Medicare Advantage Group...Generally, our Medicare Advantage Group Plan will only approve your...

Medicare Advantage Group

2021 FORMULARY(LIST OF COVERED DRUGS)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

This formulary was updated on 05/01/2021. For more recent information or other questions, please contact Blue Cross Blue Shield of Massachusetts at 1-800-200-4255, or, for TTY users, 711, from April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week, or visit bluecrossma.com/medicare-options.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

http://www.bluecrossma.com/medicare-options

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this formulary (drug list) refers to “we,” “us,” or “our,” it means Blue Cross Blue Shield of Massachusetts. When it refers to “plan” or “our plan,” it means Medicare HMO Blue or Medicare PPO Blue.

This document includes a list of the drugs (formulary) for our plan, which is current as of 05/01/2021. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/co-insurance may change on January 1, 2022, and from time to time during the year.

What is the Medicare Advantage Group Plan’s Formulary?A formulary is a list of covered drugs selected by our Medicare Advantage Group Plans in consultation with a team of health care providers, that represents the prescription therapies believed to be a necessary part of a quality treatment program. Our Medicare HMO Blue or Medicare PPO Blue plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Medicare Advantage plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.

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

• Drugs removed from the market. If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturer removes the drug from the market, wewill immediately remove the drug from our formulary and provide notice to members whotake the drug.

• Other changes. We may make other changes that affect members currently taking a drug.For instance, we may add a new generic drug to replace a brand-name drug currently onthe formulary; or add new restrictions to the brand-name drug or move it to a differentcost-sharing tier or both. Or we may make changes based on new clinical guidelines. If weremove drugs from our formulary, or add prior authorization, quantity limits, and/or steptherapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notifyaffected members of the change at least 30 days before the change becomes effective, orat the time the member requests a refill of the drug, at which time the member will receive a30-day supply of the drug.

» If we make these other changes, you or your pr escriber can ask us to make an exceptionand continue to cover the brand-name drug for you. The notice we provide you will alsoinclude information on how to request an exception, and you can also find informationin the section below entitled “How do I request an exception to the Medicare AdvantageGroup Plan’s Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs.

This drug list was last updated on 05/01/2021. bluecrossma.com/medicare-options 1


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The enclosed formulary is current as of 05/01/2021. To get updated information about the drugs covered by our plans, please contact us. Our contact information appears on the front and back cover pages.

If we have a mid-year non-maintenance formulary change, we will provide a notice in the monthly Explanation of Benefits and on our website, bluecrossma.com/medicare-options. You may ask for a copy of the most recent formulary by contacting us. Our contact information appears on the front and back cover pages.

How do I use the Formulary?There are two ways to find y our d rug w ithin t he f ormulary:• Medical Condition. The formulary begins on page 7. The drugs in this formulary are

grouped into categories depending on the type of medical conditions that they are used totreat. For example, drugs used to treat a heart condition are listed under the category,“Cardiovascular Agents.” If you know what your drug is used for, look for the categoryname in the list that begins on page 99. Then look under the category name for your drug.

• Alphabetical Listing. If you are not sure what category to look under, you should lookfor your drug in the index that begins on page 99. The index provides an alphabeticallist of all of the drugs included in this document. Both brand-name drugs and generic drugsare listed in the index. Look in the index and find your drug. Next to your drug, you will seethe page number where you can find coverage information. Turn to the page listed in theindex and find the name of your drug in the first column of the list.

What are generic drugs?Our plans cover both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:Prior Authorization: Our plans require you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don’t get approval, our plan may not cover the drug.

Quantity Limits: For certain drugs, our plans limit the amount of the drug that our plans will cover. For example, our plans provide up to 30 capsules per 30 days per prescription for Omeprazole 10 mg capsules. This may be in addition to a standard one-month or three-month supply.

2021 Formulary This drug list was last updated on 05/01/2021.

3bluecrossma.com/medicare-options

Opioid Safety Edits: For certain drugs or combinations of drugs, there may be a safety edit applied to prevent opioid overutilization. The safety edit on these medications may be cumulative with other similar, medications that you may be taking in the same class. A dosage adjustment by your physician or an exception may be required if you exceed the safety edit.

Step Therapy: In some cases, our plans require 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, our plans may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plans will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask our plan to make an exception to these restrictions or limits, or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Medicare Advantage Group Plan’s formulary?” on page 4 for information about how to request an exception.

What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Member Service and ask if your drug is covered.

If you learn that your Medicare Advantage Group Plan does not cover your drug, you have two options:• Y ou can ask Member Service for a list of similar drugs that are covered by our plans.

When you receive the list, show it to your doctor and ask him or her to prescribea similar drug that is covered by our plans.

• Y ou can ask our plans to make an exception and cover your drug. See below forinformation about how to request an exception.

This drug list was last updated on 05/01/2021.


4 2021 Formulary

How do I request an exception to the Medicare Advantage Group Plan’s Formulary?You can ask your Medicare Advantage Group Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:• Y ou can ask us to cover your drug even if it is not on our formulary. If approved, this drug

will be covered at a pre-determined cost-sharing level, and you would not be able to ask usto provide the drug at a lower cost-sharing level.

• Y ou can ask us to cover a formulary drug at a lower cost-sharing level if this drug is noton the specialty tier. If approved, this would lower the amount you must pay for your drug.

• Y ou can ask us to waive coverage restrictions or limits on your drug. For example,for certain drugs, our plans limit the amount of the drug that we will cover. If your drughas a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, our Medicare Advantage Group Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

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

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

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

This drug list was last updated on 05/01/2021.

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

If you change your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover up to a temporary 30-day supply (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. After your first 30-day supply, you are required to use the plan’s exception process.

Our transition supply will not cover drugs that Medicare does not allow Part D plans to cover, or drugs that might be covered under Medicare Part B.

For more informationFor more detailed information about your Medicare Advantage Group Plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our Medicare Advantage Group Plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

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

Medicare Advantage Group Plan’s FormularyThe formulary that begins on page 7 provides coverage information about the drugs covered by our Medicare Advantage Group Plans. If you have trouble finding your drug in the list, turn to the index that begins on page 101.

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

The information in the Requirements/Limits column tells you if our plans have any special requirements for coverage of your drug.

bluecrossma.com/medicare-optionsThis drug list was last updated on 05/01/2021.

http://www.medicare.gov


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The abbreviations you may see in the formulary (list of covered drugs) include: Quantity Limits (QL): To help ensure that the quantity and dosage of your medications remains consistent with manufacturer, clinical, and Food and Drug Administration (FDA) recommendations, we maintain a list of medications subject to QL. When you fill a prescription for a medication subject to QL, your prescription is reviewed for:

• Dose Consolidation. Dose consolidation checks to see whether you’re taking twoor more daily doses of medicine that could be replaced with one daily dose providingthe same total amount of medication.

• Recommended Monthly Dosing Level. This process checks to see that your monthlydosage of medication is consistent with both the manufacturer’s and the FDA’s monthlydosing recommendations and clinical information. Your doctor can also apply for anexception to QL guidelines when medically necessary.

Mail Order (MO): These prescription drugs are available through mail-order.

Home Infusion (HI): This prescription drug may be covered under our medical benefit. For more information, call us. Our contact information appears on the front and back cover pages.

Medical Benefit (MB): These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmacies or mail-order service.*

Prior Authorization (PA): These prescription drugs require prior authorization from the plan.

Step Therapy (ST): These prescription drugs require you to first try another drug to treat your medical condition.

Limited Pharmacy Availability (LA): This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call us. Our contact information appears on the front and back cover pages.

Medicare Part B or D (B/D): This prescription drug may be covered under Medicare Part B or D, depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

* Coverage for diabetic test strips and blood glucose monitors at a participating retail or mail order pharmacy is limited to those listed on our formulary and provided at no cost to you. There is no coverage for other brand-name test stripsand blood glucose monitors that are not listed on our formulary when purchased at a retail or mail order pharmacy.

2021 Formulary This drug list was last updated on 05/01/2021.

ANTI - INFECTIVES: ANTIFUNGALAGENTSDrug Name Tier Requirements/

LimitsAMBISOME 2 B/D PA, MO, HIamphotericin b 1 B/D PA, MO, HIcaspofungin 1 B/D PA, HIclotrimazole mucousmembrane

1 MO

CRESEMBA 2CRESEMBA 2 HIfluconazole 1 MOfluconazole in nacl(iso-osm) intravenouspiggyback 200mg/100 ml

1 MO, HI

fluconazole in nacl(iso-osm) intravenouspiggyback 400mg/200 ml

1 HI

flucytosine 1 MOgriseofulvin microsize 1 MOgriseofulvinultramicrosize

1 MO

itraconazole oralcapsule

1 MO, QL (120 per30 days)

itraconazole oralsolution

1 MO

ketoconazole oral 1 MOmicafungin 1 MO, HINOXAFILINTRAVENOUS

2 HI

NOXAFIL ORALSUSPENSION

2 MO

nystatin oralsuspension

1 MO

nystatin oral tablet 1 MO

ANTI - INFECTIVES: ANTIFUNGALAGENTS (continued)Drug Name Tier Requirements/

Limitsposaconazole oraltablet,delayedrelease (dr/ec)

1 MO

terbinafine hcl oral 1 MO, QL (30 per30 days)

voriconazoleintravenous

1 MO, HI

voriconazole oral 1 MO

You can find information on what the symbols and abbreviations on this tablemean by going to page 6.

This drug list was last updated on 05/01/2021. 7

ANTI - INFECTIVES: ANTIVIRALSDrug Name Tier Requirements/

Limitsabacavir 1 MOabacavir-lamivudine 1 MOabacavir-lamivudine-zidovudine

1 MO

acyclovir oral capsule 1 MOacyclovir oralsuspension 200 mg/5ml

1 MO

acyclovir oral tablet 1 MOacyclovir sodiumintravenous solution

1 B/D PA, MO, HI

adefovir 1 MOamantadine hcl 1 MOAPTIVUS 2 MOAPTIVUS (WITHVITAMIN E)

2

atazanavir 1 MOATRIPLA 2 MOBARACLUDE ORALSOLUTION

2 MO

BIKTARVY 2 MOCABENUVA 2 MOcidofovir 1 MO, HICIMDUO 2 MOCOMPLERA 2 MOCRIXIVAN ORALCAPSULE 200 MG

2 MO

DELSTRIGO 2 MODESCOVY 2 MOdidanosine oralcapsule,delayedrelease(dr/ec) 250mg, 400 mg

1 MO

DOVATO 2 MO

ANTI - INFECTIVES: ANTIVIRALS(continued)Drug Name Tier Requirements/

LimitsEDURANT 2 MOefavirenz 1 MOefavirenz-emtricitabin-tenofov

1 MO

efavirenz-lamivu-tenofov disop

1 MO

emtricitabine 1 MOemtricitabine-tenofovir(tdf)

1 MO

EMTRIVA 2 MOentecavir 1 MOEPCLUSA 2 PA, MO, QL (28

per 28 days)EPIVIR HBV ORALSOLUTION

2 MO

EVOTAZ 2 MOfamciclovir 1 MOfosamprenavir 1 MOfoscarnet 1FUZEONSUBCUTANEOUSRECON SOLN

2 MO

ganciclovir sodiumintravenous

1 MO, HI

ganciclovir sodiumintravenous reconsoln

1 MO, HI

GENVOYA 2 MOHARVONI 2 PA, MO, QL (28

per 28 days)INTELENCE 2 MOINVIRASE ORALTABLET

2 MO


This drug list was last updated on 05/01/2021.8


LimitsISENTRESS 2 MOISENTRESS HD 2 MOJULUCA 2 MOKALETRA ORALTABLET

2 MO

lamivudine 1 MOlamivudine-zidovudine 1 MOLEXIVA ORALSUSPENSION

2 MO

lopinavir-ritonavir 1 MOMAVYRET 3 PA, MO, QL (84

per 28 days)nevirapine oralsuspension

1

nevirapine oral tablet 1 MOnevirapine oral tabletextended release 24hr

1 MO

NORVIR ORALPOWDER INPACKET

2 MO

NORVIR ORALSOLUTION

2 MO

ODEFSEY 2 MOoseltamivir oralcapsule 30 mg


oseltamivir oralcapsule 45 mg, 75mg


oseltamivir oralsuspension forreconstitution


PIFELTRO 2 MO


LimitsPREVYMISINTRAVENOUS

2 HI

PREVYMIS ORAL 2 MOPREZCOBIX 2 MOPREZISTA ORALSUSPENSION

2 MO

PREZISTA ORALTABLET 150 MG,600 MG, 75 MG, 800MG

2 MO

RELENZADISKHALER


RETROVIRINTRAVENOUS

2 MO, HI

REYATAZ ORALPOWDER INPACKET

2 MO

ribavirin oral capsule 1ribavirin oral tablet200 mg

1 MO

rimantadine 1 MOritonavir 1 MORUKOBIA 2 MOSELZENTRY 2 MOSOVALDI 3 PA, MO, QL (28

per 28 days)stavudine oral capsule 1 MOSTRIBILD 2 MOSYMFI 2 MOSYMFI LO 2 MOSYMTUZA 2 MOSYNAGIS 3 MOTEMIXYS 2 MO




Limitstenofovir disoproxilfumarate

1 MO

TIVICAY 2 MOTIVICAY PD 2 MOTRIUMEQ 2 MOTROGARZO 2 MOTRUVADA 2 MOTYBOST 2 MOvalacyclovir 1 MOvalganciclovir oralrecon soln

1 MO

valganciclovir oraltablet

1 MO

VEMLIDY 2 MOVIEKIRA PAK 3 PA, MO, QL

(112 per 28days)

VIRACEPT ORALTABLET

2 MO

VIREAD ORALPOWDER

2 MO

VIREAD ORALTABLET 150 MG,200 MG, 250 MG

2 MO

VOSEVI 2 PA, MO, QL (28per 28 days)

XOFLUZA ORALTABLET 20 MG


XOFLUZA ORALTABLET 40 MG


ZEPATIER 3 PA, MO, QL (28per 28 days)

zidovudine 1 MO

ANTI - INFECTIVES:CEPHALOSPORINSDrug Name Tier Requirements/

Limitscefaclor oral capsule 1 MOcefaclor oralsuspension forreconstitution 125mg/5 ml

1 MO

cefaclor oralsuspension forreconstitution 250mg/5 ml, 375 mg/5 ml

1

cefaclor oral tabletextended release 12hr

1 MO

cefadroxil oral capsule 1 MOcefadroxil oralsuspension forreconstitution 250mg/5 ml, 500 mg/5 ml

1 MO

cefadroxil oral tablet 1 MOcefazolin in dextrose(iso-os) intravenouspiggyback 1 gram/50ml, 2 gram/50 ml

1 MO, HI

cefazolin injectionrecon soln 1 gram,500 mg

1 MO, HI

cefazolin injectionrecon soln 10 gram

1 HI

cefazolin injectionrecon soln 100 gram,300 g

1 HI

cefazolin intravenous 1 HIcefdinir 1 MOcefepime in dextrose,iso-osm

1

cefepime injection 1 MO, HIcefixime 1 MO



ANTI - INFECTIVES:CEPHALOSPORINS (continued)Drug Name Tier Requirements/

Limitscefotetan injection 1 HIcefoxitin in dextrose,iso-osm

1

cefoxitin intravenousrecon soln 1 gram, 2gram

1 MO, HI

cefoxitin intravenousrecon soln 10 gram

1 HI

cefpodoxime oralsuspension forreconstitution 100mg/5 ml

1 MO

cefpodoxime oralsuspension forreconstitution 50mg/5 ml

1

cefpodoxime oraltablet

1 MO

cefprozil 1 MOceftazidime injectionrecon soln 1 gram, 2gram

1 MO, HI

ceftazidime injectionrecon soln 6 gram

1 HI

ceftriaxone indextrose,iso-os

1 MO, HI

ceftriaxone injectionrecon soln 1 gram, 2gram, 250 mg, 500mg

1 MO, HI

ceftriaxone injectionrecon soln 10 gram

1 HI

ceftriaxoneintravenous

1 MO, HI

cefuroxime axetil oraltablet

1 MO

ANTI - INFECTIVES:CEPHALOSPORINS (continued)Drug Name Tier Requirements/

Limitscefuroxime sodiuminjection recon soln750 mg

1 MO, HI

cefuroxime sodiumintravenous reconsoln 1.5 gram

1 MO, HI

cefuroxime sodiumintravenous reconsoln 7.5 gram

1 HI

cephalexin 1 MOFETROJA 2SUPRAX ORALTABLET,CHEWABLE

2 MO

tazicef injection reconsoln 1 gram, 2 gram

1 HI

tazicef injection reconsoln 6 gram

1 MO, HI

tazicef intravenous 1TEFLARO 3 MO, HIZERBAXA 2 HI



ANTI - INFECTIVES:ERYTHROMYCINS / OTHERMACROLIDESDrug Name Tier Requirements/

Limitsazithromycinintravenous

1 MO, HI

azithromycin oralpacket

1 MO

azithromycin oralsuspension forreconstitution

1 MO

azithromycin oraltablet 250 mg (6pack), 500 mg (3pack)

1

azithromycin oraltablet 250 mg, 500mg, 600 mg

1 MO

clarithromycin oralsuspension forreconstitution

1 MO

clarithromycin oraltablet

1 MO

clarithromycin oraltablet extendedrelease 24 hr

1 MO

DIFICID ORALTABLET

3 MO

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

1 MO

erythrocin (asstearate) oral tablet250 mg

1 MO

ERYTHROCININTRAVENOUSRECON SOLN 500MG

2 MO, HI

ANTI - INFECTIVES:ERYTHROMYCINS / OTHERMACROLIDES (continued)Drug Name Tier Requirements/

Limitserythromycinethylsuccinate oralsuspension forreconstitution

1 MO

erythromycinethylsuccinate oraltablet

1

erythromycin oral 1 MO



ANTI - INFECTIVES:MISCELLANEOUS ANTIINFECTIVESDrug Name Tier Requirements/

Limitsalbendazole 1 MOALINIA 2 MOamikacin injectionsolution 1,000 mg/4ml

1 MO, HI

amikacin injectionsolution 500 mg/2 ml

1 MO, HI

ARIKAYCE 2 PA, LAatovaquone 1 MOatovaquone-proguanil 1 MOaztreonam injectionrecon soln 1 gram

1 MO, HI

aztreonam injectionrecon soln 2 gram

1 MO, HI

bacitracinintramuscular

1 MO

BENZNIDAZOLE 2 MOBETHKIS 3 B/D PA, MOCAPASTAT 2 HICAYSTON 2 MO, LAchloramphenicol sodsuccinate

1 HI

chloroquinephosphate

1 MO

clindamycin hcl 1 MOclindamycin in 5 %dextrose

1 MO, HI

clindamycin pediatric 1 MOclindamycinphosphate injection

1 MO, HI

clindamycinphosphateintravenous solution600 mg/4 ml

1 HI

ANTI - INFECTIVES:MISCELLANEOUS ANTIINFECTIVES(continued)Drug Name Tier Requirements/

LimitsCOARTEM 2 MOcolistin (colistimethatena)

1 MO, HI

CYCLOSERINE 2 MODALVANCE 2 MO, HIdapsone oral 1 MODAPTOMYCININTRAVENOUSRECON SOLN 350MG (BRAND)

2 MO, HI

daptomycinintravenous reconsoln 500 mg

1 MO, HI

EMVERM 3 MOertapenem 1 MO, HIethambutol 1 MOgentamicin in nacl(iso-osm) intravenouspiggyback 100mg/100 ml, 60 mg/50ml, 80 mg/50 ml

1 MO, HI

gentamicin in nacl(iso-osm) intravenouspiggyback 80 mg/100ml

1 HI

gentamicin injectionsolution 40 mg/ml

1 MO, HI

gentamicin sulfate(ped) (pf)

1 MO

hydroxychloroquine 1 MOimipenem-cilastatin 1 MO, HIIMPAVIDO 2 MOisoniazid injection 1




Limitsisoniazid oral 1 MOivermectin oral 1 MOLAMPIT 2lincomycin 1 HIlinezolid 1 MOlinezolid in dextrose5%

1 HI

linezolid-0.9% sodiumchloride

1

mefloquine 1 MOmeropenem 1 MO, HImetro i.v. 1 MO, HImetronidazole in nacl(iso-os)

1 MO, HI

metronidazole oral 1 MOneomycin 1 MOnitazoxanide 1 MOORBACTIV 2 MO, HIparomomycin 1 MOPASER 2 MOpentamidine inhalation 1 B/D PA, MOpentamidine injection 1 MOpolymyxin b sulfate 1 MO, HIpraziquantel 1 MOPRETOMANID 2PRIFTIN 2 MOPRIMAQUINE 3 MOprimaquine (generic) 1 MOpyrazinamide 1 MOpyrimethamine 1 PA, MO


Limitsquinine sulfate 1 MORECARBRIO 2rifabutin 1 MOrifampin intravenous 1 MO, HIrifampin oral 1 MOSIRTURO 2 LASIVEXTROINTRAVENOUS

2 HI

SIVEXTRO ORAL 2 MOSTREPTOMYCIN 2 MOSYNERCID 3 HItigecycline 1 HItinidazole 1 MOTOBI PODHALERINHALATIONCAPSULE, W/INHALATIONDEVICE

3 MO

tobramycin in 0.225 %nacl

1 B/D PA, MO

tobramycin inhalation 1 B/D PA, MOtobramycin sulfateinjection recon soln

1 HI

tobramycin sulfateinjection solution

1 MO, HI

TRECATOR 2 MOVANCOMYCIN IND5W INTRAVENOUSPIGGYBACK 1GRAM/200 ML(BRAND)

2




LimitsVANCOMYCIN IND5W INTRAVENOUSPIGGYBACK 500MG/100 ML, 750MG/150 ML (BRAND)

2

VANCOMYCIN INDEXTROSE ISO-OSM (BRAND)

2

VANCOMYCININJECTION(BRAND)

2

vancomycinintravenous reconsoln 1,000 mg, 500mg, 750 mg

1 MO, HI

VANCOMYCININTRAVENOUSRECON SOLN 1.25GRAM, 1.5 GRAM(BRAND)

2 HI

vancomycinintravenous reconsoln 10 gram

1 HI

VANCOMYCININTRAVENOUSRECON SOLN 250MG (BRAND)

2 HI

vancomycinintravenous reconsoln 5 gram

1 HI

vancomycin oralcapsule

1 MO

vancomycin oral reconsoln

1 MO


LimitsVIBATIVINTRAVENOUSRECON SOLN 750MG

2

XENLETAINTRAVENOUS

2

XENLETA ORAL 2 QL (10 per 30days)

XIFAXAN ORALTABLET 550 MG

2 MO



ANTI - INFECTIVES: PENICILLINSDrug Name Tier Requirements/

Limitsamoxicillin oralcapsule

1 MO

amoxicillin oralsuspension forreconstitution

1 MO

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

1 MO

amoxicillin-potclavulanate oralsuspension forreconstitution

1 MO

amoxicillin-potclavulanate oraltablet

1 MO

amoxicillin-potclavulanate oraltablet extendedrelease 12 hr

1 MO

amoxicillin-potclavulanate oraltablet,chewable

1 MO

ampicillin oral capsule500 mg

1 MO

ampicillin sodiuminjection recon soln 1gram, 10 gram, 125mg

1 MO, HI

ampicillin sodiuminjection recon soln 2gram, 250 mg, 500mg

1 MO, HI

ampicillin sodiumintravenous

1 HI

ampicillin-sulbactaminjection recon soln1.5 gram, 3 gram

1 MO, HI

ANTI - INFECTIVES: PENICILLINS(continued)Drug Name Tier Requirements/

Limitsampicillin-sulbactaminjection recon soln15 gram

1 HI

ampicillin-sulbactamintravenous

1 HI

BICILLIN L-A 3 MOdicloxacillin 1 MOnafcillin in dextroseiso-osm

1 HI

nafcillin injection reconsoln 1 gram, 2 gram

1 MO, HI

nafcillin injection reconsoln 10 gram

1 HI

nafcillin intravenousrecon soln 1 gram

1 HI

nafcillin intravenousrecon soln 2 gram

1 MO, HI

oxacillin in dextrose(iso-osm) intravenouspiggyback 1 gram/50ml

1 HI

oxacillin in dextrose(iso-osm) intravenouspiggyback 2 gram/50ml

1 MO, HI

oxacillin injectionrecon soln 1 gram,10 gram

1 HI

oxacillin injectionrecon soln 2 gram

1 MO, HI

penicillin g potassiuminjection recon soln20 million unit

1 MO, HI

penicillin g potassiuminjection recon soln 5million unit

1 MO, HI



ANTI - INFECTIVES: PENICILLINS(continued)Drug Name Tier Requirements/

Limitspenicillin g procaine 1 MOpenicillin g sodium 1 MO, HIpenicillin v potassium 1 MOpfizerpen-g 1 HIpiperacillin-tazobactamintravenous reconsoln 13.5 gram

1 HI

piperacillin-tazobactamintravenous reconsoln 2.25 gram,3.375 gram, 4.5 gram

1 MO, HI

piperacillin-tazobactamintravenous reconsoln 40.5 gram

1 HI

ANTI - INFECTIVES: QUINOLONESDrug Name Tier Requirements/

LimitsBAXDELAINTRAVENOUS

2 HI

BAXDELA ORAL 2 MOciprofloxacin hcl oral 1 MOciprofloxacin in 5 %dextrose intravenouspiggyback 200mg/100 ml

1 MO, HI

ciprofloxacin in 5 %dextrose intravenouspiggyback 400mg/200 ml

1 MO, HI

levofloxacin in d5wintravenouspiggyback 250 mg/50ml

1 HI

levofloxacin in d5wintravenouspiggyback 500mg/100 ml, 750mg/150 ml

1 MO, HI

levofloxacinintravenous

1 MO, HI

levofloxacin oral 1 MOmoxifloxacin oral 1 MOmoxifloxacin-sod.chloride(iso)

1 MO, HI

ofloxacin oral tablet300 mg

1

ofloxacin oral tablet400 mg

1 MO



ANTI - INFECTIVES: SULFA'S /RELATED AGENTSDrug Name Tier Requirements/

Limitssulfadiazine 1 MOsulfamethoxazole-trimethoprimintravenous

1 MO, HI

sulfamethoxazole-trimethoprim oral

1 MO

ANTI - INFECTIVES:TETRACYCLINESDrug Name Tier Requirements/

Limitsdemeclocycline 1 MOdoxy-100 1 MO, HIdoxycycline hyclateintravenous

1

doxycycline hyclateoral capsule

1 MO

doxycycline hyclateoral tablet

1 MO

doxycycline hyclateoral tablet,delayedrelease (dr/ec) 100mg, 150 mg, 200 mg,50 mg, 75 mg

1 MO

doxycyclinemonohydrate oralcapsule

1 MO

doxycyclinemonohydrate oralsuspension forreconstitution

1 MO

doxycyclinemonohydrate oraltablet

1 MO

minocycline oralcapsule

1 MO

minocycline oral tablet 1 MOminocycline oral tabletextended release 24hr

1 MO

mondoxyne nl oralcapsule 100 mg, 75mg

1 MO

morgidox oral capsule100 mg

1 MO

NUZYRAINTRAVENOUS

2 HI



ANTI - INFECTIVES:TETRACYCLINES (continued)Drug Name Tier Requirements/

LimitsNUZYRA ORAL 2 MOtetracycline 1 MO

ANTI - INFECTIVES: URINARYTRACT AGENTSDrug Name Tier Requirements/

Limitsfosfomycintromethamine

1 MO

methenaminehippurate

1 MO

methenaminemandelate

1 MO

nitrofurantoin 1 MOnitrofurantoinmacrocrystal

1 MO

nitrofurantoinmonohyd/m-cryst

1 MO

trimethoprim 1 MO

ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGS:ADJUNCTIVE AGENTSDrug Name Tier Requirements/

Limitsdexrazoxane hcl 1 MO, HIELITEK 2 MO, HIKEPIVANCE 2 HIleucovorin calciuminjection recon soln100 mg, 200 mg, 350mg, 50 mg

1 MO, HI

leucovorin calciuminjection recon soln500 mg

1 HI

leucovorin calciuminjection solution

1 HI

leucovorin calciumoral

1 MO

levoleucovorin calciumintravenous reconsoln 50 mg

1 MO, HI

levoleucovorin calciumintravenous solution

1 HI

mesna 1 MO, HIMESNEX ORAL 2 MOVISTOGARD 2XGEVA 3 PA, MO



ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGSDrug Name Tier Requirements/

Limitsabiraterone 1 PA, MOABRAXANE 2 PA, MO, HIADAKVEO 2 PAadriamycinintravenous reconsoln 10 mg

1 MO, HI

adriamycinintravenous solution10 mg/5 ml

1 MO, HI

adriamycinintravenous solution2 mg/ml, 20 mg/10ml, 50 mg/25 ml

1 HI

adrucil intravenoussolution 2.5 gram/50ml

1 HI

AFINITOR DISPERZ 2 PA, MOAFINITOR ORALTABLET 10 MG

2 PA, MO

ALECENSA 2 PA, MOALIMTA 2 MO, HIALIQOPA 2ALUNBRIG 2 PA, MOanastrozole 1 MOARRANON 2 HIARSENIC TRIOXIDEINTRAVENOUSSOLUTION 1 MG/ML

2

arsenic trioxideintravenous solution2 mg/ml

1 MO

ARZERRA 2 MO, HIASTAGRAF XL 3 B/D PA, MOAVASTIN 2 PA, MO, HI

ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGS(continued)Drug Name Tier Requirements/

LimitsAYVAKIT 2 PA, LAazacitidine 1 MO, HIazathioprine 1 B/D PA, MOazathioprine sodium 1 HIBALVERSA 2 PA, LABAVENCIO 2 PABELEODAQ 2 HIBENDEKA 2 MOBESPONSA 2 MO, HIbexarotene 1 PA, MObicalutamide 1 MOBLENREP 2 B/D PAbleomycin 1 MO, HIBLINCYTOINTRAVENOUS KIT

2

BORTEZOMIB 2 HIBOSULIF 2 PA, MOBRAFTOVI ORALCAPSULE 75 MG

2 PA, MO, LA

BRUKINSA 2 PA, LAbusulfan 1 HIBYNFEZIA 2CABOMETYX 2 PA, MO, LACALQUENCE 2 PA, LAcapecitabine MB MOCAPRELSA 2 PA, LAcarboplatinintravenous solution

1 MO, HI

carmustine 1 MO




Limitscisplatin intravenoussolution

1 MO, HI

cladribine 1 MO, HIclofarabine 1 HICOMETRIQ 2 PA, MOCOPIKTRA 2 PA, LACOTELLIC 2 PA, MO, LAcyclophosphamideintravenous reconsoln

1 MO

cyclophosphamideoral capsule

1 B/D PA, MO

cyclosporineintravenous

1 HI

cyclosporine modifiedoral capsule

1 B/D PA, MO

cyclosporine modifiedoral solution

1 B/D PA

cyclosporine oralcapsule

1 B/D PA, MO

CYRAMZA 2 MO, HIcytarabine 1 MO, HIcytarabine (pf)injection solution 100mg/5 ml (20 mg/ml),2 gram/20 ml (100mg/ml)

1 MO, HI

cytarabine (pf)injection solution 20mg/ml

1 HI

dacarbazine 1 MO, HIdactinomycin 1 HIDANYELZA 2 PA


LimitsDARZALEX 2 PA, MODARZALEX FASPRO 2 PA, MO, LAdaunorubicinintravenous solution

1 HI

DAURISMO 2 PA, MOdecitabine 1 MO, HIdocetaxel intravenoussolution 160 mg/16ml (10 mg/ml), 20mg/2 ml (10 mg/ml),80 mg/8 ml (10 mg/ml)

1 HI

docetaxel intravenoussolution 160 mg/8 ml(20 mg/ml), 20 mg/ml(1 ml), 80 mg/4 ml(20 mg/ml)

1 MO, HI

doxorubicinintravenous reconsoln 50 mg

1 MO, HI

doxorubicinintravenous solution10 mg/5 ml, 20mg/10 ml, 50 mg/25ml

1 MO, HI

doxorubicinintravenous solution2 mg/ml

1 HI

doxorubicin, peg-liposomal

1 MO, HI

ELIGARD 2 MOELIGARD (3 MONTH) 2 MOELIGARD (4 MONTH) 2 MOELIGARD (6 MONTH) 2 MOELZONRIS 2 B/D PA




LimitsEMCYT 2 MOEMPLICITI 2 MO, HIENHERTU 2 PA, MOENSPRYNG 2 PA, MOENVARSUS XR 3 B/D PA, MOepirubicin intravenoussolution

1 MO, HI

ERBITUX 2 PA, MO, HIERIVEDGE 2 PA, MOERLEADA 2 PA, MOerlotinib 1 PA, MOERWINAZE 2 MO, HIETOPOPHOS 2 MO, HIetoposide intravenous 1 MO, HIetoposide oral MB MOeverolimus(antineoplastic)

1 PA, MO

everolimus(immunosuppressive)

1 B/D PA, MO

exemestane 1 MOFARYDAK 2 PA, MOFIRMAGON KIT WDILUENT SYRINGE

2 MO

floxuridine 1fludarabineintravenous reconsoln

1 MO, HI

fludarabineintravenous solution

1 HI

fluorouracilintravenous

1 MO, HI


Limitsflutamide 1 MOFOLOTYN 2 MO, HIfulvestrant 1 MOGAMIFANT 2 PA, LAGAVRETO 2 PA, LAGAZYVA 2 PA, MOgemcitabineintravenous reconsoln 1 gram, 200 mg

1 MO, HI

gemcitabineintravenous reconsoln 2 gram

1 HI

gemcitabineintravenous solution1 gram/26.3 ml (38mg/ml), 2 gram/52.6ml (38 mg/ml), 200mg/5.26 ml (38 mg/ml)

1 MO, HI

gengraf oral capsule100 mg, 25 mg

1 B/D PA, MO

gengraf oral solution 1 B/D PA, MOGILOTRIF 2 PA, MOHALAVEN 2 PA, MO, HIHERCEPTINHYLECTA

2 PA, MO

HERCEPTININTRAVENOUSRECON SOLN 150MG

2 PA, MO, HI

HERZUMA 2 PA, MOHYCAMTIN ORAL MB MOhydroxyurea 1 MO




LimitsIBRANCE 2 PA, MOICLUSIG 2 PAidarubicin 1 MO, HIIDHIFA 2 PA, MO, LAifosfamide intravenousrecon soln

1 MO, HI

ifosfamide intravenoussolution 1 gram/20 ml

1 MO, HI

ifosfamide intravenoussolution 3 gram/60 ml

1 HI

imatinib 1 PA, MOIMBRUVICA 2 PAIMFINZI 2 PA, MO, HIINFUGEM 2 HIINLYTA 2 PA, MOINQOVI 2 PA, MOINREBIC 2 PA, MO, LAIRESSA 2 PA, MOirinotecan intravenoussolution 100 mg/5 ml,40 mg/2 ml

1 MO, HI

irinotecan intravenoussolution 300 mg/15ml, 500 mg/25 ml

1 HI

ISTODAX 2 MO, HIIXEMPRA 2 PA, MO, HIJAKAFI 2 PA, MOJEVTANA 2 PA, MO, HIKADCYLA 2 PA, MO, HIKANJINTI 2 PA, MO


LimitsKEYTRUDAINTRAVENOUSSOLUTION

2 PA, HI

KISQALI 2 PA, MOKISQALI FEMARACO-PACK

2 PA, MO

KOSELUGO 2 PAKYPROLIS 2 PA, HIlapatinib 1 PA, MOLENVIMA 2 PA, MOletrozole 1 MOLEUKERAN 2 MOleuprolidesubcutaneous kit

1 MO

LIBTAYO 2 PA, HILONSURF 2 PA, MOLORBRENA 2 PA, MOLUMOXITI 2 PA, HI, LALUPKYNIS 2 PA, LALUPRON DEPOT 2 MOLUPRON DEPOT (3MONTH)

2 MO

LUPRON DEPOT (4MONTH)

2 MO

LUPRON DEPOT (6MONTH)

2 MO

LUPRON DEPOT-PED

2 MO

LUPRON DEPOT-PED (3 MONTH)

2 MO

LYNPARZA ORALTABLET

2 PA, MO




LimitsLYSODREN 2MATULANE 2megestrol oralsuspension 400mg/10 ml (10 ml)

1 PA

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

1 PA, MO

megestrol oral tablet 1 PA, MOMEKINIST 2 PA, MOMEKTOVI 2 PA, MO, LAmelphalan 1 B/D PA, MOmelphalan hcl 1 HImercaptopurine 1 MOmethotrexate sodium(pf) injection reconsoln

1 B/D PA, HI

methotrexate sodium(pf) injection solution

1 B/D PA, MO, HI

methotrexate sodiuminjection

1 B/D PA, MO, HI

methotrexate sodiumoral

1 B/D PA, MO

mitomycin intravenous 1 MO, HImitoxantrone 1 MO, HIMONJUVI 2 PAMVASI 2 PA, MOMYCAPSSA 2 PA, LAmycophenolate mofetil 1 B/D PA, MOmycophenolate mofetil(hcl)

1 HI


Limitsmycophenolatesodium oral tablet,delayed release (dr/ec)

1 B/D PA, MO

MYLERAN MB MOMYLOTARG 2 MO, HINERLYNX 2 PA, MO, LANEXAVAR 2 PA, MO, LAnilutamide 1 PA, MONINLARO 2 PA, MONUBEQA 2 PA, MO, LANULOJIX 3 MO, HIoctreotide acetateinjection solution1,000 mcg/ml, 100mcg/ml, 200 mcg/ml,500 mcg/ml

1 MO

octreotide acetateinjection solution 50mcg/ml

1

octreotide acetateinjection syringe

1 MO

ODOMZO 2 PA, MO, LAOGIVRI 2 PA, MOONCASPAR 2ONIVYDE 2 PAONTRUZANT 2 PAONUREG 2 PA, MOOPDIVO 2 PA, MO, HIORGOVYX 2 PAoxaliplatin intravenousrecon soln 100 mg

1 MO, HI




Limitsoxaliplatin intravenousrecon soln 50 mg

1 HI

oxaliplatin intravenoussolution 100 mg/20ml, 50 mg/10 ml (5mg/ml)

1 MO, HI

oxaliplatin intravenoussolution 200 mg/40ml

1

paclitaxel 1 MO, HIPADCEV 2 PA, MOparaplatin 1 HIPEMAZYRE 2 PA, LAPERJETA 2 PA, MO, HIPHESGO 2 PA, MOPIQRAY 2 PA, MOPOLIVY 2 PA, MOPOMALYST 2 PA, MO, LAPORTRAZZA 2 MOPOTELIGEO 2 PAPROGRAFINTRAVENOUS

2 MO, HI

PROGRAF ORALGRANULES INPACKET

2 B/D PA, MO

PURIXAN 2QINLOCK 2 PA, LARETEVMO 2 PA, MO, LAREVLIMID 2 PA, MO, LARIABNI 2 PA, MORITUXAN 2 PA, MO, HIRITUXAN HYCELA 2 PA, MO


LimitsROMIDEPSININTRAVENOUSSOLUTION

2

ROZLYTREK 2 PA, MORUBRACA 2 PA, MO, LARUXIENCE 2 PA, MORYDAPT 2 PA, MOSANDOSTATIN LARDEPOTINTRAMUSCULARSUSPENSION,EXTENDED RELRECON

2 MO

SARCLISA 2 PASIGNIFOR 2SIGNIFOR LAR 2SIKLOS 2 MOSIMULECTINTRAVENOUSRECON SOLN 10MG

2 HI

SIMULECTINTRAVENOUSRECON SOLN 20MG

2 MO, HI

sirolimus 1 B/D PA, MOSOLTAMOX 3 MOSOMATULINEDEPOT

2 MO

SPRYCEL 2 PA, MOSTIVARGA 2 PA, MOSUTENT 2 PA, MOSYNRIBO 2




LimitsTABLOID 2 MOTABRECTA 2 PA, MOtacrolimus oral 1 B/D PA, MOTAFINLAR 2 PA, MOTAGRISSO 2 PA, MO, LATALZENNA 2 PA, MOtamoxifen 1 MOTARGRETIN 1% GEL 2 PA, MOTASIGNA 2 PA, MOTAZVERIK 2 PA, LATECENTRIQ 2 PA, MO, HITEMODARINTRAVENOUS

2 MO

temozolomide MB MOtemsirolimus 1 MOTEPMETKO 2 PA, LATHALOMID 2 PA, MOthiotepa injectionrecon soln 100 mg

1

thiotepa injectionrecon soln 15 mg

1 MO

TIBSOVO 2 PAtoposar 1 MO, HItopotecan intravenousrecon soln

1 HI

topotecan intravenoussolution 4 mg/4 ml (1mg/ml)

1 MO, HI

toremifene 1 MOTRAZIMERA 2 PA, MO


LimitsTREANDAINTRAVENOUSRECON SOLN

2 MO, HI

TRELSTARINTRAMUSCULARSUSPENSION FORRECONSTITUTION

2 MO

tretinoin(antineoplastic)

1 MO

TRODELVY 2 PATRUXIMA 2 PA, MOTUKYSA 2 PA, LATURALIO 2 LATYKERB 2 PA, MO, LAUKONIQ 2 PAUNITUXIN 2valrubicin 1 MOVANTAS 2 MOVECTIBIX 2 MO, HIVELCADE 2 MO, HIVENCLEXTA 2 PA, LAVENCLEXTASTARTING PACK

2 PA, LA

VERZENIO 2 PA, MO, LAvinblastineintravenous solution

1 MO, HI

vincasar pfs 1 MO, HIvincristine 1 MO, HIvinorelbine 1 MO, HIVITRAKVI 2 PA, MO, LAVIZIMPRO 2 PA, MO




LimitsVOTRIENT 2 PA, MOVYXEOS 2 HIXALKORI 2 PA, MOXATMEP 2 B/D PA, MOXERMELO 2 LAXOSPATA 2 PA, LAXPOVIO 2 PA, LAXTANDI ORALCAPSULE

2 PA, MO

YERVOY 2 PA, MO, HIYONDELIS 2 HIYONSA 2 PA, MOZALTRAP 2 MO, HIZANOSAR 2 MO, HIZEJULA 2 PA, LAZELBORAF 2 PA, MOZEPZELCA 2 B/D PAZIRABEV 2 PA, MOZOLADEX 2 MOZOLINZA 2 PA, MOZORTRESS ORALTABLET 1 MG

2 B/D PA, MO

ZYDELIG 2 PA, MOZYKADIA ORALTABLET

2 PA, MO

ZYTIGA ORALTABLET 500 MG

2 PA, MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTICONVULSANTSDrug Name Tier Requirements/

LimitsAPTIOM 3 MOBANZEL 3 MOBRIVIACTINTRAVENOUS

3 HI

BRIVIACT ORAL 3 MOcarbamazepine oralcapsule, ermultiphase 12 hr

1 MO

carbamazepine oralsuspension 100 mg/5ml

1 MO

carbamazepine oralsuspension 200mg/10 ml

1

carbamazepine oraltablet

1 MO

carbamazepine oraltablet extendedrelease 12 hr

1 MO

carbamazepine oraltablet,chewable

1 MO

CELONTIN ORALCAPSULE 300 MG

3 MO

clobazam 1 MOclonazepam oral tablet 1 MOclonazepam oraltablet,disintegrating

1 MO

DIACOMIT 2 PAdiazepam rectal 1 MODILANTIN 30 MG 2 MOdivalproex oralcapsule, delayed relsprinkle

1



AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTICONVULSANTS (continued)Drug Name Tier Requirements/

Limitsdivalproex oral tabletextended release 24hr

1 MO

divalproex oral tablet,delayed release (dr/ec)

1 MO

EPIDIOLEX 3 PA, MO, LAepitol 1 MOethosuximide 1 MOfelbamate 1 MOFINTEPLA 3 LAfosphenytoin 1 MO, HIFYCOMPA ORALSUSPENSION

3 MO

FYCOMPA ORALTABLET

3 MO

gabapentin oralcapsule

1 MO

gabapentin oralsolution 250 mg/5 ml

1 MO

gabapentin oralsolution 250 mg/5 ml(5 ml), 300 mg/6 ml(6 ml)

1

gabapentin oral tablet600 mg, 800 mg

1 MO

lamotrigine 1 MOlevetiracetam in nacl(iso-os) intravenouspiggyback 1,000mg/100 ml, 1,500mg/100 ml

1 HI


Limitslevetiracetam in nacl(iso-os) intravenouspiggyback 500mg/100 ml

1 MO, HI

levetiracetamintravenous

1 MO, HI

levetiracetam oralsolution 100 mg/ml

1 MO

levetiracetam oralsolution 500 mg/5 ml(5 ml)

1

levetiracetam oraltablet

1 MO

levetiracetam oraltablet extendedrelease 24 hr

1 MO

NAYZILAM 3 MOoxcarbazepine 1 MOOXTELLAR XR 3 MOphenobarbital oralelixir

1 PA, MO

phenobarbital oraltablet 100 mg, 15mg, 30 mg, 60 mg

1 PA

phenobarbital oraltablet 16.2 mg, 32.4mg, 64.8 mg, 97.2mg

1 PA, MO

phenobarbital sodiuminjection solution 130mg/ml

1 MO

phenobarbital sodiuminjection solution 65mg/ml

1




Limitsphenytoin oralsuspension 100 mg/4ml

1

phenytoin oralsuspension 125 mg/5ml

1 MO

phenytoin oral tablet,chewable

1 MO

phenytoin sodiumextended

1 MO

phenytoin sodiumintravenous solution

1

pregabalin oralcapsule

1 MO

pregabalin oralsolution

1 MO

primidone 1 MOQUDEXY XR 3 PA, MOroweepra 1 MOrufinamide 1 MOSPRITAM 3 MOsubvenite 1 MOsubvenite starter(blue) kit

1 MO

subvenite starter(green) kit

1 MO

subvenite starter(orange) kit

1 MO

SYMPAZAN 3 MOtiagabine 1 MOtopiramate oralcapsule, sprinkle

1 PA, MO


Limitstopiramate oralcapsule,sprinkle,er24hr

1 MO

topiramate oral tablet 1 PA, MOTROKENDI XR 3 PA, MOvalproate sodium 1 MO, HIvalproic acid 1 MOvalproic acid (assodium salt) oralsolution 250 mg/5 ml

1 MO

valproic acid (assodium salt) oralsolution 250 mg/5 ml(5 ml), 500 mg/10 ml(10 ml)

1

VALTOCO 2vigabatrin 1 MO, LAvigadrone 1 LAVIMPATINTRAVENOUS

3 MO, HI

VIMPAT ORALSOLUTION

3 MO

VIMPAT ORALTABLET

3 MO

XCOPRI 3 MOXCOPRIMAINTENANCEPACK

3 MO

XCOPRI TITRATIONPACK

3 MO

zonisamide 1 PA, MO



AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTIPARKINSONISM AGENTSDrug Name Tier Requirements/

LimitsAPOKYN 2 MO, LAbenztropine 1 MObenztropine 1 MO, HIbromocriptine 1 MOcarbidopa 1 MOcarbidopa-levodopaoral tablet

1 MO

carbidopa-levodopaoral tablet extendedrelease

1 MO

carbidopa-levodopaoral tablet,disintegrating

1 MO

carbidopa-levodopa-entacapone

1 MO

entacapone 1 MOINBRIJA INHALATIONCAPSULE, W/INHALATIONDEVICE

2 PA

NEUPRO 3 MONOURIANZ 3 PA, MO, LAONGENTYS ORALCAPSULE 50 MG

3 PA, MO

pramipexole oraltablet

1 MO

pramipexole oraltablet extendedrelease 24 hr

1 MO

rasagiline 1 MOropinirole oral tablet 1 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:ANTIPARKINSONISM AGENTS(continued)Drug Name Tier Requirements/

Limitsropinirole oral tabletextended release 24hr

1 MO

selegiline hcl 1 MOtolcapone 1trihexyphenidyl 1 MOZELAPAR 3 MO



AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MIGRAINE /CLUSTER HEADACHE THERAPYDrug Name Tier Requirements/

LimitsAIMOVIGAUTOINJECTOR

2 PA, MO, QL (1per 30 days)

dihydroergotamineinjection

1

dihydroergotaminenasal

1 QL (8 per 30days)

EMGALITY PEN 2 PA, MO, QL (2per 30 days)

EMGALITY SYRINGESUBCUTANEOUSSYRINGE 120 MG/ML


EMGALITY SYRINGESUBCUTANEOUSSYRINGE 300 MG/3ML (100 MG/ML X 3)


ergotamine-caffeine 1 MOmigergot 1 MOnaratriptan 1 MO, QL (18 per

30 days)NURTEC ODT 3 PA, QL (15 per

30 days)rizatriptan oral tablet 1 MO, QL (36 per

30 days)rizatriptan oral tablet,disintegrating


sumatriptan nasalspray,non-aerosol 20mg/actuation


sumatriptan nasalspray,non-aerosol 5mg/actuation


sumatriptan succinateoral


AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MIGRAINE /CLUSTER HEADACHE THERAPY(continued)Drug Name Tier Requirements/

Limitssumatriptan succinatesubcutaneouscartridge


sumatriptan succinatesubcutaneous peninjector


sumatriptan succinatesubcutaneoussolution


sumatriptan succinatesubcutaneoussyringe 6 mg/0.5 ml

1 QL (8 per 30days)

sumatriptan-naproxen 1 MO, QL (18 per30 days)

UBRELVY 3 PA, QL (16 per30 days)

ZOLMITRIPTANNASAL

2 QL (18 per 30days)

zolmitriptan oral 1 MO, QL (18 per30 days)

ZOMIG NASAL 2 MO, QL (18 per30 days)



AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:MISCELLANEOUS NEUROLOGICALTHERAPYDrug Name Tier Requirements/

LimitsAUBAGIO 2 PA, MOAUSTEDO 2 PA, MO, LAdalfampridine oraltablet extendedrelease 12 hr


dimethyl fumarate 1 PAdonepezil 1 MOEVRYSDI 2 PA, MOgalantamine oralcapsule,ext rel.pellets 24 hr

1 MO

galantamine oralsolution

1 MO

galantamine oraltablet

1 MO

GILENYA ORALCAPSULE 0.5 MG

2 PA, MO

glatiramersubcutaneoussyringe 20 mg/ml


glatiramersubcutaneoussyringe 40 mg/ml


glatopa subcutaneoussyringe 20 mg/ml


glatopa subcutaneoussyringe 40 mg/ml


INGREZZA 2 LAINGREZZAINITIATION PACK

2 LA

KESIMPTA PEN 2 PA, MOKEVEYIS 2

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:MISCELLANEOUS NEUROLOGICALTHERAPY (continued)Drug Name Tier Requirements/

LimitsLEMTRADA 2 MOMAVENCLAD (10TABLET PACK)

3 PA, MO, LA

MAVENCLAD (4TABLET PACK)

3 PA, MO, LA


3 PA, MO, LA


3 PA, MO, LA


3 PA, MO, LA


3 PA, MO, LA


3 PA, MO, LA

MAYZENT 3 PA, MOMAYZENT STARTERPACK

3 PA, MO

memantine oralcapsule,sprinkle,er24hr

1 MO

memantine oralsolution

1 MO

memantine oral tablet 1 MONUEDEXTA 2 PA, MOOCREVUS 2 MOONPATTRO 2 PA, HI, LARADICAVA 2 HIrivastigmine tartrate 1 MOrivastigminetransdermal

1 MO

RUZURGI 2



AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:MISCELLANEOUS NEUROLOGICALTHERAPY (continued)Drug Name Tier Requirements/

LimitsTECFIDERA 2 PA, MO, LATEGSEDI 2 PA, MO, LAtetrabenazine 1 PA, MOTYSABRI 2 PA, MO, HIZEPOSIA 2 PA, MOZEPOSIA STARTERKIT

2 PA, MO

ZEPOSIA STARTERPACK

2 PA, MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MUSCLERELAXANTS / ANTISPASMODICTHERAPYDrug Name Tier Requirements/

Limitsbaclofen 1 MOcarisoprodol 1 PA, MOcarisoprodol-aspirin 1 PA, MOcarisoprodol-aspirin-codeine

1 PA, MO

chlorzoxazone oraltablet 375 mg, 500mg, 750 mg

1 PA, MO

cyclobenzaprine oraltablet

1 PA, MO

dantroleneintravenous

1

dantrolene oral 1 MOmeprobamate 1 MOmetaxalone 1 PA, MOmethocarbamolinjection

1 PA, HI

methocarbamol oral 1 PA, MOneostigminemethylsulfateintravenous solution

1

orphenadrine citrateinjection

1 MO

orphenadrine citrateoral tablet extendedrelease

1 PA, MO

orphenadrine-asa-caffeine oral tablet50-770-60 mg

1 PA

orphengesic forte 1 PApyridostigminebromide oral syrup

1 MO



AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: MUSCLERELAXANTS / ANTISPASMODICTHERAPY (continued)Drug Name Tier Requirements/

Limitspyridostigminebromide oral tablet

1 MO

pyridostigminebromide oral tablet

1 MO

pyridostigminebromide oral tabletextended release

1 MO

pyridostigminebromide oral tabletextended release

1 MO

regonol 1revonto 1tizanidine 1 MOvanadom 1 PA

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NARCOTICANALGESICSDrug Name Tier Requirements/

Limitsacetaminophen-caff-dihydrocod oralcapsule

1 MO

acetaminophen-caff-dihydrocod oral tablet325-30-16 mg

1 MO

acetaminophen-codeine oral solution120 mg-12 mg /5 ml(5 ml), 300 mg-30 mg/12.5 ml

1

acetaminophen-codeine oral solution120-12 mg/5 ml

1 MO

acetaminophen-codeine oral tablet

1 MO

ascomp with codeine 1 PA, MObuprenorphine 1 PA, MObuprenorphine hclinjection solution

1 MO, HI

buprenorphine hclinjection syringe

1 HI

buprenorphine hclsublingual

1 MO

butalbital compoundw/codeine

1 PA

butalbital-acetaminop-caf-cod

1 PA, MO

butalbital-acetaminophen oralcapsule

1 PA, MO

butalbital-acetaminophen oraltablet 25-325 mg

1 PA



AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NARCOTICANALGESICS (continued)Drug Name Tier Requirements/

Limitsbutalbital-acetaminophen oraltablet 50-300 mg,50-325 mg

1 PA, MO

butalbital-acetaminophen-cafforal capsule

1 PA, MO

butalbital-acetaminophen-cafforal tablet 50-325-40mg

1 PA, MO

butalbital-aspirin-caffeine oral capsule

1 PA, MO

butalbital-aspirin-caffeine oral tablet

1 PA

codeine sulfate oraltablet

1 MO

codeine-butalbital-asa-caff

1 PA, MO

duramorph (pf)injection solution 0.5mg/ml

1 MO

duramorph (pf)injection solution 1mg/ml

1

dvorah 1endocet oral tablet10-325 mg, 2.5-325mg, 5-325 mg,7.5-325 mg

1 MO

fentanyl 1 MOfentanyl citrate (pf)injection solution

1


Limitsfentanyl citrate (pf)intravenous syringe100 mcg/2 ml (50mcg/ml)

1

fentanyl citrate buccallozenge on a handle

1 PA, MO

hydrocodone bitartrateoral capsule, oralonly, er 12hr

1 PA, MO

hydrocodone bitartrateoral tablet,oral only,ext.rel.24 hr

1 PA, MO

hydrocodone-acetaminophen oralsolution 10-325mg/15 ml(15 ml)

1

hydrocodone-acetaminophen oralsolution 7.5-325mg/15 ml

1 MO

HYDROCODONE-ACETAMINOPHENORAL SOLUTION7.5-325 MG/15 ML(BRAND)

2

hydrocodone-acetaminophen oraltablet 10-300 mg,10-325 mg, 5-300mg, 5-325 mg,7.5-300 mg, 7.5-325mg

1 MO

hydrocodone-ibuprofen oral tablet10-200 mg, 5-200mg, 7.5-200 mg

1 MO




Limitshydromorphone (pf)injection solution 10(mg/ml) (5 ml), 10mg/ml, 2 mg/ml

1

hydromorphoneinjection solution 1mg/ml

1

hydromorphoneinjection solution 2mg/ml

1 MO

hydromorphoneinjection syringe 1mg/ml, 4 mg/ml

1 MO

hydromorphoneinjection syringe 2mg/ml

1

hydromorphone oralliquid

1 MO

hydromorphone oraltablet

1 MO

hydromorphone oraltablet extendedrelease 24 hr

1 PA, MO

levorphanol tartrateoral tablet 2 mg

1 MO

levorphanol tartrateoral tablet 3 mg

1 MO

meperidine (pf)injection solution 100mg/ml, 50 mg/ml

1 PA, MO

meperidine (pf)injection solution 25mg/ml

1 PA

meperidine oral 1 MO


Limitsmethadone injectionsolution

1 HI

methadone intensol 1 PA, MOmethadone oralconcentrate

1 PA

methadone oralsolution

1 PA, MO

methadone oral tablet 1 PA, MOmethadose oralconcentrate

1 PA, MO

morphine (pf) injectionsolution 0.5 mg/ml

1

morphine (pf) injectionsolution 1 mg/ml

1 MO

morphine concentrateoral solution

1 MO

MORPHINEINJECTIONSOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML(BRAND)

2

morphine injectionsolution 8 mg/ml

1

morphine injectionsyringe 10 mg/ml

1 MO

morphine injectionsyringe 4 mg/ml, 5mg/ml, 8 mg/ml

1

morphine intravenoussolution 10 mg/ml

1 MO




LimitsMORPHINEINTRAVENOUSSOLUTION 4 MG/ML, 8 MG/ML(BRAND)

2 MO

MORPHINEINTRAVENOUSSYRINGE 10 MG/ML, 8 MG/ML(BRAND

2

MORPHINEINTRAVENOUSSYRINGE 10 MG/ML, 8 MG/ML(BRAND)

2

morphine intravenoussyringe 2 mg/ml, 4mg/ml

1

morphine oralcapsule, ermultiphase 24 hr

1 PA, MO

morphine oralcapsule,extend.release pellets

1 PA, MO

morphine oral solution 1 MOmorphine oral tablet 1 MOmorphine oral tabletextended release

1 PA, MO

oxycodone oralcapsule

1 MO

oxycodone oralconcentrate

1 MO

oxycodone oralsolution

1 MO

oxycodone oral tablet 1 MO


LimitsOXYCODONE ORALTABLET,ORAL ONLY,EXT.REL.12 HR 10MG, 20 MG, 40 MG,80 MG (BRAND)

2 PA

OXYCODONE ORALTABLET,ORAL ONLY,EXT.REL.12 HR 15MG, 30 MG, 60 MG(BRAND)

2 PA

oxycodone-acetaminophen oraltablet 10-325 mg,2.5-325 mg, 5-325mg, 7.5-325 mg

1 MO

oxycodone-acetaminophen oraltablet 2.5-300 mg

1

oxycodone-aspirin 1 MOOXYCONTIN ORALTABLET,ORAL ONLY,EXT.REL.12 HR

2 PA, MO

oxymorphone oraltablet

1 MO

oxymorphone oraltablet

1 PA, MO

oxymorphone oraltablet extendedrelease 12 hr

1 MO

oxymorphone oraltablet extendedrelease 12 hr

1 PA, MO

prolate oral tablet 1tencon oral tablet50-325 mg

1 PA, MO

vtol lq 1 PA, MO




Limitszebutal oral capsule50-325-40 mg

1 PA, MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NON-NARCOTIC ANALGESICSDrug Name Tier Requirements/

Limitsacetaminophenintravenous solution1,000 mg/100 ml (10mg/ml)

1 MO

buprenorphine-naloxone

1 MO

butorphanol tartrateinjection

1 MO, HI

butorphanol tartratenasal

1 MO

cataflam 1celecoxib 1 MO, QL (60 per

30 days)clonidine (pf) epiduralsolution 5,000mcg/10 ml

1

diclofenac potassium 1 MOdiclofenac sodium oraltablet extendedrelease 24 hr

1 MO

diclofenac sodium oraltablet,delayedrelease (dr/ec)

1 MO

diclofenac sodiumtopical drops

1 MO

diclofenac sodiumtopical gel 1 %

1 MO

diclofenac-misoprostoloral tablet,ir,delayedrel,biphasic

1 MO

diflunisal 1 MOec-naproxen 1 MOetodolac oral capsule 1 MOetodolac oral tablet 1 MO



AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH: NON-NARCOTIC ANALGESICS (continued)Drug Name Tier Requirements/

Limitsfenoprofen oral tablet 1 MOflurbiprofen oral tablet100 mg

1 MO

ibu 1 MOibuprofen lysine (pf) 1ibuprofen oralsuspension

1 MO

ibuprofen oral tablet400 mg, 600 mg, 800mg

1 MO

indomethacin oralcapsule

1 MO

indomethacin oralcapsule, extendedrelease

1 MO

indomethacin sodium 1ketoprofen oralcapsule 25 mg

1 MO

ketoprofen oralcapsule 50 mg, 75mg

1

ketoprofen oralcapsule,ext rel.pellets 24 hr 200 mg

1 MO

ketorolac injectioncartridge 30 mg/ml

1

ketorolac injectionsolution 15 mg/ml, 30mg/ml (1 ml)

1

ketorolac injectionsyringe

1

ketorolacintramuscular

1

ketorolac oral 1


LimitsLUCEMYRA 2 MO, QL (224 per

180 days)meclofenamate 1 MOmefenamic acid 1 MOmeloxicam oral tablet 1 MO, QL (30 per

30 days)nabumetone 1 MOnalbuphine 1 MO, HInaloxone injectionsolution

1 MO

naloxone injectionsyringe

1 MO

naltrexone 1 MOnaproxen oralsuspension

1 MO

naproxen oral tablet 1 MOnaproxen oral tablet,delayed release (dr/ec)

1

naproxen sodium oraltablet 275 mg, 550mg

1 MO

NARCAN NASALSPRAY,NON-AEROSOL 4 MG/ACTUATION

1 MO

oxaprozin 1 MOpentazocine-naloxone 1 MOpiroxicam 1 MOsalsalate 1 MOsulindac 1 MOtolmetin oral capsule 1 MO




Limitstolmetin oral tablet600 mg

1 MO

tramadol oral tablet 50mg

1 MO

tramadol oral tabletextended release 24hr

1 PA, MO

tramadol oral tablet, ermultiphase 24 hr

1 PA, MO

tramadol-acetaminophen

1 MO

AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:PSYCHOTHERAPEUTIC DRUGSDrug Name Tier Requirements/

LimitsABILIFY MAINTENA 3 ST, MOADASUVE 3 STalprazolam intensol 1 MOalprazolam oral tablet 1 MOalprazolam oral tabletextended release 24hr

1 MO

alprazolam oral tablet,disintegrating

1 MO

amitriptyline 1 PA, MOamitriptyline-chlordiazepoxide

1 MO

amoxapine 1 MOamphetamine sulfate 1 MOaripiprazole 1 MOARISTADA 3 ST, MOARISTADA INITIO 3 ST, MOarmodafinil 1 PA, MOasenapine maleate 1 MOatomoxetine 1 MO, QL (30 per

30 days)bupropion hcl oraltablet

1 MO

bupropion hcl oraltablet extendedrelease 24 hr 150mg, 300 mg

1 MO

bupropion hcl oraltablet sustained-release 12 hr

1 MO

buspirone 1 MO



AUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCH:PSYCHOTHERAPEUTIC DRUGS(continued)Drug Name Tier Requirements/

LimitsCAPLYTA 3 ST, MO, QL (30

per 30 days)chlordiazepoxide hcl 1 MOchlorpromazineinjection

1 MO, HI

chlorpromazine oral 1 MOcitalopram 1 MOclomipramine 1 PA, MOclonidine hcl oraltablet extendedrelease 12 hr

1 MO

clorazepatedipotassium

1 MO

clozapine 1CLOZAPINE ORALTABLET,DISINTEGRATING150 MG, 200 MG(BRAND)

1

desipramine 1 MOdesvenlafaxinesuccinate oral tabletextended release 24hr

1 MO

dexmethylphenidateoral capsule,erbiphasic 50-50 10mg, 5 mg


dexmethylphenidateoral capsule,erbiphasic 50-50 15mg, 20 mg, 25 mg,30 mg, 35 mg, 40 mg



Limitsdexmethylphenidateoral tablet

1 MO

dextroamphetamineoral capsule,extended release

1 MO

dextroamphetamineoral solution

1 MO

dextroamphetamineoral tablet

1 MO

dextroamphetamine-amphetamine oralcapsule,extendedrelease 24hr


dextroamphetamine-amphetamine oraltablet

1 MO

diazepam injection 1diazepam intensol 1diazepam oralconcentrate

1 MO

diazepam oral solution5 mg/5 ml (1 mg/ml)

1 MO

diazepam oral tablet 1 MOdoxepin oral capsule 1 PA, MOdoxepin oralconcentrate

1 PA, MO

doxepin oral tablet 1 MODRIZALMASPRINKLE

3 MO

duloxetine oralcapsule,delayedrelease (dr/ec)

1 MO

EMSAM 3 MO




Limitsergoloid 1 MOescitalopram oxalate 1 MOestazolam 1 MOeszopiclone 1 MO, QL (30 per

30 days)FANAPT 3 ST, MOFETZIMA 3 MOflumazenil 1fluoxetine oral capsule 1 MOfluoxetine oralcapsule,delayedrelease(dr/ec)

1 MO

fluoxetine oral solution 1 MOfluphenazinedecanoate

1 MO

fluphenazine hcl 1 MOflurazepam 1 MOfluvoxamine oralcapsule,extendedrelease 24hr

1 MO

fluvoxamine oral tablet 1 MOFORFIVO XL 3 MOguanfacine oral tabletextended release 24hr

1 MO

guanidine 1 MOhaloperidol 1 MOhaloperidol decanoate 1 MOhaloperidol lactateinjection

1 MO


Limitshaloperidol lactateintramuscular

1

haloperidol lactate oral 1 MOHETLIOZ 2 PA, MO, QL (30

per 30 days)imipramine hcl 1 PA, MOimipramine pamoate 1 PA, MOINVEGA SUSTENNA 3 ST, MOINVEGA TRINZA 3 ST, MOLATUDA 3 ST, MOlithium carbonate oralcapsule

1 MO

lithium carbonate oraltablet

1 MO

lithium carbonate oraltablet extendedrelease

1 MO

lithium citrate oralsolution 8 meq/5 ml

1 MO

lorazepam injectionsolution

1 MO

lorazepam injectionsyringe 2 mg/ml

1 MO

lorazepam injectionsyringe 4 mg/ml

1

lorazepam intensol 1lorazepam oralconcentrate

1 MO

lorazepam oral tablet 1 MOloxapine succinate 1 MOmaprotiline 1 MO




LimitsMARPLAN 2 MOmethamphetamine 1 PA, MOmethylphenidate hcloral cap,er sprinkle,biphasic 40-60

1 MO

methylphenidate hcloral capsule, erbiphasic 30-70 10mg, 20 mg, 30 mg


methylphenidate hcloral capsule, erbiphasic 30-70 40mg, 50 mg, 60 mg


methylphenidate hcloral capsule,erbiphasic 50-50


methylphenidate hcloral solution

1 MO

methylphenidate hcloral tablet

1 MO

methylphenidate hcloral tablet extendedrelease 10 mg


methylphenidate hcloral tablet extendedrelease 20 mg


methylphenidate hcloral tablet extendedrelease 24hr 18 mg(bx rating), 27 mg (bxrating), 54 mg (bxrating)



Limitsmethylphenidate hcloral tablet extendedrelease 24hr 18 mg,27 mg, 54 mg


methylphenidate hcloral tablet extendedrelease 24hr 36 mg


methylphenidate hcloral tablet extendedrelease 24hr 36 mg(bx rating)


methylphenidate hcloral tablet,chewable

1 MO

midazolam (pf)injection

1

midazolam injection 1midazolam oral syrup2 mg/ml

1 MO

mirtazapine 1 MOmodafinil 1 PA, MOmolindone 1 MOnefazodone 1 MOnortriptyline 1 MONUPLAZID ORALCAPSULE

3 ST, MO

NUPLAZID ORALTABLET 10 MG

3 ST, MO

olanzapineintramuscular reconsoln

1 MO

olanzapine oral tablet 1 MOolanzapine oral tablet,disintegrating

1 MO




Limitsolanzapine-fluoxetine 1 MOoxazepam 1 MOpaliperidone 1 MOparoxetine hcl oraltablet

1 MO

paroxetine hcl oraltablet extendedrelease 24 hr

1 MO

paroxetine mesylate(menop.sym)

1 MO

PAXIL ORALSUSPENSION

3 MO

pentobarbital sodiuminjection solution

1

perphenazine 1 MOperphenazine-amitriptyline

1 PA, MO

PERSERIS 3 ST, MOphenelzine 1 MOpimozide 1 MOprocentra 1 MOprotriptyline 1 MOquetiapine oral tablet 1 MOquetiapine oral tabletextended release 24hr

1 MO

ramelteon 1 MOREXULTI 3 ST, MORISPERDAL CONSTA 3 ST, MOrisperidone oralsolution

1 MO


Limitsrisperidone oral tablet 1 MOrisperidone oral tablet,disintegrating

1 MO

SAPHRIS 3 ST, MOseconal sodium 1 PASECUADO 3 ST, MOsertraline 1 MOtemazepam 1 MOthioridazine 1 MOthiothixene 1 MOtranylcypromine 1 MOtrazodone 1 MOtriazolam 1 MOtrifluoperazine 1 MOtrimipramine 1 PA, MOTRINTELLIX 3 MOvenlafaxine oralcapsule,extendedrelease 24hr

1 MO

venlafaxine oral tablet 1 MOVERSACLOZ 3 STVIIBRYD ORALTABLET

3 MO

VIIBRYD ORALTABLETS,DOSEPACK 10 MG (7)- 20MG (23)

3 MO

VRAYLAR 3 ST, MOXYREM 2 PA, LAzaleplon 1 MO, QL (30 per

30 days)




Limitszenzedi oral tablet 10mg, 5 mg

1 MO

ZENZEDI ORALTABLET 15 MG, 2.5MG, 20 MG, 30 MG,7.5 MG (BRAND)

3 MO

ziprasidone hcl 1 MOziprasidone mesylate 1zolpidem oral tablet 1 MO, QL (30 per

30 days)zolpidem oral tablet,ext releasemultiphase


ZYPREXARELPREVV

3 ST, MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS:ANTIARRHYTHMIC AGENTSDrug Name Tier Requirements/

Limitsadenosine 1amiodaroneintravenous solution

1 MO, HI

amiodaroneintravenous syringe

1

amiodarone oral tablet100 mg, 400 mg

1

amiodarone oral tablet200 mg

1 MO

bretylium tosylate 1disopyramidephosphate oralcapsule

1 MO

dofetilide 1 MOflecainide 1 MOibutilide fumarate 1lidocaine (pf) in d7.5w 1lidocaine (pf)intravenous

1 HI

lidocaine in 5 %dextrose (pf)intravenousparenteral solution 4mg/ml (0.4 %), 8 mg/ml (0.8 %)

1

mexiletine 1 MOMULTAQ 3 MOpacerone oral tablet100 mg, 200 mg, 400mg

1 MO

procainamide injection 1 HIpropafenone oralcapsule,extendedrelease 12 hr

1 MO



CARDIOVASCULAR, HYPERTENSION/ LIPIDS: ANTIARRHYTHMIC AGENTS(continued)Drug Name Tier Requirements/

Limitspropafenone oraltablet

1 MO

quinidine gluconateoral tablet extendedrelease

1 MO

quinidine sulfate oraltablet

1 MO

sorine oral tablet 120mg, 160 mg, 80 mg

1 MO

sorine oral tablet 240mg

1

sotalol af 1sotalol oral 1 MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS:ANTIHYPERTENSIVE THERAPYDrug Name Tier Requirements/

Limitsacebutolol 1 MOaliskiren 1 MOamiloride 1 MOamiloride-hydrochlorothiazide

1 MO

amlodipine 1 MOamlodipine-benazepril 1 MOamlodipine-olmesartan

1 MO

amlodipine-valsartan 1 MOamlodipine-valsartan-hcthiazid

1 MO

atenolol 1 MOatenolol-chlorthalidone 1 MObenazepril 1 MObenazepril-hydrochlorothiazide

1 MO

betaxolol oral 1 MObisoprolol fumarate 1 MObisoprolol-hydrochlorothiazide

1 MO

bumetanide injection 1 MO, HIbumetanide oral 1 MOcandesartan 1 MOcandesartan-hydrochlorothiazid

1 MO

captopril 1 MOcaptopril-hydrochlorothiazide

1 MO

cartia xt oral capsule,extended release24hr

1 MO



CARDIOVASCULAR, HYPERTENSION/ LIPIDS: ANTIHYPERTENSIVETHERAPY (continued)Drug Name Tier Requirements/

Limitscarvedilol 1 MOcarvedilol phosphateoral capsule, ermultiphase 24 hr

1

chlorothiazide sodium 1 MO, HIchlorthalidone oraltablet 25 mg, 50 mg

1 MO

clonidine (pf) epiduralsolution 1,000mcg/10 ml (100 mcg/ml)

1

clonidine hcl oraltablet

1 MO

clonidine transdermal 1 MODEMSER 2 MOdiltiazem hclintravenous

1 HI

diltiazem hcl oralcapsule,ext.rel 24hdegradable

1 MO

diltiazem hcl oralcapsule,extendedrelease 12 hr

1 MO

diltiazem hcl oralcapsule,extendedrelease 24 hr

1 MO

diltiazem hcl oralcapsule,extendedrelease 24hr 120 mg,180 mg, 240 mg, 360mg

1 MO

diltiazem hcl oralcapsule,extendedrelease 24hr 300 mg

1


Limitsdiltiazem hcl oraltablet

1 MO

diltiazem hcl oraltablet extendedrelease 24 hr

1

dilt-xr oral capsule,extrelease degradable

1 MO

doxazosin 1 MOenalapril maleate 1 MOenalaprilat intravenoussolution

1

enalapril-hydrochlorothiazide

1 MO

eplerenone 1 MOepoprostenol 1 MOepoprostenol (glycine) 1 MOesmolol in nacl (iso-osm)

1

esmolol intravenoussolution

1

ethacrynate sodium 1 HIethacrynic acid 1 MOfelodipine oral tabletextended release 24hr

1 MO

fosinopril 1 MOfosinopril-hydrochlorothiazide

1 MO

furosemide injection 1 MO, HIfurosemide oralsolution 10 mg/ml, 40mg/5 ml (8 mg/ml)

1 MO

furosemide oral tablet 1 MO




Limitsguanfacine oral tablet 1 MOhydralazine 1 MOhydralazine 1 MO, HIhydrochlorothiazide 1 MOindapamide 1 MOirbesartan 1 MOirbesartan-hydrochlorothiazide

1 MO

isradipine 1 MOlabetalol intravenoussolution

1 HI

labetalol intravenoussyringe 20 mg/4 ml (5mg/ml)

1 HI

labetalol oral 1 MOlisinopril 1 MOlisinopril-hydrochlorothiazide

1 MO

losartan 1 MOlosartan-hydrochlorothiazide

1 MO

mannitol 20 % 1mannitol 25 %intravenous solution

1 MO

matzim la oral tabletextended release 24hr

1 MO

methyldopa 1 MOmethyldopa-hydrochlorothiazide

1 MO

metolazone 1 MO


Limitsmetoprolol succinateoral tablet extendedrelease 24 hr

1 MO

metoprolol ta-hydrochlorothiaz

1 MO

metoprolol tartrateintravenous solution

1 HI

metoprolol tartrate oraltablet

1 MO

metyrosine 1 MOminoxidil oral 1 MOmoexipril 1 MOnadolol 1 MOnadolol-bendroflumethiazideoral tablet 80-5 mg

1 MO

nicardipineintravenous solution

1 HI

nicardipine oral 1 MOnifedipine oral capsule 1 MOnifedipine oral tabletextended release

1 MO

nifedipine oral tabletextended release24hr

1 MO

nimodipine 1 MOnisoldipine oral tabletextended release 24hr

1 MO

olmesartan 1 MOolmesartan-amlodipin-hcthiazid

1 MO




Limitsolmesartan-hydrochlorothiazide

1 MO

ORENITRAM 2 PA, MOosmitrol 15 % 1osmitrol 20 % 1perindopril erbumine 1 MOphenoxybenzamine 1 MOphentolamine injectionrecon soln

1

pindolol 1 MOprazosin 1 MOpropranololintravenous

1 HI

propranolol oralcapsule,extendedrelease 24 hr

1 MO

propranolol oralsolution

1 MO

propranolol oral tablet 1 MOpropranolol-hydrochlorothiazid

1 MO

quinapril 1 MOquinapril-hydrochlorothiazide

1 MO

ramipril 1 MOspironolactone 1 MOspironolacton-hydrochlorothiaz

1 MO

taztia xt oral capsule,extended release

1 MO

TEKTURNA HCT 2 MOtelmisartan 1 MO


Limitstelmisartan-amlodipine 1 MOtelmisartan-hydrochlorothiazid

1 MO

terazosin 1 MOtiadylt er 1 MOtimolol maleate oral 1 MOtorsemide oral 1 MOtrandolapril 1 MOtrandolapril-verapamiloral tablet, ir - er,biphasic 24hr

1 MO

treprostinil sodium 1 B/D PA, MOtriamterene 1 MOtriamterene-hydrochlorothiazidoral capsule 37.5-25mg

1 MO

triamterene-hydrochlorothiazidoral tablet

1 MO

UPTRAVI 2 PA, MO, LAvalsartan 1 MOvalsartan-hydrochlorothiazide

1 MO

veletri 1 MOverapamil intravenous 1 HIverapamil oralcapsule, 24 hr erpellet ct

1 MO

verapamil oralcapsule,ext rel.pellets 24 hr

1 MO

verapamil oral tablet 1 MO




Limitsverapamil oral tabletextended release

1 MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS:COAGULATION THERAPYDrug Name Tier Requirements/

Limitsaminocaproic acid 1 MOANDEXXAINTRAVENOUSRECON SOLN 200MG

2

aspirin-dipyridamoleoral capsule, ermultiphase 12 hr

1 MO

BRILINTA 3 MOCABLIVI INJECTIONKIT

2 LA

cilostazol 1 MOclopidogrel 1 MOdipyridamoleintravenous

1

dipyridamole oral 1 MODOPTELET (10 TABPACK)

2 MO, LA, QL (60per 30 days)

DOPTELET (15 TABPACK)


DOPTELET (30 TABPACK)


ELIQUIS 2 MOELIQUIS DVT-PETREAT 30D START

2 MO

enoxaparinsubcutaneoussolution


enoxaparinsubcutaneoussyringe 100 mg/ml,150 mg/ml




CARDIOVASCULAR, HYPERTENSION/ LIPIDS: COAGULATION THERAPY(continued)Drug Name Tier Requirements/

Limitsenoxaparinsubcutaneoussyringe 120 mg/0.8ml, 80 mg/0.8 ml


enoxaparinsubcutaneoussyringe 30 mg/0.3 ml






fondaparinuxsubcutaneoussyringe 10 mg/0.8 ml


fondaparinuxsubcutaneoussyringe 2.5 mg/0.5 ml


fondaparinuxsubcutaneoussyringe 5 mg/0.4 ml


fondaparinuxsubcutaneoussyringe 7.5 mg/0.6 ml


hep flush-10 (pf) MBheparin (porcine) in5 % dex intravenousparenteral solution20,000 unit/500 ml(40 unit/ml)

1 HI


Limitsheparin (porcine) in5 % dex intravenousparenteral solution25,000 unit/250 ml(100 unit/ml), 25,000unit/500 ml (50 unit/ml)

1 MO, HI

heparin (porcine) innacl (pf)

1

heparin (porcine)injection cartridge

1 MO, HI

heparin (porcine)injection solution

1 MO, HI

heparin (porcine)injection syringe5,000 unit/ml

1 MO, HI

heparin flush(porcine)-0.9nacl

MB MO

heparin lock flush(porcine) intravenoussolution

MB MO

heparin lock flushintravenous solution

MB

heparin lock flushintravenous syringe

MB MO

heparin lockflush(porcine)(pf)

MB MO

heparin(porcine) in0.45% naclintravenousparenteral solution25,000 unit/250 ml,25,000 unit/500 ml

1 MO

heparin, porcine (pf)injection solution1,000 unit/ml

1




Limitsheparin, porcine (pf)injection solution5,000 unit/0.5 ml

1 MO

heparin, porcine (pf)injection syringe5,000 unit/0.5 ml

1 MO

heparin, porcine (pf)intravenous syringe 1unit/ml

MB

heparin, porcine (pf)intravenous syringe10 unit/ml, 100 unit/ml

MB MO

jantoven 1 MOMULPLETA 2 MO, QL (7 per

180 days)NPLATE 2 MOpentoxifylline oraltablet extendedrelease

1 MO

PRADAXA 3 MOprasugrel 1 MOPRAXBIND 2PROMACTA 2 MO, LAprotamine 1TAVALISSE 2 LAwarfarin 1 MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS: LIPID/CHOLESTEROL LOWERINGAGENTSDrug Name Tier Requirements/

Limitsamlodipine-atorvastatin

1 MO

atorvastatin 1 MOcholestyramine (withsugar)

1 MO

cholestyramine light 1colestipol 1 MOezetimibe 1 MOezetimibe-simvastatin 1 MOfenofibrate micronized 1 MOfenofibratenanocrystallized oraltablet 145 mg, 48 mg

1 MO

FENOFIBRATE ORALCAPSULE (BRAND)

2 MO

fenofibrate oral tablet120 mg, 40 mg, 54mg

1 MO

fenofibrate oral tablet160 mg (generic)

1 MO

fenofibric acid 1fenofibric acid(choline) oralcapsule,delayedrelease(dr/ec)

1 MO

fluvastatin oralcapsule

1 MO

gemfibrozil 1 MOicosapent ethyl 1 PA, MOJUXTAPID 3 PA, MO, LAlovastatin 1 MO



CARDIOVASCULAR, HYPERTENSION/ LIPIDS: LIPID/CHOLESTEROLLOWERING AGENTS (continued)Drug Name Tier Requirements/

LimitsNEXLETOL 2 PA, MO, QL (30

per 30 days)NEXLIZET 2 PA, MO, QL (30

per 30 days)niacin oral tablet 500mg

1

niacin oral tabletextended release 24hr

1

omega-3 acid ethylesters

1 MO

PRALUENTSUBCUTANEOUSPEN INJECTOR 150MG/ML

2 PA, QL (2 per 28days)

PRALUENTSUBCUTANEOUSPEN INJECTOR 75MG/ML

2 PA, QL (4 per 28days)

pravastatin 1 MOprevalite 1 MOrosuvastatin 1 MOsimvastatin oral tablet 1 MOVASCEPA 3 PA, MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS:MISCELLANEOUSCARDIOVASCULAR AGENTSDrug Name Tier Requirements/

Limitscardioplegic soln 1CORLANOR ORALSOLUTION

2 PA

CORLANOR ORALTABLET

2 PA, MO

digitek 1 MOdigox 1 MOdigoxin injectionsolution

1 HI

digoxin oral solution50 mcg/ml (0.05 mg/ml)

1 MO

digoxin oral tablet 1 MOdobutamine in d5wintravenousparenteral solution1,000 mg/250 ml(4,000 mcg/ml), 250mg/250 ml (1 mg/ml),500 mg/250 ml(2,000 mcg/ml)

1

dobutamineintravenous solution250 mg/20 ml (12.5mg/ml)

1

dopamine in 5 %dextrose intravenoussolution 200 mg/250ml (800 mcg/ml), 400mg/250 ml (1,600mcg/ml), 400 mg/500ml (800 mcg/ml), 800mg/500 ml (1,600mcg/ml)

1



CARDIOVASCULAR, HYPERTENSION/ LIPIDS: MISCELLANEOUSCARDIOVASCULAR AGENTS(continued)Drug Name Tier Requirements/

Limitsdopamine in 5 %dextrose intravenoussolution 800 mg/250ml (3,200 mcg/ml)

1 MO

dopamine intravenoussolution 200 mg/5 ml(40 mg/ml)

1

dopamine intravenoussolution 400 mg/10ml (40 mg/ml)

1 MO

ENTRESTO 2 MO, QL (60 per30 days)

isoproterenol hcl 1milrinone 1milrinone in 5 %dextrose

1

norepinephrinebitartrate

1

ranolazine 1 MOsodium nitroprusside 1VECAMYL 3VYNDAMAX 2 PA, MOVYNDAQEL 2 PA, MO

CARDIOVASCULAR,HYPERTENSION / LIPIDS: NITRATESDrug Name Tier Requirements/

Limitsisosorbide dinitrateoral tablet

1 MO

isosorbidemononitrate oraltablet

1 MO

isosorbidemononitrate oraltablet extendedrelease 24 hr

1 MO

nitro-bid 1 MOnitroglycerin in 5 %dextrose intravenoussolution 100 mg/250ml (400 mcg/ml), 25mg/250 ml (100 mcg/ml), 50 mg/250 ml(200 mcg/ml)

1

nitroglycerinintravenous

1 HI

nitroglycerinsublingual

1 MO

nitroglycerintransdermal patch 24hour

1 MO

nitroglycerintranslingual spray,non-aerosol

1 MO



DERMATOLOGICALS/TOPICALTHERAPY: ANTIPSORIATIC /ANTISEBORRHEICDrug Name Tier Requirements/

Limitsacitretin 1 MOcalcipotriene scalp 1 MOcalcipotriene topicalcream

1 MO

calcipotriene topicalointment

1 MO

calcipotriene-betamethasone

1 MO

calcitriol topical 1COSENTYX 2 PA, MO, QL (2

per 28 days)COSENTYX (2SYRINGES)


COSENTYX PEN 2 PA, MO, QL (2per 28 days)

COSENTYX PEN (2PENS)


selenium sulfidetopical lotion

1 MO

SKYRIZISUBCUTANEOUSSYRINGE KIT


STELARAINTRAVENOUS

2 PA, MO, HI

STELARASUBCUTANEOUS

2 PA, MO

DERMATOLOGICALS/TOPICALTHERAPY: MISCELLANEOUSDERMATOLOGICALSDrug Name Tier Requirements/

Limitsammonium lactate 1 MOcarbocaine (pf)injection solution 15mg/ml (1.5 %)

1

chloroprocaine (pf) 1CONDYLOXTOPICAL GEL

2 MO

diclofenac sodiumtopical gel 3 %

1 MO

doxepin topical 1 MODUPIXENT PEN 2 PA, MODUPIXENT SYRINGE 2 PA, MOFLUOROURACILTOPICAL CREAM0.5 %

2 MO

fluorouracil topicalcream 5 %

1 MO

fluorouracil topicalsolution

1 MO

glydo 1 MOIMIQUIMOD TOPICALCREAM INMETERED-DOSEPUMP

1 MO

imiquimod topicalcream in packet

1 MO

lidocaine (pf) injectionsolution

1 HI

lidocaine hcl injectionsolution

1 HI

lidocaine hcllaryngotracheal

1 MO

lidocaine hcl mucousmembrane jelly

1 MO



DERMATOLOGICALS/TOPICALTHERAPY: MISCELLANEOUSDERMATOLOGICALS (continued)Drug Name Tier Requirements/

Limitslidocaine hcl mucousmembrane jelly inapplicator

1 MO

lidocaine hcl mucousmembrane solution4 % (40 mg/ml)

1 MO

lidocaine topicaladhesive patch,medicated 5 %

1 PA, MO

lidocaine topicalointment

1 MO

lidocaine viscous 1 MOlidocaine-epinephrine 1lidocaine-epinephrine(pf)

1

lidocaine-prilocainetopical cream

1 MO

methoxsalen 1 MOPANRETIN 2 PA, MOpimecrolimus 1 PA, MOpodofilox 1 MOpolocaine injectionsolution 1 % (10 mg/ml)

1

polocaine-mpf 1prudoxin 1 MOREGRANEX 2 MOSANTYL 2 MOsilver sulfadiazine 1 MOssd 1 MOtacrolimus topical 1 PA, MOUVADEX 2

DERMATOLOGICALS/TOPICALTHERAPY: MISCELLANEOUSDERMATOLOGICALS (continued)Drug Name Tier Requirements/

LimitsVALCHLOR 2 MOxylocaine dental-epinephrine

1



DERMATOLOGICALS/TOPICALTHERAPY: THERAPY FOR ACNEDrug Name Tier Requirements/

Limitsaccutane oral capsule20 mg, 30 mg, 40 mg

1

adapalene topicalcream

1 PA, MO

adapalene topical gel 1 PA, MOadapalene topical gelwith pump

1 PA, MO

adapalene topicalsolution

1 PA

adapalene topicalswab

1 PA

adapalene-benzoylperoxide

1 PA, MO

amnesteem 1avita topical cream 1 PA, MOazelaic acid 1 MOclaravis 1clindacin etz topicalswab

1 MO

clindacin p 1 MOclindamycinphosphate topicalfoam

1

clindamycinphosphate topical gel

1 MO

clindamycinphosphate topicallotion

1 MO

clindamycinphosphate topicalsolution

1 MO

clindamycinphosphate topicalswab

1 MO

DERMATOLOGICALS/TOPICALTHERAPY: THERAPY FOR ACNE(continued)Drug Name Tier Requirements/

Limitsclindamycin-benzoylperoxide

1 MO

clindamycin-tretinoin 1 PA, MOdapsone topical 1 MOery pads 1 MOerygel 1 MOerythromycin withethanol topical gel

1 MO

erythromycin withethanol topicalsolution

1 MO

erythromycin-benzoylperoxide

1 MO

FABIOR 3 MOisotretinoin 1metronidazole topical 1 MOmyorisan 1neuac 1 MOrosadan topical cream 1 MOrosadan topical gel 1 MOtazarotene topicalcream

1 PA, MO

TAZORAC TOPICALCREAM 0.05 %

3 PA, MO

TAZORAC TOPICALGEL

3 PA, MO

tretinoin microspheres 1 PA, MOtretinoin topical 1 PA, MOzenatane 1



DERMATOLOGICALS/TOPICALTHERAPY: TOPICALANTIBACTERIALSDrug Name Tier Requirements/

Limitsgentamicin topical 1 MOmafenide acetate 1 MOmupirocin ointment 1 MOsulfacetamide sodium(acne)

1 MO

SULFAMYLONTOPICAL CREAM

2 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANTIFUNGALSDrug Name Tier Requirements/

Limitsciclodan topicalsolution

1 MO

ciclopirox 1 MOclotrimazole topical 1 MOclotrimazole-betamethasone

1 MO

econazole 1 MOketoconazole topical 1 MOketodan 1 MOLULICONAZOLE 3 MOLUZU 3 MOnaftifine 1 MOnyamyc 1 MOnystatin topical cream 1 MOnystatin topicalointment

1 MO

nystatin topicalpowder

1

nystatin-triamcinolone 1 MOnystop 1 MOoxiconazole 1 MOtavaborole 1 MO

DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL ANTIVIRALSDrug Name Tier Requirements/

Limitsacyclovir topical 1 MODENAVIR 2 MO



DERMATOLOGICALS/TOPICALTHERAPY: TOPICALCORTICOSTEROIDSDrug Name Tier Requirements/

Limitsala-cort topical cream1 %

1 MO

ala-cort topical cream2.5 %

1

alclometasone 1 MOamcinonide topicalcream

1 MO

amcinonide topicallotion

1 MO

amcinonide topicalointment

1

apexicon e 1 MObeser 1 MObetamethasonedipropionate

1 MO

betamethasonevalerate

1 MO

betamethasone,augmented

1 MO

clobetasol 1 MOclobetasol-emollient 1 MOclodan 1 MOdesonide 1 MOdesoximetasone 1 MOdiflorasone topicalcream

1 MO

fluocinolone 1 MOfluocinolone andshower cap

1 MO

fluocinonide 1 MOfluocinonide-e 1 MOfluocinonide-emollient 1

DERMATOLOGICALS/TOPICALTHERAPY: TOPICALCORTICOSTEROIDS (continued)Drug Name Tier Requirements/

Limitsflurandrenolide 1 MOfluticasone propionatetopical

1 MO

halcinonide 1 MOhalobetasolpropionate topicalcream

1 MO

halobetasolpropionate topicalointment

1 MO

hydrocortisonebutyrate

1 MO

hydrocortisone butyr-emollient

1 MO

hydrocortisone topicalcream 1 %, 2.5 %

1 MO

hydrocortisone topicallotion 2.5 %

1 MO

hydrocortisone topicalointment 1 %, 2.5 %

1 MO

hydrocortisonevalerate

1 MO

mometasone topical 1 MOnolix 1 MOprednicarbate 1 MOtovet emollient 1 MOtriamcinoloneacetonide topical

1 MO

trianex 1 MOtriderm topical cream 1 MO



DERMATOLOGICALS/TOPICALTHERAPY: TOPICAL SCABICIDES /PEDICULICIDESDrug Name Tier Requirements/

Limitscrotan 1 MOivermectin topicallotion

1 MO

lindane topicalshampoo

1 MO

malathion 1 MOpermethrin topicalcream

1 MO

spinosad 1 MO

DIAGNOSTICS / MISCELLANEOUSAGENTS: ANTIDOTESDrug Name Tier Requirements/

Limitsacetylcysteineintravenous

1

DIAGNOSTICS / MISCELLANEOUSAGENTS: IRRIGATING SOLUTIONSDrug Name Tier Requirements/

Limitslactated ringersirrigation

1 MO

neomycin-polymyxin bgu

1 MO

ringer's irrigation 1 MOSORBITOLIRRIGATION

2

tis-u-sol pentalyte 1 MO

DIAGNOSTICS / MISCELLANEOUSAGENTS: MISCELLANEOUSAGENTSDrug Name Tier Requirements/

Limitsacamprosate oraltablet,delayedrelease (dr/ec)

1 MO

acetic acid irrigation 1 MOanagrelide 1 MOARALAST NPINTRAVENOUSRECON SOLN 1,000MG

2 PA, MO, HI, LA

ARALAST NPINTRAVENOUSRECON SOLN 500MG

2 PA, MO, HI, LA

bacteriostatic water(parabens)

MB

bd pre-filled normalsaline

MB

caffeine citrateintravenous

1

caffeine citrate oral 1 MOCARBAGLU 3 MO, LAcevimeline 1 MOCHEMET 2CLINIMIX 4.25%/D5WSULFIT FREE

3 B/D PA, HI

CLINIMIX E 2.75%/D5W SULF FREE

3 B/D PA, HI

clovique 1 MOd10 %-0.45 % sodiumchloride

1 HI

d2.5 %-0.45 % sodiumchloride

1 HI

d5 % and 0.9 %sodium chloride

1 MO, HI



DIAGNOSTICS / MISCELLANEOUSAGENTS: MISCELLANEOUS AGENTS(continued)Drug Name Tier Requirements/

Limitsd5 %-0.45 % sodiumchloride

1 MO, HI

deferasirox 1 MOdeferiprone 1deferoxamine 1 MOdextrose 10 % and0.2 % nacl

1 HI

dextrose 10 % inwater (d10w)

1 HI


1


1


1

dextrose 5 % in water(d5w) intravenousparenteral solution

1 MO, HI

dextrose 5 % in water(d5w) intravenouspiggyback

1 MO

dextrose 5 %-lactatedringers

1 MO, HI

dextrose 5%-0.2 %sod chloride

1 HI

dextrose 5%-0.3 %sod.chloride

1 HI


1 MO


1

disulfiram 1 MOdroxidopa 1 MO


LimitsFERRIPROX 2FERRIPROX (2TIMES A DAY)

2

GIVLAARI 2 PA, MOGLASSIA 3 PA, MO, HI, LAINCRELEX 2 PA, MO, LAJADENU SPRINKLE 2 MOkionex (with sorbitol)oral suspension

1 MO

lanthanum oral tablet,chewable

1 MO

levocarnitine (withsugar)

1 MO

levocarnitine oralsolution 100 mg/ml

1 MO

levocarnitine oraltablet

1 MO

midodrine 1 MOmonoject 0.9%sodium chloride

MB

monoject prefilladvanced ns

MB MO

nitisinone 1 MONITYR 2 MO, LAnormal saline flush MB MONORTHERA 3 MOORFADIN ORALCAPSULE 20 MG

2 LA

ORFADIN ORALSUSPENSION

2 LA

OXBRYTA 2 PA, MO, LA, QL(90 per 30days)




Limitspilocarpine hcl oral 1 MOPROLASTIN-CINTRAVENOUSRECON SOLN

2 PA, HI, LA

PROLASTIN-CINTRAVENOUSSOLUTION

2 PA, HI, LA

RAVICTI 3 MOREVCOVI 2riluzole 1 MOrisedronate oral tablet30 mg


sevelamer carbonate 1 MOsevelamer hcl oraltablet 400 mg

1 MO

sevelamer hcl oraltablet 800 mg

1

sodium benzoate-sodphenylacet

1

sodium chlor 0.9%bacteriostat

MB

sodium chloride 0.9 %(flush) injectionsyringe

MB MO

sodium chloride 0.9 %injection

MB

sodium chloride 0.9 %intravenousparenteral solution

1 MO, HI

sodium chloride 0.9 %intravenouspiggyback

1 MO, HI

sodium chlorideinjection

MB


Limitssodium chlorideirrigation

1 MO

sodium phenylbutyrateoral powder

1 MO

sodium phenylbutyrateoral tablet

1

sodium polystyrene(sorb free)

1

sodium polystyrenesulfonate oral powder

1 MO

sps (with sorbitol) oral 1 MOsps (with sorbitol)rectal

1

THIOLA 2THIOLA EC 2TIGLUTIK 3trientine 1 MOVELTASSA 3 MOwater for inject,bacteriostat

MB

water for irrigation,sterile

1 MO

XURIDEN 2zoledronic acid-mannitol-waterintravenouspiggyback 5 mg/100ml

1 MO, HI



DIAGNOSTICS / MISCELLANEOUSAGENTS: SMOKING DETERRENTSDrug Name Tier Requirements/

Limitsbupropion hcl(smoking deter) oraltablet extendedrelease

1 MO

CHANTIX 2 MOCHANTIXCONTINUINGMONTH BOX

2 MO

CHANTIX STARTINGMONTH BOX

2 MO

NICOTROL 2 MONICOTROL NS 2 MO

EAR, NOSE / THROATMEDICATIONS: MISCELLANEOUSAGENTSDrug Name Tier Requirements/

Limitsazelastine nasal 1 MO, QL (60 per

30 days)chlorhexidinegluconate mucousmembrane

1 MO

denta 5000 plus 1 MOdentagel 1 MOfluoride (sodium)dental cream

1 MO

fluoride (sodium)dental gel

1

fluoride (sodium)dental paste

1 MO

ipratropium bromidenasal spray,non-aerosol 21 mcg(0.03 %)


ipratropium bromidenasal spray,non-aerosol 42 mcg(0.06 %)


olopatadine nasal 1 MO, QL (30.5per 30 days)

oralone 1 MOparoex oral rinse 1 MOperiogard 1 MOsf 1 MOsf 5000 plus 1 MOsodium fluoride 5000dry mouth

1

sodium fluoride 5000plus

1

sodium fluoride-potnitrate

1 MO



EAR, NOSE / THROATMEDICATIONS: MISCELLANEOUSAGENTS (continued)Drug Name Tier Requirements/

Limitstriamcinoloneacetonide dental

1 MO

EAR, NOSE / THROATMEDICATIONS: MISCELLANEOUSOTIC PREPARATIONSDrug Name Tier Requirements/

Limitsacetic acid otic (ear) 1 MOciprofloxacin hcl otic(ear)

1 MO

flac otic oil 1fluocinolone acetonideoil

1 MO

hydrocortisone-aceticacid

1 MO

ofloxacin otic (ear) 1 MO

EAR, NOSE / THROATMEDICATIONS: OTIC STEROID /ANTIBIOTICDrug Name Tier Requirements/

LimitsCIPRODEX 2 MOciprofloxacin-dexamethasone

1 MO

neomycin-polymyxin-hc otic (ear)

1 MO

ENDOCRINE/DIABETES: ADRENALHORMONESDrug Name Tier Requirements/

Limitsbetamethasone acet,sod phos

1 MO

decadron oral tablet0.5 mg

1

dexabliss 1dexamethasone 1 MOdexamethasoneintensol

1 MO

dexamethasonesodium phos (pf)injection solution

1 MO

dexamethasonesodium phosphateinjection

1 MO

fludrocortisone 1 MOhidex 1hydrocortisone oral 1 MOmethylprednisoloneacetate

1 MO

methylprednisoloneoral tablet

1 B/D PA, MO

methylprednisoloneoral tablets,dosepack

1 MO

methylprednisolonesodium succ injectionrecon soln 125 mg,40 mg

1 MO, HI

methylprednisolonesodium succintravenous reconsoln 1,000 mg

1 MO, HI

methylprednisolonesodium succintravenous reconsoln 500 mg

1



ENDOCRINE/DIABETES: ADRENALHORMONES (continued)Drug Name Tier Requirements/

Limitsmillipred oral tablet 1 B/D PA, MOprednisolone oralsolution 15 mg/5 ml

1 MO

prednisolone sodiumphosphate oralsolution 10 mg/5 ml,15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4mg/ml), 25 mg/5 ml(5 mg/ml), 5 mgbase/5 ml (6.7 mg/5ml)

1 MO

prednisolone sodiumphosphate oralsolution 15 mg/5 ml(5 ml)

1

prednisolone sodiumphosphate oral tablet,disintegrating

1 B/D PA, MO

prednisone intensol 1 B/D PA, MOprednisone oralsolution

1 MO

prednisone oral tablet 1 B/D PA, MOprednisone oraltablets,dose pack

1 MO

triamcinoloneacetonide injectionsuspension 40 mg/ml

1 MO

ENDOCRINE/DIABETES:ANTITHYROID AGENTSDrug Name Tier Requirements/

Limitsmethimazole oraltablet 10 mg, 5 mg

1 MO

propylthiouracil 1 MO



ENDOCRINE/DIABETES: DIABETESTHERAPYDrug Name Tier Requirements/

Limitsacarbose 1 MOALCOHOL PADS 2AVANDIA ORALTABLET 2 MG, 4 MG

3 MO

BAQSIMI 2 MOBYDUREON BCISE 2 MO, QL (3.4 per

28 days)BYETTASUBCUTANEOUSPEN INJECTOR 10MCG/DOSE(250MCG/ML) 2.4 ML

2 MO, QL (2.4 per30 days)

BYETTASUBCUTANEOUSPEN INJECTOR 5MCG/DOSE (250MCG/ML) 1.2 ML


CYCLOSET 3 MODEXCOM RECEIVER MB QL (1 per 365

days)DEXCOM SENSOR MBDEXCOMTRANSMITTER

MB

diazoxide 1 MOGAUZE PADS 2X2 2glimepiride 1 MOglipizide oral tablet 1 MOglipizide oral tabletextended release24hr

1 MO

glipizide-metformin 1 MOGLUCAGENHYPOKIT

2 MO

ENDOCRINE/DIABETES: DIABETESTHERAPY (continued)Drug Name Tier Requirements/

LimitsGLUCAGON (HCL)EMERGENCY KIT

2

GLUCAGONEMERGENCY KIT(HUMAN)

2 MO

glyburide 1 MOglyburide micronized 1 MOglyburide-metformin 1 MOHUMALOG JUNIORKWIKPEN U-100

2 MO

HUMALOG KWIKPENINSULIN

2 MO

HUMALOG MIX 50-50INSULN U-100

2 MO

HUMALOG MIX 50-50KWIKPEN

2 MO

HUMALOG MIX 75-25KWIKPEN

2 MO

HUMALOG MIX 75-25(U-100)INSULN

2 MO

HUMALOG U-100INSULIN

2 MO

HUMULIN 70/30U-100 INSULIN

2 MO

HUMULIN 70/30U-100 KWIKPEN

2 MO

HUMULIN N NPHINSULIN KWIKPEN

2 MO

HUMULIN N NPHU-100 INSULIN

2 MO

HUMULIN RREGULAR U-100INSULN

2 MO

HUMULIN R U-500(CONC) INSULIN

2 MO




LimitsINPEN (FORHUMALOG)


INSULIN PENNEEDLE

2 MO

INSULIN SYRINGE(DISP) U-100 0.3 ML

2

INSULIN SYRINGE(DISP) U-100 1 ML

2 MO

INSULIN SYRINGE(DISP) U-100 1/2 ML

2

INVOKAMET 2 MOINVOKAMET XR 2 MOINVOKANA 2 MOJANUMET 2 MOJANUMET XR 2 MOJANUVIA 2 MOJARDIANCE 2 MOKOMBIGLYZE XR 2 MOLANTUS SOLOSTARU-100 INSULIN

2 MO

LANTUS U-100INSULIN

2 MO

metformin oralsolution

1 MO

metformin oral tablet 1 MOmetformin oral tabletextended release 24hr (generic -GLUCOPHAGE XR)

1 MO

miglitol 1 MOnateglinide 1 MONEEDLES, INSULINDISP.,SAFETY

2 MO


LimitsONETOUCH BLOODGLUCOSE METERS

MB QL (1 per 365days)

ONETOUCH ULTRABLUE TEST STRIP

MB MO, QL (300 per30 days)

ONETOUCH VERIOTEST STRIP

MB MO, QL (300 per28 days)

ONGLYZA 2 MOOZEMPICSUBCUTANEOUSPEN INJECTOR 0.25MG OR 0.5 MG(2MG/1.5 ML)

3 ST, MO, QL (1.5per 28 days)

OZEMPICSUBCUTANEOUSPEN INJECTOR 1MG/DOSE (2 MG/1.5ML)

3 ST, MO, QL (3per 28 days)

OZEMPICSUBCUTANEOUSPEN INJECTOR 1MG/DOSE (4 MG/3ML)

3 ST, QL (3 per 28days)

pioglitazone 1 MOpioglitazone-glimepiride

1 MO

pioglitazone-metformin

1 MO

repaglinide 1 MORYBELSUS 3 ST, MO, QL (30

per 30 days)SYMLINPEN 120 2 MOSYMLINPEN 60 2 MOSYNJARDY 2 MOSYNJARDY XR 2 MO




LimitsTOUJEO MAX U-300SOLOSTAR

2 MO

TOUJEO SOLOSTARU-300 INSULIN

2 MO

TRULICITY 2 MO, QL (2 per28 days)

VGO 2

ENDOCRINE/DIABETES:MISCELLANEOUS HORMONESDrug Name Tier Requirements/

LimitsALDURAZYME 2 MO, HIcabergoline 1 MOcalcitonin (salmon) 1 MOcalcitriol intravenoussolution 1 mcg/ml

1 HI

calcitriol oral capsule 1 MOcalcitriol oral solution 1CERDELGA 2 MOCEREZYMEINTRAVENOUSRECON SOLN 400UNIT

2 PA, MO, HI

CHORIONICGONADOTROPIN,HUMANINTRAMUSCULAR

2 PA, MO

cinacalcet 1 MOclomiphene citrate 1 PA, MOCRYSVITA 2 MOdanazol 1 MOdesmopressininjection

1 MO, HI

desmopressin nasalspray with pump

1 MO

desmopressin nasalspray,non-aerosol

1

desmopressin oral 1 MOdoxercalciferolintravenous

1

doxercalciferol oral 1 MOELELYSO 2 MO, HIFABRAZYME 2 MO, HIGALAFOLD 2 PA, MO, LA



ENDOCRINE/DIABETES:MISCELLANEOUS HORMONES(continued)Drug Name Tier Requirements/

LimitsISTURISA 2 PA, LAJYNARQUE 2 LAKANUMA 2 MO, HIKORLYM 3 PAKUVAN 2 MOMEPSEVII 2 MOMETHITEST 2 MOmethyltestosteroneoral capsule

1 MO

MIACALCININJECTION

3 MO

miglustat 1 MO, LAMYALEPT 2 MO, LANAGLAZYME 2 MO, HINATPARA 3 PA, MO, LANOVAREL 2 PA, MOoxandrolone 1 PA, MOPALYNZIQ 2 MO, LApamidronate 1 MO, HIPARICALCITOLHEMODIALYSISPORT INJECTION

2

paricalcitolintravenous

2 HI

PARICALCITOLINTRAVENOUSSOLUTION 2 MCG/ML (BRAND)

2 HI

PARICALCITOLINTRAVENOUSSOLUTION 5 MCG/ML (BRAND)

2 MO, HI


Limitsparicalcitol oral 1 MOPARSABIV 2 MOSAMSCA 2 MOsapropterin 1 MOSOMAVERT 2 MOSTRENSIQ 2SYNAREL 2 MOTEPEZZA 2 PA, MOtestosterone cypionateintramuscular oil 100mg/ml, 200 mg/ml

1 MO

testosterone cypionateintramuscular oil 200mg/ml (1 ml)

1

testosteroneenanthate

1 MO

testosteronetransdermal gel(generic)

1 MO

testosteronetransdermal gel inmetered-dose pump10 mg/0.5 gram(Fortesta generic)

1 MO

testosteronetransdermal gel inmetered-dose pump12.5 mg/ 1.25 gram(1 %) (Androgelgeneric)

1 MO




Limitstestosteronetransdermal gel inmetered-dose pump20.25 mg/1.25 gram(1.62 %) (Androgelgeneric)

1 MO

testosteronetransdermal gel inpacket (Androgelgeneric)

1 MO

testosteronetransdermal solutionin metered pump w/app (Axiron generic)

1 MO

tolvaptan oral tablet30 mg

1 MO

VIMIZIM 2 MOzoledronic acidintravenous solution

1 MO, HI

zoledronic acid-mannitol-waterintravenouspiggyback 4 mg/100ml

1 MO, HI

ENDOCRINE/DIABETES: THYROIDHORMONESDrug Name Tier Requirements/

Limitseuthyrox 1 MOlevo-t 1levothyroxineintravenous reconsoln

1 MO

levothyroxine oraltablet

1

levoxyl oral tablet 100mcg, 112 mcg, 125mcg, 137 mcg, 150mcg, 175 mcg, 200mcg, 25 mcg, 50mcg, 75 mcg, 88 mcg

1 MO

liothyronineintravenous

1 MO, HI

liothyronine oral 1 MOnp thyroid 1 MOunithroid 1 MO



GASTROENTEROLOGY:ANTIDIARRHEALS /ANTISPASMODICSDrug Name Tier Requirements/

Limitsatropine injectionsolution 0.4 mg/ml

1

atropine injectionsyringe 0.05 mg/ml,0.1 mg/ml

1

chlordiazepoxide-clidinium

1

CUVPOSA 3 MOdicyclomineintramuscular

1 MO

dicyclomine oralcapsule

1 MO

dicyclomine oralsolution

1 MO

dicyclomine oral tablet 1 MOdiphenoxylate-atropine

1 MO

glycopyrrolate (pf) inwater intravenoussyringe 0.4 mg/2 ml(0.2 mg/ml)

1

glycopyrrolateinjection

1 MO

glycopyrrolate oraltablet 1 mg, 2 mg

1 MO

glycopyrrolate oraltablet 1.5 mg

1

loperamide oralcapsule

1 MO

methscopolamine 1 MOMYTESI 2 MOopium tincture 1 MO

GASTROENTEROLOGY:MISCELLANEOUSGASTROINTESTINAL AGENTSDrug Name Tier Requirements/

Limitsalosetron 1 MO, QL (60 per

30 days)aprepitant 1 B/D PA, MObalsalazide 1 MObudesonide oralcapsule,delayed,extend.release

1 MO

budesonide oraltablet,delayed andext.release

1

CHOLBAM 2CIMZIA 3 PA, MO, QL (3

per 28 days)CIMZIA POWDERFOR RECONST


CIMZIA STARTER KIT 3 PA, MO, QL (3per 28 days)

CINVANTI 2 MO, HIcompro 1 MOconstulose 1 MOCREON 2 MOcromolyn oral 1 MOCYSTADANE 2dimenhydrinateinjection solution

1 MO

doxylamine-pyridoxine(vit b6)

1 MO

dronabinol 1 B/D PA, MOdroperidol injectionsolution

1 MO

EMEND ORALSUSPENSION FORRECONSTITUTION

2 B/D PA



GASTROENTEROLOGY:MISCELLANEOUSGASTROINTESTINAL AGENTS(continued)Drug Name Tier Requirements/

LimitsENTYVIO 2 PA, MOenulose 1 MOfosaprepitant 1 MOGATTEX 30-VIAL 3 PA, MOGATTEX ONE-VIAL 3 PA, MOgavilyte-c 1 MOgavilyte-g 1 MOgavilyte-n 1 MOgenerlac 1 MOgranisetron (pf)intravenous solution1 mg/ml (1 ml)

1 MO, HI

granisetron hclintravenous

1 MO, HI

granisetron hcl oral 1 B/D PA, MOhydrocortisone rectal 1 MOhydrocortisone topicalcream with perinealapplicator

1 MO

hydrocortisone-pramoxine rectalcream 1-1 %

1 MO

INFLECTRA 2 PA, MO, HIlactulose oral packet 1 MOlactulose oral solution10 gram/15 ml

1 MO

lactulose oral solution10 gram/15 ml (15ml), 20 gram/30 ml

1

LINZESS 2 MO, QL (30 per30 days)


Limitsmeclizine oral tablet12.5 mg, 25 mg

1 MO

mesalamine oralcapsule (with del reltablets)

1 MO

mesalamine oralcapsule,extendedrelease 24hr

1

mesalamine oraltablet,delayedrelease (dr/ec)

1 MO

mesalamine oraltablet,delayedrelease (dr/ec)

1 MO

mesalamine rectal 1 MOmesalamine rectal 1 MOmetoclopramide hclinjection solution

1 MO, HI

metoclopramide hclinjection syringe

1 HI

metoclopramide hcloral

1 MO

MOTEGRITY 3 MO, QL (30 per30 days)

OCALIVA 3 MO, LA, QL (30per 30 days)

ondansetron hcl (pf) 1 MO, HIondansetron hclintravenous

1 MO, HI

ondansetron hcl oralsolution

1 B/D PA, MO

ondansetron hcl oraltablet 24 mg

1 B/D PA




Limitsondansetron hcl oraltablet 4 mg, 8 mg

1 B/D PA, MO

ondansetron oraltablet,disintegrating

1 B/D PA, MO

OSMOPREP 3 MOpalonosetronintravenous solution0.25 mg/5 ml

1 MO

palonosetronintravenous syringe

1

peg 3350-electrolytesoral recon soln236-22.74-6.74 -5.86gram

1 MO

peg3350-sod sul-nacl-kcl-asb-c

1 MO

peg-electrolyte 1PENTASA 2 MOpolyethylene glycol3350 oral powder

1 MO

prochlorperazine 1 MOprochlorperazineedisylate injectionsolution 10 mg/2 ml(5 mg/ml)

1 MO

prochlorperazineedisylate injectionsolution 5 mg/ml

1

prochlorperazinemaleate oral

1 MO

procto-med hc 1 MOprocto-pak 1 MOproctosol hc topical 1 MO


Limitsproctozone-hc 1 MORECTIV 3 MORELISTOR ORAL 2 MORELISTORSUBCUTANEOUSSOLUTION

2 MO

RELISTORSUBCUTANEOUSSYRINGE

2 MO

scopolamine base 1 MOSUCRAID 2sulfasalazine oraltablet

1 MO

sulfasalazine oraltablet,delayedrelease (dr/ec)

1 MO

SYNDROS 3 B/D PAtrilyte with flavorpackets

1 MO

trimethobenzamideoral

1 B/D PA, MO

UCERIS RECTAL 3 MOursodiol 1 MOVARUBI ORAL 2 B/D PA




LimitsZENPEP ORALCAPSULE,DELAYEDRELEASE(DR/EC)10,000-32,000 -42,000UNIT,15,000-47,000 -63,000UNIT, 20,000-63,000-84,000 UNIT,25,000-79,000-105,000 UNIT,3,000-10,000 -14,000-UNIT,40,000-126,000-168,000 UNIT,5,000-17,000- 24,000UNIT

2 MO

GASTROENTEROLOGY: ULCERTHERAPYDrug Name Tier Requirements/

Limitsamoxicil-clarithromy-lansopraz

1 MO

cimetidine 1 MOcimetidine hcl oral 1 MOesomeprazolemagnesium oralcapsule,delayedrelease(dr/ec) 20 mg


esomeprazolemagnesium oralcapsule,delayedrelease(dr/ec) 40 mg


esomeprazolemagnesium oralgranules dr for suspin packet 10 mg, 20mg

1 ST, QL (30 per30 days)

esomeprazolemagnesium oralgranules dr for suspin packet 40 mg

1 ST, QL (60 per30 days)

esomeprazole sodiumintravenous reconsoln 40 mg

1 MO, HI

famotidine (pf) 1 MO, HIfamotidine (pf)-nacl(iso-os)

1 MO, HI

famotidine intravenoussolution

1 MO, HI

famotidine oralsuspension

1 MO

famotidine oral tablet20 mg, 40 mg

1 MO

lansoprazole oralcapsule,delayedrelease(dr/ec) 15 mg




GASTROENTEROLOGY: ULCERTHERAPY (continued)Drug Name Tier Requirements/

Limitslansoprazole oralcapsule,delayedrelease(dr/ec) 30 mg


lansoprazole oraltablet,disintegrat,delay rel 15 mg


lansoprazole oraltablet,disintegrat,delay rel 30 mg


misoprostol 1 MOnizatidine 1 MOomeprazole oralcapsule,delayedrelease(dr/ec) 10 mg


omeprazole oralcapsule,delayedrelease(dr/ec) 20 mg,40 mg


pantoprazoleintravenous

1 MO, HI

pantoprazole oralgranules dr for suspin packet


pantoprazole oraltablet,delayedrelease (dr/ec) 20 mg


pantoprazole oraltablet,delayedrelease (dr/ec) 40 mg


rabeprazole oraltablet,delayedrelease (dr/ec)


ranitidine hcl oralsyrup

1 MO

ranitidine hcl oraltablet 150 mg, 300mg

1 MO

GASTROENTEROLOGY: ULCERTHERAPY (continued)Drug Name Tier Requirements/

Limitssucralfate 1 MO



IMMUNOLOGY, VACCINES /BIOTECHNOLOGY:BIOTECHNOLOGY DRUGSDrug Name Tier Requirements/

LimitsACTIMMUNE 2 PA, MOARCALYST 2 MOAVONEXINTRAMUSCULARPEN INJECTOR KIT


AVONEXINTRAMUSCULARSYRINGE KIT


EGRIFTA SV 2 PA, MOFULPHILA 2 MO, QL (1.2 per

30 days)GRANIX 2 MOILARIS (PF)SUBCUTANEOUSSOLUTION

2 PA, MO

INTRON AINJECTION

2 PA, MO

LEUKINE INJECTIONRECON SOLN

2 MO, HI

MOZOBIL 2 MONEULASTA 3 PA, MONEULASTA ONPRO 3 PA, MONEUPOGEN 3 PA, MONIVESTYM 3 PA, MONYVEPRIA 3 PA, MOOMNITROPE 2 PA, MOPEGASYSSUBCUTANEOUSSOLUTION


PEGASYSSUBCUTANEOUSSYRINGE


IMMUNOLOGY, VACCINES /BIOTECHNOLOGY:BIOTECHNOLOGY DRUGS (continued)Drug Name Tier Requirements/

LimitsPEGINTRONSUBCUTANEOUSKIT 50 MCG/0.5 ML

2 QL (5 per 28days)

PLEGRIDYSUBCUTANEOUSPEN INJECTOR 125MCG/0.5 ML


PLEGRIDYSUBCUTANEOUSPEN INJECTOR 63MCG/0.5 ML- 94MCG/0.5 ML


PLEGRIDYSUBCUTANEOUSSYRINGE


REBIF (WITHALBUMIN)


REBIF REBIDOSESUBCUTANEOUSPEN INJECTOR 22MCG/0.5 ML, 44MCG/0.5 ML


REBIF REBIDOSESUBCUTANEOUSPEN INJECTOR8.8MCG/0.2ML-22MCG/0.5ML (6)


REBIF TITRATIONPACK


REBLOZYL 2 PARETACRIT 2 PA, MOSEROSTIMSUBCUTANEOUSRECON SOLN 4 MG,5 MG, 6 MG

2 PA, MO



IMMUNOLOGY, VACCINES /BIOTECHNOLOGY:BIOTECHNOLOGY DRUGS (continued)Drug Name Tier Requirements/

LimitsUDENYCA 2 MO, QL (1.2 per

30 days)ZARXIO 2 MOZIEXTENZO 2 MO, QL (1.2 per

28 days)ZORBTIVE 2 PA, MO

IMMUNOLOGY, VACCINES /BIOTECHNOLOGY: VACCINES /MISCELLANEOUSIMMUNOLOGICALSDrug Name Tier Requirements/

LimitsACTHIB (PF) 1 MOADACEL(TDAPADOLESN/ADULT)(PF)

1 MO

AFLURIA QD 2020-21(3YR UP)(PF)

MB MO

AFLURIA QD 2020-21(6-35MO)(PF)

MB

AFLURIA QUAD2020-2021(6MO UP)

MB

BCG VACCINE, LIVE(PF)

1 MO

BEXSERO 1 MOBOOSTRIX TDAP 1 MOBOTOX 3 PA, MODAPTACEL (DTAPPEDIATRIC) (PF)

1 MO

DYSPORT 3 PA, MOENGERIX-B (PF)INTRAMUSCULARSUSPENSION

1 B/D PA, MO

ENGERIX-B (PF)INTRAMUSCULARSYRINGE

1 B/D PA, MO

ENGERIX-BPEDIATRIC (PF)INTRAMUSCULARSYRINGE

1 B/D PA, MO

FLUAD 2020-2021 (65YR UP)(PF)

MB MO

FLUAD QUAD2020-21(65Y UP)(PF)

MB MO



IMMUNOLOGY, VACCINES /BIOTECHNOLOGY: VACCINES /MISCELLANEOUSIMMUNOLOGICALS (continued)Drug Name Tier Requirements/

LimitsFLUARIX QUAD2020-2021 (PF)

MB MO

FLUBLOK QUAD2020-2021 (PF)

MB MO

FLUCELVAX QUAD2020-2021

MB

FLUCELVAX QUAD2020-2021 (PF)

MB MO

FLULAVAL QUAD2020-2021 (PF)

MB MO

FLUMIST QUAD2020-2021

MB

FLUZONEHIGHDOSE QUAD20-21 PF

MB MO

FLUZONE QUAD2020-2021

MB

FLUZONE QUAD2020-2021 (PF)INTRAMUSCULARSUSPENSION

MB

FLUZONE QUAD2020-2021 (PF)INTRAMUSCULARSYRINGE

MB MO

fomepizole 1 HIGAMASTAN 2 MOGAMASTAN S/D 2GAMMAGARDLIQUID

2 PA, MO, HI

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

2 PA, MO, HI


LimitsGAMUNEX-CINJECTIONSOLUTION 1GRAM/10 ML (10 %)

2 PA, MO, HI

GAMUNEX-CINJECTIONSOLUTION 10GRAM/100 ML(10 %), 2.5 GRAM/25ML (10 %), 20GRAM/200 ML(10 %), 40GRAM/400 ML(10 %), 5 GRAM/50ML (10 %)

2 B/D PA, MO, HI

GARDASIL 9 (PF) 1 MOGRASTEK 3 MOHAVRIX (PF)INTRAMUSCULARSUSPENSION

1 MO

HAVRIX (PF)INTRAMUSCULARSYRINGE 1,440ELISA UNIT/ML

1 MO

HAVRIX (PF)INTRAMUSCULARSYRINGE 720 ELISAUNIT/0.5 ML

1 MO

HIBERIX (PF) 1 MOIMOVAX RABIESVACCINE (PF)

1

INFANRIX (DTAP)(PF)INTRAMUSCULARSUSPENSION

1 MO




LimitsINFANRIX (DTAP)(PF)INTRAMUSCULARSYRINGE

1 MO

IPOL 1IXIARO (PF) 1KINRIX (PF)INTRAMUSCULARSUSPENSION

1

KINRIX (PF)INTRAMUSCULARSYRINGE

1 MO

MENACTRA (PF)INTRAMUSCULARSOLUTION

1 MO

menquadfi (pf) 1MENVEO A-C-Y-W-135-DIP (PF)

1 MO

M-M-R II (PF) 1 MOORALAIRSUBLINGUALTABLET 300 INDXREACTIVITY

3

PEDIARIX (PF) 1 MOPEDVAX HIB (PF) 1PENTACEL (PF) 1PNEUMOVAX-23 MB MOPREVNAR 13 (PF) MB MOPROQUAD (PF) 1QUADRACEL (PF) 1RABAVERT (PF) 1 MORAGWITEK 3 MO


LimitsRECOMBIVAX HB(PF)INTRAMUSCULARSUSPENSION 10MCG/ML, 40 MCG/ML

1 B/D PA, MO

RECOMBIVAX HB(PF)INTRAMUSCULARSUSPENSION 5MCG/0.5 ML

1 B/D PA, MO

RECOMBIVAX HB(PF)INTRAMUSCULARSYRINGE 10 MCG/ML

1 B/D PA, MO

RECOMBIVAX HB(PF)INTRAMUSCULARSYRINGE 5 MCG/0.5ML

1 B/D PA

ROTARIX 1ROTATEQ VACCINE 1 MOSHINGRIX (PF) 1 MOSTAMARIL (PF) 1TDVAX 1 MOTENIVAC (PF)INTRAMUSCULARSUSPENSION

1 MO

TENIVAC (PF)INTRAMUSCULARSYRINGE

1 MO

TETANUS,DIPHTHERIA TOXPED(PF)

1 MO




LimitsTICE BCG 1 MOTRUMENBA 1 MOTWINRIX (PF)INTRAMUSCULARSYRINGE

1 MO

TYPHIM VIINTRAMUSCULARSOLUTION

1

TYPHIM VIINTRAMUSCULARSYRINGE

1 MO

VAQTA (PF) 1 MOVARIVAX (PF) 1VARIZIGINTRAMUSCULARSOLUTION

1 MO

XEOMIN 3 PA, MOYF-VAX (PF) 1ZINPLAVA 2 PA, MO, HIZOSTAVAX (PF) 1

MUSCULOSKELETAL /RHEUMATOLOGY: GOUT THERAPYDrug Name Tier Requirements/

Limitsallopurinol 1 MOallopurinol sodium 1 HIaloprim 1 HIcolchicine oral tablet 1 MOfebuxostat 1 MOKRYSTEXXA 3 MOprobenecid 1 MOprobenecid-colchicine 1 MO



MUSCULOSKELETAL /RHEUMATOLOGY: OSTEOPOROSISTHERAPYDrug Name Tier Requirements/

Limitsalendronate oralsolution


alendronate oral tablet10 mg, 5 mg


alendronate oral tablet35 mg, 70 mg


EVENITYSUBCUTANEOUSSYRINGE 105MG/1.17 ML

3 PA, QL (2.34 per30 days)

EVENITYSUBCUTANEOUSSYRINGE210MG/2.34ML( 105MG/1.17MLX2)

3 PA, MO, QL(2.34 per 30days)

FORTEO 2 PA, MO, QL (2.4per 28 days)

ibandronateintravenous

1 MO

ibandronate oral 1 MO, QL (1 per30 days)

PROLIA 3 PA, MOraloxifene 1 MOrisedronate oral tablet150 mg


risedronate oral tablet35 mg, 35 mg (12pack), 35 mg (4pack)


risedronate oral tablet5 mg


risedronate oral tablet,delayed release (dr/ec)


MUSCULOSKELETAL /RHEUMATOLOGY: OSTEOPOROSISTHERAPY (continued)Drug Name Tier Requirements/

LimitsTYMLOS 2 PA, MO, QL

(1.56 per 30days)



MUSCULOSKELETAL /RHEUMATOLOGY: OTHERRHEUMATOLOGICALSDrug Name Tier Requirements/

LimitsACTEMRA ACTPEN 3 PA, MO, QL (3.6

per 28 days)ACTEMRAINTRAVENOUS

3 PA, MO, HI, QL(40 per 28days)

ACTEMRASUBCUTANEOUS

3 PA, MO, QL (3.6per 28 days)

BENLYSTAINTRAVENOUS

2 MO, HI

BENLYSTASUBCUTANEOUS

2 MO

ENBREL MINI 2 PA, MO, QL (8per 28 days)

ENBRELSUBCUTANEOUSRECON SOLN


ENBRELSUBCUTANEOUSSOLUTION

2 PA, MO, QL (16per 28 days),QL (8 per 28days)

ENBRELSUBCUTANEOUSSYRINGE


ENBREL SURECLICK 2 PA, MO, QL (8per 28 days)

HUMIRA PEN 2 PA, MO, QL (4per 28 days)

HUMIRA PENCROHNS-UC-HSSTART


HUMIRA PEN PSOR-UVEITS-ADOL HS


MUSCULOSKELETAL /RHEUMATOLOGY: OTHERRHEUMATOLOGICALS (continued)Drug Name Tier Requirements/

LimitsHUMIRASUBCUTANEOUSSYRINGE KIT 40MG/0.8 ML


HUMIRA(CF) PEDICROHNS STARTERSUBCUTANEOUSSYRINGE KIT 80MG/0.8 ML


HUMIRA(CF) PEDICROHNS STARTERSUBCUTANEOUSSYRINGE KIT 80MG/0.8 ML-40MG/0.4 ML


HUMIRA(CF) PENCROHNS-UC-HS


HUMIRA(CF) PENPSOR-UV-ADOL HS


HUMIRA(CF) PENSUBCUTANEOUSINJECTOR KIT 40MG/0.4 ML


HUMIRA(CF) PENSUBCUTANEOUSPEN INJECTOR KIT80 MG/0.8 ML


HUMIRA(CF)SUBCUTANEOUSSYRINGE KIT 10MG/0.1 ML, 20MG/0.2 ML


HUMIRA(CF)SUBCUTANEOUSSYRINGE KIT 40MG/0.4 ML





LimitsKEVZARA 3 PA, MO, QL

(2.28 per 28days)

KINERET 2 PAleflunomide 1 MO, QL (30 per

30 days)ORENCIA (WITHMALTOSE)

2 PA, MO, HI, QL(4 per 28 days)

ORENCIACLICKJECT


ORENCIASUBCUTANEOUSSYRINGE 125 MG/ML


ORENCIASUBCUTANEOUSSYRINGE 50 MG/0.4ML


ORENCIASUBCUTANEOUSSYRINGE 87.5MG/0.7 ML


OTEZLA 2 PA, MO, QL (60per 30 days)

OTEZLA STARTERORAL TABLETS,DOSE PACK 10 MG(4)-20 MG (4)-30 MG(47)


penicillamine 1 MORIDAURA 2 MORINVOQ 2 PA, MO, QL (30

per 30 days)SIMPONI ARIA 3 PA, MO, HI


LimitsSIMPONISUBCUTANEOUSPEN INJECTOR 100MG/ML


SIMPONISUBCUTANEOUSPEN INJECTOR 50MG/0.5 ML


SIMPONISUBCUTANEOUSSYRINGE 100 MG/ML


SIMPONISUBCUTANEOUSSYRINGE 50 MG/0.5ML


XELJANZ ORALSOLUTION

2 PA, MO, QL(150 per 30days)

XELJANZ ORALTABLET


XELJANZ XR 2 PA, MO, QL (30per 30 days)



OBSTETRICS / GYNECOLOGY:ESTROGENS / PROGESTINSDrug Name Tier Requirements/

Limitsamabelz 1 MOcamila 1 MOdeblitane 1 MOdotti 1 MOerrin 1 MOestradiol oral 1 MOestradiol transdermalpatch semiweekly

1 MO

estradiol transdermalpatch weekly

1

estradiol vaginal 1 MOestradiol valerateintramuscular oil 20mg/ml, 40 mg/ml

1 MO

estradiol-norethindrone acet

1 MO

fyavolv 1 MOheather 1 MOhydroxyprogesteronecaproate

1

incassia 1 MOjencycla 1 MOjinteli 1 MOlyleq 1 MOlyllana 1 MOlyza 1medroxyprogesterone 1 MOmimvey 1 MOnora-be 1 MOnorethindrone(contraceptive)

1

norethindrone acetate 1 MO

OBSTETRICS / GYNECOLOGY:ESTROGENS / PROGESTINS(continued)Drug Name Tier Requirements/

Limitsnorethindrone ac-ethestradiol oral tablet0.5-2.5 mg-mcg

1

norethindrone ac-ethestradiol oral tablet1-5 mg-mcg

1 MO

norlyda 1 MOPREMARININJECTION

3 HI

progesterone 1 MOprogesteronemicronized

1 MO

sharobel 1 MOtulana 1 MOyuvafem 1 MO



OBSTETRICS / GYNECOLOGY:MISCELLANEOUS OB/GYNDrug Name Tier Requirements/

LimitsCLEOCIN VAGINALSUPPOSITORY

2 MO

clindamycinphosphate vaginal

1 MO

eluryng 1 MOetonogestrel-ethinylestradiol

1

GYNAZOLE-1 3 MOLUPANETA PACK (1MONTH)

3 MO

LUPANETA PACK (3MONTH)

3 MO

metronidazole vaginal 1 MOmiconazole-3 vaginalsuppository

1 MO

terconazole 1 MOtranexamic acid oral 1 MOvandazole 1 MOxulane 1 MOzafemy 1 MO

OBSTETRICS / GYNECOLOGY:ORAL CONTRACEPTIVES /RELATED AGENTSDrug Name Tier Requirements/

Limitsafirmelle 1 MOaltavera (28) 1 MOalyacen 1/35 (28) 1 MOalyacen 7/7/7 (28) 1 MOamethia 1 MOamethyst (28) 1 MOapri 1 MOaranelle (28) 1 MOashlyna 1 MOaubra 1aubra eq 1 MOaurovela 1.5/30 (21) 1 MOaurovela 1/20 (21) 1 MOaurovela 24 fe 1 MOaurovela fe 1.5/30 (28) 1 MOaurovela fe 1-20 (28) 1 MOaviane 1 MOayuna 1azurette (28) 1 MObalziva (28) 1 MObekyree (28) 1 MOblisovi 24 fe 1 MOblisovi fe 1.5/30 (28) 1 MOblisovi fe 1/20 (28) 1 MObriellyn 1 MOcamrese 1 MOcamrese lo 1 MOcaziant (28) 1 MOcharlotte 24 fe 1 MO



OBSTETRICS / GYNECOLOGY: ORALCONTRACEPTIVES / RELATEDAGENTS (continued)Drug Name Tier Requirements/

Limitschateal (28) 1chateal eq (28) 1 MOcryselle (28) 1 MOcyclafem 1/35 (28) 1 MOcyclafem 7/7/7 (28) 1 MOcyred 1cyred eq 1 MOdasetta 1/35 (28) 1 MOdasetta 7/7/7 (28) 1 MOdaysee 1 MOdesog-e.estradiol/e.estradiol

1

desogestrel-ethinylestradiol

1

drospirenone-e.estradiol-lm.fa

1

drospirenone-ethinylestradiol oral tablet3-0.02 mg

1 MO

drospirenone-ethinylestradiol oral tablet3-0.03 mg

1

elinest 1 MOELLA 2emoquette 1 MOenpresse 1 MOenskyce 1 MOestarylla 1 MOethynodiol diac-ethestradiol

1

falmina (28) 1 MO


Limitsfayosim 1 MOfemynor 1 MOgianvi (28) 1 MOhailey 1 MOhailey 24 fe 1 MOhailey fe 1.5/30 (28) 1 MOhailey fe 1/20 (28) 1 MOiclevia 1introvale 1 MOisibloom 1 MOjaimiess 1 MOjasmiel (28) 1 MOjolessa 1 MOjuleber 1 MOjunel 1.5/30 (21) 1 MOjunel 1/20 (21) 1 MOjunel fe 1.5/30 (28) 1 MOjunel fe 1/20 (28) 1 MOjunel fe 24 1 MOkaitlib fe 1 MOkalliga 1kariva (28) 1 MOkelnor 1/35 (28) 1 MOkelnor 1-50 (28) 1 MOkurvelo (28) 1 MO




Limitsl norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month0.10 mg-20 mcg(84)/10 mcg (7), 0.15mg-30 mcg (84)/10mcg (7)

1

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month0.15 mg-20 mcg/0.15 mg-25 mcg

1 MO

larin 1.5/30 (21) 1 MOlarin 1/20 (21) 1 MOlarin 24 fe 1 MOlarin fe 1.5/30 (28) 1 MOlarin fe 1/20 (28) 1 MOlarissia 1 MOlayolis fe 1 MOleena 28 1 MOlessina 1 MOlevonest (28) 1 MOlevonorgestrel-ethinylestrad oral tablet0.1-20 mg-mcg

1 MO

levonorgestrel-ethinylestrad oral tablet0.15-0.03 mg, 90-20mcg (28)

1

levonorgestrel-ethinylestrad oral tablets,dose pack,3 month

1 MO

levonorg-eth estradtriphasic

1 MO


Limitslevora-28 1 MOlillow (28) 1 MOlojaimiess 1 MOloryna (28) 1 MOlow-ogestrel (28) 1 MOlo-zumandimine (28) 1 MOlutera (28) 1 MOmarlissa (28) 1 MOmelodetta 24 fe 1 MOmerzee 1 MOmibelas 24 fe 1 MOmicrogestin 1.5/30(21)

1 MO

microgestin 1/20 (21) 1 MOmicrogestin fe 1.5/30(28)

1 MO

microgestin fe 1/20(28)

1 MO

mili 1 MOmono-linyah 1 MOnecon 0.5/35 (28) 1 MOnikki (28) 1 MOnoreth-ethinylestradiol-iron

1

norethindrone ac-ethestradiol oral tablet1.5-30 mg-mcg

1

norethindrone ac-ethestradiol oral tablet1-20 mg-mcg

1 MO




Limitsnorethindrone-e.estradiol-iron oralcapsule

1

norethindrone-e.estradiol-iron oraltablet 1 mg-20 mcg(21)/75 mg (7), 1.5mg-30 mcg (21)/75mg (7)

1

norethindrone-e.estradiol-iron oraltablet,chewable

1

norgestimate-ethinylestradiol oral tablet0.18/0.215/0.25mg-25 mcg, 0.25-35mg-mcg

1

norgestimate-ethinylestradiol oral tablet0.18/0.215/0.25mg-35 mcg (28)

1 MO

nortrel 0.5/35 (28) 1 MOnortrel 1/35 (21) 1 MOnortrel 1/35 (28) 1 MOnortrel 7/7/7 (28) 1 MOnylia 7/7/7 (28) 1nymyo 1ocella 1 MOorsythia 1 MOphilith 1 MOpimtrea (28) 1 MOpirmella 1 MOportia 28 1 MOprevifem 1 MO


Limitsreclipsen (28) 1 MOrivelsa 1 MOsetlakin 1 MOsimliya (28) 1 MOsimpesse 1 MOsprintec (28) 1 MOsronyx 1 MOsyeda 1 MOtarina 24 fe 1 MOtarina fe 1/20 (28) 1tarina fe 1-20 eq (28) 1 MOtilia fe 1 MOtri femynor 1 MOtri-estarylla 1 MOtri-legest fe 1 MOtri-linyah 1 MOtri-lo-estarylla 1 MOtri-lo-marzia 1 MOtri-lo-mili 1 MOtri-lo-sprintec 1 MOtri-mili 1 MOtri-nymyo 1tri-previfem (28) 1 MOtri-sprintec (28) 1 MOtrivora (28) 1 MOtri-vylibra 1 MOtri-vylibra lo 1 MOtydemy 1 MO




Limitsvelivet triphasicregimen (28)

1 MO

vestura (28) 1vienva 1 MOviorele (28) 1 MOvolnea (28) 1 MOvyfemla (28) 1 MOvylibra 1 MOwera (28) 1 MOwymzya fe 1 MOzarah 1 MOzovia 1/35e (28) 1 MOzovia 1-35 (28) 1zumandimine (28) 1 MO

OBSTETRICS / GYNECOLOGY:OXYTOCICSDrug Name Tier Requirements/

Limitsmethergine 1methylergonovine oral 1

OPHTHALMOLOGY: ANTIBIOTICSDrug Name Tier Requirements/

Limitsak-poly-bac 1 MObacitracin ophthalmic(eye)

1 MO

bacitracin-polymyxin bophthalmic (eye)

1 MO

ciprofloxacin hclophthalmic (eye)

1 MO

erythromycinophthalmic (eye)

1 MO

gatifloxacin 1 MOgentak ophthalmic(eye) ointment

1 MO

gentamicin ophthalmic(eye) drops

1 MO

levofloxacinophthalmic (eye)

1 MO

moxifloxacinophthalmic (eye)drops

1 MO

moxifloxacinophthalmic (eye)drops, viscous

1

NATACYN 2 MOneomycin-bacitracin-polymyxin

1 MO

neomycin-polymyxin-gramicidin

1 MO

neo-polycin 1 MOofloxacin ophthalmic(eye)

1 MO

polycin 1 MOpolymyxin b sulf-trimethoprim

1 MO

tobramycin ophthalmic(eye)

1 MO



OPHTHALMOLOGY: ANTIVIRALSDrug Name Tier Requirements/

Limitstrifluridine 1 MOZIRGAN 3 MO

OPHTHALMOLOGY: BETA-BLOCKERSDrug Name Tier Requirements/

Limitsbetaxolol ophthalmic(eye)

1 MO

carteolol 1 MOlevobunololophthalmic (eye)drops 0.5 %

1 MO

timolol maleate (pf) 1 MOtimolol maleateophthalmic (eye)

1 MO

OPHTHALMOLOGY:MISCELLANEOUSOPHTHALMOLOGICSDrug Name Tier Requirements/

Limitsatropine ophthalmic(eye) drops

1 MO

azelastine ophthalmic(eye)

1 MO

balanced salt 1BLEPHAMIDE 3 MOBLEPHAMIDE S.O.P. 3 MObss 1cromolyn ophthalmic(eye)

1 MO

CYSTARAN 2epinastine 1 MOLACRISERT 2 MOolopatadineophthalmic (eye)

1 MO

OXERVATE 2 PA, MOPHOSPHOLINEIODIDE

2 MO

pilocarpine hclophthalmic (eye)drops 1 %, 2 %, 4 %

1 MO

RESTASIS 2 MO, QL (60 per30 days)

RESTASISMULTIDOSE


sulfacetamide sodiumophthalmic (eye)

1 MO

sulfacetamide-prednisolone

1 MO



OPHTHALMOLOGY: NON-STEROIDAL ANTI-INFLAMMATORYAGENTSDrug Name Tier Requirements/

Limitsbromfenac 1 MOdiclofenac sodiumophthalmic (eye)

1 MO

flurbiprofen sodium 1 MOketorolac ophthalmic(eye)

1 MO

OPHTHALMOLOGY: ORAL DRUGSFOR GLAUCOMADrug Name Tier Requirements/

Limitsacetazolamide oralcapsule, extendedrelease

1 MO

acetazolamide oraltablet

1 MO

acetazolamide sodium 1 MO, HImethazolamide 1 MO

OPHTHALMOLOGY: OTHERGLAUCOMA DRUGSDrug Name Tier Requirements/

Limitsbimatoprostophthalmic (eye)

1 MO

brinzolamide 1 MOCOMBIGAN 2 MOdorzolamide 1 MOdorzolamide-timolol 1 MOdorzolamide-timolol(pf) ophthalmic (eye)dropperette

1 MO

latanoprost 1 MOLUMIGANOPHTHALMIC (EYE)DROPS 0.01 %

2 MO

miostat 1travoprost 1 MO

OPHTHALMOLOGY: STEROID-ANTIBIOTIC COMBINATIONSDrug Name Tier Requirements/

Limitsneomycin-bacitracin-poly-hc

1 MO

neomycin-polymyxinb-dexameth

1 MO

neomycin-polymyxin-hc ophthalmic (eye)

1 MO

neo-polycin hc 1 MOtobramycin-dexamethasone

1 MO



OPHTHALMOLOGY: STEROIDSDrug Name Tier Requirements/

Limitsdexamethasonesodium phosphateophthalmic (eye)

1 MO

fluorometholone 1 MOloteprednol etabonate 1 MOprednisolone acetate 1 MOprednisolone sodiumphosphateophthalmic (eye)

1 MO

OPHTHALMOLOGY:SYMPATHOMIMETICSDrug Name Tier Requirements/

LimitsALPHAGAN POPHTHALMIC (EYE)DROPS 0.1 %

2 MO

apraclonidine 1 MObrimonidineophthalmic (eye)drops 0.15 %

1

brimonidineophthalmic (eye)drops 0.2 %

1 MO

RESPIRATORY AND ALLERGY:ANTIHISTAMINE / ANTIALLERGENICAGENTSDrug Name Tier Requirements/

Limitsadrenalin injectionsolution 1 mg/ml

1

adrenalin injectionsolution 1 mg/ml (1ml)

1 MO

carbinoxaminemaleate

1 MO

cetirizine oral solution1 mg/ml

1 MO

clemastine oral tablet2.68 mg

1 MO

cyproheptadine 1 MOdesloratadine oraltablet

1 MO

desloratadine oraltablet,disintegrating

1 MO

dexchlorpheniraminemaleate oral solution

1

diphenhydramine hclinjection solution 50mg/ml

1 MO, HI

diphenhydramine hclinjection syringe

1 MO, HI

diphenhydramine hcloral elixir

1 PA

epinephrine injectionauto-injector 0.15mg/0.3 ml, 0.3mg/0.3 ml

1 MO

EPINEPHRINEINJECTION AUTO-INJECTOR 0.15MG/0.3 ML, 0.3MG/0.3 ML (BRAND -EPIPEN)

1 MO



RESPIRATORY AND ALLERGY:ANTIHISTAMINE / ANTIALLERGENICAGENTS (continued)Drug Name Tier Requirements/

Limitsepinephrine injectionsolution 1 mg/ml

1

epinephrine injectionsyringe 0.1 mg/ml

1

hydroxyzine hclintramuscular

1 MO

hydroxyzine hcl oralsolution 10 mg/5 ml

1 PA, MO

hydroxyzine hcl oraltablet

1 PA, MO

hydroxyzine pamoate 1 PA, MOlevocetirizine oralsolution

1 MO

levocetirizine oraltablet

1 MO

phenadoz rectalsuppository 25 mg

1 MO

promethazine injectionsolution

1 MO

promethazine oral 1 PA, MOpromethazine rectalsuppository 12.5 mg,25 mg

1

promethegan 1 MO

RESPIRATORY AND ALLERGY:PULMONARY AGENTSDrug Name Tier Requirements/

Limitsacetylcysteine 1 B/D PA, MOADEMPAS 2 PA, MO, LAADVAIR DISKUS 1 MO, QL (60 per

30 days)ADVAIR HFA 3 PA, MO, QL (24

per 30 days)albuterol sulfateinhalation hfa aerosolinhaler 90 mcg/actuation

1 QL (25.5 per 30days)

albuterol sulfateinhalation hfa aerosolinhaler 90 mcg/actuation(nda020503)

1 QL (20.1 per 30days)

albuterol sulfateinhalation solution fornebulization

1 B/D PA, MO

albuterol sulfate oralsyrup

1 MO

albuterol sulfate oraltablet

1 MO

albuterol sulfate oraltablet extendedrelease 12 hr

1 MO

alyq 1 PAambrisentan 1 PA, MO, LAaminophyllineintravenous

1 HI

ANORO ELLIPTA 2 MO, QL (60 per30 days)

ARNUITY ELLIPTA 2 MO, QL (30 per30 days)

ATROVENT HFA 2 MO, QL (25.8per 30 days)



RESPIRATORY AND ALLERGY:PULMONARY AGENTS (continued)Drug Name Tier Requirements/

Limitsazelastine-fluticasone 1 MOBEVESPIAEROSPHERE

2 MO, QL (10.7per 30 days)

bosentan 1 PA, MO, LABREO ELLIPTA 2 MO, QL (60 per

30 days)BRONCHITOL 2 PA, MO, QL

(560 per 28days)

BROVANA 2 B/D PA, MObudesonide inhalation 1 B/D PA, MOCINRYZE 2 PA, MO, HICOMBIVENTRESPIMAT


cromolyn inhalation 1 B/D PA, MODALIRESP 2 MODULERA 2 MO, QL (13 per

30 days)ESBRIET 2 PA, MOFASENRA 2 PA, MOFASENRA PEN 2 PA, MOFLOVENT DISKUSINHALATIONBLISTER WITHDEVICE 100 MCG/ACTUATION, 50MCG/ACTUATION


FLOVENT DISKUSINHALATIONBLISTER WITHDEVICE 250 MCG/ACTUATION



LimitsFLOVENT HFAAEROSOL INHALER110 MCG/ACTUATION


FLOVENT HFAAEROSOL INHALER220 MCG/ACTUATION


FLOVENT HFAAEROSOL INHALER44 MCG/ACTUATION

2 MO, QL (10.6per 30 days)

flunisolide nasal spray,non-aerosol 25 mcg(0.025 %)


fluticasone propionatenasal


HYPER-SALINHALATIONSOLUTION FORNEBULIZATION3.5 %

MB MO

icatibant 1 MOINCRUSE ELLIPTA 2 MO, QL (30 per

30 days)ipratropium bromideinhalation

1 B/D PA, MO

ipratropium-albuterol 1 B/D PA, MOKALYDECO ORALGRANULES INPACKET


KALYDECO ORALTABLET


levalbuterol hcl 1 B/D PA, MOmetaproterenol oralsyrup

1 MO




Limitsmontelukast 1 MOnebusal inhalationsolution fornebulization 3 %

MB MO

NEBUSALINHALATIONSOLUTION FORNEBULIZATION 6 %(BRAND)

MB MO

NUCALA 2 PA, MO, LAOFEV 2 PA, MOOPSUMIT 2 PA, MO, LAORKAMBI ORALGRANULES INPACKET


ORKAMBI ORALTABLET

2 PA, MO, QL(112 per 28days)

ORLADEYO 2 PAPERFOROMIST 2 B/D PA, MOpulmosal MB MOPULMOZYME 2 B/D PA, MORUCONEST 2 MO, HISEREVENT DISKUS 2 MO, QL (60 per

30 days)sildenafil (pulmonaryarterial hypertension)intravenous solution10 mg/12.5 ml

1 PA, HI

sildenafil (pulmonaryarterial hypertension)oral suspension forreconstitution 10 mg/ml

1 PA, MO


Limitssildenafil (pulmonaryarterial hypertension)oral tablet 20 mg

1 PA, MO

sodium chlorideinhalation

MB MO

SPIRIVA RESPIMAT 2 MO, QL (4 per30 days)

SPIRIVA WITHHANDIHALER


STIOLTO RESPIMAT 2 MO, QL (4 per30 days)

SYMBICORT 2 MO, QL (13.8per 30 days)

SYMDEKO ORALTABLETS,SEQUENTIAL100-150 MG (D)/ 150MG (N)


SYMDEKO ORALTABLETS,SEQUENTIAL 50-75MG (D)/ 75 MG (N)


tadalafil (pulmonaryarterial hypertension)oral tablet 20 mg

1 PA

TAKHZYRO 2 MO, LAterbutaline 1 MOtheophylline oral elixir 1theophylline oralsolution

1 MO

theophylline oral tabletextended release 12hr 300 mg, 450 mg

1 MO

theophylline oral tabletextended release 24hr

1 MO




LimitsTRACLEER ORALTABLET FORSUSPENSION

2 PA, MO, LA

TRELEGY ELLIPTA 2 MO, QL (60 per30 days)

TRIKAFTA 2 PA, MO, QL (84per 28 days)

TYVASO 2 B/D PA, MOTYVASOINSTITUTIONALSTART KIT

2 B/D PA

TYVASO REFILL KIT 2 B/D PA, MOTYVASO STARTERKIT

2 B/D PA, MO

VENTAVIS 2 B/D PA, MOXOLAIR 2 PA, MO, LAYUPELRI 3 B/D PA, MO, QL

(90 per 30days)

zafirlukast 1 MOzileuton oral tablet,extended release12hr mphase

1 MO

UROLOGICALS:ANTICHOLINERGICS /ANTISPASMODICSDrug Name Tier Requirements/

Limitsdarifenacin oral tabletextended release 24hr

1 MO

flavoxate 1 MOMYRBETRIQ 2 MOoxybutynin chlorideoral syrup

1 MO

oxybutynin chlorideoral tablet

1 MO

oxybutynin chlorideoral tablet extendedrelease 24hr

1 MO

solifenacin 1 MOtolterodine oralcapsule,extendedrelease 24hr

1 MO

tolterodine oral tablet 1 MOtrospium oral capsule,extended release24hr

1 MO

trospium oral tablet 1 MO



UROLOGICALS: BENIGNPROSTATIC HYPERPLASIA(BPH)THERAPYDrug Name Tier Requirements/

Limitsalfuzosin oral tabletextended release 24hr

1 MO

dutasteride 1 MOdutasteride-tamsulosinoral capsule, ermultiphase 24 hr

1 MO

finasteride oral tablet5 mg

1 MO

silodosin 1 MOtamsulosin oralcapsule,extendedrelease 24hr

1 MO

UROLOGICALS: MISCELLANEOUSUROLOGICALSDrug Name Tier Requirements/

Limitsalprostadil 1bethanechol chloride 1 MOCYSTAGON 2 LAELMIRON 2 MOglycine urologic 1glycine urologicsolution

1

potassium citrate oraltablet extendedrelease

1 MO

PROCYSBI 2 MOtadalafil oral tablet 2.5mg, 5 mg


VITAMINS, HEMATINICS /ELECTROLYTES: BLOODDERIVATIVESDrug Name Tier Requirements/

Limitsalbumin, human 25 % 1albuminar 25 % 1alburx (human) 25 % 1alburx (human) 5 % 1albutein 25 % 1albutein 5 % 1plasbumin 25 % 1plasbumin 5 % 1



VITAMINS, HEMATINICS /ELECTROLYTES: ELECTROLYTESDrug Name Tier Requirements/

Limitscalcium acetate(phosphat bind)

1 MO

calcium chloride 1calcium gluconateintravenous

1

effer-k oral tablet,effervescent 25 meq

1 MO

GLYCOPHOS 2klor-con 10 oral tabletextended release

1 MO

klor-con 20 meqpacket

1 MO

klor-con 8 oral tabletextended release

1 MO

klor-con m10 oraltablet,er particles/crystals

1 MO


1 MO


1 MO

klor-con/ef 1 MOk-tab oral tabletextended release 8meq

1 MO

lactated ringersintravenous

1 MO, HI

magnesium chlorideinjection

1

magnesium sulfate inwater

1

magnesium sulfateinjection solution

1 MO, HI

VITAMINS, HEMATINICS /ELECTROLYTES: ELECTROLYTES(continued)Drug Name Tier Requirements/

Limitsmagnesium sulfateinjection syringe

1 HI

NORMOSOL-R 3potassium acetateintravenous solution2 meq/ml

1

potassium chlorid-d5-0.45%nacl

1 HI

potassium chloride in0.9%nacl intravenousparenteral solution 20meq/l, 40 meq/l

1 HI

potassium chloride in5 % dex intravenousparenteral solution 20meq/l

1 HI

potassium chloride in5 % dex intravenousparenteral solution 30meq/l, 40 meq/l

1

potassium chloride in5 % dex intravenousparenteral solution 30meq/l, 40 meq/l

1 HI

potassium chloride inlr-d5 intravenousparenteral solution 20meq/l

1 HI

potassium chloride inwater intravenouspiggyback 10meq/100 ml, 20meq/100 ml, 40meq/100 ml

1 HI




Limitspotassium chloride inwater intravenouspiggyback 10 meq/50ml, 20 meq/50 ml, 30meq/100 ml

1 HI

potassium chlorideintravenous

1 HI

potassium chlorideoral capsule,extended release

1 MO

potassium chlorideoral liquid

1 MO

potassium chlorideoral packet

1

potassium chlorideoral tablet extendedrelease 10 meq, 8meq

1 MO

potassium chlorideoral tablet extendedrelease 20 meq

1

potassium chlorideoral tablet,erparticles/crystals 10meq

1 MO

potassium chlorideoral tablet,erparticles/crystals 20meq

1

potassiumchloride-0.45 % nacl

1 HI

potassium chloride-d5-0.2%naclintravenousparenteral solution 20meq/l

1 HI


Limitspotassium chloride-d5-0.2%naclintravenousparenteral solution 30meq/l, 40 meq/l

1 HI

potassium chloride-d5-0.9%nacl

1 HI

potassium phosphatem-/d-basicintravenous solution3 mmol/ml

1

ringer's intravenous 1 HIsodium acetate 1sodium bicarbonateintravenous solution1 meq/ml (8.4 %)

1

sodium bicarbonateintravenous syringe10 meq/10 ml(8.4 %), 7.5 % (0.9meq/ml), 8.4 % (1meq/ml)

1

sodium chloride0.45 % intravenousparenteral solution

1 MO, HI

sodium chloride 3 % 1 HIsodium chloride 5 % 1 MO, HIsodium chlorideintravenous

1 HI

sodium phosphate 1



VITAMINS, HEMATINICS /ELECTROLYTES: MISCELLANEOUSNUTRITION PRODUCTSDrug Name Tier Requirements/

LimitsAMINOSYN II 15 % 3 B/D PA, HIAMINOSYN-PF 7 %(SULFITE-FREE)

3 B/D PA, HI

CLINIMIX 5%/D15WSULFITE FREE

3 B/D PA, HI

CLINIMIX 4.25%/D10W SULF FREE

3 B/D PA, HI

CLINIMIX 5%-D20W(SULFITE-FREE)

3 B/D PA, HI


3 B/D PA


3 B/D PA


3 B/D PA

CLINIMIX E 4.25%/D10W SUL FREE

3 B/D PA, HI

CLINIMIX E 4.25%/D5W SULF FREE

3 B/D PA, HI

CLINIMIX E 5%/D15WSULFIT FREE

3 B/D PA, HI

CLINIMIX E 5%/D20WSULFIT FREE

3 B/D PA, HI

CLINIMIX E 8%-D10WSULFITEFREE

3 B/D PA

CLINIMIX E 8%-D14WSULFITEFREE

3 B/D PA

CLINISOL SF 15 % 3 B/D PA, HICLINOLIPID 3 B/D PADOJOLVI 3 PA, MOelectrolyte-48 in d5w 1

VITAMINS, HEMATINICS /ELECTROLYTES: MISCELLANEOUSNUTRITION PRODUCTS (continued)Drug Name Tier Requirements/

Limitsfreamine iii 10 % 1 B/D PA, HIHEPATAMINE 8% 3 B/D PA, HIintralipid intravenousemulsion 20 %

1 B/D PA, HI

INTRALIPIDINTRAVENOUSEMULSION 30 %

3 B/D PA, HI

NEPHRAMINE 5.4 % 3 B/D PA, HINORMOSOL-R PH7.4

3

plasmanate 1plenamine 1 B/D PA, HIpremasol 10 % 1 B/D PA, HIPROCALAMINE 3% 3 B/D PA, HIPROSOL 20 % 3 B/D PA, HISMOFLIPID 3 B/D PA, HItravasol 10 % 1 B/D PA, HITROPHAMINE 10 % 3 B/D PA, HI

VITAMINS, HEMATINICS /ELECTROLYTES: VITAMINS /HEMATINICSDrug Name Tier Requirements/

Limitsfluoride (sodium) oraltablet

1

fluoride (sodium) oraltablet,chewable 1 mg(2.2 mg sod. fluoride)

1 MO

prenatal vitamin oraltablet

1 MO



Index of DrugsAabacavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8abacavir-lamivudine. . . . . . . . . . . . . . . . . . . . . 8abacavir-lamivudine-zidovudine. . . . . . . . . . . 8ABILIFY MAINTENA. . . . . . . . . . . . . . . . . . . 40abiraterone. . . . . . . . . . . . . . . . . . . . . . . . . . . 20ABRAXANE. . . . . . . . . . . . . . . . . . . . . . . . . . 20acamprosate oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

acarbose. . . . . . . . . . . . . . . . . . . . . . . . . . . . 66accutane oral capsule 20 mg, 30 mg, 40 mg. 57acebutolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46acetaminophen intravenous solution 1,000mg/100 ml (10 mg/ml). . . . . . . . . . . . . . . . . 38

acetaminophen-caff-dihydrocod oral capsule 34acetaminophen-caff-dihydrocod oral tablet325-30-16 mg. . . . . . . . . . . . . . . . . . . . . . . . 34

acetaminophen-codeine oral solution 120 mg-12mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml. . . 34

acetaminophen-codeine oral solution 120-12mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

acetaminophen-codeine oral tablet. . . . . . . . 34acetazolamide oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

acetazolamide oral tablet. . . . . . . . . . . . . . . . 91acetazolamide sodium. . . . . . . . . . . . . . . . . . 91acetic acid irrigation. . . . . . . . . . . . . . . . . . . . 60acetic acid otic (ear). . . . . . . . . . . . . . . . . . . . 64acetylcysteine. . . . . . . . . . . . . . . . . . . . . . . . . 93acetylcysteine intravenous. . . . . . . . . . . . . . . 60acitretin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55ACTEMRA ACTPEN. . . . . . . . . . . . . . . . . . . 82ACTEMRA INTRAVENOUS. . . . . . . . . . . . . . 82ACTEMRA SUBCUTANEOUS. . . . . . . . . . . . 82ACTHIB (PF). . . . . . . . . . . . . . . . . . . . . . . . . 77ACTIMMUNE. . . . . . . . . . . . . . . . . . . . . . . . . 76acyclovir oral capsule. . . . . . . . . . . . . . . . . . . 8acyclovir oral suspension 200 mg/5 ml. . . . . . 8acyclovir oral tablet. . . . . . . . . . . . . . . . . . . . . 8acyclovir sodium intravenous solution. . . . . . . 8

acyclovir topical. . . . . . . . . . . . . . . . . . . . . . . 58ADACEL(TDAP ADOLESN/ADULT)(PF). . . . 77ADAKVEO. . . . . . . . . . . . . . . . . . . . . . . . . . . 20adapalene topical cream. . . . . . . . . . . . . . . . 57adapalene topical gel. . . . . . . . . . . . . . . . . . . 57adapalene topical gel with pump. . . . . . . . . . 57adapalene topical solution. . . . . . . . . . . . . . . 57adapalene topical swab. . . . . . . . . . . . . . . . . 57adapalene-benzoyl peroxide. . . . . . . . . . . . . 57ADASUVE. . . . . . . . . . . . . . . . . . . . . . . . . . . 40adefovir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8ADEMPAS. . . . . . . . . . . . . . . . . . . . . . . . . . . 93adenosine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45adrenalin injection solution 1 mg/ml. . . . . . . . 92adrenalin injection solution 1 mg/ml (1 ml). . 92adriamycin intravenous recon soln 10 mg. . . 20adriamycin intravenous solution 10 mg/5 ml. 20adriamycin intravenous solution 2 mg/ml, 20mg/10 ml, 50 mg/25 ml. . . . . . . . . . . . . . . . . 20

adrucil intravenous solution 2.5 gram/50 ml. 20ADVAIR DISKUS. . . . . . . . . . . . . . . . . . . . . . 93ADVAIR HFA. . . . . . . . . . . . . . . . . . . . . . . . . 93AFINITOR DISPERZ. . . . . . . . . . . . . . . . . . . 20AFINITOR ORAL TABLET 10 MG. . . . . . . . . 20afirmelle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85AFLURIA QD 2020-21(3YR UP)(PF). . . . . . . 77AFLURIA QD 2020-21(6-35MO)(PF). . . . . . . 77AFLURIA QUAD 2020-2021(6MO UP). . . . . 77AIMOVIG AUTOINJECTOR. . . . . . . . . . . . . . 31ak-poly-bac. . . . . . . . . . . . . . . . . . . . . . . . . . 89ala-cort topical cream 1 %. . . . . . . . . . . . . . . 59ala-cort topical cream 2.5 %. . . . . . . . . . . . . 59albendazole. . . . . . . . . . . . . . . . . . . . . . . . . . 13albumin, human 25 %. . . . . . . . . . . . . . . . . . 97albuminar 25 %. . . . . . . . . . . . . . . . . . . . . . . 97alburx (human) 25 %. . . . . . . . . . . . . . . . . . . 97alburx (human) 5 %. . . . . . . . . . . . . . . . . . . . 97albutein 25 %. . . . . . . . . . . . . . . . . . . . . . . . . 97albutein 5 %. . . . . . . . . . . . . . . . . . . . . . . . . . 97albuterol sulfate inhalation hfa aerosol inhaler90 mcg/actuation. . . . . . . . . . . . . . . . . . . . . 93

101

albuterol sulfate inhalation hfa aerosol inhaler90 mcg/actuation (nda020503). . . . . . . . . . 93

albuterol sulfate inhalation solution fornebulization. . . . . . . . . . . . . . . . . . . . . . . . . . 93

albuterol sulfate oral syrup. . . . . . . . . . . . . . . 93albuterol sulfate oral tablet. . . . . . . . . . . . . . . 93albuterol sulfate oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

alclometasone. . . . . . . . . . . . . . . . . . . . . . . . 59ALCOHOL PADS. . . . . . . . . . . . . . . . . . . . . . 66ALDURAZYME. . . . . . . . . . . . . . . . . . . . . . . . 68ALECENSA. . . . . . . . . . . . . . . . . . . . . . . . . . 20alendronate oral solution. . . . . . . . . . . . . . . . 81alendronate oral tablet 10 mg, 5 mg. . . . . . . 81alendronate oral tablet 35 mg, 70 mg. . . . . . 81alfuzosin oral tablet extended release 24 hr. 97ALIMTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20ALINIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13ALIQOPA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20aliskiren. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46allopurinol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 80allopurinol sodium. . . . . . . . . . . . . . . . . . . . . 80aloprim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80alosetron. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71ALPHAGAN P OPHTHALMIC (EYE) DROPS0.1 %. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

alprazolam intensol. . . . . . . . . . . . . . . . . . . . 40alprazolam oral tablet. . . . . . . . . . . . . . . . . . 40alprazolam oral tablet extended release 24 hr 40alprazolam oral tablet,disintegrating. . . . . . . 40alprostadil. . . . . . . . . . . . . . . . . . . . . . . . . . . . 97altavera (28). . . . . . . . . . . . . . . . . . . . . . . . . . 85ALUNBRIG. . . . . . . . . . . . . . . . . . . . . . . . . . . 20alyacen 1/35 (28). . . . . . . . . . . . . . . . . . . . . . 85alyacen 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . 85alyq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93amabelz. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84amantadine hcl. . . . . . . . . . . . . . . . . . . . . . . . 8AMBISOME. . . . . . . . . . . . . . . . . . . . . . . . . . . 7ambrisentan. . . . . . . . . . . . . . . . . . . . . . . . . . 93amcinonide topical cream. . . . . . . . . . . . . . . 59amcinonide topical lotion. . . . . . . . . . . . . . . . 59amcinonide topical ointment. . . . . . . . . . . . . 59

amethia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85amethyst (28). . . . . . . . . . . . . . . . . . . . . . . . . 85amikacin injection solution 1,000 mg/4 ml. . . 13amikacin injection solution 500 mg/2 ml. . . . 13amiloride. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46amiloride-hydrochlorothiazide. . . . . . . . . . . . 46aminocaproic acid. . . . . . . . . . . . . . . . . . . . . 50aminophylline intravenous. . . . . . . . . . . . . . . 93AMINOSYN II 15 %. . . . . . . . . . . . . . . . . . . 100AMINOSYN-PF 7 % (SULFITE-FREE). . . . 100amiodarone intravenous solution. . . . . . . . . . 45amiodarone intravenous syringe. . . . . . . . . . 45amiodarone oral tablet 100 mg, 400 mg. . . . 45amiodarone oral tablet 200 mg. . . . . . . . . . . 45amitriptyline. . . . . . . . . . . . . . . . . . . . . . . . . . 40amitriptyline-chlordiazepoxide. . . . . . . . . . . . 40amlodipine. . . . . . . . . . . . . . . . . . . . . . . . . . . 46amlodipine-atorvastatin. . . . . . . . . . . . . . . . . 52amlodipine-benazepril. . . . . . . . . . . . . . . . . . 46amlodipine-olmesartan. . . . . . . . . . . . . . . . . 46amlodipine-valsartan. . . . . . . . . . . . . . . . . . . 46amlodipine-valsartan-hcthiazid. . . . . . . . . . . 46ammonium lactate. . . . . . . . . . . . . . . . . . . . . 55amnesteem. . . . . . . . . . . . . . . . . . . . . . . . . . 57amoxapine. . . . . . . . . . . . . . . . . . . . . . . . . . . 40amoxicil-clarithromy-lansopraz. . . . . . . . . . . 74amoxicillin oral capsule. . . . . . . . . . . . . . . . . 16amoxicillin oral suspension for reconstitution 16amoxicillin oral tablet. . . . . . . . . . . . . . . . . . . 16amoxicillin oral tablet,chewable 125 mg, 250mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

amoxicillin-pot clavulanate oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 16

amoxicillin-pot clavulanate oral tablet. . . . . . 16amoxicillin-pot clavulanate oral tablet extendedrelease 12 hr. . . . . . . . . . . . . . . . . . . . . . . . 16

amoxicillin-pot clavulanate oraltablet,chewable. . . . . . . . . . . . . . . . . . . . . . . 16

amphetamine sulfate. . . . . . . . . . . . . . . . . . . 40amphotericin b. . . . . . . . . . . . . . . . . . . . . . . . . 7ampicillin oral capsule 500 mg. . . . . . . . . . . . 16ampicillin sodium injection recon soln 1 gram,10 gram, 125 mg. . . . . . . . . . . . . . . . . . . . . 16

102

ampicillin sodium injection recon soln 2 gram,250 mg, 500 mg. . . . . . . . . . . . . . . . . . . . . . 16

ampicillin sodium intravenous. . . . . . . . . . . . 16ampicillin-sulbactam injection recon soln 1.5gram, 3 gram. . . . . . . . . . . . . . . . . . . . . . . . 16

ampicillin-sulbactam injection recon soln 15gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ampicillin-sulbactam intravenous. . . . . . . . . . 16anagrelide. . . . . . . . . . . . . . . . . . . . . . . . . . . 60anastrozole. . . . . . . . . . . . . . . . . . . . . . . . . . . 20ANDEXXA INTRAVENOUS RECON SOLN 200MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

ANORO ELLIPTA. . . . . . . . . . . . . . . . . . . . . 93apexicon e. . . . . . . . . . . . . . . . . . . . . . . . . . . 59APOKYN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30apraclonidine. . . . . . . . . . . . . . . . . . . . . . . . . 92aprepitant. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71apri. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85APTIOM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27APTIVUS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8APTIVUS (WITH VITAMIN E). . . . . . . . . . . . . 8ARALAST NP INTRAVENOUS RECON SOLN1,000 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . 60

ARALAST NP INTRAVENOUS RECON SOLN500 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

aranelle (28). . . . . . . . . . . . . . . . . . . . . . . . . . 85ARCALYST. . . . . . . . . . . . . . . . . . . . . . . . . . . 76ARIKAYCE. . . . . . . . . . . . . . . . . . . . . . . . . . . 13aripiprazole. . . . . . . . . . . . . . . . . . . . . . . . . . . 40ARISTADA. . . . . . . . . . . . . . . . . . . . . . . . . . . 40ARISTADA INITIO. . . . . . . . . . . . . . . . . . . . . 40armodafinil. . . . . . . . . . . . . . . . . . . . . . . . . . . 40ARNUITY ELLIPTA. . . . . . . . . . . . . . . . . . . . 93ARRANON. . . . . . . . . . . . . . . . . . . . . . . . . . . 20ARSENIC TRIOXIDE INTRAVENOUSSOLUTION 1 MG/ML. . . . . . . . . . . . . . . . . . 20

arsenic trioxide intravenous solution 2 mg/ml 20ARZERRA. . . . . . . . . . . . . . . . . . . . . . . . . . . 20ascomp with codeine. . . . . . . . . . . . . . . . . . . 34asenapine maleate. . . . . . . . . . . . . . . . . . . . 40ashlyna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85aspirin-dipyridamole oral capsule, er multiphase12 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

ASTAGRAF XL. . . . . . . . . . . . . . . . . . . . . . . 20atazanavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8atenolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46atenolol-chlorthalidone. . . . . . . . . . . . . . . . . . 46atomoxetine. . . . . . . . . . . . . . . . . . . . . . . . . . 40atorvastatin. . . . . . . . . . . . . . . . . . . . . . . . . . . 52atovaquone. . . . . . . . . . . . . . . . . . . . . . . . . . 13atovaquone-proguanil. . . . . . . . . . . . . . . . . . 13ATRIPLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8atropine injection solution 0.4 mg/ml. . . . . . . 71atropine injection syringe 0.05 mg/ml, 0.1mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

atropine ophthalmic (eye) drops. . . . . . . . . . 90ATROVENT HFA. . . . . . . . . . . . . . . . . . . . . . 93AUBAGIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32aubra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85aubra eq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85aurovela 1.5/30 (21). . . . . . . . . . . . . . . . . . . . 85aurovela 1/20 (21). . . . . . . . . . . . . . . . . . . . . 85aurovela 24 fe. . . . . . . . . . . . . . . . . . . . . . . . 85aurovela fe 1-20 (28). . . . . . . . . . . . . . . . . . . 85aurovela fe 1.5/30 (28). . . . . . . . . . . . . . . . . . 85AUSTEDO. . . . . . . . . . . . . . . . . . . . . . . . . . . 32AVANDIA ORAL TABLET 2 MG, 4 MG. . . . . 66AVASTIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20aviane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85avita topical cream. . . . . . . . . . . . . . . . . . . . . 57AVONEX INTRAMUSCULAR PEN INJECTORKIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

AVONEX INTRAMUSCULAR SYRINGE KIT. 76ayuna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85AYVAKIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20azacitidine. . . . . . . . . . . . . . . . . . . . . . . . . . . 20azathioprine. . . . . . . . . . . . . . . . . . . . . . . . . . 20azathioprine sodium. . . . . . . . . . . . . . . . . . . . 20azelaic acid. . . . . . . . . . . . . . . . . . . . . . . . . . 57azelastine nasal. . . . . . . . . . . . . . . . . . . . . . . 63azelastine ophthalmic (eye). . . . . . . . . . . . . . 90azelastine-fluticasone. . . . . . . . . . . . . . . . . . 94azithromycin intravenous. . . . . . . . . . . . . . . . 12azithromycin oral packet. . . . . . . . . . . . . . . . 12

103

azithromycin oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 12

azithromycin oral tablet 250 mg (6 pack), 500mg (3 pack). . . . . . . . . . . . . . . . . . . . . . . . . 12

azithromycin oral tablet 250 mg, 500 mg, 600mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

aztreonam injection recon soln 1 gram. . . . . 13aztreonam injection recon soln 2 gram. . . . . 13azurette (28). . . . . . . . . . . . . . . . . . . . . . . . . 85

Bbacitracin intramuscular. . . . . . . . . . . . . . . . . 13bacitracin ophthalmic (eye). . . . . . . . . . . . . . 89bacitracin-polymyxin b ophthalmic (eye). . . . 89baclofen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33bacteriostatic water(parabens). . . . . . . . . . . 60balanced salt. . . . . . . . . . . . . . . . . . . . . . . . . 90balsalazide. . . . . . . . . . . . . . . . . . . . . . . . . . . 71BALVERSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 20balziva (28). . . . . . . . . . . . . . . . . . . . . . . . . . 85BANZEL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27BAQSIMI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 66BARACLUDE ORAL SOLUTION. . . . . . . . . . . 8BAVENCIO. . . . . . . . . . . . . . . . . . . . . . . . . . . 20BAXDELA INTRAVENOUS. . . . . . . . . . . . . . 17BAXDELA ORAL. . . . . . . . . . . . . . . . . . . . . . 17BCG VACCINE, LIVE (PF). . . . . . . . . . . . . . 77bd pre-filled normal saline. . . . . . . . . . . . . . . 60bekyree (28). . . . . . . . . . . . . . . . . . . . . . . . . . 85BELEODAQ. . . . . . . . . . . . . . . . . . . . . . . . . . 20benazepril. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46benazepril-hydrochlorothiazide. . . . . . . . . . . 46BENDEKA. . . . . . . . . . . . . . . . . . . . . . . . . . . 20BENLYSTA INTRAVENOUS. . . . . . . . . . . . . 82BENLYSTA SUBCUTANEOUS. . . . . . . . . . . 82BENZNIDAZOLE. . . . . . . . . . . . . . . . . . . . . . 13benztropine. . . . . . . . . . . . . . . . . . . . . . . . . . 30beser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59BESPONSA. . . . . . . . . . . . . . . . . . . . . . . . . . 20betamethasone acet,sod phos. . . . . . . . . . . . 64betamethasone dipropionate. . . . . . . . . . . . . 59betamethasone valerate. . . . . . . . . . . . . . . . 59

betamethasone, augmented. . . . . . . . . . . . . 59betaxolol ophthalmic (eye). . . . . . . . . . . . . . . 90betaxolol oral. . . . . . . . . . . . . . . . . . . . . . . . . 46bethanechol chloride. . . . . . . . . . . . . . . . . . . 97BETHKIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13BEVESPI AEROSPHERE. . . . . . . . . . . . . . . 94bexarotene. . . . . . . . . . . . . . . . . . . . . . . . . . . 20BEXSERO. . . . . . . . . . . . . . . . . . . . . . . . . . . 77bicalutamide. . . . . . . . . . . . . . . . . . . . . . . . . . 20BICILLIN L-A. . . . . . . . . . . . . . . . . . . . . . . . . 16BIKTARVY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8bimatoprost ophthalmic (eye). . . . . . . . . . . . 91bisoprolol fumarate. . . . . . . . . . . . . . . . . . . . 46bisoprolol-hydrochlorothiazide. . . . . . . . . . . . 46BLENREP. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20bleomycin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20BLEPHAMIDE. . . . . . . . . . . . . . . . . . . . . . . . 90BLEPHAMIDE S.O.P.. . . . . . . . . . . . . . . . . . 90BLINCYTO INTRAVENOUS KIT. . . . . . . . . . 20blisovi 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . . 85blisovi fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . 85blisovi fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . 85BOOSTRIX TDAP. . . . . . . . . . . . . . . . . . . . . 77BORTEZOMIB. . . . . . . . . . . . . . . . . . . . . . . . 20bosentan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94BOSULIF. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20BOTOX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77BRAFTOVI ORAL CAPSULE 75 MG. . . . . . . 20BREO ELLIPTA. . . . . . . . . . . . . . . . . . . . . . . 94bretylium tosylate. . . . . . . . . . . . . . . . . . . . . . 45briellyn. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85BRILINTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50brimonidine ophthalmic (eye) drops 0.15 %. 92brimonidine ophthalmic (eye) drops 0.2 %. . 92brinzolamide. . . . . . . . . . . . . . . . . . . . . . . . . . 91BRIVIACT INTRAVENOUS. . . . . . . . . . . . . . 27BRIVIACT ORAL. . . . . . . . . . . . . . . . . . . . . . 27bromfenac. . . . . . . . . . . . . . . . . . . . . . . . . . . 91bromocriptine. . . . . . . . . . . . . . . . . . . . . . . . . 30BRONCHITOL. . . . . . . . . . . . . . . . . . . . . . . . 94BROVANA. . . . . . . . . . . . . . . . . . . . . . . . . . . 94BRUKINSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 20

104

bss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90budesonide inhalation. . . . . . . . . . . . . . . . . . 94budesonide oralcapsule,delayed,extend.release. . . . . . . . . . 71

budesonide oral tablet,delayed andext.release. . . . . . . . . . . . . . . . . . . . . . . . . . 71

bumetanide injection. . . . . . . . . . . . . . . . . . . 46bumetanide oral. . . . . . . . . . . . . . . . . . . . . . . 46buprenorphine. . . . . . . . . . . . . . . . . . . . . . . . 34buprenorphine hcl injection solution. . . . . . . 34buprenorphine hcl injection syringe. . . . . . . . 34buprenorphine hcl sublingual. . . . . . . . . . . . . 34buprenorphine-naloxone. . . . . . . . . . . . . . . . 38bupropion hcl (smoking deter) oral tabletextended release. . . . . . . . . . . . . . . . . . . . . 63

bupropion hcl oral tablet. . . . . . . . . . . . . . . . 40bupropion hcl oral tablet extended release 24 hr150 mg, 300 mg. . . . . . . . . . . . . . . . . . . . . . 40

bupropion hcl oral tablet sustained-release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

buspirone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 40busulfan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20butalbital compound w/codeine. . . . . . . . . . . 34butalbital-acetaminop-caf-cod. . . . . . . . . . . . 34butalbital-acetaminophen oral capsule. . . . . 34butalbital-acetaminophen oral tablet 25-325mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

butalbital-acetaminophen oral tablet 50-300 mg,50-325 mg. . . . . . . . . . . . . . . . . . . . . . . . . . 35

butalbital-acetaminophen-caff oral capsule. . 35butalbital-acetaminophen-caff oral tablet50-325-40 mg. . . . . . . . . . . . . . . . . . . . . . . . 35

butalbital-aspirin-caffeine oral capsule. . . . . 35butalbital-aspirin-caffeine oral tablet. . . . . . . 35butorphanol tartrate injection. . . . . . . . . . . . . 38butorphanol tartrate nasal. . . . . . . . . . . . . . . 38BYDUREON BCISE. . . . . . . . . . . . . . . . . . . . 66BYETTA SUBCUTANEOUS PEN INJECTOR 10MCG/DOSE(250 MCG/ML) 2.4 ML. . . . . . . 66

BYETTA SUBCUTANEOUS PEN INJECTOR 5MCG/DOSE (250 MCG/ML) 1.2 ML. . . . . . . 66

BYNFEZIA. . . . . . . . . . . . . . . . . . . . . . . . . . . 20

CCABENUVA. . . . . . . . . . . . . . . . . . . . . . . . . . . 8

cabergoline. . . . . . . . . . . . . . . . . . . . . . . . . . . 68CABLIVI INJECTION KIT. . . . . . . . . . . . . . . . 50CABOMETYX. . . . . . . . . . . . . . . . . . . . . . . . . 20caffeine citrate intravenous. . . . . . . . . . . . . . 60caffeine citrate oral. . . . . . . . . . . . . . . . . . . . 60calcipotriene scalp. . . . . . . . . . . . . . . . . . . . . 55calcipotriene topical cream. . . . . . . . . . . . . . 55calcipotriene topical ointment. . . . . . . . . . . . 55calcipotriene-betamethasone. . . . . . . . . . . . . 55calcitonin (salmon). . . . . . . . . . . . . . . . . . . . . 68calcitriol intravenous solution 1 mcg/ml. . . . . 68calcitriol oral capsule. . . . . . . . . . . . . . . . . . . 68calcitriol oral solution. . . . . . . . . . . . . . . . . . . 68calcitriol topical. . . . . . . . . . . . . . . . . . . . . . . 55calcium acetate(phosphat bind). . . . . . . . . . . 98calcium chloride. . . . . . . . . . . . . . . . . . . . . . . 98calcium gluconate intravenous. . . . . . . . . . . 98CALQUENCE. . . . . . . . . . . . . . . . . . . . . . . . . 20camila. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84camrese. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85camrese lo. . . . . . . . . . . . . . . . . . . . . . . . . . . 85candesartan. . . . . . . . . . . . . . . . . . . . . . . . . . 46candesartan-hydrochlorothiazid. . . . . . . . . . . 46CAPASTAT. . . . . . . . . . . . . . . . . . . . . . . . . . . 13capecitabine. . . . . . . . . . . . . . . . . . . . . . . . . . 20CAPLYTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41CAPRELSA. . . . . . . . . . . . . . . . . . . . . . . . . . 20captopril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46captopril-hydrochlorothiazide. . . . . . . . . . . . . 46CARBAGLU. . . . . . . . . . . . . . . . . . . . . . . . . . 60carbamazepine oral capsule, er multiphase 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

carbamazepine oral suspension 100 mg/5 ml 27carbamazepine oral suspension 200 mg/10ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

carbamazepine oral tablet. . . . . . . . . . . . . . . 27carbamazepine oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

carbamazepine oral tablet,chewable. . . . . . . 27carbidopa. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30carbidopa-levodopa oral tablet. . . . . . . . . . . 30carbidopa-levodopa oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

105

carbidopa-levodopa oral tablet,disintegrating 30carbidopa-levodopa-entacapone. . . . . . . . . . 30carbinoxamine maleate. . . . . . . . . . . . . . . . . 92carbocaine (pf) injection solution 15 mg/ml (1.5%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

carboplatin intravenous solution. . . . . . . . . . 20cardioplegic soln. . . . . . . . . . . . . . . . . . . . . . 53carisoprodol. . . . . . . . . . . . . . . . . . . . . . . . . . 33carisoprodol-aspirin. . . . . . . . . . . . . . . . . . . . 33carisoprodol-aspirin-codeine. . . . . . . . . . . . . 33carmustine. . . . . . . . . . . . . . . . . . . . . . . . . . . 20carteolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90cartia xt oral capsule,extended release 24hr. 46carvedilol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47carvedilol phosphate oral capsule, er multiphase24 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

caspofungin. . . . . . . . . . . . . . . . . . . . . . . . . . . 7cataflam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38CAYSTON. . . . . . . . . . . . . . . . . . . . . . . . . . . 13caziant (28). . . . . . . . . . . . . . . . . . . . . . . . . . 85cefaclor oral capsule. . . . . . . . . . . . . . . . . . . 10cefaclor oral suspension for reconstitution 125mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

cefaclor oral suspension for reconstitution 250mg/5 ml, 375 mg/5 ml. . . . . . . . . . . . . . . . . . 10

cefaclor oral tablet extended release 12 hr. . 10cefadroxil oral capsule. . . . . . . . . . . . . . . . . . 10cefadroxil oral suspension for reconstitution 250mg/5 ml, 500 mg/5 ml. . . . . . . . . . . . . . . . . . 10

cefadroxil oral tablet. . . . . . . . . . . . . . . . . . . . 10cefazolin in dextrose (iso-os) intravenouspiggyback 1 gram/50 ml, 2 gram/50 ml. . . . 10

cefazolin injection recon soln 1 gram, 500 mg 10cefazolin injection recon soln 10 gram. . . . . . 10cefazolin injection recon soln 100 gram, 300g. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

cefazolin intravenous. . . . . . . . . . . . . . . . . . . 10cefdinir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10cefepime in dextrose,iso-osm. . . . . . . . . . . . 10cefepime injection. . . . . . . . . . . . . . . . . . . . . 10cefixime. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10cefotetan injection. . . . . . . . . . . . . . . . . . . . . 11cefoxitin in dextrose, iso-osm. . . . . . . . . . . . . 11

cefoxitin intravenous recon soln 1 gram, 2gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

cefoxitin intravenous recon soln 10 gram. . . 11cefpodoxime oral suspension for reconstitution100 mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . 11

cefpodoxime oral suspension for reconstitution50 mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . 11

cefpodoxime oral tablet. . . . . . . . . . . . . . . . . 11cefprozil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11ceftazidime injection recon soln 1 gram, 2gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

ceftazidime injection recon soln 6 gram. . . . . 11ceftriaxone in dextrose,iso-os. . . . . . . . . . . . 11ceftriaxone injection recon soln 1 gram, 2 gram,250 mg, 500 mg. . . . . . . . . . . . . . . . . . . . . . 11

ceftriaxone injection recon soln 10 gram. . . . 11ceftriaxone intravenous. . . . . . . . . . . . . . . . . 11cefuroxime axetil oral tablet. . . . . . . . . . . . . . 11cefuroxime sodium injection recon soln 750mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

cefuroxime sodium intravenous recon soln 1.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

cefuroxime sodium intravenous recon soln 7.5gram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

celecoxib. . . . . . . . . . . . . . . . . . . . . . . . . . . . 38CELONTIN ORAL CAPSULE 300 MG. . . . . 27cephalexin. . . . . . . . . . . . . . . . . . . . . . . . . . . 11CERDELGA. . . . . . . . . . . . . . . . . . . . . . . . . . 68CEREZYME INTRAVENOUS RECON SOLN400 UNIT. . . . . . . . . . . . . . . . . . . . . . . . . . . 68

cetirizine oral solution 1 mg/ml. . . . . . . . . . . 92cevimeline. . . . . . . . . . . . . . . . . . . . . . . . . . . 60CHANTIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 63CHANTIX CONTINUING MONTH BOX. . . . 63CHANTIX STARTING MONTH BOX. . . . . . . 63charlotte 24 fe. . . . . . . . . . . . . . . . . . . . . . . . 85chateal (28). . . . . . . . . . . . . . . . . . . . . . . . . . 86chateal eq (28). . . . . . . . . . . . . . . . . . . . . . . . 86CHEMET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60chloramphenicol sod succinate. . . . . . . . . . . 13chlordiazepoxide hcl. . . . . . . . . . . . . . . . . . . 41chlordiazepoxide-clidinium. . . . . . . . . . . . . . . 71chlorhexidine gluconate mucous membrane. 63chloroprocaine (pf). . . . . . . . . . . . . . . . . . . . . 55

106

chloroquine phosphate. . . . . . . . . . . . . . . . . 13chlorothiazide sodium. . . . . . . . . . . . . . . . . . 47chlorpromazine injection. . . . . . . . . . . . . . . . 41chlorpromazine oral. . . . . . . . . . . . . . . . . . . . 41chlorthalidone oral tablet 25 mg, 50 mg. . . . . 47chlorzoxazone oral tablet 375 mg, 500 mg, 750mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

CHOLBAM. . . . . . . . . . . . . . . . . . . . . . . . . . . 71cholestyramine (with sugar). . . . . . . . . . . . . . 52cholestyramine light. . . . . . . . . . . . . . . . . . . . 52CHORIONIC GONADOTROPIN, HUMANINTRAMUSCULAR. . . . . . . . . . . . . . . . . . . . 68

ciclodan topical solution. . . . . . . . . . . . . . . . . 58ciclopirox. . . . . . . . . . . . . . . . . . . . . . . . . . . . 58cidofovir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8cilostazol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 50CIMDUO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8cimetidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 74cimetidine hcl oral. . . . . . . . . . . . . . . . . . . . . 74CIMZIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71CIMZIA POWDER FOR RECONST. . . . . . . . 71CIMZIA STARTER KIT. . . . . . . . . . . . . . . . . . 71cinacalcet. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68CINRYZE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94CINVANTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71CIPRODEX. . . . . . . . . . . . . . . . . . . . . . . . . . 64ciprofloxacin hcl ophthalmic (eye). . . . . . . . . 89ciprofloxacin hcl oral. . . . . . . . . . . . . . . . . . . 17ciprofloxacin hcl otic (ear). . . . . . . . . . . . . . . 64ciprofloxacin in 5 % dextrose intravenouspiggyback 200 mg/100 ml. . . . . . . . . . . . . . 17

ciprofloxacin in 5 % dextrose intravenouspiggyback 400 mg/200 ml. . . . . . . . . . . . . . 17

ciprofloxacin-dexamethasone. . . . . . . . . . . . 64cisplatin intravenous solution. . . . . . . . . . . . . 21citalopram. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41cladribine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21claravis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57clarithromycin oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 12

clarithromycin oral tablet. . . . . . . . . . . . . . . . 12clarithromycin oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

clemastine oral tablet 2.68 mg. . . . . . . . . . . . 92CLEOCIN VAGINAL SUPPOSITORY. . . . . . 85clindacin etz topical swab. . . . . . . . . . . . . . . 57clindacin p. . . . . . . . . . . . . . . . . . . . . . . . . . . 57clindamycin hcl. . . . . . . . . . . . . . . . . . . . . . . 13clindamycin in 5 % dextrose. . . . . . . . . . . . . 13clindamycin pediatric. . . . . . . . . . . . . . . . . . . 13clindamycin phosphate injection. . . . . . . . . . 13clindamycin phosphate intravenous solution 600mg/4 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

clindamycin phosphate topical foam. . . . . . . 57clindamycin phosphate topical gel. . . . . . . . . 57clindamycin phosphate topical lotion. . . . . . . 57clindamycin phosphate topical solution. . . . . 57clindamycin phosphate topical swab. . . . . . . 57clindamycin phosphate vaginal. . . . . . . . . . . 85clindamycin-benzoyl peroxide. . . . . . . . . . . . 57clindamycin-tretinoin. . . . . . . . . . . . . . . . . . . 57CLINIMIX 5%/D15W SULFITE FREE. . . . . 100CLINIMIX 4.25%/D10W SULF FREE. . . . . 100CLINIMIX 4.25%/D5W SULFIT FREE. . . . . . 60CLINIMIX 5%-D20W(SULFITE-FREE). . . . 100CLINIMIX 6%-D5W (SULFITE-FREE). . . . . 100CLINIMIX 8%-D10W(SULFITE-FREE). . . . 100CLINIMIX 8%-D14W(SULFITE-FREE). . . . 100CLINIMIX E 2.75%/D5W SULF FREE. . . . . . 60CLINIMIX E 4.25%/D10W SUL FREE. . . . . 100CLINIMIX E 4.25%/D5W SULF FREE. . . . . 100CLINIMIX E 5%/D15W SULFIT FREE. . . . . 100CLINIMIX E 5%/D20W SULFIT FREE. . . . . 100CLINIMIX E 8%-D10W SULFITEFREE. . . . 100CLINIMIX E 8%-D14W SULFITEFREE. . . . 100CLINISOL SF 15 %. . . . . . . . . . . . . . . . . . . 100CLINOLIPID. . . . . . . . . . . . . . . . . . . . . . . . . 100clobazam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27clobetasol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 59clobetasol-emollient. . . . . . . . . . . . . . . . . . . . 59clodan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59clofarabine. . . . . . . . . . . . . . . . . . . . . . . . . . . 21clomiphene citrate. . . . . . . . . . . . . . . . . . . . . 68clomipramine. . . . . . . . . . . . . . . . . . . . . . . . . 41clonazepam oral tablet. . . . . . . . . . . . . . . . . . 27

107

clonazepam oral tablet,disintegrating. . . . . . 27clonidine (pf) epidural solution 1,000 mcg/10 ml(100 mcg/ml). . . . . . . . . . . . . . . . . . . . . . . . 47

clonidine (pf) epidural solution 5,000 mcg/10ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

clonidine hcl oral tablet. . . . . . . . . . . . . . . . . 47clonidine hcl oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

clonidine transdermal. . . . . . . . . . . . . . . . . . . 47clopidogrel. . . . . . . . . . . . . . . . . . . . . . . . . . . 50clorazepate dipotassium. . . . . . . . . . . . . . . . 41clotrimazole mucous membrane. . . . . . . . . . . 7clotrimazole topical. . . . . . . . . . . . . . . . . . . . 58clotrimazole-betamethasone. . . . . . . . . . . . . 58clovique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60clozapine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41CLOZAPINE ORAL TABLET,DISINTEGRATING150 MG, 200 MG (BRAND). . . . . . . . . . . . . 41

COARTEM. . . . . . . . . . . . . . . . . . . . . . . . . . . 13codeine sulfate oral tablet. . . . . . . . . . . . . . . 35codeine-butalbital-asa-caff. . . . . . . . . . . . . . . 35colchicine oral tablet. . . . . . . . . . . . . . . . . . . 80colestipol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 52colistin (colistimethate na). . . . . . . . . . . . . . . 13COMBIGAN. . . . . . . . . . . . . . . . . . . . . . . . . . 91COMBIVENT RESPIMAT. . . . . . . . . . . . . . . . 94COMETRIQ. . . . . . . . . . . . . . . . . . . . . . . . . . 21COMPLERA. . . . . . . . . . . . . . . . . . . . . . . . . . . 8compro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71CONDYLOX TOPICAL GEL. . . . . . . . . . . . . 55constulose. . . . . . . . . . . . . . . . . . . . . . . . . . . 71COPIKTRA. . . . . . . . . . . . . . . . . . . . . . . . . . . 21CORLANOR ORAL SOLUTION. . . . . . . . . . 53CORLANOR ORAL TABLET. . . . . . . . . . . . . 53COSENTYX. . . . . . . . . . . . . . . . . . . . . . . . . . 55COSENTYX (2 SYRINGES). . . . . . . . . . . . . 55COSENTYX PEN. . . . . . . . . . . . . . . . . . . . . . 55COSENTYX PEN (2 PENS). . . . . . . . . . . . . 55COTELLIC. . . . . . . . . . . . . . . . . . . . . . . . . . . 21CREON. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71CRESEMBA. . . . . . . . . . . . . . . . . . . . . . . . . . . 7CRIXIVAN ORAL CAPSULE 200 MG. . . . . . . 8cromolyn inhalation. . . . . . . . . . . . . . . . . . . . 94

cromolyn ophthalmic (eye). . . . . . . . . . . . . . . 90cromolyn oral. . . . . . . . . . . . . . . . . . . . . . . . . 71crotan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60cryselle (28). . . . . . . . . . . . . . . . . . . . . . . . . . 86CRYSVITA. . . . . . . . . . . . . . . . . . . . . . . . . . . 68CUVPOSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 71cyclafem 1/35 (28). . . . . . . . . . . . . . . . . . . . . 86cyclafem 7/7/7 (28). . . . . . . . . . . . . . . . . . . . 86cyclobenzaprine oral tablet. . . . . . . . . . . . . . 33cyclophosphamide intravenous recon soln. . 21cyclophosphamide oral capsule. . . . . . . . . . . 21CYCLOSERINE. . . . . . . . . . . . . . . . . . . . . . . 13CYCLOSET. . . . . . . . . . . . . . . . . . . . . . . . . . 66cyclosporine intravenous. . . . . . . . . . . . . . . . 21cyclosporine modified oral capsule. . . . . . . . 21cyclosporine modified oral solution. . . . . . . . 21cyclosporine oral capsule. . . . . . . . . . . . . . . 21cyproheptadine. . . . . . . . . . . . . . . . . . . . . . . . 92CYRAMZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 21cyred. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86cyred eq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86CYSTADANE. . . . . . . . . . . . . . . . . . . . . . . . . 71CYSTAGON. . . . . . . . . . . . . . . . . . . . . . . . . . 97CYSTARAN. . . . . . . . . . . . . . . . . . . . . . . . . . 90cytarabine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21cytarabine (pf) injection solution 100 mg/5 ml(20 mg/ml), 2 gram/20 ml (100 mg/ml). . . . . 21

cytarabine (pf) injection solution 20 mg/ml. . 21

Dd10 %-0.45 % sodium chloride. . . . . . . . . . . 60d2.5 %-0.45 % sodium chloride. . . . . . . . . . . 60d5 % and 0.9 % sodium chloride. . . . . . . . . . 60d5 %-0.45 % sodium chloride. . . . . . . . . . . . 61dacarbazine. . . . . . . . . . . . . . . . . . . . . . . . . . 21dactinomycin. . . . . . . . . . . . . . . . . . . . . . . . . 21dalfampridine oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

DALIRESP. . . . . . . . . . . . . . . . . . . . . . . . . . . 94DALVANCE. . . . . . . . . . . . . . . . . . . . . . . . . . 13danazol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68dantrolene intravenous. . . . . . . . . . . . . . . . . 33

108

dantrolene oral. . . . . . . . . . . . . . . . . . . . . . . . 33DANYELZA. . . . . . . . . . . . . . . . . . . . . . . . . . 21dapsone oral. . . . . . . . . . . . . . . . . . . . . . . . . 13dapsone topical. . . . . . . . . . . . . . . . . . . . . . . 57DAPTACEL (DTAP PEDIATRIC) (PF). . . . . . 77DAPTOMYCIN INTRAVENOUS RECON SOLN350 MG (BRAND). . . . . . . . . . . . . . . . . . . . 13

daptomycin intravenous recon soln 500 mg. 13darifenacin oral tablet extended release 24 hr 96DARZALEX. . . . . . . . . . . . . . . . . . . . . . . . . . 21DARZALEX FASPRO. . . . . . . . . . . . . . . . . . 21dasetta 1/35 (28). . . . . . . . . . . . . . . . . . . . . . 86dasetta 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . . 86daunorubicin intravenous solution. . . . . . . . . 21DAURISMO. . . . . . . . . . . . . . . . . . . . . . . . . . 21daysee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86deblitane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84decadron oral tablet 0.5 mg. . . . . . . . . . . . . . 64decitabine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21deferasirox. . . . . . . . . . . . . . . . . . . . . . . . . . . 61deferiprone. . . . . . . . . . . . . . . . . . . . . . . . . . . 61deferoxamine. . . . . . . . . . . . . . . . . . . . . . . . . 61DELSTRIGO. . . . . . . . . . . . . . . . . . . . . . . . . . 8demeclocycline. . . . . . . . . . . . . . . . . . . . . . . . 18DEMSER. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47DENAVIR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 58denta 5000 plus. . . . . . . . . . . . . . . . . . . . . . . 63dentagel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63DESCOVY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8desipramine. . . . . . . . . . . . . . . . . . . . . . . . . . 41desloratadine oral tablet. . . . . . . . . . . . . . . . 92desloratadine oral tablet,disintegrating. . . . . 92desmopressin injection. . . . . . . . . . . . . . . . . 68desmopressin nasal spray with pump. . . . . . 68desmopressin nasal spray,non-aerosol. . . . . 68desmopressin oral. . . . . . . . . . . . . . . . . . . . . 68desog-e.estradiol/e.estradiol. . . . . . . . . . . . . 86desogestrel-ethinyl estradiol. . . . . . . . . . . . . 86desonide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59desoximetasone. . . . . . . . . . . . . . . . . . . . . . . 59desvenlafaxine succinate oral tablet extendedrelease 24 hr. . . . . . . . . . . . . . . . . . . . . . . . 41

dexabliss. . . . . . . . . . . . . . . . . . . . . . . . . . . . 64dexamethasone. . . . . . . . . . . . . . . . . . . . . . . 64dexamethasone intensol. . . . . . . . . . . . . . . . 64dexamethasone sodium phos (pf) injectionsolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

dexamethasone sodium phosphate injection. 64dexamethasone sodium phosphate ophthalmic(eye). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

dexchlorpheniramine maleate oral solution. . 92DEXCOM RECEIVER. . . . . . . . . . . . . . . . . . 66DEXCOM SENSOR. . . . . . . . . . . . . . . . . . . . 66DEXCOM TRANSMITTER . . . . . . . . . . . . . . 66dexmethylphenidate oral capsule,er biphasic50-50 10 mg, 5 mg. . . . . . . . . . . . . . . . . . . . 41

dexmethylphenidate oral capsule,er biphasic50-50 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

dexmethylphenidate oral tablet. . . . . . . . . . . 41dexrazoxane hcl. . . . . . . . . . . . . . . . . . . . . . . 19dextroamphetamine oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

dextroamphetamine oral solution. . . . . . . . . . 41dextroamphetamine oral tablet. . . . . . . . . . . 41dextroamphetamine-amphetamine oral capsule,extended release 24hr. . . . . . . . . . . . . . . . . 41

dextroamphetamine-amphetamine oral tablet 41dextrose 10 % and 0.2 % nacl. . . . . . . . . . . . 61dextrose 10 % in water (d10w). . . . . . . . . . . 61dextrose 25 % in water (d25w). . . . . . . . . . . 61dextrose 30 % in water (d30w). . . . . . . . . . . 61dextrose 40 % in water (d40w). . . . . . . . . . . 61dextrose 5 % in water (d5w) intravenousparenteral solution. . . . . . . . . . . . . . . . . . . . 61

dextrose 5 % in water (d5w) intravenouspiggyback. . . . . . . . . . . . . . . . . . . . . . . . . . . 61

dextrose 5 %-lactated ringers. . . . . . . . . . . . 61dextrose 5%-0.2 % sod chloride. . . . . . . . . . 61dextrose 5%-0.3 % sod.chloride. . . . . . . . . . 61dextrose 50 % in water (d50w). . . . . . . . . . . 61dextrose 70 % in water (d70w). . . . . . . . . . . 61DIACOMIT. . . . . . . . . . . . . . . . . . . . . . . . . . . 27diazepam injection. . . . . . . . . . . . . . . . . . . . . 41diazepam intensol. . . . . . . . . . . . . . . . . . . . . 41diazepam oral concentrate. . . . . . . . . . . . . . 41

109

diazepam oral solution 5 mg/5 ml (1 mg/ml). 41diazepam oral tablet. . . . . . . . . . . . . . . . . . . 41diazepam rectal. . . . . . . . . . . . . . . . . . . . . . . 27diazoxide. . . . . . . . . . . . . . . . . . . . . . . . . . . . 66diclofenac potassium. . . . . . . . . . . . . . . . . . . 38diclofenac sodium ophthalmic (eye). . . . . . . 91diclofenac sodium oral tablet extended release24 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

diclofenac sodium oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

diclofenac sodium topical drops. . . . . . . . . . . 38diclofenac sodium topical gel 1 %. . . . . . . . . 38diclofenac sodium topical gel 3 %. . . . . . . . . 55diclofenac-misoprostol oral tablet,ir,delayedrel,biphasic. . . . . . . . . . . . . . . . . . . . . . . . . . 38

dicloxacillin. . . . . . . . . . . . . . . . . . . . . . . . . . . 16dicyclomine intramuscular. . . . . . . . . . . . . . . 71dicyclomine oral capsule. . . . . . . . . . . . . . . . 71dicyclomine oral solution. . . . . . . . . . . . . . . . 71dicyclomine oral tablet. . . . . . . . . . . . . . . . . . 71didanosine oral capsule,delayed release(dr/ec)250 mg, 400 mg. . . . . . . . . . . . . . . . . . . . . . . 8

DIFICID ORAL TABLET. . . . . . . . . . . . . . . . . 12diflorasone topical cream. . . . . . . . . . . . . . . . 59diflunisal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38digitek. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53digox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53digoxin injection solution. . . . . . . . . . . . . . . . 53digoxin oral solution 50 mcg/ml (0.05 mg/ml) 53digoxin oral tablet. . . . . . . . . . . . . . . . . . . . . . 53dihydroergotamine injection. . . . . . . . . . . . . . 31dihydroergotamine nasal. . . . . . . . . . . . . . . . 31DILANTIN 30 MG. . . . . . . . . . . . . . . . . . . . . . 27dilt-xr oral capsule,ext release degradable. . 47diltiazem hcl intravenous. . . . . . . . . . . . . . . . 47diltiazem hcl oral capsule,ext.rel 24hdegradable. . . . . . . . . . . . . . . . . . . . . . . . . . 47

diltiazem hcl oral capsule,extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

diltiazem hcl oral capsule,extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

diltiazem hcl oral capsule,extended release 24hr120 mg, 180 mg, 240 mg, 360 mg. . . . . . . . 47

diltiazem hcl oral capsule,extended release 24hr300 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

diltiazem hcl oral tablet. . . . . . . . . . . . . . . . . 47diltiazem hcl oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

dimenhydrinate injection solution. . . . . . . . . . 71dimethyl fumarate. . . . . . . . . . . . . . . . . . . . . 32diphenhydramine hcl injection solution 50mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

diphenhydramine hcl injection syringe. . . . . . 92diphenhydramine hcl oral elixir. . . . . . . . . . . 92diphenoxylate-atropine. . . . . . . . . . . . . . . . . 71dipyridamole intravenous. . . . . . . . . . . . . . . . 50dipyridamole oral. . . . . . . . . . . . . . . . . . . . . . 50disopyramide phosphate oral capsule. . . . . . 45disulfiram. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61divalproex oral capsule, delayed rel sprinkle. 27divalproex oral tablet extended release 24 hr 28divalproex oral tablet,delayed release (dr/ec) 28dobutamine in d5w intravenous parenteralsolution 1,000 mg/250 ml (4,000 mcg/ml), 250mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000mcg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

dobutamine intravenous solution 250 mg/20 ml(12.5 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . 53

docetaxel intravenous solution 160 mg/16 ml(10 mg/ml), 20 mg/2 ml (10 mg/ml), 80 mg/8 ml(10 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . 21

docetaxel intravenous solution 160 mg/8 ml (20mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

dofetilide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45DOJOLVI. . . . . . . . . . . . . . . . . . . . . . . . . . . 100donepezil. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32dopamine in 5 % dextrose intravenous solution200 mg/250 ml (800 mcg/ml), 400 mg/250 ml(1,600 mcg/ml), 400 mg/500 ml (800 mcg/ml),800 mg/500 ml (1,600 mcg/ml). . . . . . . . . . 53

dopamine in 5 % dextrose intravenous solution800 mg/250 ml (3,200 mcg/ml). . . . . . . . . . 54

dopamine intravenous solution 200 mg/5 ml (40mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

dopamine intravenous solution 400 mg/10 ml(40 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . 54

DOPTELET (10 TAB PACK). . . . . . . . . . . . . 50

110

DOPTELET (15 TAB PACK). . . . . . . . . . . . . 50DOPTELET (30 TAB PACK). . . . . . . . . . . . . 50dorzolamide. . . . . . . . . . . . . . . . . . . . . . . . . . 91dorzolamide-timolol. . . . . . . . . . . . . . . . . . . . 91dorzolamide-timolol (pf) ophthalmic (eye)dropperette. . . . . . . . . . . . . . . . . . . . . . . . . . 91

dotti. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84DOVATO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8doxazosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 47doxepin oral capsule. . . . . . . . . . . . . . . . . . . 41doxepin oral concentrate. . . . . . . . . . . . . . . . 41doxepin oral tablet. . . . . . . . . . . . . . . . . . . . . 41doxepin topical. . . . . . . . . . . . . . . . . . . . . . . . 55doxercalciferol intravenous. . . . . . . . . . . . . . 68doxercalciferol oral. . . . . . . . . . . . . . . . . . . . . 68doxorubicin intravenous recon soln 50 mg. . 21doxorubicin intravenous solution 10 mg/5 ml, 20mg/10 ml, 50 mg/25 ml. . . . . . . . . . . . . . . . . 21

doxorubicin intravenous solution 2 mg/ml. . . 21doxorubicin, peg-liposomal. . . . . . . . . . . . . . 21doxy-100. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18doxycycline hyclate intravenous. . . . . . . . . . 18doxycycline hyclate oral capsule. . . . . . . . . . 18doxycycline hyclate oral tablet. . . . . . . . . . . . 18doxycycline hyclate oral tablet,delayed release(dr/ec) 100 mg, 150 mg, 200 mg, 50 mg, 75mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

doxycycline monohydrate oral capsule. . . . . 18doxycycline monohydrate oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 18

doxycycline monohydrate oral tablet. . . . . . . 18doxylamine-pyridoxine (vit b6). . . . . . . . . . . . 71DRIZALMA SPRINKLE. . . . . . . . . . . . . . . . . 41dronabinol. . . . . . . . . . . . . . . . . . . . . . . . . . . 71droperidol injection solution. . . . . . . . . . . . . . 71drospirenone-e.estradiol-lm.fa. . . . . . . . . . . . 86drospirenone-ethinyl estradiol oral tablet 3-0.02mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

drospirenone-ethinyl estradiol oral tablet 3-0.03mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

droxidopa. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61DULERA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

duloxetine oral capsule,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

DUPIXENT PEN. . . . . . . . . . . . . . . . . . . . . . 55DUPIXENT SYRINGE. . . . . . . . . . . . . . . . . . 55duramorph (pf) injection solution 0.5 mg/ml. . 35duramorph (pf) injection solution 1 mg/ml. . . 35dutasteride. . . . . . . . . . . . . . . . . . . . . . . . . . . 97dutasteride-tamsulosin oral capsule, ermultiphase 24 hr. . . . . . . . . . . . . . . . . . . . . . 97

dvorah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35DYSPORT. . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Eec-naproxen. . . . . . . . . . . . . . . . . . . . . . . . . . 38econazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 58EDURANT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8efavirenz. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8efavirenz-emtricitabin-tenofov. . . . . . . . . . . . . 8efavirenz-lamivu-tenofov disop. . . . . . . . . . . . 8effer-k oral tablet, effervescent 25 meq. . . . . 98EGRIFTA SV. . . . . . . . . . . . . . . . . . . . . . . . . 76electrolyte-48 in d5w. . . . . . . . . . . . . . . . . . 100ELELYSO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 68ELIGARD. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21ELIGARD (3 MONTH). . . . . . . . . . . . . . . . . . 21ELIGARD (4 MONTH). . . . . . . . . . . . . . . . . . 21ELIGARD (6 MONTH). . . . . . . . . . . . . . . . . . 21elinest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86ELIQUIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ELIQUIS DVT-PE TREAT 30D START. . . . . . 50ELITEK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19ELLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86ELMIRON. . . . . . . . . . . . . . . . . . . . . . . . . . . . 97eluryng. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85ELZONRIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 21EMCYT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22EMEND ORAL SUSPENSION FORRECONSTITUTION. . . . . . . . . . . . . . . . . . . 71

EMGALITY PEN. . . . . . . . . . . . . . . . . . . . . . 31EMGALITY SYRINGE SUBCUTANEOUSSYRINGE 120 MG/ML. . . . . . . . . . . . . . . . . 31

EMGALITY SYRINGE SUBCUTANEOUSSYRINGE 300 MG/3 ML (100 MG/ML X 3). 31

111

emoquette. . . . . . . . . . . . . . . . . . . . . . . . . . . 86EMPLICITI. . . . . . . . . . . . . . . . . . . . . . . . . . . 22EMSAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41emtricitabine. . . . . . . . . . . . . . . . . . . . . . . . . . . 8emtricitabine-tenofovir (tdf). . . . . . . . . . . . . . . 8EMTRIVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8EMVERM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13enalapril maleate. . . . . . . . . . . . . . . . . . . . . . 47enalapril-hydrochlorothiazide. . . . . . . . . . . . . 47enalaprilat intravenous solution. . . . . . . . . . . 47ENBREL MINI. . . . . . . . . . . . . . . . . . . . . . . . 82ENBREL SUBCUTANEOUS RECON SOLN. 82ENBREL SUBCUTANEOUS SOLUTION. . . 82ENBREL SUBCUTANEOUS SYRINGE. . . . . 82ENBREL SURECLICK. . . . . . . . . . . . . . . . . . 82endocet oral tablet 10-325 mg, 2.5-325 mg,5-325 mg, 7.5-325 mg. . . . . . . . . . . . . . . . . 35

ENGERIX-B (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 77

ENGERIX-B (PF) INTRAMUSCULARSYRINGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 77

ENGERIX-B PEDIATRIC (PF)INTRAMUSCULAR SYRINGE. . . . . . . . . . . 77

ENHERTU. . . . . . . . . . . . . . . . . . . . . . . . . . . 22enoxaparin subcutaneous solution. . . . . . . . 50enoxaparin subcutaneous syringe 100 mg/ml,150 mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . 50

enoxaparin subcutaneous syringe 120 mg/0.8ml, 80 mg/0.8 ml. . . . . . . . . . . . . . . . . . . . . . 51

enoxaparin subcutaneous syringe 30 mg/0.3ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51



enpresse. . . . . . . . . . . . . . . . . . . . . . . . . . . . 86enskyce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86ENSPRYNG. . . . . . . . . . . . . . . . . . . . . . . . . . 22entacapone. . . . . . . . . . . . . . . . . . . . . . . . . . 30entecavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8ENTRESTO. . . . . . . . . . . . . . . . . . . . . . . . . . 54ENTYVIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72enulose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72ENVARSUS XR. . . . . . . . . . . . . . . . . . . . . . . 22

EPCLUSA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8EPIDIOLEX. . . . . . . . . . . . . . . . . . . . . . . . . . 28epinastine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 90epinephrine injection auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3 ml. . . . . . . . . . . . . . . . . . . . . 92

EPINEPHRINE INJECTION AUTO-INJECTOR0.15 MG/0.3 ML, 0.3 MG/0.3 ML (BRAND -EPIPEN). . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

epinephrine injection solution 1 mg/ml. . . . . . 93epinephrine injection syringe 0.1 mg/ml. . . . 93epirubicin intravenous solution. . . . . . . . . . . 22epitol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28EPIVIR HBV ORAL SOLUTION. . . . . . . . . . . . 8eplerenone. . . . . . . . . . . . . . . . . . . . . . . . . . . 47epoprostenol. . . . . . . . . . . . . . . . . . . . . . . . . 47epoprostenol (glycine). . . . . . . . . . . . . . . . . . 47ERBITUX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22ergoloid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ergotamine-caffeine. . . . . . . . . . . . . . . . . . . . 31ERIVEDGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 22ERLEADA. . . . . . . . . . . . . . . . . . . . . . . . . . . 22erlotinib. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22errin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84ertapenem. . . . . . . . . . . . . . . . . . . . . . . . . . . 13ERWINAZE. . . . . . . . . . . . . . . . . . . . . . . . . . 22ery pads. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57ery-tab oral tablet,delayed release (dr/ec) 250mg, 333 mg. . . . . . . . . . . . . . . . . . . . . . . . . 12

erygel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57erythrocin (as stearate) oral tablet 250 mg. . 12ERYTHROCIN INTRAVENOUS RECON SOLN500 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

erythromycin ethylsuccinate oral suspension forreconstitution. . . . . . . . . . . . . . . . . . . . . . . . 12

erythromycin ethylsuccinate oral tablet. . . . . 12erythromycin ophthalmic (eye). . . . . . . . . . . . 89erythromycin oral. . . . . . . . . . . . . . . . . . . . . . 12erythromycin with ethanol topical gel. . . . . . . 57erythromycin with ethanol topical solution. . . 57erythromycin-benzoyl peroxide. . . . . . . . . . . 57ESBRIET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94escitalopram oxalate. . . . . . . . . . . . . . . . . . . 42esmolol in nacl (iso-osm). . . . . . . . . . . . . . . . 47

112

esmolol intravenous solution. . . . . . . . . . . . . 47esomeprazole magnesium oral capsule,delayedrelease(dr/ec) 20 mg. . . . . . . . . . . . . . . . . . 74

esomeprazole magnesium oral capsule,delayedrelease(dr/ec) 40 mg. . . . . . . . . . . . . . . . . . 74

esomeprazole magnesium oral granules dr forsusp in packet 10 mg, 20 mg. . . . . . . . . . . . 74

esomeprazole magnesium oral granules dr forsusp in packet 40 mg. . . . . . . . . . . . . . . . . . 74

esomeprazole sodium intravenous recon soln40 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

estarylla. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86estazolam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42estradiol oral. . . . . . . . . . . . . . . . . . . . . . . . . 84estradiol transdermal patch semiweekly. . . . 84estradiol transdermal patch weekly. . . . . . . . 84estradiol vaginal. . . . . . . . . . . . . . . . . . . . . . . 84estradiol valerate intramuscular oil 20 mg/ml, 40mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

estradiol-norethindrone acet. . . . . . . . . . . . . 84eszopiclone. . . . . . . . . . . . . . . . . . . . . . . . . . 42ethacrynate sodium. . . . . . . . . . . . . . . . . . . . 47ethacrynic acid. . . . . . . . . . . . . . . . . . . . . . . . 47ethambutol. . . . . . . . . . . . . . . . . . . . . . . . . . . 13ethosuximide. . . . . . . . . . . . . . . . . . . . . . . . . 28ethynodiol diac-eth estradiol. . . . . . . . . . . . . 86etodolac oral capsule. . . . . . . . . . . . . . . . . . . 38etodolac oral tablet. . . . . . . . . . . . . . . . . . . . 38etonogestrel-ethinyl estradiol. . . . . . . . . . . . . 85ETOPOPHOS. . . . . . . . . . . . . . . . . . . . . . . . . 22etoposide intravenous. . . . . . . . . . . . . . . . . . 22etoposide oral. . . . . . . . . . . . . . . . . . . . . . . . 22euthyrox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70EVENITY SUBCUTANEOUS SYRINGE 105MG/1.17 ML. . . . . . . . . . . . . . . . . . . . . . . . . 81

EVENITY SUBCUTANEOUS SYRINGE210MG/2.34ML ( 105MG/1.17MLX2). . . . . . 81

everolimus (antineoplastic). . . . . . . . . . . . . . 22everolimus (immunosuppressive). . . . . . . . . 22EVOTAZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8EVRYSDI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32exemestane. . . . . . . . . . . . . . . . . . . . . . . . . . 22ezetimibe. . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

ezetimibe-simvastatin. . . . . . . . . . . . . . . . . . 52

FFABIOR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57FABRAZYME. . . . . . . . . . . . . . . . . . . . . . . . . 68falmina (28). . . . . . . . . . . . . . . . . . . . . . . . . . 86famciclovir. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8famotidine (pf). . . . . . . . . . . . . . . . . . . . . . . . 74famotidine (pf)-nacl (iso-os). . . . . . . . . . . . . 74famotidine intravenous solution. . . . . . . . . . . 74famotidine oral suspension. . . . . . . . . . . . . . 74famotidine oral tablet 20 mg, 40 mg. . . . . . . 74FANAPT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42FARYDAK. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22FASENRA. . . . . . . . . . . . . . . . . . . . . . . . . . . 94FASENRA PEN. . . . . . . . . . . . . . . . . . . . . . . 94fayosim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86febuxostat. . . . . . . . . . . . . . . . . . . . . . . . . . . . 80felbamate. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28felodipine oral tablet extended release 24 hr. 47femynor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86fenofibrate micronized. . . . . . . . . . . . . . . . . . 52fenofibrate nanocrystallized oral tablet 145 mg,48 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

FENOFIBRATE ORAL CAPSULE (BRAND). 52fenofibrate oral tablet 120 mg, 40 mg, 54 mg 52fenofibrate oral tablet 160 mg (generic). . . . . 52fenofibric acid. . . . . . . . . . . . . . . . . . . . . . . . . 52fenofibric acid (choline) oral capsule,delayedrelease(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . 52

fenoprofen oral tablet. . . . . . . . . . . . . . . . . . . 39fentanyl. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35fentanyl citrate (pf) injection solution. . . . . . . 35fentanyl citrate (pf) intravenous syringe 100mcg/2 ml (50 mcg/ml). . . . . . . . . . . . . . . . . . 35

fentanyl citrate buccal lozenge on a handle. . 35FERRIPROX. . . . . . . . . . . . . . . . . . . . . . . . . 61FERRIPROX (2 TIMES A DAY). . . . . . . . . . . 61FETROJA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11FETZIMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42finasteride oral tablet 5 mg. . . . . . . . . . . . . . 97FINTEPLA. . . . . . . . . . . . . . . . . . . . . . . . . . . 28

113

FIRMAGON KIT W DILUENT SYRINGE. . . . 22flac otic oil. . . . . . . . . . . . . . . . . . . . . . . . . . . 64flavoxate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96flecainide. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45FLOVENT DISKUS INHALATION BLISTERWITH DEVICE 100 MCG/ACTUATION, 50MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 94

FLOVENT DISKUS INHALATION BLISTERWITH DEVICE 250 MCG/ACTUATION. . . . 94

FLOVENT HFA AEROSOL INHALER 110MCG/ACTUATION. . . . . . . . . . . . . . . . . . . . 94



floxuridine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22FLUAD 2020-2021 (65 YR UP)(PF). . . . . . . 77FLUAD QUAD 2020-21(65Y UP)(PF). . . . . . 77FLUARIX QUAD 2020-2021 (PF). . . . . . . . . 78FLUBLOK QUAD 2020-2021 (PF). . . . . . . . . 78FLUCELVAX QUAD 2020-2021. . . . . . . . . . . 78FLUCELVAX QUAD 2020-2021 (PF). . . . . . . 78fluconazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7fluconazole in nacl (iso-osm) intravenouspiggyback 200 mg/100 ml. . . . . . . . . . . . . . . 7

fluconazole in nacl (iso-osm) intravenouspiggyback 400 mg/200 ml. . . . . . . . . . . . . . . 7

flucytosine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7fludarabine intravenous recon soln. . . . . . . . 22fludarabine intravenous solution. . . . . . . . . . 22fludrocortisone. . . . . . . . . . . . . . . . . . . . . . . . 64FLULAVAL QUAD 2020-2021 (PF). . . . . . . . 78flumazenil. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42FLUMIST QUAD 2020-2021. . . . . . . . . . . . . 78flunisolide nasal spray,non-aerosol 25 mcg(0.025 %). . . . . . . . . . . . . . . . . . . . . . . . . . . 94

fluocinolone. . . . . . . . . . . . . . . . . . . . . . . . . . 59fluocinolone acetonide oil. . . . . . . . . . . . . . . 64fluocinolone and shower cap. . . . . . . . . . . . . 59fluocinonide. . . . . . . . . . . . . . . . . . . . . . . . . . 59fluocinonide-e. . . . . . . . . . . . . . . . . . . . . . . . 59fluocinonide-emollient. . . . . . . . . . . . . . . . . . 59fluoride (sodium) dental cream. . . . . . . . . . . 63fluoride (sodium) dental gel. . . . . . . . . . . . . . 63

fluoride (sodium) dental paste. . . . . . . . . . . . 63fluoride (sodium) oral tablet. . . . . . . . . . . . . 100fluoride (sodium) oral tablet,chewable 1 mg (2.2mg sod. fluoride). . . . . . . . . . . . . . . . . . . . 100

fluorometholone. . . . . . . . . . . . . . . . . . . . . . . 92fluorouracil intravenous. . . . . . . . . . . . . . . . . 22FLUOROURACIL TOPICAL CREAM 0.5 %. 55fluorouracil topical cream 5 %. . . . . . . . . . . . 55fluorouracil topical solution. . . . . . . . . . . . . . 55fluoxetine oral capsule. . . . . . . . . . . . . . . . . . 42fluoxetine oral capsule,delayedrelease(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . 42

fluoxetine oral solution. . . . . . . . . . . . . . . . . . 42fluphenazine decanoate. . . . . . . . . . . . . . . . . 42fluphenazine hcl. . . . . . . . . . . . . . . . . . . . . . . 42flurandrenolide. . . . . . . . . . . . . . . . . . . . . . . . 59flurazepam. . . . . . . . . . . . . . . . . . . . . . . . . . . 42flurbiprofen oral tablet 100 mg. . . . . . . . . . . . 39flurbiprofen sodium. . . . . . . . . . . . . . . . . . . . 91flutamide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22fluticasone propionate nasal. . . . . . . . . . . . . 94fluticasone propionate topical. . . . . . . . . . . . 59fluvastatin oral capsule. . . . . . . . . . . . . . . . . 52fluvoxamine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

fluvoxamine oral tablet. . . . . . . . . . . . . . . . . . 42FLUZONE HIGHDOSE QUAD 20-21 PF. . . . 78FLUZONE QUAD 2020-2021. . . . . . . . . . . . 78FLUZONE QUAD 2020-2021 (PF)INTRAMUSCULAR SUSPENSION. . . . . . . 78

FLUZONE QUAD 2020-2021 (PF)INTRAMUSCULAR SYRINGE. . . . . . . . . . . 78

FOLOTYN. . . . . . . . . . . . . . . . . . . . . . . . . . . 22fomepizole. . . . . . . . . . . . . . . . . . . . . . . . . . . 78fondaparinux subcutaneous syringe 10 mg/0.8ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

fondaparinux subcutaneous syringe 2.5 mg/0.5ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

fondaparinux subcutaneous syringe 5 mg/0.4ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

fondaparinux subcutaneous syringe 7.5 mg/0.6ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

FORFIVO XL. . . . . . . . . . . . . . . . . . . . . . . . . 42FORTEO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

114

fosamprenavir. . . . . . . . . . . . . . . . . . . . . . . . . . 8fosaprepitant. . . . . . . . . . . . . . . . . . . . . . . . . 72foscarnet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8fosfomycin tromethamine. . . . . . . . . . . . . . . . 19fosinopril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47fosinopril-hydrochlorothiazide. . . . . . . . . . . . 47fosphenytoin. . . . . . . . . . . . . . . . . . . . . . . . . . 28freamine iii 10 %. . . . . . . . . . . . . . . . . . . . . 100FULPHILA. . . . . . . . . . . . . . . . . . . . . . . . . . . 76fulvestrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22furosemide injection. . . . . . . . . . . . . . . . . . . . 47furosemide oral solution 10 mg/ml, 40 mg/5 ml(8 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . 47

furosemide oral tablet. . . . . . . . . . . . . . . . . . 47FUZEON SUBCUTANEOUS RECON SOLN. 8fyavolv. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84FYCOMPA ORAL SUSPENSION. . . . . . . . . 28FYCOMPA ORAL TABLET. . . . . . . . . . . . . . . 28

Ggabapentin oral capsule. . . . . . . . . . . . . . . . . 28gabapentin oral solution 250 mg/5 ml. . . . . . 28gabapentin oral solution 250 mg/5 ml (5 ml), 300mg/6 ml (6 ml). . . . . . . . . . . . . . . . . . . . . . . 28

gabapentin oral tablet 600 mg, 800 mg. . . . . 28GALAFOLD. . . . . . . . . . . . . . . . . . . . . . . . . . 68galantamine oral capsule,ext rel. pellets 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

galantamine oral solution. . . . . . . . . . . . . . . . 32galantamine oral tablet. . . . . . . . . . . . . . . . . 32GAMASTAN. . . . . . . . . . . . . . . . . . . . . . . . . . 78GAMASTAN S/D. . . . . . . . . . . . . . . . . . . . . . 78GAMIFANT. . . . . . . . . . . . . . . . . . . . . . . . . . . 22GAMMAGARD LIQUID. . . . . . . . . . . . . . . . . 78GAMMAGARD S-D (IGA < 1 MCG/ML). . . . . 78GAMUNEX-C INJECTION SOLUTION 1GRAM/10 ML (10 %). . . . . . . . . . . . . . . . . . 78

GAMUNEX-C INJECTION SOLUTION 10GRAM/100 ML (10 %), 2.5 GRAM/25 ML(10 %), 20 GRAM/200 ML (10 %), 40GRAM/400 ML (10 %), 5 GRAM/50 ML (10%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

ganciclovir sodium intravenous. . . . . . . . . . . . 8

ganciclovir sodium intravenous recon soln. . . 8GARDASIL 9 (PF). . . . . . . . . . . . . . . . . . . . . 78gatifloxacin. . . . . . . . . . . . . . . . . . . . . . . . . . . 89GATTEX 30-VIAL. . . . . . . . . . . . . . . . . . . . . . 72GATTEX ONE-VIAL. . . . . . . . . . . . . . . . . . . . 72GAUZE PADS 2X2. . . . . . . . . . . . . . . . . . . . 66gavilyte-c. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72gavilyte-g. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72gavilyte-n. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72GAVRETO. . . . . . . . . . . . . . . . . . . . . . . . . . . 22GAZYVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22gemcitabine intravenous recon soln 1 gram, 200mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

gemcitabine intravenous recon soln 2 gram. 22gemcitabine intravenous solution 1 gram/26.3ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200mg/5.26 ml (38 mg/ml). . . . . . . . . . . . . . . . . 22

gemfibrozil. . . . . . . . . . . . . . . . . . . . . . . . . . . 52generlac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72gengraf oral capsule 100 mg, 25 mg. . . . . . . 22gengraf oral solution. . . . . . . . . . . . . . . . . . . 22gentak ophthalmic (eye) ointment. . . . . . . . . 89gentamicin in nacl (iso-osm) intravenouspiggyback 100 mg/100 ml, 60 mg/50 ml, 80mg/50 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 13

gentamicin in nacl (iso-osm) intravenouspiggyback 80 mg/100 ml. . . . . . . . . . . . . . . 13

gentamicin injection solution 40 mg/ml. . . . . 13gentamicin ophthalmic (eye) drops. . . . . . . . 89gentamicin sulfate (ped) (pf). . . . . . . . . . . . . 13gentamicin topical. . . . . . . . . . . . . . . . . . . . . 58GENVOYA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8gianvi (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 86GILENYA ORAL CAPSULE 0.5 MG. . . . . . . 32GILOTRIF. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22GIVLAARI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61GLASSIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61glatiramer subcutaneous syringe 20 mg/ml. . 32glatiramer subcutaneous syringe 40 mg/ml. . 32glatopa subcutaneous syringe 20 mg/ml. . . . 32glatopa subcutaneous syringe 40 mg/ml. . . . 32glimepiride. . . . . . . . . . . . . . . . . . . . . . . . . . . 66glipizide oral tablet. . . . . . . . . . . . . . . . . . . . . 66

115

glipizide oral tablet extended release 24hr. . 66glipizide-metformin. . . . . . . . . . . . . . . . . . . . . 66GLUCAGEN HYPOKIT. . . . . . . . . . . . . . . . . 66GLUCAGON (HCL) EMERGENCY KIT. . . . . 66GLUCAGON EMERGENCY KIT (HUMAN). . 66glyburide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66glyburide micronized. . . . . . . . . . . . . . . . . . . 66glyburide-metformin. . . . . . . . . . . . . . . . . . . . 66glycine urologic. . . . . . . . . . . . . . . . . . . . . . . 97glycine urologic solution. . . . . . . . . . . . . . . . . 97GLYCOPHOS. . . . . . . . . . . . . . . . . . . . . . . . . 98glycopyrrolate (pf) in water intravenous syringe0.4 mg/2 ml (0.2 mg/ml). . . . . . . . . . . . . . . . 71

glycopyrrolate injection. . . . . . . . . . . . . . . . . 71glycopyrrolate oral tablet 1 mg, 2 mg. . . . . . . 71glycopyrrolate oral tablet 1.5 mg. . . . . . . . . . 71glydo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55granisetron (pf) intravenous solution 1 mg/ml (1ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

granisetron hcl intravenous. . . . . . . . . . . . . . 72granisetron hcl oral. . . . . . . . . . . . . . . . . . . . 72GRANIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76GRASTEK. . . . . . . . . . . . . . . . . . . . . . . . . . . 78griseofulvin microsize. . . . . . . . . . . . . . . . . . . 7griseofulvin ultramicrosize. . . . . . . . . . . . . . . . 7guanfacine oral tablet. . . . . . . . . . . . . . . . . . 48guanfacine oral tablet extended release 24 hr 42guanidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42GYNAZOLE-1. . . . . . . . . . . . . . . . . . . . . . . . 85

Hhailey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86hailey 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . . 86hailey fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . . 86hailey fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . 86HALAVEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22halcinonide. . . . . . . . . . . . . . . . . . . . . . . . . . . 59halobetasol propionate topical cream. . . . . . 59halobetasol propionate topical ointment. . . . 59haloperidol. . . . . . . . . . . . . . . . . . . . . . . . . . . 42haloperidol decanoate. . . . . . . . . . . . . . . . . . 42haloperidol lactate injection. . . . . . . . . . . . . . 42

haloperidol lactate intramuscular. . . . . . . . . . 42haloperidol lactate oral. . . . . . . . . . . . . . . . . . 42HARVONI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8HAVRIX (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 78

HAVRIX (PF) INTRAMUSCULAR SYRINGE1,440 ELISA UNIT/ML. . . . . . . . . . . . . . . . . 78

HAVRIX (PF) INTRAMUSCULAR SYRINGE720 ELISA UNIT/0.5 ML. . . . . . . . . . . . . . . . 78

heather. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84hep flush-10 (pf). . . . . . . . . . . . . . . . . . . . . . . 51heparin (porcine) in 5 % dex intravenousparenteral solution 20,000 unit/500 ml (40unit/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

heparin (porcine) in 5 % dex intravenousparenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml). . . . . . . 51

heparin (porcine) in nacl (pf). . . . . . . . . . . . . 51heparin (porcine) injection cartridge. . . . . . . 51heparin (porcine) injection solution. . . . . . . . 51heparin (porcine) injection syringe 5,000unit/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

heparin flush(porcine)-0.9nacl. . . . . . . . . . . . 51heparin lock flush (porcine) intravenoussolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

heparin lock flush intravenous solution. . . . . 51heparin lock flush intravenous syringe. . . . . . 51heparin lockflush(porcine)(pf). . . . . . . . . . . . 51heparin(porcine) in 0.45% nacl intravenousparenteral solution 25,000 unit/250 ml, 25,000unit/500 ml. . . . . . . . . . . . . . . . . . . . . . . . . . 51

heparin, porcine (pf) injection solution 1,000unit/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

heparin, porcine (pf) injection solution 5,000unit/0.5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 52

heparin, porcine (pf) injection syringe 5,000unit/0.5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 52

heparin, porcine (pf) intravenous syringe 1unit/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 unit/ml. . . . . . . . . . . . . . . . . . . . . . . 52

HEPATAMINE 8%. . . . . . . . . . . . . . . . . . . . 100HERCEPTIN HYLECTA. . . . . . . . . . . . . . . . . 22HERCEPTIN INTRAVENOUS RECON SOLN150 MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

116

HERZUMA. . . . . . . . . . . . . . . . . . . . . . . . . . . 22HETLIOZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . 42HIBERIX (PF). . . . . . . . . . . . . . . . . . . . . . . . 78hidex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64HUMALOG JUNIOR KWIKPEN U-100. . . . . 66HUMALOG KWIKPEN INSULIN. . . . . . . . . . 66HUMALOG MIX 50-50 INSULN U-100. . . . . 66HUMALOG MIX 50-50 KWIKPEN. . . . . . . . . 66HUMALOG MIX 75-25 KWIKPEN. . . . . . . . . 66HUMALOG MIX 75-25(U-100)INSULN. . . . . 66HUMALOG U-100 INSULIN. . . . . . . . . . . . . . 66HUMIRA PEN. . . . . . . . . . . . . . . . . . . . . . . . 82HUMIRA PEN CROHNS-UC-HS START. . . . 82HUMIRA PEN PSOR-UVEITS-ADOL HS. . . 82HUMIRA SUBCUTANEOUS SYRINGE KIT 40MG/0.8 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 82

HUMIRA(CF) PEDI CROHNS STARTERSUBCUTANEOUS SYRINGE KIT 80 MG/0.8ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

HUMIRA(CF) PEDI CROHNS STARTERSUBCUTANEOUS SYRINGE KIT 80 MG/0.8ML-40 MG/0.4 ML. . . . . . . . . . . . . . . . . . . . 82

HUMIRA(CF) PEN CROHNS-UC-HS. . . . . . 82HUMIRA(CF) PEN PSOR-UV-ADOL HS. . . . 82HUMIRA(CF) PEN SUBCUTANEOUSINJECTOR KIT 40 MG/0.4 ML. . . . . . . . . . . 82

HUMIRA(CF) PEN SUBCUTANEOUS PENINJECTOR KIT 80 MG/0.8 ML. . . . . . . . . . . 82

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT10 MG/0.1 ML, 20 MG/0.2 ML. . . . . . . . . . . 82

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT40 MG/0.4 ML. . . . . . . . . . . . . . . . . . . . . . . 82

HUMULIN 70/30 U-100 INSULIN. . . . . . . . . 66HUMULIN 70/30 U-100 KWIKPEN. . . . . . . . 66HUMULIN N NPH INSULIN KWIKPEN. . . . . 66HUMULIN N NPH U-100 INSULIN. . . . . . . . 66HUMULIN R REGULAR U-100 INSULN. . . . 66HUMULIN R U-500 (CONC) INSULIN. . . . . . 66HYCAMTIN ORAL. . . . . . . . . . . . . . . . . . . . . 22hydralazine. . . . . . . . . . . . . . . . . . . . . . . . . . . 48hydrochlorothiazide. . . . . . . . . . . . . . . . . . . . 48hydrocodone bitartrate oral capsule, oral only, er12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

hydrocodone bitartrate oral tablet,oral only,ext.rel.24 hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

hydrocodone-acetaminophen oral solution10-325 mg/15 ml(15 ml). . . . . . . . . . . . . . . . 35

hydrocodone-acetaminophen oral solution7.5-325 mg/15 ml. . . . . . . . . . . . . . . . . . . . . 35

HYDROCODONE-ACETAMINOPHEN ORALSOLUTION 7.5-325 MG/15 ML (BRAND). . 35

hydrocodone-acetaminophen oral tablet 10-300mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300mg, 7.5-325 mg. . . . . . . . . . . . . . . . . . . . . . 35

hydrocodone-ibuprofen oral tablet 10-200 mg,5-200 mg, 7.5-200 mg. . . . . . . . . . . . . . . . . 35

hydrocortisone butyr-emollient. . . . . . . . . . . . 59hydrocortisone butyrate. . . . . . . . . . . . . . . . . 59hydrocortisone oral. . . . . . . . . . . . . . . . . . . . 64hydrocortisone rectal. . . . . . . . . . . . . . . . . . . 72hydrocortisone topical cream 1 %, 2.5 %. . . 59hydrocortisone topical cream with perinealapplicator. . . . . . . . . . . . . . . . . . . . . . . . . . . 72

hydrocortisone topical lotion 2.5 %. . . . . . . . 59hydrocortisone topical ointment 1 %, 2.5 %. . 59hydrocortisone valerate. . . . . . . . . . . . . . . . . 59hydrocortisone-acetic acid. . . . . . . . . . . . . . . 64hydrocortisone-pramoxine rectal cream 1-1%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml, 2 mg/ml. . . . . . . . . . . . 36

hydromorphone injection solution 1 mg/ml. . 36hydromorphone injection solution 2 mg/ml. . 36hydromorphone injection syringe 1 mg/ml, 4mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

hydromorphone injection syringe 2 mg/ml. . . 36hydromorphone oral liquid. . . . . . . . . . . . . . . 36hydromorphone oral tablet. . . . . . . . . . . . . . . 36hydromorphone oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

hydroxychloroquine. . . . . . . . . . . . . . . . . . . . 13hydroxyprogesterone caproate. . . . . . . . . . . 84hydroxyurea. . . . . . . . . . . . . . . . . . . . . . . . . . 22hydroxyzine hcl intramuscular. . . . . . . . . . . . 93hydroxyzine hcl oral solution 10 mg/5 ml. . . . 93hydroxyzine hcl oral tablet. . . . . . . . . . . . . . . 93hydroxyzine pamoate. . . . . . . . . . . . . . . . . . . 93

117

HYPER-SAL INHALATION SOLUTION FORNEBULIZATION 3.5 %. . . . . . . . . . . . . . . . . 94

Iibandronate intravenous. . . . . . . . . . . . . . . . 81ibandronate oral. . . . . . . . . . . . . . . . . . . . . . . 81IBRANCE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ibu. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39ibuprofen lysine (pf). . . . . . . . . . . . . . . . . . . . 39ibuprofen oral suspension. . . . . . . . . . . . . . . 39ibuprofen oral tablet 400 mg, 600 mg, 800mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

ibutilide fumarate. . . . . . . . . . . . . . . . . . . . . . 45icatibant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94iclevia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86ICLUSIG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23icosapent ethyl. . . . . . . . . . . . . . . . . . . . . . . . 52idarubicin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23IDHIFA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ifosfamide intravenous recon soln. . . . . . . . . 23ifosfamide intravenous solution 1 gram/20 ml 23ifosfamide intravenous solution 3 gram/60 ml 23ILARIS (PF) SUBCUTANEOUS SOLUTION. 76imatinib. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23IMBRUVICA. . . . . . . . . . . . . . . . . . . . . . . . . . 23IMFINZI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23imipenem-cilastatin. . . . . . . . . . . . . . . . . . . . 13imipramine hcl. . . . . . . . . . . . . . . . . . . . . . . . 42imipramine pamoate. . . . . . . . . . . . . . . . . . . 42IMIQUIMOD TOPICAL CREAM IN METERED-DOSE PUMP. . . . . . . . . . . . . . . . . . . . . . . . 55

imiquimod topical cream in packet. . . . . . . . . 55IMOVAX RABIES VACCINE (PF). . . . . . . . . 78IMPAVIDO. . . . . . . . . . . . . . . . . . . . . . . . . . . 13INBRIJA INHALATION CAPSULE, W/INHALATION DEVICE. . . . . . . . . . . . . . . . . 30

incassia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84INCRELEX. . . . . . . . . . . . . . . . . . . . . . . . . . . 61INCRUSE ELLIPTA. . . . . . . . . . . . . . . . . . . . 94indapamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 48indomethacin oral capsule. . . . . . . . . . . . . . . 39indomethacin oral capsule, extended release 39indomethacin sodium. . . . . . . . . . . . . . . . . . . 39

INFANRIX (DTAP) (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 78

INFANRIX (DTAP) (PF) INTRAMUSCULARSYRINGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 79

INFLECTRA. . . . . . . . . . . . . . . . . . . . . . . . . . 72INFUGEM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23INGREZZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 32INGREZZA INITIATION PACK. . . . . . . . . . . . 32INLYTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23INPEN (FOR HUMALOG). . . . . . . . . . . . . . . 67INQOVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23INREBIC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23INSULIN PEN NEEDLE. . . . . . . . . . . . . . . . . 67INSULIN SYRINGE (DISP) U-100 0.3 ML. . . 67INSULIN SYRINGE (DISP) U-100 1 ML. . . . 67INSULIN SYRINGE (DISP) U-100 1/2 ML. . . 67INTELENCE. . . . . . . . . . . . . . . . . . . . . . . . . . . 8intralipid intravenous emulsion 20 %. . . . . . 100INTRALIPID INTRAVENOUS EMULSION 30%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

INTRON A INJECTION. . . . . . . . . . . . . . . . . 76introvale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86INVEGA SUSTENNA. . . . . . . . . . . . . . . . . . . 42INVEGA TRINZA. . . . . . . . . . . . . . . . . . . . . . 42INVIRASE ORAL TABLET. . . . . . . . . . . . . . . . 8INVOKAMET. . . . . . . . . . . . . . . . . . . . . . . . . 67INVOKAMET XR. . . . . . . . . . . . . . . . . . . . . . 67INVOKANA. . . . . . . . . . . . . . . . . . . . . . . . . . . 67IPOL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79ipratropium bromide inhalation. . . . . . . . . . . 94ipratropium bromide nasal spray,non-aerosol 21mcg (0.03 %). . . . . . . . . . . . . . . . . . . . . . . . 63

ipratropium bromide nasal spray,non-aerosol 42mcg (0.06 %). . . . . . . . . . . . . . . . . . . . . . . . 63

ipratropium-albuterol. . . . . . . . . . . . . . . . . . . 94irbesartan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 48irbesartan-hydrochlorothiazide. . . . . . . . . . . 48IRESSA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23irinotecan intravenous solution 100 mg/5 ml, 40mg/2 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

irinotecan intravenous solution 300 mg/15 ml,500 mg/25 ml. . . . . . . . . . . . . . . . . . . . . . . . 23

ISENTRESS. . . . . . . . . . . . . . . . . . . . . . . . . . . 9

118

ISENTRESS HD. . . . . . . . . . . . . . . . . . . . . . . 9isibloom. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86isoniazid injection. . . . . . . . . . . . . . . . . . . . . . 13isoniazid oral. . . . . . . . . . . . . . . . . . . . . . . . . 14isoproterenol hcl. . . . . . . . . . . . . . . . . . . . . . 54isosorbide dinitrate oral tablet. . . . . . . . . . . . 54isosorbide mononitrate oral tablet. . . . . . . . . 54isosorbide mononitrate oral tablet extendedrelease 24 hr. . . . . . . . . . . . . . . . . . . . . . . . 54

isotretinoin. . . . . . . . . . . . . . . . . . . . . . . . . . . 57isradipine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ISTODAX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ISTURISA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69itraconazole oral capsule. . . . . . . . . . . . . . . . . 7itraconazole oral solution. . . . . . . . . . . . . . . . . 7ivermectin oral. . . . . . . . . . . . . . . . . . . . . . . . 14ivermectin topical lotion. . . . . . . . . . . . . . . . . 60IXEMPRA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23IXIARO (PF). . . . . . . . . . . . . . . . . . . . . . . . . . 79

JJADENU SPRINKLE. . . . . . . . . . . . . . . . . . . 61jaimiess. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86JAKAFI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23jantoven. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52JANUMET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 67JANUMET XR. . . . . . . . . . . . . . . . . . . . . . . . 67JANUVIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 67JARDIANCE. . . . . . . . . . . . . . . . . . . . . . . . . . 67jasmiel (28). . . . . . . . . . . . . . . . . . . . . . . . . . 86jencycla. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84JEVTANA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23jinteli. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84jolessa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86juleber. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86JULUCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9junel 1.5/30 (21). . . . . . . . . . . . . . . . . . . . . . . 86junel 1/20 (21). . . . . . . . . . . . . . . . . . . . . . . . 86junel fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . . . 86junel fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . . 86junel fe 24. . . . . . . . . . . . . . . . . . . . . . . . . . . 86JUXTAPID. . . . . . . . . . . . . . . . . . . . . . . . . . . 52

JYNARQUE. . . . . . . . . . . . . . . . . . . . . . . . . . 69

Kk-tab oral tablet extended release 8 meq. . . 98KADCYLA. . . . . . . . . . . . . . . . . . . . . . . . . . . 23kaitlib fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86KALETRA ORAL TABLET. . . . . . . . . . . . . . . . 9kalliga. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86KALYDECO ORAL GRANULES IN PACKET. 94KALYDECO ORAL TABLET. . . . . . . . . . . . . . 94KANJINTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23KANUMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69kariva (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 86kelnor 1-50 (28). . . . . . . . . . . . . . . . . . . . . . . 86kelnor 1/35 (28). . . . . . . . . . . . . . . . . . . . . . . 86KEPIVANCE. . . . . . . . . . . . . . . . . . . . . . . . . . 19KESIMPTA PEN. . . . . . . . . . . . . . . . . . . . . . . 32ketoconazole oral. . . . . . . . . . . . . . . . . . . . . . . 7ketoconazole topical. . . . . . . . . . . . . . . . . . . 58ketodan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58ketoprofen oral capsule 25 mg. . . . . . . . . . . 39ketoprofen oral capsule 50 mg, 75 mg. . . . . 39ketoprofen oral capsule,ext rel. pellets 24 hr 200mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

ketorolac injection cartridge 30 mg/ml. . . . . . 39ketorolac injection solution 15 mg/ml, 30 mg/ml(1 ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

ketorolac injection syringe. . . . . . . . . . . . . . . 39ketorolac intramuscular. . . . . . . . . . . . . . . . . 39ketorolac ophthalmic (eye). . . . . . . . . . . . . . . 91ketorolac oral. . . . . . . . . . . . . . . . . . . . . . . . . 39KEVEYIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32KEVZARA. . . . . . . . . . . . . . . . . . . . . . . . . . . 83KEYTRUDA INTRAVENOUS SOLUTION. . . 23KINERET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83KINRIX (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 79

KINRIX (PF) INTRAMUSCULAR SYRINGE. 79kionex (with sorbitol) oral suspension. . . . . . 61KISQALI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23KISQALI FEMARA CO-PACK. . . . . . . . . . . . 23klor-con 10 oral tablet extended release. . . . 98

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klor-con 20 meq packet. . . . . . . . . . . . . . . . . 98klor-con 8 oral tablet extended release. . . . . 98klor-con m10 oral tablet,er particles/crystals. 98klor-con m15 oral tablet,er particles/crystals. 98klor-con m20 oral tablet,er particles/crystals. 98klor-con/ef. . . . . . . . . . . . . . . . . . . . . . . . . . . 98KOMBIGLYZE XR. . . . . . . . . . . . . . . . . . . . . 67KORLYM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69KOSELUGO. . . . . . . . . . . . . . . . . . . . . . . . . . 23KRYSTEXXA. . . . . . . . . . . . . . . . . . . . . . . . . 80kurvelo (28). . . . . . . . . . . . . . . . . . . . . . . . . . 86KUVAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69KYPROLIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Ll norgest/e.estradiol-e.estrad oral tablets,dosepack,3 month 0.10 mg-20 mcg (84)/10 mcg (7),0.15 mg-30 mcg (84)/10 mcg (7). . . . . . . . . 87

l norgest/e.estradiol-e.estrad oral tablets,dosepack,3 month 0.15 mg-20 mcg/ 0.15 mg-25mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

labetalol intravenous solution. . . . . . . . . . . . 48labetalol intravenous syringe 20 mg/4 ml (5mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

labetalol oral. . . . . . . . . . . . . . . . . . . . . . . . . 48LACRISERT. . . . . . . . . . . . . . . . . . . . . . . . . . 90lactated ringers intravenous. . . . . . . . . . . . . . 98lactated ringers irrigation. . . . . . . . . . . . . . . . 60lactulose oral packet. . . . . . . . . . . . . . . . . . . 72lactulose oral solution 10 gram/15 ml. . . . . . 72lactulose oral solution 10 gram/15 ml (15 ml), 20gram/30 ml. . . . . . . . . . . . . . . . . . . . . . . . . . 72

lamivudine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9lamivudine-zidovudine. . . . . . . . . . . . . . . . . . . 9lamotrigine. . . . . . . . . . . . . . . . . . . . . . . . . . . 28LAMPIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14lansoprazole oral capsule,delayed release(dr/ec) 15 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . 74

lansoprazole oral capsule,delayed release(dr/ec) 30 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . 75

lansoprazole oral tablet,disintegrat, delay rel 15mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

lansoprazole oral tablet,disintegrat, delay rel 30mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

lanthanum oral tablet,chewable. . . . . . . . . . . 61LANTUS SOLOSTAR U-100 INSULIN. . . . . 67LANTUS U-100 INSULIN. . . . . . . . . . . . . . . . 67lapatinib. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23larin 1.5/30 (21). . . . . . . . . . . . . . . . . . . . . . . 87larin 1/20 (21). . . . . . . . . . . . . . . . . . . . . . . . . 87larin 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . 87larin fe 1.5/30 (28). . . . . . . . . . . . . . . . . . . . . 87larin fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . . . 87larissia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87latanoprost. . . . . . . . . . . . . . . . . . . . . . . . . . . 91LATUDA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42layolis fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87leena 28. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87leflunomide. . . . . . . . . . . . . . . . . . . . . . . . . . . 83LEMTRADA. . . . . . . . . . . . . . . . . . . . . . . . . . 32LENVIMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23lessina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87letrozole. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23leucovorin calcium injection recon soln 100 mg,200 mg, 350 mg, 50 mg. . . . . . . . . . . . . . . . 19

leucovorin calcium injection recon soln 500mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

leucovorin calcium injection solution. . . . . . . 19leucovorin calcium oral. . . . . . . . . . . . . . . . . 19LEUKERAN. . . . . . . . . . . . . . . . . . . . . . . . . . 23LEUKINE INJECTION RECON SOLN. . . . . . 76leuprolide subcutaneous kit. . . . . . . . . . . . . . 23levalbuterol hcl. . . . . . . . . . . . . . . . . . . . . . . . 94levetiracetam in nacl (iso-os) intravenouspiggyback 1,000 mg/100 ml, 1,500 mg/100ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

levetiracetam in nacl (iso-os) intravenouspiggyback 500 mg/100 ml. . . . . . . . . . . . . . 28

levetiracetam intravenous. . . . . . . . . . . . . . . 28levetiracetam oral solution 100 mg/ml. . . . . . 28levetiracetam oral solution 500 mg/5 ml (5ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

levetiracetam oral tablet. . . . . . . . . . . . . . . . . 28levetiracetam oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

levo-t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70levobunolol ophthalmic (eye) drops 0.5 %. . . 90

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levocarnitine (with sugar). . . . . . . . . . . . . . . . 61levocarnitine oral solution 100 mg/ml. . . . . . 61levocarnitine oral tablet. . . . . . . . . . . . . . . . . 61levocetirizine oral solution. . . . . . . . . . . . . . . 93levocetirizine oral tablet. . . . . . . . . . . . . . . . . 93levofloxacin in d5w intravenous piggyback 250mg/50 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 17

levofloxacin in d5w intravenous piggyback 500mg/100 ml, 750 mg/150 ml. . . . . . . . . . . . . . 17

levofloxacin intravenous. . . . . . . . . . . . . . . . 17levofloxacin ophthalmic (eye). . . . . . . . . . . . 89levofloxacin oral. . . . . . . . . . . . . . . . . . . . . . . 17levoleucovorin calcium intravenous recon soln50 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

levoleucovorin calcium intravenous solution. 19levonest (28). . . . . . . . . . . . . . . . . . . . . . . . . 87levonorg-eth estrad triphasic. . . . . . . . . . . . . 87levonorgestrel-ethinyl estrad oral tablet 0.1-20mg-mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

levonorgestrel-ethinyl estrad oral tablet0.15-0.03 mg, 90-20 mcg (28). . . . . . . . . . . 87

levonorgestrel-ethinyl estrad oral tablets,dosepack,3 month. . . . . . . . . . . . . . . . . . . . . . . . 87

levora-28. . . . . . . . . . . . . . . . . . . . . . . . . . . . 87levorphanol tartrate oral tablet 2 mg. . . . . . . 36levorphanol tartrate oral tablet 3 mg. . . . . . . 36levothyroxine intravenous recon soln. . . . . . 70levothyroxine oral tablet. . . . . . . . . . . . . . . . . 70levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,137 mcg, 150 mcg, 175 mcg, 200 mcg, 25mcg, 50 mcg, 75 mcg, 88 mcg. . . . . . . . . . . 70

LEXIVA ORAL SUSPENSION. . . . . . . . . . . . . 9LIBTAYO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23lidocaine (pf) in d7.5w. . . . . . . . . . . . . . . . . . 45lidocaine (pf) injection solution. . . . . . . . . . . . 55lidocaine (pf) intravenous. . . . . . . . . . . . . . . . 45lidocaine hcl injection solution. . . . . . . . . . . . 55lidocaine hcl laryngotracheal. . . . . . . . . . . . . 55lidocaine hcl mucous membrane jelly. . . . . . 55lidocaine hcl mucous membrane jelly inapplicator. . . . . . . . . . . . . . . . . . . . . . . . . . . 56

lidocaine hcl mucous membrane solution 4 %(40 mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . 56

lidocaine in 5 % dextrose (pf) intravenousparenteral solution 4 mg/ml (0.4 %), 8 mg/ml(0.8 %). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

lidocaine topical adhesive patch,medicated 5%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

lidocaine topical ointment. . . . . . . . . . . . . . . 56lidocaine viscous. . . . . . . . . . . . . . . . . . . . . . 56lidocaine-epinephrine. . . . . . . . . . . . . . . . . . . 56lidocaine-epinephrine (pf). . . . . . . . . . . . . . . 56lidocaine-prilocaine topical cream. . . . . . . . . 56lillow (28). . . . . . . . . . . . . . . . . . . . . . . . . . . . 87lincomycin. . . . . . . . . . . . . . . . . . . . . . . . . . . 14lindane topical shampoo. . . . . . . . . . . . . . . . 60linezolid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14linezolid in dextrose 5%. . . . . . . . . . . . . . . . . 14linezolid-0.9% sodium chloride. . . . . . . . . . . 14LINZESS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72liothyronine intravenous. . . . . . . . . . . . . . . . . 70liothyronine oral. . . . . . . . . . . . . . . . . . . . . . . 70lisinopril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48lisinopril-hydrochlorothiazide. . . . . . . . . . . . . 48lithium carbonate oral capsule. . . . . . . . . . . . 42lithium carbonate oral tablet. . . . . . . . . . . . . . 42lithium carbonate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

lithium citrate oral solution 8 meq/5 ml. . . . . 42lo-zumandimine (28). . . . . . . . . . . . . . . . . . . 87lojaimiess. . . . . . . . . . . . . . . . . . . . . . . . . . . . 87LONSURF. . . . . . . . . . . . . . . . . . . . . . . . . . . 23loperamide oral capsule. . . . . . . . . . . . . . . . . 71lopinavir-ritonavir. . . . . . . . . . . . . . . . . . . . . . . 9lorazepam injection solution. . . . . . . . . . . . . 42lorazepam injection syringe 2 mg/ml. . . . . . . 42lorazepam injection syringe 4 mg/ml. . . . . . . 42lorazepam intensol. . . . . . . . . . . . . . . . . . . . . 42lorazepam oral concentrate. . . . . . . . . . . . . . 42lorazepam oral tablet. . . . . . . . . . . . . . . . . . . 42LORBRENA. . . . . . . . . . . . . . . . . . . . . . . . . . 23loryna (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 87losartan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48losartan-hydrochlorothiazide. . . . . . . . . . . . . 48loteprednol etabonate. . . . . . . . . . . . . . . . . . 92lovastatin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

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low-ogestrel (28). . . . . . . . . . . . . . . . . . . . . . 87loxapine succinate. . . . . . . . . . . . . . . . . . . . . 42LUCEMYRA. . . . . . . . . . . . . . . . . . . . . . . . . . 39LULICONAZOLE. . . . . . . . . . . . . . . . . . . . . . 58LUMIGAN OPHTHALMIC (EYE) DROPS 0.01%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

LUMOXITI. . . . . . . . . . . . . . . . . . . . . . . . . . . 23LUPANETA PACK (1 MONTH). . . . . . . . . . . 85LUPANETA PACK (3 MONTH). . . . . . . . . . . 85LUPKYNIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 23LUPRON DEPOT. . . . . . . . . . . . . . . . . . . . . . 23LUPRON DEPOT (3 MONTH). . . . . . . . . . . . 23LUPRON DEPOT (4 MONTH). . . . . . . . . . . . 23LUPRON DEPOT (6 MONTH). . . . . . . . . . . . 23LUPRON DEPOT-PED. . . . . . . . . . . . . . . . . 23LUPRON DEPOT-PED (3 MONTH). . . . . . . 23lutera (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 87LUZU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58lyleq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84lyllana. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84LYNPARZA ORAL TABLET. . . . . . . . . . . . . . 23LYSODREN. . . . . . . . . . . . . . . . . . . . . . . . . . 24lyza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

MM-M-R II (PF). . . . . . . . . . . . . . . . . . . . . . . . . 79mafenide acetate. . . . . . . . . . . . . . . . . . . . . . 58magnesium chloride injection. . . . . . . . . . . . 98magnesium sulfate in water. . . . . . . . . . . . . . 98magnesium sulfate injection solution. . . . . . . 98magnesium sulfate injection syringe. . . . . . . 98malathion. . . . . . . . . . . . . . . . . . . . . . . . . . . . 60mannitol 20 %. . . . . . . . . . . . . . . . . . . . . . . . 48mannitol 25 % intravenous solution. . . . . . . . 48maprotiline. . . . . . . . . . . . . . . . . . . . . . . . . . . 42marlissa (28). . . . . . . . . . . . . . . . . . . . . . . . . 87MARPLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . 43MATULANE. . . . . . . . . . . . . . . . . . . . . . . . . . 24matzim la oral tablet extended release 24 hr. 48MAVENCLAD (10 TABLET PACK). . . . . . . . . 32MAVENCLAD (4 TABLET PACK). . . . . . . . . . 32MAVENCLAD (5 TABLET PACK). . . . . . . . . . 32

MAVENCLAD (6 TABLET PACK). . . . . . . . . . 32MAVENCLAD (7 TABLET PACK). . . . . . . . . . 32MAVENCLAD (8 TABLET PACK). . . . . . . . . . 32MAVENCLAD (9 TABLET PACK). . . . . . . . . . 32MAVYRET. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9MAYZENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32MAYZENT STARTER PACK. . . . . . . . . . . . . 32meclizine oral tablet 12.5 mg, 25 mg. . . . . . . 72meclofenamate. . . . . . . . . . . . . . . . . . . . . . . . 39medroxyprogesterone. . . . . . . . . . . . . . . . . . 84mefenamic acid. . . . . . . . . . . . . . . . . . . . . . . 39mefloquine. . . . . . . . . . . . . . . . . . . . . . . . . . . 14megestrol oral suspension 400 mg/10 ml (10ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

megestrol oral suspension 400 mg/10 ml (40mg/ml), 625 mg/5 ml (125 mg/ml). . . . . . . . 24

megestrol oral tablet. . . . . . . . . . . . . . . . . . . 24MEKINIST. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24MEKTOVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24melodetta 24 fe. . . . . . . . . . . . . . . . . . . . . . . 87meloxicam oral tablet. . . . . . . . . . . . . . . . . . . 39melphalan. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24melphalan hcl. . . . . . . . . . . . . . . . . . . . . . . . . 24memantine oral capsule,sprinkle,er 24hr. . . . 32memantine oral solution. . . . . . . . . . . . . . . . . 32memantine oral tablet. . . . . . . . . . . . . . . . . . 32MENACTRA (PF) INTRAMUSCULARSOLUTION. . . . . . . . . . . . . . . . . . . . . . . . . . 79

menquadfi (pf). . . . . . . . . . . . . . . . . . . . . . . . 79MENVEO A-C-Y-W-135-DIP (PF). . . . . . . . . 79meperidine (pf) injection solution 100 mg/ml, 50mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

meperidine (pf) injection solution 25 mg/ml. . 36meperidine oral. . . . . . . . . . . . . . . . . . . . . . . 36meprobamate. . . . . . . . . . . . . . . . . . . . . . . . . 33MEPSEVII. . . . . . . . . . . . . . . . . . . . . . . . . . . 69mercaptopurine. . . . . . . . . . . . . . . . . . . . . . . 24meropenem. . . . . . . . . . . . . . . . . . . . . . . . . . 14merzee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87mesalamine oral capsule (with del rel tablets) 72mesalamine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

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mesalamine oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

mesalamine rectal. . . . . . . . . . . . . . . . . . . . . 72mesna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19MESNEX ORAL. . . . . . . . . . . . . . . . . . . . . . . 19metaproterenol oral syrup. . . . . . . . . . . . . . . 94metaxalone. . . . . . . . . . . . . . . . . . . . . . . . . . . 33metformin oral solution. . . . . . . . . . . . . . . . . 67metformin oral tablet. . . . . . . . . . . . . . . . . . . 67metformin oral tablet extended release 24 hr(generic - GLUCOPHAGE XR). . . . . . . . . . 67

methadone injection solution. . . . . . . . . . . . . 36methadone intensol. . . . . . . . . . . . . . . . . . . . 36methadone oral concentrate. . . . . . . . . . . . . 36methadone oral solution. . . . . . . . . . . . . . . . 36methadone oral tablet. . . . . . . . . . . . . . . . . . 36methadose oral concentrate. . . . . . . . . . . . . 36methamphetamine. . . . . . . . . . . . . . . . . . . . . 43methazolamide. . . . . . . . . . . . . . . . . . . . . . . . 91methenamine hippurate. . . . . . . . . . . . . . . . . 19methenamine mandelate. . . . . . . . . . . . . . . . 19methergine. . . . . . . . . . . . . . . . . . . . . . . . . . . 89methimazole oral tablet 10 mg, 5 mg. . . . . . . 65METHITEST. . . . . . . . . . . . . . . . . . . . . . . . . . 69methocarbamol injection. . . . . . . . . . . . . . . . 33methocarbamol oral. . . . . . . . . . . . . . . . . . . . 33methotrexate sodium (pf) injection recon soln 24methotrexate sodium (pf) injection solution. . 24methotrexate sodium injection. . . . . . . . . . . . 24methotrexate sodium oral. . . . . . . . . . . . . . . 24methoxsalen. . . . . . . . . . . . . . . . . . . . . . . . . . 56methscopolamine. . . . . . . . . . . . . . . . . . . . . . 71methyldopa. . . . . . . . . . . . . . . . . . . . . . . . . . . 48methyldopa-hydrochlorothiazide. . . . . . . . . . 48methylergonovine oral. . . . . . . . . . . . . . . . . . 89methylphenidate hcl oral cap,er sprinkle,biphasic 40-60. . . . . . . . . . . . . . . . . . . . . . . 43

methylphenidate hcl oral capsule, er biphasic30-70 10 mg, 20 mg, 30 mg. . . . . . . . . . . . . 43

methylphenidate hcl oral capsule, er biphasic30-70 40 mg, 50 mg, 60 mg. . . . . . . . . . . . . 43

methylphenidate hcl oral capsule,er biphasic 50-50. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

methylphenidate hcl oral solution. . . . . . . . . 43methylphenidate hcl oral tablet. . . . . . . . . . . 43methylphenidate hcl oral tablet extendedrelease 10 mg. . . . . . . . . . . . . . . . . . . . . . . 43

methylphenidate hcl oral tablet extendedrelease 20 mg. . . . . . . . . . . . . . . . . . . . . . . 43

methylphenidate hcl oral tablet extendedrelease 24hr 18 mg (bx rating), 27 mg (bxrating), 54 mg (bx rating). . . . . . . . . . . . . . . 43

methylphenidate hcl oral tablet extendedrelease 24hr 18 mg, 27 mg, 54 mg. . . . . . . 43

methylphenidate hcl oral tablet extendedrelease 24hr 36 mg. . . . . . . . . . . . . . . . . . . 43

methylphenidate hcl oral tablet extendedrelease 24hr 36 mg (bx rating). . . . . . . . . . . 43

methylphenidate hcl oral tablet,chewable. . . 43methylprednisolone acetate. . . . . . . . . . . . . . 64methylprednisolone oral tablet. . . . . . . . . . . . 64methylprednisolone oral tablets,dose pack. . 64methylprednisolone sodium succ injection reconsoln 125 mg, 40 mg. . . . . . . . . . . . . . . . . . . 64

methylprednisolone sodium succ intravenousrecon soln 1,000 mg. . . . . . . . . . . . . . . . . . . 64

methylprednisolone sodium succ intravenousrecon soln 500 mg. . . . . . . . . . . . . . . . . . . . 64

methyltestosterone oral capsule. . . . . . . . . . 69metoclopramide hcl injection solution. . . . . . 72metoclopramide hcl injection syringe. . . . . . . 72metoclopramide hcl oral. . . . . . . . . . . . . . . . . 72metolazone. . . . . . . . . . . . . . . . . . . . . . . . . . . 48metoprolol succinate oral tablet extendedrelease 24 hr. . . . . . . . . . . . . . . . . . . . . . . . 48

metoprolol ta-hydrochlorothiaz. . . . . . . . . . . 48metoprolol tartrate intravenous solution. . . . . 48metoprolol tartrate oral tablet. . . . . . . . . . . . . 48metro i.v.. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14metronidazole in nacl (iso-os). . . . . . . . . . . . 14metronidazole oral. . . . . . . . . . . . . . . . . . . . . 14metronidazole topical. . . . . . . . . . . . . . . . . . . 57metronidazole vaginal. . . . . . . . . . . . . . . . . . 85metyrosine. . . . . . . . . . . . . . . . . . . . . . . . . . . 48mexiletine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45MIACALCIN INJECTION. . . . . . . . . . . . . . . . 69mibelas 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . 87

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micafungin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7miconazole-3 vaginal suppository. . . . . . . . . 85microgestin 1.5/30 (21). . . . . . . . . . . . . . . . . 87microgestin 1/20 (21). . . . . . . . . . . . . . . . . . . 87microgestin fe 1.5/30 (28). . . . . . . . . . . . . . . 87microgestin fe 1/20 (28). . . . . . . . . . . . . . . . . 87midazolam (pf) injection. . . . . . . . . . . . . . . . . 43midazolam injection. . . . . . . . . . . . . . . . . . . . 43midazolam oral syrup 2 mg/ml. . . . . . . . . . . . 43midodrine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61migergot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31miglitol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67miglustat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69mili. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87millipred oral tablet. . . . . . . . . . . . . . . . . . . . . 65milrinone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54milrinone in 5 % dextrose. . . . . . . . . . . . . . . 54mimvey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84minocycline oral capsule. . . . . . . . . . . . . . . . 18minocycline oral tablet. . . . . . . . . . . . . . . . . . 18minocycline oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

minoxidil oral. . . . . . . . . . . . . . . . . . . . . . . . . 48miostat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91mirtazapine. . . . . . . . . . . . . . . . . . . . . . . . . . . 43misoprostol. . . . . . . . . . . . . . . . . . . . . . . . . . . 75mitomycin intravenous. . . . . . . . . . . . . . . . . . 24mitoxantrone. . . . . . . . . . . . . . . . . . . . . . . . . 24modafinil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43moexipril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48molindone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43mometasone topical. . . . . . . . . . . . . . . . . . . . 59mondoxyne nl oral capsule 100 mg, 75 mg. . 18MONJUVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24mono-linyah. . . . . . . . . . . . . . . . . . . . . . . . . . 87monoject 0.9% sodium chloride. . . . . . . . . . . 61monoject prefill advanced ns. . . . . . . . . . . . . 61montelukast. . . . . . . . . . . . . . . . . . . . . . . . . . 95morgidox oral capsule 100 mg. . . . . . . . . . . . 18morphine (pf) injection solution 0.5 mg/ml. . . 36morphine (pf) injection solution 1 mg/ml. . . . 36morphine concentrate oral solution. . . . . . . . 36

MORPHINE INJECTION SOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5 MG/ML(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

morphine injection solution 8 mg/ml. . . . . . . 36morphine injection syringe 10 mg/ml. . . . . . . 36morphine injection syringe 4 mg/ml, 5 mg/ml, 8mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

morphine intravenous solution 10 mg/ml. . . . 36MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML (BRAND). . . . . . . . . . . . . . . . 37

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML, 8 MG/ML (BRAND. . . . . . . . . . . . . . . . . 37

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML, 8 MG/ML (BRAND). . . . . . . . . . . . . . . . 37

morphine intravenous syringe 2 mg/ml, 4mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

morphine oral capsule, er multiphase 24 hr. . 37morphine oral capsule,extend.release pellets 37morphine oral solution. . . . . . . . . . . . . . . . . . 37morphine oral tablet. . . . . . . . . . . . . . . . . . . . 37morphine oral tablet extended release. . . . . 37MOTEGRITY. . . . . . . . . . . . . . . . . . . . . . . . . 72moxifloxacin ophthalmic (eye) drops. . . . . . . 89moxifloxacin ophthalmic (eye) drops, viscous 89moxifloxacin oral. . . . . . . . . . . . . . . . . . . . . . 17moxifloxacin-sod.chloride(iso). . . . . . . . . . . . 17MOZOBIL. . . . . . . . . . . . . . . . . . . . . . . . . . . . 76MULPLETA. . . . . . . . . . . . . . . . . . . . . . . . . . . 52MULTAQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45mupirocin ointment. . . . . . . . . . . . . . . . . . . . 58MVASI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24MYALEPT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69MYCAPSSA. . . . . . . . . . . . . . . . . . . . . . . . . . 24mycophenolate mofetil. . . . . . . . . . . . . . . . . . 24mycophenolate mofetil (hcl). . . . . . . . . . . . . . 24mycophenolate sodium oral tablet,delayedrelease (dr/ec). . . . . . . . . . . . . . . . . . . . . . . 24

MYLERAN. . . . . . . . . . . . . . . . . . . . . . . . . . . 24MYLOTARG. . . . . . . . . . . . . . . . . . . . . . . . . . 24myorisan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57MYRBETRIQ. . . . . . . . . . . . . . . . . . . . . . . . . 96MYTESI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

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Nnabumetone. . . . . . . . . . . . . . . . . . . . . . . . . . 39nadolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48nadolol-bendroflumethiazide oral tablet 80-5mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

nafcillin in dextrose iso-osm. . . . . . . . . . . . . . 16nafcillin injection recon soln 1 gram, 2 gram. 16nafcillin injection recon soln 10 gram. . . . . . . 16nafcillin intravenous recon soln 1 gram. . . . . 16nafcillin intravenous recon soln 2 gram. . . . . 16naftifine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58NAGLAZYME. . . . . . . . . . . . . . . . . . . . . . . . . 69nalbuphine. . . . . . . . . . . . . . . . . . . . . . . . . . . 39naloxone injection solution. . . . . . . . . . . . . . . 39naloxone injection syringe. . . . . . . . . . . . . . . 39naltrexone. . . . . . . . . . . . . . . . . . . . . . . . . . . 39naproxen oral suspension. . . . . . . . . . . . . . . 39naproxen oral tablet. . . . . . . . . . . . . . . . . . . . 39naproxen oral tablet,delayed release (dr/ec). 39naproxen sodium oral tablet 275 mg, 550 mg 39naratriptan. . . . . . . . . . . . . . . . . . . . . . . . . . . 31NARCAN NASAL SPRAY,NON-AEROSOL 4MG/ACTUATION. . . . . . . . . . . . . . . . . . . . . 39

NATACYN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 89nateglinide. . . . . . . . . . . . . . . . . . . . . . . . . . . 67NATPARA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69NAYZILAM. . . . . . . . . . . . . . . . . . . . . . . . . . . 28nebusal inhalation solution for nebulization 3%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

NEBUSAL INHALATION SOLUTION FORNEBULIZATION 6 % (BRAND). . . . . . . . . . 95

necon 0.5/35 (28). . . . . . . . . . . . . . . . . . . . . . 87NEEDLES, INSULIN DISP.,SAFETY. . . . . . . 67nefazodone. . . . . . . . . . . . . . . . . . . . . . . . . . 43neo-polycin. . . . . . . . . . . . . . . . . . . . . . . . . . 89neo-polycin hc. . . . . . . . . . . . . . . . . . . . . . . . 91neomycin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14neomycin-bacitracin-poly-hc. . . . . . . . . . . . . 91neomycin-bacitracin-polymyxin. . . . . . . . . . . 89neomycin-polymyxin b gu. . . . . . . . . . . . . . . 60neomycin-polymyxin b-dexameth. . . . . . . . . 91neomycin-polymyxin-gramicidin. . . . . . . . . . . 89

neomycin-polymyxin-hc ophthalmic (eye). . . 91neomycin-polymyxin-hc otic (ear). . . . . . . . . 64neostigmine methylsulfate intravenoussolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

NEPHRAMINE 5.4 %. . . . . . . . . . . . . . . . . . 100NERLYNX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24neuac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57NEULASTA. . . . . . . . . . . . . . . . . . . . . . . . . . . 76NEULASTA ONPRO. . . . . . . . . . . . . . . . . . . 76NEUPOGEN. . . . . . . . . . . . . . . . . . . . . . . . . . 76NEUPRO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30nevirapine oral suspension. . . . . . . . . . . . . . . 9nevirapine oral tablet. . . . . . . . . . . . . . . . . . . . 9nevirapine oral tablet extended release 24 hr. 9NEXAVAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24NEXLETOL. . . . . . . . . . . . . . . . . . . . . . . . . . . 53NEXLIZET. . . . . . . . . . . . . . . . . . . . . . . . . . . 53niacin oral tablet 500 mg. . . . . . . . . . . . . . . . 53niacin oral tablet extended release 24 hr. . . . 53nicardipine intravenous solution. . . . . . . . . . 48nicardipine oral. . . . . . . . . . . . . . . . . . . . . . . 48NICOTROL. . . . . . . . . . . . . . . . . . . . . . . . . . . 63NICOTROL NS. . . . . . . . . . . . . . . . . . . . . . . 63nifedipine oral capsule. . . . . . . . . . . . . . . . . . 48nifedipine oral tablet extended release. . . . . 48nifedipine oral tablet extended release 24hr. 48nikki (28). . . . . . . . . . . . . . . . . . . . . . . . . . . . 87nilutamide. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24nimodipine. . . . . . . . . . . . . . . . . . . . . . . . . . . 48NINLARO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24nisoldipine oral tablet extended release 24 hr 48nitazoxanide. . . . . . . . . . . . . . . . . . . . . . . . . . 14nitisinone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61nitro-bid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54nitrofurantoin. . . . . . . . . . . . . . . . . . . . . . . . . 19nitrofurantoin macrocrystal. . . . . . . . . . . . . . 19nitrofurantoin monohyd/m-cryst. . . . . . . . . . . 19nitroglycerin in 5 % dextrose intravenoussolution 100 mg/250 ml (400 mcg/ml), 25mg/250 ml (100 mcg/ml), 50 mg/250 ml (200mcg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

nitroglycerin intravenous. . . . . . . . . . . . . . . . 54nitroglycerin sublingual. . . . . . . . . . . . . . . . . 54

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nitroglycerin transdermal patch 24 hour. . . . . 54nitroglycerin translingual spray,non-aerosol. 54NITYR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61NIVESTYM. . . . . . . . . . . . . . . . . . . . . . . . . . . 76nizatidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 75nolix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59nora-be. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84norepinephrine bitartrate. . . . . . . . . . . . . . . . 54noreth-ethinyl estradiol-iron. . . . . . . . . . . . . . 87norethindrone (contraceptive). . . . . . . . . . . . 84norethindrone ac-eth estradiol oral tablet 0.5-2.5mg-mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

norethindrone ac-eth estradiol oral tablet 1-20mg-mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

norethindrone ac-eth estradiol oral tablet 1-5mg-mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

norethindrone ac-eth estradiol oral tablet 1.5-30mg-mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

norethindrone acetate. . . . . . . . . . . . . . . . . . 84norethindrone-e.estradiol-iron oral capsule. . 88norethindrone-e.estradiol-iron oral tablet 1mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg(21)/75 mg (7). . . . . . . . . . . . . . . . . . . . . . . 88

norethindrone-e.estradiol-iron oraltablet,chewable. . . . . . . . . . . . . . . . . . . . . . . 88

norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-25 mcg, 0.25-35 mg-mcg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-35 mcg (28). . . . . . . . . 88

norlyda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84normal saline flush. . . . . . . . . . . . . . . . . . . . . 61NORMOSOL-R. . . . . . . . . . . . . . . . . . . . . . . 98NORMOSOL-R PH 7.4. . . . . . . . . . . . . . . . 100NORTHERA. . . . . . . . . . . . . . . . . . . . . . . . . . 61nortrel 0.5/35 (28). . . . . . . . . . . . . . . . . . . . . 88nortrel 1/35 (21). . . . . . . . . . . . . . . . . . . . . . . 88nortrel 1/35 (28). . . . . . . . . . . . . . . . . . . . . . . 88nortrel 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . . 88nortriptyline. . . . . . . . . . . . . . . . . . . . . . . . . . . 43NORVIR ORAL POWDER IN PACKET. . . . . . 9NORVIR ORAL SOLUTION. . . . . . . . . . . . . . . 9NOURIANZ. . . . . . . . . . . . . . . . . . . . . . . . . . 30NOVAREL. . . . . . . . . . . . . . . . . . . . . . . . . . . 69

NOXAFIL INTRAVENOUS. . . . . . . . . . . . . . . . 7NOXAFIL ORAL SUSPENSION. . . . . . . . . . . 7np thyroid. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70NPLATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52NUBEQA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24NUCALA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95NUEDEXTA. . . . . . . . . . . . . . . . . . . . . . . . . . 32NULOJIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24NUPLAZID ORAL CAPSULE. . . . . . . . . . . . . 43NUPLAZID ORAL TABLET 10 MG. . . . . . . . 43NURTEC ODT. . . . . . . . . . . . . . . . . . . . . . . . 31NUZYRA INTRAVENOUS. . . . . . . . . . . . . . . 18NUZYRA ORAL. . . . . . . . . . . . . . . . . . . . . . . 19nyamyc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58nylia 7/7/7 (28). . . . . . . . . . . . . . . . . . . . . . . . 88nymyo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88nystatin oral suspension. . . . . . . . . . . . . . . . . 7nystatin oral tablet. . . . . . . . . . . . . . . . . . . . . . 7nystatin topical cream. . . . . . . . . . . . . . . . . . 58nystatin topical ointment. . . . . . . . . . . . . . . . 58nystatin topical powder. . . . . . . . . . . . . . . . . 58nystatin-triamcinolone. . . . . . . . . . . . . . . . . . 58nystop. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58NYVEPRIA. . . . . . . . . . . . . . . . . . . . . . . . . . . 76

OOCALIVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 72ocella. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88OCREVUS. . . . . . . . . . . . . . . . . . . . . . . . . . . 32octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml. . 24

octreotide acetate injection solution 50mcg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

octreotide acetate injection syringe. . . . . . . . 24ODEFSEY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9ODOMZO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24OFEV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95ofloxacin ophthalmic (eye). . . . . . . . . . . . . . . 89ofloxacin oral tablet 300 mg. . . . . . . . . . . . . . 17ofloxacin oral tablet 400 mg. . . . . . . . . . . . . . 17ofloxacin otic (ear). . . . . . . . . . . . . . . . . . . . . 64OGIVRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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olanzapine intramuscular recon soln. . . . . . . 43olanzapine oral tablet. . . . . . . . . . . . . . . . . . . 43olanzapine oral tablet,disintegrating. . . . . . . 43olanzapine-fluoxetine. . . . . . . . . . . . . . . . . . . 44olmesartan. . . . . . . . . . . . . . . . . . . . . . . . . . . 48olmesartan-amlodipin-hcthiazid. . . . . . . . . . . 48olmesartan-hydrochlorothiazide. . . . . . . . . . . 49olopatadine nasal. . . . . . . . . . . . . . . . . . . . . . 63olopatadine ophthalmic (eye). . . . . . . . . . . . . 90omega-3 acid ethyl esters. . . . . . . . . . . . . . . 53omeprazole oral capsule,delayed release(dr/ec)10 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

omeprazole oral capsule,delayed release(dr/ec)20 mg, 40 mg. . . . . . . . . . . . . . . . . . . . . . . . 75

OMNITROPE. . . . . . . . . . . . . . . . . . . . . . . . . 76ONCASPAR. . . . . . . . . . . . . . . . . . . . . . . . . . 24ondansetron hcl (pf). . . . . . . . . . . . . . . . . . . . 72ondansetron hcl intravenous. . . . . . . . . . . . . 72ondansetron hcl oral solution. . . . . . . . . . . . . 72ondansetron hcl oral tablet 24 mg. . . . . . . . . 72ondansetron hcl oral tablet 4 mg, 8 mg. . . . . 73ondansetron oral tablet,disintegrating. . . . . . 73ONETOUCH BLOOD GLUCOSE METERS. 67ONETOUCH ULTRA BLUE TEST STRIP. . . 67ONETOUCH VERIO TEST STRIP. . . . . . . . . 67ONGENTYS ORAL CAPSULE 50 MG. . . . . 30ONGLYZA. . . . . . . . . . . . . . . . . . . . . . . . . . . 67ONIVYDE. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24ONPATTRO. . . . . . . . . . . . . . . . . . . . . . . . . . 32ONTRUZANT. . . . . . . . . . . . . . . . . . . . . . . . . 24ONUREG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24OPDIVO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24opium tincture. . . . . . . . . . . . . . . . . . . . . . . . 71OPSUMIT. . . . . . . . . . . . . . . . . . . . . . . . . . . . 95ORALAIR SUBLINGUAL TABLET 300 INDXREACTIVITY. . . . . . . . . . . . . . . . . . . . . . . . . 79

oralone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63ORBACTIV. . . . . . . . . . . . . . . . . . . . . . . . . . . 14ORENCIA (WITH MALTOSE). . . . . . . . . . . . 83ORENCIA CLICKJECT. . . . . . . . . . . . . . . . . 83ORENCIA SUBCUTANEOUS SYRINGE 125MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

ORENCIA SUBCUTANEOUS SYRINGE 50MG/0.4 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 83

ORENCIA SUBCUTANEOUS SYRINGE 87.5MG/0.7 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 83

ORENITRAM. . . . . . . . . . . . . . . . . . . . . . . . . 49ORFADIN ORAL CAPSULE 20 MG. . . . . . . . 61ORFADIN ORAL SUSPENSION. . . . . . . . . . 61ORGOVYX. . . . . . . . . . . . . . . . . . . . . . . . . . . 24ORKAMBI ORAL GRANULES IN PACKET. . 95ORKAMBI ORAL TABLET. . . . . . . . . . . . . . . 95ORLADEYO. . . . . . . . . . . . . . . . . . . . . . . . . . 95orphenadrine citrate injection. . . . . . . . . . . . . 33orphenadrine citrate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

orphenadrine-asa-caffeine oral tablet 50-770-60mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

orphengesic forte. . . . . . . . . . . . . . . . . . . . . . 33orsythia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88oseltamivir oral capsule 30 mg. . . . . . . . . . . . 9oseltamivir oral capsule 45 mg, 75 mg. . . . . . 9oseltamivir oral suspension for reconstitution. 9osmitrol 15 %. . . . . . . . . . . . . . . . . . . . . . . . . 49osmitrol 20 %. . . . . . . . . . . . . . . . . . . . . . . . . 49OSMOPREP. . . . . . . . . . . . . . . . . . . . . . . . . . 73OTEZLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83OTEZLA STARTER ORAL TABLETS,DOSEPACK 10 MG (4)-20 MG (4)-30 MG (47). . . 83

oxacillin in dextrose(iso-osm) intravenouspiggyback 1 gram/50 ml. . . . . . . . . . . . . . . . 16

oxacillin in dextrose(iso-osm) intravenouspiggyback 2 gram/50 ml. . . . . . . . . . . . . . . . 16

oxacillin injection recon soln 1 gram, 10 gram 16oxacillin injection recon soln 2 gram. . . . . . . 16oxaliplatin intravenous recon soln 100 mg. . . 24oxaliplatin intravenous recon soln 50 mg. . . . 25oxaliplatin intravenous solution 100 mg/20 ml,50 mg/10 ml (5 mg/ml). . . . . . . . . . . . . . . . . 25

oxaliplatin intravenous solution 200 mg/40 ml 25oxandrolone. . . . . . . . . . . . . . . . . . . . . . . . . . 69oxaprozin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39oxazepam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44OXBRYTA. . . . . . . . . . . . . . . . . . . . . . . . . . . 61oxcarbazepine. . . . . . . . . . . . . . . . . . . . . . . . 28

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OXERVATE. . . . . . . . . . . . . . . . . . . . . . . . . . 90oxiconazole. . . . . . . . . . . . . . . . . . . . . . . . . . 58OXTELLAR XR. . . . . . . . . . . . . . . . . . . . . . . 28oxybutynin chloride oral syrup. . . . . . . . . . . . 96oxybutynin chloride oral tablet. . . . . . . . . . . . 96oxybutynin chloride oral tablet extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

oxycodone oral capsule. . . . . . . . . . . . . . . . . 37oxycodone oral concentrate. . . . . . . . . . . . . . 37oxycodone oral solution. . . . . . . . . . . . . . . . . 37oxycodone oral tablet. . . . . . . . . . . . . . . . . . . 37OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG, 80 MG(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 15 MG, 30 MG, 60 MG(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

oxycodone-acetaminophen oral tablet 10-325mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg. . . . 37

oxycodone-acetaminophen oral tablet 2.5-300mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

oxycodone-aspirin. . . . . . . . . . . . . . . . . . . . . 37OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR. . . . . . . . . . . . . . . . . . . . . . . . . . 37

oxymorphone oral tablet. . . . . . . . . . . . . . . . 37oxymorphone oral tablet extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

OZEMPIC SUBCUTANEOUS PEN INJECTOR0.25 MG OR 0.5 MG(2 MG/1.5 ML). . . . . . . 67

OZEMPIC SUBCUTANEOUS PEN INJECTOR1 MG/DOSE (2 MG/1.5 ML). . . . . . . . . . . . . 67

OZEMPIC SUBCUTANEOUS PEN INJECTOR1 MG/DOSE (4 MG/3 ML). . . . . . . . . . . . . . 67

Ppacerone oral tablet 100 mg, 200 mg, 400mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

paclitaxel. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25PADCEV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25paliperidone. . . . . . . . . . . . . . . . . . . . . . . . . . 44palonosetron intravenous solution 0.25 mg/5ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

palonosetron intravenous syringe. . . . . . . . . 73PALYNZIQ. . . . . . . . . . . . . . . . . . . . . . . . . . . 69pamidronate. . . . . . . . . . . . . . . . . . . . . . . . . . 69

PANRETIN. . . . . . . . . . . . . . . . . . . . . . . . . . . 56pantoprazole intravenous. . . . . . . . . . . . . . . 75pantoprazole oral granules dr for susp inpacket. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

pantoprazole oral tablet,delayed release (dr/ec)20 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

pantoprazole oral tablet,delayed release (dr/ec)40 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

paraplatin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25PARICALCITOL HEMODIALYSIS PORTINJECTION. . . . . . . . . . . . . . . . . . . . . . . . . . 69

paricalcitol intravenous. . . . . . . . . . . . . . . . . 69PARICALCITOL INTRAVENOUS SOLUTION 2MCG/ML (BRAND). . . . . . . . . . . . . . . . . . . . 69

PARICALCITOL INTRAVENOUS SOLUTION 5MCG/ML (BRAND). . . . . . . . . . . . . . . . . . . . 69

paricalcitol oral. . . . . . . . . . . . . . . . . . . . . . . . 69paroex oral rinse. . . . . . . . . . . . . . . . . . . . . . 63paromomycin. . . . . . . . . . . . . . . . . . . . . . . . . 14paroxetine hcl oral tablet. . . . . . . . . . . . . . . . 44paroxetine hcl oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

paroxetine mesylate(menop.sym). . . . . . . . . 44PARSABIV. . . . . . . . . . . . . . . . . . . . . . . . . . . 69PASER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14PAXIL ORAL SUSPENSION. . . . . . . . . . . . . 44PEDIARIX (PF). . . . . . . . . . . . . . . . . . . . . . . 79PEDVAX HIB (PF). . . . . . . . . . . . . . . . . . . . . 79peg 3350-electrolytes oral recon soln236-22.74-6.74 -5.86 gram. . . . . . . . . . . . . 73

peg-electrolyte. . . . . . . . . . . . . . . . . . . . . . . . 73peg3350-sod sul-nacl-kcl-asb-c. . . . . . . . . . . 73PEGASYS SUBCUTANEOUS SOLUTION. . 76PEGASYS SUBCUTANEOUS SYRINGE. . . 76PEGINTRON SUBCUTANEOUS KIT 50MCG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . . . 76

PEMAZYRE. . . . . . . . . . . . . . . . . . . . . . . . . . 25penicillamine. . . . . . . . . . . . . . . . . . . . . . . . . 83penicillin g potassium injection recon soln 20million unit. . . . . . . . . . . . . . . . . . . . . . . . . . 16

penicillin g potassium injection recon soln 5million unit. . . . . . . . . . . . . . . . . . . . . . . . . . 16

penicillin g procaine. . . . . . . . . . . . . . . . . . . . 17penicillin g sodium. . . . . . . . . . . . . . . . . . . . . 17

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penicillin v potassium. . . . . . . . . . . . . . . . . . . 17PENTACEL (PF). . . . . . . . . . . . . . . . . . . . . . 79pentamidine inhalation. . . . . . . . . . . . . . . . . . 14pentamidine injection. . . . . . . . . . . . . . . . . . . 14PENTASA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73pentazocine-naloxone. . . . . . . . . . . . . . . . . . 39pentobarbital sodium injection solution. . . . . 44pentoxifylline oral tablet extended release. . . 52PERFOROMIST. . . . . . . . . . . . . . . . . . . . . . . 95perindopril erbumine. . . . . . . . . . . . . . . . . . . 49periogard. . . . . . . . . . . . . . . . . . . . . . . . . . . . 63PERJETA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25permethrin topical cream. . . . . . . . . . . . . . . . 60perphenazine. . . . . . . . . . . . . . . . . . . . . . . . . 44perphenazine-amitriptyline. . . . . . . . . . . . . . . 44PERSERIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 44pfizerpen-g. . . . . . . . . . . . . . . . . . . . . . . . . . . 17phenadoz rectal suppository 25 mg. . . . . . . . 93phenelzine. . . . . . . . . . . . . . . . . . . . . . . . . . . 44phenobarbital oral elixir. . . . . . . . . . . . . . . . . 28phenobarbital oral tablet 100 mg, 15 mg, 30 mg,60 mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

phenobarbital oral tablet 16.2 mg, 32.4 mg, 64.8mg, 97.2 mg. . . . . . . . . . . . . . . . . . . . . . . . . 28

phenobarbital sodium injection solution 130mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

phenobarbital sodium injection solution 65mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

phenoxybenzamine. . . . . . . . . . . . . . . . . . . . 49phentolamine injection recon soln. . . . . . . . . 49phenytoin oral suspension 100 mg/4 ml. . . . 29phenytoin oral suspension 125 mg/5 ml. . . . 29phenytoin oral tablet,chewable. . . . . . . . . . . 29phenytoin sodium extended. . . . . . . . . . . . . . 29phenytoin sodium intravenous solution. . . . . 29PHESGO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25philith. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88PHOSPHOLINE IODIDE. . . . . . . . . . . . . . . . 90PIFELTRO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,4 %. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

pilocarpine hcl oral. . . . . . . . . . . . . . . . . . . . . 62pimecrolimus. . . . . . . . . . . . . . . . . . . . . . . . . 56

pimozide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44pimtrea (28). . . . . . . . . . . . . . . . . . . . . . . . . . 88pindolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49pioglitazone. . . . . . . . . . . . . . . . . . . . . . . . . . 67pioglitazone-glimepiride. . . . . . . . . . . . . . . . . 67pioglitazone-metformin. . . . . . . . . . . . . . . . . 67piperacillin-tazobactam intravenous recon soln13.5 gram. . . . . . . . . . . . . . . . . . . . . . . . . . . 17

piperacillin-tazobactam intravenous recon soln2.25 gram, 3.375 gram, 4.5 gram. . . . . . . . . 17

piperacillin-tazobactam intravenous recon soln40.5 gram. . . . . . . . . . . . . . . . . . . . . . . . . . . 17

PIQRAY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25pirmella. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88piroxicam. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39plasbumin 25 %. . . . . . . . . . . . . . . . . . . . . . . 97plasbumin 5 %. . . . . . . . . . . . . . . . . . . . . . . . 97plasmanate. . . . . . . . . . . . . . . . . . . . . . . . . . 100PLEGRIDY SUBCUTANEOUS PEN INJECTOR125 MCG/0.5 ML. . . . . . . . . . . . . . . . . . . . . 76

PLEGRIDY SUBCUTANEOUS PEN INJECTOR63 MCG/0.5 ML- 94 MCG/0.5 ML. . . . . . . . 76

PLEGRIDY SUBCUTANEOUS SYRINGE. . . 76plenamine. . . . . . . . . . . . . . . . . . . . . . . . . . . 100PNEUMOVAX-23. . . . . . . . . . . . . . . . . . . . . . 79podofilox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56POLIVY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25polocaine injection solution 1 % (10 mg/ml). 56polocaine-mpf. . . . . . . . . . . . . . . . . . . . . . . . 56polycin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89polyethylene glycol 3350 oral powder. . . . . . 73polymyxin b sulf-trimethoprim. . . . . . . . . . . . 89polymyxin b sulfate. . . . . . . . . . . . . . . . . . . . 14POMALYST. . . . . . . . . . . . . . . . . . . . . . . . . . 25portia 28. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88PORTRAZZA. . . . . . . . . . . . . . . . . . . . . . . . . 25posaconazole oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

potassium acetate intravenous solution 2meq/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

potassium chlorid-d5-0.45%nacl. . . . . . . . . . 98potassium chloride in 0.9%nacl intravenousparenteral solution 20 meq/l, 40 meq/l. . . . . 98

129

potassium chloride in 5 % dex intravenousparenteral solution 20 meq/l. . . . . . . . . . . . . 98

potassium chloride in 5 % dex intravenousparenteral solution 30 meq/l, 40 meq/l. . . . . 98

potassium chloride in lr-d5 intravenousparenteral solution 20 meq/l. . . . . . . . . . . . . 98

potassium chloride in water intravenouspiggyback 10 meq/100 ml, 20 meq/100 ml, 40meq/100 ml. . . . . . . . . . . . . . . . . . . . . . . . . 98

potassium chloride in water intravenouspiggyback 10 meq/50 ml, 20 meq/50 ml, 30meq/100 ml. . . . . . . . . . . . . . . . . . . . . . . . . 99

potassium chloride intravenous. . . . . . . . . . . 99potassium chloride oral capsule, extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

potassium chloride oral liquid. . . . . . . . . . . . 99potassium chloride oral packet. . . . . . . . . . . 99potassium chloride oral tablet extended release10 meq, 8 meq. . . . . . . . . . . . . . . . . . . . . . . 99

potassium chloride oral tablet extended release20 meq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

potassium chloride oral tablet,er particles/crystals 10 meq. . . . . . . . . . . . . . . . . . . . . . 99

potassium chloride oral tablet,er particles/crystals 20 meq. . . . . . . . . . . . . . . . . . . . . . 99

potassium chloride-0.45 % nacl. . . . . . . . . . . 99potassium chloride-d5-0.2%nacl intravenousparenteral solution 20 meq/l. . . . . . . . . . . . . 99

potassium chloride-d5-0.2%nacl intravenousparenteral solution 30 meq/l, 40 meq/l. . . . . 99

potassium chloride-d5-0.9%nacl. . . . . . . . . . 99potassium citrate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

potassium phosphate m-/d-basic intravenoussolution 3 mmol/ml. . . . . . . . . . . . . . . . . . . . 99

POTELIGEO. . . . . . . . . . . . . . . . . . . . . . . . . 25PRADAXA. . . . . . . . . . . . . . . . . . . . . . . . . . . 52PRALUENT SUBCUTANEOUS PEN INJECTOR150 MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . 53

PRALUENT SUBCUTANEOUS PEN INJECTOR75 MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . . 53

pramipexole oral tablet. . . . . . . . . . . . . . . . . 30pramipexole oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

prasugrel. . . . . . . . . . . . . . . . . . . . . . . . . . . . 52pravastatin. . . . . . . . . . . . . . . . . . . . . . . . . . . 53

PRAXBIND. . . . . . . . . . . . . . . . . . . . . . . . . . . 52praziquantel. . . . . . . . . . . . . . . . . . . . . . . . . . 14prazosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49prednicarbate. . . . . . . . . . . . . . . . . . . . . . . . . 59prednisolone acetate. . . . . . . . . . . . . . . . . . . 92prednisolone oral solution 15 mg/5 ml. . . . . . 65prednisolone sodium phosphate ophthalmic(eye). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

prednisolone sodium phosphate oral solution 10mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml(6.7 mg/5 ml). . . . . . . . . . . . . . . . . . . . . . . . 65

prednisolone sodium phosphate oral solution 15mg/5 ml (5 ml). . . . . . . . . . . . . . . . . . . . . . . 65

prednisolone sodium phosphate oraltablet,disintegrating. . . . . . . . . . . . . . . . . . . . 65

prednisone intensol. . . . . . . . . . . . . . . . . . . . 65prednisone oral solution. . . . . . . . . . . . . . . . . 65prednisone oral tablet. . . . . . . . . . . . . . . . . . 65prednisone oral tablets,dose pack. . . . . . . . . 65pregabalin oral capsule. . . . . . . . . . . . . . . . . 29pregabalin oral solution. . . . . . . . . . . . . . . . . 29PREMARIN INJECTION. . . . . . . . . . . . . . . . 84premasol 10 %. . . . . . . . . . . . . . . . . . . . . . . 100prenatal vitamin oral tablet. . . . . . . . . . . . . . 100PRETOMANID. . . . . . . . . . . . . . . . . . . . . . . . 14prevalite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53previfem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88PREVNAR 13 (PF). . . . . . . . . . . . . . . . . . . . 79PREVYMIS INTRAVENOUS. . . . . . . . . . . . . . 9PREVYMIS ORAL. . . . . . . . . . . . . . . . . . . . . . 9PREZCOBIX. . . . . . . . . . . . . . . . . . . . . . . . . . 9PREZISTA ORAL SUSPENSION. . . . . . . . . . 9PREZISTA ORAL TABLET 150 MG, 600 MG, 75MG, 800 MG. . . . . . . . . . . . . . . . . . . . . . . . . . 9

PRIFTIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14PRIMAQUINE. . . . . . . . . . . . . . . . . . . . . . . . 14primaquine (generic). . . . . . . . . . . . . . . . . . . 14primidone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29probenecid. . . . . . . . . . . . . . . . . . . . . . . . . . . 80probenecid-colchicine. . . . . . . . . . . . . . . . . . 80procainamide injection. . . . . . . . . . . . . . . . . . 45PROCALAMINE 3%. . . . . . . . . . . . . . . . . . 100

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procentra. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44prochlorperazine. . . . . . . . . . . . . . . . . . . . . . 73prochlorperazine edisylate injection solution 10mg/2 ml (5 mg/ml). . . . . . . . . . . . . . . . . . . . 73

prochlorperazine edisylate injection solution 5mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

prochlorperazine maleate oral. . . . . . . . . . . . 73procto-med hc. . . . . . . . . . . . . . . . . . . . . . . . 73procto-pak. . . . . . . . . . . . . . . . . . . . . . . . . . . 73proctosol hc topical. . . . . . . . . . . . . . . . . . . . 73proctozone-hc. . . . . . . . . . . . . . . . . . . . . . . . 73PROCYSBI. . . . . . . . . . . . . . . . . . . . . . . . . . . 97progesterone. . . . . . . . . . . . . . . . . . . . . . . . . 84progesterone micronized. . . . . . . . . . . . . . . . 84PROGRAF INTRAVENOUS. . . . . . . . . . . . . 25PROGRAF ORAL GRANULES IN PACKET. 25PROLASTIN-C INTRAVENOUS RECONSOLN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

PROLASTIN-C INTRAVENOUS SOLUTION 62prolate oral tablet. . . . . . . . . . . . . . . . . . . . . . 37PROLIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81PROMACTA. . . . . . . . . . . . . . . . . . . . . . . . . . 52promethazine injection solution. . . . . . . . . . . 93promethazine oral. . . . . . . . . . . . . . . . . . . . . 93promethazine rectal suppository 12.5 mg, 25mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

promethegan. . . . . . . . . . . . . . . . . . . . . . . . . 93propafenone oral capsule,extended release 12hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

propafenone oral tablet. . . . . . . . . . . . . . . . . 46propranolol intravenous. . . . . . . . . . . . . . . . . 49propranolol oral capsule,extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

propranolol oral solution. . . . . . . . . . . . . . . . 49propranolol oral tablet. . . . . . . . . . . . . . . . . . 49propranolol-hydrochlorothiazid. . . . . . . . . . . 49propylthiouracil. . . . . . . . . . . . . . . . . . . . . . . . 65PROQUAD (PF). . . . . . . . . . . . . . . . . . . . . . . 79PROSOL 20 %. . . . . . . . . . . . . . . . . . . . . . . 100protamine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 52protriptyline. . . . . . . . . . . . . . . . . . . . . . . . . . . 44prudoxin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56pulmosal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

PULMOZYME. . . . . . . . . . . . . . . . . . . . . . . . 95PURIXAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25pyrazinamide. . . . . . . . . . . . . . . . . . . . . . . . . 14pyridostigmine bromide oral syrup. . . . . . . . . 33pyridostigmine bromide oral tablet. . . . . . . . . 34pyridostigmine bromide oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

pyrimethamine. . . . . . . . . . . . . . . . . . . . . . . . 14

QQINLOCK. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25QUADRACEL (PF). . . . . . . . . . . . . . . . . . . . . 79QUDEXY XR. . . . . . . . . . . . . . . . . . . . . . . . . 29quetiapine oral tablet. . . . . . . . . . . . . . . . . . . 44quetiapine oral tablet extended release 24 hr 44quinapril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49quinapril-hydrochlorothiazide. . . . . . . . . . . . . 49quinidine gluconate oral tablet extendedrelease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

quinidine sulfate oral tablet. . . . . . . . . . . . . . 46quinine sulfate. . . . . . . . . . . . . . . . . . . . . . . . 14

RRABAVERT (PF). . . . . . . . . . . . . . . . . . . . . . 79rabeprazole oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

RADICAVA. . . . . . . . . . . . . . . . . . . . . . . . . . . 32RAGWITEK. . . . . . . . . . . . . . . . . . . . . . . . . . 79raloxifene. . . . . . . . . . . . . . . . . . . . . . . . . . . . 81ramelteon. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ramipril. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49ranitidine hcl oral syrup. . . . . . . . . . . . . . . . . 75ranitidine hcl oral tablet 150 mg, 300 mg. . . . 75ranolazine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 54rasagiline. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30RAVICTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62REBIF (WITH ALBUMIN). . . . . . . . . . . . . . . . 76REBIF REBIDOSE SUBCUTANEOUS PENINJECTOR 22 MCG/0.5 ML, 44 MCG/0.5ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

REBIF REBIDOSE SUBCUTANEOUS PENINJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML(6). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

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REBIF TITRATION PACK. . . . . . . . . . . . . . . 76REBLOZYL. . . . . . . . . . . . . . . . . . . . . . . . . . 76RECARBRIO. . . . . . . . . . . . . . . . . . . . . . . . . 14reclipsen (28). . . . . . . . . . . . . . . . . . . . . . . . . 88RECOMBIVAX HB (PF) INTRAMUSCULARSUSPENSION 10 MCG/ML, 40 MCG/ML. . 79

RECOMBIVAX HB (PF) INTRAMUSCULARSUSPENSION 5 MCG/0.5 ML. . . . . . . . . . . 79

RECOMBIVAX HB (PF) INTRAMUSCULARSYRINGE 10 MCG/ML. . . . . . . . . . . . . . . . . 79

RECOMBIVAX HB (PF) INTRAMUSCULARSYRINGE 5 MCG/0.5 ML. . . . . . . . . . . . . . . 79

RECTIV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73regonol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34REGRANEX. . . . . . . . . . . . . . . . . . . . . . . . . . 56RELENZA DISKHALER. . . . . . . . . . . . . . . . . . 9RELISTOR ORAL. . . . . . . . . . . . . . . . . . . . . 73RELISTOR SUBCUTANEOUS SOLUTION. . 73RELISTOR SUBCUTANEOUS SYRINGE. . . 73repaglinide. . . . . . . . . . . . . . . . . . . . . . . . . . . 67RESTASIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 90RESTASIS MULTIDOSE. . . . . . . . . . . . . . . . 90RETACRIT. . . . . . . . . . . . . . . . . . . . . . . . . . . 76RETEVMO. . . . . . . . . . . . . . . . . . . . . . . . . . . 25RETROVIR INTRAVENOUS. . . . . . . . . . . . . . 9REVCOVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62REVLIMID. . . . . . . . . . . . . . . . . . . . . . . . . . . 25revonto. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34REXULTI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44REYATAZ ORAL POWDER IN PACKET. . . . . 9RIABNI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25ribavirin oral capsule. . . . . . . . . . . . . . . . . . . . 9ribavirin oral tablet 200 mg. . . . . . . . . . . . . . . 9RIDAURA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 83rifabutin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14rifampin intravenous. . . . . . . . . . . . . . . . . . . 14rifampin oral. . . . . . . . . . . . . . . . . . . . . . . . . . 14riluzole. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62rimantadine. . . . . . . . . . . . . . . . . . . . . . . . . . . 9ringer's intravenous. . . . . . . . . . . . . . . . . . . . 99ringer's irrigation. . . . . . . . . . . . . . . . . . . . . . 60RINVOQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83risedronate oral tablet 150 mg. . . . . . . . . . . . 81

risedronate oral tablet 30 mg. . . . . . . . . . . . . 62risedronate oral tablet 35 mg, 35 mg (12 pack),35 mg (4 pack). . . . . . . . . . . . . . . . . . . . . . . 81

risedronate oral tablet 5 mg. . . . . . . . . . . . . . 81risedronate oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

RISPERDAL CONSTA. . . . . . . . . . . . . . . . . . 44risperidone oral solution. . . . . . . . . . . . . . . . . 44risperidone oral tablet. . . . . . . . . . . . . . . . . . 44risperidone oral tablet,disintegrating. . . . . . . 44ritonavir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9RITUXAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25RITUXAN HYCELA. . . . . . . . . . . . . . . . . . . . 25rivastigmine tartrate. . . . . . . . . . . . . . . . . . . . 32rivastigmine transdermal. . . . . . . . . . . . . . . . 32rivelsa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88rizatriptan oral tablet. . . . . . . . . . . . . . . . . . . 31rizatriptan oral tablet,disintegrating. . . . . . . . 31ROMIDEPSIN INTRAVENOUS SOLUTION. 25ropinirole oral tablet. . . . . . . . . . . . . . . . . . . . 30ropinirole oral tablet extended release 24 hr. 30rosadan topical cream. . . . . . . . . . . . . . . . . . 57rosadan topical gel. . . . . . . . . . . . . . . . . . . . . 57rosuvastatin. . . . . . . . . . . . . . . . . . . . . . . . . . 53ROTARIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 79ROTATEQ VACCINE. . . . . . . . . . . . . . . . . . . 79roweepra. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29ROZLYTREK. . . . . . . . . . . . . . . . . . . . . . . . . 25RUBRACA. . . . . . . . . . . . . . . . . . . . . . . . . . . 25RUCONEST. . . . . . . . . . . . . . . . . . . . . . . . . . 95rufinamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 29RUKOBIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9RUXIENCE. . . . . . . . . . . . . . . . . . . . . . . . . . . 25RUZURGI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 32RYBELSUS. . . . . . . . . . . . . . . . . . . . . . . . . . 67RYDAPT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Ssalsalate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39SAMSCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69SANDOSTATIN LAR DEPOTINTRAMUSCULAR SUSPENSION,EXTENDED REL RECON. . . . . . . . . . . . . . 25

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SANTYL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56SAPHRIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44sapropterin. . . . . . . . . . . . . . . . . . . . . . . . . . . 69SARCLISA. . . . . . . . . . . . . . . . . . . . . . . . . . . 25scopolamine base. . . . . . . . . . . . . . . . . . . . . 73seconal sodium. . . . . . . . . . . . . . . . . . . . . . . 44SECUADO. . . . . . . . . . . . . . . . . . . . . . . . . . . 44selegiline hcl. . . . . . . . . . . . . . . . . . . . . . . . . 30selenium sulfide topical lotion. . . . . . . . . . . . 55SELZENTRY. . . . . . . . . . . . . . . . . . . . . . . . . . . 9SEREVENT DISKUS. . . . . . . . . . . . . . . . . . . 95SEROSTIM SUBCUTANEOUS RECON SOLN4 MG, 5 MG, 6 MG. . . . . . . . . . . . . . . . . . . . 76

sertraline. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44setlakin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88sevelamer carbonate. . . . . . . . . . . . . . . . . . . 62sevelamer hcl oral tablet 400 mg. . . . . . . . . . 62sevelamer hcl oral tablet 800 mg. . . . . . . . . . 62sf. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63sf 5000 plus. . . . . . . . . . . . . . . . . . . . . . . . . . 63sharobel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84SHINGRIX (PF). . . . . . . . . . . . . . . . . . . . . . . 79SIGNIFOR. . . . . . . . . . . . . . . . . . . . . . . . . . . 25SIGNIFOR LAR. . . . . . . . . . . . . . . . . . . . . . . 25SIKLOS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25sildenafil (pulmonary arterial hypertension)intravenous solution 10 mg/12.5 ml. . . . . . . 95

sildenafil (pulmonary arterial hypertension) oralsuspension for reconstitution 10 mg/ml. . . . 95

sildenafil (pulmonary arterial hypertension) oraltablet 20 mg. . . . . . . . . . . . . . . . . . . . . . . . . 95

silodosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97silver sulfadiazine. . . . . . . . . . . . . . . . . . . . . 56simliya (28). . . . . . . . . . . . . . . . . . . . . . . . . . 88simpesse. . . . . . . . . . . . . . . . . . . . . . . . . . . . 88SIMPONI ARIA. . . . . . . . . . . . . . . . . . . . . . . 83SIMPONI SUBCUTANEOUS PEN INJECTOR100 MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . 83

SIMPONI SUBCUTANEOUS PEN INJECTOR50 MG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . 83

SIMPONI SUBCUTANEOUS SYRINGE 100MG/ML. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

SIMPONI SUBCUTANEOUS SYRINGE 50MG/0.5 ML. . . . . . . . . . . . . . . . . . . . . . . . . . 83

SIMULECT INTRAVENOUS RECON SOLN 10MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

SIMULECT INTRAVENOUS RECON SOLN 20MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

simvastatin oral tablet. . . . . . . . . . . . . . . . . . 53sirolimus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25SIRTURO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14SIVEXTRO INTRAVENOUS. . . . . . . . . . . . . 14SIVEXTRO ORAL. . . . . . . . . . . . . . . . . . . . . 14SKYRIZI SUBCUTANEOUS SYRINGE KIT. . 55SMOFLIPID. . . . . . . . . . . . . . . . . . . . . . . . . 100sodium acetate. . . . . . . . . . . . . . . . . . . . . . . 99sodium benzoate-sod phenylacet. . . . . . . . . 62sodium bicarbonate intravenous solution 1 meq/ml (8.4 %). . . . . . . . . . . . . . . . . . . . . . . . . . . 99

sodium bicarbonate intravenous syringe 10meq/10 ml (8.4 %), 7.5 % (0.9 meq/ml), 8.4 %(1 meq/ml). . . . . . . . . . . . . . . . . . . . . . . . . . 99

sodium chlor 0.9% bacteriostat. . . . . . . . . . . 62sodium chloride 0.45 % intravenous parenteralsolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

sodium chloride 0.9 % (flush) injectionsyringe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

sodium chloride 0.9 % injection. . . . . . . . . . . 62sodium chloride 0.9 % intravenous parenteralsolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

sodium chloride 0.9 % intravenous piggyback 62sodium chloride 3 %. . . . . . . . . . . . . . . . . . . 99sodium chloride 5 %. . . . . . . . . . . . . . . . . . . 99sodium chloride inhalation. . . . . . . . . . . . . . . 95sodium chloride injection. . . . . . . . . . . . . . . . 62sodium chloride intravenous. . . . . . . . . . . . . 99sodium chloride irrigation. . . . . . . . . . . . . . . . 62sodium fluoride 5000 dry mouth. . . . . . . . . . 63sodium fluoride 5000 plus. . . . . . . . . . . . . . . 63sodium fluoride-pot nitrate. . . . . . . . . . . . . . . 63sodium nitroprusside. . . . . . . . . . . . . . . . . . . 54sodium phenylbutyrate oral powder. . . . . . . . 62sodium phenylbutyrate oral tablet. . . . . . . . . 62sodium phosphate. . . . . . . . . . . . . . . . . . . . . 99sodium polystyrene (sorb free). . . . . . . . . . . 62sodium polystyrene sulfonate oral powder. . . 62

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solifenacin. . . . . . . . . . . . . . . . . . . . . . . . . . . 96SOLTAMOX. . . . . . . . . . . . . . . . . . . . . . . . . . 25SOMATULINE DEPOT. . . . . . . . . . . . . . . . . . 25SOMAVERT. . . . . . . . . . . . . . . . . . . . . . . . . . 69SORBITOL IRRIGATION. . . . . . . . . . . . . . . . 60sorine oral tablet 120 mg, 160 mg, 80 mg. . . 46sorine oral tablet 240 mg. . . . . . . . . . . . . . . . 46sotalol af. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46sotalol oral. . . . . . . . . . . . . . . . . . . . . . . . . . . 46SOVALDI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9spinosad. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60SPIRIVA RESPIMAT. . . . . . . . . . . . . . . . . . . 95SPIRIVA WITH HANDIHALER. . . . . . . . . . . . 95spironolacton-hydrochlorothiaz. . . . . . . . . . . 49spironolactone. . . . . . . . . . . . . . . . . . . . . . . . 49sprintec (28). . . . . . . . . . . . . . . . . . . . . . . . . . 88SPRITAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29SPRYCEL. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25sps (with sorbitol) oral. . . . . . . . . . . . . . . . . . 62sps (with sorbitol) rectal. . . . . . . . . . . . . . . . . 62sronyx. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88ssd. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56STAMARIL (PF). . . . . . . . . . . . . . . . . . . . . . . 79stavudine oral capsule. . . . . . . . . . . . . . . . . . . 9STELARA INTRAVENOUS. . . . . . . . . . . . . . 55STELARA SUBCUTANEOUS. . . . . . . . . . . . 55STIOLTO RESPIMAT. . . . . . . . . . . . . . . . . . . 95STIVARGA. . . . . . . . . . . . . . . . . . . . . . . . . . . 25STRENSIQ. . . . . . . . . . . . . . . . . . . . . . . . . . . 69STREPTOMYCIN. . . . . . . . . . . . . . . . . . . . . . 14STRIBILD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9subvenite. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29subvenite starter (blue) kit. . . . . . . . . . . . . . . 29subvenite starter (green) kit. . . . . . . . . . . . . . 29subvenite starter (orange) kit. . . . . . . . . . . . . 29SUCRAID. . . . . . . . . . . . . . . . . . . . . . . . . . . . 73sucralfate. . . . . . . . . . . . . . . . . . . . . . . . . . . . 75sulfacetamide sodium (acne). . . . . . . . . . . . . 58sulfacetamide sodium ophthalmic (eye). . . . 90sulfacetamide-prednisolone. . . . . . . . . . . . . . 90sulfadiazine. . . . . . . . . . . . . . . . . . . . . . . . . . 18sulfamethoxazole-trimethoprim intravenous. 18

sulfamethoxazole-trimethoprim oral. . . . . . . . 18SULFAMYLON TOPICAL CREAM. . . . . . . . 58sulfasalazine oral tablet. . . . . . . . . . . . . . . . . 73sulfasalazine oral tablet,delayed release(dr/ec). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

sulindac. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39sumatriptan nasal spray,non-aerosol 20mg/actuation. . . . . . . . . . . . . . . . . . . . . . . . . 31

sumatriptan nasal spray,non-aerosol 5mg/actuation. . . . . . . . . . . . . . . . . . . . . . . . . 31

sumatriptan succinate oral. . . . . . . . . . . . . . . 31sumatriptan succinate subcutaneouscartridge. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

sumatriptan succinate subcutaneous peninjector. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

sumatriptan succinate subcutaneous solution 31sumatriptan succinate subcutaneous syringe 6mg/0.5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 31

sumatriptan-naproxen. . . . . . . . . . . . . . . . . . 31SUPRAX ORAL TABLET,CHEWABLE. . . . . . 11SUTENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25syeda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88SYMBICORT. . . . . . . . . . . . . . . . . . . . . . . . . 95SYMDEKO ORAL TABLETS, SEQUENTIAL100-150 MG (D)/ 150 MG (N). . . . . . . . . . . 95

SYMDEKO ORAL TABLETS, SEQUENTIAL50-75 MG (D)/ 75 MG (N). . . . . . . . . . . . . . 95

SYMFI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9SYMFI LO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9SYMLINPEN 120. . . . . . . . . . . . . . . . . . . . . . 67SYMLINPEN 60. . . . . . . . . . . . . . . . . . . . . . . 67SYMPAZAN. . . . . . . . . . . . . . . . . . . . . . . . . . 29SYMTUZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9SYNAGIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9SYNAREL. . . . . . . . . . . . . . . . . . . . . . . . . . . 69SYNDROS. . . . . . . . . . . . . . . . . . . . . . . . . . . 73SYNERCID. . . . . . . . . . . . . . . . . . . . . . . . . . . 14SYNJARDY. . . . . . . . . . . . . . . . . . . . . . . . . . . 67SYNJARDY XR. . . . . . . . . . . . . . . . . . . . . . . 67SYNRIBO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

TTABLOID. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

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TABRECTA. . . . . . . . . . . . . . . . . . . . . . . . . . . 26tacrolimus oral. . . . . . . . . . . . . . . . . . . . . . . . 26tacrolimus topical. . . . . . . . . . . . . . . . . . . . . . 56tadalafil (pulmonary arterial hypertension) oraltablet 20 mg. . . . . . . . . . . . . . . . . . . . . . . . . 95

tadalafil oral tablet 2.5 mg, 5 mg. . . . . . . . . . 97TAFINLAR. . . . . . . . . . . . . . . . . . . . . . . . . . . 26TAGRISSO. . . . . . . . . . . . . . . . . . . . . . . . . . . 26TAKHZYRO. . . . . . . . . . . . . . . . . . . . . . . . . . 95TALZENNA. . . . . . . . . . . . . . . . . . . . . . . . . . . 26tamoxifen. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26tamsulosin oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

TARGRETIN 1% GEL. . . . . . . . . . . . . . . . . . 26tarina 24 fe. . . . . . . . . . . . . . . . . . . . . . . . . . . 88tarina fe 1-20 eq (28). . . . . . . . . . . . . . . . . . . 88tarina fe 1/20 (28). . . . . . . . . . . . . . . . . . . . . 88TASIGNA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26tavaborole. . . . . . . . . . . . . . . . . . . . . . . . . . . 58TAVALISSE. . . . . . . . . . . . . . . . . . . . . . . . . . 52tazarotene topical cream. . . . . . . . . . . . . . . . 57tazicef injection recon soln 1 gram, 2 gram. . 11tazicef injection recon soln 6 gram. . . . . . . . . 11tazicef intravenous. . . . . . . . . . . . . . . . . . . . . 11TAZORAC TOPICAL CREAM 0.05 %. . . . . . 57TAZORAC TOPICAL GEL. . . . . . . . . . . . . . . 57taztia xt oral capsule, extended release. . . . 49TAZVERIK. . . . . . . . . . . . . . . . . . . . . . . . . . . 26TDVAX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79TECENTRIQ. . . . . . . . . . . . . . . . . . . . . . . . . 26TECFIDERA. . . . . . . . . . . . . . . . . . . . . . . . . . 33TEFLARO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11TEGSEDI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33TEKTURNA HCT. . . . . . . . . . . . . . . . . . . . . . 49telmisartan. . . . . . . . . . . . . . . . . . . . . . . . . . . 49telmisartan-amlodipine. . . . . . . . . . . . . . . . . . 49telmisartan-hydrochlorothiazid. . . . . . . . . . . . 49temazepam. . . . . . . . . . . . . . . . . . . . . . . . . . 44TEMIXYS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9TEMODAR INTRAVENOUS. . . . . . . . . . . . . 26temozolomide. . . . . . . . . . . . . . . . . . . . . . . . . 26temsirolimus. . . . . . . . . . . . . . . . . . . . . . . . . . 26

tencon oral tablet 50-325 mg. . . . . . . . . . . . . 37TENIVAC (PF) INTRAMUSCULARSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 79

TENIVAC (PF) INTRAMUSCULARSYRINGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 79

tenofovir disoproxil fumarate. . . . . . . . . . . . . 10TEPEZZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 69TEPMETKO. . . . . . . . . . . . . . . . . . . . . . . . . . 26terazosin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49terbinafine hcl oral. . . . . . . . . . . . . . . . . . . . . . 7terbutaline. . . . . . . . . . . . . . . . . . . . . . . . . . . 95terconazole. . . . . . . . . . . . . . . . . . . . . . . . . . . 85testosterone cypionate intramuscular oil 100mg/ml, 200 mg/ml. . . . . . . . . . . . . . . . . . . . . 69

testosterone cypionate intramuscular oil 200mg/ml (1 ml). . . . . . . . . . . . . . . . . . . . . . . . . 69

testosterone enanthate. . . . . . . . . . . . . . . . . 69testosterone transdermal gel (generic). . . . . 69testosterone transdermal gel in metered-dosepump 10 mg/0.5 gram (Fortesta generic). . . 69

testosterone transdermal gel in metered-dosepump 12.5 mg/ 1.25 gram (1 %) (Androgelgeneric). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

testosterone transdermal gel in metered-dosepump 20.25 mg/1.25 gram (1.62 %) (Androgelgeneric). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

testosterone transdermal gel in packet(Androgel generic). . . . . . . . . . . . . . . . . . . . 70

testosterone transdermal solution in meteredpump w/app (Axiron generic). . . . . . . . . . . . 70

TETANUS,DIPHTHERIA TOX PED(PF). . . . 79tetrabenazine. . . . . . . . . . . . . . . . . . . . . . . . . 33tetracycline. . . . . . . . . . . . . . . . . . . . . . . . . . . 19THALOMID. . . . . . . . . . . . . . . . . . . . . . . . . . . 26theophylline oral elixir. . . . . . . . . . . . . . . . . . 95theophylline oral solution. . . . . . . . . . . . . . . . 95theophylline oral tablet extended release 12 hr300 mg, 450 mg. . . . . . . . . . . . . . . . . . . . . . 95

theophylline oral tablet extended release 24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

THIOLA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62THIOLA EC. . . . . . . . . . . . . . . . . . . . . . . . . . 62thioridazine. . . . . . . . . . . . . . . . . . . . . . . . . . . 44thiotepa injection recon soln 100 mg. . . . . . . 26

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thiotepa injection recon soln 15 mg. . . . . . . . 26thiothixene. . . . . . . . . . . . . . . . . . . . . . . . . . . 44tiadylt er. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49tiagabine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29TIBSOVO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26TICE BCG. . . . . . . . . . . . . . . . . . . . . . . . . . . 80tigecycline. . . . . . . . . . . . . . . . . . . . . . . . . . . 14TIGLUTIK. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62tilia fe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88timolol maleate (pf). . . . . . . . . . . . . . . . . . . . 90timolol maleate ophthalmic (eye). . . . . . . . . . 90timolol maleate oral. . . . . . . . . . . . . . . . . . . . 49tinidazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14tis-u-sol pentalyte. . . . . . . . . . . . . . . . . . . . . . 60TIVICAY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10TIVICAY PD. . . . . . . . . . . . . . . . . . . . . . . . . . 10tizanidine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE. . . . . . . . . . . . . . . . . 14

tobramycin in 0.225 % nacl. . . . . . . . . . . . . . 14tobramycin inhalation. . . . . . . . . . . . . . . . . . . 14tobramycin ophthalmic (eye). . . . . . . . . . . . . 89tobramycin sulfate injection recon soln. . . . . 14tobramycin sulfate injection solution. . . . . . . 14tobramycin-dexamethasone. . . . . . . . . . . . . 91tolcapone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30tolmetin oral capsule. . . . . . . . . . . . . . . . . . . 39tolmetin oral tablet 600 mg. . . . . . . . . . . . . . 40tolterodine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

tolterodine oral tablet. . . . . . . . . . . . . . . . . . . 96tolvaptan oral tablet 30 mg. . . . . . . . . . . . . . 70topiramate oral capsule, sprinkle. . . . . . . . . . 29topiramate oral capsule,sprinkle,er 24hr. . . . 29topiramate oral tablet. . . . . . . . . . . . . . . . . . . 29toposar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26topotecan intravenous recon soln. . . . . . . . . 26topotecan intravenous solution 4 mg/4 ml (1mg/ml). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

toremifene. . . . . . . . . . . . . . . . . . . . . . . . . . . 26torsemide oral. . . . . . . . . . . . . . . . . . . . . . . . 49TOUJEO MAX U-300 SOLOSTAR. . . . . . . . 68

TOUJEO SOLOSTAR U-300 INSULIN. . . . . 68tovet emollient. . . . . . . . . . . . . . . . . . . . . . . . 59TRACLEER ORAL TABLET FORSUSPENSION. . . . . . . . . . . . . . . . . . . . . . . 96

tramadol oral tablet 50 mg. . . . . . . . . . . . . . . 40tramadol oral tablet extended release 24 hr. 40tramadol oral tablet, er multiphase 24 hr. . . . 40tramadol-acetaminophen. . . . . . . . . . . . . . . . 40trandolapril. . . . . . . . . . . . . . . . . . . . . . . . . . . 49trandolapril-verapamil oral tablet, ir - er, biphasic24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

tranexamic acid oral. . . . . . . . . . . . . . . . . . . . 85tranylcypromine. . . . . . . . . . . . . . . . . . . . . . . 44travasol 10 %. . . . . . . . . . . . . . . . . . . . . . . . 100travoprost. . . . . . . . . . . . . . . . . . . . . . . . . . . . 91TRAZIMERA. . . . . . . . . . . . . . . . . . . . . . . . . 26trazodone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44TREANDA INTRAVENOUS RECON SOLN. 26TRECATOR. . . . . . . . . . . . . . . . . . . . . . . . . . 14TRELEGY ELLIPTA. . . . . . . . . . . . . . . . . . . . 96TRELSTAR INTRAMUSCULAR SUSPENSIONFOR RECONSTITUTION. . . . . . . . . . . . . . . 26

treprostinil sodium. . . . . . . . . . . . . . . . . . . . . 49tretinoin (antineoplastic). . . . . . . . . . . . . . . . . 26tretinoin microspheres. . . . . . . . . . . . . . . . . . 57tretinoin topical. . . . . . . . . . . . . . . . . . . . . . . . 57tri femynor. . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-estarylla. . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-legest fe. . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-linyah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-lo-estarylla. . . . . . . . . . . . . . . . . . . . . . . . . 88tri-lo-marzia. . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-lo-mili. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-lo-sprintec. . . . . . . . . . . . . . . . . . . . . . . . . 88tri-mili. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-nymyo. . . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-previfem (28). . . . . . . . . . . . . . . . . . . . . . . 88tri-sprintec (28). . . . . . . . . . . . . . . . . . . . . . . . 88tri-vylibra. . . . . . . . . . . . . . . . . . . . . . . . . . . . 88tri-vylibra lo. . . . . . . . . . . . . . . . . . . . . . . . . . 88triamcinolone acetonide dental. . . . . . . . . . . 64triamcinolone acetonide injection suspension 40mg/ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

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triamcinolone acetonide topical. . . . . . . . . . . 59triamterene. . . . . . . . . . . . . . . . . . . . . . . . . . . 49triamterene-hydrochlorothiazid oral capsule37.5-25 mg. . . . . . . . . . . . . . . . . . . . . . . . . . 49

triamterene-hydrochlorothiazid oral tablet. . . 49trianex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59triazolam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44triderm topical cream. . . . . . . . . . . . . . . . . . . 59trientine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62trifluoperazine. . . . . . . . . . . . . . . . . . . . . . . . . 44trifluridine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 90trihexyphenidyl. . . . . . . . . . . . . . . . . . . . . . . . 30TRIKAFTA. . . . . . . . . . . . . . . . . . . . . . . . . . . 96trilyte with flavor packets. . . . . . . . . . . . . . . . 73trimethobenzamide oral. . . . . . . . . . . . . . . . . 73trimethoprim. . . . . . . . . . . . . . . . . . . . . . . . . . 19trimipramine. . . . . . . . . . . . . . . . . . . . . . . . . . 44TRINTELLIX. . . . . . . . . . . . . . . . . . . . . . . . . . 44TRIUMEQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10trivora (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 88TRODELVY. . . . . . . . . . . . . . . . . . . . . . . . . . . 26TROGARZO. . . . . . . . . . . . . . . . . . . . . . . . . . 10TROKENDI XR. . . . . . . . . . . . . . . . . . . . . . . 29TROPHAMINE 10 %. . . . . . . . . . . . . . . . . . 100trospium oral capsule,extended release 24hr 96trospium oral tablet. . . . . . . . . . . . . . . . . . . . 96TRULICITY. . . . . . . . . . . . . . . . . . . . . . . . . . . 68TRUMENBA. . . . . . . . . . . . . . . . . . . . . . . . . . 80TRUVADA. . . . . . . . . . . . . . . . . . . . . . . . . . . 10TRUXIMA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26TUKYSA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26tulana. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84TURALIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26TWINRIX (PF) INTRAMUSCULARSYRINGE. . . . . . . . . . . . . . . . . . . . . . . . . . . 80

TYBOST. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10tydemy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88TYKERB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26TYMLOS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 81TYPHIM VI INTRAMUSCULAR SOLUTION. 80TYPHIM VI INTRAMUSCULAR SYRINGE. . 80TYSABRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

TYVASO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96TYVASO INSTITUTIONAL START KIT. . . . . 96TYVASO REFILL KIT. . . . . . . . . . . . . . . . . . . 96TYVASO STARTER KIT. . . . . . . . . . . . . . . . . 96

UUBRELVY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31UCERIS RECTAL. . . . . . . . . . . . . . . . . . . . . 73UDENYCA. . . . . . . . . . . . . . . . . . . . . . . . . . . 77UKONIQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26unithroid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70UNITUXIN. . . . . . . . . . . . . . . . . . . . . . . . . . . 26UPTRAVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49ursodiol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73UVADEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Vvalacyclovir. . . . . . . . . . . . . . . . . . . . . . . . . . . 10VALCHLOR. . . . . . . . . . . . . . . . . . . . . . . . . . 56valganciclovir oral recon soln. . . . . . . . . . . . . 10valganciclovir oral tablet. . . . . . . . . . . . . . . . 10valproate sodium. . . . . . . . . . . . . . . . . . . . . . 29valproic acid. . . . . . . . . . . . . . . . . . . . . . . . . . 29valproic acid (as sodium salt) oral solution 250mg/5 ml. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

valproic acid (as sodium salt) oral solution 250mg/5 ml (5 ml), 500 mg/10 ml (10 ml). . . . . 29

valrubicin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26valsartan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49valsartan-hydrochlorothiazide. . . . . . . . . . . . 49VALTOCO. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29vanadom. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34VANCOMYCIN IN D5W INTRAVENOUSPIGGYBACK 1 GRAM/200 ML (BRAND). . 14

VANCOMYCIN IN D5W INTRAVENOUSPIGGYBACK 500 MG/100 ML, 750 MG/150ML (BRAND). . . . . . . . . . . . . . . . . . . . . . . . 15

VANCOMYCIN IN DEXTROSE ISO-OSM(BRAND). . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

VANCOMYCIN INJECTION (BRAND). . . . . . 15vancomycin intravenous recon soln 1,000 mg,500 mg, 750 mg. . . . . . . . . . . . . . . . . . . . . . 15

VANCOMYCIN INTRAVENOUS RECON SOLN1.25 GRAM, 1.5 GRAM (BRAND). . . . . . . . 15

137

vancomycin intravenous recon soln 10 gram 15VANCOMYCIN INTRAVENOUS RECON SOLN250 MG (BRAND). . . . . . . . . . . . . . . . . . . . 15

vancomycin intravenous recon soln 5 gram. 15vancomycin oral capsule. . . . . . . . . . . . . . . . 15vancomycin oral recon soln. . . . . . . . . . . . . . 15vandazole. . . . . . . . . . . . . . . . . . . . . . . . . . . . 85VANTAS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26VAQTA (PF). . . . . . . . . . . . . . . . . . . . . . . . . . 80VARIVAX (PF). . . . . . . . . . . . . . . . . . . . . . . . 80VARIZIG INTRAMUSCULAR SOLUTION. . . 80VARUBI ORAL. . . . . . . . . . . . . . . . . . . . . . . . 73VASCEPA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 53VECAMYL. . . . . . . . . . . . . . . . . . . . . . . . . . . 54VECTIBIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26VELCADE. . . . . . . . . . . . . . . . . . . . . . . . . . . 26veletri. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49velivet triphasic regimen (28). . . . . . . . . . . . . 89VELTASSA. . . . . . . . . . . . . . . . . . . . . . . . . . . 62VEMLIDY. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10VENCLEXTA. . . . . . . . . . . . . . . . . . . . . . . . . 26VENCLEXTA STARTING PACK. . . . . . . . . . 26venlafaxine oral capsule,extended release24hr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

venlafaxine oral tablet. . . . . . . . . . . . . . . . . . 44VENTAVIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 96verapamil intravenous. . . . . . . . . . . . . . . . . . 49verapamil oral capsule, 24 hr er pellet ct. . . . 49verapamil oral capsule,ext rel. pellets 24 hr. . 49verapamil oral tablet. . . . . . . . . . . . . . . . . . . 49verapamil oral tablet extended release. . . . . 50VERSACLOZ. . . . . . . . . . . . . . . . . . . . . . . . . 44VERZENIO. . . . . . . . . . . . . . . . . . . . . . . . . . . 26vestura (28). . . . . . . . . . . . . . . . . . . . . . . . . . 89VGO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68VIBATIV INTRAVENOUS RECON SOLN 750MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

VIEKIRA PAK. . . . . . . . . . . . . . . . . . . . . . . . . 10vienva. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89vigabatrin. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29vigadrone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29VIIBRYD ORAL TABLET. . . . . . . . . . . . . . . . 44

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG(7)- 20 MG (23). . . . . . . . . . . . . . . . . . . . . . 44

VIMIZIM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70VIMPAT INTRAVENOUS. . . . . . . . . . . . . . . . 29VIMPAT ORAL SOLUTION. . . . . . . . . . . . . . 29VIMPAT ORAL TABLET. . . . . . . . . . . . . . . . . 29vinblastine intravenous solution. . . . . . . . . . . 26vincasar pfs. . . . . . . . . . . . . . . . . . . . . . . . . . 26vincristine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26vinorelbine. . . . . . . . . . . . . . . . . . . . . . . . . . . 26viorele (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 89VIRACEPT ORAL TABLET. . . . . . . . . . . . . . 10VIREAD ORAL POWDER. . . . . . . . . . . . . . . 10VIREAD ORAL TABLET 150 MG, 200 MG, 250MG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

VISTOGARD. . . . . . . . . . . . . . . . . . . . . . . . . 19VITRAKVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26VIZIMPRO. . . . . . . . . . . . . . . . . . . . . . . . . . . 26volnea (28). . . . . . . . . . . . . . . . . . . . . . . . . . . 89voriconazole intravenous. . . . . . . . . . . . . . . . . 7voriconazole oral. . . . . . . . . . . . . . . . . . . . . . . 7VOSEVI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10VOTRIENT. . . . . . . . . . . . . . . . . . . . . . . . . . . 27VRAYLAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44vtol lq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37vyfemla (28). . . . . . . . . . . . . . . . . . . . . . . . . . 89vylibra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89VYNDAMAX. . . . . . . . . . . . . . . . . . . . . . . . . . 54VYNDAQEL. . . . . . . . . . . . . . . . . . . . . . . . . . 54VYXEOS. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Wwarfarin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52water for inject, bacteriostat. . . . . . . . . . . . . . 62water for irrigation, sterile. . . . . . . . . . . . . . . 62wera (28). . . . . . . . . . . . . . . . . . . . . . . . . . . . 89wymzya fe. . . . . . . . . . . . . . . . . . . . . . . . . . . 89

XXALKORI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27XATMEP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27XCOPRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

138

XCOPRI MAINTENANCE PACK. . . . . . . . . . 29XCOPRI TITRATION PACK. . . . . . . . . . . . . . 29XELJANZ ORAL SOLUTION. . . . . . . . . . . . . 83XELJANZ ORAL TABLET. . . . . . . . . . . . . . . 83XELJANZ XR. . . . . . . . . . . . . . . . . . . . . . . . . 83XENLETA INTRAVENOUS. . . . . . . . . . . . . . 15XENLETA ORAL. . . . . . . . . . . . . . . . . . . . . . 15XEOMIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80XERMELO. . . . . . . . . . . . . . . . . . . . . . . . . . . 27XGEVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19XIFAXAN ORAL TABLET 550 MG. . . . . . . . . 15XOFLUZA ORAL TABLET 20 MG. . . . . . . . . 10XOFLUZA ORAL TABLET 40 MG. . . . . . . . . 10XOLAIR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96XOSPATA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27XPOVIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27XTANDI ORAL CAPSULE. . . . . . . . . . . . . . . 27xulane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85XURIDEN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 62xylocaine dental-epinephrine. . . . . . . . . . . . . 56XYREM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

YYERVOY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27YF-VAX (PF). . . . . . . . . . . . . . . . . . . . . . . . . 80YONDELIS. . . . . . . . . . . . . . . . . . . . . . . . . . . 27YONSA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27YUPELRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 96yuvafem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Zzafemy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85zafirlukast. . . . . . . . . . . . . . . . . . . . . . . . . . . . 96zaleplon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ZALTRAP. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27ZANOSAR. . . . . . . . . . . . . . . . . . . . . . . . . . . 27zarah. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89ZARXIO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77zebutal oral capsule 50-325-40 mg. . . . . . . . 38ZEJULA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27ZELAPAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30ZELBORAF. . . . . . . . . . . . . . . . . . . . . . . . . . . 27

zenatane. . . . . . . . . . . . . . . . . . . . . . . . . . . . 57ZENPEP ORAL CAPSULE,DELAYEDRELEASE(DR/EC) 10,000-32,000 -42,000UNIT, 15,000-47,000 -63,000 UNIT,20,000-63,000- 84,000 UNIT, 25,000-79,000-105,000 UNIT, 3,000-10,000 -14,000-UNIT,40,000-126,000- 168,000 UNIT, 5,000-17,000-24,000 UNIT. . . . . . . . . . . . . . . . . . . . . . . . . 74

zenzedi oral tablet 10 mg, 5 mg. . . . . . . . . . . 45ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20MG, 30 MG, 7.5 MG (BRAND). . . . . . . . . . . 45

ZEPATIER. . . . . . . . . . . . . . . . . . . . . . . . . . . 10ZEPOSIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33ZEPOSIA STARTER KIT. . . . . . . . . . . . . . . . 33ZEPOSIA STARTER PACK. . . . . . . . . . . . . . 33ZEPZELCA. . . . . . . . . . . . . . . . . . . . . . . . . . . 27ZERBAXA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 11zidovudine. . . . . . . . . . . . . . . . . . . . . . . . . . . 10ZIEXTENZO. . . . . . . . . . . . . . . . . . . . . . . . . . 77zileuton oral tablet,extended release 12hrmphase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

ZINPLAVA. . . . . . . . . . . . . . . . . . . . . . . . . . . 80ziprasidone hcl. . . . . . . . . . . . . . . . . . . . . . . . 45ziprasidone mesylate. . . . . . . . . . . . . . . . . . . 45ZIRABEV. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27ZIRGAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90ZOLADEX. . . . . . . . . . . . . . . . . . . . . . . . . . . 27zoledronic acid intravenous solution. . . . . . . 70zoledronic acid-mannitol-water intravenouspiggyback 4 mg/100 ml. . . . . . . . . . . . . . . . 70

zoledronic acid-mannitol-water intravenouspiggyback 5 mg/100 ml. . . . . . . . . . . . . . . . 62

ZOLINZA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27ZOLMITRIPTAN NASAL. . . . . . . . . . . . . . . . 31zolmitriptan oral. . . . . . . . . . . . . . . . . . . . . . . 31zolpidem oral tablet. . . . . . . . . . . . . . . . . . . . 45zolpidem oral tablet,ext release multiphase. . 45ZOMIG NASAL. . . . . . . . . . . . . . . . . . . . . . . 31zonisamide. . . . . . . . . . . . . . . . . . . . . . . . . . . 29ZORBTIVE. . . . . . . . . . . . . . . . . . . . . . . . . . . 77ZORTRESS ORAL TABLET 1 MG. . . . . . . . . 27ZOSTAVAX (PF). . . . . . . . . . . . . . . . . . . . . . 80zovia 1-35 (28). . . . . . . . . . . . . . . . . . . . . . . . 89zovia 1/35e (28). . . . . . . . . . . . . . . . . . . . . . . 89

139

zumandimine (28). . . . . . . . . . . . . . . . . . . . . 89ZYDELIG. . . . . . . . . . . . . . . . . . . . . . . . . . . . 27ZYKADIA ORAL TABLET. . . . . . . . . . . . . . . . 27ZYPREXA RELPREVV. . . . . . . . . . . . . . . . . 45ZYTIGA ORAL TABLET 500 MG. . . . . . . . . . 27

140

138 2021 Formulary

NONDISCRIMINATION NOTICEBlue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity.

Blue Cross Blue Shield of Massachusetts provides:• Fr ee aids and services to people with disabilities to communicate effectively with us,

such as qualified sign language interpreters and written information in other formats(large print or other formats).

• Fr ee language services to people whose primary language is not English, such as qualifiedinterpreters and information written in other languages.

If you need these services, contact the Medicare Advantage Appeals and Grievance Manager.

If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Medicare Advantage Appeals and Grievance Manager by mail at P.O. Box 55007, Boston, MA 02205; phone at 1-800-200-4255 (TTY: 711) from April 1 through September 30, 8:00 a.m. to 8:00 p.m., Monday through Friday, or October 1 through March 31, 8:00 a.m. to 8:00 p.m., seven days week; fax at 617-246-8506; or email at [email protected]. You can file a grievance in person, by mail, fax, or email, or you can call 1-800-200-4255 (TTY: 711).

If you need help filing a grievance, the Medicare Advantage Appeals and Grievance Manager 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 online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD).

Complaint forms are available at hhs.gov.

mailto:MedicareAdvantageRXAppeals%40bcbsma.com?subject=

http://ocrportal.hhs.gov

http://www.hhs.gov

139

TRANSLATION RESOURCES Proficiency of Language Assistance Services

bluecrossma.com/medicare-options

English: ATTENTION: If you don't speak English, language assistance services, free of charge, are available to you. Call 1-800-200-4255 (TTY: 711).

Spanish/Español: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711).

Portuguese/Português: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711).

Chinese/繁體中文: 1-800-200-4255 (TTY: 711).

French Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711).

Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-200-4255 (TTY: 711).

Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-200-4255 (телетайп: 711).

Arabic/االعربیة:ملحوظة: إذا كنت تتحدث العربیة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 1-800-200-4255

.(ھاتف الصم والبكم: 711)

Mon-Khmer, Cambodian/ :1-800-200-4255 (TTY: 711).

French/Français: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-200-4255 (ATS: 711).

Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711).

Korean/ : 1-800-200-4255 (TTY: 711)

Greek/λληνικά: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711).

Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-200-4255 (TTY: 711).

Hindi/ :1-800-200-4255 (TTY: 711)

Gujarati/ :1-800-200-4255 (TTY: 711)


bluecrossma.com/medicare-options | Medicare Plan Sales: 1-800-678-2265 (TTY: 711)

April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday

October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week.

Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age,

disability, sex, sexual orientation, or gender identity.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711).

This formulary was updated on 05/01/2021. For more recent information or other questions, please contact Blue Cross Blue Shield of Massachusetts at 1-800-200-4255, or, for TTY users, 711, from April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through March 31,

8:00 a.m. to 8:00 p.m. ET, seven days a week, or visit bluecrossma.com/medicare-options.

The Formulary may change at any time. You will receive notice when necessary.

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks of the medications listed are the property of their respective manufacturers.

© 2021 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000758150 55-0184-21 (5/21)



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