EmblemHealth Select Care Prime Network for NY …...(Urdu)اردو توجہ دیں: یہ ایک...

EMBLEMHEALTH QUALIFIED HEALTH PLAN FORMULARY FOR NY STATE OF HEALTH 2018 FormularyIf you have general questions about prescription drug coverage, please contact Customer Service at 1-877-842-3625 (TTY 711), 8 am to 6 pm, Monday through Friday.

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EMBLEMHEALTH QUALIFIED HEALTH PLAN FORMULARY FOR NY STATE OF HEALTH This guide tells you about our drug plan and has our formulary – the list of drugs we cover. It is up to date as of January 1, 2018. It may change over time, such as when:

• We add a new, less costly generic drug to our list.• We learn that a drug on our list may not be safe or effective.

Check to make sure that this list still has the drugs you need. If you have any questions, call us at 1-877-842-3625 (TTY 711). Our hours are 8 am to 6 pm, Monday through Friday.

In general, we will pay for your drugs only when you get them at a drug store in our network. For a list of stores near you and the latest list of drugs in our plan, go to emblemhealth.com.

Keep in mind that your benefits, as well as this drug list and drug stores in our network, may change on January 1, 2019.

How do I use this guide?

You can look for your drug using the index. This starts on page 108. Or, if you already know what your drug is used for, look for the section name in the Table of Contents. Then look there for your drug.

Sections are based on what the drugs are used to treat. For example, drugs used for a heart condition are under “Cardiovascular, Hypertension & Lipids.” The first column of the chart lists the drug name. Brand name drugs are upper case (for example, SYNTHROID). Generic drugs are shown in lower-case italics (for example, atenolol ).

What are generic drugs and drug tiers?

A generic drug is one that is approved by the U.S. Food & Drug Administration (FDA) as having the same active ingredient as the brand name drug. We cover both brand name and generic drugs. In general, generic drugs cost you less than brand name drugs.

You can also save money by using a preferred brand drug instead of one that is nonpreferred. Use the numbers in the table below as a guide to these drugs. You’ll see them listed next to each drug on the list.

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Tier Number Tier Name

ACA Zero Cost Share Preventive Drugs (there may be some limits on this drug; see below)

1 Generic

2 Preferred Brand

3 Nonpreferred Brand

Are there any limits on drug coverage?

There may be special requirements or limits on what we cover for some drugs. The table below explains these. Their abbreviations are in the right column. When one of these applies to a drug in the list, you’ll see the abbreviation next to the drug. You can also find out if your drug has any other requirements or limits when you look at the list. You can get more information about this by going to emblemhealth.com.

Drug Coverage Requirements

Requirement or Limit Abbreviation

Affordable Care Act. There may be some limits on this drug. ACA

Limited Availability. You may only be able to get this drug at some drug stores. LA

Prior Authorization. This means that you will need to get approval before you can get this drug. If you don’t get approval, we may not pay for the drug.

PA

Step Therapy. You will need to first try certain drugs before we will pay for another drug. For example:

• If Drug A and Drug B can both be used, we may not pay for Drug B unless you try Drug A first.

• If Drug A does not work for you, we will then pay for Drug B.

ST

Quantity Limit. There is a limit to how much of this drug we will pay for. QL

You can ask us to make an exception to a restriction or limit on a drug. We can also give you a list of other, similar drugs that may work. Speak with your doctor about this first.

Where can I get more information?

If you have any questions about this drug list, or about your benefits, go to emblemhealth.com. You can also call us at 1-877-842-3625 (TTY 711). Our hours are, 8 am to 6 pm, Monday through Friday.

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Disclaimer

Please see your Contract or Certificate of Coverage for plan details. It will tell you what is covered and how much you pay for your drugs. A drug being listed in this guide does not guarantee that we will pay for it. Some drugs may need approval (prior authorization) before we pay. For some drugs, we will only pay for certain doses and/or strengths. The drugs on this list may change based on a decision by EmblemHealth. As new generic drugs become available, the brand name version will no longer be a preferred choice.

This is a list of the drugs that are prescribed most often for members that use the Select Care Formulary. To help keep your costs down, ask your doctor to prescribe generic drugs when possible.

NOTE: Not all drugs in this list are paid for by all drug benefit plans, so coverage is not guaranteed. Check your benefits for copay and any other requirements you may have under your plan. If you have other questions about your drug benefits, please call the phone number on the back of your ID card.

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ATTENTION: This is an important document. If you need help to understand it, please call the telephone number marked “customer service” on the back of your member ID card [TTY/TDD: 711]. We can give you an interpreter for free in the language you speak.

Español (Spanish)ATENCIÓN: Este es un documento importante. Si necesita ayuda para entenderlo, llame al número telefónico marcado “customer service” que se encuentra en el dorso de su tarjeta de identificación de miembro [TTY/TDD: 711]. Le podemos proporcionar un intérprete que habla su idioma sin ningún costo.

中文 (Traditional Chinese)注意：這是重要的文件。如果您需要協助來瞭解文件內容，請致電您會員卡背面標記為“customer service”的電話號碼[TTY/TDD：711]。我們可以為您免費提供您所使用語言的翻譯人員。

Pусский (Russian)ВНИМАНИЕ! Это важный документ. Если у Вас возникли трудности с пониманием этого документа и Вам необходима помощь, позвоните по телефону отдела обслуживания клиентов (customer service), указанному на обратной стороне Вашей идентификационной карточки [служба текстового телефона (TTY/TDD): 711]. Мы можем бесплатно предоставить Вам переводчика, который говорит на Вашем языке.

Kreyòl Ayisyen (Haitian Creole)ATANSYON: Sa a se yon dokiman ki enpòtan. Si ou bezwen èd pou konprann li, tanpri rele nimewo ki make “customer service” nan do kat ID manm ou [TTY/TDD: 711]. Nou kapab ba ou yon entèprèt gratis nan lang ou pale a.

한국어 (Korean)주의: 이것은 중요한 문서입니다. 이 문서를 이해하는 데 도움이 필요하시면 회원ID 카드의 뒷면에“customer service” 라고 표시된 전화번호[TTY/TDD: 711]로 연락해 주십시오. 저희는 귀하가 사용하는 언어에 대해 무료 통역사를 제공할 수 있습니다.

Italiano (Italian)ATTENZIONE. Questo è un documento importante. Per qualsiasi chiarimento telefoni all “customer service” al numero stampato sul retro della Sua tessera (per i non udenti: 711). Possiamo mettere a disposizione gratis un interprete nella Sua lingua.

(Yiddish) שידיא customer” מעלדונג: דאס איז א וויכטיגע דאקומענט. אויב איר דארפט הילף עס צו פארשטיין, ביטע רופט דעם טעלעפון נומבער גערופן

service“ אויף אייער קארטל [TTY/TDD: 711]. מיר קענען אייך געבן אן איבערזעצער פריי אין די שפראך וואס איר רעדט.

বাাংলা (Bengali)দৃষ্টি আকর্ষণ করছি: এটি একটি গুরুত্বপূর্ণ নথি। এটি বুঝতে আপনার যদি সাহায্যের প্রয়োজন হয়, তাহলে অনুগ্রহ করে আপনার মেম্বার আইডি কার্ডের

উল্টোপিঠে “customer service” চিহ্নিত টেলিফোন নম্বরে [TTY/TDD: 711] কল করুন। আপনি যে ভাষায় কথা বলেন সে-ভাষার জন্য বিনামূল্যে আমরা আপনাকে একজন দোভাষী দিতে পারি।

Polski (Polish)UWAGA: To jest ważny dokument. Jeżeli potrzebujesz pomocy w celu zrozumienia jego treści, zadzwoń do „customer service” pod numer telefonu podany na odwrocie karty identyfikacyjnej ubezpieczonego (member ID card) [TTY/TDD: 711]. Możemy bezpłatnie zapewnić usługi tłumacza języka, którym się posługujesz.

(ARABIC) ةيبرعلا ىلع ”customer service» ـب هيلإ راشملا مقرلاب لاصتالا ىجرٌي ،اهاوتحم مهفل ةدعاسم ىلإ ةجاحب تنك اذإ .ةمهم ةقيثو هذه :هابتنا

.ًاناجم اهثدحتت يتلا ةغللاب كل يروف مجرتم ريفوت اننكمُي .[TTY/TDD:711] كتيوضع ةقاطب رهظ

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

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GETTING HELP IN A LANGUAGE OTHER THAN ENGLISH

(Yiddish) אידיש

ם טעלעפון נומבער גערופן : דאס איז א וויכטיגע דאקומענט. אויב איר דארפט הילף עס צו פארשטיין, ביטע רופט דעמעלדונג“customer service” אויף אייער קארטל ]TTY/TDD: 711[ .אין די שפראך וואס איר פריי מיר קענען אייך געבן אן איבערזעצער

רעדט.বাাাাংলা (Bengali)

দষৃ্টি আকর্ষণ করষ্টি: এটি একটি গুরুত্বপূণষ নষ্টি। এটি বুঝতে আপনার যষ্টদ সাহাতের প্রত াজন হ , োহতল অনুগ্রহ কতর আপনারমেম্বার আইষ্টি কাতিষ র উতটাষ্টপতে “customer service” ষ্টিষ্টিে মেষ্টলত ান নম্বতর [TTY/TDD: 711] কল করুন। আপষ্টন ময ভার্া কিাবতলন মস-ভার্ার জন্য ষ্টবনােূতে আেরা আপনাতক একজন মদাভার্ী ষ্টদতে পাষ্টর।

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Français (French)ATTENTION : ce document est important. Si vous avez besoin d’aide pour en comprendre le contenu, veuillez composer le numéro «customer service » au dos de votre carte de membre [Sourds et malentendants : 711]. Nous pouvons mettre gratuitement à votre disposition un interprète dans votre langue.

(Urdu)ودرا «customer service» مرک ہارب وت ےہ ترورض یک ددم ےیل ےک ےنھجمس ےسا وک پآ رگا ۔ےہزیواتسد مہا کیا ہی :ںید ہجوت

نابز وج پآ ۔[711 :یڈ یڈ یٹ/یئاو یٹ یٹ] ےہ جرد رپ تشپ یک ڈراک یڈ یئآ ربمم ےک پآ وج ںیرک لاک رپ ربمن ےلاو۔ںیہ ےتکسرک مہارف مجرتم تفم وک پآ مہ ںیم سا ںیہ ےتلوب

Tagalog (Tagalog)NANAWAGAN NG PANSIN: Ito ay isang mahalagang dokumento. Kung kailangan mo ng tulong para maintindihan ito, pakitawagan ang numero ng telepono na minarkahang “customer service” sa likod ng inyong ID card ng miyembro [TTY/TDD: 711]. Maaari ka naming bigyan ng libreng interpreter sa wikang iyong sinasalita.

Ελληνικά (Greek)ΠΡΟΣΟΧΗ: Αυτό το έγγραφο είναι σημαντικό. Εάν χρειάζεστε βοήθεια για να το κατανοήσετε, καλέστε μας στον αριθμό που σημειώνεται ως «customer service» στο πίσω μέρος της κάρτας της συνδρομής σας [αριθμός για άτομα με προβλήματα ακοής (ΤΤΥ/TDD): 711]. Μπορούμε να σας προσφέρουμε δωρεάν διερμηνεία στη μητρική σας γλώσσα.

Shqip (Albanian)VINI RE: Ky është një dokument i rëndësishëm. Nëse ju nevojitet ndihmë për ta kuptuar, ju lutemi telefononi në numrin ku shkruhet “customer service”, i cili gjendet ne anen e pasme të kartës tuaj identifikuese të anëtarësisë [Shërbimi rele TTY/TDD: 711]. Ne mund t’ju ofrojmë pa pagesë një përkthyes në gjuhën që flisni ju.

NOTICE OF NONDISCRIMINATION POLICY

EmblemHealth complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. EmblemHealth does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

EmblemHealth:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: – Qualified sign language interpreters – 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:

– Qualified interpreters – Information written in other languages

If you need these services, please call the telephone number marked “customer service” on the back of your member ID card. TTY/TDD: 711.

If you believe that EmblemHealth 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 EmblemHealth Grievance and Appeals Department, PO Box 2844, New York, NY 10116, or call the telephone number marked “customer service” on the back of your member ID card. (Dial 711 for TTY/TDD services.) You can file a grievance in person, by mail or by phone. If you need help filing a grievance, EmblemHealth’s Grievance and Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office of Civil Rights electronically through the Office of Civil Rights Complaint Portal, available at 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, (dial 1-800-537-7697 for TTY services).

Complaint forms are available at hhs.gov/ocr/office/file/index.html.

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Table of Contents

ANTI - INFECTIVES .......................................................................................................................................... 3

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS .......................................................................... 11

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ........................................................................... 14

CARDIOVASCULAR, HYPERTENSION & LIPIDS ..................................................................................... 31

DERMATOLOGICALS/TOPICAL THERAPY ............................................................................................... 39

DIAGNOSTICS & MISCELLANEOUS AGENTS .......................................................................................... 50

EAR, NOSE & THROAT MEDICATIONS...................................................................................................... 53

ENDOCRINE/DIABETES ................................................................................................................................ 54

GASTROENTEROLOGY ................................................................................................................................. 60

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY .................................................................................. 67

MUSCULOSKELETAL & RHEUMATOLOGY ............................................................................................. 71

OBSTETRICS & GYNECOLOGY ................................................................................................................... 73

OPHTHALMOLOGY ........................................................................................................................................ 81

RESPIRATORY, ALLERGY, COUGH & COLD ............................................................................................ 86

UROLOGICALS ................................................................................................................................................ 91

VITAMINS, HEMATINICS & ELECTROLYTES .......................................................................................... 93

Index ................................................................................................................................................................. 108

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List of Abbreviations

ACA: Affordable Care Act.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more

information, please call Customer Service.

OTC: Over the Counter. An OTC drug is a non-prescription drug.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.

This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we

may not cover the drug.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical

condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat

your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for

you, we will then cover Drug B.

You can find information on what the symbols and abbreviations on this table mean by going to the beginning

of this table.

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Drug Name Drug Tier Requirements / Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

clotrimazole mucous membrane 1

CRESEMBA ORAL 3 PA

fluconazole oral suspension for reconstitution 1

fluconazole oral tablet 100 mg, 200 mg, 50 mg 1

fluconazole oral tablet 150 mg 1 QL

flucytosine 1

griseofulvin microsize 1

itraconazole 1

ketoconazole oral 1

NOXAFIL ORAL 3 PA

nystatin oral powder 150 million unit, 500 million

unit

1

nystatin oral suspension 1

nystatin oral tablet 1

ONMEL 3

ORAVIG 3

SPORANOX ORAL SOLUTION 3

terbinafine hcl oral 1

voriconazole oral 1

ANTIVIRALS

abacavir 1 QL

abacavir-lamivudine 1 QL

abacavir-lamivudine-zidovudine 1 QL

acyclovir oral capsule 1

acyclovir oral suspension 200 mg/5 ml 1

acyclovir oral tablet 1

adefovir 1 PA

amantadine hcl 1

APTIVUS 2 QL


of this table.

4


ATRIPLA 2 QL

BARACLUDE ORAL SOLUTION 2

COMPLERA 2 QL

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 QL

DAKLINZA 3 PA

DESCOVY 3 QL

didanosine 1 QL

EDURANT 2 QL

EMTRIVA 2 QL

entecavir 1

EPCLUSA 2 PA; QL

EPIVIR HBV ORAL SOLUTION 2

EVOTAZ 3 QL

famciclovir 1

FUZEON SUBCUTANEOUS RECON SOLN 2 PA; QL

GENVOYA 2 QL

HARVONI 2 PA

INTELENCE 2 QL

INVIRASE 2 QL

ISENTRESS HD 3 QL

ISENTRESS ORAL POWDER IN PACKET 3 QL

ISENTRESS ORAL TABLET 2 QL

ISENTRESS ORAL TABLET,CHEWABLE 2 QL

KALETRA ORAL TABLET 2 QL

lamivudine oral solution 1 QL

lamivudine oral tablet 100 mg 1

lamivudine oral tablet 150 mg, 300 mg 1 QL

lamivudine-zidovudine 1 QL

LEXIVA 2 QL

lopinavir-ritonavir 1 QL

nevirapine 1 QL


of this table.

5


NORVIR 2 QL

ODEFSEY 3 QL

OLYSIO 3 PA

oseltamivir 1 QL

PREZCOBIX 3 QL

PREZISTA ORAL SUSPENSION 2 QL

PREZISTA ORAL TABLET 150 MG, 600 MG,

75 MG, 800 MG

2 QL

RELENZA DISKHALER 2 QL

RESCRIPTOR 2 QL

REYATAZ ORAL CAPSULE 150 MG, 200 MG,

300 MG

2 QL

REYATAZ ORAL POWDER IN PACKET 2 QL

rimantadine 1

SELZENTRY 2 QL

SITAVIG 3

SOVALDI 2 PA

stavudine 1 QL

STRIBILD 2 QL

SUSTIVA 2 QL

TAMIFLU ORAL SUSPENSION FOR

RECONSTITUTION

2 QL

TECHNIVIE 3 PA

TIVICAY 3 QL

TRIUMEQ 3 QL

TRUVADA ORAL TABLET 100-150 MG, 133-

200 MG, 167-250 MG

3 QL

TRUVADA ORAL TABLET 200-300 MG 2 QL

TYBOST 3 QL

valacyclovir 1

valganciclovir 1

VEMLIDY 3 PA

VIDEX 2 GRAM PEDIATRIC 2 QL


of this table.

6


VIEKIRA PAK 3 PA

VIEKIRA XR 3 PA

VIRACEPT ORAL TABLET 2 QL

VIREAD ORAL POWDER 3 QL

VIREAD ORAL TABLET 2 QL

ZEPATIER 3 PA; QL

ZIAGEN ORAL SOLUTION 2 QL

zidovudine 1 QL

CEPHALOSPORINS

cefaclor oral capsule 1

cefaclor oral suspension for reconstitution 125

mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

1

cefaclor oral tablet extended release 12 hr 1

cefadroxil oral capsule 1

cefadroxil oral suspension for reconstitution 250

mg/5 ml, 500 mg/5 ml

1

cefadroxil oral tablet 1

cefdinir 1

cefditoren pivoxil 1

cefixime 1

cefpodoxime 1

cefprozil 1

ceftibuten 1

CEFTIN ORAL SUSPENSION FOR

RECONSTITUTION

2

cefuroxime axetil oral tablet 1

cephalexin 1

SUPRAX ORAL CAPSULE 3

SUPRAX ORAL SUSPENSION FOR

RECONSTITUTION 100 MG/5 ML, 500 MG/5

ML

3

SUPRAX ORAL TABLET,CHEWABLE 3

ERYTHROMYCINS & OTHER MACROLIDES


of this table.

7


azithromycin oral 1

clarithromycin 1

DIFICID 3

e.e.s. 400 oral tablet 1

ERYPED 200 3

ERYPED 400 3

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

333 mg

1

ERY-TAB ORAL TABLET,DELAYED

RELEASE (DR/EC) 500 MG

2

erythrocin (as stearate) oral tablet 250 mg 1

erythromycin ethylsuccinate oral suspension for

reconstitution

1

erythromycin ethylsuccinate oral tablet 1

erythromycin oral capsule,delayed release(dr/ec) 1

erythromycin oral tablet 1

PCE 3

ZMAX 3

MISCELLANEOUS ANTIINFECTIVES

ALBENZA 2 PA

ALINIA 3 QL

atovaquone 1

atovaquone-proguanil 1

BETHKIS 3

BILTRICIDE 3

CAYSTON 3 PA; LA; QL

chloroquine phosphate 1

clindamycin hcl 1

clindamycin palmitate hcl 1 QL

clindamycin pediatric 1 QL

COARTEM 2 QL

CYCLOSERINE 3


of this table.

8


dapsone 1

DARAPRIM 3 PA

EMVERM 3

ethambutol 1

hydroxychloroquine 1

IMPAVIDO 3 PA

isoniazid oral 1

ivermectin 1

KITABIS PAK 3

linezolid oral 1 PA; QL

mefloquine 1

metronidazole oral 1

NEBUPENT 3

neomycin 1

paromomycin 1

PASER 3

PRIFTIN 3

PRIMAQUINE 3

pyrazinamide 1

quinine sulfate 1

rifabutin 1

RIFAMATE 3

rifampin oral 1

RIFATER 3

SIRTURO 3 LA

SIVEXTRO ORAL 3

tinidazole 1 QL

TOBI PODHALER 3

tobramycin in 0.225 % nacl 1 PA

TOBRAMYCIN WITH NEBULIZER 3

TRECATOR 3


of this table.

9


XIFAXAN ORAL TABLET 200 MG 3 QL

XIFAXAN ORAL TABLET 550 MG 2

PENICILLINS

amoxicillin oral capsule 1

amoxicillin oral suspension for reconstitution 1

amoxicillin oral tablet 1

amoxicillin oral tablet,chewable 125 mg, 250 mg 1

amoxicillin-pot clavulanate 1

ampicillin oral capsule 1

AUGMENTIN ORAL SUSPENSION FOR

RECONSTITUTION 125-31.25 MG/5 ML

3

dicloxacillin 1

MOXATAG 3

penicillin v potassium 1

QUINOLONES

ciprofloxacin 1

ciprofloxacin (mixture) 1

ciprofloxacin hcl oral 1

FACTIVE 3 QL

levofloxacin oral 1

moxifloxacin oral 1

ofloxacin oral tablet 300 mg, 400 mg 1

SULFA'S & RELATED AGENTS

sulfadiazine 1

sulfamethoxazole-trimethoprim oral 1

sulfatrim 1

TETRACYCLINES

avidoxy 1

AVIDOXY DK 3 ST

demeclocycline 1

DORYX MPC 3 ST


of this table.

10


doxycycline hyclate oral capsule 1

doxycycline hyclate oral tablet 100 mg, 20 mg 1

doxycycline hyclate oral tablet 150 mg, 75 mg 1 PA

doxycycline hyclate oral tablet,delayed release

(dr/ec)

1 ST

doxycycline monohydrate oral capsule 1

DOXYCYCLINE MONOHYDRATE ORAL

CAPSULE,IR - DELAY REL,BIPHASE

3 ST

doxycycline monohydrate oral suspension for

reconstitution

1

doxycycline monohydrate oral tablet 1

minocycline 1

mondoxyne nl 1

MORGIDOX 1X 50 3 ST

MORGIDOX 2X100 3 ST

morgidox oral capsule 100 mg 1

ORACEA 3 ST

SOLODYN ORAL TABLET EXTENDED

RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65

MG, 80 MG

3 ST

TARGADOX 3 ST

tetracycline 1

VIBRAMYCIN ORAL SYRUP 3 ST

URINARY TRACT AGENTS

methenamine hippurate 1

methenamine mandelate 1

MONUROL 3

nitrofurantoin 1

nitrofurantoin macrocrystal 1

nitrofurantoin monohyd/m-cryst 1

PRIMSOL 3

trimethoprim 1

VANCOMYCIN


of this table.

11


vancomycin oral capsule 1

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

leucovorin calcium oral 1

MESNEX ORAL 2

VISTOGARD 3

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

AFINITOR 3 PA; QL

AFINITOR DISPERZ 3 PA; QL

ALECENSA 3 PA

ALUNBRIG 3 PA; LA; QL

anastrozole 1

ASTAGRAF XL 3

AZASAN 3

azathioprine 1

bexarotene 1 QL

bicalutamide 1

BOSULIF 3 PA; QL

CABOMETYX 3 PA

capecitabine 1

CAPRELSA 3 PA; LA; QL

COMETRIQ 3 PA

COTELLIC 3 PA

CYCLOPHOSPHAMIDE ORAL CAPSULE 3

cyclosporine modified oral capsule 1

cyclosporine modified oral solution 1 QL

cyclosporine oral capsule 1

DROXIA 2

EMCYT 2 PA

ENVARSUS XR 3

ERIVEDGE 3 PA


of this table.

12


etoposide oral 1

exemestane 1

FARESTON 2

FARYDAK 3 PA

flutamide 1

gengraf oral capsule 1

gengraf oral solution 1 QL

GILOTRIF 3 PA

GLEOSTINE 3

GLIADEL WAFER 3

HEXALEN 2 PA

HYCAMTIN ORAL 3 PA; QL

hydroxyurea 1

IBRANCE 3 PA; QL

ICLUSIG 3 PA; QL

IDHIFA 3 PA

imatinib oral tablet 100 mg 1 PA; QL

imatinib oral tablet 400 mg 1 PA

IMBRUVICA 3 PA; QL

INLYTA 3 PA

IRESSA 3 PA

JAKAFI 3 PA

KISQALI 3 PA; QL

KISQALI FEMARA CO-PACK 3 PA; QL

LENVIMA 3 PA

letrozole 1

LEUKERAN 2

leuprolide subcutaneous kit 1 PA

LONSURF 3 PA

LYNPARZA 3 PA

LYSODREN 2


of this table.

13


MATULANE 2 PA

megestrol oral suspension 400 mg/10 ml (40

mg/ml), 625 mg/5 ml

1

megestrol oral tablet 1 PA

MEKINIST 3 PA

melphalan 1

mercaptopurine 1

methotrexate sodium oral 1

mycophenolate mofetil oral capsule 1

mycophenolate mofetil oral suspension for

reconstitution

1 QL

mycophenolate mofetil oral tablet 1

mycophenolate sodium 1

MYLERAN 2

NEXAVAR 3 PA; LA; QL

nilutamide 1 PA

NINLARO 3 PA

octreotide acetate 1 PA; LA

ODOMZO 3 PA; LA

PURIXAN 3

RAPAMUNE ORAL SOLUTION 2 QL

RUBRACA ORAL TABLET 200 MG, 300 MG 3 PA; LA; QL

RUBRACA ORAL TABLET 250 MG 3 PA; QL

RYDAPT 3 PA

SANDIMMUNE ORAL SOLUTION 2 QL

SIGNIFOR 3 PA; LA

sirolimus 1

SOLTAMOX 3

SPRYCEL 3 PA; QL

STIVARGA 3 PA

SUTENT 3 PA; QL

SYNRIBO 3 PA


of this table.

14


TABLOID 2 PA

tacrolimus oral 1

TAFINLAR 3 PA; QL

TAGRISSO 3 PA; QL

tamoxifen 1

TARCEVA 2 PA; QL

TARGRETIN TOPICAL 3 PA; QL

TASIGNA 3 PA; QL

temozolomide 1 PA

THALOMID 2 PA

tretinoin (chemotherapy) 1 PA

TREXALL 3

TYKERB 3 PA; LA; QL

VENCLEXTA ORAL TABLET 100 MG 3 PA

VOTRIENT 3 PA; QL

XALKORI 3 PA

XERMELO 3 PA; QL

XTANDI 3 PA; QL

ZEJULA 3 PA; LA; QL

ZELBORAF 3 PA; QL

ZOLINZA 3 PA; QL

ZORTRESS 3

ZYDELIG 3 PA

ZYKADIA 3 PA

ZYTIGA 3 QL

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

ANTICONVULSANTS

APTIOM 3

BANZEL 3

BRIVIACT ORAL 3 PA

carbamazepine oral capsule, er multiphase 12 hr 1


of this table.

15


carbamazepine oral suspension 100 mg/5 ml 1

carbamazepine oral tablet 1

carbamazepine oral tablet extended release 12 hr 1

carbamazepine oral tablet,chewable 1

CELONTIN ORAL CAPSULE 300 MG 2

clonazepam 1

DIASTAT 2 QL

diazepam rectal 1 QL

DILANTIN 2

divalproex 1

epitol 1

EQUETRO 3

ethosuximide 1

felbamate 1

FYCOMPA ORAL SUSPENSION 3

FYCOMPA ORAL TABLET 3

gabapentin oral capsule 1

gabapentin oral solution 250 mg/5 ml 1

gabapentin oral tablet 600 mg, 800 mg 1

GABITRIL ORAL TABLET 12 MG, 16 MG 3

GRALISE 3 ST

GRALISE 30-DAY STARTER PACK 3 ST

LAMICTAL STARTER 3

LAMICTAL XR STARTER ORAL TABLET

EXTENDED REL,DOSE PACK 25 MG (21) -50

MG (7), 25MG (14)-50 MG (14)-100MG (7), 50

MG(14)-100MG (14)-200 MG (7)

3

lamotrigine oral tablet 1

lamotrigine oral tablet disintegrating, dose pk 1

lamotrigine oral tablet extended release 24hr 1

lamotrigine oral tablet, chewable dispersible 1

lamotrigine oral tablet,disintegrating 1


of this table.

16


levetiracetam oral 1

LYRICA 2

ONFI ORAL SUSPENSION 3

ONFI ORAL TABLET 10 MG, 20 MG 3

oxcarbazepine 1

OXTELLAR XR 3

PEGANONE 3

phenobarbital 1

phenytoin oral suspension 125 mg/5 ml 1

phenytoin oral tablet,chewable 1

phenytoin sodium extended 1

primidone 1

QUDEXY XR 3

roweepra 1

SABRIL 3 LA

tiagabine 1

topiramate oral capsule, sprinkle 1

TOPIRAMATE ORAL

CAPSULE,SPRINKLE,ER 24HR

3

topiramate oral tablet 1

TROKENDI XR 3

valproic acid 1

valproic acid (as sodium salt) oral solution 250

mg/5 ml

1

vigabatrin 1

VIMPAT ORAL SOLUTION 3

VIMPAT ORAL TABLET 3

zonisamide 1

ANTIPARKINSONISM AGENTS

APOKYN 3 PA; LA; QL

benztropine oral 1

bromocriptine 1


of this table.

17


carbidopa 1

carbidopa-levodopa 1

carbidopa-levodopa-entacapone 1

DUOPA 3

entacapone 1

NEUPRO 3 PA

pramipexole 1

rasagiline 1

ropinirole 1

RYTARY 3

selegiline hcl 1

tolcapone 1

trihexyphenidyl 1

XADAGO 3 PA; QL

ZELAPAR 3

MIGRAINE & CLUSTER HEADACHE THERAPY

almotriptan malate 1 QL

eletriptan hbr 1 QL

ERGOMAR 3

ergotamine-caffeine 1

frovatriptan 1 QL

isometh-dichloral-acetaminophn 1

isomethepten-caf-acetaminophen oral tablet 65-

20-325 mg

1

migergot 1

naratriptan 1 QL

nodolor 1

ONZETRA XSAIL 3

rizatriptan 1 QL

sumatriptan 1 ST; QL

sumatriptan succinate oral 1 QL


of this table.

18


sumatriptan succinate subcutaneous cartridge 1 QL

sumatriptan succinate subcutaneous pen injector 1 QL

sumatriptan succinate subcutaneous solution 1 QL

sumatriptan succinate subcutaneous syringe 6

mg/0.5 ml

1 QL

SUMAVEL DOSEPRO 3 QL

TREXIMET 2 ST; QL

ZEMBRACE SYMTOUCH 3 QL

zolmitriptan 1 QL

ZOMIG NASAL 2 QL

MISCELLANEOUS NEUROLOGICAL THERAPY

AMPYRA 3 PA; LA

AUSTEDO 3 PA; LA; QL

donepezil 1

galantamine 1

HORIZANT 3 ST

INGREZZA 3 PA; LA; QL

KEVEYIS 3 PA

memantine oral solution 1

memantine oral tablet 1

MEMANTINE ORAL TABLETS,DOSE PACK 3

NAMENDA TITRATION PAK 2

NAMENDA XR 2

NAMZARIC 3

rivastigmine 1

rivastigmine tartrate 1

tetrabenazine 1 PA

MUSCLE RELAXANTS & ANTISPASMODIC THERAPY

AMRIX 3

baclofen 1

carisoprodol oral tablet 250 mg 1


of this table.

19


carisoprodol oral tablet 350 mg 1 QL

carisoprodol-asa-codeine 1 PA; QL

carisoprodol-aspirin 1 QL

chlorzoxazone oral tablet 500 mg 1

cyclobenzaprine oral tablet 1

dantrolene 1

LORZONE 3

meprobamate 1

MESTINON ORAL SYRUP 2

metaxall 1

metaxalone 1

methocarbamol oral 1

orphenadrine citrate oral 1

pyridostigmine bromide 1

tizanidine 1

NARCOTIC ANALGESICS

ABSTRAL 3 PA

acetaminophen-caff-dihydrocod oral capsule 1 PA

acetaminophen-codeine oral solution 120-12 mg/5

ml

1 PA; QL

acetaminophen-codeine oral tablet 1 PA; QL

ARYMO ER 3 ST; QL

ascomp with codeine 1 PA

aspirin-caffeine-dihydrocodein 1 PA

BELBUCA 3 PA; QL

BUPRENORPHINE PATCH; TRANSDERMAL

WEEKLY

3 PA

buprenorphine hcl sublingual 1 QL

butalbital compound w/codeine 1 PA

butalbital-acetaminop-caf-cod 1 PA

butalbital-acetaminophen oral tablet 50-325 mg 1 QL


of this table.

20


butalbital-acetaminophen-caff oral capsule 50-

300-40 mg

1 PA

butalbital-acetaminophen-caff oral capsule 50-

325-40 mg

1

butalbital-acetaminophen-caff oral tablet 50-325-

40 mg

1

butalbital-aspirin-caffeine 1 PA

BUTRANS 3 PA

capacet 1

CAPITAL WITH CODEINE 3 PA; QL

codeine sulfate oral tablet 1 PA

codeine-butalbital-asa-caff 1 PA

diskets 1 PA

EMBEDA ORAL CAPSULE,ORAL

ONLY,EXT.REL PELL

3 ST; QL

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

mg, 7.5-325 mg

1 PA; QL

fentanyl citrate 1 PA; QL

fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

1 PA

FENTANYL TRANSDERMAL PATCH 72

HOUR 37.5 MCG/HOUR, 62.5 MCG/HOUR,

87.5 MCG/HOUR

3 PA

FENTORA 3 PA

hydrocodone-acetaminophen oral solution 7.5-325

mg/15 ml

1 PA; QL

hydrocodone-acetaminophen oral tablet 10-300

mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg,

7.5-325 mg

1 PA; QL

hydrocodone-acetaminophen oral tablet 2.5-325

mg

1 PA

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

200 mg, 7.5-200 mg

1 PA

hydromorphone oral liquid 1 PA; QL

hydromorphone oral tablet 1 PA


of this table.

21


hydromorphone oral tablet extended release 24 hr 1 PA; QL

hydromorphone rectal 1 PA

HYSINGLA ER 3 ST; QL

IBUDONE ORAL TABLET 5-200 MG 3 PA

ibuprofen-oxycodone 1 PA; QL

IONSYS 3

KADIAN ORAL CAPSULE,EXTEND.RELEASE

PELLETS 200 MG, 40 MG

3 ST; QL

LAZANDA 3 PA

levorphanol tartrate 1 PA

lorcet (hydrocodone) 1 PA; QL

lorcet hd 1 PA; QL

lorcet plus oral tablet 7.5-325 mg 1 PA; QL

LORTAB ELIXIR ORAL SOLUTION 10-300

MG/15 ML

3 PA; QL

marten-tab 1 QL

meperidine oral solution 1 PA; QL

meperidine oral tablet 1 PA

methadone oral concentrate 1 PA; QL

methadone oral solution 1 PA; QL

methadone oral tablet 1 PA

methadone oral tablet,soluble 1 PA

methadose oral concentrate 1 PA; QL

methadose oral tablet,soluble 1 PA

MORPHABOND ER 3 ST

morphine concentrate oral solution 1 PA; QL

morphine oral capsule, er multiphase 24 hr 1 PA; QL

morphine oral capsule,extend.release pellets 1 PA; QL

morphine oral solution 1 PA; QL

morphine oral tablet 1 PA

morphine oral tablet extended release 1 PA; QL

morphine rectal 1 PA


of this table.

22


OXAYDO 3 PA

oxycodone oral capsule 1 PA

oxycodone oral concentrate 1 PA; QL

oxycodone oral solution 1 PA; QL

oxycodone oral tablet 10 mg, 15 mg, 30 mg, 5 mg 1 PA

oxycodone oral tablet 20 mg 1 PA; QL

OXYCODONE ORAL TABLET,ORAL

ONLY,EXT.REL.12 HR

3 ST; QL

oxycodone-acetaminophen oral solution 1 PA; QL

oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 5-325 mg, 7.5-325 mg

1 PA; QL

oxycodone-aspirin 1 PA

oxymorphone 1 PA; QL

PRIMLEV 3 PA

SUBSYS 3 PA

SYNALGOS-DC 3 PA

tencon oral tablet 50-325 mg 1 QL

TREZIX ORAL CAPSULE 320.5-30-16 MG 3 PA

verdrocet 1 PA

vicodin 1 PA; QL

vicodin es 1 PA; QL

vicodin hp 1 PA; QL

XTAMPZA ER 3 ST; QL

xylon 10 1 PA

zamicet 1 PA; QL

zebutal oral capsule 50-325-40 mg 1

ZOHYDRO ER ORAL CAPSULE, ORAL

ONLY, ER 12HR

3 ST; QL

NON-NARCOTIC ANALGESICS

aspir-81 ACA ACA; OTC

aspirin low dose ACA ACA; OTC

aspirin oral tablet ACA ACA; OTC


of this table.

23


aspirin oral tablet,chewable ACA ACA; OTC

aspirin oral tablet,delayed release (dr/ec) 325 mg,

81 mg

ACA ACA; OTC

aspir-low ACA ACA; OTC

aspir-trin ACA ACA; OTC

bayer aspirin ACA ACA; OTC

BUNAVAIL 3

buprenorphine-naloxone 1 QL

butorphanol tartrate nasal 1 PA; QL

CAMBIA 3 PA

celecoxib oral capsule 100 mg, 200 mg, 400 mg 1 QL

celecoxib oral capsule 50 mg 1

children's aspirin ACA ACA; OTC

choline,magnesium salicylate 1

CONZIP 3 ST; QL

diclofenac potassium 1

diclofenac sodium oral 1

diclofenac sodium topical drops 1 QL

diclofenac sodium topical gel 1 % 1 QL

diclofenac-misoprostol 1

diflunisal 1

DUEXIS 3 PA

e.c. prin ACA ACA; OTC

ecotrin ACA ACA; OTC

ecotrin low strength ACA ACA; OTC

etodolac 1

EVZIO 3

FENOPROFEN ORAL CAPSULE 3 ST

fenoprofen oral tablet 1

FENORTHO 3 ST

FLECTOR 3 PA

flurbiprofen 1


of this table.

24


ibuprofen oral suspension 1

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

INDOCIN ORAL 3 ST

INDOCIN RECTAL 3

indomethacin oral 1

ketoprofen oral capsule 1

ketoprofen oral capsule,ext rel. pellets 24 hr 200

mg

1

ketorolac oral 1 QL

lite coat aspirin ACA ACA; OTC

meclofenamate 1

mefenamic acid 1

meloxicam 1 QL

nabumetone 1

NALFON ORAL CAPSULE 400 MG 3 ST

naloxone 1

naltrexone 1

NAPRELAN CR ORAL TABLET, ER

MULTIPHASE 24 HR 750 MG

3 ST

naproxen 1

naproxen sodium oral tablet 275 mg, 550 mg 1

naproxen sodium oral tablet, er multiphase 24 hr 1

NARCAN NASAL SPRAY,NON-AEROSOL 4

MG/ACTUATION

2

NUCYNTA 2

NUCYNTA ER 2

oxaprozin 1

PENNSAID TOPICAL SOLUTION IN

METERED-DOSE PUMP

3 ST

pentazocine-naloxone 1 PA

piroxicam 1

salsalate 1

SPRIX 3 PA


of this table.

25


SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1

MG

2

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 8-

2 MG

2 QL

sulindac 1

TIVORBEX 3 ST

tolmetin 1

TRAMADOL ORAL CAPSULE,ER BIPHASE

24 HR 17-83

3 ST; QL

TRAMADOL ORAL CAPSULE,ER BIPHASE

24 HR 25-75

3 ST; QL

tramadol oral tablet 1

tramadol oral tablet extended release 24 hr 1 QL

tramadol oral tablet, er multiphase 24 hr 1 QL

tramadol-acetaminophen 1 QL

VIMOVO 2 PA; QL

VIVLODEX 3 ST

ZIPSOR 3 ST

ZORVOLEX 3 ST

ZUBSOLV 3

PSYCHOTHERAPEUTIC DRUGS

ADASUVE 3

ADDERALL XR 2

ADDYI 3 PA

ADZENYS XR-ODT 3 ST

alprazolam 1

alprazolam intensol 1 QL

amitriptyline 1

amitriptyline-chlordiazepoxide 1

amoxapine 1

APLENZIN 3

APTENSIO XR 3 ST


of this table.

26


aripiprazole oral solution 1 QL

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

mg, 5 mg

1 QL

aripiprazole oral tablet 2 mg 1

aripiprazole oral tablet,disintegrating 1

armodafinil 1 PA

atomoxetine 1

BELSOMRA 3 PA; QL

BRISDELLE 3

bupropion hcl oral tablet 1

bupropion hcl oral tablet extended release 12 hr 1

bupropion hcl oral tablet extended release 24 hr

150 mg

1 QL

bupropion hcl oral tablet extended release 24 hr

300 mg

1

buspirone 1

BUTISOL ORAL TABLET 30 MG 3

chlordiazepoxide hcl 1

chlorpromazine oral tablet 10 mg, 200 mg, 50 mg 1

citalopram 1 QL

clomipramine 1 PA

clonidine hcl oral tablet extended release 12 hr 1

clorazepate dipotassium 1

clozapine oral tablet 1

clozapine oral tablet,disintegrating 100 mg, 12.5

mg, 25 mg

1

CLOZAPINE ORAL

TABLET,DISINTEGRATING 150 MG, 200 MG

3 ST

COTEMPLA XR-ODT 3 ST

DAYTRANA 3 ST

desipramine 1

DESVENLAFAXINE 3

DESVENLAFAXINE FUMARATE 3


of this table.

27


desvenlafaxine succinate 1

dexmethylphenidate 1

dextroamphetamine 1

dextroamphetamine-amphetamine oral

capsule,extended release 24hr

1 PA

dextroamphetamine-amphetamine oral tablet 1

diazepam intensol 1 QL

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

diazepam oral tablet 1

doxepin oral capsule 1

doxepin oral concentrate 1 QL

duloxetine 1 QL

DYANAVEL XR 3 ST

EDLUAR 3 ST

EMSAM 3

ergoloid 1

escitalopram oxalate oral solution 1 QL

escitalopram oxalate oral tablet 1

estazolam 1

eszopiclone 1 QL

EVEKEO 3 PA

FANAPT 3 ST

FAZACLO ORAL TABLET,DISINTEGRATING

150 MG, 200 MG

3 ST

FETZIMA 3

fluoxetine oral capsule 1

fluoxetine oral capsule,delayed release(dr/ec) 1 QL

fluoxetine oral solution 1 QL

fluoxetine oral tablet 10 mg, 20 mg 1

FLUOXETINE ORAL TABLET 60 MG 3 ST

fluphenazine hcl oral concentrate 1 QL

fluphenazine hcl oral elixir 1 QL


of this table.

28


fluphenazine hcl oral tablet 1

flurazepam 1

fluvoxamine oral capsule,extended release 24hr 1 ST

fluvoxamine oral tablet 1

FORFIVO XL 3

guanfacine oral tablet extended release 24 hr 1

guanidine 1

haloperidol 1

haloperidol lactate oral 1 QL

HETLIOZ 3 PA

imipramine hcl 1

imipramine pamoate 1

KHEDEZLA 3

LATUDA 3 ST

lithium carbonate 1

lithium citrate oral solution 8 meq/5 ml 1 QL

lorazepam intensol 1 QL

lorazepam oral concentrate 1 QL

lorazepam oral tablet 1

loxapine succinate 1

maprotiline 1

MARPLAN 3

metadate er 1

methamphetamine 1

methylphenidate hcl oral capsule, er biphasic 30-

70

1

methylphenidate hcl oral capsule,er biphasic 50-

50

1

methylphenidate hcl oral solution 1 QL

methylphenidate hcl oral tablet 1

methylphenidate hcl oral tablet extended release 1


of this table.

29


methylphenidate hcl oral tablet extended release

24hr

1 QL

methylphenidate hcl oral tablet,chewable 1

midazolam oral syrup 2 mg/ml 1

mirtazapine 1

modafinil 1 PA

MYDAYIS 3 ST; QL

nefazodone 1

nortriptyline oral capsule 1

nortriptyline oral solution 1 QL

NUPLAZID 2 PA; QL

olanzapine oral 1

olanzapine-fluoxetine 1

oxazepam 1

paliperidone 1 PA

paroxetine hcl oral tablet 1

paroxetine hcl oral tablet extended release 24 hr 1

PAXIL ORAL SUSPENSION 3 ST; QL

perphenazine 1

perphenazine-amitriptyline 1

PEXEVA 3 ST

phenelzine 1

pimozide 1

procentra 1

protriptyline 1

quazepam 1

quetiapine 1

QUILLICHEW ER 3 ST

QUILLIVANT XR 3 ST

REXULTI 3 ST

risperidone oral solution 1 QL

risperidone oral tablet 1


of this table.

30


risperidone oral tablet,disintegrating 1

RITALIN LA ORAL CAPSULE,ER BIPHASIC

50-50 10 MG

3 ST

ROZEREM 3 PA

SAPHRIS (BLACK CHERRY) SUBLINGUAL

TABLET 2.5 MG, 5 MG

3 ST

seconal sodium 1 PA

sertraline oral concentrate 1 QL

sertraline oral tablet 1

SILENOR 3 ST

temazepam 1

thioridazine 1

thiothixene 1

tranylcypromine 1

trazodone 1

triazolam 1

trifluoperazine 1

trimipramine 1

TRINTELLIX 3

venlafaxine 1

VERSACLOZ 3 ST

VIIBRYD ORAL TABLET 2

VIIBRYD ORAL TABLETS,DOSE PACK 10

MG (7)- 20 MG (23)

2

VRAYLAR 3 PA; QL

VYVANSE 3 ST

XYREM 3 PA; LA; QL

zaleplon 1 QL

zenzedi oral tablet 10 mg, 5 mg 1

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20

MG, 30 MG, 7.5 MG

3 ST

ziprasidone hcl 1

zolpidem oral 1 QL


of this table.

31


zolpidem sublingual 1

ZOLPIMIST 3 ST; QL

CARDIOVASCULAR, HYPERTENSION & LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone oral 1

disopyramide phosphate oral capsule 1

dofetilide 1

flecainide 1

mexiletine 1

MULTAQ 3

NORPACE CR 2

pacerone oral tablet 100 mg, 200 mg, 400 mg 1

propafenone 1

quinidine gluconate oral 1

quinidine sulfate oral tablet 1

sotalol af 1

sotalol oral 1

SOTYLIZE 3

ANTIHYPERTENSIVE THERAPY

acebutolol 1

afeditab cr 1 QL

ALDACTAZIDE ORAL TABLET 50-50 MG 3

amiloride 1

amiloride-hydrochlorothiazide 1

amlodipine 1 QL

amlodipine-benazepril 1 QL

amlodipine-olmesartan 1 ST; QL

amlodipine-valsartan 1

amlodipine-valsartan-hcthiazid 1

atenolol 1

atenolol-chlorthalidone 1


of this table.

32


benazepril 1

benazepril-hydrochlorothiazide 1

betaxolol oral 1

BIDIL 3

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide 1

bumetanide oral 1

BYSTOLIC 3 ST

BYVALSON 3

candesartan 1 QL

candesartan-hydrochlorothiazid 1 QL

captopril 1

captopril-hydrochlorothiazide 1

CARDIZEM LA ORAL TABLET EXTENDED

RELEASE 24 HR 120 MG

3

CARDURA XL 3

cartia xt 1 QL

carvedilol 1

chlorothiazide 1

chlorthalidone oral tablet 25 mg, 50 mg 1

clonidine 1

clonidine hcl oral tablet 1

clorpres oral tablet 0.1-15 mg, 0.2-15 mg 1

CLORPRES ORAL TABLET 0.3-15 MG 3

COREG CR 2

DEMSER 3

diltiazem hcl oral capsule,ext.rel 24h degradable

240 mg

1 QL

diltiazem hcl oral capsule,extended release 12 hr 1

diltiazem hcl oral capsule,extended release 24 hr

240 mg, 420 mg

1 QL

diltiazem hcl oral capsule,extended release 24hr 1 QL


of this table.

33


diltiazem hcl oral tablet 1

diltiazem hcl oral tablet extended release 24 hr

180 mg, 240 mg, 300 mg, 360 mg

1

dilt-xr 1 QL

DIURIL 3

doxazosin 1

DUTOPROL 3

DYRENIUM 3

EDARBI 2 ST

EDARBYCLOR 2 ST

enalapril maleate 1

enalapril-hydrochlorothiazide 1

EPANED ORAL SOLUTION 3 ST

eplerenone 1

eprosartan 1 QL

ethacrynic acid 1

felodipine 1 QL

fosinopril 1

fosinopril-hydrochlorothiazide 1

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8

mg/ml)

1

furosemide oral tablet 1

guanfacine oral tablet 1

HEMANGEOL 3

hydralazine oral 1

hydrochlorothiazide 1

indapamide 1

INDERAL XL 3 ST

INNOPRAN XL 3 ST

irbesartan 1 QL

irbesartan-hydrochlorothiazide 1 QL

isradipine 1


of this table.

34


labetalol oral 1

lisinopril 1

lisinopril-hydrochlorothiazide 1

losartan 1 QL

losartan-hydrochlorothiazide 1

matzim la 1

methyclothiazide 1

methyldopa 1

methyldopa-hydrochlorothiazide 1

metolazone 1

metoprolol succinate 1

METOPROLOL SU-HYDROCHLOROTHIAZ 3

metoprolol ta-hydrochlorothiaz 1

metoprolol tartrate oral 1

minoxidil oral 1

moexipril 1

moexipril-hydrochlorothiazide 1

nadolol 1

nadolol-bendroflumethiazide 1

nicardipine oral 1

nifedipine oral capsule 10 mg 1

nifedipine oral capsule 20 mg 1 QL

nifedipine oral tablet extended release 1 QL

nifedipine oral tablet extended release 24hr 1 QL

nimodipine 1

nisoldipine 1

NYMALIZE 3

olmesartan 1 ST; QL

olmesartan-amlodipin-hcthiazid 1 ST; QL

olmesartan-hydrochlorothiazide 1 ST; QL

ORENITRAM ORAL TABLET EXTENDED

RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG

3 PA


of this table.

35


ORENITRAM ORAL TABLET EXTENDED

RELEASE 5 MG

3

perindopril erbumine 1

phenoxybenzamine 1

pindolol 1

prazosin 1

PRESTALIA 3

propranolol oral 1

propranolol-hydrochlorothiazid 1

QBRELIS 3 ST

quinapril 1

quinapril-hydrochlorothiazide 1

ramipril 1

spironolactone 1

spironolacton-hydrochlorothiaz 1

taztia xt 1 QL

TEKTURNA 3

TEKTURNA HCT 3

telmisartan 1 ST; QL

telmisartan-amlodipine 1 ST; QL

telmisartan-hydrochlorothiazid 1 ST; QL

terazosin 1

timolol maleate oral 1

torsemide oral 1

trandolapril 1

trandolapril-verapamil 1

triamterene-hydrochlorothiazid 1

UPTRAVI ORAL TABLET 3 PA; QL

UPTRAVI ORAL TABLETS,DOSE PACK 3 PA; LA

valsartan 1 QL

valsartan-hydrochlorothiazide 1 QL

verapamil oral 1


of this table.

36


CARDIAC GLYCOSIDES

digitek 1

digox 1

digoxin oral solution 50 mcg/ml 1

digoxin oral tablet 1

LANOXIN ORAL 2

COAGULATION THERAPY

AMICAR 3

aspirin-dipyridamole 1

BRILINTA 2 QL

cilostazol 1

clopidogrel oral tablet 300 mg 1

clopidogrel oral tablet 75 mg 1 QL

COUMADIN ORAL 2

dipyridamole oral 1

DURLAZA 3

ELIQUIS 2

enoxaparin 1 PA; QL

fondaparinux 1 PA

FRAGMIN SUBCUTANEOUS SOLUTION 3 PA; QL

FRAGMIN SUBCUTANEOUS SYRINGE 3 PA; QL

jantoven 1

MEPHYTON 2

pentoxifylline 1

PRADAXA ORAL CAPSULE 150 MG, 75 MG 3 QL

prasugrel 1

PROMACTA 3 PA; LA

ticlopidine 1

warfarin 1

XARELTO, XARELTO STARTER PACK 2

YOSPRALA 3


of this table.

37


ZONTIVITY 3

LIPID/CHOLESTEROL LOWERING AGENTS

ALTOPREV 3 ST; QL

amlodipine-atorvastatin 1

ANTARA ORAL CAPSULE 30 MG, 90 MG 3 ST

atorvastatin oral tablet 10 mg, 20 mg ACA ACA; QL

atorvastatin oral tablet 40 mg, 80 mg 1 QL

cholestyramine (with sugar) 1

cholestyramine light 1

COLESTID FLAVORED ORAL PACKET 3

COLESTID ORAL GRANULES 3

colestipol 1

ezetimibe 1

ezetimibe-simvastatin 1 QL

fenofibrate micronized 1

fenofibrate nanocrystallized 1

FENOFIBRATE ORAL CAPSULE 3 ST

fenofibrate oral tablet 1

fenofibric acid 1

fenofibric acid (choline) 1

FLOLIPID 3 ST; QL

fluvastatin ACA ACA; QL

gemfibrozil 1

JUXTAPID 3 PA; LA

KYNAMRO 3 PA; LA

LIPOFEN 3 ST

LIVALO 3 ST

lovastatin ACA ACA; QL

niacin oral tablet extended release 24 hr 1 QL

omega-3 acid ethyl esters 1

PRALUENT PEN 2 PA; LA; QL


of this table.

38


pravastatin ACA ACA; QL

prevalite 1

REPATHA PUSHTRONEX 2 PA; QL

REPATHA SURECLICK 2 PA; QL

REPATHA SYRINGE 2 PA; QL

rosuvastatin oral tablet 10 mg, 5 mg ACA ACA; QL

rosuvastatin oral tablet 20 mg, 40 mg 1 QL

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg ACA ACA; QL

simvastatin oral tablet 80 mg 1 QL

TRIGLIDE ORAL TABLET 160 MG 3 ST

triklo 1

WELCHOL 3

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR 3

ENTRESTO 3 PA

RANEXA 2

VECAMYL 3

NITRATES

DILATRATE-SR 3

GONITRO 3

ISORDIL 3

isosorbide dinitrate oral 1

isosorbide mononitrate 1

MINITRAN 3

nitro-bid 1

NITRO-DUR TRANSDERMAL PATCH 24

HOUR 0.2 MG/HR, 0.3 MG/HR, 0.4 MG/HR, 0.6

MG/HR, 0.8 MG/HR

3

nitroglycerin oral 1

nitroglycerin sublingual 1

nitroglycerin transdermal patch 24 hour 1

nitroglycerin translingual 1


of this table.

39


nitro-time 1

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

acitretin 1

calcipotriene 1

calcipotriene-betamethasone 1 PA

calcitrene 1

calcitriol topical 1 QL

COAL TAR 3

COSENTYX 3 ST; LA

COSENTYX (2 SYRINGES) 3 ST; LA

COSENTYX PEN 3 ST; LA

COSENTYX PEN (2 PENS) 3 ST; LA

drithocreme hp 1

EPIFOAM 3

hydrocortisone-pramoxine topical 1

OVACE PLUS 3

OVACE PLUS SHAMPOO 3

OVACE PLUS WASH 3

PRAMOSONE 3

PRAMOSONE E 3

seb-prev 1

selenium sulfide topical lotion 1

selenium sulfide topical shampoo 2.25 % 1

SELRX 3

SILIQ 3 ST

SORILUX 3

sulfacetamide sodium topical 1

TACLONEX TOPICAL SUSPENSION 3 PA

TALTZ AUTOINJECTOR 3 ST

TALTZ AUTOINJECTOR (2 PACK) 3 ST


of this table.

40


TALTZ AUTOINJECTOR (3 PACK) 3 ST

TALTZ SYRINGE 3 ST

TALTZ SYRINGE (2 PACK) 3 ST

TALTZ SYRINGE (3 PACK) 3 ST

TERSI FOAM 3

ZITHRANOL 3

BURN THERAPY

silver sulfadiazine 1

ssd 1

thermazene 1

KERATOLYTICS

BENSAL HP TOPICAL OINTMENT 3 % 3 ST

INOVA 4-1 3 ST

INOVA 8-2 3 ST

KERALYT SCALP COMPLETE 3 ST

PODOCON 3 ST

POTASSIUM HYDROXIDE 3 ST

salicylic acid er-ceramides topical kit,cleanser and

cream er

1

salicylic acid topical cream 1

salicylic acid topical cream,extended release 1

salicylic acid topical film forming liquid w/appl 1

salicylic acid topical film-forming soln er w/ appl 1

salicylic acid topical foam 1

salicylic acid topical gel 1

salicylic acid topical liquid 26 % 1

salicylic acid topical lotion 1

salicylic acid topical lotion,extended release 1

salicylic acid topical shampoo 1

SALKERA 3 ST

salvax 1


of this table.

41


SALVAX DUO PLUS 3 ST

ULTRASAL-ER 3 ST

VIRASAL 3 ST

MISCELLANEOUS DERMATOLOGICALS

AMELUZ 3

ammonium lactate 1

bp-50% urea 1

CARAC 3

cem-urea 1

CONDYLOX TOPICAL GEL 2 ST

diclofenac sodium topical gel 3 % 1 PA; QL

doxepin topical 1 QL

DUPIXENT 3 PA

ELIDEL 3 ST; QL

EUCRISA 3 ST

FLUOROPLEX 2

FLUOROURACIL TOPICAL CREAM 0.5 % 3

fluorouracil topical cream 5 % 1

fluorouracil topical solution 1

GORDONS UREA TOPICAL OINTMENT 40 % 3 ST

HYDRO 35 3 ST

IODOFLEX 3

IODOSORB 3

KERAFOAM 3 ST

KERALAC 3 ST

LEVULAN 3

methoxsalen 1

PANRETIN 3 QL

PICATO 3

podofilox 1

prudoxin 1 QL


of this table.

42


rea lo 39 1

rea lo 40 topical lotion 1

REGRANEX 3

silver nitrate 1

silver nitrate applicators 1

tacrolimus topical 1 ST; QL

TOLAK 3

umecta topical foam 1

URAMAXIN TOPICAL FOAM 3 ST

urea nail stick 1

urea topical cream 39 %, 40 %, 45 %, 47 %, 50 % 1

urea topical foam 1

urea topical gel 45 % 1

urea topical lotion 40 %, 45 % 1

UTOPIC 3 ST

VALCHLOR 3

ZONALON 3 QL

THERAPY FOR ACNE

ABSORICA 3

ACANYA TOPICAL GEL WITH PUMP 3 ST; QL

adapalene topical cream 1 PA

adapalene topical gel 0.1 % 1

adapalene topical gel 0.3 % 1 PA

adapalene topical gel with pump 1 PA

ADAPALENE TOPICAL LOTION 3 ST

adapalene-benzoyl peroxide 1

AKTIPAK 3 ST

amnesteem 1

AVAR LS 3 ST

avar topical cleanser 1

AVAR TOPICAL FOAM 3 ST


of this table.

43


AVAR TOPICAL PADS, MEDICATED 3 ST

AVAR-E GREEN 3 ST

AVAR-E LS 3 ST

avita topical cream 1 PA

AVITA TOPICAL GEL 3 ST

AZELEX 3 ST

BENZEFOAM 3 ST

BENZEFOAM ULTRA 3 ST

benzepro topical towelette 1

benzoyl peroxide topical cleanser 7 % 1

bpo topical gel 1

bpo topical towelette 6 % 1

claravis 1

cleansing wash topical cleanser 1

CLINDACIN ETZ TOPICAL KIT 3 ST

clindacin p 1

CLINDACIN PAC 3 ST

CLINDAGEL 3 ST

clindamycin phosphate topical 1

clindamycin-benzoyl peroxide 1

DIFFERIN TOPICAL LOTION 3 ST

EPIDUO FORTE 3 ST

ery pads 1

erygel 1

erythromycin with ethanol 1

erythromycin-benzoyl peroxide 1

FABIOR 3 PA

FINACEA 3 ST

INOVA 3 ST

metronidazole topical 1

MIRVASO 3 ST


of this table.

44


neuac 1

NEUAC KIT 3 ST

NORITATE 3

NUOX 3 ST

ONEXTON TOPICAL GEL WITH PUMP 3 ST

PLEXION 3 ST

PLEXION CLEANSING CLOTHS 3 ST

RHOFADE 3 ST

rosadan topical cream 1

rosadan topical gel 1

ROSADAN TOPICAL KIT, CLEANSER AND

GEL

3

ROSADAN TOPICAL KIT,CLEANSER AND

CREAM

3

ROSULA 3 ST

rosula cleansing cloths 1

SOOLANTRA 3 ST

sss 10-5 1

sulfacetamide sodium-sulfur topical cleanser 1

sulfacetamide sodium-sulfur topical cream 1

sulfacetamide sodium-sulfur topical lotion 1

sulfacetamide sodium-sulfur topical pads,

medicated 10-4 %

1

sulfacetamide sodium-sulfur topical suspension 1

sulfacetamide sod-sulfur-urea topical cleanser 1

sulfacetamide-sulfur-cleansr23 1

sulfacleanse 8-4 1

sulfact na-sul-avobnz-otn-ocsa 1

SUMADAN 3 ST

SUMADAN XLT 3 ST

SUMAXIN CP 3 ST

SUMAXIN TOPICAL CLEANSER 3 ST


of this table.

45


SUMAXIN TS 3 ST

tazarotene 1 PA

TAZORAC TOPICAL CREAM 0.05 % 2 PA

TAZORAC TOPICAL GEL 2 PA

tretinoin 1 PA

TRETIN-X CREAM KIT 3 ST

TRETIN-X TOPICAL CREAM 0.075 % 3 ST

VANOXIDE-HC 3

VELTIN 3 ST

zenatane 1

TOPICAL ANESTHETICS

BUCALSEP 3

glydo 1

lidocaine hcl laryngotracheal 1

lidocaine hcl mucous membrane jelly 1

lidocaine hcl mucous membrane jelly in applicator 1

lidocaine hcl mucous membrane solution 4 % (40

mg/ml)

1

lidocaine hcl-hydrocortison ac topical 1

lidocaine topical adhesive patch,medicated 1 PA

lidocaine topical ointment 1 PA

lidocaine viscous 1

lidocaine-prilocaine 1

lta pre-attached 1

TOPICAL ANTIBACTERIALS

ALTABAX 3

CENTANY 3 ST

CENTANY AT 3 ST

CORTISPORIN TOPICAL 2

gentamicin topical 1

iodoquinol-hc 1


of this table.

46


lugols topical 1

mupirocin 1

mupirocin calcium 1

NEO-SYNALAR 3

NEO-SYNALAR KIT 3

sulfacetamide sodium (acne) 1

SULFAMYLON 3 ST

TOPICAL ANTIFUNGALS

ciclodan 1

CICLODAN KIT 3

ciclopirox 1

ciclopirox-ure-camph-menth-euc 1

clotrimazole topical 1

clotrimazole-betamethasone 1

econazole 1

ECOZA 3

ERTACZO 3

EXELDERM 3

EXODERM 3

JUBLIA 3 PA

KERYDIN 3 PA

ketoconazole topical 1

LOPROX KIT 3

LUZU 3

MENTAX 3

naftifine 1

NAFTIN TOPICAL GEL 3

nyamyc 1

nyata 1

nystatin topical 1

nystatin-triamcinolone 1


of this table.

47


nystop 1

OXISTAT TOPICAL LOTION 3

TRIACETIN 3

TRIPLE DYE 3

VUSION 3 QL

XOLEGEL 3 QL

TOPICAL ANTIVIRALS

acyclovir topical 1

DENAVIR 3 PA; QL

XERESE 3 QL

ZOVIRAX TOPICAL CREAM 3 PA

TOPICAL CORTICOSTEROIDS

ala-cort topical cream 1

alclometasone 1 PA

amcinonide 1

apexicon e 1

betamethasone dipropionate 1

betamethasone valerate topical cream 1

betamethasone valerate topical foam 1 PA; QL

betamethasone valerate topical lotion 1

betamethasone valerate topical ointment 1

betamethasone, augmented topical cream 1

betamethasone, augmented topical gel 1 PA

betamethasone, augmented topical lotion 1 PA

betamethasone, augmented topical ointment 1

CAPEX 3 ST

clobetasol scalp 1

clobetasol topical cream 1

clobetasol topical foam 1 PA

clobetasol topical gel 1 PA

clobetasol topical lotion 1 PA


of this table.

48


clobetasol topical ointment 1 PA

clobetasol topical shampoo 1 PA

clobetasol topical spray,non-aerosol 1 PA

clobetasol-emollient topical cream 1

clobetasol-emollient topical foam 1 PA

CLOCORTOLONE PIVALATE 3 ST

clodan 1 PA

CLODAN KIT 3 ST

CLODERM 3 ST

CORDRAN TAPE LARGE ROLL 3 ST

cormax scalp 1

DERMASORB HC COMPLETE KIT 3 ST

DERMASORB TA COMPLETE KIT 3 ST

DESONATE 3 ST

desonide 1 PA

desoximetasone topical cream 0.05 % 1 PA

desoximetasone topical cream 0.25 % 1

desoximetasone topical gel 1 PA

desoximetasone topical ointment 1 PA

diflorasone 1 PA

fluocinolone and shower cap 1 PA

fluocinolone topical cream 0.01 % 1 PA

fluocinolone topical cream 0.025 % 1

fluocinolone topical oil 1 PA

fluocinolone topical ointment 1

fluocinolone topical solution 1 PA

fluocinonide topical cream 0.05 % 1

fluocinonide topical cream 0.1 % 1 PA; QL

fluocinonide topical gel 1 PA

fluocinonide topical ointment 1 PA

fluocinonide topical solution 1


of this table.

49


fluocinonide-e 1 PA

fluocinonide-emollient 1 PA

flurandrenolide 1 PA

fluticasone topical cream 1

fluticasone topical lotion 1 PA

fluticasone topical ointment 1

halobetasol propionate 1 PA

HALOG 3 ST

hydrocortisone butyrate 1 PA

hydrocortisone butyr-emollient 1 PA; QL

hydrocortisone topical cream 1 %, 2.5 % 1

hydrocortisone topical lotion 2.5 % 1

hydrocortisone topical ointment 1 %, 2.5 % 1

hydrocortisone valerate 1 PA

hydrocortisone-min oil-wht pet 1 PA

LOCOID LIPOCREAM 3 ST; QL

LOCOID TOPICAL LOTION 3 ST

mometasone topical 1

nolix 1 PA

NUCORT 3 ST; QL

PANDEL 3 ST; QL

prednicarbate 1

scalacort 1

SCALACORT DK 3 ST

SERNIVO 3 ST

SYNALAR CREAM KIT 3 ST

SYNALAR OINTMENT KIT 3 ST

SYNALAR TS 3 ST

TEXACORT 3 ST

TOPICORT TOPICAL SPRAY,NON-AEROSOL 3 ST

triamcinolone acetonide topical aerosol 1 PA


of this table.

50


triamcinolone acetonide topical cream 1

triamcinolone acetonide topical lotion 1

triamcinolone acetonide topical ointment 0.025 %,

0.1 %, 0.5 %

1

trianex 1 PA

triderm topical cream 1

ULTRAVATE TOPICAL LOTION 3 ST

ULTRAVATE X 3 ST

VERDESO 3 ST

TOPICAL ENZYMES

SANTYL 3 QL

TOPICAL SCABICIDES / PEDICULICIDES

EURAX 3

lindane topical shampoo 1

malathion 1

permethrin topical cream 1

SKLICE 3

spinosad 1 QL

ULESFIA 3

DIAGNOSTICS & MISCELLANEOUS AGENTS

ANOREXIANTS

BELVIQ 3 PA

BELVIQ XR 3 PA

benzphetamine 1 PA

CONTRAVE 3 PA

diethylpropion 1 PA

LOMAIRA 3 PA

phendimetrazine tartrate 1 PA

phentermine 1 PA

QSYMIA 3 PA

SAXENDA 3 PA


of this table.

51


XENICAL 3 PA

IRRIGATING SOLUTIONS

SORBITOL IRRIGATION SOLUTION 3 % 3

SORBITOL-MANNITOL 3

tis-u-sol pentalyte 1

MISCELLANEOUS AGENTS

acamprosate 1

alendronate oral tablet 40 mg 1 QL

anagrelide 1

BUPHENYL ORAL TABLET 3 PA

caffeine citrate oral 1

CARBAGLU 3 LA

CARNITOR (SUGAR-FREE) 3 PA

cevimeline 1

CHEMET 2

disulfiram 1

etidronate disodium 1

EXJADE 3 PA; LA

FERRIPROX 3 PA

INCRELEX 3 PA; LA; QL

INFASURF 3

JADENU 3 PA

JADENU SPRINKLE 3 PA

levocarnitine (with sugar) 1

levocarnitine oral tablet 1 PA

LIPOCHOL PLUS 3

LITHOSTAT 3

METOPIRONE 3

midodrine 1

NITYR 3

NORTHERA 3


of this table.

52


NUTRESTORE 3 PA

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5

MG

3 LA

ORFADIN ORAL CAPSULE 20 MG 3

ORFADIN ORAL SUSPENSION 3 LA

pilocarpine hcl oral tablet 5 mg 1

RADIOGARDASE 3

RAVICTI 3

riluzole 1

risedronate oral tablet 30 mg 1 QL

sodium phenylbutyrate 1 PA

SURVANTA 3

SYPRINE 3

THIOLA 3

XURIDEN 3 PA

SMOKING DETERRENTS

bupropion hcl (smoking deter) ACA ACA

CHANTIX ACA ACA

CHANTIX CONTINUING MONTH BOX ACA ACA

CHANTIX STARTING MONTH BOX ACA ACA

NICODERM CQ ACA ACA; OTC

nicorelief ACA ACA; OTC

NICORETTE BUCCAL GUM 2 MG ACA ACA; OTC

nicorette buccal gum 4 mg ACA ACA; OTC

NICORETTE BUCCAL LOZENGE ACA ACA; OTC

NICORETTE BUCCAL MINI LOZENGE ACA ACA; OTC

nicotine (polacrilex) ACA ACA; OTC

nicotine transdermal patch 24 hour 14 mg/24 hr,

21 mg/24 hr, 7 mg/24 hr

ACA ACA; OTC

nicotine transdermal patch, td daily, sequential ACA ACA; OTC

NICOTROL ACA ACA

NICOTROL NS ACA ACA


of this table.

53


nts step 1 ACA ACA; OTC

quit 2 buccal gum ACA ACA; OTC

QUIT 2 BUCCAL LOZENGE ACA ACA; OTC

quit 4 buccal gum ACA ACA; OTC

QUIT 4 BUCCAL LOZENGE ACA ACA; OTC

stop smoking aid ACA ACA; OTC

ZYBAN ACA ACA

EAR, NOSE & THROAT MEDICATIONS

MISCELLANEOUS AGENTS

azelastine nasal 1 QL

BACTROBAN NASAL 2

chlorhexidine gluconate mucous membrane 1

CLINPRO 5000 3

DEBACTEROL 3

denta 5000 plus 1

dentagel 1

fluoride (sodium) dental 1

FLUORIDEX DAILY DEFENSE DENTAL

PASTE

3

ipratropium bromide nasal 1 QL

olopatadine nasal 1 QL

oralone 1

paroex oral rinse 1

periogard 1

pilocarpine hcl oral tablet 7.5 mg 1

PREVIDENT 5000 BOOSTER PLUS 3

PREVIDENT 5000 DRY MOUTH 3

PREVIDENT 5000 ENAMEL PROTECT 3

PREVIDENT 5000 SENSITIVE 3

Q-CARE RX Q4 3

sf 1


of this table.

54


sf 5000 plus 1

triamcinolone acetonide dental 1

TYZINE NASAL DROPS 0.1 % 3

TYZINE NASAL SPRAY,NON-AEROSOL 3

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic (ear) 1

CETRAXAL 3

ciprofloxacin hcl otic (ear) 1

floxin otic (ear) drops 1

fluocinolone acetonide oil 1

ofloxacin otic (ear) 1

OTIPRIO 3

OTIC STEROID / ANTIBIOTIC

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 2

neomycin-polymyxin-hc otic (ear) 1

OTOVEL 3

ENDOCRINE/DIABETES

ADRENAL HORMONES

cortisone 1

deltasone oral tablet 20 mg 1

dexamethasone 1

dexamethasone intensol 1

DEXPAK 10 DAY 3

DEXPAK 13 DAY 3

DEXPAK 6 DAY 3

EMFLAZA 3 PA; LA

fludrocortisone 1

hydrocortisone oral 1

LOCORT 3


of this table.

55


MEDROL ORAL TABLET 2 MG 3

methylprednisolone 1

millipred dp 1

millipred oral tablet 1

prednisolone oral solution 15 mg/5 ml 1

prednisolone sodium phosphate oral solution 10

mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4

mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7

mg/5 ml)

1

prednisolone sodium phosphate oral

tablet,disintegrating

1

prednisone 1

prednisone intensol 1

RAYOS 3

veripred 20 1

ZONACORT 3

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg 1

propylthiouracil 1

SSKI 3

GLUCOSE ELEVATING AGENTS

GLUCAGON EMERGENCY KIT (HUMAN) 3 QL

PROGLYCEM 3

INSULIN THERAPY

AFREZZA 3

APIDRA 3 ST

APIDRA SOLOSTAR 3 ST

BASAGLAR KWIKPEN 3 ST

HUMALOG 3 ST

HUMALOG JUNIOR KWIKPEN 3

HUMALOG KWIKPEN 3 ST

HUMALOG MIX 50-50 3 ST


of this table.

56


HUMALOG MIX 50-50 KWIKPEN 3 ST

HUMALOG MIX 75-25 3 ST

HUMALOG MIX 75-25 KWIKPEN 3 ST

HUMULIN N KWIKPEN 3 ST

HUMULIN R U-500 (CONC) KWIKPEN 3 PA

HUMULIN R U-500 (CONCENTRATED) 3 PA

LANTUS 3 ST

LANTUS SOLOSTAR 3 ST

LEVEMIR 2

LEVEMIR FLEXTOUCH 2

NOVOLOG 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70-30 2

NOVOLOG MIX 70-30 FLEXPEN 2

NOVOLOG PENFILL 2

RELION NOVOLIN 70/30 2

RELION NOVOLIN N 2

RELION NOVOLIN R 2

SOLIQUA 100/33 3 PA

TOUJEO SOLOSTAR 3 ST

TRESIBA FLEXTOUCH U-100 2

TRESIBA FLEXTOUCH U-200 2

XULTOPHY 100/3.6 2 QL

MISCELLANEOUS HORMONES

ANADROL-50 3

ANDRODERM 3 ST

ANDROGEL TRANSDERMAL GEL IN

METERED-DOSE PUMP 20.25 MG/1.25 GRAM

(1.62 %)

2 QL

ANDROGEL TRANSDERMAL GEL IN

PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62

% (40.5 MG/2.5 GRAM)

2 QL


of this table.

57


BRAVELLE 3 PA

cabergoline 1

calcitonin (salmon) 1 QL

calcitriol oral 1

CERDELGA 3 PA

CETROTIDE SUBCUTANEOUS KIT 0.25 MG 2 PA

CHORIONIC GONADOTROPIN, HUMAN 3 PA

clomiphene citrate 1 PA

danazol 1

DDAVP NASAL SOLUTION 3

desmopressin nasal solution 1

desmopressin nasal spray,non-aerosol 1

desmopressin oral 1

doxercalciferol oral 1

FOLLISTIM AQ SUBCUTANEOUS 3 PA

FORTESTA 3 ST; QL

GONAL-F 2 PA

GONAL-F RFF 2 PA

GONAL-F RFF REDI-JECT 2 PA

KORLYM 2 PA

KUVAN ORAL POWDER IN PACKET 500 MG 3 PA

KUVAN ORAL TABLET,SOLUBLE 3 PA

MENOPUR 2 PA

METHITEST 3

methyltestosterone oral capsule 1

NATESTO 3 ST

NATPARA 3 PA; LA

NOVAREL INTRAMUSCULAR RECON SOLN

10,000 UNIT

3 PA

OVIDREL 2 PA

oxandrolone 1

paricalcitol oral 1


of this table.

58


PREGNYL 3 PA

RAYALDEE 3

SAMSCA 3

SENSIPAR 2 PA

SOMAVERT 3 LA

STIMATE 3

STRIANT 3

SYNAREL 3

TESTIM 3 ST; QL

TESTOSTERONE TRANSDERMAL GEL 3 ST; QL

TESTOSTERONE TRANSDERMAL GEL IN

METERED-DOSE PUMP 10 MG/0.5 GRAM

/ACTUATION

3 ST; QL

testosterone transdermal gel in metered-dose

pump 12.5 mg/ 1.25 gram (1 %)

1 QL

testosterone transdermal gel in packet 1 QL

testosterone transdermal solution in metered pump

w/app

1 QL

VOGELXO 3 ST; QL

ZAVESCA 3 LA

NON-INSULIN HYPOGLYCEMIC AGENTS

acarbose 1

ACTOPLUS MET XR 3

ADLYXIN 3 ST

ALOGLIPTIN-PIOGLITAZONE 3

AVANDIA ORAL TABLET 2 MG, 4 MG 2

BYDUREON 2

BYETTA 2 QL

chlorpropamide 1

CYCLOSET 3

FARXIGA 2

glimepiride 1


of this table.

59


glipizide 1

glipizide-metformin 1

glyburide 1

glyburide micronized 1

glyburide-metformin 1

GLYXAMBI 3

INVOKAMET 2

INVOKAMET XR 2

INVOKANA 2

JANUMET 2

JANUMET XR 2

JANUVIA 2

KOMBIGLYZE XR 2

metformin oral tablet 1

metformin oral tablet extended release 24 hr 500

mg

1

metformin oral tablet extended release 24 hr 750

mg

1 QL

miglitol 1

nateglinide 1

ONGLYZA 2

OSENI 3

pioglitazone 1 QL

pioglitazone-glimepiride 1

pioglitazone-metformin 1 QL

repaglinide 1

repaglinide-metformin 1

RIOMET 2 PA; QL

SYMLINPEN 120 2 QL

SYMLINPEN 60 2 QL

TANZEUM 3 ST

tolazamide 1


of this table.

60


tolbutamide 1

TRULICITY 3 ST

VICTOZA 2 QL

XIGDUO XR 2

THYROID HORMONES

ARMOUR THYROID 2

levothyroxine oral 1

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,

137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50

mcg, 75 mcg, 88 mcg

1

liothyronine oral 1

nature-throid 1

np thyroid 1

SYNTHROID 2

THYROLAR-1 2

THYROLAR-1/2 2

THYROLAR-1/4 2

THYROLAR-2 2

THYROLAR-3 2

TIROSINT 3

unithroid 1

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65

mg, 97.5 mg

1

WP THYROID ORAL TABLET 130 MG, 32.5

MG, 65 MG, 81.25 MG

3

GASTROENTEROLOGY

ANTIDIARRHEALS & ANTISPASMODICS

anaspaz 1

belladonna alkaloids-opium 1 PA

belladonna-opium 1 PA

chlordiazepoxide-clidinium 1

CUVPOSA 3


of this table.

61


dicyclomine oral capsule 1

dicyclomine oral solution 1

dicyclomine oral tablet 1

diphenoxylate-atropine 1

DONNATAL ORAL TABLET 3

ed-spaz 1

glycopyrrolate oral tablet 1 mg, 2 mg 1

hyoscyamine sulfate 1

hyosyne 1

loperamide oral capsule 1

methscopolamine 1

MOTOFEN 3

MYTESI 3

opium tincture 1

oscimin 1

oscimin sl 1

oscimin sr 1

paregoric 1

phenobarb-hyoscy-atropine-scop oral tablet 1

phenohytro 1

propantheline 1

SYMAX DUOTAB 3

symax fastabs 1

symax-sl 1

symax-sr 1

MISCELLANEOUS GASTROINTESTINAL AGENTS

AKYNZEO 3

alophen ACA ACA; OTC

alosetron 1

AMITIZA 3

ANA-LEX KIT 3


of this table.

62


ANALPRAM-HC RECTAL CREAM 1-1 % 3

anucort-hc 1

ANZEMET ORAL 3 QL

aprepitant 1

APRISO 2

ASACOL HD 3 ST

AURYXIA 3

balsalazide 1

bisacodyl oral ACA ACA; OTC

bisa-lax ACA ACA; OTC

budesonide oral 1 PA

calcium acetate oral capsule 1

calcium acetate oral tablet 667 mg 1

CANASA 3 ST

CESAMET 3

CHENODAL 3 LA

CHOLBAM 3

citrate of magnesia ACA ACA; OTC

citroma ACA ACA; OTC

clearlax ACA ACA; OTC

colocort 1

compro 1

constulose 1

CORTIFOAM 3

CREON 2

cromolyn oral 1

CYSTADANE 3

DELZICOL ORAL CAPSULE (WITH DEL REL

TABLETS)

3 ST

DICLEGIS 2

DIPENTUM 3 ST

dronabinol 1 PA

You can find information on what the symbols and abbreviations on this table mean by going

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