KANSAS ACA MEMBER PRESCRIPTION DRUG LIST 2019hix 2019 bcbskc ks eff dte 07-01-2019.docx . kansas aca...

HIX 2019 BCBSKC KS eff dte 07-01-2019.docx

KANSAS ACA MEMBER

PRESCRIPTION DRUG LIST

2019

2

Table of Contents

ANTI - INFECTIVES ........................................................................................................................................ 4

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ..................................................................... 13

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ....................................................................... 20

CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 39

DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 47

DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 57

EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 60

ENDOCRINE/DIABETES .............................................................................................................................. 61

GASTROENTEROLOGY .............................................................................................................................. 79

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 85

MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 89

OBSTETRICS & GYNECOLOGY ................................................................................................................ 91

OPHTHALMOLOGY ..................................................................................................................................... 97

RESPIRATORY, ALLERGY, COUGH & COLD ..................................................................................... 101

UROLOGICALS ............................................................................................................................................ 106

VITAMINS, HEMATINICS & ELECTROLYTES ................................................................................... 108

Index ................................................................................................................................................................ 115

3

Please see the benefit schedule in your member certificate for member cost sharing associated with

Generic and Brand (Preferred and Non Preferred) drugs.

List of Abbreviations for Prescription Drugs Drug Category: 1: Generic Drug and Generic Specialty Drug 2: Preferred Drug and Non Preferred Generic Drug 3: Non Preferred Drug and Preferred Specialty Drug 4: Non Preferred Specialty Drug 5: Zero Cost Share Preventive Drug 6: Medical Service Drugs 7: Infertility Drug ACA*: Affordable Care Act is a zero cost share preventive drug. M: Maintenance drug. MSD: Medical Service Drug. This drug is only covered under the medical benefit. OTC*: Over the Counter drug. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. S: Specialty drug. SLA: Specialty Limited Availability. This prescription may be available only at certain pharmacies. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. *Your plan has tobacco use coverage through the Routine Preventive Care benefit. Tobacco use includes two tobacco cessation attempts per year (both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by an in-network health care provider without prior authorization.

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.

4

Drug Name Drug

Category Requirements

/ Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

AMBISOME 6 MSD

amphotericin b 6 MSD

ANCOBON 3

CANCIDAS 6 MSD

caspofungin 6 MSD

clotrimazole 1

CRESEMBA INTRAVENOUS

6 MSD

CRESEMBA ORAL 2

DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION

3

DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG

3

DIFLUCAN ORAL TABLET 150 MG

3 QL

ERAXIS(WATER DILUENT)

6 MSD

fluconazole in

dextrose(iso-o) 6 MSD

fluconazole in nacl

(iso-osm) 6 MSD

fluconazole oral

suspension for

reconstitution

1

fluconazole oral

tablet 100 mg, 200

mg, 50 mg

1

fluconazole oral

tablet 150 mg 1 QL

flucytosine 1

Drug Name Drug


/ Limits

griseofulvin

microsize 1

griseofulvin

ultramicrosize 1

itraconazole oral

capsule 1 QL

itraconazole oral

solution 1

ketoconazole 1

NOXAFIL 2

nystatin 1

ONMEL 3 QL

ORAVIG 3

SPORANOX 3

SPORANOX PULSEPAK

3 QL

terbinafine hcl 1

TOLSURA 3

VFEND 3

VFEND IV 6 MSD

voriconazole

intravenous 6 MSD

voriconazole oral 1

ANTIVIRALS

abacavir 1 S; QL

abacavir-lamivudine 1 S; QL

abacavir-

lamivudine-

zidovudine

1 S; QL

acyclovir 1

adefovir 1

amantadine hcl 1 M

APTIVUS 3 S; QL

atazanavir 1 S


5

Drug Name Drug


/ Limits

ATRIPLA 4 S; QL

BARACLUDE ORAL SOLUTION

2

BARACLUDE ORAL TABLET

3

BIKTARVY 3 S

cidofovir 6 MSD

CIMDUO 3 S

COMBIVIR 4 S; QL

COMPLERA 3 S; QL

CRIXIVAN 3 S; QL

CYTOVENE 6 MSD

DAKLINZA 4 PA; ST; S; SLA

DELSTRIGO 4 S

DESCOVY 3 S

didanosine 1 S; QL

DOVATO 3 S

EDURANT 3 S; QL

efavirenz 1 S; QL

EMTRIVA 3 S; QL

entecavir 1

EPCLUSA 3 PA; S; SLA

EPIVIR 4 S; QL

EPIVIR HBV ORAL SOLUTION

2

EPIVIR HBV ORAL TABLET

3 QL

EPZICOM 4 S; QL

EVOTAZ 4 S; QL

famciclovir 1 QL

FLUMADINE 3

fosamprenavir 1 S; QL

Drug Name Drug


/ Limits

FOSCAVIR 6 MSD

FUZEON 3 S; QL

GANCICLOVIR 6 MSD

ganciclovir sodium 6 MSD

GENVOYA 3 S

HARVONI 3 PA; S; SLA; QL

HEPSERA 3

INTELENCE 3 S; QL

INVIRASE 3 S; QL

ISENTRESS 3 S; QL

ISENTRESS HD 3 S

JULUCA 3 S

KALETRA ORAL SOLUTION

4 S; QL

KALETRA ORAL TABLET

3 S; QL

lamivudine oral

solution 1 S; QL

lamivudine oral

tablet 100 mg 1 QL

lamivudine oral

tablet 150 mg, 300

mg

1 S; QL

lamivudine-

zidovudine 1 S; QL

LEDIPASVIR-SOFOSBUVIR

4 PA; S; QL

LEXIVA ORAL SUSPENSION

3 S; QL

LEXIVA ORAL TABLET

4 S; QL

lopinavir-ritonavir 1 S; QL

MAVYRET 4 ST; S

nevirapine 1 S; QL


6

Drug Name Drug


/ Limits

NORVIR ORAL CAPSULE

3 S; QL

NORVIR ORAL POWDER IN PACKET

3 S

NORVIR ORAL SOLUTION

3 S; QL

NORVIR ORAL TABLET

4 S; QL

ODEFSEY 3 S

oseltamivir 1 QL

PIFELTRO 4 S

PREVYMIS INTRAVENOUS

6 MSD

PREVYMIS ORAL 2 QL

PREZCOBIX 4 S

PREZISTA 3 S; QL

RELENZA DISKHALER

2 QL

RESCRIPTOR 3 S; QL

RETROVIR INTRAVENOUS

6 MSD

RETROVIR ORAL 4 S; QL

REYATAZ ORAL CAPSULE

4 S

REYATAZ ORAL POWDER IN PACKET

3 S

ribavirin 1 S; SLA

rimantadine 1

ritonavir 1 S; QL

SELZENTRY ORAL SOLUTION

3 S

SELZENTRY ORAL TABLET 150 MG, 300 MG

3 S; QL

Drug Name Drug


/ Limits

SELZENTRY ORAL TABLET 25 MG, 75 MG

3 S

SOFOSBUVIR-VELPATASVIR

4 PA; S

SOVALDI 4 PA; S; SLA; QL

stavudine 1 S; QL

STRIBILD 3 S; QL

SUSTIVA 4 S; QL

SYMFI 3 S

SYMFI LO 3 S

SYMTUZA 4 S

SYNAGIS 6 MSD

TAMIFLU 3 QL

tenofovir disoproxil

fumarate 1 S; QL

TIVICAY ORAL TABLET 10 MG, 25 MG

3 S

TIVICAY ORAL TABLET 50 MG

3 S; QL

TRIUMEQ 3 S; QL

TRIZIVIR 4 S; QL

TROGARZO 6 PA; MSD

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG

3 S

TRUVADA ORAL TABLET 200-300 MG

3 S; QL

TYBOST 4 S; QL

valacyclovir 1 QL

VALCYTE 3


7

Drug Name Drug


/ Limits

valganciclovir 1

VALTREX 3 ST; QL

VEMLIDY 2

VIDEX 2 GRAM PEDIATRIC

3 S; QL

VIDEX EC 4 S; QL

VIEKIRA PAK 4 PA; S; SLA; QL

VIRACEPT 3 S; QL

VIRAMUNE 4 S; QL

VIRAMUNE XR 4 S; QL

VIRAZOLE 4 S; SLA

VIREAD ORAL POWDER

3 S; QL

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

3 S; QL

VIREAD ORAL TABLET 300 MG

4 S; QL

VOSEVI 3 S; SLA

XOFLUZA 2 QL

ZEPATIER 3 PA; ST; S; SLA

ZERIT 4 S; QL

ZIAGEN 4 S; QL

zidovudine 1 S; QL

ZOVIRAX 3

CEPHALOSPORINS

AVYCAZ 6 MSD

cefaclor 1

cefadroxil 1

cefazolin 6 MSD

Drug Name Drug


/ Limits

CEFAZOLIN IN 0.9% SOD CHLORIDE

6 MSD

cefazolin in dextrose

(iso-os) intravenous

piggyback 1 gram/50

ml, 2 gram/50 ml

6 MSD

CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/100 ML

6 MSD

CEFAZOLIN IN DEXTROSE 5 %

6 MSD

CEFAZOLIN IN STERILE WATER

6 MSD

cefdinir 1

cefditoren pivoxil 1

cefepime 6 MSD

cefepime in

dextrose,iso-osm 6 MSD

cefixime 1

CEFOTAN 6 MSD

cefotaxime 6 MSD

cefotetan 6 MSD

cefoxitin 6 MSD

cefpodoxime 1

cefprozil 1

ceftriaxone in

dextrose,iso-os 6 MSD

ceftriaxone injection

recon soln 1 gram,

10 gram, 2 gram,

250 mg, 500 mg

6 MSD


8

Drug Name Drug


/ Limits

CEFTRIAXONE INJECTION RECON SOLN 100 GRAM

6 MSD

cefuroxime axetil 1

cefuroxime sodium 6 MSD

cephalexin 1

CLAFORAN 6 MSD

KEFLEX 3

MAXIPIME 6 MSD

SPECTRACEF 3

SUPRAX 3

TAZICEF 6 MSD

TEFLARO 6 MSD

ERYTHROMYCINS & OTHER

MACROLIDES

azithromycin

intravenous 6 MSD

azithromycin oral 1

clarithromycin 1

DIFICID 3

e.e.s. 400 1

E.E.S. GRANULES 3

ERYPED 200 3

ERYPED 400 3

ery-tab oral

tablet,delayed

release (dr/ec) 250

mg, 333 mg

1

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

3

erythrocin (as

stearate) 1

Drug Name Drug


/ Limits

erythromycin 1

erythromycin

ethylsuccinate 1

ZITHROMAX INTRAVENOUS

6 MSD

ZITHROMAX ORAL

3

ZITHROMAX TRI-PAK

3

ZITHROMAX Z-PAK

3

MISCELLANEOUS

ANTIINFECTIVES

AEMCOLO 3

albendazole 1

ALBENZA 3 QL

ALINIA 2 QL

amikacin 6 MSD

ARAKODA 3

ARIKAYCE 2 SLA

atovaquone 1

atovaquone-

proguanil 1 QL

BENZNIDAZOLE 2 PA

BETHKIS 6 MSD

BILTRICIDE 3

CAPASTAT 6 MSD

CAYSTON 3 S; SLA; QL

chloramphenicol sod

succinate 6 MSD

chloroquine

phosphate 1

CLEOCIN HCL 3


9

Drug Name Drug


/ Limits

CLEOCIN INJECTION

6 MSD

cleocin intravenous

solution 300 mg/2 ml 6 MSD

CLEOCIN INTRAVENOUS SOLUTION 600 MG/4 ML, 900 MG/6 ML

6 MSD

CLEOCIN PEDIATRIC

3

clindamycin hcl 1

CLINDAMYCIN IN 0.9 % SOD CHLOR

6 MSD

clindamycin in 5 %

dextrose 6 MSD

clindamycin

palmitate hcl 1

clindamycin

pediatric 1

clindamycin

phosphate 6 MSD

COARTEM 2 QL

colistin

(colistimethate na) 1

COLY-MYCIN M PARENTERAL

3

CUBICIN 6 MSD

CUBICIN RF 6 MSD

CYCLOSERINE 3

dapsone 1 M

daptomycin 6 MSD

DARAPRIM 2 PA; SLA; QL

DORIPENEM 6 MSD

EMVERM 2 QL

ertapenem 6 MSD

Drug Name Drug


/ Limits

ethambutol 1

FLAGYL 3

gentamicin 6 MSD

gentamicin in nacl

(iso-osm)

intravenous

piggyback 100

mg/100 ml, 60 mg/50

ml, 70 mg/50 ml, 80

mg/100 ml, 80 mg/50

ml, 90 mg/100 ml

1

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML

2

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 120 MG/100 ML

3

gentamicin sulfate

(ped) (pf) 1

gentamicin sulfate

(pf) intravenous

solution 100 mg/10

ml

1

GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML

3

GENTAMICIN-SODIUM CITRATE

6 PA; MSD

hydroxychloroquine 1 M

imipenem-cilastatin 6 MSD

IMPAVIDO 3 S; QL

INVANZ 6 MSD

isoniazid 1


10

Drug Name Drug


/ Limits

ivermectin 1 QL

KITABIS PAK 3 S; SLA

KRINTAFEL 3

LINCOCIN 6 MSD

lincomycin 6 MSD

linezolid 1 PA

linezolid in dextrose

5% 6 MSD

MALARONE 3 QL

MALARONE PEDIATRIC

3 QL

mefloquine 1 QL

MEPRON 3

meropenem 6 MSD

MEROPENEM-0.9% SODIUM CHLORIDE

6 MSD

MERREM 6 MSD

metro i.v. 6 MSD

metronidazole 1

metronidazole in

nacl (iso-os) 6 MSD

MYAMBUTOL 3

MYCOBUTIN 3

NEBUPENT 2 QL

neomycin 1

paromomycin 1

PASER 3

PLAQUENIL 3 ST; M

polymyxin b sulfate 6 MSD

praziquantel 1

PRIFTIN 2

PRIMAQUINE 2 M; QL

Drug Name Drug


/ Limits

PRIMAXIN IV 6 MSD

pyrazinamide 1

QUALAQUIN 3 QL

quinine sulfate 1 QL

rifabutin 1

RIFADIN INTRAVENOUS

6 MSD

RIFADIN ORAL 3

RIFAMATE 3

rifampin intravenous 6 MSD

rifampin oral 1

RIFATER 3

SIRTURO 2 SLA

SIVEXTRO 3 PA

SOLOSEC 3 PA

STREPTOMYCIN 6 MSD

STROMECTOL 3 QL

SYNERCID 6 MSD

tigecycline 6 MSD

tinidazole 1 QL

TOBI 3 ST; QL

TOBI PODHALER 2 QL

tobramycin in 0.225

% nacl 1 QL

tobramycin sulfate 6 MSD

TOBRAMYCIN WITH NEBULIZER

4 S

TRECATOR 3

TYGACIL 6 MSD

VABOMERE 6 MSD

XIFAXAN 2

ZEMDRI 6 MSD


11

Drug Name Drug


/ Limits

ZYVOX INTRAVENOUS

6 MSD

ZYVOX ORAL 3 PA

PENICILLINS

amoxicillin 1

amoxicillin-pot

clavulanate 1

ampicillin 1

ampicillin sodium 6 MSD

ampicillin-sulbactam 6 MSD

AUGMENTIN ES-600

3

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML

2

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 250-62.5 MG/5 ML

3

AUGMENTIN ORAL TABLET

3

AUGMENTIN XR 3

BICILLIN C-R 6 MSD

dicloxacillin 1

MOXATAG 3

nafcillin 6 MSD

oxacillin 6 MSD

oxacillin in

dextrose(iso-osm) 6 MSD

penicillin g

potassium 6 MSD

Drug Name Drug


/ Limits

penicillin v

potassium 1

pfizerpen-g 6 MSD

PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 13.5 GRAM

6 MSD

piperacillin-

tazobactam

intravenous recon

soln 2.25 gram,

3.375 gram, 4.5

gram, 40.5 gram

6 MSD

UNASYN 6 MSD

QUINOLONES

AVELOX 3

AVELOX IN NACL (ISO-OSMOTIC)

6 MSD

BAXDELA INTRAVENOUS

6 MSD

BAXDELA ORAL 3

CIPRO 3

CIPRO XR 3

ciprofloxacin 1

ciprofloxacin

(mixture) 1

ciprofloxacin hcl 1

FACTIVE 3 QL

LEVAQUIN 3

levofloxacin in d5w 6 MSD

levofloxacin

intravenous 6 MSD

levofloxacin oral 1

moxifloxacin 1


12

Drug Name Drug


/ Limits

moxifloxacin-

sod.chloride(iso) 6 MSD

ofloxacin 1

SULFA'S & RELATED AGENTS

BACTRIM 3

BACTRIM DS 3

sulfadiazine 1

sulfamethoxazole-

trimethoprim

intravenous

6 MSD

sulfamethoxazole-

trimethoprim oral 1

sulfatrim 1

TETRACYCLINES

ACTICLATE 3 ST

avidoxy 1

coremino 1 ST; QL

demeclocycline 1

DORYX 3 ST

DORYX MPC 3 ST

doxycycline hyclate 1

doxycycline

monohydrate oral

capsule

1

DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE

3 ST

doxycycline

monohydrate oral

suspension for

reconstitution

1

Drug Name Drug


/ Limits

doxycycline

monohydrate oral

tablet

1

MINOCIN 3 ST

minocycline oral

capsule 1

minocycline oral

tablet 1

minocycline oral

tablet extended

release 24 hr 105

mg, 115 mg, 135 mg,

45 mg, 65 mg, 80

mg, 90 mg

1 ST; QL

minocycline oral

tablet extended

release 24 hr 55 mg

2 ST; QL

MINOLIRA ER 3

mondoxyne nl 1

MONODOX 3 ST

morgidox 1

NUZYRA (7 DAY WITH LOAD DOSE)

3

ORACEA 2 ST

SEYSARA 3 ST

SOLODYN 2 ST; QL

soloxide 1

TARGADOX 3 ST

tetracycline 1

VIBRAMYCIN 3 ST

XERAVA 6 MSD

XIMINO 3 ST

URINARY TRACT AGENTS

FURADANTIN 3


13

Drug Name Drug


/ Limits

HIPREX 3

MACROBID 3

MACRODANTIN 3

methenamine

hippurate 1

methenamine

mandelate 1

MONUROL 3

nitrofurantoin 1

nitrofurantoin

macrocrystal 1

nitrofurantoin

monohyd/m-cryst 1

PRIMSOL 3

trimethoprim 1

TRIMPEX 3

VANCOMYCIN

FIRVANQ 3

VANCOCIN 3

VANCOMYCIN HCL IN WATER

6 MSD

VANCOMYCIN IN 0.9 % SODIUM CHL

6 MSD

VANCOMYCIN IN DEXTROSE 5 %

6 MSD

VANCOMYCIN INJECTION

6 MSD

vancomycin

intravenous recon

soln 1,000 mg, 10

gram, 5 gram, 500

mg, 750 mg

6 MSD

Drug Name Drug


/ Limits

VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM, 250 MG

6 MSD

vancomycin oral 1

VANCOMYCIN-WATER INJECT (PEG)

6 MSD

VIBATIV 6 MSD

ANTINEOPLASTIC &

IMMUNOSUPPRESSANT

DRUGS

ADJUNCTIVE AGENTS

amifostine

crystalline 6 MSD

dexrazoxane hcl 6 MSD

ELITEK 6 MSD

ETHYOL 6 MSD

FUSILEV 6 PA; MSD

KEPIVANCE 6 MSD

KHAPZORY 6 MSD

leucovorin calcium

injection 6 MSD

leucovorin calcium

oral 1

LEVOLEUCOVORIN CALCIUM INTRAVENOUS RECON SOLN 175 MG

6 MSD

levoleucovorin

calcium intravenous

recon soln 50 mg

6 MSD

levoleucovorin

calcium intravenous

solution

6 MSD


14

Drug Name Drug


/ Limits

mesna 6 MSD

MESNEX INTRAVENOUS

6 PA; MSD

MESNEX ORAL 2

TOTECT 6 MSD

VISTOGARD 2 SLA

VORAXAZE 6 MSD

XGEVA 6 PA; MSD

ZINECARD (AS HCL)

6 MSD

ANTINEOPLASTIC &

IMMUNOSUPPRESSANT DRUGS

abiraterone 1 S; QL

ABRAXANE 6 PA; MSD

ADCETRIS 6 PA; MSD

adriamycin

intravenous recon

soln 10 mg

6 PA; MSD

ADRIAMYCIN INTRAVENOUS RECON SOLN 50 MG

6 PA; MSD

adriamycin

intravenous solution 6 MSD

adrucil 6 MSD

AFINITOR 3 S; QL

AFINITOR DISPERZ

3 S; QL

ALECENSA 3 S; SLA

ALIQOPA 6 PA; MSD

ALKERAN 3

ALKERAN (AS HCL)

6 MSD

ALUNBRIG 4 PA; S

anastrozole 1

Drug Name Drug


/ Limits

ARIMIDEX 3

AROMASIN 4 S

ARRANON 6 PA; MSD

ARSENIC TRIOXIDE

6 MSD

ARZERRA 6 MSD

ASTAGRAF XL 3 ST

AVASTIN 6 PA; MSD

azacitidine 6 MSD

AZASAN 3

azathioprine 1

BALVERSA 3

BAVENCIO 6 PA; MSD

BELEODAQ 6 MSD

BENDAMUSTINE 6 MSD

BENDEKA 6 MSD

BESPONSA 6 PA; MSD

bexarotene 1 S

bicalutamide 1

BICNU 6 PA; MSD

bleomycin 6 PA; MSD

BLINCYTO 6 PA; MSD

BORTEZOMIB 6 MSD

BOSULIF 3 S; SLA

BRAFTOVI 3

busulfan 6 MSD

BUSULFEX 6 MSD

CABOMETYX 3 S

CALQUENCE 3 SLA

CAMPTOSAR 6 PA; MSD

capecitabine 1 S

CAPRELSA 3 S; SLA; QL


15

Drug Name Drug


/ Limits

carboplatin 6 PA; MSD

carmustine 6 MSD

CASODEX 3

CELLCEPT 3

CELLCEPT INTRAVENOUS

6 MSD

cisplatin 6 PA; MSD

cladribine 6 PA; MSD

clofarabine 6 MSD

CLOLAR 6 PA; MSD

COMETRIQ 2 SLA; QL

COPIKTRA 4 SLA

COSMEGEN 6 PA; MSD

COTELLIC 3 S; SLA

cyclophosphamide

intravenous 6 MSD

cyclophosphamide

oral 1

cyclosporine

intravenous 6 MSD

cyclosporine

modified 1

cyclosporine oral 1

CYRAMZA 6 MSD

cytarabine 6 PA; MSD

cytarabine (pf)

injection solution 100 mg/5 ml (20

mg/ml)

6 MSD

cytarabine (pf)

injection solution 2

gram/20 ml (100

mg/ml), 20 mg/ml

6 PA; MSD

dacarbazine 6 PA; MSD

DACOGEN 6 PA; MSD

Drug Name Drug


/ Limits

dactinomycin 6 MSD

DARZALEX 6 MSD

daunorubicin

intravenous recon

soln

6 PA; MSD

daunorubicin


DAURISMO 4 S

decitabine 6 MSD

DOCEFREZ 6 MSD

docetaxel

intravenous solution 160 mg/16 ml (10

mg/ml), 160 mg/8 ml

(20 mg/ml), 20 mg/2

ml (10 mg/ml), 20

mg/ml (1 ml), 80

mg/4 ml (20 mg/ml),

80 mg/8 ml (10

mg/ml)

6 MSD

DOCETAXEL INTRAVENOUS SOLUTION 20 MG/ML

6 MSD

DOXIL 6 PA; MSD

doxorubicin

intravenous recon

soln

6 MSD

doxorubicin

intravenous solution 10 mg/5 ml, 2 mg/ml

6 MSD

doxorubicin

intravenous solution 20 mg/10 ml, 50

mg/25 ml

6 PA; MSD

doxorubicin, peg-

liposomal 6 PA; MSD

DROXIA 3 S

ELIGARD 3 S


16

Drug Name Drug


/ Limits

ELIGARD (3 MONTH)

3 S; QL

ELIGARD (4 MONTH)

3 S

ELIGARD (6 MONTH)

3 S

ELLENCE 6 PA; MSD

ELZONRIS 6 MSD

EMCYT 3 S

EMPLICITI 6 MSD

ENVARSUS XR 3 ST

epirubicin 6 MSD

ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML

6 MSD

ERBITUX INTRAVENOUS SOLUTION 200 MG/100 ML

6 PA; MSD

ERIVEDGE 3 S; SLA

ERLEADA 3 PA; S

ERWINAZE 6 PA; MSD

etoposide

intravenous 6 MSD

etoposide oral 1 S

EVOMELA 6 MSD

exemestane 1 S

FARESTON 4 S

FARYDAK 4 S

FASLODEX 6 PA; MSD

FEMARA 3

FIRMAGON KIT W DILUENT SYRINGE

3 PA; S; SLA

Drug Name Drug


/ Limits

floxuridine 6 PA; MSD

fludarabine 6 MSD

fluorouracil 6 MSD

flutamide 1

FOLOTYN 6 PA; MSD

GAMIFANT 2

GAZYVA 6 PA; MSD

gemcitabine

intravenous recon

soln

6 MSD

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)

6 MSD

GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML

6 MSD

gengraf 1 PA

GILOTRIF 3 S

GLEEVEC 4 S; QL

GLEOSTINE 3 S

GLIADEL WAFER 6 MSD

HALAVEN 6 PA; MSD

HERCEPTIN HYLECTA

6 PA; MSD

HERCEPTIN INTRAVENOUS RECON SOLN 150 MG

6 PA; MSD

HERCEPTIN INTRAVENOUS RECON SOLN 440 MG

6 MSD


17

Drug Name Drug


/ Limits

HYCAMTIN INTRAVENOUS

6 MSD

HYCAMTIN ORAL 3 S

HYDREA 3

hydroxyurea 1

IBRANCE 3 S

ICLUSIG 2 SLA

IDAMYCIN PFS 6 PA; MSD

idarubicin 6 PA; MSD

IDHIFA 3 PA; S

IFEX 6 PA; MSD

ifosfamide 6 MSD

ifosfamide-mesna 6 MSD

imatinib 1 S; QL

IMBRUVICA 2 SLA

IMFINZI 6 PA; MSD

IMLYGIC 6 MSD

IMURAN 3

INFUGEM 6 MSD

INLYTA 3 S; SLA; QL

IRESSA 3 S; SLA

irinotecan 6 MSD

ISTODAX 6 PA; MSD

IXEMPRA 6 PA; MSD

JAKAFI 3 S; SLA; QL

JEVTANA 6 PA; MSD

KADCYLA 6 PA; MSD

KISQALI 4 PA; S

KISQALI FEMARA CO-PACK

4 PA; S

KYMRIAH 6 MSD

KYPROLIS 6 MSD

Drug Name Drug


/ Limits

LARTRUVO 6 MSD

LENVIMA 3 S

letrozole 1

LEUKERAN 2

leuprolide 1 S

LIBTAYO 6 MSD

lipodox 6 PA; MSD

lipodox 50 6 PA; MSD

LONSURF 3 S

LORBRENA 3 S

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG

3 S; QL

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG

4 S; QL

LUPRON DEPOT (4 MONTH)

4 S

LUPRON DEPOT (6 MONTH)

4 S

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG

3 S

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG

4 S

LUPRON DEPOT-PED

3 S

LYNPARZA 3 S

LYSODREN 3 S

MARQIBO 6 PA; MSD


18

Drug Name Drug


/ Limits

MATULANE 2 SLA

megestrol oral

suspension 1

megestrol oral tablet 1 S

MEKINIST 3 S

MEKTOVI 3

melphalan 1

melphalan hcl 6 MSD

mercaptopurine 1

methotrexate sodium 1

methotrexate sodium

(pf) 1

mitomycin 6 PA; MSD

mitoxantrone 6 PA; MSD

MUTAMYCIN 6 MSD

mycophenolate

mofetil 1

mycophenolate

mofetil hcl 6 MSD

mycophenolate

sodium 1

MYFORTIC 3

MYLERAN 3 S

MYLOTARG 6 PA; MSD

NAVELBINE 6 PA; MSD

NEORAL 3 PA

NERLYNX 3 PA; S

NEXAVAR 3 S; QL

NILANDRON 4 S

nilutamide 1 S

NINLARO 3 S; SLA

NIPENT 6 PA; MSD

NULOJIX 6 MSD

Drug Name Drug


/ Limits

octreotide acetate 1 S; SLA

ODOMZO 4 S

ONCASPAR 6 PA; MSD

ONIVYDE 6 MSD

OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML

6 MSD

OPDIVO INTRAVENOUS SOLUTION 240 MG/24 ML

6 PA; MSD

oxaliplatin 6 PA; MSD

paclitaxel 6 MSD

PERJETA 6 PA; MSD

PORTRAZZA 6 MSD

POTELIGEO 6 MSD

PROGRAF ORAL CAPSULE

3

PROGRAF ORAL GRANULES IN PACKET

2

PURIXAN 2 SLA

RAPAMUNE ORAL SOLUTION

2

RAPAMUNE ORAL TABLET

3

RITUXAN 6 PA; MSD

RITUXAN HYCELA

6 PA; MSD

ROMIDEPSIN 6 MSD

RUBRACA 2 PA; SLA

RYDAPT 3 PA; S

SANDIMMUNE INTRAVENOUS

6 MSD


19

Drug Name Drug


/ Limits

SANDIMMUNE ORAL CAPSULE

3

SANDIMMUNE ORAL SOLUTION

2

SANDOSTATIN 4 PA; S; SLA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG

6 MSD

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 20 MG, 30 MG

6 PA; MSD

SIGNIFOR 6 MSD

SIGNIFOR LAR 6 MSD

SIKLOS 4 ST; S

SIMULECT 6 MSD

sirolimus 1

SOLTAMOX 3

SOMATULINE DEPOT

3 PA; S; SLA

SPRYCEL 3 S; QL

STIVARGA 3 S

SUPPRELIN LA 6 MSD

SUTENT 3 S; QL

SYLVANT 6 PA; MSD

SYNRIBO 6 MSD

TABLOID 3 S

tacrolimus 1

Drug Name Drug


/ Limits

TAFINLAR 3 S

TAGRISSO 3 S

TALZENNA 3 S

tamoxifen 1

TARCEVA 3 S; QL

TARGRETIN ORAL

4 S

TARGRETIN TOPICAL

2 PA

TASIGNA 3 S; QL

TAXOTERE 6 PA; MSD

TECENTRIQ 6 MSD

TEMODAR 4 S

temozolomide 1 S

temsirolimus 6 MSD

TENIPOSIDE 6 PA; MSD

TEPADINA 6 MSD

THALOMID 3 S

thiotepa 6 PA; MSD

TIBSOVO 2 S

toposar 6 MSD

topotecan 6 MSD

toremifene 1 S

TORISEL 6 PA; MSD

TREANDA 6 MSD

TRELSTAR 6 PA; MSD

tretinoin

(chemotherapy) 1 S

TREXALL 3

TRIPTODUR 6 MSD

TRISENOX 6 PA; MSD

TYKERB 3 S; QL


20

Drug Name Drug


/ Limits

UNITUXIN 6 MSD

VANTAS 6 PA; MSD

VECTIBIX 6 MSD

VELCADE 6 PA; MSD

VENCLEXTA 2 SLA

VENCLEXTA STARTING PACK

2 SLA

VERZENIO 3 S

VIDAZA 6 PA; MSD

vinblastine 6 PA; MSD

vincasar pfs 6 MSD

vincristine 6 PA; MSD

vinorelbine 6 MSD

VITRAKVI 3 S

VIZIMPRO 3 S

VOTRIENT 3 S; QL

VYXEOS 6 PA; MSD

XALKORI 3 PA; S; QL

XATMEP 4 ST; S

XELODA 4 S

XERMELO 2 PA; SLA

XOSPATA 3 S

XTANDI 3 S; QL

YERVOY 6 PA; MSD

YONDELIS 6 MSD

YONSA 3 PA; S

ZALTRAP 6 MSD

ZANOSAR 6 MSD

ZEJULA 2 PA; SLA

ZELBORAF 3 S; QL

ZEVALIN (Y-90) 6 MSD

ZOLADEX 6 PA; MSD

Drug Name Drug


/ Limits

ZOLINZA 3 S; QL

ZORTRESS 2

ZYDELIG 2 SLA

ZYKADIA 3 S; SLA

ZYTIGA ORAL TABLET 250 MG

4 S; QL

ZYTIGA ORAL TABLET 500 MG

3 S; QL

AUTONOMIC & CNS DRUGS,

NEUROLOGY & PSYCH

ANTICONVULSANTS

APTIOM 3

BANZEL 2

BRIVIACT 3 ST

carbamazepine 1

CARBATROL 3

CELONTIN 2

clobazam 1

clonazepam 1

DEPACON 6 MSD

DEPAKENE 3 ST

DEPAKOTE 3 ST

DEPAKOTE ER 3 ST

DEPAKOTE SPRINKLES

3 ST

DIACOMIT 2

DIASTAT 3

DIASTAT ACUDIAL

3

diazepam 1

DILANTIN 2

DILANTIN EXTENDED

3


21

Drug Name Drug


/ Limits

DILANTIN INFATABS

3

DILANTIN-125 3

divalproex 1

EPIDIOLEX 3 S

epitol 1

EQUETRO 3

ethosuximide 1

felbamate 1

FELBATOL 3

fosphenytoin 6 MSD

FYCOMPA 2

gabapentin 1

GABITRIL 3

GRALISE 2 ST; QL

GRALISE 30-DAY STARTER PACK

2 ST; QL

KEPPRA INTRAVENOUS

6 MSD

KEPPRA ORAL 3 ST

KEPPRA XR 3 ST

KLONOPIN 3

LAMICTAL 3 ST

LAMICTAL ODT 3 ST

LAMICTAL ODT STARTER (BLUE)

3 ST

LAMICTAL ODT STARTER (GREEN)

3 ST

LAMICTAL ODT STARTER (ORANGE)

3 ST

Drug Name Drug


/ Limits

LAMICTAL STARTER (BLUE) KIT

3 ST

LAMICTAL STARTER (GREEN) KIT

3 ST

LAMICTAL STARTER (ORANGE) KIT

3 ST

LAMICTAL XR 3 ST

LAMICTAL XR STARTER (BLUE)

3 ST

LAMICTAL XR STARTER (GREEN)

3 ST

LAMICTAL XR STARTER (ORANGE)

3 ST

lamotrigine 1

levetiracetam in nacl

(iso-os) 6 MSD

levetiracetam

intravenous 6 MSD

levetiracetam oral 1

LYRICA 2 ST

LYRICA CR 3 ST

MYSOLINE 3

NEURONTIN 3 ST

ONFI 3

oxcarbazepine 1

OXTELLAR XR 3 ST

PEGANONE 2

phenobarbital 1

PHENYTEK 3

phenytoin 1


22

Drug Name Drug


/ Limits

phenytoin sodium

extended 1

primidone 1

QUDEXY XR 2 ST

roweepra 1

roweepra xr 1

SABRIL 3 PA; S; SLA

SPRITAM 3 ST

subvenite 1

subvenite starter

(blue) kit 1

subvenite starter

(green) kit 1

subvenite starter

(orange) kit 1

SYMPAZAN 3

TEGRETOL 3

TEGRETOL XR 3

tiagabine 1

TOPAMAX 3 ST

topiramate oral

capsule, sprinkle 1 PA

TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR

3 ST

topiramate oral

tablet 1 PA

TRILEPTAL 3 ST

TROKENDI XR 3 ST

valproate sodium 6 MSD

valproic acid 1

valproic acid (as

sodium salt) 1

Drug Name Drug


/ Limits

vigabatrin 1 PA; S; SLA

vigadrone 1 PA; S; SLA

VIMPAT 2

ZARONTIN 3

ZONEGRAN ORAL CAPSULE 100 MG

3 PA

ZONEGRAN ORAL CAPSULE 25 MG

3

zonisamide 1 PA

ANTIPARKINSONISM AGENTS

APOKYN 3 S; SLA

AZILECT 3 M

benztropine 1

bromocriptine 1

carbidopa 1 M

carbidopa-levodopa 1 M

carbidopa-levodopa-

entacapone 1 M

COMTAN 3 M

DUOPA 6 MSD

entacapone 1 M

GOCOVRI 3 PA; ST; SLA

INBRIJA 2 M

LODOSYN 3 M

MIRAPEX 3 M

MIRAPEX ER 3 M

NEUPRO 3 ST; M

OSMOLEX ER 3 PA; ST; M

PARLODEL 3

pramipexole 1 M

rasagiline 1 M

REQUIP 3 M


23

Drug Name Drug


/ Limits

REQUIP XL 3 M

ropinirole 1 M

RYTARY 3 M

selegiline hcl 1 M

SINEMET 3 M

SINEMET CR 3 M

STALEVO 100 3 M

STALEVO 125 3 M

STALEVO 150 3 M

STALEVO 200 3 M

STALEVO 50 3 M

STALEVO 75 3 M

TASMAR 3 M

tolcapone 1 M

trihexyphenidyl 1

XADAGO 3 ST; M

ZELAPAR 3 M

MIGRAINE & CLUSTER

HEADACHE THERAPY

AIMOVIG AUTOINJECTOR

2 M; QL

AJOVY 2 ST; M; QL

almotriptan malate 1 QL

AMERGE 3 ST; QL

CAFERGOT 3

D.H.E.45 3

dihydroergotamine

injection 1

dihydroergotamine

nasal 1 QL

eletriptan 1 QL

EMGALITY PEN 2 M; QL

Drug Name Drug


/ Limits

EMGALITY SYRINGE

2 M; QL

ERGOMAR 3

ergotamine-caffeine 1

FROVA 3 ST; QL

frovatriptan 1 QL

IMITREX 3 ST; QL

IMITREX STATDOSE PEN

3 ST; QL

IMITREX STATDOSE REFILL

3 ST; QL

MAXALT 3 ST; QL

MAXALT-MLT 3 ST; QL

migergot 1

MIGRANAL 3 QL

naratriptan 1 QL

ONZETRA XSAIL 3 ST; QL

RELPAX 3 ST; QL

rizatriptan 1 QL

sumatriptan 1 QL

sumatriptan

succinate 1 QL

sumatriptan-

naproxen 1 QL

SUMAVEL DOSEPRO

3 ST; QL

TREXIMET 3 ST; QL

ZEMBRACE SYMTOUCH

3 ST; QL

zolmitriptan 1 QL

ZOMIG NASAL 2 ST; QL

ZOMIG ORAL 3 ST; QL

ZOMIG ZMT 3 ST; QL


24

Drug Name Drug


/ Limits

MISCELLANEOUS

NEUROLOGICAL THERAPY

AMPYRA 4 PA; ST; S; SLA; QL

ARICEPT 3 ST; M

AUSTEDO 3 PA; S; SLA

dalfampridine 1 PA; ST; S; SLA; QL

donepezil oral tablet 10 mg, 5 mg

1 M

donepezil oral tablet 23 mg

1 ST; M

donepezil oral

tablet,disintegrating 1 M

EXELON 3 ST; M; QL

EXONDYS 51 6 MSD

FIRDAPSE 2

galantamine oral

capsule,ext rel.

pellets 24 hr

1 M; QL

galantamine oral

solution 1 M; QL

galantamine oral

tablet 12 mg 1 M

galantamine oral

tablet 4 mg, 8 mg 1 M; QL

HORIZANT 3 ST; QL

INGREZZA 3 PA; SLA

INGREZZA INITIATION PACK

3

KEVEYIS 3 PA; SLA

memantine oral

capsule,sprinkle,er

24hr

1 M; QL

memantine oral

solution 1 M

Drug Name Drug


/ Limits

memantine oral

tablet 1 M

MEMANTINE ORAL TABLETS,DOSE PACK

3 M; QL

NAMENDA 3 ST; M

NAMENDA TITRATION PAK

3 M; QL

NAMENDA XR 3 ST; M; QL

NAMZARIC 2 ST

NUEDEXTA 2 PA

ONPATTRO 6 MSD

RADICAVA 6 MSD

RAZADYNE ER 3 ST; M; QL

RAZADYNE ORAL TABLET 12 MG

3 ST; M

RAZADYNE ORAL TABLET 4 MG, 8 MG

3 ST; M; QL

rivastigmine 1 M; QL

rivastigmine tartrate 1 M; QL

TEGSEDI 4 S

tetrabenazine 1 PA

TYSABRI 6 MSD

XENAZINE 3 PA; ST

MUSCLE RELAXANTS &

ANTISPASMODIC THERAPY

AMRIX 3 ST

atracurium 6 MSD

baclofen oral tablet 10 mg, 20 mg

1 M

BACLOFEN ORAL TABLET 5 MG

3 M

BRIDION 6 MSD


25

Drug Name Drug


/ Limits

carisoprodol 1

carisoprodol-asa-

codeine 1

carisoprodol-aspirin 1

chlorzoxazone oral

tablet 250 mg 1 PA

chlorzoxazone oral

tablet 375 mg, 500

mg, 750 mg

1

cisatracurium 6 MSD

cyclobenzaprine 1

CYCLOTENS REFILL

3

CYCLOTENS STARTER

3

DANTRIUM 3 M

dantrolene 1 M

FEXMID 3 ST

LORZONE 3 ST

meprobamate 1

MESTINON ORAL SYRUP

2 M

MESTINON ORAL TABLET

3 M

MESTINON TIMESPAN

3 M

metaxall 1

metaxalone 1

methocarbamol

injection 6 MSD

methocarbamol oral 1

NIMBEX 6 MSD

NORGESIC FORTE 3

orphenadrine citrate 1

Drug Name Drug


/ Limits

pyridostigmine

bromide 1 M

ROBAXIN INJECTION

6 MSD

ROBAXIN ORAL 3

ROBAXIN-750 3

SKELAXIN 3

SOMA 3

tizanidine 1

ZANAFLEX 3

NARCOTIC ANALGESICS

ABSTRAL 3 ST; QL

acetaminophen-caff-

dihydrocod 1 QL

acetaminophen-

codeine 1 QL

ACTIQ 3 ST; QL

ALLZITAL 3 ST; QL

APADAZ 3

ARYMO ER 3 ST; QL

ascomp with codeine 1

BELBUCA 2 PA; ST

BENZHYDROCODONE-ACETAMINOPHEN

3

BUPAP 3 ST; QL

BUPRENEX 6 MSD

buprenorphine hcl

injection 6 MSD

buprenorphine hcl

sublingual 1


26

Drug Name Drug


/ Limits

buprenorphine

transdermal patch

weekly 10 mcg/hour,

15 mcg/hour, 20

mcg/hour, 5

mcg/hour

2 ST; QL

BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 7.5 MCG/HOUR

3 ST; QL

butalbital compound

w/codeine 1

butalbital-

acetaminop-caf-cod 1 QL

butalbital-

acetaminophen 1 QL

butalbital-

acetaminophen-caff 1 QL

butalbital-aspirin-

caffeine 1

BUTRANS 3 ST; QL

codeine sulfate 1

DEMEROL 3

DEMEROL (PF) 6 MSD

DILAUDID (PF) 6 MSD

DILAUDID ORAL LIQUID

3

DILAUDID ORAL TABLET 2 MG, 4 MG

3

DILAUDID ORAL TABLET 8 MG

3 QL

diskets 1 ST

DOLOPHINE 3 ST

DSUVIA 3

DURAGESIC 3 ST

dvorah 1 QL

Drug Name Drug


/ Limits

EMBEDA 3 ST; QL

endocet 1 QL

ESGIC 3 ST; QL

EXALGO ER 3 ST; QL

fentanyl 1 ST

FENTANYL (PF)-BUPIVACAINE-NACL

6 MSD

fentanyl citrate 1 ST; QL

FENTANYL CITRATE (PF) INTRAVENOUS PT CONTROLLED ANALGESIA SYRING

6 MSD

fentanyl citrate (pf)

intravenous syringe 100 mcg/2 ml (50

mcg/ml)

6 MSD

FENTANYL CITRATE (PF) INTRAVENOUS SYRINGE 250 MCG/5 ML (50 MCG/ML), 50 MCG/ML

6 MSD

FENTANYL CITRATE (PF)-0.9%NACL INTRAVENOUS SOLUTION 10 MCG/ML, 20 MCG/ML

6 MSD

fentanyl citrate (pf)-

0.9%nacl

intravenous solution 5 mcg/ml

6 MSD

fentanyl citrate (pf)-

0.9%nacl

intravenous syringe

6 MSD


27

Drug Name Drug


/ Limits

FENTANYL-ROPIVACAINE-NACL (PF)

6 MSD

FENTORA 3 ST; QL

FIORICET 3 ST; QL

FIORINAL 3 ST

FIORINAL-CODEINE #3

3

hydrocodone-

acetaminophen 1 QL

hydrocodone-

ibuprofen 1

HYDROMORPHONE (PF) IN WATER

6 MSD

HYDROMORPHONE (PF) INJECTION SOLUTION 1 MG/ML, 4 MG/ML

6 MSD

hydromorphone (pf)

injection solution 2

mg/ml

6 MSD

HYDROMORPHONE (PF)-0.9 % NACL

6 MSD

HYDROMORPHONE IN 0.9 % NACL INJECTION

6 MSD

HYDROMORPHONE IN 0.9 % NACL INTRAVENOUS PATIENT CONTROL.ANALGESIA SOLN

6 MSD

HYDROMORPHONE IN 0.9 % NACL INTRAVENOUS PREFILLED PUMP RESERVOIR

6 MSD

Drug Name Drug


/ Limits

hydromorphone in

0.9 % nacl

intravenous pt

controlled analgesia

syring 15 mg/30 ml

(0.5 mg/ml)

6 MSD

HYDROMORPHONE IN 0.9 % NACL INTRAVENOUS PT CONTROLLED ANALGESIA SYRING 5 MG/25 ML (0.2 MG/ML), 6 MG/30 ML (0.2 MG/ML)

6 MSD

HYDROMORPHONE IN 0.9 % NACL INTRAVENOUS SOLUTION

6 MSD

HYDROMORPHONE IN 0.9 % NACL INTRAVENOUS SYRINGE

6 MSD

hydromorphone

injection solution 6 MSD

HYDROMORPHONE INJECTION SYRINGE 0.5 MG/0.5 ML

6 MSD

hydromorphone

injection syringe 1

mg/ml, 2 mg/ml, 4

mg/ml

6 MSD

HYDROMORPHONE INTRAVENOUS

6 MSD

hydromorphone oral

liquid 1

hydromorphone oral

tablet 2 mg, 4 mg 1


28

Drug Name Drug


/ Limits

hydromorphone oral

tablet 8 mg 1 QL

hydromorphone oral

tablet extended

release 24 hr

1 ST; QL

hydromorphone

rectal 1

HYSINGLA ER 2 ST; QL

IBUDONE 3

ibuprofen-oxycodone 1

KADIAN 3 ST; QL

LAZANDA 3 ST; QL

levorphanol tartrate

oral tablet 2 mg 1

LEVORPHANOL TARTRATE ORAL TABLET 3 MG

3

lorcet (hydrocodone) 1 QL

lorcet hd 1 QL

lorcet plus 1 QL

LORTAB ELIXIR 3 QL

meperidine 1

methadone 1 ST

methadose 1 ST

MITIGO (PF) 6 MSD

MORPHABOND ER

3 ST; QL

morphine (pf) in 0.9

% nacl intravenous

pt controlled

analgesia syring 30

mg/30 ml (1 mg/ml)

6 MSD

Drug Name Drug


/ Limits

MORPHINE (PF) IN 0.9 % NACL INTRAVENOUS PT CONTROLLED ANALGESIA SYRING 55 MG/55 ML (1 MG/ML)

6 MSD


% nacl intravenous

solution 1 mg/ml

6 MSD

MORPHINE (PF) IN 0.9 % NACL INTRAVENOUS SOLUTION 5 MG/ML

6 MSD


% nacl intravenous

syringe 0.5 mg/ml, 2

mg/2 ml (1 mg/ml)

6 MSD

MORPHINE (PF) IN 0.9 % NACL INTRAVENOUS SYRINGE 2 MG/ML, 4 MG/ML, 5 MG/5 ML (1 MG/ML)

6 MSD

morphine (pf)

injection 6 MSD

morphine (pf)

intravenous patient

control.analgesia

soln

6 MSD

MORPHINE (PF) INTRAVENOUS SYRINGE

6 MSD

morphine

concentrate 1

MORPHINE IN 0.9 % SODIUM CHLOR

6 MSD

morphine injection 6 MSD


29

Drug Name Drug


/ Limits

MORPHINE INTRAMUSCULAR

6 MSD

morphine

intravenous pt

controlled analgesia

syring

6 MSD

morphine

intravenous solution 10 mg/ml, 100 mg/4

ml, 25 mg/ml, 250

mg/10 ml, 50 mg/ml

6 MSD

MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML

6 MSD

morphine

intravenous syringe 10 mg/ml, 2 mg/ml, 4

mg/ml

6 MSD

MORPHINE INTRAVENOUS SYRINGE 8 MG/ML

6 MSD

morphine oral

capsule, er

multiphase 24 hr

1 ST; QL

morphine oral

capsule,extend.relea

se pellets

1 ST; QL

morphine oral

solution 1

morphine oral tablet 1

morphine oral tablet

extended release 1 ST; QL

morphine rectal 1

MS CONTIN 3 ST; QL

NALOCET 3 QL

NORCO 3 ST; QL

Drug Name Drug


/ Limits

OPANA 3

OXAYDO ORAL TABLET, ORAL ONLY 5 MG

3 QL

OXAYDO ORAL TABLET, ORAL ONLY 7.5 MG

3

oxycodone oral

capsule 1 QL

oxycodone oral

concentrate 1 QL

oxycodone oral

solution 1

oxycodone oral

tablet 10 mg, 20 mg 1

oxycodone oral

tablet 15 mg, 30 mg,

5 mg

1 QL

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

3 ST; QL

oxycodone-

acetaminophen 1 QL

oxycodone-aspirin 1

OXYCONTIN 2 ST; QL

oxymorphone oral

tablet 1

oxymorphone oral

tablet extended

release 12 hr

1 ST; QL

PERCOCET 3 QL

phrenilin forte(with

caffeine) 1 QL

PRIMLEV 3 QL

PROBUPHINE 6 MSD


30

Drug Name Drug


/ Limits

ROXICODONE 3 QL

ROXYBOND ORAL TABLET, ORAL ONLY 15 MG, 30 MG

3

ROXYBOND ORAL TABLET, ORAL ONLY 5 MG

3 QL

SUBLOCADE 6 MSD

SUBSYS 3 ST; QL

tencon 1 QL

TREZIX 3 QL

TYLENOL-CODEINE #3

3 QL

TYLENOL-CODEINE #4

3 QL

VANATOL LQ 3 ST; QL

VANATOL S 3 ST; QL

vicodin 1 QL

vicodin es 1 QL

vicodin hp 1 QL

XTAMPZA ER 3 ST; QL

xylon 10 1

zebutal 1 QL

ZOHYDRO ER 3 ST; QL

NON-NARCOTIC ANALGESICS

adult aspirin

regimen 5 M; ACA; OTC

ANAPROX DS 3 ST; M

ARTHROTEC 50 3 ST; M

ARTHROTEC 75 3 ST; M

aspir-81 5 M; ACA; OTC

aspirin low dose 5 M; ACA; OTC

aspirin oral tablet 5 ACA; OTC

Drug Name Drug


/ Limits

aspirin oral

tablet,chewable 5 M; ACA; OTC

aspirin oral

tablet,delayed

release (dr/ec) 325

mg

5 ACA; OTC

aspirin oral

tablet,delayed

release (dr/ec) 81

mg

5 M; ACA; OTC

aspir-low 5 M; ACA; OTC

aspir-trin 5 ACA; OTC

bayer aspirin 5 ACA; OTC

BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG

3 QL

BUNAVAIL BUCCAL FILM 6.3-1 MG

3

buprenorphine-

naloxone sublingual

film 12-3 mg

1

buprenorphine-

naloxone sublingual

film 2-0.5 mg, 4-1

mg, 8-2 mg

1 QL

buprenorphine-

naloxone sublingual

tablet 2-0.5 mg

1 QL

buprenorphine-

naloxone sublingual

tablet 8-2 mg

1

butorphanol tartrate

injection 6 MSD

butorphanol tartrate

nasal 1 QL

CAMBIA 3 ST; QL

CAPSFENAC PAK 3 ST; M


31

Drug Name Drug


/ Limits

CELEBREX 3 ST; M; QL

celecoxib 1 ST; M; QL

children's aspirin 5 M; ACA; OTC

choline,magnesium

salicylate 1

CONZIP 3 ST; QL

DAYPRO 3 ST; M

DICLO GEL 3 ST; M

DICLO GEL-XRYLIX SHEET

3 ST; M

DICLOFENAC EPOLAMINE

3 ST; QL

diclofenac potassium 1

diclofenac sodium

oral 1 M

diclofenac sodium

topical drops 1 M; QL

diclofenac sodium

topical gel 1 ST; M; QL

diclofenac-

misoprostol 1 M

DICLOFEX DC 3 ST; M

DICLOFONO 3 ST; M

DICLOPAK 3 ST; M

DICLOPR 3 ST; M

diflunisal 1 M

DISALCID 3

DITHOL 3 ST; M

DUEXIS 3 ST; M; QL

e.c. prin 5 ACA; OTC

EC-NAPROSYN 3 ST; M

ecotrin 5 ACA; OTC

ecotrin low strength 5 M; ACA; OTC

Drug Name Drug


/ Limits

etodolac 1 M

EUFLEXXA 6 MSD

EVZIO 3 ST

FELDENE 3 ST; M

FENOPROFEN ORAL CAPSULE

3 ST; M

fenoprofen oral

tablet 1 M

FENORTHO 3 ST; M

FLECTOR 2 ST; QL

flurbiprofen 1 M

FROTEK 3 ST; M

ibu 1 M

ibuprofen 1 M

INDOCIN 3 ST

indomethacin 1

ketoprofen 1 M

ketorolac injection 6 MSD

ketorolac

intramuscular 6 MSD

ketorolac oral 1 QL

LEXIXRYL 3 ST; M

lite coat aspirin 5 ACA; OTC

LODINE 3 ST; M

LUCEMYRA 3 ST

meclofenamate 1 M

mefenamic acid 1

meloxicam oral

suspension 1 M

meloxicam oral

tablet 15 mg 1 M

meloxicam oral

tablet 7.5 mg 1 M; QL


32

Drug Name Drug


/ Limits

MOBIC ORAL TABLET 15 MG

3 ST; M

MOBIC ORAL TABLET 7.5 MG

3 ST; M; QL

nabumetone 1 M

nalbuphine 6 MSD

NALFON 3 ST; M

naloxone 1

naltrexone 1

NAPRELAN CR 3 ST; M

NAPROSYN 3 ST; M

naproxen 1 M

naproxen sodium 1 M

NARCAN 2

NUCYNTA 2 QL

NUCYNTA ER 2 ST; QL

NUDROXIPAK 3 ST

oxaprozin 1 M

PENNSAID 3 ST; M; QL

pentazocine-

naloxone 1

piroxicam 1 M

QMIIZ ODT 3 ST; M

READYSHARP KETOROLAC

6 MSD

salsalate 1

SPRIX 3 ST; SLA; QL

st joseph aspirin 5 M; ACA; OTC

SUBOXONE SUBLINGUAL FILM 12-3 MG

2

Drug Name Drug


/ Limits

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG

2 QL

sulindac 1 M

TALWIN 6 MSD

TIVORBEX 3 ST; M

tolmetin 1 M

TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 17-83

3 ST; QL

TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 25-75

3 ST; QL

tramadol oral tablet 1 QL

tramadol oral tablet

extended release 24

hr

1 ST; QL

tramadol oral tablet,

er multiphase 24 hr 1 ST; QL

tramadol-

acetaminophen 1 QL

ULTRACET 3 QL

ULTRAM 3 QL

VIMOVO 3 ST; M; QL

VIVITROL 6 MSD

VIVLODEX 3 ST; M

VOLTAREN 3 ST; M; QL

VOLTAREN-XR 3 ST; M

ZIPSOR 3 ST; QL

ZORVOLEX 3 ST; M; QL


33

Drug Name Drug


/ Limits

ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 11.4-2.9 MG, 2.9-0.71 MG, 8.6-2.1 MG

2

ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 5.7-1.4 MG

2 QL

PSYCHOTHERAPEUTIC DRUGS

ABILIFY 3 ST; QL

ABILIFY MAINTENA

6 MSD

ABILIFY MYCITE ORAL TABLET WITH SENSOR AND PATCH 10 MG, 15 MG, 5 MG

3

ABILIFY MYCITE ORAL TABLET WITH SENSOR AND PATCH 2 MG, 20 MG, 30 MG

3 QL

ADASUVE 3

ADDERALL 3 ST; QL

ADDERALL XR 3 ST; QL

ADDYI 3 PA

ADZENYS ER 3 ST

ADZENYS XR-ODT

3 ST

alprazolam 1

alprazolam intensol 1

AMBIEN 3 ST; QL

AMBIEN CR 3 ST; QL

amitriptyline 1

Drug Name Drug


/ Limits

amitriptyline-

chlordiazepoxide 1

amoxapine 1

amphetamine sulfate 1 PA

ANAFRANIL 3

APLENZIN 3 ST; M; QL

APTENSIO XR 3 ST

aripiprazole oral

solution 1

aripiprazole oral

tablet 1 QL

aripiprazole oral

tablet,disintegrating 1 QL

ARISTADA 6 MSD

ARISTADA INITIO 6 MSD

armodafinil 1 PA; QL

ATIVAN INJECTION

6 MSD

ATIVAN ORAL 3

atomoxetine 1 QL

BELSOMRA 3 ST

BRISDELLE 3 ST; M; QL

bupropion hcl oral

tablet 1 M

bupropion hcl oral

tablet extended

release 24 hr 150 mg

1 M

bupropion hcl oral

tablet extended

release 24 hr 300 mg

1 M; QL

BUPROPION HCL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG

3 ST; M; QL


34

Drug Name Drug


/ Limits

bupropion hcl oral

tablet sustained-

release 12 hr

1 M; QL

buspirone 1 M

BUTISOL 3

CELEXA 3 ST; M; QL

chlordiazepoxide hcl 1

chlorpromazine 1

citalopram 1 M

clomipramine 1

clonidine hcl 1 QL

clorazepate

dipotassium 1

clozapine oral tablet 1

clozapine oral

tablet,disintegrating 100 mg, 12.5 mg, 25

mg

1

CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG

3

CLOZARIL 3

CONCERTA 3 ST; QL

COTEMPLA XR-ODT

3 ST

CYMBALTA 3 ST; M; QL

DAYTRANA 2 ST; QL

desipramine 1

DESOXYN 3 QL

DESVENLAFAXINE

3 ST; M; QL

desvenlafaxine

succinate 1 M; QL

Drug Name Drug


/ Limits

DEXEDRINE SPANSULE

3 ST; QL

dexmethylphenidate 1 QL

dextroamphetamine 1 QL

dextroamphetamine-

amphetamine 1 QL

diazepam injection 6 MSD

diazepam intensol 1

diazepam oral 1

DORAL 3

doxepin 1

duloxetine oral

capsule,delayed

release(dr/ec) 20

mg, 30 mg, 60 mg

1 M; QL

duloxetine oral

capsule,delayed

release(dr/ec) 40 mg

1 M

DYANAVEL XR 3 ST

EDLUAR 3 ST; QL

EFFEXOR XR 3 ST; M; QL

EMSAM 3 M; QL

ergoloid 1 M

escitalopram oxalate 1 M

estazolam 1

eszopiclone 1 QL

EVEKEO 3 PA

FANAPT 3 QL

FAZACLO 3

FETZIMA 2 ST; M; QL

flumazenil 6 MSD

fluoxetine oral

capsule 1 M; QL


35

Drug Name Drug


/ Limits

fluoxetine oral

capsule,delayed

release(dr/ec)

1 M; QL

fluoxetine oral

solution 1 M

fluoxetine oral tablet 10 mg, 20 mg

1 M; QL

fluoxetine oral tablet 60 mg

1

fluphenazine

decanoate 6 MSD

fluphenazine hcl 1

flurazepam 1

fluvoxamine 1 M; QL

FOCALIN 3 QL

FOCALIN XR 3 ST; QL

FORFIVO XL 3 ST; M; QL

GEODON INTRAMUSCULAR

6 MSD

GEODON ORAL 3 QL

guanfacine 1 QL

guanidine 1

HALCION 3

HALDOL 6 MSD

HALDOL DECANOATE

3

haloperidol 1

haloperidol

decanoate 1

haloperidol lactate

injection 6 MSD

haloperidol lactate

oral 1

HETLIOZ 4 S; SLA; QL

Drug Name Drug


/ Limits

imipramine hcl 1

imipramine pamoate 1

INTERMEZZO 3 ST; QL

INTUNIV ER 3 ST; QL

INVEGA 3 QL

KAPVAY 3 ST; QL

KHEDEZLA 3 ST; M; QL

LATUDA 2 QL

LEXAPRO 3 ST; M; QL

lithium carbonate 1

lithium citrate 1

LITHOBID 3

LORAZEPAM IN 0.9% SOD CHLORIDE

6 MSD

LORAZEPAM IN DEXTROSE 5 %

6 MSD

lorazepam injection 6 MSD

lorazepam intensol 1

lorazepam oral 1

loxapine succinate 1

LUNESTA 3 ST; QL

maprotiline 1

MARPLAN 3 M

metadate er 1 QL

methamphetamine 1 QL

METHYLIN 3 QL

methylphenidate hcl

oral capsule, er

biphasic 30-70 10

mg, 30 mg, 40 mg,

50 mg, 60 mg

1


36

Drug Name Drug


/ Limits

methylphenidate hcl

oral capsule, er

biphasic 30-70 20

mg

1 QL

methylphenidate hcl

oral capsule,er

biphasic 50-50 10

mg, 30 mg, 40 mg,

60 mg

1

methylphenidate hcl

oral capsule,er

biphasic 50-50 20

mg

1 QL

methylphenidate hcl

oral solution 1 QL

methylphenidate hcl

oral tablet 1 QL

methylphenidate hcl

oral tablet extended

release 10 mg

1

methylphenidate hcl


release 20 mg

1 QL

methylphenidate hcl


release 24hr 18 mg,

27 mg, 36 mg, 54 mg

1 QL

METHYLPHENIDATE HCL ORAL TABLET EXTENDED RELEASE 24HR 72 MG

3 ST

methylphenidate hcl

oral tablet,chewable 1 QL

midazolam 6 MSD

midazolam (pf) 6 MSD

midazolam (pf) in

0.9 % nacl

intravenous solution

6 MSD

Drug Name Drug


/ Limits

MIDAZOLAM (PF) IN 0.9 % NACL INTRAVENOUS SYRINGE

6 MSD

MIDAZOLAM IN 0.9 % SOD CHLORID

6 MSD

MIDAZOLAM IN DEXTROSE 5 %

6 MSD

mirtazapine 1 QL

modafinil 1 PA; QL

molindone 1

MYDAYIS 2 ST

NARDIL 3 M

nefazodone 1 M

NORPRAMIN 3

nortriptyline 1

NUPLAZID 4 S; SLA

NUVIGIL 3 PA; ST; QL

olanzapine

intramuscular 6 MSD

olanzapine oral 1 QL

olanzapine-

fluoxetine 1

ORAP 3

oxazepam 1

paliperidone 1 QL

PAMELOR 3

PARNATE 3 M

paroxetine hcl 1 M; QL

paroxetine

mesylate(menop.sym

)

1 M; QL

PAXIL CR 3 ST; M; QL


37

Drug Name Drug


/ Limits

PAXIL ORAL SUSPENSION

3 ST; M

PAXIL ORAL TABLET

3 ST; M; QL

perphenazine 1

perphenazine-

amitriptyline 1

PERSERIS 3

PEXEVA 3 ST; M; QL

phenelzine 1 M

pimozide 1

PRISTIQ 3 ST; M; QL

procentra 1 QL

protriptyline 1

PROVIGIL ORAL TABLET 100 MG

3 ST; QL

PROVIGIL ORAL TABLET 200 MG

3 PA; QL

PROZAC ORAL CAPSULE 10 MG, 40 MG

3 ST; M; QL

PROZAC ORAL CAPSULE 20 MG

3 ST; M

QUAZEPAM 3

quetiapine oral

tablet 100 mg, 25

mg, 50 mg

1 PA; QL

quetiapine oral

tablet 200 mg, 300

mg, 400 mg

1 QL

quetiapine oral

tablet extended

release 24 hr

1 QL

QUILLICHEW ER 2 ST

QUILLIVANT XR 2 ST; QL

RELEXXII 3 ST

Drug Name Drug


/ Limits

REMERON 3 QL

REMERON SOLTAB

3 QL

RESTORIL 3

REXULTI 3 QL

RISPERDAL ORAL SOLUTION

3

RISPERDAL ORAL TABLET

3 QL

risperidone oral

solution 1

risperidone oral

tablet 1 QL

risperidone oral

tablet,disintegrating 1 QL

RITALIN 3 QL

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 30 MG, 40 MG

3 ST

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 20 MG

3 ST; QL

ROZEREM 2 ST; QL

SAPHRIS 3 QL

SARAFEM 3 ST; M; QL

seconal sodium 1

SEROQUEL ORAL TABLET 100 MG, 25 MG, 50 MG

3 PA; ST; QL

SEROQUEL ORAL TABLET 200 MG, 300 MG, 400 MG

3 ST; QL

SEROQUEL XR 3 ST; QL


38

Drug Name Drug


/ Limits

sertraline oral

concentrate 1 M

sertraline oral tablet 1 M; QL

SILENOR 3 ST; QL

SPRAVATO 4 S; SLA

STRATTERA 3 ST; QL

SURMONTIL 3

SYMBYAX 3

temazepam 1

thioridazine 1

thiothixene 1

TOFRANIL 3

TRANXENE T-TAB

3

tranylcypromine 1 M

trazodone 1

triazolam 1

trifluoperazine 1

trimipramine 1

TRINTELLIX 3 ST; QL

VALIUM 3 ST

venlafaxine oral

capsule,extended

release 24hr 150 mg

1 M

venlafaxine oral

capsule,extended

release 24hr 37.5

mg, 75 mg

1 M; QL

venlafaxine oral

tablet 1 M; QL

venlafaxine oral

tablet extended

release 24hr

1 ST; M; QL

VERSACLOZ 3

Drug Name Drug


/ Limits

VIIBRYD ORAL TABLET

2 ST; M; QL

VIIBRYD ORAL TABLETS,DOSE PACK

2 ST; QL

VRAYLAR 3

VYVANSE 2 ST; QL

WELLBUTRIN SR 3 ST; M; QL

WELLBUTRIN XL 3 ST; M; QL

XANAX 3 ST

XANAX XR 3 ST

XYREM 3 PA; S; SLA; QL

zaleplon 1 QL

zenzedi oral tablet 10 mg, 5 mg

1 QL

ZENZEDI ORAL TABLET 15 MG

3 QL

ZENZEDI ORAL TABLET 2.5 MG, 20 MG, 30 MG, 7.5 MG

3

ziprasidone hcl 1 QL

ZOLOFT ORAL CONCENTRATE

3 ST; M

ZOLOFT ORAL TABLET

3 ST; M; QL

zolpidem 1 QL

ZOLPIMIST 3 ST; QL

ZYPREXA INTRAMUSCULAR

6 MSD

ZYPREXA ORAL 3 QL

ZYPREXA ZYDIS 3 QL


39

Drug Name Drug


/ Limits

CARDIOVASCULAR,

HYPERTENSION & LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone 1 M

BETAPACE 3 M

BETAPACE AF 3 M

disopyramide

phosphate 1 M

dofetilide 1

flecainide 1 M

mexiletine 1 M

MULTAQ 3 M

NORPACE 3 M

NORPACE CR 3 M

pacerone 1 M

procainamide 6 MSD

propafenone 1 M

quinidine gluconate 1 M

quinidine sulfate 1 M

RYTHMOL SR 3 M

sotalol 1 M

sotalol af 1 M

SOTYLIZE 2 M

TIKOSYN 3 ST

ANTIHYPERTENSIVE THERAPY

ACCUPRIL 3 M

ACCURETIC 3 M

acebutolol 1 M

ADALAT CC 3 ST; M

afeditab cr 1 M

ALDACTAZIDE 3 M

Drug Name Drug


/ Limits

ALDACTONE 3 M

aliskiren 1 M

ALTACE 3 M

amiloride 1 M

amiloride-

hydrochlorothiazide 1 M

amlodipine 1 M

amlodipine-

benazepril 1 M

amlodipine-

olmesartan 1 M

amlodipine-

valsartan 1 M

amlodipine-

valsartan-hcthiazid 1 M

ATACAND 3 ST; M

ATACAND HCT 3 ST; M

atenolol 1 M

atenolol-

chlorthalidone 1 M

AVALIDE 3 ST; M

AVAPRO 3 ST; M

AZOR 3 ST; M

benazepril 1 M

benazepril-


BENICAR 3 ST; M

BENICAR HCT 3 ST; M

betaxolol 1 M

BIDIL 3 M

bisoprolol fumarate 1 M

bisoprolol-


BREVIBLOC 6 MSD


40

Drug Name Drug


/ Limits

BREVIBLOC IN NACL (ISO-OSM)

6 MSD

bumetanide 1 M

BYSTOLIC 2 ST; M

CALAN 3 ST; M

CALAN SR 3 ST; M

candesartan 1 M

candesartan-

hydrochlorothiazid 1 M

captopril 1 M

captopril-


CARDIZEM 3 M

CARDIZEM CD 3 M

CARDIZEM LA 3 M

CARDURA 3 ST; M; QL

CARDURA XL 3 M; QL

CAROSPIR 3 ST; M

cartia xt 1 M

carvedilol 1 M

carvedilol phosphate 1 M

CATAPRES 3 M

CATAPRES-TTS-1 3 M; QL



chlorothiazide 1 M

chlorothiazide

sodium 6 MSD

chlorthalidone 1 M

clonidine 1 M; QL

clonidine hcl 1 M

COREG 3 ST; M

COREG CR 3 ST; M

Drug Name Drug


/ Limits

CORGARD 3 ST; M

COZAAR 3 ST; M

DEMADEX 3 M

DEMSER 2

DIBENZYLINE 3

diltiazem 1 M

dilt-xr 1 M

DIOVAN 3 ST; M

DIOVAN HCT 3 ST; M

DIURIL 3 M

DIURIL IV 6 MSD

doxazosin 1 M; QL

DUTOPROL 3 ST; M

DYAZIDE 3 M

DYRENIUM 3 M

EDARBI 2 ST; M

EDARBYCLOR 2 ST; M

EDECRIN 3 M

enalapril maleate 1 M

enalaprilat 6 MSD

enalapril-


EPANED 3 M

eplerenone 1 M

epoprostenol

(glycine) 6 MSD

eprosartan 1 M

esmolol 6 MSD

ethacrynate sodium 6 MSD

ethacrynic acid 1 M

EXFORGE 3 ST; M

EXFORGE HCT 3 ST; M


41

Drug Name Drug


/ Limits

felodipine 1 M

FLOLAN 6 MSD

fosinopril 1 M

fosinopril-


FUROSEMIDE IN 0.9 % NACL

6 MSD

furosemide injection 6 MSD

furosemide oral 1 M

guanfacine 1 M

HEMANGEOL 3 SLA

hydralazine injection 6 MSD

hydralazine oral 1 M


HYZAAR 3 ST; M

indapamide 1 M

INDERAL LA 3 ST; M

INDERAL XL 3 ST; M

INNOPRAN XL 3 ST; M

INSPRA 3 M

irbesartan 1 M

irbesartan-


isradipine 1 M

KAPSPARGO SPRINKLE

3 ST; M

LABETALOL IN DEXTROSE 5 %

6 MSD

labetalol


Drug Name Drug


/ Limits

labetalol

intravenous syringe 20 mg/4 ml (5

mg/ml), 25 mg/5 ml

(5 mg/ml)

6 MSD

LABETALOL INTRAVENOUS SYRINGE 50 MG/10 ML (5 MG/ML)

6 MSD

labetalol oral 1 M

LASIX 3 M

lisinopril 1 M

lisinopril-


LOPRESSOR INTRAVENOUS

6 MSD

LOPRESSOR ORAL

3 ST; M

losartan 1 M

losartan-


LOTENSIN 3 M

LOTENSIN HCT 3 M

LOTREL 3 ST; M

matzim la 1 M

MAXZIDE 3 M

MAXZIDE-25MG 3 M

methyclothiazide 1 M

methyldopa 1 M

methyldopa-


methyldopate 6 MSD

metolazone 1 M

metoprolol succinate 1 M


42

Drug Name Drug


/ Limits

METOPROLOL SU-HYDROCHLOROTHIAZ

3 ST; M

metoprolol ta-

hydrochlorothiaz 1 M

metoprolol tartrate

intravenous 6 MSD

metoprolol tartrate

oral 1 M

MICARDIS 3 ST; M

MICARDIS HCT 3 ST; M

MICROZIDE 3 M

MINIPRESS 3 M

minoxidil 1 M

moexipril 1 M

nadolol 1 M

nadolol-

bendroflumethiazide 1 M

nicardipine 1 M

nifedipine 1 M

nimodipine 1

nisoldipine 1 M

NORVASC 3 ST; M

NYMALIZE 3

olmesartan 1 M

olmesartan-

amlodipin-hcthiazid 1 M

olmesartan-


ORENITRAM 4 PA; S; SLA

osmitrol 20 % 6 MSD

perindopril

erbumine 1 M

Drug Name Drug


/ Limits

phenoxybenzamine 1

phentolamine 6 MSD

pindolol 1 M

prazosin 1 M

PRESTALIA 3 ST; M

PRINIVIL 3 M

PROCARDIA 3 ST; M

PROCARDIA XL 3 ST; M

propranolol 1 M

propranolol-


QBRELIS 3 M

quinapril 1 M

quinapril-


ramipril 1 M

REMODULIN 6 MSD

SODIUM EDECRIN

6 MSD

spironolactone 1 M

spironolacton-

hydrochlorothiaz 1 M

SULAR 3 ST; M

TARKA 3 M

taztia xt 1 M

TEKTURNA 2 ST; M

TEKTURNA HCT 2 ST; M

telmisartan 1 M

telmisartan-

amlodipine 1 M

telmisartan-


TENORETIC 100 3 ST; M


43

Drug Name Drug


/ Limits

TENORETIC 50 3 ST; M

TENORMIN 3 ST; M

terazosin 1 M; QL

TIAZAC 3 M

timolol maleate 1 M

TOPROL XL 3 ST; M

torsemide 1 M

trandolapril 1 M

trandolapril-

verapamil 1 M

treprostinil sodium 6 MSD

triamterene-


TRIBENZOR 3 ST; M

TWYNSTA 3 ST; M

UPTRAVI 3 PA; S; SLA

valsartan 1 M

valsartan-


VASERETIC 3 M

VASOTEC 3 M

veletri 6 MSD

verapamil 1 M

VERELAN 3 ST; M

VERELAN PM 3 ST; M

ZESTORETIC 3 M

ZESTRIL 3 M

ZIAC 3 ST; M

CARDIAC GLYCOSIDES

digitek 1 M

digox 1 M

digoxin injection 6 MSD

Drug Name Drug


/ Limits

digoxin oral 1 M

LANOXIN INJECTION

6 MSD

LANOXIN ORAL 3 M

LANOXIN PEDIATRIC

6 MSD

COAGULATION THERAPY

ADVATE 6 MSD

ADYNOVATE 6 MSD

AFSTYLA 6 MSD

AGGRENOX 3 M

ALPHANATE 6 MSD

ALPHANINE SD 6 MSD

ALPROLIX 6 MSD

AMICAR ORAL SOLUTION

2

AMICAR ORAL TABLET

3

aminocaproic acid 1

ANDEXXA 6 MSD

ANGIOMAX 6 MSD

ARGATROBAN 6 MSD

ARGATROBAN IN 0.9 % SOD CHLOR

6 MSD

ARGATROBAN IN NACL (ISO-OS)

6 MSD

ARIXTRA 3

aspirin-dipyridamole 1 M

BENEFIX 6 MSD

BEVYXXA 3 QL

BIVALIRUDIN 6 MSD

BIVALIRUDIN-0.9 % SODIUM CHLOR

6 MSD


44

Drug Name Drug


/ Limits

BRILINTA 2 M

CABLIVI 6 MSD

CEPROTIN (BLUE BAR)

6 MSD

CEPROTIN (GREEN BAR)

6 MSD

cilostazol 1 M

clopidogrel oral

tablet 300 mg 1 QL

clopidogrel oral

tablet 75 mg 1 M; QL

COAGADEX 6 MSD

CORIFACT 6 MSD

COUMADIN 3

DEFITELIO 6 MSD

dipyridamole 1 M

DOPTELET (15 TAB PACK)

3 PA; S

EFFIENT 3 M

ELIQUIS ORAL TABLET

2 PA; M

ELIQUIS ORAL TABLETS,DOSE PACK

2 PA

ELOCTATE 6 MSD

enoxaparin

subcutaneous

solution

6 MSD

enoxaparin

subcutaneous

syringe

1

FEIBA NF 6 MSD

FIBRYGA 6 MSD

fondaparinux 1

FRAGMIN 2

Drug Name Drug


/ Limits

HELIXATE FS 6 MSD

HEMLIBRA 6 MSD

HEMOFIL M HIGH 6 MSD

HEMOFIL M LOW 6 MSD

HEMOFIL M MID 6 MSD

HEMOFIL M SUPER HIGH

6 MSD

hep flush-10 (pf) 1

heparin (porcine) 1

HEPARIN (PORCINE) IN 0.9% NACL

6 MSD

heparin (porcine) in

5 % dex 6 MSD

heparin (porcine) in

nacl (pf) 1

heparin

flush(porcine)-

0.9nacl

6 MSD

heparin lock flush 1

heparin lock flush

(porcine) 1

heparin

lockflush(porcine)(pf

)

1

HEPARIN(PORCINE) IN 0.45% NACL

6 MSD

heparin, porcine (pf)

injection 1

heparin, porcine (pf)

intravenous 1

HEPARIN, PORCINE (PF) SUBCUTANEOUS

3

HUMATE-P 6 MSD

IDELVION 6 MSD


45

Drug Name Drug


/ Limits

IXINITY 6 MSD

jantoven 1

JIVI 6 MSD

KOATE 6 MSD

KOGENATE FS 6 MSD

KOVALTRY 6 MSD

LOVENOX SUBCUTANEOUS SOLUTION

6 MSD

LOVENOX SUBCUTANEOUS SYRINGE

3 ST

MEPHYTON 3

MONONINE 6 MSD

MULPLETA 3 PA; S

NOVOEIGHT 6 MSD

NOVOSEVEN RT 6 MSD

NPLATE 6 MSD

NUWIQ 6 MSD

OBIZUR 6 MSD

pentoxifylline 1 M

phytonadione

(vitamin k1) 1

PLAVIX 3 ST; M; QL

PRADAXA 3 PA; M

prasugrel 1 M

PRAXBIND 6 MSD

PROFILNINE 6 MSD

PROMACTA 2 PA

REBINYN 6 MSD

RECOMBINATE 6 MSD

RIASTAP 6 MSD

RIXUBIS 6 MSD

Drug Name Drug


/ Limits

SAVAYSA 3 PA; M

TAVALISSE 3 PA

tranexamic acid 6 MSD

TRETTEN 6 MSD

VONVENDI 6 MSD

warfarin 1

WILATE 6 MSD

XARELTO ORAL TABLET

2 PA; M

XARELTO ORAL TABLETS,DOSE PACK

2 PA

XYNTHA 6 MSD

XYNTHA SOLOFUSE

6 MSD

YOSPRALA 3 ST; M

ZONTIVITY 2 PA; M

LIPID/CHOLESTEROL LOWERING

AGENTS

ALTOPREV 3 ST; M; QL

amlodipine-

atorvastatin 1 M; QL

ANTARA 3 ST; M; QL

atorvastatin oral

tablet 10 mg, 20 mg 5 M; ACA; QL

atorvastatin oral


CADUET 3 ST; M; QL

cholestyramine (with

sugar) 1 M

cholestyramine light 1 M

colesevelam 1 M

COLESTID 3 ST; M


46

Drug Name Drug


/ Limits

COLESTID FLAVORED

3 ST; M

colestipol 1 M

CRESTOR 3 ST; M; QL

ezetimibe 1 ST; M

ezetimibe-

simvastatin 1 M; QL

fenofibrate

micronized 1 M; QL

fenofibrate

nanocrystallized

oral tablet 145 mg,

48 mg

1 M; QL

FENOFIBRATE NANOCRYSTALLIZED ORAL TABLET 160 MG

3 ST; M; QL

FENOFIBRATE ORAL CAPSULE

3 ST; M; QL

fenofibrate oral

tablet 1 M; QL

fenofibric acid 1 M; QL

fenofibric acid

(choline) 1 M; QL

FENOGLIDE 3 ST; M; QL

FIBRICOR 3 ST; M; QL

FLOLIPID 3 ST; M

fluvastatin 5 M; ACA; QL

gemfibrozil 1 M; QL

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG

3 PA; S; QL

JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG

3 PA; S

LESCOL XL 3 ST; M; QL

Drug Name Drug


/ Limits

LIPITOR 3 ST; M; QL

LIPOFEN 2 ST; M; QL

LIVALO 2 ST; M; QL

LOPID 3 M; QL

lovastatin 5 M; ACA; QL

LOVAZA 3 PA; M

niacin 1 M

NIACOR 3 M

NIASPAN EXTENDED-RELEASE

3 M

omega-3 acid ethyl

esters 1 PA; M

PRALUENT PEN 3 PA; S; SLA

PRAVACHOL 3 ST; M; QL

pravastatin 5 M; ACA; QL

prevalite 1 M

QUESTRAN 3 ST; M

QUESTRAN LIGHT

3 ST; M

REPATHA PUSHTRONEX

4 PA; S; SLA

REPATHA SURECLICK

4 PA; S; SLA

REPATHA SYRINGE

4 PA; S; SLA

rosuvastatin oral

tablet 10 mg, 5 mg 5 M; ACA; QL

rosuvastatin oral


simvastatin oral

tablet 10 mg, 20 mg,

40 mg, 5 mg

5 M; ACA; QL

simvastatin oral

tablet 80 mg 1 M; QL


47

Drug Name Drug


/ Limits

TRICOR 3 ST; M; QL

TRIGLIDE 3 ST; M; QL

triklo 1 PA; M

TRILIPIX 3 ST; M; QL

VASCEPA 2 PA; M

VYTORIN 10-10 3 ST; M; QL




WELCHOL 3 ST; M

ZETIA 3 ST; M

ZOCOR 3 ST; M; QL

ZYPITAMAG 3 ST; M

MISCELLANEOUS

CARDIOVASCULAR AGENTS

CORLANOR 2 PA; M

ENTRESTO 2 PA; M

GIAPREZA 6 MSD

NIPRIDE RTU 6 MSD

RANEXA 2 M

ranolazine 1 M

VECAMYL 3 SLA

NITRATES

DILATRATE-SR 2 M

GONITRO 3

ISOCHRON 3 M

ISORDIL 3 M

ISORDIL TITRADOSE

3 M

isosorbide dinitrate 1 M

isosorbide

mononitrate 1 M

Drug Name Drug


/ Limits

MINITRAN 3 M

nitro-bid 1 M

NITRO-DUR 3 M

nitroglycerin oral 1 M

nitroglycerin

sublingual 1

nitroglycerin

transdermal 1 M

nitroglycerin

translingual 1

NITROLINGUAL 3

NITROMIST 3

NITROSTAT 3

nitro-time 1 M

DERMATOLOGICALS/TOPICA

L THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

acitretin 1

ANALPRAM-HC 3 ST

calcipotriene 1 QL

calcipotriene-

betamethasone 1 QL

calcitrene 1 QL

calcitriol 1 QL

COAL TAR 2

COSENTYX 3 ST; S; SLA; QL

COSENTYX (2 SYRINGES)

3 ST; S; SLA; QL

COSENTYX PEN 3 ST; S; SLA; QL

COSENTYX PEN (2 PENS)

3 ST; S; SLA; QL


48

Drug Name Drug


/ Limits

DOVONEX 3 QL

drithocreme hp 1

ENSTILAR 2

EPIFOAM 3 ST

hydrocortisone-

pramoxine 1

ILUMYA 6 PA; ST; S; MSD

OVACE 3

OVACE PLUS SHAMPOO

3

OVACE PLUS TOPICAL CLEANSER

3

OVACE PLUS TOPICAL CREAM

3 ST

OVACE PLUS TOPICAL FOAM

3

OVACE PLUS TOPICAL LOTION

3 ST

OVACE PLUS WASH

3

PRAMOSONE 3 ST

selenium sulfide 1

SELRX 3

SILIQ 4 ST; S

SKYRIZI 3 PA; ST; S

SORIATANE 3

SORILUX 3 QL

STELARA INTRAVENOUS

6 MSD

STELARA SUBCUTANEOUS

3 PA; ST; S

sulfacetamide

sodium 1

Drug Name Drug


/ Limits

TACLONEX TOPICAL OINTMENT

3 QL

TACLONEX TOPICAL SUSPENSION

2

TALTZ AUTOINJECTOR

4 ST; S; SLA

TALTZ AUTOINJECTOR (2 PACK)

4 ST; S; SLA

TALTZ AUTOINJECTOR (3 PACK)

4 ST; S; SLA

TALTZ SYRINGE 4 ST; S; SLA

TERSI FOAM 3

TREMFYA SUBCUTANEOUS AUTO-INJECTOR

3 ST; S

TREMFYA SUBCUTANEOUS SYRINGE

3 PA; ST; S

VECTICAL 3 QL

ZITHRANOL 3

BURN THERAPY

SILVADENE 3

silver sulfadiazine 1

ssd 1

KERATOLYTICS

BENSAL HP 3

INOVA 4-1 3 ST

KERALYT RX 3

PODOCON 3

SALEX 3

salicylic acid 1


49

Drug Name Drug


/ Limits

salimez 1

SALIMEZ FORTE 3

SALKERA 3

salvax 1

SALVAX DUO PLUS

3

ULTRASAL-ER 3

VIRASAL 3

MISCELLANEOUS

DERMATOLOGICALS

ALEVICYN PLUS 3

AMELUZ 6 MSD

ATOPADERM 3

ATOPICLAIR 3

ATRAPRO CP 3

ATRAPRO HYDROGEL

3

avo cream 1

BIAFINE EMULSION

3

CARAC 2

celacyn 1

CERAMAX 3

CONDYLOX 3

CORTANE-B 3

DEXERYL 3

diclofenac sodium 1 PA

doxepin 1 ST; QL

DUPIXENT 3 PA; S

EFUDEX 3

eletone 1

ELIDEL 2 ST; QL

Drug Name Drug


/ Limits

EPICERAM 3

EUCRISA 3 PA; ST; QL

FLUOROPLEX 3

FLUOROURACIL TOPICAL CREAM 0.5 %

3 ST

fluorouracil topical

cream 5 % 1 PA

fluorouracil topical

solution 1 PA

hpr 1

hpr plus 1

hpr plus hydrogel 1

HPR PLUS-MB HYDROGEL

3

HYDRO 35 3

HYDRO 40 3

HYLATOPIC 3

HYLATOPICPLUS 3

KERAFOAM 3

KERALAC 3

LEVICYN ANTIPRURITIC

3

LEVICYN ANTIPRURITIC SG

3

LEVULAN 6 MSD

LOUTREX 3

LOYON 3

luxamend 1

methoxsalen 1

MIMYX 3

NEOCERA 3

NEOSALUS 3


50

Drug Name Drug


/ Limits

nivatopic plus 1

NUTRASEB 3

OXSORALEN ULTRA

3

PANRETIN 3

PENLEN 3

PICATO 2 QL

pimecrolimus 1 ST; QL

podofilox 1

PRESERA 3

PROMISEB 3

PROTOPIC 3 ST; QL

pruclair 1

prudoxin 1 ST; QL

prumyx 1

prutect 1

QBREXZA 2

QUTENZA 6 MSD

REGRANEX 2 QL

RESTIZAN 3

silver nitrate 1

silver nitrate

applicators 1

SOLARAZE 3 PA

SOLOX GEL 3

sonafine 1

sp antipruritic 1

sp scar management 1

tacrolimus 1 ST; QL

TOLAK 3

TRIXYLITRAL 3

umecta 1

Drug Name Drug


/ Limits

urea 1

urea nail stick 1

UTOPIC 3

VALCHLOR 3 PA; S; SLA

VEREGEN 3

XCLAIR 3

ZONALON 3 ST; QL

THERAPY FOR ACNE

ABSORICA 2 QL

ACANYA 2 ST; QL

ACZONE 3 ST

adapalene topical

cream 1 QL

adapalene topical

gel 1 QL

adapalene topical

gel with pump 1 QL

ADAPALENE TOPICAL LOTION

3 ST; QL

adapalene topical

solution 1

adapalene topical

swab 1

adapalene-benzoyl

peroxide 1 QL

AKTIPAK 3 ST

ALTRENO 3

amnesteem 1 QL

ATRALIN 3 QL

AVAR LS 3 ST

avar topical cleanser 1

AVAR TOPICAL PADS, MEDICATED

3 ST


51

Drug Name Drug


/ Limits

AVAR-E GREEN 3 ST

AVAR-E LS 3 ST

avita topical cream 1 QL

AVITA TOPICAL GEL

3 QL

azelaic acid 2

AZELEX 3 ST; QL

BENZACLIN 3 ST

BENZACLIN PUMP

3 ST; QL

BENZAMYCIN 3 ST

benzepro 1

benzoyl peroxide 1

bp 10-1 1

bpo 1

claravis 1 QL

cleansing wash 1

CLEOCIN T 3 ST

CLINDACIN ETZ 3 ST

clindacin p 1

CLINDACIN PAC 3 ST

CLINDAGEL 3 ST

clindamycin

phosphate topical

foam

1

clindamycin

phosphate topical

gel

1

CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY

3 ST

clindamycin

phosphate topical

lotion

1

Drug Name Drug


/ Limits

clindamycin

phosphate topical

solution

1

clindamycin

phosphate topical

swab

1

clindamycin-benzoyl

peroxide topical gel 1.2 %(1 % base) -5

%

1 QL

clindamycin-benzoyl

peroxide topical gel 1-5 %

1

clindamycin-benzoyl

peroxide topical gel

with pump

1 QL

clindamycin-

tretinoin 1

dapsone 1

DIFFERIN 3 ST; QL

DUAC 3 ST; QL

EPIDUO 3 ST; QL

EPIDUO FORTE 2 ST

ery pads 1

erygel 1

erythromycin with

ethanol 1

erythromycin-

benzoyl peroxide 1

EVOCLIN 3 ST

FABIOR 3 PA; QL

FINACEA TOPICAL FOAM

2 ST

FINACEA TOPICAL GEL

3 ST

INOVA 3 ST


52

Drug Name Drug


/ Limits

isotretinoin 1 QL

METROCREAM 3 ST

METROGEL 3 ST

METROLOTION 3 ST

metronidazole 1

MIRVASO 2 ST

myorisan 1 QL

neuac 1 QL

NEUAC KIT 3 ST

NORITATE 3 ST

ONEXTON 2 ST; QL

PLEXION 3 ST

PLEXION CLEANSING CLOTHS

3 ST

RETIN-A MICRO 3

RETIN-A MICRO PUMP

3

RETIN-A TOPICAL CREAM 0.025 %

3 QL

RETIN-A TOPICAL CREAM 0.05 %, 0.1 %

3

RETIN-A TOPICAL GEL 0.01 %

3

RETIN-A TOPICAL GEL 0.025 %

3 QL

RHOFADE 3 ST

rosadan topical

cream 1

rosadan topical gel 1

ROSADAN TOPICAL KIT, CLEANSER AND GEL

3 ST

Drug Name Drug


/ Limits

ROSADAN TOPICAL KIT,CLEANSER AND CREAM

3 ST

ROSANIL 3 ST

ROSULA 3 ST

rosula cleansing

cloths 1

SOOLANTRA 2 ST

sss 10-5 1

sulfacetamide

sodium-sulfur 1

sulfacetamide sod-

sulfur-urea 1

sulfacleanse 8-4 1

SUMADAN 3 ST

SUMAXIN 3 ST

SUMAXIN TS 3 ST

tazarotene 1 PA; QL

TAZORAC TOPICAL CREAM 0.05 %

2 PA; QL

TAZORAC TOPICAL CREAM 0.1 %

3 PA; QL

TAZORAC TOPICAL GEL

2 PA; QL

tretinoin

microspheres 1

tretinoin topical

cream 0.025 % 1 QL

tretinoin topical

cream 0.05 %, 0.1 % 1

tretinoin topical gel 0.01 %

1


53

Drug Name Drug


/ Limits

tretinoin topical gel 0.025 %, 0.05 %

1 QL

TRETIN-X 3

TRETIN-X CREAM KIT

3

VANOXIDE-HC 3 ST

VELTIN 3 ST

zenatane 1 QL

ZIANA 3 ST

TOPICAL ANESTHETICS

AGONEAZE 3

ANASTIA 3

ANODYNE LPT 3

ASTERO 3

DERMACINRX EMPRICAINE

3

DOLOTRANZ 3

ethyl chloride 1

glydo 1

LDO PLUS 3

LEVA SET 3

lidocaine (pf)


LIDOCAINE (PF) INJECTION SYRINGE 100 MG/5 ML (2 %), 200 MG/10 ML (2 %), 200 MG/20 ML (1 %), 40 MG/2 ML (2%), 400 MG/20 ML (2 %)

6 MSD

lidocaine (pf)

injection syringe 50

mg/5 ml (1 %)

6 MSD

Drug Name Drug


/ Limits

lidocaine hcl


lidocaine hcl

injection syringe 10

mg/ml (1 %), 100

mg/10 ml (1 %)

6 MSD

LIDOCAINE HCL INJECTION SYRINGE 100 MG/5 ML (2 %), 30 MG/3 ML (1%), 50 MG/5 ML (1 %)

6 MSD

LIDOCAINE HCL INTRADERMAL

6 MSD

lidocaine hcl

laryngotracheal 1

lidocaine hcl mucous

membrane 1

lidocaine hcl topical

cream 3 % 1

LIDOCAINE HCL TOPICAL CREAM 3.88 %

3

lidocaine hcl-

hydrocortison ac 1

lidocaine topical

adhesive

patch,medicated

1 PA

lidocaine topical

ointment 1

lidocaine viscous 1

lidocaine-prilocaine 1

LIDODERM 3 ST

LIDOPAC 3

lidopin topical

cream 3 % 1

LIDOPIN TOPICAL CREAM 3.25 %

3


54

Drug Name Drug


/ Limits

LIDO-PRILO CAINE PACK

3

LIDORX 3

LIDOTRAL 3

lidozion 1

LIDTOPIC MAX 3

LIPROZONEPAK 3

lta pre-attached 1

MEDOLOR PAK 3

NUMBONEX 3

P-CARE X (PF) 6 MSD

PLIAGLIS 3 ST

PRIKAAN 3

PRIKAAN LITE 3

PRILOLID 3

PRILOVIX 3

PRILOVIX LITE 3

READYSHARP LIDOCAINE (PF)

6 MSD

relador pak 1

relador pak plus 1

SYNERA 3

TRANZAREL 3

XYLOCAINE 6 MSD

XYLOCAINE-MPF 6 MSD

ZINGO 6 MSD

ZTLIDO 2

TOPICAL ANTIBACTERIALS

ALTABAX 3

CENTANY 3

CENTANY AT 3

CORTISPORIN 3

Drug Name Drug


/ Limits

dermazene 1

gentamicin 1

hydrocortisone-

iodoquinol 1

hydrocortisone-

iodoquinol-aloe 1

KLARON 3 ST

lugols 1

mafenide acetate 1

mupirocin 1

mupirocin calcium 1

NEO-SYNALAR 3

NEO-SYNALAR KIT

3

SILVRSTAT 3

sulfacetamide

sodium (acne) 1

SULFAMYLON TOPICAL CREAM

2

SULFAMYLON TOPICAL PACKET

3

XEPI 3

TOPICAL ANTIFUNGALS

ciclodan 1

CICLODAN KIT TOPICAL COMBO PACK

3

CICLODAN KIT TOPICAL SOLUTION

3 ST

ciclopirox 1

clotrimazole-

betamethasone 1

econazole 1

ECOZA 3


55

Drug Name Drug


/ Limits

ERTACZO 3

EXELDERM 3

EXODERM 3

EXTINA 3

JUBLIA 3 ST; QL

KERYDIN 3 ST; QL

ketoconazole 1

LOPROX 3

LOPROX (AS OLAMINE)

3

LOPROX KIT 3

LOTRISONE 3

LULICONAZOLE 3 ST; QL

LUZU 3 QL

MICONAZOLE NITRATE-ZINC OX-PET

3

naftifine 1

NAFTIN 3

NIZORAL 3

nyamyc 1

nystatin 1

nystatin-

triamcinolone 1

nystop 1

oxiconazole 1

OXISTAT 3

PENLAC 3 ST

TRIACETIN 2

TRIPLE DYE 3

VUSION 3

XOLEGEL 3

Drug Name Drug


/ Limits

TOPICAL ANTIVIRALS

acyclovir 1 QL

DENAVIR 3

XERESE 3 ST

ZOVIRAX TOPICAL CREAM

2 QL

ZOVIRAX TOPICAL OINTMENT

3 QL

TOPICAL CORTICOSTEROIDS

ALA-SCALP 3 ST

alclometasone 1

amcinonide 1

apexicon e 1 QL

AQUA GLYCOLIC HC

3 ST

betamethasone

dipropionate 1

betamethasone

valerate 1

betamethasone,

augmented 1

BRYHALI 3 ST

CAPEX 3 ST; QL

clobetasol 1

clobetasol-emollient 1

CLOBEX 3 ST

CLOCORTOLONE PIVALATE

3 ST; QL

clodan 1

CLODAN KIT 3 ST

CLODERM 3 ST; QL

CORDRAN 3 ST


56

Drug Name Drug


/ Limits

CORDRAN TAPE LARGE ROLL

3 ST; QL

cormax 1

CUTIVATE 3 ST

DERMA-SMOOTHE/FS BODY OIL

3 ST; QL

DERMA-SMOOTHE/FS SCALP OIL

3 ST; QL

DERMATOP 3 ST

DESONATE 3 ST

desonide 1 QL

DESOWEN 3 ST; QL

desoximetasone

topical cream 1 QL

desoximetasone

topical gel 1 QL

desoximetasone

topical ointment 1 QL

desoximetasone

topical spray,non-

aerosol

1

diflorasone 1 QL

DIPROLENE 3 ST

DUOBRII 3

ELLZIA PAK 3

ELOCON 3 ST

fluocinolone 1 QL

fluocinolone and

shower cap 1 QL

fluocinonide 1

fluocinonide-

emollient 1

flurandrenolide 1

Drug Name Drug


/ Limits

fluticasone

propionate 1

halobetasol

propionate topical

cream

1 QL

HALOBETASOL PROPIONATE TOPICAL FOAM

3 ST

halobetasol

propionate topical

ointment

1 QL

HALOG 3 ST

hydrocortisone 1

hydrocortisone

butyrate 1

hydrocortisone

butyr-emollient 1

hydrocortisone

valerate 1

IMPOYZ 3 ST

KENALOG 3 ST

LEXETTE 3 ST

LOCOID 3 ST

LOCOID LIPOCREAM

3 ST

LUXIQ 3 ST

mometasone 1

nolix 1

OLUX 3 ST

OLUX-E 3 ST

PANDEL 3 ST

prednicarbate 1

PSORCON 3 ST; QL

scalacort 1

SERNIVO 3 ST


57

Drug Name Drug


/ Limits

SILALITE PAK 3

SYNALAR 3 ST; QL

SYNALAR CREAM KIT

3 ST

SYNALAR OINTMENT KIT

3 ST

SYNALAR TS 3 ST

TEMOVATE 3 ST

TEXACORT 3 ST

TOPICORT TOPICAL CREAM

3 ST; QL

TOPICORT TOPICAL GEL

3 ST; QL

TOPICORT TOPICAL OINTMENT

3 ST; QL

TOPICORT TOPICAL SPRAY,NON-AEROSOL

3 ST

triamcinolone

acetonide 1

trianex 1

triderm 1

TRIDESILON 3 ST; QL

ULTRAVATE TOPICAL CREAM

3 ST; QL

ULTRAVATE TOPICAL LOTION

3 ST

ULTRAVATE TOPICAL OINTMENT

3 ST; QL

ULTRAVATE X 3 ST

VANOS 3 ST; QL

VERDESO 3 ST

TOPICAL ENZYMES

Drug Name Drug


/ Limits

SANTYL 2

TOPICAL SCABICIDES /

PEDICULICIDES

crotan 1

ELIMITE 3

EURAX 3

lindane 1

malathion 1

NATROBA 3 QL

OVIDE 3

permethrin 1

SKLICE 3

spinosad 1 QL

ULESFIA 3

DIAGNOSTICS &

MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS

lactated ringers 1

PHYSIOLYTE 3

PHYSIOSOL IRRIGATION

3

ringer's 1

SORBITOL-MANNITOL

3

tis-u-sol pentalyte 1

VASHE WOUND THERAPY

6 MSD


ABLYSINOL 6 MSD

acamprosate 1

ADAGEN 6 MSD

AGRYLIN 3 M


58

Drug Name Drug


/ Limits

alendronate 1 M; QL

AMMONUL 6 MSD

AMPHADASE 6 MSD

anagrelide 1 M

ANTABUSE 3

aqua care sterile

water 1

ARALAST NP 6 MSD

BUPHENYL 3

caffeine citrate 1

CARBAGLU 3 PA; S; SLA

CARNITOR 3 M

CARNITOR (SUGAR-FREE)

3 M

cevimeline 1 M

CHEMET 2

CHOLETEC 6 MSD

deferasirox 1 S

disulfiram 1

ENDARI 3 PA; ST; SLA

etidronate disodium 1 M

EVOXAC 3 M

EXJADE 4 S; SLA

FERRIPROX 3 S; SLA

FERRLECIT 6 MSD

GLASSIA 6 MSD

GLEOLAN 3

ic green 6 MSD

INCRELEX 3 PA; ST; S; SLA

indocyanine green 6 MSD

INFASURF 6 MSD

Drug Name Drug


/ Limits

JADENU 3 S

JADENU SPRINKLE

3 S

KIT FOR TC 99M-SESTAMIBI NO.1

6 MSD

KIT PREP OF TC-99M-MEBROFENIN

6 MSD

KIT PREP OF TC-99M-SOD PYROPH

6 MSD

levocarnitine 1 M

levocarnitine (with

sugar) 1 M

LIPOCHOL PLUS 3

LIQUIVIDA HYDRATION KIT

6 MSD

LITHOSTAT 3

METOPIRONE 3 SLA

midodrine 1

NITYR 2 SLA

NORTHERA 4 PA; S; SLA

ORFADIN 2 SLA

pilocarpine hcl 1

PROLASTIN-C 6 MSD

RADIOGARDASE 6 MSD

RAVICTI 3 S; SLA

RECLAST 6 MSD

RILUTEK 3

riluzole 1

risedronate 1 QL

SALAGEN (PILOCARPINE)

3

sodium benzoate-sod

phenylacet 6 MSD


59

Drug Name Drug


/ Limits

sodium chlor 0.9%

bacteriostat 6 MSD

sodium chloride 0.9

% 6 MSD

sodium chloride 0.9

% (flush) 1

sodium ferric

gluconat-sucrose 6 MSD

sodium

phenylbutyrate 1

SOLIRIS 6 MSD

SURVANTA 6 MSD

SYPRINE 3 PA; QL

THALLOUS CHLORIDE TL-201

6 MSD

THIOLA 3 SLA

TIGLUTIK 3

trientine 1 PA; QL

ULTOMIRIS 6 MSD

water for irrigation,

sterile 1

XURIDEN 2 SLA

ZEMAIRA 6 MSD

zoledronic acid-

mannitol-water 6 MSD

SMOKING DETERRENTS

bupropion hcl

(smoking deter) 5 M; ACA

CHANTIX 5 ACA

CHANTIX CONTINUING MONTH BOX

5 ACA

CHANTIX STARTING MONTH BOX

5 ACA

Drug Name Drug


/ Limits

NICODERM CQ TRANSDERMAL PATCH 24 HOUR 14 MG/24 HR, 7 MG/24 HR

5 ACA; OTC

NICODERM CQ TRANSDERMAL PATCH 24 HOUR 21 MG/24 HR

5 M; ACA; OTC

nicorelief 5 ACA; OTC

NICORETTE BUCCAL GUM 2 MG

5 ACA; OTC

nicorette buccal gum 4 mg

5 ACA; OTC

NICORETTE BUCCAL LOZENGE

5 ACA; OTC

NICORETTE BUCCAL MINI LOZENGE

5 ACA; OTC

nicotine (polacrilex) 5 ACA; OTC

nicotine transdermal

patch 24 hour 14

mg/24 hr, 7 mg/24

hr

5 ACA; OTC


patch 24 hour 21

mg/24 hr

5 M; ACA; OTC


patch, td daily,

sequential

5 ACA; OTC

NICOTROL 5 ACA

NICOTROL NS 5 ACA

quit 2 buccal gum 5 ACA; OTC

QUIT 2 BUCCAL LOZENGE

5 ACA; OTC

quit 4 buccal gum 5 ACA; OTC


60

Drug Name Drug


/ Limits

QUIT 4 BUCCAL LOZENGE

5 ACA; OTC

stop smoking aid 5 ACA; OTC

ZYBAN 5 M; ACA

EAR, NOSE & THROAT

MEDICATIONS


ARESTIN 6 MSD

ASTEPRO 3 QL

azelastine 1 QL

chlorhexidine

gluconate 1

CLINPRO 5000 3 M

DEBACTEROL 3

denta 5000 plus 1 M

dentagel 1 M

EPISIL 3

FLUORIDEX DAILY DEFENSE

3 M

GELCLAIR 3

ipratropium bromide 1 QL

MUGARD 3

olopatadine 1 QL

oralone 1

ORAMAGICRX 3

paroex oral rinse 1

PATANASE 3 QL

PERIDEX 3

periogard 1

pilocarpine hcl 1

PREVIDENT 3 M

Drug Name Drug


/ Limits

PREVIDENT 5000 BOOSTER PLUS

3 M

PREVIDENT 5000 DRY MOUTH

3 M

PREVIDENT 5000 ENAMEL PROTECT

3 M

PREVIDENT 5000 PLUS

3 M

PREVIDENT 5000 SENSITIVE

3 M

PROTHELIAL 4 S; SLA

Q-CARE RX Q4 3

SALAGEN (PILOCARPINE)

3

sf 1 M

sf 5000 plus 1 M

triamcinolone

acetonide 1

TYZINE 3

MISCELLANEOUS OTIC

PREPARATIONS

acetic acid 1

CETRAXAL 3 ST

ciprofloxacin hcl 1

DERMOTIC OIL 3

flac otic oil 1

fluocinolone

acetonide oil 1

hydrocortisone-

acetic acid 1

ofloxacin 1

OTIPRIO 3

OTIC STEROID / ANTIBIOTIC

CIPRO HC 3


61

Drug Name Drug


/ Limits

CIPRODEX 2

COLY-MYCIN S 3

neomycin-

polymyxin-hc 1

OTOVEL 2

ENDOCRINE/DIABETES

ADRENAL HORMONES

ACTHAR H.P. 6 MSD

BETAMETH AC,SOD PHOS(PF)-WATER

6 MSD

BETAMETHASONE ACE,SOD PHOS-WTR

6 MSD

betamethasone

acet,sod phos 6 MSD

BETAMETHASONE SOD PHOSPH-WATER

6 PA; MSD

CELESTONE SOLUSPAN

6 MSD

CORTEF 3 M

cortisone 1

CORTROSYN 6 MSD

cosyntropin 6 MSD

decadron 1

deltasone 1

DEXAMETHASONE AC, SOD PH-WATER

6 MSD

DEXAMETHASONE ACE-NACL,ISO-OSM

6 MSD

dexamethasone

intensol 1

Drug Name Drug


/ Limits

dexamethasone oral

elixir 1

dexamethasone oral

solution 1

dexamethasone oral

tablet 1

dexamethasone oral

tablets,dose pack 1 ST

dexamethasone

sodium phosphate 6 MSD

DEXPAK 10 DAY 3 ST

DEXPAK 13 DAY 3 ST

DEXPAK 6 DAY 3 ST

DXEVO 3 ST

EMFLAZA 3 PA; ST; SLA

fludrocortisone 1 M

hidex 1 ST

hydrocortisone 1 M

KENALOG 6 MSD

MEDROL 3

MEDROL (PAK) 3

METHYLPRED AC(PF)-NACL,ISO-OSM

6 MSD

METHYLPREDNISOL AC-BUPIVAC-WAT

6 MSD

methylprednisolone 1

METHYLPREDNISOLONE ACET-WATER

6 MSD

millipred 1

millipred dp 1

ORAPRED ODT 3

P-CARE K40 6 MSD


62

Drug Name Drug


/ Limits

P-CARE K80 6 MSD

POD-CARE 100K 6 MSD

prednisolone 1

prednisolone sodium

phosphate 1

prednisone 1

prednisone intensol 1

PRO-C-DURE 5 6 MSD

PRO-C-DURE 6 6 MSD

RAYOS 3 ST

READYSHARP DEXAMETHASONE

6 MSD

TAPERDEX 3 ST

TRIAMCINOL AC (PF) IN 0.9%NACL

6 MSD

TRIAMCINOL ACE-BUPIV-0.9% NACL

6 MSD

TRIAMCINOLONE ACETON-0.9% NACL

6 MSD

triamcinolone

acetonide 6 MSD

TRIAMCINOLONE DIA(PF)-0.9%NACL

6 MSD

TRIAMCINOLONE DIACET-0.9% NACL

6 MSD

veripred 20 1

ANTITHYROID AGENTS

methimazole 1 M

propylthiouracil 1 M

SSKI 3 M

Drug Name Drug


/ Limits

TAPAZOLE 3 M

BLOOD GLUCOSE MONITORING

DEVICES & SUPPLIES

ACCU-CHEK AVIVA PLUS TEST STRP

3 ST; OTC; QL

ACCU-CHEK COMPACT PLUS TEST

3 ST; OTC; QL

ACCU-CHEK GUIDE

3 ST; OTC

ACCU-CHEK SMARTVIEW TEST STRIP

3 ST; OTC; QL

ACCUTREND GLUCOSE

3 ST; OTC; QL

ADVANCED GLUC METER TEST STRIP

3 ST; OTC

ADVOCATE REDI-CODE

3 ST; OTC; QL

ADVOCATE TEST STRIPS

3 ST; OTC; QL

AGAMATRIX AMP TEST STRIPS

3 ST; OTC; QL

ASSURE 4 STRIPS 3 ST; OTC; QL

ASSURE PLATINUM

3 ST; OTC; QL

ASSURE PRISM MULTI STRIP

3 ST; OTC

BIONIME RIGHTEST TEST STRIPS

3 ST; OTC; QL

BLOOD GLUCOSE TEST

3 ST; OTC; QL

CARESENS N TEST STRIPS

3 ST; OTC; QL


63

Drug Name Drug


/ Limits

CARETOUCH TEST STRIP

3 ST; OTC

CLEVER CHOICE MICRO TEST STRIP

3 ST; OTC; QL

CLEVER CHOICE PRO

3 ST; OTC; QL

CLEVER CHOICE TALK TEST

3 ST; OTC

CLEVER CHOICE TEST STRIPS

3 ST; OTC; QL

CLEVER CHOICE VOICE+ TEST

3 ST; OTC; QL

CONTOUR NEXT TEST STRIPS

3 ST; OTC; QL

CONTOUR TEST STRIPS

3 ST; OTC; QL

COOL GLUCOSE TEST STRIP

3 ST; OTC; QL

DIATRUE PLUS TEST STRIP

3 ST; OTC

EASY PLUS II TEST

3 ST; OTC; QL

EASY STEP 3 ST; OTC; QL

EASY TALK GLUCOSE TEST

3 ST; OTC; QL

EASY TOUCH TEST STRIP

3 ST; OTC; QL

EASY TRAK GLUCOSE TEST

3 ST; OTC; QL

EASYGLUCO PLUS

3 ST; OTC

EASYGLUCO TEST

3 ST; OTC; QL

EASYMAX 3 ST; OTC; QL

Drug Name Drug


/ Limits

ELEMENT COMPACT TEST STRIPS

3 ST; OTC

ELEMENT TEST STRIPS

3 ST; OTC; QL

EMBRACE BLOOD GLUCOSE SYSTEM

3 ST; OTC; QL

EMBRACE EVO TEST STRIPS

3 ST; OTC

EMBRACE PRO TEST STRIPS

3 ST; OTC

EMBRACE TALK TEST STRIPS

3 ST; OTC

EVENCARE G2 3 ST; OTC; QL

EVENCARE G3 TEST

3 ST; OTC; QL

EVENCARE MINI GLUCOSE TEST STR

3 ST; OTC

EVOLUTION TEST STRIPS

3 ST; OTC; QL

EZ SMART PLUS TEST

3 ST; OTC; QL

EZ SMART TEST 3 ST; OTC; QL

FIFTY50 TEST STRIP

3 ST; OTC; QL

FORA D15G STRIPS

3 ST; OTC; QL

FORA D20 3 ST; OTC; QL

FORA D40-G31 TEST STRIPS

3 ST; OTC; QL

FORA G20 3 ST; OTC; QL

FORA G30-PREMIUM V10 TEST STRP

3 ST; OTC; QL


64

Drug Name Drug


/ Limits

FORA GD50 TEST STRIPS

3 ST; OTC

FORA GTEL GLUCOSE TEST STRIP

3 ST; OTC

FORA TEST STRIP 3 ST; OTC; QL

FORA TN'G VOICE TEST STRIPS

3 ST; OTC

FORA V10 3 ST; OTC

FORA V10-V12-D10-D20 STRIPS

3 ST; OTC

FORA V12 GLUCOSE

3 ST; OTC

FORA V20 3 ST; OTC; QL

FORACARE GD20 3 ST; OTC; QL

FORACARE GD40 3 ST; OTC; QL

FORTISCARE GLUCOSE TEST STRIPS

3 ST; OTC

FREESTYLE INSULINX

3 ST; OTC; QL

FREESTYLE INSULINX TEST STRIPS

3 ST; OTC; QL

FREESTYLE LITE STRIPS

3 ST; OTC; QL

FREESTYLE PRECISION NEO STRIPS

3 ST; OTC

FREESTYLE TEST 3 ST; OTC; QL

GE100 BLOOD GLUCOSE TEST STRIP

3 ST; OTC; QL

GENSTRIP TEST STRIP

3 ST; OTC

GLUCO NAVII TEST STRIP

3 ST; OTC; QL

Drug Name Drug


/ Limits

GLUCOCARD 01 SENSOR PLUS

3 ST; OTC

GLUCOCARD EXPRESSION

3 ST; OTC; QL

GLUCOCARD SHINE TEST STRIPS

3 ST; OTC

GLUCOCARD VITAL SENSOR

3 ST; OTC; QL

GLUCOCARD VITAL TEST STRIPS

3 ST; OTC; QL

GLUCOCOM GLUCOSE

3 ST; OTC; QL

GM100 3 ST; OTC; QL

HEALTHPRO TEST STRIPS

3 ST; OTC

IGLUCOSE TEST STRIP

3 ST; OTC

INFINITY TEST STRIPS

3 ST; OTC; QL

INFINITY VOICE TEST STRIP

3 ST; OTC

MICRO BLOOD GLUCOSE

3 ST; OTC

MICRODOT BLOOD GLUCOSE SYSTEM

3 ST; OTC; QL

MYGLUCOHEALTH

3 ST; OTC; QL

NEUTEK 2TEK TEST STRIPS

3 ST; OTC; QL

NOVA MAX GLUCOSE TEST

3 ST; OTC; QL

ON CALL EXPRESS TEST STRIP

3 ST; OTC


65

Drug Name Drug


/ Limits

ON CALL PLUS TEST STRIP

3 ST; OTC; QL

ON CALL VIVID TEST STRIP

3 ST; OTC; QL

ONETOUCH ULTRA BLUE TEST STRIP

2 ST; OTC; QL

ONETOUCH VERIO

2 ST; OTC; QL

OPTIUM EZ 3 ST; OTC; QL

OPTIUM TEST 3 ST; OTC; QL

OPTUMRX 3 ST; OTC; QL

PHARMACIST CHOICE

3 ST; OTC; QL

PRECISION PCX PLUS TEST

3 ST; OTC; QL

PRECISION PCX TEST

3 ST; OTC; QL

PRECISION POINT OF CARE TEST

3 ST; OTC; QL

PRECISION Q-I-D TEST

3 ST; OTC; QL

PRECISION XTRA TEST

3 ST; OTC; QL

PREMIER TEST STRIP

3 ST; OTC

PREMIUM V10 3 ST; OTC; QL

PRO VOICE V8-V9 TEST STRIP

3 ST; OTC

PRODIGY NO CODING

3 ST; OTC; QL

QUINTET AC 3 ST; OTC

REFUAH PLUS 3 ST; OTC; QL

RELION CONFIRM-MICRO

3 ST; OTC; QL

Drug Name Drug


/ Limits

RELION PRIME TEST STRIPS

3 ST; OTC; QL

REVEAL TEST STRIP

3 ST; OTC; QL

RIGHTEST GS550 TEST STRIPS

3 ST; OTC; QL

SMART SENSE TEST STRIPS

3 ST; OTC

SMARTEST TEST 3 ST; OTC; QL

SOLUS V2 TEST STRIPS

3 ST; OTC; QL

SURE-TEST EASYPLUS MINI

3 ST; OTC; QL

TELCARE TEST STRIPS

3 ST; OTC; QL

TEST N'GO TEST 3 ST; OTC; QL

TRUE METRIX GLUCOSE TEST STRIP

3 ST; OTC

TRUETEST TEST STRIPS

3 ST; OTC

TRUETRACK TEST

3 ST; OTC; QL

ULTIMA TEST STRIPS

3 ST; OTC

ULTRATRAK 3 ST; OTC

ULTRATRAK ULTIMATE

3 ST; OTC; QL

UNISTRIP1 TEST STRIP

3 ST; OTC

VERASENS TEST STRIP

3 ST; OTC

WAVESENSE JAZZ

3 ST; OTC

WAVESENSE PRESTO

3 ST; OTC; QL


66

Drug Name Drug


/ Limits

DIABETES, SUPPLIES, & DURABLE

MEDICAL EQUIPMENT

GLUCAGEN DIAGNOSTIC KIT

2

GLUCAGON HCL 3

INSULIN SYRINGE-NEEDLE U-100

3 M

GLUCOSE ELEVATING AGENTS

GLUCAGEN HYPOKIT

2

GLUCAGON EMERGENCY KIT (HUMAN)

2

PROGLYCEM 2 M

INSULIN

SYRINGES/MISCELLANEOUS

DURABLE MEDICAL EQU

2TEK GLUCOSE/BLOOD PRESSURE

3 ST; OTC; QL

ACCU-CHEK AVIVA PLUS METER

3 ST; OTC; QL

ACCU-CHEK COMPACT PLUS CONTROL

3 OTC

ACCU-CHEK GUIDE GLUCOSE METER

3 ST; OTC

ACCU-CHEK GUIDE L1-L2 CTRL SOL

3 OTC

ACCU-CHEK GUIDE ME GLUCOSE MTR

3 ST; OTC

ACCU-CHEK NANO

3 ST; OTC; QL

Drug Name Drug


/ Limits

ACCU-CHEK SMARTVIEW CONTRL SOL

3 OTC

ACCUTREND GLUCOSE CONTROL

3 OTC

ADVANCED GLUCOSE METER

3 ST; OTC

ADVOCATE BLOOD GLUCOSE MONITOR

3 ST; OTC; QL

ADVOCATE DUO 3 ST; OTC; QL

ADVOCATE LOW CONTROL

3 OTC

ADVOCATE REDI-CODE DUO METER

3 ST; OTC; QL

ADVOCATE REDI-CODE GLU MONITOR

3 ST; OTC; QL

ADVOCATE REDI-CODE+ CTRL LOW

3 OTC

AGAMATRIX AMP GLUC MONITOR SYS

3 ST; OTC

AGAMATRIX CONTROL HIGH

3 OTC

ASSURE 4 CONTROL SOLUTION

3 OTC

ASSURE DOSE NORMAL CONTROL

3 OTC

ASSURE PLATINUM

3 ST; OTC; QL

ASSURE PRISM CONTROL 1-2 SOLN

3 OTC


67

Drug Name Drug


/ Limits

ASSURE PRISM MULTI METER

3 ST; OTC

AUTOJECT 2 INJECTION DEVICE

2 OTC

AUTOPEN 1 TO 21 UNITS

2 OTC

AUTOSOFT 30 6 MSD

AUTOSOFT 90 6 MSD

BD MICROTAINER LANCET

2 OTC

BD ULTRA FINE LANCETS

2 OTC

BD ULTRA-FINE NANO PEN NEEDLE

2 M; OTC

BIONIME RIGHTEST GM300 SYSTEM

3 ST; OTC

BLOOD GLUCOSE CONTROL, NORMAL

3 OTC

BLOOD-GLUCOSE METER

3 ST; OTC; QL

BREEZE 2 CONTROL SOLUTION,HIGH

3 OTC

CARESENS CONTROL A NORMAL

3 OTC

CARESENS N 3 ST; OTC

CARESENS N VOICE

3 ST; OTC

CARETOUCH GLUCOSE MONITORING

3 ST; OTC

Drug Name Drug


/ Limits

CLEVER CHEK BLOOD GLUCOSE

3 ST; OTC

CLEVER CHOICE GLUCOSE MONITOR

3 ST; OTC; QL

CLEVER CHOICE LEVEL 2 CONTROL

3 OTC

CLEVER CHOICE MICRO

3 ST; OTC; QL

CLEVER CHOICE PRO

3 ST; OTC; QL

CLEVER CHOICE TALK GLUCOSE SYS

3 ST; OTC

CONTOUR CONTROL SOLUTION, NML

3 OTC

CONTOUR LINK 3 ST; OTC; QL

CONTOUR NEXT EZ METER

3 ST; OTC; QL

CONTOUR NEXT LEV 2 CONTROL SOL

3 OTC

CONTOUR NEXT LINK

3 ST; OTC; QL

CONTOUR NEXT LINK 2.4

3 ST; OTC; QL

CONTOUR NEXT METER

3 ST; OTC

CONTOUR NEXT ONE METER

3 ST; OTC

COOL BLOOD GLUCOSE METER

3 ST; OTC; QL

COOL CONTROL A SOLUTION

3 OTC

DEXCOM G6 RECEIVER

6 MSD


68

Drug Name Drug


/ Limits

DIATRUE CONTROL SOLN NORMAL

3 OTC

DIATRUE PLUS BLOOD GLUCOSE MET

3 ST; OTC; QL

EASY PLUS II HIGH CONTROL

3 ST; OTC

EASY STEP BLOOD GLUCOSE METER

3 ST; OTC; QL

EASY STEP HIGH CONTROL SOLN

3 OTC

EASY TALK HIGH CONTROL

3 OTC

EASY TOUCH GLUCOSE MONITOR

3 ST; OTC; QL

EASY TRAK LOW CONTROL

3 OTC

EASYGLUCO MONITORING SYSTEM

3 ST; OTC; QL

EASYGLUCO PLUS NORMAL CONTROL

3 OTC

EASYMAX L BLOOD GLUCOSE METER

3 ST; OTC

EASYMAX LOW CONTROL

3 OTC

EASYMAX NG 3 ST; OTC

EASYMAX NORMAL CONTROL

3 OTC

EASYMAX V SPEAKING GLUCOSE SYS

3 ST; OTC; QL

Drug Name Drug


/ Limits

EASYMAX V2 BLOOD GLUCOSE METER

3 ST; OTC; QL

ECLIPSE NEEDLE 3 M

ELEMENT COMPACT GLUCOSE METER

3 ST; OTC; QL

ELEMENT COMPACT NORMAL CONTROL

3 OTC

ELEMENT COMPACT V GLUCOSE MTR

3 ST; OTC

ELEMENT NORMAL CONTROL

3 OTC

ELEMENT PLUS BLOOD GLUCOSE KIT

3 ST; OTC; QL

EMBRACE BLOOD GLUCOSE SYSTEM

3 ST; OTC; QL

EMBRACE EVO LEVEL 1

3 OTC

EMBRACE GLUCOSE CONTROL LOW

3 OTC

EMBRACE PRO GLUCOSE METER

3 ST; OTC

EMBRACE TALK BLOOD GLUCOSE SYS

3 ST; OTC

EMBRACE TALK CONTROL-LOW (L1)

3 OTC

EVENCARE G2 3 ST; OTC; QL

EVENCARE G3 GLUCOSE METER

3 ST; OTC


69

Drug Name Drug


/ Limits

EVENCARE MINI MONITOR SYSTEM

3 ST; OTC

EVERSENSE SENSOR-HOLDER

6 MSD

EVOLUTION BLOOD GLUCOSE METER

3 ST; OTC; QL

EVOLUTION NORMAL CONTROL

3 OTC

EZ SMART PLUS SYSTEM

3 ST; OTC

EZ SMART SYSTEM

3 ST; OTC; QL



FORA G20 3 ST; OTC

FORA G30A 3 ST; OTC; QL

FORA GD50 BLOOD GLUCOSE SYSTEM

3 ST; OTC

FORA NORMAL CONTROL

3 OTC

FORA PREMIUM V10 GLUCOSE METER

3 ST; OTC

FORA TEST N'GO VOICE METER

3 ST; OTC

FORA TN'G VOICE METER

3 ST; OTC


FORA V12 BLOOD GLUCOSE SYSTEM

3 ST; OTC


FORA V30A 3 ST; OTC

Drug Name Drug


/ Limits

FORACARE GD20 GLUCOSE METER

3 ST; OTC; QL

FORACARE GD40A GLUCOSE METER

3 ST; OTC

FORACARE GD40B GLUCOSE METER

3 ST; OTC

FORACARE GDH LOW CONTROL

3 OTC

FORTISCARE BLOOD GLUCOSE SYST

3 ST; OTC

FORTISCARE NORMAL

3 OTC

FREESTYLE CONTROL

3 OTC

FREESTYLE FLASH SYSTEM

3 ST; OTC; QL

FREESTYLE FREEDOM

3 ST; OTC; QL

FREESTYLE FREEDOM LITE

3 ST; OTC; QL

FREESTYLE INSULINX

3 ST; OTC; QL

FREESTYLE LIBRE 10 DAY READER

6 MSD

FREESTYLE LIBRE 10 DAY SENSOR

6 MSD

FREESTYLE LITE METER

3 ST; OTC; QL

FREESTYLE PRECISION NEO METER

3 ST; OTC

FREESTYLE SIDEKICK II

3 ST; OTC; QL


70

Drug Name Drug


/ Limits

FREESTYLE SYSTEM KIT

3 ST; OTC; QL

GE100 BLOOD GLUCOSE SYSTEM

3 ST; OTC; QL

GE100 CONTROL SOLUTION NORMAL

3 OTC

GLUCO NAVII GLUCOSE MONITOR

3 ST; OTC

GLUCOCARD 01 METER

3 ST; OTC; QL

GLUCOCARD 01 NORMAL CONTROL

3 OTC

GLUCOCARD EXPRESSION

3 ST; OTC; QL

GLUCOCARD SHINE CONNEX METER

3 ST; OTC

GLUCOCARD SHINE EXPRESS METER

3 ST; OTC

GLUCOCARD SHINE METER

3 ST; OTC

GLUCOCARD SHINE XL METER

3 ST; OTC

GLUCOCARD VITAL

3 ST; OTC; QL

GLUCOCOM BLOOD GLUCOSE

3 ST; OTC; QL

GLUCOCOM CONTROL NORMAL

3 OTC

GLUCOSE CONTROL

3 OTC

GM100 3 ST; OTC; QL

Drug Name Drug


/ Limits

HEALTHPRO GLUCOSE MONITOR

3 ST; OTC

HEALTHPRO HIGH-LOW CONTROL

3 OTC

IGLUCOSE BLOOD GLUCOSE MONITOR

3 ST; OTC

INFINITY CONTROL SOLUTION NORM

3 OTC

INFINITY STARTER KIT

3 ST; OTC; QL

INFINITY VOICE CTRL SOLN-LVL 2

3 OTC

INFINITY VOICE GLUCOSE MONITOR

3 ST; OTC

JAZZ WIRELESS 2 METER KIT

3 ST; OTC; QL

LANCETS 2 OTC

LANCING DEVICE 2 OTC

MEDISENSE 3 OTC

MEDISENSE GLUCOSE KETONE

3 OTC

MICRODOT BLOOD GLUCOSE SYSTEM

3 ST; OTC

MYGLUCOHEALTH

3 ST; OTC; QL

MYGLUCOHEALTH CONTROL SOLUTION

3 OTC

NOVA MAX BLOOD GLUCOSE METER

3 ST; OTC; QL


71

Drug Name Drug


/ Limits

NOVA MAX GLUCOSE CONTROL

3 OTC

NOVAMAX PLUS GLU-KET

3 OTC

NOVOPEN ECHO 3

OMNIPOD DASH INSULIN POD

6 MSD

ON CALL EXPRESS CONTROL

3 OTC

ON CALL EXPRESS METER

3 ST; OTC

ON CALL PLUS CONTROL

3 OTC

ON CALL PLUS METER

3 ST; OTC

ON CALL VIVID CONTROL

3 OTC

ON CALL VIVID METER

3 ST; OTC; QL

ON CALL VIVID PAL METER

3 ST; OTC; QL

ONETOUCH ULTRA CONTROL

2 OTC

ONETOUCH ULTRA2 METER

2 ST; OTC; QL

ONETOUCH ULTRAMINI

2 ST; OTC; QL

ONETOUCH VERIO FLEX

2 ST; OTC

ONETOUCH VERIO IQ METER

2 ST; OTC; QL

ONETOUCH VERIO SYSTEM

2 ST; OTC

OPTUMRX 3 ST; OTC

Drug Name Drug


/ Limits

PEN NEEDLE, DIABETIC

3 M; OTC

PHARMACIST CHOICE GLUCOSE SYS

3 ST; OTC; QL

PRECISION XTRA MONITOR

2 ST; OTC; QL

PREMIER BLU GLUCOSE METER

3 ST; OTC

PREMIER VOICE GLUCOSE METER

3 ST; OTC

PREMIUM BLOOD GLUCOSE MONITOR

3 ST; OTC; QL

PREMIUM V10 3 ST; OTC; QL

PRESTO PRO BLOOD GLUCOSE METER

3 ST; OTC; QL

PRO VOICE V8 GLUCOSE MONITOR

3 ST; OTC

PRO VOICE V9 GLUCOSE MONITOR

3 ST; OTC

PRODIGY AUTOCODE METER

3 ST; OTC; QL

PRODIGY AUTOCODE MONITOR SYST

3 ST; OTC

PRODIGY CONTROL SOLUTION, LOW

3 OTC

PRODIGY CONTROL SOLUTION,HIGH

3 OTC

PRODIGY POCKET METER

3 ST; OTC; QL


72

Drug Name Drug


/ Limits

PRODIGY VOICE GLUCOSE METER

3 ST; OTC; QL

QUINTET BLOOD GLUCOSE METER

3 ST; OTC

REFUAH PLUS GLUCOSE CONTROL

3 OTC

REFUAH PLUS GLUCOSE MONITOR

3 ST; OTC

RELION ALL-IN-ONE METER

3 ST; OTC

RELION CONFIRM 3 ST; OTC; QL

RELION MICRO GLUCOSE MONITOR

3 ST; OTC; QL

RELION PRIME METER

3 ST; OTC; QL

REVEAL BLOOD GLUCOSE METER

3 ST; OTC; QL

RIGHTEST CONTROL SOLUTION HIGH

3 OTC

RIGHTEST GM550 SYSTEM

3 ST; OTC; QL

SIDEKICK BLOOD GLUCOSE SYSTEM

3 ST; OTC

SMART SENSE MONITORING SYSTEM

3 ST; OTC

SMARTEST CONTROL

3 OTC

SMARTEST EJECT 3 ST; OTC

SMARTEST PERSONA STARTER

3 ST; OTC; QL

Drug Name Drug


/ Limits

SMARTEST PRONTO STARTER

3 ST; OTC; QL

SMARTEST PROTEGE

3 ST; OTC

SOLUS V2 AUDIBLE METER

3 ST; OTC

SOLUS V2 AUDIBLE METER KIT

3 ST; OTC; QL

SOLUS V2 CONTROL SOLUTION,HIGH

3 OTC

SURE-TEST EASYPLUS MINI METER

3 ST; OTC

T:SLIM X2 BASAL-IQ INSULIN PMP

6 MSD

TELCARE BGM 3 ST; OTC

TELCARE BLOOD GLUCOSE KIT

3 ST; OTC; QL

TELCARE CONTROL

3 OTC

TEST N'GO BLOOD GLUCOSE SYSTEM

3 ST; OTC

TRUE METRIX AIR GLUCOSE METER

3 ST; OTC

TRUE METRIX GLUCOSE METER

3 ST; OTC

TRUE METRIX GO GLUCOSE METER

3 ST; OTC

TRUE METRIX LEVEL 1

3 OTC

TRUECONTROL LEVEL 0

3 OTC


73

Drug Name Drug


/ Limits

TRUERESULT BLOOD GLUCOSE SYSTM

3 ST; OTC; QL

TRUETRACK BLOOD GLUCOSE SYSTEM

3 ST; OTC; QL

TRUETRACK SMART SYSTEM

3 ST; OTC; QL

TRUSTEEL INFUSION SET 32"

6 MSD

ULTIMA MONITOR

3 ST; OTC; QL

ULTRATRAK GLUCOSE METER

3 ST; OTC; QL

ULTRATRAK ULTIMATE

3 ST; OTC

UNISTRIP LOW CONTROL

3 OTC

VARISOFT INFUSION SET 43"

6 MSD

VERASENS BLOOD GLUCOSE METER

3 ST; OTC

VERASENS CONTROL SOLN-LEVEL 1

3 OTC

VERASENS METER STARTER KIT

3 ST; OTC

V-GO 20 6 MSD

V-GO 30 6 MSD

V-GO 40 6 MSD

WAVESENSE AMP 3 ST; OTC

WAVESENSE CONTROL SOLUTION

3 OTC

WAVESENSE PRESTO

3 ST; OTC; QL

Drug Name Drug


/ Limits

INSULIN THERAPY

ADMELOG SOLOSTAR U-100 INSULIN

3 ST; M; QL

ADMELOG U-100 INSULIN LISPRO

3 ST; M; QL

AFREZZA INHALATION CARTRIDGE WITH INHALER 12 UNIT, 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60), 8 UNIT, 8 UNIT (90)/ 12 UNIT (90)

3 M

AFREZZA INHALATION CARTRIDGE WITH INHALER 4 UNIT

3 M; QL

APIDRA SOLOSTAR U-100 INSULIN

3 ST; M; QL

APIDRA U-100 INSULIN

3 ST; M; QL

BASAGLAR KWIKPEN U-100 INSULIN

3 M; QL

FIASP FLEXTOUCH U-100 INSULIN

3 ST; M

FIASP U-100 INSULIN

3 ST; M

HUMALOG JUNIOR KWIKPEN U-100

2 M

HUMALOG KWIKPEN INSULIN

2 M; QL


74

Drug Name Drug


/ Limits

HUMALOG MIX 50-50 INSULN U-100

2 M; QL

HUMALOG MIX 50-50 KWIKPEN

2 M; QL

HUMALOG MIX 75-25 KWIKPEN

2 M; QL

HUMALOG MIX 75-25(U-100)INSULN

2 M; QL

HUMALOG U-100 INSULIN

2 M; QL

HUMULIN 70/30 U-100 INSULIN

2 M; QL

HUMULIN 70/30 U-100 KWIKPEN

2 M; QL

HUMULIN N NPH INSULIN KWIKPEN

2 M

HUMULIN N NPH U-100 INSULIN

2 M; QL

HUMULIN R REGULAR U-100 INSULN

2 M; QL

HUMULIN R U-500 (CONC) INSULIN

2 M; QL

HUMULIN R U-500 (CONC) KWIKPEN

2 M

INSULIN LISPRO 3 M; QL

LANTUS SOLOSTAR U-100 INSULIN

2 M; QL

LANTUS U-100 INSULIN

2 M; QL

LEVEMIR FLEXTOUCH U-100 INSULN

2 M; QL

Drug Name Drug


/ Limits

LEVEMIR U-100 INSULIN

2 M; QL

NOVOLIN 70-30 FLEXPEN U-100

3 ST; M; QL

NOVOLOG FLEXPEN U-100 INSULIN

3 ST; M; QL

NOVOLOG MIX 70-30 U-100 INSULN

3 ST; M; QL

NOVOLOG MIX 70-30FLEXPEN U-100

3 ST; M; QL

NOVOLOG PENFILL U-100 INSULIN

3 ST; M; QL

NOVOLOG U-100 INSULIN ASPART

3 ST; M; QL

RELION NOVOLIN 70/30

3 ST; M; QL

RELION NOVOLIN N

3 ST; M; QL

RELION NOVOLIN R

3 ST; M; QL

SOLIQUA 100/33 2 ST; M

TOUJEO MAX U-300 SOLOSTAR

2 M; QL

TOUJEO SOLOSTAR U-300 INSULIN

2 M; QL

TRESIBA FLEXTOUCH U-100

2 M

TRESIBA FLEXTOUCH U-200

2 M

TRESIBA U-100 INSULIN

2 M


75

Drug Name Drug


/ Limits

XULTOPHY 100/3.6

2 ST; M

MISCELLANEOUS HORMONES

ALDURAZYME 6 MSD

ANADROL-50 3

ANDRODERM 2 PA

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

2

ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)

3 ST

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

2

ANDROID 3 ST

AVEED 6 PA; MSD

BRAVELLE 7 ST

BRINEURA 6 MSD

cabergoline 1 M; QL

calcitonin (salmon) 1 M

calcitriol 1 M

CERDELGA 3 S; SLA

CEREZYME 6 MSD

CETROTIDE 7

Drug Name Drug


/ Limits

CHORIONIC GONADOTROPIN, HUMAN

7

cinacalcet 1 PA

clomiphene citrate 7

CRYSVITA 6 MSD

danazol 1

DDAVP NASAL SOLUTION

2 M

DDAVP NASAL SPRAY WITH PUMP

3 M

DDAVP ORAL 3 M

DEPO-TESTOSTERONE

3 PA

desmopressin 1 M

doxercalciferol

intravenous 6 MSD

doxercalciferol oral 1 M

ELAPRASE 6 MSD

ELELYSO 6 MSD

FABRAZYME 6 MSD

FOLLISTIM AQ 7 ST

FORTESTA 3 ST

GALAFOLD 4 PA; S

ganirelix 7 ST; S

GONAL-F 7

GONAL-F RFF 7

GONAL-F RFF REDI-JECT

7

HECTOROL 6 MSD

JYNARQUE ORAL TABLET

4 PA; SLA; QL


76

Drug Name Drug


/ Limits

JYNARQUE ORAL TABLETS, SEQUENTIAL

3 PA; SLA

KANUMA 6 MSD

KORLYM 3 PA; SLA

KUVAN 3 PA; S; SLA

LUMIZYME 6 MSD

MENOPUR 7

MEPSEVII 6 MSD

METHITEST 2

methyltestosterone 1

MIACALCIN 6 MSD

miglustat 1 S

MYALEPT 3 PA; S; SLA

NAGLAZYME 6 MSD

NATESTO 3 ST

NATPARA 3 PA; S; SLA

NOCDURNA (MEN)

3 M

NOCDURNA (WOMEN)

3 M

NOCTIVA 3 ST; M

NOVAREL 7

ORILISSA 3 PA; S

OVIDREL 7

OXANDRIN 3

oxandrolone 1

PALYNZIQ 3 PA; S

pamidronate

intravenous recon

soln

6 PA; MSD

Drug Name Drug


/ Limits

pamidronate


mg/ml), 90 mg/10 ml

(9 mg/ml)

6 PA; MSD

pamidronate


mg/ml)

6 MSD

PARICALCITOL HEMODIALYSIS PORT INJECTION

6 MSD

paricalcitol

intravenous 6 MSD

paricalcitol oral 1 M

PREGNYL 7

RAYALDEE 3 M

ROCALTROL 3 M

SAMSCA 3 PA; S; QL

SENSIPAR 2 PA

serophene 7

SOMAVERT 3 S; SLA

STIMATE 2

STRENSIQ 2 SLA

STRIANT 3 PA

SYNAREL 2

TESTIM 3 ST

testosterone 1

testosterone

cypionate 1 PA

testosterone

enanthate 1 PA

TESTRED 3 ST

VIMIZIM 6 MSD

VOGELXO 3 ST


77

Drug Name Drug


/ Limits

VPRIV 6 MSD

XYOSTED 3 PA

ZAVESCA 4 S

ZEMPLAR INTRAVENOUS

6 MSD

ZEMPLAR ORAL 3 M

zoledronic acid 6 MSD

zoledronic acid-

mannitol-water 6 MSD

ZOLEDRONIC AC-MANNITOL-0.9NACL

6 MSD

NON-INSULIN HYPOGLYCEMIC

AGENTS

acarbose 1 M

ACTOPLUS MET 3 ST; M; QL

ACTOPLUS MET XR

3 ST; M; QL

ACTOS 3 ST; M; QL

ADLYXIN 3 ST; M

ALOGLIPTIN 3 ST; M; QL

ALOGLIPTIN-METFORMIN

3 ST; M; QL

ALOGLIPTIN-PIOGLITAZONE

3 M; QL

AMARYL 3 M

AVANDIA 3 ST; M; QL

BYDUREON 2 ST; M

BYDUREON BCISE

2 ST; M

BYETTA 2 ST; M; QL

chlorpropamide 1 M

CYCLOSET 3 M; QL

DM2 3 M

Drug Name Drug


/ Limits

DUETACT 3 ST; M; QL

FARXIGA 2 ST; M; QL

FORTAMET 3 ST; M

glimepiride 1 M

glipizide 1 M

glipizide-metformin 1 M

GLUCOPHAGE 3 ST; M

GLUCOPHAGE XR 3 ST; M

GLUCOTROL 3 M

GLUCOTROL XL 3 M

GLUMETZA 3 ST; M; QL

glyburide 1 M

glyburide

micronized 1 M

glyburide-metformin 1 M

GLYNASE 3 M

GLYSET 3 M

GLYXAMBI 2 ST; M

INVOKAMET 2 ST; M; QL

INVOKAMET XR 2 ST; M; QL

INVOKANA 2 ST; M; QL

JANUMET 2 ST; M; QL

JANUMET XR 2 ST; M; QL

JANUVIA 2 ST; M; QL

JARDIANCE 2 ST; M; QL

JENTADUETO 2 ST; M; QL

JENTADUETO XR 2 ST; M

KAZANO 3 ST; M; QL

KOMBIGLYZE XR 3 ST; M; QL

METFORMIN ORAL SOLUTION

3 ST; M; QL


78

Drug Name Drug


/ Limits

metformin oral

tablet 1 M

metformin oral

tablet extended

release 24 hr

1 M

metformin oral

tablet extended

release 24hr

1 ST; M

metformin oral

tablet,er

gast.retention 24 hr

1 M; QL

miglitol 1 M

nateglinide 1 M

NESINA 3 ST; M; QL

ONGLYZA 3 ST; M; QL

OSENI 3 M; QL

OZEMPIC 2 ST; M

pioglitazone 1 M; QL

pioglitazone-

glimepiride 1 M; QL

pioglitazone-

metformin 1 M; QL

PRANDIN 3 M

PRECOSE 3 M

QTERN 3 PA; ST; M

repaglinide 1 M

repaglinide-

metformin 1 M; QL

RIOMET 3 ST; M; QL

SEGLUROMET 2 ST; M

STARLIX 3 M

STEGLATRO 2 ST; M

STEGLUJAN 3 ST; M

SYMLINPEN 120 2 ST; M; QL

Drug Name Drug


/ Limits

SYMLINPEN 60 2 ST; M; QL

SYNJARDY 2 ST; M

SYNJARDY XR 2 ST; M

tolazamide 1 M

tolbutamide 1 M

TRADJENTA 2 ST; QL

TRULICITY 2 ST; M; QL

VICTOZA 2-PAK 3 ST; M; QL

VICTOZA 3-PAK 3 ST; M; QL

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-1,000 MG, 5-500 MG

2 ST; M; QL

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG

2 ST; M

THYROID HORMONES

ARMOUR THYROID

2 M

CYTOMEL 3 ST; M

EUTHYROX 3 M

LEVO-T 3 M

levothyroxine

intravenous 6 MSD

levothyroxine oral 1 M

levoxyl 1 M

liothyronine 1 M

nature-throid 1 M

np thyroid 1 M

SYNTHROID 3 M

thyroid (pork) 1 M


79

Drug Name Drug


/ Limits

THYROLAR-1 3 M

THYROLAR-1/2 3 M

THYROLAR-1/4 3 M

THYROLAR-2 3 M

THYROLAR-3 3 M

TIROSINT 3 M

TIROSINT-SOL 3 M

unithroid 1 M

westhroid 1 M

WP THYROID 3 M

GASTROENTEROLOGY

ANTIDIARRHEALS &

ANTISPASMODICS

anaspaz 1

atropine 6 MSD

atropine in 0.9 %

sod chloride

intravenous syringe 0.8 mg/2 ml (0.4

mg/ml)

6 MSD

ATROPINE IN 0.9 % SOD CHLORIDE INTRAVENOUS SYRINGE 1 MG/2.5 ML (0.4 MG/ML), 2 MG/5 ML (0.4 MG/ML)

6 MSD

belladonna

alkaloids-opium 1

BENTYL 6 MSD

chlordiazepoxide-

clidinium 1

CUVPOSA 3

dicyclomine

intramuscular 6 MSD

Drug Name Drug


/ Limits

dicyclomine oral 1

diphenoxylate-

atropine 1

DONNATAL 3

ed-spaz 1

GLYCATE 3

GLYCOPYRROLATE (PF) IN WATER INJECTION

6 MSD

glycopyrrolate (pf)

in water intravenous

syringe 0.4 mg/2 ml

(0.2 mg/ml), 1 mg/5

ml (0.2 mg/ml)

6 MSD

GLYCOPYRROLATE (PF) IN WATER INTRAVENOUS SYRINGE 0.6 MG/3 ML (0.2 MG/ML)

6 MSD

glycopyrrolate

injection 6 MSD

GLYCOPYRROLATE INTRAVENOUS

6 MSD

glycopyrrolate oral 1

GLYRX-PF 6 MSD

hyoscyamine sulfate 1

hyosyne 1

LEVBID 3

LEVSIN INJECTION

6 MSD

LEVSIN ORAL 3

LEVSIN/SL 3

LIBRAX (WITH CLIDINIUM)

3 ST

LOMOTIL 3


80

Drug Name Drug


/ Limits

methscopolamine 1

MOTOFEN 3

MYTESI 3

NULEV 3

opium tincture 1

oscimin 1

oscimin sl 1

oscimin sr 1

paregoric 1

phenobarb-hyoscy-

atropine-scop 1

phenohytro 1

propantheline 1

SYMAX DUOTAB 3

symax fastabs 1

symax-sl 1

symax-sr 1

MISCELLANEOUS

GASTROINTESTINAL AGENTS

ACTIGALL 3 M

AKYNZEO (FOSNETUPITANT)

6 MSD

AKYNZEO (NETUPITANT)

2 QL

alophen 5 ACA; OTC

alosetron 1

ALOXI 6 MSD

AMITIZA 2

ANALPRAM-HC 3

ANALPRAM-HC SINGLES

3

anucort-hc 1

Drug Name Drug


/ Limits

ANUSOL-HC 3 ST

aprepitant 1 QL

APRISO 2 M

ASACOL HD 3 ST; M

AURYXIA 3

AZULFIDINE 3 M

AZULFIDINE EN-TABS

3 M

balsalazide 1

bisacodyl 5 ACA; OTC

bisa-lax 5 ACA; OTC

BONJESTA 3

budesonide 1

calcium acetate 1

CANASA 2

CESAMET 3 QL

CHENODAL 2 PA; SLA

CHOLBAM 2 PA; SLA

CIMZIA 4 PA; ST; S; SLA

CIMZIA POWDER FOR RECONST

4 PA; ST; S; SLA

CINVANTI 6 MSD

citrate of magnesia 5 ACA; OTC

citroma 5 ACA; OTC

clearlax 5 ACA; OTC

CLENPIQ 5 ACA

COLAZAL 3

COLYTE WITH FLAVOR PACKS

3

COMPAZINE 3

compro 1

constulose 1


81

Drug Name Drug


/ Limits

CORTENEMA 3

CORTIFOAM 3 ST

CREON 2

cromolyn 1

CYSTADANE 2 SLA

DELZICOL 3 ST; M

DICLEGIS 3

DIPENTUM 3 ST; M

dronabinol 1

ducodyl 5 ACA; OTC

EMEND (FOSAPREPITANT)

6 MSD

EMEND ORAL CAPSULE

3 QL

EMEND ORAL CAPSULE,DOSE PACK

3 QL

EMEND ORAL SUSPENSION FOR RECONSTITUTION

3

ENTOCORT EC 3

ENTYVIO 6 MSD

enulose 1

fleet laxative 5 ACA; OTC

FOSRENOL 3 ST

GASTROCROM 3

GATTEX 30-VIAL 4 S; SLA

gavilax 5 ACA; OTC

gavilyte-c 5 ACA

gavilyte-g 5 ACA

gavilyte-n 5 ACA

generlac 1

Drug Name Drug


/ Limits

gentle laxative 5 ACA; OTC

gentlelax 5 ACA; OTC

GIALAX 5 ACA

glycolax 5 ACA; OTC

GOLYTELY ORAL POWDER IN PACKET

5 ACA

GOLYTELY ORAL RECON SOLN

3

granisetron hcl 1 QL

healthylax 5 ACA; OTC

hemmorex-hc 1

hydrocortisone 1

hydrocortisone

acetate 1

hydrocortisone-

pramoxine 1

INFLECTRA 6 MSD

KRISTALOSE 3 M

lactulose oral packet 1 M

lactulose oral

solution 1

lanthanum 1

laxaclear 5 PA; ACA; OTC

laxative (bisacodyl) 5 ACA; OTC

laxative feminine 5 ACA; OTC

laxative peg 3350 5 ACA; OTC

LIALDA 3 M

lidocaine hcl-

hydrocortison ac 1

LINZESS 2

LOKELMA 2

LOTRONEX 3


82

Drug Name Drug


/ Limits

magnesium citrate 5 ACA; OTC

MARINOL 3

mesalamine oral

tablet,delayed

release (dr/ec) 1.2

gram

1 M

mesalamine oral

tablet,delayed

release (dr/ec) 800

mg

2 ST; M

mesalamine rectal 1

mesalamine with

cleansing wipe 1

metoclopramide hcl

injection 6 MSD

metoclopramide hcl

oral 1

MICORT-HC 3 ST

milk of magnesia 5 ACA; OTC

milk of magnesia

concentrated 5 ACA; OTC

miralax 5 ACA; OTC

MOTEGRITY 3

MOVANTIK 2

MOVIPREP 5 ACA

natura-lax 5 ACA; OTC

NULYTELY WITH FLAVOR PACKS

3

OCALIVA 3 PA; S; SLA

ondansetron 1 QL

ondansetron hcl (pf) 6 MSD

ondansetron hcl

intravenous 6 MSD

ondansetron hcl oral 1 QL

oral saline laxative 5 ACA; OTC

Drug Name Drug


/ Limits

OSMOPREP 5 ACA

PALONOSETRON INTRAVENOUS SOLUTION 0.25 MG/2 ML

6 MSD

palonosetron

intravenous solution 0.25 mg/5 ml

6 MSD

palonosetron

intravenous syringe 6 MSD

PANCREAZE 3 ST

peg 3350-

electrolytes 5 ACA

peg-electrolyte soln 5 ACA

PENTASA 2 M

PERTZYE 3 ST

PHOSLYRA 2

phosphate laxative 5 ACA; OTC

PLENVU 5 ACA

polyethylene glycol

3350 5 ACA; OTC

powderlax 5 ACA; OTC

pramcort 1

PREPOPIK 5 ACA

prochlorperazine 1

prochlorperazine

edisylate 6 MSD

prochlorperazine

maleate 1

PROCORT 3

PROCTOCORT 3

PROCTOFOAM HC 3

procto-med hc 1

proctosol hc 1


83

Drug Name Drug


/ Limits

proctozone-hc 1

purelax 5 ACA; OTC

RECTIV 2

REGLAN 3

RELISTOR ORAL 3

RELISTOR SUBCUTANEOUS

2

REMICADE 6 MSD

RENAGEL 3 ST

RENFLEXIS 6 PA; ST; MSD

RENVELA 3

ROWASA 3

SANCUSO 2 QL

sevelamer carbonate 1

sevelamer hcl 1

SFROWASA 3

smoothlax 5 ACA; OTC

sodium polystyrene

sulfonate oral 1

sodium polystyrene

sulfonate rectal

enema 30 gram/120

ml

1

SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML

3

SOLESTA 6 MSD

sps (with sorbitol) 1

SUCRAID 3 S; SLA

sulfasalazine 1 M

SUPREP BOWEL PREP KIT

5 ACA

Drug Name Drug


/ Limits

SUSTOL 6 MSD

SYMPROIC 2

SYNDROS 3 PA

TIGAN INTRAMUSCULAR

6 MSD

TIGAN ORAL 3

TRANSDERM-SCOP

3

trilyte with flavor

packets 5 ACA

trimethobenzamide 1

TRULANCE 2 ST

UCERIS ORAL 3

UCERIS RECTAL 2

URSO 250 3 M

URSO FORTE 3 M

ursodiol 1 M

VARUBI 2

VELPHORO 2

VELTASSA 3 S; SLA

VIBERZI 2

VIOKACE 2

woman's laxative 5 ACA; OTC

women's gentle

laxative(bisac) 5 ACA; OTC

women's laxative

(bisacodyl) 5 ACA; OTC

ZENPEP 2

ZOFRAN 3 QL

ZUPLENZ 3 QL

ULCER THERAPY

ACIPHEX 3 ST; M; QL


84

Drug Name Drug


/ Limits

ACIPHEX SPRINKLE

3 ST; M; QL

amoxicil-

clarithromy-

lansopraz

1 QL

CARAFATE ORAL SUSPENSION

2 M

CARAFATE ORAL TABLET

3 M

cimetidine 1 M

cimetidine hcl 1 M

CYTOTEC 3 M

DEXILANT 3 ST; M; QL

ESOMEP-EZS 3 ST; M; QL

esomeprazole

magnesium 1 M; QL

esomeprazole

sodium 6 MSD

ESOMEPRAZOLE STRONTIUM

3 ST; M; QL

famotidine (pf) 6 MSD

famotidine (pf)-nacl

(iso-os) 6 MSD

FAMOTIDINE IN 0.9 % NACL

6 MSD

famotidine

intravenous 6 MSD

famotidine oral 1 M

lansoprazole oral

capsule,delayed

release(dr/ec)

1 M; QL

lansoprazole oral

tablet,disintegrat,

delay rel

1 ST; M; QL

misoprostol 1 M

NEXIUM 3 ST; M; QL

Drug Name Drug


/ Limits

NEXIUM IV 6 MSD

NEXIUM PACKET 2 ST; M; QL

nizatidine 1 M

OMECLAMOX-PAK

3 QL

omeppi 1 ST; M; QL

omeprazole oral

capsule,delayed

release(dr/ec) 10 mg

1 M; QL

omeprazole oral

capsule,delayed

release(dr/ec) 20

mg, 40 mg

1 M

omeprazole-sodium

bicarbonate oral

capsule

1 ST; M; QL

omeprazole-sodium

bicarbonate oral

packet

1 ST; QL

pantoprazole 1 M; QL

PEPCID 3 M

PREVACID 3 ST; M; QL

PREVACID SOLUTAB

3 ST; M; QL

PRILOSEC 3 ST; M; QL

PROTONIX 3 ST; M; QL

PYLERA 2

rabeprazole 1 M; QL

ranitidine hcl

injection 6 MSD

ranitidine hcl oral 1 M

sucralfate 1 M

ZANTAC 6 MSD

ZEGERID ORAL CAPSULE

3 ST; M; QL


85

Drug Name Drug


/ Limits

ZEGERID ORAL PACKET

3 ST; QL

IMMUNOLOGY, VACCINES &

BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ARANESP (IN POLYSORBATE)

6 MSD

EPOGEN 6 MSD

FULPHILA 6 MSD

GRANIX SUBCUTANEOUS SOLUTION

6 MSD

GRANIX SUBCUTANEOUS SYRINGE

6 PA; MSD

LEUKINE 6 PA; MSD

MACRILEN 6 MSD

MIRCERA 6 MSD

MOZOBIL 6 MSD

NEULASTA 6 MSD

NEUPOGEN 6 MSD

NIVESTYM INJECTION

6 MSD

NIVESTYM SUBCUTANEOUS

6 PA; MSD

PROCRIT 6 MSD

UDENYCA 6 MSD

GROWTH HORMONES

EGRIFTA 3 PA; S

GENOTROPIN 3 PA; S

GENOTROPIN MINIQUICK

3 PA; S

HUMATROPE 4 PA; ST; S

Drug Name Drug


/ Limits

NORDITROPIN FLEXPRO

3 PA; ST; S

NUTROPIN AQ NUSPIN

4 PA; ST; S

OMNITROPE 4 PA; ST; S

SAIZEN 4 PA; ST; S

SAIZEN SAIZENPREP

4 PA; ST; S

SEROSTIM 3 PA; ST; S

ZOMACTON 4 PA; ST; S

ZORBTIVE 4 PA; ST; S; SLA

INTERFERONS

AUBAGIO 4 ST; S; SLA; QL

AVONEX 3 PA; ST; S; QL

AVONEX (WITH ALBUMIN)

3 PA; ST; S; QL

BETASERON 3 PA; ST; S; QL

COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML

4 ST; S; QL

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

3 PA; ST; S; QL

EXTAVIA SUBCUTANEOUS KIT

4 PA; S; QL

EXTAVIA SUBCUTANEOUS RECON SOLN

4 PA; ST; S; QL

GILENYA 3 PA; ST; S; SLA; QL

glatiramer 1 PA; ST; S; QL


86

Drug Name Drug


/ Limits

glatopa

subcutaneous

syringe 20 mg/ml

1 PA; ST; S; QL

glatopa

subcutaneous

syringe 40 mg/ml

1 ST; S; QL

LEMTRADA 6 MSD

MAVENCLAD (10 TABLET PACK)

3 ST

MAYZENT 4 ST; S

moderiba 1 ST; S; SLA

OCREVUS 6 MSD

PEGASYS 3 PA; S; SLA; QL

PEGASYS PROCLICK

3 PA; S; SLA; QL

PEGINTRON 4 PA; S; SLA; QL

PLEGRIDY 3 ST; S; QL

POMALYST 3 S; QL

REBETOL 4 ST; S; SLA

REBIF (WITH ALBUMIN)

3 PA; ST; S; QL

REBIF REBIDOSE 3 PA; ST; S; QL

REBIF TITRATION PACK

3 PA; ST; S; QL

REVLIMID 3 S

ribasphere 1 ST; S; SLA

ribasphere ribapak 1 ST; S; SLA

ribavirin 1 S; SLA

SYLATRON 3 PA; S; SLA; QL

TECFIDERA 3 ST; S; SLA; QL

INTERLEUKINS

Drug Name Drug


/ Limits

ACTIMMUNE 6 MSD; SLA

ALDARA 3 QL

ALFERON N 6 MSD

ARCALYST 4 PA; ST; S; SLA

ILARIS (PF) 6 MSD

IMIQUIMOD TOPICAL CREAM IN METERED-DOSE PUMP

3 ST; QL

imiquimod topical

cream in packet 1 QL

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML)

3 S; SLA

INTRON A INJECTION RECON SOLN 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

3 PA; S; SLA

INTRON A INJECTION SOLUTION

3 S; SLA

KINERET 3 PA; ST; SLA; QL

PROLEUKIN 6 PA; MSD

ZYCLARA 3 ST; QL

VACCINES & MISCELLANEOUS

IMMUNOLOGICALS

ACTHIB (PF) 5 MSD; ACA

ADACEL(TDAP ADOLESN/ADULT)(PF)

5 MSD; ACA

AFLURIA 2018-2019

5 ACA


87

Drug Name Drug


/ Limits

AFLURIA 2018-2019 (PF)

5 ACA

AFLURIA QUAD 2018-2019

5 ACA

AFLURIA QUAD 2018-2019 (PF)

5 ACA

ATGAM 6 MSD

BCG VACCINE, LIVE (PF)

6 MSD

BEXSERO 5 MSD; ACA

BIVIGAM 6 MSD

BOOSTRIX TDAP 5 MSD; ACA

BOTOX 6 MSD

BOTOX COSMETIC

6 MSD

CUVITRU 6 MSD

DAPTACEL (DTAP PEDIATRIC) (PF)

5 MSD; ACA

DYSPORT 6 MSD

ENGERIX-B (PF) 5 MSD; ACA

ENGERIX-B PEDIATRIC (PF)

5 MSD; ACA

EZ FLU 2018-19(FLUCELVAX)(PF)

5 ACA

FLEBOGAMMA DIF

6 MSD

FLUAD 2018-2019 (65 YR UP)(PF)

5 ACA

FLUARIX QUAD 2018-2019 (PF)

5 ACA

FLUBLOK QUAD 2018-2019 (PF)

5 ACA

FLUCELVAX QUAD 2018-2019

5 ACA

Drug Name Drug


/ Limits

FLUCELVAX QUAD 2018-2019 (PF)

5 ACA

FLULAVAL QUAD 2018-2019

5 ACA

FLULAVAL QUAD 2018-2019 (PF)

5 ACA

FLUMIST QUAD 2018-2019

5 ACA

FLUZONE HIGH-DOSE 2018-19 (PF)

5 ACA

FLUZONE QUAD 2018-2019

5 ACA

FLUZONE QUAD 2018-2019 (PF)

5 ACA

FLUZONE QUAD PEDI 2018-19 (PF)

5 ACA

GAMASTAN 6 MSD

GAMASTAN S/D 6 MSD

GAMMAGARD LIQUID

6 MSD

GAMMAGARD S-D (IGA < 1 MCG/ML)

6 MSD

GAMMAKED 6 MSD

GAMMAPLEX 6 MSD

GAMMAPLEX (WITH SORBITOL)

6 MSD

GAMUNEX-C 6 MSD

GARDASIL 9 (PF) 5 ACA

GRASTEK 2 PA

HAVRIX (PF) 5 MSD; ACA

HEPAGAM B 6 MSD

HEPLISAV-B (PF) 5 MSD; ACA

HIBERIX (PF) 5 MSD; ACA


88

Drug Name Drug


/ Limits

HIZENTRA 6 MSD

HYPERHEP B S/D 6 MSD

HYPERHEP B S-D NEONATAL

6 MSD

HYPERRAB (PF) 6 MSD

HYPERRAB S/D (PF)

6 MSD

HYPERTET S/D (PF)

6 MSD

HYQVIA 6 MSD

IMOGAM RABIES-HT (PF)

6 MSD

INFANRIX (DTAP) (PF)

5 MSD; ACA

IPOL 5 ACA

KEDRAB (PF) 6 MSD

KINRIX (PF) 5 MSD; ACA

MENACTRA (PF) 5 MSD; ACA

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

5 MSD; ACA

M-M-R II (PF) 5 MSD; ACA

MYOBLOC 6 MSD

NABI-HB 6 MSD

OCTAGAM 6 MSD

ODACTRA 2

ORALAIR 3 PA; SLA

PEDIARIX (PF) 5 MSD; ACA

PEDVAX HIB (PF) 5 ACA

PENTACEL (PF) 5 ACA

PENTACEL ACTHIB COMPONENT (PF)

5 MSD; ACA

PNEUMOVAX 23 5 MSD; ACA

PREVNAR 13 (PF) 5 ACA

Drug Name Drug


/ Limits

PRIVIGEN 6 MSD

PROQUAD (PF) 5 MSD; ACA

PROVENGE 6 PA; MSD

QUADRACEL (PF) 5 MSD; ACA

RABAVERT (PF) 6 MSD

RAGWITEK 2 PA

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML

5 MSD; ACA

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML

2 MSD

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML

5 MSD; ACA

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML

2 MSD

ROTARIX 5 MSD; ACA

ROTATEQ VACCINE

5 MSD; ACA

SHINGRIX (PF) 5 MSD; ACA

TDVAX 5 MSD; ACA

TENIVAC (PF) 5 MSD; ACA

TETANUS,DIPHTHERIA TOX PED(PF)

5 MSD; ACA

THYMOGLOBULIN

6 MSD


89

Drug Name Drug


/ Limits

TICE BCG 6 MSD

TRUMENBA 5 ACA

TWINRIX (PF) 5 MSD; ACA

TYPHIM VI 6 MSD

VAQTA (PF) 5 MSD; ACA

VARIVAX (PF) 5 ACA

VARIZIG 5 MSD; ACA

VAXCHORA VACCINE

6 MSD

VIVOTIF 6 MSD

XEOMIN 6 MSD

YF-VAX (PF) 6 MSD

ZINPLAVA 6 MSD

ZOSTAVAX (PF) 5 ACA

MUSCULOSKELETAL &

RHEUMATOLOGY

GOUT THERAPY

allopurinol 1 M

COLCHICINE 3 ST

COLCRYS 2

DUZALLO 3 ST

KRYSTEXXA 6 MSD

MITIGARE 2

probenecid 1 M

probenecid-

colchicine 1 M

ULORIC 2 ST; M

ZYLOPRIM 3 M

OSTEOPOROSIS THERAPY

ACTONEL 3 ST; M; QL

alendronate 1 M; QL

ATELVIA 3 ST; M; QL

Drug Name Drug


/ Limits

BINOSTO 3 ST; M; QL

BONIVA INTRAVENOUS

6 MSD

BONIVA ORAL 3 ST; M; QL

EVENITY 6 MSD

EVISTA 3 PA; M

FORTEO 3 PA; ST; S; SLA; QL

FOSAMAX 3 ST; M; QL

FOSAMAX PLUS D

3 ST; M; QL

ibandronate

intravenous 6 MSD

ibandronate oral 1 M; QL

PROLIA 6 PA; MSD

raloxifene 1 PA; M

risedronate 1 M; QL

TYMLOS 3 S

OTHER RHEUMATOLOGICALS

ACTEMRA ACTPEN

3 PA; ST; S; SLA

ACTEMRA INTRAVENOUS

6 MSD

ACTEMRA SUBCUTANEOUS

3 PA; ST; S; SLA; QL

ARAVA 3 QL

BENLYSTA INTRAVENOUS

6 MSD

BENLYSTA SUBCUTANEOUS

3 PA; S; SLA

CUPRIMINE 3 ST; M

DEPEN TITRATABS

2 M

D-PENAMINE 2 M


90

Drug Name Drug


/ Limits

ENBREL 3 PA; ST; S; QL

ENBREL MINI 3 PA; ST; S; QL

ENBREL SURECLICK

3 PA; ST; S; QL

HUMIRA 3 PA; ST; S; QL

HUMIRA PEDIATRIC CROHNS START

3 PA; ST; S; QL

HUMIRA PEN 3 PA; ST; S; QL

HUMIRA PEN CROHNS-UC-HS START

3 PA; ST; S; QL

HUMIRA PEN PSOR-UVEITS-ADOL HS

3 PA; ST; S; QL

HUMIRA(CF) 3 PA; ST; S; QL

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML

3 PA; ST; S

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML

3 PA; ST; S; QL

HUMIRA(CF) PEN 3 PA; ST; S; QL

HUMIRA(CF) PEN CROHNS-UC-HS

3 PA; ST; S

HUMIRA(CF) PEN PSOR-UV-ADOL HS

3 PA; ST; S

KEVZARA 4 ST; S

leflunomide 1 QL

OLUMIANT 4 ST; S

Drug Name Drug


/ Limits

ORENCIA 4 PA; ST; S

ORENCIA (WITH MALTOSE)

6 MSD

ORENCIA CLICKJECT

4 PA; ST; S

OTEZLA 3 PA; ST; S; SLA; QL

OTEZLA STARTER

3 PA; ST; S; SLA; QL

OTREXUP (PF) 3 S; QL

RASUVO (PF) 3 S; QL

RIDAURA 2 M

SAVELLA ORAL TABLET

2 ST; M; QL

SAVELLA ORAL TABLETS,DOSE PACK

2 ST; QL

SIMPONI ARIA 6 MSD

SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML

3 PA; ST; S; QL

SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML

4 PA; ST; S; QL

SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML

3 PA; ST; S; QL

SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML

4 PA; ST; S; QL

XELJANZ 3 ST; S; QL

XELJANZ XR 3 ST; S; QL


91

Drug Name Drug


/ Limits

OBSTETRICS &

GYNECOLOGY

DIAPHRAGMS AND OTHER NON-

ORAL CONTRACEPTIVES

CAYA CONTOURED

5 ACA

FC2 FEMALE CONDOM

5 ACA; OTC

FEMCAP 5 ACA

KYLEENA 6 MSD

LILETTA 6 MSD

MIRENA 6 MSD

PARAGARD T 380A

6 MSD

SKYLA 6 MSD

WIDE-SEAL DIAPHRAGM

5 ACA

ESTROGENS & PROGESTINS

ACTIVELLA 3 M

ALORA 3 M; QL

amabelz 1 M

ANGELIQ 3 M

AYGESTIN 3 M

BIJUVA 3

camila 5 M; ACA; QL

CLIMARA 3 M; QL

CLIMARA PRO 3 ST; M; QL

COMBIPATCH 2 M

covaryx 1

covaryx h.s. 1

CRINONE VAGINAL GEL 4 %

2

Drug Name Drug


/ Limits

CRINONE VAGINAL GEL 8 %

7

deblitane 5 M; ACA; QL

DELESTROGEN 3

DEPO-ESTRADIOL 2

DEPO-PROVERA 5 ACA; QL

DEPO-SUBQ PROVERA 104

5 ACA; QL

DIVIGEL TRANSDERMAL GEL IN PACKET 0.25 MG/0.25 GRAM (0.1 %), 0.5 MG/0.5 GRAM (0.1 %), 1 MG/GRAM (0.1 %)

2 M; QL

DIVIGEL TRANSDERMAL GEL IN PACKET 0.75 MG/0.75 GRAM (0.1%)

2 M

DUAVEE 2

eemt 1

eemt hs 1

ELESTRIN 3 M; QL

ENDOMETRIN 7 ST

errin 5 M; ACA; QL

ESTRACE 3 M

estradiol oral 1 M

estradiol

transdermal 1 M; QL

estradiol vaginal 1 M

estradiol valerate 1

estradiol-

norethindrone acet 1 M


92

Drug Name Drug


/ Limits

ESTRING 2 M; QL

ESTROGEL 3 ST; M; QL

estrogens-

methyltestosterone 1

EVAMIST 3 QL

FEMHRT LOW DOSE

3 M

FEMRING 3 ST; M; QL

fyavolv 1 M

heather 5 M; ACA; QL

hydroxyprogest(pf)(p

reg presv) 6 MSD

hydroxyprogesterone

cap(ppres) 6 MSD

hydroxyprogesterone

caproate 6 MSD

IMVEXXY MAINTENANCE PACK

3

IMVEXXY STARTER PACK

3

incassia 5 M; ACA; QL

jencycla 5 M; ACA; QL

jinteli 1 M

jolivette 5 M; ACA; QL

lopreeza 1 M

lyza 5 M; ACA; QL

MAKENA 6 MSD

MAKENA (PF) 6 MSD

medroxyprogesteron

e intramuscular 5 ACA; QL

medroxyprogesteron

e oral 1 M

MENEST 3 M

Drug Name Drug


/ Limits

MENOSTAR 3 M; QL

mimvey 1 M

mimvey lo 1 M

MINIVELLE 3 M; QL

nora-be 5 M; ACA; QL

norethindrone

(contraceptive) 5 M; ACA; QL

norethindrone

acetate 1 M

norethindrone ac-eth

estradiol 1 M

norlyda 5 M; ACA; QL

norlyroc 5 M; ACA; QL

ORTHO MICRONOR

5 ST; M; ACA; QL

PREFEST 3 M

PREMARIN 2 M

PREMPHASE 2 M

PREMPRO 2 M

progesterone 7

progesterone

micronized 1 M

PROMETRIUM 3 M

PROVERA 3 M

sharobel 5 M; ACA; QL

tulana 5 M; ACA; QL

VAGIFEM 3 M

VIVELLE-DOT 3 M; QL

yuvafem 1 M

MISCELLANEOUS OB/GYN

AVC VAGINAL 3

CERVIDIL 3

CLEOCIN 3


93

Drug Name Drug


/ Limits

clindamycin

phosphate 1

CLINDESSE 3

fem ph 1

GYNAZOLE-1 3

gynol ii 5 ACA; OTC

INTRAROSA 3

isoxsuprine 1 M

LUPANETA PACK (1 MONTH)

3 QL

LUPANETA PACK (3 MONTH)

3 QL

LYSTEDA 3

METROGEL VAGINAL

3

metronidazole 1

NEXPLANON 6 MSD

NUVARING 5 M; ACA; QL

NUVESSA 3

OSPHENA 3

PREPIDIL 3

PROSTIN E2 3

RELAGARD 3

terconazole 1 QL

TODAY CONTRACEPTIVE SPONGE

5 ACA; OTC

tranexamic acid 1

TRIMO-SAN JELLY

2

vaginal

contraceptive foam 5 ACA; OTC

vandazole 1

Drug Name Drug


/ Limits

VCF CONTRACEPTIVE FILM

5 ACA; OTC

VCF CONTRACEPTIVE GEL

5 ACA; OTC

xulane 5 M; ACA; QL

ORAL CONTRACEPTIVES &

RELATED AGENTS

AFTERA 5 ACA; OTC; QL

altavera (28) 5 M; ACA; QL

alyacen 1/35 (28) 5 M; ACA; QL

alyacen 7/7/7 (28) 5 M; ACA; QL

amethia 5 M; ACA; QL

amethia lo 5 M; ACA; QL

amethyst (28) 5 M; ACA; QL

apri 5 M; ACA; QL

aranelle (28) 5 M; ACA; QL

ashlyna 5 M; ACA; QL

aubra 5 M; ACA; QL

aubra eq 5 M; ACA; QL

aurovela 1.5/30 (21) 5 M; ACA; QL

aurovela 24 fe 5 M; ACA; QL

aurovela fe 1-20

(28) 5 M; ACA; QL

aviane 5 M; ACA; QL

azurette (28) 5 M; ACA; QL

BALCOLTRA 5 ST; M; ACA; QL

balziva (28) 5 M; ACA; QL

bekyree (28) 5 M; ACA; QL

BEYAZ 5 ST; M; ACA; QL


94

Drug Name Drug


/ Limits

blisovi 24 fe 5 M; ACA; QL

blisovi fe 1.5/30 (28) 5 M; ACA; QL

blisovi fe 1/20 (28) 5 M; ACA; QL

briellyn 5 M; ACA; QL

camrese 5 M; ACA; QL

camrese lo 5 M; ACA; QL

caziant (28) 5 M; ACA; QL

chateal (28) 5 M; ACA; QL

chateal eq (28) 5 M; ACA; QL

cryselle (28) 5 M; ACA; QL

cyclafem 1/35 (28) 5 M; ACA; QL

cyclafem 7/7/7 (28) 5 M; ACA; QL

CYCLESSA (28) 5 ST; M; ACA; QL

cyred 5 M; ACA; QL

cyred eq 5 M; ACA; QL

dasetta 1/35 (28) 5 M; ACA; QL

dasetta 7/7/7 (28) 5 M; ACA; QL

daysee 5 M; ACA; QL

delyla (28) 5 M; ACA; QL

desog-

e.estradiol/e.estradio

l

5 M; ACA; QL

desogestrel-ethinyl

estradiol 5 M; ACA; QL

drospirenone-

e.estradiol-lm.fa 5 M; ACA; QL

drospirenone-ethinyl


econtra ez 5 ACA; OTC; QL

econtra one-step 5 ACA; OTC; QL

elinest 5 M; ACA; QL

Drug Name Drug


/ Limits

ELLA 5 ACA; QL

emoquette 5 M; ACA; QL

enpresse 5 M; ACA; QL

enskyce 5 M; ACA; QL

estarylla 5 M; ACA; QL

ESTROSTEP FE-28 5 ST; M; ACA; QL

ethynodiol diac-eth


falmina (28) 5 M; ACA; QL

fayosim 5 M; ACA; QL

femynor 5 M; ACA; QL

GENERESS FE 5 ST; M; ACA; QL

gianvi (28) 5 M; ACA; QL

hailey 24 fe 5 M; ACA; QL

introvale 5 M; ACA; QL

isibloom 5 M; ACA; QL

jasmiel (28) 5 M; ACA; QL

jolessa 5 M; ACA; QL

juleber 5 M; ACA; QL

junel 1.5/30 (21) 5 M; ACA; QL

junel 1/20 (21) 5 M; ACA; QL

junel fe 1.5/30 (28) 5 M; ACA; QL

junel fe 1/20 (28) 5 M; ACA; QL

junel fe 24 5 M; ACA; QL

kaitlib fe 5 M; ACA; QL

kariva (28) 5 M; ACA; QL

kelnor 1/35 (28) 5 M; ACA; QL

kelnor 1-50 5 M; ACA; QL

kurvelo (28) 5 M; ACA; QL

l norgest/e.estradiol-

e.estrad 5 M; ACA; QL


95

Drug Name Drug


/ Limits

larin 1.5/30 (21) 5 M; ACA; QL

larin 1/20 (21) 5 M; ACA; QL

larin 24 fe 5 M; ACA; QL

larin fe 1.5/30 (28) 5 M; ACA; QL

larin fe 1/20 (28) 5 M; ACA; QL

larissia 5 M; ACA; QL

layolis fe 5 M; ACA; QL

leena 28 5 M; ACA; QL

lessina 5 M; ACA; QL

levonest (28) 5 M; ACA; QL

levonorgestrel 5 ACA; OTC; QL

levonorgestrel-

ethinyl estrad 5 M; ACA; QL

levonorg-eth estrad

triphasic 5 M; ACA; QL

levora-28 5 M; ACA; QL

lillow (28) 5 M; ACA; QL

LO LOESTRIN FE 5 ST; M; ACA; QL

LOESTRIN 1.5/30 (21)

5 ST; M; ACA; QL

LOESTRIN 1/20 (21)

5 ST; M; ACA; QL

LOESTRIN FE 1.5/30 (28-DAY)

5 ST; M; ACA; QL

LOESTRIN FE 1/20 (28-DAY)

5 ST; M; ACA; QL

loryna (28) 5 M; ACA; QL

LOSEASONIQUE 5 ST; M; ACA; QL

low-ogestrel (28) 5 M; ACA; QL

lutera (28) 5 M; ACA; QL

marlissa (28) 5 M; ACA; QL

Drug Name Drug


/ Limits

melodetta 24 fe 5 M; ACA; QL

mibelas 24 fe 5 M; ACA; QL

microgestin 1.5/30

(21) 5 M; ACA; QL

microgestin 1/20

(21) 5 M; ACA; QL

MICROGESTIN 24 FE

5 ST; M; ACA; QL

microgestin fe 1.5/30

(28) 5 M; ACA; QL

microgestin fe 1/20

(28) 5 M; ACA; QL

mili 5 M; ACA; QL

MINASTRIN 24 FE 5 ST; M; ACA; QL

MIRCETTE (28) 5 ST; M; ACA; QL

mono-linyah 5 M; ACA; QL

my choice 5 ACA; OTC; QL

my way 5 ACA; OTC; QL

NATAZIA 5 ST; M; ACA; QL

necon 0.5/35 (28) 5 M; ACA; QL

new day 5 ACA; OTC; QL

nikki (28) 5 M; ACA; QL

noreth-ethinyl

estradiol-iron 5 M; ACA; QL

norethindrone ac-eth


norethindrone-

e.estradiol-iron 5 M; ACA; QL

norgestimate-ethinyl



96

Drug Name Drug


/ Limits

nortrel 0.5/35 (28) 5 M; ACA; QL

nortrel 1/35 (21) 5 M; ACA; QL

nortrel 1/35 (28) 5 M; ACA; QL

nortrel 7/7/7 (28) 5 M; ACA; QL

ocella 5 M; ACA; QL

ogestrel (28) 5 M; ACA; QL

opcicon one-step 5 ACA; OTC; QL

option-2 5 ACA; OTC; QL

orsythia 5 M; ACA; QL

ORTHO TRI-CYCLEN (28)

5 ST; M; ACA; QL

ORTHO TRI-CYCLEN LO (28)

5 ST; M; ACA; QL

ORTHO-CYCLEN (28)

5 ST; M; ACA; QL

ORTHO-NOVUM 1/35 (28)

5 ST; M; ACA; QL

ORTHO-NOVUM 7/7/7 (28)

5 ST; M; ACA; QL

philith 5 M; ACA; QL

pimtrea (28) 5 M; ACA; QL

pirmella 5 M; ACA; QL

PLAN B ONE-STEP 5 ACA; OTC; QL

portia 28 5 M; ACA; QL

previfem 5 M; ACA; QL

QUARTETTE 5 ST; M; ACA; QL

rajani 5 M; ACA; QL

reclipsen (28) 5 M; ACA; QL

rivelsa 5 M; ACA; QL

Drug Name Drug


/ Limits

SAFYRAL 5 ST; M; ACA; QL

SEASONIQUE 5 ST; M; ACA; QL

setlakin 5 M; ACA; QL

simliya (28) 5 M; ACA; QL

sprintec (28) 5 M; ACA; QL

sronyx 5 M; ACA; QL

syeda 5 M; ACA; QL

TAKE ACTION 5 ACA; OTC; QL

tarina 24 fe 5 M; ACA; QL

tarina fe 1/20 (28) 5 M; ACA; QL

TAYTULLA 5 ST; M; ACA; QL

tilia fe 5 M; ACA; QL

tri femynor 5 M; ACA; QL

tri-estarylla 5 M; ACA; QL

tri-legest fe 5 M; ACA; QL

tri-linyah 5 M; ACA; QL

tri-lo-estarylla 5 M; ACA; QL

tri-lo-marzia 5 M; ACA; QL

tri-lo-sprintec 5 M; ACA; QL

tri-mili 5 M; ACA; QL

tri-previfem (28) 5 M; ACA; QL

tri-sprintec (28) 5 M; ACA; QL

trivora (28) 5 M; ACA; QL

tri-vylibra 5 M; ACA; QL

tri-vylibra lo 5 M; ACA; QL

tydemy 5 M; ACA; QL

velivet triphasic

regimen (28) 5 M; ACA; QL

vienva 5 M; ACA; QL


97

Drug Name Drug


/ Limits

viorele (28) 5 M; ACA; QL

vyfemla (28) 5 M; ACA; QL

vylibra 5 M; ACA; QL

wera (28) 5 M; ACA; QL

wymzya fe 5 M; ACA; QL

YASMIN (28) 5 ST; M; ACA; QL

YAZ (28) 5 ST; M; ACA; QL

zarah 5 M; ACA; QL

zovia 1/35e (28) 5 M; ACA; QL

OXYTOCICS

methergine 1

methylergonovine 1

OPHTHALMOLOGY

ANTIBIOTICS

ak-poly-bac 1

AZASITE 2

bacitracin 1

bacitracin-

polymyxin b 1

BESIVANCE 3

BETADINE OPHTHALMIC PREP

3

CEFUROXIME (PF) IN 0.9% NACL

6 MSD

CILOXAN 3

ciprofloxacin hcl 1

erythromycin 1

gatifloxacin 1

gentak 1

gentamicin 1

Drug Name Drug


/ Limits

levofloxacin 1

MOXEZA 2

moxifloxacin 1

MOXIFLOXACIN (PF)-BSS NO.2

6 MSD

MOXIFLOXACIN IN NACL,ISO-O(PF)

6 MSD

NATACYN 2

neomycin-

bacitracin-

polymyxin

1 M

neomycin-

polymyxin-

gramicidin

1

neo-polycin 1 M

OCUFLOX 3

ofloxacin 1

polycin 1

polymyxin b sulf-

trimethoprim 1

POLYTRIM 3

tobramycin 1

TOBREX 3

VIGAMOX 3

ZYMAXID 3

ANTIVIRALS

trifluridine 1

ZIRGAN 3

BETA-BLOCKERS

betaxolol 1 M

BETIMOL 3 M

BETOPTIC S 3 M

carteolol 1 M


98

Drug Name Drug


/ Limits

ISTALOL 3 ST; M

levobunolol 1 M

metipranolol 1 M

timolol maleate 1 M

TIMOPTIC 3 M

TIMOPTIC OCUDOSE (PF)

3 M

TIMOPTIC-XE 3 M

CHOLINESTERASE INHIBITOR

MIOTICS

PHOSPHOLINE IODIDE

2 M

CYCLOPLEGIC MYDRIATICS

atropine 1 M

ATROPINE IN 0.9 % SOD CHLORIDE

3 M

CYCLOGYL 3 M

cyclopentolate 1 M

CYCLOPEN-TROPIC-PHENYLEPH-WATR

3 M

homatropaire 1 M

homatropine hbr 1 M

ISOPTO ATROPINE

3 M

MYDRIACYL 3 M

mydriatic3 (trop-

cyclopent-pe) 1 M

PAREMYD 3

tropicamide 1 M

DIRECT ACTING MIOTICS

ISOPTO CARPINE 3 M

MIOCHOL-E 3

Drug Name Drug


/ Limits

pilocarpine hcl 1 M

MISCELLANEOUS

OPHTHALMOLOGICS

acuicyn 1

AKTEN (PF) 3

ALCAINE 3

ALOCRIL 3 ST

ALOMIDE 3 ST

altacaine 1

ALTAFLUOR BENOX

6 MSD

azelastine 1

BEPREVE 2 ST

BEVACIZUMAB 6 PA; MSD

CEQUA 3 PA; M

cromolyn 1

CYSTARAN 2 PA; SLA

DEXAMET-MOXIFL-KETORO-NACL(PF)

6 MSD

epinastine 1

EYLEA 6 MSD

flucaine 1

fluorescein-

proparacaine 1

hypocyn 1

JETREA (PF) 6 MSD

LACRISERT 3

LASTACAFT 3 ST

lidocaine-

phenylephrn in

water

6 MSD


99

Drug Name Drug


/ Limits

LIDOCAN-PHENYLEPH-BSS NO.2(PF)

6 MSD

LUCENTIS 6 MSD

LUXTURNA 6 MSD

MACUGEN 6 MSD

olopatadine 1

OMIDRIA 6 MSD

OXERVATE 3 S

PATADAY 3 ST

PATANOL 3 ST

PAZEO 2 ST

PHOTREXA CROSS-LINKING KIT

6 MSD

PHOTREXA VISCOUS

6 MSD

PREDNISOLN SP-GATIFLOX-BROMFEN

3

PREDNISOLONE SOD PH-BROMFENAC

3

proparacaine 1

RACEPINEPH-LIDOCAINE-BSS 7(PF)

6 MSD

RESTASIS 2 PA; M; QL

RESTASIS MULTIDOSE

2 PA; M; QL

tetcaine 1

tetracaine hcl 1

TETRACAINE HCL (PF)

3

TETRAVISC 3

Drug Name Drug


/ Limits

TETRAVISC FORTE

3

VISUDYNE 6 MSD

VITRASE 6 MSD

XIIDRA 2 M; QL

NON-STEROIDAL ANTI-

INFLAMMATORY AGENTS

ACULAR 3

ACULAR LS 3

ACUVAIL (PF) 3 ST

bromfenac 1

BROMSITE 3

diclofenac sodium 1 QL

flurbiprofen sodium 1

ILEVRO 2

ketorolac 1

NEVANAC 3 ST

PROLENSA 2

ORAL DRUGS FOR GLAUCOMA

acetazolamide 1 M

acetazolamide

sodium 6 MSD

methazolamide 1 M

OTHER GLAUCOMA DRUGS

AZOPT 3 M

bimatoprost 1 ST; M

COMBIGAN 2 M

COSOPT 3 M

COSOPT (PF) 3 M

dorzolamide 1 M

dorzolamide-timolol 1 M


100

Drug Name Drug


/ Limits

dorzolamide-timolol

(pf) ophthalmic (eye)

dropperette

1 M

DORZOLAMIDE-TIMOLOL (PF) OPHTHALMIC (EYE) DROPS

3 M

latanoprost 1 ST; M

LUMIGAN 2 ST; M

MITOSOL 3

RHOPRESSA 2 M

ROCKLATAN 3 M

SIMBRINZA 3 M

TRAVATAN Z 2 ST; M

TRUSOPT 3 M

VYZULTA 3 PA; M

XALATAN 3 ST; M

XELPROS 3 ST; M

ZIOPTAN (PF) 3 ST; M

STEROID-ANTIBIOTIC

COMBINATIONS

DEXAMETH-MOXIFLOX(PF)-NACL,ISO

6 MSD

MAXITROL 3

neomycin-

bacitracin-poly-hc 1

neomycin-polymyxin

b-dexameth 1

neomycin-

polymyxin-hc 1

neo-polycin hc 1

PRED-G 3

PRED-G S.O.P. 3

Drug Name Drug


/ Limits

PREDNISOLONE ACET-GATIFLOXACIN

3

PREDNISOLONE SOD PH-GATIFLOXAC

3

TOBRADEX OPHTHALMIC (EYE) DROPS,SUSPENSION

3

TOBRADEX OPHTHALMIC (EYE) OINTMENT

2

TOBRADEX ST 2

tobramycin-

dexamethasone 1

TRIAMCINOLON-MOXIFLOX-WATR(PF)

6 MSD

ZYLET 2

STEROIDS

ALREX 2 ST

dexamethasone

sodium phosphate 1

DEXTENZA 6 MSD

DUREZOL 3

FLAREX 3

fluorometholone 1

FML FORTE 3

FML LIQUIFILM 3

FML S.O.P. 3

ILUVIEN 6 MSD

INVELTYS 2 ST

LOTEMAX 2

LOTEMAX SM 2


101

Drug Name Drug


/ Limits

MAXIDEX 3

OZURDEX 6 MSD

PRED FORTE 3

PRED MILD 3

prednisolone acetate 1

prednisolone sodium

phosphate 1

RETISERT 6 MSD

YUTIQ 6 MSD

STEROID-SULFONAMIDE

COMBINATIONS

BLEPHAMIDE 3

BLEPHAMIDE S.O.P.

3

sulfacetamide-

prednisolone 1

SULFONAMIDES

BLEPH-10 3

sulfacetamide

sodium 1

SYMPATHOMIMETICS

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

2 M

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.15 %

3 M

apraclonidine 1 M

brimonidine 1 M

IOPIDINE 3 M

VASOCONSTRICTOR

DECONGESTANTS

CYCLOMYDRIL 3 M

Drug Name Drug


/ Limits

phenylephrine hcl 1

RESPIRATORY, ALLERGY,

COUGH & COLD

ANTIHISTAMINE &

ANTIALLERGENIC AGENTS

ADYPHREN 3

ADYPHREN AMP 3

ADYPHREN AMP II

3

ADYPHREN II 3

AUVI-Q INJECTION AUTO-INJECTOR 0.1 MG/0.1 ML

3 ST

AUVI-Q INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML

3 ST; QL

carbinoxamine

maleate 1

cetirizine 1

CLARINEX 3 QL

clemastine 1

cyproheptadine 1

desloratadine 1 QL

dexchlorpheniramin

e maleate 1

diphenhydramine hcl 6 MSD

EPINEPHRINE INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML

3 ST; QL


102

Drug Name Drug


/ Limits

EPINEPHRINE INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML

2 ST; QL

epinephrine

injection auto-

injector 0.3 mg/0.3

ml

2 ST; QL

EPINEPHRINESNAP-EMS

3

EPINEPHRINESNAP-V

3

EPIPEN 2-PAK 2 QL

EPIPEN JR 2-PAK 2 QL

EPISNAP 6 MSD

hydroxyzine hcl 1

hydroxyzine

pamoate 1

KARBINAL ER 3

phenadoz 1

PHENERGAN INJECTION

6 MSD

phenergan rectal 1

promethazine

injection 6 MSD

promethazine oral 1

promethazine rectal 1

promethegan 1

RYCLORA 3

RYVENT 3

SYMJEPI 3

VISTARIL 3

COUGH & COLD THERAPY

benzonatate 1

BROMFED DM 3

Drug Name Drug


/ Limits

brompheniramine-

pseudoeph-dm 1

CAPCOF 3

centergy 1

cheratussin ac 1

CLARINEX-D 12 HOUR

3 QL

codeine-guaifenesin 1

CODITUSSIN AC 3

CODITUSSIN DAC 3

g tussin ac 1

guaiatussin ac 1

guaifenesin ac 1

guaifenesin dac 1

HISTEX-AC 3

hydrocodone-

chlorpheniramine 1

hydrocodone-cpm-

pseudoephed 1

HYDROCODONE-GUAIFENESIN

3 ST

hydrocodone-

homatropine 1

hydromet 1

lortuss ex 1

MAR-COF CG 3

MAXI-TUSS CD 3

m-clear wc 1

M-END PE 3

NINJACOF-XG 3

OBREDON 3 ST

POLY-TUSSIN AC 3


103

Drug Name Drug


/ Limits

promethazine-

codeine 1

promethazine-dm 1

promethazine-

phenyleph-codeine 1

promethazine-

phenylephrine 1

PRO-RED AC (W/ DEXCHLORPHENIR)

3

RESPA-AR 3

robafen ac 1

rydex 1

SEMPREX-D 3

TESSALON PERLES

3

tusnel c 1

TUSNEL PEDIATRIC

3

TUSSICAPS 3 ST

TUSSIONEX PENNKINETIC ER

3

TUXARIN ER 3

TUZISTRA XR 3 ST

virtussin ac 1

virtussin dac 1

ZODRYL AC 25 3

ZODRYL AC 30 3

ZODRYL AC 35 3

ZODRYL AC 40 3

ZODRYL AC 50 3

ZODRYL AC 60 3

ZODRYL AC 80 3

ZODRYL DAC 25 3

Drug Name Drug


/ Limits

ZODRYL DAC 30 3

ZODRYL DAC 35 3

ZODRYL DAC 40 3

ZODRYL DAC 50 3

ZODRYL DAC 60 3

ZODRYL DAC 80 3

ZODRYL DEC 25 3

ZODRYL DEC 30 3

ZODRYL DEC 35 3

ZODRYL DEC 40 3

ZODRYL DEC 50 3

ZODRYL DEC 60 3

ZODRYL DEC 80 3

Z-TUSS AC 3

PULMONARY AGENTS

ACCOLATE 3 M; QL

acetylcysteine 1

ADCIRCA 4 PA; ST; S; QL

ADEMPAS 3 PA; S; SLA

ADRENALIN 3

ADVAIR DISKUS 3 ST; M; QL

ADVAIR HFA 2 ST; M; QL

AEROSPAN 3 M

AIRDUO RESPICLICK

3 ST; M; QL

ALBUTEROL SULFATE INHALATION HFA AEROSOL INHALER

3 QL

albuterol sulfate

inhalation solution

for nebulization

1


104

Drug Name Drug


/ Limits

albuterol sulfate oral 1 M

ALVESCO 3 ST; M; QL

alyq 1 ST; S; QL

ambrisentan 1 ST; S

aminophylline 6 MSD

ANORO ELLIPTA 2 M; QL

ARCAPTA NEOHALER

2 M; QL

ARMONAIR RESPICLICK

2 M; QL

ARNUITY ELLIPTA

2 M

ASMANEX HFA 2 M

ASMANEX TWISTHALER

2 M; QL

ATROVENT HFA 2 M; QL

BECONASE AQ 3 ST; QL

BERINERT 6 MSD

BEVESPI AEROSPHERE

2 M

BREO ELLIPTA 2 ST; M; QL

BROVANA 3 M; QL

budesonide 1 M; QL

CINQAIR 6 MSD

CINRYZE 6 MSD

COMBIVENT RESPIMAT

2 QL

cromolyn 1 M

CUROSURF 3

DALIRESP ORAL TABLET 250 MCG

2 PA

DALIRESP ORAL TABLET 500 MCG

2 PA; QL

DULERA 2 ST; M; QL

Drug Name Drug


/ Limits

DYMISTA 2 ST; QL

ELIXOPHYLLIN 3 M

ESBRIET ORAL CAPSULE

3 PA; S; SLA; QL

ESBRIET ORAL TABLET

3 PA; S; SLA

FASENRA 6 MSD

FIRAZYR 3 PA; S; SLA

FLOVENT DISKUS 2 M; QL

FLOVENT HFA 2 M; QL

flunisolide 1 QL

fluticasone

propionate 1 QL

FLUTICASONE PROPION-SALMETEROL INHALATION AEROSOL POWDR BREATH ACTIVATED

2 ST; M; QL

fluticasone propion-

salmeterol

inhalation blister

with device

1 PA; M; QL

HAEGARDA 6 PA; MSD

HYPER-SAL 3

INCRUSE ELLIPTA

2 M

ipratropium bromide 1 M

ipratropium-

albuterol 1 QL

KALBITOR 6 MSD

KALYDECO ORAL GRANULES IN PACKET 25 MG

3 PA; S


105

Drug Name Drug


/ Limits

KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG

3 PA; S; SLA

KALYDECO ORAL TABLET

3 PA; S; SLA

LETAIRIS 3 PA; ST; S

levalbuterol hcl 1

LEVALBUTEROL TARTRATE

3 ST; QL

LONHALA MAGNAIR REFILL

3 PA; M

LONHALA MAGNAIR STARTER

3 PA; M

metaproterenol 1 M

mometasone 1 QL

montelukast oral

granules in packet 1 M

montelukast oral

tablet 1 M; QL

montelukast oral

tablet,chewable 1 M; QL

NASONEX 3 ST; QL

nebusal inhalation

solution for

nebulization 3 %

1

NEBUSAL INHALATION SOLUTION FOR NEBULIZATION 6 %

3

NUCALA 6 MSD

OFEV 3 PA; S; SLA; QL

OMNARIS 3 ST; QL

OPSUMIT 3 PA; S

Drug Name Drug


/ Limits

ORKAMBI 3 S; SLA

PERFOROMIST 2 M; QL

PROAIR HFA 2 QL

PROAIR RESPICLICK

2

PROVENTIL HFA 3 ST; QL

PULMICORT 3 ST; M; QL

PULMICORT FLEXHALER

2 M; QL

pulmosal 1

PULMOZYME 2

QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION

2 ST

QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION

2 ST; QL

QVAR REDIHALER

2 M

REVATIO 4 PA; ST; S; QL

RUCONEST 6 MSD

SEEBRI NEOHALER

3 M

SEREVENT DISKUS

2 M; QL

sildenafil

(antihypertensive) 1 PA; S; QL

SINGULAIR ORAL GRANULES IN PACKET

3 ST; M

SINGULAIR ORAL TABLET

3 ST; M; QL

SINGULAIR ORAL TABLET,CHEWABLE

3 ST; M; QL


106

Drug Name Drug


/ Limits

sodium chloride 1

SPIRIVA RESPIMAT

2 M

SPIRIVA WITH HANDIHALER

2 ST; M; QL

STIOLTO RESPIMAT

2 M

STRIVERDI RESPIMAT

2 M

SURFAXIN 6 MSD

SYMBICORT 2 ST; M; QL

SYMDEKO 3 PA; S

tadalafil

(antihypertensive) 1 PA; ST; S; QL

TAKHZYRO 4 PA; S

terbutaline oral 1 M

terbutaline

subcutaneous 6 MSD

THEO-24 3 M

theochron 1 M

theophylline 1 M

TICALAST 3 ST

TRACLEER 3 PA; S; SLA

TRELEGY ELLIPTA

2 M

TUDORZA PRESSAIR

2 M; QL

TYVASO 6 MSD

TYVASO REFILL KIT

6 MSD

TYVASO STARTER KIT

6 MSD

UTIBRON NEOHALER

3 M

VENTAVIS 4 ST; S

Drug Name Drug


/ Limits

VENTOLIN HFA 2 QL

wixela inhub 1 PA; M; QL

XHANCE 3 ST

XOLAIR 6 MSD

XOPENEX 3

XOPENEX CONCENTRATE

3

XOPENEX HFA 3 ST; QL

YUPELRI 2 M

zafirlukast 1 M; QL

ZETONNA 3 ST; QL

zileuton 1 ST; M; QL

ZYFLO 3 ST; M

UROLOGICALS

ANTICHOLINERGICS &

ANTISPASMODICS

darifenacin 1 M

DETROL 3 ST; M

DETROL LA 3 ST; M

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG

3 ST; M

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 5 MG

3 ST; M; QL

ENABLEX 3 ST; M

flavoxate 1 M


107

Drug Name Drug


/ Limits

GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP

2 ST

GELNIQUE TRANSDERMAL GEL IN PACKET

2 ST; M; QL

MYRBETRIQ 2 ST; M

oxybutynin chloride

oral syrup 1 M

oxybutynin chloride

oral tablet 1 M

oxybutynin chloride


release 24hr 10 mg,

15 mg

1 M

oxybutynin chloride


release 24hr 5 mg

1 M; QL

OXYTROL 3 ST; M; QL

solifenacin 1 M

tolterodine 1 M

TOVIAZ 2 ST; M

trospium 1 M

VESICARE 2 ST; M

BENIGN PROSTATIC

HYPERPLASIA (BPH) THERAPY

alfuzosin 1 M

AVODART 3 ST; M

CIALIS 3 ST; QL

dutasteride 1 ST; M

dutasteride-

tamsulosin 1 ST; M

finasteride 1 M

FLOMAX 3 ST; M

Drug Name Drug


/ Limits

JALYN 3 ST; M

PROSCAR 3 ST; M

RAPAFLO 2 M

silodosin 1 M

tadalafil 1 PA; QL

tamsulosin 1 M

UROXATRAL 3 ST; M

CHOLINERGIC STIMULANTS

bethanechol chloride 1

URECHOLINE 3

MISCELLANEOUS UROLOGICALS

CYSTAGON 2 PA; SLA

cytra k crystals 1

ELMIRON 2

hyophen 1

IFE-BIMIX 30/1 6 MSD

IFE-PG20 6 MSD

K-PHOS NO 2 3

K-PHOS ORIGINAL

2

methen-sod phos-

meth blue-hyos 1

ORACIT 3

phosphasal 1

potassium citrate 1 M

PROCYSBI 4 PA; ST; S; SLA

SHOHL'S MODIFIED

3

URELLE 3

uretron d-s 1

URIBEL 3


108

Drug Name Drug


/ Limits

urimar-t 1

urin ds 1

uro-458 1

UROCIT-K 10 3 M

UROCIT-K 15 3 M

UROCIT-K 5 3 M

urogesic-blue 1

uro-mp 1

UROQID-ACID NO.2

3

uryl 1

ustell 1

utira-c 1

vardenafil 1

URINARY ANESTHETICS

phenazopyridine 1

PYRIDIUM 3

VITAMINS, HEMATINICS &

ELECTROLYTES

ELECTROLYTES

calcium 500 + d 1 OTC

calcium 600 + d(3) 1 OTC

calcium 600 with

vitamin d3 1 OTC

calcium citrate-

vitamin d2 1 OTC

calcium citrate-

vitamin d3 1 OTC

CALCIUM GLUC IN NACL, ISO-OSM

6 MSD

Drug Name Drug


/ Limits

calcium gluconate in

0.9% nacl

intravenous solution 1 gram/100 ml

6 MSD

CALCIUM GLUCONATE IN 0.9% NACL INTRAVENOUS SOLUTION 1 GRAM/50 ML, 2 GRAM/100 ML, 2 GRAM/50 ML, 3 GRAM/100 ML

6 MSD

CALCIUM GLUCONATE IN 0.9% NACL INTRAVENOUS SYRINGE

6 MSD

CALCIUM GLUCONATE IN D5W

6 MSD

CALCIUM GLUCONATE IN WATER

6 MSD

EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ

3 M

effer-k oral tablet,

effervescent 25 meq 1 M

GALZIN 3

klor-con 1 M

klor-con 10 1 M

klor-con 8 1 M

klor-con m10 1 M

klor-con m15 1 M

klor-con m20 1 M

klor-con sprinkle 1 M

klor-con/ef 1 M


109

Drug Name Drug


/ Limits

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ

3 M

k-tab oral tablet

extended release 8

meq

1 M

lugols 1

oyster shell + d3 1 OTC

oyster shell calcium-

vit d3 1 OTC

POTABA 3 M

potassium chloride 1 M

sodium chloride 6 MSD

sodium chloride 0.45

% 6 MSD

sodium chloride 3 % 6 MSD

sodium chloride 5 % 6 MSD

strong iodine 1

MISCELLANEOUS VITAMINS,

HEMATINICS, & ELECTROLYTES

ISOLYTE-S 6 MSD

VITAMINS & HEMATINICS

AZESCO 3

b complex-vitamin

b12 5 ACA; OTC

b complex-vitamin c-

folic acid 5 ACA; OTC

balance b-100 5 ACA; OTC

balanced b-100 5 ACA; OTC

balanced b-100

complex 5 ACA; OTC

bal-care dha 1

Drug Name Drug


/ Limits

BAL-CARE DHA ESSENTIAL

3

b-complex with

vitamin c oral tablet 5 ACA; OTC

b-complex with

vitamin c oral tablet 400-500 mcg-mg

1 OTC

CADEAU DHA 3

calcium pnv 1

cholecalciferol

(vitamin d3) 1 OTC

CITRANATAL (DUAL-IRON)

3

CITRANATAL 90 DHA (ALGAL OIL)

3

CITRANATAL ASSURE

3

CITRANATAL B-CALM (FE GLUC)

3

CITRANATAL BLOOM

3

CITRANATAL DHA (ALGAL OIL)

3

CITRANATAL HARMONY (IRON FUM)

3

classic prenatal 5 ACA; OTC

c-nate dha 1

complete natal dha 1

completenate 1

complex b-100 1 OTC

CONCEPT DHA 3

CONCEPT OB 3

cyanocobalamin

(vitamin b-12) 1

dialyvite 800 5 ACA; OTC


110

Drug Name Drug


/ Limits

DRISDOL 3

DUET DHA BALANCED

3

DUET DHA WITH OMEGA-3

3

ENBRACE HR 3

ergocalciferol

(vitamin d2) 1

EXTRA-VIRT PLUS DHA

3

FLORIVA (FLUORIDE-VITAMIN D3)

5 M; ACA; OTC

FLUORABON 5 M; ACA; OTC

fluoride (sodium)

oral drops 5 M; ACA; OTC

fluoride (sodium)

oral tablet,chewable 0.25 mg(0.55 mg

sod. fluoride), 0.5

mg (1.1 mg sodium

fluorid)

5 M; ACA; OTC

fluoride (sodium)

oral tablet,chewable 1 mg (2.2 mg sod.

fluoride)

1 M; OTC

fluoritab oral

tablet,chewable 0.5

mg (1.1 mg sodium

fluorid)

5 M; ACA; OTC

fluoritab oral

tablet,chewable 1

mg (2.2 mg sod.

fluoride)

1 M; OTC

FLURA-DROPS 5 M; ACA; OTC

FOLET ONE 3

folic acid oral tablet 1 mg

1 M

Drug Name Drug


/ Limits

folic acid oral tablet 400 mcg, 800 mcg

5 M; ACA; OTC

folivane-ob 1

foltabs 800 1 OTC

full spectrum b-

vitamin c 5 ACA; OTC

hemenatal ob 1

hemenatal ob + dha 1

INFUVITE ADULT 6 MSD

INFUVITE PEDIATRIC

6 MSD

INJECTAFER 6 MSD

kobee 1 OTC

KOSHER PRENATAL PLUS IRON

3

kpn 1 OTC

ludent fluoride oral

tablet,chewable 0.25

mg(0.55 mg sod.

fluoride), 0.5 mg

(1.1 mg sodium

fluorid)

5 M; ACA; OTC

ludent fluoride oral

tablet,chewable 1

mg (2.2 mg sod.

fluoride)

1 M; OTC

m.v.i. adult 6 MSD

MARNATAL-F 3

m-natal plus 1

multi-vitamin with

fluoride oral drops 5 ACA; OTC

multi-vitamin with

fluoride oral


mg, 0.5 mg

5 ACA; OTC


111

Drug Name Drug


/ Limits

multi-vitamin with

fluoride oral

tablet,chewable 1

mg

1 OTC

multivitamins with

fluoride oral


mg, 0.5 mg

5 ACA; OTC

multivitamins with

fluoride oral

tablet,chewable 1

mg

1 OTC

mvc-fluoride oral


mg, 0.5 mg

5 ACA; OTC

mvc-fluoride oral

tablet,chewable 1

mg

1 OTC

mynatal 1

mynatal advance 1

mynatal plus 1

mynatal-z 1

mynate 90 plus 1

NASCOBAL 2 M

NATACHEW (FE BIS-GLYCINATE)

3

natural b-100

complex 5 ACA; OTC

NEEVODHA (WITH ALGAL OIL)

3

NESTABS 3

NESTABS ABC 3

NESTABS DHA 3

NESTABS ONE 3

newgen 1

NEXAVIR 3

Drug Name Drug


/ Limits

OB COMPLETE ONE

3

OB COMPLETE PETITE

3

OB COMPLETE PREMIER

3

OB COMPLETE WITH DHA

3

obstetrix dha 1

OBSTETRIX EC 3 M

OBSTETRIX ONE 3

OBTREX DHA 3

O-CAL PRENATAL

3

one daily prenatal 5 ACA; OTC

perry prenatal 5 ACA; OTC

pnv 29-1 1

pnv ob+dha 1

pnv-dha 1

pnv-dha + docusate 1

pnv-ferrous

fumarate-docu-fa 1

pnv-omega 1

pnv-select 1

pnv-vp-u 1

pr natal 400 1

pr natal 400 ec 1

pr natal 430 1

pr natal 430 ec 1

PREFERA-OB 3

PREFERA-OB PLUS DHA

3

prena1 chew 1


112

Drug Name Drug


/ Limits

prena1 pearl 1

prena1 true 1

prenaissance 1

prenaissance plus 1

PRENATA 3

prenatabs fa 1

prenatabs rx 1

prenatal 5 ACA; OTC

prenatal 19 1 OTC

prenatal 19 (with

docusate) 1 OTC

prenatal complete 5 ACA; OTC

prenatal formula 5 ACA; OTC

prenatal multi-dha

(algal oil) 1 OTC

prenatal one daily 5 ACA; OTC

prenatal plus 1

prenatal plus

(calcium carb) 1

PRENATAL PLUS DHA

3

prenatal vitamin 5 ACA; OTC

prenatal vitamin

plus low iron 1

prenatal vitamin

with minerals 5 ACA; OTC

prenatal vits96-iron

fum-folic 5 ACA; OTC

prenatal-u 1

PRENATE AM 3

PRENATE CHEWABLE

3

Drug Name Drug


/ Limits

PRENATE DHA (FERR ASP GLYCIN)

3

PRENATE ELITE (IRON ASP GLYC)

3

PRENATE ENHANCE

3

PRENATE ESSENTIAL(IRON-ASP-GL)

3

PRENATE MINI (FERR ASP GLYCIN)

3

PRENATE PIXIE 3

PRENATE RESTORE

3

PRENATE STAR 3

preplus 1

pretab 1

PRIMACARE 3

PROVIDA DHA 3

PROVIDA OB 3

PUREFE OB PLUS 3

rena-vite 5 ACA; OTC

R-NATAL OB 3

SELECT-OB 3

SELECT-OB (FOLIC ACID)

3

SELECT-OB + DHA

3

se-natal 19 1

se-natal 19 (with

docusate) 1

stress formula 5 ACA; OTC


113

Drug Name Drug


/ Limits

stress formula with

iron 1 OTC

stress formula with

iron(sulf) 1 OTC

super b complex-

vitamin c 1 OTC

super b maxi

complex 1 OTC

super b-50 complex

plus 1 OTC

super quints 1 OTC

super quints b-50 5 ACA; OTC

superplex-t 1 OTC

taron-c dha 1

taron-prex prenatal-

dha 1

THRIVITE RX 3

tl g-fol os 1

total b/c 1 OTC

TRICARE 3

TRIFERIC 6 MSD

trinatal rx 1 1

trinate 1

TRISTART DHA 3

triveen-duo dha 1

tri-vitamin with

fluoride 5 ACA; OTC

trust natal dha 1

ultra b-100 complex 1 OTC

VENOFER 6 MSD

vinate care 1

VINATE DHA RF 3

vinate ii 1

Drug Name Drug


/ Limits

vinate m 1 M

vinate one 1

virt-advance 1

virt-c dha 1

virt-nate dha 1

virt-pn dha 1

virt-pn plus 1

VIRTPREX 3

virt-select 1

virt-vite gt 1

VITAFOL FE+ (WITH DOCUSATE)

3

VITAFOL GUMMIES

3

VITAFOL NANO 3

VITAFOL ULTRA 3

VITAFOL-OB 3

VITAFOL-OB+DHA

3

VITAFOL-ONE 3

VITAMED MD ONE RX

3

VITAMEDMD REDICHEW RX

3

vitamin b complex 5 ACA; OTC

vitamin b complex-

folic acid 5 ACA; OTC

vitamin d3 1 OTC

vitamins a,c,d and

fluoride 5 ACA; OTC

VITAPEARL 3

VITATRUE 3

vp-ch plus 1


114

Drug Name Drug


/ Limits

vp-ch-pnv 1

VP-PNV-DHA 3

zatean-pn dha 1

zatean-pn plus 1

Drug Name Drug


/ Limits

zingiber 1


115

Index 2 2TEK GLUCOSE/BLOOD

PRESSURE ...................... 65 A abacavir .................................. 3 abacavir-lamivudine ............... 3 abacavir-lamivudine-

zidovudine .......................... 3 ABILIFY .............................. 32 ABILIFY MAINTENA ........ 32 ABILIFY MYCITE .............. 32 abiraterone ............................ 13 ABLYSINOL ....................... 56 ABRAXANE ........................ 13 ABSORICA .......................... 49 ABSTRAL ............................ 24 acamprosate .......................... 56 ACANYA ............................. 49 acarbose ................................ 76 ACCOLATE....................... 102 ACCU-CHEK AVIVA PLUS

METER ............................ 65 ACCU-CHEK AVIVA PLUS

TEST STRP ...................... 61 ACCU-CHEK COMPACT

PLUS CONTROL ............ 65 ACCU-CHEK COMPACT

PLUS TEST...................... 61 ACCU-CHEK GUIDE ......... 61 ACCU-CHEK GUIDE

GLUCOSE METER ......... 65 ACCU-CHEK GUIDE L1-L2

CTRL SOL ....................... 65 ACCU-CHEK GUIDE ME

GLUCOSE MTR .............. 65 ACCU-CHEK NANO .......... 65 ACCU-CHEK SMARTVIEW

CONTRL SOL ................. 65 ACCU-CHEK SMARTVIEW

TEST STRIP .................... 61 ACCUPRIL .......................... 38 ACCURETIC ....................... 38 ACCUTREND GLUCOSE .. 61 ACCUTREND GLUCOSE

CONTROL ....................... 65 acebutolol ............................. 38

acetaminophen-caff-dihydrocod ........................ 24

acetaminophen-codeine ........ 24 acetazolamide ....................... 98 acetazolamide sodium .......... 98 acetic acid ............................. 59 acetylcysteine ..................... 102 ACIPHEX ............................. 82 ACIPHEX SPRINKLE......... 83 acitretin ................................. 46 ACTEMRA .......................... 88 ACTEMRA ACTPEN .......... 88 ACTHAR H.P. ..................... 60 ACTHIB (PF) ....................... 85 ACTICLATE ........................ 11 ACTIGALL .......................... 79 ACTIMMUNE ..................... 85 ACTIQ .................................. 24 ACTIVELLA........................ 90 ACTONEL ........................... 88 ACTOPLUS MET ................ 76 ACTOPLUS MET XR ......... 76 ACTOS ................................. 76 acuicyn.................................. 97 ACULAR.............................. 98 ACULAR LS ........................ 98 ACUVAIL (PF) .................... 98 acyclovir ........................... 3, 54 ACZONE .............................. 49 ADACEL(TDAP

ADOLESN/ADULT)(PF) 85 ADAGEN ............................. 56 ADALAT CC ....................... 38 adapalene .............................. 49 ADAPALENE ...................... 49 adapalene-benzoyl peroxide . 49 ADASUVE ........................... 32 ADCETRIS .......................... 13 ADCIRCA .......................... 102 ADDERALL ........................ 32 ADDERALL XR .................. 32 ADDYI ................................. 32 adefovir ................................... 3 ADEMPAS ......................... 102 ADLYXIN ............................ 76 ADMELOG SOLOSTAR U-

100 INSULIN ................... 72

ADMELOG U-100 INSULIN LISPRO ............................ 72

ADRENALIN ..................... 102 adriamycin ............................ 13 ADRIAMYCIN .................... 13 adrucil ................................... 13 adult aspirin regimen ............ 29 ADVAIR DISKUS ............. 102 ADVAIR HFA .................... 102 ADVANCED GLUC METER

TEST STRIP ..................... 61 ADVANCED GLUCOSE

METER ............................. 65 ADVATE .............................. 42 ADVOCATE BLOOD

GLUCOSE MONITOR .... 65 ADVOCATE DUO .............. 65 ADVOCATE LOW

CONTROL ....................... 65 ADVOCATE REDI-CODE .. 61 ADVOCATE REDI-CODE

DUO METER ................... 65 ADVOCATE REDI-CODE

GLU MONITOR .............. 65 ADVOCATE REDI-CODE+

CTRL LOW ...................... 65 ADVOCATE TEST STRIPS 61 ADYNOVATE ..................... 42 ADYPHREN ...................... 100 ADYPHREN AMP ............. 100 ADYPHREN AMP II ......... 100 ADYPHREN II ................... 100 ADZENYS ER ..................... 32 ADZENYS XR-ODT ........... 32 AEMCOLO ............................ 7 AEROSPAN ....................... 102 afeditab cr ............................. 38 AFINITOR ........................... 13 AFINITOR DISPERZ .......... 13 AFLURIA 2018-2019 .......... 85 AFLURIA 2018-2019 (PF) .. 86 AFLURIA QUAD 2018-2019

.......................................... 86 AFLURIA QUAD 2018-2019

(PF) ................................... 86 AFREZZA ............................ 72 AFSTYLA ............................ 42


116

AFTERA .............................. 92 AGAMATRIX AMP GLUC

MONITOR SYS ............... 65 AGAMATRIX AMP TEST

STRIPS ............................. 61 AGAMATRIX CONTROL

HIGH ................................ 65 AGGRENOX ....................... 42 AGONEAZE ........................ 52 AGRYLIN ............................ 56 AIMOVIG AUTOINJECTOR

.......................................... 22 AIRDUO RESPICLICK .... 102 AJOVY ................................. 22 ak-poly-bac ........................... 96 AKTEN (PF) ........................ 97 AKTIPAK ............................ 49 AKYNZEO

(FOSNETUPITANT) ....... 79 AKYNZEO (NETUPITANT)

.......................................... 79 ALA-SCALP ........................ 54 albendazole ............................. 7 ALBENZA ............................. 7 albuterol sulfate .......... 102, 103 ALBUTEROL SULFATE.. 102 ALCAINE ............................ 97 alclometasone ....................... 54 ALDACTAZIDE .................. 38 ALDACTONE ..................... 38 ALDARA ............................. 85 ALDURAZYME .................. 74 ALECENSA ......................... 13 alendronate ..................... 57, 88 ALEVICYN PLUS ............... 48 ALFERON N........................ 85 alfuzosin ............................. 106 ALINIA .................................. 7 ALIQOPA ............................ 13 aliskiren ................................ 38 ALKERAN ........................... 13 ALKERAN (AS HCL) ......... 13 allopurinol ............................ 88 ALLZITAL........................... 24 almotriptan malate ................ 22 ALOCRIL............................. 97 ALOGLIPTIN ...................... 76

ALOGLIPTIN-METFORMIN .......................................... 76

ALOGLIPTIN-PIOGLITAZONE ............. 76

ALOMIDE............................ 97 alophen ................................. 79 ALORA ................................ 90 alosetron ............................... 79 ALOXI.................................. 79 ALPHAGAN P ................... 100 ALPHANATE ...................... 42 ALPHANINE SD ................. 42 alprazolam ............................ 32 alprazolam intensol............... 32 ALPROLIX .......................... 42 ALREX ................................. 99 ALTABAX ........................... 53 altacaine ................................ 97 ALTACE .............................. 38 ALTAFLUOR BENOX ....... 97 altavera (28) .......................... 92 ALTOPREV ......................... 44 ALTRENO ........................... 49 ALUNBRIG ......................... 13 ALVESCO.......................... 103 alyacen 1/35 (28) .................. 92 alyacen 7/7/7 (28) ................. 92 alyq ..................................... 103 amabelz ................................. 90 amantadine hcl ........................ 3 AMARYL ............................. 76 AMBIEN .............................. 32 AMBIEN CR ........................ 32 AMBISOME .......................... 3 ambrisentan ........................ 103 amcinonide ........................... 54 AMELUZ ............................. 48 AMERGE ............................. 22 amethia ................................. 92 amethia lo ............................. 92 amethyst (28) ........................ 92 AMICAR .............................. 42 amifostine crystalline ........... 12 amikacin ................................. 7 amiloride ............................... 38 amiloride-hydrochlorothiazide

.......................................... 38 aminocaproic acid................. 42

aminophylline ..................... 103 amiodarone ........................... 38 AMITIZA ............................. 79 amitriptyline ......................... 32 amitriptyline-chlordiazepoxide

.......................................... 32 amlodipine ............................ 38 amlodipine-atorvastatin ........ 44 amlodipine-benazepril .......... 38 amlodipine-olmesartan ......... 38 amlodipine-valsartan ............ 38 amlodipine-valsartan-hcthiazid

.......................................... 38 AMMONUL ......................... 57 amnesteem ............................ 49 amoxapine ............................. 32 amoxicil-clarithromy-lansopraz

.......................................... 83 amoxicillin ............................ 10 amoxicillin-pot clavulanate .. 10 AMPHADASE ..................... 57 amphetamine sulfate ............. 32 amphotericin b ........................ 3 ampicillin .............................. 10 ampicillin sodium ................. 10 ampicillin-sulbactam ............ 10 AMPYRA ............................. 23 AMRIX ................................. 23 ANADROL-50 ..................... 74 ANAFRANIL ....................... 32 anagrelide ............................. 57 ANALPRAM-HC ........... 46, 79 ANALPRAM-HC SINGLES79 ANAPROX DS ..................... 29 anaspaz ................................. 78 ANASTIA ............................. 52 anastrozole ............................ 13 ANCOBON ............................ 3 ANDEXXA .......................... 42 ANDRODERM .................... 74 ANDROGEL ........................ 74 ANDROID ............................ 74 ANGELIQ ............................ 90 ANGIOMAX ........................ 42 ANODYNE LPT .................. 52 ANORO ELLIPTA ............. 103 ANTABUSE ......................... 57 ANTARA ............................. 44


117

anucort-hc ............................. 79 ANUSOL-HC ....................... 79 APADAZ .............................. 24 apexicon e ............................. 54 APIDRA SOLOSTAR U-100

INSULIN .......................... 72 APIDRA U-100 INSULIN ... 72 APLENZIN .......................... 32 APOKYN ............................. 21 apraclonidine ...................... 100 aprepitant .............................. 79 apri ........................................ 92 APRISO ................................ 79 APTENSIO XR .................... 32 APTIOM............................... 19 APTIVUS ............................... 3 aqua care sterile water .......... 57 AQUA GLYCOLIC HC....... 54 ARAKODA ............................ 7 ARALAST NP ..................... 57 aranelle (28).......................... 92 ARANESP (IN

POLYSORBATE) ............ 84 ARAVA ................................ 88 ARCALYST ......................... 85 ARCAPTA NEOHALER ... 103 ARESTIN ............................. 59 ARGATROBAN .................. 42 ARGATROBAN IN 0.9 %

SOD CHLOR ................... 42 ARGATROBAN IN NACL

(ISO-OS) .......................... 42 ARICEPT ............................. 23 ARIKAYCE ........................... 7 ARIMIDEX .......................... 13 aripiprazole ........................... 32 ARISTADA .......................... 32 ARISTADA INITIO ............ 32 ARIXTRA ............................ 42 armodafinil ........................... 32 ARMONAIR RESPICLICK

........................................ 103 ARMOUR THYROID ......... 77 ARNUITY ELLIPTA ......... 103 AROMASIN......................... 13 ARRANON .......................... 13 ARSENIC TRIOXIDE ......... 13 ARTHROTEC 50 ................. 29

ARTHROTEC 75 ................. 29 ARYMO ER ......................... 24 ARZERRA ........................... 13 ASACOL HD ....................... 79 ascomp with codeine ............ 24 ashlyna .................................. 92 ASMANEX HFA ............... 103 ASMANEX TWISTHALER

........................................ 103 aspir-81 ................................. 29 aspirin ................................... 29 aspirin low dose .................... 29 aspirin-dipyridamole ............ 42 aspir-low ............................... 29 aspir-trin ............................... 29 ASSURE 4 CONTROL

SOLUTION ...................... 65 ASSURE 4 STRIPS.............. 61 ASSURE DOSE NORMAL

CONTROL ....................... 65 ASSURE PLATINUM ... 61, 65 ASSURE PRISM CONTROL

1-2 SOLN ......................... 65 ASSURE PRISM MULTI

METER ............................ 66 ASSURE PRISM MULTI

STRIP ............................... 61 ASTAGRAF XL................... 13 ASTEPRO ............................ 59 ASTERO .............................. 52 ATACAND .......................... 38 ATACAND HCT ................. 38 atazanavir................................ 3 ATELVIA ............................. 88 atenolol ................................. 38 atenolol-chlorthalidone ......... 38 ATGAM ............................... 86 ATIVAN ............................... 32 atomoxetine .......................... 32 ATOPADERM ..................... 48 ATOPICLAIR ...................... 48 atorvastatin ........................... 44 atovaquone.............................. 7 atovaquone-proguanil ............. 7 atracurium ............................. 23 ATRALIN ............................ 49 ATRAPRO CP ..................... 48 ATRAPRO HYDROGEL .... 48

ATRIPLA ............................... 4 atropine ........................... 78, 97 atropine in 0.9 % sod chloride

.......................................... 78 ATROPINE IN 0.9 % SOD

CHLORIDE ................ 78, 97 ATROVENT HFA .............. 103 AUBAGIO ............................ 84 aubra ..................................... 92 aubra eq ................................ 92 AUGMENTIN ...................... 10 AUGMENTIN ES-600 ......... 10 AUGMENTIN XR ............... 10 aurovela 1.5/30 (21) .............. 92 aurovela 24 fe ....................... 92 aurovela fe 1-20 (28) ............ 92 AURYXIA ............................ 79 AUSTEDO ........................... 23 AUTOJECT 2 INJECTION

DEVICE ........................... 66 AUTOPEN 1 TO 21 UNITS 66 AUTOSOFT 30 .................... 66 AUTOSOFT 90 .................... 66 AUVI-Q .............................. 100 AVALIDE ............................ 38 AVANDIA ........................... 76 AVAPRO .............................. 38 avar ....................................... 49 AVAR ................................... 49 AVAR LS ............................. 49 AVAR-E GREEN ................. 50 AVAR-E LS ......................... 50 AVASTIN ............................. 13 AVC VAGINAL .................. 91 AVEED ................................. 74 AVELOX .............................. 10 AVELOX IN NACL (ISO-

OSMOTIC) ....................... 10 aviane .................................... 92 avidoxy ................................. 11 avita ...................................... 50 AVITA .................................. 50 avo cream .............................. 48 AVODART ......................... 106 AVONEX ............................. 84 AVONEX (WITH ALBUMIN)

.......................................... 84 AVYCAZ ............................... 6


118

AYGESTIN .......................... 90 azacitidine............................. 13 AZASAN .............................. 13 AZASITE ............................. 96 azathioprine .......................... 13 azelaic acid ........................... 50 azelastine ........................ 59, 97 AZELEX .............................. 50 AZESCO ............................ 108 AZILECT ............................. 21 azithromycin ........................... 7 AZOPT ................................. 98 AZOR ................................... 38 AZULFIDINE ...................... 79 AZULFIDINE EN-TABS .... 79 azurette (28).......................... 92 B b complex-vitamin b12....... 108 b complex-vitamin c-folic acid

........................................ 108 bacitracin .............................. 96 bacitracin-polymyxin b ........ 96 baclofen ................................ 23 BACLOFEN ......................... 23 BACTRIM ............................ 11 BACTRIM DS...................... 11 balance b-100 ..................... 108 balanced b-100 ................... 108 balanced b-100 complex..... 108 bal-care dha ........................ 108 BAL-CARE DHA

ESSENTIAL................... 108 BALCOLTRA ...................... 92 balsalazide ............................ 79 BALVERSA ......................... 13 balziva (28) ........................... 92 BANZEL .............................. 19 BARACLUDE ....................... 4 BASAGLAR KWIKPEN U-

100 INSULIN ................... 72 BAVENCIO ......................... 13 BAXDELA ........................... 10 bayer aspirin ......................... 29 BCG VACCINE, LIVE (PF) 86 b-complex with vitamin c ... 108 BD MICROTAINER

LANCET .......................... 66

BD ULTRA FINE LANCETS .......................................... 66

BD ULTRA-FINE NANO PEN NEEDLE .................. 66

BECONASE AQ ................ 103 bekyree (28) .......................... 92 BELBUCA ........................... 24 BELEODAQ ........................ 13 belladonna alkaloids-opium . 78 BELSOMRA ........................ 32 benazepril ............................. 38 benazepril-hydrochlorothiazide

.......................................... 38 BENDAMUSTINE .............. 13 BENDEKA ........................... 13 BENEFIX ............................. 42 BENICAR ............................ 38 BENICAR HCT ................... 38 BENLYSTA ......................... 88 BENSAL HP ........................ 47 BENTYL .............................. 78 BENZACLIN ....................... 50 BENZACLIN PUMP ........... 50 BENZAMYCIN ................... 50 benzepro ............................... 50 BENZHYDROCODONE-

ACETAMINOPHEN........ 24 BENZNIDAZOLE ................. 7 benzonatate ......................... 101 benzoyl peroxide .................. 50 benztropine ........................... 21 BEPREVE ............................ 97 BERINERT ........................ 103 BESIVANCE........................ 96 BESPONSA.......................... 13 BETADINE OPHTHALMIC

PREP ................................ 96 BETAMETH AC,SOD

PHOS(PF)-WATER ......... 60 BETAMETHASONE

ACE,SOD PHOS-WTR.... 60 betamethasone acet,sod phos 60 betamethasone dipropionate . 54 BETAMETHASONE SOD

PHOSPH-WATER ........... 60 betamethasone valerate......... 54 betamethasone, augmented ... 54 BETAPACE ......................... 38

BETAPACE AF ................... 38 BETASERON ....................... 84 betaxolol ......................... 38, 96 bethanechol chloride ........... 106 BETHKIS ............................... 7 BETIMOL ............................ 96 BETOPTIC S ........................ 96 BEVACIZUMAB ................. 97 BEVESPI AEROSPHERE . 103 BEVYXXA ........................... 42 bexarotene ............................. 13 BEXSERO ............................ 86 BEYAZ ................................. 92 BIAFINE EMULSION ......... 48 bicalutamide ......................... 13 BICILLIN C-R ..................... 10 BICNU .................................. 13 BIDIL ................................... 38 BIJUVA ................................ 90 BIKTARVY ........................... 4 BILTRICIDE .......................... 7 bimatoprost ........................... 98 BINOSTO ............................. 88 BIONIME RIGHTEST

GM300 SYSTEM ............. 66 BIONIME RIGHTEST TEST

STRIPS ............................. 61 bisacodyl ............................... 79 bisa-lax ................................. 79 bisoprolol fumarate ............... 38 bisoprolol-hydrochlorothiazide

.......................................... 38 BIVALIRUDIN .................... 42 BIVALIRUDIN-0.9 %

SODIUM CHLOR ............ 42 BIVIGAM ............................. 86 bleomycin ............................. 13 BLEPH-10 .......................... 100 BLEPHAMIDE .................. 100 BLEPHAMIDE S.O.P. ....... 100 BLINCYTO .......................... 13 blisovi 24 fe .......................... 93 blisovi fe 1.5/30 (28) ............ 93 blisovi fe 1/20 (28) ............... 93 BLOOD GLUCOSE

CONTROL, NORMAL .... 66 BLOOD GLUCOSE TEST .. 61


119

BLOOD-GLUCOSE METER .......................................... 66

BONIVA .............................. 88 BONJESTA .......................... 79 BOOSTRIX TDAP .............. 86 BORTEZOMIB .................... 13 BOSULIF ............................. 13 BOTOX ................................ 86 BOTOX COSMETIC ........... 86 bp 10-1.................................. 50 bpo ........................................ 50 BRAFTOVI .......................... 13 BRAVELLE ......................... 74 BREEZE 2 CONTROL

SOLUTION,HIGH ........... 66 BREO ELLIPTA ................ 103 BREVIBLOC ....................... 38 BREVIBLOC IN NACL (ISO-

OSM) ................................ 39 BRIDION ............................. 23 briellyn ................................. 93 BRILINTA ........................... 43 brimonidine ........................ 100 BRINEURA ......................... 74 BRISDELLE ........................ 32 BRIVIACT ........................... 19 BROMFED DM ................. 101 bromfenac ............................. 98 bromocriptine ....................... 21 brompheniramine-pseudoeph-

dm ................................... 101 BROMSITE .......................... 98 BROVANA ........................ 103 BRYHALI ............................ 54 budesonide .................... 79, 103 bumetanide ........................... 39 BUNAVAIL ......................... 29 BUPAP ................................. 24 BUPHENYL......................... 57 BUPRENEX ......................... 24 buprenorphine....................... 25 BUPRENORPHINE ............. 25 buprenorphine hcl ................. 24 buprenorphine-naloxone....... 29 bupropion hcl.................. 32, 33 BUPROPION HCL .............. 32 bupropion hcl (smoking deter)

.......................................... 58

buspirone .............................. 33 busulfan ................................ 13 BUSULFEX ......................... 13 butalbital compound w/codeine

.......................................... 25 butalbital-acetaminop-caf-cod

.......................................... 25 butalbital-acetaminophen ..... 25 butalbital-acetaminophen-caff

.......................................... 25 butalbital-aspirin-caffeine .... 25 BUTISOL ............................. 33 butorphanol tartrate .............. 29 BUTRANS ........................... 25 BYDUREON ........................ 76 BYDUREON BCISE ........... 76 BYETTA .............................. 76 BYSTOLIC .......................... 39 C cabergoline ........................... 74 CABLIVI .............................. 43 CABOMETYX ..................... 13 CADEAU DHA .................. 108 CADUET .............................. 44 CAFERGOT ......................... 22 caffeine citrate ...................... 57 CALAN ................................ 39 CALAN SR .......................... 39 calcipotriene ......................... 46 calcipotriene-betamethasone 46 calcitonin (salmon) ............... 74 calcitrene .............................. 46 calcitriol .......................... 46, 74 calcium 500 + d .................. 107 calcium 600 + d(3) ............. 107 calcium 600 with vitamin d3

........................................ 107 calcium acetate ..................... 79 calcium citrate-vitamin d2 .. 107 calcium citrate-vitamin d3 .. 107 CALCIUM GLUC IN NACL,

ISO-OSM........................ 107 calcium gluconate in 0.9% nacl

........................................ 107 CALCIUM GLUCONATE IN

0.9% NACL .................... 107 CALCIUM GLUCONATE IN

D5W ............................... 107

CALCIUM GLUCONATE IN WATER .......................... 107

calcium pnv ........................ 108 CALQUENCE ...................... 13 CAMBIA .............................. 29 camila ................................... 90 CAMPTOSAR ...................... 13 camrese ................................. 93 camrese lo ............................. 93 CANASA .............................. 79 CANCIDAS ............................ 3 candesartan ........................... 39 candesartan-hydrochlorothiazid

.......................................... 39 CAPASTAT ........................... 7 CAPCOF ............................. 101 capecitabine .......................... 13 CAPEX ................................. 54 CAPRELSA .......................... 13 CAPSFENAC PAK .............. 29 captopril ................................ 39 captopril-hydrochlorothiazide

.......................................... 39 CARAC ................................ 48 CARAFATE ......................... 83 CARBAGLU ........................ 57 carbamazepine ...................... 19 CARBATROL ...................... 19 carbidopa .............................. 21 carbidopa-levodopa .............. 21 carbidopa-levodopa-

entacapone ........................ 21 carbinoxamine maleate ....... 100 carboplatin ............................ 14 CARDIZEM ......................... 39 CARDIZEM CD ................... 39 CARDIZEM LA ................... 39 CARDURA ........................... 39 CARDURA XL .................... 39 CARESENS CONTROL A

NORMAL ......................... 66 CARESENS N ...................... 66 CARESENS N TEST STRIPS

.......................................... 61 CARESENS N VOICE ......... 66 CARETOUCH GLUCOSE

MONITORING ................ 66


120

CARETOUCH TEST STRIP .......................................... 62

carisoprodol .......................... 24 carisoprodol-asa-codeine ...... 24 carisoprodol-aspirin .............. 24 carmustine ............................ 14 CARNITOR ......................... 57 CARNITOR (SUGAR-FREE)

.......................................... 57 CAROSPIR .......................... 39 carteolol ................................ 96 cartia xt ................................. 39 carvedilol .............................. 39 carvedilol phosphate ............. 39 CASODEX ........................... 14 caspofungin ............................ 3 CATAPRES ......................... 39 CATAPRES-TTS-1 .............. 39 CATAPRES-TTS-2 .............. 39 CATAPRES-TTS-3 .............. 39 CAYA CONTOURED ......... 90 CAYSTON ............................. 7 caziant (28) ........................... 93 cefaclor ................................... 6 cefadroxil ................................ 6 cefazolin ................................. 6 CEFAZOLIN IN 0.9% SOD

CHLORIDE ........................ 6 cefazolin in dextrose (iso-os) . 6 CEFAZOLIN IN DEXTROSE

(ISO-OS) ............................ 6 CEFAZOLIN IN DEXTROSE

5 %...................................... 6 CEFAZOLIN IN STERILE

WATER .............................. 6 cefdinir ................................... 6 cefditoren pivoxil ................... 6 cefepime ................................. 6 cefepime in dextrose,iso-osm . 6 cefixime .................................. 6 CEFOTAN ............................. 6 cefotaxime .............................. 6 cefotetan ................................. 6 cefoxitin .................................. 6 cefpodoxime ........................... 6 cefprozil .................................. 6 ceftriaxone .............................. 6 CEFTRIAXONE .................... 7

ceftriaxone in dextrose,iso-os . 6 CEFUROXIME (PF) IN 0.9%

NACL ............................... 96 cefuroxime axetil .................... 7 cefuroxime sodium ................. 7 celacyn .................................. 48 CELEBREX ......................... 30 celecoxib ............................... 30 CELESTONE SOLUSPAN . 60 CELEXA .............................. 33 CELLCEPT .......................... 14 CELLCEPT INTRAVENOUS

.......................................... 14 CELONTIN .......................... 19 CENTANY ........................... 53 CENTANY AT..................... 53 centergy .............................. 101 cephalexin ............................... 7 CEPROTIN (BLUE BAR) ... 43 CEPROTIN (GREEN BAR) 43 CEQUA ................................ 97 CERAMAX .......................... 48 CERDELGA ......................... 74 CEREZYME ........................ 74 CERVIDIL ........................... 91 CESAMET ........................... 79 cetirizine ............................. 100 CETRAXAL ......................... 59 CETROTIDE ........................ 74 cevimeline ............................ 57 CHANTIX ............................ 58 CHANTIX CONTINUING

MONTH BOX .................. 58 CHANTIX STARTING

MONTH BOX .................. 58 chateal (28) ........................... 93 chateal eq (28) ...................... 93 CHEMET.............................. 57 CHENODAL ........................ 79 cheratussin ac ..................... 101 children's aspirin ................... 30 chloramphenicol sod succinate

............................................ 7 chlordiazepoxide hcl............. 33 chlordiazepoxide-clidinium .. 78 chlorhexidine gluconate ....... 59 chloroquine phosphate ............ 7 chlorothiazide ....................... 39

chlorothiazide sodium .......... 39 chlorpromazine ..................... 33 chlorpropamide ..................... 76 chlorthalidone ....................... 39 chlorzoxazone ....................... 24 CHOLBAM .......................... 79 cholecalciferol (vitamin d3) 108 cholestyramine (with sugar) . 44 cholestyramine light ............. 44 CHOLETEC ......................... 57 choline,magnesium salicylate

.......................................... 30 CHORIONIC

GONADOTROPIN, HUMAN ........................... 74

CIALIS ............................... 106 ciclodan ................................. 53 CICLODAN KIT .................. 53 ciclopirox .............................. 53 cidofovir ................................. 4 cilostazol ............................... 43 CILOXAN ............................ 96 CIMDUO ................................ 4 cimetidine ............................. 83 cimetidine hcl ....................... 83 CIMZIA ................................ 79 CIMZIA POWDER FOR

RECONST ........................ 79 cinacalcet .............................. 74 CINQAIR ........................... 103 CINRYZE ........................... 103 CINVANTI ........................... 79 CIPRO .................................. 10 CIPRO HC ............................ 59 CIPRO XR ............................ 10 CIPRODEX .......................... 60 ciprofloxacin ......................... 10 ciprofloxacin (mixture) ......... 10 ciprofloxacin hcl ....... 10, 59, 96 cisatracurium ........................ 24 cisplatin ................................. 14 citalopram ............................. 33 CITRANATAL (DUAL-

IRON) ............................. 108 CITRANATAL 90 DHA

(ALGAL OIL) ................ 108 CITRANATAL ASSURE .. 108


121

CITRANATAL B-CALM (FE GLUC) ............................ 108

CITRANATAL BLOOM ... 108 CITRANATAL DHA

(ALGAL OIL) ................ 108 CITRANATAL HARMONY

(IRON FUM) .................. 108 citrate of magnesia ............... 79 citroma .................................. 79 cladribine .............................. 14 CLAFORAN .......................... 7 claravis ................................. 50 CLARINEX ........................ 100 CLARINEX-D 12 HOUR .. 101 clarithromycin ........................ 7 classic prenatal ................... 108 cleansing wash...................... 50 clearlax ................................. 79 clemastine ........................... 100 CLENPIQ ............................. 79 cleocin .................................... 8 CLEOCIN......................... 8, 91 CLEOCIN HCL...................... 7 CLEOCIN PEDIATRIC ......... 8 CLEOCIN T ......................... 50 CLEVER CHEK BLOOD

GLUCOSE ....................... 66 CLEVER CHOICE

GLUCOSE MONITOR .... 66 CLEVER CHOICE LEVEL 2

CONTROL ....................... 66 CLEVER CHOICE MICRO 66 CLEVER CHOICE MICRO

TEST STRIP .................... 62 CLEVER CHOICE PRO 62, 66 CLEVER CHOICE TALK

GLUCOSE SYS ............... 66 CLEVER CHOICE TALK

TEST ................................ 62 CLEVER CHOICE TEST

STRIPS ............................. 62 CLEVER CHOICE VOICE+

TEST ................................ 62 CLIMARA ........................... 90 CLIMARA PRO ................... 90 CLINDACIN ETZ................ 50 clindacin p ............................ 50 CLINDACIN PAC ............... 50

CLINDAGEL ....................... 50 clindamycin hcl ...................... 8 CLINDAMYCIN IN 0.9 %

SOD CHLOR ..................... 8 clindamycin in 5 % dextrose .. 8 clindamycin palmitate hcl ...... 8 clindamycin pediatric ............. 8 clindamycin phosphate .... 8, 50,

92 CLINDAMYCIN

PHOSPHATE ................... 50 clindamycin-benzoyl peroxide

.......................................... 50 clindamycin-tretinoin ........... 50 CLINDESSE ........................ 92 CLINPRO 5000 .................... 59 clobazam ............................... 19 clobetasol .............................. 54 clobetasol-emollient ............. 54 CLOBEX .............................. 54 CLOCORTOLONE

PIVALATE ...................... 54 clodan ................................... 54 CLODAN KIT ...................... 54 CLODERM .......................... 54 clofarabine ............................ 14 CLOLAR .............................. 14 clomiphene citrate ................ 74 clomipramine ........................ 33 clonazepam ........................... 19 clonidine ............................... 39 clonidine hcl ................... 33, 39 clopidogrel ............................ 43 clorazepate dipotassium ....... 33 clotrimazole ............................ 3 clotrimazole-betamethasone . 53 clozapine ............................... 33 CLOZAPINE ........................ 33 CLOZARIL .......................... 33 c-nate dha ........................... 108 COAGADEX........................ 43 COAL TAR .......................... 46 COARTEM ............................ 8 codeine sulfate ...................... 25 codeine-guaifenesin ............ 101 CODITUSSIN AC .............. 101 CODITUSSIN DAC ........... 101 COLAZAL ........................... 79

COLCHICINE ...................... 88 COLCRYS ............................ 88 colesevelam .......................... 44 COLESTID ........................... 44 COLESTID FLAVORED .... 45 colestipol ............................... 45 colistin (colistimethate na) ..... 8 COLY-MYCIN M

PARENTERAL .................. 8 COLY-MYCIN S ................. 60 COLYTE WITH FLAVOR

PACKS ............................. 79 COMBIGAN ........................ 98 COMBIPATCH .................... 90 COMBIVENT RESPIMAT 103 COMBIVIR ............................ 4 COMETRIQ ......................... 14 COMPAZINE ....................... 79 COMPLERA .......................... 4 complete natal dha .............. 108 completenate ....................... 108 complex b-100 .................... 108 compro .................................. 79 COMTAN ............................. 21 CONCEPT DHA ................ 108 CONCEPT OB ................... 108 CONCERTA ......................... 33 CONDYLOX ........................ 48 constulose ............................. 79 CONTOUR CONTROL

SOLUTION, NML ........... 66 CONTOUR LINK ................ 66 CONTOUR NEXT EZ

METER ............................. 66 CONTOUR NEXT LEV 2

CONTROL SOL ............... 66 CONTOUR NEXT LINK ..... 66 CONTOUR NEXT LINK 2.4

.......................................... 66 CONTOUR NEXT METER . 66 CONTOUR NEXT ONE

METER ............................. 66 CONTOUR NEXT TEST

STRIPS ............................. 62 CONTOUR TEST STRIPS .. 62 CONZIP ................................ 30 COOL BLOOD GLUCOSE

METER ............................. 66


122

COOL CONTROL A SOLUTION ...................... 66

COOL GLUCOSE TEST STRIP ............................... 62

COPAXONE ........................ 84 COPIKTRA .......................... 14 CORDRAN .......................... 54 CORDRAN TAPE LARGE

ROLL ............................... 55 COREG ................................ 39 COREG CR .......................... 39 coremino ............................... 11 CORGARD .......................... 39 CORIFACT .......................... 43 CORLANOR ........................ 46 cormax .................................. 55 CORTANE-B ....................... 48 CORTEF............................... 60 CORTENEMA ..................... 80 CORTIFOAM ...................... 80 cortisone ............................... 60 CORTISPORIN .................... 53 CORTROSYN ...................... 60 COSENTYX......................... 46 COSENTYX (2 SYRINGES)

.......................................... 46 COSENTYX PEN ................ 46 COSENTYX PEN (2 PENS) 46 COSMEGEN ........................ 14 COSOPT............................... 98 COSOPT (PF) ...................... 98 cosyntropin ........................... 60 COTELLIC........................... 14 COTEMPLA XR-ODT ........ 33 COUMADIN ........................ 43 covaryx ................................. 90 covaryx h.s. .......................... 90 COZAAR ............................. 39 CREON ................................ 80 CRESEMBA .......................... 3 CRESTOR ............................ 45 CRINONE ............................ 90 CRIXIVAN ............................ 4 cromolyn................. 80, 97, 103 crotan .................................... 56 cryselle (28) .......................... 93 CRYSVITA .......................... 74 CUBICIN ............................... 8

CUBICIN RF .......................... 8 CUPRIMINE ........................ 88 CUROSURF ....................... 103 CUTIVATE .......................... 55 CUVITRU ............................ 86 CUVPOSA ........................... 78 cyanocobalamin (vitamin b-12)

........................................ 108 cyclafem 1/35 (28)................ 93 cyclafem 7/7/7 (28) .............. 93 CYCLESSA (28) .................. 93 cyclobenzaprine .................... 24 CYCLOGYL ........................ 97 CYCLOMYDRIL ............... 100 cyclopentolate ....................... 97 CYCLOPEN-TROPIC-

PHENYLEPH-WATR...... 97 cyclophosphamide ................ 14 CYCLOSERINE .................... 8 CYCLOSET ......................... 76 cyclosporine.......................... 14 cyclosporine modified .......... 14 CYCLOTENS REFILL ........ 24 CYCLOTENS STARTER .... 24 CYMBALTA........................ 33 cyproheptadine ................... 100 CYRAMZA .......................... 14 cyred ..................................... 93 cyred eq ................................ 93 CYSTADANE ...................... 80 CYSTAGON ...................... 106 CYSTARAN ........................ 97 cytarabine ............................. 14 cytarabine (pf) ...................... 14 CYTOMEL ........................... 77 CYTOTEC............................ 83 CYTOVENE .......................... 4 cytra k crystals .................... 106 D D.H.E.45 ............................... 22 dacarbazine ........................... 14 DACOGEN .......................... 14 dactinomycin ........................ 14 DAKLINZA ........................... 4 dalfampridine........................ 23 DALIRESP ......................... 103 danazol.................................. 74 DANTRIUM ........................ 24

dantrolene ............................. 24 dapsone ............................. 8, 50 DAPTACEL (DTAP

PEDIATRIC) (PF) ............ 86 daptomycin ............................. 8 DARAPRIM ........................... 8 darifenacin .......................... 105 DARZALEX ......................... 14 dasetta 1/35 (28) ................... 93 dasetta 7/7/7 (28) .................. 93 daunorubicin ......................... 14 DAURISMO ......................... 14 DAYPRO .............................. 30 daysee ................................... 93 DAYTRANA ........................ 33 DDAVP ................................ 74 DEBACTEROL .................... 59 deblitane ............................... 90 decadron ............................... 60 decitabine .............................. 14 deferasirox ............................ 57 DEFITELIO .......................... 43 DELESTROGEN ................. 90 DELSTRIGO .......................... 4 deltasone ............................... 60 delyla (28) ............................. 93 DELZICOL ........................... 80 DEMADEX .......................... 39 demeclocycline ..................... 11 DEMEROL ........................... 25 DEMEROL (PF) ................... 25 DEMSER .............................. 39 DENAVIR ............................ 54 denta 5000 plus ..................... 59 dentagel ................................. 59 DEPACON ........................... 19 DEPAKENE ......................... 19 DEPAKOTE ......................... 19 DEPAKOTE ER ................... 19 DEPAKOTE SPRINKLES ... 19 DEPEN TITRATABS .......... 88 DEPO-ESTRADIOL ............ 90 DEPO-PROVERA ................ 90 DEPO-SUBQ PROVERA 104

.......................................... 90 DEPO-TESTOSTERONE .... 74 DERMACINRX

EMPRICAINE .................. 52


123

DERMA-SMOOTHE/FS BODY OIL ....................... 55

DERMA-SMOOTHE/FS SCALP OIL ...................... 55

DERMATOP ........................ 55 dermazene............................. 53 DERMOTIC OIL ................. 59 DESCOVY ............................. 4 desipramine .......................... 33 desloratadine....................... 100 desmopressin ........................ 74 desog-e.estradiol/e.estradiol . 93 desogestrel-ethinyl estradiol . 93 DESONATE ......................... 55 desonide ................................ 55 DESOWEN .......................... 55 desoximetasone .................... 55 DESOXYN ........................... 33 DESVENLAFAXINE .......... 33 desvenlafaxine succinate ...... 33 DETROL ............................ 105 DETROL LA ...................... 105 dexamethasone ..................... 60 DEXAMETHASONE AC,

SOD PH-WATER ............ 60 DEXAMETHASONE ACE-

NACL,ISO-OSM.............. 60 dexamethasone intensol........ 60 dexamethasone sodium

phosphate .................... 60, 99 DEXAMETH-

MOXIFLOX(PF)-NACL,ISO........................ 99

DEXAMET-MOXIFL-KETORO-NACL(PF) ...... 97

dexchlorpheniramine maleate ........................................ 100

DEXCOM G6 RECEIVER .. 66 DEXEDRINE SPANSULE .. 33 DEXERYL ........................... 48 DEXILANT .......................... 83 dexmethylphenidate ............. 33 DEXPAK 10 DAY ............... 60 DEXPAK 13 DAY ............... 60 DEXPAK 6 DAY ................. 60 dexrazoxane hcl .................... 12 DEXTENZA......................... 99 dextroamphetamine .............. 33

dextroamphetamine-amphetamine .................... 33

DIACOMIT .......................... 19 dialyvite 800 ....................... 108 DIASTAT ............................. 19 DIASTAT ACUDIAL .......... 19 DIATRUE CONTROL SOLN

NORMAL ......................... 67 DIATRUE PLUS BLOOD

GLUCOSE MET .............. 67 DIATRUE PLUS TEST STRIP

.......................................... 62 diazepam ......................... 19, 33 diazepam intensol ................. 33 DIBENZYLINE ................... 39 DICLEGIS ............................ 80 DICLO GEL ......................... 30 DICLO GEL-XRYLIX

SHEET.............................. 30 DICLOFENAC EPOLAMINE

.......................................... 30 diclofenac potassium ............ 30 diclofenac sodium..... 30, 48, 98 diclofenac-misoprostol ......... 30 DICLOFEX DC .................... 30 DICLOFONO ....................... 30 DICLOPAK .......................... 30 DICLOPR ............................. 30 dicloxacillin .......................... 10 dicyclomine .......................... 78 didanosine ............................... 4 DIFFERIN ............................ 50 DIFICID ................................. 7 diflorasone ............................ 55 DIFLUCAN ............................ 3 diflunisal ............................... 30 digitek ................................... 42 digox ..................................... 42 digoxin .................................. 42 dihydroergotamine................ 22 DILANTIN ........................... 19 DILANTIN EXTENDED..... 19 DILANTIN INFATABS ...... 20 DILANTIN-125.................... 20 DILATRATE-SR ................. 46 DILAUDID .......................... 25 DILAUDID (PF) .................. 25 diltiazem ............................... 39

dilt-xr .................................... 39 DIOVAN .............................. 39 DIOVAN HCT ..................... 39 DIPENTUM ......................... 80 diphenhydramine hcl .......... 100 diphenoxylate-atropine ......... 78 DIPROLENE ........................ 55 dipyridamole ......................... 43 DISALCID ........................... 30 diskets ................................... 25 disopyramide phosphate ....... 38 disulfiram .............................. 57 DITHOL ............................... 30 DITROPAN XL .................. 105 DIURIL ................................. 39 DIURIL IV ........................... 39 divalproex ............................. 20 DIVIGEL .............................. 90 DM2 ...................................... 76 DOCEFREZ ......................... 14 docetaxel ............................... 14 DOCETAXEL ...................... 14 dofetilide ............................... 38 DOLOPHINE ....................... 25 DOLOTRANZ ...................... 52 donepezil ............................... 23 DONNATAL ........................ 78 DOPTELET (15 TAB PACK)

.......................................... 43 DORAL ................................ 33 DORIPENEM ......................... 8 DORYX ................................ 11 DORYX MPC ...................... 11 dorzolamide .......................... 98 dorzolamide-timolol ............. 98 dorzolamide-timolol (pf) ...... 99 DORZOLAMIDE-TIMOLOL

(PF) ................................... 99 DOVATO ............................... 4 DOVONEX .......................... 47 doxazosin .............................. 39 doxepin ........................... 33, 48 doxercalciferol ...................... 74 DOXIL .................................. 14 doxorubicin ........................... 14 doxorubicin, peg-liposomal .. 14 doxycycline hyclate .............. 11 doxycycline monohydrate .... 11


124

DOXYCYCLINE MONOHYDRATE........... 11

D-PENAMINE ..................... 88 DRISDOL........................... 109 drithocreme hp...................... 47 dronabinol............................. 80 drospirenone-e.estradiol-lm.fa

.......................................... 93 drospirenone-ethinyl estradiol

.......................................... 93 DROXIA .............................. 14 DSUVIA ............................... 25 DUAC................................... 50 DUAVEE ............................. 90 ducodyl ................................. 80 DUET DHA BALANCED . 109 DUET DHA WITH OMEGA-3

........................................ 109 DUETACT ........................... 76 DUEXIS ............................... 30 DULERA ............................ 103 duloxetine ............................. 33 DUOBRII ............................. 55 DUOPA ................................ 21 DUPIXENT .......................... 48 DURAGESIC ....................... 25 DUREZOL ........................... 99 dutasteride .......................... 106 dutasteride-tamsulosin ........ 106 DUTOPROL......................... 39 DUZALLO ........................... 88 dvorah ................................... 25 DXEVO ................................ 60 DYANAVEL XR ................. 33 DYAZIDE ............................ 39 DYMISTA .......................... 103 DYRENIUM ........................ 39 DYSPORT ............................ 86 E e.c. prin ................................. 30 e.e.s. 400 ................................. 7 E.E.S. GRANULES ............... 7 EASY PLUS II HIGH

CONTROL ....................... 67 EASY PLUS II TEST .......... 62 EASY STEP ......................... 62 EASY STEP BLOOD

GLUCOSE METER ......... 67

EASY STEP HIGH CONTROL SOLN ............ 67

EASY TALK GLUCOSE TEST ................................ 62

EASY TALK HIGH CONTROL ....................... 67

EASY TOUCH GLUCOSE MONITOR ....................... 67

EASY TOUCH TEST STRIP .......................................... 62

EASY TRAK GLUCOSE TEST ................................ 62

EASY TRAK LOW CONTROL ....................... 67

EASYGLUCO MONITORING SYSTEM 67

EASYGLUCO PLUS ........... 62 EASYGLUCO PLUS

NORMAL CONTROL ..... 67 EASYGLUCO TEST ........... 62 EASYMAX .......................... 62 EASYMAX L BLOOD

GLUCOSE METER ......... 67 EASYMAX LOW CONTROL

.......................................... 67 EASYMAX NG ................... 67 EASYMAX NORMAL

CONTROL ....................... 67 EASYMAX V SPEAKING

GLUCOSE SYS ............... 67 EASYMAX V2 BLOOD

GLUCOSE METER ......... 67 ECLIPSE NEEDLE .............. 67 EC-NAPROSYN .................. 30 econazole .............................. 53 econtra ez .............................. 93 econtra one-step .................... 93 ecotrin ................................... 30 ecotrin low strength .............. 30 ECOZA ................................. 53 EDARBI ............................... 39 EDARBYCLOR ................... 39 EDECRIN ............................. 39 EDLUAR .............................. 33 ed-spaz .................................. 78 EDURANT ............................. 4 eemt ...................................... 90 eemt hs .................................. 90

efavirenz ................................. 4 effer-k ................................. 107 EFFER-K ............................ 107 EFFEXOR XR ...................... 33 EFFIENT .............................. 43 EFUDEX .............................. 48 EGRIFTA ............................. 84 ELAPRASE .......................... 74 ELELYSO ............................ 74 ELEMENT COMPACT

GLUCOSE METER ......... 67 ELEMENT COMPACT

NORMAL CONTROL ..... 67 ELEMENT COMPACT TEST

STRIPS ............................. 62 ELEMENT COMPACT V

GLUCOSE MTR .............. 67 ELEMENT NORMAL

CONTROL ....................... 67 ELEMENT PLUS BLOOD

GLUCOSE KIT ................ 67 ELEMENT TEST STRIPS ... 62 ELESTRIN ........................... 90 eletone ................................... 48 eletriptan ............................... 22 ELIDEL ................................ 48 ELIGARD ............................. 14 ELIGARD (3 MONTH) ....... 15 ELIGARD (4 MONTH) ....... 15 ELIGARD (6 MONTH) ....... 15 ELIMITE .............................. 56 elinest .................................... 93 ELIQUIS ............................... 43 ELITEK ................................ 12 ELIXOPHYLLIN ............... 103 ELLA .................................... 93 ELLENCE ............................ 15 ELLZIA PAK ....................... 55 ELMIRON .......................... 106 ELOCON .............................. 55 ELOCTATE ......................... 43 ELZONRIS ........................... 15 EMBEDA ............................. 25 EMBRACE BLOOD

GLUCOSE SYSTEM . 62, 67 EMBRACE EVO LEVEL 1 . 67 EMBRACE EVO TEST

STRIPS ............................. 62


125

EMBRACE GLUCOSE CONTROL LOW ............. 67

EMBRACE PRO GLUCOSE METER ............................ 67

EMBRACE PRO TEST STRIPS ............................. 62

EMBRACE TALK BLOOD GLUCOSE SYS ............... 67

EMBRACE TALK CONTROL-LOW (L1) .... 67

EMBRACE TALK TEST STRIPS ............................. 62

EMCYT ................................ 15 EMEND ................................ 80 EMEND (FOSAPREPITANT)

.......................................... 80 EMFLAZA ........................... 60 EMGALITY PEN ................ 22 EMGALITY SYRINGE ....... 22 emoquette ............................. 93 EMPLICITI .......................... 15 EMSAM ............................... 33 EMTRIVA .............................. 4 EMVERM .............................. 8 ENABLEX ......................... 105 enalapril maleate .................. 39 enalaprilat ............................. 39 enalapril-hydrochlorothiazide

.......................................... 39 ENBRACE HR ................... 109 ENBREL .............................. 89 ENBREL MINI .................... 89 ENBREL SURECLICK ....... 89 ENDARI ............................... 57 endocet ................................. 25 ENDOMETRIN ................... 90 ENGERIX-B (PF) ................ 86 ENGERIX-B PEDIATRIC

(PF) ................................... 86 enoxaparin ............................ 43 enpresse ................................ 93 enskyce ................................. 93 ENSTILAR........................... 47 entacapone ............................ 21 entecavir ................................. 4 ENTOCORT EC .................. 80 ENTRESTO ......................... 46 ENTYVIO ............................ 80

enulose .................................. 80 ENVARSUS XR .................. 15 EPANED .............................. 39 EPCLUSA .............................. 4 EPICERAM .......................... 48 EPIDIOLEX ......................... 20 EPIDUO ............................... 50 EPIDUO FORTE .................. 50 EPIFOAM ............................ 47 epinastine .............................. 97 epinephrine ......................... 101 EPINEPHRINE .......... 100, 101 EPINEPHRINESNAP-EMS

........................................ 101 EPINEPHRINESNAP-V .... 101 EPIPEN 2-PAK .................. 101 EPIPEN JR 2-PAK ............. 101 epirubicin .............................. 15 EPISIL .................................. 59 EPISNAP ............................ 101 epitol ..................................... 20 EPIVIR ................................... 4 EPIVIR HBV .......................... 4 eplerenone ............................ 39 EPOGEN .............................. 84 epoprostenol (glycine) .......... 39 eprosartan ............................. 39 EPZICOM .............................. 4 EQUETRO ........................... 20 ERAXIS(WATER DILUENT)

............................................ 3 ERBITUX ............................. 15 ergocalciferol (vitamin d2) . 109 ergoloid ................................. 33 ERGOMAR .......................... 22 ergotamine-caffeine .............. 22 ERIVEDGE .......................... 15 ERLEADA ........................... 15 errin ...................................... 90 ERTACZO............................ 54 ertapenem ............................... 8 ERWINAZE ......................... 15 ery pads................................. 50 erygel .................................... 50 ERYPED 200 ......................... 7 ERYPED 400 ......................... 7 ery-tab ..................................... 7 ERY-TAB ............................... 7

erythrocin (as stearate) ........... 7 erythromycin ..................... 7, 96 erythromycin ethylsuccinate ... 7 erythromycin with ethanol .... 50 erythromycin-benzoyl peroxide

.......................................... 50 ESBRIET ............................ 103 escitalopram oxalate ............. 33 ESGIC ................................... 25 esmolol ................................. 39 ESOMEP-EZS ...................... 83 esomeprazole magnesium ..... 83 esomeprazole sodium ........... 83 ESOMEPRAZOLE

STRONTIUM ................... 83 estarylla ................................. 93 estazolam .............................. 33 ESTRACE ............................ 90 estradiol ................................ 90 estradiol valerate ................... 90 estradiol-norethindrone acet . 90 ESTRING ............................. 91 ESTROGEL .......................... 91 estrogens-methyltestosterone 91 ESTROSTEP FE-28 ............. 93 eszopiclone ........................... 33 ethacrynate sodium ............... 39 ethacrynic acid ...................... 39 ethambutol .............................. 8 ethosuximide ......................... 20 ethyl chloride ........................ 52 ethynodiol diac-eth estradiol 93 ETHYOL .............................. 12 etidronate disodium .............. 57 etodolac ................................. 30 etoposide ............................... 15 EUCRISA ............................. 48 EUFLEXXA ......................... 30 EURAX ................................ 56 EUTHYROX ........................ 77 EVAMIST ............................ 91 EVEKEO .............................. 33 EVENCARE G2 ............. 62, 67 EVENCARE G3 GLUCOSE

METER ............................. 67 EVENCARE G3 TEST ........ 62 EVENCARE MINI

GLUCOSE TEST STR ..... 62


126

EVENCARE MINI MONITOR SYSTEM ...... 68

EVENITY............................. 88 EVERSENSE SENSOR-

HOLDER .......................... 68 EVISTA ................................ 88 EVOCLIN ............................ 50 EVOLUTION BLOOD

GLUCOSE METER ......... 68 EVOLUTION NORMAL

CONTROL ....................... 68 EVOLUTION TEST STRIPS

.......................................... 62 EVOMELA .......................... 15 EVOTAZ ................................ 4 EVOXAC ............................. 57 EVZIO .................................. 30 EXALGO ER ....................... 25 EXELDERM ........................ 54 EXELON .............................. 23 exemestane ........................... 15 EXFORGE ........................... 39 EXFORGE HCT .................. 39 EXJADE ............................... 57 EXODERM .......................... 54 EXONDYS 51 ...................... 23 EXTAVIA ............................ 84 EXTINA ............................... 54 EXTRA-VIRT PLUS DHA 109 EYLEA ................................. 97 EZ FLU 2018-

19(FLUCELVAX)(PF) .... 86 EZ SMART PLUS SYSTEM

.......................................... 68 EZ SMART PLUS TEST ..... 62 EZ SMART SYSTEM ......... 68 EZ SMART TEST ................ 62 ezetimibe .............................. 45 ezetimibe-simvastatin ........... 45 F FABIOR ............................... 50 FABRAZYME ..................... 74 FACTIVE ............................. 10 falmina (28) .......................... 93 famciclovir ............................. 4 famotidine............................. 83 famotidine (pf)...................... 83 famotidine (pf)-nacl (iso-os) 83

FAMOTIDINE IN 0.9 % NACL ............................... 83

FANAPT .............................. 33 FARESTON ......................... 15 FARXIGA ............................ 76 FARYDAK ........................... 15 FASENRA .......................... 103 FASLODEX ......................... 15 fayosim ................................. 93 FAZACLO............................ 33 FC2 FEMALE CONDOM ... 90 FEIBA NF ............................ 43 felbamate .............................. 20 FELBATOL.......................... 20 FELDENE ............................ 30 felodipine .............................. 40 fem ph ................................... 92 FEMARA ............................. 15 FEMCAP .............................. 90 FEMHRT LOW DOSE ........ 91 FEMRING ............................ 91 femynor ................................ 93 fenofibrate ............................ 45 FENOFIBRATE ................... 45 fenofibrate micronized ......... 45 fenofibrate nanocrystallized . 45 FENOFIBRATE

NANOCRYSTALLIZED . 45 fenofibric acid....................... 45 fenofibric acid (choline) ....... 45 FENOGLIDE........................ 45 fenoprofen ............................ 30 FENOPROFEN .................... 30 FENORTHO ......................... 30 fentanyl ................................. 25 FENTANYL (PF)-

BUPIVACAINE-NACL ... 25 fentanyl citrate ...................... 25 fentanyl citrate (pf) ............... 25 FENTANYL CITRATE (PF)

.......................................... 25 fentanyl citrate (pf)-0.9%nacl

.......................................... 25 FENTANYL CITRATE (PF)-

0.9%NACL ....................... 25 FENTANYL-

ROPIVACAINE-NACL (PF) ................................... 26

FENTORA ............................ 26 FERRIPROX ........................ 57 FERRLECIT ......................... 57 FETZIMA ............................. 33 FEXMID ............................... 24 FIASP FLEXTOUCH U-100

INSULIN .......................... 72 FIASP U-100 INSULIN ....... 72 FIBRICOR ............................ 45 FIBRYGA ............................. 43 FIFTY50 TEST STRIP ......... 62 FINACEA ............................. 50 finasteride ........................... 106 FIORICET ............................ 26 FIORINAL ........................... 26 FIORINAL-CODEINE #3 .... 26 FIRAZYR ........................... 103 FIRDAPSE ........................... 23 FIRMAGON KIT W

DILUENT SYRINGE ...... 15 FIRVANQ ............................ 12 flac otic oil ............................ 59 FLAGYL ................................ 8 FLAREX ............................... 99 flavoxate ............................. 105 FLEBOGAMMA DIF .......... 86 flecainide .............................. 38 FLECTOR ............................ 30 fleet laxative ......................... 80 FLOLAN .............................. 40 FLOLIPID ............................ 45 FLOMAX ........................... 106 FLORIVA (FLUORIDE-

VITAMIN D3) ................ 109 FLOVENT DISKUS .......... 103 FLOVENT HFA ................. 103 floxuridine ............................ 15 FLUAD 2018-2019 (65 YR

UP)(PF) ............................. 86 FLUARIX QUAD 2018-2019

(PF) ................................... 86 FLUBLOK QUAD 2018-2019

(PF) ................................... 86 flucaine ................................. 97 FLUCELVAX QUAD 2018-

2019 .................................. 86 FLUCELVAX QUAD 2018-

2019 (PF) .......................... 86


127

fluconazole ............................. 3 fluconazole in dextrose(iso-o) 3 fluconazole in nacl (iso-osm) . 3 flucytosine .............................. 3 fludarabine ............................ 15 fludrocortisone ..................... 60 FLULAVAL QUAD 2018-

2019 .................................. 86 FLULAVAL QUAD 2018-

2019 (PF) .......................... 86 FLUMADINE ........................ 4 flumazenil ............................. 33 FLUMIST QUAD 2018-2019

.......................................... 86 flunisolide ........................... 103 fluocinolone .......................... 55 fluocinolone acetonide oil .... 59 fluocinolone and shower cap 55 fluocinonide .......................... 55 fluocinonide-emollient ......... 55 FLUORABON ................... 109 fluorescein-proparacaine ...... 97 fluoride (sodium) ................ 109 FLUORIDEX DAILY

DEFENSE ........................ 59 fluoritab .............................. 109 fluorometholone ................... 99 FLUOROPLEX .................... 48 fluorouracil ..................... 15, 48 FLUOROURACIL ............... 48 fluoxetine ........................ 33, 34 fluphenazine decanoate ........ 34 fluphenazine hcl ................... 34 FLURA-DROPS ................ 109 flurandrenolide ..................... 55 flurazepam ............................ 34 flurbiprofen........................... 30 flurbiprofen sodium .............. 98 flutamide............................... 15 fluticasone propionate .. 55, 103 fluticasone propion-salmeterol

........................................ 103 FLUTICASONE PROPION-

SALMETEROL ............. 103 fluvastatin ............................. 45 fluvoxamine .......................... 34 FLUZONE HIGH-DOSE

2018-19 (PF) .................... 86

FLUZONE QUAD 2018-2019 .......................................... 86

FLUZONE QUAD 2018-2019 (PF) ................................... 86

FLUZONE QUAD PEDI 2018-19 (PF)..................... 86

FML FORTE ........................ 99 FML LIQUIFILM ................ 99 FML S.O.P. .......................... 99 FOCALIN ............................. 34 FOCALIN XR ...................... 34 FOLET ONE ...................... 109 folic acid ............................. 109 folivane-ob.......................... 109 FOLLISTIM AQ .................. 74 FOLOTYN ........................... 15 foltabs 800 .......................... 109 fondaparinux ......................... 43 FORA D10 ........................... 68 FORA D15G STRIPS .......... 62 FORA D20 ..................... 62, 68 FORA D40-G31 TEST

STRIPS ............................. 62 FORA G20 ..................... 62, 68 FORA G30A......................... 68 FORA G30-PREMIUM V10

TEST STRP ...................... 62 FORA GD50 BLOOD

GLUCOSE SYSTEM ....... 68 FORA GD50 TEST STRIPS 63 FORA GTEL GLUCOSE

TEST STRIP..................... 63 FORA NORMAL CONTROL

.......................................... 68 FORA PREMIUM V10

GLUCOSE METER ......... 68 FORA TEST N'GO VOICE

METER ............................ 68 FORA TEST STRIP ............. 63 FORA TN'G VOICE METER

.......................................... 68 FORA TN'G VOICE TEST

STRIPS ............................. 63 FORA V10 ..................... 63, 68 FORA V10-V12-D10-D20

STRIPS ............................. 63 FORA V12 BLOOD

GLUCOSE SYSTEM ....... 68

FORA V12 GLUCOSE ........ 63 FORA V20 ...................... 63, 68 FORA V30A ......................... 68 FORACARE GD20 .............. 63 FORACARE GD20

GLUCOSE METER ......... 68 FORACARE GD40 .............. 63 FORACARE GD40A

GLUCOSE METER ......... 68 FORACARE GD40B

GLUCOSE METER ......... 68 FORACARE GDH LOW

CONTROL ....................... 68 FORFIVO XL ....................... 34 FORTAMET ......................... 76 FORTEO ............................... 88 FORTESTA .......................... 74 FORTISCARE BLOOD

GLUCOSE SYST ............. 68 FORTISCARE GLUCOSE

TEST STRIPS .................. 63 FORTISCARE NORMAL ... 68 FOSAMAX ........................... 88 FOSAMAX PLUS D ............ 88 fosamprenavir ......................... 4 FOSCAVIR ............................ 4 fosinopril ............................... 40 fosinopril-hydrochlorothiazide

.......................................... 40 fosphenytoin ......................... 20 FOSRENOL ......................... 80 FRAGMIN ............................ 43 FREESTYLE CONTROL .... 68 FREESTYLE FLASH

SYSTEM .......................... 68 FREESTYLE FREEDOM .... 68 FREESTYLE FREEDOM

LITE ................................. 68 FREESTYLE INSULINX ... 63,

68 FREESTYLE INSULINX

TEST STRIPS .................. 63 FREESTYLE LIBRE 10 DAY

READER .......................... 68 FREESTYLE LIBRE 10 DAY

SENSOR ........................... 68 FREESTYLE LITE METER 68 FREESTYLE LITE STRIPS 63


128

FREESTYLE PRECISION NEO METER ................... 68

FREESTYLE PRECISION NEO STRIPS.................... 63

FREESTYLE SIDEKICK II 68 FREESTYLE SYSTEM KIT 69 FREESTYLE TEST ............. 63 FROTEK .............................. 30 FROVA ................................ 22 frovatriptan ........................... 22 full spectrum b-vitamin c ... 109 FULPHILA........................... 84 FURADANTIN .................... 11 furosemide ............................ 40 FUROSEMIDE IN 0.9 %

NACL ............................... 40 FUSILEV ............................. 12 FUZEON ................................ 4 fyavolv .................................. 91 FYCOMPA .......................... 20 G g tussin ac ........................... 101 gabapentin ............................ 20 GABITRIL ........................... 20 GALAFOLD ........................ 74 galantamine .......................... 23 GALZIN ............................. 107 GAMASTAN ....................... 86 GAMASTAN S/D ................ 86 GAMIFANT ......................... 15 GAMMAGARD LIQUID .... 86 GAMMAGARD S-D (IGA < 1

MCG/ML) ........................ 86 GAMMAKED ...................... 86 GAMMAPLEX .................... 86 GAMMAPLEX (WITH

SORBITOL) ..................... 86 GAMUNEX-C ..................... 86 GANCICLOVIR .................... 4 ganciclovir sodium ................. 4 ganirelix ................................ 74 GARDASIL 9 (PF)............... 86 GASTROCROM .................. 80 gatifloxacin ........................... 96 GATTEX 30-VIAL .............. 80 gavilax .................................. 80 gavilyte-c .............................. 80 gavilyte-g .............................. 80

gavilyte-n .............................. 80 GAZYVA ............................. 15 GE100 BLOOD GLUCOSE

SYSTEM .......................... 69 GE100 BLOOD GLUCOSE

TEST STRIP..................... 63 GE100 CONTROL

SOLUTION NORMAL .... 69 GELCLAIR .......................... 59 GELNIQUE ........................ 106 gemcitabine .......................... 15 GEMCITABINE .................. 15 gemfibrozil ........................... 45 GENERESS FE .................... 93 generlac ................................ 80 gengraf .................................. 15 GENOTROPIN .................... 84 GENOTROPIN MINIQUICK

.......................................... 84 GENSTRIP TEST STRIP .... 63 gentak ................................... 96 gentamicin .................. 8, 53, 96 gentamicin in nacl (iso-osm) .. 8 GENTAMICIN IN NACL

(ISO-OSM) ......................... 8 gentamicin sulfate (ped) (pf) .. 8 gentamicin sulfate (pf)............ 8 GENTAMICIN SULFATE

(PF) ..................................... 8 GENTAMICIN-SODIUM

CITRATE ........................... 8 gentle laxative....................... 80 gentlelax ............................... 80 GENVOYA ............................ 4 GEODON ............................. 34 GIALAX ............................... 80 gianvi (28) ............................ 93 GIAPREZA .......................... 46 GILENYA ............................ 84 GILOTRIF ............................ 15 GLASSIA ............................. 57 glatiramer.............................. 84 glatopa .................................. 85 GLEEVEC ............................ 15 GLEOLAN ........................... 57 GLEOSTINE ........................ 15 GLIADEL WAFER .............. 15 glimepiride............................ 76

glipizide ................................ 76 glipizide-metformin .............. 76 GLUCAGEN DIAGNOSTIC

KIT ................................... 65 GLUCAGEN HYPOKIT ...... 65 GLUCAGON EMERGENCY

KIT (HUMAN) ................. 65 GLUCAGON HCL ............... 65 GLUCO NAVII GLUCOSE

MONITOR ....................... 69 GLUCO NAVII TEST STRIP

.......................................... 63 GLUCOCARD 01 METER .. 69 GLUCOCARD 01 NORMAL

CONTROL ....................... 69 GLUCOCARD 01 SENSOR

PLUS ................................ 63 GLUCOCARD EXPRESSION

.................................... 63, 69 GLUCOCARD SHINE

CONNEX METER ........... 69 GLUCOCARD SHINE

EXPRESS METER .......... 69 GLUCOCARD SHINE

METER ............................. 69 GLUCOCARD SHINE TEST

STRIPS ............................. 63 GLUCOCARD SHINE XL

METER ............................. 69 GLUCOCARD VITAL ........ 69 GLUCOCARD VITAL

SENSOR ........................... 63 GLUCOCARD VITAL TEST

STRIPS ............................. 63 GLUCOCOM BLOOD

GLUCOSE ........................ 69 GLUCOCOM CONTROL

NORMAL ......................... 69 GLUCOCOM GLUCOSE .... 63 GLUCOPHAGE ................... 76 GLUCOPHAGE XR ............ 76 GLUCOSE CONTROL ........ 69 GLUCOTROL ...................... 76 GLUCOTROL XL ................ 76 GLUMETZA ........................ 76 glyburide ............................... 76 glyburide micronized ............ 76 glyburide-metformin ............. 76


129

GLYCATE ........................... 78 glycolax ................................ 80 glycopyrrolate....................... 78 GLYCOPYRROLATE......... 78 glycopyrrolate (pf) in water .. 78 GLYCOPYRROLATE (PF) IN

WATER ............................ 78 glydo ..................................... 52 GLYNASE ........................... 76 GLYRX-PF .......................... 78 GLYSET............................... 76 GLYXAMBI ........................ 76 GM100 ........................... 63, 69 GOCOVRI ............................ 21 GOLYTELY......................... 80 GONAL-F ............................ 74 GONAL-F RFF .................... 74 GONAL-F RFF REDI-JECT 74 GONITRO ............................ 46 GRALISE ............................. 20 GRALISE 30-DAY STARTER

PACK ............................... 20 granisetron hcl ...................... 80 GRANIX .............................. 84 GRASTEK ........................... 86 griseofulvin microsize ............ 3 griseofulvin ultramicrosize ..... 3 guaiatussin ac ..................... 101 guaifenesin ac ..................... 101 guaifenesin dac ................... 101 guanfacine ...................... 34, 40 guanidine .............................. 34 GYNAZOLE-1 ..................... 92 gynol ii.................................. 92 H HAEGARDA ..................... 103 hailey 24 fe ........................... 93 HALAVEN........................... 15 HALCION ............................ 34 HALDOL ............................. 34 HALDOL DECANOATE .... 34 halobetasol propionate.......... 55 HALOBETASOL

PROPIONATE ................. 55 HALOG ................................ 55 haloperidol ............................ 34 haloperidol decanoate ........... 34 haloperidol lactate ................ 34

HARVONI.............................. 4 HAVRIX (PF) ...................... 86 HEALTHPRO GLUCOSE

MONITOR ....................... 69 HEALTHPRO HIGH-LOW

CONTROL ....................... 69 HEALTHPRO TEST STRIPS

.......................................... 63 healthylax ............................. 80 heather .................................. 91 HECTOROL ......................... 74 HELIXATE FS ..................... 43 HEMANGEOL ..................... 40 hemenatal ob....................... 109 hemenatal ob + dha ............ 109 HEMLIBRA ......................... 43 hemmorex-hc ........................ 80 HEMOFIL M HIGH ............. 43 HEMOFIL M LOW.............. 43 HEMOFIL M MID ............... 43 HEMOFIL M SUPER HIGH43 hep flush-10 (pf) ................... 43 HEPAGAM B....................... 86 heparin (porcine) .................. 43 HEPARIN (PORCINE) IN

0.9% NACL ...................... 43 heparin (porcine) in 5 % dex 43 heparin (porcine) in nacl (pf) 43 heparin flush(porcine)-0.9nacl

.......................................... 43 heparin lock flush ................. 43 heparin lock flush (porcine) . 43 heparin lockflush(porcine)(pf)

.......................................... 43 HEPARIN(PORCINE) IN

0.45% NACL .................... 43 heparin, porcine (pf) ............. 43 HEPARIN, PORCINE (PF) . 43 HEPLISAV-B (PF)............... 86 HEPSERA .............................. 4 HERCEPTIN ........................ 15 HERCEPTIN HYLECTA .... 15 HETLIOZ ............................. 34 HIBERIX (PF) ...................... 86 hidex ..................................... 60 HIPREX................................ 12 HISTEX-AC ....................... 101 HIZENTRA .......................... 87

homatropaire ......................... 97 homatropine hbr .................... 97 HORIZANT .......................... 23 hpr ......................................... 48 hpr plus ................................. 48 hpr plus hydrogel .................. 48 HPR PLUS-MB HYDROGEL

.......................................... 48 HUMALOG JUNIOR

KWIKPEN U-100 ............ 72 HUMALOG KWIKPEN

INSULIN .......................... 72 HUMALOG MIX 50-50

INSULN U-100 ................ 73 HUMALOG MIX 50-50

KWIKPEN ........................ 73 HUMALOG MIX 75-25

KWIKPEN ........................ 73 HUMALOG MIX 75-25(U-

100)INSULN .................... 73 HUMALOG U-100 INSULIN

.......................................... 73 HUMATE-P ......................... 43 HUMATROPE ..................... 84 HUMIRA .............................. 89 HUMIRA PEDIATRIC

CROHNS START ............ 89 HUMIRA PEN ..................... 89 HUMIRA PEN CROHNS-UC-

HS START ....................... 89 HUMIRA PEN PSOR-

UVEITS-ADOL HS ......... 89 HUMIRA(CF) ...................... 89 HUMIRA(CF) PEDI

CROHNS STARTER ....... 89 HUMIRA(CF) PEN .............. 89 HUMIRA(CF) PEN

CROHNS-UC-HS ............. 89 HUMIRA(CF) PEN PSOR-

UV-ADOL HS .................. 89 HUMULIN 70/30 U-100

INSULIN .......................... 73 HUMULIN 70/30 U-100

KWIKPEN ........................ 73 HUMULIN N NPH INSULIN

KWIKPEN ........................ 73 HUMULIN N NPH U-100

INSULIN .......................... 73


130

HUMULIN R REGULAR U-100 INSULN .................... 73

HUMULIN R U-500 (CONC) INSULIN .......................... 73

HUMULIN R U-500 (CONC) KWIKPEN ....................... 73

HYCAMTIN ........................ 16 hydralazine ........................... 40 HYDREA ............................. 16 HYDRO 35 ........................... 48 HYDRO 40 ........................... 48 hydrochlorothiazide .............. 40 hydrocodone-acetaminophen 26 hydrocodone-chlorpheniramine

........................................ 101 hydrocodone-cpm-

pseudoephed ................... 101 HYDROCODONE-

GUAIFENESIN ............. 101 hydrocodone-homatropine . 101 hydrocodone-ibuprofen ........ 26 hydrocortisone .......... 55, 60, 80 hydrocortisone acetate .......... 80 hydrocortisone butyrate ........ 55 hydrocortisone butyr-emollient

.......................................... 55 hydrocortisone valerate ........ 55 hydrocortisone-acetic acid.... 59 hydrocortisone-iodoquinol ... 53 hydrocortisone-iodoquinol-aloe

.......................................... 53 hydrocortisone-pramoxine .. 47,

80 hydromet............................. 101 hydromorphone .............. 26, 27 HYDROMORPHONE ......... 26 hydromorphone (pf) ............. 26 HYDROMORPHONE (PF) . 26 HYDROMORPHONE (PF) IN

WATER ............................ 26 HYDROMORPHONE (PF)-

0.9 % NACL ..................... 26 hydromorphone in 0.9 % nacl

.......................................... 26 HYDROMORPHONE IN 0.9

% NACL ........................... 26 hydroxychloroquine ............... 8

hydroxyprogest(pf)(preg presv) .......................................... 91

hydroxyprogesterone cap(ppres) ......................... 91

hydroxyprogesterone caproate .......................................... 91

hydroxyurea .......................... 16 hydroxyzine hcl .................. 101 hydroxyzine pamoate ......... 101 HYLATOPIC ....................... 48 HYLATOPICPLUS.............. 48 hyophen .............................. 106 hyoscyamine sulfate ............. 78 hyosyne ................................. 78 HYPERHEP B S/D .............. 87 HYPERHEP B S-D

NEONATAL .................... 87 HYPERRAB (PF)................. 87 HYPERRAB S/D (PF) ......... 87 HYPER-SAL ...................... 103 HYPERTET S/D (PF) .......... 87 hypocyn ................................ 97 HYQVIA .............................. 87 HYSINGLA ER ................... 27 HYZAAR ............................. 40 I ibandronate ........................... 88 IBRANCE ............................ 16 ibu ......................................... 30 IBUDONE ............................ 27 ibuprofen .............................. 30 ibuprofen-oxycodone............ 27 ic green ................................. 57 ICLUSIG .............................. 16 IDAMYCIN PFS .................. 16 idarubicin .............................. 16 IDELVION ........................... 43 IDHIFA ................................ 16 IFE-BIMIX 30/1 ................. 106 IFE-PG20............................ 106 IFEX ..................................... 16 ifosfamide ............................. 16 ifosfamide-mesna ................. 16 IGLUCOSE BLOOD

GLUCOSE MONITOR .... 69 IGLUCOSE TEST STRIP .... 63 ILARIS (PF) ......................... 85 ILEVRO ............................... 98

ILUMYA .............................. 47 ILUVIEN .............................. 99 imatinib ................................. 16 IMBRUVICA ....................... 16 IMFINZI ............................... 16 imipenem-cilastatin ................ 8 imipramine hcl ...................... 34 imipramine pamoate ............. 34 imiquimod ............................. 85 IMIQUIMOD ....................... 85 IMITREX ............................. 22 IMITREX STATDOSE PEN 22 IMITREX STATDOSE

REFILL ............................. 22 IMLYGIC ............................. 16 IMOGAM RABIES-HT (PF)

.......................................... 87 IMPAVIDO ............................ 8 IMPOYZ ............................... 55 IMURAN .............................. 16 IMVEXXY MAINTENANCE

PACK ............................... 91 IMVEXXY STARTER PACK

.......................................... 91 INBRIJA ............................... 21 incassia ................................. 91 INCRELEX .......................... 57 INCRUSE ELLIPTA .......... 103 indapamide ........................... 40 INDERAL LA ...................... 40 INDERAL XL ...................... 40 INDOCIN ............................. 30 indocyanine green ................. 57 indomethacin ........................ 30 INFANRIX (DTAP) (PF) ..... 87 INFASURF ........................... 57 INFINITY CONTROL

SOLUTION NORM ......... 69 INFINITY STARTER KIT .. 69 INFINITY TEST STRIPS .... 63 INFINITY VOICE CTRL

SOLN-LVL 2 .................... 69 INFINITY VOICE GLUCOSE

MONITOR ....................... 69 INFINITY VOICE TEST

STRIP ............................... 63 INFLECTRA ........................ 80 INFUGEM ............................ 16


131

INFUVITE ADULT ........... 109 INFUVITE PEDIATRIC.... 109 INGREZZA .......................... 23 INGREZZA INITIATION

PACK ............................... 23 INJECTAFER .................... 109 INLYTA ............................... 16 INNOPRAN XL ................... 40 INOVA ................................. 50 INOVA 4-1 ........................... 47 INSPRA ................................ 40 INSULIN LISPRO ............... 73 INSULIN SYRINGE-

NEEDLE U-100 ............... 65 INTELENCE .......................... 4 INTERMEZZO .................... 34 INTRAROSA ....................... 92 INTRON A ........................... 85 introvale ................................ 93 INTUNIV ER ....................... 34 INVANZ................................. 8 INVEGA............................... 34 INVELTYS .......................... 99 INVIRASE ............................. 4 INVOKAMET ...................... 76 INVOKAMET XR ............... 76 INVOKANA ........................ 76 IOPIDINE........................... 100 IPOL ..................................... 87 ipratropium bromide ..... 59, 103 ipratropium-albuterol ......... 103 irbesartan .............................. 40 irbesartan-hydrochlorothiazide

.......................................... 40 IRESSA ................................ 16 irinotecan .............................. 16 ISENTRESS ........................... 4 ISENTRESS HD .................... 4 isibloom ................................ 93 ISOCHRON ......................... 46 ISOLYTE-S ........................ 108 isoniazid ................................. 8 ISOPTO ATROPINE ........... 97 ISOPTO CARPINE .............. 97 ISORDIL .............................. 46 ISORDIL TITRADOSE ....... 46 isosorbide dinitrate ............... 46 isosorbide mononitrate ......... 46

isotretinoin ............................ 51 isoxsuprine............................ 92 isradipine .............................. 40 ISTALOL ............................. 97 ISTODAX ............................ 16 itraconazole ............................ 3 ivermectin ............................... 9 IXEMPRA ............................ 16 IXINITY ............................... 44 J JADENU .............................. 57 JADENU SPRINKLE .......... 57 JAKAFI ................................ 16 JALYN ............................... 106 jantoven ................................ 44 JANUMET ........................... 76 JANUMET XR ..................... 76 JANUVIA ............................. 76 JARDIANCE ........................ 76 jasmiel (28) ........................... 93 JAZZ WIRELESS 2 METER

KIT ................................... 69 jencycla ................................. 91 JENTADUETO .................... 76 JENTADUETO XR .............. 76 JETREA (PF) ....................... 97 JEVTANA ............................ 16 jinteli ..................................... 91 JIVI ....................................... 44 jolessa ................................... 93 jolivette ................................. 91 JUBLIA ................................ 54 juleber ................................... 93 JULUCA ................................. 4 junel 1.5/30 (21) ................... 93 junel 1/20 (21) ...................... 93 junel fe 1.5/30 (28) ............... 93 junel fe 1/20 (28) .................. 93 junel fe 24 ............................. 93 JUXTAPID ........................... 45 JYNARQUE ................... 74, 75 K KADCYLA .......................... 16 KADIAN .............................. 27 kaitlib fe ................................ 93 KALBITOR ........................ 103 KALETRA ............................. 4 KALYDECO .............. 103, 104

KANUMA ............................ 75 KAPSPARGO SPRINKLE .. 40 KAPVAY ............................. 34 KARBINAL ER ................. 101 kariva (28) ............................ 93 KAZANO ............................. 76 KEDRAB (PF) ...................... 87 KEFLEX ................................. 7 kelnor 1/35 (28) .................... 93 kelnor 1-50 ............................ 93 KENALOG ..................... 55, 60 KEPIVANCE ....................... 12 KEPPRA ............................... 20 KEPPRA XR ........................ 20 KERAFOAM ........................ 48 KERALAC ........................... 48 KERALYT RX ..................... 47 KERYDIN ............................ 54 ketoconazole ..................... 3, 54 ketoprofen ............................. 30 ketorolac ......................... 30, 98 KEVEYIS ............................. 23 KEVZARA ........................... 89 KHAPZORY ........................ 12 KHEDEZLA ......................... 34 KINERET ............................. 85 KINRIX (PF) ........................ 87 KISQALI .............................. 16 KISQALI FEMARA CO-

PACK ............................... 16 KIT FOR TC 99M-

SESTAMIBI NO.1 ........... 57 KIT PREP OF TC-99M-

MEBROFENIN ................ 57 KIT PREP OF TC-99M-SOD

PYROPH .......................... 57 KITABIS PAK ....................... 9 KLARON ............................. 53 KLONOPIN .......................... 20 klor-con ............................... 107 klor-con 10 .......................... 107 klor-con 8 ............................ 107 klor-con m10 ...................... 107 klor-con m15 ...................... 107 klor-con m20 ...................... 107 klor-con sprinkle ................. 107 klor-con/ef .......................... 107 KOATE ................................. 44


132

kobee .................................. 109 KOGENATE FS ................... 44 KOMBIGLYZE XR ............. 76 KORLYM............................. 75 KOSHER PRENATAL PLUS

IRON .............................. 109 KOVALTRY ........................ 44 K-PHOS NO 2 .................... 106 K-PHOS ORIGINAL ......... 106 kpn ...................................... 109 KRINTAFEL .......................... 9 KRISTALOSE ..................... 80 KRYSTEXXA ...................... 88 k-tab .................................... 108 K-TAB ................................ 108 kurvelo (28) .......................... 93 KUVAN ............................... 75 KYLEENA ........................... 90 KYMRIAH ........................... 16 KYPROLIS .......................... 16 L l norgest/e.estradiol-e.estrad . 93 labetalol ................................ 40 LABETALOL ...................... 40 LABETALOL IN DEXTROSE

5 %.................................... 40 LACRISERT ........................ 97 lactated ringers ..................... 56 lactulose ................................ 80 LAMICTAL ......................... 20 LAMICTAL ODT ................ 20 LAMICTAL ODT STARTER

(BLUE) ............................. 20 LAMICTAL ODT STARTER

(GREEN) .......................... 20 LAMICTAL ODT STARTER

(ORANGE)....................... 20 LAMICTAL STARTER

(BLUE) KIT ..................... 20 LAMICTAL STARTER

(GREEN) KIT .................. 20 LAMICTAL STARTER

(ORANGE) KIT ............... 20 LAMICTAL XR ................... 20 LAMICTAL XR STARTER

(BLUE) ............................. 20 LAMICTAL XR STARTER

(GREEN) .......................... 20

LAMICTAL XR STARTER (ORANGE) ....................... 20

lamivudine .............................. 4 lamivudine-zidovudine ........... 4 lamotrigine............................ 20 LANCETS ............................ 69 LANCING DEVICE ............ 69 LANOXIN ............................ 42 LANOXIN PEDIATRIC ...... 42 lansoprazole .......................... 83 lanthanum ............................. 80 LANTUS SOLOSTAR U-100

INSULIN .......................... 73 LANTUS U-100 INSULIN .. 73 larin 1.5/30 (21) .................... 94 larin 1/20 (21) ....................... 94 larin 24 fe.............................. 94 larin fe 1.5/30 (28) ................ 94 larin fe 1/20 (28) ................... 94 larissia ................................... 94 LARTRUVO ........................ 16 LASIX .................................. 40 LASTACAFT ....................... 97 latanoprost ............................ 99 LATUDA.............................. 34 laxaclear................................ 80 laxative (bisacodyl) .............. 80 laxative feminine .................. 80 laxative peg 3350.................. 80 layolis fe ............................... 94 LAZANDA ........................... 27 LDO PLUS ........................... 52 LEDIPASVIR-SOFOSBUVIR

............................................ 4 leena 28................................. 94 leflunomide ........................... 89 LEMTRADA ........................ 85 LENVIMA............................ 16 LESCOL XL......................... 45 lessina ................................... 94 LETAIRIS .......................... 104 letrozole ................................ 16 leucovorin calcium ............... 12 LEUKERAN ........................ 16 LEUKINE ............................. 84 leuprolide .............................. 16 LEVA SET ........................... 52 levalbuterol hcl ................... 104

LEVALBUTEROL TARTRATE ................... 104

LEVAQUIN ......................... 10 LEVBID ............................... 78 LEVEMIR FLEXTOUCH U-

100 INSULN .................... 73 LEVEMIR U-100 INSULIN 73 levetiracetam ......................... 20 levetiracetam in nacl (iso-os) 20 LEVICYN ANTIPRURITIC 48 LEVICYN ANTIPRURITIC

SG ..................................... 48 levobunolol ........................... 97 levocarnitine ......................... 57 levocarnitine (with sugar) ..... 57 levofloxacin .................... 10, 96 levofloxacin in d5w .............. 10 levoleucovorin calcium ........ 12 LEVOLEUCOVORIN

CALCIUM ........................ 12 levonest (28) ......................... 94 levonorgestrel ....................... 94 levonorgestrel-ethinyl estrad 94 levonorg-eth estrad triphasic 94 levora-28 ............................... 94 levorphanol tartrate ............... 27 LEVORPHANOL

TARTRATE ..................... 27 LEVO-T ................................ 77 levothyroxine ........................ 77 levoxyl .................................. 77 LEVSIN ................................ 78 LEVSIN/SL .......................... 78 LEVULAN ........................... 48 LEXAPRO ............................ 34 LEXETTE ............................. 55 LEXIVA ................................. 4 LEXIXRYL .......................... 30 LIALDA ............................... 80 LIBRAX (WITH

CLIDINIUM) ................... 78 LIBTAYO ............................. 16 lidocaine ............................... 52 lidocaine (pf) ........................ 52 LIDOCAINE (PF) ................ 52 lidocaine hcl .......................... 52 LIDOCAINE HCL ............... 52


133

lidocaine hcl-hydrocortison ac .................................... 52, 80

lidocaine viscous .................. 52 lidocaine-phenylephrn in water

.......................................... 97 lidocaine-prilocaine .............. 52 LIDOCAN-PHENYLEPH-

BSS NO.2(PF) .................. 98 LIDODERM ......................... 52 LIDOPAC............................. 52 lidopin................................... 52 LIDOPIN .............................. 52 LIDO-PRILO CAINE PACK

.......................................... 53 LIDORX ............................... 53 LIDOTRAL .......................... 53 lidozion ................................. 53 LIDTOPIC MAX ................. 53 LILETTA ............................. 90 lillow (28) ............................. 94 LINCOCIN ............................. 9 lincomycin .............................. 9 lindane .................................. 56 linezolid .................................. 9 linezolid in dextrose 5% ......... 9 LINZESS .............................. 80 liothyronine .......................... 77 LIPITOR............................... 45 LIPOCHOL PLUS ............... 57 lipodox .................................. 16 lipodox 50 ............................. 16 LIPOFEN ............................. 45 LIPROZONEPAK ................ 53 LIQUIVIDA HYDRATION

KIT ................................... 57 lisinopril ............................... 40 lisinopril-hydrochlorothiazide

.......................................... 40 lite coat aspirin ..................... 30 lithium carbonate .................. 34 lithium citrate ....................... 34 LITHOBID ........................... 34 LITHOSTAT ........................ 57 LIVALO ............................... 45 LO LOESTRIN FE............... 94 LOCOID ............................... 55 LOCOID LIPOCREAM ....... 55 LODINE ............................... 30

LODOSYN ........................... 21 LOESTRIN 1.5/30 (21) ........ 94 LOESTRIN 1/20 (21) ........... 94 LOESTRIN FE 1.5/30 (28-

DAY) ................................ 94 LOESTRIN FE 1/20 (28-DAY)

.......................................... 94 LOKELMA .......................... 80 LOMOTIL ............................ 78 LONHALA MAGNAIR

REFILL .......................... 104 LONHALA MAGNAIR

STARTER ...................... 104 LONSURF ............................ 16 LOPID .................................. 45 lopinavir-ritonavir .................. 4 lopreeza ................................ 91 LOPRESSOR ....................... 40 LOPROX .............................. 54 LOPROX (AS OLAMINE) .. 54 LOPROX KIT ...................... 54 lorazepam ............................. 34 LORAZEPAM IN 0.9% SOD

CHLORIDE ...................... 34 LORAZEPAM IN

DEXTROSE 5 % .............. 34 lorazepam intensol ................ 34 LORBRENA ........................ 16 lorcet (hydrocodone) ............ 27 lorcet hd ................................ 27 lorcet plus ............................. 27 LORTAB ELIXIR ................ 27 lortuss ex............................. 101 loryna (28) ............................ 94 LORZONE ........................... 24 losartan ................................. 40 losartan-hydrochlorothiazide 40 LOSEASONIQUE................ 94 LOTEMAX .......................... 99 LOTEMAX SM .................... 99 LOTENSIN .......................... 40 LOTENSIN HCT ................. 40 LOTREL ............................... 40 LOTRISONE ........................ 54 LOTRONEX ........................ 80 LOUTREX ........................... 48 lovastatin .............................. 45 LOVAZA.............................. 45

LOVENOX ........................... 44 low-ogestrel (28) .................. 94 loxapine succinate ................ 34 LOYON ................................ 48 lta pre-attached ..................... 53 LUCEMYRA ........................ 30 LUCENTIS ........................... 98 ludent fluoride .................... 109 lugols ............................ 53, 108 LULICONAZOLE ............... 54 LUMIGAN ........................... 99 LUMIZYME ......................... 75 LUNESTA ............................ 34 LUPANETA PACK (1

MONTH) .......................... 92 LUPANETA PACK (3

MONTH) .......................... 92 LUPRON DEPOT ................ 16 LUPRON DEPOT (3

MONTH) .......................... 16 LUPRON DEPOT (4

MONTH) .......................... 16 LUPRON DEPOT (6

MONTH) .......................... 16 LUPRON DEPOT-PED ....... 16 lutera (28) ............................. 94 luxamend .............................. 48 LUXIQ .................................. 55 LUXTURNA ........................ 98 LUZU ................................... 54 LYNPARZA ......................... 16 LYRICA ............................... 20 LYRICA CR ......................... 20 LYSODREN ......................... 16 LYSTEDA ............................ 92 lyza ....................................... 91 M m.v.i. adult .......................... 109 MACRILEN ......................... 84 MACROBID ......................... 12 MACRODANTIN ................ 12 MACUGEN .......................... 98 mafenide acetate ................... 53 magnesium citrate ................. 81 MAKENA ............................. 91 MAKENA (PF) .................... 91 MALARONE ......................... 9 MALARONE PEDIATRIC .... 9


134

malathion .............................. 56 maprotiline ........................... 34 MAR-COF CG ................... 101 MARINOL ........................... 81 marlissa (28) ......................... 94 MARNATAL-F .................. 109 MARPLAN .......................... 34 MARQIBO ........................... 16 MATULANE ....................... 17 matzim la .............................. 40 MAVENCLAD (10 TABLET

PACK) .............................. 85 MAVYRET ............................ 4 MAXALT ............................. 22 MAXALT-MLT ................... 22 MAXIDEX ......................... 100 MAXIPIME ............................ 7 MAXITROL ......................... 99 MAXI-TUSS CD................ 101 MAXZIDE ........................... 40 MAXZIDE-25MG ................ 40 MAYZENT .......................... 85 m-clear wc .......................... 101 meclofenamate ..................... 30 MEDISENSE ....................... 69 MEDISENSE GLUCOSE

KETONE .......................... 69 MEDOLOR PAK ................. 53 MEDROL ............................. 60 MEDROL (PAK) ................. 60 medroxyprogesterone ........... 91 mefenamic acid .................... 30 mefloquine .............................. 9 megestrol .............................. 17 MEKINIST ........................... 17 MEKTOVI ........................... 17 melodetta 24 fe ..................... 94 meloxicam ............................ 30 melphalan ............................. 17 melphalan hcl ....................... 17 memantine ............................ 23 MEMANTINE ..................... 23 MENACTRA (PF) ............... 87 M-END PE ......................... 101 MENEST .............................. 91 MENOPUR .......................... 75 MENOSTAR ........................ 91

MENVEO A-C-Y-W-135-DIP (PF) ................................... 87

meperidine ............................ 27 MEPHYTON ........................ 44 meprobamate ........................ 24 MEPRON ............................... 9 MEPSEVII............................ 75 mercaptopurine ..................... 17 meropenem ............................. 9 MEROPENEM-0.9%

SODIUM CHLORIDE ....... 9 MERREM ............................... 9 mesalamine ........................... 81 mesalamine with cleansing

wipe .................................. 81 mesna .................................... 13 MESNEX.............................. 13 MESTINON ......................... 24 MESTINON TIMESPAN .... 24 metadate er ........................... 34 metaproterenol .................... 104 metaxall ................................ 24 metaxalone............................ 24 metformin ............................. 77 METFORMIN ...................... 76 methadone ............................ 27 methadose ............................. 27 methamphetamine ................ 34 methazolamide...................... 98 methenamine hippurate ........ 12 methenamine mandelate ....... 12 methen-sod phos-meth blue-

hyos ................................ 106 methergine ............................ 96 methimazole ......................... 61 METHITEST ........................ 75 methocarbamol ..................... 24 methotrexate sodium ............ 17 methotrexate sodium (pf) ..... 17 methoxsalen .......................... 48 methscopolamine .................. 79 methyclothiazide .................. 40 methyldopa ........................... 40 methyldopa-

hydrochlorothiazide .......... 40 methyldopate ........................ 40 methylergonovine ................. 96 METHYLIN ......................... 34

methylphenidate hcl ........ 34, 35 METHYLPHENIDATE HCL

.......................................... 35 METHYLPRED AC(PF)-

NACL,ISO-OSM .............. 60 METHYLPREDNISOL AC-

BUPIVAC-WAT .............. 60 methylprednisolone .............. 60 METHYLPREDNISOLONE

ACET-WATER ................ 60 methyltestosterone ................ 75 metipranolol .......................... 97 metoclopramide hcl .............. 81 metolazone ............................ 40 METOPIRONE .................... 57 metoprolol succinate ............. 40 METOPROLOL SU-

HYDROCHLOROTHIAZ 41 metoprolol ta-hydrochlorothiaz

.......................................... 41 metoprolol tartrate ................ 41 metro i.v. ................................. 9 METROCREAM .................. 51 METROGEL ........................ 51 METROGEL VAGINAL ..... 92 METROLOTION ................. 51 metronidazole ............. 9, 51, 92 metronidazole in nacl (iso-os) 9 mexiletine ............................. 38 MIACALCIN ....................... 75 mibelas 24 fe ......................... 94 MICARDIS ........................... 41 MICARDIS HCT .................. 41 MICONAZOLE NITRATE-

ZINC OX-PET .................. 54 MICORT-HC ........................ 81 MICRO BLOOD GLUCOSE

.......................................... 63 MICRODOT BLOOD

GLUCOSE SYSTEM . 63, 69 microgestin 1.5/30 (21) ........ 94 microgestin 1/20 (21) ........... 94 MICROGESTIN 24 FE ........ 94 microgestin fe 1.5/30 (28) .... 94 microgestin fe 1/20 (28) ....... 94 MICROZIDE ........................ 41 midazolam ............................ 35 midazolam (pf) ..................... 35


135

midazolam (pf) in 0.9 % nacl .......................................... 35

MIDAZOLAM (PF) IN 0.9 % NACL ............................... 35

MIDAZOLAM IN 0.9 % SOD CHLORID ........................ 35

MIDAZOLAM IN DEXTROSE 5 % .............. 35

midodrine ............................. 57 migergot ............................... 22 miglitol ................................. 77 miglustat ............................... 75 MIGRANAL ........................ 22 mili ....................................... 94 milk of magnesia .................. 81 milk of magnesia concentrated

.......................................... 81 millipred ............................... 60 millipred dp .......................... 60 mimvey ................................. 91 mimvey lo ............................. 91 MIMYX ................................ 48 MINASTRIN 24 FE ............. 94 MINIPRESS ......................... 41 MINITRAN .......................... 46 MINIVELLE ........................ 91 MINOCIN ............................ 11 minocycline .......................... 11 MINOLIRA ER .................... 11 minoxidil .............................. 41 MIOCHOL-E ....................... 97 miralax .................................. 81 MIRAPEX ............................ 21 MIRAPEX ER ...................... 21 MIRCERA ............................ 84 MIRCETTE (28) .................. 94 MIRENA .............................. 90 mirtazapine ........................... 35 MIRVASO ........................... 51 misoprostol ........................... 83 MITIGARE .......................... 88 MITIGO (PF) ....................... 27 mitomycin............................. 17 MITOSOL ............................ 99 mitoxantrone......................... 17 M-M-R II (PF) ...................... 87 m-natal plus ........................ 109 MOBIC ................................. 31

modafinil .............................. 35 moderiba ............................... 85 moexipril .............................. 41 molindone ............................. 35 mometasone .................. 55, 104 mondoxyne nl ....................... 11 MONODOX ......................... 11 mono-linyah.......................... 94 MONONINE ........................ 44 montelukast ........................ 104 MONUROL .......................... 12 morgidox .............................. 11 MORPHABOND ER ........... 27 morphine ......................... 27, 28 MORPHINE ......................... 28 morphine (pf) ........................ 27 MORPHINE (PF) ................. 27 morphine (pf) in 0.9 % nacl.. 27 MORPHINE (PF) IN 0.9 %

NACL ............................... 27 morphine concentrate ........... 27 MORPHINE IN 0.9 %

SODIUM CHLOR ............ 27 MOTEGRITY ...................... 81 MOTOFEN ........................... 79 MOVANTIK ........................ 81 MOVIPREP .......................... 81 MOXATAG.......................... 10 MOXEZA ............................. 96 moxifloxacin ................... 10, 96 MOXIFLOXACIN (PF)-BSS

NO.2 ................................. 96 MOXIFLOXACIN IN

NACL,ISO-O(PF) ............ 96 moxifloxacin-sod.chloride(iso)

.......................................... 11 MOZOBIL ............................ 84 MS CONTIN ........................ 28 MUGARD ............................ 59 MULPLETA ......................... 44 MULTAQ ............................. 38 multi-vitamin with fluoride109,

110 multivitamins with fluoride 110 mupirocin.............................. 53 mupirocin calcium ................ 53 MUTAMYCIN ..................... 17 mvc-fluoride ....................... 110

my choice .............................. 94 my way ................................. 94 MYALEPT ........................... 75 MYAMBUTOL ...................... 9 MYCOBUTIN ........................ 9 mycophenolate mofetil ......... 17 mycophenolate mofetil hcl ... 17 mycophenolate sodium ......... 17 MYDAYIS ........................... 35 MYDRIACYL ...................... 97 mydriatic3 (trop-cyclopent-pe)

.......................................... 97 MYFORTIC ......................... 17 MYGLUCOHEALTH .... 63, 69 MYGLUCOHEALTH

CONTROL SOLUTION .. 69 MYLERAN .......................... 17 MYLOTARG ....................... 17 mynatal ............................... 110 mynatal advance ................. 110 mynatal plus ........................ 110 mynatal-z ............................ 110 mynate 90 plus .................... 110 MYOBLOC .......................... 87 myorisan ............................... 51 MYRBETRIQ ..................... 106 MYSOLINE ......................... 20 MYTESI ............................... 79 N NABI-HB ............................. 87 nabumetone ........................... 31 nadolol .................................. 41 nadolol-bendroflumethiazide 41 nafcillin ................................. 10 naftifine ................................. 54 NAFTIN ............................... 54 NAGLAZYME ..................... 75 nalbuphine ............................ 31 NALFON .............................. 31 NALOCET ........................... 28 naloxone ............................... 31 naltrexone ............................. 31 NAMENDA .......................... 23 NAMENDA TITRATION

PAK .................................. 23 NAMENDA XR ................... 23 NAMZARIC ......................... 23 NAPRELAN CR .................. 31


136

NAPROSYN ........................ 31 naproxen ............................... 31 naproxen sodium .................. 31 naratriptan............................. 22 NARCAN ............................. 31 NARDIL ............................... 35 NASCOBAL ...................... 110 NASONEX ......................... 104 NATACHEW (FE BIS-

GLYCINATE) ................ 110 NATACYN .......................... 96 NATAZIA ............................ 94 nateglinide ............................ 77 NATESTO ............................ 75 NATPARA ........................... 75 NATROBA........................... 56 natural b-100 complex ........ 110 natura-lax .............................. 81 nature-throid ......................... 77 NAVELBINE ....................... 17 NEBUPENT ........................... 9 nebusal ................................ 104 NEBUSAL ......................... 104 necon 0.5/35 (28).................. 94 NEEVODHA (WITH ALGAL

OIL) ................................ 110 nefazodone ........................... 35 NEOCERA ........................... 48 neomycin ................................ 9 neomycin-bacitracin-poly-hc 99 neomycin-bacitracin-

polymyxin......................... 96 neomycin-polymyxin b-

dexameth .......................... 99 neomycin-polymyxin-

gramicidin......................... 96 neomycin-polymyxin-hc 60, 99 neo-polycin ........................... 96 neo-polycin hc ...................... 99 NEORAL .............................. 17 NEOSALUS ......................... 48 NEO-SYNALAR ................. 53 NEO-SYNALAR KIT .......... 53 NERLYNX ........................... 17 NESINA ............................... 77 NESTABS .......................... 110 NESTABS ABC ................. 110 NESTABS DHA ................ 110

NESTABS ONE ................. 110 neuac ..................................... 51 NEUAC KIT......................... 51 NEULASTA ......................... 84 NEUPOGEN ........................ 84 NEUPRO .............................. 21 NEURONTIN ....................... 20 NEUTEK 2TEK TEST

STRIPS ............................. 63 NEVANAC .......................... 98 nevirapine ............................... 4 new day................................. 94 newgen................................ 110 NEXAVAR .......................... 17 NEXAVIR .......................... 110 NEXIUM .............................. 83 NEXIUM IV ......................... 83 NEXIUM PACKET ............. 83 NEXPLANON...................... 92 niacin .................................... 45 NIACOR ............................... 45 NIASPAN EXTENDED-

RELEASE ........................ 45 nicardipine ............................ 41 NICODERM CQ .................. 58 nicorelief ............................... 58 nicorette ................................ 58 NICORETTE ........................ 58 nicotine ................................. 58 nicotine (polacrilex) ............. 58 NICOTROL .......................... 58 NICOTROL NS .................... 58 nifedipine .............................. 41 nikki (28) .............................. 94 NILANDRON ...................... 17 nilutamide ............................. 17 NIMBEX .............................. 24 nimodipine ............................ 41 NINJACOF-XG.................. 101 NINLARO ............................ 17 NIPENT ................................ 17 NIPRIDE RTU ..................... 46 nisoldipine ............................ 41 nitro-bid ................................ 46 NITRO-DUR ........................ 46 nitrofurantoin ........................ 12 nitrofurantoin macrocrystal .. 12

nitrofurantoin monohyd/m-cryst .................................. 12

nitroglycerin ......................... 46 NITROLINGUAL ................ 46 NITROMIST ........................ 46 NITROSTAT ........................ 46 nitro-time .............................. 46 NITYR .................................. 57 nivatopic plus ........................ 49 NIVESTYM ......................... 84 nizatidine .............................. 83 NIZORAL ............................. 54 NOCDURNA (MEN) ........... 75 NOCDURNA (WOMEN) .... 75 NOCTIVA ............................ 75 nolix ...................................... 55 nora-be .................................. 91 NORCO ................................ 28 NORDITROPIN FLEXPRO 84 noreth-ethinyl estradiol-iron . 94 norethindrone (contraceptive)

.......................................... 91 norethindrone acetate ............ 91 norethindrone ac-eth estradiol

.................................... 91, 94 norethindrone-e.estradiol-iron

.......................................... 94 NORGESIC FORTE ............ 24 norgestimate-ethinyl estradiol

.......................................... 94 NORITATE .......................... 51 norlyda .................................. 91 norlyroc ................................. 91 NORPACE ........................... 38 NORPACE CR ..................... 38 NORPRAMIN ...................... 35 NORTHERA ........................ 57 nortrel 0.5/35 (28) ................. 95 nortrel 1/35 (21) .................... 95 nortrel 1/35 (28) .................... 95 nortrel 7/7/7 (28) ................... 95 nortriptyline .......................... 35 NORVASC ........................... 41 NORVIR ................................. 5 NOVA MAX BLOOD

GLUCOSE METER ......... 69 NOVA MAX GLUCOSE

CONTROL ....................... 70


137

NOVA MAX GLUCOSE TEST ................................ 63

NOVAMAX PLUS GLU-KET .......................................... 70

NOVAREL ........................... 75 NOVOEIGHT ...................... 44 NOVOLIN 70-30 FLEXPEN

U-100 ................................ 73 NOVOLOG FLEXPEN U-100

INSULIN .......................... 73 NOVOLOG MIX 70-30 U-100

INSULN ........................... 73 NOVOLOG MIX 70-

30FLEXPEN U-100 ......... 73 NOVOLOG PENFILL U-100

INSULIN .......................... 73 NOVOLOG U-100 INSULIN

ASPART........................... 73 NOVOPEN ECHO ............... 70 NOVOSEVEN RT ............... 44 NOXAFIL .............................. 3 np thyroid ............................. 77 NPLATE............................... 44 NUCALA ........................... 104 NUCYNTA .......................... 31 NUCYNTA ER .................... 31 NUDROXIPAK ................... 31 NUEDEXTA ........................ 23 NULEV ................................ 79 NULOJIX ............................. 17 NULYTELY WITH FLAVOR

PACKS ............................. 81 NUMBONEX ....................... 53 NUPLAZID .......................... 35 NUTRASEB ......................... 49 NUTROPIN AQ NUSPIN ... 84 NUVARING......................... 92 NUVESSA ........................... 92 NUVIGIL ............................. 35 NUWIQ ................................ 44 NUZYRA (7 DAY WITH

LOAD DOSE) .................. 11 nyamyc ................................. 54 NYMALIZE ......................... 41 nystatin ............................. 3, 54 nystatin-triamcinolone .......... 54 nystop ................................... 54

O OB COMPLETE ONE ....... 110 OB COMPLETE PETITE .. 110 OB COMPLETE PREMIER

........................................ 110 OB COMPLETE WITH DHA

........................................ 110 OBIZUR ............................... 44 OBREDON ......................... 101 obstetrix dha ....................... 110 OBSTETRIX EC ................ 110 OBSTETRIX ONE ............. 110 OBTREX DHA .................. 110 O-CAL PRENATAL .......... 110 OCALIVA ............................ 81 ocella .................................... 95 OCREVUS ........................... 85 OCTAGAM .......................... 87 octreotide acetate .................. 17 OCUFLOX ........................... 96 ODACTRA ........................... 87 ODEFSEY .............................. 5 ODOMZO ............................ 17 OFEV.................................. 104 ofloxacin ................... 11, 59, 96 ogestrel (28) .......................... 95 olanzapine ............................. 35 olanzapine-fluoxetine ........... 35 olmesartan ............................ 41 olmesartan-amlodipin-

hcthiazid ........................... 41 olmesartan-

hydrochlorothiazide .......... 41 olopatadine ..................... 59, 98 OLUMIANT ......................... 89 OLUX ................................... 55 OLUX-E ............................... 55 OMECLAMOX-PAK .......... 83 omega-3 acid ethyl esters ..... 45 omeppi .................................. 83 omeprazole ........................... 83 omeprazole-sodium

bicarbonate ....................... 83 OMIDRIA ............................ 98 OMNARIS.......................... 104 OMNIPOD DASH INSULIN

POD .................................. 70 OMNITROPE ....................... 84

ON CALL EXPRESS CONTROL ....................... 70

ON CALL EXPRESS METER .......................................... 70

ON CALL EXPRESS TEST STRIP ............................... 63

ON CALL PLUS CONTROL .......................................... 70

ON CALL PLUS METER .... 70 ON CALL PLUS TEST STRIP

.......................................... 64 ON CALL VIVID CONTROL

.......................................... 70 ON CALL VIVID METER .. 70 ON CALL VIVID PAL

METER ............................. 70 ON CALL VIVID TEST

STRIP ............................... 64 ONCASPAR ......................... 17 ondansetron ........................... 81 ondansetron hcl ..................... 81 ondansetron hcl (pf) .............. 81 one daily prenatal ............... 110 ONETOUCH ULTRA BLUE

TEST STRIP ..................... 64 ONETOUCH ULTRA

CONTROL ....................... 70 ONETOUCH ULTRA2

METER ............................. 70 ONETOUCH ULTRAMINI . 70 ONETOUCH VERIO ........... 64 ONETOUCH VERIO FLEX 70 ONETOUCH VERIO IQ

METER ............................. 70 ONETOUCH VERIO

SYSTEM .......................... 70 ONEXTON ........................... 51 ONFI ..................................... 20 ONGLYZA ........................... 77 ONIVYDE ............................ 17 ONMEL .................................. 3 ONPATTRO ......................... 23 ONZETRA XSAIL ............... 22 OPANA ................................ 28 opcicon one-step ................... 95 OPDIVO ............................... 17 opium tincture ....................... 79 OPSUMIT ........................... 104


138

option-2 ................................ 95 OPTIUM EZ ......................... 64 OPTIUM TEST .................... 64 OPTUMRX .................... 64, 70 ORACEA ............................. 11 ORACIT ............................. 106 oral saline laxative ................ 81 ORALAIR ............................ 87 oralone .................................. 59 ORAMAGICRX................... 59 ORAP ................................... 35 ORAPRED ODT .................. 60 ORAVIG ................................ 3 ORENCIA ............................ 89 ORENCIA (WITH

MALTOSE) ...................... 89 ORENCIA CLICKJECT ...... 89 ORENITRAM ...................... 41 ORFADIN ............................ 57 ORILISSA ............................ 75 ORKAMBI ......................... 104 orphenadrine citrate .............. 24 orsythia ................................. 95 ORTHO MICRONOR.......... 91 ORTHO TRI-CYCLEN (28) 95 ORTHO TRI-CYCLEN LO

(28) ................................... 95 ORTHO-CYCLEN (28) ....... 95 ORTHO-NOVUM 1/35 (28) 95 ORTHO-NOVUM 7/7/7 (28)

.......................................... 95 oscimin ................................. 79 oscimin sl.............................. 79 oscimin sr ............................. 79 oseltamivir .............................. 5 OSENI .................................. 77 osmitrol 20 % ....................... 41 OSMOLEX ER .................... 21 OSMOPREP ......................... 81 OSPHENA ........................... 92 OTEZLA .............................. 89 OTEZLA STARTER............ 89 OTIPRIO .............................. 59 OTOVEL .............................. 60 OTREXUP (PF) ................... 89 OVACE ................................ 47 OVACE PLUS ..................... 47 OVACE PLUS SHAMPOO . 47

OVACE PLUS WASH ......... 47 OVIDE.................................. 56 OVIDREL ............................ 75 oxacillin ................................ 10 oxacillin in dextrose(iso-osm)

.......................................... 10 oxaliplatin ............................. 17 OXANDRIN ......................... 75 oxandrolone .......................... 75 oxaprozin .............................. 31 OXAYDO ............................. 28 oxazepam .............................. 35 oxcarbazepine ....................... 20 OXERVATE ........................ 98 oxiconazole ........................... 54 OXISTAT ............................. 54 OXSORALEN ULTRA ....... 49 OXTELLAR XR .................. 20 oxybutynin chloride ............ 106 oxycodone ............................ 28 OXYCODONE ..................... 28 oxycodone-acetaminophen ... 28 oxycodone-aspirin ................ 28 OXYCONTIN ...................... 28 oxymorphone ........................ 28 OXYTROL ......................... 106 oyster shell + d3 ................. 108 oyster shell calcium-vit d3 . 108 OZEMPIC ............................ 77 OZURDEX ......................... 100 P pacerone................................ 38 paclitaxel .............................. 17 paliperidone .......................... 35 palonosetron ......................... 81 PALONOSETRON .............. 81 PALYNZIQ .......................... 75 PAMELOR ........................... 35 pamidronate .......................... 75 PANCREAZE ...................... 81 PANDEL .............................. 55 PANRETIN .......................... 49 pantoprazole ......................... 83 PARAGARD T 380A ........... 90 paregoric ............................... 79 PAREMYD .......................... 97 paricalcitol ............................ 75 PARICALCITOL ................. 75

PARLODEL ......................... 21 PARNATE ............................ 35 paroex oral rinse ................... 59 paromomycin .......................... 9 paroxetine hcl ....................... 35 paroxetine

mesylate(menop.sym) ....... 35 PASER .................................... 9 PATADAY ........................... 98 PATANASE ......................... 59 PATANOL ........................... 98 PAXIL .................................. 36 PAXIL CR ............................ 35 PAZEO ................................. 98 P-CARE K40 ........................ 60 P-CARE K80 ........................ 61 P-CARE X (PF) .................... 53 PEDIARIX (PF) ................... 87 PEDVAX HIB (PF) .............. 87 peg 3350-electrolytes ............ 81 PEGANONE ......................... 20 PEGASYS ............................ 85 PEGASYS PROCLICK ........ 85 peg-electrolyte soln .............. 81 PEGINTRON ....................... 85 PEN NEEDLE, DIABETIC . 70 penicillin g potassium ........... 10 penicillin v potassium ........... 10 PENLAC ............................... 54 PENLEN ............................... 49 PENNSAID .......................... 31 PENTACEL (PF) .................. 87 PENTACEL ACTHIB

COMPONENT (PF) ......... 87 PENTASA ............................ 81 pentazocine-naloxone ........... 31 pentoxifylline ........................ 44 PEPCID ................................ 83 PERCOCET .......................... 28 PERFOROMIST ................. 104 PERIDEX ............................. 59 perindopril erbumine ............ 41 periogard ............................... 59 PERJETA ............................. 17 permethrin ............................. 56 perphenazine ......................... 36 perphenazine-amitriptyline ... 36 perry prenatal ...................... 110


139

PERSERIS ............................ 36 PERTZYE ............................ 81 PEXEVA .............................. 36 pfizerpen-g ........................... 10 PHARMACIST CHOICE .... 64 PHARMACIST CHOICE

GLUCOSE SYS ............... 70 phenadoz............................. 101 phenazopyridine ................. 107 phenelzine............................. 36 phenergan ........................... 101 PHENERGAN .................... 101 phenobarb-hyoscy-atropine-

scop................................... 79 phenobarbital ........................ 20 phenohytro ............................ 79 phenoxybenzamine ............... 41 phentolamine ........................ 41 phenylephrine hcl ............... 100 PHENYTEK ......................... 20 phenytoin .............................. 20 phenytoin sodium extended .. 21 philith ................................... 95 PHOSLYRA ......................... 81 phosphasal .......................... 106 phosphate laxative ................ 81 PHOSPHOLINE IODIDE .... 97 PHOTREXA CROSS-

LINKING KIT.................. 98 PHOTREXA VISCOUS ...... 98 phrenilin forte(with caffeine) 28 PHYSIOLYTE ..................... 56 PHYSIOSOL IRRIGATION 56 phytonadione (vitamin k1) ... 44 PICATO ............................... 49 PIFELTRO ............................. 5 pilocarpine hcl .......... 57, 59, 97 pimecrolimus ........................ 49 pimozide ............................... 36 pimtrea (28) .......................... 95 pindolol................................. 41 pioglitazone .......................... 77 pioglitazone-glimepiride ...... 77 pioglitazone-metformin ........ 77 piperacillin-tazobactam ........ 10 PIPERACILLIN-

TAZOBACTAM .............. 10 pirmella................................. 95

piroxicam .............................. 31 PLAN B ONE-STEP ............ 95 PLAQUENIL.......................... 9 PLAVIX ............................... 44 PLEGRIDY .......................... 85 PLENVU .............................. 81 PLEXION ............................. 51 PLEXION CLEANSING

CLOTHS .......................... 51 PLIAGLIS ............................ 53 PNEUMOVAX 23 ............... 87 pnv 29-1 .............................. 110 pnv ob+dha ......................... 110 pnv-dha ............................... 110 pnv-dha + docusate ............. 110 pnv-ferrous fumarate-docu-fa

........................................ 110 pnv-omega .......................... 110 pnv-select............................ 110 pnv-vp-u ............................. 110 POD-CARE 100K ................ 61 PODOCON ........................... 47 podofilox .............................. 49 polycin .................................. 96 polyethylene glycol 3350 ..... 81 polymyxin b sulfate ................ 9 polymyxin b sulf-trimethoprim

.......................................... 96 POLYTRIM.......................... 96 POLY-TUSSIN AC ............ 101 POMALYST ........................ 85 portia 28 ................................ 95 PORTRAZZA ...................... 17 POTABA ............................ 108 potassium chloride .............. 108 potassium citrate ................. 106 POTELIGEO ........................ 17 powderlax ............................. 81 pr natal 400 ......................... 110 pr natal 400 ec .................... 110 pr natal 430 ......................... 110 pr natal 430 ec .................... 110 PRADAXA ........................... 44 PRALUENT PEN................. 45 pramcort................................ 81 pramipexole .......................... 21 PRAMOSONE ..................... 47 PRANDIN ............................ 77

prasugrel ............................... 44 PRAVACHOL ...................... 45 pravastatin ............................. 45 PRAXBIND .......................... 44 praziquantel ............................ 9 prazosin ................................. 41 PRECISION PCX PLUS TEST

.......................................... 64 PRECISION PCX TEST ...... 64 PRECISION POINT OF

CARE TEST ..................... 64 PRECISION Q-I-D TEST .... 64 PRECISION XTRA

MONITOR ....................... 70 PRECISION XTRA TEST ... 64 PRECOSE ............................. 77 PRED FORTE .................... 100 PRED MILD ....................... 100 PRED-G ................................ 99 PRED-G S.O.P. .................... 99 prednicarbate ........................ 55 PREDNISOLN SP-

GATIFLOX-BROMFEN . 98 prednisolone ......................... 61 prednisolone acetate ........... 100 PREDNISOLONE ACET-

GATIFLOXACIN ............ 99 PREDNISOLONE SOD PH-

BROMFENAC ................. 98 PREDNISOLONE SOD PH-

GATIFLOXAC ................. 99 prednisolone sodium phosphate

.................................. 61, 100 prednisone ............................. 61 prednisone intensol ............... 61 PREFERA-OB .................... 110 PREFERA-OB PLUS DHA

........................................ 110 PREFEST ............................. 91 PREGNYL ............................ 75 PREMARIN ......................... 91 PREMIER BLU GLUCOSE

METER ............................. 70 PREMIER TEST STRIP ...... 64 PREMIER VOICE GLUCOSE

METER ............................. 70 PREMIUM BLOOD

GLUCOSE MONITOR .... 70


140

PREMIUM V10 ............. 64, 70 PREMPHASE ...................... 91 PREMPRO ........................... 91 prena1 chew........................ 110 prena1 pearl ........................ 111 prena1 true .......................... 111 prenaissance ....................... 111 prenaissance plus ................ 111 PRENATA ......................... 111 prenatabs fa ........................ 111 prenatabs rx ........................ 111 prenatal ............................... 111 prenatal 19 .......................... 111 prenatal 19 (with docusate) 111 prenatal complete ............... 111 prenatal formula ................. 111 prenatal multi-dha (algal oil)

........................................ 111 prenatal one daily ............... 111 prenatal plus ....................... 111 prenatal plus (calcium carb)111 PRENATAL PLUS DHA... 111 prenatal vitamin .................. 111 prenatal vitamin plus low iron

........................................ 111 prenatal vitamin with minerals

........................................ 111 prenatal vits96-iron fum-folic

........................................ 111 prenatal-u ............................ 111 PRENATE AM .................. 111 PRENATE CHEWABLE ... 111 PRENATE DHA (FERR ASP

GLYCIN) ....................... 111 PRENATE ELITE (IRON ASP

GLYC) ............................ 111 PRENATE ENHANCE ...... 111 PRENATE

ESSENTIAL(IRON-ASP-GL) ................................. 111

PRENATE MINI (FERR ASP GLYCIN) ....................... 111

PRENATE PIXIE ............... 111 PRENATE RESTORE ....... 111 PRENATE STAR ............... 111 PREPIDIL ............................ 92 preplus ................................ 111 PREPOPIK ........................... 81

PRESERA ............................ 49 PRESTALIA ........................ 41 PRESTO PRO BLOOD

GLUCOSE METER ......... 70 pretab .................................. 111 PREVACID .......................... 83 PREVACID SOLUTAB....... 83 prevalite ................................ 45 PREVIDENT ........................ 59 PREVIDENT 5000 BOOSTER

PLUS ................................ 59 PREVIDENT 5000 DRY

MOUTH ........................... 59 PREVIDENT 5000 ENAMEL

PROTECT ........................ 59 PREVIDENT 5000 PLUS .... 59 PREVIDENT 5000

SENSITIVE ...................... 59 previfem................................ 95 PREVNAR 13 (PF) .............. 87 PREVYMIS ............................ 5 PREZCOBIX .......................... 5 PREZISTA ............................. 5 PRIFTIN ................................. 9 PRIKAAN ............................ 53 PRIKAAN LITE................... 53 PRILOLID ............................ 53 PRILOSEC ........................... 83 PRILOVIX ........................... 53 PRILOVIX LITE .................. 53 PRIMACARE ..................... 111 PRIMAQUINE ....................... 9 PRIMAXIN IV ....................... 9 primidone.............................. 21 PRIMLEV ............................ 28 PRIMSOL ............................. 12 PRINIVIL ............................. 41 PRISTIQ ............................... 36 PRIVIGEN ........................... 87 PRO VOICE V8 GLUCOSE

MONITOR ....................... 70 PRO VOICE V8-V9 TEST

STRIP ............................... 64 PRO VOICE V9 GLUCOSE

MONITOR ....................... 70 PROAIR HFA .................... 104 PROAIR RESPICLICK ..... 104 probenecid ............................ 88

probenecid-colchicine ........... 88 PROBUPHINE ..................... 28 procainamide ........................ 38 PROCARDIA ....................... 41 PROCARDIA XL ................. 41 PRO-C-DURE 5 ................... 61 PRO-C-DURE 6 ................... 61 procentra ............................... 36 prochlorperazine ................... 81 prochlorperazine edisylate .... 81 prochlorperazine maleate ...... 81 PROCORT ............................ 81 PROCRIT ............................. 84 PROCTOCORT .................... 81 PROCTOFOAM HC ............ 81 procto-med hc ....................... 81 proctosol hc .......................... 81 proctozone-hc ....................... 82 PROCYSBI ......................... 106 PRODIGY AUTOCODE

METER ............................. 70 PRODIGY AUTOCODE

MONITOR SYST ............. 70 PRODIGY CONTROL

SOLUTION, LOW ........... 70 PRODIGY CONTROL

SOLUTION,HIGH ........... 70 PRODIGY NO CODING ..... 64 PRODIGY POCKET METER

.......................................... 70 PRODIGY VOICE GLUCOSE

METER ............................. 71 PROFILNINE ....................... 44 progesterone ......................... 91 progesterone micronized ...... 91 PROGLYCEM ..................... 65 PROGRAF ............................ 17 PROLASTIN-C .................... 57 PROLENSA ......................... 98 PROLEUKIN ....................... 85 PROLIA ................................ 88 PROMACTA ........................ 44 promethazine ...................... 101 promethazine-codeine ......... 102 promethazine-dm ................ 102 promethazine-phenyleph-

codeine ............................ 102


141

promethazine-phenylephrine ........................................ 102

promethegan ....................... 101 PROMETRIUM ................... 91 PROMISEB .......................... 49 propafenone .......................... 38 propantheline ........................ 79 proparacaine ......................... 98 propranolol ........................... 41 propranolol-hydrochlorothiazid

.......................................... 41 propylthiouracil .................... 61 PROQUAD (PF) .................. 87 PRO-RED AC (W/

DEXCHLORPHENIR) .. 102 PROSCAR .......................... 106 PROSTIN E2 ........................ 92 PROTHELIAL ..................... 59 PROTONIX .......................... 83 PROTOPIC........................... 49 protriptyline .......................... 36 PROVENGE......................... 87 PROVENTIL HFA ............. 104 PROVERA ........................... 91 PROVIDA DHA ................ 111 PROVIDA OB.................... 111 PROVIGIL ........................... 36 PROZAC .............................. 36 pruclair ................................. 49 prudoxin ............................... 49 prumyx ................................. 49 prutect ................................... 49 PSORCON ........................... 55 PULMICORT ..................... 104 PULMICORT FLEXHALER

........................................ 104 pulmosal ............................. 104 PULMOZYME................... 104 PUREFE OB PLUS ............ 111 purelax .................................. 82 PURIXAN ............................ 17 PYLERA .............................. 83 pyrazinamide .......................... 9 PYRIDIUM ........................ 107 pyridostigmine bromide ....... 24 Q QBRELIS ............................. 41 QBREXZA ........................... 49

Q-CARE RX Q4 ................... 59 QMIIZ ODT ......................... 31 QNASL ............................... 104 QTERN ................................. 77 QUADRACEL (PF) ............. 87 QUALAQUIN ........................ 9 QUARTETTE ...................... 95 QUAZEPAM ........................ 36 QUDEXY XR....................... 21 QUESTRAN ......................... 45 QUESTRAN LIGHT ............ 45 quetiapine ............................. 36 QUILLICHEW ER ............... 36 QUILLIVANT XR ............... 36 quinapril................................ 41 quinapril-hydrochlorothiazide

.......................................... 41 quinidine gluconate .............. 38 quinidine sulfate ................... 38 quinine sulfate ........................ 9 QUINTET AC ...................... 64 QUINTET BLOOD

GLUCOSE METER ......... 71 quit 2 ..................................... 58 QUIT 2 ................................. 58 quit 4 ..................................... 58 QUIT 4 ................................. 59 QUTENZA ........................... 49 QVAR REDIHALER ......... 104 R RABAVERT (PF) ................ 87 rabeprazole ........................... 83 RACEPINEPH-LIDOCAINE-

BSS 7(PF) ......................... 98 RADICAVA ......................... 23 RADIOGARDASE .............. 57 RAGWITEK ......................... 87 rajani ..................................... 95 raloxifene .............................. 88 ramipril ................................. 41 RANEXA ............................. 46 ranitidine hcl ......................... 83 ranolazine ............................. 46 RAPAFLO .......................... 106 RAPAMUNE........................ 17 rasagiline .............................. 21 RASUVO (PF) ..................... 89 RAVICTI .............................. 57

RAYALDEE ......................... 75 RAYOS ................................. 61 RAZADYNE ........................ 23 RAZADYNE ER .................. 23 READYSHARP

DEXAMETHASONE ...... 61 READYSHARP

KETOROLAC .................. 31 READYSHARP LIDOCAINE

(PF) ................................... 53 REBETOL ............................ 85 REBIF (WITH ALBUMIN) . 85 REBIF REBIDOSE .............. 85 REBIF TITRATION PACK . 85 REBINYN ............................ 44 RECLAST ............................ 57 reclipsen (28) ........................ 95 RECOMBINATE ................. 44 RECOMBIVAX HB (PF) ..... 87 RECTIV ................................ 82 REFUAH PLUS ................... 64 REFUAH PLUS GLUCOSE

CONTROL ....................... 71 REFUAH PLUS GLUCOSE

MONITOR ....................... 71 REGLAN .............................. 82 REGRANEX ........................ 49 relador pak ............................ 53 relador pak plus .................... 53 RELAGARD ........................ 92 RELENZA DISKHALER ...... 5 RELEXXII ............................ 36 RELION ALL-IN-ONE

METER ............................. 71 RELION CONFIRM ............ 71 RELION CONFIRM-MICRO

.......................................... 64 RELION MICRO GLUCOSE

MONITOR ....................... 71 RELION NOVOLIN 70/30 .. 73 RELION NOVOLIN N ........ 73 RELION NOVOLIN R ......... 73 RELION PRIME METER .... 71 RELION PRIME TEST

STRIPS ............................. 64 RELISTOR ........................... 82 RELPAX ............................... 22 REMERON ........................... 36


142

REMERON SOLTAB .......... 36 REMICADE ......................... 82 REMODULIN ...................... 41 RENAGEL ........................... 82 rena-vite .............................. 111 RENFLEXIS ........................ 82 RENVELA ........................... 82 repaglinide ............................ 77 repaglinide-metformin .......... 77 REPATHA PUSHTRONEX 45 REPATHA SURECLICK .... 45 REPATHA SYRINGE ......... 45 REQUIP ............................... 21 REQUIP XL ......................... 22 RESCRIPTOR ........................ 5 RESPA-AR......................... 102 RESTASIS ........................... 98 RESTASIS MULTIDOSE ... 98 RESTIZAN........................... 49 RESTORIL ........................... 36 RETIN-A .............................. 51 RETIN-A MICRO ................ 51 RETIN-A MICRO PUMP .... 51 RETISERT ......................... 100 RETROVIR ............................ 5 REVATIO .......................... 104 REVEAL BLOOD GLUCOSE

METER ............................ 71 REVEAL TEST STRIP ........ 64 REVLIMID .......................... 85 REXULTI ............................. 36 REYATAZ ............................. 5 RHOFADE ........................... 51 RHOPRESSA ....................... 99 RIASTAP ............................. 44 ribasphere ............................. 85 ribasphere ribapak ................ 85 ribavirin ............................ 5, 85 RIDAURA ............................ 89 rifabutin .................................. 9 RIFADIN ................................ 9 RIFAMATE ........................... 9 rifampin .................................. 9 RIFATER ............................... 9 RIGHTEST CONTROL

SOLUTION HIGH ........... 71 RIGHTEST GM550 SYSTEM

.......................................... 71

RIGHTEST GS550 TEST STRIPS ............................. 64

RILUTEK ............................. 57 riluzole .................................. 57 rimantadine ............................. 5 ringer's .................................. 56 RIOMET ............................... 77 risedronate ...................... 57, 88 RISPERDAL ........................ 36 risperidone ............................ 36 RITALIN .............................. 36 RITALIN LA ........................ 36 ritonavir .................................. 5 RITUXAN ............................ 17 RITUXAN HYCELA ........... 17 rivastigmine .......................... 23 rivastigmine tartrate .............. 23 rivelsa ................................... 95 RIXUBIS .............................. 44 rizatriptan.............................. 22 R-NATAL OB .................... 111 robafen ac ........................... 102 ROBAXIN ............................ 24 ROBAXIN-750 .................... 24 ROCALTROL ...................... 75 ROCKLATAN ..................... 99 ROMIDEPSIN...................... 17 ropinirole .............................. 22 rosadan.................................. 51 ROSADAN ........................... 51 ROSANIL ............................. 51 ROSULA .............................. 51 rosula cleansing cloths.......... 51 rosuvastatin ........................... 45 ROTARIX ............................ 87 ROTATEQ VACCINE......... 87 ROWASA ............................. 82 roweepra ............................... 21 roweepra xr ........................... 21 ROXICODONE.................... 29 ROXYBOND ....................... 29 ROZEREM ........................... 36 RUBRACA ........................... 17 RUCONEST ....................... 104 RYCLORA ......................... 101 RYDAPT .............................. 17 rydex ................................... 102 RYTARY.............................. 22

RYTHMOL SR .................... 38 RYVENT ............................ 101 S SABRIL ................................ 21 SAFYRAL ............................ 95 SAIZEN ................................ 84 SAIZEN SAIZENPREP ....... 84 SALAGEN (PILOCARPINE)

.................................... 57, 59 SALEX ................................. 47 salicylic acid ......................... 47 salimez .................................. 48 SALIMEZ FORTE ............... 48 SALKERA ............................ 48 salsalate ................................. 31 salvax .................................... 48 SALVAX DUO PLUS ......... 48 SAMSCA .............................. 75 SANCUSO ........................... 82 SANDIMMUNE ............. 17, 18 SANDOSTATIN .................. 18 SANDOSTATIN LAR

DEPOT ............................. 18 SANTYL .............................. 56 SAPHRIS .............................. 36 SARAFEM ........................... 36 SAVAYSA ........................... 44 SAVELLA ............................ 89 scalacort ................................ 55 SEASONIQUE ..................... 95 seconal sodium ..................... 36 SEEBRI NEOHALER ........ 104 SEGLUROMET ................... 77 SELECT-OB ....................... 111 SELECT-OB (FOLIC ACID)

........................................ 111 SELECT-OB + DHA .......... 111 selegiline hcl ......................... 22 selenium sulfide .................... 47 SELRX ................................. 47 SELZENTRY ......................... 5 SEMPREX-D ..................... 102 se-natal 19 ........................... 111 se-natal 19 (with docusate) . 111 SENSIPAR ........................... 75 SEREVENT DISKUS ........ 104 SERNIVO ............................. 55 serophene .............................. 75


143

SEROQUEL ......................... 36 SEROQUEL XR .................. 36 SEROSTIM .......................... 84 sertraline ............................... 37 setlakin ................................. 95 sevelamer carbonate ............. 82 sevelamer hcl ........................ 82 SEYSARA ............................ 11 sf 59 sf 5000 plus .......................... 59 SFROWASA ........................ 82 sharobel ................................ 91 SHINGRIX (PF) ................... 87 SHOHL'S MODIFIED ....... 106 SIDEKICK BLOOD

GLUCOSE SYSTEM ....... 71 SIGNIFOR ........................... 18 SIGNIFOR LAR .................. 18 SIKLOS ................................ 18 SILALITE PAK ................... 56 sildenafil (antihypertensive)

........................................ 104 SILENOR ............................. 37 SILIQ .................................... 47 silodosin ............................. 106 SILVADENE ....................... 47 silver nitrate .......................... 49 silver nitrate applicators ....... 49 silver sulfadiazine ................. 47 SILVRSTAT ........................ 53 SIMBRINZA ........................ 99 simliya (28) .......................... 95 SIMPONI ............................. 89 SIMPONI ARIA ................... 89 SIMULECT .......................... 18 simvastatin ............................ 45 SINEMET............................. 22 SINEMET CR ...................... 22 SINGULAIR ...................... 104 sirolimus ............................... 18 SIRTURO ............................... 9 SIVEXTRO ............................ 9 SKELAXIN .......................... 24 SKLICE ................................ 56 SKYLA................................. 90 SKYRIZI .............................. 47 SMART SENSE

MONITORING SYSTEM 71

SMART SENSE TEST STRIPS ............................. 64

SMARTEST CONTROL ..... 71 SMARTEST EJECT............. 71 SMARTEST PERSONA

STARTER ........................ 71 SMARTEST PRONTO

STARTER ........................ 71 SMARTEST PROTEGE ...... 71 SMARTEST TEST............... 64 smoothlax ............................. 82 sodium benzoate-sod

phenylacet ......................... 57 sodium chlor 0.9% bacteriostat

.......................................... 58 sodium chloride .......... 105, 108 sodium chloride 0.45 % ...... 108 sodium chloride 0.9 % .......... 58 sodium chloride 0.9 % (flush)

.......................................... 58 sodium chloride 3 % ........... 108 sodium chloride 5 % ........... 108 SODIUM EDECRIN ............ 41 sodium ferric gluconat-sucrose

.......................................... 58 sodium phenylbutyrate ......... 58 sodium polystyrene sulfonate

.......................................... 82 SODIUM POLYSTYRENE

SULFONATE ................... 82 SOFOSBUVIR-

VELPATASVIR ................. 5 SOLARAZE ......................... 49 SOLESTA ............................ 82 solifenacin .......................... 106 SOLIQUA 100/33 ................ 73 SOLIRIS ............................... 58 SOLODYN ........................... 11 SOLOSEC .............................. 9 SOLOX GEL ........................ 49 soloxide ................................ 11 SOLTAMOX ........................ 18 SOLUS V2 AUDIBLE

METER ............................ 71 SOLUS V2 CONTROL

SOLUTION,HIGH ........... 71 SOLUS V2 TEST STRIPS ... 64 SOMA .................................. 24

SOMATULINE DEPOT ...... 18 SOMAVERT ........................ 75 sonafine ................................. 49 SOOLANTRA ...................... 51 SORBITOL-MANNITOL .... 56 SORIATANE ....................... 47 SORILUX ............................. 47 sotalol ................................... 38 sotalol af ............................... 38 SOTYLIZE ........................... 38 SOVALDI ............................... 5 sp antipruritic ........................ 49 sp scar management .............. 49 SPECTRACEF ....................... 7 spinosad ................................ 56 SPIRIVA RESPIMAT ........ 105 SPIRIVA WITH

HANDIHALER .............. 105 spironolactone ....................... 41 spironolacton-hydrochlorothiaz

.......................................... 41 SPORANOX ........................... 3 SPORANOX PULSEPAK ..... 3 SPRAVATO ......................... 37 sprintec (28) .......................... 95 SPRITAM ............................. 21 SPRIX ................................... 31 SPRYCEL ............................. 18 sps (with sorbitol) ................. 82 sronyx ................................... 95 ssd ......................................... 47 SSKI ..................................... 61 sss 10-5 ................................. 51 st joseph aspirin .................... 31 STALEVO 100 ..................... 22 STALEVO 125 ..................... 22 STALEVO 150 ..................... 22 STALEVO 200 ..................... 22 STALEVO 50 ....................... 22 STALEVO 75 ....................... 22 STARLIX ............................. 77 stavudine ................................. 5 STEGLATRO ....................... 77 STEGLUJAN ....................... 77 STELARA ............................ 47 STIMATE ............................. 75 STIOLTO RESPIMAT ....... 105 STIVARGA .......................... 18


144

stop smoking aid................... 59 STRATTERA ....................... 37 STRENSIQ ........................... 75 STREPTOMYCIN ................. 9 stress formula ..................... 111 stress formula with iron ...... 112 stress formula with iron(sulf)

........................................ 112 STRIANT ............................. 75 STRIBILD .............................. 5 STRIVERDI RESPIMAT .. 105 STROMECTOL ..................... 9 strong iodine ....................... 108 SUBLOCADE ...................... 29 SUBOXONE ........................ 31 SUBSYS ............................... 29 subvenite............................... 21 subvenite starter (blue) kit .... 21 subvenite starter (green) kit .. 21 subvenite starter (orange) kit 21 SUCRAID ............................ 82 sucralfate .............................. 83 SULAR ................................. 41 sulfacetamide sodium ... 47, 100 sulfacetamide sodium (acne) 53 sulfacetamide sodium-sulfur 51 sulfacetamide sod-sulfur-urea

.......................................... 51 sulfacetamide-prednisolone 100 sulfacleanse 8-4 .................... 51 sulfadiazine........................... 11 sulfamethoxazole-trimethoprim

.......................................... 11 SULFAMYLON................... 53 sulfasalazine ......................... 82 sulfatrim ............................... 11 sulindac................................. 31 SUMADAN .......................... 51 sumatriptan ........................... 22 sumatriptan succinate ........... 22 sumatriptan-naproxen ........... 22 SUMAVEL DOSEPRO ....... 22 SUMAXIN ........................... 51 SUMAXIN TS...................... 51 super b complex-vitamin c . 112 super b maxi complex ........ 112 super b-50 complex plus .... 112 super quints ........................ 112

super quints b-50 ................ 112 superplex-t .......................... 112 SUPPRELIN LA .................. 18 SUPRAX ................................ 7 SUPREP BOWEL PREP KIT

.......................................... 82 SURE-TEST EASYPLUS

MINI ................................. 64 SURE-TEST EASYPLUS

MINI METER .................. 71 SURFAXIN ........................ 105 SURMONTIL ....................... 37 SURVANTA ........................ 58 SUSTIVA ............................... 5 SUSTOL ............................... 82 SUTENT ............................... 18 syeda ..................................... 95 SYLATRON ......................... 85 SYLVANT ........................... 18 SYMAX DUOTAB .............. 79 symax fastabs ....................... 79 symax-sl................................ 79 symax-sr ............................... 79 SYMBICORT ..................... 105 SYMBYAX .......................... 37 SYMDEKO ........................ 105 SYMFI .................................... 5 SYMFI LO ............................. 5 SYMJEPI ............................ 101 SYMLINPEN 120 ................ 77 SYMLINPEN 60 .................. 77 SYMPAZAN ........................ 21 SYMPROIC.......................... 82 SYMTUZA ............................. 5 SYNAGIS ............................... 5 SYNALAR ........................... 56 SYNALAR CREAM KIT .... 56 SYNALAR OINTMENT KIT

.......................................... 56 SYNALAR TS ..................... 56 SYNAREL............................ 75 SYNDROS ........................... 82 SYNERA .............................. 53 SYNERCID ............................ 9 SYNJARDY ......................... 77 SYNJARDY XR................... 77 SYNRIBO ............................ 18 SYNTHROID ....................... 77

SYPRINE ............................. 58 T T

SLIM X2 BASAL-IQ INSULIN PMP ............. 71

TABLOID ............................. 18 TACLONEX ......................... 47 tacrolimus ....................... 18, 49 tadalafil ............................... 106 tadalafil (antihypertensive) . 105 TAFINLAR .......................... 18 TAGRISSO ........................... 18 TAKE ACTION ................... 95 TAKHZYRO ...................... 105 TALTZ AUTOINJECTOR .. 47 TALTZ AUTOINJECTOR (2

PACK) .............................. 47 TALTZ AUTOINJECTOR (3

PACK) .............................. 47 TALTZ SYRINGE ............... 47 TALWIN .............................. 31 TALZENNA ......................... 18 TAMIFLU .............................. 5 tamoxifen .............................. 18 tamsulosin ........................... 106 TAPAZOLE ......................... 61 TAPERDEX ......................... 61 TARCEVA ........................... 18 TARGADOX ........................ 11 TARGRETIN ....................... 18 tarina 24 fe ............................ 95 tarina fe 1/20 (28) ................. 95 TARKA ................................ 41 taron-c dha .......................... 112 taron-prex prenatal-dha ...... 112 TASIGNA ............................. 18 TASMAR ............................. 22 TAVALISSE ........................ 44 TAXOTERE ......................... 18 TAYTULLA ......................... 95 tazarotene .............................. 51 TAZICEF ................................ 7 TAZORAC ........................... 51 taztia xt ................................. 41 TDVAX ................................ 87 TECENTRIQ ........................ 18 TECFIDERA ........................ 85 TEFLARO .............................. 7


145

TEGRETOL ......................... 21 TEGRETOL XR ................... 21 TEGSEDI ............................. 23 TEKTURNA ........................ 41 TEKTURNA HCT ............... 41 TELCARE BGM .................. 71 TELCARE BLOOD

GLUCOSE KIT ................ 71 TELCARE CONTROL ........ 71 TELCARE TEST STRIPS ... 64 telmisartan ............................ 41 telmisartan-amlodipine ......... 41 telmisartan-hydrochlorothiazid

.......................................... 41 temazepam ............................ 37 TEMODAR .......................... 18 TEMOVATE ........................ 56 temozolomide ....................... 18 temsirolimus ......................... 18 tencon ................................... 29 TENIPOSIDE ....................... 18 TENIVAC (PF) .................... 87 tenofovir disoproxil fumarate . 5 TENORETIC 100 ................. 41 TENORETIC 50 ................... 42 TENORMIN ......................... 42 TEPADINA .......................... 18 terazosin ............................... 42 terbinafine hcl ......................... 3 terbutaline ........................... 105 terconazole ........................... 92 TERSI FOAM ...................... 47 TESSALON PERLES ........ 102 TEST N'GO BLOOD

GLUCOSE SYSTEM ....... 71 TEST N'GO TEST ............... 64 TESTIM ............................... 75 testosterone ........................... 75 testosterone cypionate .......... 75 testosterone enanthate .......... 75 TESTRED ............................ 75 TETANUS,DIPHTHERIA

TOX PED(PF) .................. 87 tetcaine ................................. 98 tetrabenazine......................... 23 tetracaine hcl ........................ 98 TETRACAINE HCL (PF) .... 98 tetracycline ........................... 11

TETRAVISC ........................ 98 TETRAVISC FORTE .......... 98 TEXACORT ......................... 56 THALLOUS CHLORIDE TL-

201 .................................... 58 THALOMID ......................... 18 THEO-24 ............................ 105 theochron ............................ 105 theophylline ........................ 105 THIOLA ............................... 58 thioridazine ........................... 37 thiotepa ................................. 18 thiothixene ............................ 37 THRIVITE RX ................... 112 THYMOGLOBULIN ........... 87 thyroid (pork) ....................... 77 THYROLAR-1 ..................... 78 THYROLAR-1/2 .................. 78 THYROLAR-1/4 .................. 78 THYROLAR-2 ..................... 78 THYROLAR-3 ..................... 78 tiagabine ............................... 21 TIAZAC ............................... 42 TIBSOVO ............................. 18 TICALAST ......................... 105 TICE BCG ............................ 88 TIGAN.................................. 82 tigecycline .............................. 9 TIGLUTIK ........................... 58 TIKOSYN ............................ 38 tilia fe .................................... 95 timolol maleate ............... 42, 97 TIMOPTIC ........................... 97 TIMOPTIC OCUDOSE (PF)

.......................................... 97 TIMOPTIC-XE .................... 97 tinidazole ................................ 9 TIROSINT ............................ 78 TIROSINT-SOL ................... 78 tis-u-sol pentalyte ................. 56 TIVICAY................................ 5 TIVORBEX .......................... 31 tizanidine .............................. 24 tl g-fol os ............................ 112 TOBI ....................................... 9 TOBI PODHALER ................ 9 TOBRADEX ........................ 99 TOBRADEX ST................... 99

tobramycin ............................ 96 tobramycin in 0.225 % nacl .... 9 tobramycin sulfate .................. 9 TOBRAMYCIN WITH

NEBULIZER ...................... 9 tobramycin-dexamethasone .. 99 TOBREX .............................. 96 TODAY CONTRACEPTIVE

SPONGE ........................... 92 TOFRANIL .......................... 37 TOLAK ................................. 49 tolazamide ............................. 77 tolbutamide ........................... 77 tolcapone ............................... 22 tolmetin ................................. 31 TOLSURA .............................. 3 tolterodine ........................... 106 TOPAMAX .......................... 21 TOPICORT ........................... 56 topiramate ............................. 21 TOPIRAMATE .................... 21 toposar .................................. 18 topotecan ............................... 18 TOPROL XL ........................ 42 toremifene ............................. 18 TORISEL .............................. 18 torsemide .............................. 42 total b/c ............................... 112 TOTECT ............................... 13 TOUJEO MAX U-300

SOLOSTAR ..................... 73 TOUJEO SOLOSTAR U-300

INSULIN .......................... 73 TOVIAZ ............................. 106 TRACLEER ....................... 105 TRADJENTA ....................... 77 tramadol ................................ 31 TRAMADOL ....................... 31 tramadol-acetaminophen ...... 31 trandolapril ........................... 42 trandolapril-verapamil .......... 42 tranexamic acid ............... 44, 92 TRANSDERM-SCOP .......... 82 TRANXENE T-TAB ............ 37 tranylcypromine .................... 37 TRANZAREL ...................... 53 TRAVATAN Z ..................... 99 trazodone .............................. 37


146

TREANDA ........................... 18 TRECATOR ........................... 9 TRELEGY ELLIPTA ........ 105 TRELSTAR .......................... 18 TREMFYA ........................... 47 treprostinil sodium................ 42 TRESIBA FLEXTOUCH U-

100 .................................... 73 TRESIBA FLEXTOUCH U-

200 .................................... 73 TRESIBA U-100 INSULIN . 73 tretinoin .......................... 51, 52 tretinoin (chemotherapy) ...... 18 tretinoin microspheres .......... 51 TRETIN-X ........................... 52 TRETIN-X CREAM KIT..... 52 TRETTEN ............................ 44 TREXALL ............................ 18 TREXIMET .......................... 22 TREZIX ................................ 29 tri femynor ............................ 95 TRIACETIN ......................... 54 TRIAMCINOL AC (PF) IN

0.9%NACL ....................... 61 TRIAMCINOL ACE-BUPIV-

0.9% NACL ...................... 61 TRIAMCINOLONE

ACETON-0.9% NACL .... 61 triamcinolone acetonide 56, 59,

61 TRIAMCINOLONE DIA(PF)-

0.9%NACL ....................... 61 TRIAMCINOLONE DIACET-

0.9% NACL ...................... 61 TRIAMCINOLON-

MOXIFLOX-WATR(PF). 99 triamterene-hydrochlorothiazid

.......................................... 42 trianex ................................... 56 triazolam ............................... 37 TRIBENZOR ....................... 42 TRICARE ........................... 112 TRICOR ............................... 46 triderm .................................. 56 TRIDESILON ...................... 56 trientine................................. 58 tri-estarylla ........................... 95 TRIFERIC .......................... 112

trifluoperazine ...................... 37 trifluridine ............................. 96 TRIGLIDE............................ 46 trihexyphenidyl ..................... 22 triklo ..................................... 46 tri-legest fe ............................ 95 TRILEPTAL ......................... 21 tri-linyah ............................... 95 TRILIPIX ............................. 46 tri-lo-estarylla ....................... 95 tri-lo-marzia .......................... 95 tri-lo-sprintec ........................ 95 trilyte with flavor packets ..... 82 trimethobenzamide ............... 82 trimethoprim ......................... 12 tri-mili ................................... 95 trimipramine ......................... 37 TRIMO-SAN JELLY ........... 92 TRIMPEX ............................ 12 trinatal rx 1 ......................... 112 trinate .................................. 112 TRINTELLIX ....................... 37 TRIPLE DYE ....................... 54 tri-previfem (28) ................... 95 TRIPTODUR........................ 18 TRISENOX .......................... 18 tri-sprintec (28) ..................... 95 TRISTART DHA ............... 112 TRIUMEQ .............................. 5 triveen-duo dha ................... 112 tri-vitamin with fluoride ..... 112 trivora (28) ............................ 95 tri-vylibra .............................. 95 tri-vylibra lo .......................... 95 TRIXYLITRAL.................... 49 TRIZIVIR ............................... 5 TROGARZO .......................... 5 TROKENDI XR ................... 21 tropicamide ........................... 97 trospium .............................. 106 TRUE METRIX AIR

GLUCOSE METER ......... 71 TRUE METRIX GLUCOSE

METER ............................ 71 TRUE METRIX GLUCOSE

TEST STRIP..................... 64 TRUE METRIX GO

GLUCOSE METER ......... 71

TRUE METRIX LEVEL 1 ... 71 TRUECONTROL LEVEL 0 71 TRUERESULT BLOOD

GLUCOSE SYSTM ......... 72 TRUETEST TEST STRIPS . 64 TRUETRACK BLOOD

GLUCOSE SYSTEM ....... 72 TRUETRACK SMART

SYSTEM .......................... 72 TRUETRACK TEST ............ 64 TRULANCE ......................... 82 TRULICITY ......................... 77 TRUMENBA ........................ 88 TRUSOPT ............................ 99 trust natal dha ..................... 112 TRUSTEEL INFUSION SET

32 ...................................... 72 TRUVADA ............................. 5 TUDORZA PRESSAIR ..... 105 tulana .................................... 91 tusnel c ................................ 102 TUSNEL PEDIATRIC ....... 102 TUSSICAPS ....................... 102 TUSSIONEX PENNKINETIC

ER ................................... 102 TUXARIN ER .................... 102 TUZISTRA XR .................. 102 TWINRIX (PF) ..................... 88 TWYNSTA ........................... 42 TYBOST ................................. 5 tydemy .................................. 95 TYGACIL ............................... 9 TYKERB .............................. 18 TYLENOL-CODEINE #3 .... 29 TYLENOL-CODEINE #4 .... 29 TYMLOS .............................. 88 TYPHIM VI .......................... 88 TYSABRI ............................. 23 TYVASO ............................ 105 TYVASO REFILL KIT ...... 105 TYVASO STARTER KIT . 105 TYZINE ................................ 59 U UCERIS ................................ 82 UDENYCA ........................... 84 ULESFIA .............................. 56 ULORIC ............................... 88 ULTIMA MONITOR ........... 72


147

ULTIMA TEST STRIPS ...... 64 ULTOMIRIS ........................ 58 ultra b-100 complex ........... 112 ULTRACET ......................... 31 ULTRAM ............................. 31 ULTRASAL-ER................... 48 ULTRATRAK ...................... 64 ULTRATRAK GLUCOSE

METER ............................ 72 ULTRATRAK ULTIMATE 64,

72 ULTRAVATE ...................... 56 ULTRAVATE X .................. 56 umecta .................................. 49 UNASYN ............................. 10 UNISTRIP LOW CONTROL

.......................................... 72 UNISTRIP1 TEST STRIP ... 64 unithroid ............................... 78 UNITUXIN .......................... 19 UPTRAVI............................. 42 urea ....................................... 49 urea nail stick ....................... 49 URECHOLINE .................. 106 URELLE............................. 106 uretron d-s .......................... 106 URIBEL ............................. 106 urimar-t ............................... 107 urin ds ................................. 107 uro-458 ............................... 107 UROCIT-K 10 .................... 107 UROCIT-K 15 .................... 107 UROCIT-K 5 ...................... 107 urogesic-blue ...................... 107 uro-mp ................................ 107 UROQID-ACID NO.2 ....... 107 UROXATRAL ................... 106 URSO 250 ............................ 82 URSO FORTE...................... 82 ursodiol ................................. 82 uryl ..................................... 107 ustell ................................... 107 UTIBRON NEOHALER.... 105 utira-c ................................. 107 UTOPIC ............................... 49 V VABOMERE ......................... 9 VAGIFEM ............................ 91

vaginal contraceptive foam .. 92 valacyclovir ............................ 5 VALCHLOR ........................ 49 VALCYTE ............................. 5 valganciclovir ......................... 6 VALIUM .............................. 37 valproate sodium .................. 21 valproic acid ......................... 21 valproic acid (as sodium salt)

.......................................... 21 valsartan................................ 42 valsartan-hydrochlorothiazide

.......................................... 42 VALTREX ............................. 6 VANATOL LQ .................... 29 VANATOL S ....................... 29 VANCOCIN ......................... 12 vancomycin .......................... 12 VANCOMYCIN .................. 12 VANCOMYCIN HCL IN

WATER ............................ 12 VANCOMYCIN IN 0.9 %

SODIUM CHL ................. 12 VANCOMYCIN IN

DEXTROSE 5 % .............. 12 VANCOMYCIN-WATER

INJECT (PEG) ................. 12 vandazole .............................. 92 VANOS ................................ 56 VANOXIDE-HC .................. 52 VANTAS .............................. 19 VAQTA (PF) ........................ 88 vardenafil ............................ 107 VARISOFT INFUSION SET

43 ...................................... 72 VARIVAX (PF) ................... 88 VARIZIG.............................. 88 VARUBI ............................... 82 VASCEPA ............................ 46 VASERETIC ........................ 42 VASHE WOUND THERAPY

.......................................... 56 VASOTEC............................ 42 VAXCHORA VACCINE..... 88 VCF CONTRACEPTIVE

FILM ................................ 92 VCF CONTRACEPTIVE GEL

.......................................... 92

VECAMYL .......................... 46 VECTIBIX ........................... 19 VECTICAL .......................... 47 VELCADE ........................... 19 veletri .................................... 42 velivet triphasic regimen (28)

.......................................... 95 VELPHORO ......................... 82 VELTASSA .......................... 82 VELTIN ................................ 52 VEMLIDY .............................. 6 VENCLEXTA ...................... 19 VENCLEXTA STARTING

PACK ............................... 19 venlafaxine ........................... 37 VENOFER .......................... 112 VENTAVIS ........................ 105 VENTOLIN HFA ............... 105 verapamil .............................. 42 VERASENS BLOOD

GLUCOSE METER ......... 72 VERASENS CONTROL

SOLN-LEVEL 1 ............... 72 VERASENS METER

STARTER KIT ................. 72 VERASENS TEST STRIP ... 64 VERDESO ............................ 56 VEREGEN ........................... 49 VERELAN ........................... 42 VERELAN PM ..................... 42 veripred 20 ............................ 61 VERSACLOZ ....................... 37 VERZENIO .......................... 19 VESICARE ......................... 106 VFEND ................................... 3 VFEND IV .............................. 3 V-GO 20 ............................... 72 V-GO 30 ............................... 72 V-GO 40 ............................... 72 VIBATIV .............................. 12 VIBERZI .............................. 82 VIBRAMYCIN .................... 11 vicodin .................................. 29 vicodin es .............................. 29 vicodin hp ............................. 29 VICTOZA 2-PAK ................ 77 VICTOZA 3-PAK ................ 77 VIDAZA ............................... 19


148

VIDEX 2 GRAM PEDIATRIC ............................................ 6

VIDEX EC ............................. 6 VIEKIRA PAK ...................... 6 vienva ................................... 95 vigabatrin .............................. 21 vigadrone .............................. 21 VIGAMOX........................... 96 VIIBRYD ............................. 37 VIMIZIM ............................. 75 VIMOVO ............................. 31 VIMPAT............................... 21 vinate care .......................... 112 VINATE DHA RF ............. 112 vinate ii ............................... 112 vinate m .............................. 112 vinate one ........................... 112 vinblastine ............................ 19 vincasar pfs ........................... 19 vincristine ............................. 19 vinorelbine ............................ 19 VIOKACE ............................ 82 viorele (28) ........................... 96 VIRACEPT ............................ 6 VIRAMUNE .......................... 6 VIRAMUNE XR .................... 6 VIRASAL............................. 48 VIRAZOLE ............................ 6 VIREAD ................................. 6 virt-advance ........................ 112 virt-c dha ............................ 112 virt-nate dha........................ 112 virt-pn dha .......................... 112 virt-pn plus ......................... 112 VIRTPREX ........................ 112 virt-select ............................ 112 virtussin ac.......................... 102 virtussin dac........................ 102 virt-vite gt ........................... 112 VISTARIL .......................... 101 VISTOGARD ....................... 13 VISUDYNE ......................... 98 VITAFOL FE+ (WITH

DOCUSATE) ................. 112 VITAFOL GUMMIES ....... 112 VITAFOL NANO .............. 112 VITAFOL ULTRA ............ 112 VITAFOL-OB .................... 112

VITAFOL-OB+DHA ......... 112 VITAFOL-ONE ................. 112 VITAMED MD ONE RX .. 112 VITAMEDMD REDICHEW

RX .................................. 112 vitamin b complex .............. 112 vitamin b complex-folic acid

........................................ 112 vitamin d3 ........................... 112 vitamins a,c,d and fluoride . 112 VITAPEARL ...................... 112 VITATRUE ........................ 112 VITRAKVI ........................... 19 VITRASE ............................. 98 VIVELLE-DOT.................... 91 VIVITROL ........................... 31 VIVLODEX ......................... 31 VIVOTIF .............................. 88 VIZIMPRO ........................... 19 VOGELXO ........................... 75 VOLTAREN ........................ 31 VOLTAREN-XR.................. 31 VONVENDI ......................... 44 VORAXAZE ........................ 13 voriconazole ........................... 3 VOSEVI ................................. 6 VOTRIENT .......................... 19 vp-ch plus ........................... 112 vp-ch-pnv............................ 113 VP-PNV-DHA.................... 113 VPRIV .................................. 76 VRAYLAR ........................... 37 VUSION ............................... 54 vyfemla (28) ......................... 96 vylibra ................................... 96 VYTORIN 10-10 .................. 46 VYTORIN 10-20 .................. 46 VYTORIN 10-40 .................. 46 VYTORIN 10-80 .................. 46 VYVANSE ........................... 37 VYXEOS .............................. 19 VYZULTA ........................... 99 W warfarin ................................ 44 water for irrigation, sterile .... 58 WAVESENSE AMP ............ 72 WAVESENSE CONTROL

SOLUTION ...................... 72

WAVESENSE JAZZ ............ 64 WAVESENSE PRESTO 64, 72 WELCHOL ........................... 46 WELLBUTRIN SR .............. 37 WELLBUTRIN XL .............. 37 wera (28) ............................... 96 westhroid .............................. 78 WIDE-SEAL DIAPHRAGM

.......................................... 90 WILATE ............................... 44 wixela inhub ....................... 105 woman's laxative .................. 82 women's gentle laxative(bisac)

.......................................... 82 women's laxative (bisacodyl)82 WP THYROID ..................... 78 wymzya fe ............................ 96 X XADAGO ............................. 22 XALATAN ........................... 99 XALKORI ............................ 19 XANAX ................................ 37 XANAX XR ......................... 37 XARELTO ........................... 44 XATMEP .............................. 19 XCLAIR ............................... 49 XELJANZ ............................. 89 XELJANZ XR ...................... 89 XELODA .............................. 19 XELPROS ............................ 99 XENAZINE .......................... 23 XEOMIN .............................. 88 XEPI ..................................... 53 XERAVA ............................. 11 XERESE ............................... 54 XERMELO ........................... 19 XGEVA ................................ 13 XHANCE ........................... 105 XIFAXAN .............................. 9 XIGDUO XR ........................ 77 XIIDRA ................................ 98 XIMINO ............................... 11 XOFLUZA ............................. 6 XOLAIR ............................. 105 XOLEGEL ............................ 54 XOPENEX ......................... 105 XOPENEX CONCENTRATE

........................................ 105


149

XOPENEX HFA ................ 105 XOSPATA ........................... 19 XTAMPZA ER .................... 29 XTANDI............................... 19 xulane ................................... 92 XULTOPHY 100/3.6 ........... 74 XURIDEN ............................ 58 XYLOCAINE....................... 53 XYLOCAINE-MPF ............. 53 xylon 10 ................................ 29 XYNTHA ............................. 44 XYNTHA SOLOFUSE ........ 44 XYOSTED ........................... 76 XYREM ............................... 37 Y YASMIN (28) ...................... 96 YAZ (28) .............................. 96 YERVOY ............................. 19 YF-VAX (PF) ....................... 88 YONDELIS .......................... 19 YONSA ................................ 19 YOSPRALA ......................... 44 YUPELRI ........................... 105 YUTIQ ............................... 100 yuvafem ................................ 91 Z zafirlukast ........................... 105 zaleplon ................................ 37 ZALTRAP ............................ 19 ZANAFLEX ......................... 24 ZANOSAR ........................... 19 ZANTAC .............................. 83 zarah ..................................... 96 ZARONTIN ......................... 21 zatean-pn dha...................... 113 zatean-pn plus ..................... 113 ZAVESCA ........................... 76 zebutal .................................. 29 ZEGERID ....................... 83, 84 ZEJULA ............................... 19 ZELAPAR ............................ 22 ZELBORAF ......................... 19 ZEMAIRA ............................ 58 ZEMBRACE SYMTOUCH . 22 ZEMDRI................................. 9 ZEMPLAR ........................... 76 zenatane ................................ 52

ZENPEP ............................... 82 zenzedi .................................. 37 ZENZEDI ............................. 37 ZEPATIER ............................. 6 ZERIT ..................................... 6 ZESTORETIC ...................... 42 ZESTRIL .............................. 42 ZETIA .................................. 46 ZETONNA ......................... 105 ZEVALIN (Y-90) ................. 19 ZIAC ..................................... 42 ZIAGEN ................................. 6 ZIANA.................................. 52 zidovudine .............................. 6 zileuton ............................... 105 ZINECARD (AS HCL) ........ 13 zingiber ............................... 113 ZINGO.................................. 53 ZINPLAVA .......................... 88 ZIOPTAN (PF) ..................... 99 ziprasidone hcl ...................... 37 ZIPSOR ................................ 31 ZIRGAN ............................... 96 ZITHRANOL ....................... 47 ZITHROMAX ........................ 7 ZITHROMAX TRI-PAK ....... 7 ZITHROMAX Z-PAK ........... 7 ZOCOR ................................ 46 ZODRYL AC 25 ................ 102 ZODRYL AC 30 ................ 102 ZODRYL AC 35 ................ 102 ZODRYL AC 40 ................ 102 ZODRYL AC 50 ................ 102 ZODRYL AC 60 ................ 102 ZODRYL AC 80 ................ 102 ZODRYL DAC 25 ............. 102 ZODRYL DAC 30 ............. 102 ZODRYL DAC 35 ............. 102 ZODRYL DAC 40 ............. 102 ZODRYL DAC 50 ............. 102 ZODRYL DAC 60 ............. 102 ZODRYL DAC 80 ............. 102 ZODRYL DEC 25 .............. 102 ZODRYL DEC 30 .............. 102 ZODRYL DEC 35 .............. 102 ZODRYL DEC 40 .............. 102 ZODRYL DEC 50 .............. 102

ZODRYL DEC 60 .............. 102 ZODRYL DEC 80 .............. 102 ZOFRAN .............................. 82 ZOHYDRO ER .................... 29 ZOLADEX ........................... 19 zoledronic acid ...................... 76 zoledronic acid-mannitol-water

.................................... 58, 76 ZOLEDRONIC AC-

MANNITOL-0.9NACL .... 76 ZOLINZA ............................. 19 zolmitriptan ........................... 22 ZOLOFT ............................... 37 zolpidem ............................... 37 ZOLPIMIST ......................... 37 ZOMACTON ....................... 84 ZOMIG ................................. 22 ZOMIG ZMT ........................ 22 ZONALON ........................... 49 ZONEGRAN ........................ 21 zonisamide ............................ 21 ZONTIVITY ......................... 44 ZORBTIVE .......................... 84 ZORTRESS .......................... 19 ZORVOLEX ......................... 31 ZOSTAVAX (PF) ................ 88 zovia 1/35e (28) .................... 96 ZOVIRAX ........................ 6, 54 ZTLIDO ................................ 53 Z-TUSS AC ........................ 102 ZUBSOLV ............................ 32 ZUPLENZ ............................ 82 ZYBAN ................................ 59 ZYCLARA ........................... 85 ZYDELIG ............................. 19 ZYFLO ............................... 105 ZYKADIA ............................ 19 ZYLET ................................. 99 ZYLOPRIM .......................... 88 ZYMAXID ........................... 96 ZYPITAMAG ....................... 46 ZYPREXA ............................ 37 ZYPREXA ZYDIS ............... 37 ZYTIGA ............................... 19 ZYVOX ................................ 10

Insured/CP-10.14.2016

Discrimination is Against the Law Blue KC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue KC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue KC:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic

formats, other formats) • Provides free language services to people whose primary language is not English, such

as: ○ Qualified interpreters ○ Information written in other languages

If you need these services, contact Customer Service, 844-395-7126 (Toll free), [email protected]. If you believe that Blue KC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Appeals Department, PO Box 419169, Kansas City, MO 64141-6169, 816-395-3537, TTY: 816-842-5607, [email protected]. You can file a grievance in person or by mail, or email. If you need help filing a grievance, the Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. If you, or someone you’re helping, has questions about Blue KC, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-844-395-7126. Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue KC, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-395-7126. Chinese: 如果您，或是您正在協助的對象，有關於 Blue KC方面的問題，您有權利免費以您的母語得到幫

助和訊息。洽詢一位翻譯員，請撥電話1-844-395-7126。 Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue KC, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-395-7126. German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Blue KC haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-395-7126 an.

Insured/CP-10.14.2016

Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 [Blue KC]에 관해서 질문이 있다면 귀하는 그러한

도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기

위해서는 1-844-395-7126 로 전화하십시오. Serbo-Croatian: Ukoliko Vi ili neko kome Vi pomažete ima pitanje o Blue KC, imate pravo da besplatno dobijete pomoć i informacije na Vašem jeziku. Da biste razgovarali sa prevodiocem, nazovite 1-844-395-7126. Arabic:

الضرورية بلغتك من دون اية تكلفة. ، فلديك الحق في الحصول على المساعدة والمعلومات Blue KC إن كان لديك أو لدى شخص تساعده أسئلة بخصوص .7126-395-844-1. للتحدث مع مترجم اتصل بـ

Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Blue KC, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону1-844-395-7126. French: Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Blue KC, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-395-7126. Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue KC, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa1-844-395-7126. Laotian: ຖ້ າທ່ ານ, ຫຼື ຄົນ ◌່ ທທ່ ານກໍ າລັງຊ່ ວຍເຫຼື ອ, ມ ◌ໍ ຄາຖາມກ່ ຽວກັບ Blue KC, ທ່ ານມ ◌ິ ສດ ◌່ ທຈະໄດ້ຮັບການຊ່ ວຍເຫຼື ອແລະ◌ໍ ຂ້ ມູ ນຂ່ າວສານ ◌່ ທເປັ ນພາສາຂອງທ່ ານໍ ◌່ ບມ ຄ່ າໃຊ້ຈ່ າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ ໂທຫາ 1-844-395-7126. Pennsylvanian Dutch: Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Blue KC, hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 1-844-395-7126 uffrufe. Persian:

زبان خود را به طور ، داشته باشيد حق اين را داريد که کمکو اطالعات به Blue KC اگر شما، يا کسی که شما به او کمک ميکنيد ، سوال در مورد .تماس حاصل نماييد 7126-395-844-1.رايگان دريافت نماييد

Cushite: Isin yookan namni biraa isin deeggartan Blue KC irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1-844-395-7126 tiin bilbilaa. Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue KC, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-395-7126. For TTY services, please call 1-816-842-5607.

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