Excellus 3 Tier (Commercial)

A nonprofit independent licensee of the Blue Cross Blue Shield Association

3-TIER FORMULARY GUIDEIncludes generic and brand-name medications

ExcellusBCBS.comB-1354 Y18 / 12291-18FLRX

August 2019

Dear Member,

The prescription drug benefit is one of the most important and frequently

utilized elements of health plan coverage. To help you identify which

medications are covered under your plan, we are pleased to provide the

3-Tier Formulary Guide. This booklet provides you with easy to understand

information about your prescription drug coverage including descriptions of

prescription drug safety and cost-saving programs.

The 3-Tier Formulary Guide lists commonly prescribed medications and their

tier classifications. The medications listed have been approved by the Food

and Drug Administration (FDA) as safe and effective and were selected in

consultation with a team of health care professionals because they meet our

criteria for safety, quality and value. We continually review and update

our formulary.

The drugs listed in the formulary and program descriptions may not apply to all plans.

This booklet includes the Formulary Guide and prescription drug benefit information. Please refer to this booklet when you see your healthcare practioner or are prescribed a medication.

The drugs listed in the formulary and program descriptions may not apply to all plans. Please see your plan documents for a complete description of your pharmacy benefit.

If you have questions or need additional information, please visit our website, ExcellusBCBS.com or contact the Pharmacy Help Desk at 1-800-499-1275.

What is a Formulary?A formulary is a list of brand-name and generic drugs that are covered under your prescription drug benefit.

How is the Formulary Developed?Drugs listed on the formulary were selected by our independent Pharmacy and Therapeutics (P&T) Committee, which is made up of practicing health care providers and clinical pharmacists. The P&T Committee reviews each drug based upon scientific evidence, findings by federal government agencies, professional medical associations and journals to help ensure that the medications covered meet criteria for safety, effectiveness and value.

How do I use the Formulary?There are two ways to find your drug within the formulary:

Medical ConditionDrugs are listed in alphabetical order according to drug categories. For example, drugs used to treat heart conditions are listed under the category “Cardiovascular.” Drugs are listed in alphabetical order by condition.

Alphabetical ListingIf you are not sure what category to look under, look for your drug in the Index that follows the formulary. The Index provides an alphabetical listing of all of the drugs included in the formulary and the page where they can be found in the formulary.

3-Tier Drug BenefitYour 3-tier prescription drug benefit allows you to make informed choices and encourages value when choosing your prescription medications. Your copayment will vary depending on the tier in which your prescription drug is placed.

• Tier One drugs are typically generics and have the lowest copayment amount.

• Tier Two drugs are brand drugs that have unique, significant clinical advantages and offer overall greater value over the other products in the same drug class.

• Tier Three drugs are all other brand drugs, including new brand drugs and drugs that have generic equivalents. Tier Three drugs have the highest copayment amount.

The 3-Tier Formulary Guide lists commonly used medications and their tier designations. Because there are thousands of medications included in your pharmacy benefit, we list only the most commonly prescribed.

Your plan may not cover all medications listed in this booklet. Please see your plan documents for a complete description of your pharmacy benefit, or call the Pharmacy Help Desk at 1-800-499-1275.

Can the Formulary Change?Our P&T Committee regularly reviews the drugs on our formulary to be sure they meet the criteria for safety, effectiveness and value. The list is subject to change. Drugs may be added, removed, or change tier designation at any time.

Generics Are Real MedicineGeneric drugs: safe, effective, affordable!

To help keep your prescription drug costs down, choose a generic drug over a brand. Generics are as safe and effective as their brand-name counterparts – they just cost a lot less.

In fact, you’ll save money when you choose a generic because generics have the lowest copay. That means you’ll always pay the lowest out-of-pocket amount for a generic.

Generic drugs treat your illness or condition with the same effectiveness and safety as their brand-name equivalents because they have to meet the same rigorous FDA requirements as brand-name drugs.

Experience has shown that more than 90 percent of members who start on a generic will stay on a generic. So the next time you need your brand prescription filled, ask your doctor or pharmacist if a generic is right for you.

Where Can I Purchase My Prescription Medications?You have access to more than 65,000 participating pharmacies in our nationwide Pharmacy Network, including national chains and most independents. Just show your Member Card at any participating pharmacy; it identifies you as having prescription drug coverage. A list of participating pharmacies in your area is available on our website, ExcellusBCBS.com

Mail Service PharmacyGet your prescriptions delivered right to your door!

When you use Express Scripts Home Delivery PharmacySM or Wegmans® Home Delivery Pharmacy, you get the convenience of home delivery and the ease of ordering new prescriptions and refills either by phone or via our website, ExcellusBCBS.com. Some benefits offer

opay savings for ordering prescriptions cthrough Express Scripts Home Delivery PharmacySM

or Wegmans® Home Delivery Pharmacy.

Using a home delivery pharmacy is ideal for those who take prescription medication on a continuing basis. For more information on how to use Express Scripts Home Delivery PharmacySM or Wegmans® Home Delivery Pharmacy, please visit our website at ExcellusBCBS.com or contact the Pharmacy Help Desk at 1-800-499-1275.

Specialty PharmacySpecialty pharmacies focus on you and your individual health care needs. Because they work exclusively with specialty medications, they are experts in handling and administering these complex medications. Nationally recognized specialty pharmacy Accredo Health participates in our network. Accredo Health offers outstanding customer service and is dedicated to providing quality care to our members. With a single, toll-free phone call they take care of all the details – they will contact your doctor for your prescription and arrange delivery to your home. There are several local/regional specialty pharmacies also participating in our specialty pharmacy network. A complete listing of participating specialty pharmacies is available on our website, ExcellusBCBS.com

Are There Any Restrictions On Coverage?Some covered drugs may have additional requirements or limits for coverage. If a drug has requirements or limits, it will be noted in the formulary.

If your health-care practitioner determines that you need a medication that has a requirement or limit, we have an exception process in place. Your health-care practitioner must submit a request to the Health Plan supporting your need.

Coverage requirements or limits may include:

Prior Authorization Prior authorization helps ensure that a prescribed drug is safe and appropriate for your medical condition. Certain medications require that your doctor gets approval before the medication is covered. Our clinical pharmacists and physicians review medication requests to make sure that the choice of drug or dose is appropriately prescribed based

on FDA and manufacturer guidelines, medical literature, safety, use and benefit design.

Step Therapy In some cases you may be required to first try one or more drugs to treat your medical condition before another drug for that condition will be covered. The medication treatment moves along a series of “steps.” 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, we will then cover Drug B.

Specialty Drug Benefit Specialty medications are designed for conditions like multiple sclerosis, rheumatoid arthritis, hepatitis C, and others that are difficult to treat with traditional medications. These medications are self-administered, either taken orally or by injection.

Your prescription drug benefit may require that you purchase certain specialty medications at a specialty pharmacy that participates in the Specialty Pharmacy Network in order to receive coverage. If a participating specialty pharmacy is not used, you may be responsible for the full cost of the prescription. A complete listing of participating specialty pharmacies can be found on our website, ExcellusBCBS.com

Quantity Limits For certain drugs, we limit the amount of the drug that we will cover. The amount of drug we cover is based on FDA approved dosing and usage guidelines.

Generic Advantage Program The Generic Advantage program promotes the use of generic medications. If you fill your prescription with a brand-name medication when there is a generic equivalent available, you will pay the difference between the pharmacy’s charge for the more costly brand-name medication and our price for the less expensive generic. Check your benefits summary to find out if the Generic Advantage program applies to your plan.

Key:

UPPERCASE – Brand name medicationlowercase – generic medication

PA = Prior Authorization required

QL = Quantity Limit applies

ST = Step Therapy required

S = Specialty Drugs

MS = Drug must be purchased at a participating network specialty pharmacy for coverage

LIST OF COVERED PRESCRIPTION MEDICATIONS

PRODUCT DESCRIPTION TIER LIMITS/RESTRICTIONS/NOTES

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

ANAPROX 3

ANAPROX DS 3

ARTHROTEC 50 3 QL

ARTHROTEC 75 3 QL

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

butalbital/aspirin/caffeine 50-325-40 tablet 1

CAMBIA 3

QL

ST

CELEBREX (50 MG CAPSULE, 100 MG CAPSULE, 200 MG CAPSULE, 400MG CAPSULE)

3 QL

celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule, 400 mg capsule) 1 QL

choline salicylate/magnesium salicylate 1

DAYPRO 3 QL

DICLOFENAC EPOLAMINE 3

QL

PA

diclofenac potassium 1

diclofenac sodium (1.5 % drops, 25 mg tablet dr, 50 mg tablet dr, 75 mg tabletdr, 100 mg tab er 24h)

1

diclofenac sodium/misoprostol 1 QL

DICLOPR 3

QL

PA

diflunisal 1

DISALCID 3

DITHOL 3

QL

PA

DUEXIS 3

QL

PA

EC-NAPROSYN 3

PAGE 5 LAST UPDATED 08/2019


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 er 24h)

1

FELDENE 3

FENOPROFEN CALCIUM (200 MG CAPSULE, 400 MG CAPSULE) 3 PA

fenoprofen calcium 600 mg tablet 1 PA

FENORTHO 3 PA

FIORINAL 3 QL

FLECTOR 3

QL

PA

flurbiprofen 1

ibu 1

ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) 1

INDOCIN (25 MG/5 ML SUSPENSION, 50 MG SUPPOSITORY) 3

indomethacin (25 mg capsule, 50 mg capsule, 75 mg capsule er) 1

ketoprofen 1

ketorolac tromethamine 10 mg tablet 1 QL

LODINE 3

MECLOFENAMATE SODIUM 3

mefenamic acid 1

meloxicam (7.5 mg tablet, 15 mg tablet) 1

MELOXICAM 7.5 MG/5ML ORAL SUSP 3

MOBIC (7.5 MG TABLET, 7.5 MG/5 ML SUSPENSION, 15 MG TABLET) 3

nabumetone (500 mg tablet, 750 mg tablet) 1 QL

NALFON 3 PA

NAPRELAN 3 PA

NAPROSYN (125 MG/5 ML SUSPEN, 250 MG TABLET, 375 MG TABLET, 500MG TABLET)

3

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

1

NAPROXEN 125 MG/5ML ORAL SUSP 3

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

naproxen sodium (375 mg tbmp 24hr, 500 mg tbmp 24hr) 1 PA

NUDROXIPAK 3

QL

PA



oxaprozin 600 mg tablet 1 QL

PENNSAID 2% PUMP 3

QL

PA

piroxicam 1

PONSTEL 3

profeno 1 PA

QMIIZ ODT (ODT 7.5 MG TABLET, ODT 15 MG TABLET) 3

QL

PA

salsalate 1

SPRIX 3

QL

PA

S

sulindac 1

TIVORBEX 3

QL

PA

tolmetin sodium 1

VIMOVO 3

QL

PA

VIVLODEX 3 PA

VOLTAREN-XR 3

ZIPSOR 3

QL

PA

ZORVOLEX 3

QL

PA

OPIOID ANALGESICS, LONG-ACTING

ARYMO ER 3 PA

AVINZA 3 PA

BELBUCA 3 PA

BUPRENORPHINE 7.5 MCG/HR PATCH TDWK 3 PA

buprenorphine patch 1 PA



BUTRANS 3 PA

CONZIP 3 PA

DOLOPHINE HCL 3

DURAGESIC 3 PA

EMBEDA 3 PA

EXALGO 3 PA

fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72, 50mcg/hr patch td72,75mcg/hr patch td72, 100 mcg/hr patch td72)

1 PA

fentanyl (37.5mcg/hr patch td72, 62.5mcg/hr patch td72, 87.5mcg/hr patchtd72)

1 PA

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

1 PA

HYSINGLA ER 3 PA

KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 30 MG CAPSULE,ER 50 MG CAPSULE, ER 60 MG CAPSULE, ER 100 MG CAPSULE)

3 PA

KADIAN (ER 40 MG CAPSULE, ER 200 MG CAPSULE) 3 PA

KADIAN ER 80 MG CAPSULE 3

PA

ST

levorphanol tartrate 2 mg tablet 1 PA

LEVORPHANOL TARTRATE 3 MG TABLET 3 PA

methadone hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/5 mlsolution, 10 mg/ml oral conc, 40 mg tablet sol)

1 PA

methadone intensol 1 PA

METHADOSE 10 MG/ML ORAL CONC 3 PA

methadose 40 mg tablet dispr 1 PA

MORPHABOND ER 3 PA



morphine sulfate (10 mg cap er pel, 15 mg tablet er, 20 mg cap er pel, 30 mgcap er pel, 30 mg cpmp 24hr, 30 mg tablet er, 40 mg cap er pel, 45 mg cpmp24hr, 50 mg cap er pel, 60 mg cap er pel, 60 mg cpmp 24hr, 60 mg tablet er, 75mg cpmp 24hr, 80 mg cap er pel, 90 mg cpmp 24hr, 100 mg cap er pel, 100 mgtablet er, 120 mg cpmp 24hr, 200 mg tablet er)

1 PA

MS CONTIN 3 PA

NUCYNTA ER 2 PA

OXYCODONE HCL (10 MG TAB ER 12H, 15 MG TAB ER 12H, 20 MG TAB ER12H, 30 MG TAB ER 12H, 40 MG TAB ER 12H, 60 MG TAB ER 12H, 80 MGTAB ER 12H)

3 PA

OXYCONTIN 3 PA

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

1 PA

TRAMADOL ER CAPS 3 PA

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

1 PA

ULTRAM ER 3 PA

XTAMPZA ER 2 PA

ZOHYDRO ER 3 PA

OPIOID ANALGESICS, SHORT-ACTING

ABSTRAL 3

QL

PA

acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg-15mgtablet, 300mg-30mg tablet, 300mg-60mg tablet, 300mg/12.5 solution)

1

acetaminophen/caff/dihydrocod 320.5-30mg capsule 1

ACETAMINOPHEN/CAFF/DIHYDROCOD 325-30-16 TABLET 3

ACTIQ 3

QL

PA

APADAZ 3

ascomp with codeine 1

aspirin/caffeine/dihydrocodeine bitartrate 1

butalbital/acetaminophen/caffeine/codeine phosphate(butalbit/acetamin/caff/codeine 50-300-30 capsule,butalbit/acetamin/caff/codeine 50-325-30 capsule)

1 QL

butorphanol tartrate 10 mg/ml spray 1 QL

CAPITAL W-CODEINE 3

carisoprodol/aspirin/codeine phosphate 1

codeine phosphate/butalbital/aspirin/caffeine 1



codeine sulfate 1

DEMEROL (50 MG TABLET, 100 MG TABLET) 3

DILAUDID (2 MG TABLET, 4 MG TABLET, 5 MG/5 ML ORAL LIQUID, 8 MGTABLET)

3

endocet 1

FENTANYL CITRATE (100 MCG TABLET EFF, 200 MCG TABLET EFF, 400MCG TABLET EFF, 600 MCG TABLET EFF, 800 MCG TABLET EFF)

3

QL

PA

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

1

QL

PA

FENTORA 3

QL

PA

FIORICET WITH CODEINE 3 QL

FIORINAL WITH CODEINE #3 3

HYCET 3

hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 2.5-108/5solution, hydrocodone/acetaminophen 2.5-325 mg tablet,hydrocodone/acetaminophen 5 mg-300mg tablet, hydrocodone/acetaminophen5 mg-325mg tablet, hydrocodone/acetaminophen 5-217mg/10 solution,hydrocodone/acetaminophen 7.5-300 mg tablet, hydrocodone/acetaminophen7.5-325 mg tablet, hydrocodone/acetaminophen 7.5-325/15 solution,hydrocodone/acetaminophen 10-325/15 solution, hydrocodone/acetaminophen10mg-300mg tablet, hydrocodone/acetaminophen 10mg-325mg tablet)

1

hydrocodone/ibuprofen 1

hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 3 mg supp.rect, 4 mg tablet, 8mg tablet)

1

IBUDONE 3

ibuprofen/oxycodone hcl 1

LAZANDA 3

QL

PA

lorcet 1

lorcet hd 1

lorcet plus 1

lortab (5-325 mg tablet, 7.5-325 mg tablet, 10-325 mg tablet) 1

LORTAB 10 MG-300 MG/15 ML ELXR 3

meperidine hcl (50 mg tablet, 50 mg/5 ml solution, 100 mg tablet) 1

MORPHINE SULFATE (15 MG TABLET, 30 MG TABLET) 2



morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 10 mg/5 ml solution, 20 mgsupp.rect, 20 mg/5 ml solution, 30 mg supp.rect, 100 mg/5ml solution)

1

NALOCET 3

NORCO 3

NUCYNTA 2

OPANA (5 MG TABLET, 10 MG TABLET) 3

opium/belladonna alkaloids 1

OXAYDO 3

OXECTA 3

OXYCODONE 10MG/0.5ML ORAL SYRINGE 3

oxycodone hcl (5 mg capsule, 5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 15mg tablet, 20 mg tablet, 20 mg/ml oral conc, 30 mg tablet)

1

oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5-325 mg tablet,hcl/acetaminophen 5 mg-325mg tablet, hcl/acetaminophen 5-325/5 ml solution,hcl/acetaminophen 7.5-325 mg tablet, hcl/acetaminophen 10mg-325mg tablet)

1

oxycodone hcl/aspirin 1

oxymorphone hcl (5 mg tablet, 10 mg tablet) 1

PANLOR 3 QL

pentazocine hcl/naloxone hcl 1

PERCOCET 3

PRIMLEV 3

ROXICODONE 3

ROXYBOND 3

SUBSYS (100 MCG SPRAY, 200 MCG SPRAY, 400 MCG SPRAY, 600 MCGSPRAY, 800 MCG SPRAY, 1,200 MCG SPRAY, 1,600 MCG SPRAY)

3

QL

PA

SYNALGOS-DC 3

tramadol hcl 50 mg tablet 1

tramadol hcl/acetaminophen 1

TREZIX 3

TYLENOL-CODEINE NO.3 3


ULTRACET 3

ULTRAM 3

verdrocet 1

vicodin 1



vicodin es 1

vicodin hp 1

XARTEMIS XR 3 PA

XODOL 10-300 3

XODOL 5-300 3

XODOL 7.5-300 3

xylon 10 1

ZAMICET 3

ANESTHETICS

LOCAL ANESTHETICS

ANACAINE 3

ANASTIA 3

ANODYNE LPT 3

QL

PA

APRIZIO PAK 3

QL

PA

DERMACINRX EMPRICAINE 3 PA

dermacinrx prizopak 1

QL

PA

DOLOTRANZ 3

QL

PA

EMLA 3

glydo 1

lido-k 1

LIDO-PRILO CAINE PACK 3

QL

PA

lidocaine (5 % adh. patch, 5 % oint. (g)) 1

lidocaine hcl (2 % jel/pf app, 2 % jelly(ml), 2 % solution, 3 % cream (g), 3 %lotion, 4 % solution, 40 mg/ml solution)

1

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

1

LIDODERM 3

LIDOPAC 3

QL

PA



lidopin 3% cream 1

LIDOPIN 3.25% CREAM 3

LIDOPRIL 3

QL

PA

LIDOPRIL XR 3

QL

PA

LIDOTRANS 5 PAK 3

QL

PA

LIPROZONEPAK 3 PA

MEDOLOR PAK 3 PA

NEURCAINE 3

QL

PA

NUMBONEX 3

NUVAKAAN 3

QL

PA

PAINGO KFT 3

QL

PA

PRILOLID 3 PA

RELADOR PAK 3

QL

PA

SOLUPAK 3

QL

PA

ZTLIDO 3 QL

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING

acamprosate calcium 1 QL

ANTABUSE 3

disulfiram 1

naltrexone hcl 1

REVIA 3



OPIOID DEPENDENCE TREATMENTS

BUNAVAIL 3

buprenorphine hcl (2 mg tab subl, 8 mg tab subl) 1

buprenorphine hcl/naloxone hcl 1

LUCEMYRA 3 QL

SUBOXONE 2

ZUBSOLV 2

OPIOID REVERSAL AGENTS

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

NARCAN 2

SMOKING CESSATION AGENTS

buproban 1

bupropion hcl 150 mg tab er 12h 1

CHANTIX 3 QL

NICOTROL 3 QL

NICOTROL NS 3 QL

ZYBAN 3

ANTIBACTERIALS

AMINOGLYCOSIDES

ARIKAYCE 3

QL

PA

S

gentak 1

gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g), 0.3 % drops, 0.3 % oint.(g))

1

neomycin sulfate 1

paromomycin sulfate 1

tobramycin 1

TOBREX (DROP, OINTMENT) 3

ANTIBACTERIALS, OTHER

AEMCOLO 3

AKTIPAK 3

QL

ST



ALTABAX 3

bacitracin 500 unit/g oint. (g) 1

BACTROBAN (CREAM, OINTMENT) 3

BACTROBAN NASAL 3

BENZAMYCIN 3

CENTANY 3

CENTANY AT 3

QL

PA

CLEOCIN (2% CREAM, 100 MG OVULE) 3

CLEOCIN HCL 3

CLEOCIN PALMITATE 3

CLEOCIN T (T GEL, T LOTION, T PLEDGETS, T SOLUTION) 3 ST

clindacin etz 1% pledget 1

CLINDACIN ETZ KIT 3

QL

PA

clindacin p 1

CLINDACIN PAC 3

QL

PA

CLINDAGEL 3 ST

clindamycin hcl 1

clindamycin palmitate hcl 1

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

1

CLINDAMYCIN PHOSPHATE 1 % GEL DAILY 3 ST

CLINDESSE 3

erythromycin base/benzoyl peroxide 1

EVOCLIN 3 ST

FIRVANQ 2

FLAGYL 3

FLAGYL ER 3

FURADANTIN 3

HIPREX 3



hyophen 1

linezolid 100 mg/5ml susp recon 1

linezolid 600 mg tablet 1 QL

MACROBID 3

MACRODANTIN 3

methenamine hippurate 1

methenamine mandelate 1

methenamine/sod phosph,monobasic/methylene blue/hyoscyamine 1

METROGEL-VAGINAL 3

metronidazole (0.75 % gel w/appl, 250 mg tablet, 375 mg capsule, 500 mgtablet)

1

MONUROL 3

mupirocin 1

mupirocin calcium 1

nitrofurantoin 1

nitrofurantoin macrocrystal 1

nitrofurantoin monohydrate/macrocrystals 1

NUVESSA 3 QL

phosphasal 1

PRIMSOL 3

SIVEXTRO 200 MG TABLET 3 PA

SOLOSEC 3

SULFAMYLON (8.5% CREAM, POWDER PACKET) 3

TINDAMAX 3

tinidazole 1

trimethoprim 1

TRIMPEX 3

ur n-c 1

URELLE 3

uretron d-s 1

URIBEL 3

urimar-t 1

urin d.s. 1



uro-458 1

uro-mp 1

urogesic-blue 1

uryl 1

utira-c 1

VANCOCIN HCL 3

vancomycin hcl (125 mg capsule, 250 mg capsule) 1

vandazole 1

ZYVOX 100 MG/5 ML SUSPENSION 3

ZYVOX 600 MG TABLET 3 QL

BETA-LACTAM, CEPHALOSPORINS

CEDAX (180 MG/5 ML SUSPENSION, 400 MG CAPSULE) 3

cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 375mg/5ml susp recon, 500 mg capsule, 500 mg tab er 12h)

1

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

1

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

cefditoren pivoxil 1

cefixime (100 mg/5ml susp recon, 200 mg/5ml susp recon, 400 mg capsule) 1

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

1

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

1

CEFTIBUTEN 3

CEFTIN (250 MG TABLET, 500 MG TABLET) 3

cefuroxime axetil 1

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

1

DAXBIA 3

KEFLEX 3

SPECTRACEF 3

SUPRAX (100 MG TABLET CHEWABLE, 100 MG/5 ML SUSPENSION, 200MG TABLET CHEWABLE, 200 MG/5 ML SUSPENSION, 400 MG CAPSULE,500 MG/5 ML SUSPENSION)

3



BETA-LACTAM, PENICILLINS

amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon,250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susprecon, 500 mg capsule, 500 mg tablet, 875 mg tablet)

1

AMOXICILLIN 775 MG TBMP 24HR 3

amoxicillin/potassium clavulanate (amoxicillin/potassium 200-28.5/5 susp recon,amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium 250-125 mgtablet, 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 susprecon, amoxicillin/potassium 875-125 mg tablet, amoxicillin/potassium 1000-62.5 tab er 12h)

1

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

1

AUGMENTIN (125-31.25 MG/5 ML, 250-62.5 MG/5 ML, 500-125 TABLET, 875-125 TABLET)

3

AUGMENTIN ES-600 3

AUGMENTIN XR 3

dicloxacillin sodium 1

MOXATAG 3 PA

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

1

MACROLIDES

AZASITE 3

azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 250mg tablet, 500 mg tablet, 600 mg tablet)

1

BIAXIN (250 MG TABLET, 250 MG/5 ML SUSPENSION, 500 MG TABLET) 3

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

1

DIFICID 3 ST

E.E.S. 200 3

E.E.S. 400 3

ery 1

ery-tab 1

ERYGEL 3

ERYPED 200 3

ERYPED 400 3

erythrocin stearate 1

erythromycin base (5 mg/gram oint. (g), 250 mg capsule dr, 250 mg tablet, 500mg tablet)

1

erythromycin base in ethanol (in 2 % gel (gram), in 2 % med. swab, in 2 %solution)

1



erythromycin ethylsuccinate (200 mg/5ml susp recon, 400 mg tablet, 400mg/5ml susp recon)

1

ILOTYCIN 3

PCE 3

ZITHROMAX (1 GM POWDER PACKET, 100 MG/5 ML SUSP, 200 MG/5 MLSUSP, 250 MG TABLET, 250 MG Z-PAK TABLET, 500 MG TABLET, 600 MGTABLET)

3

ZITHROMAX TRI-PAK 3

ZMAX 3

QUINOLONES

AVELOX 3

AVELOX ABC PACK 3

BAXDELA 450 MG TABLET 3 QL

BESIVANCE 3

CETRAXAL 3 QL

CILOXAN (EYE DROPS, OINTMENT) 3

CIPRO (5% SUSPENSION, 10% SUSPENSION, 250 MG TABLET, 500 MGTABLET)

3

CIPRO XR 3

ciprofloxacin 1

ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750mg tablet)

1

ciprofloxacin hcl 0.2 % droperette 1 QL

ciprofloxacin/ciprofloxacin hcl 1

FACTIVE 3

FLOXIN 3

gatifloxacin 1

LEVAQUIN (25 MG/ML SOLUTION, 250 MG TABLET, 500 MG TABLET, 750MG TABLET)

3

levofloxacin (0.5 % drops, 250 mg tablet, 250mg/10ml solution, 500 mg tablet,500mg/20ml solution, 750 mg tablet)

1

MOXEZA 2

moxifloxacin hcl 1

OCUFLOX 3

ofloxacin (0.3 % drops, 300 mg tablet, 400 mg tablet) 1

OTIPRIO 3

VIGAMOX 3

ZYMAXID 3



SULFONAMIDES

AVC 3

BACTRIM 3

BACTRIM DS 3

BLEPH-10 3

KLARON 3

SILVADENE 3

silver sulfadiazine 1

ssd 1

sulfacetamide sodium (10 % drops, 10 % oint. (g), 10 % suspension) 1

sulfadiazine 1

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

1

sulfatrim 1

thermazene 1

TETRACYCLINES

ACTICLATE 3 PA

ADOXA 3

avidoxy 1

demeclocycline hcl 1

DORYX 3 ST

DORYX MPC 3 ST

doxycycline hyclate (20 mg tablet, 50 mg capsule, 50 mg tablet, 50 mg tablet dr,75 mg tablet dr, 100 mg capsule, 100 mg tablet, 100 mg tablet dr, 150 mg tabletdr, 200 mg tablet dr)

1

doxycycline hyclate (75 mg tablet, 150 mg tablet) 1

QL

PA

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

1

DOXYCYCLINE MONOHYDRATE 40 MG CAP IR DR 3

QL

ST

MINOCIN (50 MG CAP, 75 MG CAP, 100 MG CAP) 3



minocycline hcl (45 mg tab er 24h, 65 mg tab er 24h, 80 mg tab er 24h, 90 mgtab er 24h, 105 mg tab er 24h, 115mg tab er 24h, 135 mg tab er 24h)

1

QL

PA

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

1

MINOCYCLINE HCL 55 MG TAB ER 24H 3

QL

PA

MINOLIRA ER 3

QL

PA

mondoxyne nl 1

MONODOX 3

MORGIDOX (1X100 MG KIT, 1X50 MG KIT, 2X100 MG KIT) 3

QL

PA

morgidox (50 mg capsule, 100 mg capsule) 1

NUZYRA (150 MG TABLET, 150 MG TABLET-7 DAY, 150 MG-7 DAY WITHLOAD)

3 PA

ORACEA 3

QL

ST

SEYSARA 3

QL

PA

SOLODYN 3

QL

PA

TARGADOX 3

tetracycline hcl 1

VIBRAMYCIN (25 MG/5 ML SUSP, 50 MG/5 ML SYRUP, 100 MG CAPSULE) 3

XIMINO 3

QL

PA

ANTICONVULSANTS

ANTICONVULSANTS, OTHER

BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 25 MG TABLET, 50 MGTABLET, 75 MG TABLET, 100 MG TABLET)

3

QL

PA

DIACOMIT 3

QL

PA

S



EPIDIOLEX 3

QL

PA

S

MS

KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500 MG TABLET, 750MG TABLET, 1,000 MG TABLET)

3

KEPPRA XR (500 MG TABLET, 750 MG TABLET) 3 QL

levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tablet, 500 mg/5mlsolution, 750 mg tablet, 1000 mg tablet)

1

levetiracetam (500 mg tab er 24h, 750 mg tab er 24h) 1 QL

POTIGA 3

roweepra 1

roweepra xr 500 mg tablet 1

roweepra xr 750 mg tablet 1 QL

SPRITAM (250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MGTABLET)

3

QL

PA

CALCIUM CHANNEL MODIFYING AGENTS

CELONTIN 3

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

ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3

ZONEGRAN 3

zonisamide 1

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

clobazam (10 mg tablet, 20 mg tablet) 1 QL

clobazam 2.5 mg/ml oral susp 1

DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLE 3

DIASTAT 3 QL

DIASTAT ACUDIAL 3 QL

diazepam (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) 1



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

1

gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 300mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg tablet)

1

GABITRIL 3

GRALISE (ER 300 MG TABLET, ER 600 MG TABLET) 3

QL

PA

GRALISE 30-DAY STARTER PACK 3 PA

MYSOLINE 3

NEURONTIN (100 MG CAPSULE, 250 MG/5 ML SOLN, 300 MG CAPSULE,400 MG CAPSULE, 600 MG TABLET, 800 MG TABLET)

3

ONFI (10 MG TABLET, 20 MG TABLET) 3 QL

ONFI 2.5 MG/ML SUSPENSION 3

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

primidone 1

SABRIL 3

QL

PA

S

MS

SYMPAZAN 3

QL

ST

tiagabine hcl 1

valproic acid 1

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

1

vigabatrin 1

QL

PA

S

MS

GLUTAMATE REDUCING AGENTS

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

FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5 ML SUSP) 3

FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MGTABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET)

3 QL

LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET, 25 MGTABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)

3

LAMICTAL (BLUE) 3



LAMICTAL (GREEN) 3

LAMICTAL (ORANGE) 3

LAMICTAL ODT 3 QL

LAMICTAL XR 3

lamotrigine (25 mg tab rapdis, 25(42)-100 tab ds pk, 25(84)-100 tab ds pk, 50mg tab rapdis, 100 mg tab rapdis, 200 mg tab rapdis)

1 QL

lamotrigine (5 mg tb chw dsp, 25 mg tab er 24, 25 mg tablet, 25 mg tb chw dsp,25(21)-50 tb rd dspk, 25-50-100 tb rd dspk, 25mg (35) tab ds pk, 50 mg tab er24, 50(42)-100 tb rd dspk, 100 mg tab er 24, 100 mg tablet, 150 mg tablet, 200mg tab er 24, 200 mg tablet, 250 mg tab er 24, 300 mg tab er 24)

1

QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 150MG CAPSULE, 200 MG CAPSULE)

3

QL

PA

TOPAMAX 3

topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet,100 mg tablet, 200 mg tablet)

1

TOPIRAMATE ER CAPS 3

QL

PA

TROKENDI XR 3

QL

PA

SODIUM CHANNEL AGENTS

APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MGTABLET)

3

QL

PA

BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) 3

carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg tab er 12h, 100mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tab er 12h, 200 mg tablet, 300mg cpmp 12hr, 400 mg tab er 12h)

1

CARBATROL 3

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

DILANTIN-125 2

epitol 1

oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mgtablet)

1

OXTELLAR XR (150 MG TABLET, 300 MG TABLET, 600 MG TABLET) 3

QL

PA

PEGANONE 3

PHENYTEK 2

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

phenytoin sodium extended 1



TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) 3

TEGRETOL XR 3

TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5 ML SUSP, 600MG TABLET)

3

VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)

2

ANTIDEMENTIA AGENTS

ANTIDEMENTIA AGENTS, OTHER

ergoloid mesylates 1

CHOLINESTERASE INHIBITORS

ARICEPT 3

donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 23mg tablet)

1

EXELON (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 4.6MG/24HR PATCH, 6 MG CAPSULE, 9.5 MG/24HR PATCH, 13.3 MG/24HRPATCH)

3

galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet,12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel)

1

NAMZARIC 3

QL

PA

RAZADYNE 3

RAZADYNE ER 3

rivastigmine 1

rivastigmine tartrate 1

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST

memantine hcl (2 mg/ml solution, 5 mg tablet, 5 mg-10 mg tab ds pk, 10 mgtablet)

1

memantine hcl (7 mg cap spr 24, 14 mg cap spr 24, 21 mg cap spr 24, 28 mgcap spr 24)

1 QL

NAMENDA (2 MG/ML SOLUTION, 5 MG TABLET, 5-10 MG TITRATION PK,10 MG TABLET)

3

NAMENDA XR 3 QL

ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER

amitriptyline hcl/chlordiazepoxide 1

APLENZIN 3

QL

ST

bupropion hcl (150 mg tab er 24h, 300 mg tab er 24h) 1 QL

bupropion hcl (75 mg tablet, 100 mg tab sr 12h, 100 mg tablet, 150 mg tab sr12h, 200 mg tab sr 12h)

1



BUPROPION HCL 450 MG TAB ER 24H 3

QL

ST

FORFIVO XL 3

QL

ST

mirtazapine 1

olanzapine/fluoxetine hcl 1

perphenazine/amitriptyline hcl 1

REMERON 3

SYMBYAX 3

WELLBUTRIN 3

WELLBUTRIN SR 3

WELLBUTRIN XL (150 MG TABLET, 300 MG TABLET) 3 QL

MONOAMINE OXIDASE INHIBITORS

EMSAM 3

QL

ST

MARPLAN 3

NARDIL 3

PARNATE 3

phenelzine sulfate 1

tranylcypromine sulfate 1

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS)

BRISDELLE 3

QL

PA

CELEXA (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL

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

citalopram hydrobromide 10 mg/5 ml solution 1

DESVENLAFAXINE ER 3 QL

DESVENLAFAXINE FUMARATE 3

QL

ST

desvenlafaxine succinate 1 QL

EFFEXOR XR (37.5 MG CAPSULE, 75 MG CAPSULE, 150 MG CAPSULE) 3 QL



escitalopram oxalate (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 20 mgtablet)

1

FETZIMA 3 QL

fluoxetine hcl (10 mg capsule, 10 mg tablet, 20 mg capsule, 20 mg tablet, 20mg/5 ml solution, 40 mg capsule, 60 mg tablet)

1

fluoxetine hcl 90 mg capsule dr 1 QL

fluvoxamine maleate (100 mg cap er 24h, 150 mg cap er 24h) 1 QL

fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet) 1

KHEDEZLA 3

QL

ST

LEXAPRO (5 MG TABLET, 5 MG/5 ML SOLUTION, 10 MG TABLET, 20 MGTABLET)

3

maprotiline hcl 1

nefazodone hcl (150 mg tablet, 200 mg tablet, 250 mg tablet) 1

nefazodone hcl (50 mg tablet, 100 mg tablet) 1 QL

OLEPTRO ER (ER 150 MG TABLET, ER 300 MG TABLET) 3

QL

ST

paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet) 1

paroxetine hcl (12.5 mg tab er 24h, 25 mg tab er 24h, 37.5 mg tab er 24h) 1 QL

paroxetine mesylate 1

QL

PA

PAXIL (10 MG TABLET, 10 MG/5 ML SUSPENSION, 20 MG TABLET, 30 MGTABLET, 40 MG TABLET)

3

PAXIL CR 3 QL

PEXEVA 3

QL

ST

PRISTIQ (ER 25 MG TABLET, ER 50 MG TABLET, ER 100 MG TABLET) 3 QL

PROZAC (10 MG, 40 MG) 3 QL

PROZAC 20 MG PULVULE 3

PROZAC WEEKLY 3 QL

SARAFEM 3

sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1

trazodone hcl 1

TRINTELLIX 3 QL



VENLAFAXINE ER TAB (TIER DEPENDENT ON MANUFACTURER. UCB T3,OTHERS T1)

3

QL

ST

venlafaxine hcl (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100mg tablet)

1

venlafaxine hcl (37.5 mg cap er 24h, 75 mg cap er 24h, 150 mg cap er 24h) 1 QL

VIIBRYD (10 MG TABLET, 10-20-40 MG STARTER PK, 20 MG TABLET, 40MG TABLET)

3 QL

VIIBRYD 10-20 MG STARTER PACK 3

ZOLOFT (20 MG/ML ORAL CONC, 25 MG TABLET, 50 MG TABLET, 100 MGTABLET)

3

TRICYCLICS

amitriptyline hcl 1

amoxapine 1

ANAFRANIL 3

clomipramine hcl 1

desipramine hcl 1

doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mg capsule, 50 mgcapsule, 75 mg capsule, 100 mg capsule, 150 mg capsule)

1

imipramine hcl 1

imipramine pamoate 1

NORPRAMIN 3

nortriptyline hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) 1

NORTRIPTYLINE HCL (10 MG/5 ML SOLUTION, 20 MG/10ML SOLUTION) 3

QL

PA

PAMELOR 3

protriptyline hcl 1

SURMONTIL 3

TOFRANIL 3

TOFRANIL-PM 3

trimipramine maleate 1

ANTIEMETICS

ANTIEMETICS, OTHER

BONJESTA 3

QL

PA

COMPAZINE (5 MG TABLET, 10 MG TABLET) 3



compazine 25 mg suppository 1

compro 1

DICLEGIS 3

QL

PA

doxylamine succinate/pyridoxine hcl (b6) 1

QL

PA

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

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

metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10mlsolution)

1

METOZOLV ODT 3 QL

MOTEGRITY 3

QL

ST

perphenazine 1

phenadoz 1

phenergan (12.5 mg, 25 mg, 50 mg) 1

prochlorperazine 1

prochlorperazine maleate 1

promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect, 50 mg supp.rect, 50 mgtablet)

1

promethegan 1

REGLAN 3

scopolamine 1

TIGAN 300 MG CAPSULE 3

TRANSDERM-SCOP 3

trimethobenzamide hcl 1

EMETOGENIC THERAPY ADJUNCTS

AKYNZEO 300-0.5 MG CAPSULE 3 QL

ANZEMET (50 MG TABLET, 100 MG TABLET) 3

QL

ST

aprepitant (40 mg capsule, 80 mg capsule, 125 mg capsule, 125mg-80mg capds pk)

1 QL

CESAMET 3

dronabinol 1



EMEND (40 MG CAPSULE, 80 MG CAPSULE, 125 MG CAPSULE, 125 MGPOWDER PACKET, TRIPACK)

3 QL

granisetron hcl 1 mg tablet 1 QL

MARINOL 3

ondansetron 1

ondansetron hcl (4 mg tablet, 4 mg/5 ml solution, 8 mg tablet, 24 mg tablet) 1

SANCUSO 3

QL

ST

SUSTOL 3

SYNDROS 3 PA

VARUBI 90 MG TABLET 3

ZOFRAN (4 MG TABLET, 4 MG/5 ML ORAL SOLN, 8 MG TABLET) 3

ZOFRAN ODT 3

ZUPLENZ 3

QL

ST

ANTIFUNGALS

ANCOBON 3

ciclodan 0.77% cream 1

ciclodan 8% solution 1 QL

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

ciclopirox 8 % solution 1 QL

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

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

CRESEMBA 186 MG CAPSULE 3

DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/ML SUSPENSION, 50 MGTABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)

3

econazole nitrate 1

ECOZA 3

QL

ST

ERTACZO 3 ST

EXELDERM (CREAM, SOLUTION) 3

EXTINA 3 ST



fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mgtablet, 150 mg tablet, 200 mg tablet)

1

flucytosine 1

GRIFULVIN V 3

GRIS-PEG 3

griseofulvin ultramicrosize 1

griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) 1

GYNAZOLE 1 3

itraconazole (10 mg/ml solution, 100 mg capsule) 1

JUBLIA 3

QL

PA

KERYDIN 3 PA

ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo, 200 mg tablet) 1

ketodan (foam, foam kit) 1

LAMISIL (125 MG GRANULES PACKET, 187.5 MG GRANULES PACK) 3

QL

PA

LAMISIL 250 MG TABLET 3

LOPROX (0.77% CREAM, 0.77% TOPICAL SUSP, 1% SHAMPOO) 3

LOPROX (CREAM KIT, SUSPENSION KIT) 3

QL

PA

LULICONAZOLE 3 QL

LUZU 3

QL

ST

MENTAX 3 ST

miconazole nitrate 200 mg supp.vag 1

MICONAZOLE NITRATE/ZINC OXIDE/PETROLATUM,WHITE 3

naftifine hcl (1 % cream (g), 1 % gel (gram)) 1

naftifine hcl 2 % cream (g) 1 QL

NAFTIN (1% GEL, 2% GEL) 3 ST

NAFTIN 2% CREAM 3 QL

NATACYN 3

NIZORAL 3



NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET) 3

nyamyc 1

NYATA 3

nystatin (500k unit tablet, 100000/g cream (g), 100000/g oint. (g), 100000/gpowder, 100000/ml oral susp)

1

nystatin/triamcinolone acetonide 1

nystop 1

ONMEL 3

QL

PA

ORAVIG 3 PA

oxiconazole nitrate 1

OXISTAT 1% CREAM 3

OXISTAT 1% LOTION 3 ST

PENLAC 3 QL

SPORANOX (10 MG/ML SOLUTION, 100 MG CAPSULE) 3

TERAZOL 3 3

TERAZOL 7 3

terbinafine hcl 250 mg tablet 1

terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) 1

TOLSURA 3

QL

PA

VFEND (40 MG/ML SUSPENSION, 50 MG TABLET) 3

VFEND 200 MG TABLET 3 QL

voriconazole (50 mg tablet, 200 mg/5ml susp recon) 1

voriconazole 200 mg tablet 1 QL

VUSION 3

XOLEGEL 3 ST

ANTIGOUT AGENTS

allopurinol 1

COLCHICINE 3 QL

COLCRYS 2 QL

MITIGARE 3 QL



probenecid 1

probenecid/colchicine 1

ULORIC 2

QL

ST

ZYLOPRIM 3

ANTIMIGRAINE AGENTS

ANTIMIGRAINE AGENTS, OTHER

AIMOVIG AUTOINJECTOR 2

QL

PA

AIMOVIG AUTOINJECTOR (2 PACK) 2

QL

PA

AJOVY 2

QL

PA

EMGALITY PEN 2

QL

PA

EMGALITY SYRINGE (100 MG/ML SYR(1 OF 3), 120 MG/ML SYRINGE, 300MG (100 MG X3SYR))

2

QL

PA

ERGOT ALKALOIDS

CAFERGOT 3

D.H.E.45 3

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

DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY SPRAY/PUMP 3 QL

ERGOMAR 3

ergotamine tartrate/caffeine 1

MIGERGOT 3

MIGRANAL 3 QL

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

almotriptan malate 1 QL

AMERGE 3 QL

AXERT 3 QL

eletriptan hydrobromide 1 QL



FROVA 3 QL

frovatriptan succinate 1 QL

IMITREX (4 MG/0.5 ML CARTRIDGES, 4 MG/0.5 ML PEN INJECT, 5 MGNASAL SPRAY, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML PEN INJECT, 6MG/0.5 ML VIAL, 20 MG NASAL SPRAY, 25 MG TABLET, 50 MG TABLET,100 MG TABLET)

3 QL

MAXALT 3 QL

MAXALT MLT 3 QL

naratriptan hcl 1 QL

ONZETRA XSAIL 3

QL

ST

RELPAX 3 QL

rizatriptan benzoate 1 QL

sumatriptan (5 mg spray, 20 mg spray) 1 QL

sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen injctr, 6 mg/0.5mlcartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml vial, 25 mgtablet, 50 mg tablet, 100 mg tablet)

1 QL

sumatriptan succinate/naproxen sodium 1 QL

SUMAVEL DOSEPRO (4 MG/0.5 ML, 6 MG/0.5 ML) 3

QL

ST

TREXIMET 3 QL

ZEMBRACE SYMTOUCH 3

QL

ST

zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet, 5 mg tab rapdis, 5 mg tablet) 1 QL

ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 3

QL

ST

ZOMIG (2.5 MG TABLET, 5 MG TABLET) 3 QL

ZOMIG ZMT 3 QL

ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS

GUANIDINE HCL 3

MESTINON (60 MG TABLET, 60 MG/5 ML SYRUP, 180 MG TIMESPAN) 3

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



PYRIDOSTIGMINE BROMIDE 30 MG TABLET 3

pyridostigmine bromide 60 mg/5 ml syrup 1

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER

dapsone (25 mg tablet, 100 mg tablet) 1

MYCOBUTIN 3

rifabutin 1

ANTITUBERCULARS

cycloserine 1

ethambutol hcl 1

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

MYAMBUTOL 3

PASER 3

PRIFTIN 3

pyrazinamide 1

RIFADIN (150 MG CAPSULE, 300 MG CAPSULE) 3

RIFAMATE 3

rifampin (150 mg capsule, 300 mg capsule) 1

RIFATER 3

SIRTURO 3

TRECATOR 3

ANTINEOPLASTICS

ALKYLATING AGENTS

ALKERAN 2 MG TABLET 3

cyclophosphamide (25 mg capsule, 50 mg capsule) 1

GLEOSTINE 3

HEXALEN 3

LEUKERAN 2

lomustine 1

MATULANE 2 S

melphalan 1

MYLERAN 2



TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, 140 MGCAPSULE, 180 MG CAPSULE, 250 MG CAPSULE)

3

S

MS

temozolomide 1

S

MS

VALCHLOR 3

QL

PA

S

MS

ANTIANDROGENS

abiraterone acetate 1

QL

S

MS

bicalutamide 1

CASODEX 3

ERLEADA 3

QL

PA

S

MS

flutamide 1

NILANDRON 3

nilutamide 1

XTANDI 2

QL

PA

S

MS

YONSA 3

QL

PA

S

MS

ZYTIGA (250 MG TABLET, 500 MG TABLET) 2

QL

PA

S

MS



ANTIANGIOGENIC AGENTS

POMALYST 3

QL

PA

S

MS

REVLIMID 2

QL

PA

S

MS

THALOMID 3

QL

S

MS

ANTIESTROGENS/MODIFIERS

EMCYT 3

FARESTON 2

SOLTAMOX 3

QL

PA

tamoxifen citrate 1

toremifene citrate 1

ANTIMETABOLITES

capecitabine 1

S

MS

DROXIA 3

EFUDEX 3

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

HYDREA 3

hydroxyurea 1

mercaptopurine 1

PURIXAN 3

QL

PA

S

SIKLOS (100 MG TABLET, 1,000 MG TABLET) 3 PA



TABLOID 2

XELODA 3

S

MS

ANTINEOPLASTICS, OTHER

ALUNBRIG (30 MG TABLET, 90 MG TABLET, 90 MG-180 MG TAB PACK, 180MG TABLET)

3

QL

PA

S

MS

BALVERSA (3 MG TABLET, 4 MG TABLET, 5 MG TABLET) 3

QL

PA

S

COPIKTRA 15 MG CAPSULE 3

QL

PA

S

COPIKTRA 25 MG CAPSULE 3

QL

PA

HEMANGEOL 3 S

IDHIFA 3

QL

PA

S

MS

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

LONSURF 3

PA

S

MS

LYSODREN 2

NINLARO 3

PA

S

MS

RUBRACA (200 MG TABLET, 250 MG TABLET, 300 MG TABLET) 3

QL

PA

S



RYDAPT 3

QL

PA

S

MS

SYLATRON 3

PA

S

MS

TIBSOVO 3

QL

PA

VITRAKVI (20 MG/ML SOLUTION, 25 MG CAPSULE, 100 MG CAPSULE) 3

QL

PA

S

MS

VIZIMPRO 3

QL

PA

S

MS

XOSPATA 3

QL

PA

S

MS

ZOLINZA 3

QL

PA

S

MS

AROMATASE INHIBITORS, 3RD GENERATION

anastrozole 1

ARIMIDEX 3

AROMASIN 3

exemestane 1

FEMARA 3

letrozole 1



ENZYME INHIBITORS

etoposide 50 mg capsule 1

HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 2

QL

PA

S

MS

LORBRENA (25 MG TABLET, 100 MG TABLET) 3

QL

PA

S

MS

PIQRAY (200 MG DAILY, 250 MG DAILY, 300 MG DAILY) 3

QL

PA

S

MS

MOLECULAR TARGET INHIBITORS

AFINITOR 2

QL

PA

S

MS

ALECENSA 3

PA

S

MS

BOSULIF (100 MG TABLET, 400 MG TABLET, 500 MG TABLET) 3

QL

PA

S

MS

BRAFTOVI (50 MG CAPSULE, 75 MG CAPSULE) 3

QL

PA

S

CABOMETYX 3

QL

PA

S

MS



CALQUENCE 3

QL

PA

S

CAPRELSA (100 MG TABLET, 300 MG TABLET) 2

QL

PA

S

COMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK) 2

QL

PA

S

COTELLIC 3

PA

S

MS

DAURISMO (25 MG TABLET, 100 MG TABLET) 3

QL

PA

S

MS

ERIVEDGE 3

QL

PA

S

MS

erlotinib hcl 1

QL

S

MS

FARYDAK 3

QL

PA

S

MS

GILOTRIF 3

QL

PA

S

MS



GLEEVEC (100 MG TABLET, 400 MG TABLET) 3

QL

ST

S

MS

IBRANCE 2

QL

PA

S

MS

ICLUSIG (15 MG TABLET, 45 MG TABLET) 3

QL

PA

S

imatinib mesylate (100 mg tablet, 400 mg tablet) 1

QL

S

MS

IMBRUVICA (70 MG CAPSULE, 140 MG CAPSULE, 140 MG TABLET, 280MG TABLET, 420 MG TABLET, 560 MG TABLET)

3

QL

PA

S

INLYTA (1 MG TABLET, 5 MG TABLET) 3

QL

PA

S

MS

IRESSA 3

QL

PA

S

MS

JAKAFI 2

QL

PA

S

MS

KISQALI 3

QL

PA

S

MS



KISQALI FEMARA CO-PACK (200 MG, 400 MG, 600 MG) 3

QL

PA

S

MS

LENVIMA (4 MG CAPSULE, 8 MG DAILY DOSE, 10 MG DAILY DOSE, 12 MGDAILY DOSE, 14 MG DAILY DOSE, 18 MG DAILY DOSE, 20 MG DAILYDOSE, 24 MG DAILY DOSE)

3

QL

PA

S

MS

LYNPARZA (100 MG TABLET, 150 MG TABLET) 3

QL

PA

S

MS

LYNPARZA 50 MG CAPSULE 3

PA

S

MS

MEKINIST (0.5 MG TABLET, 2 MG TABLET) 3

QL

PA

S

MS

MEKTOVI 3

QL

PA

S

MS

NERLYNX 3

QL

PA

S

MS

NEXAVAR 2

QL

PA

S

MS

ODOMZO 3

PA

S

MS



SPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG TABLET, 80 MGTABLET, 100 MG TABLET, 140 MG TABLET)

2

QL

PA

S

MS

STIVARGA 2

QL

PA

S

MS

SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 37.5 MG CAPSULE, 50 MGCAPSULE)

2

QL

PA

S

MS

TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE) 3

QL

PA

S

MS

TAGRISSO 3

PA

S

MS

TALZENNA (0.25 MG CAPSULE, 1 MG CAPSULE) 3

QL

PA

S

MS

TARCEVA 3

QL

PA

S

MS

TASIGNA (50 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE) 3

QL

PA

S

MS



TYKERB 2

QL

PA

S

MS

VENCLEXTA 3

QL

PA

S

VERZENIO 2

QL

PA

MS

VOTRIENT 2

QL

PA

S

MS

XALKORI 3

QL

PA

S

MS

ZEJULA 3

QL

PA

ZELBORAF 2

QL

PA

S

MS

ZYDELIG 3

QL

PA

S

MS

ZYKADIA (150 MG CAPSULE, 150 MG TABLET) 3

QL

PA

S

MS



RETINOIDS

bexarotene 1

QL

PA

S

MS

PANRETIN 3

TARGRETIN 1% GEL 3

PA

S

MS

TARGRETIN 75 MG CAPSULE 3

QL

PA

S

MS

tretinoin 10 mg capsule 1

TREATMENT ADJUNCTS

MESNEX 400 MG TABLET 3

ANTIPARASITICS

ANTIHELMINTHICS

albendazole 1

ALBENZA 3

BENZNIDAZOLE (12.5 MG TABLET, 100 MG TABLET) 3 QL

BILTRICIDE 3

EMVERM 3

QL

PA

ivermectin 1

praziquantel 1

SKLICE 3 QL

STROMECTOL 3

ANTIPROTOZOALS

ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) 3

ARAKODA 3

atovaquone 1



atovaquone/proguanil hcl 1

chloroquine phosphate 1

COARTEM 3

DARAPRIM 3 S

hydroxychloroquine sulfate 1

IMPAVIDO 3

QL

PA

KRINTAFEL 2

MALARONE 3

mefloquine hcl 1

MEPRON 3

NEBUPENT 3

PLAQUENIL 3

PRIMAQUINE PHOSPHATE 3

QUALAQUIN 3 PA

quinine sulfate 1 PA

PEDICULICIDES/SCABICIDES

crotan 1 QL

ELIMITE 3

EURAX 3 QL

lindane 1 QL

malathion 1

OVIDE 3

permethrin 5 % cream (g) 1

ANTIPARKINSON AGENTS

ANTICHOLINERGICS

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

ANTIPARKINSON AGENTS, OTHER

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

carbidopa/levodopa/entacapone 1



COMTAN 3

entacapone 1

GOCOVRI 3

QL

PA

OSMOLEX ER 3

QL

PA

STALEVO 3

TASMAR 3

tolcapone 1

DOPAMINE AGONISTS

APOKYN 3

S

MS

bromocriptine mesylate 1

MIRAPEX 3

MIRAPEX ER 3

NEUPRO 3

QL

PA

PARLODEL 3

pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.375 mg tab er 24h, 0.5mg tablet, 0.75 mg tab er 24h, 0.75 mg tablet, 1 mg tablet, 1.5 mg tab er 24h,1.5 mg tablet, 2.25 mg tab er 24h, 3 mg tab er 24h, 3.75 mg tab er 24h, 4.5 mgtab er 24h)

1

REQUIP 3

REQUIP XL 3 QL

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

1

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

1 QL

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS

carbidopa 1



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

1

LODOSYN 3

RYTARY (ER 23.75 MG-95 MG CAP, ER 36.25 MG-145 MG CAP, ER 48.75MG-195 MG CAP, ER 61.25 MG-245 MG CAP)

3

QL

PA

SINEMET 10-100 3

SINEMET 25-100 3

SINEMET 25-250 3

SINEMET CR 3

MONOAMINE OXIDASE B (MAO-B) INHIBITORS

AZILECT 3 QL

ELDEPRYL 3

rasagiline mesylate 1 QL

selegiline hcl 1

XADAGO (50 MG TABLET, 100 MG TABLET) 3

QL

ST

ZELAPAR 3

QL

PA

ANTIPSYCHOTICS

1ST GENERATION/TYPICAL

ADASUVE 3

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

1

fluphenazine decanoate 1

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

1

haloperidol 1

haloperidol lactate (2 mg/ml oral conc, 5 mg/ml vial) 1

loxapine succinate 1

molindone hcl 1

ORAP 3

pimozide 1

thioridazine hcl 1



thiothixene 1

trifluoperazine hcl 1

2ND GENERATION/ATYPICAL

ABILIFY (2 MG TABLET, 5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20MG TABLET, 30 MG TABLET)

3 QL

ABILIFY DISCMELT 3 QL

ABILIFY MYCITE 3

QL

PA

aripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet, 10 mg tab rapdis, 10mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 30 mg tablet)

1 QL

FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MGTABLET, 10 MG TABLET, 12 MG TABLET)

3

QL

ST

FANAPT TITRATION PACK 3 ST

GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MGCAPSULE)

3

INVEGA 3 QL

LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 80 MG TABLET,120 MG TABLET)

3

QL

ST

NUPLAZID (10 MG TABLET, 17 MG TABLET, 34 MG CAPSULE) 3

QL

PA

S

MS

olanzapine (2.5 mg tablet, 5 mg tab rapdis, 5 mg tablet, 7.5 mg tablet, 10 mgtab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tab rapdis, 20mg tablet)

1

paliperidone 1 QL

quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet,300 mg tablet)

1

quetiapine fumarate (50 mg tab er 24h, 150 mg tab er 24h, 200 mg tab er 24h,300 mg tab er 24h, 400 mg tab er 24h, 400 mg tablet)

1 QL

REXULTI 3

QL

ST

RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 1 MG/MLSOLUTION, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET)

3

RISPERDAL M-TAB 3



risperidone (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab rapdis, 0.5 mgtablet, 1 mg tab rapdis, 1 mg tablet, 1 mg/ml solution, 2 mg tab rapdis, 2 mgtablet, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet)

1

SAPHRIS 3

QL

ST

SEROQUEL (25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MGTABLET, 300 MG TABLET)

3

SEROQUEL 400 MG TABLET 3 QL

SEROQUEL XR (50 MG TABLET, 150 MG TABLET, 200 MG TABLET, 300 MGTABLET, 400 MG TABLET)

3 QL

VRAYLAR 3

QL

ST

ziprasidone hcl 1

ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 10 MGTABLET, 15 MG TABLET, 20 MG TABLET)

3

ZYPREXA ZYDIS 3

TREATMENT-RESISTANT

clozapine (12.5 mg tab rapdis, 25 mg tab rapdis, 25 mg tablet, 50 mg tablet,100 mg tab rapdis, 100 mg tablet, 150 mg tab rapdis, 200 mg tab rapdis, 200mg tablet)

1

CLOZARIL 3

FAZACLO 3

VERSACLOZ 3

ANTISPASTICITY AGENTS

baclofen (10 mg tablet, 20 mg tablet) 1

baclofen 5 mg tablet 1

DANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 3

dantrolene sodium 1

tizanidine hcl 1

ZANAFLEX 3

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS

PREVYMIS (240 MG TABLET, 480 MG TABLET) 3

VALCYTE (50 MG/ML SOLUTION, 450 MG TABLET) 3

valganciclovir hcl (50 mg/ml soln recon, 450 mg tablet) 1

ZIRGAN 3



ANTI-HEPATITIS B (HBV) AGENTS

adefovir dipivoxil 1

BARACLUDE (0.05 MG/ML SOLUTION, 0.5 MG TABLET, 1 MG TABLET) 3 QL

entecavir 1 QL

EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 3

HEPSERA 3

lamivudine 100 mg tablet 1

TYZEKA 3 QL

VEMLIDY 3

ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS

DAKLINZA (30 MG TABLET, 60 MG TABLET, 90 MG TABLET) 3

QL

PA

ST

S

MS

EPCLUSA 3

QL

PA

S

MS

HARVONI 3

QL

PA

S

MS

LEDIPASVIR/SOFOSBUVIR 3

QL

PA

S

MS

MAVYRET 3

QL

PA

S

MS



OLYSIO 3

QL

PA

ST

S

MS

SOFOSBUVIR/VELPATASVIR 3

QL

PA

S

MS

SOVALDI 3

QL

PA

S

MS

TECHNIVIE 3

QL

PA

ST

S

MS

VIEKIRA PAK 3

QL

PA

ST

S

MS

VIEKIRA XR 3

QL

PA

ST

S

MS

VOSEVI 3

QL

PA

S

MS



ZEPATIER 3

QL

PA

ST

S

MS

ANTI-HEPATITIS C (HCV) AGENTS, OTHER

COPEGUS 3

PA

S

MS

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

3

S

MS

moderiba 1

PA

S

MS

PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) 3

QL

PA

S

MS

PEGASYS PROCLICK 3

QL

PA

S

MS

PEGINTRON 3

QL

PA

S

MS

PEGINTRON REDIPEN 3

QL

PA

S

MS

REBETOL (40 MG/ML SOLUTION, 200 MG CAPSULE) 3

PA

S

MS



ribasphere (200 mg capsule, 200 mg tablet) 1

PA

S

MS

RIBASPHERE (400 MG TABLET, 600 MG TABLET) 3

PA

S

MS

RIBASPHERE RIBAPAK 3

PA

S

MS

RIBATAB 3

PA

MS

ribavirin (200 mg capsule, 200 mg tablet) 1

PA

S

MS

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)

BIKTARVY 2 S

GENVOYA 2 S

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

2

QL

S

ISENTRESS 100 MG POWDER PACKET 2 S

ISENTRESS HD 2

QL

S

STRIBILD 3

QL

S

TIVICAY (10 MG TABLET, 25 MG TABLET, 50 MG TABLET) 3 S

VITEKTA 150 MG TABLET 3

QL

S

VITEKTA 85 MG TABLET 3 S



ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

ATRIPLA 3

QL

ST

S

COMPLERA 3 S

DELSTRIGO 3

QL

S

EDURANT 3 S

efavirenz 1 S

INTELENCE 2 S

nevirapine (100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h) 1 S

NEVIRAPINE 50 MG/5 ML ORAL SUSP 2 S

ODEFSEY 3 S

PIFELTRO 3

QL

S

RESCRIPTOR 2 S

SUSTIVA 3 S

SYMFI 2

QL

S

SYMFI LO 2

QL

S

VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 3 S

VIRAMUNE XR 3 S

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate 20 mg/ml solution 1

abacavir sulfate 300 mg tablet 1 S

abacavir sulfate/lamivudine 1 S

abacavir sulfate/lamivudine/zidovudine 1 S

CIMDUO 2

QL

S



COMBIVIR 3 S

didanosine 1 S

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 3 S

EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG TABLET) 3 S

EPZICOM 3 S

lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet) 1 S

lamivudine/zidovudine 1 S

RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 3 S

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

1 S

tenofovir disoproxil fumarate 1 S

TRIZIVIR 3 S

TRUVADA 2 S

VIDEX 2 S

VIDEX EC 3 S

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MGTABLET, POWDER)

3 S

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

3 S

ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 3 S

zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) 1 S

ANTI-HIV AGENTS, OTHER

DESCOVY 2 S

DOVATO 3

JULUCA 3 S

SELZENTRY (25 MG TABLET, 75 MG TABLET, 150 MG TABLET, 300 MGTABLET)

2 S

SELZENTRY 20 MG/ML ORAL SOLN 2 S

TRIUMEQ 3 S

TYBOST 2

QL

S



ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 3 S

atazanavir sulfate 1 S

CRIXIVAN 3 S

EVOTAZ 3

QL

S

INVIRASE 3 S

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

3 S

LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 3 S

lopinavir/ritonavir 1 S

NORVIR (80 MG/ML SOLUTION, 100 MG POWDER PACKET, 100 MGSOFTGEL CAP, 100 MG TABLET)

3 S

PREZCOBIX 3 S

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

3 S

REYATAZ 3 S

ritonavir 1 S

SYMTUZA 3 QL

VIRACEPT 3 S

ANTI-INFLUENZA AGENTS

FLUMADINE 3

oseltamivir phosphate (6 mg/ml susp recon, 30 mg capsule, 45 mg capsule, 75mg capsule)

1 QL

RELENZA 3 QL

rimantadine hcl 1

TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75MG CAPSULE)

3 QL

ANTIHERPETIC AGENTS

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

acyclovir (5 % cream (g), 5 % oint. (g)) 1 QL

ALFERON N 3

DENAVIR 3 QL

famciclovir (125 mg tablet, 250 mg tablet) 1



famciclovir 500 mg tablet 1 QL

FAMVIR (125 MG TABLET, 250 MG TABLET) 3

FAMVIR 500 MG TABLET 3 QL

SITAVIG 3 PA

trifluridine 1

valacyclovir hcl 1

VALTREX 3

VIROPTIC 3

XERESE 3 PA

ZOVIRAX (200 MG CAPSULE, 200 MG/5 ML SUSP, 400 MG TABLET, 800MG TABLET)

3

ZOVIRAX (CREAM, OINTMENT) 3 QL

ANXIOLYTICS

ANXIOLYTICS, OTHER

buspirone hcl 1

meprobamate 1

midazolam hcl 2 mg/ml syrup 1

BENZODIAZEPINES

alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab er 24h, 0.5 mg tabrapdis, 0.5 mg tablet, 1 mg tab er 24h, 1 mg tab rapdis, 1 mg tablet, 2 mg tab er24h, 2 mg tab rapdis, 2 mg tablet, 3 mg tab er 24h)

1

alprazolam intensol 1

ATIVAN (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3

chlordiazepoxide hcl 1

clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5mg tablet, 1 mg tab rapdis, 1 mg tablet, 2 mg tab rapdis, 2 mg tablet)

1

clorazepate dipotassium 1

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

1

KLONOPIN 3

lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oral conc) 1

lorazepam intensol 1

oxazepam 1

TRANXENE T-TAB 3

VALIUM 3

XANAX 3



XANAX XR 3

BIPOLAR AGENTS

MOOD STABILIZERS

EQUETRO 3

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

1

lithium citrate 1

LITHOBID 3

BLOOD GLUCOSE REGULATORS

DIABETIC BENEFIT and/or DME BENEFIT APPLIES. Please refer to member contract for copayment amount. If Diabetic BenefitDOES NOT apply please refer to the following tier classifications:

ANTIDIABETIC AGENTS

acarbose 1

ACTOPLUS MET 3

ACTOPLUS MET XR (15-1,000 MG TB, 30-1,000 MG TB) 3 QL

ACTOS 3

ADLYXIN 3 QL

ALOGLIPTIN BENZOATE 3

QL

ST

ALOGLIPTIN BENZOATE/METFORMIN HCL 3

QL

ST

ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 3

QL

ST

AMARYL 3

AVANDIA 3

BYDUREON 2 QL

BYDUREON BCISE 2 QL

BYDUREON PEN 2 QL

BYETTA (5 MCG PEN INJ, 10 MCG PEN INJ) 2 QL

CHLORPROPAMIDE 3

CYCLOSET 3 QL

DIABETA 3



DUETACT 3 QL

FARXIGA 2

FORTAMET 3 ST

glimepiride 1

glipizide (2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 10 mg tab er 24, 10 mgtablet)

1

glipizide/metformin hcl 1

GLUCOPHAGE 3

GLUCOPHAGE XR 3

GLUCOTROL 3

GLUCOTROL XL 3

GLUCOVANCE 3

GLUMETZA 3 ST

glyburide 1

glyburide,micronized 1

glyburide/metformin hcl 1

GLYNASE 3

GLYSET 3

GLYXAMBI 3 QL

INVOKAMET (50-1,000 MG TABLET, 150-1,000 MG TABLET, 150-500 MGTABLET)

2

INVOKAMET 50-500 MG TABLET 2 QL

INVOKAMET XR 2

INVOKANA (100 MG TABLET, 300 MG TABLET) 2 QL

JANUMET 2 QL

JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET, 100-1,000 MGTABLET)

2 QL

JANUVIA 2 QL

JARDIANCE 10 MG TABLET 3 QL

JARDIANCE 25 MG TABLET 3

JENTADUETO 2 QL

JENTADUETO XR (2.5 MG, 5 MG TB) 2 QL



KAZANO 3

QL

ST

KOMBIGLYZE XR (2.5-1,000 MG TAB, 5-1,000 MG TAB, 5-500 MG TABLET) 3

QL

ST

metformin er 500mg & 1000mg tab (generic version of glumetza) 1 ST

metformin hcl (500 mg tab er 24, 1000 mg tab er 24) 1 ST

metformin hcl (500 mg tab er 24h, 500 mg tablet, 750 mg tab er 24h, 850 mgtablet, 1000 mg tablet)

1

METFORMIN HCL 500 MG/5ML SOLUTION 3

miglitol 1

nateglinide 1

NESINA 3

QL

ST

ONGLYZA 3

QL

ST

OSENI 3

QL

ST

OZEMPIC (0.25-0.5 MG PEN, 1 MG PEN) 2 QL

pioglitazone hcl 1

pioglitazone hcl/glimepiride 1 QL

pioglitazone hcl/metformin hcl 1

PRANDIN 3

PRECOSE 3

QTERN 10 MG-5 MG TABLET 3 QL

QTERN 5 MG-5 MG TABLET 3

repaglinide 1

REPAGLINIDE/METFORMIN 3

RIOMET 3

SEGLUROMET 2 QL

STARLIX 3

STEGLATRO 2 QL



STEGLUJAN 3 QL

SYMLINPEN 120 3

SYMLINPEN 60 3

SYNJARDY 3

SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET, 12.5-1,000 MGTAB, 25-1,000 MG TABLET)

3 QL

TANZEUM 30 MG PEN INJECT 3 QL

TANZEUM 50 MG PEN INJECT 3

tolazamide 1

tolbutamide 1

TRADJENTA 2 QL

TRULICITY 2 QL

VICTOZA 2-PAK 2 QL

VICTOZA 3-PAK 2 QL

XIGDUO XR (2.5 MG-1,000 MG TAB, 5 MG-1,000 MG TABLET, 5 MG-500 MGTABLET, 10 MG-1,000 MG TAB, 10 MG-500 MG TABLET)

2 QL

BLOOD GLUCOSE SUPPLIES

Lifescan and Abbott are preferred test meters/strips and Step Therapy applies prior to all other meters and strips.

FREESTYLE FREEDOM LITE METER 2

FREESTYLE INSULINX GLUCOSE SYS 2

FREESTYLE INSULINX TEST STRIPS 2 QL

FREESTYLE LITE METER 2

FREESTYLE LITE TEST STRIPS 2 QL

FREESTYLE PREC NEO TEST STRIPS 2 QL

FREESTYLE PRECISION NEO METER 2

FREESTYLE TEST STRIPS 2 QL

ONETOUCH ULTRA BLUE STRIPS 2 QL

ONETOUCH ULTRA2 GLUCOSE SYST 2

ONETOUCH ULTRAMINI METER 2

ONETOUCH VERIO FLEX SYSTEM KIT 2

ONETOUCH VERIO IQ SYSTEM KIT 2

ONETOUCH VERIO METER SYSTEM 2



ONETOUCH VERIO SYNC SYST KIT 2

ONETOUCH VERIO TEST STRIP 2 QL

PRECISION XTRA MONITOR 2

PRECISION XTRA TEST STRIPS 2 QL

GLYCEMIC AGENTS

GLUCAGEN 1 MG HYPOKIT 2

GLUCAGON EMERGENCY KIT 2 QL

PROGLYCEM 3

INSULINS

ADMELOG 3

ADMELOG SOLOSTAR 3

AFREZZA 3

APIDRA 3

APIDRA SOLOSTAR 3

BASAGLAR KWIKPEN U-100 3

FIASP 3

FIASP FLEXTOUCH 3

HUMALOG 2

HUMALOG JUNIOR KWIKPEN 2

HUMALOG KWIKPEN U-100 2


HUMALOG MIX 50-50 2

HUMALOG MIX 50-50 KWIKPEN 2

HUMALOG MIX 75-25 2


HUMULIN 70-30 2

HUMULIN 70/30 KWIKPEN 2

HUMULIN N 2

HUMULIN N KWIKPEN 2

HUMULIN R 2

HUMULIN R U-500 2

HUMULIN R U-500 KWIKPEN 2



INSULIN LISPRO (100/ML INSULN PEN, 100/ML VIAL) 2

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2

LEVEMIR FLEXTOUCH 2

NOVOLIN 70-30 2

NOVOLIN 70-30 FLEXPEN 2

NOVOLIN N 2

NOVOLIN R 2

NOVOLOG 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70-30 2

NOVOLOG MIX 70-30 FLEXPEN 2

SOLIQUA 100-33 3 QL

TOUJEO MAX SOLOSTAR 2

TOUJEO SOLOSTAR 2

TRESIBA 2

TRESIBA FLEXTOUCH U-100 2


XULTOPHY 100-3.6 3 QL

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS

ARIXTRA 3 S

BEVYXXA 3 QL

COUMADIN 2

ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 2 QL

ELIQUIS 5 MG STARTER PACK 2 QL

enoxaparin sodium 1 S

fondaparinux sodium 1 S

FRAGMIN 3 S

IPRIVASK 3 S



jantoven 1

LOVENOX 3 S

PRADAXA (75 MG CAPSULE, 150 MG CAPSULE) 3

QL

ST

PRADAXA 110 MG CAPSULE 3 ST

SAVAYSA 3

QL

ST

warfarin sodium 1

XARELTO (2.5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MGTABLET)

2 QL

XARELTO STARTER PACK 2

ZONTIVITY 3

QL

PA

BLOOD FORMATION MODIFIERS

AGRYLIN 3

anagrelide hcl 1

ARANESP 2

S

MS

CABLIVI 11 MG KIT 3

QL

PA

S

DOPTELET ((10 TAB 20 MG TAB, (15 TAB 20 MG TAB) 3

QL

PA

S

MS

EPOGEN 2

S

MS

FULPHILA 3

QL

S

MS

GRANIX (300 MCG/0.5 ML SAFE SYR, 300 MCG/0.5 ML SYRINGE, 300MCG/ML VIAL, 480 MCG/0.8 ML SAFE SYR, 480 MCG/0.8 ML SYRINGE, 480MCG/1.6 ML VIAL)

3

QL

PA

S

MS



LEUKINE 3

QL

S

MS

MOZOBIL 3

QL

PA

S

MS

MULPLETA 3

QL

PA

S

MS

NEULASTA 3

QL

S

MS

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

3

QL

PA

S

MS

NIVESTYM (300 MCG/0.5 ML SYRING, 480 MCG/0.8 ML SYRING) 3

PA

S

MS

PROCRIT 2

S

MS

PROMACTA 3

QL

PA

S

MS

RETACRIT 3

S

MS

TAVALISSE 3

QL

PA

S



UDENYCA 3

QL

S

MS

ZARXIO 2

S

MS

HEMOSTASIS AGENTS

AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET, 1,000 MG TABLET) 3

aminocaproic acid (250 mg/ml solution, 500 mg tablet, 1000 mg tablet) 1

LYSTEDA 3 QL

MEPHYTON 3

phytonadione (vit k1) 5 mg tablet 1

tranexamic acid 650 mg tablet 1 QL

PLATELET MODIFYING AGENTS

AGGRENOX 3

aspirin/dipyridamole 1

BRILINTA 60 MG TABLET 2

BRILINTA 90 MG TABLET 2 QL

cilostazol 1

clopidogrel bisulfate 300 mg tablet 1

clopidogrel bisulfate 75 mg tablet 1 QL

dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1

EFFIENT (5 MG TABLET, 10 MG TABLET) 3 QL

PERSANTINE 3

PLAVIX 300 MG TABLET 3

PLAVIX 75 MG TABLET 3 QL

PLETAL 3

prasugrel hcl (5 mg tablet, 10 mg tablet) 1 QL

ticlopidine hcl 1



CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS

CATAPRES 3

CATAPRES-TTS 3 QL

clonidine (0.1mg/24hr patch tdwk, 0.2mg/24hr patch tdwk, 0.3mg/24hr patchtdwk)

1 QL

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

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

methyldopa 1

midodrine hcl 1

NORTHERA 3

QL

PA

S

MS

TENEX 3

ALPHA-ADRENERGIC BLOCKING AGENTS

CARDURA 3

DIBENZYLINE 3

doxazosin mesylate 1

MINIPRESS 3

phenoxybenzamine hcl 1

prazosin hcl 1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS

ATACAND 3

AVAPRO 3

BENICAR 3

candesartan cilexetil 1

COZAAR 3

DIOVAN 3

EDARBI 3 ST

eprosartan mesylate 1

irbesartan 1



losartan potassium 1

MICARDIS 3

olmesartan medoxomil 1

telmisartan 1

valsartan 1

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS

ACCUPRIL 3

ACEON 3

ALTACE 3

benazepril hcl 1

captopril 1

enalapril maleate 1

EPANDED SOLUTION 3 PA

fosinopril sodium 1

lisinopril 1

LOTENSIN 3

MAVIK 3

moexipril hcl 1

perindopril erbumine 1

PRINIVIL 3

QBRELIS 3

QL

PA

quinapril hcl 1

ramipril 1

trandolapril 1

VASOTEC 3

ZESTRIL 3

ANTIARRHYTHMICS

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

BETAPACE 3

BETAPACE AF 3

CORDARONE 3



disopyramide phosphate 1

dofetilide 1

flecainide acetate 1

mexiletine hcl 1

MULTAQ 2 QL

NORPACE 3

NORPACE CR 3

pacerone 1

propafenone hcl (150 mg tablet, 225 mg cap er 12h, 225 mg tablet, 300 mgtablet, 325 mg cap er 12h, 425 mg cap er 12h)

1

quinidine gluconate 324 mg tablet er 1

quinidine sulfate 1

RYTHMOL 3

RYTHMOL SR 3

sorine 1

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

SOTYLIZE 3 PA

TIKOSYN 3

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl 1

atenolol 1

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

bisoprolol fumarate 1

BYSTOLIC 3

carvedilol 1

carvedilol phosphate 1 QL

COREG 3

COREG CR 3 QL

CORGARD 3

INDERAL LA 3

INDERAL XL 3

INNOPRAN XL 3

KAPSPARGO SPRINKLE 3



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

LEVATOL 3

LOPRESSOR (50 MG TABLET, 100 MG TABLET) 3

metoprolol succinate 1

metoprolol tartrate (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet,100 mg tablet)

1

nadolol 1

pindolol 1

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

1

SECTRAL 3

TENORMIN 3

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

TOPROL XL 3

ZEBETA 3

CALCIUM CHANNEL BLOCKING AGENTS

ADALAT CC 3

afeditab cr 1

amlodipine besylate 1

CALAN 3

CALAN SR 3

CARDIZEM 3

CARDIZEM CD 3

CARDIZEM LA 3

cartia xt 1

dilt-xr 1



diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h,90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120mg cap sa 24h, 120 mg tablet, 180 mg cap er 24h, 180 mg cap er deg, 180 mgcap sa 24h, 180 mg tab er 24h, 240 mg cap er 24h, 240 mg cap er deg, 240 mgcap sa 24h, 240 mg tab er 24h, 300 mg cap er 24h, 300 mg cap sa 24h, 300mg tab er 24h, 360 mg cap er 24h, 360 mg cap sa 24h, 360 mg tab er 24h, 420mg cap sa 24h, 420 mg tab er 24h)

1

felodipine 1

isradipine 1

matzim la 1

nicardipine hcl (20 mg capsule, 30 mg capsule) 1

nifedical xl 1

nifedipine (10 mg capsule, 20 mg capsule, 30 mg tab er 24, 30 mg tablet er, 60mg tab er 24, 60 mg tablet er, 90 mg tab er 24, 90 mg tablet er)

1

nimodipine 1

nisoldipine 1 QL

NORVASC 3

NYMALIZE (30 MG/10 ML SOLUTION, 60 MG/20 ML SOLUTION) 3 QL

PROCARDIA 3

PROCARDIA XL 3

SULAR 3 QL

taztia xt 1

TIAZAC 3

verapamil hcl (40 mg tablet, 80 mg tablet, 100 mg cap24h pct, 120 mg cap24hpel, 120 mg tablet, 120 mg tablet er, 180 mg cap24h pel, 180 mg tablet er, 200mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 360mg cap24h pel)

1

VERELAN 3

VERELAN PM 3

CARDIOVASCULAR AGENTS, OTHER

ACCURETIC 3

ALDACTAZIDE 3

aliskiren hemifumarate 1 QL

amiloride hcl/hydrochlorothiazide 1

amlodipine besylate/atorvastatin calcium 1 QL

amlodipine besylate/benazepril hcl 1

amlodipine besylate/olmesartan medoxomil 1 QL



amlodipine besylate/valsartan 1

QL

PA

amlodipine besylate/valsartan/hydrochlorothiazide 1

QL

PA

ATACAND HCT 3

atenolol/chlorthalidone 1

AVALIDE 3

AZOR 3 QL

benazepril hcl/hydrochlorothiazide 1

BENICAR HCT 3

BIDIL 3 QL

bisoprolol fumarate/hydrochlorothiazide 1

BYVALSON 3 QL

CADUET 3 QL

candesartan cilexetil/hydrochlorothiazide 1

captopril/hydrochlorothiazide 1

CORLANOR 3 QL

CORZIDE 3

DEMSER 3

digitek 1

digox 1

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

DIOVAN HCT 3

DUTOPROL 3 QL

DYAZIDE 3

EDARBYCLOR 3 ST

enalapril maleate/hydrochlorothiazide 1

ENTRESTO 3

QL

ST

EXFORGE 3 QL

EXFORGE HCT 3 QL



fosinopril sodium/hydrochlorothiazide 1

HYZAAR 3

irbesartan/hydrochlorothiazide 1

isoxsuprine hcl 1

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

2

lisinopril/hydrochlorothiazide 1

LOPRESSOR HCT 3

losartan potassium/hydrochlorothiazide 1

LOTENSIN HCT 3

LOTREL 3

MAXZIDE 3

MAXZIDE-25 MG 3

methyldopa/hydrochlorothiazide 1

METOPROLOL SUCCINATE/HYDROCHLOROTHIAZIDE 3 QL

metoprolol tartrate/hydrochlorothiazide 1

MICARDIS HCT 3

moexipril hcl/hydrochlorothiazide 1

nadolol/bendroflumethiazide 1

olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide 1 QL

olmesartan medoxomil/hydrochlorothiazide 1

pentoxifylline 1

PRESTALIA (7 MG-5 MG TABLET, 14 MG-10 MG TABLET) 3 QL

PRESTALIA 3.5 MG-2.5 MG TABLET 3

propranolol hcl/hydrochlorothiazide 1

quinapril hcl/hydrochlorothiazide 1

RANEXA (ER 500 MG TABLET, ER 1,000 MG TABLET) 3 QL

RESERPINE 3

spironolactone/hydrochlorothiazide 1

TARKA 3 QL

TEKTURNA 3 QL

TEKTURNA HCT 3 QL



telmisartan/amlodipine besylate 1 QL

telmisartan/hydrochlorothiazide 1

TENORETIC 100 3

TENORETIC 50 3

trandolapril/verapamil hcl 1 QL

triamterene/hydrochlorothiazide 1

TRIBENZOR 3 QL

TWYNSTA 3 QL

valsartan/hydrochlorothiazide 1

VASERETIC 3

VECAMYL 3

VYNDAQEL 3

QL

PA

S

MS

ZESTORETIC 3

ZIAC 3

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide (125 mg tablet, 250 mg tablet, 500 mg capsule er) 1

DIAMOX SEQUELS 3

KEVEYIS 3

PA

S

DIURETICS, LOOP

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

DEMADEX 3

EDECRIN 3

ethacrynic acid 1

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

1

LASIX 3

torsemide 1



DIURETICS, POTASSIUM-SPARING

ALDACTONE 3

amiloride hcl 1

CAROSPIR 3 QL

DYRENIUM 3

eplerenone 1

INSPRA 3

spironolactone 1

DIURETICS, THIAZIDE

chlorothiazide 1

chlorthalidone 1

DIURIL 3

hydrochlorothiazide 1

indapamide 1

methyclothiazide 1

metolazone 1

MICROZIDE 3

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

ANTARA 3

fenofibrate (40 mg tablet, 120 mg tablet, 160 mg tablet) 1 QL

fenofibrate (50 mg capsule, 54 mg tablet, 150 mg capsule) 1

fenofibrate nanocrystallized (48 mg tablet, 145mg tablet) 1 QL

FENOFIBRATE NANOCRYSTALLIZED 160 MG TABLET 3 QL

fenofibrate,micronized 1

fenofibric acid 1

fenofibric acid (choline) 1 QL

FENOGLIDE 3 QL

FIBRICOR 3

gemfibrozil 1

LIPOCHOL PLUS 3

LIPOFEN 3



LOFIBRA (67 MG CAPSULE, 134 MG CAPSULE, 200 MG CAPSULE) 3

LOFIBRA 160 MG TABLET 3 QL

LOFIBRA 54 MG TABLET 3

LOPID 3

TRICOR (48 MG TABLET, 145 MG TABLET) 3 QL

TRIGLIDE 3 QL

TRILIPIX 3 QL

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

ALTOPREV 3 QL

atorvastatin calcium 1

CRESTOR (5 MG TABLET, 10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL

EZALLOR SPRINKLE 3

FLOLIPID 3

fluvastatin sodium (20 mg capsule, 40 mg capsule, 80 mg tab er 24h) 1 QL

LESCOL 3 QL

LESCOL XL 3 QL

LIPITOR 3

LIVALO 3

QL

ST

lovastatin (10 mg tablet, 20 mg tablet) 1

lovastatin 40 mg tablet 1 QL

PRAVACHOL 3

pravastatin sodium 1

rosuvastatin calcium (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL

simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet) 1 QL

ZOCOR (5 MG TABLET, 10 MG TABLET, 20 MG TABLET, 40 MG TABLET, 80MG TABLET)

3 QL

ZYPITAMAG 3 ST

DYSLIPIDEMICS, OTHER

cholestyramine (with sugar) (4 g powd pack, 4 g powder) 1



cholestyramine/aspartame (cholestyramine/aspartame 4 g powd pack,cholestyramine/aspartame 4 g powder)

1

colesevelam hcl 1

COLESTID (1 GM TABLET, FLAVORED GRANULES, GRANULES,GRANULES PACKET)

3

colestipol hcl 1

ezetimibe 1

ezetimibe/simvastatin 1

JUXTAPID 3

QL

PA

S

KYNAMRO 3

PA

S

LOVAZA 3 QL

niacin (500 mg tab er 24h, 750 mg tab er 24h, 1000 mg tab er 24h) 1 QL

NIACOR 3

NIASPAN (ER 500 MG TABLET, ER 750 MG TABLET, ER 1,000 MG TABLET) 3 QL

omega-3 acid ethyl esters 1 QL

PRALUENT 2

QL

PA

prevalite (packet, powder) 1

QUESTRAN (PACKET, POWDER) 3

QUESTRAN LIGHT 3

REPATHA 2

QL

PA

VASCEPA 0.5 GM CAPSULE 3

VASCEPA 1 GM CAPSULE 3 QL

VYTORIN 3

WELCHOL 3

ZETIA 3

VASODILATORS, DIRECT-ACTING ARTERIAL

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

minoxidil (2.5 mg tablet, 10 mg tablet) 1



VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS

DILATRATE-SR 3

GONITRO 3 PA

ISORDIL 3

ISORDIL TITRADOSE 3

isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, 40mg tablet er)

1

isosorbide mononitrate (10 mg tablet, 20 mg tablet) 1

isosorbide mononitrate (30 mg tab er 24h, 60 mg tab er 24h, 120 mg tab er24h)

1

minitran 1

NITRO-BID 3

NITRO-DUR 3

nitro-time 1

nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24,0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er)

1

nitroglycerin (0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl) 1

nitroglycerin 400mcg/spr spray 1

QL

PA

NITROLINGUAL 3 QL

NITROMIST 3

QL

PA

NITROSTAT 3

CENTRAL NERVOUS SYSTEM AGENTS

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES

ADDERALL 3

ADDERALL XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20MG CAPSULE, 25 MG CAPSULE, 30 MG CAPSULE)

3 QL

ADZENYS ER 3

QL

PA

ADZENYS XR-ODT 3

QL

PA

amphetamine sulfate 1

DESOXYN 3 PA

DEXEDRINE (SPANSULE 5 MG, SPANSULE 10 MG, SPANSULE 15 MG) 3



dexedrine 10 mg tablet 1

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

1 QL

dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate(dextroamphetamine/amphetamine 5 mg tablet,dextroamphetamine/amphetamine 7.5 mg tablet,dextroamphetamine/amphetamine 10 mg tablet,dextroamphetamine/amphetamine 12.5 mg tablet,dextroamphetamine/amphetamine 15 mg tablet,dextroamphetamine/amphetamine 20 mg tablet,dextroamphetamine/amphetamine 30 mg tablet)

1

dextroamphetamine sulfate (5 mg capsule er, 5 mg tablet, 5 mg/5 ml solution,10 mg capsule er, 10 mg tablet, 15 mg capsule er)

1

DYANAVEL XR 3

QL

PA

EVEKEO 3

EVEKEO ODT 3 QL

methamphetamine hcl 1 PA

MYDAYIS 3

QL

PA

PROCENTRA 3

VYVANSE 2 QL

ZENZEDI (2.5 MG TABLET, 7.5 MG TABLET, 15 MG TABLET, 20 MGTABLET, 30 MG TABLET)

3

zenzedi (5 mg tablet, 10 mg tablet) 1

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES

ADHANSIA XR (25 MG CAPSULE, 35 MG CAPSULE, 45 MG CAPSULE, 55MG CAPSULE, 70 MG CAPSULE, 85 MG CAPSULE)

3

QL

PA

APTENSIO XR (10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 30MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE)

3

QL

PA

atomoxetine hcl 1

clonidine hcl 0.1 mg tab er 12h 1 QL

CONCERTA 3 QL

COTEMPLA XR-ODT 3

QL

PA



DAYTRANA 3

QL

PA

dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1

dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50, 15 mg cpbp 50-50, 20 mg cpbp 50-50, 25 mg cpbp 50-50, 30 mg cpbp 50-50, 35 mg cpbp 50-50, 40 mg cpbp 50-50)

1 QL

FOCALIN 3

FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20 MGCAPSULE, 25 MG CAPSULE, 30 MG CAPSULE, 35 MG CAPSULE, 40 MGCAPSULE)

3 QL

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

1 QL

INTUNIV (ER 1 MG TABLET, ER 2 MG TABLET, ER 3 MG TABLET, ER 4 MGTABLET)

3 QL

JORNAY PM (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MGCAPSULE, 100 MG CAPSULE)

3

QL

PA

KAPVAY 3 QL

METADATE CD (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE)

3 QL

metadate er 1

METHYLIN (2.5 MG CHEWABLE TAB, 5 MG CHEWABLE TABLET, 5 MG/5ML SOLUTION, 10 MG CHEWABLE TABLET, 10 MG/5 ML SOLUTION)

3

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

1 QL

methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24, 36 mg tab er 24, 50 mgcpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70, 60 mg cpbp 50-50)

1 QL

methylphenidate hcl (2.5 mg tab chew, 5 mg tab chew, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab chew, 10 mg tablet, 10 mg tablet er, 10 mg/5 ml solution, 20mg tablet, 20 mg tablet er)

1

METHYLPHENIDATE HCL 72 MG TAB ER 24 3 QL

QUILLICHEW ER (ER 20 MG CHEW TAB, ER 30 MG CHEW TAB, ER 40 MGCHEW TAB)

3

QL

PA

QUILLIVANT XR 3

QL

PA

RELEXXII 3 QL

RITALIN 3

RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MGCAPSULE, 60 MG CAPSULE)

3 QL

STRATTERA 3

CENTRAL NERVOUS SYSTEM, OTHER

ADIPEX-P 3



ALLZITAL 3

AUSTEDO (6 MG TABLET, 9 MG TABLET, 12 MG TABLET) 3

QL

PA

S

MS

BELVIQ 3

QL

PA

BELVIQ XR 3

QL

PA

benzphetamine hcl 1

BONTRIL PDM 3

BUPAP 3 QL

butalbital/acetaminophen (butalbital/acetaminophen capsule,butalbital/acetaminophen tablet)

1 QL

butalbital/acetaminophen 50mg-325mg tablet 1

butalbital/acetaminophen/caffeine 1

CONTRAVE 3

QL

PA

diethylpropion hcl (25 mg tablet, 75 mg tablet er) 1

ESGIC 50-325-40 MG TABLET 3

esgic capsule 1

FIORICET 3

HORIZANT (ER 300 MG TABLET, ER 600 MG TABLET) 3

QL

PA

INGREZZA 3

QL

PA

S

INGREZZA INITIATION PACK 3

QL

PA

S

LOMAIRA 3

marten-tab 1

NUEDEXTA 3

QL

PA



phendimetrazine tartrate (35 mg tablet, 105 mg capsule er) 1

phentermine hcl 1

QSYMIA (3.75 MG-23 MG CAPSULE, 7.5 MG-46 MG CAPSULE, 11.25 MG-69MG CAPSULE, 15 MG-92 MG CAPSULE)

3

QL

PA

REGIMEX 3

RILUTEK 3

riluzole 1

SUPRENZA ODT 3

QL

PA

TEGSEDI 3

QL

PA

S

MS

TENCON 3

tetrabenazine (12.5 mg tablet, 25 mg tablet) 1

QL

PA

S

MS

TIGLUTIK 3 QL

VANATOL LQ 3

XENAZINE (12.5 MG TABLET, 25 MG TABLET) 3

QL

S

MS

zebutal 1

FIBROMYALGIA AGENTS

CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE, 60 MG CAPSULE) 3 QL

duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 60 mg capsule dr) 1 QL

duloxetine hcl 40 mg capsule dr 1

IRENKA 3

LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MGCAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300MG CAPSULE)

2

LYRICA 20 MG/ML ORAL SOLUTION 2 QL



LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET, CR 330 MGTABLET)

3

QL

PA

SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MGTABLET, TITRATION PACK)

3

QL

ST

MULTIPLE SCLEROSIS AGENTS

AMPYRA 3

QL

S

MS

AUBAGIO 3

QL

ST

S

MS

AVONEX 2

QL

S

MS

BETASERON 3

QL

ST

S

MS

COPAXONE (20 MG/ML SYRINGE, 40 MG/ML SYRINGE) 2

QL

S

MS

dalfampridine 1

QL

S

MS

EXTAVIA 3

PA

S

MS

FIRDAPSE 3

QL

PA

S

GILENYA 0.5 MG CAPSULE 2

QL

S

MS



glatiramer acetate (20 mg/ml syringe, 40 mg/ml syringe) 1

QL

S

MS

glatopa 20 mg/ml syringe 1

QL

ST

S

MS

glatopa 40 mg/ml syringe 1

QL

S

MS

MAVENCLAD 3

QL

PA

S

MS

MAYZENT (0.25 MG TABLET, 2 MG TABLET) 3

QL

PA

S

MS

PLEGRIDY 2

QL

S

MS

PLEGRIDY PEN 2

QL

S

MS

REBIF 2

QL

S

MS

TECFIDERA 2

QL

S

MS

ZINBRYTA 3

QL

ST

S



DENTAL AND ORAL AGENTS

cevimeline hcl 1

chlorhexidine gluconate 0.12 % mouthwash 1

EVOXAC 3

oralone 1

paroex 1

PERIDEX 3

periogard 1

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

SALAGEN 3

triamcinolone acetonide 0.1 % paste (g) 1

DERMATOLOGICAL AGENTS

8-MOP 3

ABSORICA 3 PA

ACANYA 3

QL

PA

acitretin 1 QL

ACZONE 3

QL

ST

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

1

adapalene (0.1 % med. swab, 0.1 % solution) 1

QL

ST

ADAPALENE 0.1 % LOTION 3 ST

adapalene/benzoyl peroxide 1 QL

ALDARA 3

ALEVICYN PLUS 3

ALTRENO 3 QL

AMELUZ 3

ammonium lactate 1

amnesteem 1

ANA-LEX 3



ANALPRAM HC (1% CREAM, 2.5%-1% CREAM, 2.5%-1% CRM SINGLE,2.5%-1% LOTION)

3

ATRALIN 3

ATRAPRO DERMAL SPRAY 3

avar cleanser 1

AVAR-E 3

AVAR-E GREEN 3

avita 1

azelaic acid 1

AZELEX 3

BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP) 3 QL

benzepro 6% foaming cloths 1 QL

benzepro 7% creamy wash 1

benzoyl peroxide 7 % cleanser 1

benzoyl peroxide microspheres 1

bpo (4% gel, 8% gel) 1

bpo 6% foaming cloths 1 QL

calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005 % solution) 1

calcipotriene/betamethasone dipropionate 1

calcitrene 1

CALCITRIOL 3 MCG/G OINT. (G) 3

CAPSFENAC PAK 3

QL

PA

CARAC 3 PA

claravis 1

clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) 1

QL

PA

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

1 QL

clindamycin phosphate/tretinoin 1 PA

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

1

CONDYLOX (GEL, TOPICAL SOLN) 3

CORTISPORIN (CREAM, OINTMENT) 3



COSENTYX 2

QL

PA

ST

S

MS

dapsone 5 % gel (gram) 1 QL

DERMACINRX CLORHEXACIN 3

QL

PA

DERMACINRX LEXITRAL 3

QL

PA

DERMACINRX SURGICAL PHARMAPAK 3

QL

PA

DERMACINRX THERAZOLE PAK 3

QL

PA

DICLO GEL 3

QL

PA

DICLO GEL-XRYLIX SHEET 3

QL

PA

diclofenac sodium 1 % gel (gram) 1 QL

diclofenac sodium 3 % gel (gram) 1 PA

DICLOFEX DC 3

QL

PA

DICLOZOR 3

QL

PA

DIFFERIN (0.1% CREAM, 0.1% GEL, 0.3% GEL, 0.3% GEL PUMP) 3

DIFFERIN 0.1% LOTION 3 ST

DOVONEX 3

DOXEPIN HCL 5 % CREAM (G) 3

DRITHOCREME HP 3

DRYSOL 3

DUAC 3



DUOBRII 3

QL

PA

DUPIXENT 200 MG/1.14 ML SYRING 3

QL

PA

S

MS

ELIDEL 3 QL

ENSTILAR 3

QL

PA

EPIDUO 3 QL

EPIDUO FORTE 3 QL

EPIFOAM 3

EUCRISA 3

QL

ST

FABIOR 3

QL

PA

FINACEA 3

FLUOROPLEX 3

FLUOROURACIL 0.5% CREAM 3 PA

GORDON'S UREA 3

hydrocortisone acetate/iodoquinol/aloe vera 1

hydrocortisone acetate/lidocaine hcl/aloe vera (hydrocortisone/lidocaine/aloe0.55%-2.8% gel w/appl, hydrocortisone/lidocaine/aloe 2.5-3%(7g) kit)

1

hydrocortisone acetate/pramoxine hcl 1

hydroquinone microspheres 1

IMIQUIMOD 3.75 % CRM MD PMP 3

imiquimod 5 % cream pack 1

LEVULAN 3

LEXIXRYL 3

QL

PA



lidocaine hcl/hydrocortisone acetate (lidocaine/hydrocortisone 3 %-0.5 % cream(g), lidocaine/hydrocortisone 3 %-0.5 % cream/appl, lidocaine/hydrocortisone 3%-0.5 % kit, lidocaine/hydrocortisone 3%-1%(7 g) cream/appl,lidocaine/hydrocortisone 3%-1%(7 g) kit, lidocaine/hydrocortisone 3-2.5%(7g)gel w/appl)

1

LOTRISONE 3

methoxsalen 10 mg cap lq rap 1

METROCREAM 3

METROGEL 3

METROLOTION 3

metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 % lotion, 1 % gel(gram), 1 % gel w/pump)

1

MICORT HC 2.5% CREAM 3

MICROCYN 3

MICROCYN HYDROGEL 3

myorisan 1

NATROBA 3

NEO-SYNALAR 0.5%-0.025% CREAM 3

neuac gel 1

NORITATE 3 ST

NOVACORT 3

NUDICLO SOLUPAK 3

QL

PA

NUOX 3

ONEXTON GEL PUMP 3

QL

PA

OVACE 3

OVACE PLUS (9.8% FOAM, 10% CREAM, 10% SHAMPOO, 10% WASH) 3

OVACE PLUS WASH 3

OXSORALEN-ULTRA 3

PACNEX 3

PACNEX HP 3

PACNEX LP 3

PICATO (0.015% GEL, 0.05% GEL) 2 QL

pimecrolimus 1 QL



PLEXION (CLNSING CLOTH, CREAM, LOTION) 3

PLIXDA 3

QL

ST

podofilox 1

PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1% OINTMENT, 2.5%-1%CREAM, 2.5%-1% LOTION, 2.5%-1% OINTMENT)

3

PRAMOSONE E 3

PROCORT 3

PROCTOFOAM-HC 3

PROTOPIC 3 QL

PRUDOXIN 3

QBREXZA 3 QL

RECTIV 3 QL

REGRANEX 3 QL

RETIN-A 3

RETIN-A MICRO 3

RETIN-A MICRO PUMP 3

ROSADAN (CREAM KIT, GEL KIT) 3

QL

PA

rosadan (cream, gel) 1

ROSANIL 3

ROSULA 10%-5% CLOTHS 3

SANTYL 3

seb-prev 1

selenium sulfide 1

SELRX 3

SILIQ 3

QL

PA

ST

S

MS

silver nitrate/potassium nitrate 1



SKYRIZI 2

QL

PA

S

MS

SOLARAZE 3 PA

SOOLANTRA 3

QL

ST

SORIATANE 3 QL

SORILUX 3

QL

PA

SPINOSAD 3

sss 10-5 cream 1

STELARA (45 MG/0.5 ML SYRINGE, 90 MG/ML SYRINGE) 2

QL

PA

S

MS

STELARA 45 MG/0.5 ML VIAL 2

PA

S

MS

sulfacetamide sodium (10 % cleanser, 10 % clnsr gel, 10 % shampoo) 1

sulfacetamide sodium/sulfur (sodium/sulfur 9.8%-4.8% cream (g), sodium/sulfur9.8%-4.8% lotion, sodium/sulfur 10-5%(w/v) lotion, sodium/sulfur 10-5%(w/w)cleanser, sodium/sulfur 10-5%(w/w) cream (g), sodium/sulfur 10-5%(w/w) lotion,sodium/sulfur 10-5%(w/w) suspension)

1

TACLONEX 0.005%-0.064% SUSPENS 3

QL

PA

TACLONEX OINTMENT 3

tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 1 QL

TALTZ 3

QL

PA

ST

S

MS

tazarotene 1



TAZORAC 3

TOLAK 2

TREMFYA 2

QL

PA

S

MS

TRETIN-X (0.025% CREAM COMB PCK, 0.05% COMBO PACK, 0.1%COMBO PACK)

3

TRETIN-X (0.0375% CREAM, 0.075% CREAM) 3

QL

PA

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 1

tretinoin/emollient base 1 PA

tri-chlor 1

ULESFIA 3

VECTICAL 3

VELTIN 3 PA

VEREGEN 3

VOLTAREN 3 QL

VYTONE 3

XELITRAL 3

QL

PA

XEPI 3 QL

XRYLIX 3

QL

PA

zenatane 1

ZEYOCAINE 3

QL

PA

ZIANA 3 PA

ZONALON 3

ZYCLARA (2.5% CREAM PUMP, 3.75% CREAM, 3.75% CREAM PUMP) 3

ZYPRAM 3



ELECTROLYTES/MINERALS/METALS/VITAMINS

ELECTROLYTE/MINERAL REPLACEMENT

CARBAGLU 3

PA

S

MS

CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET) 3

CARNITOR SF 3

clinpro 5000 1

cytra-k crystals packet 1

denta 5000 plus 1

dentagel 1

EFFER-K (10 TABLET EFF, 20 TABLET EFF) 3

effer-k 25 meq tablet eff 1

ENDARI 3

QL

PA

ICAR-C PLUS 3

k effervescent 1

K-TAB ER 3

klor-con 10 1

klor-con 20 meq packet 1

KLOR-CON 25 MEQ PACKET 3

klor-con 8 1

klor-con m10 1

klor-con m15 1

klor-con m20 1

klor-con sprinkle 1

klor-con-ef 1

levocarnitine (with sugar) 1

levocarnitine 330 mg tablet 1

NESTABS ONE 3

NUTRESTORE 3 PA

ORACIT 3



potassium bicarbonate/citric acid 1

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

1

potassium chloride/potassium bicarbonate/citric acid 1

potassium citrate 1

potassium citrate/citric acid 3300-1002 packet 1

prevident (0.2%, dental) 1

PREVIDENT (1.1% GEL, 5000 BOOSTER PLUS) 3

PREVIDENT 5000 3

PREVIDENT 5000 ENAMEL PROTECT 3

PREVIDENT 5000 PLUS 3

PREVIDENT 5000 SENSITIVE 3

sf 1

sf 5000 plus 1

tl g-fol os 1

UROCIT-K 3

ELECTROLYTE/MINERAL/METAL MODIFIERS

CHEMET 3

CUPRIMINE 3

QL

PA

deferasirox 1

S

MS

EXJADE 3

S

MS

FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 3 S

GALZIN 3

JADENU 3

S

MS

JYNARQUE (15 MG TABLET, 30 MG TABLET, 45 MG-15 MG TABLET, 60MG-30 MG TABLET, 90 MG-30 MG TABLET)

3

QL

PA

S

KAYEXALATE 3



kionex (15 gm/60 ml suspension, powder) 1

penicillamine 1

QL

PA

RADIOGARDASE 3

SAMSCA 3

QL

S

MS

sodium polystyrene sulfonate 1

sps 1

SYPRINE 3 PA

trientine hcl 1 PA

DEPEN 2

PHOSPHATE BINDERS

AURYXIA 3 QL

calcium acetate 1

eliphos 1

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

3 QL

FOSRENOL (750 MG POWDER PACKET, 1,000 MG POWDER PACK) 3

lanthanum carbonate (500 mg tab chew, 750 mg tab chew, 1000 mg tab chew) 1 QL

PHOSLO 3

PHOSLYRA 3

RENAGEL 3

RENVELA 3

sevelamer carbonate (2.4 g powd pack, 800 mg tablet) 1

sevelamer carbonate 0.8 g powd pack 1 QL

sevelamer hcl 1

VELPHORO 3 QL

VELTASSA 3 ST

VITAMINS

BRAND RX PRENATAL VITAMINS ARE T3 AND GENERIC RX PRENATALVITAMINS ARE T1

3

cyanocobalamin (vitamin b-12) 1000mcg/ml vial 1



ENTERAL FORMULA REQUIRES PRIOR AUTHORIZATION. BRANDS ARETIER 3 & GENERICS ARE TIER 1.

3 PA

folic acid 1 mg tablet 1

NASCOBAL 3

OB COMPLETE PETITE 3

POTABA 3

XURIDEN 3

QL

PA

S

GASTROINTESTINAL AGENTS

ANTISPASMODICS, GASTROINTESTINAL

ANASPAZ 3

BENTYL (10 MG CAPSULE, 20 MG TABLET) 3

chlordiazepoxide/clidinium bromide 1

CUVPOSA 3

QL

PA

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

ed-spaz 1

GLYCATE 3

QL

PA

glycopyrrolate (1 mg tablet, 2 mg tablet) 1

glycopyrrolate 1.5 mg tablet 1

QL

PA

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 1

LEVBID 3

LEVSIN 0.125 MG TABLET 3

LEVSIN-SL 3

LIBRAX 3

methscopolamine bromide 1

nulev 1

oscimin 1

oscimin sl 1



oscimin sr 1

propantheline bromide 1

ROBINUL 1 MG TABLET 3

ROBINUL FORTE 3

symax 1

SYMAX DUOTAB 3

symax-sl 1

symax-sr 1

GASTROINTESTINAL AGENTS, OTHER

ACTIGALL 3

CHENODAL 3 S

cromolyn sodium 20 mg/ml oral conc 1

diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025/5 liquid, hcl/atropine2.5-.025mg tablet)

1

ENTEREG 3

FULYZAQ 3

QL

PA

GASTROCROM 3

GATTEX 3

QL

PA

S

MS

lansoprazole/amoxicillin trihydrate/clarithromycin 1

LOMOTIL 3

loperamide hcl 2 mg capsule 1

MOTOFEN 3

MOVANTIK 2 QL

MYALEPT 3

PA

S

MS

MYTESI 3

QL

PA

OMECLAMOX-PAK 3

QL

PA



opium tincture 1

paregoric 1

PREVPAC 3

PYLERA 3

RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML SYRINGE, 12 MG/0.6 MLVIAL, 150 MG TABLET)

3

SYMPROIC 3

QL

ST

URSO 3

URSO FORTE 3

ursodiol 1

XENICAL 3 PA

XIFAXAN 200 MG TABLET 3

XIFAXAN 550 MG TABLET 3 QL

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

cimetidine 1

cimetidine hcl 1

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

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

PEPCID (40 MG TABLET, 40 MG/5 ML ORAL SUSP) 3

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

1

ZANTAC 300 MG TABLET 3

IRRITABLE BOWEL SYNDROME AGENTS

alosetron hcl 1 QL

AMITIZA 3

QL

ST

LINZESS 2 QL

LOTRONEX 3 QL

TRULANCE 3

QL

ST

VIBERZI 3



LAXATIVES

CLENPIQ 3

COLYTE WITH FLAVOR PACKETS 3

constulose 1

enulose 1

gavilyte-c 1

gavilyte-g 1

gavilyte-n 1

generlac 1

GIALAX 3

GOLYTELY (PACKET, SOLUTION) 3

KRISTALOSE 3 PA

lactulose (10 g/15 ml solution, 20 g/30 ml solution) 1

lactulose 10 g packet 1

QL

PA

MOVIPREP 3 QL

NULYTELY WITH FLAVOR PACKS 3

OSMOPREP 3

peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride (peg3350/sodsulf,bicarb,cl/kcl 236-22.74g soln recon, peg3350/sod sulf,bicarb,cl/kcl 240-22.72g soln recon)

1

peg-prep 1

PLENVU 3

PREPOPIK 2

sodium chloride/sodium bicarbonate/potassium chloride/peg 1

SUPREP 2

trilyte with flavor packets 1

PROTECTANTS

CARAFATE (1 GM TABLET, 1 GM/10 ML SUSP) 3

CYTOTEC 3

misoprostol 1

sucralfate 1



PROTON PUMP INHIBITORS

ACIPHEX 3 QL

ACIPHEX SPRINKLE 3

QL

PA

DEXILANT 3

QL

ST

ESOMEP-EZS 3

QL

PA

esomeprazole magnesium 1 QL

ESOMEPRAZOLE STRONTIUM 3 PA

lansoprazole (15 mg capsule dr, 15 mg tab rap dr, 30 mg capsule dr, 30 mg tabrap dr)

1 QL

NEXIUM 3

QL

ST

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

omeprazole/sodium bicarbonate 1

QL

ST

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

PREVACID (15 MG SOLUTAB, 30 MG SOLUTAB, DR 30 MG CAPSULE) 3 QL

PRILOSEC 3 QL

PROTONIX 3 QL

rabeprazole sodium 20 mg tablet dr 1 QL

ZEGERID (20 MG PACKET, 40 MG CAPSULE, 40 MG PACKET) 3

QL

ST

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

BUPHENYL (500 MG TABLET, POWDER) 3

CERDELGA 3

PA

S

MS

CHOLBAM 3

PA

S



CREON 2

CYSTADANE 3 S

CYSTAGON 2 S

GALAFOLD 3

QL

PA

S

MS

KUVAN 3

PA

S

MS

miglustat 1

QL

PA

S

MS

NITYR 3

PA

S

OCALIVA 3

QL

PA

S

MS

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

3

PA

S

PALYNZIQ 3

PA

S

MS

PANCREAZE 3

pancrelipase 5,000 1

PERTZYE 3

PROCYSBI (DR 25 MG CAPSULE, DR 75 MG CAPSULE) 3

QL

PA

S

MS



RAVICTI 3

QL

PA

S

MS

sodium phenylbutyrate (0.94 g/g powder, 500 mg tablet) 1

STRENSIQ (18 MG/0.45 ML VIAL, 28 MG/0.7 ML VIAL, 40 MG/ML VIAL, 80MG/0.8 ML VIAL)

3

QL

PA

S

SUCRAID 3

PA

S

ULTRESA 3

VIOKACE 3

ZAVESCA 3

QL

PA

S

MS

ZENPEP 2

GENITOURINARY AGENTS

ANTISPASMODICS, URINARY

darifenacin hydrobromide 1 QL

DETROL 3 QL

DETROL LA 3 QL

DITROPAN XL 3

ENABLEX 3 QL

flavoxate hcl 1

GELNIQUE (3% GEL, 10% GEL PUMP, 10% GEL SACHET, 10% GELSACHETS)

3

QL

ST

MYRBETRIQ 2 QL

oxybutynin chloride (5 mg tab er 24, 5 mg tablet, 5 mg/5 ml syrup, 10 mg tab er24, 15 mg tab er 24)

1

OXYTROL 3 ST

solifenacin succinate 1 QL



tolterodine tartrate (1 mg tablet, 2 mg cap er 24h, 2 mg tablet, 4 mg cap er 24h) 1 QL

TOVIAZ 2 QL

trospium chloride (20 mg tablet, 60 mg cap er 24h) 1 QL

VESICARE 2 QL

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin hcl 1 QL

AVODART 3 QL

CARDURA XL 3

CIALIS (2.5 MG TABLET, 5 MG TABLET) 3 QL

dutasteride 1 QL

dutasteride/tamsulosin hcl 1 QL

finasteride 5 mg tablet 1

FLOMAX 3 QL

JALYN 3 QL

PROSCAR 3

RAPAFLO 3 QL

silodosin 1 QL

tadalafil (2.5 mg tablet, 5 mg tablet) 1 QL

tamsulosin hcl 1 QL

UROXATRAL 3 QL

GENITOURINARY AGENTS, OTHER

ADDYI 3 PA

bethanechol chloride 1

CAVERJECT (IMPULSE 10 MCG KIT, 20 MCG VIAL, IMPULSE 20 MCG KIT,40 MCG VIAL)

3 QL

CIALIS (10 MG TABLET, 20 MG TABLET) 3 QL

conceptrol 0 C Covered in full

EDEX 3 QL

ELMIRON 3



FEM PH 3

gynol ii 0 C Covered in full

K-PHOS NO.2 3

K-PHOS ORIGINAL 3

LEVITRA 3 QL

LITHOSTAT 3

MUSE 3 QL

phenazopyridine hcl 1

PYRIDIUM 3

RELAGARD 3

RIMSO-50 3

sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mg tablet) 1 QL

STAXYN 3 QL

STENDRA 3 QL

tadalafil 10 mg tablet 1 QL

tadalafil 20 mg tablet (generic version of Adcirca) 1

QL

PA

S

MS

THIOLA 3

QL

S

THIOLA EC (EC 100 MG TABLET, EC 300 MG TABLET) 3

QL

S

today contraceptive sponge 0 C Covered in full

URECHOLINE 3

UROQID-ACID NO.2 3

vardenafil hcl 1 QL

vcf (film, foam, gel) 0 C Covered in full

VIAGRA 3 QL



HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

ACTHAR 3

QL

PA

S

MS

ala-cort 1

ALA-SCALP 3

alclometasone dipropionate 1

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

anucort-hc 1

ANUSOL-HC 25 MG SUPPOSITORY 3

APEXICON E 3

BESER KIT 3

QL

PA

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

BRYHALI 3

QL

ST

CAPEX SHAMPOO 3

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 1

CLOBEX 3

CLOCORTOLONE PIVALATE 0.1 % CREAM(G) 3 ST

CLODAN 0.05% KIT 3

QL

PA

clodan 0.05% shampoo 1

CLODERM 3 ST

CORDRAN (0.025% CREAM, 0.05% CREAM, 0.05% LOTION, 0.05%OINTMENT)

3 ST

CORDRAN (4 MCG/SQ CM TAPE LARGE, 4 MCG/SQ CM TAPE SMALL) 3 QL

cormax 1



CORTEF 3

cortisone acetate 1

CUTIVATE (CREAM, LOTION) 3

decadron 0.5 mg/5 ml elixir 1

deltasone 1

DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL) 3

DERMACINRX CINLONE-I CPI 3

QL

PA

DERMACINRX SILAPAK 3

QL

PA

DERMACINRX SILAZONE 3

QL

PA

DERMATOP 3

DERMAZONE 3

QL

PA

DESONATE 3 ST

desonide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 1

DESOWEN (CREAM, LOTION) 3

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

1

dexamethasone ((21) tab ds pk, (35) tab ds pk, (51) tab ds pk) 1

QL

PA

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

1

DEXAMETHASONE INTENSOL 3

DIFLORASONE DIACETATE 3

DIPROLENE (LOTION, OINTMENT) 3

DIPROLENE AF 3

DXEVO 3

QL

PA

ELLZIA PAK 3

QL

PA

ELOCON (CREAM, LOTION, OINTMENT) 3



EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORAL SUSP, 30MG TABLET, 36 MG TABLET)

3

QL

PA

S

MS

fludrocortisone acetate 1

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

1

fluocinolone acetonide/shower cap 1

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

flurandrenolide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 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)) 1

HALOBETASOL PROPIONATE 0.05 % FOAM 3

QL

ST

HALOG 3 ST

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), 5 mg tablet, 10 mg tablet, 20 mgtablet)

1

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

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

hydrocortisone butyrate 0.1 % lotion 1 ST

hydrocortisone butyrate/emoll 0.1 % cream (g) 1

hydrocortisone valerate 1

hydrocortisone/mineral oil/petrolatum,white 1

IMPOYZ 3 ST

KENALOG 3

QL

ST

KORLYM 3

QL

PA

S

LEXETTE 3

QL

ST



LOCOID (CREAM, LOTION, OINTMENT, SOLUTION) 3 ST

LOCOID LIPOCREAM 3 ST

LUXIQ 3

MEDROL 3

methylprednisolone 1

MICORT-HC 2.5% CREAM 3

MILLIPRED (5 MG TABLET, 10 MG/5 ML SOLUTION) 3

MILLIPRED DP 3

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

nolix 0.05% cream 1

NUCORT 3

NUTRIARX 3

QL

PA

OLUX 3

OLUX-E 3

ORAPRED ODT 3

PANDEL 3 ST

PEDIADERM HC 3

QL

PA

PEDIAPRED 3

prednicarbate 1

prednisolone 15 mg/5 ml solution 1

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

1

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

1

prednisone intensol 1

procto-med hc 1

procto-pak 1

PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 3

proctosol-hc 1

proctozone-hc 1

PSORCON 3



RAYOS 3 PA

SANADERMRX 3

QL

PA

scalacort 1

SERNIVO 3

QL

ST

SILALITE PAK 3

QL

PA

SILAZONE-II 3

QL

PA

SYNALAR (0.01% SOLUTION, 0.025% CREAM, 0.025% OINTMENT) 3

SYNALAR TS 3

QL

PA

TAPERDEX 3

QL

PA

TEMOVATE 3

TEXACORT 3

TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT, 0.25% CREAM,0.25% OINTMENT, 0.25% SPRAY)

3

TRI-SILA 3

QL

PA

triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g),0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.5 % cream (g), 0.5 % oint. (g))

1

triamcinolone acetonide 0.147mg/g aerosol 1 QL

TRIANEX 3

triderm 1

TRIDESILON 3

ULTRAVATE (CREAM, OINTMENT) 3

ULTRAVATE 0.05% LOTION 3

QL

ST

ULTRAVATE X 3

QL

PA

VANOS 3 ST



VERDESO 3 ST

VERIPRED 20 3

WHYTEDERM TRILASIL PAK 3

QL

PA

ZODEX (6 1.5 MG TABLET, 12 1.5 MG TABLET) 3

QL

PA

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

BRAVELLE 3

QL

PA

S

MS

chorionic gonadotropin, human 10000 unit vial 1

QL

PA

S

MS

DDAVP (0.1 MG TABLET, 0.2 MG TABLET, 10 MCG/0.1 ML SOLUTION) 3

DDAVP (4 MCG/ML AMPUL, 4 MCG/ML VIAL) 3

S

MS

DDAVP 0.01% NASAL SPRAY 3

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

1

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

S

MS

desmopressin acetate (non-refrigerated) 1

EGRIFTA (1 MG VIAL, 2 MG VIAL) 3

QL

PA

S

FOLLISTIM AQ 3

QL

PA

ST

S

MS



GENOTROPIN 3

PA

ST

S

MS

GONAL-F 2

QL

PA

S

MS

HUMATROPE 3

PA

ST

S

MS

INCRELEX 3

PA

S

MS

MENOPUR 3

PA

S

MS

NOCDURNA 3 QL

NOCTIVA 3

QL

S

NORDITROPIN FLEXPRO 3

PA

ST

S

MS

novarel 10,000 units vial 1

QL

PA

S

MS

NUTROPIN AQ 3

PA

ST

S

MS



OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG) 2

PA

S

MS

OVIDREL 3

PA

S

MS

pregnyl 1

QL

PA

S

MS

SAIZEN 3

QL

PA

ST

S

MS

SEROSTIM 3

QL

PA

S

MS

STIMATE 3 S

ZOMACTON 3

QL

PA

S

MS

ZORBTIVE 3

QL

PA

S

MS

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)

ANABOLIC STEROIDS

ANADROL-50 3

OXANDRIN 3

oxandrolone 1



ANDROGENS

ANDRODERM 2 PA

ANDROGEL 2 PA

ANDROID 3 PA

androxy 1 PA

AXIRON 3 PA

danazol 1

DEPO-TESTOSTERONE 3

FORTESTA 3 PA

methitest 1 PA

methyltestosterone 1 PA

NATESTO 3

QL

PA

STRIANT 3 PA

TESTIM 3 PA

testosterone (1.25g-1.62 gel packet, 2.5g-1.62% gel packet, 20.25/1.25 gel mdpmp, 25mg(1%) gel packet, 30mg/1.5ml sol md pmp)

1 PA

testosterone (10 mg (2%) gel md pmp, 12.5/1.25g gel md pmp, 50 mg (1%) gel(gram)

1 PA

TESTOSTERONE (50 MG (1%) GEL PACKET AND 12.5/1.25G PUMP). SOMEMANUFACTURERS ARE T3 AND OTHERS T1

3 PA

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

testosterone enanthate 200 mg/ml vial 1

TESTRED 3 PA

VOGELXO 3 PA

XYOSTED 3

QL

PA

ESTROGENS

ACTIVELLA 3

aftera 0 C Covered in full

ALORA 3

altavera 0 C Covered in full



alyacen 0 C Covered in full

amabelz 1

amethia 0 C Covered in full

amethia lo 0 C Covered in full

amethyst 0 C Covered in full

ANGELIQ 3

apri 0 C Covered in full

aranelle 0 C Covered in full

ashlyna 0 C Covered in full

aubra 0 C Covered in full

aubra eq 0 C Covered in full

aurovela 1 mg-20 mcg tablet 1

aurovela 24 fe 1

aviane 0 C Covered in full

azurette 0 C Covered in full

balcoltra 0 C Covered in full

balziva 0 C Covered in full

bekyree 0 C Covered in full

BEYAZ 3

BIJUVA 3

blisovi 24 fe 0 C Covered in full

blisovi fe 0 C Covered in full

BREVICON 3

briellyn 0 C Covered in full

camrese 0 C Covered in full

camrese lo 0 C Covered in full

caziant 0 C Covered in full

chateal 0 C Covered in full



chateal eq 0 C Covered in full

CLIMARA 3 QL

CLIMARA PRO 2

COMBIPATCH 3

covaryx 1

covaryx h.s. 1

cryselle 0 C Covered in full

cyclafem 0 C Covered in full

CYCLESSA 3

cyred 0 C Covered in full

dasetta 0 C Covered in full

daysee 0 C Covered in full

DELESTROGEN 3

delyla 0 C Covered in full

DEPO-ESTRADIOL 3

desogestrel-ethinyl estradiol 0 C Covered in full

desogestrel-ethinyl estradiol/ethinyl estradiol 0 C Covered in full

DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 0.75 MG GELPACKET, 1 MG GEL PACKET)

3

drospirenone/ethinyl estradiol/levomefolate calcium 0 C Covered in full

econtra one-step 0 C Covered in full

eemt 1

eemt h.s. 1

ELESTRIN 3

elinest 0 C Covered in full

emoquette 0 C Covered in full

ENJUVIA (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET)

3 QL

enpresse 0 C Covered in full

enskyce 0 C Covered in full

estarylla 0 C Covered in full



ESTRACE (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3

ESTRACE 0.01% CREAM 2

estradiol (.025mg/24h patch tdwk, .0375mg/24 patch tdwk, 0.05mg/24h patchtdwk, 0.06mg/24h patch tdwk, .075mg/24h patch tdwk, 0.1mg/24hr patch tdwk)

1 QL

estradiol (0.01 % cream/appl, .025mg/24h patch tdsw, .0375mg/24 patch tdsw,0.05mg/24h patch tdsw, .075mg/24h patch tdsw, 0.1mg/24hr patch tdsw, 0.5mg tablet, 1 mg tablet, 2 mg tablet, 10 mcg tablet)

1

estradiol valerate 1

estradiol/norethindrone acetate 1

ESTRING 3

ESTROGEL 3

estrogens,esterified/methyltestosterone 1

estropipate 1

ESTROSTEP FE 3

ethinyl estradiol/drospirenone 0 C Covered in full

ethynodiol d-ethinyl estradiol 1 mg-35mcg tablet 0 C Covered in full

ethynodiol d-ethinyl estradiol 1 mg-50mcg tablet 0 C Covered in full

EVAMIST 3

falmina 0 C Covered in full

fayosim 0 C Covered in full

FEMHRT 3

FEMRING 3

femynor 0 C Covered in full

fyavolv 1

GENERESS FE 3

gianvi 0 C Covered in full

gildagia 0 C Covered in full

gildess 24 fe 0 C Covered in full

IMVEXXY 3

introvale 0 C Covered in full

isibloom 0 C Covered in full

jevantique lo 1

jinteli 1



jolessa 0 C Covered in full

juleber 0 C Covered in full

junel 0 C Covered in full

junel fe 0 C Covered in full

junel fe 24 0 C Covered in full

kaitlib fe 0 C Covered in full

kariva 0 C Covered in full

kelnor 1-35 0 C Covered in full

kelnor 1-50 0 C Covered in full

kimidess 0 C Covered in full

kurvelo 0 C Covered in full

l-norgest/e.estradiol-e.estrad 0.15mg(84) tbdspk 3mo 0 C Covered in full

larin 0 C Covered in full

larin 24 fe 0 C Covered in full

larin fe 0 C Covered in full

larissia 0 C Covered in full

layolis fe 0 C Covered in full

leena 0 C Covered in full

lessina 0 C Covered in full

levonest 0 C Covered in full

levonorgestrel 0 C Covered in full

levonorgestrel-ethinyl estradiol 0 C Covered in full

levonorgestrel/ethinyl estradiol and ethinyl estradiol (l-norgest/e.estradiol-e.estrad 100-20(84) tbdspk 3mo, l-norgest/e.estradiol-e.estrad 150-30(84)tbdspk 3mo)

0 C Covered in full

levora-28 0 C Covered in full

lillow 0 C Covered in full

lo loestrin fe 0 C Covered in full

LOESTRIN 3



LOESTRIN FE 3

lomedia 24 fe 0 C Covered in full

lopreeza 1

loryna 0 C Covered in full

LOSEASONIQUE 3

low-ogestrel 0 C Covered in full

lutera 0 C Covered in full

marlissa 0 C Covered in full

melodetta 24 fe 0 C Covered in full

MENEST 3

MENOSTAR 3 QL

mibelas 24 fe 0 C Covered in full

microgestin 0 C Covered in full

microgestin 24 fe 0 C Covered in full

microgestin fe 0 C Covered in full

mili 0 C Covered in full

mimvey 1

mimvey lo 1

MINASTRIN 24 FE 3

MINIVELLE 3

MIRCETTE 3

mono-linyah 0 C Covered in full

mononessa 0 C Covered in full

my choice 0 C Covered in full

my way 0 C Covered in full

myzilra 0 C Covered in full

natazia 0 C Covered in full

necon (0.5-35-28 tablet, 1-50-28 tablet, 7-7-7-28 tablet) 0 C Covered in full

new day 0 C Covered in full



nikki 0 C Covered in full

norethindrone ac-eth estradiol 1mg-20mcg tablet 0 C Covered in full

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

norethindrone acetate-ethinyl estradiol/ferrous fumarate 0 C Covered in full

norethindrone-ethinyl estradiol/ferrous fumarate 0 C Covered in full

norgestimate-ethinyl estradiol 0 C Covered in full

nortrel 0 C Covered in full

nuvaring 0 C Covered in full

ocella 0 C Covered in full

ogestrel 0 C Covered in full

orsythia 0 C Covered in full

ORTHO TRI-CYCLEN 3

ORTHO TRI-CYCLEN LO 3

ORTHO-CYCLEN 3

ORTHO-NOVUM 3

philith 0 C Covered in full

pimtrea 0 C Covered in full

pirmella 0 C Covered in full

plan b one-step 0 C Covered in full

portia 0 C Covered in full

PREFEST 3

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET, VAGINAL CREAM-APPL)

2

PREMPHASE 2

PREMPRO 2

previfem 0 C Covered in full

QUARTETTE 3

quasense 0 C Covered in full

rajani 0 C Covered in full

reclipsen 0 C Covered in full



rivelsa 0 C Covered in full

SAFYRAL 3

SEASONIQUE 3

setlakin 0 C Covered in full

sprintec 0 C Covered in full

sronyx 0 C Covered in full

syeda 0 C Covered in full

take action 0 C Covered in full

tarina 24 fe 1

tarina fe 0 C Covered in full

taytulla 0 C Covered in full

tilia fe 0 C Covered in full

tri femynor 0 C Covered in full

tri-estarylla 0 C Covered in full

tri-legest fe 0 C Covered in full

tri-linyah 0 C Covered in full

tri-lo-estarylla 0 C Covered in full

tri-lo-marzia 0 C Covered in full

tri-lo-sprintec 0 C Covered in full

tri-mili 0 C Covered in full

TRI-NORINYL 3

tri-previfem 0 C Covered in full

tri-sprintec 0 C Covered in full

tri-vylibra 0 C Covered in full

tri-vylibra lo 1

trinessa 0 C Covered in full

trinessa lo 0 C Covered in full

trivora-28 0 C Covered in full



tydemy 0 C Covered in full

VAGIFEM 3

velivet 0 C Covered in full

vestura 0 C Covered in full

vienva 0 C Covered in full

viorele 0 C Covered in full

VIVELLE-DOT 3

vyfemla 0 C Covered in full

vylibra 0 C Covered in full

wera 0 C Covered in full

wymzya fe 0 C Covered in full

xulane 0 C Covered in full

YASMIN 28 3

YAZ 3

yuvafem 1

zarah 0 C Covered in full

zenchent 0 C Covered in full

zenchent fe 0 C Covered in full

zovia 1-35e 0 C Covered in full

zovia 1-50e 0 C Covered in full

PROGESTERONE AGONISTS/ANTAGONISTS

ella 0 C Covered in full

PROGESTINS

AYGESTIN 3

camila 0 C Covered in full

CRINONE 4% GEL 3

CRINONE 8% GEL 3 S

deblitane 0 C Covered in full

depo-subq provera 104 0 C Covered in full



econtra ez 0 C Covered in full

ENDOMETRIN 3

PA

S

errin 0 C Covered in full

fallback solo 0 C Covered in full

heather 0 C Covered in full

incassia 0 C Covered in full

jencycla 0 C Covered in full

jolivette 0 C Covered in full

kyleena 0 C Covered in full as medicalbenefit

liletta 0 C Covered in full as medicalbenefit

lyza 0 C Covered in full

medroxyprogesterone acetate (150 mg/ml syringe, 150 mg/ml vial) 0 C Covered in full

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

MEGACE 3

MEGACE ES 3

megestrol acetate (20 mg tablet, 40 mg tablet) 1

megestrol acetate (400mg/10ml oral susp, 625mg/5ml oral susp) 1

mirena 0 C Covered in full as medicalbenefit

nexplanon 0 C Covered in full as medicalbenefit

next choice one dose 0 C Covered in full

NOR-Q-D 3

nora-be 0 C Covered in full

norethindrone 0 C Covered in full

norethindrone acetate 1

norlyda 0 C Covered in full

norlyroc 0 C Covered in full

opcicon one-step 0 C Covered in full



option 2 0 C Covered in full

ORTHO MICRONOR 3

progesterone 1

S

MS

progesterone, micronized 1

PROMETRIUM 3

PROVERA 3

sharobel 0 C Covered in full

skyla 0 C Covered in full as medicalbenefit

SLYND 3

tulana 0 C Covered in full

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS

clomiphene citrate 1

DUAVEE 2

EVISTA 3

OSPHENA 3 ST

raloxifene hcl 1

serophene 1

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

ARMOUR THYROID 3

CYTOMEL 3

levo-t 1

levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcgtablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcgtablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet)

1

levoxyl 1

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

NATURE-THROID 3

np thyroid 1

SYNTHROID 3

THYROLAR-1 3

THYROLAR-1/2 3

THYROLAR-1/4 3



THYROLAR-2 3

THYROLAR-3 3

TIROSINT 3

TIROSINT-SOL 3

unithroid 1

WESTHROID 3

WP THYROID 3

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

cabergoline 1

CETROTIDE 3

PA

S

MS

GANIRELIX ACETATE 3

PA

S

MS

leuprolide acetate 1

PA

S

LUPANETA PACK 3

S

MS

octreotide acetate (50 mcg/ml ampul, 50 mcg/ml syringe, 50 mcg/ml vial, 100mcg/ml ampul, 100 mcg/ml syringe, 100 mcg/ml vial, 200 mcg/ml vial, 500mcg/ml ampul, 500 mcg/ml syringe, 500 mcg/ml vial, 1000mcg/ml vial)

1

S

MS

ORILISSA (150 MG TABLET, 200 MG TABLET) 3

QL

PA

SANDOSTATIN 3

S

MS

SANDOSTATIN LAR 3

S

MS

SANDOSTATIN LAR DEPOT 3

S

MS

SIGNIFOR 3

PA

S

MS



SOMATULINE DEPOT 3

QL

S

MS

SOMAVERT 3

PA

S

MS

SYNAREL 3

HORMONAL AGENTS, SUPPRESSANT (THYROID)

ANTITHYROID AGENTS

methimazole 1

propylthiouracil 1

SSKI 3

TAPAZOLE 3

IMMUNOLOGICAL AGENTS

ANGIOEDEMA AGENTS

BERINERT 500 UNIT KIT 3

QL

PA

S

MS

CINRYZE 3

QL

PA

S

MS

FIRAZYR 3

QL

PA

S

MS

HAEGARDA 2

QL

PA

S

MS



RUCONEST 3

QL

PA

S

MS

TAKHZYRO 2

QL

PA

S

MS

IMMUNE SUPPRESSANTS

ASTAGRAF XL (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 3

QL

PA

S

AZASAN 3

ST

S

azathioprine 1 S

CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 MG TABLET) 3 S

CIMZIA (200 MG/ML STARTER KIT, 200 MG/ML SYRINGE KIT) 3

QL

PA

ST

S

MS

cyclosporine (25 mg capsule, 100 mg capsule) 1 S

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

1 S

ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML SYRINGE) 2

QL

PA

S

MS

ENBREL MINI 2

QL

PA

S

MS



ENBREL SURECLICK 2

QL

PA

S

MS

ENVARSUS XR (0.75 MG TABLET, 1 MG TABLET, 4 MG TABLET) 3

QL

PA

S

gengraf (25 mg capsule, 50 mg capsule, 100 mg capsule, 100 mg/ml solution) 1 S

HUMIRA 2

QL

PA

S

MS

IMURAN 3 S

KINERET 3

QL

PA

ST

S

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

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

mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet) 1 S

mycophenolate sodium 1 S

MYFORTIC 3 S

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

3 S

OLUMIANT 3

QL

PA

S

MS

ORENCIA 3

QL

PA

ST

S

MS



OTREXUP 3 PA

PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 3 S

PROGRAF 0.2 MG GRANULE PACKET 3 ST

RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORAL SOLN, 2 MGTABLET)

3 S

RASUVO 3 PA

RHEUMATREX 3

SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE, 100 MG/ML SOLN) 3 S

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

3

QL

PA

ST

S

MS

sirolimus (0.5 mg tablet, 1 mg tablet, 1 mg/ml solution, 2 mg tablet) 1 S

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 1 S

TREXALL 3

XATMEP 3 PA

XELJANZ 10 MG TABLET 2

QL

PA

S

MS

XELJANZ 5 MG TABLET 2

PA

S

MS

XELJANZ XR 2

QL

PA

S

MS

ZORTRESS 3 S



IMMUNOMODULATORS

ACTEMRA 162 MG/0.9 ML SYRINGE 2

QL

PA

S

MS

ACTEMRA ACTPEN 2

QL

PA

S

MS

ACTIMMUNE 3

PA

S

MS

ARAVA 3

ARCALYST 3

PA

S

MS

BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 3

QL

PA

S

MS

DUPIXENT 300 MG/2 ML SYRINGE 3

QL

PA

S

MS

GRASTEK 3 QL

KEVZARA 3

QL

PA

ST

S

MS

leflunomide 1

ORALAIR 3

QL

S



OTEZLA 2

QL

PA

S

MS

RAGWITEK 3 QL

RIDAURA 3

VACCINES

XOFLUZA 3 QL

INFLAMMATORY BOWEL DISEASE AGENTS

AMINOSALICYLATES

APRISO 3 QL

ASACOL HD 3

balsalazide disodium 1

CANASA 3

COLAZAL 3

DELZICOL 2

DIPENTUM 3

GIAZO 3

QL

PA

LIALDA 3

mesalamine (1.2 g tablet dr, 4 g/60 ml enema, 400 mg cap(drtab), 1000 mgsupp.rect)

1

mesalamine 800 mg tablet dr 1

mesalamine with cleansing wipes 1

QL

PA

PENTASA 2

ROWASA 4 GM/60 ML ENEMA KIT 3

QL

PA

SFROWASA 3

GLUCOCORTICOIDS

budesonide 3 mg capdr - er 1

budesonide 9 mg tabdr - er 1 QL



colocort 1

CORTENEMA 3

CORTIFOAM 3

ENTOCORT EC 3

hydrocortisone 100mg/60ml enema 1

UCERIS 2 MG RECTAL FOAM 3

QL

PA

UCERIS 9 MG ER TABLET 3 QL

SULFONAMIDES

AZULFIDINE 3

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

METABOLIC BONE DISEASE AGENTS

ACTONEL (5 MG TABLET, 30 MG TABLET, 35 MG TABLET, 150 MGTABLET)

3 QL

alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70mg tablet)

1 QL

alendronate sodium 70 mg/75ml solution 1

ATELVIA 3 QL

BINOSTO 3 QL

BONIVA 150 MG TABLET 3 QL

calcitonin,salmon,synthetic 1

calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) 1

cinacalcet hcl 1

DICLOVIX 3

QL

PA

doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule) 1

DRISDOL 3

ergocalciferol (vitamin d2) 50000 unit capsule 1

etidronate disodium 1

FORTEO 3

PA

S

MS

FORTICAL 3



FOSAMAX 3 QL

FOSAMAX PLUS D 3 QL

HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 MCG CAPSULE) 3

ibandronate sodium 150 mg tablet 1 QL

MIACALCIN 200 UNIT NASAL SPRAY 3

NATPARA 3

QL

PA

S

MS

paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 1

RAYALDEE 3

risedronate sodium (5 mg tablet, 30 mg tablet, 35 mg tablet, 35 mg tablet dr,150 mg tablet)

1 QL

ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1 MCG/ML ORALSOLN)

3

SENSIPAR 3

TRIXYLITRAL 3

QL

PA

TYMLOS 2

QL

PA

S

MS

ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 3

MISCELLANEOUS THERAPEUTIC AGENTS

BD PEN NEEDLES T2. ALL OTHER MANUFACTURERS T3. 2

cervical cap 0 C Covered in full

CETYLEV 3

COMFORT PAC-MELOXICAM 3

QL

PA

COMFORT PAC-NAPROXEN 3

QL

PA

condoms, female 0 C Covered in full

diaphragms, contoured 0 C Covered in full



diaphragms, wide seal 0 C Covered in full

FLEXIPAK 3

QL

PA

FOAM/GAUZE BANDAGE/LIDOCAINE/CHLORHEXIDINE/ISOPROPYLALCOHOL

3

QL

PA

INBRIJA 3

QL

PA

S

MS

INFLAMMACIN 3

QL

PA

INTRAROSA 3 QL

isometheptene mucate/dichloralphenazone/acetaminophen 1

LOKELMA (5 POWDER PACKET, 10 POWDER PACKET) 2 QL

methergine 1 QL

methylergonovine maleate 0.2 mg tablet 1 QL

nodolor 1

NUDICLO TABPAK 3

QL

PA

NUDROXIPAK DSDR-50 3

QL

PA


QL

PA

NUDROXIPAK E-400 3

QL

PA

NUDROXIPAK I-800 3

QL

PA

NUDROXIPAK N-500 3

QL

PA

ODACTRA 3 QL

paragard t 380-a 0 C Covered in full as medicalbenefit



RUZURGI 3

QL

PA

S

SAXENDA 3

QL

PA

SILVER/BANDAGE/FOAM/GAUZE/LIDOCAINE/CHLORHEXIDIN/ISOPROPANOL

3

QL

PA

SYRINGE, INSULIN U-500 WITH NEEDLE, DISPOSABLE, 0.5 ML 3

XENAFLAMM 3

QL

PA

XERMELO 3

QL

PA

MODIFIED SOLID FOODS

All modified solid foods are covered as brands with Prior Authorization

OPHTHALMIC AGENTS

OPHTHALMIC AGENTS, OTHER

AKTEN 3

ALCAINE 3

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

bacitracin/polymyxin b sulfate 500-10k/g oint. (g) 1

BLEPHAMIDE 3

BLEPHAMIDE S.O.P. 3

CEQUA 3 QL

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

CYSTARAN 3

PA

S

ISOPTO ATROPINE 3

LACRISERT 3

MAXITROL (DROPS, OINTMENT) 3

MITOSOL 3

NAPHAZOLINE 0.1% 3

neo-polycin 1



neo-polycin hc 1

neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone 1

neomycin sulfate/bacitracin/polymyxin b 1

neomycin sulfate/polymyxin b sulfate/gramicidin d 1

neomycin/polymyxin b sulfate/dexamethasone (neomycin/polymyxinb/dexametha 0.1 % drops susp, neomycin/polymyxin b/dexametha 3.5-10k-.1oint. (g))

1

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

OXERVATE 3

QL

PA

S

MS

PAREMYD 3

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

polycin 1

polymyxin b sulfate/trimethoprim 1

POLYTRIM 3

PRED-G (1% DROPS, S.O.P. OINTMENT) 3

proparacaine hcl 1

RESTASIS 2 QL

RESTASIS MULTIDOSE 2 QL

sulfacetamide sodium/prednisolone sodium phosphate 1

TETRAVISC 3

TETRAVISC FORTE 3

TOBRADEX (DROPS, OINTMENT) 3

TOBRADEX ST 3

tobramycin/dexamethasone 1

tropicamide (0.5 % drops, 1 % drops) 1

XIIDRA 2 QL

ZYLET 3

OPHTHALMIC ANTI-ALLERGY AGENTS

ALOCRIL 3

ALOMIDE 3



azelastine hcl 0.05 % drops 1

BEPREVE 3

cromolyn sodium 4 % drops 1

ELESTAT 3

EMADINE 3

epinastine hcl 1

LASTACAFT 3

olopatadine hcl (0.1 % drops, 0.2 % drops) 1

PATADAY 3

PATANOL 3

PAZEO 3

OPHTHALMIC ANTI-INFLAMMATORIES

ACULAR 3

ACULAR LS 3

ACUVAIL 3

ALREX 3

bromfenac sodium 1

BROMSITE 3 QL

dexamethasone sodium phosphate 0.1 % drops 1

diclofenac sodium 0.1 % drops 1

DUREZOL 3

FLAREX 3

fluorometholone 1

flurbiprofen sodium 1

FML 3

FML FORTE 3

FML S.O.P. 3

ILEVRO 3

INVELTYS 3

ketorolac tromethamine (0.4 % drops, 0.5 % drops) 1

LOTEMAX (EYE DROPS, EYE OINTMENT, OPHTHALMIC GEL) 2

loteprednol etabonate 1



MAXIDEX 3

NEVANAC 3

OCUFEN 3

OMNIPRED 3

PRED FORTE 3

PRED MILD 3

prednisolone acetate 1

prednisolone sodium phosphate 1 % drops 1

PROLENSA 3 QL

VEXOL 3

OPHTHALMIC ANTIGLAUCOMA AGENTS

ALPHAGAN P 2

apraclonidine hcl 1

AZOPT 3

BETAGAN 3

betaxolol hcl 0.5 % drops 1

BETIMOL 3

BETOPTIC S 3

brimonidine tartrate 1

carteolol hcl 1

COMBIGAN 2 QL

COSOPT 3

COSOPT PF 3 QL

dorzolamide hcl 1

dorzolamide hcl/timolol maleate 1

dorzolamide/timolol/pf 2 %-0.5 % droperette 1 QL

IOPIDINE (0.5% DROPS, 1% DROPS) 3

ISOPTO CARPINE 3

ISTALOL 3

levobunolol hcl 1

methazolamide 1

metipranolol 1



NEPTAZANE 3

PHOSPHOLINE IODIDE 3

pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) 1

RESCULA 3

RHOPRESSA 3

QL

ST

ROCKLATAN 3

QL

ST

SIMBRINZA 3 QL

timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % drop daily, 0.5 % drops,0.5 % sol-gel)

1

TIMOPTIC (0.25% DROP, 0.5% DROP) 3

TIMOPTIC (0.25% DROPS, 0.5% DROPS) 3

TIMOPTIC OCUDOSE 3

TIMOPTIC-XE (0.25% EYE GEL-SOLN, 0.5% GEL-SOLUTION) 3

TIMOPTIC-XE (0.25% SOLN, 0.5% SOLN) 3

TRUSOPT 3

VYZULTA 3 ST

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS

BIMATOPROST 0.03 % DROPS (INTO THE EYE FOR GLAUCOMA) 2

latanoprost 1 QL

LUMIGAN 2

TRAVATAN Z 2

XALATAN 3 QL

XELPROS 3

QL

ST

ZIOPTAN 3

QL

ST

OTIC AGENTS

acetasol hc 1

acetic acid 2 % solution 1

acetic acid/aluminum acetate 1



CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

CORTISPORIN-TC 3

DERMOTIC 3

fluocinolone acetonide oil 1

hydrocortisone/acetic acid 1

neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxinb/hydrocort drops susp, neomycin/polymyxin b/hydrocort solution)

1

OTOVEL 3 QL

RESPIRATORY TRACT/PULMONARY AGENTS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

AEROSPAN 3

QL

ST

ALVESCO (80 MCG INHALER, 160 MCG INHALER) 3

QL

ST

ARMONAIR RESPICLICK 2 QL

ARNUITY ELLIPTA 2 QL

ASMANEX 2 QL

ASMANEX HFA 2 QL

BECONASE AQ 3 QL

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

1 QL

FLOVENT DISKUS 2 QL

FLOVENT HFA (HFA 44 MCG INHALER, HFA 110 MCG INHALER, HFA 220MCG INHALER)

2 QL

flunisolide 1 QL

fluticasone propionate 50 mcg spray susp 1

mometasone furoate 50 mcg spray/pump 1

NASONEX 3

OMNARIS 3 QL

PULMICORT 3 QL



PULMICORT FLEXHALER (90 MCG, 180 MCG) 3

QL

ST

QNASL 2 QL

QNASL CHILDREN 2 QL

QVAR 2 QL

QVAR REDIHALER 2 QL

RHINOCORT AQUA 3

TICANASE 3

QL

PA

TICASPRAY 3

QL

PA

triamcinolone acetonide 55 mcg spray 1

VERAMYST 3 QL

XHANCE 3 QL

ZETONNA 3 QL

ANTIHISTAMINES

arbinoxa 1

ASTEPRO 3 QL

azelastine hcl 137 mcg spray/pump 1

azelastine hcl 205.5 mcg spray/pump 1 QL

carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid) 1

carbinoxamine maleate 6 mg tablet 1

QL

PA

cetirizine hcl 1 mg/ml solution 1

CLARINEX (0.5 MG/ML (2.5 MG/5), 5 MG TABLET) 3

clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet) 1

cyproheptadine hcl 1

QL

PA

desloratadine 1

diphenhydramine hcl 12.5mg/5ml elixir 1



hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg tablet, 50 mg tablet,50 mg/25ml solution)

1

hydroxyzine pamoate 1

KARBINAL ER 3 QL

levocetirizine dihydrochloride 2.5 mg/5ml solution 1 QL

levocetirizine dihydrochloride 5 mg tablet 1

olopatadine hcl 0.6 % spray/pump 1 QL

PATANASE 3 QL

promethazine hcl (6.25mg/5ml syrup, 12.5 mg tablet, 25 mg tablet) 1

RYCLORA 3 QL

RYVENT 3

QL

PA

VISTARIL 3

XYZAL (2.5 MG/5 ML SOLUTION, 5 MG TABLET) 3

ANTILEUKOTRIENES

ACCOLATE 3

montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mgtablet)

1 QL

SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MG TABLET CHEW,10 MG TABLET)

3 QL

zafirlukast 1

zileuton 1 QL

ZYFLO 3 QL

ZYFLO CR 3 QL

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT 3

ATROVENT HFA 2

INCRUSE ELLIPTA 3 QL

ipratropium bromide 1

LONHALA MAGNAIR REFILL 3

QL

ST

LONHALA MAGNAIR STARTER 3

QL

ST



SEEBRI NEOHALER 3

SPIRIVA 2

SPIRIVA RESPIMAT 2

TUDORZA PRESSAIR 3 QL

YUPELRI 3

QL

ST

BRONCHODILATORS, SYMPATHOMIMETIC

ADRENACLICK 3 QL

albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg tablet, 2 mg/5ml syrup, 2.5 mg/0.5 vial-neb, 2.5 mg/3ml vial-neb, 4 mg tab er 12h, 4 mgtablet, 5 mg/ml solution, 8 mg tab er 12h)

1

ALBUTEROL SULFATE 90 MCG HFA AER AD (Alternative to Ventolin HFA and Proair HFA only) 2 QL

ARCAPTA NEOHALER 3 QL

AUVI-Q (0.15 MG, 0.3 MG) 3 QLPA

BROVANA 3

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

EPIPEN 2 QL

EPIPEN 2-PAK 2 QL

EPIPEN JR 2-PAK 2 QL

FORADIL 2 QL

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

1

levalbuterol tartrate 1

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

PERFOROMIST 3 QL

PROAIR HFA 2 QL

PROAIR RESPICLICK 2 QL

PROVENTIL HFA 3 QL

SEREVENT DISKUS 2

STRIVERDI RESPIMAT 2 QL


3 QLALBUTEROL SULFATE 90 MCG HFA AER AD (Alternative to Proventil HFA only)


SYMJEPI 3 QL

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

VENTOLIN HFA 2 QL

VOSPIRE ER 3

XOPENEX 3

XOPENEX CONCENTRATE 3

XOPENEX HFA 3

CYSTIC FIBROSIS AGENTS

BETHKIS 3

QL

S

MS

CAYSTON 3

S

MS

KALYDECO 3

QL

PA

S

MS

KITABIS PAK 3

S

MS

ORKAMBI (100 MG-125 MG TABLET, 100-125 MG GRANULE PKT, 150-188MG GRANULE PKT, 200 MG-125 MG TABLET)

3

QL

PA

S

MS

PULMOZYME 3

S

MS

SYMDEKO 3

QL

PA

S

MS

TOBI PODHALER 3

QL

S

MS



tobramycin/nebulizer 1

S

MS

MAST CELL STABILIZERS

cromolyn sodium 20 mg/2 ml ampul-neb 1

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE

caffeine citrate 60 mg/3 ml solution 1

DALIRESP (250 MCG TABLET, 500 MCG TABLET) 3

QL

ST

ELIXOPHYLLIN 3

THEO-24 3

theochron 1

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

1

PULMONARY ANTIHYPERTENSIVES

ADCIRCA 3

QL

PA

S

MS

ADEMPAS 3

QL

PA

S

MS

ambrisentan 1

QL

PA

S

MS

bosentan 1

QL

PA

S

MS

LETAIRIS 3

QL

PA

S

MS



OPSUMIT 3

QL

PA

S

MS

ORENITRAM ER 3

PA

S

MS

REVATIO (10 MG/ML ORAL SUSP, 20 MG TABLET) 3

QL

PA

S

MS

sildenafil citrate (10 mg/ml susp recon, 20 mg tablet) 1

QL

PA

S

MS

TRACLEER (62.5 MG TABLET, 125 MG TABLET) 3

PA

S

MS

TRACLEER 32 MG TABLET FOR SUSP 3

QL

PA

S

MS

TYVASO 3

QL

PA

S

MS

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

3

QL

PA

S

PULMONARY FIBROSIS AGENTS

ESBRIET (267 MG CAPSULE, 267 MG TABLET, 801 MG TABLET) 2

QL

PA

S

MS



OFEV 2

QL

PA

S

MS

RESPIRATORY TRACT AGENTS, OTHER

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

ADVAIR DISKUS 2 QL

ADVAIR HFA 2 QL

AIRDUO RESPICLICK 3

QL

ST

ANORO ELLIPTA 2 QL

benzonatate 1

BEVESPI AEROSPHERE 2 QL

BREO ELLIPTA 100-25 MCG INH 2 QL

BREO ELLIPTA 200-25 MCG INH 2

bromfed dm 1

brompheniramine maleate/pseudoephedrine hcl/dextromethorphan 1

centergy dm 1

CLARINEX-D 12 HOUR 3

COMBIVENT RESPIMAT 2 QL

CUROSURF 3

DULERA 3 QL

DYMISTA 3

QL

PA

FLOWTUSS 3 QL

fluticasone propionate/salmeterol xinafoate (propion/salmeterol 100-50 mcg blstw/dev, propion/salmeterol 250-50 mcg blst w/dev, propion/salmeterol 500-50mcg blst w/dev)

1 QL

FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE(PROPION/SALMETEROL 55-14 MCG AER POW BA,PROPION/SALMETEROL 113-14 MCG AER POW BA,PROPION/SALMETEROL 232-14 MCG AER POW BA)

2 QL

GUAIFENESIN/HYDROCODONE BITARTRATE 3

QL

PA



HYCOFENIX 3

hydrocodone bitart/chlorpheniramine maleate/pseudoephedrine 1

hydrocodone bitartrate/homatropine methylbromide (bit/homatrop 5 mg-1.5mgtablet, bit/homatrop 5-1.5 mg/5 syrup)

1

hydrocodone polistirex/chlorpheniramine polistirex 1 QL

hydromet 1

ipratropium bromide/albuterol sulfate 1

nebusal 3% vial 1

NUCALA (100 MG/ML AUTO-INJECTOR, 100 MG/ML SYRINGE) 3

QL

PA

S

MS

OBREDON 3 QL

phenylephrine hcl/promethazine hcl 1

promethazine hcl/codeine 1

promethazine/dextromethorphan 6.25-15/5 syrup 1

promethazine/phenylephrine hcl/codeine 1

REZIRA 3

ribavirin 6 g vial-neb 1 MS

SEMPREX-D 3

sodium chloride for inhalation 1

STIOLTO RESPIMAT 2 QL

SYMBICORT 2 QL

TESSALON PERLE 3

TICALAST 3

QL

PA

TOBI 3

S

MS

tobramycin in 0.225 % sodium chloride 1 S

TRELEGY ELLIPTA 3

QL

ST

TUSSICAPS 3



tussigon 1

TUSSIONEX 3

QL

ST

TUZISTRA XR 3

TYZINE 3

UTIBRON NEOHALER 2

VIRAZOLE 3

VITUZ 3 QL

wixela inhub 1 QL

ZUTRIPRO 3

SKELETAL MUSCLE RELAXANTS

AMRIX 3

QL

PA

carisoprodol 250 mg tablet 1

QL

PA

carisoprodol 350 mg tablet 1

carisoprodol/aspirin 1

chlorzoxazone (250 mg tablet, 375 mg tablet, 750 mg tablet) 1

QL

PA

chlorzoxazone 500 mg tablet 1 QL

COMFORT PAC-CYCLOBENZAPRINE 3

QL

PA

COMFORT PAC-TIZANIDINE 3

QL

PA

cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 1

cyclobenzaprine hcl 7.5 mg tablet 1

QL

PA

FEXMID 3

QL

PA

LORZONE 3

QL

PA



metaxall 1 QL

metaxalone 400 mg tablet 1

metaxalone 800 mg tablet 1 QL

methocarbamol (500 mg tablet, 750 mg tablet) 1

NORGESIC FORTE 3

QL

ST

orphenadrine citrate 100 mg tablet er 1

orphengesic forte 1

QL

ST

PARAFON FORTE DSC 3 QL

ROBAXIN 500 MG TABLET 3

ROBAXIN-750 3

SKELAXIN 3 QL

SOMA 250 MG TABLET 3

QL

PA

SOMA 350 MG TABLET 3

SLEEP DISORDER AGENTS

GABA RECEPTOR MODULATORS

AMBIEN (5 MG TABLET, 10 MG TABLET) 3 QL

AMBIEN CR 3 QL

DORAL 3

EDLUAR 3

QL

ST

estazolam 1

eszopiclone 1 QL

flurazepam hcl 1

HALCION 3

INTERMEZZO 3

QL

ST

LUNESTA 3 QL



RESTORIL 3

SONATA (5 MG CAPSULE, 10 MG CAPSULE) 3 QL

temazepam 1

triazolam 1

zaleplon (5 mg capsule, 10 mg capsule) 1 QL

zolpidem tartrate (1.75 mg tab subl, 3.5 mg tab subl, 5 mg tablet, 6.25 mg tabmphase, 10 mg tablet, 12.5 mg tab mphase)

1 QL

ZOLPIMIST 3

QL

ST

SLEEP DISORDERS, OTHER

armodafinil (50 mg tablet, 150 mg tablet, 200 mg tablet, 250 mg tablet) 1 QL

BELSOMRA 3

QL

ST

BUTISOL SODIUM 3

HETLIOZ 3

QL

PA

S

MS

modafinil 1 QL

NUVIGIL (50 MG TABLET, 150 MG TABLET, 200 MG TABLET, 250 MGTABLET)

3 QL

PROVIGIL 3 QL

ROZEREM 3

QL

ST

SECONAL SODIUM 3

SILENOR 3

QL

ST

SUNOSI 3

QL

PA

XYREM 3

QL

PA

S



Uncategorized

Unclassified

citalopram hydrobromide 20 mg/10ml solution 1

SKYRIZI (2 SYRINGES) KIT 2

QL

PA

S

MS


Index of covered drugs

88-MOP 87

Aabacavir sulfate 56

abacavir sulfate/lamivudine 56

abacavir sulfate/lamivudine/zidovudine 56

ABILIFY 50

ABILIFY DISCMELT 50

ABILIFY MYCITE 50

abiraterone acetate 36

ABSORICA 87

ABSTRAL 9

acamprosate calcium 13

ACANYA 87

acarbose 60

ACCOLATE 143

ACCUPRIL 70

ACCURETIC 73

acebutolol hcl 71

ACEON 70

acetaminophen with codeine phosphate 9

acetaminophen/caff/dihydrocod 325-30-16

tablet 9

acetaminophen/caffeine/dihydrocodeine

bitartrate 9

ACETASOL HC 140

acetazolamide 76

acetic acid 140

acetic acid/aluminum acetate 140

acetylcysteine 148

ACIPHEX 102

ACIPHEX SPRINKLE 102

acitretin 87

ACTEMRA 131

ACTEMRA ACTPEN 131

ACTHAR 107

ACTICLATE 20

ACTIGALL 99

ACTIMMUNE 131

ACTIQ 9

ACTIVELLA 115

ACTONEL 133

ACTOPLUS MET 60

ACTOPLUS MET XR 60

ACTOS 60

ACULAR 138

ACULAR LS 138

ACUVAIL 138

acyclovir 58

ACZONE 87

ADALAT CC 72

adapalene 87

adapalene/benzoyl peroxide 87

ADASUVE 49

ADCIRCA 146

ADDERALL 80

ADDERALL XR 80

ADDYI 105

adefovir dipivoxil 52

ADEMPAS 146

ADHANSIA XR 81

ADIPEX-P 82

ADLYXIN 60

ADMELOG 64

ADMELOG SOLOSTAR 64

ADOXA 20

ADRENACLICK 144

ADVAIR DISKUS 148

ADVAIR HFA 148

ADZENYS ER 80

ADZENYS XR-ODT 80

AEMCOLO 14

AEROSPAN 141

AFEDITAB CR 72

AFINITOR 40

AFREZZA 64

AFTERA 115

AGGRENOX 68

AGRYLIN 66

AIMOVIG AUTOINJECTOR 33

AIMOVIG AUTOINJECTOR (2 PACK) 33

AIRDUO RESPICLICK 148

AJOVY 33

AKTEN 136

AKTIPAK 14

AKYNZEO 29

ALA-CORT 107

ALA-SCALP 107

albendazole 46

ALBENZA 46

albuterol sulfate 144

ALCAINE 136

alclometasone dipropionate 107

ALDACTAZIDE 73

ALDACTONE 77

ALDARA 87

ALECENSA 40

alendronate sodium 133

ALEVICYN PLUS 87

ALFERON N 58

alfuzosin hcl 105

ALINIA 46

aliskiren hemifumarate 73

ALKERAN 35

allopurinol 32

ALLZITAL 83

almotriptan malate 33

ALOCRIL 137

alogliptin benzoate 60

alogliptin benzoate/metformin hcl 60

alogliptin benzoate/pioglitazone hcl 60

ALOMIDE 137

ALORA 115

alosetron hcl 100

ALPHAGAN P 139

alprazolam 59

ALPRAZOLAM INTENSOL 59

ALREX 138

ALTABAX 15

ALTACE 70

ALTAVERA 115


ALTOPREV 78

ALTRENO 87

ALUNBRIG 38

ALVESCO 141

ALYACEN 116

AMABELZ 116

amantadine hcl 47

AMARYL 60

AMBIEN 151

AMBIEN CR 151

ambrisentan 146

amcinonide 107

AMELUZ 87

AMERGE 33

AMETHIA 116

AMETHIA LO 116

AMETHYST 116

AMICAR 68

amiloride hcl 77

amiloride hcl/hydrochlorothiazide 73

aminocaproic acid 68

amiodarone hcl 70

AMITIZA 100

amitriptyline hcl 28

amitriptyline hcl/chlordiazepoxide 25

amlodipine besylate 72

amlodipine besylate/atorvastatin calcium 73

amlodipine besylate/benazepril hcl 73

amlodipine besylate/olmesartan medoxomil 73

amlodipine besylate/valsartan 74

amlodipine

besylate/valsartan/hydrochlorothiazide 74

ammonium lactate 87

AMNESTEEM 87

amoxapine 28

amoxicillin 18

amoxicillin/potassium clavulanate 18

amphetamine sulfate 80

ampicillin trihydrate 18

AMPYRA 85

AMRIX 150

ANA-LEX 87

ANACAINE 12

ANADROL-50 114

ANAFRANIL 28

anagrelide hcl 66

ANALPRAM HC 88

ANAPROX 5

ANAPROX DS 5

ANASPAZ 98

ANASTIA 12

anastrozole 39

ANCOBON 30

ANDRODERM 115

ANDROGEL 115

ANDROID 115

ANDROXY 115

ANGELIQ 116

ANODYNE LPT 12

ANORO ELLIPTA 148

ANTABUSE 13

ANTARA 77

ANUCORT-HC 107

ANUSOL-HC 107

ANZEMET 29

APADAZ 9

APEXICON E 107

APIDRA 64

APIDRA SOLOSTAR 64

APLENZIN 25

APOKYN 48

apraclonidine hcl 139

aprepitant 29

APRI 116

APRISO 132

APRIZIO PAK 12

APTENSIO XR 81

APTIOM 24

APTIVUS 58

ARAKODA 46

ARANELLE 116

ARANESP 66

ARAVA 131

ARBINOXA 142

ARCALYST 131

ARCAPTA NEOHALER 144

ARICEPT 25

ARIKAYCE 14

ARIMIDEX 39

aripiprazole 50

ARIXTRA 65

armodafinil 152

ARMONAIR RESPICLICK 141

ARMOUR THYROID 125

ARNUITY ELLIPTA 141

AROMASIN 39

ARTHROTEC 50 5

ARTHROTEC 75 5

ARYMO ER 7

ASACOL HD 132

ASCOMP WITH CODEINE 9

ASHLYNA 116

ASMANEX 141

ASMANEX HFA 141

aspirin/caffeine/dihydrocodeine bitartrate 9

aspirin/dipyridamole 68

ASTAGRAF XL 128

ASTEPRO 142

ATACAND 69

ATACAND HCT 74

atazanavir sulfate 58

ATELVIA 133

atenolol 71

atenolol/chlorthalidone 74

ATIVAN 59

atomoxetine hcl 81

atorvastatin calcium 78

atovaquone 46

atovaquone/proguanil hcl 47

ATRALIN 88

ATRAPRO DERMAL SPRAY 88

ATRIPLA 56

atropine sulfate 136


ATROVENT 143

ATROVENT HFA 143

AUBAGIO 85

AUBRA 116

AUBRA EQ 116

AUGMENTIN 18

AUGMENTIN ES-600 18

AUGMENTIN XR 18

AUROVELA 116

AUROVELA 24 FE 116

AURYXIA 97

AUSTEDO 83

AUVI-Q 144

AVALIDE 74

AVANDIA 60

AVAPRO 69

AVAR 88

AVAR-E 88

AVAR-E GREEN 88

AVC 20

AVELOX 19

AVELOX ABC PACK 19

AVIANE 116

AVIDOXY 20

AVINZA 7

AVITA 88

AVODART 105

Avonex 85

AXERT 33

AXIRON 115

AYGESTIN 123

AZASAN 128

AZASITE 18

azathioprine 128

azelaic acid 88

azelastine hcl 138,142

AZELEX 88

AZILECT 49

azithromycin 18

AZOPT 139

AZOR 74

AZULFIDINE 133

AZURETTE 116

Bbacitracin 15

bacitracin/polymyxin b sulfate 136

baclofen 51

BACTRIM 20

BACTRIM DS 20

BACTROBAN 15

BACTROBAN NASAL 15

BALCOLTRA 116

balsalazide disodium 132

BALVERSA 38

BALZIVA 116

BANZEL 24

BARACLUDE 52

BASAGLAR KWIKPEN U-100 64

BAXDELA 19

bd pen needles t2. all other manufacturers

t3. 134

BECONASE AQ 141

BEKYREE 116

BELBUCA 7

BELSOMRA 152

BELVIQ 83

BELVIQ XR 83

benazepril hcl 70

benazepril hcl/hydrochlorothiazide 74

BENICAR 69

BENICAR HCT 74

BENLYSTA 131

BENTYL 98

BENZACLIN 88

BENZAMYCIN 15

BENZEPRO 88

benznidazole 46

benzonatate 148

benzoyl peroxide 88

benzoyl peroxide microspheres 88

benzphetamine hcl 83

benztropine mesylate 47

BEPREVE 138

BERINERT 127

BESER KIT 107

BESIVANCE 19

BETAGAN 139

betamethasone dipropionate 107

betamethasone dipropionate/propylene

glycol 107

betamethasone valerate 107

BETAPACE 70

BETAPACE AF 70

BETASERON 85

betaxolol hcl 71,139

bethanechol chloride 105

BETHKIS 145

BETIMOL 139

BETOPTIC S 139

BEVESPI AEROSPHERE 148

BEVYXXA 65

bexarotene 46

BEYAZ 116

BIAXIN 18

bicalutamide 36

BIDIL 74

BIJUVA 116

BIKTARVY 55

BILTRICIDE 46

bimatoprost 0.03 % drops (into the eye for

glaucoma) 140

BINOSTO 133

bisoprolol fumarate 71

bisoprolol fumarate/hydrochlorothiazide 74

BLEPH-10 20

BLEPHAMIDE 136

BLEPHAMIDE S.O.P. 136

BLISOVI 24 FE 116

BLISOVI FE 116

BONIVA 133

BONJESTA 28

BONTRIL PDM 83


bosentan 146

BOSULIF 40

BPO 88

BRAFTOVI 40

BRAND RX PRENATAL VITAMINS ARE T3

AND GENERIC RX PRENATAL VITAMINS

ARE T1 97

BRAVELLE 112

BREO ELLIPTA 148

BREVICON 116

BRIELLYN 116

BRILINTA 68

brimonidine tartrate 139

BRISDELLE 26

BRIVIACT 21

BROMFED DM 148

bromfenac sodium 138

bromocriptine mesylate 48

brompheniramine maleate/pseudoephedrine

hcl/dextromethorphan 148

BROMSITE 138

BROVANA 144

BRYHALI 107

budesonide 132,141

bumetanide 76

BUNAVAIL 14

BUPAP 83

BUPHENYL 102

buprenorphine 7

buprenorphine hcl 14

buprenorphine hcl/naloxone hcl 14

buprenorphine patch 7

BUPROBAN 14

bupropion hcl 14,25,26

buspirone hcl 59

butalbital/acetaminophen 83

butalbital/acetaminophen/caffeine 83

butalbital/acetaminophen/caffeine/codeine

phosphate 9

butalbital/aspirin/caffeine 5

BUTISOL SODIUM 152

butorphanol tartrate 9

BUTRANS 8

BYDUREON 60

BYDUREON BCISE 60

BYDUREON PEN 60

BYETTA 60

BYSTOLIC 71

BYVALSON 74

Ccabergoline 126

CABLIVI 66

CABOMETYX 40

CADUET 74

CAFERGOT 33

caffeine citrate 146

CALAN 72

CALAN SR 72

calcipotriene 88

calcipotriene/betamethasone dipropionate 88

calcitonin,salmon,synthetic 133

CALCITRENE 88

calcitriol 88,133

calcium acetate 97

CALQUENCE 41

CAMBIA 5

CAMILA 123

CAMRESE 116

CAMRESE LO 116

CANASA 132

candesartan cilexetil 69

candesartan cilexetil/hydrochlorothiazide 74

capecitabine 37

CAPEX SHAMPOO 107

CAPITAL W-CODEINE 9

CAPRELSA 41

CAPSFENAC PAK 88

captopril 70

captopril/hydrochlorothiazide 74

CARAC 88

CARAFATE 101

CARBAGLU 95

carbamazepine 24

CARBATROL 24

carbidopa 48

carbidopa/levodopa 49

carbidopa/levodopa/entacapone 47

carbinoxamine maleate 142

CARDIZEM 72

CARDIZEM CD 72

CARDIZEM LA 72

CARDURA 69

CARDURA XL 105

carisoprodol 150

carisoprodol/aspirin 150

carisoprodol/aspirin/codeine phosphate 9

CARNITOR 95

CARNITOR SF 95

CAROSPIR 77

carteolol hcl 139

CARTIA XT 72

carvedilol 71

carvedilol phosphate 71

CASODEX 36

CATAPRES 69

CATAPRES-TTS 69

CAVERJECT 105

CAYSTON 145

CAZIANT 116

CEDAX 17

cefaclor 17

cefadroxil 17

cefdinir 17

cefditoren pivoxil 17

cefixime 17

cefpodoxime proxetil 17

cefprozil 17

ceftibuten 17

CEFTIN 17

cefuroxime axetil 17

CELEBREX 5

celecoxib 5


CELEXA 26

CELLCEPT 128

CELONTIN 22

CENTANY 15

CENTANY AT 15

CENTERGY DM 148

cephalexin 17

CEQUA 136

CERDELGA 102

cervical cap 134

CESAMET 29

cetirizine hcl 142

CETRAXAL 19

CETROTIDE 126

CETYLEV 134

cevimeline hcl 87

CHANTIX 14

CHATEAL 116

CHATEAL EQ 117

CHEMET 96

CHENODAL 99

chlordiazepoxide hcl 59

chlordiazepoxide/clidinium bromide 98

chlorhexidine gluconate 87

chloroquine phosphate 47

chlorothiazide 77

chlorpromazine hcl 49

chlorpropamide 60

chlorthalidone 77

chlorzoxazone 150

CHOLBAM 102

cholestyramine (with sugar) 78

cholestyramine/aspartame 79

choline salicylate/magnesium salicylate 5

chorionic gonadotropin, human 112

CIALIS 105

CICLODAN 30

ciclopirox 30

ciclopirox olamine 30

cilostazol 68

CILOXAN 19

CIMDUO 56

cimetidine 100

cimetidine hcl 100

CIMZIA 128

cinacalcet hcl 133

CINRYZE 127

CIPRO 19

CIPRO HC 141

CIPRO XR 19

CIPRODEX 141

ciprofloxacin 19

ciprofloxacin hcl 19

ciprofloxacin/ciprofloxacin hcl 19

citalopram hydrobromide 26,153

CLARAVIS 88

CLARINEX 142

CLARINEX-D 12 HOUR 148

clarithromycin 18

clemastine fumarate 142

CLENPIQ 101

CLEOCIN 15

CLEOCIN HCL 15

CLEOCIN PALMITATE 15

CLEOCIN T 15

CLIMARA 117

CLIMARA PRO 117

CLINDACIN ETZ 15

CLINDACIN P 15

CLINDACIN PAC 15

CLINDAGEL 15

clindamycin hcl 15

clindamycin palmitate hcl 15

clindamycin phosphate 15

clindamycin phosphate/benzoyl peroxide 88

clindamycin phosphate/tretinoin 88

CLINDESSE 15

CLINPRO 5000 95

clobazam 22

clobetasol propionate 107

clobetasol propionate/emollient base 107

CLOBEX 107

clocortolone pivalate 0.1 % cream(g) 107

CLODAN 107

CLODERM 107

clomiphene citrate 125

clomipramine hcl 28

clonazepam 59

clonidine 69

clonidine hcl 69,81

clopidogrel bisulfate 68

clorazepate dipotassium 59

clotrimazole 30

clotrimazole/betamethasone dipropionate 88

clozapine 51

CLOZARIL 51

COARTEM 47

codeine phosphate/butalbital/aspirin/caffeine 9

codeine sulfate 10

COLAZAL 132

colchicine 32

COLCRYS 32

colesevelam hcl 79

COLESTID 79

colestipol hcl 79

COLOCORT 133

COLY-MYCIN S 141

COLYTE WITH FLAVOR PACKETS 101

COMBIGAN 139

COMBIPATCH 117

COMBIVENT RESPIMAT 148

COMBIVIR 57

COMETRIQ 41

COMFORT PAC-CYCLOBENZAPRINE 150

COMFORT PAC-MELOXICAM 134

COMFORT PAC-NAPROXEN 134

COMFORT PAC-TIZANIDINE 150

COMPAZINE 28,29

COMPLERA 56

COMPRO 29

COMTAN 48

CONCEPTROL 105

CONCERTA 81


condoms, female 134

CONDYLOX 88

CONSTULOSE 101

CONTRAVE 83

CONZIP 8

COPAXONE 85

COPEGUS 54

COPIKTRA 38

CORDARONE 70

CORDRAN 107

COREG 71

COREG CR 71

CORGARD 71

CORLANOR 74

CORMAX 107

CORTEF 108

CORTENEMA 133

CORTIFOAM 133

cortisone acetate 108

CORTISPORIN 88

CORTISPORIN-TC 141

CORZIDE 74

COSENTYX 89

COSOPT 139

COSOPT PF 139

COTELLIC 41

COTEMPLA XR-ODT 81

COUMADIN 65

COVARYX 117

COVARYX H.S. 117

COZAAR 69

CREON 103

CRESEMBA 30

CRESTOR 78

CRINONE 123

CRIXIVAN 58

cromolyn sodium 99,138,146

CROTAN 47

CRYSELLE 117

CUPRIMINE 96

CUROSURF 148

CUTIVATE 108

CUVPOSA 98

cyanocobalamin (vitamin b-12) 97

CYCLAFEM 117

CYCLESSA 117

cyclobenzaprine hcl 150

cyclopentolate hcl 136

cyclophosphamide (25 mg capsule, 50 mg

capsule) 35

cycloserine 35

CYCLOSET 60

cyclosporine 128

cyclosporine, modified 128

CYMBALTA 84

cyproheptadine hcl 142

CYRED 117

CYSTADANE 103

CYSTAGON 103

CYSTARAN 136

CYTOMEL 125

CYTOTEC 101

CYTRA-K 95

DD.H.E.45 33

DAKLINZA 52

dalfampridine 85

DALIRESP 146

danazol 115

DANTRIUM 51

dantrolene sodium 51

dapsone 35,89

DARAPRIM 47

darifenacin hydrobromide 104

DASETTA 117

DAURISMO 41

DAXBIA 17

DAYPRO 5

DAYSEE 117

DAYTRANA 82

DDAVP 112

DEBLITANE 123

DECADRON 108

deferasirox 96

DELESTROGEN 117

DELSTRIGO 56

DELTASONE 108

DELYLA 117

DELZICOL 132

DEMADEX 76

demeclocycline hcl 20

DEMEROL 10

DEMSER 74

DENAVIR 58

DENTA 5000 PLUS 95

DENTAGEL 95

DEPAKENE 22

DEPAKOTE 22

DEPAKOTE ER 22

DEPAKOTE SPRINKLE 22

DEPEN 97

DEPO-ESTRADIOL 117

DEPO-SUBQ PROVERA 104 123

DEPO-TESTOSTERONE 115

DERMA-SMOOTHE-FS 108

DERMACINRX CINLONE-I CPI 108

DERMACINRX CLORHEXACIN 89

DERMACINRX EMPRICAINE 12

DERMACINRX LEXITRAL 89

DERMACINRX PRIZOPAK 12

DERMACINRX SILAPAK 108

DERMACINRX SILAZONE 108

DERMACINRX SURGICAL PHARMAPAK 89

DERMACINRX THERAZOLE PAK 89

DERMATOP 108

DERMAZONE 108

DERMOTIC 141

DESCOVY 57

desipramine hcl 28

desloratadine 142

desmopressin acetate 112

desmopressin acetate (non-refrigerated) 112


desogestrel-ethinyl estradiol 117

desogestrel-ethinyl estradiol/ethinyl

estradiol 117

DESONATE 108

desonide 108

DESOWEN 108

desoximetasone 108

DESOXYN 80

desvenlafaxine er 26

desvenlafaxine fumarate 26

desvenlafaxine succinate 26

DETROL 104

DETROL LA 104

dexamethasone 108

DEXAMETHASONE INTENSOL 108

dexamethasone sodium phosphate 138

DEXEDRINE 80,81

DEXILANT 102

dexmethylphenidate hcl 82

dextroamphetamine sulf-

saccharate/amphetamine sulf-aspartate 81

dextroamphetamine sulfate 81

DIABETA 60

DIACOMIT 21

DIAMOX SEQUELS 76

diaphragms, contoured 134

diaphragms, wide seal 135

DIASTAT 22

DIASTAT ACUDIAL 22

diazepam 22,59

DIBENZYLINE 69

DICLEGIS 29

DICLO GEL 89

DICLO GEL-XRYLIX SHEET 89

diclofenac epolamine 5

diclofenac potassium 5

diclofenac sodium 5,89,138

diclofenac sodium/misoprostol 5

DICLOFEX DC 89

DICLOPR 5

DICLOVIX 133

dicloxacillin sodium 18

DICLOZOR 89

dicyclomine hcl 98

didanosine 57

diethylpropion hcl 83

DIFFERIN 89

DIFICID 18

diflorasone diacetate 108

DIFLUCAN 30

diflunisal 5

DIGITEK 74

DIGOX 74

digoxin 74

dihydroergotamine mesylate 33

dihydroergotamine mesylate 0.5mg/spry

spray/pump 33

DILANTIN 24

DILANTIN-125 24

DILATRATE-SR 80

DILAUDID 10

DILT-XR 72

diltiazem hcl 73

DIOVAN 69

DIOVAN HCT 74

DIPENTUM 132

diphenhydramine hcl 142

diphenoxylate hcl/atropine sulfate 99

DIPROLENE 108

DIPROLENE AF 108

dipyridamole 68

DISALCID 5

disopyramide phosphate 71

disulfiram 13

DITHOL 5

DITROPAN XL 104

DIURIL 77

divalproex sodium 23

DIVIGEL 117

dofetilide 71

DOLOPHINE HCL 8

DOLOTRANZ 12

donepezil hcl 25

DOPTELET 66

DORAL 151

DORYX 20

DORYX MPC 20

dorzolamide hcl 139

dorzolamide hcl/timolol maleate 139

dorzolamide hcl/timolol maleate/pf 139

DOVATO 57

DOVONEX 89

doxazosin mesylate 69

doxepin hcl 28

doxepin hcl 5 % cream (g) 89

doxercalciferol 133

doxycycline hyclate 20

doxycycline monohydrate 20

doxycycline monohydrate 40 mg cap ir dr 20

doxylamine succinate/pyridoxine hcl (b6) 29

DRISDOL 133

DRITHOCREME HP 89

dronabinol 29

drospirenone/ethinyl estradiol/levomefolate

calcium 117

DROXIA 37

DRYSOL 89

DUAC 89

DUAVEE 125

DUETACT 61

DUEXIS 5

DULERA 148

duloxetine hcl 84

DUOBRII 90

DUPIXENT 90,131

DURAGESIC 8

DUREZOL 138

dutasteride 105

dutasteride/tamsulosin hcl 105

DUTOPROL 74

DXEVO 108

DYANAVEL XR 81

DYAZIDE 74


DYMISTA 148

DYRENIUM 77

EE.E.S. 200 18

E.E.S. 400 18

EC-NAPROSYN 5

econazole nitrate 30

ECONTRA EZ 124

ECONTRA ONE-STEP 117

ECOZA 30

ED-SPAZ 98

EDARBI 69

EDARBYCLOR 74

EDECRIN 76

EDEX 105

EDLUAR 151

EDURANT 56

EEMT 117

EEMT H.S. 117

efavirenz 56

EFFER-K 95

EFFEXOR XR 26

EFFIENT 68

EFUDEX 37

EGRIFTA 112

ELDEPRYL 49

ELESTAT 138

ELESTRIN 117

eletriptan hydrobromide 33

ELIDEL 90

ELIMITE 47

ELINEST 117

ELIPHOS 97

ELIQUIS 65

ELIXOPHYLLIN 146

ELLA 123

ELLZIA PAK 108

ELMIRON 105

ELOCON 108

EMADINE 138

EMBEDA 8

EMCYT 37

EMEND 30

EMFLAZA 109

EMGALITY PEN 33

EMGALITY SYRINGE 33

EMLA 12

EMOQUETTE 117

EMSAM 26

EMTRIVA 57

EMVERM 46

ENABLEX 104

enalapril maleate 70

enalapril maleate/hydrochlorothiazide 74

ENBREL 128

ENBREL MINI 128

ENBREL SURECLICK 129

ENDARI 95

ENDOCET 10

ENDOMETRIN 124

ENJUVIA 117

enoxaparin sodium 65

ENPRESSE 117

ENSKYCE 117

ENSTILAR 90

entacapone 48

entecavir 52

Enteral Formula Requires Prior Authorization.

Brands are Tier 3 & generics are Tier 1. 98

ENTEREG 99

ENTOCORT EC 133

ENTRESTO 74

ENULOSE 101

ENVARSUS XR 129

EPANDED SOLUTION 70

EPCLUSA 52

EPIDIOLEX 22

EPIDUO 90

EPIDUO FORTE 90

EPIFOAM 90

epinastine hcl 138

epinephrine 144

EPIPEN 144

EPIPEN 2-PAK 144

EPIPEN JR 2-PAK 144

EPITOL 24

EPIVIR 57

EPIVIR HBV 52

eplerenone 77

EPOGEN 66

eprosartan mesylate 69

EPZICOM 57

EQUETRO 60

ergocalciferol (vitamin d2) 133

ergoloid mesylates 25

ERGOMAR 33

ergotamine tartrate/caffeine 33

ERIVEDGE 41

ERLEADA 36

erlotinib hcl 41

ERRIN 124

ERTACZO 30

ERY 18

ERY-TAB 18

ERYGEL 18

ERYPED 200 18

ERYPED 400 18

ERYTHROCIN STEARATE 18

erythromycin base 18

erythromycin base in ethanol 18

erythromycin base/benzoyl peroxide 15

erythromycin ethylsuccinate 19

ESBRIET 147

escitalopram oxalate 27

ESGIC 83

ESOMEP-EZS 102

esomeprazole magnesium 102

esomeprazole strontium 102

ESTARYLLA 117

estazolam 151

ESTRACE 118

estradiol 118


estradiol valerate 118

estradiol/norethindrone acetate 118

ESTRING 118

ESTROGEL 118

estrogens,esterified/methyltestosterone 118

estropipate 118

ESTROSTEP FE 118

eszopiclone 151

ethacrynic acid 76

ethambutol hcl 35

ethinyl estradiol/drospirenone 118

ethosuximide 22

ethynodiol diacetate-ethinyl estradiol 118

etidronate disodium 133

etodolac 6

etoposide 40

EUCRISA 90

EURAX 47

EVAMIST 118

EVEKEO 81

EVEKEO ODT 81

EVISTA 125

EVOCLIN 15

EVOTAZ 58

EVOXAC 87

EXALGO 8

EXELDERM 30

EXELON 25

exemestane 39

EXFORGE 74

EXFORGE HCT 74

EXJADE 96

EXTAVIA 85

EXTINA 30

EZALLOR SPRINKLE 78

ezetimibe 79

ezetimibe/simvastatin 79

FFABIOR 90

FACTIVE 19

FALLBACK SOLO 124

FALMINA 118

famciclovir 58,59

famotidine 100

FAMVIR 59

FANAPT 50

FARESTON 37

FARXIGA 61

FARYDAK 41

FAYOSIM 118

FAZACLO 51

felbamate 23

FELBATOL 23

FELDENE 6

felodipine 73

FEM PH 106

FEMARA 39

FEMHRT 118

FEMRING 118

FEMYNOR 118

fenofibrate 77

fenofibrate nanocrystallized 77

fenofibrate,micronized 77

fenofibric acid 77

fenofibric acid (choline) 77

FENOGLIDE 77

fenoprofen calcium 6

fenoprofen calcium (200 mg capsule, 400 mg

capsule) 6

FENORTHO 6

fentanyl 8

fentanyl (37.5mcg/hr patch td72, 62.5mcg/hr

patch td72, 87.5mcg/hr patch td72) 8

fentanyl citrate 10

FENTORA 10

FERRIPROX 96

FETZIMA 27

FEXMID 150

FIASP 64

FIASP FLEXTOUCH 64

FIBRICOR 77

FINACEA 90

finasteride 105

FIORICET 83

FIORICET WITH CODEINE 10

FIORINAL 6

FIORINAL WITH CODEINE #3 10

FIRAZYR 127

FIRDAPSE 85

FIRVANQ 15

FLAGYL 15

FLAGYL ER 15

FLAREX 138

flavoxate hcl 104

flecainide acetate 71

FLECTOR 6

FLEXIPAK 135

FLOLIPID 78

FLOMAX 105

FLOVENT DISKUS 141

FLOVENT HFA 141

FLOWTUSS 148

FLOXIN 19

fluconazole 31

flucytosine 31

fludrocortisone acetate 109

FLUMADINE 58

flunisolide 141

fluocinolone acetonide 109

fluocinolone acetonide oil 141

fluocinolone acetonide/shower cap 109

fluocinonide 109

fluocinonide/emollient base 109

fluorometholone 138

FLUOROPLEX 90

fluorouracil 37

fluorouracil 0.5% cream 90

fluoxetine hcl 27

fluphenazine decanoate 49

fluphenazine hcl 49

flurandrenolide 109

flurazepam hcl 151


flurbiprofen 6

flurbiprofen sodium 138

flutamide 36

fluticasone propionate 109,141

fluticasone propionate/salmeterol xinafoate 148

fluvastatin sodium 78

fluvoxamine maleate 27

FML 138

FML FORTE 138

FML S.O.P. 138

foam/gauze

bandage/lidocaine/chlorhexidine/isopropyl

alcohol 135

FOCALIN 82

FOCALIN XR 82

folic acid 98

FOLLISTIM AQ 112

fondaparinux sodium 65

FORADIL 144

FORFIVO XL 26

FORTAMET 61

FORTEO 133

FORTESTA 115

FORTICAL 133

FOSAMAX 134

FOSAMAX PLUS D 134

fosinopril sodium 70

fosinopril sodium/hydrochlorothiazide 75

FOSRENOL 97

FRAGMIN 65

freestyle freedom lite meter 63

freestyle insulinx glucose sys 63

freestyle insulinx test strips 63

freestyle lite meter 63

freestyle lite test strips 63

freestyle prec neo test strips 63

freestyle precision neo meter 63

freestyle test strips 63

FROVA 34

frovatriptan succinate 34

FULPHILA 66

FULYZAQ 99

FURADANTIN 15

furosemide 76

FYAVOLV 118

FYCOMPA 23

Ggabapentin 23

GABITRIL 23

GALAFOLD 103

galantamine hbr 25

GALZIN 96

ganirelix acetate 126

GASTROCROM 99

gatifloxacin 19

GATTEX 99

GAVILYTE-C 101

GAVILYTE-G 101

GAVILYTE-N 101

GELNIQUE 104

gemfibrozil 77

GENERESS FE 118

GENERLAC 101

GENGRAF 129

GENOTROPIN 113

GENTAK 14

gentamicin sulfate 14

GENVOYA 55

GEODON 50

GIALAX 101

GIANVI 118

GIAZO 132

GILDAGIA 118

GILDESS 24 FE 118

GILENYA 85

GILOTRIF 41

glatiramer acetate 86

GLATOPA 86

GLEEVEC 42

GLEOSTINE 35

glimepiride 61

glipizide 61

glipizide/metformin hcl 61

GLUCAGEN 64

GLUCAGON EMERGENCY KIT 64

GLUCOPHAGE 61

GLUCOPHAGE XR 61

GLUCOTROL 61

GLUCOTROL XL 61

GLUCOVANCE 61

GLUMETZA 61

glyburide 61

glyburide,micronized 61

glyburide/metformin hcl 61

GLYCATE 98

glycopyrrolate 98

GLYDO 12

GLYNASE 61

GLYSET 61

GLYXAMBI 61

GOCOVRI 48

GOLYTELY 101

Gonal-f 113

GONITRO 80

GORDON'S UREA 90

GRALISE 23

granisetron hcl 30

GRANIX 66

GRASTEK 131

GRIFULVIN V 31

GRIS-PEG 31

griseofulvin ultramicrosize 31

griseofulvin, microsize 31

guaifenesin/hydrocodone bitartrate 148

guanfacine hcl 69,82

guanidine hcl 34

GYNAZOLE 1 31

GYNOL II 106

HHAEGARDA 127

HALCION 151


halobetasol propionate 109

HALOG 109

haloperidol 49

haloperidol lactate 49

HARVONI 52

HEATHER 124

HECTOROL 134

HEMANGEOL 38

HEMMOREX-HC 109

HEPSERA 52

HETLIOZ 152

HEXALEN 35

HIPREX 15

HORIZANT 83

HUMALOG 64

HUMALOG JUNIOR KWIKPEN 64



HUMALOG MIX 50-50 64


HUMALOG MIX 75-25 64


HUMATROPE 113

Humira 129

HUMULIN 70-30 64

HUMULIN 70/30 KWIKPEN 64

HUMULIN N 64

HUMULIN N KWIKPEN 64

HUMULIN R 64

HUMULIN R U-500 64

HUMULIN R U-500 KWIKPEN 64

HYCAMTIN 40

HYCET 10

HYCOFENIX 149

hydralazine hcl 79

HYDREA 37

hydrochlorothiazide 77

hydrocodone bitart/chlorpheniramine

maleate/pseudoephedrine 149

hydrocodone bitartrate/acetaminophen 10

hydrocodone bitartrate/homatropine

methylbromide 149

hydrocodone polistirex/chlorpheniramine

polistirex 149

hydrocodone/ibuprofen 10

hydrocortisone 109,133

hydrocortisone acetate 109

hydrocortisone acetate/iodoquinol/aloe vera 90

hydrocortisone acetate/lidocaine hcl/aloe

vera 90

hydrocortisone acetate/pramoxine hcl 90

hydrocortisone butyrate 109

hydrocortisone butyrate/emollient base 109

hydrocortisone valerate 109

hydrocortisone/acetic acid 141

hydrocortisone/mineral oil/petrolatum,white 109

HYDROMET 149

hydromorphone hcl 8,10

hydroquinone microspheres 90

hydroxychloroquine sulfate 47

hydroxyurea 37

hydroxyzine hcl 143

hydroxyzine pamoate 143

HYOPHEN 16

hyoscyamine sulfate 98

HYOSYNE 98

HYSINGLA ER 8

HYZAAR 75

Iibandronate sodium 134

IBRANCE 42

IBU 6

IBUDONE 10

ibuprofen 6

ibuprofen/oxycodone hcl 10

ICAR-C PLUS 95

ICLUSIG 42

IDHIFA 38

ILEVRO 138

ILOTYCIN 19

imatinib mesylate 42

IMBRUVICA 42

imipramine hcl 28

imipramine pamoate 28

imiquimod 90

IMITREX 34

IMPAVIDO 47

IMPOYZ 109

IMURAN 129

IMVEXXY 118

INBRIJA 135

INCASSIA 124

INCRELEX 113

INCRUSE ELLIPTA 143

indapamide 77

INDERAL LA 71

INDERAL XL 71

INDOCIN 6

indomethacin 6

INFLAMMACIN 135

INGREZZA 83

INGREZZA INITIATION PACK 83

INLYTA 42

INNOPRAN XL 71

INSPRA 77

insulin lispro 65

INTELENCE 56

INTERMEZZO 151

INTRAROSA 135

INTRON A 54

INTROVALE 118

INTUNIV 82

INVEGA 50

INVELTYS 138

INVIRASE 58

INVOKAMET 61

INVOKAMET XR 61

INVOKANA 61

IOPIDINE 139

ipratropium bromide 143

ipratropium bromide/albuterol sulfate 149


IPRIVASK 65

irbesartan 69

irbesartan/hydrochlorothiazide 75

IRENKA 84

IRESSA 42

ISENTRESS 55

ISENTRESS HD 55

ISIBLOOM 118

isometheptene

mucate/dichloralphenazone/acetaminophen 135

isoniazid 35

ISOPTO ATROPINE 136

ISOPTO CARPINE 139

ISORDIL 80

ISORDIL TITRADOSE 80

isosorbide dinitrate 80

isosorbide mononitrate 80

isoxsuprine hcl 75

isradipine 73

ISTALOL 139

itraconazole 31

ivermectin 46

JJadenu 96

JAKAFI 42

JALYN 105

JANTOVEN 66

JANUMET 61

JANUMET XR 61

JANUVIA 61

JARDIANCE 61

JENCYCLA 124

JENTADUETO 61

JENTADUETO XR 61

JEVANTIQUE LO 118

JINTELI 118

JOLESSA 119

JOLIVETTE 124

JORNAY PM 82

JUBLIA 31

JULEBER 119

JULUCA 57

JUNEL 119

JUNEL FE 119

JUNEL FE 24 119

JUXTAPID 79

JYNARQUE 96

KK EFFERVESCENT 95

K-PHOS NO.2 106

K-PHOS ORIGINAL 106

K-TAB ER 95

KADIAN 8

KAITLIB FE 119

KALETRA 58

KALYDECO 145

KAPSPARGO SPRINKLE 71

KAPVAY 82

KARBINAL ER 143

KARIVA 119

KAYEXALATE 96

KAZANO 62

KEFLEX 17

KELNOR 1-35 119

KELNOR 1-50 119

KENALOG 109

KEPPRA 22

KEPPRA XR 22

KERYDIN 31

ketoconazole 31

KETODAN 31

ketoprofen 6

ketorolac tromethamine 6,138

KEVEYIS 76

KEVZARA 131

KHEDEZLA 27

KIMIDESS 119

KINERET 129

KIONEX 97

KISQALI 42

KISQALI FEMARA CO-PACK 43

KITABIS PAK 145

KLARON 20

KLONOPIN 59

KLOR-CON 95

KLOR-CON 10 95

KLOR-CON 8 95

KLOR-CON M10 95

KLOR-CON M15 95

KLOR-CON M20 95

KLOR-CON SPRINKLE 95

KLOR-CON-EF 95

KOMBIGLYZE XR 62

KORLYM 109

KRINTAFEL 47

KRISTALOSE 101

KURVELO 119

KUVAN 103

KYLEENA 124

KYNAMRO 79

Llabetalol hcl 72

LACRISERT 136

lactulose 101

LAMICTAL 23

LAMICTAL (BLUE) 23

LAMICTAL (GREEN) 24

LAMICTAL (ORANGE) 24

LAMICTAL ODT 24

LAMICTAL XR 24

LAMISIL 31

lamivudine 52,57

lamivudine/zidovudine 57

lamotrigine 24

LANOXIN 75

lansoprazole 102

lansoprazole/amoxicillin

trihydrate/clarithromycin 99

lanthanum carbonate 97

LANTUS 65


LANTUS SOLOSTAR 65

LARIN 119

LARIN 24 FE 119

LARIN FE 119

LARISSIA 119

LASIX 76

LASTACAFT 138

latanoprost 140

LATUDA 50

LAYOLIS FE 119

LAZANDA 10

ledipasvir/sofosbuvir 52

LEENA 119

leflunomide 131

LENVIMA 43

LESCOL 78

LESCOL XL 78

LESSINA 119

LETAIRIS 146

letrozole 39

leucovorin calcium 38

LEUKERAN 35

LEUKINE 67

leuprolide acetate 126

levalbuterol hcl 144

levalbuterol tartrate 144

LEVAQUIN 19

LEVATOL 72

LEVBID 98

LEVEMIR 65

LEVEMIR FLEXTOUCH 65

levetiracetam 22

LEVITRA 106

LEVO-T 125

levobunolol hcl 139

levocarnitine 95

levocarnitine (with sugar) 95

levocetirizine dihydrochloride 143

levofloxacin 19

LEVONEST 119

levonorgestrel 119

levonorgestrel-ethinyl estradiol 119

levonorgestrel/ethinyl estradiol and ethinyl

estradiol 119

LEVORA-28 119

levorphanol tartrate 8

levothyroxine sodium 125

LEVOXYL 125

LEVSIN 98

LEVSIN-SL 98

LEVULAN 90

LEXAPRO 27

LEXETTE 109

LEXIVA 58

LEXIXRYL 90

LIALDA 132

LIBRAX 98

LIDO-K 12

LIDO-PRILO CAINE PACK 12

lidocaine 12

lidocaine hcl 12

lidocaine hcl/hydrocortisone acetate 91

lidocaine/prilocaine 12

LIDODERM 12

LIDOPAC 12

LIDOPIN 13

LIDOPRIL 13

LIDOPRIL XR 13

LIDOTRANS 5 PAK 13

LILETTA 124

LILLOW 119

lindane 47

linezolid 16

LINZESS 100

liothyronine sodium 125

LIPITOR 78

LIPOCHOL PLUS 77

LIPOFEN 77

LIPROZONEPAK 13

lisinopril 70

lisinopril/hydrochlorothiazide 75

lithium carbonate 60

lithium citrate 60

LITHOBID 60

LITHOSTAT 106

LIVALO 78

LO LOESTRIN FE 119

LOCOID 110

LOCOID LIPOCREAM 110

LODINE 6

LODOSYN 49

LOESTRIN 119

LOESTRIN FE 120

LOFIBRA 78

LOKELMA 135

LOMAIRA 83

LOMEDIA 24 FE 120

LOMOTIL 99

lomustine 35

LONHALA MAGNAIR REFILL 143

LONHALA MAGNAIR STARTER 143

LONSURF 38

loperamide hcl 99

LOPID 78

lopinavir/ritonavir 58

LOPREEZA 120

LOPRESSOR 72

LOPRESSOR HCT 75

LOPROX 31

lorazepam 59

LORAZEPAM INTENSOL 59

LORBRENA 40

LORCET 10

LORCET HD 10

LORCET PLUS 10

LORTAB 10

LORYNA 120

LORZONE 150

losartan potassium 70

losartan potassium/hydrochlorothiazide 75

LOSEASONIQUE 120

LOTEMAX 138

LOTENSIN 70


LOTENSIN HCT 75

loteprednol etabonate 138

LOTREL 75

LOTRISONE 91

LOTRONEX 100

lovastatin 78

LOVAZA 79

LOVENOX 66

LOW-OGESTREL 120

loxapine succinate 49

LUCEMYRA 14

luliconazole 31

LUMIGAN 140

LUNESTA 151

LUPANETA PACK 126

LUTERA 120

LUXIQ 110

LUZU 31

LYNPARZA 43

LYRICA 84

LYRICA CR 85

LYSODREN 38

LYSTEDA 68

LYZA 124

MMACROBID 16

MACRODANTIN 16

MALARONE 47

malathion 47

maprotiline hcl 27

MARINOL 30

MARLISSA 120

MARPLAN 26

MARTEN-TAB 83

MATULANE 35

MATZIM LA 73

MAVENCLAD 86

MAVIK 70

MAVYRET 52

MAXALT 34

MAXALT MLT 34

MAXIDEX 139

MAXITROL 136

MAXZIDE 75

MAXZIDE-25 MG 75

MAYZENT 86

meclizine hcl 29

meclofenamate sodium 6

MEDOLOR PAK 13

MEDROL 110

medroxyprogesterone acetate 124

mefenamic acid 6

mefloquine hcl 47

MEGACE 124

MEGACE ES 124

megestrol acetate 124

MEKINIST 43

MEKTOVI 43

MELODETTA 24 FE 120

meloxicam 6

melphalan 35

memantine hcl 25

MENEST 120

MENOPUR 113

MENOSTAR 120

MENTAX 31

meperidine hcl 10

MEPHYTON 68

meprobamate 59

MEPRON 47

mercaptopurine 37

mesalamine 132

mesalamine 800 mg tablet dr 132

mesalamine with cleansing wipes 132

MESNEX 46

MESTINON 34

METADATE CD 82

METADATE ER 82

metaproterenol sulfate 144

METAXALL 151

metaxalone 151

metformin er 500mg & 1000mg tab (generic

version of glumetza) 62

metformin hcl 62

methadone hcl 8

METHADONE INTENSOL 8

METHADOSE 8

methamphetamine hcl 81

methazolamide 139

methenamine hippurate 16

methenamine mandelate 16

methenamine/sod

phosph,monobasic/methylene

blue/hyoscyamine 16

METHERGINE 135

methimazole 127

METHITEST 115

methocarbamol 151

methotrexate sodium 129

methotrexate sodium/pf 129

methoxsalen 91

methscopolamine bromide 98

methyclothiazide 77

methyldopa 69

methyldopa/hydrochlorothiazide 75

methylergonovine maleate 135

METHYLIN 82

methylphenidate hcl 82

methylprednisolone 110

methyltestosterone 115

metipranolol 139

metoclopramide hcl 29

metolazone 77

metoprolol succinate 72

metoprolol succinate/hydrochlorothiazide 75

metoprolol tartrate 72

metoprolol tartrate/hydrochlorothiazide 75

METOZOLV ODT 29

METROCREAM 91

METROGEL 91

METROGEL-VAGINAL 16

METROLOTION 91


metronidazole 16,91

mexiletine hcl 71

MIACALCIN 134

MIBELAS 24 FE 120

MICARDIS 70

MICARDIS HCT 75

miconazole nitrate 31

miconazole nitrate/zinc

oxide/petrolatum,white 31

MICORT-HC 91,110

MICROCYN 91

MICROCYN HYDROGEL 91

MICROGESTIN 120

MICROGESTIN 24 FE 120

MICROGESTIN FE 120

MICROZIDE 77

midazolam hcl 59

midodrine hcl 69

MIGERGOT 33

miglitol 62

miglustat 103

MIGRANAL 33

MILI 120

MILLIPRED 110

MILLIPRED DP 110

MIMVEY 120

MIMVEY LO 120

MINASTRIN 24 FE 120

MINIPRESS 69

MINITRAN 80

MINIVELLE 120

MINOCIN 20

minocycline hcl 21

MINOLIRA ER 21

minoxidil 79

MIRAPEX 48

MIRAPEX ER 48

MIRCETTE 120

MIRENA 124

mirtazapine 26

misoprostol 101

MITIGARE 32

MITOSOL 136

MOBIC 6

modafinil 152

MODERIBA 54

moexipril hcl 70

moexipril hcl/hydrochlorothiazide 75

molindone hcl 49

mometasone furoate 110,141

MONDOXYNE NL 21

MONO-LINYAH 120

MONODOX 21

MONONESSA 120

montelukast sodium 143

MONUROL 16

MORGIDOX 21

MORPHABOND ER 8

morphine sulfate 9,11

morphine sulfate (15 mg tablet, 30 mg tablet)

10

MOTEGRITY 29

MOTOFEN 99

MOVANTIK 99

MOVIPREP 101

MOXATAG 18

MOXEZA 19

moxifloxacin hcl 19

MOZOBIL 67

MS CONTIN 9

MULPLETA 67

MULTAQ 71

mupirocin 16

mupirocin calcium 16

MUSE 106

MY CHOICE 120

MY WAY 120

MYALEPT 99

MYAMBUTOL 35

MYCOBUTIN 35

mycophenolate mofetil 129

mycophenolate sodium 129

MYDAYIS 81

MYFORTIC 129

MYLERAN 35

MYORISAN 91

MYRBETRIQ 104

MYSOLINE 23

MYTESI 99

MYZILRA 120

Nnabumetone 6

nadolol 72

nadolol/bendroflumethiazide 75

naftifine hcl 31

NAFTIN 31

NALFON 6

NALOCET 11

naloxone hcl 14

naltrexone hcl 13

NAMENDA 25

NAMENDA XR 25

NAMZARIC 25

naphazoline 0.1% 136

NAPRELAN 6

NAPROSYN 6

naproxen 6

naproxen sodium 6

naratriptan hcl 34

NARCAN 14

NARDIL 26

NASCOBAL 98

NASONEX 141

NATACYN 31

NATAZIA 120

nateglinide 62

NATESTO 115

NATPARA 134

NATROBA 91

NATURE-THROID 125

NEBUPENT 47

NEBUSAL 149


NECON 120

nefazodone hcl 27

NEO-POLYCIN 136

NEO-POLYCIN HC 137

NEO-SYNALAR 91

neomycin sulfate 14

neomycin sulfate/bacitracin zinc/polymyxin

b/hydrocortisone 137

neomycin sulfate/bacitracin/polymyxin b 137

neomycin sulfate/polymyxin b sulfate/gramicidin

d 137

neomycin sulfate/polymyxin b

sulfate/hydrocortisone 137,141

neomycin/polymyxin b

sulfate/dexamethasone 137

NEORAL 129

NEPTAZANE 140

NERLYNX 43

NESINA 62

NESTABS ONE 95

NEUAC 91

NEULASTA 67

NEUPOGEN 67

NEUPRO 48

NEURCAINE 13

NEURONTIN 23

NEVANAC 139

nevirapine 56

nevirapine 50 mg/5 ml oral susp 56

NEW DAY 120

NEXAVAR 43

NEXIUM 102

NEXPLANON 124

NEXT CHOICE ONE DOSE 124

niacin 79

NIACOR 79

NIASPAN 79

nicardipine hcl 73

NICOTROL 14

NICOTROL NS 14

NIFEDICAL XL 73

nifedipine 73

NIKKI 121

NILANDRON 36

nilutamide 36

nimodipine 73

NINLARO 38

nisoldipine 73

NITRO-BID 80

NITRO-DUR 80

NITRO-TIME 80

nitrofurantoin 16

nitrofurantoin macrocrystal 16

nitrofurantoin monohydrate/macrocrystals 16

nitroglycerin 80

NITROLINGUAL 80

NITROMIST 80

NITROSTAT 80

NITYR 103

NIVESTYM 67

nizatidine 100

NIZORAL 31

NOCDURNA 113

NOCTIVA 113

NODOLOR 135

NOLIX 110

NOR-Q-D 124

NORA-BE 124

NORCO 11

NORDITROPIN FLEXPRO 113

norethindrone 124

norethindrone acetate 124

norethindrone acetate-ethinyl estradiol 121

norethindrone acetate-ethinyl estradiol/ferrous

fumarate 121

norethindrone-ethinyl estradiol/ferrous

fumarate 121

NORGESIC FORTE 151

norgestimate-ethinyl estradiol 121

NORITATE 91

NORLYDA 124

NORLYROC 124

NORPACE 71

NORPACE CR 71

NORPRAMIN 28

NORTHERA 69

NORTREL 121

nortriptyline hcl 28

NORVASC 73

NORVIR 58

NOVACORT 91

NOVAREL 113

NOVOLIN 70-30 65

NOVOLIN 70-30 FLEXPEN 65

NOVOLIN N 65

NOVOLIN R 65

NOVOLOG 65

NOVOLOG FLEXPEN 65

NOVOLOG MIX 70-30 65

NOVOLOG MIX 70-30 FLEXPEN 65

NOXAFIL 32

NP THYROID 125

NUCALA 149

NUCORT 110

NUCYNTA 11

NUCYNTA ER 9

NUDICLO 91,135

NUDROXIPAK 6



NUDROXIPAK E-400 135

NUDROXIPAK I-800 135

NUDROXIPAK N-500 135

NUEDEXTA 83

NULEV 98

NULYTELY WITH FLAVOR PACKS 101

NUMBONEX 13

NUOX 91

NUPLAZID 50

NUTRESTORE 95

NUTRIARX 110

NUTROPIN AQ 113

NUVAKAAN 13


NUVARING 121

NUVESSA 16

NUVIGIL 152

NUZYRA 21

NYAMYC 32

NYATA 32

NYMALIZE 73

nystatin 32

nystatin/triamcinolone acetonide 32

NYSTOP 32

OOB COMPLETE PETITE 98

OBREDON 149

OCALIVA 103

OCELLA 121

octreotide acetate 126

OCUFEN 139

OCUFLOX 19

ODACTRA 135

ODEFSEY 56

ODOMZO 43

OFEV 148

ofloxacin 19

OGESTREL 121

olanzapine 50

olanzapine/fluoxetine hcl 26

OLEPTRO ER 27

olmesartan medoxomil 70

olmesartan medoxomil/amlodipine

besylate/hydrochlorothiazide 75

olmesartan medoxomil/hydrochlorothiazide 75

olopatadine hcl 138,143

OLUMIANT 129

OLUX 110

OLUX-E 110

OLYSIO 53

OMECLAMOX-PAK 99

omega-3 acid ethyl esters 79

omeprazole 102

omeprazole/sodium bicarbonate 102

OMNARIS 141

OMNIPRED 139

OMNITROPE 114

ondansetron 30

ondansetron hcl 30

onetouch ultra blue strips 63

onetouch ultra2 glucose syst 63

onetouch ultramini meter 63

onetouch verio flex system kit 63

onetouch verio iq system kit 63

onetouch verio meter system 63

onetouch verio sync syst kit 64

onetouch verio test strip 64

ONEXTON 91

ONFI 23

ONGLYZA 62

ONMEL 32

ONZETRA XSAIL 34

OPANA 11

OPCICON ONE-STEP 124

opium tincture 100

opium/belladonna alkaloids 11

OPSUMIT 147

OPTION 2 125

ORACEA 21

ORACIT 95

Oralair 131

ORALONE 87

ORAP 49

ORAPRED ODT 110

ORAVIG 32

ORENCIA 129

ORENITRAM ER 147

ORFADIN 103

ORILISSA 126

ORKAMBI 145

orphenadrine citrate 151

ORPHENGESIC FORTE 151

ORSYTHIA 121

ORTHO MICRONOR 125

ORTHO TRI-CYCLEN 121

ORTHO TRI-CYCLEN LO 121

ORTHO-CYCLEN 121

ORTHO-NOVUM 121

OSCIMIN 98

OSCIMIN SL 98

OSCIMIN SR 99

oseltamivir phosphate 58

OSENI 62

OSMOLEX ER 48

OSMOPREP 101

OSPHENA 125

OTEZLA 132

OTIPRIO 19

OTOVEL 141

OTREXUP 130

OVACE 91

OVACE PLUS 91

OVACE PLUS WASH 91

OVIDE 47

OVIDREL 114

OXANDRIN 114

oxandrolone 114

oxaprozin 7

OXAYDO 11

oxazepam 59

oxcarbazepine 24

OXECTA 11

OXERVATE 137

oxiconazole nitrate 32

OXISTAT 32

OXSORALEN-ULTRA 91

OXTELLAR XR 24

oxybutynin chloride 104

oxycodone 10mg/0.5ml oral syringe 11

oxycodone hcl 9,11

oxycodone hcl/acetaminophen 11

oxycodone hcl/aspirin 11

OXYCONTIN 9

oxymorphone hcl 9,11

OXYTROL 104

OZEMPIC 62


PPACERONE 71

PACNEX 91

PACNEX HP 91

PACNEX LP 91

PAINGO KFT 13

paliperidone 50

PALYNZIQ 103

PAMELOR 28

PANCREAZE 103

PANCRELIPASE 5,000 103

PANDEL 110

PANLOR 11

PANRETIN 46

pantoprazole sodium 102

PARAFON FORTE DSC 151

PARAGARD T 380-A 135

paregoric 100

PAREMYD 137

paricalcitol 134

PARLODEL 48

PARNATE 26

PAROEX 87

paromomycin sulfate 14

paroxetine hcl 27

paroxetine mesylate 27

PASER 35

PATADAY 138

PATANASE 143

PATANOL 138

PAXIL 27

PAXIL CR 27

PAZEO 138

PCE 19

PEDIADERM HC 110

PEDIAPRED 110

peg 3350/sod sulf/sod bicarb/sod

chloride/potassium chloride 101

PEG-PREP 101

PEGANONE 24

PEGASYS 54

PEGASYS PROCLICK 54

PEGINTRON 54

PEGINTRON REDIPEN 54

penicillamine 97

penicillin v potassium 18

PENLAC 32

PENNSAID 7

PENTASA 132

pentazocine hcl/naloxone hcl 11

pentoxifylline 75

PEPCID 100

PERCOCET 11

PERFOROMIST 144

PERIDEX 87

perindopril erbumine 70

PERIOGARD 87

permethrin 47

perphenazine 29

perphenazine/amitriptyline hcl 26

PERSANTINE 68

PERTZYE 103

PEXEVA 27

PHENADOZ 29

phenazopyridine hcl 106

phendimetrazine tartrate 84

phenelzine sulfate 26

PHENERGAN 29

phenobarbital 23

phenoxybenzamine hcl 69

phentermine hcl 84

phenylephrine hcl 137

phenylephrine hcl/promethazine hcl 149

PHENYTEK 24

phenytoin 24

phenytoin sodium extended 24

PHILITH 121

PHOSLO 97

PHOSLYRA 97

PHOSPHASAL 16

PHOSPHOLINE IODIDE 140

phytonadione (vit k1) 68

PICATO 91

PIFELTRO 56

pilocarpine hcl 87,140

pimecrolimus 91

pimozide 49

PIMTREA 121

pindolol 72

pioglitazone hcl 62

pioglitazone hcl/glimepiride 62

pioglitazone hcl/metformin hcl 62

PIQRAY 40

PIRMELLA 121

piroxicam 7

PLAN B ONE-STEP 121

PLAQUENIL 47

PLAVIX 68

PLEGRIDY 86

PLEGRIDY PEN 86

PLENVU 101

PLETAL 68

PLEXION 92

PLIXDA 92

podofilox 92

POLYCIN 137

polymyxin b sulfate/trimethoprim 137

POLYTRIM 137

POMALYST 37

PONSTEL 7

PORTIA 121

POTABA 98

potassium bicarbonate/citric acid 96

potassium chloride 96

potassium chloride/potassium

bicarbonate/citric acid 96

potassium citrate 96

potassium citrate/citric acid 96

POTIGA 22

PRADAXA 66

PRALUENT 79

pramipexole di-hcl 48


PRAMOSONE 92

PRAMOSONE E 92

PRANDIN 62

prasugrel hcl 68

PRAVACHOL 78

pravastatin sodium 78

praziquantel 46

prazosin hcl 69

precision xtra monitor 64

precision xtra test strips 64

PRECOSE 62

PRED FORTE 139

PRED MILD 139

PRED-G 137

prednicarbate 110

prednisolone 110

prednisolone acetate 139

prednisolone sodium phosphate 110,139

prednisone 110

PREDNISONE INTENSOL 110

PREFEST 121

PREGNYL 114

PREMARIN 121

PREMPHASE 121

PREMPRO 121

PREPOPIK 101

PRESTALIA 75

PREVACID 102

PREVALITE 79

PREVIDENT 96

PREVIDENT 5000 96

PREVIDENT 5000 ENAMEL PROTECT 96

PREVIDENT 5000 PLUS 96

PREVIDENT 5000 SENSITIVE 96

PREVIFEM 121

PREVPAC 100

PREVYMIS 51

PREZCOBIX 58

PREZISTA 58

PRIFTIN 35

PRILOLID 13

PRILOSEC 102

primaquine phosphate 47

primidone 23

PRIMLEV 11

PRIMSOL 16

PRINIVIL 70

PRISTIQ 27

PROAIR HFA 144

PROAIR RESPICLICK 144

probenecid 33

probenecid/colchicine 33

PROCARDIA 73

PROCARDIA XL 73

PROCENTRA 81

prochlorperazine 29

prochlorperazine maleate 29

PROCORT 92

PROCRIT 67

PROCTO-MED HC 110

PROCTO-PAK 110

PROCTOCORT 110

PROCTOFOAM-HC 92

PROCTOSOL-HC 110

PROCTOZONE-HC 110

PROCYSBI 103

PROFENO 7

progesterone 125

progesterone, micronized 125

PROGLYCEM 64

PROGRAF 130

PROLENSA 139

PROMACTA 67

promethazine hcl 29,143

promethazine hcl/codeine 149

promethazine hcl/dextromethorphan hbr 149

promethazine/phenylephrine hcl/codeine 149

PROMETHEGAN 29

PROMETRIUM 125

propafenone hcl 71

propantheline bromide 99

proparacaine hcl 137

propranolol hcl 72

propranolol hcl/hydrochlorothiazide 75

propylthiouracil 127

PROSCAR 105

PROTONIX 102

PROTOPIC 92

protriptyline hcl 28

PROVENTIL HFA 144

PROVERA 125

PROVIGIL 152

PROZAC 27

PROZAC WEEKLY 27

PRUDOXIN 92

PSORCON 110

PULMICORT 141

PULMICORT FLEXHALER 142

PULMOZYME 145

PURIXAN 37

PYLERA 100

pyrazinamide 35

PYRIDIUM 106

pyridostigmine bromide 34,35

QQBRELIS 70

QBREXZA 92

QMIIZ ODT 7

QNASL 142

QNASL CHILDREN 142

QSYMIA 84

QTERN 62

QUALAQUIN 47

QUARTETTE 121

QUASENSE 121

QUDEXY XR 24

QUESTRAN 79

QUESTRAN LIGHT 79

quetiapine fumarate 50

QUILLICHEW ER 82

QUILLIVANT XR 82

quinapril hcl 70


quinapril hcl/hydrochlorothiazide 75

quinidine gluconate 71

quinidine sulfate 71

quinine sulfate 47

QVAR 142

QVAR REDIHALER 142

Rrabeprazole sodium 102

RADIOGARDASE 97

RAGWITEK 132

RAJANI 121

raloxifene hcl 125

ramipril 70

RANEXA 75

ranitidine hcl 100

RAPAFLO 105

RAPAMUNE 130

rasagiline mesylate 49

RASUVO 130

RAVICTI 104

RAYALDEE 134

RAYOS 111

RAZADYNE 25

RAZADYNE ER 25

REBETOL 54

Rebif 86

RECLIPSEN 121

RECTIV 92

REGIMEX 84

REGLAN 29

REGRANEX 92

RELADOR PAK 13

RELAGARD 106

RELENZA 58

RELEXXII 82

RELISTOR 100

RELPAX 34

REMERON 26

RENAGEL 97

RENVELA 97

repaglinide 62

repaglinide/metformin 62

REPATHA 79

REQUIP 48

REQUIP XL 48

RESCRIPTOR 56

RESCULA 140

reserpine 75

RESTASIS 137

RESTASIS MULTIDOSE 137

RESTORIL 152

RETACRIT 67

RETIN-A 92

RETIN-A MICRO 92

RETIN-A MICRO PUMP 92

RETROVIR 57

REVATIO 147

REVIA 13

REVLIMID 37

REXULTI 50

REYATAZ 58

REZIRA 149

RHEUMATREX 130

RHINOCORT AQUA 142

RHOPRESSA 140

RIBASPHERE 55

RIBASPHERE RIBAPAK 55

RIBATAB 55

ribavirin 55,149

RIDAURA 132

rifabutin 35

RIFADIN 35

RIFAMATE 35

rifampin 35

RIFATER 35

RILUTEK 84

riluzole 84

rimantadine hcl 58

RIMSO-50 106

RIOMET 62

risedronate sodium 134

RISPERDAL 50

RISPERDAL M-TAB 50

risperidone 51

RITALIN 82

RITALIN LA 82

ritonavir 58

rivastigmine 25

rivastigmine tartrate 25

RIVELSA 122

rizatriptan benzoate 34

ROBAXIN 151

ROBAXIN-750 151

ROBINUL 99

ROBINUL FORTE 99

ROCALTROL 134

ROCKLATAN 140

ropinirole hcl 48

ROSADAN 92

ROSANIL 92

ROSULA 92

rosuvastatin calcium 78

ROWASA 132

ROWEEPRA 22

ROWEEPRA XR 22

ROXICODONE 11

ROXYBOND 11

ROZEREM 152

RUBRACA 38

RUCONEST 128

RUZURGI 136

RYCLORA 143

RYDAPT 39

RYTARY 49

RYTHMOL 71

RYTHMOL SR 71

RYVENT 143

SSABRIL 23

SAFYRAL 122

SAIZEN 114


SALAGEN 87

salsalate 7

SAMSCA 97

SANADERMRX 111

SANCUSO 30

SANDIMMUNE 130

SANDOSTATIN 126

SANDOSTATIN LAR 126

SANDOSTATIN LAR DEPOT 126

SANTYL 92

SAPHRIS 51

SARAFEM 27

SAVAYSA 66

SAVELLA 85

SAXENDA 136

SCALACORT 111

scopolamine 29

SEASONIQUE 122

SEB-PREV 92

SECONAL SODIUM 152

SECTRAL 72

SEEBRI NEOHALER 144

SEGLUROMET 62

selegiline hcl 49

selenium sulfide 92

SELRX 92

SELZENTRY 57

SEMPREX-D 149

SENSIPAR 134

SEREVENT DISKUS 144

SERNIVO 111

SEROPHENE 125

SEROQUEL 51

SEROQUEL XR 51

SEROSTIM 114

sertraline hcl 27

SETLAKIN 122

sevelamer carbonate 97

sevelamer hcl 97

SEYSARA 21

SF 96

SF 5000 PLUS 96

SFROWASA 132

SHAROBEL 125

SIGNIFOR 126

SIKLOS 37

SILALITE PAK 111

SILAZONE-II 111

sildenafil citrate 106,147

SILENOR 152

SILIQ 92

silodosin 105

SILVADENE 20

silver nitrate/potassium nitrate 92

silver sulfadiazine 20

silver/bandage/foam/gauze/lidocaine/chlorhexid

in/isopropanol 136

SIMBRINZA 140

SIMPONI 130

simvastatin 78

SINEMET 10-100 49

SINEMET 25-100 49

SINEMET 25-250 49

SINEMET CR 49

SINGULAIR 143

sirolimus 130

SIRTURO 35

SITAVIG 59

SIVEXTRO 16

SKELAXIN 151

SKLICE 46

SKYLA 125

SKYRIZI 93

SKYRIZI (2 SYRINGES) KIT 153

SLYND 125

sodium chloride for inhalation 149

sodium chloride/sodium bicarbonate/potassium

chloride/peg 101

sodium phenylbutyrate 104

sodium polystyrene sulfonate 97

sofosbuvir/velpatasvir 53

SOLARAZE 93

solifenacin succinate 104

SOLIQUA 100-33 65

SOLODYN 21

SOLOSEC 16

SOLTAMOX 37

SOLUPAK 13

SOMA 151

SOMATULINE DEPOT 127

SOMAVERT 127

SONATA 152

SOOLANTRA 93

SORIATANE 93

SORILUX 93

SORINE 71

sotalol hcl 71

SOTYLIZE 71

SOVALDI 53

SPECTRACEF 17

spinosad 93

SPIRIVA 144

SPIRIVA RESPIMAT 144

spironolactone 77

spironolactone/hydrochlorothiazide 75

SPORANOX 32

SPRINTEC 122

SPRITAM 22

SPRIX 7

SPRYCEL 44

SPS 97

SRONYX 122

SSD 20

SSKI 127

SSS 10-5 93

STALEVO 48

STARLIX 62

stavudine 57

STAXYN 106

STEGLATRO 62

STEGLUJAN 63

STELARA 93

STENDRA 106


STIMATE 114

STIOLTO RESPIMAT 149

STIVARGA 44

STRATTERA 82

STRENSIQ 104

STRIANT 115

STRIBILD 55

STRIVERDI RESPIMAT 144

STROMECTOL 46

SUBOXONE 14

SUBSYS 11

SUCRAID 104

sucralfate 101

SULAR 73

sulfacetamide sodium 20,93

sulfacetamide sodium/prednisolone sodium

phosphate 137

sulfacetamide sodium/sulfur 93

sulfadiazine 20

sulfamethoxazole/trimethoprim 20

SULFAMYLON 16

sulfasalazine 133

SULFATRIM 20

sulindac 7

sumatriptan 34

sumatriptan succinate 34

sumatriptan succinate/naproxen sodium 34

SUMAVEL DOSEPRO 34

SUNOSI 152

SUPRAX 17

SUPRENZA ODT 84

SUPREP 101

SURMONTIL 28

SUSTIVA 56

SUSTOL 30

SUTENT 44

SYEDA 122

SYLATRON 39

SYMAX 99

SYMAX DUOTAB 99

SYMAX-SL 99

SYMAX-SR 99

SYMBICORT 149

SYMBYAX 26

SYMDEKO 145

SYMFI 56

SYMFI LO 56

SYMJEPI 145

SYMLINPEN 120 63

SYMLINPEN 60 63

SYMPAZAN 23

SYMPROIC 100

SYMTUZA 58

SYNALAR 111

SYNALAR TS 111

SYNALGOS-DC 11

SYNAREL 127

SYNDROS 30

SYNJARDY 63

SYNJARDY XR 63

SYNTHROID 125

SYPRINE 97

syringe, insulin u-500 with needle, disposable,

0.5 ml 136

TTABLOID 38

TACLONEX 93

tacrolimus 93,130

tadalafil 105,106

TAFINLAR 44

TAGRISSO 44

TAKE ACTION 122

TAKHZYRO 128

Taltz 93

TALZENNA 44

TAMIFLU 58

tamoxifen citrate 37

tamsulosin hcl 105

TANZEUM 63

TAPAZOLE 127

TAPERDEX 111

TARCEVA 44

TARGADOX 21

TARGRETIN 46

TARINA 24 FE 122

TARINA FE 122

TARKA 75

TASIGNA 44

TASMAR 48

TAVALISSE 67

TAYTULLA 122

tazarotene 93

TAZORAC 94

TAZTIA XT 73

TECFIDERA 86

TECHNIVIE 53

TEGRETOL 25

TEGRETOL XR 25

TEGSEDI 84

TEKTURNA 75

TEKTURNA HCT 75

telmisartan 70

telmisartan/amlodipine besylate 76

telmisartan/hydrochlorothiazide 76

temazepam 152

TEMODAR 36

TEMOVATE 111

temozolomide 36

TENCON 84

TENEX 69

tenofovir disoproxil fumarate 57

TENORETIC 100 76

TENORETIC 50 76

TENORMIN 72

TERAZOL 3 32

TERAZOL 7 32

terazosin hcl 69

terbinafine hcl 32

terbutaline sulfate 145

terconazole 32

TESSALON PERLE 149

TESTIM 115


testosterone 115

testosterone (10 mg (2%) gel md pmp,

12.5/1.25g gel md pmp, 50 mg (1%) gel

(gram) 115

testosterone (50 mg (1%) gel packet and

12.5/1.25g pump). some manufacturers are t3

and others t1 115

testosterone cypionate 115

testosterone enanthate 115

TESTRED 115

tetrabenazine 84

tetracycline hcl 21

TETRAVISC 137

TETRAVISC FORTE 137

TEXACORT 111

THALOMID 37

THEO-24 146

THEOCHRON 146

theophylline anhydrous 146

THERMAZENE 20

THIOLA 106

THIOLA EC 106

thioridazine hcl 49

thiothixene 50

THYROLAR-1 125

THYROLAR-1/2 125

THYROLAR-1/4 125

THYROLAR-2 126

THYROLAR-3 126

tiagabine hcl 23

TIAZAC 73

TIBSOVO 39

TICALAST 149

TICANASE 142

TICASPRAY 142

ticlopidine hcl 68

TIGAN 29

TIGLUTIK 84

TIKOSYN 71

TILIA FE 122

timolol maleate 72,140

TIMOPTIC 140

TIMOPTIC OCUDOSE 140

TIMOPTIC-XE 140

TINDAMAX 16

tinidazole 16

TIROSINT 126

TIROSINT-SOL 126

TIVICAY 55

TIVORBEX 7

tizanidine hcl 51

TL G-FOL OS 96

TOBI 149

TOBI PODHALER 145

TOBRADEX 137

TOBRADEX ST 137

tobramycin 14

tobramycin in 0.225 % sodium chloride 149

tobramycin/dexamethasone 137

tobramycin/nebulizer 146

TOBREX 14

TODAY CONTRACEPTIVE SPONGE 106

TOFRANIL 28

TOFRANIL-PM 28

TOLAK 94

tolazamide 63

tolbutamide 63

tolcapone 48

tolmetin sodium 7

TOLSURA 32

tolterodine tartrate 105

TOPAMAX 24

TOPICORT 111

topiramate 24

topiramate er caps 24

TOPROL XL 72

toremifene citrate 37

torsemide 76

TOUJEO MAX SOLOSTAR 65

TOUJEO SOLOSTAR 65

TOVIAZ 105

TRACLEER 147

TRADJENTA 63

tramadol er caps 9

tramadol hcl 9,11

tramadol hcl/acetaminophen 11

trandolapril 70

trandolapril/verapamil hcl 76

tranexamic acid 68

TRANSDERM-SCOP 29

TRANXENE T-TAB 59

tranylcypromine sulfate 26

TRAVATAN Z 140

trazodone hcl 27

TRECATOR 35

TRELEGY ELLIPTA 149

TREMFYA 94

TRESIBA 65



TRETIN-X 94

tretinoin 46,94

tretinoin microspheres 94

tretinoin/emollient base 94

TREXALL 130

TREXIMET 34

TREZIX 11

TRI FEMYNOR 122

TRI-CHLOR 94

TRI-ESTARYLLA 122

TRI-LEGEST FE 122

TRI-LINYAH 122

TRI-LO-ESTARYLLA 122

TRI-LO-MARZIA 122

TRI-LO-SPRINTEC 122

TRI-MILI 122

TRI-NORINYL 122

TRI-PREVIFEM 122

TRI-SILA 111

TRI-SPRINTEC 122

TRI-VYLIBRA 122

TRI-VYLIBRA LO 122

triamcinolone acetonide 87,111,142


triamterene/hydrochlorothiazide 76

TRIANEX 111

triazolam 152

TRIBENZOR 76

TRICOR 78

TRIDERM 111

TRIDESILON 111

trientine hcl 97

trifluoperazine hcl 50

trifluridine 59

TRIGLIDE 78

trihexyphenidyl hcl 47

TRILEPTAL 25

TRILIPIX 78

TRILYTE WITH FLAVOR PACKETS 101

trimethobenzamide hcl 29

trimethoprim 16

trimipramine maleate 28

TRIMPEX 16

TRINESSA 122

TRINESSA LO 122

TRINTELLIX 27

TRIUMEQ 57

TRIVORA-28 122

TRIXYLITRAL 134

TRIZIVIR 57

TROKENDI XR 24

tropicamide 137

trospium chloride 105

TRULANCE 100

TRULICITY 63

TRUSOPT 140

TRUVADA 57

TUDORZA PRESSAIR 144

TULANA 125

TUSSICAPS 149

TUSSIGON 150

TUSSIONEX 150

TUZISTRA XR 150

TWYNSTA 76

TYBOST 57

TYDEMY 123

TYKERB 45



TYMLOS 134

Tyvaso 147

TYZEKA 52

TYZINE 150

UUCERIS 133

UDENYCA 68

ULESFIA 94

ULORIC 33

ULTRACET 11

ULTRAM 11

ULTRAM ER 9

ULTRAVATE 111

ULTRAVATE X 111

ULTRESA 104

UNITHROID 126

UPTRAVI 147

UR N-C 16

URECHOLINE 106

URELLE 16

URETRON D-S 16

URIBEL 16

URIMAR-T 16

URIN D.S. 16

URO-458 17

URO-MP 17

UROCIT-K 96

UROGESIC-BLUE 17

UROQID-ACID NO.2 106

UROXATRAL 105

URSO 100

URSO FORTE 100

ursodiol 100

URYL 17

UTIBRON NEOHALER 150

UTIRA-C 17

VVAGIFEM 123

valacyclovir hcl 59

VALCHLOR 36

VALCYTE 51

valganciclovir hcl 51

VALIUM 59

valproic acid 23

valproic acid (as sodium salt) (valproate

sodium) 23

valsartan 70

valsartan/hydrochlorothiazide 76

VALTREX 59

VANATOL LQ 84

VANCOCIN HCL 17

vancomycin hcl 17

VANDAZOLE 17

VANOS 111

vardenafil hcl 106

VARUBI 30

VASCEPA 79

VASERETIC 76

VASOTEC 70

VCF 106

VECAMYL 76

VECTICAL 94

VELIVET 123

VELPHORO 97

VELTASSA 97

VELTIN 94

VEMLIDY 52

VENCLEXTA 45

venlafaxine er tab (tier dependent on

manufacturer. ucb t3, others t1) 28

venlafaxine hcl 28

VENTOLIN HFA 145

VERAMYST 142

verapamil hcl 73

VERDESO 112

VERDROCET 11


VEREGEN 94

VERELAN 73

VERELAN PM 73

VERIPRED 20 112

VERSACLOZ 51

VERZENIO 45

VESICARE 105

VESTURA 123

VEXOL 139

VFEND 32

VIAGRA 106

VIBERZI 100

VIBRAMYCIN 21

VICODIN 11

VICODIN ES 12

VICODIN HP 12

VICTOZA 2-PAK 63

VICTOZA 3-PAK 63

VIDEX 57

VIDEX EC 57

VIEKIRA PAK 53

VIEKIRA XR 53

VIENVA 123

vigabatrin 23

VIGAMOX 19

VIIBRYD 28

VIMOVO 7

VIMPAT 25

VIOKACE 104

VIORELE 123

VIRACEPT 58

VIRAMUNE 56

VIRAMUNE XR 56

VIRAZOLE 150

VIREAD 57

VIROPTIC 59

VISTARIL 143

VITEKTA 55

VITRAKVI 39

VITUZ 150

VIVELLE-DOT 123

VIVLODEX 7

VIZIMPRO 39

VOGELXO 115

VOLTAREN 94

VOLTAREN-XR 7

voriconazole 32

VOSEVI 53

VOSPIRE ER 145

VOTRIENT 45

VRAYLAR 51

VUSION 32

VYFEMLA 123

VYLIBRA 123

VYNDAQEL 76

VYTONE 94

VYTORIN 79

VYVANSE 81

VYZULTA 140

Wwarfarin sodium 66

WELCHOL 79

WELLBUTRIN 26

WELLBUTRIN SR 26

WELLBUTRIN XL 26

WERA 123

WESTHROID 126

WHYTEDERM TRILASIL PAK 112

WIXELA INHUB 150

WP THYROID 126

WYMZYA FE 123

XXADAGO 49

XALATAN 140

XALKORI 45

XANAX 59

XANAX XR 60

XARELTO 66

XARTEMIS XR 12

XATMEP 130

XELITRAL 94

XELJANZ 130

XELJANZ XR 130

XELODA 38

XELPROS 140

XENAFLAMM 136

XENAZINE 84

XENICAL 100

XEPI 94

XERESE 59

XERMELO 136

XHANCE 142

XIFAXAN 100

XIGDUO XR 63

XIIDRA 137

XIMINO 21

XODOL 10-300 12

XODOL 5-300 12

XODOL 7.5-300 12

XOFLUZA 132

XOLEGEL 32

XOPENEX 145

XOPENEX CONCENTRATE 145

XOPENEX HFA 145

XOSPATA 39

XRYLIX 94

XTAMPZA ER 9

XTANDI 36

XULANE 123

XULTOPHY 100-3.6 65

XURIDEN 98

XYLON 10 12

XYOSTED 115

XYREM 152

XYZAL 143

YYASMIN 28 123

YAZ 123

YONSA 36

YUPELRI 144


YUVAFEM 123

Zzafirlukast 143

zaleplon 152

ZAMICET 12

ZANAFLEX 51

ZANTAC 100

ZARAH 123

ZARONTIN 22

ZARXIO 68

ZAVESCA 104

ZEBETA 72

ZEBUTAL 84

ZEGERID 102

ZEJULA 45

ZELAPAR 49

ZELBORAF 45

ZEMBRACE SYMTOUCH 34

ZEMPLAR 134

ZENATANE 94

ZENCHENT 123

ZENCHENT FE 123

ZENPEP 104

ZENZEDI 81

ZEPATIER 54

ZERIT 57

ZESTORETIC 76

ZESTRIL 70

ZETIA 79

ZETONNA 142

ZEYOCAINE 94

ZIAC 76

ZIAGEN 57

ZIANA 94

zidovudine 57

zileuton 143

ZINBRYTA 86

ZIOPTAN 140

ziprasidone hcl 51

ZIPSOR 7

ZIRGAN 51

ZITHROMAX 19

ZITHROMAX TRI-PAK 19

ZMAX 19

ZOCOR 78

ZODEX 112

ZOFRAN 30

ZOFRAN ODT 30

ZOHYDRO ER 9

ZOLINZA 39

zolmitriptan 34

ZOLOFT 28

zolpidem tartrate 152

ZOLPIMIST 152

ZOMACTON 114

ZOMIG 34

ZOMIG ZMT 34

ZONALON 94

ZONEGRAN 22

zonisamide 22

ZONTIVITY 66

ZORBTIVE 114

ZORTRESS 130

ZORVOLEX 7

ZOVIA 1-35E 123

ZOVIA 1-50E 123

ZOVIRAX 59

ZTLIDO 13

ZUBSOLV 14

ZUPLENZ 30

ZUTRIPRO 150

ZYBAN 14

ZYCLARA 94

ZYDELIG 45

ZYFLO 143

ZYFLO CR 143

ZYKADIA 45

ZYLET 137

ZYLOPRIM 33

ZYMAXID 19

ZYPITAMAG 78

ZYPRAM 94

ZYPREXA 51

ZYPREXA ZYDIS 51

ZYTIGA 36

ZYVOX 17


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