GB Cigna Leon No WRAP 2020 - lmchealthplans.com · Leon Medical Centers Health Plans – Leon Cares...

(list of covered drugs)

ComprehensiveFormulary

January 1st - December 31st

INT_20_77507_C

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Formulary ID 00020089, Version 17

This formulary was updated on 08/01/2020. For more recent information or other questions, please contact Leon Medical Centers Health Plans Member Services, at 305.559.5366 or toll-free 1.866.393.5366 or, for TTY users 711, we’re here from 8 a.m. to 8 p.m., seven days a week from October 1st through March 31st and Monday through Friday the rest of the year, or visit LMChealthplans.com.

LEON CARES

MEDICARE2020

INT_20_77507_C_Leon Comprehensive Formulary.indd 1 8/28/19 4:04 PM

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Note to existing members: This formulary has changed since last year. Please review this document to

make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Leon Medical Centers Health Plans. When it refers to “plan” or “our plan,” it means Leon Medical Centers Health Plans – Leon Cares (HMO).

This document includes list of the drugs (formulary) for our plan which is current as of September 1, 2020.For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

What is the Leon Medical Centers Health Plans – Leon Cares (HMO) Formulary?

A formulary is a list of covered drugs selected by Leon Medical Centers Health Plans – Leon Cares (HMO) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Leon Medical Centers Health Plans – Leon Cares (HMO) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Leon Medical Centers Health Plans – Leon Cares (HMO) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?

Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes

during the year:

New generic drugs. We may immediately remove a brand name drug on our Drug List if we arereplacing it with a new generic drug that will appear on the same or lower cost sharing tier and with thesame or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brandname drug on our Drug List, but immediately move it to a different cost-sharing tier or add newrestrictions. If you are currently taking that brand name drug, we may not tell you in advance before wemake that change, but we will later provide you with information about the specific change(s) we havemade.o If we make such a change, you or your prescriber can ask us to make an exception and continue

to cover the brand name drug for you. The notice we provide you will also include information onhow to request an exception, and you can also find information in the section below entitled “Howdo I request an exception to the Leon Medical Centers Health Plans – Leon Cares (HMO)’Formulary?”

Drugs removed from the market. If the Food and Drug Administration deems a drug on our formularyto be unsafe or the drug’s manufacturer removes the drug from the market, we will immediatelyremove the drug from our formulary and provide notice to members who take the drug.

Other changes. We may make other changes that affect members currently taking a drug. Forinstance we may add a generic drug that is not new to market to replace a brand name drug currently

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on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. We may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. o If we make these other changes, you or your prescriber can ask us to make an exception and

continue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can also find information in the section belowentitled “How do I request an exception to the Leon Medical Centers Health Plans’ Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year.

The enclosed formulary is current as of September 1, 2020. To get updated information about the drugs covered by Leon Medical Centers Health Plans – Leon Cares (HMO), please contact us. Our contact information appears on the front and back cover pages. Formularies located on our website are reviewed and updated on a monthly basis. If there are significant changes made to the printed formulary within the covered year, you may be notified by mail identifying the changes.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 9. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR, HYPERTENSION / LIPIDS. If you know what your drug is used for, look for the category name in the list that begins on page number 9. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 107. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

Leon Medical Centers Health Plans – Leon Cares (HMO) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

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Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Prior Authorization: Leon Medical Centers Health Plans – Leon Cares (HMO) requires you or yourphysician to get prior authorization for certain drugs. This means that you will need to get approvalfrom Leon Medical Centers Health Plans – Leon Cares (HMO) before you fill your prescriptions. If youdon’t get approval, Leon Medical Centers Health Plans – Leon Cares (HMO) may not cover the drug.

Quantity Limits: For certain drugs, Leon Medical Centers Health Plans – Leon Cares (HMO) limits theamount of the drug that Leon Medical Centers Health Plans – Leon Cares (HMO) will cover. Forexample, Leon Medical Centers Health Plans – Leon Cares (HMO) provides 60 tablets per prescriptionfor Avandia. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Leon Medical Centers Health Plans – Leon Cares (HMO) requires youto first try certain drugs to treat your medical condition before we will cover another drug for thatcondition. For example, if Drug A and Drug B both treat your medical condition, Leon MedicalCenters Health Plans – Leon Cares (HMO) may not cover Drug B unless you try Drug A first. If DrugA does not work for you, Leon Medical Centers Health Plans – Leon Cares (HMO) will then coverDrug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Leon Medical Centers Health Plans – Leon Cares (HMO) to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Leon Medical Centers Health Plans – Leon Cares (HMO)’ formulary?” on page 4 for information about how to request an exception.

What are over-the counter (OTC) drugs?

OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Leon Medical Centers Health Plans – Leon Cares (HMO) pays for certain OTC drugs. Leon Medical Centers Health Plans – Leon Cares (HMO) will provide these OTC drugs at no cost to you. The cost to Leon Medical Centers Health Plans – Leon Cares (HMO) of these OTC drugs will not count toward your total Part D drug costs (that is, the cost of the OTC drugs does not count for the coverage gap.

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3 DAY VAGINAL CREA CLOTRIMAZOLE SOLN MICONAZOLE CREA

ALAWAY SOLN DIPHENHIST LIQD POLYETHYLENE GLYCOL 3350 PACK

ALLERGY RELIEF TABS GUAIFENESIN DAC SOLN REMEDY ANTIFUNGAL POWD

AMMONIUM LACTATE CREA HYDROCORTISONE CREA SLO-NIACIN TBCR

AMMONIUM LACTATE LOTN KETOTIFEN FUMARATE SOLN SODIUM CHLORIDE OINT

ANTIFUNGAL CREA LEVONORGESTREL TABS SODIUM CHLORIDE SOLN

ATHLETES FOOT SPRAY AERP LORATADINE TABS TRAVEL SICKNESS CHEW

CETIRIZINE HCL TABS MECLIZINE HCL TABS VINATE CARE CHEW

CLOTRIMAZOLE CREA MI-ACID SUSP VIRTUSSIN A/C SOLN

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.

If you learn that Leon Medical Centers Health Plans – Leon Cares (HMO) does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by Leon Medical CentersHealth Plans – Leon Cares (HMO). When you receive the list, show it to your doctor and ask him orher to prescribe a similar drug that is covered by Leon Medical Centers Health Plans – Leon Cares(HMO).

You can ask Leon Medical Centers Health Plans – Leon Cares (HMO) to make an exception and coveryour drug. See below for information about how to request an exception.

How do I request an exception to the Leon Medical Centers Health Plans – Leon Cares (HMO)’ Formulary?

You can ask Leon Medical Centers Health Plans – Leon Cares (HMO) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be coveredat a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at alower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on thespecialty tier. If approved this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,Leon Medical Centers Health Plans – Leon Cares (HMO) limits the amount of the drug that we willcover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

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Generally, Leon Medical Centers Health Plans – Leon Cares (HMO) will only approve your request for an exception if the alternative drugs included on the plan’s formulary, [the lower cost-sharing drug] or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30 day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

If a level of care change is received by the plan in accordance with Medicare’s definition, an override will be allowed. The plan will identify those individuals who are impacted to ensure continuity of care by directing them through the appropriate steps.

For more information

For more detailed information about your Leon Medical Centers Health Plans – Leon Cares (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Leon Medical Centers Health Plans – Leon Cares (HMO), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

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Leon Medical Centers Health Plans – Leon Cares (HMO)’ Formulary

The formulary below provides coverage information about the drugs covered by Leon Medical Centers Health Plans – Leon Cares (HMO). If you have trouble finding your drug in the list, turn to the Index that begins on page 107.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., EDARBI) and generic drugs are listed in lower-case italics (e.g., atenolol).

The information in the Requirements/Limits column tells you if Leon Medical Centers Health Plans – Leon Cares (HMO) has any special requirements for coverage of your drug.

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List of Abbreviations

#: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

EA: Each.

GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.

HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Member Services at 1-866-393-5366. Hours are from 8 a.m. to 8 p.m., seven days a week from October 1st through March 31st and Monday through Friday the rest of the year. TTY/TDD users should call 711.

NDS: Non-Extended Day Supply. This prescription drug is not available for an extended days' supply.

PA: Prior Authorization. Leon Medical Centers Health Plans – Leon Cares (HMO) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Leon Medical Centers Health Plans – Leon Cares (HMO) before you fill your prescriptions. If you don't get approval, Leon Medical Centers Health Plans – Leon Cares (HMO) may not cover the drug.

QL: Quantity Limit. For certain drugs, Leon Medical Centers Health Plans – Leon Cares (HMO) limits the amount of the drug that Leon Medical Centers Health Plans – Leon Cares (HMO) will cover. For example, Leon Medical Centers Health Plans – Leon Cares (HMO) provides 60 per prescription for AVANDIA TABS. This may be in addition to a standard one month or three month supply.

ST: Step Therapy. In some cases, Leon Medical Centers Health Plans – Leon Cares (HMO) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Leon Medical Centers Health Plans – Leon Cares (HMO) may not cover drug B unless you try Drug A first. If Drug A does not work for you, Leon Medical Centers Health Plans – Leon Cares (HMO) will then cover Drug B.

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Drug Tier and Cost – Share Table

Preferred retail cost-sharing (in-network)

(up to a 30-day supply)

Standard retail cost-sharing (in-network)


Preferred retail cost-sharing (in-network) (up to a 90-day supply)

Standard retail cost-sharing (in-network)


Cost-Sharing Tier 1

(generic and some brand drugs)

$0 copay $5 copay $0 copay $15 copay

Cost-Sharing Tier 2

(preferred brand) $0 copay $10 copay $0 copay $30 copay

Cost-Sharing Tier 3

(non-preferred drugs) $40 copay $50 copay $80 copay $150 copay

Cost-Sharing Tier 4

(specialty drugs) 33% coinsurance 33% coinsurance

A long-term supply is not available for drugs in tier 4

A long-term supply is not available for drugs in tier 4

Leon Medical Centers Health Plans' pharmacy network offers limited lower-cost, preferred pharmacies in urban and suburban Miami-Dade County, FL. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please contact our Member Services number at 305-559-5366 or toll-free 1-866-393-5366 for additional information. (TTY users should call 711). Hours are from 8 a.m. to 8 p.m., seven days a week from October 1st through March 31st and Monday through Friday the rest of the year. You may also consult the online pharmacy directory at LMChealthplans.com.

You can find information on what the symbols and abbreviations on this table mean by going to page 7.

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Drug Name Drug Tier Requirements/Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

ABELCET 2 HI

AMBISOME 2 HI

amphotericin b 1 GC; HI

caspofungin 4 HI; NDS

clotrimazole mucous membrane 1 GC

CRESEMBA 4 NDS

ERAXIS(WATER DILUENT) 2 HI

fluconazole 1 GC

fluconazole in nacl (iso-osm) intravenous

piggyback 200 mg/100 ml, 400 mg/200 ml

1 GC; HI

flucytosine 4 NDS

griseofulvin microsize 1 GC

griseofulvin ultramicrosize 1 GC

itraconazole oral capsule 1 GC

itraconazole oral solution 4 NDS

ketoconazole oral 1 GC

micafungin 1 GC; HI

MYCAMINE 2 HI

NOXAFIL ORAL 4 NDS

nystatin oral suspension 1 GC

nystatin oral tablet 1 GC

ORAVIG 2

posaconazole oral tablet,delayed release (dr/ec) 4 NDS

terbinafine hcl oral 1 GC

voriconazole intravenous 4 PA; NDS

voriconazole oral suspension for reconstitution 4 PA; NDS

voriconazole oral tablet 1 PA; GC

ANTIVIRALS

abacavir 1 GC

abacavir-lamivudine 1 GC

abacavir-lamivudine-zidovudine 4 NDS

acyclovir oral capsule 1 GC


10


acyclovir oral suspension 200 mg/5 ml 1 GC

acyclovir oral tablet 1 GC

acyclovir sodium intravenous solution 1 B/D PA; GC

adefovir 1 PA; GC

amantadine hcl 1 GC

APTIVUS 4 NDS

APTIVUS (WITH VITAMIN E) 2

atazanavir 1 GC

ATRIPLA 4 NDS

BARACLUDE ORAL SOLUTION 2

BIKTARVY 4 NDS

cidofovir 1 B/D PA; GC

CIMDUO 4 NDS

COMPLERA 4 NDS

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2

DELSTRIGO 4 NDS

DESCOVY 4 QL (30 EA per 30 days); NDS

didanosine oral capsule,delayed release(dr/ec)

250 mg, 400 mg

1 GC

DOVATO 4 QL (30 EA per 30 days); NDS

EDURANT 4 NDS

efavirenz oral capsule 1 GC

EFAVIRENZ ORAL TABLET 4 NDS

EMTRIVA 2

entecavir 1 GC

EPCLUSA 4 PA; QL (28 EA per 28 days); NDS

EPIVIR HBV ORAL SOLUTION 2

EVOTAZ 4 NDS

famciclovir 1 GC

fosamprenavir 4 NDS

FUZEON SUBCUTANEOUS RECON SOLN 4 QL (60 EA per 30 days); NDS

ganciclovir sodium 1 B/D PA; GC

GENVOYA 4 NDS

HARVONI ORAL PELLETS IN PACKET 33.75-

150 MG

4 PA; QL (28 EA per 28 days); NDS


11


HARVONI ORAL PELLETS IN PACKET 45-

200 MG


HARVONI ORAL TABLET 4 PA; QL (28 EA per 28 days); NDS

INTELENCE ORAL TABLET 100 MG, 200 MG 4 NDS

INTELENCE ORAL TABLET 25 MG 2

INVIRASE ORAL TABLET 4 NDS

ISENTRESS HD 4 NDS

ISENTRESS ORAL POWDER IN PACKET 2

ISENTRESS ORAL TABLET 4 NDS

ISENTRESS ORAL TABLET,CHEWABLE 2

JULUCA 4 NDS

KALETRA ORAL TABLET 100-25 MG 2

KALETRA ORAL TABLET 200-50 MG 4 NDS

lamivudine oral solution 1 GC

lamivudine oral tablet 100 mg 1 GC; QL (30 EA per 30 days)

lamivudine oral tablet 150 mg, 300 mg 1 GC

lamivudine-zidovudine 1 GC

LEXIVA ORAL SUSPENSION 2

lopinavir-ritonavir 1 GC

MAVYRET 4 PA; QL (84 EA per 28 days); NDS

nevirapine 1 GC

NORVIR ORAL POWDER IN PACKET 2

NORVIR ORAL SOLUTION 2

NORVIR ORAL TABLET 2

ODEFSEY 4 QL (30 EA per 30 days); NDS

oseltamivir 1 GC

PIFELTRO 4 NDS

PREZCOBIX 4 NDS

PREZISTA ORAL SUSPENSION 4 NDS

PREZISTA ORAL TABLET 150 MG, 75 MG 2

PREZISTA ORAL TABLET 600 MG, 800 MG 4 NDS

RELENZA DISKHALER 2

RETROVIR INTRAVENOUS 2

REYATAZ ORAL POWDER IN PACKET 4 NDS


12


ribavirin oral capsule 1 GC

ribavirin oral tablet 200 mg 1 GC

rimantadine 1 GC

ritonavir 1 GC

SELZENTRY ORAL SOLUTION 4 NDS

SELZENTRY ORAL TABLET 150 MG, 300 MG,

75 MG

4 NDS

SELZENTRY ORAL TABLET 25 MG 2

stavudine oral capsule 1 GC

STRIBILD 4 NDS

SYMFI 4 NDS

SYMFI LO 4 NDS

SYMTUZA 4 QL (30 EA per 30 days); NDS

SYNAGIS 4 PA; NDS

tenofovir disoproxil fumarate 1 GC

TIVICAY ORAL TABLET 10 MG 2

TIVICAY ORAL TABLET 25 MG, 50 MG 4 NDS

TIVICAY PD 4 QL (180 EA per 30 days); NDS

TRIUMEQ 4 QL (30 EA per 30 days); NDS

TROGARZO 4 NDS

TRUVADA 4 NDS

TYBOST 2

valacyclovir 1 GC

valganciclovir 4 NDS

VEMLIDY 4 NDS

VIRACEPT ORAL TABLET 4 NDS

VIREAD ORAL POWDER 4 NDS

VIREAD ORAL TABLET 150 MG, 200 MG, 250

MG

4 NDS

VOSEVI 4 PA; QL (30 EA per 30 days); NDS

XOFLUZA 2

zidovudine 1 GC

CEPHALOSPORINS

cefaclor oral capsule 1 GC


13


cefaclor oral suspension for reconstitution 125

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

1 GC

cefaclor oral tablet extended release 12 hr 1 GC

cefadroxil oral capsule 1 GC

cefadroxil oral suspension for reconstitution 250

mg/5 ml, 500 mg/5 ml

1 GC

cefadroxil oral tablet 1 GC

cefazolin 1 GC; HI

cefazolin in dextrose (iso-os) intravenous

piggyback 1 gram/50 ml

1 GC; HI

CEFAZOLIN IN DEXTROSE (ISO-OS)

INTRAVENOUS PIGGYBACK 2 GRAM/100

ML

2 HI

cefazolin in dextrose (iso-os) intravenous

piggyback 2 gram/50 ml

2 HI

cefdinir 1 GC

CEFEPIME IN DEXTROSE 5 % 1 GC; HI

cefepime in dextrose,iso-osm 1 GC; HI

cefepime injection 1 GC; HI

cefixime 1 GC

cefotetan 1 GC; HI

CEFOTETAN IN DEXTROSE, ISO-OSM 1 GC; HI

cefoxitin 1 GC; HI

cefoxitin in dextrose, iso-osm 1 GC; HI

cefpodoxime 1 GC

cefprozil 1 GC

ceftazidime 1 GC; HI

CEFTAZIDIME IN D5W 1 GC; HI

ceftriaxone in dextrose,iso-os 1 GC; HI

ceftriaxone injection recon soln 1 gram, 10 gram,

2 gram, 250 mg, 500 mg

1 GC; HI

CEFTRIAXONE INJECTION RECON SOLN

100 GRAM

1 GC; HI

ceftriaxone intravenous 1 GC; HI

cefuroxime axetil oral tablet 1 GC

cefuroxime sodium injection recon soln 750 mg 1 GC; HI


14


cefuroxime sodium intravenous 1 GC; HI

cephalexin 1 GC

SUPRAX ORAL CAPSULE 2

SUPRAX ORAL SUSPENSION FOR

RECONSTITUTION 500 MG/5 ML

2

SUPRAX ORAL TABLET,CHEWABLE 2

tazicef 1 GC; HI

TEFLARO 2 HI

ZERBAXA 2 HI

ERYTHROMYCINS / OTHER MACROLIDES

azithromycin intravenous 1 GC; HI

azithromycin oral 1 GC

clarithromycin 1 GC

DIFICID 4 NDS

e.e.s. 400 oral tablet 1 GC

ERYPED 400 4 NDS

ERY-TAB 2

erythromycin ethylsuccinate oral suspension for

reconstitution 200 mg/5 ml

1 GC

erythromycin ethylsuccinate oral suspension for

reconstitution 400 mg/5 ml

4 NDS

erythromycin ethylsuccinate oral tablet 1 GC

erythromycin oral tablet,delayed release (dr/ec) 1 GC

MISCELLANEOUS ANTIINFECTIVES

albendazole 4 NDS

ALINIA 4 NDS

amikacin injection solution 1,000 mg/4 ml, 500

mg/2 ml

1 GC; HI

ARIKAYCE 4 PA; NDS

ATOVAQUONE 2

atovaquone-proguanil 1 GC

aztreonam 1 GC; HI

bacitracin intramuscular 1 GC

BETHKIS 2 B/D PA; QL (280 ML per 28 days)

CAPASTAT 2 B/D PA


15


CAYSTON 4 NDS

chloramphenicol sod succinate 1 GC; HI

chloroquine phosphate 1 GC

clindamycin hcl 1 GC

CLINDAMYCIN IN 0.9 % SOD CHLOR

INTRAVENOUS PIGGYBACK 300 MG/50 ML,

900 MG/50 ML

1 GC; HI

CLINDAMYCIN IN 0.9 % SOD CHLOR

INTRAVENOUS PIGGYBACK 600 MG/50 ML

1 GC

clindamycin in 5 % dextrose 1 GC

clindamycin palmitate hcl 1 GC

clindamycin pediatric 1 GC

clindamycin phosphate injection 1 GC; HI

clindamycin phosphate intravenous solution 600

mg/4 ml

1 GC; HI

COARTEM 2

colistin (colistimethate na) 4 HI; NDS

CYCLOSERINE 1 GC

DALVANCE 4 HI; NDS

dapsone oral 1 GC

DAPTOMYCIN INTRAVENOUS RECON

SOLN 350 MG

4 HI; NDS

daptomycin intravenous recon soln 500 mg 4 HI; NDS

DARAPRIM 2

EMVERM 4 NDS

ertapenem 1 GC; HI

ethambutol 1 GC

FIRVANQ 2

gentamicin in nacl (iso-osm) intravenous

piggyback 100 mg/100 ml, 60 mg/50 ml, 80

mg/100 ml, 80 mg/50 ml

1 GC; HI

GENTAMICIN IN NACL (ISO-OSM)


1 GC; HI

GENTAMICIN IN NACL (ISO-OSM)


1 GC

gentamicin injection solution 40 mg/ml 1 GC; HI

gentamicin sulfate (ped) (pf) 1 GC; HI


16


hydroxychloroquine 1 GC

imipenem-cilastatin 1 GC; HI

isoniazid oral 1 GC

ivermectin oral 1 GC

lincomycin 1 GC; HI

linezolid in dextrose 5% 1 GC; HI

linezolid oral suspension for reconstitution 4 NDS

linezolid oral tablet 1 GC

linezolid-0.9% sodium chloride 1 GC; HI

mefloquine 1 GC

meropenem 1 GC; HI

MEROPENEM-0.9% SODIUM CHLORIDE 1 GC; HI

metro i.v. 1 GC; HI

metronidazole in nacl (iso-os) 1 GC; HI

metronidazole oral 1 GC

NEBUPENT 2 B/D PA

neomycin 1 GC

ORBACTIV 4 B/D PA; NDS

paromomycin 1 GC

PASER 2

PENTAM 2 B/D PA

pentamidine 1 B/D PA; GC

polymyxin b sulfate 1 GC; HI

praziquantel 1 GC

PRIFTIN 2

primaquine 1 GC

pyrazinamide 1 GC

pyrimethamine 1 GC; NDS

quinine sulfate 1 GC

rifabutin 1 GC

rifampin intravenous 1 B/D PA; GC

rifampin oral 1 GC

RIFATER 2

SIRTURO 4 NDS


17


SIVEXTRO INTRAVENOUS 4 HI; NDS

SIVEXTRO ORAL 4 PA; NDS

streptomycin 1 GC

SYNERCID 2 HI

TIGECYCLINE 4 HI; NDS

tinidazole 1 GC

TOBI PODHALER INHALATION CAPSULE,

W/INHALATION DEVICE

4 NDS

tobramycin in 0.225 % nacl 4 B/D PA; QL (280 ML per 28 days);

NDS

tobramycin sulfate 1 GC; HI

TRECATOR 2

VANCOMYCIN IN 0.9 % SODIUM CHL

INTRAVENOUS PIGGYBACK

2 HI

VANCOMYCIN IN DEXTROSE 5 %

INTRAVENOUS PIGGYBACK

2 HI

VANCOMYCIN INJECTION 1 GC; HI

vancomycin intravenous recon soln 1,000 mg, 10

gram, 5 gram, 500 mg, 750 mg

1 GC; HI

VANCOMYCIN INTRAVENOUS RECON

SOLN 1.25 GRAM, 250 MG

2 HI

VANCOMYCIN INTRAVENOUS RECON

SOLN 1.5 GRAM

2

vancomycin oral capsule 1 GC

vancomycin oral recon soln 1 GC

VANCOMYCIN-WATER INJECT (PEG)


ML, 1.5 GRAM/300 ML

2 HI

VANCOMYCIN-WATER INJECT (PEG)


ML, 500 MG/100 ML

2

XIFAXAN ORAL TABLET 200 MG 2

XIFAXAN ORAL TABLET 550 MG 4 NDS

PENICILLINS

amoxicillin oral capsule 1 GC

amoxicillin oral suspension for reconstitution 1 GC

amoxicillin oral tablet 1 GC


18


amoxicillin oral tablet,chewable 125 mg, 250 mg 1 GC

amoxicillin-pot clavulanate 1 GC

ampicillin oral capsule 500 mg 1 GC

ampicillin sodium 1 GC; HI

ampicillin-sulbactam 1 GC; HI

BICILLIN C-R 2

BICILLIN L-A 2

dicloxacillin 1 GC

nafcillin 1 GC; HI

nafcillin in dextrose iso-osm 1 GC; HI

OXACILLIN IN DEXTROSE(ISO-OSM) 2 HI

oxacillin injection 1 GC; HI

PENICILLIN G POT IN DEXTROSE 2 HI

penicillin g potassium 1 GC; HI

penicillin g procaine 1 GC

penicillin g sodium 1 GC; HI

penicillin v potassium 1 GC

PIPERACILLIN-TAZOBACTAM

INTRAVENOUS RECON SOLN 13.5 GRAM

1 GC; HI

piperacillin-tazobactam intravenous recon soln

2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

1 GC; HI

ZOSYN IN DEXTROSE (ISO-OSM) 2 HI

QUINOLONES

ciprofloxacin 1 GC

ciprofloxacin hcl oral 1 GC

ciprofloxacin in 5 % dextrose 1 GC; HI

levofloxacin in d5w 1 GC; HI

levofloxacin intravenous 1 GC

levofloxacin oral 1 GC

moxifloxacin oral 1 GC

MOXIFLOXACIN-SOD.ACE,SUL-WATER 1 GC; HI

moxifloxacin-sod.chloride(iso) 1 GC; HI

ofloxacin oral tablet 300 mg, 400 mg 1 GC

SULFA'S / RELATED AGENTS


19


sulfadiazine 1 GC

sulfamethoxazole-trimethoprim intravenous 1 GC; HI

sulfamethoxazole-trimethoprim oral 1 GC

sulfatrim 1 GC

TETRACYCLINES

demeclocycline 1 GC

doxy-100 1 GC; HI

doxycycline hyclate intravenous 1 GC; HI

doxycycline hyclate oral capsule 1 GC

doxycycline hyclate oral tablet 1 GC

doxycycline hyclate oral tablet,delayed release

(dr/ec) 100 mg, 150 mg, 75 mg

1 GC

doxycycline monohydrate oral capsule 1 GC

DOXYCYCLINE MONOHYDRATE ORAL

CAPSULE,IR - DELAY REL,BIPHASE

1 GC

doxycycline monohydrate oral suspension for

reconstitution

1 GC

doxycycline monohydrate oral tablet 1 GC

minocycline oral capsule 1 GC

minocycline oral tablet 1 GC

minocycline oral tablet extended release 24 hr 105

mg, 115 mg, 135 mg, 45 mg, 65 mg, 80 mg, 90 mg

1 GC

minocycline oral tablet extended release 24 hr 55

mg

4 NDS

mondoxyne nl oral capsule 100 mg, 75 mg 1 GC

morgidox 1 GC

NUZYRA INTRAVENOUS 4 QL (15 EA per 14 days); NDS

NUZYRA ORAL 4 QL (30 EA per 14 days); NDS

ORACEA 2

SOLODYN ORAL TABLET EXTENDED

RELEASE 24 HR 105 MG, 55 MG, 80 MG

4 NDS

tetracycline 1 GC

VIBRAMYCIN ORAL SYRUP 2

URINARY TRACT AGENTS

methenamine hippurate 1 GC

MONUROL 2


20


nitrofurantoin 1 GC

nitrofurantoin macrocrystal 1 GC

nitrofurantoin monohyd/m-cryst 1 GC

trimethoprim 1 GC

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

dexrazoxane hcl 1 GC; HI

ELITEK 4 B/D PA; NDS

ETHYOL 2 HI

FUSILEV 4 B/D PA; NDS

KEPIVANCE 4 B/D PA; NDS

leucovorin calcium injection recon soln 100 mg,

350 mg, 50 mg, 500 mg

1 GC; HI

leucovorin calcium injection recon soln 200 mg 1 GC

leucovorin calcium injection solution 10 mg/ml 1 GC; HI

leucovorin calcium oral 1 GC

levoleucovorin calcium intravenous recon soln 50

mg

4 B/D PA; NDS

levoleucovorin calcium intravenous solution 4 B/D PA; NDS

mesna 1 GC; HI

MESNEX ORAL 2

TOTECT INTRAVENOUS RECON SOLN 500

MG

3 HI

XGEVA 4 B/D PA; NDS

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

abiraterone 4 PA; NDS

ABRAXANE 4 B/D PA; NDS

adriamycin intravenous recon soln 10 mg 3

ADRIAMYCIN INTRAVENOUS RECON SOLN

50 MG

3

adriamycin intravenous solution 10 mg/5 ml, 2

mg/ml, 20 mg/10 ml

3

adriamycin intravenous solution 50 mg/25 ml 1 GC; HI

adrucil intravenous solution 2.5 gram/50 ml 1 B/D PA; GC; HI

AFINITOR DISPERZ 4 PA; NDS


21


AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5

MG

4 PA; NDS

afinitor oral tablet 7.5 mg 4 PA; NDS

ALECENSA 4 PA; QL (240 EA per 30 days); NDS

ALIMTA 4 B/D PA; NDS

ALIQOPA 4 B/D PA; NDS

ALKERAN (AS HCL) 3 HI

ALUNBRIG ORAL TABLET 180 MG, 90 MG 4 PA; QL (30 EA per 30 days); NDS

ALUNBRIG ORAL TABLET 30 MG 4 PA; QL (180 EA per 30 days); NDS

ALUNBRIG ORAL TABLETS,DOSE PACK 4 PA; QL (60 EA per 365 days); NDS

anastrozole 1 GC

ARRANON 2 HI

ARSENIC TRIOXIDE INTRAVENOUS

SOLUTION 1 MG/ML

1 B/D PA; GC

arsenic trioxide intravenous solution 2 mg/ml 1 B/D PA; GC

ARZERRA 4 B/D PA; NDS

ASTAGRAF XL 2 PA

AVASTIN 4 B/D PA; NDS

AYVAKIT 4 PA; QL (30 EA per 30 days); NDS

azacitidine 1 GC; HI

AZASAN 2 PA

azathioprine 1 PA; GC

azathioprine sodium 1 PA; GC

BALVERSA ORAL TABLET 3 MG 4 PA; QL (90 EA per 30 days); NDS



BAVENCIO 4 B/D PA; NDS

BELEODAQ 4 B/D PA; NDS

BENDEKA 4 B/D PA; NDS

BESPONSA 4 B/D PA; NDS

bexarotene 4 PA; NDS

bicalutamide 1 GC

BICNU 2 HI

bleomycin 1 B/D PA; GC; HI

BORTEZOMIB 4 B/D PA; NDS


22


BOSULIF 4 PA; NDS

BRAFTOVI 4 PA; QL (180 EA per 30 days); NDS

BRUKINSA 4 PA; NDS

busulfan 1 GC; HI

BUSULFEX 2 HI

CABOMETYX 4 PA; NDS

CALQUENCE 4 PA; QL (60 EA per 30 days); NDS

CAMPTOSAR INTRAVENOUS SOLUTION 100

MG/5 ML, 40 MG/2 ML

3 HI

CAPRELSA ORAL TABLET 100 MG 4 PA; QL (60 EA per 30 days); NDS

CAPRELSA ORAL TABLET 300 MG 4 PA; QL (30 EA per 30 days); NDS

carboplatin intravenous solution 1 GC; HI

carmustine 1 GC; HI

cisplatin intravenous solution 1 GC; HI

cladribine 1 B/D PA; GC; HI

clofarabine 1 GC; HI

COMETRIQ 4 PA; NDS

COPIKTRA 4 PA; NDS

COSMEGEN 4 B/D PA; NDS

COTELLIC 4 PA; QL (63 EA per 28 days); NDS

cyclophosphamide intravenous recon soln 4 B/D PA; NDS

cyclophosphamide oral capsule 1 B/D PA; GC

cyclosporine intravenous 1 PA; GC

cyclosporine modified 1 PA; GC

cyclosporine oral capsule 1 PA; GC

CYRAMZA 4 B/D PA; NDS

cytarabine 1 B/D PA; GC; HI

cytarabine (pf) injection solution 1 B/D PA; GC; HI

dacarbazine 1 GC; HI

dactinomycin 4 B/D PA; NDS

DARZALEX 4 B/D PA; NDS

DARZALEX FASPRO 4 PA; NDS

daunorubicin intravenous solution 1 GC; HI

DAURISMO ORAL TABLET 100 MG 4 PA; QL (30 EA per 30 days); NDS


23


DAURISMO ORAL TABLET 25 MG 4 PA; QL (60 EA per 30 days); NDS

decitabine 4 B/D PA; NDS

docetaxel intravenous solution 160 mg/16 ml (10

mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/ml (1 ml),

80 mg/4 ml (20 mg/ml)

4 B/D PA; NDS

docetaxel intravenous solution 20 mg/2 ml (10

mg/ml), 80 mg/8 ml (10 mg/ml)

1 B/D PA; GC

doxorubicin intravenous recon soln 50 mg 3

doxorubicin intravenous solution 10 mg/5 ml, 2

mg/ml, 20 mg/10 ml

1 GC

doxorubicin intravenous solution 50 mg/25 ml 1 GC; HI

doxorubicin, peg-liposomal 4 B/D PA; NDS

DROXIA 2

ELIGARD 2 B/D PA

ELIGARD (3 MONTH) 2 B/D PA



ELLENCE 3 HI

ELZONRIS 4 B/D PA; NDS

EMCYT 2

EMPLICITI 4 PA; NDS

ENHERTU 4 PA; NDS

ENVARSUS XR 2 PA

epirubicin intravenous solution 1 GC; HI

ERBITUX 4 B/D PA; NDS

ERIVEDGE 4 PA; QL (28 EA per 28 days); NDS

ERLEADA 4 PA; NDS

erlotinib 4 PA; NDS

ERWINAZE 4 B/D PA; NDS

ETOPOPHOS 2 HI

etoposide intravenous 1 GC; HI

everolimus (antineoplastic) 4 PA; NDS

everolimus (immunosuppressive) oral tablet 0.25

mg

2 PA

everolimus (immunosuppressive) oral tablet 0.5

mg, 0.75 mg

4 PA; NDS


24


EVOMELA 4 B/D PA; NDS

exemestane 1 GC

FARYDAK 4 PA; NDS

FASLODEX 4 B/D PA; NDS

FIRMAGON KIT W DILUENT SYRINGE

SUBCUTANEOUS RECON SOLN 120 MG

4 B/D PA; NDS

FIRMAGON KIT W DILUENT SYRINGE

SUBCUTANEOUS RECON SOLN 80 MG

2 B/D PA

fludarabine 1 GC; HI

fluorouracil intravenous 1 B/D PA; GC; HI

flutamide 1 GC

FOLOTYN 4 B/D PA; NDS

fulvestrant 4 B/D PA; NDS

GAZYVA 4 B/D PA; NDS

gemcitabine intravenous recon soln 1 GC; HI

gemcitabine intravenous solution 1 gram/26.3 ml

(38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200

mg/5.26 ml (38 mg/ml)

2 HI

GEMCITABINE INTRAVENOUS SOLUTION

100 MG/ML

4 HI; NDS

gengraf oral capsule 100 mg, 25 mg 1 PA; GC

gengraf oral solution 1 PA; GC

GILOTRIF 4 PA; NDS

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG,

40 MG

2

HALAVEN 4 B/D PA; NDS

HERCEPTIN HYLECTA 4 B/D PA; NDS

HERCEPTIN INTRAVENOUS RECON SOLN

150 MG

4 B/D PA; NDS

HERZUMA 4 B/D PA; NDS

hydroxyurea 1 GC

IBRANCE 4 PA; QL (21 EA per 28 days); NDS

ICLUSIG 4 PA; NDS

idarubicin 1 GC; HI

IDHIFA 4 PA; QL (30 EA per 30 days); NDS

ifosfamide 1 GC; HI


25


imatinib 1 PA; GC

IMBRUVICA ORAL CAPSULE 140 MG 4 PA; QL (120 EA per 30 days); NDS

IMBRUVICA ORAL CAPSULE 70 MG 4 PA; QL (30 EA per 30 days); NDS

IMBRUVICA ORAL TABLET 4 PA; QL (30 EA per 30 days); NDS

IMFINZI 4 B/D PA; NDS

INFUGEM 4 B/D PA; NDS

INLYTA ORAL TABLET 1 MG 4 PA; QL (180 EA per 30 days); NDS

INLYTA ORAL TABLET 5 MG 4 PA; QL (120 EA per 30 days); NDS

INREBIC 4 PA; QL (120 EA per 30 days); NDS

IRESSA 4 PA; QL (30 EA per 30 days); NDS

irinotecan 1 GC; HI

ISTODAX 4 B/D PA; NDS

IXEMPRA 4 B/D PA; NDS

JAKAFI 4 PA; QL (60 EA per 30 days); NDS

JEVTANA 4 B/D PA; NDS

KADCYLA 4 B/D PA; NDS

KANJINTI 4 B/D PA; NDS

KEYTRUDA INTRAVENOUS SOLUTION 4 B/D PA; NDS

KISQALI 4 PA; QL (63 EA per 28 days); NDS

KISQALI FEMARA CO-PACK ORAL TABLET

200 MG/DAY(200 MG X 1)-2.5 MG



400 MG/DAY(200 MG X 2)-2.5 MG



600 MG/DAY(200 MG X 3)-2.5 MG


KYPROLIS 4 B/D PA; NDS

LENVIMA 4 PA; NDS

letrozole 1 GC

LEUKERAN 2

leuprolide subcutaneous kit 1 B/D PA; GC

LIBTAYO 4 B/D PA; QL (7 ML per 21 days);

NDS

LONSURF ORAL TABLET 15-6.14 MG 4 PA; QL (100 EA per 28 days); NDS

LONSURF ORAL TABLET 20-8.19 MG 4 PA; QL (80 EA per 28 days); NDS

LORBRENA ORAL TABLET 100 MG 4 PA; QL (30 EA per 30 days); NDS


26


LORBRENA ORAL TABLET 25 MG 4 PA; QL (90 EA per 30 days); NDS

LUMOXITI 4 B/D PA; NDS

LUPRON DEPOT (3 MONTH) 4 B/D PA; NDS



LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT 3.75 MG

4 B/D PA; NDS

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT 7.5 MG

2 B/D PA

LUPRON DEPOT-PED (3 MONTH)

INTRAMUSCULAR SYRINGE KIT 11.25 MG

4 PA; NDS

LUPRON DEPOT-PED (3 MONTH)

INTRAMUSCULAR SYRINGE KIT 30 MG

4 B/D PA; NDS

LUPRON DEPOT-PED INTRAMUSCULAR KIT

11.25 MG, 15 MG

4 PA; NDS

LUPRON DEPOT-PED INTRAMUSCULAR KIT

7.5 MG (PED)

2 B/D PA

LYNPARZA ORAL TABLET 4 PA; QL (120 EA per 30 days); NDS

LYSODREN 2

MATULANE 4 NDS

megestrol oral suspension 400 mg/10 ml (10 ml),

400 mg/10 ml (40 mg/ml), 625 mg/5 ml (125

mg/ml)

1 GC

megestrol oral tablet 1 GC

MEKINIST 4 PA; NDS

MEKTOVI 4 PA; QL (180 EA per 30 days); NDS

melphalan 3 B/D PA

melphalan hcl 1 GC; HI

mercaptopurine 1 GC

methotrexate sodium 1 GC

methotrexate sodium (pf) 1 GC

mitomycin intravenous 1 GC; HI

mitoxantrone 1 GC; HI

MUTAMYCIN 3 HI

MVASI 4 B/D PA; NDS

mycophenolate mofetil 1 PA; GC


27


mycophenolate mofetil (hcl) 1 PA; GC

mycophenolate sodium 1 PA; GC

MYLOTARG 4 B/D PA; NDS

NAVELBINE 3 HI

NERLYNX 4 PA; NDS

NEXAVAR 4 PA; NDS

nilutamide 4 NDS

NINLARO 4 PA; QL (3 EA per 28 days); NDS

NIPENT 4 B/D PA; NDS

NUBEQA 4 PA; QL (120 EA per 30 days); NDS

NULOJIX 4 PA; NDS

octreotide acetate injection solution 1 PA; GC

ODOMZO 4 PA; QL (30 EA per 30 days); NDS

OGIVRI 4 B/D PA; NDS

ONCASPAR 4 B/D PA; NDS

ONIVYDE 4 PA; NDS

ONTRUZANT 4 B/D PA; NDS

OPDIVO 4 B/D PA; NDS

oxaliplatin 1 GC; HI

paclitaxel 1 GC; HI

PADCEV 4 PA; NDS

PEMAZYRE 4 PA; QL (14 EA per 21 days); NDS

PERJETA 4 B/D PA; NDS

PIQRAY 4 PA; NDS

POMALYST 4 PA; QL (21 EA per 28 days); NDS

PORTRAZZA 4 B/D PA; NDS

POTELIGEO 4 B/D PA; NDS

PROGRAF INTRAVENOUS 2 PA

PROGRAF ORAL GRANULES IN PACKET 2 PA

PURIXAN 2

QINLOCK 4 PA; NDS

RAPAMUNE ORAL SOLUTION 2 PA

RETEVMO 4 PA; NDS

REVLIMID 4 PA; NDS


28


RITUXAN 4 B/D PA; NDS

RITUXAN HYCELA 4 B/D PA; NDS

ROMIDEPSIN INTRAVENOUS SOLUTION 4 B/D PA; NDS

ROZLYTREK ORAL CAPSULE 100 MG 4 PA; QL (150 EA per 30 days); NDS

ROZLYTREK ORAL CAPSULE 200 MG 4 PA; QL (90 EA per 30 days); NDS

RUBRACA 4 PA; QL (120 EA per 30 days); NDS

RUXIENCE 4 B/D PA; NDS

RYDAPT 4 PA; NDS

SANDIMMUNE ORAL SOLUTION 2 PA

SANDOSTATIN LAR DEPOT

INTRAMUSCULAR SUSPENSION,EXTENDED

REL RECON

4 PA; NDS

SARCLISA 4 PA; NDS

SIGNIFOR 4 NDS

SIMULECT 4 B/D PA; NDS

sirolimus 1 PA; GC

SOLTAMOX 2

SOMATULINE DEPOT 4 PA; NDS

SPRYCEL 4 PA; NDS

STIVARGA 4 PA; QL (120 EA per 28 days); NDS

SUTENT 4 PA; NDS

SYNRIBO 4 PA; NDS

TABLOID 2

TABRECTA 4 PA; NDS

tacrolimus oral 1 PA; GC

TAFINLAR 4 PA; NDS

TAGRISSO 4 PA; QL (30 EA per 30 days); NDS

TALZENNA 4 PA; QL (90 EA per 30 days); NDS

tamoxifen 1 GC

TARGRETIN TOPICAL 4 QL (60 GM per 30 days); NDS

TASIGNA 4 PA; NDS

TAZVERIK 4 PA; NDS

TECENTRIQ 4 B/D PA; NDS

TEMODAR INTRAVENOUS 4 B/D PA; NDS

temsirolimus 4 B/D PA; NDS


29


THALOMID 4 PA; NDS

thiotepa 1 GC

TIBSOVO 4 PA; QL (60 EA per 30 days); NDS

toposar 1 GC; HI

topotecan intravenous recon soln 4 B/D PA; NDS

topotecan intravenous solution 4 mg/4 ml (1

mg/ml)

1 B/D PA; GC

toremifene 4 QL (30 EA per 30 days); NDS

TORISEL 4 B/D PA; NDS

TRAZIMERA 4 B/D PA; NDS

TREANDA INTRAVENOUS RECON SOLN 4 B/D PA; NDS

TRELSTAR INTRAMUSCULAR SUSPENSION

FOR RECONSTITUTION

4 B/D PA; NDS

tretinoin (antineoplastic) 4 NDS

TREXALL 2 B/D PA

TRIPTODUR 4 B/D PA; QL (1 EA per 168 days);

NDS

TRISENOX INTRAVENOUS SOLUTION 2

MG/ML

2 B/D PA

TRODELVY 4 PA; NDS

TRUXIMA 4 PA; NDS

TUKYSA ORAL TABLET 150 MG 4 PA; QL (120 EA per 30 days); NDS

TUKYSA ORAL TABLET 50 MG 4 PA; QL (300 EA per 30 days); NDS

TYKERB 4 PA; NDS

UNITUXIN 4 B/D PA; NDS

VECTIBIX 2 B/D PA; HI

VELCADE 4 B/D PA; NDS

VENCLEXTA ORAL TABLET 10 MG 2 PA; QL (60 EA per 30 days)

VENCLEXTA ORAL TABLET 100 MG 4 PA; QL (120 EA per 30 days); NDS

VENCLEXTA ORAL TABLET 50 MG 2 PA; QL (30 EA per 30 days)

VENCLEXTA STARTING PACK 4 PA; QL (84 EA per 365 days); NDS

VERZENIO 4 PA; QL (60 EA per 30 days); NDS

VIDAZA 3 HI

vinblastine intravenous solution 1 B/D PA; GC; HI

vincasar pfs intravenous solution 1 mg/ml 1 B/D PA; GC; HI


30


vincristine intravenous solution 1 mg/ml 1 B/D PA; GC; HI

vincristine intravenous solution 2 mg/2 ml 1 B/D PA; GC

vinorelbine 1 GC; HI

VITRAKVI ORAL CAPSULE 100 MG 4 PA; QL (60 EA per 30 days); NDS

VITRAKVI ORAL CAPSULE 25 MG 4 PA; QL (180 EA per 30 days); NDS

VITRAKVI ORAL SOLUTION 4 PA; QL (300 ML per 30 days); NDS

VIZIMPRO 4 PA; NDS

VOTRIENT 4 PA; NDS

VYXEOS 4 B/D PA; NDS

XALKORI 4 PA; QL (60 EA per 30 days); NDS

XATMEP 2 PA

XOSPATA 4 PA; QL (90 EA per 30 days); NDS

XPOVIO ORAL TABLET 100 MG/WEEK (20

MG X 5)



MG X 2), 60MG TWICE WEEK (120

MG/WEEK)

4 PA; NDS

XPOVIO ORAL TABLET 40MG TWICE WEEK

(80 MG/WEEK), 80 MG/WEEK (20 MG X 4)



MG X 3)


XPOVIO ORAL TABLET 80MG TWICE WEEK

(160 MG/WEEK)


XTANDI 4 PA; QL (120 EA per 30 days); NDS

YERVOY 4 B/D PA; NDS

YONDELIS 4 B/D PA; NDS

YONSA 4 PA; QL (120 EA per 30 days); NDS

ZALTRAP 4 B/D PA; NDS

ZANOSAR 2 B/D PA

ZEJULA 4 PA; QL (90 EA per 30 days); NDS

ZELBORAF 4 PA; QL (240 EA per 30 days); NDS

ZIRABEV 4 B/D PA; NDS

ZOLINZA 4 NDS

ZORTRESS ORAL TABLET 0.25 MG 2 PA

ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG,

1 MG

4 PA; NDS


31


ZYDELIG 4 PA; NDS

ZYKADIA ORAL TABLET 4 PA; NDS

ZYTIGA ORAL TABLET 500 MG 4 PA; NDS

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

APTIOM ORAL TABLET 200 MG 4 QL (180 EA per 30 days); NDS

APTIOM ORAL TABLET 400 MG 2 QL (90 EA per 30 days)

APTIOM ORAL TABLET 600 MG, 800 MG 2 QL (60 EA per 30 days)

BANZEL ORAL SUSPENSION 4 NDS

BANZEL ORAL TABLET 200 MG 2

BANZEL ORAL TABLET 400 MG 4 NDS

BRIVIACT INTRAVENOUS 4 QL (600 ML per 30 days); NDS

BRIVIACT ORAL SOLUTION 4 QL (600 ML per 30 days); NDS

BRIVIACT ORAL TABLET 4 QL (60 EA per 30 days); NDS

carbamazepine oral capsule, er multiphase 12 hr 1 GC

carbamazepine oral suspension 100 mg/5 ml 1 GC

carbamazepine oral tablet 1 GC

carbamazepine oral tablet extended release 12 hr 1 GC

carbamazepine oral tablet,chewable 1 GC

CELONTIN ORAL CAPSULE 300 MG 2

clobazam oral suspension 4 NDS

clobazam oral tablet 1 GC

clonazepam 1 GC

DIASTAT 2

DIASTAT ACUDIAL 2

diazepam rectal 1 GC

DILANTIN 30 MG 2

divalproex 1 GC

EPIDIOLEX 4 PA; NDS

epitol 1 GC

EQUETRO 3

ethosuximide 1 GC

felbamate oral suspension 4 NDS

felbamate oral tablet 1 GC


32


FYCOMPA ORAL SUSPENSION 2

FYCOMPA ORAL TABLET 2

gabapentin oral capsule 1 GC

gabapentin oral solution 1 GC

gabapentin oral tablet 600 mg, 800 mg 1 GC

LAMICTAL XR STARTER (BLUE) 3

LAMICTAL XR STARTER (GREEN) 3

LAMICTAL XR STARTER (ORANGE) 3

lamotrigine oral tablet 1 GC

lamotrigine oral tablet extended release 24hr 1 GC

lamotrigine oral tablet, chewable dispersible 1 GC

lamotrigine oral tablet,disintegrating 1 GC

lamotrigine oral tablets,dose pack 1 GC

levetiracetam in nacl (iso-os) 1 GC

levetiracetam intravenous 1 B/D PA; GC

levetiracetam oral 1 GC

LYRICA 3

LYRICA CR ORAL TABLET EXTENDED

RELEASE 24 HR 165 MG, 82.5 MG

2 QL (90 EA per 30 days)

LYRICA CR ORAL TABLET EXTENDED

RELEASE 24 HR 330 MG


NAYZILAM 4 PA; QL (10 EA per 30 days); NDS

oxcarbazepine 1 GC

OXTELLAR XR 3

PEGANONE 2

phenobarbital 1 GC

phenytoin oral suspension 1 GC

phenytoin oral tablet,chewable 1 GC

phenytoin sodium extended 1 GC

pregabalin 1 GC

primidone 1 GC

QUDEXY XR 3

roweepra 1 GC

roweepra xr 1 GC


33


SPRITAM ORAL TABLET FOR SUSPENSION

1,000 MG, 250 MG, 500 MG


SPRITAM ORAL TABLET FOR SUSPENSION

750 MG


SYMPAZAN 4 PA; QL (60 EA per 30 days); NDS

tiagabine 1 GC

topiramate 1 GC

TROKENDI XR ORAL CAPSULE,EXTENDED

RELEASE 24HR 100 MG, 25 MG, 50 MG


TROKENDI XR ORAL CAPSULE,EXTENDED

RELEASE 24HR 200 MG


valproic acid 1 GC

valproic acid (as sodium salt) oral solution 1 GC

VALTOCO 4 PA; QL (10 EA per 30 days); NDS

vigabatrin 4 NDS

vigadrone 4 NDS

VIMPAT INTRAVENOUS 2

VIMPAT ORAL SOLUTION 2

VIMPAT ORAL TABLET 2

XCOPRI 4 PA; NDS

XCOPRI MAINTENANCE PACK 4 PA; NDS

XCOPRI TITRATION PACK 3 PA

zonisamide 1 GC

ANTIPARKINSONISM AGENTS

APOKYN 4 B/D PA; NDS

benztropine 1 GC

bromocriptine 1 GC

carbidopa 1 GC

carbidopa-levodopa 1 GC

carbidopa-levodopa-entacapone 1 GC

DUOPA 2

entacapone 1 GC

NEUPRO 2

pramipexole 1 GC

rasagiline 1 GC


34


ropinirole 1 GC

RYTARY 2

selegiline hcl 1 GC

tolcapone 4 NDS

trihexyphenidyl 1 GC

ZELAPAR 2

MIGRAINE / CLUSTER HEADACHE THERAPY

AIMOVIG AUTOINJECTOR 2 PA; QL (1 ML per 30 days)

almotriptan malate 1 GC; QL (8 EA per 28 days)

dihydroergotamine 4 NDS

eletriptan 1 GC; QL (12 EA per 28 days)

ERGOMAR 2

ergotamine-caffeine 1 GC

frovatriptan 1 GC; QL (12 EA per 28 days)

migergot 4 NDS

naratriptan 1 GC; QL (18 EA per 28 days)

RELPAX 2 QL (12 EA per 28 days)

rizatriptan 1 GC; QL (36 EA per 28 days)

sumatriptan 3 QL (18 EA per 28 days)

sumatriptan succinate oral 1 GC; QL (18 EA per 28 days)

sumatriptan succinate subcutaneous cartridge 1 GC; QL (8 ML per 28 days)

sumatriptan succinate subcutaneous pen injector 1 GC; QL (8 ML per 28 days)

sumatriptan succinate subcutaneous solution 1 GC; QL (9 ML per 28 days)

sumatriptan succinate subcutaneous syringe 6

mg/0.5 ml

1 GC; QL (8 ML per 28 days)

zolmitriptan 1 GC; QL (8 EA per 28 days)

ZOMIG NASAL 2 QL (12 EA per 28 days)

MISCELLANEOUS NEUROLOGICAL THERAPY

AUSTEDO ORAL TABLET 12 MG, 9 MG 4 PA; QL (120 EA per 30 days); NDS

AUSTEDO ORAL TABLET 6 MG 4 PA; QL (60 EA per 30 days); NDS

dalfampridine 1 PA; GC; QL (60 EA per 30 days)

donepezil oral tablet 10 mg, 5 mg 1 GC

donepezil oral tablet 23 mg 1 GC; QL (30 EA per 30 days)

donepezil oral tablet,disintegrating 1 GC


35


FIRDAPSE 4 PA; NDS

galantamine 1 GC

GILENYA ORAL CAPSULE 0.5 MG 4 PA; QL (30 EA per 30 days); NDS

glatiramer subcutaneous syringe 20 mg/ml 4 PA; QL (30 ML per 30 days); NDS

GLATIRAMER SUBCUTANEOUS SYRINGE

40 MG/ML

4 PA; QL (12 ML per 28 days); NDS

glatopa subcutaneous syringe 20 mg/ml 4 PA; QL (30 ML per 30 days); NDS

GLATOPA SUBCUTANEOUS SYRINGE 40

MG/ML


HORIZANT 2

memantine oral capsule,sprinkle,er 24hr 1 PA; GC; QL (30 EA per 30 days)

memantine oral solution 1 PA; GC; QL (300 ML per 30 days)

memantine oral tablet 10 mg 1 PA; GC; QL (60 EA per 30 days)

memantine oral tablet 5 mg 1 PA; GC; QL (90 EA per 30 days)

memantine oral tablets,dose pack 1 PA; GC; QL (98 EA per 365 days)

NAMZARIC ORAL CAP,SPRINKLE,ER 24HR

DOSE PACK

3 PA; QL (56 EA per 365 days)

NAMZARIC ORAL CAPSULE,SPRINKLE,ER

24HR

3 PA; QL (30 EA per 30 days)

NUEDEXTA 2 PA

OCREVUS 4 PA; NDS

rivastigmine 1 GC

rivastigmine tartrate 1 GC

TECFIDERA ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 120 MG



RELEASE(DR/EC) 120 MG (14)- 240 MG (46)



RELEASE(DR/EC) 240 MG


tetrabenazine 4 PA; NDS

TYSABRI 4 PA; NDS

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY

baclofen intrathecal 1 B/D PA; GC

baclofen oral 1 GC

carisoprodol 1 PA; GC

carisoprodol-aspirin 1 PA; GC


36


carisoprodol-aspirin-codeine 1 PA; GC; NDS

chlorzoxazone oral tablet 375 mg, 500 mg, 750 mg 1 GC

cyclobenzaprine oral tablet 1 PA; GC

dantrolene oral 1 GC

GABLOFEN INTRATHECAL SOLUTION 2 B/D PA

LIORESAL 2 B/D PA

LORZONE 2

meprobamate 1 GC

MESTINON ORAL SYRUP 4 NDS

metaxalone 1 GC

methocarbamol oral 1 GC

orphenadrine citrate oral 1 GC

pyridostigmine bromide oral syrup 4 NDS

pyridostigmine bromide oral tablet 60 mg 1 GC

pyridostigmine bromide oral tablet extended

release

1 GC

regonol 2 B/D PA

tizanidine 1 GC

NARCOTIC ANALGESICS

acetaminophen-caff-dihydrocod oral capsule 1 GC; QL (300 EA per 30 days); NDS

acetaminophen-codeine oral solution 120 mg-12

mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg

/12.5 ml

1 GC; QL (2700 ML per 30 days); NDS

acetaminophen-codeine oral tablet 300-15 mg,

300-30 mg

1 GC; QL (360 EA per 30 days); NDS

acetaminophen-codeine oral tablet 300-60 mg 1 GC; QL (180 EA per 30 days); NDS

ascomp with codeine 1 GC; QL (180 EA per 30 days)

bupap oral tablet 50-300 mg 1 GC

buprenorphine 1 GC; QL (4 EA per 28 days); NDS

buprenorphine hcl injection solution 1 B/D PA; GC; QL (150 ML per 30

days)

buprenorphine hcl injection syringe 1 B/D PA; GC; QL (150 ML per 30

days); NDS

buprenorphine hcl sublingual 1 GC

butalbital compound w/codeine 1 GC; QL (180 EA per 30 days)

butalbital-acetaminop-caf-cod 1 GC; QL (180 EA per 30 days)


37


butalbital-acetaminophen oral tablet 50-300 mg,

50-325 mg

1 GC

butalbital-acetaminophen-caff oral capsule 1 GC

butalbital-acetaminophen-caff oral tablet 50-325-

40 mg

1 GC

butalbital-aspirin-caffeine oral capsule 1 GC

codeine sulfate oral tablet 15 mg 1 GC; QL (720 EA per 30 days); NDS



DURAMORPH (PF) 3 HI; NDS

endocet oral tablet 10-325 mg 1 GC; QL (180 EA per 30 days); NDS

endocet oral tablet 2.5-325 mg, 5-325 mg 1 GC; QL (360 EA per 30 days); NDS

endocet oral tablet 7.5-325 mg 1 GC; QL (240 EA per 30 days); NDS

fentanyl citrate (pf) injection solution 1 B/D PA; GC; NDS

fentanyl citrate (pf) intravenous syringe 100 mcg/2

ml (50 mcg/ml)

1 B/D PA; GC; NDS

fentanyl citrate buccal lozenge on a handle 1,200

mcg, 1,600 mcg, 800 mcg


fentanyl citrate buccal lozenge on a handle 200

mcg, 400 mcg, 600 mcg

1 PA; GC; QL (120 EA per 30 days);

NDS

fentanyl citrate buccal tablet, effervescent 4 PA; QL (120 EA per 30 days); NDS

fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr,

75 mcg/hr


fentanyl transdermal patch 72 hour 62.5

mcg/hour, 87.5 mcg/hour

4 QL (10 EA per 30 days); NDS

hydrocodone bitartrate 3 PA; QL (60 EA per 30 days); NDS

hydrocodone-acetaminophen oral solution 10-325

mg/15 ml(15 ml), 7.5-325 mg/15 ml

1 GC; QL (2700 ML per 30 days); NDS

hydrocodone-acetaminophen oral tablet 10-300

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


hydrocodone-acetaminophen oral tablet 5-300 mg,

5-325 mg


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

200 mg, 7.5-200 mg


hydromorphone (pf) injection solution 10 (mg/ml)

(5 ml), 10 mg/ml

1 B/D PA; GC; QL (120 ML per 30

days); NDS

hydromorphone (pf) injection solution 2 mg/ml 1 B/D PA; GC; NDS


38


hydromorphone injection solution 2 mg/ml 1 GC; NDS

hydromorphone injection syringe 1 mg/ml, 2

mg/ml

1 GC; NDS

hydromorphone injection syringe 4 mg/ml 1 B/D PA; GC; QL (360 ML per 30

days); NDS

hydromorphone oral liquid 1 GC; QL (1200 ML per 30 days); NDS

hydromorphone oral tablet 2 mg, 4 mg 1 GC; QL (180 EA per 30 days); NDS

hydromorphone oral tablet 8 mg 1 GC; QL (120 EA per 30 days); NDS

hydromorphone oral tablet extended release 24 hr

12 mg


hydromorphone oral tablet extended release 24 hr

16 mg, 32 mg, 8 mg


ibuprofen-oxycodone 1 GC; QL (28 EA per 30 days); NDS

INFUMORPH P/F 2 B/D PA; QL (200 ML per 30 days);

NDS

KADIAN ORAL CAPSULE,EXTEND.RELEASE

PELLETS 200 MG


KADIAN ORAL CAPSULE,EXTEND.RELEASE

PELLETS 40 MG


lorcet (hydrocodone) 1 GC; QL (360 EA per 30 days); NDS

lorcet hd 1 GC; QL (180 EA per 30 days); NDS

lorcet plus oral tablet 7.5-325 mg 1 GC; QL (180 EA per 30 days); NDS

meperidine (pf) injection solution 100 mg/ml 1 B/D PA; GC; QL (360 ML per 30

days); NDS


days); NDS


days); NDS

meperidine oral solution 1 GC; QL (900 ML per 30 days); NDS

meperidine oral tablet 1 GC; QL (180 EA per 30 days); NDS

methadone injection solution 1 B/D PA; GC; QL (150 ML per 30

days); NDS

methadone intensol 1 GC; QL (500 ML per 30 days); NDS

methadone oral concentrate 1 GC; QL (500 ML per 30 days); NDS

methadone oral solution 10 mg/5 ml 1 GC; QL (450 ML per 30 days); NDS

methadone oral solution 5 mg/5 ml 1 GC; QL (600 ML per 30 days); NDS

methadone oral tablet 10 mg 1 GC; QL (120 EA per 30 days); NDS


39


methadone oral tablet 5 mg 1 GC; QL (180 EA per 30 days); NDS

MITIGO (PF) 1 B/D PA; GC; QL (200 ML per 30

days); NDS

morphine (pf) injection solution 0.5 mg/ml, 1

mg/ml

1 GC; HI; NDS

morphine concentrate oral solution 1 GC; QL (240 ML per 30 days); NDS

MORPHINE INJECTION SOLUTION 10

MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML

2 NDS

morphine injection solution 8 mg/ml 2 NDS

morphine injection syringe 10 mg/ml, 4 mg/ml, 8

mg/ml

1 GC; HI; NDS

MORPHINE INJECTION SYRINGE 2 MG/ML 1 GC; HI; NDS

morphine injection syringe 5 mg/ml 2 HI; NDS

morphine intravenous solution 10 mg/ml 2 NDS

MORPHINE INTRAVENOUS SOLUTION 4

MG/ML, 8 MG/ML

2 NDS

MORPHINE INTRAVENOUS SYRINGE 10

MG/ML, 8 MG/ML

1 GC; HI; NDS

morphine intravenous syringe 2 mg/ml 2 HI; NDS

morphine intravenous syringe 4 mg/ml 1 GC; HI; NDS

morphine oral capsule, er multiphase 24 hr 1 GC; QL (60 EA per 30 days); NDS

morphine oral capsule,extend.release pellets 10

mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg


morphine oral capsule,extend.release pellets 40

mg


morphine oral solution 10 mg/5 ml 1 GC; QL (700 ML per 30 days); NDS

morphine oral solution 20 mg/5 ml (4 mg/ml) 1 GC; QL (900 ML per 30 days); NDS

morphine oral tablet 1 GC; QL (120 EA per 30 days); NDS

morphine oral tablet extended release 1 GC; QL (90 EA per 30 days); NDS

oxycodone oral capsule 1 GC; QL (120 EA per 30 days); NDS

oxycodone oral concentrate 1 GC; QL (120 ML per 30 days); NDS

oxycodone oral solution 1 GC; QL (1200 ML per 30 days); NDS

oxycodone oral tablet 1 GC; QL (180 EA per 30 days); NDS

oxycodone oral tablet,oral only,ext.rel.12 hr 1 GC; QL (60 EA per 30 days); NDS

oxycodone-acetaminophen oral tablet 10-325 mg 1 GC; QL (180 EA per 30 days); NDS

oxycodone-acetaminophen oral tablet 2.5-300 mg 1 GC; NDS


40


oxycodone-acetaminophen oral tablet 2.5-325 mg,

5-325 mg


oxycodone-acetaminophen oral tablet 7.5-325 mg 1 GC; QL (240 EA per 30 days); NDS

oxycodone-aspirin 1 GC; QL (180 EA per 30 days); NDS

oxymorphone oral tablet 1 GC; QL (180 EA per 30 days); NDS

oxymorphone oral tablet extended release 12 hr 10

mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg


oxymorphone oral tablet extended release 12 hr 40

mg


pentazocine-naloxone 1 GC; QL (360 EA per 30 days); NDS

PRIMLEV 3 QL (360 EA per 30 days); NDS

SUBSYS 4 PA; QL (120 EA per 30 days); NDS

tencon oral tablet 50-325 mg 1 GC

VANATOL LQ 2

vtol lq 1 GC

XTAMPZA ER 2 QL (60 EA per 30 days); NDS

zebutal oral capsule 50-325-40 mg 1 GC

ZOHYDRO ER CAPSULE, ORAL ONLY, ER

12HR


NON-NARCOTIC ANALGESICS

buprenorphine-naloxone sublingual film 12-3 mg 1 GC; QL (60 EA per 30 days)

buprenorphine-naloxone sublingual film 2-0.5 mg,

4-1 mg, 8-2 mg

1 GC; QL (90 EA per 30 days)

buprenorphine-naloxone sublingual tablet 1 GC; QL (90 EA per 30 days)

butorphanol injection solution 1 mg/ml 1 GC; QL (480 ML per 30 days); NDS

butorphanol injection solution 2 mg/ml 1 GC; QL (240 ML per 30 days); NDS

butorphanol nasal 1 GC; QL (5 ML per 30 days); NDS

CAMBIA 3

celecoxib 1 GC

diclofenac epolamine 1 PA; GC

diclofenac potassium 1 GC

diclofenac sodium oral 1 GC

diclofenac sodium topical drops 1 GC

diclofenac sodium topical gel 1 % 1 GC; QL (1000 GM per 30 days)

diclofenac-misoprostol 1 GC


41


diflunisal 1 GC

ec-naproxen 1 GC

etodolac 1 GC

fenoprofen oral capsule 400 mg 1 GC

fenoprofen oral tablet 1 GC

FLECTOR 3 PA

flurbiprofen oral tablet 100 mg 1 GC

ibu 1 GC

ibuprofen oral suspension 1 GC

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

INDOCIN ORAL 3

indomethacin oral 1 GC

ketoprofen oral capsule,ext rel. pellets 24 hr 200

mg

1 GC

KETOROLAC NASAL 2

ketorolac oral 1 GC

meclofenamate 1 GC

mefenamic acid 1 GC

meloxicam oral tablet 1 GC

nabumetone 1 GC

nalbuphine injection solution 10 mg/ml 1 B/D PA; GC; QL (180 ML per 30

days); NDS

nalbuphine injection solution 20 mg/ml 1 B/D PA; GC; QL (90 ML per 30

days); NDS

naloxone injection solution 1 GC

naloxone injection syringe 1 mg/ml 1 GC

naltrexone 1 GC

NAPRELAN CR ORAL TABLET, ER

MULTIPHASE 24 HR 750 MG

3

naproxen 1 GC

naproxen sodium oral tablet 275 mg, 550 mg 1 GC

naproxen sodium oral tablet, er multiphase 24 hr 1 GC

NARCAN NASAL SPRAY,NON-AEROSOL 4

MG/ACTUATION


NUCYNTA 2 QL (180 EA per 30 days); NDS

NUCYNTA ER 2 QL (60 EA per 30 days); NDS


42


oxaprozin 1 GC

piroxicam 1 GC

salsalate 1 GC

SPRIX 2

sulindac 1 GC

TIVORBEX 3

tolmetin 1 GC

tramadol oral capsule,er biphase 24 hr 17-83 1 GC; QL (30 EA per 30 days); NDS

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

mg, 200 mg


tramadol oral tablet 100 mg 1 GC; QL (120 EA per 30 days)

tramadol oral tablet 50 mg 1 GC; QL (240 EA per 30 days); NDS

tramadol oral tablet extended release 24 hr 1 GC; QL (30 EA per 30 days); NDS

tramadol oral tablet, er multiphase 24 hr 100 mg,

200 mg


tramadol-acetaminophen 1 GC; QL (240 EA per 30 days); NDS

VIVITROL 4 B/D PA; NDS

ZIPSOR 3

ZORVOLEX 3

ZUBSOLV SUBLINGUAL TABLET 0.7-0.18

MG, 11.4-2.9 MG


ZUBSOLV SUBLINGUAL TABLET 1.4-0.36

MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG


PSYCHOTHERAPEUTIC DRUGS

ABILIFY MAINTENA 4 QL (1 EA per 28 days); NDS

ADZENYS XR-ODT 3

alprazolam 1 GC

ALPRAZOLAM INTENSOL 2

amitriptyline 1 GC

amitriptyline-chlordiazepoxide 1 GC

amoxapine 1 GC

amphetamine sulfate 1 GC

APLENZIN 4 NDS

APTENSIO XR 3

aripiprazole 1 GC


43


ARISTADA INITIO 4 QL (4.8 ML per 365 days); NDS

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 1,064

MG/3.9 ML

4 QL (3.9 ML per 56 days); NDS


SUSPENSION,EXTENDED REL SYRING 441

MG/1.6 ML




MG/2.4 ML




MG/3.2 ML


armodafinil 1 PA; GC

atomoxetine 1 GC

BELSOMRA 2

BRISDELLE 2 QL (30 EA per 30 days)

bupropion hcl 1 GC

buspirone 1 GC

CAPLYTA 4 ST; QL (30 EA per 30 days); NDS

chlordiazepoxide hcl 1 GC

chlorpromazine 1 GC

citalopram 1 GC

clomipramine 1 GC

clonidine hcl oral tablet extended release 12 hr 1 GC

clorazepate dipotassium oral tablet 15 mg, 3.75

mg


clorazepate dipotassium oral tablet 7.5 mg 1 GC; QL (360 EA per 30 days)

clozapine 1 GC

DAYTRANA 2

desipramine 1 GC

desvenlafaxine oral tablet extended release 24 hr 1 ST; GC

desvenlafaxine succinate 1 ST; GC

dexmethylphenidate 1 GC

dextroamphetamine 1 GC

dextroamphetamine-amphetamine 1 GC

diazepam injection syringe 1 GC


44


diazepam intensol 1 GC

diazepam oral concentrate 1 GC

DIAZEPAM ORAL SOLUTION 5 MG/5 ML (1

MG/ML)

2

diazepam oral tablet 1 GC

doxepin oral 1 GC

DRIZALMA SPRINKLE ORAL CAPSULE,

DELAYED REL SPRINKLE 20 MG



DELAYED REL SPRINKLE 30 MG, 40 MG



DELAYED REL SPRINKLE 60 MG


duloxetine 1 GC

EDLUAR 2

EMSAM 4 NDS

ergoloid 1 GC

escitalopram oxalate 1 GC

estazolam 1 GC

eszopiclone 1 GC

EVEKEO 2

FANAPT ORAL TABLET 4 NDS

FANAPT ORAL TABLETS,DOSE PACK 3

FETZIMA ORAL CAPSULE,EXT REL 24HR

DOSE PACK

2 ST; QL (56 EA per 365 days)

FETZIMA ORAL CAPSULE,EXTENDED

RELEASE 24 HR


fluoxetine oral capsule 1 GC

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

fluoxetine oral solution 1 GC

fluoxetine oral tablet 10 mg, 20 mg 1 GC

fluphenazine decanoate 1 GC

fluphenazine hcl 1 GC

flurazepam 1 GC

fluvoxamine oral capsule,extended release 24hr 1 GC; QL (60 EA per 30 days)

fluvoxamine oral tablet 1 GC

FORFIVO XL 2


45


GEODON INTRAMUSCULAR 2

guanfacine oral tablet extended release 24 hr 1 GC

guanidine 1 GC

HALDOL DECANOATE 3

haloperidol 1 GC

haloperidol decanoate 1 GC

haloperidol lactate injection 1 GC

haloperidol lactate oral 1 GC

HETLIOZ 4 PA; QL (30 EA per 30 days); NDS

imipramine hcl 1 GC

imipramine pamoate 1 GC

INVEGA SUSTENNA INTRAMUSCULAR

SYRINGE 117 MG/0.75 ML



SYRINGE 156 MG/ML

4 QL (1 ML per 28 days); NDS






2 QL (0.25 ML per 28 days)



2 QL (0.5 ML per 28 days)

INVEGA TRINZA INTRAMUSCULAR












LATUDA 4 NDS

lithium carbonate 1 GC

lithium citrate oral solution 8 meq/5 ml 1 GC

lorazepam injection syringe 1 GC

lorazepam intensol 1 GC

lorazepam oral concentrate 1 GC

lorazepam oral tablet 1 GC

loxapine succinate 1 GC


46


maprotiline 1 GC

MARPLAN 2

methamphetamine 3 PA

methylphenidate hcl oral cap,er sprinkle,biphasic

40-60

1 GC

methylphenidate hcl oral capsule, er biphasic 30-

70

1 GC

methylphenidate hcl oral capsule,er biphasic 50-

50 10 mg, 20 mg, 40 mg, 60 mg

1 GC

methylphenidate hcl oral solution 1 GC

methylphenidate hcl oral tablet 1 GC

methylphenidate hcl oral tablet extended release 1 GC

methylphenidate hcl oral tablet extended release

24hr 18 mg, 18 mg (bx rating), 27 mg, 27 mg (bx

rating), 36 mg, 36 mg (bx rating), 54 mg, 54 mg

(bx rating)

1 GC

methylphenidate hcl oral tablet,chewable 1 GC

mirtazapine 1 GC

modafinil 1 PA; GC

molindone 1 GC

nefazodone 1 GC

nortriptyline 1 GC

NUPLAZID ORAL CAPSULE 4 PA; QL (30 EA per 30 days); NDS

NUPLAZID ORAL TABLET 10 MG 4 PA; QL (30 EA per 30 days); NDS

olanzapine 1 GC

olanzapine-fluoxetine 3

oxazepam 1 GC

paliperidone 1 GC

paroxetine hcl oral tablet 1 GC

paroxetine hcl oral tablet extended release 24 hr 1 GC

paroxetine mesylate(menop.sym) 1 GC; QL (30 EA per 30 days)

PAXIL ORAL SUSPENSION 2 ST

perphenazine 1 GC

perphenazine-amitriptyline 1 GC

PERSERIS 4 NDS

phenelzine 1 GC


47


pimozide 1 GC

protriptyline 1 GC

quetiapine 1 GC

QUILLIVANT XR 2

ramelteon 1 GC

REXULTI 4 NDS

RISPERDAL CONSTA INTRAMUSCULAR

SUSPENSION,EXTENDED REL RECON 12.5

MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML


RISPERDAL CONSTA INTRAMUSCULAR

SUSPENSION,EXTENDED REL RECON 50

MG/2 ML


risperidone oral solution 1 GC

risperidone oral tablet 1 GC

risperidone oral tablet,disintegrating 1 GC

RITALIN LA ORAL CAPSULE,ER BIPHASIC

50-50 10 MG

2

SAPHRIS 2 QL (60 EA per 30 days)

SECUADO 3 QL (30 EA per 30 days)

sertraline 1 GC

SILENOR 2

temazepam 1 GC

thioridazine 1 GC

thiothixene 1 GC

tranylcypromine 1 GC

trazodone 1 GC

triazolam 1 GC

trifluoperazine 1 GC

trimipramine 1 GC

TRINTELLIX 2 ST; QL (30 EA per 30 days)

venlafaxine 1 GC

VERSACLOZ 2

VIIBRYD ORAL TABLET 2 ST; QL (30 EA per 30 days)

VIIBRYD ORAL TABLETS,DOSE PACK 10

MG (7)- 20 MG (23)


VRAYLAR ORAL CAPSULE 4 NDS


48


VRAYLAR ORAL CAPSULE,DOSE PACK 2

VYVANSE 2

XYREM 4 NDS

zaleplon 1 GC

zenzedi oral tablet 10 mg, 5 mg 3

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20

MG, 30 MG, 7.5 MG

3

ziprasidone hcl 1 GC

ziprasidone mesylate 1 GC; NDS

zolpidem 1 GC

ZOLPIMIST 2

ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION 210

MG




MG




MG


CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone intravenous solution 1 B/D PA; GC

amiodarone oral 1 GC

dofetilide 1 GC

flecainide 1 GC

lidocaine (pf) intravenous syringe 100 mg/5 ml (2

%)

1 GC

lidocaine (pf) intravenous syringe 50 mg/5 ml (1

%)

1 B/D PA; GC

mexiletine 1 GC

MULTAQ 2

NEXTERONE 2 B/D PA

NORPACE CR 2

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

procainamide injection 1 B/D PA; GC

propafenone 1 GC


49


quinidine gluconate oral 1 GC

quinidine sulfate oral tablet 1 GC

sorine 1 GC

sotalol af 1 GC

sotalol oral 1 GC

SOTYLIZE 2

ANTIHYPERTENSIVE THERAPY

acebutolol 1 GC

ALDACTAZIDE ORAL TABLET 50-50 MG 2

aliskiren 1 GC

amiloride 1 GC

amiloride-hydrochlorothiazide 1 GC

amlodipine 1 GC

amlodipine-benazepril 1 GC

amlodipine-olmesartan 1 GC

amlodipine-valsartan 1 GC

amlodipine-valsartan-hcthiazid 1 GC

atenolol 1 GC

atenolol-chlorthalidone 1 GC

benazepril 1 GC

benazepril-hydrochlorothiazide 1 GC

betaxolol oral 1 GC

BIDIL 2

bisoprolol fumarate 1 GC

bisoprolol-hydrochlorothiazide 1 GC

bumetanide injection 1 GC; HI

bumetanide oral 1 GC

BYSTOLIC 2

candesartan oral tablet 16 mg, 4 mg, 8 mg 1 GC; QL (60 EA per 30 days)

candesartan oral tablet 32 mg 1 GC; QL (30 EA per 30 days)

candesartan-hydrochlorothiazid 1 GC

captopril 3

captopril-hydrochlorothiazide 3

CARDENE IV IN SODIUM CHLORIDE 2


50


CARDIZEM LA ORAL TABLET EXTENDED

RELEASE 24 HR 120 MG

2

CARDURA XL 2

cartia xt 1 GC

carvedilol 1 GC

carvedilol phosphate 1 ST; GC

chlorothiazide oral tablet 500 mg 1 GC

chlorothiazide sodium 1 GC; HI

chlorthalidone oral tablet 25 mg, 50 mg 1 GC

clonidine 1 GC

clonidine hcl oral tablet 1 GC

DEMSER 2

diltiazem hcl intravenous 1 B/D PA; GC

diltiazem hcl oral capsule,extended release 12 hr 1 GC

diltiazem hcl oral capsule,extended release 24 hr 1 GC

diltiazem hcl oral capsule,extended release 24hr 1 GC

diltiazem hcl oral tablet 1 GC

diltiazem hcl oral tablet extended release 24 hr 1 GC

dilt-xr 1 GC

DIURIL 2

doxazosin 1 GC

DUTOPROL 2

DYRENIUM 2

EDARBI 2 QL (30 EA per 30 days)

EDARBYCLOR 2

enalapril maleate 1 GC

enalapril-hydrochlorothiazide 1 GC

EPANED ORAL SOLUTION 2

eplerenone 1 GC

eprosartan 1 GC

ethacrynate sodium 4 B/D PA; NDS

ethacrynic acid 1 GC

felodipine 1 GC

fosinopril 1 GC


51


fosinopril-hydrochlorothiazide 1 GC

furosemide injection 1 GC; HI

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

mg/ml)

1 GC

furosemide oral tablet 1 GC

guanfacine oral tablet 1 GC

hydralazine injection 1 B/D PA; GC

hydralazine oral 1 GC

hydrochlorothiazide 1 GC

indapamide 1 GC

irbesartan 1 GC

irbesartan-hydrochlorothiazide 1 GC

isradipine 1 GC

labetalol intravenous solution 1 B/D PA; GC

labetalol oral 1 GC

lisinopril 1 GC

lisinopril-hydrochlorothiazide 1 GC

losartan 1 GC

losartan-hydrochlorothiazide 1 GC

mannitol 20 % 3

mannitol 25 % intravenous solution 3

matzim la 1 GC

methyldopa 1 GC

methyldopa-hydrochlorothiazide 1 GC

metolazone 1 GC

metoprolol succinate 1 GC

metoprolol ta-hydrochlorothiaz 1 GC

metoprolol tartrate intravenous 1 B/D PA; GC

metoprolol tartrate oral 1 GC

minoxidil oral 1 GC

moexipril 1 GC

nadolol 1 GC

nadolol-bendroflumethiazide oral tablet 80-5 mg 1 GC

nicardipine intravenous solution 1 GC


52


nicardipine oral 1 GC

nifedipine 1 GC

nimodipine 1 GC

nisoldipine 1 GC

olmesartan 1 GC

olmesartan-amlodipin-hcthiazid 1 GC

olmesartan-hydrochlorothiazide 1 GC

ORENITRAM ORAL TABLET EXTENDED

RELEASE 0.125 MG, 0.25 MG

2 PA

ORENITRAM ORAL TABLET EXTENDED

RELEASE 1 MG, 2.5 MG, 5 MG

4 PA; NDS

OSMITROL 10 % 3

osmitrol 15 % 3

osmitrol 20 % 3

OSMITROL 5 % 3

perindopril erbumine 1 GC

phenoxybenzamine 4 NDS

pindolol 1 GC

prazosin 1 GC

propranolol intravenous 1 B/D PA; GC

propranolol oral 1 GC

propranolol-hydrochlorothiazid 1 GC

quinapril 1 GC

quinapril-hydrochlorothiazide 1 GC

ramipril 1 GC

REMODULIN 4 B/D PA; NDS

spironolactone 1 GC

spironolacton-hydrochlorothiaz 1 GC

taztia xt 1 GC

TEKTURNA HCT 2

telmisartan oral tablet 20 mg, 40 mg 1 GC; QL (30 EA per 30 days)

telmisartan oral tablet 80 mg 1 GC; QL (60 EA per 30 days)

telmisartan-amlodipine 1 GC

telmisartan-hydrochlorothiazid oral tablet 40-12.5

mg, 80-25 mg



53


telmisartan-hydrochlorothiazid oral tablet 80-12.5

mg


terazosin 1 GC

tiadylt er 1 GC

timolol maleate oral 1 GC

torsemide oral 1 GC

trandolapril 1 GC

trandolapril-verapamil 1 GC

treprostinil sodium 4 B/D PA; NDS

triamterene 1 GC

triamterene-hydrochlorothiazid oral capsule 37.5-

25 mg

1 GC

triamterene-hydrochlorothiazid oral tablet 1 GC

UPTRAVI 4 PA; NDS

valsartan oral tablet 160 mg, 40 mg, 80 mg 1 GC; QL (60 EA per 30 days)

valsartan oral tablet 320 mg 1 GC; QL (30 EA per 30 days)

valsartan-hydrochlorothiazide 1 GC; QL (30 EA per 30 days)

verapamil intravenous solution 1 B/D PA; GC

verapamil oral 1 GC

COAGULATION THERAPY

aminocaproic acid oral 3

ARGATROBAN 4 B/D PA; NDS

ARGATROBAN IN 0.9 % SOD CHLOR

INTRAVENOUS SOLUTION

4 B/D PA; NDS

aspirin-dipyridamole 1 GC; QL (60 EA per 30 days)

BRILINTA 2

cilostazol 1 GC

clopidogrel 1 GC

dipyridamole oral 1 GC

EDEX INTRACAVERNOSAL KIT 10 MCG 1 GC; #; QL (6 EA per 30 days)

ELIQUIS 2

ELIQUIS DVT-PE TREAT 30D START 2

enoxaparin 1 GC

fondaparinux subcutaneous syringe 10 mg/0.8 ml,

5 mg/0.4 ml

4 NDS


54


fondaparinux subcutaneous syringe 2.5 mg/0.5 ml,

7.5 mg/0.6 ml

1 GC

FRAGMIN SUBCUTANEOUS SOLUTION 2

FRAGMIN SUBCUTANEOUS SYRINGE 2

heparin (porcine) in 5 % dex intravenous

parenteral solution 20,000 unit/500 ml (40

unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000

unit/500 ml (50 unit/ml)

2 HI

heparin (porcine) in nacl (pf) 2 HI

heparin (porcine) injection cartridge 3

heparin (porcine) injection solution 1 GC; HI

heparin (porcine) injection syringe 5,000 unit/ml 3

heparin(porcine) in 0.45% nacl intravenous

parenteral solution 25,000 unit/250 ml, 25,000

unit/500 ml

2 HI

heparin, porcine (pf) injection solution 3

heparin, porcine (pf) injection syringe 5,000

unit/0.5 ml

1 GC; HI

HEPARIN, PORCINE (PF) INJECTION

SYRINGE 5,000 UNIT/ML

1 GC

HEPARIN, PORCINE (PF) SUBCUTANEOUS 3

jantoven 1 GC

NPLATE SUBCUTANEOUS RECON SOLN 250

MCG, 500 MCG

4 NDS

pentoxifylline 1 GC

phytonadione (vitamin k1) oral tablet 5 mg 1 GC; #

PRADAXA 2 QL (60 EA per 30 days)

prasugrel 1 GC

PROMACTA 4 PA; NDS

warfarin 1 GC

XARELTO 2

ZONTIVITY 2

LIPID/CHOLESTEROL LOWERING AGENTS

ALTOPREV ORAL TABLET EXTENDED

RELEASE 24 HR 20 MG, 40 MG


amlodipine-atorvastatin 1 GC

atorvastatin 1 GC


55


cholestyramine (with sugar) 1 GC

cholestyramine light 1 GC

colesevelam oral powder in packet 1 GC

colestipol 1 GC

endur-acin 1 GC; #

ezetimibe 1 GC; QL (30 EA per 30 days)

ezetimibe-simvastatin 1 GC

fenofibrate micronized 1 GC

fenofibrate nanocrystallized oral tablet 145 mg, 48

mg

1 GC

fenofibrate oral capsule 1 GC

fenofibrate oral tablet 120 mg, 40 mg 1 ST; GC

fenofibrate oral tablet 160 mg, 54 mg 1 GC

fenofibric acid 1 GC

fenofibric acid (choline) 1 GC

fluvastatin 1 GC

gemfibrozil 1 GC

LIVALO 2

lovastatin 1 GC

niacin oral tablet 500 mg 1 GC

niacin oral tablet extended release 24 hr 1 GC

niacin oral tablet extended release 250 mg, 500

mg, 750 mg

1 GC; #

niacor 1 GC

omega-3 acid ethyl esters 1 GC; QL (120 EA per 30 days)

pravastatin 1 GC

prevalite 1 GC

REPATHA 2 PA; QL (3 ML per 28 days)

REPATHA PUSHTRONEX 2 PA; QL (3.5 ML per 28 days)

REPATHA SURECLICK 2 PA; QL (3 ML per 28 days)

rosuvastatin 1 GC

simvastatin oral tablet 1 GC

SLO-NIACIN ORAL TABLET EXTENDED

RELEASE 250 MG, 750 MG

1 GC; #

slo-niacin oral tablet extended release 500 mg 1 GC; #


56


VASCEPA 2

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR ORAL TABLET 2

digitek 1 GC

digox 1 GC

digoxin oral solution 50 mcg/ml (0.05 mg/ml) 1 GC

digoxin oral tablet 1 GC

ENTRESTO 2

lanoxin oral tablet 62.5 mcg (0.0625 mg) 1 GC

ranolazine 1 GC

VECAMYL 4 NDS

NITRATES

ISORDIL 2

isosorbide dinitrate oral tablet 1 GC

isosorbide mononitrate 1 GC

minitran 1 GC

NITRO-BID 2

NITRO-DUR TRANSDERMAL PATCH 24

HOUR 0.3 MG/HR, 0.8 MG/HR

2

nitroglycerin intravenous 1 B/D PA; GC

nitroglycerin oral capsule, extended release 2.5

mg, 6.5 mg

1 GC; #

nitroglycerin sublingual 1 GC

nitroglycerin transdermal patch 24 hour 1 GC

nitroglycerin translingual spray,non-aerosol 1 GC

nitro-time oral capsule, extended release 2.5 mg,

6.5 mg

1 GC; #

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

acitretin 1 GC

calcipotriene scalp 1 GC; QL (60 ML per 30 days)

calcipotriene topical cream 1 GC; QL (120 GM per 30 days)

calcipotriene topical ointment 1 GC; QL (120 GM per 30 days)

calcipotriene-betamethasone 1 GC

calcitriol topical 1 GC


57


COSENTYX 4 PA; NDS

COSENTYX (2 SYRINGES) 4 PA; NDS

COSENTYX PEN 4 PA; NDS

COSENTYX PEN (2 PENS) 4 PA; NDS

drithocreme hp 1 GC; #

hydrocortisone-pramoxine topical 1 GC; #

PRAMOSONE TOPICAL LOTION 1 GC

selenium sulfide topical lotion 1 GC

SKYRIZI SUBCUTANEOUS SYRINGE KIT 4 PA; QL (2 EA per 28 days); NDS

SORILUX 2

STELARA INTRAVENOUS 4 B/D PA; NDS

STELARA SUBCUTANEOUS SYRINGE 4 NDS

sulfacetamide sodium topical cleanser 1 GC; #

TACLONEX TOPICAL SUSPENSION 2

VECTICAL 2

KERATOLYTICS

KERALYT RX 1 GC; #

salicylic acid er-ceramides topical kit,cleanser and

cream er

1 GC; #

salicylic acid topical cream 1 GC; #

salicylic acid topical cream,extended release 1 GC; #

salicylic acid topical foam 1 GC; #

salicylic acid topical gel 1 GC; #

salicylic acid topical lotion 1 GC; #

salicylic acid topical lotion,extended release 1 GC; #

salicylic acid topical shampoo 1 GC; #

salimez 1 GC; #

salvax 1 GC; #

SALVAX DUO PLUS 1 GC; #

MISCELLANEOUS DERMATOLOGICALS

acyclovir topical cream 1 GC; QL (5 GM per 30 days)

acyclovir topical ointment 1 GC

ammonium lactate 1 GC

CONDYLOX TOPICAL GEL 2


58


DENAVIR 2

diclofenac sodium topical gel 3 % 1 PA; GC

DRYSOL 1 GC; #

DRYSOL DAB-O-MATIC 1 GC; #

DUPIXENT SYRINGE 4 PA; NDS

fluorouracil topical cream 0.5 % 4 NDS

fluorouracil topical cream 5 % 1 GC

fluorouracil topical solution 1 GC

geri-hydrolac topical cream 1 GC; #

glydo 1 GC; QL (60 ML per 30 days)

imiquimod topical cream in metered-dose pump 1 PA; GC

imiquimod topical cream in packet 1 GC

lidocaine (pf) injection solution 1 B/D PA; GC

lidocaine hcl injection solution 1 B/D PA; GC

lidocaine hcl laryngotracheal 1 GC

lidocaine hcl mucous membrane jelly 1 GC; QL (60 ML per 30 days)

lidocaine hcl mucous membrane jelly in applicator 1 GC; QL (60 ML per 30 days)

lidocaine hcl mucous membrane solution 4 % (40

mg/ml)

1 GC

lidocaine topical adhesive patch,medicated 5 % 1 PA; GC

lidocaine topical ointment 1 GC; QL (50 GM per 30 days)

lidocaine viscous 1 GC

lidocaine-prilocaine topical cream 1 GC; QL (30 GM per 30 days)

methoxsalen 1 GC

PANRETIN 4 NDS

PICATO 2

pimecrolimus 1 PA; GC; QL (100 GM per 90 days)

podofilox 1 GC

REGRANEX 4 PA; NDS

SANTYL 2

silver sulfadiazine 1 GC

skin treatment 1 GC; #

ssd 1 GC

SYNERA 2


59


tacrolimus topical 1 PA; GC; QL (100 GM per 90 days)

TOLAK 2

UVADEX 2 B/D PA

VALCHLOR 4 PA; NDS

VEREGEN 2

XERESE 2

ZTLIDO 3 PA; QL (90 EA per 30 days)

ZYCLARA 2 PA

THERAPY FOR ACNE

ABSORICA 4 PA; NDS

ABSORICA LD 4 PA; NDS

ACANYA TOPICAL GEL WITH PUMP 2

ACZONE TOPICAL GEL WITH PUMP 2

adapalene topical cream 1 PA; GC

adapalene topical gel 1 PA; GC

adapalene topical gel with pump 1 PA; GC

adapalene-benzoyl peroxide 1 GC

amnesteem 1 PA; GC

avar topical cleanser 1 GC; #

avita 1 PA; GC

azelaic acid 1 GC

AZELEX 2

bp 10-1 1 GC; #

claravis 1 PA; GC

cleansing wash topical cleanser 1 GC; #

clindacin etz topical swab 1 GC

clindacin p 1 GC

clindamycin phosphate topical foam 1 GC

clindamycin phosphate topical gel 1 GC

CLINDAMYCIN PHOSPHATE TOPICAL GEL,

ONCE DAILY

1 GC

clindamycin phosphate topical lotion 1 GC

clindamycin phosphate topical solution 1 GC

clindamycin phosphate topical swab 1 GC


60


clindamycin-benzoyl peroxide 1 GC

clindamycin-tretinoin 1 PA; GC

dapsone topical 1 GC

DIFFERIN TOPICAL LOTION 2 PA

EPIDUO FORTE 2

ery pads 1 GC

erythromycin with ethanol topical gel 1 GC

erythromycin with ethanol topical solution 1 GC

erythromycin-benzoyl peroxide 1 GC

FABIOR 2

FINACEA TOPICAL FOAM 2

isotretinoin 1 PA; GC

metronidazole topical 1 GC

MIRVASO TOPICAL GEL WITH PUMP 2

myorisan 1 PA; GC

neuac 1 GC

NORITATE 2

RETIN-A MICRO TOPICAL GEL WITH PUMP

0.06 %, 0.08 %

2 PA

rosadan topical cream 1 GC

rosadan topical gel 1 GC

sulfacetamide sodium-sulfur topical cleanser 10-5

% (w/w)

1 GC; #

sulfacetamide sodium-sulfur topical suspension 8-

4 %

1 GC; #

sulfacleanse 8-4 1 GC; #

tazarotene 1 GC

TAZORAC TOPICAL CREAM 0.05 % 2

TAZORAC TOPICAL GEL 2 QL (100 GM per 30 days)

tretinoin microspheres 1 PA; GC

tretinoin topical 1 PA; GC

VELTIN 2

zenatane 1 PA; GC

TOPICAL ANTIBACTERIALS

ALTABAX 2


61


CORTISPORIN TOPICAL CREAM 2

gentamicin topical 1 GC

mafenide acetate 1 GC

mupirocin 1 GC

mupirocin calcium 1 GC

neo-synalar 1 GC

sulfacetamide sodium (acne) 1 GC

SULFAMYLON TOPICAL CREAM 2

TOPICAL ANTIFUNGALS

ANTIFUNGAL 1 GC; #

antifungal (clotrimazole) 1 GC; #

anti-fungal topical powder 1 GC; #

athlete's foot 1 GC; #

athlete's foot (clotrimazole) 1 GC; #

athletic foot cream 1 GC; #

baza antifungal 1 GC; #

ciclodan topical solution 1 GC

ciclopirox topical cream 1 GC

ciclopirox topical gel 1 ST; GC

ciclopirox topical shampoo 1 ST; GC; QL (120 ML per 28 days)

ciclopirox topical solution 1 GC

ciclopirox topical suspension 1 GC

clotrimazole af 1 GC; #

clotrimazole topical 1 GC

clotrimazole-betamethasone 1 GC

desenex topical powder 1 GC; #

econazole 1 GC; QL (85 GM per 28 days)

ERTACZO 2 ST

EXELDERM 2

inzo antifungal 1 GC; #

itch relief (clotrimazole) 1 GC; #

jock itch (clotrimazole) 1 GC; #

KERYDIN 2

ketoconazole topical 1 GC


62


LOTRIMIN AF (CLOTRIMAZOLE) TOPICAL

CREAM

1 GC; #

lotrimin af powder 1 GC; #

LOTRIMIN AF TOPICAL POWDER 1 GC; #

LULICONAZOLE 2 ST

LUZU 2 ST

MENTAX 2

micatin 1 GC; #

miconazole nitrate topical 1 GC; #

miconazorb af 1 GC; #

micro-guard 1 GC; #

naftifine topical cream 1 ST; GC; QL (60 GM per 28 days)

NAFTIN TOPICAL GEL 3

nyamyc 1 GC

nystatin topical 1 GC

nystatin-triamcinolone 1 GC

nystop 1 GC

oxiconazole 1 ST; GC

OXISTAT TOPICAL LOTION 2 ST

remedy phytoplex antifungal topical powder 1 GC; #

ringworm 1 GC; #

secura antifungal 1 GC; #

zeasorb af 1 GC; #

TOPICAL CORTICOSTEROIDS

ala-cort topical cream 1 % 1 GC

alclometasone 1 GC

amcinonide 1 GC

APEXICON E 2

betamethasone dipropionate 1 GC

betamethasone valerate topical cream 1 GC

betamethasone valerate topical foam 3

betamethasone valerate topical lotion 1 GC

betamethasone valerate topical ointment 1 GC

betamethasone, augmented 1 GC


63


CAPEX 2

clobetasol scalp 1 GC

clobetasol topical cream 1 GC

clobetasol topical foam 3 QL (100 GM per 28 days)

clobetasol topical gel 1 GC

clobetasol topical lotion 1 GC

clobetasol topical ointment 1 GC

clobetasol topical shampoo 3 QL (236 ML per 28 days)

clobetasol topical spray,non-aerosol 3 QL (125 ML per 28 days)

clobetasol-emollient 1 GC

CLOCORTOLONE PIVALATE 1 GC

clodan 3 QL (236 ML per 28 days)

CORDRAN TAPE LARGE ROLL 2

DESONATE 2

desonide topical cream 1 GC

desonide topical lotion 1 GC

desonide topical ointment 1 GC

desoximetasone topical cream 3 ST

desoximetasone topical gel 3 ST

desoximetasone topical ointment 1 ST; GC

desoximetasone topical spray,non-aerosol 1 GC

diflorasone 1 GC

fluocinolone 1 GC

fluocinolone and shower cap 1 GC

fluocinonide 1 GC

fluocinonide-e 1 GC

fluocinonide-emollient 1 GC

flurandrenolide topical cream 1 GC

flurandrenolide topical lotion 3

fluticasone propionate topical 1 GC

halcinonide 1 GC

halobetasol propionate topical cream 1 GC

halobetasol propionate topical ointment 1 GC

HALOG TOPICAL CREAM 2


64


HALOG TOPICAL OINTMENT 2

hydrocortisone butyrate 1 GC

hydrocortisone butyr-emollient 1 GC

hydrocortisone topical cream 0.5 % 1 GC; #

hydrocortisone topical cream 1 %, 2.5 % 1 GC

hydrocortisone topical lotion 2.5 % 1 GC

hydrocortisone topical ointment 1 %, 2.5 % 1 GC

hydrocortisone valerate 1 GC

LOCOID TOPICAL LOTION 2

mometasone topical 1 GC

nolix topical lotion 3

prednicarbate 3

SYNALAR TOPICAL CREAM 2

texacort 1 GC

TOPICORT TOPICAL SPRAY,NON-AEROSOL 2

triamcinolone acetonide topical 1 GC

trianex 4 NDS

triderm topical cream 0.1 % 1 GC

TOPICAL SCABICIDES / PEDICULICIDES

crotan 1 GC

lindane topical shampoo 1 GC

malathion 1 GC

permethrin topical cream 1 GC

SKLICE 2

DIAGNOSTICS / MISCELLANEOUS AGENTS

ANOREXIANTS

XENICAL 2 PA

IRRIGATING SOLUTIONS

lactated ringers irrigation 1 GC

neomycin-polymyxin b gu 1 GC

PHYSIOLYTE 2

PHYSIOSOL IRRIGATION 2

ringer's irrigation 2

tis-u-sol pentalyte 2


65


MISCELLANEOUS AGENTS

acamprosate 1 GC

anagrelide 1 GC

ARALAST NP 4 B/D PA; NDS

AURYXIA 2 PA

CARBAGLU 4 PA; NDS

CARNITOR INTRAVENOUS 2 HI

cevimeline 1 GC

CHEMET 2

CLINIMIX 4.25%/D5W SULFIT FREE 2 HI

CLINIMIX E 2.75%/D5W SULF FREE 2 HI

D10 %-0.45 % SODIUM CHLORIDE 2 HI

D2.5 %-0.45 % SODIUM CHLORIDE 2 HI

D5 % AND 0.9 % SODIUM CHLORIDE 2 HI

D5 %-0.45 % SODIUM CHLORIDE 2 HI

DEFERASIROX ORAL TABLET 180 MG 4 NDS

deferasirox oral tablet 360 mg, 90 mg 4 NDS

deferoxamine 3

DESFERAL INJECTION RECON SOLN 500

MG

3

DEXTROSE 10 % AND 0.2 % NACL 2 HI

DEXTROSE 10 % IN WATER (D10W) 2 HI

dextrose 20 % in water (d20w) 2 HI




DEXTROSE 5 % IN WATER (D5W)

INTRAVENOUS PARENTERAL SOLUTION

2 HI

dextrose 5 % in water (d5w) intravenous

piggyback

2 HI

dextrose 5 %-lactated ringers 2 HI

DEXTROSE 5%-0.2 % SOD CHLORIDE 2 HI

dextrose 5%-0.3 % sod.chloride 2 HI

dextrose 50 % in water (d50w) intravenous

parenteral solution

2 HI


66



DEXTROSE WITH SODIUM CHLORIDE 2 HI

disulfiram 1 GC

FERRIPROX (2 TIMES A DAY) 4 NDS

FERRIPROX ORAL SOLUTION 4 NDS

FERRIPROX ORAL TABLET 1,000 MG 4 NDS

FERRIPROX ORAL TABLET 500 MG 2

FOSRENOL ORAL POWDER IN PACKET 4 NDS

GLASSIA 4 B/D PA; NDS

INCRELEX 4 NDS

JADENU 4 NDS

JADENU SPRINKLE 4 NDS

kionex (with sorbitol) 1 GC

lanthanum 1 GC

levocarnitine (with sugar) 1 GC

levocarnitine oral solution 100 mg/ml 1 GC

levocarnitine oral tablet 1 GC

LITHOSTAT 2

midodrine 1 GC

NITISINONE 4 NDS

NORTHERA ORAL CAPSULE 100 MG 4 PA; QL (90 EA per 30 days); NDS

NORTHERA ORAL CAPSULE 200 MG, 300

MG


ORFADIN 4 NDS

pilocarpine hcl oral 1 GC

PROLASTIN-C 4 B/D PA; NDS

RAVICTI 2 PA

RENAGEL ORAL TABLET 800 MG 3

riluzole 1 GC

sevelamer carbonate 1 GC

sevelamer hcl 1 GC

SODIUM CHLORIDE 0.9 % INTRAVENOUS

PARENTERAL SOLUTION

2 HI

sodium chloride 0.9 % intravenous piggyback 2 HI

sodium chloride irrigation 1 GC


67


sodium phenylbutyrate 4 PA; NDS

sodium polystyrene (sorb free) 1 GC

sodium polystyrene sulfonate oral powder 1 GC

sps (with sorbitol) 1 GC

trientine 4 QL (240 EA per 30 days); NDS

VELPHORO 2

VELTASSA 2

water for irrigation, sterile 1 GC

XIAFLEX 4 PA; NDS

zoledronic acid-mannitol-water intravenous

piggyback 5 mg/100 ml

1 PA; GC

SMOKING DETERRENTS

bupropion hcl (smoking deter) 1 GC; QL (60 EA per 30 days)

CHANTIX 2

CHANTIX CONTINUING MONTH BOX 2

CHANTIX STARTING MONTH BOX 2

NICOTROL 2

NICOTROL NS 2

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTS

azelastine nasal 1 GC

chlorhexidine gluconate mucous membrane 1 GC

FLUORIDE (SODIUM) DENTAL PASTE 3

ipratropium bromide nasal 1 GC

olopatadine nasal 1 GC

oralone 1 GC

paroex oral rinse 1 GC

periogard 1 GC

sodium fluoride-pot nitrate 3

triamcinolone acetonide dental 1 GC

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic (ear) 1 GC

flac otic oil 1 GC

fluocinolone acetonide oil 1 GC


68


hydrocortisone-acetic acid 1 GC

OTIC STEROID / ANTIBIOTIC

CIPRO HC 2

CIPRODEX 2

CORTISPORIN-TC 2

neomycin-polymyxin-hc otic (ear) 1 GC

ENDOCRINE/DIABETES

ADRENAL HORMONES

ACTHAR 4 B/D PA; QL (5 ML per 5 days); NDS

cortisone 1 GC

DEPO-MEDROL 2

dexamethasone intensol 1 GC

dexamethasone oral elixir 1 GC

dexamethasone oral solution 1 GC

dexamethasone oral tablet 1 GC

dexamethasone sodium phos (pf) injection solution 1 GC

dexamethasone sodium phosphate injection

solution

1 GC

dexamethasone sodium phosphate injection

syringe

3

fludrocortisone 1 GC

hydrocortisone oral 1 GC

KENALOG INJECTION 3

MEDROL ORAL TABLET 2 MG 2

methylprednisolone 1 GC

methylprednisolone acetate 1 GC

methylprednisolone sodium succ injection recon

soln 125 mg, 40 mg

1 GC; HI

methylprednisolone sodium succ intravenous 1 GC; HI

MILLIPRED ORAL TABLET 2

prednisolone oral solution 15 mg/5 ml 1 GC

prednisolone sodium phosphate oral 1 GC

prednisone 1 GC

prednisone intensol 1 GC

RAYOS 2


69


SOLU-CORTEF ACT-O-VIAL (PF) 2 HI

SOLU-MEDROL 2 HI

triamcinolone acetonide injection 1 GC

TRIESENCE (PF) 3

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg 1 GC

propylthiouracil 1 GC

DIABETES THERAPY

acarbose 1 GC

AFREZZA INHALATION CARTRIDGE WITH

INHALER 12 UNIT, 4 UNIT, 4 UNIT (90)/ 8

UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60), 8

UNIT, 8 UNIT (90)/ 12 UNIT (90)

2

alcohol pads 1 GC

alogliptin 1 GC

alogliptin-metformin 1 GC

alogliptin-pioglitazone 1 GC

AVANDIA ORAL TABLET 2 MG, 4 MG 3 QL (60 EA per 30 days)

BAQSIMI 2

BYDUREON BCISE 3 QL (4 ML per 28 days)

BYDUREON SUBCUTANEOUS PEN

INJECTOR


CYCLOSET 2

diazoxide 1 GC

FARXIGA ORAL TABLET 10 MG 3 QL (30 EA per 30 days)

FARXIGA ORAL TABLET 5 MG 3 QL (60 EA per 30 days)

gauze pads 2 x 2 1 GC

glimepiride 1 GC

glipizide 1 GC

glipizide-metformin 1 GC

GLUCAGEN HYPOKIT 2

GLUCAGON (HCL) EMERGENCY KIT 2

GLUCAGON EMERGENCY KIT (HUMAN) 2

glyburide 1 GC

glyburide micronized 1 GC


70


glyburide-metformin 1 GC

GLYXAMBI 2

GVOKE HYPOPEN 1-PACK 2

GVOKE HYPOPEN 2-PACK 2

GVOKE PFS 1-PACK SYRINGE 2

GVOKE PFS 2-PACK SYRINGE 2

HUMALOG JUNIOR KWIKPEN U-100 2

HUMALOG KWIKPEN INSULIN 2

HUMALOG MIX 50-50 INSULN U-100 2

HUMALOG MIX 50-50 KWIKPEN 2

HUMALOG MIX 75-25 KWIKPEN 2

HUMALOG MIX 75-25(U-100)INSULN 2

HUMALOG U-100 INSULIN 2

HUMULIN 70/30 U-100 INSULIN 2

HUMULIN 70/30 U-100 KWIKPEN 2

HUMULIN N NPH INSULIN KWIKPEN 2

HUMULIN N NPH U-100 INSULIN 2

HUMULIN R REGULAR U-100 INSULN 2

HUMULIN R U-500 (CONC) INSULIN 2 B/D PA

HUMULIN R U-500 (CONC) KWIKPEN 2

INSULIN LISPRO 2

INSULIN LISPRO PROTAMIN-LISPRO 2

insulin pen needle 1 GC

insulin syringe (disp) u-100 0.3 ml, 1 ml, 1/2 ml 1 GC

INVOKAMET 3 QL (60 EA per 30 days)

INVOKAMET XR 3 QL (60 EA per 30 days)

INVOKANA 3 QL (30 EA per 30 days)

JANUMET 2

JANUMET XR 2

JANUVIA 2

JARDIANCE 2

JENTADUETO 2

JENTADUETO XR 2

LANTUS SOLOSTAR U-100 INSULIN 2


71


LANTUS U-100 INSULIN 2

LEVEMIR FLEXTOUCH U-100 INSULN 2

LEVEMIR U-100 INSULIN 2

metformin oral tablet 1 GC

metformin oral tablet extended release 24 hr 1 GC

miglitol 1 GC

nateglinide 1 GC

needles, insulin disp.,safety 1 GC

OMNIPOD DASH 5 PACK POD 1 GC; QL (30 EA per 30 days)

OMNIPOD INSULIN MANAGEMENT 1 GC; QL (1 EA per 365 days)

OMNIPOD INSULIN REFILL 1 GC; QL (30 EA per 30 days)

OZEMPIC 2 QL (3 ML per 28 days)

pioglitazone 1 GC

pioglitazone-glimepiride 1 GC

pioglitazone-metformin 1 GC

PROGLYCEM 2

RELION NOVOLIN 70-30 FLEXPEN

INNER,SUV,LATEX-FREE

2

RELION NOVOLIN 70-30 VIAL LATEX-FREE 2

RELION NOVOLIN N 100 UNIT/ML 2

RELION NOVOLIN N 100 UNIT/ML FLEXPEN 2

RELION NOVOLIN R 100 UNIT/ML 2

RELION NOVOLIN R 100 UNIT/ML FLEXPEN 2

repaglinide 1 GC

repaglinide-metformin 1 GC

SOLIQUA 100/33 2 QL (18 ML per 30 days)

SYMLINPEN 120 4 NDS

SYMLINPEN 60 4 NDS

SYNJARDY 2

SYNJARDY XR 2

TOUJEO MAX U-300 SOLOSTAR 2

TOUJEO SOLOSTAR U-300 INSULIN 2

TRADJENTA 2

TRESIBA FLEXTOUCH U-100 2


72


TRESIBA FLEXTOUCH U-200 2

TRESIBA U-100 INSULIN 2

TRIJARDY XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 10-5-1,000 MG, 25-5-1,000 MG


TRIJARDY XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 12.5-2.5-1,000 MG, 5-2.5-1,000

MG


TRULICITY 2

V-GO 20 1 GC

V-GO 30 1 GC

V-GO 40 1 GC

VICTOZA 2-PAK 2

VICTOZA 3-PAK 2

XIGDUO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 10-1,000 MG, 10-500 MG


XIGDUO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-

500 MG


XULTOPHY 100/3.6 2 QL (15 ML per 30 days)

MISCELLANEOUS HORMONES

ALDURAZYME 4 PA; NDS

ANADROL-50 2

ANDRODERM 2

ANDROGEL TRANSDERMAL GEL IN

METERED-DOSE PUMP 20.25 MG/1.25 GRAM

(1.62 %)

2

ANDROGEL TRANSDERMAL GEL IN

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

% (40.5 MG/2.5 GRAM)

2

AVEED 2

cabergoline 1 GC

calcitonin (salmon) 1 GC

calcitriol intravenous solution 1 mcg/ml 1 GC

calcitriol oral 1 GC

CEREZYME INTRAVENOUS RECON SOLN

400 UNIT

4 B/D PA; NDS

CHORIONIC GONADOTROPIN, HUMAN

INTRAMUSCULAR

1 PA; GC


73


cinacalcet oral tablet 30 mg, 60 mg 4 QL (60 EA per 30 days); NDS

cinacalcet oral tablet 90 mg 4 QL (120 EA per 30 days); NDS

danazol 1 GC

DEPO-TESTOSTERONE 2

desmopressin injection 1 GC

desmopressin nasal spray with pump 1 GC

desmopressin nasal spray,non-aerosol 1 GC

desmopressin oral 1 GC

doxercalciferol intravenous 1 B/D PA; GC

doxercalciferol oral 1 GC

ELAPRASE 4 PA; NDS

ELELYSO 4 B/D PA; NDS

FABRAZYME 4 B/D PA; NDS

KORLYM 4 PA; NDS

KUVAN 4 NDS

LUMIZYME 4 B/D PA; NDS

METHITEST 2

methyltestosterone oral capsule 4 NDS

MIACALCIN INJECTION 2

miglustat 4 NDS

MYALEPT 4 PA; NDS

NAGLAZYME 4 PA; NDS

NATESTO 2

NATPARA 4 PA; NDS

oxandrolone 1 GC

pamidronate 1 B/D PA; GC

PARICALCITOL HEMODIALYSIS PORT

INJECTION

3 B/D PA

paricalcitol intravenous 1 B/D PA; GC

paricalcitol oral 1 GC

SAMSCA 4 NDS

SOMAVERT 4 B/D PA; NDS

STIMATE 4 NDS

SYNAREL 2


74


testosterone cypionate intramuscular oil 100

mg/ml, 200 mg/ml, 200 mg/ml (1 ml)

1 GC

testosterone enanthate 1 GC

testosterone transdermal 1 GC

zoledronic acid intravenous solution 1 B/D PA; GC

zoledronic acid-mannitol-water intravenous

piggyback 4 mg/100 ml

1 B/D PA; GC

ZOLEDRONIC AC-MANNITOL-0.9NACL 1 B/D PA; GC

THYROID HORMONES

EUTHYROX 2

LEVO-T 2

levothyroxine intravenous recon soln 100 mcg 1 GC

levothyroxine intravenous recon soln 200 mcg,

500 mcg

4 B/D PA; NDS

LEVOTHYROXINE INTRAVENOUS

SOLUTION

1 GC

levothyroxine oral 1 GC

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

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

mcg, 75 mcg, 88 mcg

1 GC

liothyronine oral 1 GC

SYNTHROID 2

THYROLAR-1 2

THYROLAR-1/2 2

THYROLAR-1/4 2

THYROLAR-2 2

THYROLAR-3 2

TIROSINT 2

TIROSINT-SOL 2

unithroid 1 GC

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICS

anaspaz 1 GC; #

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 1 GC

chlordiazepoxide-clidinium 1 GC; #

CUVPOSA 2


75


dicyclomine intramuscular 1 GC

dicyclomine oral capsule 1 GC

dicyclomine oral solution 1 GC

dicyclomine oral tablet 1 GC

diphenoxylate-atropine 1 GC

ed-spaz 1 GC; #

GLYCOPYRROLATE (PF) IN WATER

INJECTION

1 GC

glycopyrrolate (pf) in water intravenous syringe

0.4 mg/2 ml (0.2 mg/ml)

1 GC

glycopyrrolate injection 1 GC

glycopyrrolate oral 1 GC

hyoscyamine sulfate oral elixir 1 GC; #

hyoscyamine sulfate oral tablet 1 GC; #

hyoscyamine sulfate oral tablet,disintegrating 1 GC; #

hyoscyamine sulfate sublingual 1 GC; #

hyosyne oral elixir 1 GC; #

loperamide oral capsule 1 GC

MOTOFEN 2

MYTESI 2

NULEV 1 GC; #

oscimin oral tablet 1 GC; #

oscimin sl 1 GC; #

propantheline 1 GC

symax fastabs 1 GC; #

symax-sl 1 GC; #

MISCELLANEOUS GASTROINTESTINAL AGENTS

advanced antacid-antigas oral suspension 200-

200-20 mg/5 ml

1 GC; #

ALMACONE ORAL SUSPENSION 1 GC; #

alosetron 1 GC

ALOXI 3 HI

alum-mag hydroxide-simeth oral suspension 200-

200-20 mg/5 ml

1 GC; #

AMITIZA 2 QL (60 EA per 30 days)


76


antacid 1 GC; #

antacid anti-gas oral suspension 200-200-20 mg/5

ml

1 GC; #

antacid extra-strength oral suspension 200-200-20

mg/5 ml

1 GC; #

antacid liquid 1 GC; #

antacid m 1 GC; #

antacid plus anti-gas oral suspension 200-200-20

mg/5 ml

1 GC; #

antacid regular strength 1 GC; #

antacid-antigas oral suspension 200-200-20 mg/5

ml

1 GC; #

anucort-hc 1 GC; #

aprepitant 1 B/D PA; GC

APRISO 2

ASACOL HD 2

balsalazide 1 GC

budesonide oral capsule,delayed,extend.release 1 GC

budesonide oral tablet,delayed and ext.release 4 NDS

CHENODAL 4 NDS

CIMZIA 4 PA; NDS

CIMZIA POWDER FOR RECONST 4 PA; NDS

CIMZIA STARTER KIT 4 PA; NDS

comfort gel 1 GC; #

compro 1 GC

constulose 1 GC

CORTIFOAM 2

CREON 2

cromolyn oral 1 GC

CYSTADANE 4 NDS

DIPENTUM 2

dronabinol 1 B/D PA; GC

EMEND ORAL SUSPENSION FOR

RECONSTITUTION

2 B/D PA

enulose 1 GC

GATTEX 30-VIAL 4 NDS


77


GATTEX ONE-VIAL 4 NDS

gavilyte-c 1 GC

gavilyte-g 1 GC

gavilyte-n 1 GC

generlac 1 GC

geri-lanta oral suspension 200-200-20 mg/5 ml 1 GC; #

geri-mox antacid-antigas 1 GC; #

GOLYTELY ORAL RECON SOLN 2

granisetron (pf) intravenous solution 1 mg/ml (1

ml)

1 GC; HI

granisetron hcl intravenous 1 GC; HI

granisetron hcl oral 1 PA; GC

hemmorex-hc rectal suppository 25 mg 1 GC; #

hydrocortisone acetate rectal 1 GC; #

hydrocortisone rectal 1 GC

hydrocortisone topical cream with perineal

applicator

1 GC

hydrocortisone-pramoxine rectal cream 1-1 % 1 GC

hydrocortisone-pramoxine rectal cream 2.5-1 %,

2.5-1 % (4g)

1 GC; #

KRISTALOSE 2

lactulose 1 GC

LINZESS 2

liquid antacid oral suspension 200-200-20 mg/5

ml

1 GC; #

mag-al plus 1 GC; #

meclizine oral tablet 12.5 mg, 25 mg 1 GC

meclizine oral tablet,chewable 1 GC; #

mesalamine 1 GC

mesalamine with cleansing wipe 1 GC

metoclopramide hcl injection solution 1 GC

metoclopramide hcl oral 1 GC

mi-acid oral suspension 200-200-20 mg/5 ml 1 GC; #

mintox 1 GC; #

motion sickness relief(mecliz) oral tablet,chewable 1 GC; #


78


motion-time 1 GC; #

OCALIVA 4 PA; QL (30 EA per 30 days); NDS

ondansetron 1 B/D PA; GC

ondansetron hcl 1 B/D PA; GC

ondansetron hcl (pf) 1 B/D PA; GC

OSMOPREP 3

palonosetron intravenous solution 0.25 mg/5 ml 1 GC; HI

peg 3350-electrolytes oral recon soln 236-22.74-

6.74 -5.86 gram

1 GC

peg-electrolyte 1 GC

PENTASA 2

PLENVU 2

prochlorperazine 1 GC

prochlorperazine edisylate 1 GC

prochlorperazine maleate oral 1 GC

PROCTOFOAM HC 1 GC

procto-med hc 1 GC

procto-pak 1 GC

proctosol hc topical 1 GC

proctozone-hc 1 GC

RECTIV 2

RELISTOR SUBCUTANEOUS SOLUTION 4 NDS

RELISTOR SUBCUTANEOUS SYRINGE 4 NDS

RENFLEXIS 4 PA; NDS

ri-gel 1 GC; #

ri-mox 1 GC; #

SANCUSO 2

scopolamine base 1 GC

SUCRAID 4 NDS

sulfasalazine 1 GC

SUPREP BOWEL PREP KIT 2

travel sickness (meclizine) 1 GC; #

trilyte with flavor packets 1 GC

trimethobenzamide oral 1 PA; GC


79


TRULANCE 2

UCERIS RECTAL 2

ursodiol 1 GC

VIBERZI 3 PA; QL (60 EA per 30 days)

VIOKACE ORAL TABLET 10,440-39,150-

39,150 UNIT

3

VIOKACE ORAL TABLET 20,880-78,300-

78,300 UNIT

4 NDS

ZENPEP ORAL CAPSULE,DELAYED

RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT,

15,000-47,000 -63,000 UNIT, 20,000-63,000-

84,000 UNIT, 25,000-79,000- 105,000 UNIT,

3,000-10,000 -14,000-UNIT, 40,000-126,000-

168,000 UNIT, 5,000-17,000- 24,000 UNIT

2

ZUPLENZ 2 B/D PA

ULCER THERAPY

amoxicil-clarithromy-lansopraz 1 GC

CARAFATE ORAL SUSPENSION 2

cimetidine 1 GC

cimetidine hcl oral 1 GC

DEXILANT 2 ST

esomeprazole magnesium oral capsule,delayed

release(dr/ec)

1 GC

esomeprazole sodium 1 B/D PA; GC

famotidine (pf) 1 GC

famotidine (pf)-nacl (iso-os) 1 GC

famotidine intravenous solution 1 GC

famotidine oral suspension 1 GC

famotidine oral tablet 20 mg, 40 mg 1 GC

lansoprazole 1 GC

misoprostol 1 GC

nizatidine 1 GC

OMECLAMOX-PAK 2

omeprazole oral capsule,delayed release(dr/ec) 1 GC

pantoprazole intravenous 1 B/D PA; GC

pantoprazole oral tablet,delayed release (dr/ec) 1 GC


80


PROTONIX ORAL GRANULES DR FOR SUSP

IN PACKET


PYLERA 2

rabeprazole oral tablet,delayed release (dr/ec) 1 GC

ranitidine hcl oral syrup 1 GC

ranitidine hcl oral tablet 150 mg, 300 mg 1 GC

sucralfate 1 GC

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ACTIMMUNE 4 PA; NDS

ARANESP (IN POLYSORBATE) INJECTION

SOLUTION 100 MCG/ML, 200 MCG/ML, 25

MCG/ML, 300 MCG/ML, 40 MCG/ML, 60

MCG/ML

2 PA

ARANESP (IN POLYSORBATE) INJECTION

SYRINGE

2 PA

ARCALYST 4 PA; NDS

AVONEX INTRAMUSCULAR PEN INJECTOR

KIT


AVONEX INTRAMUSCULAR SYRINGE KIT 4 PA; QL (1 EA per 28 days); NDS

BETASERON SUBCUTANEOUS KIT 4 PA; QL (14 EA per 28 days); NDS

FULPHILA 3

GENOTROPIN 4 PA; NDS

GENOTROPIN MINIQUICK SUBCUTANEOUS

SYRINGE 0.2 MG/0.25 ML

2 PA

GENOTROPIN MINIQUICK SUBCUTANEOUS

SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML,

0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25

ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8

MG/0.25 ML, 2 MG/0.25 ML

4 PA; NDS

GRANIX 4 PA; NDS

INTRON A INJECTION RECON SOLN 4 PA; NDS

INTRON A INJECTION SOLUTION 10

MILLION UNIT/ML

4 PA; NDS

INTRON A INJECTION SOLUTION 6

MILLION UNIT/ML

2 PA

LEUKINE INJECTION RECON SOLN 4 PA; NDS

MOZOBIL 4 B/D PA; NDS


81


NIVESTYM 4 PA; NDS

PEGASYS 4 PA; QL (4 ML per 28 days); NDS

PEGASYS PROCLICK SUBCUTANEOUS PEN

INJECTOR 180 MCG/0.5 ML


PROCRIT INJECTION SOLUTION 10,000

UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,

3,000 UNIT/ML, 4,000 UNIT/ML

3 PA

PROCRIT INJECTION SOLUTION 20,000

UNIT/ML, 40,000 UNIT/ML

4 PA; NDS

PROLEUKIN 4 B/D PA; NDS

RETACRIT 2 PA

SYLATRON SUBCUTANEOUS KIT 200 MCG,

300 MCG

4 PA; NDS

UDENYCA 3

ZIEXTENZO 4 PA; NDS

VACCINES / MISCELLANEOUS IMMUNOLOGICALS

ACTHIB (PF) 2

ADACEL(TDAP ADOLESN/ADULT)(PF) 2

ATGAM 2 B/D PA

BCG VACCINE, LIVE (PF) 2 B/D PA

BEXSERO 2

BIVIGAM 4 B/D PA; NDS

BOOSTRIX TDAP 2

BOTOX 2 PA

CUVITRU 4 B/D PA; NDS

DAPTACEL (DTAP PEDIATRIC) (PF) 2

DYSPORT 2 PA

ENGERIX-B (PF) INTRAMUSCULAR

SYRINGE

2 B/D PA

ENGERIX-B PEDIATRIC (PF)

INTRAMUSCULAR SYRINGE

2 B/D PA

FLEBOGAMMA DIF 4 B/D PA; NDS

fomepizole 1 B/D PA; GC

GAMASTAN 2 B/D PA

GAMASTAN S/D 2 B/D PA

GAMMAGARD LIQUID 4 B/D PA; NDS


82


GAMMAKED INJECTION SOLUTION 1

GRAM/10 ML (10 %), 10 GRAM/100 ML (10

%), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML

(10 %)

4 B/D PA; NDS

GAMMAPLEX 4 B/D PA; NDS

GAMMAPLEX (WITH SORBITOL) 4 B/D PA; NDS

GAMUNEX-C 4 B/D PA; NDS

GARDASIL 9 (PF) 2

HAVRIX (PF) INTRAMUSCULAR

SUSPENSION 1,440 ELISA UNIT/ML

2

HAVRIX (PF) INTRAMUSCULAR SYRINGE 2

HIBERIX (PF) 2

HIZENTRA 4 B/D PA; NDS

IMOVAX RABIES VACCINE (PF) 2 B/D PA

INFANRIX (DTAP) (PF) INTRAMUSCULAR

SUSPENSION

2

IPOL 2

IXIARO (PF) 2

KINRIX (PF) 2

MENACTRA (PF) INTRAMUSCULAR

SOLUTION

2

MENVEO A-C-Y-W-135-DIP (PF) 2

M-M-R II (PF) 2

OCTAGAM 4 B/D PA; NDS

PEDIARIX (PF) 2

PEDVAX HIB (PF) 2

PENTACEL (PF) INTRAMUSCULAR KIT

15LF-48MCG-62DU -10 MCG/0.5ML

2

PRIVIGEN 4 B/D PA; NDS

PROQUAD (PF) 2

QUADRACEL (PF) 2

RABAVERT (PF) 2 B/D PA

RECOMBIVAX HB (PF) 2 B/D PA

ROTARIX 2

ROTATEQ VACCINE 2

SHINGRIX (PF) 2 QL (2 EA per 999 days)


83


STAMARIL (PF) 2 QL (1 EA per 999 days)

TDVAX 2

TENIVAC (PF) INTRAMUSCULAR SYRINGE 2

TETANUS,DIPHTHERIA TOX PED(PF) 2

THYMOGLOBULIN 2 B/D PA

TICE BCG 3

TRUMENBA 2

TWINRIX (PF) INTRAMUSCULAR SYRINGE 2

TYPHIM VI 2

VAQTA (PF) 2

VARIVAX (PF) 2

VARIZIG INTRAMUSCULAR SOLUTION 2

XEOMIN 2 PA

YF-VAX (PF) 2

ZOSTAVAX (PF) 2 QL (1 EA per 999 days)

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

allopurinol 1 GC

allopurinol sodium 1 GC

colchicine 1 GC

febuxostat 1 GC; QL (30 EA per 30 days)

MITIGARE 2

probenecid 1 GC

probenecid-colchicine 1 GC

OSTEOPOROSIS THERAPY

alendronate oral solution 1 GC

alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg 1 GC

BINOSTO 2 ST

FORTEO 4 PA; NDS

FOSAMAX PLUS D 2 ST

ibandronate intravenous solution 1 PA; GC

ibandronate oral 1 GC

PROLIA 2 B/D PA

raloxifene 1 GC; QL (30 EA per 30 days)


84


risedronate oral tablet 150 mg 1 GC; QL (1 EA per 30 days)

risedronate oral tablet 30 mg, 5 mg 1 GC; QL (30 EA per 30 days)

risedronate oral tablet 35 mg, 35 mg (12 pack), 35

mg (4 pack)


risedronate oral tablet,delayed release (dr/ec) 1 GC; QL (4 EA per 28 days)

TYMLOS 4 PA; QL (1.56 ML per 30 days); NDS

OTHER RHEUMATOLOGICALS

ACTEMRA ACTPEN 4 PA; NDS

ACTEMRA INTRAVENOUS 4 B/D PA; NDS

ACTEMRA SUBCUTANEOUS 4 PA; NDS

BENLYSTA INTRAVENOUS RECON SOLN

120 MG

4 PA; NDS

BENLYSTA INTRAVENOUS RECON SOLN

400 MG


BENLYSTA SUBCUTANEOUS 4 PA; NDS

DEPEN TITRATABS 2

ENBREL MINI 4 PA; NDS

ENBREL SUBCUTANEOUS RECON SOLN 4 PA; NDS

ENBREL SUBCUTANEOUS SYRINGE 4 PA; NDS

ENBREL SURECLICK 4 PA; NDS

HUMIRA 4 PA; NDS

HUMIRA PEN 4 PA; NDS

HUMIRA PEN CROHNS-UC-HS START 4 PA; NDS

HUMIRA PEN PSOR-UVEITS-ADOL HS 4 PA; NDS

HUMIRA(CF) 4 PA; NDS

HUMIRA(CF) PEDI CROHNS STARTER 4 PA; NDS

HUMIRA(CF) PEN CROHNS-UC-HS 4 PA; NDS

HUMIRA(CF) PEN PSOR-UV-ADOL HS 4 PA; NDS

HUMIRA(CF) PEN SUBCUTANEOUS

INJECTOR KIT 40 MG/0.4 ML

4 PA; NDS

leflunomide 1 GC

ORENCIA 4 PA; NDS

ORENCIA (WITH MALTOSE) 4 PA; NDS

ORENCIA CLICKJECT 4 PA; NDS

OTEZLA 4 PA; QL (60 EA per 30 days); NDS


85


OTEZLA STARTER ORAL TABLETS,DOSE

PACK 10 MG (4)-20 MG (4)-30 MG (47)


OTREXUP (PF) SUBCUTANEOUS AUTO-

INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15

MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML,

22.5 MG/0.4 ML, 25 MG/0.4 ML

2 PA

penicillamine oral capsule 4 NDS

penicillamine oral tablet 1 GC

RASUVO (PF) SUBCUTANEOUS AUTO-

INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15

MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML,

22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6

ML, 7.5 MG/0.15 ML

2 PA

RIDAURA 2

RINVOQ 4 PA; QL (30 EA per 30 days); NDS

SAVELLA 2

SIMPONI 4 PA; NDS

SIMPONI ARIA 4 B/D PA; NDS

XELJANZ 4 PA; QL (60 EA per 30 days); NDS

XELJANZ XR 4 PA; QL (30 EA per 30 days); NDS

OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINS

ALORA 2

amabelz 1 GC

ANGELIQ 2

camila 1 GC

CLIMARA PRO 2

COMBIPATCH 2

CRINONE 2 PA

deblitane 1 GC

DELESTROGEN INTRAMUSCULAR OIL 10

MG/ML

3

DEPO-ESTRADIOL 2

DEPO-PROVERA INTRAMUSCULAR

SUSPENSION 150 MG/ML

3


SUSPENSION 400 MG/ML

2 B/D PA


86



SYRINGE

3

DEPO-SUBQ PROVERA 104 2

DIVIGEL 2

dotti 1 GC

DUAVEE 2

ELESTRIN 2

errin 1 GC

estradiol 1 GC

estradiol valerate intramuscular oil 20 mg/ml, 40

mg/ml

1 GC

estradiol-norethindrone acet 1 GC

ESTRING 3

estrogel 1 GC

EVAMIST 2

fyavolv 1 GC

heather 1 GC

hydroxyprogesterone caproate 4 NDS

incassia 1 GC

jencycla 1 GC

jinteli 1 GC

lyza 1 GC

medroxyprogesterone 1 GC

MENEST ORAL TABLET 0.3 MG, 0.625 MG,

1.25 MG

2

MENOSTAR 2

mimvey 1 GC

MINIVELLE 2

nora-be 1 GC

norethindrone (contraceptive) 1 GC

norethindrone acetate 1 GC

norethindrone ac-eth estradiol oral tablet 0.5-2.5

mg-mcg, 1-5 mg-mcg

1 GC

norlyda 1 GC

PREFEST 2


87


PREMARIN 2

PREMPHASE 2

PREMPRO 2

progesterone micronized 1 GC

sharobel 1 GC

yuvafem 1 GC

MISCELLANEOUS OB/GYN

3-day vaginal 1 GC; #

CLEOCIN VAGINAL SUPPOSITORY 2

clindamycin phosphate vaginal 1 GC

CLINDESSE 2

clotrimazole 3 day 1 GC; #

clotrimazole vaginal cream 1 GC; #

clotrimazole-3 1 GC; #

clotrimazole-7 1 GC; #

eluryng 1 GC

etonogestrel-ethinyl estradiol 1 GC

GYNAZOLE-1 2

LUPANETA PACK (1 MONTH) 2 B/D PA

LUPANETA PACK (3 MONTH) 2 B/D PA

metronidazole vaginal 1 GC

miconazole 7 vaginal cream 1 GC; #

miconazole nitrate vaginal cream 1 GC; #

miconazole-3 vaginal suppository 1 GC

MONISTAT 7 VAGINAL CREAM 1 GC; #

NUVARING 3

NUVESSA 2

terconazole 1 GC

tranexamic acid oral 1 GC

vandazole 1 GC

xulane 1 GC

ORAL CONTRACEPTIVES / RELATED AGENTS

afirmelle 1 GC

altavera (28) 1 GC


88


alyacen 1/35 (28) 1 GC

alyacen 7/7/7 (28) 1 GC

amethia 1 GC

amethia lo 1 GC

amethyst (28) 1 GC

apri 1 GC

aranelle (28) 1 GC

ashlyna 1 GC

aubra 1 GC

aubra eq 1 GC

aurovela 1.5/30 (21) 1 GC

aurovela 1/20 (21) 1 GC

aurovela 24 fe 1 GC

aurovela fe 1.5/30 (28) 1 GC

aurovela fe 1-20 (28) 1 GC

aviane 1 GC

ayuna 1 GC

azurette (28) 1 GC

balziva (28) 1 GC

bekyree (28) 1 GC

BEYAZ 2

blisovi 24 fe 1 GC

blisovi fe 1.5/30 (28) 1 GC

blisovi fe 1/20 (28) 1 GC

briellyn 1 GC

camrese 1 GC

camrese lo 1 GC

caziant (28) 1 GC

charlotte 24 fe 1 GC

chateal (28) 1 GC

chateal eq (28) 1 GC

cryselle (28) 1 GC

cyclafem 1/35 (28) 1 GC

cyclafem 7/7/7 (28) 1 GC


89


cyred 1 GC

cyred eq 1 GC

dasetta 1/35 (28) 1 GC

dasetta 7/7/7 (28) 1 GC

daysee 1 GC

desog-e.estradiol/e.estradiol 1 GC

desogestrel-ethinyl estradiol 1 GC

drospirenone-e.estradiol-lm.fa 1 GC

drospirenone-ethinyl estradiol 1 GC

elinest 1 GC

emoquette 1 GC

enpresse 1 GC

enskyce 1 GC

estarylla 1 GC

ethynodiol diac-eth estradiol 1 GC

falmina (28) 1 GC

fayosim 1 GC

femynor 1 GC

GENERESS FE 2

gianvi (28) 1 GC

hailey 1 GC

hailey 24 fe 1 GC

hailey fe 1.5/30 (28) 1 GC

hailey fe 1/20 (28) 1 GC

introvale 1 GC

isibloom 1 GC

jaimiess 1 GC

jasmiel (28) 1 GC

jolessa 1 GC

juleber 1 GC

junel 1.5/30 (21) 1 GC

junel 1/20 (21) 1 GC

junel fe 1.5/30 (28) 1 GC

junel fe 1/20 (28) 1 GC


90


junel fe 24 1 GC

kaitlib fe 1 GC

kalliga 1 GC

kariva (28) 1 GC

kelnor 1/35 (28) 1 GC

kelnor 1-50 1 GC

kurvelo (28) 1 GC

l norgest/e.estradiol-e.estrad 1 GC

larin 1.5/30 (21) 1 GC

larin 1/20 (21) 1 GC

larin 24 fe 1 GC

larin fe 1.5/30 (28) 1 GC

larin fe 1/20 (28) 1 GC

larissia 1 GC

layolis fe 1 GC

leena 28 1 GC

lessina 1 GC

levonest (28) 1 GC

levonorgestrel-ethinyl estrad 1 GC

levonorg-eth estrad triphasic 1 GC

levora-28 1 GC

lillow (28) 1 GC

LO LOESTRIN FE 2

lojaimiess 1 GC

lopreeza oral tablet 1-0.5 mg 1 GC

loryna (28) 1 GC

low-ogestrel (28) 1 GC

lo-zumandimine (28) 1 GC

lutera (28) 1 GC

marlissa (28) 1 GC

melodetta 24 fe 1 GC

mibelas 24 fe 1 GC

microgestin 1.5/30 (21) 1 GC

microgestin 1/20 (21) 1 GC


91


microgestin fe 1.5/30 (28) 1 GC

microgestin fe 1/20 (28) 1 GC

mili 1 GC

MINASTRIN 24 FE 2

mono-linyah 1 GC

NATAZIA 2

necon 0.5/35 (28) 1 GC

nikki (28) 1 GC

noreth-ethinyl estradiol-iron 1 GC

norethindrone ac-eth estradiol oral tablet 1-20

mg-mcg, 1.5-30 mg-mcg

1 GC

norethindrone-e.estradiol-iron oral tablet 1 mg-20

mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7)

1 GC

norethindrone-e.estradiol-iron oral

tablet,chewable

1 GC

norgestimate-ethinyl estradiol 1 GC

nortrel 0.5/35 (28) 1 GC

nortrel 1/35 (21) 1 GC

nortrel 1/35 (28) 1 GC

nortrel 7/7/7 (28) 1 GC

ocella 1 GC

orsythia 1 GC

philith 1 GC

pimtrea (28) 1 GC

pirmella 1 GC

portia 28 1 GC

previfem 1 GC

QUARTETTE 2

reclipsen (28) 1 GC

rivelsa 1 GC

SAFYRAL 2

setlakin 1 GC

simliya (28) 1 GC

simpesse 1 GC

sprintec (28) 1 GC


92


sronyx 1 GC

syeda 1 GC

tarina 24 fe 1 GC

tarina fe 1/20 (28) 1 GC

tarina fe 1-20 eq (28) 1 GC

tilia fe 1 GC

tri femynor 1 GC

tri-estarylla 1 GC

tri-legest fe 1 GC

tri-linyah 1 GC

tri-lo-estarylla 1 GC

tri-lo-marzia 1 GC

tri-lo-mili 1 GC

tri-lo-sprintec 1 GC

tri-mili 1 GC

tri-previfem (28) 1 GC

tri-sprintec (28) 1 GC

trivora (28) 1 GC

tri-vylibra 1 GC

tri-vylibra lo 1 GC

tydemy 1 GC

velivet triphasic regimen (28) 1 GC

vienva 1 GC

viorele (28) 1 GC

volnea (28) 1 GC

vyfemla (28) 1 GC

vylibra 1 GC

wera (28) 1 GC

wymzya fe 1 GC

zarah 1 GC

zovia 1/35e (28) 1 GC

zumandimine (28) 1 GC

OXYTOCICS

methylergonovine oral 1 GC


93


OPHTHALMOLOGY

ANTIBIOTICS

ak-poly-bac 1 GC

AZASITE 2

bacitracin ophthalmic (eye) 1 GC

bacitracin-polymyxin b ophthalmic (eye) 1 GC

BESIVANCE 2

CILOXAN OPHTHALMIC (EYE) OINTMENT 2

ciprofloxacin hcl ophthalmic (eye) 1 GC

erythromycin ophthalmic (eye) 1 GC

gatifloxacin 1 GC

gentak ophthalmic (eye) ointment 1 GC

gentamicin ophthalmic (eye) drops 1 GC

levofloxacin ophthalmic (eye) 1 GC

MOXEZA 2

moxifloxacin ophthalmic (eye) 1 GC

NATACYN 2

neomycin-bacitracin-polymyxin 1 GC

neomycin-polymyxin-gramicidin 1 GC

neo-polycin 1 GC

ofloxacin ophthalmic (eye) 1 GC

ofloxacin otic (ear) 1 GC

polycin 1 GC

polymyxin b sulf-trimethoprim 1 GC

tobramycin 1 GC

TOBREX OPHTHALMIC (EYE) OINTMENT 2

ANTIVIRALS

trifluridine 1 GC

ZIRGAN 2

BETA-BLOCKERS

betaxolol ophthalmic (eye) 1 GC

BETIMOL 2

BETOPTIC S 2

carteolol 1 GC


94


levobunolol ophthalmic (eye) drops 0.5 % 1 GC

timolol maleate ophthalmic (eye) drops 1 GC

timolol maleate ophthalmic (eye) gel forming

solution

1 GC

TIMOPTIC OCUDOSE (PF) OPHTHALMIC

(EYE) DROPPERETTE 0.5 %

2

MISCELLANEOUS OPHTHALMOLOGICS

alaway 1 GC; #

allergy eye (ketotifen) 1 GC; #

ALOMIDE 2

altachlore 1 GC; #

atropine ophthalmic (eye) drops 1 GC

azelastine ophthalmic (eye) 1 ST; GC

BLEPHAMIDE 2

BLEPHAMIDE S.O.P. 2

children's alaway 1 GC; #

cromolyn ophthalmic (eye) 1 GC

cyclopentolate 1 GC; #

CYSTARAN 4 PA; QL (60 ML per 28 days); NDS

epinastine 1 ST; GC

eye itch relief 1 GC; #

EYLEA 3

ISOPTO ATROPINE 3

itchy eye drops 1 GC; #

ketotifen fumarate 1 GC; #

LACRISERT 2

LUCENTIS 3

MURO 128 OPHTHALMIC (EYE) DROPS 5 % 1 GC; #

MURO 128 OPHTHALMIC (EYE) OINTMENT 1 GC; #

olopatadine ophthalmic (eye) 1 GC

PAZEO 2 ST

PHOSPHOLINE IODIDE 2

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,

4 %

1 GC

RESTASIS 2 QL (60 EA per 30 days)


95


RESTASIS MULTIDOSE 2 QL (11 ML per 30 days)

sodium chloride ophthalmic (eye) 1 GC; #

sulfacetamide sodium ophthalmic (eye) 1 GC

sulfacetamide-prednisolone 1 GC

tropicamide 1 GC; #

wal-zyr (ketotifen) 1 GC; #

XIIDRA 2

ZADITOR 1 GC; #

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

bromfenac 1 GC

diclofenac sodium ophthalmic (eye) 1 GC

flurbiprofen sodium 1 GC

ILEVRO 2

ketorolac ophthalmic (eye) 1 GC

PROLENSA 2

ORAL DRUGS FOR GLAUCOMA

acetazolamide 1 GC

acetazolamide sodium 1 GC; HI

methazolamide 1 GC

OTHER GLAUCOMA DRUGS

AZOPT 2 ST

bimatoprost ophthalmic (eye) 1 GC

COMBIGAN 2

COSOPT (PF) 3

dorzolamide 1 GC

dorzolamide-timolol 1 GC

dorzolamide-timolol (pf) ophthalmic (eye)

dropperette

1 GC

latanoprost 1 GC

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01

%

2

RHOPRESSA 3 ST

ROCKLATAN 3 ST

SIMBRINZA 2


96


travoprost 1 GC

ZIOPTAN (PF) 3 QL (30 EA per 30 days)

STEROID-ANTIBIOTIC COMBINATIONS

neomycin-bacitracin-poly-hc 1 GC

neomycin-polymyxin b-dexameth 1 GC

neomycin-polymyxin-hc ophthalmic (eye) 1 GC

neo-polycin hc 1 GC

PRED-G 3

PRED-G S.O.P. 3

TOBRADEX 2

TOBRADEX ST 2

tobramycin-dexamethasone 1 GC

ZYLET 2

STEROIDS

ALREX 2

dexamethasone sodium phosphate ophthalmic

(eye)

1 GC

DUREZOL 2

fluorometholone 1 GC

FML FORTE 2

FML S.O.P. 2

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 2

LOTEMAX OPHTHALMIC (EYE) OINTMENT 2

LOTEMAX SM 2

loteprednol etabonate 1 GC

OZURDEX 3

PRED MILD 2

prednisolone acetate 1 GC

prednisolone sodium phosphate ophthalmic (eye) 1 GC

SYMPATHOMIMETICS

ALPHAGAN P OPHTHALMIC (EYE) DROPS

0.1 %

2

apraclonidine 1 GC

brimonidine 1 GC


97


IOPIDINE OPHTHALMIC (EYE)

DROPPERETTE

2

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTS

24hour allergy 1 GC; #

all day allergy (cetirizine) oral tablet 1 GC; #

allerclear 1 GC; #

allergy (diphenhydramine) oral liquid 1 GC; #

allergy relief (cetirizine) oral tablet 1 GC; #

allergy relief (loratadine) oral tablet 1 GC; #

allergy relief(diphenhydramin) oral liquid 1 GC; #

aller-tec 1 GC; #

BENADRYL ALLERGY ORAL LIQUID 1 GC; #

benzonatate oral capsule 100 mg, 200 mg 1 GC; #

carbinoxamine maleate oral liquid 1 GC

carbinoxamine maleate oral tablet 4 mg 1 GC

cetirizine oral solution 1 mg/ml 1 GC

cetirizine oral tablet 10 mg 1 GC; #

CETIRIZINE ORAL TABLET 5 MG 1 GC; #

children's allergy (diphenhyd) oral liquid 1 GC; #

children's aurodryl allergy 1 GC; #

children's diphenhydramine 1 GC; #

children's wal-dryl allergy oral liquid 1 GC; #

CLARINEX-D 12 HOUR 2 QL (60 EA per 30 days)

CLARITIN ORAL TABLET 1 GC; #

clemastine oral tablet 2.68 mg 1 GC

CODEINE-GUAIFENESIN 1 GC; #

cyproheptadine 1 GC

desloratadine oral tablet 1 GC

dexchlorpheniramine maleate oral solution 1 GC

diphedryl allergy 1 GC; #

diphedryl oral liquid 1 GC; #

diphenhydramine hcl injection solution 50 mg/ml 1 GC

diphenhydramine hcl injection syringe 3


98


diphenhydramine hcl oral elixir 1 GC; #

diphenhydramine hcl oral liquid 1 GC; #


epinephrine injection auto-injector 1 GC; QL (2 EA per 30 days)

epinephrine injection solution 1 mg/ml 1 GC

EPIPEN 2 QL (2 EA per 30 days)

EPIPEN 2-PAK 2 QL (2 EA per 30 days)

EPIPEN JR 2 QL (2 EA per 30 days)

EPIPEN JR 2-PAK 2 QL (2 EA per 30 days)

g tussin ac 1 GC; #

geri-dryl oral liquid 1 GC; #

guaiatussin ac 1 GC; #

hydrocodone-chlorpheniramine 1 GC; #

hydrocodone-homatropine oral syrup 5-1.5 mg/5

ml

1 GC; #

hydromet 1 GC; #

hydroxyzine hcl oral solution 10 mg/5 ml 1 GC

hydroxyzine hcl oral tablet 1 GC

hydroxyzine pamoate 1 GC

levocetirizine 1 GC

loradamed 1 GC; #

loratadine oral tablet 1 GC; #

maxi-tuss ac 1 GC; #

m-dryl 1 GC; #

promethazine injection solution 1 GC

promethazine oral 1 GC

promethazine rectal suppository 12.5 mg, 25 mg 1 GC

promethazine-codeine 1 GC; #

promethazine-dm 1 GC; #

promethazine-phenyleph-codeine 1 GC; #

promethegan rectal suppository 25 mg, 50 mg 1 GC

SEMPREX-D 2

siladryl sa 1 GC; #

virtussin ac 1 GC; #


99


virtussin dac 1 GC; #

wal-dryl allergy oral liquid 1 GC; #

wal-itin oral tablet 1 GC; #

wal-zyr (cetirizine) oral tablet 1 GC; #

ZYRTEC ORAL TABLET 1 GC; #

PULMONARY AGENTS

acetylcysteine 1 B/D PA; GC

ADEMPAS 4 PA; QL (90 EA per 30 days); NDS

albuterol sulfate inhalation hfa aerosol inhaler 1 GC

albuterol sulfate inhalation solution for

nebulization

1 B/D PA; GC

albuterol sulfate oral 1 GC

alyq 4 PA; NDS

ambrisentan 4 PA; NDS

aminophylline intravenous 1 GC

ANORO ELLIPTA 2

ARCAPTA NEOHALER 2

ARNUITY ELLIPTA 2

ATROVENT HFA 2

azelastine-fluticasone 1 GC

BECONASE AQ 2 QL (50 GM per 30 days)

BERINERT INTRAVENOUS KIT 4 B/D PA; NDS

bosentan 4 PA; QL (60 EA per 30 days); NDS

BREO ELLIPTA 2

BROVANA 2 B/D PA

budesonide inhalation 1 B/D PA; GC

CINRYZE 4 B/D PA; QL (20 EA per 30 days);

NDS

COMBIVENT RESPIMAT 2

cromolyn inhalation 1 B/D PA; GC

DALIRESP 3

DULERA 2

DYMISTA 2

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML 2

ESBRIET 4 PA; NDS


100


flunisolide nasal spray,non-aerosol 25 mcg (0.025

%)

1 GC

fluticasone propionate nasal 1 GC

fluticasone propion-salmeterol inhalation aerosol

powdr breath activated

1 GC

fluticasone propion-salmeterol inhalation blister

with device


icatibant 4 PA; NDS

INCRUSE ELLIPTA 2

ipratropium bromide inhalation 1 B/D PA; GC

ipratropium-albuterol 1 B/D PA; GC

KALYDECO 4 PA; NDS

LETAIRIS 4 PA; NDS

levalbuterol hcl 1 B/D PA; GC

levalbuterol tartrate 1 GC

metaproterenol oral syrup 1 GC

mometasone nasal 1 GC

montelukast 1 GC

OFEV 4 PA; NDS

OPSUMIT 4 PA; QL (30 EA per 30 days); NDS

ORKAMBI 4 PA; NDS

PERFOROMIST 2 B/D PA; QL (120 ML per 30 days)

PROAIR HFA 2

PROAIR RESPICLICK 2

PULMOZYME 4 PA; QL (150 ML per 30 days); NDS

QNASL 2

QVAR REDIHALER 2

RUCONEST 4 PA; NDS

sildenafil (pulmonary arterial hypertension)

intravenous solution 10 mg/12.5 ml

1 PA; GC

sildenafil (pulmonary arterial hypertension) oral

tablet 20 mg

1 PA; GC; QL (90 EA per 30 days)

SPIRIVA RESPIMAT 2 QL (4 GM per 30 days)

SPIRIVA WITH HANDIHALER 2 QL (30 EA per 30 days)

STIOLTO RESPIMAT 2

STRIVERDI RESPIMAT 2


101


SYMBICORT 2

tadalafil (pulmonary arterial hypertension) oral

tablet 20 mg

4 PA; NDS

terbutaline 1 GC

THEO-24 2

theophylline oral elixir 1 GC

theophylline oral solution 1 GC

theophylline oral tablet extended release 12 hr 1 GC

theophylline oral tablet extended release 24 hr 1 GC

TRACLEER ORAL TABLET FOR

SUSPENSION

4 PA; NDS

TRELEGY ELLIPTA 2 QL (60 EA per 30 days)

TUDORZA PRESSAIR 2

TYVASO 4 B/D PA; NDS

TYVASO INSTITUTIONAL START KIT 4 B/D PA; NDS

TYVASO REFILL KIT 4 B/D PA; NDS

TYVASO STARTER KIT 4 B/D PA; NDS

VENTAVIS 4 B/D PA; NDS

wixela inhub 1 GC; QL (60 EA per 30 days)

XHANCE 2 ST; QL (16 ML per 30 days)

XOLAIR 4 PA; NDS

YUPELRI 3 B/D PA

zafirlukast 1 GC

zileuton 1 GC

ZYFLO 2

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICS

darifenacin 1 GC

flavoxate 1 GC

GELNIQUE TRANSDERMAL GEL IN PACKET 2

MYRBETRIQ 2

oxybutynin chloride 1 GC

OXYTROL 2

solifenacin 1 GC; QL (30 EA per 30 days)


102


tolterodine 1 GC

TOVIAZ 2

trospium 1 GC

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

alfuzosin 1 GC

dutasteride 1 GC

dutasteride-tamsulosin 1 GC

finasteride oral tablet 5 mg 1 GC

tamsulosin 1 GC

MISCELLANEOUS UROLOGICALS

bethanechol chloride 1 GC

CYSTAGON 2

cytra-2 1 GC; #

EDEX 1 GC; #; QL (6 EA per 30 days)

ELMIRON 2

hyophen 1 GC; #

K-PHOS ORIGINAL 1 GC

ORACIT 1 GC; #

phosphasal 1 GC; #

potassium citrate 1 GC

PROCYSBI 4 PA; NDS

RENACIDIN IRRIGATION SOLUTION 1980.6

MG-59.4 MG-980.4MG/30ML

3

SHOHL'S MODIFIED 1 GC; #

sildenafil 1 GC; #; QL (8 EA per 30 days)

sodium citrate-citric acid 1 GC; #

uretron d-s oral tablet 81.6-10.8-40.8 mg 1 GC; #

urin ds 1 GC; #

utira-c 1 GC; #

virtrate-2 1 GC; #

URINARY ANESTHETICS

phenazopyridine oral tablet 100 mg, 200 mg 1 GC; #

VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES


103


calcium acetate(phosphat bind) 1 GC

calcium gluconate intravenous 3

klor-con 1 GC

KLOR-CON 10 2

klor-con 8 1 GC

klor-con m10 1 GC

KLOR-CON M15 2

klor-con m20 1 GC

K-TAB ORAL TABLET EXTENDED RELEASE

20 MEQ

2

lactated ringers intravenous 2 HI

MAGNESIUM SULFATE IN D5W


ML

1 GC; HI

magnesium sulfate in water 1 B/D PA; GC

magnesium sulfate injection 1 B/D PA; GC

NORMOSOL-R 2 HI

NORMOSOL-R IN 5 % DEXTROSE 2 HI

PHOSLYRA 2

POTASSIUM CHLORID-D5-0.45%NACL 2 HI

POTASSIUM CHLORIDE IN 0.9%NACL

INTRAVENOUS PARENTERAL SOLUTION 20

MEQ/L, 40 MEQ/L

2 HI

POTASSIUM CHLORIDE IN 5 % DEX


MEQ/L

2 HI

potassium chloride in 5 % dex intravenous

parenteral solution 30 meq/l

2

potassium chloride in 5 % dex intravenous


2 HI

POTASSIUM CHLORIDE IN LR-D5


MEQ/L

2 HI

potassium chloride in lr-d5 intravenous parenteral

solution 40 meq/l

2 HI

POTASSIUM CHLORIDE IN WATER

INTRAVENOUS PIGGYBACK 10 MEQ/100

ML, 20 MEQ/100 ML, 40 MEQ/100 ML

2 HI


104


potassium chloride in water intravenous

piggyback 10 meq/50 ml, 20 meq/50 ml

2 HI

potassium chloride in water intravenous

piggyback 30 meq/100 ml

2

potassium chloride intravenous 1 GC; HI

potassium chloride oral 1 GC

potassium chloride-0.45 % nacl 1 GC; HI

POTASSIUM CHLORIDE-D5-0.2%NACL


MEQ/L

2 HI

potassium chloride-d5-0.2%nacl intravenous

parenteral solution 30 meq/l, 40 meq/l

2

potassium chloride-d5-0.3%nacl intravenous


2 HI

POTASSIUM CHLORIDE-D5-0.9%NACL 2 HI

ringer's intravenous 2 HI

sodium bicarbonate intravenous syringe 10

meq/10 ml (8.4 %), 7.5 % (0.9 meq/ml)

1 B/D PA; GC

sodium bicarbonate intravenous syringe 8.4 % (1

meq/ml)

1 GC

SODIUM CHLORIDE 0.45 % INTRAVENOUS

PARENTERAL SOLUTION

2 HI

SODIUM CHLORIDE 3 % 2 HI

SODIUM CHLORIDE 5 % 2 HI

sodium chloride intravenous 2 HI

TPN ELECTROLYTES 2 HI

MISCELLANEOUS NUTRITION PRODUCTS

AMINOSYN II 10 % 2 HI

AMINOSYN II 15 % 2 HI

AMINOSYN-PF 7 % (SULFITE-FREE) 2 HI

CLINIMIX 5%/D15W SULFITE FREE 2 HI

CLINIMIX 4.25%/D10W SULF FREE 2 HI

CLINIMIX 5%-D20W(SULFITE-FREE) 2 HI

CLINIMIX E 4.25%/D10W SUL FREE 2 HI

CLINIMIX E 4.25%/D5W SULF FREE 2 HI

CLINIMIX E 5%/D15W SULFIT FREE 2 HI

CLINIMIX E 5%/D20W SULFIT FREE 2 HI


105


CLINISOL SF 15 % 2 HI

electrolyte-48 in d5w 2 HI

FREAMINE HBC 6.9 % 2 HI

freamine iii 10 % 2 HI

HEPATAMINE 8% 2 HI

INTRALIPID INTRAVENOUS EMULSION 20

%, 30 %

2 HI

IONOSOL-MB IN D5W 2 HI

ISOLYTE S PH 7.4 2 HI

ISOLYTE-P IN 5 % DEXTROSE 2 HI

ISOLYTE-S 2 HI

KABIVEN 2 B/D PA

NEPHRAMINE 5.4 % 2 HI

NORMOSOL-M IN 5 % DEXTROSE 2 HI

NORMOSOL-R PH 7.4 2 HI

NUTRILIPID 2 HI

PERIKABIVEN 2 B/D PA

PLASMA-LYTE 148 2 HI

PLASMA-LYTE A 2 HI

PLENAMINE 2 HI

PREMASOL 10 % 2 HI

PROCALAMINE 3% 2 HI

PROSOL 20 % 2 HI

TRAVASOL 10 % 2 HI

TROPHAMINE 10 % 2 HI

VITAMINS / HEMATINICS

cyanocobalamin (vitamin b-12) injection 1 GC; #


ergocalciferol (vitamin d2) oral capsule 1,250 mcg

(50,000 unit)

1 GC; #

fluoride (sodium) oral tablet 1 GC

fluoride (sodium) oral tablet,chewable 1 mg (2.2

mg sod. fluoride)

1 GC

folic acid oral tablet 1 mg 1 GC; #

mynephrocaps 1 GC; #


106


mynephron 1 GC; #

prenatal vitamin oral tablet 1 GC

renal caps 1 GC; #

reno caps 1 GC; #

triphrocaps 1 GC; #

VIRT-CAPS 1 GC; #

VITAL-D RX 1 GC; #

107

Index

2 24hour allergy ...................... 97

3 3-day vaginal ........................ 87

A abacavir .................................. 9

abacavir-lamivudine ............... 9

abacavir-lamivudine-

zidovudine .......................... 9

ABELCET .............................. 9

ABILIFY MAINTENA ........ 42

abiraterone ............................ 20

ABRAXANE ........................ 20

ABSORICA .......................... 59

ABSORICA LD ................... 59

acamprosate .......................... 65

ACANYA ............................. 59

acarbose ................................ 69

acebutolol ............................. 49

acetaminophen-caff-

dihydrocod ........................ 36

acetaminophen-codeine ........ 36

acetazolamide ....................... 95

acetazolamide sodium .......... 95

acetic acid ............................. 67

acetylcysteine ....................... 99

acitretin ................................. 56

ACTEMRA .......................... 84

ACTEMRA ACTPEN .......... 84

ACTHAR ............................. 68

ACTHIB (PF) ....................... 81

ACTIMMUNE ..................... 80

acyclovir ..................... 9, 10, 57

acyclovir sodium .................. 10

ACZONE .............................. 59

ADACEL(TDAP

ADOLESN/ADULT)(PF) 81

adapalene .............................. 59

adapalene-benzoyl peroxide . 59

adefovir................................. 10

ADEMPAS ........................... 99

adriamycin ............................ 20

ADRIAMYCIN .................... 20

adrucil ................................... 20

advanced antacid-antigas...... 75

ADZENYS XR-ODT ........... 42

afinitor .................................. 21

AFINITOR ........................... 21

AFINITOR DISPERZ .......... 20

afirmelle................................ 87

AFREZZA ............................ 69

AIMOVIG AUTOINJECTOR

.......................................... 34

ak-poly-bac ........................... 93

ala-cort .................................. 62

alaway ................................... 94

albendazole ........................... 14

albuterol sulfate .................... 99

alclometasone ....................... 62

alcohol pads .......................... 69

ALDACTAZIDE .................. 49

ALDURAZYME .................. 72

ALECENSA ......................... 21

alendronate ........................... 83

alfuzosin ............................. 102

ALIMTA .............................. 21

ALINIA ................................ 14

ALIQOPA ............................ 21

aliskiren ................................ 49

ALKERAN (AS HCL) ......... 21

all day allergy (cetirizine) ..... 97

allerclear ............................... 97

allergy (diphenhydramine) ... 97

allergy eye (ketotifen) .......... 94

allergy relief (cetirizine) ....... 97

allergy relief (loratadine) ...... 97

allergy relief(diphenhydramin)

.......................................... 97

aller-tec ................................. 97

allopurinol ............................ 83

allopurinol sodium ................ 83

ALMACONE ....................... 75

almotriptan malate ................ 34

alogliptin ............................... 69

alogliptin-metformin ............ 69

alogliptin-pioglitazone.......... 69

ALOMIDE............................ 94

ALORA ................................ 85

alosetron ............................... 75

ALOXI.................................. 75

ALPHAGAN P ..................... 96

alprazolam ............................ 42

ALPRAZOLAM INTENSOL

.......................................... 42

ALREX ................................. 96

ALTABAX ........................... 60

altachlore .............................. 94

altavera (28) .......................... 87

ALTOPREV ......................... 54

alum-mag hydroxide-simeth . 75

ALUNBRIG ......................... 21

alyacen 1/35 (28) .................. 88

alyacen 7/7/7 (28) ................. 88

alyq ....................................... 99

amabelz ................................. 85

amantadine hcl ...................... 10

AMBISOME ........................... 9

ambrisentan ........................... 99

amcinonide ........................... 62

amethia ................................. 88

amethia lo ............................. 88

amethyst (28) ........................ 88

amikacin ............................... 14

amiloride ............................... 49

amiloride-hydrochlorothiazide

.......................................... 49

aminocaproic acid ................. 53

aminophylline ....................... 99

AMINOSYN II 10 % .......... 104

AMINOSYN II 15 % .......... 104

AMINOSYN-PF 7 %

(SULFITE-FREE) .......... 104

amiodarone ........................... 48

AMITIZA ............................. 75

amitriptyline ......................... 42

amitriptyline-chlordiazepoxide

.......................................... 42

amlodipine ............................ 49

amlodipine-atorvastatin ........ 54

amlodipine-benazepril .......... 49

amlodipine-olmesartan ......... 49

amlodipine-valsartan ............ 49

amlodipine-valsartan-hcthiazid

.......................................... 49

ammonium lactate ................ 57

amnesteem ............................ 59

amoxapine ............................. 42

amoxicil-clarithromy-lansopraz

.......................................... 79

amoxicillin ...................... 17, 18

amoxicillin-pot clavulanate .. 18

amphetamine sulfate ............. 42

amphotericin b ........................ 9

ampicillin .............................. 18

ampicillin sodium ................. 18

ampicillin-sulbactam ............ 18

ANADROL-50 ..................... 72

108

anagrelide ............................. 65

anaspaz ................................. 74

anastrozole ............................ 21

ANDRODERM .................... 72

ANDROGEL ........................ 72

ANGELIQ ............................ 85

ANORO ELLIPTA .............. 99

antacid .................................. 76

antacid anti-gas ..................... 76

antacid extra-strength ........... 76

antacid liquid ........................ 76

antacid m .............................. 76

antacid plus anti-gas ............. 76

antacid regular strength ........ 76

antacid-antigas ...................... 76

anti-fungal ............................ 61

ANTIFUNGAL .................... 61

antifungal (clotrimazole) ...... 61

anucort-hc ............................. 76

APEXICON E ...................... 62

APLENZIN .......................... 42

APOKYN ............................. 33

apraclonidine ........................ 96

aprepitant .............................. 76

apri ........................................ 88

APRISO ................................ 76

APTENSIO XR .................... 42

APTIOM............................... 31

APTIVUS ............................. 10

APTIVUS (WITH VITAMIN

E) ...................................... 10

ARALAST NP ..................... 65

aranelle (28).......................... 88

ARANESP (IN

POLYSORBATE) ............ 80

ARCALYST ......................... 80

ARCAPTA NEOHALER ..... 99

ARGATROBAN .................. 53

ARGATROBAN IN 0.9 %

SOD CHLOR ................... 53

ARIKAYCE ......................... 14

aripiprazole ........................... 42

ARISTADA .......................... 43

ARISTADA INITIO ............ 43

armodafinil ........................... 43

ARNUITY ELLIPTA ........... 99

ARRANON .......................... 21

arsenic trioxide ..................... 21

ARSENIC TRIOXIDE ......... 21

ARZERRA ........................... 21

ASACOL HD ....................... 76

ascomp with codeine ............ 36

ashlyna .................................. 88

aspirin-dipyridamole ............ 53

ASTAGRAF XL................... 21

atazanavir.............................. 10

atenolol ................................. 49

atenolol-chlorthalidone ......... 49

ATGAM ............................... 81

athlete's foot .......................... 61

athlete's foot (clotrimazole) .. 61

athletic foot cream ................ 61

atomoxetine .......................... 43

atorvastatin ........................... 54

ATOVAQUONE .................. 14

atovaquone-proguanil ........... 14

ATRIPLA ............................. 10

atropine ........................... 74, 94

ATROVENT HFA ............... 99

aubra ..................................... 88

aubra eq ................................ 88

aurovela 1.5/30 (21) ............. 88

aurovela 1/20 (21) ................ 88

aurovela 24 fe ....................... 88

aurovela fe 1.5/30 (28) ......... 88

aurovela fe 1-20 (28) ............ 88

AURYXIA............................ 65

AUSTEDO ........................... 34

AVANDIA ........................... 69

avar ....................................... 59

AVASTIN ............................ 21

AVEED ................................ 72

aviane.................................... 88

avita ...................................... 59

AVONEX ............................. 80

ayuna .................................... 88

AYVAKIT ............................ 21

azacitidine ............................. 21

AZASAN .............................. 21

AZASITE ............................. 93

azathioprine .......................... 21

azathioprine sodium ............. 21

azelaic acid ........................... 59

azelastine ........................ 67, 94

azelastine-fluticasone ........... 99

AZELEX .............................. 59

azithromycin ......................... 14

AZOPT ................................. 95

aztreonam ............................. 14

azurette (28) .......................... 88

B bacitracin ........................ 14, 93

bacitracin-polymyxin b......... 93

baclofen ................................ 35

balsalazide ............................ 76

BALVERSA ......................... 21

balziva (28) ........................... 88

BANZEL .............................. 31

BAQSIMI ............................. 69

BARACLUDE ...................... 10

BAVENCIO ......................... 21

baza antifungal ...................... 61

BCG VACCINE, LIVE (PF) 81

BECONASE AQ .................. 99

bekyree (28) .......................... 88

BELEODAQ ......................... 21

BELSOMRA ........................ 43

BENADRYL ALLERGY ..... 97

benazepril ............................. 49

benazepril-hydrochlorothiazide

.......................................... 49

BENDEKA ........................... 21

BENLYSTA ......................... 84

benzonatate ........................... 97

benztropine ........................... 33

BERINERT ........................... 99

BESIVANCE ........................ 93

BESPONSA .......................... 21

betamethasone dipropionate . 62

betamethasone valerate ......... 62

betamethasone, augmented ... 62

BETASERON ....................... 80

betaxolol ......................... 49, 93

bethanechol chloride ........... 102

BETHKIS ............................. 14

BETIMOL ............................ 93

BETOPTIC S ........................ 93

bexarotene ............................. 21

BEXSERO ............................ 81

BEYAZ ................................. 88

bicalutamide ......................... 21

BICILLIN C-R ..................... 18

BICILLIN L-A ..................... 18

BICNU .................................. 21

BIDIL ................................... 49

BIKTARVY ......................... 10

bimatoprost ........................... 95

BINOSTO ............................. 83

bisoprolol fumarate ............... 49

bisoprolol-hydrochlorothiazide

.......................................... 49

BIVIGAM ............................. 81

bleomycin ............................. 21

BLEPHAMIDE .................... 94

BLEPHAMIDE S.O.P. ......... 94

blisovi 24 fe .......................... 88

109

blisovi fe 1.5/30 (28) ............ 88

blisovi fe 1/20 (28) ............... 88

BOOSTRIX TDAP .............. 81

BORTEZOMIB .................... 21

bosentan ................................ 99

BOSULIF ............................. 22

BOTOX ................................ 81

bp 10-1.................................. 59

BRAFTOVI .......................... 22

BREO ELLIPTA .................. 99

briellyn ................................. 88

BRILINTA ........................... 53

brimonidine .......................... 96

BRISDELLE ........................ 43

BRIVIACT ........................... 31

bromfenac ............................. 95

bromocriptine ....................... 33

BROVANA .......................... 99

BRUKINSA ......................... 22

budesonide ...................... 76, 99

bumetanide ........................... 49

bupap .................................... 36

buprenorphine....................... 36

buprenorphine hcl ................. 36

buprenorphine-naloxone....... 40

bupropion hcl........................ 43

bupropion hcl (smoking deter)

.......................................... 67

buspirone .............................. 43

busulfan ................................ 22

BUSULFEX ......................... 22

butalbital compound w/codeine

.......................................... 36

butalbital-acetaminop-caf-cod

.......................................... 36

butalbital-acetaminophen ..... 37

butalbital-acetaminophen-caff

.......................................... 37

butalbital-aspirin-caffeine .... 37

butorphanol........................... 40

BYDUREON ........................ 69

BYDUREON BCISE ........... 69

BYSTOLIC .......................... 49

C cabergoline ........................... 72

CABOMETYX..................... 22

calcipotriene ......................... 56

calcipotriene-betamethasone 56

calcitonin (salmon) ............... 72

calcitriol .......................... 56, 72

calcium acetate(phosphat bind)

........................................ 103

calcium gluconate ............... 103

CALQUENCE ...................... 22

CAMBIA .............................. 40

camila ................................... 85

CAMPTOSAR...................... 22

camrese ................................. 88

camrese lo ............................. 88

candesartan ........................... 49

candesartan-hydrochlorothiazid

.......................................... 49

CAPASTAT ......................... 14

CAPEX ................................. 63

CAPLYTA............................ 43

CAPRELSA.......................... 22

captopril ................................ 49

captopril-hydrochlorothiazide

.......................................... 49

CARAFATE ......................... 79

CARBAGLU ........................ 65

carbamazepine ...................... 31

carbidopa .............................. 33

carbidopa-levodopa .............. 33

carbidopa-levodopa-

entacapone ........................ 33

carbinoxamine maleate ......... 97

carboplatin ............................ 22

CARDENE IV IN SODIUM

CHLORIDE ...................... 49

CARDIZEM LA ................... 50

CARDURA XL .................... 50

carisoprodol .......................... 35

carisoprodol-aspirin .............. 35

carisoprodol-aspirin-codeine 36

carmustine ............................ 22

CARNITOR.......................... 65

carteolol ................................ 93

cartia xt ................................. 50

carvedilol .............................. 50

carvedilol phosphate ............. 50

caspofungin ............................ 9

CAYSTON ........................... 15

caziant (28) ........................... 88

cefaclor ........................... 12, 13

cefadroxil .............................. 13

cefazolin ............................... 13

cefazolin in dextrose (iso-os) 13

CEFAZOLIN IN DEXTROSE

(ISO-OS) .......................... 13

cefdinir.................................. 13

cefepime ............................... 13

CEFEPIME IN DEXTROSE 5

% ....................................... 13

cefepime in dextrose,iso-osm

.......................................... 13

cefixime ................................ 13

cefotetan ............................... 13

CEFOTETAN IN

DEXTROSE, ISO-OSM ... 13

cefoxitin ................................ 13

cefoxitin in dextrose, iso-osm

.......................................... 13

cefpodoxime ......................... 13

cefprozil ................................ 13

ceftazidime ........................... 13

CEFTAZIDIME IN D5W ..... 13

ceftriaxone ............................ 13

CEFTRIAXONE .................. 13

ceftriaxone in dextrose,iso-os

.......................................... 13

cefuroxime axetil .................. 13

cefuroxime sodium ......... 13, 14

celecoxib ............................... 40

CELONTIN .......................... 31

cephalexin ............................. 14

CEREZYME ......................... 72

cetirizine ............................... 97

CETIRIZINE ........................ 97

cevimeline ............................. 65

CHANTIX ............................ 67

CHANTIX CONTINUING

MONTH BOX .................. 67

CHANTIX STARTING

MONTH BOX .................. 67

charlotte 24 fe ....................... 88

chateal (28) ........................... 88

chateal eq (28) ...................... 88

CHEMET .............................. 65

CHENODAL ........................ 76

children's alaway .................. 94

children's allergy (diphenhyd)

.......................................... 97

children's aurodryl allergy .... 97

children's diphenhydramine .. 97

children's wal-dryl allergy .... 97

chloramphenicol sod succinate

.......................................... 15

chlordiazepoxide hcl ............. 43

chlordiazepoxide-clidinium .. 74

chlorhexidine gluconate ........ 67

chloroquine phosphate .......... 15

chlorothiazide ....................... 50

chlorothiazide sodium .......... 50

chlorpromazine ..................... 43

chlorthalidone ....................... 50

110

chlorzoxazone....................... 36

cholestyramine (with sugar) . 55

cholestyramine light ............. 55

CHORIONIC

GONADOTROPIN,

HUMAN ........................... 72

ciclodan ................................ 61

ciclopirox .............................. 61

cidofovir ............................... 10

cilostazol............................... 53

CILOXAN ............................ 93

CIMDUO .............................. 10

cimetidine ............................. 79

cimetidine hcl ....................... 79

CIMZIA ................................ 76

CIMZIA POWDER FOR

RECONST ........................ 76

CIMZIA STARTER KIT ..... 76

cinacalcet .............................. 73

CINRYZE............................. 99

CIPRO HC............................ 68

CIPRODEX .......................... 68

ciprofloxacin......................... 18

ciprofloxacin hcl ............. 18, 93

ciprofloxacin in 5 % dextrose

.......................................... 18

cisplatin ................................ 22

citalopram ............................. 43

cladribine .............................. 22

claravis ................................. 59

CLARINEX-D 12 HOUR .... 97

clarithromycin ...................... 14

CLARITIN ........................... 97

cleansing wash...................... 59

clemastine ............................. 97

CLEOCIN............................. 87

CLIMARA PRO ................... 85

clindacin etz.......................... 59

clindacin p ............................ 59

clindamycin hcl .................... 15

CLINDAMYCIN IN 0.9 %

SOD CHLOR ................... 15

clindamycin in 5 % dextrose 15

clindamycin palmitate hcl .... 15

clindamycin pediatric ........... 15

clindamycin phosphate .. 15, 59,

87

CLINDAMYCIN

PHOSPHATE ................... 59

clindamycin-benzoyl peroxide

.......................................... 60

clindamycin-tretinoin ........... 60

CLINDESSE ........................ 87

CLINIMIX 5%/D15W

SULFITE FREE ............. 104

CLINIMIX 4.25%/D10W

SULF FREE ................... 104

CLINIMIX 4.25%/D5W

SULFIT FREE .................. 65

CLINIMIX 5%-

D20W(SULFITE-FREE) 104

CLINIMIX E 2.75%/D5W

SULF FREE ..................... 65


SUL FREE ...................... 104


SULF FREE ................... 104

CLINIMIX E 5%/D15W

SULFIT FREE ................ 104

CLINIMIX E 5%/D20W

SULFIT FREE ................ 104

CLINISOL SF 15 % ........... 105

clobazam ............................... 31

clobetasol .............................. 63

clobetasol-emollient ............. 63

CLOCORTOLONE

PIVALATE ...................... 63

clodan ................................... 63

clofarabine ............................ 22

clomipramine ........................ 43

clonazepam ........................... 31

clonidine ............................... 50

clonidine hcl ................... 43, 50

clopidogrel ............................ 53

clorazepate dipotassium ....... 43

clotrimazole ................ 9, 61, 87

clotrimazole 3 day ................ 87

clotrimazole af ...................... 61

clotrimazole-3 ....................... 87

clotrimazole-7 ....................... 87

clotrimazole-betamethasone . 61

clozapine ............................... 43

COARTEM .......................... 15

codeine sulfate ...................... 37

CODEINE-GUAIFENESIN . 97

colchicine.............................. 83

colesevelam .......................... 55

colestipol .............................. 55

colistin (colistimethate na) ... 15

COMBIGAN ........................ 95

COMBIPATCH .................... 85

COMBIVENT RESPIMAT . 99

COMETRIQ ......................... 22

comfort gel ........................... 76

COMPLERA ........................ 10

compro .................................. 76

CONDYLOX ........................ 57

constulose ............................. 76

COPIKTRA .......................... 22

CORDRAN TAPE LARGE

ROLL ................................ 63

CORLANOR ........................ 56

CORTIFOAM ....................... 76

cortisone ............................... 68

CORTISPORIN .................... 61

CORTISPORIN-TC ............. 68

COSENTYX ......................... 57

COSENTYX (2 SYRINGES)

.......................................... 57

COSENTYX PEN ................ 57

COSENTYX PEN (2 PENS) 57

COSMEGEN ........................ 22

COSOPT (PF) ....................... 95

COTELLIC ........................... 22

CREON ................................. 76

CRESEMBA ........................... 9

CRINONE ............................ 85

CRIXIVAN ........................... 10

cromolyn ................... 76, 94, 99

crotan .................................... 64

cryselle (28) .......................... 88

CUVITRU ............................ 81

CUVPOSA ........................... 74

cyanocobalamin (vitamin b-12)

........................................ 105

cyclafem 1/35 (28) ................ 88

cyclafem 7/7/7 (28) ............... 88

cyclobenzaprine .................... 36

cyclopentolate ....................... 94

cyclophosphamide ................ 22

CYCLOSERINE ................... 15

CYCLOSET ......................... 69

cyclosporine .......................... 22

cyclosporine modified .......... 22

cyproheptadine ..................... 97

CYRAMZA .......................... 22

cyred ..................................... 89

cyred eq ................................ 89

CYSTADANE ...................... 76

CYSTAGON ...................... 102

CYSTARAN ......................... 94

cytarabine ............................. 22

cytarabine (pf) ...................... 22

cytra-2 ................................. 102

111

D D10 %-0.45 % SODIUM

CHLORIDE ...................... 65

D2.5 %-0.45 % SODIUM

CHLORIDE ...................... 65

D5 % AND 0.9 % SODIUM

CHLORIDE ...................... 65

D5 %-0.45 % SODIUM

CHLORIDE ...................... 65

dacarbazine ........................... 22

dactinomycin ........................ 22

dalfampridine ....................... 34

DALIRESP ........................... 99

DALVANCE ........................ 15

danazol ................................. 73

dantrolene ............................. 36

dapsone ........................... 15, 60

DAPTACEL (DTAP

PEDIATRIC) (PF)............ 81

daptomycin ........................... 15

DAPTOMYCIN ................... 15

DARAPRIM ......................... 15

darifenacin .......................... 101

DARZALEX ........................ 22

DARZALEX FASPRO ........ 22

dasetta 1/35 (28) ................... 89

dasetta 7/7/7 (28) .................. 89

daunorubicin ......................... 22

DAURISMO................... 22, 23

daysee ................................... 89

DAYTRANA ....................... 43

deblitane ............................... 85

decitabine ............................. 23

deferasirox ............................ 65

DEFERASIROX .................. 65

deferoxamine ........................ 65

DELESTROGEN ................. 85

DELSTRIGO ........................ 10

demeclocycline ..................... 19

DEMSER .............................. 50

DENAVIR ............................ 58

DEPEN TITRATABS .......... 84

DEPO-ESTRADIOL ............ 85

DEPO-MEDROL ................. 68

DEPO-PROVERA ......... 85, 86

DEPO-SUBQ PROVERA 104

.......................................... 86

DEPO-TESTOSTERONE .... 73

DESCOVY ........................... 10

desenex ................................. 61

DESFERAL .......................... 65

desipramine .......................... 43

desloratadine ......................... 97

desmopressin ........................ 73

desog-e.estradiol/e.estradiol . 89

desogestrel-ethinyl estradiol . 89

DESONATE ......................... 63

desonide ................................ 63

desoximetasone .................... 63

desvenlafaxine ...................... 43

desvenlafaxine succinate ...... 43

dexamethasone ..................... 68

dexamethasone intensol ........ 68

dexamethasone sodium phos

(pf) .................................... 68

dexamethasone sodium

phosphate .................... 68, 96

dexchlorpheniramine maleate

.......................................... 97

DEXILANT .......................... 79

dexmethylphenidate.............. 43

dexrazoxane hcl .................... 20

dextroamphetamine .............. 43

dextroamphetamine-

amphetamine .................... 43

DEXTROSE 10 % AND 0.2 %

NACL ............................... 65

DEXTROSE 10 % IN WATER

(D10W) ............................. 65

dextrose 20 % in water (d20w)

.......................................... 65


.......................................... 65


.......................................... 65


.......................................... 65

dextrose 5 % in water (d5w). 65

DEXTROSE 5 % IN WATER

(D5W) ............................... 65

dextrose 5 %-lactated ringers65

DEXTROSE 5%-0.2 % SOD

CHLORIDE ...................... 65

dextrose 5%-0.3 %

sod.chloride ...................... 65


.......................................... 65


.......................................... 66

DEXTROSE WITH SODIUM

CHLORIDE ...................... 66

DIASTAT ............................. 31

DIASTAT ACUDIAL .......... 31

diazepam ................... 31, 43, 44

DIAZEPAM ......................... 44

diazepam intensol ................. 44

diazoxide ............................... 69

diclofenac epolamine ............ 40

diclofenac potassium ............ 40

diclofenac sodium ..... 40, 58, 95

diclofenac-misoprostol ......... 40

dicloxacillin .......................... 18

dicyclomine .......................... 75

didanosine ............................. 10

DIFFERIN ............................ 60

DIFICID ............................... 14

diflorasone ............................ 63

diflunisal ............................... 41

digitek ................................... 56

digox ..................................... 56

digoxin .................................. 56

dihydroergotamine ................ 34

DILANTIN 30 MG ............... 31

diltiazem hcl ......................... 50

dilt-xr .................................... 50

DIPENTUM ......................... 76

diphedryl ............................... 97

diphedryl allergy ................... 97

diphenhydramine hcl ...... 97, 98

diphenoxylate-atropine ......... 75

dipyridamole ......................... 53

disulfiram .............................. 66

DIURIL ................................. 50

divalproex ............................. 31

DIVIGEL .............................. 86

docetaxel ............................... 23

dofetilide ............................... 48

donepezil ............................... 34

dorzolamide .......................... 95

dorzolamide-timolol ............. 95

dorzolamide-timolol (pf) ...... 95

dotti ....................................... 86

DOVATO ............................. 10

doxazosin .............................. 50

doxepin ................................. 44

doxercalciferol ...................... 73

doxorubicin ........................... 23

doxorubicin, peg-liposomal .. 23

doxy-100 ............................... 19

doxycycline hyclate .............. 19

doxycycline monohydrate .... 19

DOXYCYCLINE

MONOHYDRATE ........... 19

drithocreme hp ...................... 57

DRIZALMA SPRINKLE ..... 44

dronabinol ............................. 76

112

drospirenone-e.estradiol-lm.fa

.......................................... 89

drospirenone-ethinyl estradiol

.......................................... 89

DROXIA .............................. 23

DRYSOL .............................. 58

DRYSOL DAB-O-MATIC .. 58

DUAVEE ............................. 86

DULERA .............................. 99

duloxetine ............................. 44

DUOPA ................................ 33

DUPIXENT SYRINGE........ 58

DURAMORPH (PF) ............ 37

DUREZOL ........................... 96

dutasteride .......................... 102

dutasteride-tamsulosin ........ 102

DUTOPROL......................... 50

DYMISTA ............................ 99

DYRENIUM ........................ 50

DYSPORT ............................ 81

E e.e.s. 400 ............................... 14

ec-naproxen .......................... 41

econazole .............................. 61

EDARBI ............................... 50

EDARBYCLOR ................... 50

EDEX ............. 53, 98, 102, 105

EDLUAR .............................. 44

ed-spaz .................................. 75

EDURANT ........................... 10

efavirenz ............................... 10

EFAVIRENZ ........................ 10

ELAPRASE .......................... 73

electrolyte-48 in d5w .......... 105

ELELYSO ............................ 73

ELESTRIN ........................... 86

eletriptan ............................... 34

ELIGARD ............................ 23

ELIGARD (3 MONTH) ....... 23



elinest ................................... 89

ELIQUIS .............................. 53

ELIQUIS DVT-PE TREAT

30D START ..................... 53

ELITEK ................................ 20

ELIXOPHYLLIN ................. 99

ELLENCE ............................ 23

ELMIRON .......................... 102

eluryng .................................. 87

ELZONRIS........................... 23

EMCYT ................................ 23

EMEND ................................ 76

emoquette ............................. 89

EMPLICITI .......................... 23

EMSAM ............................... 44

EMTRIVA ............................ 10

EMVERM ............................ 15

enalapril maleate................... 50

enalapril-hydrochlorothiazide

.......................................... 50

ENBREL .............................. 84

ENBREL MINI .................... 84

ENBREL SURECLICK ....... 84

endocet.................................. 37

endur-acin ............................. 55

ENGERIX-B (PF) ................ 81

ENGERIX-B PEDIATRIC

(PF) ................................... 81

ENHERTU ........................... 23

enoxaparin ............................ 53

enpresse ................................ 89

enskyce ................................. 89

entacapone ............................ 33

entecavir ............................... 10

ENTRESTO.......................... 56

enulose .................................. 76

ENVARSUS XR .................. 23

EPANED .............................. 50

EPCLUSA ............................ 10

EPIDIOLEX ......................... 31

EPIDUO FORTE .................. 60

epinastine .............................. 94

epinephrine ........................... 98

EPIPEN ................................ 98

EPIPEN 2-PAK .................... 98

EPIPEN JR ........................... 98

EPIPEN JR 2-PAK ............... 98

epirubicin .............................. 23

epitol ..................................... 31

EPIVIR HBV ........................ 10

eplerenone ............................ 50

eprosartan ............................. 50

EQUETRO ........................... 31

ERAXIS(WATER DILUENT)

............................................ 9

ERBITUX ............................. 23

ergocalciferol (vitamin d2) . 105

ergoloid ................................. 44

ERGOMAR .......................... 34

ergotamine-caffeine .............. 34

ERIVEDGE .......................... 23

ERLEADA ........................... 23

erlotinib ................................ 23

errin ....................................... 86

ERTACZO ............................ 61

ertapenem ............................. 15

ERWINAZE ......................... 23

ery pads ................................. 60

ERYPED 400 ........................ 14

ERY-TAB ............................. 14

erythromycin ................... 14, 93

erythromycin ethylsuccinate . 14

erythromycin with ethanol .... 60

erythromycin-benzoyl peroxide

.......................................... 60

ESBRIET .............................. 99

escitalopram oxalate ............. 44

esomeprazole magnesium ..... 79

esomeprazole sodium ........... 79

estarylla ................................. 89

estazolam .............................. 44

estradiol ................................ 86

estradiol valerate ................... 86

estradiol-norethindrone acet . 86

ESTRING ............................. 86

estrogel ................................. 86

eszopiclone ........................... 44

ethacrynate sodium ............... 50

ethacrynic acid ...................... 50

ethambutol ............................ 15

ethosuximide ......................... 31

ethynodiol diac-eth estradiol 89

ETHYOL .............................. 20

etodolac ................................. 41

etonogestrel-ethinyl estradiol87

ETOPOPHOS ....................... 23

etoposide ............................... 23

EUTHYROX ........................ 74

EVAMIST ............................ 86

EVEKEO .............................. 44

everolimus (antineoplastic) .. 23

everolimus

(immunosuppressive) ....... 23

EVOMELA ........................... 24

EVOTAZ .............................. 10

EXELDERM ........................ 61

exemestane ........................... 24

eye itch relief ........................ 94

EYLEA ................................. 94

ezetimibe ............................... 55

ezetimibe-simvastatin ........... 55

F FABIOR ............................... 60

FABRAZYME ..................... 73

falmina (28) .......................... 89

113

famciclovir ........................... 10

famotidine............................. 79

famotidine (pf)...................... 79

famotidine (pf)-nacl (iso-os) 79

FANAPT .............................. 44

FARXIGA ............................ 69

FARYDAK........................... 24

FASLODEX ......................... 24

fayosim ................................. 89

febuxostat ............................. 83

felbamate .............................. 31

felodipine .............................. 50

femynor ................................ 89

fenofibrate ............................ 55

fenofibrate micronized ......... 55

fenofibrate nanocrystallized . 55

fenofibric acid ...................... 55

fenofibric acid (choline) ....... 55

fenoprofen ............................ 41

fentanyl ................................. 37

fentanyl citrate ...................... 37

fentanyl citrate (pf) ............... 37

FERRIPROX ........................ 66

FERRIPROX (2 TIMES A

DAY) ................................ 66

FETZIMA............................. 44

FINACEA............................. 60

finasteride ........................... 102

FIRDAPSE ........................... 35

FIRMAGON KIT W

DILUENT SYRINGE ...... 24

FIRVANQ ............................ 15

flac otic oil ............................ 67

flavoxate ............................. 101

FLEBOGAMMA DIF .......... 81

flecainide .............................. 48

FLECTOR ............................ 41

fluconazole ............................. 9

fluconazole in nacl (iso-osm) . 9

flucytosine .............................. 9

fludarabine ............................ 24

fludrocortisone ..................... 68

flunisolide ........................... 100

fluocinolone .......................... 63

fluocinolone acetonide oil .... 67

fluocinolone and shower cap 63

fluocinonide .......................... 63

fluocinonide-e....................... 63

fluocinonide-emollient ......... 63

fluoride (sodium) ................ 105

FLUORIDE (SODIUM) ....... 67

fluorometholone ................... 96

fluorouracil ..................... 24, 58

fluoxetine .............................. 44

fluphenazine decanoate ........ 44

fluphenazine hcl ................... 44

flurandrenolide ..................... 63

flurazepam ............................ 44

flurbiprofen ........................... 41

flurbiprofen sodium .............. 95

flutamide ............................... 24

fluticasone propionate .. 63, 100

fluticasone propion-salmeterol

........................................ 100

fluvastatin ............................. 55

fluvoxamine .......................... 44

FML FORTE ........................ 96

FML S.O.P. .......................... 96

folic acid ............................. 105

FOLOTYN ........................... 24

fomepizole ............................ 81

fondaparinux ................... 53, 54

FORFIVO XL....................... 44

FORTEO .............................. 83

FOSAMAX PLUS D ............ 83

fosamprenavir ....................... 10

fosinopril .............................. 50

fosinopril-hydrochlorothiazide

.......................................... 51

FOSRENOL ......................... 66

FRAGMIN............................ 54

FREAMINE HBC 6.9 % .... 105

freamine iii 10 % ................ 105

frovatriptan ........................... 34

FULPHILA ........................... 80

fulvestrant ............................. 24

furosemide ............................ 51

FUSILEV.............................. 20

FUZEON .............................. 10

fyavolv .................................. 86

FYCOMPA ........................... 32

G g tussin ac ............................. 98

gabapentin ............................ 32

GABLOFEN ......................... 36

galantamine .......................... 35

GAMASTAN ....................... 81

GAMASTAN S/D ................ 81

GAMMAGARD LIQUID .... 81

GAMMAKED ...................... 82

GAMMAPLEX .................... 82

GAMMAPLEX (WITH

SORBITOL) ..................... 82

GAMUNEX-C...................... 82

ganciclovir sodium ............... 10

GARDASIL 9 (PF) ............... 82

gatifloxacin ........................... 93

GATTEX 30-VIAL .............. 76

GATTEX ONE-VIAL .......... 77

gauze pad .............................. 69

gavilyte-c .............................. 77

gavilyte-g .............................. 77

gavilyte-n .............................. 77

GAZYVA ............................. 24

GELNIQUE ........................ 101

gemcitabine ........................... 24

GEMCITABINE ................... 24

gemfibrozil ........................... 55

GENERESS FE .................... 89

generlac ................................. 77

gengraf .................................. 24

GENOTROPIN ..................... 80

GENOTROPIN MINIQUICK

.......................................... 80

gentak ................................... 93

gentamicin ................ 15, 61, 93

gentamicin in nacl (iso-osm) 15

GENTAMICIN IN NACL

(ISO-OSM) ....................... 15

gentamicin sulfate (ped) (pf) 15

GENVOYA .......................... 10

GEODON ............................. 45

geri-dryl ................................ 98

geri-hydrolac ......................... 58

geri-lanta ............................... 77

geri-mox antacid-antigas ...... 77

gianvi (28) ............................ 89

GILENYA ............................ 35

GILOTRIF ............................ 24

GLASSIA ............................. 66

glatiramer .............................. 35

GLATIRAMER .................... 35

glatopa .................................. 35

GLATOPA ........................... 35

GLEOSTINE ........................ 24

glimepiride ............................ 69

glipizide ................................ 69

glipizide-metformin .............. 69

GLUCAGEN HYPOKIT ...... 69

GLUCAGON (HCL)

EMERGENCY KIT .......... 69

GLUCAGON EMERGENCY

KIT (HUMAN) ................. 69

glyburide ............................... 69

glyburide micronized ............ 69

glyburide-metformin ............. 70

114

glycopyrrolate....................... 75

glycopyrrolate (pf) in water .. 75

GLYCOPYRROLATE (PF) IN

WATER ............................ 75

glydo ..................................... 58

GLYXAMBI ........................ 70

GOLYTELY......................... 77

granisetron (pf) ..................... 77

granisetron hcl ...................... 77

GRANIX .............................. 80

griseofulvin microsize ............ 9

griseofulvin ultramicrosize ..... 9

guaiatussin ac ....................... 98

guanfacine ...................... 45, 51

guanidine .............................. 45

GVOKE HYPOPEN 1-PACK

.......................................... 70

GVOKE HYPOPEN 2-PACK

.......................................... 70

GVOKE PFS 1-PACK

SYRINGE......................... 70

GVOKE PFS 2-PACK

SYRINGE......................... 70

GYNAZOLE-1 ..................... 87

H hailey .................................... 89

hailey 24 fe ........................... 89

hailey fe 1.5/30 (28) ............. 89

hailey fe 1/20 (28) ................ 89

HALAVEN........................... 24

halcinonide ........................... 63

HALDOL DECANOATE .... 45

halobetasol propionate.......... 63

HALOG .......................... 63, 64

haloperidol ............................ 45

haloperidol decanoate ........... 45

haloperidol lactate ................ 45

HARVONI ..................... 10, 11

HAVRIX (PF) ...................... 82

heather .................................. 86

hemmorex-hc ........................ 77

heparin (porcine) .................. 54

heparin (porcine) in 5 % dex 54

heparin (porcine) in nacl (pf) 54

heparin(porcine) in 0.45% nacl

.......................................... 54

heparin, porcine (pf) ............. 54

HEPARIN, PORCINE (PF) . 54

HEPATAMINE 8%............ 105

HERCEPTIN ........................ 24

HERCEPTIN HYLECTA .... 24

HERZUMA .......................... 24

HETLIOZ ............................. 45

HIBERIX (PF) ...................... 82

HIZENTRA .......................... 82

HORIZANT.......................... 35

HUMALOG JUNIOR

KWIKPEN U-100 ............ 70

HUMALOG KWIKPEN

INSULIN .......................... 70

HUMALOG MIX 50-50

INSULN U-100 ................ 70

HUMALOG MIX 50-50

KWIKPEN........................ 70

HUMALOG MIX 75-25

KWIKPEN........................ 70

HUMALOG MIX 75-25(U-

100)INSULN .................... 70

HUMALOG U-100 INSULIN

.......................................... 70

HUMIRA .............................. 84

HUMIRA PEN ..................... 84

HUMIRA PEN CROHNS-UC-

HS START ....................... 84

HUMIRA PEN PSOR-

UVEITS-ADOL HS ......... 84

HUMIRA(CF) ...................... 84

HUMIRA(CF) PEDI

CROHNS STARTER ....... 84

HUMIRA(CF) PEN .............. 84

HUMIRA(CF) PEN

CROHNS-UC-HS ............ 84

HUMIRA(CF) PEN PSOR-

UV-ADOL HS .................. 84

HUMULIN 70/30 U-100

INSULIN .......................... 70

HUMULIN 70/30 U-100

KWIKPEN........................ 70

HUMULIN N NPH INSULIN

KWIKPEN........................ 70

HUMULIN N NPH U-100

INSULIN .......................... 70

HUMULIN R REGULAR U-

100 INSULN .................... 70

HUMULIN R U-500 (CONC)

INSULIN .......................... 70

HUMULIN R U-500 (CONC)

KWIKPEN........................ 70

hydralazine ........................... 51

hydrochlorothiazide .............. 51

hydrocodone bitartrate .......... 37

hydrocodone-acetaminophen 37

hydrocodone-chlorpheniramine

.......................................... 98

hydrocodone-homatropine .... 98

hydrocodone-ibuprofen ........ 37

hydrocortisone .......... 64, 68, 77

hydrocortisone acetate .......... 77

hydrocortisone butyrate ........ 64

hydrocortisone butyr-emollient

.......................................... 64

hydrocortisone valerate ........ 64

hydrocortisone-acetic acid .... 68

hydrocortisone-pramoxine ... 57,

77

hydromet ............................... 98

hydromorphone ..................... 38

hydromorphone (pf) .............. 37

hydroxychloroquine .............. 16

hydroxyprogesterone caproate

.......................................... 86

hydroxyurea .......................... 24

hydroxyzine hcl .................... 98

hydroxyzine pamoate ............ 98

hyophen .............................. 102

hyoscyamine sulfate ............. 75

hyosyne ................................. 75

I ibandronate ........................... 83

IBRANCE ............................. 24

ibu ......................................... 41

ibuprofen ............................... 41

ibuprofen-oxycodone ............ 38

icatibant .............................. 100

ICLUSIG .............................. 24

idarubicin .............................. 24

IDHIFA ................................. 24

ifosfamide ............................. 24

ILEVRO ............................... 95

imatinib ................................. 25

IMBRUVICA ....................... 25

IMFINZI ............................... 25

imipenem-cilastatin .............. 16

imipramine hcl ...................... 45

imipramine pamoate ............. 45

imiquimod ............................. 58

IMOVAX RABIES VACCINE

(PF) ................................... 82

incassia ................................. 86

INCRELEX .......................... 66

INCRUSE ELLIPTA .......... 100

indapamide ........................... 51

INDOCIN ............................. 41

indomethacin ........................ 41

INFANRIX (DTAP) (PF) ..... 82

INFUGEM ............................ 25

115

INFUMORPH P/F ................ 38

INLYTA ............................... 25

INREBIC .............................. 25

INSULIN LISPRO ............... 70

INSULIN LISPRO

PROTAMIN-LISPRO ...... 70

insulin pen needle ................. 70

insulin syringe (disp) u-100.. 70

INTELENCE ........................ 11

INTRALIPID ..................... 105

INTRON A ........................... 80

introvale ................................ 89

INVEGA SUSTENNA ......... 45

INVEGA TRINZA ............... 45

INVIRASE ........................... 11

INVOKAMET ...................... 70

INVOKAMET XR ............... 70

INVOKANA ........................ 70

inzo antifungal ...................... 61

IONOSOL-MB IN D5W .... 105

IOPIDINE............................. 97

IPOL ..................................... 82

ipratropium bromide ..... 67, 100

ipratropium-albuterol ......... 100

irbesartan .............................. 51

irbesartan-hydrochlorothiazide

.......................................... 51

IRESSA ................................ 25

irinotecan .............................. 25

ISENTRESS ......................... 11

ISENTRESS HD .................. 11

isibloom ................................ 89

ISOLYTE S PH 7.4 ............ 105

ISOLYTE-P IN 5 %

DEXTROSE ................... 105

ISOLYTE-S ........................ 105

isoniazid ............................... 16

ISOPTO ATROPINE ........... 94

ISORDIL .............................. 56

isosorbide dinitrate ............... 56

isosorbide mononitrate ......... 56

isotretinoin ............................ 60

isradipine .............................. 51

ISTODAX ............................ 25

itch relief (clotrimazole) ....... 61

itchy eye drops ..................... 94

itraconazole ............................ 9

ivermectin ............................. 16

IXEMPRA ............................ 25

IXIARO (PF) ........................ 82

J JADENU .............................. 66

JADENU SPRINKLE .......... 66

jaimiess ................................. 89

JAKAFI ................................ 25

jantoven ................................ 54

JANUMET ........................... 70

JANUMET XR ..................... 70

JANUVIA ............................. 70

JARDIANCE ........................ 70

jasmiel (28) ........................... 89

jencycla ................................. 86

JENTADUETO .................... 70

JENTADUETO XR .............. 70

JEVTANA ............................ 25

jinteli ..................................... 86

jock itch (clotrimazole) ........ 61

jolessa ................................... 89

juleber ................................... 89

JULUCA ............................... 11

junel 1.5/30 (21) ................... 89

junel 1/20 (21) ...................... 89

junel fe 1.5/30 (28) ............... 89

junel fe 1/20 (28) .................. 89

junel fe 24 ............................. 90

K KABIVEN .......................... 105

KADCYLA .......................... 25

KADIAN .............................. 38

kaitlib fe ................................ 90

KALETRA ........................... 11

kalliga ................................... 90

KALYDECO ...................... 100

KANJINTI ............................ 25

kariva (28) ............................ 90

kelnor 1/35 (28) .................... 90

kelnor 1-50 ........................... 90

KENALOG ........................... 68

KEPIVANCE ....................... 20

KERALYT RX ..................... 57

KERYDIN ............................ 61

ketoconazole ..................... 9, 61

ketoprofen ............................. 41

ketorolac ......................... 41, 95

KETOROLAC ...................... 41

ketotifen fumarate................. 94

KEYTRUDA ........................ 25

KINRIX (PF) ........................ 82

kionex (with sorbitol) ........... 66

KISQALI .............................. 25

KISQALI FEMARA CO-

PACK ............................... 25

klor-con .............................. 103

KLOR-CON 10 .................. 103

klor-con 8 ............................ 103

klor-con m10 ...................... 103

KLOR-CON M15 ............... 103

klor-con m20 ...................... 103

KORLYM ............................. 73

K-PHOS ORIGINAL ......... 102

KRISTALOSE ...................... 77

K-TAB ................................ 103

kurvelo (28) .......................... 90

KUVAN ................................ 73

KYPROLIS ........................... 25

L l norgest/e.estradiol-e.estrad . 90

labetalol ................................ 51

LACRISERT ........................ 94

lactated ringers .............. 64, 103

lactulose ................................ 77

LAMICTAL XR STARTER

(BLUE) ............................. 32

LAMICTAL XR STARTER

(GREEN) .......................... 32

LAMICTAL XR STARTER

(ORANGE) ....................... 32

lamivudine ............................ 11

lamivudine-zidovudine ......... 11

lamotrigine ............................ 32

lanoxin .................................. 56

lansoprazole .......................... 79

lanthanum ............................. 66

LANTUS SOLOSTAR U-100

INSULIN .......................... 70

LANTUS U-100 INSULIN .. 71

larin 1.5/30 (21) .................... 90

larin 1/20 (21) ....................... 90

larin 24 fe .............................. 90

larin fe 1.5/30 (28) ................ 90

larin fe 1/20 (28) ................... 90

larissia ................................... 90

latanoprost ............................ 95

LATUDA .............................. 45

layolis fe ............................... 90

leena 28 ................................. 90

leflunomide ........................... 84

LENVIMA ............................ 25

lessina ................................... 90

LETAIRIS .......................... 100

letrozole ................................ 25

leucovorin calcium ............... 20

LEUKERAN ......................... 25

LEUKINE ............................. 80

leuprolide .............................. 25

levalbuterol hcl ................... 100

116

levalbuterol tartrate ............ 100

LEVEMIR FLEXTOUCH U-

100 INSULN .................... 71

LEVEMIR U-100 INSULIN 71

levetiracetam ........................ 32

levetiracetam in nacl (iso-os) 32

levobunolol ........................... 94

levocarnitine ......................... 66

levocarnitine (with sugar)..... 66

levocetirizine ........................ 98

levofloxacin .................... 18, 93

levofloxacin in d5w .............. 18

levoleucovorin calcium ........ 20

levonest (28) ......................... 90

levonorgestrel-ethinyl estrad 90

levonorg-eth estrad triphasic 90

levora-28............................... 90

LEVO-T ............................... 74

levothyroxine ........................ 74

LEVOTHYROXINE ............ 74

levoxyl .................................. 74

LEXIVA ............................... 11

LIBTAYO ............................ 25

lidocaine ............................... 58

lidocaine (pf) .................. 48, 58

lidocaine hcl ......................... 58

lidocaine viscous .................. 58

lidocaine-prilocaine .............. 58

lillow (28) ............................. 90

lincomycin ............................ 16

lindane .................................. 64

linezolid ................................ 16

linezolid in dextrose 5% ....... 16

linezolid-0.9% sodium chloride

.......................................... 16

LINZESS .............................. 77

LIORESAL........................... 36

liothyronine .......................... 74

liquid antacid ........................ 77

lisinopril ............................... 51

lisinopril-hydrochlorothiazide

.......................................... 51

lithium carbonate .................. 45

lithium citrate ....................... 45

LITHOSTAT ........................ 66

LIVALO ............................... 55

LO LOESTRIN FE............... 90

LOCOID ............................... 64

lojaimiess .............................. 90

LONSURF ............................ 25

loperamide ............................ 75

lopinavir-ritonavir ................ 11

lopreeza ................................ 90

loradamed ............................. 98

loratadine .............................. 98

lorazepam ............................. 45

lorazepam intensol ................ 45

LORBRENA .................. 25, 26

lorcet (hydrocodone) ............ 38

lorcet hd ................................ 38

lorcet plus ............................. 38

loryna (28) ............................ 90

LORZONE ........................... 36

losartan ................................. 51

losartan-hydrochlorothiazide 51

LOTEMAX .......................... 96

LOTEMAX SM .................... 96

loteprednol etabonate ........... 96

LOTRIMIN AF .................... 62

LOTRIMIN AF

(CLOTRIMAZOLE) ........ 62

lotrimin af powder ................ 62

lovastatin .............................. 55

low-ogestrel (28) .................. 90

loxapine succinate ................ 45

lo-zumandimine (28) ............ 90

LUCENTIS ........................... 94

LULICONAZOLE ............... 62

LUMIGAN ........................... 95

LUMIZYME ........................ 73

LUMOXITI .......................... 26

LUPANETA PACK (1

MONTH) .......................... 87

LUPANETA PACK (3

MONTH) .......................... 87

LUPRON DEPOT ................ 26

LUPRON DEPOT (3

MONTH) .......................... 26

LUPRON DEPOT (4

MONTH) .......................... 26

LUPRON DEPOT (6

MONTH) .......................... 26

LUPRON DEPOT-PED ....... 26

LUPRON DEPOT-PED (3

MONTH) .......................... 26

lutera (28) ............................. 90

LUZU ................................... 62

LYNPARZA ......................... 26

LYRICA ............................... 32

LYRICA CR ......................... 32

LYSODREN ......................... 26

lyza ....................................... 86

M mafenide acetate ................... 61

mag-al plus ........................... 77

magnesium sulfate .............. 103

MAGNESIUM SULFATE IN

D5W ............................... 103

magnesium sulfate in water 103

malathion .............................. 64

mannitol 20 % ....................... 51

mannitol 25 % ....................... 51

maprotiline ............................ 46

marlissa (28) ......................... 90

MARPLAN ........................... 46

MATULANE ........................ 26

matzim la .............................. 51

MAVYRET .......................... 11

maxi-tuss ac .......................... 98

m-dryl ................................... 98

meclizine ............................... 77

meclofenamate ...................... 41

MEDROL ............................. 68

medroxyprogesterone ........... 86

mefenamic acid ..................... 41

mefloquine ............................ 16

megestrol .............................. 26

MEKINIST ........................... 26

MEKTOVI ............................ 26

melodetta 24 fe ..................... 90

meloxicam ............................ 41

melphalan ............................. 26

melphalan hcl ........................ 26

memantine ............................ 35

MENACTRA (PF) ................ 82

MENEST .............................. 86

MENOSTAR ........................ 86

MENTAX ............................. 62

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

(PF) ................................... 82

meperidine ............................ 38

meperidine (pf) ..................... 38

meprobamate ........................ 36

mercaptopurine ..................... 26

meropenem ........................... 16

MEROPENEM-0.9%

SODIUM CHLORIDE ..... 16

mesalamine ........................... 77

mesalamine with cleansing

wipe .................................. 77

mesna .................................... 20

MESNEX .............................. 20

MESTINON ......................... 36

metaproterenol .................... 100

metaxalone ............................ 36

metformin ............................. 71

117

methadone ...................... 38, 39

methadone intensol ............... 38

methamphetamine ................ 46

methazolamide ..................... 95

methenamine hippurate ........ 19

methimazole ......................... 69

METHITEST ........................ 73

methocarbamol ..................... 36

methotrexate sodium ............ 26

methotrexate sodium (pf) ..... 26

methoxsalen .......................... 58

methyldopa ........................... 51

methyldopa-

hydrochlorothiazide .......... 51

methylergonovine ................. 92

methylphenidate hcl ............. 46

methylprednisolone .............. 68

methylprednisolone acetate .. 68

methylprednisolone sodium

succ ................................... 68

methyltestosterone ................ 73

metoclopramide hcl .............. 77

metolazone ........................... 51

metoprolol succinate ............ 51

metoprolol ta-hydrochlorothiaz

.......................................... 51

metoprolol tartrate ................ 51

metro i.v. .............................. 16

metronidazole ........... 16, 60, 87

metronidazole in nacl (iso-os)

.......................................... 16

mexiletine ............................. 48

MIACALCIN ....................... 73

mi-acid .................................. 77

mibelas 24 fe ........................ 90

micafungin .............................. 9

micatin .................................. 62

miconazole 7 ........................ 87

miconazole nitrate .......... 62, 87

miconazole-3 ........................ 87

miconazorb af ....................... 62

microgestin 1.5/30 (21) ........ 90

microgestin 1/20 (21) ........... 90

microgestin fe 1.5/30 (28) .... 91

microgestin fe 1/20 (28) ....... 91

micro-guard .......................... 62

midodrine ............................. 66

migergot ............................... 34

miglitol ................................. 71

miglustat ............................... 73

mili ....................................... 91

MILLIPRED......................... 68

mimvey ................................. 86

MINASTRIN 24 FE ............. 91

minitran ................................ 56

MINIVELLE ........................ 86

minocycline .......................... 19

minoxidil .............................. 51

mintox ................................... 77

mirtazapine ........................... 46

MIRVASO............................ 60

misoprostol ........................... 79

MITIGARE .......................... 83

MITIGO (PF) ....................... 39

mitomycin ............................. 26

mitoxantrone ......................... 26

M-M-R II (PF) ...................... 82

modafinil .............................. 46

moexipril .............................. 51

molindone ............................. 46

mometasone .................. 64, 100

mondoxyne nl ....................... 19

MONISTAT 7 ...................... 87

mono-linyah.......................... 91

montelukast ........................ 100

MONUROL .......................... 19

morgidox .............................. 19

morphine ............................... 39

MORPHINE ......................... 39

morphine (pf) ........................ 39

morphine concentrate ........... 39

motion sickness relief(mecliz)

.......................................... 77

motion-time .......................... 78

MOTOFEN ........................... 75

MOXEZA ............................. 93

moxifloxacin ................... 18, 93

MOXIFLOXACIN-

SOD.ACE,SUL-WATER . 18

moxifloxacin-sod.chloride(iso)

.......................................... 18

MOZOBIL ............................ 80

MULTAQ ............................. 48

mupirocin.............................. 61

mupirocin calcium ................ 61

MURO 128 ........................... 94

MUTAMYCIN ..................... 26

MVASI ................................. 26

MYALEPT ........................... 73

MYCAMINE .......................... 9

mycophenolate mofetil ......... 26

mycophenolate mofetil (hcl) 27

mycophenolate sodium ......... 27

MYLOTARG ....................... 27

mynephrocaps ..................... 105

mynephron .......................... 106

myorisan ............................... 60

MYRBETRIQ ..................... 101

MYTESI ............................... 75

N nabumetone ........................... 41

nadolol .................................. 51

nadolol-bendroflumethiazide 51

nafcillin ................................. 18

nafcillin in dextrose iso-osm 18

naftifine ................................. 62

NAFTIN ............................... 62

NAGLAZYME ..................... 73

nalbuphine ............................ 41

naloxone ............................... 41

naltrexone ............................. 41

NAMZARIC ......................... 35

NAPRELAN CR .................. 41

naproxen ............................... 41

naproxen sodium .................. 41

naratriptan ............................. 34

NARCAN ............................. 41

NATACYN ........................... 93

NATAZIA ............................ 91

nateglinide ............................ 71

NATESTO ............................ 73

NATPARA ........................... 73

NAVELBINE ....................... 27

NAYZILAM ......................... 32

NEBUPENT ......................... 16

necon 0.5/35 (28) .................. 91

needles, insulin disp.,safety .. 71

nefazodone ............................ 46

neomycin .............................. 16

neomycin-bacitracin-poly-hc 96

neomycin-bacitracin-

polymyxin ......................... 93

neomycin-polymyxin b gu .... 64

neomycin-polymyxin b-

dexameth ........................... 96

neomycin-polymyxin-

gramicidin ......................... 93

neomycin-polymyxin-hc . 68, 96

neo-polycin ........................... 93

neo-polycin hc ...................... 96

neo-synalar ........................... 61

NEPHRAMINE 5.4 % ........ 105

NERLYNX ........................... 27

neuac ..................................... 60

NEUPRO .............................. 33

nevirapine ............................. 11

118

NEXAVAR .......................... 27

NEXTERONE ...................... 48

niacin .................................... 55

niacor .................................... 55

nicardipine ...................... 51, 52

NICOTROL .......................... 67

NICOTROL NS.................... 67

nifedipine .............................. 52

nikki (28) .............................. 91

nilutamide ............................. 27

nimodipine ............................ 52

NINLARO ............................ 27

NIPENT ................................ 27

nisoldipine ............................ 52

NITISINONE ....................... 66

NITRO-BID ......................... 56

NITRO-DUR ........................ 56

nitrofurantoin ........................ 20

nitrofurantoin macrocrystal .. 20

nitrofurantoin monohyd/m-

cryst .................................. 20

nitroglycerin ......................... 56

nitro-time .............................. 56

NIVESTYM ......................... 81

nizatidine .............................. 79

nolix ...................................... 64

nora-be .................................. 86

noreth-ethinyl estradiol-iron . 91

norethindrone (contraceptive)

.......................................... 86

norethindrone acetate ........... 86

norethindrone ac-eth estradiol

.................................... 86, 91

norethindrone-e.estradiol-iron

.......................................... 91

norgestimate-ethinyl estradiol

.......................................... 91

NORITATE .......................... 60

norlyda .................................. 86

NORMOSOL-M IN 5 %

DEXTROSE ................... 105

NORMOSOL-R ................. 103

NORMOSOL-R IN 5 %

DEXTROSE ................... 103

NORMOSOL-R PH 7.4 ..... 105

NORPACE CR ..................... 48

NORTHERA ........................ 66

nortrel 0.5/35 (28) ................ 91

nortrel 1/35 (21) ................... 91

nortrel 1/35 (28) ................... 91

nortrel 7/7/7 (28) .................. 91

nortriptyline .......................... 46

NORVIR ............................... 11

NOVOLIN 70/30 U-100

INSULIN .......................... 71

NOVOLIN 70-30 FLEXPEN

U-100 ................................ 71

NOVOLIN N FLEXPEN ..... 71

NOVOLIN N NPH U-100

INSULIN .......................... 71

NOVOLIN R FLEXPEN...... 71

NOVOLIN R REGULAR U-

100 INSULN .................... 71

NOXAFIL .............................. 9

NPLATE ............................... 54

NUBEQA ............................. 27

NUCYNTA .......................... 41

NUCYNTA ER .................... 41

NUEDEXTA ........................ 35

NULEV ................................ 75

NULOJIX ............................. 27

NUPLAZID .......................... 46

NUTRILIPID...................... 105

NUVARING ......................... 87

NUVESSA............................ 87

NUZYRA ............................. 19

nyamyc ................................. 62

nystatin ............................. 9, 62

nystatin-triamcinolone .......... 62

nystop ................................... 62

O OCALIVA ............................ 78

ocella .................................... 91

OCREVUS ........................... 35

OCTAGAM .......................... 82

octreotide acetate .................. 27

ODEFSEY ............................ 11

ODOMZO ............................ 27

OFEV.................................. 100

ofloxacin ......................... 18, 93

OGIVRI ................................ 27

olanzapine ............................. 46

olanzapine-fluoxetine ........... 46

olmesartan ............................ 52

olmesartan-amlodipin-

hcthiazid ........................... 52

olmesartan-

hydrochlorothiazide .......... 52

olopatadine ..................... 67, 94

OMECLAMOX-PAK .......... 79

omega-3 acid ethyl esters ..... 55

omeprazole ........................... 79

OMNIPOD DASH 5 PACK

POD .................................. 71

OMNIPOD INSULIN

MANAGEMENT ............. 71

OMNIPOD INSULIN REFILL

.......................................... 71

ONCASPAR ......................... 27

ondansetron ........................... 78

ondansetron hcl ..................... 78

ondansetron hcl (pf) .............. 78

ONIVYDE ............................ 27

ONTRUZANT ...................... 27

OPDIVO ............................... 27

OPSUMIT ........................... 100

ORACEA .............................. 19

ORACIT ............................. 102

oralone .................................. 67

ORAVIG ................................. 9

ORBACTIV .......................... 16

ORENCIA ............................ 84

ORENCIA (WITH

MALTOSE) ...................... 84

ORENCIA CLICKJECT ...... 84

ORENITRAM ...................... 52

ORFADIN ............................ 66

ORKAMBI ......................... 100

orphenadrine citrate .............. 36

orsythia ................................. 91

oscimin ................................. 75

oscimin sl .............................. 75

oseltamivir ............................ 11

OSMITROL 10 % ................ 52

osmitrol 15 % ....................... 52

osmitrol 20 % ....................... 52

OSMITROL 5 % .................. 52

OSMOPREP ......................... 78

OTEZLA ............................... 84

OTEZLA STARTER ............ 85

OTREXUP (PF) .................... 85

oxacillin ................................ 18

OXACILLIN IN

DEXTROSE(ISO-OSM) .. 18

oxaliplatin ............................. 27

oxandrolone .......................... 73

oxaprozin .............................. 42

oxazepam .............................. 46

oxcarbazepine ....................... 32

oxiconazole ........................... 62

OXISTAT ............................. 62

OXTELLAR XR .................. 32

oxybutynin chloride ............ 101

oxycodone ............................. 39

oxycodone-acetaminophen .. 39,

40

119

oxycodone-aspirin ................ 40

oxymorphone ........................ 40

OXYTROL ......................... 101

OZEMPIC ............................ 71

OZURDEX ........................... 96

P pacerone ............................... 48

paclitaxel .............................. 27

PADCEV .............................. 27

paliperidone .......................... 46

palonosetron ......................... 78

pamidronate .......................... 73

PANRETIN .......................... 58

pantoprazole ......................... 79

paricalcitol ............................ 73

PARICALCITOL ................. 73

paroex oral rinse ................... 67

paromomycin ........................ 16

paroxetine hcl ....................... 46

paroxetine

mesylate(menop.sym) ...... 46

PASER ................................. 16

PAXIL .................................. 46

PAZEO ................................. 94

PEDIARIX (PF) ................... 82

PEDVAX HIB (PF) .............. 82

peg 3350-electrolytes ........... 78

PEGANONE ........................ 32

PEGASYS ............................ 81

PEGASYS PROCLICK ....... 81

peg-electrolyte ...................... 78

PEMAZYRE ........................ 27

penicillamine ........................ 85

PENICILLIN G POT IN

DEXTROSE ..................... 18

penicillin g potassium........... 18

penicillin g procaine ............. 18

penicillin g sodium ............... 18

penicillin v potassium........... 18

PENTACEL (PF) ................. 82

PENTAM ............................. 16

pentamidine .......................... 16

PENTASA ............................ 78

pentazocine-naloxone ........... 40

pentoxifylline ....................... 54

PERFOROMIST ................ 100

PERIKABIVEN ................. 105

perindopril erbumine ............ 52

periogard............................... 67

PERJETA ............................. 27

permethrin ............................ 64

perphenazine......................... 46

perphenazine-amitriptyline ... 46

PERSERIS ............................ 46

phenazopyridine ................. 102

phenelzine ............................. 46

phenobarbital ........................ 32

phenoxybenzamine ............... 52

phenytoin .............................. 32

phenytoin sodium extended .. 32

philith.................................... 91

PHOSLYRA ....................... 103

phosphasal .......................... 102

PHOSPHOLINE IODIDE .... 94

PHYSIOLYTE ..................... 64

PHYSIOSOL IRRIGATION 64

phytonadione (vitamin k1) ... 54

PICATO................................ 58

PIFELTRO ........................... 11

pilocarpine hcl ................ 66, 94

pimecrolimus ........................ 58

pimozide ............................... 47

pimtrea (28) .......................... 91

pindolol ................................. 52

pioglitazone .......................... 71

pioglitazone-glimepiride ...... 71

pioglitazone-metformin ........ 71

piperacillin-tazobactam ........ 18

PIPERACILLIN-

TAZOBACTAM .............. 18

PIQRAY ............................... 27

pirmella ................................. 91

piroxicam .............................. 42

PLASMA-LYTE 148 ......... 105

PLASMA-LYTE A ............ 105

PLENAMINE ..................... 105

PLENVU .............................. 78

podofilox .............................. 58

polycin .................................. 93

polymyxin b sulfate .............. 16

polymyxin b sulf-trimethoprim

.......................................... 93

POMALYST ........................ 27

portia 28 ................................ 91

PORTRAZZA ...................... 27

posaconazole .......................... 9

POTASSIUM CHLORID-D5-

0.45%NACL ................... 103

potassium chloride .............. 104

POTASSIUM CHLORIDE IN

0.9%NACL ..................... 103

potassium chloride in 5 % dex

........................................ 103


5 % DEX ......................... 103

potassium chloride in lr-d5 . 103


LR-D5 ............................. 103

potassium chloride in water 104


WATER .......................... 103

potassium chloride-0.45 % nacl

........................................ 104

potassium chloride-d5-

0.2%nacl ......................... 104

POTASSIUM CHLORIDE-

D5-0.2%NACL ............... 104

potassium chloride-d5-

0.3%nacl ......................... 104

POTASSIUM CHLORIDE-

D5-0.9%NACL ............... 104

potassium citrate ................. 102

POTELIGEO ........................ 27

PRADAXA ........................... 54

pramipexole .......................... 33

PRAMOSONE ..................... 57

prasugrel ............................... 54

pravastatin ............................. 55

praziquantel .......................... 16

prazosin ................................. 52

PRED MILD ......................... 96

PRED-G ................................ 96

PRED-G S.O.P. .................... 96

prednicarbate ........................ 64

prednisolone ......................... 68

prednisolone acetate ............. 96

prednisolone sodium phosphate

.................................... 68, 96

prednisone ............................. 68

prednisone intensol ............... 68

PREFEST ............................. 86

pregabalin ............................. 32

PREMARIN ......................... 87

PREMASOL 10 % ............. 105

PREMPHASE ....................... 87

PREMPRO ........................... 87

prenatal vitamin oral tablet . 106

prevalite ................................ 55

previfem ................................ 91

PREZCOBIX ........................ 11

PREZISTA ........................... 11

PRIFTIN ............................... 16

primaquine ............................ 16

primidone .............................. 32

PRIMLEV ............................. 40

120

PRIVIGEN ........................... 82

PROAIR HFA .................... 100

PROAIR RESPICLICK ..... 100

probenecid ............................ 83

probenecid-colchicine .......... 83

procainamide ........................ 48

PROCALAMINE 3% ......... 105

prochlorperazine ................... 78

prochlorperazine edisylate.... 78

prochlorperazine maleate oral

.......................................... 78

PROCRIT ............................. 81

PROCTOFOAM HC ............ 78

procto-med hc ....................... 78

procto-pak............................. 78

proctosol hc .......................... 78

proctozone-hc ....................... 78

PROCYSBI ........................ 102

progesterone micronized ...... 87

PROGLYCEM ..................... 71

PROGRAF ........................... 27

PROLASTIN-C .................... 66

PROLENSA ......................... 95

PROLEUKIN ....................... 81

PROLIA ............................... 83

PROMACTA ........................ 54

promethazine ........................ 98

promethazine-codeine .......... 98

promethazine-dm .................. 98

promethazine-phenyleph-

codeine ............................. 98

promethegan ......................... 98

propafenone .......................... 48

propantheline ........................ 75

propranolol ........................... 52

propranolol-hydrochlorothiazid

.......................................... 52

propylthiouracil .................... 69

PROQUAD (PF) .................. 82

PROSOL 20 % ................... 105

PROTONIX .......................... 80

protriptyline .......................... 47

PULMOZYME................... 100

PURIXAN ............................ 27

PYLERA .............................. 80

pyrazinamide ........................ 16

pyridostigmine bromide ....... 36

pyrimethamine ...................... 16

Q QINLOCK ............................ 27

QNASL............................... 100

QUADRACEL (PF) ............. 82

QUARTETTE ...................... 91

QUDEXY XR....................... 32

quetiapine ............................. 47

QUILLIVANT XR ............... 47

quinapril................................ 52

quinapril-hydrochlorothiazide

.......................................... 52

quinidine gluconate .............. 49

quinidine sulfate ................... 49

quinine sulfate ...................... 16

QVAR REDIHALER ......... 100

R RABAVERT (PF) ................ 82

rabeprazole ........................... 80

raloxifene .............................. 83

ramelteon .............................. 47

ramipril ................................. 52

ranitidine hcl ......................... 80

ranolazine ............................. 56

RAPAMUNE........................ 27

rasagiline .............................. 33

RASUVO (PF) ..................... 85

RAVICTI .............................. 66

RAYOS ................................ 68

reclipsen (28) ........................ 91

RECOMBIVAX HB (PF) .... 82

RECTIV................................ 78

regonol .................................. 36

REGRANEX ........................ 58

RELENZA DISKHALER .... 11

RELISTOR ........................... 78

RELPAX .............................. 34

remedy phytoplex antifungal 62

REMODULIN ...................... 52

RENACIDIN ...................... 102

RENAGEL ........................... 66

renal caps ............................ 106

RENFLEXIS ........................ 78

reno caps ............................. 106

repaglinide ............................ 71

repaglinide-metformin .......... 71

REPATHA............................ 55

REPATHA PUSHTRONEX 55

REPATHA SURECLICK .... 55

RESTASIS............................ 94

RESTASIS MULTIDOSE ... 95

RETACRIT .......................... 81

RETEVMO ........................... 27

RETIN-A MICRO ................ 60

RETROVIR .......................... 11

REVLIMID .......................... 27

REXULTI ............................. 47

REYATAZ ........................... 11

RHOPRESSA ....................... 95

ribavirin ................................ 12

RIDAURA ............................ 85

rifabutin ................................ 16

rifampin ................................ 16

RIFATER ............................. 16

ri-gel ..................................... 78

riluzole .................................. 66

rimantadine ........................... 12

ri-mox ................................... 78

ringer's .......................... 64, 104

ringworm .............................. 62

RINVOQ ............................... 85

risedronate ............................ 84

RISPERDAL CONSTA ....... 47

risperidone ............................ 47

RITALIN LA ........................ 47

ritonavir ................................ 12

RITUXAN ............................ 28

RITUXAN HYCELA ........... 28

rivastigmine .......................... 35

rivastigmine tartrate .............. 35

rivelsa ................................... 91

rizatriptan .............................. 34

ROCKLATAN ..................... 95

ROMIDEPSIN ...................... 28

ropinirole .............................. 34

rosadan .................................. 60

rosuvastatin ........................... 55

ROTARIX ............................ 82

ROTATEQ VACCINE ......... 82

roweepra ............................... 32

roweepra xr ........................... 32

ROZLYTREK ...................... 28

RUBRACA ........................... 28

RUCONEST ....................... 100

RUXIENCE .......................... 28

RYDAPT .............................. 28

RYTARY .............................. 34

S SAFYRAL ............................ 91

salicylic acid ......................... 57

salicylic acid er-ceramides ... 57

salimez .................................. 57

salsalate ................................. 42

salvax .................................... 57

SALVAX DUO PLUS ......... 57

SAMSCA .............................. 73

SANCUSO ........................... 78

SANDIMMUNE ................... 28

121

SANDOSTATIN LAR

DEPOT ............................. 28

SANTYL .............................. 58

SAPHRIS ............................. 47

SARCLISA........................... 28

SAVELLA ............................ 85

scopolamine base.................. 78

SECUADO ........................... 47

secura antifungal .................. 62

selegiline hcl ......................... 34

selenium sulfide.................... 57

SELZENTRY ....................... 12

SEMPREX-D ....................... 98

sertraline ............................... 47

setlakin ................................. 91

sevelamer carbonate ............. 66

sevelamer hcl ........................ 66

sharobel ................................ 87

SHINGRIX (PF) ................... 82

SHOHL'S MODIFIED ....... 102

SIGNIFOR ........................... 28

siladryl sa.............................. 98

sildenafil ............................. 102

sildenafil (pulmonary arterial

hypertension) .................. 100

SILENOR ............................. 47

silver sulfadiazine ................. 58

SIMBRINZA ........................ 95

simliya (28) .......................... 91

simpesse ............................... 91

SIMPONI ............................. 85

SIMPONI ARIA ................... 85

SIMULECT .......................... 28

simvastatin ............................ 55

sirolimus ............................... 28

SIRTURO ............................. 16

SIVEXTRO .......................... 17

skin treatment ....................... 58

SKLICE ................................ 64

SKYRIZI .............................. 57

slo-niacin .............................. 55

SLO-NIACIN ....................... 55

sodium bicarbonate ............ 104

sodium chloride ...... 66, 95, 104

SODIUM CHLORIDE 0.45 %

........................................ 104

sodium chloride 0.9 % .......... 66

SODIUM CHLORIDE 0.9 %

.......................................... 66

SODIUM CHLORIDE 3 % 104

SODIUM CHLORIDE 5 % 104

sodium citrate-citric acid .... 102

sodium fluoride-pot nitrate ... 67

sodium phenylbutyrate ......... 67

sodium polystyrene (sorb free)

.......................................... 67

sodium polystyrene sulfonate

.......................................... 67

solifenacin .......................... 101

SOLIQUA 100/33 ................ 71

SOLODYN ........................... 19

SOLTAMOX ........................ 28

SOLU-CORTEF ACT-O-

VIAL (PF) ........................ 69

SOLU-MEDROL ................. 69

SOMATULINE DEPOT ...... 28

SOMAVERT ........................ 73

SORILUX ............................. 57

sorine .................................... 49

sotalol ................................... 49

sotalol af ............................... 49

SOTYLIZE ........................... 49

SPIRIVA RESPIMAT ........ 100

SPIRIVA WITH

HANDIHALER .............. 100

spironolactone ...................... 52

spironolacton-hydrochlorothiaz

.......................................... 52

sprintec (28) .......................... 91

SPRITAM ............................. 33

SPRIX ................................... 42

SPRYCEL ............................ 28

sps (with sorbitol) ................. 67

sronyx ................................... 92

ssd ......................................... 58

STAMARIL (PF) ................. 83

stavudine ............................... 12

STELARA ............................ 57

STIMATE ............................. 73

STIOLTO RESPIMAT....... 100

STIVARGA .......................... 28

streptomycin ......................... 17

STRIBILD ............................ 12

STRIVERDI RESPIMAT .. 100

SUBSYS ............................... 40

SUCRAID ............................ 78

sucralfate .............................. 80

sulfacetamide sodium ..... 57, 95

sulfacetamide sodium (acne) 61

sulfacetamide sodium-sulfur 60

sulfacetamide-prednisolone .. 95

sulfacleanse 8-4 .................... 60

sulfadiazine ........................... 19

sulfamethoxazole-trimethoprim

.......................................... 19

SULFAMYLON ................... 61

sulfasalazine ......................... 78

sulfatrim ................................ 19

sulindac ................................. 42

sumatriptan ........................... 34

sumatriptan succinate ........... 34

SUPRAX .............................. 14

SUPREP BOWEL PREP KIT

.......................................... 78

SUTENT ............................... 28

syeda ..................................... 92

SYLATRON ......................... 81

symax fastabs ........................ 75

symax-sl ................................ 75

SYMBICORT ..................... 101

SYMFI .................................. 12

SYMFI LO ............................ 12

SYMLINPEN 120 ................ 71

SYMLINPEN 60 .................. 71

SYMPAZAN ........................ 33

SYMTUZA ........................... 12

SYNAGIS ............................. 12

SYNALAR ........................... 64

SYNAREL ............................ 73

SYNERA .............................. 58

SYNERCID .......................... 17

SYNJARDY ......................... 71

SYNJARDY XR ................... 71

SYNRIBO ............................. 28

SYNTHROID ....................... 74

T TABLOID ............................. 28

TABRECTA ......................... 28

TACLONEX ......................... 57

tacrolimus ....................... 28, 59

tadalafil (pulmonary arterial

hypertension) oral tablet 20

mg ................................... 101

TAFINLAR .......................... 28

TAGRISSO ........................... 28

TALZENNA ......................... 28

tamoxifen .............................. 28

tamsulosin ........................... 102

TARGRETIN ....................... 28

tarina 24 fe ............................ 92

tarina fe 1/20 (28) ................. 92

tarina fe 1-20 eq (28) ............ 92

TASIGNA ............................. 28

tazarotene .............................. 60

tazicef ................................... 14

122

TAZORAC ........................... 60

taztia xt ................................. 52

TAZVERIK .......................... 28

TDVAX ................................ 83

TECENTRIQ ........................ 28

TECFIDERA ........................ 35

TEFLARO ............................ 14

TEKTURNA HCT ............... 52

telmisartan ............................ 52

telmisartan-amlodipine ......... 52

telmisartan-hydrochlorothiazid

.................................... 52, 53

temazepam ............................ 47

TEMODAR .......................... 28

temsirolimus ......................... 28

tencon ................................... 40

TENIVAC (PF) .................... 83

tenofovir disoproxil fumarate

.......................................... 12

terazosin ............................... 53

terbinafine hcl ......................... 9

terbutaline ........................... 101

terconazole ........................... 87

testosterone ........................... 74

testosterone cypionate .......... 74

testosterone enanthate .......... 74

TETANUS,DIPHTHERIA

TOX PED(PF) .................. 83

tetrabenazine......................... 35

tetracycline ........................... 19

texacort ................................. 64

THALOMID......................... 29

THEO-24 ............................ 101

theophylline ........................ 101

thioridazine ........................... 47

thiotepa ................................. 29

thiothixene ............................ 47

THYMOGLOBULIN ........... 83

THYROLAR-1 ..................... 74

THYROLAR-1/2 .................. 74

THYROLAR-1/4 .................. 74

THYROLAR-2 ..................... 74

THYROLAR-3 ..................... 74

tiadylt er................................ 53

tiagabine ............................... 33

TIBSOVO............................. 29

TICE BCG ............................ 83

TIGECYCLINE ................... 17

tilia fe.................................... 92

timolol maleate ............... 53, 94

TIMOPTIC OCUDOSE (PF)

.......................................... 94

tinidazole .............................. 17

TIROSINT ............................ 74

TIROSINT-SOL ................... 74

tis-u-sol pentalyte ................. 64

TIVICAY.............................. 12

TIVICAY PD ....................... 12

TIVORBEX .......................... 42

tizanidine .............................. 36

TOBI PODHALER .............. 17

TOBRADEX ........................ 96

TOBRADEX ST................... 96

tobramycin ............................ 93

tobramycin in 0.225 % nacl .. 17

tobramycin sulfate ................ 17

tobramycin-dexamethasone .. 96

TOBREX .............................. 93

TOLAK ................................ 59

tolcapone .............................. 34

tolmetin ................................. 42

tolterodine ........................... 102

TOPICORT .......................... 64

topiramate ............................. 33

toposar .................................. 29

topotecan .............................. 29

toremifene ............................. 29

TORISEL.............................. 29

torsemide .............................. 53

TOTECT ............................... 20

TOUJEO MAX U-300

SOLOSTAR ..................... 71

TOUJEO SOLOSTAR U-300

INSULIN .......................... 71

TOVIAZ ............................. 102

TPN ELECTROLYTES ..... 104

TRACLEER ....................... 101

TRADJENTA ....................... 71

tramadol ................................ 42

tramadol-acetaminophen ...... 42

trandolapril ........................... 53

trandolapril-verapamil .......... 53

tranexamic acid..................... 87

tranylcypromine.................... 47

TRAVASOL 10 % ............. 105

travel sickness (meclizine) ... 78

travoprost .............................. 96

TRAZIMERA ....................... 29

trazodone .............................. 47

TREANDA ........................... 29

TRECATOR ......................... 17

TRELEGY ELLIPTA......... 101

TRELSTAR .......................... 29

treprostinil sodium ................ 53

TRESIBA FLEXTOUCH U-

100 .................................... 71

TRESIBA FLEXTOUCH U-

200 .................................... 72

TRESIBA U-100 INSULIN . 72

tretinoin (antineoplastic) ....... 29

tretinoin microspheres .......... 60

tretinoin topical ..................... 60

TREXALL ............................ 29

tri femynor ............................ 92

triamcinolone acetonide . 64, 67,

69

triamterene ............................ 53

triamterene-hydrochlorothiazid

.......................................... 53

trianex ................................... 64

triazolam ............................... 47

triderm .................................. 64

trientine ................................. 67

TRIESENCE (PF) ................ 69

tri-estarylla ............................ 92

trifluoperazine ....................... 47

trifluridine ............................. 93

trihexyphenidyl ..................... 34

TRIJARDY XR .................... 72

tri-legest fe ............................ 92

tri-linyah ............................... 92

tri-lo-estarylla ....................... 92

tri-lo-marzia .......................... 92

tri-lo-mili .............................. 92

tri-lo-sprintec ........................ 92

trilyte with flavor packets ..... 78

trimethobenzamide ............... 78

trimethoprim ......................... 20

tri-mili ................................... 92

trimipramine ......................... 47

TRINTELLIX ....................... 47

triphrocaps .......................... 106

tri-previfem (28) ................... 92

TRIPTODUR ........................ 29

TRISENOX .......................... 29

tri-sprintec (28) ..................... 92

TRIUMEQ ............................ 12

trivora (28) ............................ 92

tri-vylibra .............................. 92

tri-vylibra lo .......................... 92

TRODELVY ......................... 29

TROGARZO ........................ 12

TROKENDI XR ................... 33

TROPHAMINE 10 % ......... 105

tropicamide ........................... 95

trospium .............................. 102

123

TRULANCE......................... 79

TRULICITY ......................... 72

TRUMENBA ....................... 83

TRUVADA .......................... 12

TRUXIMA ........................... 29

TUDORZA PRESSAIR ..... 101

TUKYSA .............................. 29

TWINRIX (PF) .................... 83

TYBOST .............................. 12

tydemy .................................. 92

TYKERB .............................. 29

TYMLOS ............................. 84

TYPHIM VI ......................... 83

TYSABRI ............................. 35

TYVASO ............................ 101

TYVASO INSTITUTIONAL

START KIT.................... 101

TYVASO REFILL KIT ..... 101

TYVASO STARTER KIT . 101

U UCERIS ................................ 79

UDENYCA .......................... 81

unithroid ............................... 74

UNITUXIN .......................... 29

UPTRAVI............................. 53

uretron d-s .......................... 102

urin ds ................................. 102

ursodiol ................................. 79

utira-c ................................. 102

UVADEX ............................. 59

V valacyclovir .......................... 12

VALCHLOR ........................ 59

valganciclovir ....................... 12

valproic acid ......................... 33

valproic acid (as sodium salt)

.......................................... 33

valsartan ............................... 53

valsartan-hydrochlorothiazide

.......................................... 53

VALTOCO ........................... 33

VANATOL LQ .................... 40

vancomycin .......................... 17

VANCOMYCIN .................. 17

VANCOMYCIN IN 0.9 %

SODIUM CHL ................. 17

VANCOMYCIN IN

DEXTROSE 5 % .............. 17

VANCOMYCIN-WATER

INJECT (PEG) ................. 17

vandazole .............................. 87

VAQTA (PF) ........................ 83

VARIVAX (PF) ................... 83

VARIZIG.............................. 83

VASCEPA ............................ 56

VECAMYL .......................... 56

VECTIBIX ........................... 29

VECTICAL .......................... 57

VELCADE ........................... 29

velivet triphasic regimen (28)

.......................................... 92

VELPHORO ......................... 67

VELTASSA.......................... 67

VELTIN................................ 60

VEMLIDY............................ 12

VENCLEXTA ...................... 29

VENCLEXTA STARTING

PACK ............................... 29

venlafaxine ........................... 47

VENTAVIS ........................ 101

verapamil .............................. 53

VEREGEN ........................... 59

VERSACLOZ ...................... 47

VERZENIO .......................... 29

V-GO 20 ............................... 72

V-GO 30 ............................... 72

V-GO 40 ............................... 72

VIBERZI .............................. 79

VIBRAMYCIN .................... 19

VICTOZA 2-PAK ................ 72

VICTOZA 3-PAK ................ 72

VIDAZA ............................... 29

vienva ................................... 92

vigabatrin .............................. 33

vigadrone .............................. 33

VIIBRYD ............................. 47

VIMPAT ............................... 33

vinblastine ............................ 29

vincasar pfs ........................... 29

vincristine ............................. 30

vinorelbine ............................ 30

VIOKACE ............................ 79

viorele (28) ........................... 92

VIRACEPT .......................... 12

VIREAD ............................... 12

VIRT-CAPS ....................... 106

virtrate-2 ............................. 102

virtussin ac ............................ 98

virtussin dac .......................... 99

VITAL-D RX ..................... 106

VITRAKVI ........................... 30

VIVITROL ........................... 42

VIZIMPRO ........................... 30

volnea (28) ............................ 92

voriconazole ........................... 9

VOSEVI ............................... 12

VOTRIENT .......................... 30

VRAYLAR ..................... 47, 48

vtol lq .................................... 40

vyfemla (28) ......................... 92

vylibra ................................... 92

VYVANSE ........................... 48

VYXEOS .............................. 30

W wal-dryl allergy .................... 99

wal-itin .................................. 99

wal-zyr (cetirizine) ............... 99

wal-zyr (ketotifen) ................ 95

warfarin ................................. 54

water for irrigation, sterile .... 67

wera (28) ............................... 92

wixela inhub ....................... 101

wymzya fe ............................ 92

X XALKORI ............................ 30

XARELTO ........................... 54

XATMEP .............................. 30

XCOPRI ............................... 33

XCOPRI MAINTENANCE

PACK ............................... 33

XCOPRI TITRATION PACK

.......................................... 33

XELJANZ ............................. 85

XELJANZ XR ...................... 85

XENICAL ............................. 64

XEOMIN .............................. 83

XERESE ............................... 59

XGEVA ................................ 20

XHANCE ........................... 101

XIAFLEX ............................. 67

XIFAXAN ............................ 17

XIGDUO XR ........................ 72

XIIDRA ................................ 95

XOFLUZA ........................... 12

XOLAIR ............................. 101

XOSPATA ............................ 30

XPOVIO ............................... 30

XTAMPZA ER ..................... 40

XTANDI ............................... 30

xulane ................................... 87

XULTOPHY 100/3.6 ........... 72

XYREM ................................ 48

Y YERVOY ............................. 30

YF-VAX (PF) ....................... 83

YONDELIS .......................... 30

124

YONSA ................................ 30

YUPELRI ........................... 101

yuvafem ................................ 87

Z ZADITOR ............................ 95

zafirlukast ........................... 101

zaleplon ................................ 48

ZALTRAP ............................ 30

ZANOSAR ........................... 30

zarah ..................................... 92

zeasorb af.............................. 62

zebutal .................................. 40

ZEJULA ............................... 30

ZELAPAR ............................ 34

ZELBORAF ......................... 30

zenatane ................................ 60

ZENPEP ............................... 79

zenzedi .................................. 48

ZENZEDI ............................. 48

ZERBAXA ........................... 14

zidovudine ............................ 12

ZIEXTENZO ........................ 81

zileuton ............................... 101

ZIOPTAN (PF) ..................... 96

ziprasidone hcl ...................... 48

ziprasidone mesylate ............ 48

ZIPSOR ................................ 42

ZIRABEV ............................. 30

ZIRGAN ............................... 93

ZOHYDRO ER .................... 40

zoledronic acid ..................... 74

zoledronic acid-mannitol-water

.................................... 67, 74

ZOLEDRONIC AC-

MANNITOL-0.9NACL ... 74

ZOLINZA ............................. 30

zolmitriptan .......................... 34

zolpidem ............................... 48

ZOLPIMIST ......................... 48

ZOMIG ................................. 34

zonisamide ............................ 33

ZONTIVITY ......................... 54

ZORTRESS .......................... 30

ZORVOLEX ......................... 42

ZOSTAVAX (PF) ................ 83

ZOSYN IN DEXTROSE (ISO-

OSM) ................................ 18

zovia 1/35e (28) .................... 92

ZTLIDO ................................ 59

ZUBSOLV ............................ 42

zumandimine (28) ................. 92

ZUPLENZ ............................ 79

ZYCLARA ........................... 59

ZYDELIG ............................. 31

ZYFLO ............................... 101

ZYKADIA ............................ 31

ZYLET ................................. 96

ZYPREXA RELPREVV ...... 48

ZYRTEC ............................... 99

ZYTIGA ............................... 31

This formulary was updated on 08/01/2020. For more recent information or other questions, please contact Leon Medical Centers Health Plans Member Services, at 305.559.5366 or toll-free 1.866.393.5366 or, for TTY users 711, we’re here from 8 a.m. to 8 p.m., seven days a week from October 1st through March 31st and Monday through Friday the rest of the year, or visit LMChealthplans.com.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. HealthSpring of Florida, Inc. operates under the assumed name of “Leon Medical Centers Health Plans” in the Miami-Dade service area. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. “Leon Medical Centers” is a registered trademark of Leon Medical Centers. Leon Medical Centers Health Plans is an HMO plan with a Medicare contract and a contract with the Florida Medicaid program. Enrollment in Leon Medical Centers Health Plans depends on contract renewal. © 2019 Cigna

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