream (g), 0.005 % oint. (g)) 3QL 2 / day

HCG

calcipotriene 0.005 % solution 1 QL 2 / day

CALCITRENE 1 QL 2 / day

calcitriol 3 mcg/g oint. (g) 1 QL 3.334 / day

CARAC 2

CLARAVIS 3PA

HCG

COSENTYX (2 SYRINGES) 4

QL 0.357 / day

PA

S

COSENTYX PEN 4

QL 0.357 / day

PA

S

COSENTYX PEN (2 PENS) 4

QL 0.357 / day

PA

S

COSENTYX SYRINGE 4

QL 0.357 / day

PA

S

dapsone 5 % gel (gram) 1 QL 3 / day

diclofenac sodium 3 % gel (gram) 1 QL 100 / 30 days



DUPIXENT 4

QL 0.15 / day

PA


S

finasteride 1 mg tablet 1

FLUOROPLEX 2

fluorouracil (0.5 % cream (g), 2 % solution, 5 % cream (g), 5 %solution) 1

FORMADON 1

formaldehyde 1

imiquimod 5 % cream pack 1QL 0.434 / day


MIRVASO (GEL, GEL PUMP) 2 QL 1 / day

MYORISAN 3PA

HCG

podofilox 0.5 % solution 1

PYROGALLIC ACID 1

SOOLANTRA 2 QL 1.5 / day

tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 3

QL 100 / 30 days

ST

HCG

TALTZ AUTOINJECTOR 4

QL 0.15 / day

PA

S

TALTZ AUTOINJECTOR (2 PACK) 4

QL 0.15 / day

PA

S




QL 0.15 / day

PA

S

TALTZ SYRINGE 4

QL 0.15 / day

PA

S

TALTZ SYRINGE (2 PACK) 4

QL 0.15 / day

PA

S


QL 0.15 / day

PA

S

TARGRETIN 1% GEL 4PA

S

tazarotene 0.1 % cream (g) 3QL 1.47 / day

HCG

trichloroacetic acid (25 % soln recon, 75 % soln recon) 1

VALCHLOR 4

QL 3 / day

PA

S

ZENATANE 3PA

HCG



SOMATOSTATIN AGONISTS AND ANTAGONISTS

SOMATOSTATIN AGONISTS

octreotide acetate (50 mcg/ml ampul, 50 mcg/ml syringe, 100mcg/ml ampul, 100 mcg/ml syringe, 100 mcg/ml vial, 500mcg/ml ampul, 500 mcg/ml syringe, 500 mcg/ml vial)

4PA

S

octreotide acetate (50 mcg/ml vial, 200 mcg/ml vial,1000mcg/ml vial) 4

PA

S

SANDOSTATIN 0.05 MG/ML AMPUL 4

QL 30 / day

PA

S


QL 15 / day

PA

S


QL 3 / day

PA

S

SANDOSTATIN 0.2 MG/ML VIAL 4

QL 8 / day

PA

S

SANDOSTATIN 1 MG/ML VIAL 4

QL 1.5 / day

PA

S

SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL, 30 MG KT, 30MG VL) 4

QL 0.04 / day

PA

S

SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 4

QL 0.07 / day

PA

S



SIGNIFOR 4PA

S

SIGNIFOR LAR (20 MG KIT, 20 MG VIAL) 4

QL 0.1 / day

PA

S


QL 0.067 / day

PA

S


QL 0.04 / day

PA

S

SOMATOTROPIN AGONISTS AND ANTAGONISTS

SOMATOTROPIN AGONISTS

EGRIFTA 4

QL 2 / day

PA

S

INCRELEX 4PA

S

SOMATOTROPIN ANTAGONISTS

SOMAVERT 4 S

SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ALPHA- AND BETA-ADRENERGIC AGONISTS

bupivacaine hcl/epinephrine 1

bupivacaine hcl/epinephrine bitartrate 1

bupivacaine hcl/epinephrine/pf 1



lidocaine hcl/epinephrine (hcl/epinephrine 0.5-1:200k vial,hcl/epinephrine 1%-1:100k vial, hcl/epinephrine 1.5-1:200kampul, hcl/epinephrine 1.5-1:200k vial, hcl/epinephrine 2 %-1:100k vial, hcl/epinephrine 2%-1:200k vial)

1

lidocaine hcl/epinephrine bitartrate 1

NORTHERA 4

QL 84 / 14 days

PA

S

SENSORCAINE-EPINEPHRINE 1

SENSORCAINE-MPF EPINEPHRINE (SENSORC MPF 0.25%-EPI,SENSORCN-MPF 0.5%-EPI) 1

XYLOCAINE DENTAL-EPINEPHRINE 1

ALPHA-ADRENERGIC AGONISTS

midodrine hcl 1

phenylephrine hcl 10 mg/ml vial 1

THYROID AND ANTITHYROID AGENTS

ANTITHYROID AGENTS

methimazole (5 mg tablet, 10 mg tablet) 1

propylthiouracil 50 mg tablet 1

THYROID AGENTS

LEVO-T 1

levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 100 mcgtablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150mcg tablet, 175mcg tablet)

1 LCG

levothyroxine sodium (75 mcg tablet, 88 mcg tablet, 200 mcgtablet, 300 mcg tablet) 1

LEVOXYL (25 MCG TABLET, 50 MCG TABLET, 100 MCG TABLET) 1 LCG

LEVOXYL (75 MCG TABLET, 88 MCG TABLET, 112 MCG TABLET,125 MCG TABLET, 137 MCG TABLET, 150 MCG TABLET, 175MCG TABLET, 200 MCG TABLET)

1



liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcgtablet) 1

NP THYROID 1

SYNTHROID 2

UNITHROID (25 MCG TABLET, 50 MCG TABLET, 100 MCGTABLET, 112 MCG TABLET) 1 LCG

UNITHROID (75 MCG TABLET, 88 MCG TABLET, 125 MCGTABLET, 137 MCG TABLET, 150 MCG TABLET, 175 MCG TABLET,200 MCG TABLET, 300 MCG TABLET)

1

Uncategorized

Unclassified

0.9 % sodium chloride 0.9 % syringe cp 1

AFINITOR (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 4

QL 2 / day

PA

S

AFINITOR 2.5 MG TABLET 4

QL 1 / day

PA

S

AFINITOR DISPERZ 4PA

S

AFLURIA 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR

AFLURIA QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018VIAL) 0 HCR

ALECENSA 4

QL 8 / day

PA


S

ALUNBRIG 4

QL 6 / day

PA


S



anastrozole 1 mg tablet 1

azacitidine 4 S

B-PLEX PLUS 1

BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 4PA

S

bexarotene 4PA

S

bicalutamide 1

bismuth tribromoph/petrolatum 5"x9" bandage 1

BLEO 15K 4 S

bleomycin sulfate 4 S

BOSULIF 100 MG TABLET 4

QL 4 / day

PA

S

PS

BOSULIF 500 MG TABLET 4

QL 1 / day

PA

S

PS

bupivacaine hcl/dex-water/pf 0.75 % ampul 1

bupivacaine hcl/pf (hcl/pf 2.5 mg/ml ampul, hcl/pf 5 mg/mlampul, hcl/pf 7.5 mg/ml ampul) 1

butalbital/aspirin/caffeine 50-325-40 tablet 1 QL 6 / day

CABOMETYX 20 MG TABLET 4

QL 4 / day

PA

S


QL 2 / day

PA

S




QL 1.5 / day

PA

S

capecitabine 4 S

CAPRELSA 100 MG TABLET 4

QL 2 / day

PA

S

CAPRELSA 300 MG TABLET 4

QL 1 / day

PA

S

catheter (12fr-16" each, 14 fr-16 " each, 16fr-16" each) 1

catheter 14 fr each 1

CERAMAX 1

cervical cap 22mm each 0 HCR

chloroprocaine hcl/pf 1

chlorzoxazone 250 mg tablet 1

COMETRIQ 100 MG DAILY-DOSE PK 4

QL 2 / day

PA

S

COMETRIQ 140 MG DAILY-DOSE PK 4

QL 4 / day

PA

S

COMETRIQ 60 MG DAILY-DOSE PACK 4

QL 3 / day

PA

S

compressor, for nebulizer 1

conception assistance supplies combination no.1 1



COTELLIC 4

QL 2.5 / day

PA


S

cytarabine 4 S

cytarabine/pf (cytarabine/pf 2 g/20 ml vial, cytarabine/pf 100mg/5ml vial) 4 S

cytarabine/pf 20 mg/ml vial 4 S

dexchlorpheniramine maleate 1

diaphragms, wide seal 0 HCR

EMCYT 4 S

ERIVEDGE 4

QL 1 / day

PA

S

ERWINAZE 4 S

ethyl acetate 1

exemestane 1

EXJADE 4PA

S

FARESTON 2

FARYDAK 4PA

S

FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 4PA

S

fexofenadine hcl/pseudoephedrine hcl 1 QL 1 / day

floxuridine 500 mg vial 4 S



FLUAD 2017-2018 0AL At least 65 yrs old

HCR

FLUARIX QUAD 2017-2018 0 HCR

FLUBLOK 2017-2018 0 HCR

FLUBLOK QUAD 2017-2018 0 HCR

FLUCELVAX QUAD 2017-2018 (2017-2018 SYR, 2017-2018VIAL) 0 HCR

FLULAVAL QUAD 2017-2018 (2017-2018 SYR, 2017-2018VIAL) 0 HCR

flutamide 1

FLUVIRIN 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR

FLUZONE HIGH-DOSE 2017-2018 0AL At least 65 yrs old

HCR

FLUZONE INTRADERM QUAD 2017-18 0 HCR

FLUZONE QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018VIAL) 0 HCR

FLUZONE QUAD PEDI 2017-2018 0 HCR

foam bandage 1

gel dressing 1

GILOTRIF 4

QL 1 / day

PA

S

GLEEVEC 100 MG TABLET 4

QL 8 / day

PA

S

PS

GLEEVEC 400 MG TABLET 4

QL 2 / day

PA

S

PS



glutaraldehyde 1

glycopyrrolate 1.5 mg tablet 1

HEXALEN 4PA

S

HUMALOG JUNIOR KWIKPEN 2

HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 4PA

S

hydrocolloid dressing (4" 4" bandage, 6" 6" bandage, 8" 8"bandage) 1

hydroxyurea 500 mg capsule 1

HYQVIA HY COMPONENT 4PA

S

IBRANCE 100 MG CAPSULE 4

QL 1.25 / day

PA

S


QL 1 / day

PA

S


QL 1.667 / day

PA

S

ICLUSIG 15 MG TABLET 4

QL 2 / day

PA

S

ICLUSIG 45 MG TABLET 4

QL 1 / day

PA

S

IMBRUVICA 4

QL 4 / day

PA

S



INGREZZA 80 MG CAPSULE 4

QL 1 / day

PA


S

inhaler, assist devices spacer 2

inhaler,assist device,accesory each 1

INLYTA 4

QL 4 / day

PA

S

PS

IPOL SINGLE DOSE SYRINGE 2

IRESSA 4

QL 1 / day

PA

S

isoproterenol hcl 1

JADENU 4PA

S

JADENU SPRINKLE 4PA

S

JAKAFI 4

QL 2 / day

PA

S

KISQALI 200 MG DAILY DOSE 4

QL 3 / day

PA


S


QL 1.5 / day

PA


S




QL 1 / day

PA


S

KISQALI FEMARA 200 MG CO-PACK 4

QL 3 / day

PA


S


QL 1.5 / day

PA


S


QL 1 / day

PA


S

lancing device/lancets 2

LENVIMA 4

QL 3 / day

PA

S

letrozole 2.5 mg tablet 1

lidocaine hcl (5 mg/ml vial, 10 mg/ml syringe, 10 mg/ml vial, 50mg/5 ml syringe) 1

lidocaine hcl/pf 10 mg/ml ampul 1 MED Medical Drug

lidocaine hcl/pf (hcl/pf 10 mg/ml syringe, hcl/pf 10 mg/ml vial,hcl/pf 15 mg/ml ampul, hcl/pf 200mg/10ml syringe) 1

lomustine 1

LONSURF 15 MG-6.14 MG TABLET 4

QL 2.15 / day

PA

S



LONSURF 20 MG-8.19 MG TABLET 4

QL 3 / day

PA

S

LYNPARZA (50 MG CAPSULE, 100 MG TABLET, 150 MG TABLET) 4PA

S

LYSODREN 4 S

MATULANE 4 S

MAVYRET 4

QL 3 / day

PA


S

PS

megestrol acetate (400mg/10ml oral susp, 625mg/5ml oralsusp) 1

megestrol acetate (20 mg tablet, 40 mg tablet) 1

MEKINIST 0.5 MG TABLET 4

QL 4 / day

PA

S

MEKINIST 2 MG TABLET 4

QL 1 / day

PA

S

melphalan 1

mepivacaine hcl/pf 1

methadone hcl 5 mg/0.5ml syringe 1QL 2 / day

PA

METHERGINE 1

methylene blue/gentian violet/foam bandage 1



methylergonovine maleate 0.2 mg tablet 1

methylergonovine maleate (.2mg/ml(1) ampul, .2mg/ml(1) vial) 1

middle ear inflation device 1

MUSTARGEN 4 S

MYLERAN 4 S

nebulizer 1

nebulizer accessories (each, kit) 1

NEXAVAR 4

QL 4 / day

PA

S

NILANDRON 4 S

nilutamide 4PA

S

NINLARO 4

QL 0.124 / day

PA


S

NOVAREL 5,000 UNIT VIAL 4PA

S

ODOMZO 4

QL 1 / day

PA

S

ONCASPAR 4 S

ORAFATE 4 S

oxytocin 10 unit/ml vial 1

pen needle, diabetic 2



POLOCAINE (1% VIAL, 2% VIAL, 3% CARTRIDGE) 1

POLOCAINE-MPF 1

PROTHELIAL 4 S

ropivacaine hcl in 0.9 % sodium chloride/pf (ropivacae chl/pf0.1% 400ml els pmp hr, ropivacae chl/pf 0.2% 550ml els pmphr)

1

ropivacaine hcl/pf (hcl/pf 2 mg/ml vial, hcl/pf 5 mg/ml vial,hcl/pf 7.5 mg/ml vial, hcl/pf 10 mg/ml vial) 1

RUBRACA (200 MG TABLET, 250 MG TABLET) 4

QL 2 / day

PA


S

RUBRACA 300 MG TABLET 4

QL 2 / day

PA


S

RYDAPT 4

QL 2 / day

PA


S

SENSORCAINE 1

SENSORCAINE WITH DEXTROSE 1

SENSORCAINE-MPF (0.25% AMPUL, 0.25% VIAL, 0.5% AMPUL,0.5% VIAL, 0.75% AMPUL, 0.75% VIAL) 1

silver (4" x 8" bandage, 4"x48" bandage, 8"x16" bandage,16"x16" bandage) 1

silver sulfadiazine/foam bandage (sulfadiaz/foam bandage 5%-2"x 2" bandage, sulfadiaz/foam bandage 5 %-4"x 4"bandage, sulfadiaz/foam bandage 5 %-6"x 6" bandage,sulfadiaz/foam bandage 5 %-8"x 8" bandage)

1

silver/foam bandage 1



sodium succinate 1

SPRYCEL (100 MG TABLET, 140 MG TABLET) 4

QL 1 / day

PA

S

SPRYCEL (70 MG TABLET, 80 MG TABLET) 4

QL 2 / day

PA

S

SPRYCEL 20 MG TABLET 4

QL 9 / day

PA

S

SPRYCEL 50 MG TABLET 4

QL 3 / day

PA

S

STIVARGA 4

QL 4 / day

PA

S

STRENSIQ 4

PA

AL Up to 18 yrs old

S

PS

SUCRAID 4 S

SUTENT (37.5 MG CAPSULE, 50 MG CAPSULE) 4

QL 1 / day

PA

S

PS

SUTENT 12.5 MG CAPSULE 4

QL 7 / day

PA

S

PS



SUTENT 25 MG CAPSULE 4

QL 3 / day

PA

S

PS

SWABFLUSH 1

SYNRIBO 4PA

S

SYPRINE 4PA

S

syringe with needle, insulin, safety, 0.3 ml 2


syringe with needle, insulin, safety, 1 ml 2

syringe with needle,disposable,insulin 1 ml (syringe disp syrin,syringe 28gx1/2" disp syrin, syringe 29 g x1/2" disp syrin,syringe 30g x5/16" disp syrin, syringe 30gx1/2" disp syrin)

2

syringe with needle,insulin,0.3 ml 2

syringe with needle,insulin,0.5 ml (ml 28 gauge disp syrin, ml29 g x1/2" disp syrin, ml 30g x5/16" disp syrin, ml 30gx1/2"disp syrin)

2

syringe, disposable irrigation, 70 ml 1

syringe, insulin u-500 with needle, disposable, 0.5 ml 2

TAFINLAR 50 MG CAPSULE 4

QL 6 / day

PA

S

TAFINLAR 75 MG CAPSULE 4

QL 4 / day

PA

S

TAGRISSO 4

QL 1 / day

PA


S

PS



tamoxifen citrate (10 mg tablet, 20 mg tablet) 0 HCR

TARCEVA (100 MG TABLET, 150 MG TABLET) 4

QL 1 / day

PA

S

TARCEVA 25 MG TABLET 4

QL 6 / day

PA

S

TARGRETIN 75 MG CAPSULE 4PA

S

TASIGNA 4

QL 4 / day

PA

S

PS

TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE,140 MG CAPSULE, 180 MG CAPSULE, 250 MG CAPSULE) 4

PA

S

temozolomide 4PA

S

tetracaine hcl/pf 10 mg/ml ampul 1

thiotepa 15 mg vial 4 S

tretinoin 10 mg capsule 4QL 90 / 365 days

S

TYKERB 4

QL 6 / day

PA

S

PS

VALSTAR 4 S

VAXCHORA BUFFER COMPONENT 2



VENCLEXTA 4

QL 4 / day

PA

S

VENCLEXTA STARTING PACK 4

QL 1.5 / day

PA

S

VOSEVI 4

QL 1 / day

PA


S

PS

VOTRIENT 4

QL 4 / day

PA

S

water for inj.,bacteriostatic 1

water for inj.,bacteriostatic/methylparaben/propylparaben 1

water for injection,sterile (ampul, vial) 1

XALKORI 4

QL 2 / day

PA

S

XELODA 4

QL 4 / day

PA

S

XTANDI 4

QL 4 / day

PA

S

yohimbine hcl 5.4 mg tablet 1

ZEJULA 4

QL 3 / day

PA


S



ZELBORAF 4

QL 8 / day

PA

S

ZOLINZA 4

QL 4 / day

PA

S

ZYDELIG 4

QL 2 / day

PA

S

ZYKADIA 4

QL 8 / day

PA


S

ZYTIGA 250 MG TABLET 4

QL 4 / day

PA

S

PS

ZYTIGA 500 MG TABLET 4

QL 2 / day

PA

S

PS

VASODILATING AGENTS

NITRATES AND NITRITES

ISOCHRON 1 QL 4 / day

isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30mg tablet) 1 QL 12 / day

isosorbide dinitrate 40 mg tablet er 1 QL 4 / day



isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30 mg taber 24h, 60 mg tab er 24h, 120 mg tab er 24h) 1 QL 2 / day

MINITRAN 1 QL 1 / day

NITRO-BID 2 QL 4 / day

NITRO-TIME 1 QL 4 / day

nitroglycerin (2.5 mg capsule er, 6.5 mg capsule er, 9 mgcapsule er) 1 QL 4 / day

nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24,0.4mg/hr patch td24, 0.6mg/hr patch td24) 1 QL 1 / day

nitroglycerin 400mcg/spr spray 3QL 0.8 / day

HCG

nitroglycerin (0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl) 1 QL 6 / day

PHOSPHODIESTERASE TYPE 5 INHIBITORS

CIALIS (10 MG TABLET, 20 MG TABLET) 2QL 0.2 / day

GL Male

CIALIS (2.5 MG TABLET, 5 MG TABLET) 2QL 1 / day

GL Male

VIAGRA 2

QL 0.2 / day

GL Male


VASODILATING AGENTS, MISCELLANEOUS

alprostadil 500 mcg/ml vial 1

isoxsuprine hcl (10 mg tablet, 20 mg tablet) 1

papaverine hcl 30 mg/ml vial 1

papaverine hcl/alprostadil in bacteriostatic water 1



VITAMINS

MULTIVITAMIN PREPARATIONS

ELDERCAPS 1

MATERNITY 1 GL Female

multivitamin-minerals no.44/cholecalciferol (vit d3)/vit k1 1

pedi multivit 65/cholecalciferol(vit d3)/phytonadione(vit k) 1

pediatric multivit no.22/cholecalciferol(d3)/phytonadione(k) 1

THERAPEUTIC VITAMIN W-MINERALS 1

V-C FORTE 1

VIC-FORTE 1

VITAMIN A

ped mvit a,c,d3 no.21/fluoride 0.25 mg/ml drops 1

VITAMIN B COMPLEX

B-12 KIT 1

cyanocobalamin (vitamin b-12) 1000mcg/ml vial 1

cyanocobalamin/folic acid/pyridoxine 1

FOLBEE 1

FOLBEE PLUS CZ 1

folic acid 1 mg tablet 1

folic acid 5 mg/ml vial 1

FOLPLEX 2.2 1

hydroxocobalamin 1000mcg/ml vial 1

pyridoxine hcl (vitamin b6) 100 mg/ml vial 1

RENA-VITE RX 1

thiamine hcl 100 mg/ml vial 1

thiamine hcl/riboflavin/niacinamide/dexpanthenol/pyridoxine 1

VIRT-CAPS SOFTGEL 1



VIRT-GARD 1

VIRT-VITE 1

VIRT-VITE PLUS 1

VP-VITE RX 1

ZOLATE 1

VITAMIN C

ascorbic acid 500 mg/ml vial 1

VITAMIN D

calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/mlsolution) 1

doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcgcapsule) 4 S

ergocalciferol (vitamin d2) 50000 unit capsule 1

HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 MCGCAPSULE) 4 S

paricalcitol (1 mcg capsule, 2 mcg capsule, 4mcg capsule) 4 S

RAYALDEE 4 S

ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 4PA

S


Index of Covered Drugs

00.9 % sodium chloride 93,155

AA-METHAPRED 105

abacavir sulfate 66

abacavir sulfate/lamivudine 66

abacavir sulfate/lamivudine/zidovudine 66

acamprosate calcium 84

acarbose 43

ACD 93

acebutolol hcl 27

acetaminophen with codeine phosphate 5

acetaminophen/caffeine/dihydrocodeine bitartrate 5

ACETASOL HC 21

acetazolamide 52

acetazolamide sodium 52

acetic acid 21

acetic acid/aluminum acetate 21

acetylcysteine 134

acetylcysteine in sterile water/pf 98

acitretin 148

ACTEMRA 128

ACTHIB 71

ACTIMMUNE 130

ACTOPLUS MET XR 44

ACUVAIL 25

acyclovir 22,76

ADACEL TDAP 71

adapalene 148,149

ADCIRCA 141

adefovir dipivoxil 76

ADEMPAS 141

ADVAIR DISKUS 3

ADVAIR HFA 3

AEROSPAN 87

AFEDITAB CR 83

AFINITOR 155

AFINITOR DISPERZ 155

AFLURIA 2016-2017 71

AFLURIA 2017-2018 155

AFLURIA QUAD 2016-2017 71

AFLURIA QUAD 2017-2018 155

AK-POLY-BAC 19

AKYNZEO 48

ALA-CORT 144

albuterol sulfate 3

alclometasone dipropionate 144

ALECENSA 155

alendronate sodium 127

alfentanil hcl 8

alfuzosin hcl 4

allopurinol 126

almotriptan malate 58

alosetron hcl 99

ALPHAGAN P 52

ALPHAQUIN HP 88

alprazolam 79

alprostadil 171

ALTACAINE 98

ALTAFLUOR 98

ALTAVERA 106

ALUNBRIG 155

ALYACEN 106

AMABELZ 95

amantadine hcl 60

amcinonide 144

AMETHIA 106

AMETHIA LO 106

AMETHYST 107

amikacin sulfate 30

amiloride hcl 89

amiloride hcl/hydrochlorothiazide 89

amiodarone hcl 28

AMITIZA 100

amitriptyline hcl 42

amitriptyline hcl/chlordiazepoxide 42

amlodipine besylate 83

amlodipine besylate/atorvastatin calcium 57

amlodipine besylate/benazepril hcl 83

amlodipine besylate/olmesartan medoxomil 83

amlodipine besylate/valsartan 83

amlodipine besylate/valsartan/hydrochlorothiazide 83

ammonium lactate 95

AMNESTEEM 149

amoxapine 43

amoxicillin 138

amoxicillin/potassium clavulanate 138,139

amphotericin b 50

ampicillin sodium 139

ampicillin sodium/sulbactam sodium 139

ampicillin trihydrate 139

AMPYRA 134

amyl nitrite 125

anagrelide hcl 69

anastrozole 156

ANDRODERM 106

ANDROGEL 106

ANORO ELLIPTA 3

antivenin,latrodectus mactans 70

antivenin,micrurus fulvius 70

ANUCORT-HC 144

ANUSOL-HC 144

APOKYN 92

apraclonidine hcl 98

aprepitant 49

APRI 107

APRISO 99

APTIVUS 68

ARANELLE 107

ARANESP 81

ARBINOXA 53

ARCALYST 135

aripiprazole 61

ARIXTRA 35

armodafinil 18

ARNUITY ELLIPTA 87

ASCOMP WITH CODEINE 8

ascorbic acid 173

ASHLYNA 107

aspirin/caffeine/dihydrocodeine bitartrate 69

aspirin/dipyridamole 69

ASTAGRAF XL 133

ASTRAMORPH-PF 8

atenolol 27,28

atenolol/chlorthalidone 28

ATIVAN 38

atomoxetine hcl 84

atorvastatin calcium 57

atovaquone 61

atovaquone/proguanil hcl 60

ATRIPLA 66

atropine sulfate 33,99

AUBAGIO 130

AUBRA 107

AUGMENTIN 139

AUSTEDO 84

AVANDAMET 44

AVANDIA 48

AVAR 22

AVAR-E 22

AVAR-E GREEN 22

AVIANE 107

AVIDOXY 31

AVITA 147

AVONEX 130

AVONEX PEN 131

azacitidine 156

azathioprine 128

azathioprine sodium 128

azelastine hcl 97

azithromycin 125

AZOPT 52

aztreonam 125

AZUPHEN MB 18

AZURETTE 107

BB-12 KIT 172

B-DONNA 33

B-PLEX PLUS 156

BACIIM 32

bacitracin 19,32

bacitracin/polymyxin b sulfate 19

baclofen 144

bacteriostatic sodium chloride 93

BACTROBAN NASAL 19

balanced salt irrig soln no.2 98

balsalazide disodium 99

BALZIVA 107

BARACLUDE 76

BEKYREE 107

benazepril hcl 140

benazepril hcl/hydrochlorothiazide 90

BENLYSTA 156

benoxinate hcl/fluorescein sodium 98

BENZEPRO 147

benzonatate 141

benzoyl peroxide 147

benzphetamine hcl 15

benztropine mesylate 35

betamethasone acetate/betamethasone sodium

phosphate 105

betamethasone dipropionate 144

betamethasone dipropionate/propylene glycol 144

betamethasone valerate 144

BETASERON 131

betaxolol hcl 28,52

bethanechol chloride 80

BETHKIS 30

bexarotene 156

BEXSERO 71

bicalutamide 156

bimatoprost 53

BIOGLO 88

BIOTHRAX 71

bismuth tribromophenate/petrolatum,white 156

bisoprolol fumarate 28

bisoprolol fumarate/hydrochlorothiazide 28

BLANCHE 88

BLEO 15K 156

bleomycin sulfate 156

BLISOVI 24 FE 107

BLISOVI FE 107

BOOSTRIX TDAP 71

BOSULIF 156

BOTOX COSMETIC 135

BP 10-1 22

BP-50% UREA 148

BPO 148

BRAVELLE 119

BREO ELLIPTA 3

BRIELLYN 107

BRILINTA 69

brimonidine tartrate 52

BROMFED DM 54

bromfenac sodium 25

bromocriptine mesylate 92

brompheniramine maleate/pseudoephedrine

hcl/dextromethorphan 54

BSS 98

budesonide 24,87,105

bumetanide 89

BUPHENYL 93

bupivacaine hcl/dextrose-water/pf 156

bupivacaine hcl/epinephrine 153

bupivacaine hcl/epinephrine bitartrate 153

bupivacaine hcl/epinephrine/pf 153

bupivacaine hcl/pf 156

buprenorphine hcl 13

buprenorphine hcl/naloxone hcl 14

BUPROBAN 39

bupropion hcl 39

buspirone hcl 78

butalbital/acetaminophen/caffeine 5

butalbital/acetaminophen/caffeine/codeine phosphate 5

butalbital/aspirin/caffeine 69,156

butorphanol tartrate 14

BYDUREON 46

BYDUREON PEN 46

BYETTA 46

BYSTOLIC 81

BYVALSON 81

Ccabergoline 92

CABOMETYX 156,157

caffeine citrate 17

caffeine/sodium benzoate 17

calcipotriene 149

calcipotriene/betamethasone dipropionate 144

calcitonin,salmon,synthetic 121

CALCITRENE 149

calcitriol 149,173

calcium acetate 124

CAMILA 108

CAMRESE 108

CAMRESE LO 108

CANASA 99

candesartan cilexetil 139

candesartan cilexetil/hydrochlorothiazide 90

CAPACET 5

capecitabine 157

CAPRELSA 157

captopril 140

captopril/hydrochlorothiazide 90

CARAC 149

CARAFATE 74

CARBAGLU 93

carbamazepine 36

CARBATROL 36

carbidopa 84

carbidopa/levodopa 60

carbidopa/levodopa/entacapone 60

carbinoxamine maleate 53

cardioplegic solution no.1 93

carisoprodol 143

carisoprodol/aspirin 138

carisoprodol/aspirin/codeine phosphate 8

carteolol hcl 52

CARTIA XT 29

carvedilol 4

catheter 157

CATHFLO ACTIVASE 69

CAYSTON 125

CAZIANT 108

cefaclor 86

cefadroxil 85

cefazolin sodium 86

cefdinir 86

cefditoren pivoxil 86

cefepime hcl 86

cefixime 86

cefotaxime sodium 86

cefotetan disodium 86

cefpodoxime proxetil 86

cefprozil 86

ceftazidime 86

ceftibuten 86

CEFTIN 86

ceftriaxone sodium 86

cefuroxime axetil 86

cefuroxime sodium 86

celecoxib 136

CELLCEPT 133

CENTERGY 54

CENTERGY DM 54

cephalexin 86

CERAMAX 157

CERDELGA 135

CERVARIX 71

cervical cap 157

CESAMET 49

cetirizine hcl 54

CETROTIDE 130

cevimeline hcl 80

CHANTIX 80

CHATEAL 108

CHENODAL 101

chlordiazepoxide hcl 79

chlordiazepoxide/clidinium bromide 33

chlorhexidine gluconate 21

chloroprocaine hcl/pf 157

chloroquine phosphate 60

chlorothiazide 89

chlorpromazine hcl 64

chlorpropamide 47

chlorthalidone 90

chlorzoxazone 143,157

CHOLBAM 101

cholestyramine (with sugar) 56

cholestyramine/aspartame 56

choline salicylate/magnesium salicylate 138

chorionic gonadotropin, human 119

CIALIS 171

CICLODAN 51

ciclopirox 51

ciclopirox olamine 51

CIDALEAZE 147

cilostazol 69

cimetidine 74

cimetidine hcl 74

CIMZIA 101

CIPRODEX 19

ciprofloxacin 31

ciprofloxacin hcl 19,31

ciprofloxacin/ciprofloxacin hcl 31

citalopram hydrobromide 40

citric acid/sodium citrate 92

CLARAVIS 149

clarithromycin 59

CLEANSING WASH 22

clemastine fumarate 53

CLEOCIN 21

CLIMARA PRO 95

CLINDACIN ETZ 21

CLINDACIN P 21

clindamycin hcl 33

clindamycin palmitate hcl 33

clindamycin phosphate 21,33

clindamycin phosphate/benzoyl peroxide 21

clindamycin phosphate/tretinoin 21

CLINPRO 5000 127

clobetasol propionate 144

clobetasol propionate/emollient base 145

clocortolone pivalate 145

CLODAN 145

clomiphene citrate 95

clomipramine hcl 43

clonazepam 38

clonidine 123,124

clonidine hcl 124

clopidogrel bisulfate 69

clorazepate dipotassium 38

clotrimazole 51

clotrimazole/betamethasone dipropionate 51

clozapine 61

coal tar 148

cocaine hcl 98

codeine phosphate/butalbital/aspirin/caffeine 8

codeine sulfate 8

colchicine 126

COLCRYS 126

colestipol hcl 56

colistin (as colistimethate sodium) 33

COLOCORT 145

COMBIGAN 52

COMBIVENT RESPIMAT 3

COMBIVIR 66

COMETRIQ 157

COMPAZINE 49

COMPLERA 66

COMPOUND 347 103

compressor, for nebulizer 157

COMPRO 49

conception assistance supplies combination no.1 157

CONSTULOSE 93

COPAXONE 131

COPEGUS 76

CORDARONE 28

CORLANOR 84

CORMAX 145

cortisone acetate 105

COSENTYX (2 SYRINGES) 149

COSENTYX PEN 149

COSENTYX PEN (2 PENS) 149

COSENTYX SYRINGE 149

cosyntropin 88

COTELLIC 158

COUMADIN 35

COVARYX 95

COVARYX H.S. 95

CREON 101

CRIXIVAN 68

cromolyn sodium 25

CRYSELLE 108

CUVITRU 70

cyanocobalamin (vitamin b-12) 172

cyanocobalamin/folic acid/pyridoxine 172

CYCLAFEM 108

cyclobenzaprine hcl 143

cyclopentolate hcl 99

cyclopentolate hcl/lidocaine

hcl/phenylephrine/tropicamide 98

cyclopentolate hcl/tropicamide/phenylephrine hcl in

water 99

cyclophosphamide 133

cycloserine 59

cyclosporine 128

cyclosporine, modified 128

cyproheptadine hcl 53

CYRED 108

CYSTADANE 135

CYSTAGON 135

CYSTARAN 98

cytarabine 158

cytarabine/pf 158

CYTRA-2 92

CYTRA-K 92

DDAKLINZA 104

danazol 106

dantrolene sodium 144

dapsone 59,149

DAPTACEL DTAP 71

darifenacin hydrobromide 103

DASETTA 108

DAYSEE 108

DEBLITANE 108

deferoxamine mesylate 125

DELTASONE 105

DELYLA 108

demeclocycline hcl 31

DENTA 5000 PLUS 127

DENTAGEL 127

DEPADE 85

DEPAKOTE ER 36

DEPAKOTE SPRINKLE 36

DEPEN 128

DEPO-SUBQ PROVERA 104 123

DERMAZENE 22

DESCOVY 66

desipramine hcl 43

desloratadine 54

desmopressin acetate 53

desmopressin acetate (non-refrigerated) 121

desogestrel-ethinyl estradiol 109

desogestrel-ethinyl estradiol/ethinyl estradiol 109

desonide 145

desoximetasone 145

desvenlafaxine 40

desvenlafaxine fumarate 40

desvenlafaxine succinate 40

dexamethasone 105

DEXAMETHASONE INTENSOL 105

dexamethasone sod phosphate 24

dexchlorpheniramine maleate 158

DEXEDRINE 15

dexmethylphenidate hcl 17

dextroamphetamine sulf-saccharate/amphetamine sulf-

aspartate 16

dextroamphetamine sulfate 16

diaphragms, wide seal 158

diazepam 38

diclofenac potassium 136

diclofenac sodium 25,136,149

diclofenac sodium/misoprostol 74

dicloxacillin sodium 139

dicyclomine hcl 33

didanosine 66

diethylpropion hcl 14

diflorasone diacetate 145

diflunisal 136

DIGITEK 26

DIGOX 26

digoxin 26

dihydroergotamine mesylate 4

DILANTIN 27

DILANTIN-125 27

DILT-XR 29

diltiazem hcl 29

dimenhydrinate 49

diphenhydramine hcl 54

diphenoxylate hcl/atropine sulfate 33

dipyridamole 69

disopyramide phosphate 27

disulfiram 125

divalproex sodium 37

DIVIGEL 95

dofetilide 28

donepezil hcl 80

dorzolamide hcl 52

dorzolamide hcl/timolol maleate 52

doxazosin mesylate 4

doxepin hcl 43,147

doxercalciferol 173

doxycycline hyclate 19,32

doxycycline monohydrate 32

dronabinol 49

droperidol 78

drospirenone/ethinyl estradiol/levomefolate calcium 109

DUAVEE 95

duloxetine hcl 40

DUOPA 60

DUPIXENT 150

DURAMORPH 8

dutasteride 125

dutasteride/tamsulosin hcl 5

DYMISTA 55

Eeconazole nitrate 51

ED-SPAZ 33

edetate calcium disodium 126

EDURANT 66

EEMT 96

EEMT H.S. 96

EFFER-K 94

EGRIFTA 153

ELDERCAPS 172

eletriptan hbr 58

ELIDEL 133

ELIGARD 119

ELINEST 109

ELLA 109

EMBEDA 8

EMCYT 158

EMFLAZA 105

EMOQUETTE 109

EMTRIVA 66

enalapril maleate 140

enalapril maleate/hydrochlorothiazide 90

ENBREL 128

ENDOCET 5

ENDOMETRIN 123

ENGERIX-B ADULT 71

ENGERIX-B PEDIATRIC-ADOLESCENT 71

ENJUVIA 96

enoxaparin sodium 36

ENPRESSE 109

ENSKYCE 109

entacapone 60

entecavir 76

ENULOSE 93

ENVARSUS XR 133

EPCLUSA 104

epinastine hcl 98

epinephrine 3

epinephrine hcl/pf 3

epinephrine/pf 3

EPITOL 37

EPIVIR 67

EPIVIR HBV 67

eplerenone 90

EPOGEN 81

eprosartan mesylate 139

EPZICOM 67

ergocalciferol (vitamin d2) 173

ergoloid mesylates 4

ergotamine tartrate/caffeine 4

ERIVEDGE 158

ERRIN 109

ERWINAZE 158

ERY 22

ERYPED 200 30

erythromycin base 19,30

erythromycin base/benzoyl peroxide 22

erythromycin base/ethyl alcohol 22

erythromycin ethylsuccinate 31

ESBRIET 141

escitalopram oxalate 40,41

ESGIC 6

esomeprazole magnesium 74

esomeprazole strontium 74

ESTARYLLA 109

estazolam 79

ESTRACE 96

estradiol 96

estradiol valerate 96

estradiol/norethindrone acetate 96

ESTRING 96

estrogens,esterified/methyltestosterone 96

estropipate 96

eszopiclone 78

ethacrynic acid 89

ethambutol hcl 59

ethinyl estradiol/drospirenone 109

ethosuximide 39

ethyl acetate 158

ethyl alcohol 135

ethyl chloride 147

ethynodiol diacetate-ethinyl estradiol 109

etidronate disodium 127

etodolac 137

EUCRISA 145

EVOTAZ 68

exemestane 158

EXJADE 158

EXODERM 51

EXTAVIA 131

EZ FLU 16-17 (FLUZON QUAD PED) 71

EZ FLU 2016-2017 (AFLURIA) 71

EZ FLU 2016-2017 (FLUVIRIN) 71

ezetimibe 56

ezetimibe/simvastatin 56

FFALMINA 109

famciclovir 76

famotidine 74

FARESTON 158

FARYDAK 158

FAYOSIM 110

felbamate 37

felodipine 82

FEMYNOR 110

fenofibrate 56

fenofibrate nanocrystallized 56

fenofibrate,micronized 56,57

fenofibric acid 57

fenofibric acid (choline) 57

fenoprofen calcium 137

fentanyl 8

fentanyl citrate 8

fentanyl citrate in 0.9 % sodium chloride/pf 8

fentanyl citrate/bupivacaine hcl in 0.9 % sodium

chloride/pf 9

fentanyl citrate/pf 9

fentanyl citrate/ropivacaine hcl/sodium chloride 0.9%/pf 9

FEROCON 26

FEROTRINSIC 26

FERRIPROX 158

FERROCITE PLUS 26

fexofenadine hcl 54

fexofenadine hcl/pseudoephedrine hcl 158

finasteride 125,150

FIRAZYR 128

FIRMAGON 130

flavoxate hcl 103

flecainide acetate 27

FLOVENT DISKUS 87

FLOVENT HFA 87

floxuridine 158

FLUAD 2016-2017 71

FLUAD 2017-2018 159

FLUARIX QUAD 2016-2017 71

FLUARIX QUAD 2017-2018 159

FLUBLOK 2016-2017 72

FLUBLOK 2017-2018 159

FLUBLOK QUAD 2017-2018 159

FLUCAINE 88

FLUCELVAX QUAD 2016-2017 72

FLUCELVAX QUAD 2017-2018 159

fluconazole 50

flucytosine 51

fludrocortisone acetate 105

FLULAVAL QUAD 2016-2017 72

FLULAVAL QUAD 2017-2018 159

flunisolide 24

fluocinolone acetonide 145

fluocinolone acetonide oil 24

fluocinolone acetonide/shower cap 145

fluocinonide 145

fluocinonide/emollient base 145

FLUOR-A-DAY 127

FLUOR-I-STRIP AT 88

fluoride (sodium) 127

FLUORIDEX 127

FLUORIDEX DAILY DEFENSE 127

FLUORIDEX SENSITIVITY RELIEF 127

FLUORITAB 127

fluorometholone 24

FLUOROPLEX 150

fluorouracil 150

fluoxetine hcl 41

fluphenazine decanoate 64

fluphenazine hcl 64,65

FLURA-DROPS 128

flurazepam hcl 79

flurbiprofen 137

flurbiprofen sodium 25

FLUROX 98

flutamide 159

fluticasone propionate 24,145

fluticasone propionate/salmeterol xinafoate 3

fluvastatin sodium 57

FLUVIRIN 2016-2017 72

FLUVIRIN 2017-2018 159

fluvoxamine maleate 41

FLUZONE HIGH-DOSE 2016-2017 72

FLUZONE HIGH-DOSE 2017-2018 159

FLUZONE INTRADERM QUAD 2016-17 72

FLUZONE INTRADERM QUAD 2017-18 159

FLUZONE QUAD 2016-2017 72

FLUZONE QUAD 2017-2018 159

FLUZONE QUAD PEDI 2016-2017 72

FLUZONE QUAD PEDI 2017-2018 159

foam bandage 159

FOLBEE 172

FOLBEE PLUS CZ 172

folic acid 172

FOLLISTIM AQ 119

FOLPLEX 2.2 172

fondaparinux sodium 35

FORMADON 150

formaldehyde 150

FORTEO 121

fosamprenavir calcium 68

fosinopril sodium 140

fosinopril sodium/hydrochlorothiazide 90

FOSRENOL 124

FRAGMIN 36

frovatriptan succinate 59

FUL-GLO 88

FULYZAQ 100

furosemide 89

FUZEON 65

FYAVOLV 97

Ggabapentin 6

GABITRIL 37

galantamine hbr 80

GAMMAGARD LIQUID 70

GAMMAKED 70

GAMUNEX-C 70

ganirelix acetate 130

GARDASIL 72

GARDASIL 9 72

gatifloxacin 19

GATTEX 101

GAVILYTE-C 100

GAVILYTE-G 100

GAVILYTE-N 100

gel dressing 159

gemfibrozil 57

GENERLAC 93

GENGRAF 129

GENOTROPIN 122

GENTAK 19

gentamicin sulfate 19,20,22,30

gentamicin sulfate/pf 30

GENVOYA 65

GIANVI 110

GILDAGIA 110

GILDESS 110

GILDESS 24 FE 110

GILDESS FE 110

GILENYA 131

GILOTRIF 159

GLATOPA 131

GLEEVEC 159

glimepiride 47

glipizide 47

glipizide/metformin hcl 44

GLUCAGEN 55

GLUCAGON EMERGENCY KIT 55

glucagon hcl 55

glutaraldehyde 160

glyburide 47

glyburide,micronized 48

glyburide/metformin hcl 44

glycopyrrolate 34,160

GLYDO 98

GOLYTELY 100

GONAL-F 119

GONAL-F RFF 120

GONAL-F RFF REDI-JECT 120

granisetron hcl 48

GRANIX 81

griseofulvin ultramicrosize 50

griseofulvin, microsize 50

guaiacol 23

guanfacine hcl 84

guanidine hcl 80

HH.P. ACTHAR 88

halobetasol propionate 145

haloperidol 64

haloperidol decanoate 64

haloperidol lactate 64

HARVONI 104

HAVRIX 72

HEATHER 110

HECTOROL 173

HEMANGEOL 28

HEMATINIC PLUS 26

HEMATINIC WITH FOLIC ACID 26

HEMAX 26

HEMMOREX-HC 145

HEMOCYTE-F 26

heparin sodium,porcine 36

heparin sodium,porcine/pf 36

HEPSERA 76

HETLIOZ 78

HEXALEN 160

HIBERIX 72

HIZENTRA 70

HOMATROPAIRE 99

homatropine hbr 99

HUMALOG 46

HUMALOG JUNIOR KWIKPEN 160



HUMALOG MIX 50-50 47


HUMALOG MIX 75-25 47


HUMATROPE 122

HUMIRA 101

HUMIRA PEDIATRIC CROHN'S 102

HUMIRA PEN 102

HUMIRA PEN CROHN-UC-HS STARTER 102

HUMIRA PEN PSORIASIS-UVEITIS 102

HUMULIN R U-500 47

HUMULIN R U-500 KWIKPEN 47

HYCAMTIN 160

hydralazine hcl 124

hydrochlorothiazide 89

hydrocodone bitart/chlorpheniramine

maleate/pseudoephedrine 9

hydrocodone bitartrate/acetaminophen 6

hydrocodone bitartrate/homatropine methylbromide 34

hydrocodone polistirex/chlorpheniramine polistirex 54

hydrocodone/ibuprofen 9

hydrocolloid dressing 160

hydrocortisone 105,145

hydrocortisone acetate 145

hydrocortisone acetate/iodoquinol/aloe vera 23

hydrocortisone acetate/lidocaine hcl/aloe vera 145

hydrocortisone acetate/pramoxine hcl 146

hydrocortisone butyrate 146

hydrocortisone butyrate/emollient base 146

hydrocortisone valerate 146

hydrocortisone/acetic acid 21

hydrocortisone/iodoquinol 23

hydrocortisone/mineral oil/petrolatum,white 146

HYDROMET 34

hydromorphone hcl 9,10

hydromorphone hcl/pf 10

hydroquinone 88

hydroquinone microspheres 88

hydroxocobalamin 172

hydroxychloroquine sulfate 60

hydroxyprogesterone caproate 123

hydroxyurea 160

hydroxyzine hcl 78

hydroxyzine pamoate 78

HYOPHEN 18

hyoscyamine sulfate 34

HYOSYNE 34

HYPERHEP B S-D 70

HYPERRAB S-D 70

HYPERTET S-D 70

HYQVIA 70

HYQVIA HY COMPONENT 160

HYQVIA IG COMPONENT 70

Iibandronate sodium 127

IBRANCE 160

IBUDONE 10

ibuprofen 137

ibuprofen/oxycodone hcl 10

ICLUSIG 160

ILARIS 135

ILOTYCIN 20

IMBRUVICA 160

imipramine hcl 43

imipramine pamoate 43

imiquimod 150

IMOGAM RABIES-HT 70

IMOVAX RABIES VACCINE 72

IMPAVIDO 61

INCRELEX 153

INCRUSE ELLIPTA 34

indapamide 90

INDIGO CARMINE 88

indigotindisulfonate sodium in water for injection,sterile 88

INDIOMIN MB 18

indocyanine green 88

indomethacin 126

INFANRIX DTAP 71

INFED 26

INGREZZA 84,161

inhaler, assist devices 161

inhaler, assist devices, accessories 161

INLYTA 161

INTELENCE 66

INTRON A 75

INTROVALE 110

INVIRASE 68

INVOKAMET 44

INVOKAMET XR 44

INVOKANA 47

IPOL 72,161

ipratropium bromide 34,98

ipratropium bromide/albuterol sulfate 3

IPRIVASK 36

irbesartan 140

irbesartan/hydrochlorothiazide 91

IRESSA 161

ISENTRESS 65

ISENTRESS HD 65

ISIBLOOM 110

ISOCHRON 170

isoflurane 103

isometheptene mucate/caffeine/acetaminophen 6

isometheptene

mucate/dichloralphenazone/acetaminophen 6

isoniazid 59

isoproterenol hcl 161

isosorbide dinitrate 170

isosorbide mononitrate 171

isoxsuprine hcl 171

isradipine 82

itraconazole 50

ivermectin 18

IXIARO 72

JJADENU 161

JADENU SPRINKLE 161

JAKAFI 161

JANTOVEN 35

JANUMET 44

JANUMET XR 44,45

JANUVIA 46

JARDIANCE 47

JENCYCLA 110

JENTADUETO 45

JENTADUETO XR 45

JINTELI 97

JOLESSA 110

JOLIVETTE 111

JULEBER 111

JUNEL 111

JUNEL FE 111

JUNEL FE 24 111

JUXTAPID 55

KK EFFERVESCENT 94

K-SOL 94

KAITLIB FE 111

KALETRA 68

KALYDECO 87

KARIVA 111

KELNOR 1-35 111

ketamine hcl 103

ketoconazole 50,51

ketoprofen 137

ketorolac tromethamine 25,137

KEVEYIS 135

KEVZARA 129

KIMIDESS 111

KINRIX 72

KIONEX 124

KISQALI 161,162

KISQALI FEMARA CO-PACK 162

KITABIS PAK 30

KLOFENSAID II 137

KLOR-CON 94

KLOR-CON 10 94

KLOR-CON 8 94

KLOR-CON M10 94

KLOR-CON M15 94

KLOR-CON M20 94

KLOR-CON SPRINKLE 94

KLOR-CON-EF 94

KORLYM 44

KRISTALOSE 93

KURVELO 111

KUVAN 135

KYNAMRO 55

Llabetalol hcl 5

lactic acid 95

lactulose 93

lamivudine 67

lamivudine/zidovudine 67

lamotrigine 37

lancing device/lancets 162

LANOXIN 26

LANOXIN PEDIATRIC 26

lansoprazole 74

lansoprazole/amoxicillin trihydrate/clarithromycin 74

lanthanum carbonate 124

LANTUS 47

LANTUS SOLOSTAR 47

LARIN 111

LARIN 24 FE 111

LARIN FE 111

LARISSIA 112

latanoprost 53

LATRIX 148

LAYOLIS FE 112

LEENA 112

leflunomide 129

LENVIMA 162

LESSINA 112

LETAIRIS 142

letrozole 162

leucovorin calcium 126

LEUKINE 81

leuprolide acetate 120

levalbuterol hcl 3

levetiracetam 37

LEVO-T 154

levobunolol hcl 52

levocarnitine 135

levocarnitine (with sugar) 135

levocetirizine dihydrochloride 54

levofloxacin 20,31

LEVONEST 112

levonorgestrel 112

levonorgestrel-ethinyl estradiol 112

levonorgestrel/ethinyl estradiol and ethinyl

estradiol 112,113

LEVORA-28 113

levorphanol tartrate 10

levothyroxine sodium 154

LEVOXYL 154

LEXIVA 68

LIALDA 99

lidocaine 147

lidocaine hcl 27,98,147,162

lidocaine hcl/epinephrine 154

lidocaine hcl/epinephrine bitartrate 154

lidocaine hcl/hydrocortisone acetate 146

lidocaine hcl/pf 27,162

lidocaine/prilocaine 147

lidocaine/tetracaine 147

LIDOPIN 147

LIDOPRIL 147

LIDORX 147

LILLOW 113

lincomycin hcl 33

lindane 24

linezolid 33

LINZESS 102

liothyronine sodium 155

lisinopril 140

lisinopril/hydrochlorothiazide 91

lithium carbonate 84

lithium citrate 84

LO LOESTRIN FE 113

LOESTRIN FE 113

LOMAIRA 14

LOMEDIA 24 FE 113

lomustine 162

LONSURF 162,163

loperamide hcl 100

lopinavir/ritonavir 68

LOPREEZA 97

lorazepam 39

LORAZEPAM INTENSOL 39

LORCET 6

LORCET HD 6

LORCET PLUS 6

LORTAB 7

LORYNA 113

LORZONE 143

losartan potassium 140

losartan potassium/hydrochlorothiazide 91

lovastatin 57

LOVENOX 36

LOW-OGESTREL 113

loxapine succinate 61

LP LITE PAK 147

LUCENTIS 98

LUDENT FLUORIDE 128

LUGOL'S 23,50

LUMIGAN 53

LUPANETA PACK 120

LUPRON DEPOT 120

LUPRON DEPOT (LUPANETA) 120

LUPRON DEPOT-PED 120

LUTERA 113

LUXAMEND 95

LYNPARZA 163

LYSIPLEX PLUS 93

LYSODREN 163

LYZA 113

MM-M-R II VACCINE 72

magnesium chloride 37

magnesium sulfate 26

MAKENA 123

malathion 24

mannitol/sorbitol solution 89

maprotiline hcl 43

MARGESIC 7

MARLISSA 113

MARTEN-TAB 7

MATERNITY 172

MATULANE 163

MATZIM LA 29

MAVYRET 163

MD-GASTROVIEW 89

meclizine hcl 49

meclofenamate sodium 137

MEDROL 105

medroxyprogesterone acetate 123

mefenamic acid 137

mefloquine hcl 60

megestrol acetate 163

MEKINIST 163

MELODETTA 24 FE 114

meloxicam 137,138

MELPAQUE HP 88

melphalan 163

memantine hcl 85

MENACTRA 72

MENEST 97

MENHIBRIX 72

MENOMUNE-A-C-Y-W-135 72

MENOPUR 120

MENVEO A-C-Y-W-135-DIP 72

MENVEO MENA COMPONENT 72

MENVEO MENCYW-135 COMPONENT 72

meperidine hcl 10

meperidine hcl/pf 10,11

MEPHYTON 126

mepivacaine hcl/pf 163

meprobamate 78

mercaptopurine 134

mesalamine 99

mesalamine with cleansing wipes 99

MESNEX 136

MESTINON 80

METADATE ER 17

metaproterenol sulfate 3

METAXALL 143

metaxalone 143

metformin hcl 45

methadone hcl 11,163

METHADONE INTENSOL 11

methamphetamine hcl 16

methazolamide 52

methenamine hippurate 18

methenamine mandelate 18

methenamine/sod phosph,monobasic/methylene

blue/hyoscyamine 18

METHERGINE 163

methimazole 154

methocarbamol 143

methotrexate sodium 129

methotrexate sodium/pf 129

methoxsalen 88

methscopolamine bromide 34

methyclothiazide 89

methyldopa 124

methyldopa/hydrochlorothiazide 91

methylene blue/gentian violet/foam bandage 163

methylergonovine maleate 164

methylphenidate hcl 17,18

methylprednisolone 105

methylprednisolone acetate 105

methylprednisolone sodium succinate 105

methyltestosterone 106

metipranolol 52

metoclopramide hcl 102,103

metolazone 90

metoprolol succinate 28

metoprolol tartrate 28

metoprolol tartrate/hydrochlorothiazide 28

metronidazole 22,60

mexiletine hcl 27

MIACALCIN 121

MIBELAS 24 FE 114

MICROGESTIN 114

MICROGESTIN 24 FE 114

MICROGESTIN FE 114

midazolam hcl 79

midazolam hcl/pf 79

middle ear inflation device 164

midodrine hcl 154

miglitol 43

MIMVEY 97

MIMVEY LO 97

MINITRAN 171

minocycline hcl 32

minoxidil 124

MIRCERA 81

mirtazapine 39

MIRVASO 150

misoprostol 74

modafinil 18

MODERIBA 76

moexipril hcl 140

moexipril hcl/hydrochlorothiazide 91

molindone hcl 61

mometasone furoate 24,146

MONDOXYNE NL 32

MONO-LINYAH 114

MONOJECT 0.9% SODIUM CHLORIDE 94

MONOJECT PREFILL 94

MONOJECT PREFILL ADVANCED 94

MONONESSA 114

montelukast sodium 25

MORGIDOX 32

morphine sulfate 11,12

morphine sulfate/pf 12

MOVIPREP 100

MOXEZA 20

moxifloxacin hcl 20,31

MOZOBIL 81

multivitamin-minerals no.44/cholecalciferol (vit d3)/vit

k1 172

mupirocin 22

mupirocin calcium 22

MUSTARGEN 164

MYALEPT 121

mycophenolate mofetil 134

mycophenolate sodium 134

MYFORTIC 134

MYLERAN 164

MYORISAN 150

MYRBETRIQ 80

MYTESI 100

MYZILRA 114

NNABI-HB 70

nabumetone 138

nadolol 28

nadolol/bendroflumethiazide 28

nafcillin sodium 139

naftifine hcl 51

nalbuphine hcl 14

naloxone hcl 85

naltrexone hcl 85

naphazoline hcl 99

naproxen 126

naproxen sodium 126

naratriptan hcl 59

NATAZIA 114

nateglinide 47

NATPARA 121

nebulizer 164

nebulizer accessories 164

NEBUSAL 94

NECON 114

nefazodone hcl 42

NEO-POLYCIN 20

NEO-POLYCIN HC 20

neomycin sulfate 30

neomycin sulfate/bacitracin zinc/polymyxin

b/hydrocortisone 20

neomycin sulfate/bacitracin/polymyxin b 20

neomycin sulfate/polymyxin b sulfate/gramicidin d 20

neomycin sulfate/polymyxin b sulfate/hydrocortisone 20

neomycin/polymyxin b sulfate/dexamethasone 20

NEORAL 129

NEUAC 22

NEULASTA 81

NEUPOGEN 82

nevirapine 66

NEXAVAR 164

niacin 55

nicardipine hcl 83

NIFEDICAL XL 83

nifedipine 83

NIKKI 114

NILANDRON 164

nilutamide 164

nimodipine 83

NINLARO 164

nisoldipine 82

NITRO-BID 171

NITRO-TIME 171

nitrofurantoin 18

nitrofurantoin macrocrystal 18

nitrofurantoin monohydrate/macrocrystals 18

nitroglycerin 171

nizatidine 74

NODOLOR 7

NORA-BE 114

NORCO 7

NORDITROPIN FLEXPRO 122

norethindrone 115

norethindrone acetate 123

norethindrone acetate-ethinyl estradiol 97,115

norethindrone acetate-ethinyl estradiol/ferrous

fumarate 115

norethindrone-ethinyl estradiol/ferrous fumarate 115

norgestimate-ethinyl estradiol 115

NORINYL 1+50 115

NORLYDA 115

NORLYROC 115

NORPACE CR 27

NORTHERA 154

NORTREL 115

nortriptyline hcl 43

NORVIR 68

NOVAREL 120,164

NP THYROID 155

NUEDEXTA 85

NULEV 34

NUPLAZID 61

NUTROPIN AQ 122

NUTROPIN AQ NUSPIN 122

NUVARING 115

NYAMYC 51

NYATA 51

nystatin 50,52

nystatin/triamcinolone acetonide 52

NYSTOP 52

OOBSTETRIX ONE 26

OCALIVA 102

OCELLA 115

octreotide acetate 152

OCUCOAT 98

ODEFSEY 66

ODOMZO 164

OFEV 141

ofloxacin 20,31

OGESTREL 115

olanzapine 62

olanzapine/fluoxetine hcl 41

olmesartan medoxomil 140

olmesartan medoxomil/amlodipine

besylate/hydrochlorothiazide 91

olmesartan medoxomil/hydrochlorothiazide 91

olopatadine hcl 98

OLYSIO 104

omega-3 acid ethyl esters 55

omeprazole 75

omeprazole/sodium bicarbonate 75

OMNITROPE 122

ONCASPAR 164

ondansetron 48

ondansetron hcl 48,49

ondansetron hcl/pf 49

ONFI 39

opium tincture 100

opium/belladonna alkaloids 12

OPSUMIT 142

ORAFATE 164

ORALAIR 135

ORALONE 146

ORENCIA 129

ORENCIA CLICKJECT 129

ORENITRAM ER 142

ORFADIN 135

ORKAMBI 87

orphenadrine citrate 144

ORSYTHIA 115

OSCIMIN 34

OSCIMIN SL 34

OSCIMIN SR 34

oseltamivir phosphate 76

OTEZLA 129

OVIDREL 121

oxacillin sodium 139

oxandrolone 106

oxaprozin 138

oxazepam 79

oxcarbazepine 37

oxiconazole nitrate 51

oxybutynin chloride 103

oxycodone hcl 12

oxycodone hcl/acetaminophen 7

oxycodone hcl/aspirin 13

oxymorphone hcl 13

oxytocin 164

PPACERONE 28

PACNEX 148

paliperidone 62

pantoprazole sodium 75

papaverine hcl 171

papaverine hcl/alprostadil in bacteriostatic water 171

paregoric 100

paricalcitol 173

PAROEX 21

paromomycin sulfate 30

paroxetine hcl 41,42

paroxetine mesylate 42

pedi multivit 65/cholecalciferol(vit d3)/phytonadione(vit

k) 172

PEDIARIX 71

pediatric multivit

no.22/cholecalciferol(d3)/phytonadione(k) 172

pediatric multivit with a,c,d3 no.21/sodium fluoride 172

pediatric multivitamin no.150 with sodium fluoride 128

pediatric multivitamin no.2/sodium fluoride 128

pediatric multivitamin no.45/sodium fluoride/ferrous

sulfate 26

PEDVAXHIB 73

peg 3350/sod sulf/sod bicarb/sod chloride/potassium

chloride 100

PEG-PREP 100

PEGASYS 75

PEGASYS PROCLICK 75

PEGINTRON 75

PEGINTRON REDIPEN 75

pen needle, diabetic 164

penicillin g potassium 139

penicillin g procaine 139

penicillin g sodium 139

penicillin v potassium 139

PENTACEL 73

PENTACEL DTAP-IPV COMPONENT 73

pentazocine hcl/naloxone hcl 14

pentobarbital sodium 79

pentoxifylline 82

perindopril erbumine 140

PERIOGARD 21

permethrin 24

perphenazine 65

perphenazine/amitriptyline hcl 43

PHENADOZ 78

phenazopyridine hcl 147

phendimetrazine tartrate 15

phenelzine sulfate 40

PHENERGAN 78

phenobarbital 38

phenobarbital sodium 38

phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine

hb 34

PHENOHYTRO 34

phenol 23

phenoxybenzamine hcl 4

phentermine hcl 15

phentolamine mesylate 4

phentolamine mesylate/alprostadil in bacteriostatic water 4

phenylephrine hcl 99,154

phenylephrine hcl/promethazine hcl 54

PHENYTEK 27

phenytoin 27

phenytoin sodium extended 27

PHILITH 116

PHOSPHA 250 NEUTRAL 92

PHOSPHASAL 18

physostigmine salicylate 80

phytonadione (vit k1) 126

pilocarpine hcl 53,80

pimozide 61

PIMTREA 116

pindolol 28

pioglitazone hcl 48

pioglitazone hcl/glimepiride 48

pioglitazone hcl/metformin hcl 45

PIRMELLA 116

piroxicam 138

PLEGRIDY 131

PLEGRIDY PEN 132

PNEUMOVAX 23 73

podofilox 150

POLOCAINE 165

POLOCAINE-MPF 165

POLYCIN 20

polyethylene glycol 3350 100

polymyxin b sulfate 33

polymyxin b sulfate/trimethoprim 20

POLYSACCHARIDE IRON FORTE 26

POMALYST 132

PORTIA 116

potassium bicarbonate/citric acid 94

potassium chloride 94

potassium chloride/potassium bicarbonate/citric acid 94

potassium citrate 92

potassium citrate/citric acid 92

potassium hydroxide 148

potassium iodide/iodine 50

povidone-iodine 21

PR BENZOYL PEROXIDE 148

PRADAXA 36

pralidoxime chloride 126

PRALUENT PEN 58

PRALUENT SYRINGE 58

PRAMCORT 146

pramipexole di-hcl 92

prasugrel hcl 69

pravastatin sodium 57

prazosin hcl 4

prednicarbate 146

prednisolone 105

prednisolone acetate 25

prednisolone sod phosphate 25,105

prednisone 105

PREDNISONE INTENSOL 105

PREGNYL 121

PREMARIN 97

PREMPHASE 97

PREMPRO 97

PREVALITE 56

PREVIFEM 116

PREVNAR 13 73

PREZCOBIX 68

PREZISTA 68

primaquine phosphate 60

primidone 38

PROAIR HFA 3

PROAIR RESPICLICK 3

probenecid 94

probenecid/colchicine 95

procainamide hcl 27

prochlorperazine 49

prochlorperazine edisylate 50

prochlorperazine maleate 50

PROCRIT 82

PROCTO-MED HC 146

PROCTO-PAK 146

PROCTOFOAM-HC 146

PROCTOSOL-HC 146

PROCTOZONE-HC 146

PROCYSBI 135

progesterone 123

progesterone, micronized 123

PROGRAF 134

PROMACTA 82

promethazine hcl 54,78

promethazine hcl/codeine 54

promethazine hcl/dextromethorphan hbr 55

promethazine/phenylephrine hcl/codeine 13

PROMETHEGAN 79

propafenone hcl 27

propantheline bromide 34

proparacaine hcl 99

proparacaine hcl/fluorescein sodium 88

propranolol hcl 28

propranolol hcl/hydrochlorothiazide 28

propylthiouracil 154

PROQUAD 73

PROTHELIAL 165

protriptyline hcl 43

PULMICORT FLEXHALER 87

PULMOSAL 94

PULMOZYME 141

PURIXAN 134

PYLERA 32

pyrazinamide 59

pyridostigmine bromide 80

pyridoxine hcl (vitamin b6) 172

PYROGALLIC ACID 150

QQUADRACEL DTAP-IPV 73

QUASENSE 116

quazepam 79

quetiapine fumarate 62,63

quinapril hcl 140

quinapril hcl/hydrochlorothiazide 91

quinidine gluconate 27

quinidine sulfate 27

quinine sulfate 60

RRABAVERT 73

rabeprazole sodium 75

RAJANI 116

raloxifene hcl 95

ramipril 141

RANEXA 84

ranitidine hcl 74

RAPAFLO 5

RAPAMUNE 134

rasagiline mesylate 40

RAVICTI 93

RAYALDEE 173

REA LO 40 148

REBETOL 77

REBIF 132

REBIF REBIDOSE 132

RECLIPSEN 116

RECOMBIVAX HB 73

RECOTHROM 53

REMEVEN 148

REMODULIN 142

RENA-VITE RX 172

RENVELA 124

repaglinide 47

repaglinide/metformin hcl 45

REPATHA PUSHTRONEX 58

REPATHA SURECLICK 58

REPATHA SYRINGE 58

REPREXAIN 13

RESCRIPTOR 66

reserpine 124

RESTASIS 25

RESTASIS MULTIDOSE 25

RETROVIR 67

REVATIO 142

REVLIMID 132

REYATAZ 68

RIBASPHERE 77

RIBASPHERE RIBAPAK 77

RIBATAB 77

ribavirin 77

RIDAURA 129

rifabutin 33

rifampin 33

riluzole 85

rimantadine hcl 75

risedronate sodium 127

risperidone 63

rivastigmine 80

rivastigmine tartrate 80

RIVELSA 116

rizatriptan benzoate 59

ropinirole hcl 92

ropivacaine hcl in 0.9 % sodium chloride/pf 165

ropivacaine hcl/pf 165

ROSADAN 22

ROSANIL 23

rosuvastatin calcium 57

ROTARIX 73

ROTATEQ 73

ROWEEPRA 37

RUBRACA 165

RYDAPT 165

SSABRIL 37

saccharin 94

SAIZEN 122

SAIZEN-SAIZENPREP 122

SALACYN 148

salicylic acid 148

salicylic acid/ammonium lactate/aloe vera 148

salsalate 138

SAMSCA 90

SANADERMRX 146

SANCUSO 49

SANDIMMUNE 129

SANDOSTATIN 152

SANDOSTATIN LAR DEPOT 152

SCALACORT 146

scopolamine 49

scopolamine hydrobromide 34

SEB-PREV 23

selegiline hcl 40

selenium sulfide 23

SELZENTRY 65

SENSIPAR 136

SENSORCAINE 165

SENSORCAINE WITH DEXTROSE 165

SENSORCAINE-EPINEPHRINE 154

SENSORCAINE-MPF 165

SENSORCAINE-MPF EPINEPHRINE 154

SEREVENT DISKUS 4

SEROPHENE 95

SEROQUEL XR 64

SEROSTIM 122

sertraline hcl 42

SETLAKIN 116

sevelamer carbonate 124

sevoflurane 103

SF 128

SF 5000 PLUS 128

SHAROBEL 116

SIGNIFOR 153

SIGNIFOR LAR 153

sildenafil citrate 142

silver 165

silver nitrate 23,148

silver nitrate/potassium nitrate 148

silver sulfadiazine 23

silver sulfadiazine/foam bandage 165

silver/foam bandage 165

SIMPONI 129

simvastatin 57

sirolimus 134

sodium chloride for inhalation 94

sodium chloride/sodium bicarbonate/potassium

chloride/peg 100

sodium citrate 35

sodium phenylbutyrate 93

sodium polystyrene sulfonate 125

sodium succinate 166

sodium/potassium/potassium citrate/sodium citrate/cit

ac 93

SOJOURN 103

SOLIQUA 100-33 46

SOMAVERT 153

SOOLANTRA 150

sorbitol solution 100

SORINE 28

sotalol hcl 28

SOVALDI 104

spinosad 24

SPIRIVA 34

SPIRIVA RESPIMAT 34

spironolactone 90

spironolactone/hydrochlorothiazide 90

SPRINTEC 116

SPRYCEL 166

SPS 125

SRONYX 117

SSD 23

SSS 10-5 23

STAMARIL 73

stavudine 67

STELARA 130

STIMATE 53

STIOLTO RESPIMAT 34

STIVARGA 166

STRENSIQ 166

streptomycin sulfate 30

STRIBILD 65

STRIVERDI RESPIMAT 4

SUBOXONE 14

SUCRAID 166

sucralfate 74

sulfacetamide sodium 20,23

sulfacetamide sodium/prednisolone sodium phosphate 20

sulfacetamide sodium/sulfur 24

sulfacetamide sodium/sulfur/skin cleanser comb no.23 24

sulfacetamide sodium/sulfur/urea 24

SULFACLEANSE 8-4 24

sulfadiazine 31

sulfamethoxazole/trimethoprim 31

sulfasalazine 31

SULFATRIM 31

sulindac 138

sumatriptan 59

sumatriptan succinate 59

SUSTIVA 66

SUTENT 166,167

SWABFLUSH 167

SYEDA 117

SYLATRON 75

SYMAX 34

SYMAX-SL 34

SYMAX-SR 35

SYMBICORT 4

SYMLINPEN 120 43

SYMLINPEN 60 43

SYNAREL 121

SYNJARDY 45

SYNJARDY XR 45

SYNRIBO 167

SYNTHROID 155

SYPRINE 167

SYREX 94



syringe with needle, insulin, safety, 1 ml 167

syringe with needle,disposable,insulin 1 ml 167



syringe, disposable irrigation, 70 ml 167

syringe, insulin u-500 with needle, disposable, 0.5 ml 167

Ttacrolimus 134,150

TAFINLAR 167

TAGRISSO 167

TALTZ AUTOINJECTOR 150



TALTZ SYRINGE 151



tamoxifen citrate 168

tamsulosin hcl 5

TARCEVA 168

TARGRETIN 151,168

TARINA FE 117

TARON-CRYSTALS 93

TASIGNA 168

TAYTULLA 117

tazarotene 151

TAZICEF 87

TAZTIA XT 29

TECFIDERA 132

TECHNIVIE 68

TEGRETOL XR 37

telmisartan 140

telmisartan/amlodipine besylate 84

telmisartan/hydrochlorothiazide 91

temazepam 79

TEMODAR 168

temozolomide 168

TENCON 7

TENIVAC 71

terazosin hcl 4

terbinafine hcl 50

terbutaline sulfate 4

terconazole 51

TERRELL 103

testosterone cypionate 106

testosterone enanthate 106

tetanus and diphtheria toxoids, adult 71

tetanus,diphtheria toxoid ped/pf 71

TETCAINE 99

tetrabenazine 85

tetracaine hcl 99

tetracaine hcl/pf 99,168

tetracycline hcl 32

TETRAVISC 99

TETRAVISC FORTE 99

THALOMID 133

THEOCHRON 82

theophylline anhydrous 82

THERACYS 73

THERAPEUTIC VITAMIN W-MINERALS 172

THERMAZENE 24

thiamine hcl 172

thiamine

hcl/riboflavin/niacinamide/dexpanthenol/pyridoxine 172

thioridazine hcl 65

thiotepa 168

thiothixene 65

tiagabine hcl 37

ticlopidine hcl 69

TIKOSYN 29

TILIA FE 117

timolol maleate 28,52

tinidazole 61

TIVICAY 65

tizanidine hcl 144

TOBI 30

TOBI PODHALER 30

tobramycin 20

tobramycin in 0.225 % sodium chloride 30

tobramycin sulfate 30

tobramycin/dexamethasone 20

tobramycin/nebulizer 30

tolazamide 48

tolbutamide 48

tolcapone 60

tolmetin sodium 138

tolterodine tartrate 103

TOPAMAX 37

topiramate 37,38

torsemide 89

TOUJEO SOLOSTAR 47

TRACLEER 142

TRADJENTA 46

tramadol hcl 13

tramadol hcl/acetaminophen 7

trandolapril 141

trandolapril/verapamil hcl 83

tranexamic acid 53

TRANSDERM-SCOP 49

tranylcypromine sulfate 40

TRAVATAN Z 53

travoprost (benzalkonium) 53

trazodone hcl 42

tretinoin 147,168

tretinoin microspheres 147

tretinoin/emollient base 147

TREXALL 130

TRI FEMYNOR 117

TRI-ESTARYLLA 117

TRI-LEGEST FE 117

TRI-LINYAH 117

TRI-LO-ESTARYLLA 117

TRI-LO-MARZIA 117

TRI-LO-SPRINTEC 117

TRI-PREVIFEM 117

TRI-SPRINTEC 118

triacetin 50

triamcinolone acetonide 25,106,146

triamterene/hydrochlorothiazide 89

TRIANEX 146

triazolam 79,80

trichloroacetic acid 151

TRICITRATES 93

TRIDERM 146

TRIFERIC 26

trifluoperazine hcl 65

trifluridine 21

trihexyphenidyl hcl 35

TRIKLO 55

TRILYTE WITH FLAVOR PACKETS 100

trimethobenzamide hcl 50

trimethoprim 18

trimipramine maleate 43

TRINESSA 118

TRINESSA LO 118

TRIUMEQ 65

TRIVORA-28 118

TRIZIVIR 67

tropicamide 99

trospium chloride 103

TRULICITY 46

TRUVADA 67

TUSSIGON 35

TWINRIX 73

TYBOST 136

TYKERB 168

TYMLOS 121

TYPHIM VI 73

TYVASO 142

TYVASO INSTITUTIONAL START KIT 143

TYVASO REFILL KIT 143

TYVASO STARTER KIT 143

TYZEKA 77

UULORIC 126

UMECTA 148

UNITHROID 155

UPTRAVI 143

UR N-C 18

URE-K 148

urea 148

URELLE 18

URETRON D-S 18

URIBEL 19

URIMAR-T 19

URIN D.S. 19

URO-458 19

URO-BLUE 19

URO-L 19

UROPHEN MB 19

ursodiol 101

URYL 19

USTELL 19

UTA 19

UTIRA-C 19

UVADEX 88

VV-C FORTE 172

valacyclovir hcl 78

VALCHLOR 151

valganciclovir hcl 78

valproic acid 38

valproic acid (as sodium salt) (valproate sodium) 38

valsartan 140

valsartan/hydrochlorothiazide 91,92

VALSTAR 168

vancomycin hcl 32

VANDAZOLE 22

VAQTA 73

VARIVAX VACCINE 73

VARIZIG 70

VARUBI 49

vasopressin 122

VAXCHORA ACTIVE COMPONENT 73

VAXCHORA BUFFER COMPONENT 168

VAXCHORA VACCINE 73

VECAMYL 124

VELIVET 118

VEMLIDY 78

VENCLEXTA 169

VENCLEXTA STARTING PACK 169

venlafaxine hcl 40

VENTOLIN HFA 4

verapamil hcl 29

VERDROCET 7

VESICARE 104

VESTURA 118

VIAGRA 171

VIBERZI 102

VIC-FORTE 172

VICODIN 7

VICODIN ES 7

VICODIN HP 8

VICTOZA 2-PAK 46

VICTOZA 3-PAK 46

VIDEX 67

VIDEX EC 67

VIEKIRA PAK 68

VIEKIRA XR 69

VIENVA 118

vigabatrin 38

VIGAMOX 21

VIORELE 118

VIRACEPT 69

VIRAMUNE 66

VIRAMUNE XR 66

VIREAD 67

VIRT-CAPS 172

VIRT-GARD 173

VIRT-PHOS 250 NEUTRAL 92

VIRT-VITE 173

VIRT-VITE PLUS 173

VIRTRATE-2 93

VIRTRATE-3 93

VIRTRATE-K 93

VISTOGARD 126

VIVITROL 85

VIVOTIF 73

VIVOTIF BERNA 73

voriconazole 50

VOSEVI 169

VOTRIENT 169

VP-VITE RX 173

VYFEMLA 118

VYNATAL-FA 26

VYVANSE 16

Wwarfarin sodium 35

water for inj.,bacteriostatic 169

water for

inj.,bacteriostatic/methylparaben/propylparaben 169

water for injection,sterile 169

WELCHOL 44

WERA 118

WYMZYA FE 118

XXALKORI 169

XARELTO 35,36

XELJANZ 130

XELJANZ XR 130

XELODA 169

XENAZINE 85

XERMELO 100

XTANDI 169

XULANE 118

XURIDEN 136

XYLOCAINE DENTAL-EPINEPHRINE 154

XYLON 10 13

XYREM 85

YYF-VAX 73

yohimbine hcl 169

YUVAFEM 97

Zzafirlukast 25

zaleplon 79

ZARAH 119

ZARONTIN 39

ZARXIO 82

ZAVESCA 136

ZEBUTAL 8

ZEJULA 169

ZELBORAF 170

ZEMPLAR 173

ZENATANE 151

ZENCHENT 119

ZENCHENT FE 119

ZENCIA 24

ZENPEP 101

ZENZEDI 16

ZEOSA 119

ZEPATIER 104

ZERIT 67

ZIAGEN 67

zidovudine 67

ZINBRYTA 133

ziprasidone hcl 64

ZMAX 125

ZOLATE 173

ZOLINZA 170

zolmitriptan 59

zolpidem tartrate 79

ZOMACTON 122

ZOMIG 59

ZONEGRAN 38

zonisamide 38

ZORBTIVE 122

ZORTRESS 134

ZOSTAVAX 73

ZOVIA 1-35E 119

ZOVIA 1-50E 119

ZOVIRAX 22

ZYDELIG 170

ZYKADIA 170

ZYTIGA 170

NOTICE ABOUT NON-DISCRIMINATION

GlobalHealth, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. GlobalHealth does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

GlobalHealth:

Provides free aids and services to people with disabilities to communicate effectively with us, suchas:

o Qualified sign language interpreters

o Written information in other formats (large print, audio, accessible electronic formats,other formats)

Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters

o Information written in other languages

If you need these services, contact the Director of Compliance and Legal Services.

If you believe that GlobalHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: ATTN: Director of Compliance and Legal Services, 701 NE 10th St, Ste. 300, Oklahoma City, OK 73104-5403, Fax: (405) 280-5894, or E-mail: [email protected]. You can file a grievance in person or by mail, fax, or e-mail. If you need help filing a grievance, the Compliance Attorney is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Language Translation

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-280-5600 (TTY: 711).

Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-280-5600 (TTY: 711).

Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-280-

5600 (TTY: 711).

Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-877-280-5600 OR (TTY: 711)번으로 전화해 주십시오.

German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche


https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

Language Translation

Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-280-5600 (TTY: 711).

Arabic 4692-082-778-1 117) .اتصل .إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان :ملحوظة (ھاتف الصم والبكم برقم

Burmese သတိျပဳရန ္- အကယ္၍ သင္သည္ ျမန္မာစကား ကို ေျပာပါက၊ ဘာသာစကား အကူအညီ၊ အခမ့ဲ၊

သင့္အတြက ္စီစဥ္ေဆာင္ရြက္ေပးပါမည္။ ဖုန္းနံပါတ္ 1-877-280-5600 (TTY: 711) သု႔ိ ေခၚဆိုပါ။

Hmong LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-877-280-5600 (TTY: 711).

Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-280-5600 (TTY: 711).

French ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-280-5600 (ATS: 711).

Laotian ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້

ທ່ານ. ໂທຣ 1-877-280-5600 (TTY: 711).

Thai เรยีน: ถา้คณุพดูภาษาไทยคณุสามารถใชบ้รกิารชว่ยเหลอืทางภาษาไดฟ้ร ีโทร 1-877-280-5600 (TTY: 711).

Urdu 280-877-1 کریں کال ۔ ہیں دستیاب میں مفت خدمات کی مدد کی زبان کو آپ تو ہیں، بولتے اردو آپ اگر :خبردار-5600 (TTY: 711).

Cherokee Hagsesda: iyuhno hyiwoniha [tsalagi gawonihisdi]. Call 1-877-280-5600 (TTY: 711).

Persian می کنید، تسھیالت زبانی بصورت رایگان برای شمااگر بھ زبان فارسی گفتگو :توجھ

1-877-280-5600 (TTY: 711) با تماس بگیرید .فراھم می باشد.

MSTDF18

GlobalHealth, Inc.

PO Box 2393Oklahoma City, OK 73101-2393

www.GlobalHealth.com/state Effective: 2018 Lists Updated 11/2017

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