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Tufts Health RITogether

Pharmacy program and Preferred Drug List

December 1, 2018

Introduction

Pharmacy program

We aim to provide high-quality, cost-effective options for drug therapy. We work with your health care providers and pharmacists to make sure we cover the most important

and useful drugs for a variety of conditions and diseases. We cover both first-time prescriptions and refills. We also cover some over-the-counter (OTC) drugs if your provider writes a prescription and it is filled at a pharmacy.

Our pharmacy program does not cover all drugs and prescriptions. Some drugs must

meet certain clinical guidelines before we can cover them. Your provider must ask us for prior approval before we will cover these drugs.

Preferred Drug List (PDL)

We list all drugs according to their therapeutic category and drug class, followed by generic or brand drug name. Use the index to find a drug according to its generic or

brand name. In general, we cover brand-name medications only when a generic medication is not available or if we give prior approval for the brand-name drug.

Co-payments

Outpatient drugs that are medically necessary are covered when they are prescribed by

a provider who is licensed to prescribe drugs. Some drugs on the

Tufts Health RITogether formulary are only covered when your provider submits a prior approval request. Eligibility for outpatient prescription drug benefits and co-payment amounts are based on your individual benefit plan.

The PDL applies only to drugs you get at retail and specialty pharmacies. The PDL does not apply to drugs you get if you are in the hospital. Drugs you get while in the hospital are covered as part of your stay.

For the most current PDL coverage information, please visit tuftshealthplan.com or call us at 866.738.4116 (TTY: 711).

Prior approval

Some drugs always require prior approval, which means your provider must ask us for

approval before we will cover the drug. One of our clinicians will review this request. We will cover the drug according to our clinical guidelines if:

There is a medical reason you need the particular drug

Depending on the drug, other drugs on the PDL have not worked

If we do not approve the request for prior approval, you or your authorized

representative, if you identify one, can appeal the decision. See your Member Handbook for our member grievances and appeals information.

Step therapy program

We cover some types of drugs only through our step therapy program. Our step

therapy program requires you to try first-level drugs before we will cover another drug of that type. If you and your provider feel a certain drug is not appropriate for treating your health condition, your provider can ask us for prior approval for the other drug.

One of our clinicians will review the request. We will cover the drug according to our clinical guidelines. If we do not approve the request for prior approval, you or your authorized representative, if you identify one, can appeal the decision. See your

Member Handbook for our grievances and appeals information.

Quantity limit

To make sure the drugs you take are safe and that you are getting the right amount,

we may limit how much you can get at one time. Your provider can ask us for prior

approval if you need more than we cover. One of our clinicians will review the request. We will cover the drug according to our clinical guidelines if there is a medical reason you need this particular amount. If we do not approve the request for prior approval,

you or your authorized representative, if you identify one, can appeal the decision. See your Member Handbook for our grievances and appeals information.

Generic drugs

Generic drugs have the same active ingredients and work the same as brand-name

drugs. Rhode Island has a Generic First Program and requires that all members use generic drugs first. When generic drugs are available, we will not cover the brand-name drug without giving prior approval. If you and your provider feel a generic drug is not

right for treating your health condition and that the brand-name drug is medically necessary, your provider can ask for prior approval. One of our clinicians will review the request. If we do not approve the request for prior approval, you or your authorized

representative, if you identify one, can appeal the decision. See your Member Handbook for our grievances and appeals information.

New-to-market drugs

We review new drugs for safety and effectiveness before we add them to our PDL.

Coverage limits

The Requirements/Limits column in the PDL shows when a drug has a certain

requirement or limit for coverage. Coverage limits include:

AGE — Age restriction may apply

This medication requires prior approval if the drug is not covered based on your age. Your provider should send us a prior approval request if the drug is

medically necessary.

PA — Prior approval

This medication requires prior approval. Your provider may prescribe a different

medication on the PDL or send us a prior approval request.

QL — Quantity limit

This medication is limited to a specific amount. If a larger amount is medically necessary, your provider should send us a prior approval request.

ST — Step therapy

This medication requires prior approval if you have not already used a first-line medication on the PDL. Your provider may prescribe another medication on the

PDL or send us a prior approval request.

Specialty pharmacy program

A specialty pharmacy may supply you with some drugs often used to treat chronic

conditions like hepatitis C or multiple sclerosis. These types of drugs need additional expertise and support. Specialty pharmacies have knowledge in these areas. These

pharmacies can give extra support to members and providers.

CVS Specialty is our specialty pharmacy and can provide you with these drugs. In

addition to providing specific specialty drugs, CVS Specialty will:

Deliver drugs to your home, provider’s office or any delivery address you choose (except for a P.O. box)

Answer your questions and offer help with your drugs

Give you information, materials and ongoing support to help you manage your

health condition and make sure you take your drugs the right way

Have staff pharmacists available who can help you at 800.237.2767.

THP-OCR-NOTICE-0716

DISCRIMINATION IS AGAINST THE LAW

Tufts Health Plan complies with applicable Federal civil rights laws and does not discriminate

on the basis of race, color, national origin, age, disability, or sex. Tufts Health Plan does not

exclude people or treat them differently because of race, color, national origin, age, disability,

or sex.

Tufts Health Plan:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

— Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

— Qualified interpreters

— Information written in other languages

If you need these services, contact Tufts Health Plan at 888.257.1985.

If you believe that Tufts Health Plan has failed to provide these services or discriminated in another way

on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Tufts Health Plan

Attention: Civil Rights Coordinator, Legal Dept.

705 Mount Auburn St.

Watertown, MA 02472

Phone: 888.880.8699 ext. 48000, [TTY number— 711 or 800.439.2370]

Fax: 617.972.9048

Email: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a

grievance, the Tufts Health Plan Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human

Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint

Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

Phone: 800.368.1019, 800.537.7697 (TDD)

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

tuftshealthplan.com | 888.257.1985

THP-OCR-NOTICE-0716

LA DISCRIMINACIÓN ES

CONTRA LA LEY

Tufts Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina

por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Tufts Health Plan no

excluye a las personas ni las trata de forma diferente debido a su raza, color, nacionalidad,

edad, discapacidad o sexo.

Tufts Health Plan:

Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera

eficaz con nosotros, como los siguientes:

— Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos)

Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes:

— Intérpretes capacitados

— Información escrita en otros idiomas

Si necesita recibir estos servicios, comuníquese con Servicios para Miembros de Tufts Health Plan a 888.257.1985.

Si considera que Tufts Health Plan no le proporcionó estos servicios o lo discriminó de otra manera por motivos de

raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona:

Tufts Health Plan

Attention: Civil Rights Coordinator, Legal Dept.

705 Mount Auburn St.

Watertown, MA 02472

Phone: 888.880.8699 ext. 48000, [TTY number— 866-930-9252]

Fax: 617.972.9048

Email: [email protected]

Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Si necesita ayuda para hacerlo, el

coordinador de derechos civiles con Tufts Health Plan está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles)

del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera

electrónica a través de Office for Civil Rights Complaint Portal, disponible en

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los

números que figuran a continuación:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

Phone: 800.368.1019, 800.537.7697 (TDD)

Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

tuftshealthplan.com | 888.257.1985

For no-cost translation in English, call 866.738.4116.

Arabic 866.738.4116 الرقم على الاتصال یرجى العربیة، باللغة المجانیة الترجمة خدمة على للحصول

Chinese 若需免費的中文版本，請撥打 866.738.4116。

French Pour demander une traduction gratuite en français, composez le 866.738.4116.

German Um eine kostenlose deutsche Übersetzung zu erhalten, rufen Sie bitte die folgende Telefonnummer

an: 866.738.4116.

Greek Για δωρεάν μετάφραση στα ελληνικά, καλέστε στο 866.738.4116.

Haitian Creole Pou tradiksyon gratis nan Kreyòl Ayisyen, rele 866.738.4116.

Italian Per la traduzione in italiano senza costi aggiuntivi, è possibile chiamare il numero 866.738.4116.

Japanese 日本語の無料翻訳については 866.738.4116 に電話してください。

Khmer (Cambodian) សមរាបស់សវាបកបបរបសោយឥតគតិថ្ ៃ លជា ភាោ ប ្ប មរ សមូទរូសព័្ទសៅកានស់សម 866.738.4116 ។

Korean 한국어로 무료 통역을 원하시면, 866.738.4116 로 전화하십시오.

Laotian ໍ ສາໍ ລບການແປພາສາເໍ ປນພາສາລາ ວທໍ ໍ

ບໄ ໍ ດເສຍ ຄາໃ ໍ ຊຈາຍ , ໃໍ ຫໂທຫາເ ບ 866.738.4116.

Navajo Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 866.738.4116.

naisreP تلفن شماره بھ فارسی بھ رایگان ترجمھ برای .866.738.4116.بزنید زنگ

Polish Aby uzyskać bezpłatne tłumaczenie w języku polskim, należy zadzwonić na numer 866.738.4116.

Portuguese Para tradução grátis para português, ligue para o número 866.738.4116.

Russian Для получения услуг бесплатного перевода на русский язык позвоните по номеру 866.738.4116.

Spanish Para servicio de traducción gratuito en español, llame al 866.738.4116.

Tagalog Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 866.738.4116.

Vietnamese Để có bản dịch tiếng Việt không phải trả phí, gọi theo số 866.738.4116.

List-Languages-THP-Number-07/16

Table of Contents

BLOOD DISORDER................................................................................................................................................. 3CALORIC UNDERNUTRITION..............................................................................................................................7CHRONIC LUNG OR BREATHING PASSAGE PROBLEM................................................................................ 8COLD SYMPTOMS................................................................................................................................................12COLLAGEN VASCULAR DISEASE.................................................................................................................... 14CONDITION RESULTING FROM A DEFECTIVE IMMUNE SYSTEM...........................................................17DISEASE AFFECTING THE BODY'S METABOLISM.......................................................................................25DISEASE OF THE HEART AND BLOOD VESSELS..........................................................................................34DISEASE OF THE URINARY TRACT................................................................................................................. 43DISORDER OF NERVE......................................................................................................................................... 47DISORDER OF NERVOUS SYSTEM................................................................................................................... 58DISORDER OF REPRODUCTIVE SYSTEM....................................................................................................... 68DISORDER OF RESPIRATORY SYSTEM...........................................................................................................76DISORDER OF THE DIGESTIVE SYSTEM........................................................................................................ 82DISORDER OF THE ENDOCRINE GLANDS......................................................................................................90EAR PROBLEM......................................................................................................................................................95EYE DISORDER..................................................................................................................................................... 96FEVER..................................................................................................................................................................... 98INFECTION.............................................................................................................................................................98INFLAMMATION OF THE SEROUS MEMBRANES IN THE BODY.............................................................107INFLAMMATORY DISORDER.......................................................................................................................... 107INJURY TO A MUCOUS MEMBRANE............................................................................................................. 124LUNG DISEASE................................................................................................................................................... 125MAJOR TRAUMATIC INJURY.......................................................................................................................... 130MARGINAL ZONE LYMPHOMA...................................................................................................................... 131MUSCLE OR BONE DISORDER........................................................................................................................ 131NEUROPSYCHIATRIC DISORDER...................................................................................................................141NOT FEELING WELL..........................................................................................................................................151NUTRITIONAL DISORDER................................................................................................................................151OTHER OVER-THE-COUNTER DRUGS...........................................................................................................152OTHER PRESCRIPTION DRUGS.......................................................................................................................157OVERDOSE...........................................................................................................................................................178PAIN.......................................................................................................................................................................179PATIENT DEMOGRAPHICS...............................................................................................................................187PREGNANCY....................................................................................................................................................... 188PROCEDURE........................................................................................................................................................ 189REACTION DUE TO AN ALLERGEN............................................................................................................... 192RECENT OPERATION.........................................................................................................................................194SKIN CONDITION............................................................................................................................................... 197SLOW DRUG ELIMINATION BY KIDNEY......................................................................................................207TACHYARRHYTHMIA.......................................................................................................................................207TUMOR................................................................................................................................................................. 207

1

2

Drug Status NotesBLOOD DISORDER

ACTIMMUNE SUBCUTANEOUS SOLUTION Brand PA; SP

ADEMPAS ORAL TABLET Brand PA; SP

Advate Intravenous Solution Reconstituted MB/RX PA; SP

Adynovate Intravenous Solution Reconstituted MB/RX PA; SP

Afstyla Intravenous Kit MB/RX PA; SP

Alphanate/VWF Complex/Human Intravenous Solution Reconstituted

MB/RX PA; SP

AlphaNine SD Intravenous Solution Reconstituted

MB/RX PA; SP

Alprolix Intravenous Solution Reconstituted MB/RX PA; SP

ANADROL-50 ORAL TABLET Brand PA

anagrelide hcl oral capsule Generic

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.4ML, 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

Brand SP; QL (4 ML per 30 days)

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML


aspirin-dipyridamole er oral capsule extended release 12 hour

Generic PA; QL (60 EA per 30 days)

AURYXIA ORAL TABLET Brand PA

Bebulin Intravenous Solution Reconstituted MB/RX PA; SP

BeneFIX Intravenous Kit MB/RX PA; SP

BeneFIX Intravenous Solution Reconstituted 1000 UNIT, 2000 UNIT, 500 UNIT

MB/RX PA; SP

BEVYXXA ORAL CAPSULE Brand PA

BRILINTA ORAL TABLET Brand PA; QL (60 EA per 30 days)

CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM

Medical Benefit PA; SP

Coagadex Intravenous Solution Reconstituted MB/RX PA; SP

Corifact Intravenous Kit MB/RX PA; SP

^ = Mandates May Apply¥ = Additional Limits May Apply# = Drug specific notes MB/RX = Drug available through pharmacy and medical benefitsSP = Medication can be filled at a specialty pharmacy

3

Drug Status Notesdipyridamole oral tablet Generic

DOPTELET ORAL TABLET 20 MG Brand PA

DROXIA ORAL CAPSULE Brand

ELIQUIS ORAL TABLET Brand PA; QL (60 EA per 30 days)

Eloctate Intravenous Solution Reconstituted MB/RX PA; SP

ENDARI ORAL PACKET Brand PA

enoxaparin sodium injection solution Generic

enoxaparin sodium subcutaneous solution Generic

EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

Brand SP



FARYDAK ORAL CAPSULE Brand PA; SP

Feiba Intravenous Solution Reconstituted MB/RX PA; SP

folic acid oral tablet 1 mg Generic

fondaparinux sodium subcutaneous solution Generic

FULPHILA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand QL (0.6 ML per 14 days)

GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED


GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML

Medical Benefit PA

GAMMAPLEX INTRAVENOUS SOLUTION5 GM/50ML Medical Benefit PA

GAMUNEX-C INJECTION SOLUTION Medical Benefit PA; SP

GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand

PA; SP; QL (10 Syringes per 14 days)

Helixate FS Intravenous Kit MB/RX PA; SP

HEMLIBRA SUBCUTANEOUS SOLUTION Brand PA

Hemofil M Intravenous Solution Reconstituted 1000 UNIT, 1501-2000 UNIT, 1700 UNIT, 220-400 UNIT, 250 UNIT, 500 UNIT, 801-1500 UNIT

MB/RX PA; SP


4

Drug Status Notesheparin sodium (porcine) injection solution10000 unit/ml, 20000 unit/ml, 5000 unit/ml

Generic

Humate-P Intravenous Solution Reconstituted 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT

MB/RX PA; SP

Idelvion Intravenous Solution Reconstituted MB/RX PA; SP

IMBRUVICA ORAL CAPSULE 70 MG Brand PA

IMBRUVICA ORAL TABLET Brand PA

IPRIVASK SUBCUTANEOUS SOLUTION RECONSTITUTED Brand QL (24 vials per 12 days)

Ixinity Intravenous Solution Reconstituted MB/RX PA; SP

JADENU ORAL TABLET Brand PA; SP

JADENU SPRINKLE ORAL PACKET Brand PA

JAKAFI ORAL TABLET Brand PA; SP

Koate Intravenous Solution Reconstituted MB/RX PA; SP

Koate-DVI Intravenous Solution Reconstituted MB/RX PA; SP

Kogenate FS Bio-Set Intravenous Kit MB/RX PA; SP

Kogenate FS Intravenous Kit MB/RX PA; SP

Kovaltry Intravenous Solution Reconstituted MB/RX PA; SP

leucovorin calcium oral tablet Generic

LEUKERAN ORAL TABLET Brand

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG Medical Benefit PA


Monoclate-P Intravenous Kit 1000 UNIT, 1500 UNIT

MB/RX PA; SP

Mononine Intravenous Solution Reconstituted 1000 UNIT

MB/RX PA; SP

NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT Brand SP; QL (0.6 ML per 14 days)

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP; QL (0.6 ML per 14 days)

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML Brand


NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE Brand



5

Drug Status NotesNINLARO ORAL CAPSULE Brand PA; SP

Novoeight Intravenous Solution Reconstituted MB/RX PA; SP

NovoSeven RT Intravenous Solution Reconstituted

MB/RX PA; SP

Nuwiq Intravenous Kit MB/RX PA; SP

Nuwiq Intravenous Solution Reconstituted MB/RX PA; SP

Obizur Intravenous Solution Reconstituted MB/RX PA; SP

OCTAGAM INTRAVENOUS SOLUTION 10 GM/100ML, 2 GM/20ML, 20 GM/200ML, 5 GM/50ML


phytonadione oral tablet Generic

PRADAXA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)

prasugrel hcl oral tablet Generic PA

PRIVIGEN INTRAVENOUS SOLUTION Medical Benefit PA

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

Brand SP



Profilnine Intravenous Solution Reconstituted MB/RX PA; SP

Profilnine SD Intravenous Solution Reconstituted MB/RX PA; SP

PROMACTA ORAL TABLET Brand SP

Rebinyn Intravenous Solution Reconstituted MB/RX PA; SP

Recombinate Intravenous Solution Reconstituted MB/RX PA; SP

Rixubis Intravenous Solution Reconstituted MB/RX PA; SP

SAVAYSA ORAL TABLET Brand PA

SIKLOS ORAL TABLET 100 MG Brand PA

SOLIRIS INTRAVENOUS SOLUTION 10 MG/ML Medical Benefit PA; SP

TAVALISSE ORAL TABLET Brand QL (60 EA per 30 days)

THALOMID ORAL CAPSULE Brand SP

Tretten Intravenous Solution Reconstituted MB/RX PA; SP

Vonvendi Intravenous Solution Reconstituted MB/RX PA; SP


6

Drug Status Noteswarfarin sodium oral tablet Generic

Wilate Intravenous Kit MB/RX PA; SP

Wilate Intravenous Solution Reconstituted 1000-1000 UNIT, 500-500 UNIT

MB/RX PA; SP

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG Brand PA; QL (30 EA per 30 days)

XARELTO ORAL TABLET 2.5 MG Brand PA; QL (60 EA per 30 days)

XARELTO STARTER PACK ORAL TABLET THERAPY PACK Brand

PA; ¥ (1 Fill per life of plan); QL (51 EA per 21 days)

XATMEP ORAL SOLUTION Brand PA

Xyntha Intravenous Kit MB/RX PA; SP

Xyntha Solofuse Intravenous Kit MB/RX PA; SP

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE Brand SP; QL (10 Syringes per 14 days)

ZONTIVITY ORAL TABLET Brand PA

CALORIC UNDERNUTRITION


calcium acetate (phos binder) oral capsule Generic

calcium acetate (phos binder) oral tablet Generic

CRYSVITA SUBCUTANEOUS SOLUTION Medical Benefit PA

cyanocobalamin injection solution Generic

ergocalciferol oral capsule Generic

folbee oral tablet Generic



levocarnitine oral solution Generic

levocarnitine oral tablet Generic

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml

Generic

multi vitamin/fluoride oral tablet chewable Brand

multi vitamin/minerals oral tablet Generic

multi-vit/fluoride oral solution Generic

multi-vit/fluoride/iron oral solution Generic

multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg

Generic


7

Drug Status Notesmulti-vitamin/fluoride oral tablet chewable 0.5 mg

Brand

mynephrocaps oral capsule Generic

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION Brand PA; SP

RENAL ORAL CAPSULE Generic

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG Brand PA; SP

tri-vit/fluoride/iron oral solution Brand

tri-vitamin/fluoride oral solution Generic

vitamin d (ergocalciferol) oral capsule 50000 unit Generic

ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP

CHRONIC LUNG OR BREATHING PASSAGE PROBLEM


ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE

BrandPA; Age Limit (Min 4 Years and Max 11 Years)

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250-50 MCG/DOSE, 500-50 MCG/DOSE

Brand PA

ADVAIR HFA INHALATION AEROSOL Brand PA

albuterol sulfate er oral tablet extended release 12 hour

Generic

albuterol sulfate inhalation nebulization solution Generic

albuterol sulfate oral syrup Generic

albuterol sulfate oral tablet Generic

ALVESCO INHALATION AEROSOL SOLUTION Brand

ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand PA

ARCAPTA NEOHALER INHALATION CAPSULE Brand QL (1 EA per 30 days)

ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand


8

Drug Status NotesASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand


Brand


Brand


Brand

ASMANEX HFA INHALATION AEROSOL Brand

ATROVENT HFA INHALATION AEROSOL SOLUTION Brand

azelastine hcl nasal solution 0.1 % Brand

BECONASE AQ NASAL SUSPENSION Brand PA

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED Brand PA; QL (1 EA per 30 days)

budesonide inhalation suspension Generic

CAYSTON INHALATION SOLUTION RECONSTITUTED Brand

CINQAIR INTRAVENOUS SOLUTION Medical Benefit PA

CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION Brand

cromolyn sodium inhalation nebulization solution Generic

DALIRESP ORAL TABLET Brand PA; STPA

DULERA INHALATION AEROSOL Brand PA

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML Brand PA; SP; QL (2 ML per 28 days)

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML Brand PA; QL (4 ML per 28 days)

epoprostenol sodium intravenous solution reconstituted 0.5 mg

Medical Benefit PA; QL (4 EA per 30 days)




9

Drug Status NotesESBRIET ORAL CAPSULE Brand SP; QL (270 EA per 30 days)

ESBRIET ORAL TABLET Brand SP; QL (270 EA per 30 days)

FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Medical Benefit PA

FLOLAN INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand

FLOVENT HFA INHALATION AEROSOL Brand

fluticasone propionate nasal suspension Generic

fluticasone-salmeterol inhalation aerosol powder breath activated

Generic

FORADIL AEROLIZER INHALATION CAPSULE Brand

INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand

ipratropium bromide inhalation solution Generic

ipratropium bromide nasal solution Generic

ipratropium-albuterol inhalation solution Generic

KALYDECO ORAL PACKET Brand PA; SP; QL (60 EA per 30 days)

KALYDECO ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)

LETAIRIS ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)

levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml

Generic

levalbuterol tartrate inhalation aerosol Generic PA

metaproterenol sulfate oral syrup Generic

metaproterenol sulfate oral tablet Generic

montelukast sodium oral packet Generic

montelukast sodium oral tablet Generic

montelukast sodium oral tablet chewable Generic

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA

OFEV ORAL CAPSULE Brand QL (60 EA per 30 days)

OMNARIS NASAL SUSPENSION Brand PA


10

Drug Status NotesOPSUMIT ORAL TABLET Brand PA; SP

ORALAIR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG Brand PA; SP

ORENITRAM ORAL TABLET EXTENDED RELEASE 5 MG Brand PA

ORKAMBI ORAL PACKET Brand PA; QL (56 EA per 28 days)

ORKAMBI ORAL TABLET Brand PA; QL (120 EA per 30 days)

PERFOROMIST INHALATION NEBULIZATION SOLUTION Brand

PROAIR HFA INHALATION AEROSOL SOLUTION Brand PA

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand PA

PROVENTIL HFA INHALATION AEROSOL SOLUTION Brand PA

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand

PULMOZYME INHALATION SOLUTION Brand SP

QVAR INHALATION AEROSOL SOLUTION Brand

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED Brand QL (10.6 GM per 30 days)

REMODULIN INJECTION SOLUTION Medical Benefit PA; SP

REVATIO ORAL SUSPENSION RECONSTITUTED Brand PA; SP

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand

sildenafil citrate oral tablet 20 mg Generic PA; QL (90 EA per 30 days)

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

Brand

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION Brand


11

Drug Status NotesSYMBICORT INHALATION AEROSOL160-4.5 MCG/ACT Brand PA

SYMBICORT INHALATION AEROSOL 80-4.5 MCG/ACT Brand

PA; ¥ (PA applies to members 0-5 years of age and members 12 years of age and older (no PA required for members 6 through 11 years of age))

SYMDEKO ORAL TABLET THERAPY PACK Brand PA; QL (56 EA per 28 days)

tadalafil (pah) oral tablet Generic PA; SP; QL (60 EA per 30 days)

terbutaline sulfate oral tablet Generic

theophylline er oral tablet extended release 12 hour

Generic


Generic

theophylline oral solution Generic

TOBI PODHALER INHALATION CAPSULE Brand PA; SP; QL (1 EA per 60 days)

tobramycin inhalation nebulization solution Generic

TRACLEER ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)

TRACLEER ORAL TABLET SOLUBLE Brand PA; SP; QL (120 EA per 30 days)

Tyvaso Inhalation Solution MB/RX PA; SP

Tyvaso Refill Inhalation Solution MB/RX PA; SP

Tyvaso Starter Inhalation Solution MB/RX PA; SP

UPTRAVI ORAL TABLET Brand PA; SP

UPTRAVI ORAL TABLET THERAPY PACK Brand PA; SP

VELETRI INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

Ventavis Inhalation Solution MB/RX PA; SP; QL (9 Vials per 1 day)

VENTOLIN HFA INHALATION AEROSOL SOLUTION Brand

XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP; QL (6 vials per 28 days)

zafirlukast oral tablet Brand

ZETONNA NASAL AEROSOL SOLUTION Brand PA

COLD SYMPTOMS



12

Drug Status NotesBECONASE AQ NASAL SUSPENSION Brand PA

benzonatate oral capsule 100 mg, 200 mg Generic

budesonide nasal suspension Generic PA

cetirizine hcl oral solution 1 mg/ml Generic PA

cetirizine hcl oral syrup 1 mg/ml Generic PA

CLARINEX ORAL SYRUP Brand PA


clemastine fumarate oral tablet 2.68 mg Generic

cyproheptadine hcl oral syrup Generic

cyproheptadine hcl oral tablet Generic

desloratadine oral tablet Generic PA

flunisolide nasal solution 25 mcg/act (0.025%) Generic


guaifenesin er oral tablet extended release 12 hour 600 mg

Generic

hydrocod polst-cpm polst er oral suspension extended release

Generic

hydrocodone-homatropine oral syrup Generic

hydrocodone-homatropine oral tablet Generic

hydromet oral syrup Generic


levocetirizine dihydrochloride oral solution Generic PA

levocetirizine dihydrochloride oral tablet Generic PA

mometasone furoate nasal suspension Generic PA




ODACTRA SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)



phenyleph-promethazine-cod oral syrup Generic

promethazine vc plain oral syrup Generic


13

Drug Status Notespromethazine vc/codeine oral syrup Generic

promethazine-codeine oral syrup Generic

promethazine-dm oral syrup Generic

promethazine-phenylephrine oral syrup Generic

pseudoephedrine hcl oral tablet 60 mg Generic

QNASL CHILDRENS NASAL AEROSOL SOLUTION Brand PA

QNASL NASAL AEROSOL SOLUTION Brand PA

SEMPREX-D ORAL CAPSULE Brand PA

triamcinolone acetonide nasal aerosol Generic

TUSSIGON ORAL TABLET Generic

VERAMYST NASAL SUSPENSION Brand PA


COLLAGEN VASCULAR DISEASE

ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML Medical Benefit PA; SP; QL (4 vials per 28 days)



ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand

PA; SP; QL (4 syringes per 28 days)

azathioprine oral tablet Generic

BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA

BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA

celecoxib oral capsule Generic STPA; QL (60 EA per 30 days)

cevimeline hcl oral capsule Generic

CIMZIA PREFILLED SUBCUTANEOUS KIT Brand PA; SP; QL (2 EA per 28 days)

CIMZIA STARTER KIT SUBCUTANEOUS KIT Brand

PA; SP; ¥ (For first 4 weeks of treatment); QL (6 Syringes per 28 days)

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG Brand PA; SP; QL (2 EA per 28 days)


14

Drug Status NotesCOSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand


COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR

BrandPA; SP; QL (2 Syringes per 28 days)

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

BrandPA; SP; QL (1 Syringe per 28 days)

COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand

PA; SP; QL (1 Syringe per 28 days)

diclofenac sodium er oral tablet extended release 24 hour

Generic

EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE Brand PA; SP; QL (4 each per 28 days)

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML Brand


ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML Brand


ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED Brand


ENBREL SURECLICK SUBCUTANEOUS SOLUTION Brand


ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand


etodolac er oral tablet extended release 24 hour Generic

flurbiprofen oral tablet Generic

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

Brand PA; SP; ¥ (1 Fill per life of plan)

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; QL (2 EA per 28 days)

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; ¥ (1 Fill per life of plan)


15

Drug Status NotesHUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT Brand PA; SP; QL (2 EA per 28 days)

hydroxychloroquine sulfate oral tablet Generic

INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

ketoprofen er oral capsule extended release 24 hour

Generic

KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (2.28 ML per 30 days)

KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (2.28 ML per 30 days)

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; QL (28 Syringes per 28 days)

leflunomide oral tablet Generic

meloxicam oral suspension Generic

meloxicam oral tablet Generic

methotrexate oral tablet Generic

MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; QL (30 Vials per 30 days)

nabumetone oral tablet Generic

OLUMIANT ORAL TABLET Brand PA

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (4 ML per 28 days)

ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit

PA; SP; QL (4 VIALS per 28 days)

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML Brand PA; SP; QL (4 ML per 28 days)

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.4ML, 87.5 MG/0.7ML

Brand PA; QL (1.6 ML per 28 days)

oxaprozin oral tablet Generic

PANRETIN EXTERNAL GEL Brand PA

pilocarpine hcl oral tablet Generic

piroxicam oral capsule Generic

REMICADE INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA


16

Drug Status NotesRENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

RITUXAN INTRAVENOUS SOLUTION Medical Benefit PA; SP

salsalate oral tablet Generic

SIMPONI ARIA INTRAVENOUS SOLUTION Medical Benefit PA; SP; QL (5 vials per 8 Weeks)

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand

PA; SP; QL (1 syringe per 28 days)

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand


sulfasalazine oral tablet delayed release Generic

tolmetin sodium oral capsule Generic

tolmetin sodium oral tablet Generic

TREXALL ORAL TABLET Brand

XELJANZ ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP; QL (30 EA per 30 days)

CONDITION RESULTING FROM A DEFECTIVE IMMUNE SYSTEM

abacavir sulfate oral solution Generic

abacavir sulfate oral tablet Generic

abacavir sulfate-lamivudine oral tablet Brand

abacavir-lamivudine-zidovudine oral tablet Brand








MB/RX PA; SP

ANADROL-50 ORAL TABLET Brand PA

APTIVUS ORAL CAPSULE Brand


17

Drug Status NotesAPTIVUS ORAL SOLUTION Brand

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (4 Vials per 28 days)

atazanavir sulfate oral capsule Generic

ATRIPLA ORAL TABLET Brand





Berinert Intravenous Kit MB/RX SP

BIKTARVY ORAL TABLET Brand

BIVIGAM INTRAVENOUS SOLUTION 10 GM/100ML Medical Benefit PA





CIMDUO ORAL TABLET Brand





COMPLERA ORAL TABLET Brand

cortisone acetate oral tablet Generic

COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand







18

Drug Status NotesCOSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand


CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Brand

cromolyn sodium oral concentrate Generic

Cuvitru Subcutaneous Solution MB/RX PA

cyclosporine modified oral capsule Generic

cyclosporine modified oral solution Generic

cyclosporine oral capsule Generic

DESCOVY ORAL TABLET Brand


Generic

didanosine oral capsule delayed release Generic

dronabinol oral capsule Generic

EDURANT ORAL TABLET Brand

efavirenz oral capsule Generic

efavirenz oral tablet Generic


EMTRIVA ORAL CAPSULE Brand

EMTRIVA ORAL SOLUTION Brand













EVOTAZ ORAL TABLET Brand

FIRAZYR SUBCUTANEOUS SOLUTION Brand PA; SP; QL (3 ML per 1 Fill)


19

Drug Status NotesFLEBOGAMMA DIF INTRAVENOUS SOLUTION Medical Benefit PA


fosamprenavir calcium oral tablet Generic


FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED Brand SP

Gammagard Injection Solution 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 30 GM/300ML, 5 GM/50ML

MB/RX PA

Gammagard Injection Solution 20 GM/200ML MB/RX PA; SP




Medical Benefit PA



GENGRAF ORAL CAPSULE Generic

GENGRAF ORAL SOLUTION Generic

GENVOYA ORAL TABLET Brand



guanidine hcl oral tablet Brand PA

Hizentra Subcutaneous Solution 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

MB/RX PA; SP


MB/RX PA; SP

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML


HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML



20

Drug Status NotesHUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT Brand PA; SP; QL (2 EA per 28 days)



HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT Brand PA; SP; QL (2 EA per 28 days)

hydrocortisone oral tablet Generic


Hyqvia Subcutaneous Kit MB/RX PA; SP

ILARIS SUBCUTANEOUS SOLUTION Medical Benefit PA; SP


INTELENCE ORAL TABLET Brand

INVIRASE ORAL CAPSULE Brand

INVIRASE ORAL TABLET Brand

ISENTRESS HD ORAL TABLET Brand QL (60 EA per 30 days)

ISENTRESS ORAL PACKET Brand QL (60 EA per 30 days)

ISENTRESS ORAL TABLET Brand

ISENTRESS ORAL TABLET CHEWABLE Brand

JULUCA ORAL TABLET Brand

KALETRA ORAL SOLUTION Brand

KALETRA ORAL TABLET Brand


Generic




lamivudine oral solution Brand

lamivudine oral tablet 150 mg, 300 mg Brand

lamivudine-zidovudine oral tablet Brand



21

Drug Status NotesLEXIVA ORAL SUSPENSION Brand


Generic




methylprednisolone oral tablet Generic

methylprednisolone oral tablet therapy pack Generic

methylprednisolone sodium succ injection solution reconstituted 125 mg, 40 mg

Generic


mycophenolate mofetil oral capsule Generic

mycophenolate mofetil oral suspension reconstituted

Generic

mycophenolate mofetil oral tablet Generic

mycophenolic acid oral tablet delayed release Generic








nevirapine er oral tablet extended release 24 hour Generic

nevirapine oral suspension Generic

nevirapine oral tablet Generic


NORVIR ORAL CAPSULE Brand

NORVIR ORAL PACKET Brand

NORVIR ORAL SOLUTION Brand

NOXAFIL ORAL SUSPENSION Brand PA


22

Drug Status NotesNOXAFIL ORAL TABLET DELAYED RELEASE Brand PA


OCTAGAM INTRAVENOUS SOLUTION Medical Benefit PA; SP

ODEFSEY ORAL TABLET Brand












prednisolone oral solution Generic

prednisolone oral syrup 15 mg/5ml Generic

prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

Generic

prednisolone sodium phosphate oral tablet dispersible

Generic

PREVYMIS INTRAVENOUS SOLUTION Medical Benefit PA

PREVYMIS ORAL TABLET Brand PA

PREZCOBIX ORAL TABLET Brand

PREZISTA ORAL SUSPENSION Brand

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG Brand



pyridostigmine bromide er oral tablet extended release

Generic

pyridostigmine bromide oral tablet Generic


23

Drug Status NotesRAPAMUNE ORAL SOLUTION Brand


RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

RESCRIPTOR ORAL TABLET Brand

REYATAZ ORAL PACKET Brand

ritonavir oral tablet Generic


Ruconest Intravenous Solution Reconstituted MB/RX SP


SELZENTRY ORAL SOLUTION Brand QL (1800 ML per 30 days)

SELZENTRY ORAL TABLET Brand







sirolimus oral tablet Generic


stavudine oral capsule Brand

stavudine oral solution reconstituted Brand

STRIBILD ORAL TABLET Brand


SYMFI LO ORAL TABLET Brand

SYMFI ORAL TABLET Brand

SYMTUZA ORAL TABLET Brand

SYNDROS ORAL SOLUTION Brand PA

tacrolimus oral capsule Generic


tenofovir disoproxil fumarate oral tablet Generic

TIVICAY ORAL TABLET Brand


24

Drug Status Notestolmetin sodium oral capsule Generic



TRIUMEQ ORAL TABLET Brand

TRUVADA ORAL TABLET 200-300 MG Brand

TYBOST ORAL TABLET Brand

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM Brand

VIRACEPT ORAL TABLET Brand

VIREAD ORAL POWDER Brand

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG Brand



MB/RX PA; SP




zidovudine oral capsule Brand

zidovudine oral syrup Brand

zidovudine oral tablet Brand


ZORTRESS ORAL TABLET Brand SP

DISEASE AFFECTING THE BODY'S METABOLISM

acarbose oral tablet Generic

acetazolamide oral tablet Generic

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA

ADLYXIN STARTER PACK SUBCUTANEOUS PEN-INJECTOR KIT Brand PA

ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA


25

Drug Status Notesalendronate sodium oral tablet 40 mg Generic QL (1 EA per 6 Months)

ALLI ORAL CAPSULE Brand PA

allopurinol oral tablet Generic

alogliptin benzoate oral tablet Generic PA; QL (30 EA per 30 days)

alogliptin-metformin hcl oral tablet Generic PA; QL (60 EA per 30 days)

alogliptin-pioglitazone oral tablet Generic PA; QL (30 EA per 30 days)

amiloride hcl oral tablet Generic

amlodipine-atorvastatin oral tablet Generic PA; QL (30 EA per 30 days)

ANTARA ORAL CAPSULE 30 MG, 90 MG Brand PA; QL (30 EA per 30 days)


atorvastatin calcium oral tablet Generic


AVANDAMET ORAL TABLET 2-1000 MG Brand PA

AVANDIA ORAL TABLET Brand PA

BELVIQ ORAL TABLET Brand PA

BELVIQ XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA

benzphetamine hcl oral tablet Generic PA


BRINEURA SOLUTION Medical Benefit PA

bumetanide oral tablet Generic

BYDUREON SUBCUTANEOUS PEN-INJECTOR Brand PA

BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER Brand PA

BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION Brand PA

BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA



calcitriol oral capsule Generic

calcitriol oral solution Generic


26

Drug Status Notescalcium acetate (phos binder) oral capsule Generic


captopril oral tablet Generic

CARBAGLU ORAL TABLET Brand PA


CERDELGA ORAL CAPSULE Brand PA; SP

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT Medical Benefit PA; SP



chlorothiazide oral tablet Generic

chlorpropamide oral tablet Generic

chlorthalidone oral tablet 25 mg, 50 mg Generic

CHOLBAM ORAL CAPSULE Brand PA

cholestyramine light oral packet Generic

cholestyramine light oral powder Generic

cholestyramine oral packet Generic

cholestyramine oral powder Generic

Cinryze Intravenous Solution Reconstituted MB/RX PA

colchicine oral tablet Generic

colchicine-probenecid oral tablet Generic

colesevelam hcl oral tablet Generic PA

colestipol hcl oral packet Generic

colestipol hcl oral tablet Generic

constulose oral solution Generic

CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA


CYSTAGON ORAL CAPSULE Brand PA; SP

danazol oral capsule Generic

desmopressin ace rhinal tube nasal solution Generic

desmopressin ace spray refrig nasal solution Generic

desmopressin acetate oral tablet Generic

desmopressin acetate spray nasal solution Generic


27

Drug Status Notesdiethylpropion hcl er oral tablet extended release 24 hour

Generic PA

diethylpropion hcl oral tablet Generic PA


DUZALLO ORAL TABLET Brand PA


ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

enulose oral solution Generic

ethacrynic acid oral tablet Generic PA

etidronate disodium oral tablet Generic

ezetimibe oral tablet Generic PA; QL (30 EA per 30 days)

ezetimibe-simvastatin oral tablet Generic PA; QL (30 EA per 30 days)

FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA

FARXIGA ORAL TABLET Brand PA; QL (30 EA per 30 days)

fenofibrate micronized oral capsule 130 mg, 43 mg


fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

Generic QL (30 EA per 30 days)

fenofibrate oral capsule 150 mg, 50 mg Generic PA; QL (30 EA per 30 days)

fenofibrate oral tablet 120 mg, 145 mg, 40 mg, 48 mg


fenofibrate oral tablet 160 mg, 54 mg Generic QL (30 EA per 30 days)

fenofibric acid oral capsule delayed release Generic PA; QL (30 EA per 30 days)

fenofibric acid oral tablet Generic PA; QL (30 EA per 30 days)


flolipid oral suspension Brand PA

fluvastatin sodium er oral tablet extended release 24 hour


fluvastatin sodium oral capsule Generic PA; QL (30 EA per 30 days)

furosemide injection solution 10 mg/ml Generic

furosemide oral solution 10 mg/ml, 8 mg/ml Generic

furosemide oral tablet Generic

gemfibrozil oral tablet Generic


28

Drug Status Notesgenerlac oral solution Generic

glimepiride oral tablet Generic

glipizide er oral tablet extended release 24 hour Generic

glipizide oral tablet Generic

glipizide xl oral tablet extended release 24 hour Generic

glipizide-metformin hcl oral tablet Generic

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED Brand

GLUCAGON EMERGENCY INJECTION KIT Brand

glyburide micronized oral tablet Generic

glyburide oral tablet Generic

glyburide-metformin oral tablet Generic

HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION Brand

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

Brand


indapamide oral tablet Generic

indomethacin er oral capsule extended release Generic

indomethacin oral capsule Generic

INVOKAMET ORAL TABLET BrandPA; STPA; QL (60 EA per 30 days)

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand

PA; STPA; QL (60 Tablets per 30 days)

INVOKANA ORAL TABLET 100 MG Brand STPA; QL (60 EA per 30 days)


JUXTAPID ORAL CAPSULE Brand PA; QL (30 EA per 30 days)



KANUMA INTRAVENOUS SOLUTION Medical Benefit PA

KEVEYIS ORAL TABLET Brand PA

KIONEX ORAL POWDER Generic


29

Drug Status NotesKIONEX ORAL SUSPENSION Generic

KORLYM ORAL TABLET Brand PA

KRYSTEXXA INTRAVENOUS SOLUTION Medical Benefit PA; SP

KUVAN ORAL PACKET Brand PA; SP

KUVAN ORAL TABLET SOLUBLE Brand PA; SP

KYNAMRO SUBCUTANEOUS SOLUTION Brand PA; SP; QL (4 EA per 28 days)

KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; SP; QL (4 EA per 28 days)

lactulose encephalopathy oral solution Generic

lactulose oral solution Generic



LIVALO ORAL TABLET Brand PA; QL (30 EA per 30 days)

lovastatin oral tablet Generic

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)

LYRICA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)

LYRICA ORAL SOLUTION Brand PA; QL (900 ML per 30 days)


Generic

metformin hcl er (mod) oral tablet extended release 24 hour

Generic PA

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg

Generic PA

metformin hcl er oral tablet extended release 24 hour

Generic

metformin hcl oral tablet Generic

methamphetamine hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (150 EA per 30 days)

methyclothiazide oral tablet Generic

metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml

Generic

metoclopramide hcl oral tablet Generic

metolazone oral tablet Generic

micronized colestipol hcl oral tablet Generic


30

Drug Status Notesmiglitol oral tablet Generic


nateglinide oral tablet Generic

NATPARA SUBCUTANEOUS CARTRIDGE BrandPA; SP; QL (2 Cartridges per 21 days)

niacin er (antihyperlipidemic) oral tablet extended release

Generic

niacin er oral capsule extended release Generic

NIACOR ORAL TABLET Generic

NITYR ORAL TABLET Brand PA


NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml

Generic PA; SP; QL (30 ML per 30 days)

octreotide acetate injection solution 500 mcg/ml Brand PA; SP; QL (30 ML per 30 days)

ORFADIN ORAL CAPSULE Brand PA

ORFADIN ORAL SUSPENSION Brand PA



oxandrolone oral tablet 10 mg Generic PA; QL (60 EA per 30 days)

oxandrolone oral tablet 2.5 mg Generic PA; QL (240 EA per 30 days)

PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML

Brand PA

PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML Brand PA; QL (1 Unit per 1 day)

phendimetrazine tartrate er oral capsule extended release 24 hour

Generic PA

phendimetrazine tartrate oral tablet Generic PA

phentermine hcl oral capsule Generic PA

phentermine hcl oral tablet Generic PA

PHOSPHA 250 NEUTRAL ORAL TABLET Generic

pioglitazone hcl oral tablet Generic


31

Drug Status Notespioglitazone hcl-glimepiride oral tablet Generic

pioglitazone hcl-metformin hcl oral tablet Generic

pot bicarb-pot chloride oral tablet effervescent Generic

potassium bicarbonate oral tablet effervescent Generic

potassium chloride crys er oral tablet extended release

Generic

potassium chloride er oral capsule extended release

Generic

potassium chloride er oral tablet extended release Generic

potassium chloride oral packet Generic

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

Generic

PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA; SP; QL (2 ML per 28 days)

pravastatin sodium oral tablet Generic

probenecid oral tablet Generic


QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA

RAVICTI ORAL LIQUID Brand PA; SP

repaglinide oral tablet Generic

repaglinide-metformin hcl oral tablet Generic

REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE Brand

PA; SP; # (Preferred product); QL (1 ML per 28 days)

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand


REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand


risedronate sodium oral tablet 30 mg Generic PA; QL (30 EA per 30 days)

rosuvastatin calcium oral tablet Generic PA; QL (30 EA per 30 days)


SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA



32

Drug Status NotesSIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 30 MG

Medical Benefit PA

simvastatin oral tablet Generic

sodium polystyrene sulfonate oral powder Generic

sodium polystyrene sulfonate oral suspension Generic

sodium polystyrene sulfonate rectal suspension Generic


SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED Brand PA; SP; QL (30 EA per 30 days)

spironolactone oral tablet Generic

spironolactone-hctz oral tablet Generic

SPS ORAL SUSPENSION Generic

STRENSIQ SUBCUTANEOUS SOLUTION Brand PA; QL (24 Vials per 28 days)

SUPRENZA ORAL TABLET DISPERSIBLE Brand PA


SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA



TANZEUM SUBCUTANEOUS PEN-INJECTOR Brand PA



tolazamide oral tablet Generic

tolbutamide oral tablet Generic

torsemide oral tablet Generic

triamterene-hctz oral capsule Generic

triamterene-hctz oral tablet Generic

trientine hcl oral capsule Generic PA

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA

VELTASSA ORAL PACKET Brand PA


33

Drug Status NotesVICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA

VPRIV INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP

XENICAL ORAL CAPSULE Brand PA

XGEVA SUBCUTANEOUS SOLUTION Medical Benefit PA; SP; QL (1 vial per 30 days)

XIFAXAN ORAL TABLET 200 MG Brand PA; QL (9 EA per 30 days)


XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA


XURIDEN ORAL PACKET Brand PA; QL (120 Packets per 30 days)


ZURAMPIC ORAL TABLET Brand PA

ZYPITAMAG ORAL TABLET Brand PA

DISEASE OF THE HEART AND BLOOD VESSELS

acebutolol hcl oral capsule Generic


almotriptan malate oral tablet Generic PA; QL (9 EA per 30 days)


MB/RX PA; SP

amiloride hcl oral tablet Generic

amiloride-hydrochlorothiazide oral tablet Generic

aminocaproic acid oral tablet Generic

amiodarone hcl oral tablet Generic

amlodipine besy-benazepril hcl oral capsule Generic QL (30 EA per 30 days)

amlodipine besylate oral tablet Generic

amlodipine besylate-valsartan oral tablet Generic PA; QL (30 EA per 30 days)


amlodipine-olmesartan oral tablet Generic PA

amlodipine-valsartan-hctz oral tablet Generic PA; QL (30 EA per 30 days)



34

Drug Status Notesaspirin-dipyridamole er oral capsule extended release 12 hour


atenolol oral tablet Generic

atenolol-chlorthalidone oral tablet Generic

benazepril hcl oral tablet Generic

benazepril-hydrochlorothiazide oral tablet Generic

betaxolol hcl oral tablet Generic


BIDIL ORAL TABLET Brand PA

bisoprolol fumarate oral tablet Generic

bisoprolol-hydrochlorothiazide oral tablet Generic

BOTOX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA; SP


bumetanide oral tablet Generic

BYSTOLIC ORAL TABLET BrandPA; STPA; QL (30 EA per 30 days)

candesartan cilexetil oral tablet Generic PA


captopril-hydrochlorothiazide oral tablet Generic

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG Brand PA



carvedilol oral tablet Generic

carvedilol phosphate er oral capsule extended release 24 hour

GenericPA; STPA; QL (30 EA per 30 days)

cilostazol oral tablet Generic

clonidine hcl oral tablet Generic

clonidine hcl transdermal patch weekly Generic

clopidogrel bisulfate oral tablet Generic

CLORPRES ORAL TABLET Generic

CORLANOR ORAL TABLET Brand PA

DEMSER ORAL CAPSULE Brand

DIGITEK ORAL TABLET Generic


35

Drug Status NotesDIGOX ORAL TABLET Generic

digoxin oral solution Generic

digoxin oral tablet Generic

dihydroergotamine mesylate nasal solution Generic

diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

Generic

diltiazem hcl er beads oral capsule extended release 24 hour

Generic

diltiazem hcl er coated beads oral capsule extended release 24 hour

Generic

diltiazem hcl er coated beads oral tablet extended release 24 hour

Generic PA

diltiazem hcl er oral capsule extended release 12 hour

Generic

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

Generic

diltiazem hcl oral tablet Generic

disopyramide phosphate oral capsule Generic

divalproex sodium er oral tablet extended release 24 hour

Generic

divalproex sodium oral capsule delayed release sprinkle

Generic

divalproex sodium oral tablet delayed release Generic

dofetilide oral capsule Generic

doxazosin mesylate oral tablet Generic

EDARBI ORAL TABLET Brand PA

eletriptan hydrobromide oral tablet Generic PA; QL (9 EA per 30 days)


enalapril maleate oral tablet Generic

enalapril-hydrochlorothiazide oral tablet Generic



ENTRESTO ORAL TABLET Brand PA

epinephrine hcl injection solution 1 mg/ml Generic

eplerenone oral tablet Generic PA; QL (60 EA per 30 days)


36

Drug Status Notesepoprostenol sodium intravenous solution reconstituted 0.5 mg




eprosartan mesylate oral tablet Generic PA


Feiba Intravenous Solution Reconstituted MB/RX PA; SP

felodipine er oral tablet extended release 24 hour Generic

flecainide acetate oral tablet Generic



fosinopril sodium oral tablet Generic

fosinopril sodium-hctz oral tablet Generic

frovatriptan succinate oral tablet Generic PA; QL (9 EA per 30 days)

furosemide oral solution 10 mg/ml, 8 mg/ml Generic

furosemide oral tablet Generic




Medical Benefit PA



guanfacine hcl oral tablet Generic

HEMLIBRA SUBCUTANEOUS SOLUTION Brand PA

HEMMOREX-HC RECTAL SUPPOSITORY Generic

heparin (porcine) in nacl intravenous solution5000-0.9 ut/500ml-%

Brand

heparin sodium (porcine) injection solution10000 unit/ml, 20000 unit/ml, 5000 unit/ml

Generic


MB/RX PA; SP

hydralazine hcl oral tablet Generic


37

Drug Status Noteshydrochlorothiazide oral capsule Generic

hydrochlorothiazide oral tablet Generic

hydrocortisone ace-pramoxine external cream2.5-1 %

Generic

hydrocortisone ace-pramoxine rectal cream Generic

hydrocortisone acetate rectal suppository Generic

HYDROXYprogesterone Caproate Intramuscular Oil

MB/RX¥ (Single Dose Vial Preferred); QL (1 ML per 7 days)

indapamide oral tablet Generic


irbesartan oral tablet Generic STPA

irbesartan-hydrochlorothiazide oral tablet Generic STPA

isosorbide dinitrate er oral tablet extended release

Generic

isosorbide dinitrate oral tablet Generic

isosorbide mononitrate er oral tablet extended release 24 hour

Generic

isosorbide mononitrate oral tablet Generic

isradipine oral capsule Generic PA


labetalol hcl oral tablet Generic


lisinopril oral tablet Generic

lisinopril-hydrochlorothiazide oral tablet Generic

losartan potassium oral tablet Generic

losartan potassium-hctz oral tablet Generic



MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR Generic PA

meclizine hcl oral tablet Generic

medroxyprogesterone acetate oral tablet Generic

MESNEX ORAL TABLET Brand


38

Drug Status Notesmethyldopa oral tablet Generic

methyldopa-hydrochlorothiazide oral tablet Generic

methylergonovine maleate oral tablet Generic

metoprolol succinate er oral tablet extended release 24 hour

Generic

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

Generic

metoprolol tartrate oral tablet 37.5 mg, 75 mg Brand PA

metoprolol-hydrochlorothiazide oral tablet Generic

mexiletine hcl oral capsule Generic

midodrine hcl oral tablet Generic

MIGERGOT RECTAL SUPPOSITORY Generic

minoxidil oral tablet Generic

moexipril hcl oral tablet Generic

moexipril-hydrochlorothiazide oral tablet Generic

nadolol oral tablet 20 mg, 40 mg, 80 mg Generic

nadolol-bendroflumethiazide oral tablet Generic

naratriptan hcl oral tablet Generic STPA; QL (9 EA per 30 days)

NATAZIA ORAL TABLET Generic

nicardipine hcl oral capsule Generic

nifedipine er oral tablet extended release 24 hour Generic

nifedipine er osmotic release oral tablet extended release 24 hour

Generic

nifedipine oral capsule Generic

nimodipine oral capsule Generic PA

nisoldipine er oral tablet extended release 24 hour

Generic

nitroglycerin sublingual tablet sublingual Generic

nitroglycerin transdermal patch 24 hour Generic

nitroglycerin translingual aerosol solution Generic

nitroglycerin translingual solution Generic

norethindrone acetate oral tablet Generic

NORTHERA ORAL CAPSULE Brand PA

NovoSeven RT Intravenous Solution Reconstituted

MB/RX PA; SP


39

Drug Status NotesNUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED Medical Benefit PA


OCTAGAM INTRAVENOUS SOLUTION 10 GM/100ML, 2 GM/20ML, 20 GM/200ML, 5 GM/50ML


olmesartan medoxomil oral tablet Generic STPA

olmesartan medoxomil-hctz oral tablet Generic STPA

omeprazole-sodium bicarbonate oral packet Generic PA

OPSUMIT ORAL TABLET Brand PA; SP



pentoxifylline er oral tablet extended release Generic

perindopril erbumine oral tablet Generic

phenoxybenzamine hcl oral capsule Generic

pindolol oral tablet Generic


PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA; SP; QL (2 ML per 28 days)

pramcort rectal cream Generic


prazosin hcl oral capsule Generic


progesterone intramuscular oil Generic PA


propafenone hcl er oral capsule extended release 12 hour

Generic

propafenone hcl oral tablet Generic

propranolol hcl er oral capsule extended release 24 hour

Generic

propranolol hcl oral solution 40 mg/5ml Generic

propranolol hcl oral tablet Generic

propranolol-hctz oral tablet Generic

quinapril hcl oral tablet Generic


40

Drug Status Notesquinapril-hydrochlorothiazide oral tablet Generic

quinidine gluconate er oral tablet extended release

Generic

quinidine sulfate er oral tablet extended release Generic

quinidine sulfate oral tablet Generic

ramipril oral capsule Generic

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA; QL (60 EA per 30 days)

ranitidine hcl oral capsule Generic

ranitidine hcl oral syrup Generic

ranitidine hcl oral tablet 150 mg, 300 mg Generic


REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE Brand


REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand


REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand


reserpine oral tablet Generic


rizatriptan benzoate oral tablet Generic STPA; QL (9 EA per 30 days)

rizatriptan benzoate oral tablet dispersible Generic STPA; QL (9 EA per 30 days)




sotalol hcl (af) oral tablet 120 mg, 80 mg Generic

sotalol hcl oral tablet Generic


spironolactone-hctz oral tablet Generic

sumatriptan nasal solution Generic QL (6 Units per 30 days)

sumatriptan succinate oral tablet Generic QL (9 EA per 30 days)

sumatriptan succinate refill subcutaneous solution cartridge



41

Drug Status Notessumatriptan succinate subcutaneous solution 6 mg/0.5ml


sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml


sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml




TEKTURNA HCT ORAL TABLET Brand PA; QL (30 EA per 30 days)

TEKTURNA ORAL TABLET Brand PA; QL (30 EA per 30 days)

telmisartan oral tablet Generic PA

telmisartan-hctz oral tablet Generic PA

terazosin hcl oral capsule Generic

timolol maleate oral tablet Generic

topiramate er oral capsule er 24 hour sprinkle100 mg, 25 mg, 50 mg


topiramate er oral capsule er 24 hour sprinkle150 mg, 200 mg


topiramate oral capsule sprinkle 15 mg Generic

topiramate oral capsule sprinkle 25 mg Generic QL (180 EA per 30 days)

topiramate oral tablet 100 mg, 50 mg Generic QL (90 EA per 30 days)

topiramate oral tablet 200 mg Generic

topiramate oral tablet 25 mg Generic QL (180 EA per 30 days)

torsemide oral tablet Generic



trandolapril oral tablet Generic

trandolapril-verapamil hcl er oral tablet extended release

Generic

tranexamic acid oral tablet Generic PA

triamterene-hctz oral capsule Generic

triamterene-hctz oral tablet Generic

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG

Brand PA; QL (30 EA per 30 days)


42

Drug Status NotesTROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG Brand PA; QL (60 EA per 30 days)






valsartan oral tablet Generic STPA

valsartan-hydrochlorothiazide oral tablet Generic STPA



verapamil hcl er oral capsule extended release 24 hour

Generic

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

Generic

verapamil hcl oral tablet Generic


warfarin sodium oral tablet Generic



MB/RX PA; SP





zolmitriptan oral tablet Generic STPA; QL (9 EA per 30 days)

zolmitriptan oral tablet dispersible Generic STPA; QL (9 EA per 30 days)

ZOMIG NASAL SOLUTION BrandPA; STPA; QL (6 Units per 30 days)


DISEASE OF THE URINARY TRACT

AFINITOR ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)


43

Drug Status Notesalfuzosin hcl er oral tablet extended release 24 hour

Generic








bethanechol chloride oral tablet Generic




clindamycin phosphate vaginal cream Generic




darifenacin hydrobromide er oral tablet extended release 24 hour

Generic PA



doxercalciferol oral capsule Generic

dutasteride oral capsule Generic PA; QL (30 EA per 30 days)

dutasteride-tamsulosin hcl oral capsule Generic PA; QL (30 EA per 30 days)

ELIGARD SUBCUTANEOUS KIT Medical Benefit PA; SP

EMCYT ORAL CAPSULE Brand


Brand SP


44

Drug Status NotesEPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML



finasteride oral tablet 5 mg Generic

flavoxate hcl oral tablet Generic

GELNIQUE TRANSDERMAL GEL Brand PA



GLYDO EXTERNAL GEL Generic



imipramine hcl oral tablet Generic

INTRAROSA VAGINAL INSERT Brand PA; QL (28 EA per 28 days)

JYNARQUE ORAL TABLET THERAPY PACK Brand

leuprolide acetate injection kit Medical Benefit PA; SP

lidocaine hcl external gel 2 % Generic



LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT Medical Benefit PA




methenamine hippurate oral tablet Generic

methenamine mandelate oral tablet Generic

metolazone oral tablet Generic

metronidazole vaginal gel Generic

miconazole 3 vaginal suppository Generic



45

Drug Status Notesmycophenolate mofetil oral suspension reconstituted

Generic



MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA



OSPHENA ORAL TABLET Brand PA

oxybutynin chloride er oral tablet extended release 24 hour

Generic

oxybutynin chloride oral syrup Generic

oxybutynin chloride oral tablet Generic

OXYTROL TRANSDERMAL PATCH TWICE WEEKLY Brand PA

paricalcitol oral capsule Generic PA

phenazopyridine hcl oral tablet 100 mg, 200 mg Generic

PREMARIN VAGINAL CREAM Brand

PREMPHASE ORAL TABLET Brand

PREMPRO ORAL TABLET Brand


Brand SP




RAPAFLO ORAL CAPSULE Brand PA

RAPAMUNE ORAL SOLUTION Brand

SENSIPAR ORAL TABLET Brand PA



SOLOSEC ORAL PACKET Brand PA



46

Drug Status Notestamsulosin hcl oral capsule Generic

terazosin hcl oral capsule Generic

terconazole vaginal cream Generic

terconazole vaginal suppository Generic

tinidazole oral tablet Generic

tolterodine tartrate er oral capsule extended release 24 hour

Generic

tolterodine tartrate oral tablet Generic

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA

tranexamic acid oral tablet Generic PA

trospium chloride er oral capsule extended release 24 hour

Generic

trospium chloride oral tablet Generic

VANDAZOLE VAGINAL GEL Generic

VESICARE ORAL TABLET 10 MG Generic PA

VESICARE ORAL TABLET 5 MG Brand PA

ZOLADEX SUBCUTANEOUS IMPLANT10.8 MG Medical Benefit PA; QL (1 EA per 84 days)

ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG Medical Benefit PA; QL (1 EA per 28 days)


DISORDER OF NERVE

AFINITOR DISPERZ ORAL TABLET SOLUBLE Brand PA; SP; QL (60 EA per 30 days)


amantadine hcl oral capsule Generic

amantadine hcl oral syrup Generic

amantadine hcl oral tablet Generic


amphetamine-dextroamphet er oral capsule extended release 24 hour

GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)

amphetamine-dextroamphetamine oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)


47

Drug Status NotesAPTIOM ORAL TABLET Brand PA

armodafinil oral tablet 150 mg, 200 mg, 250 mg Generic PA; QL (30 Tablets per 30 days)

armodafinil oral tablet 50 mg Generic PA; QL (60 Tablets per 30 days)



atomoxetine hcl oral capsule Generic PA; QL (60 EA per 30 days)

atropine sulfate ophthalmic solution Generic

AUBAGIO ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)

AUSTEDO ORAL TABLET Brand PA; QL (60 EA per 30 days)

AVONEX INTRAMUSCULAR KIT Brand SP

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT Brand SP

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT Brand SP

baclofen oral tablet Generic

BELSOMRA ORAL TABLET Brand PA

benztropine mesylate oral tablet Generic

BETASERON SUBCUTANEOUS KIT Brand SP

BETASERON SUBCUTANEOUS SOLUTION RECONSTITUTED Brand SP


BRIVIACT ORAL SOLUTION Brand PA

BRIVIACT ORAL TABLET Brand PA

bromocriptine mesylate oral capsule Generic

bromocriptine mesylate oral tablet Generic

caffeine citrate oral solution Generic

carbamazepine er oral capsule extended release 12 hour

Generic

carbamazepine er oral tablet extended release 12 hour

Generic

carbamazepine oral suspension Generic

carbamazepine oral tablet Generic

carbamazepine oral tablet chewable Generic

carbidopa oral tablet Generic


48

Drug Status Notescarbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

Generic

carbidopa-levodopa oral tablet Generic

carbidopa-levodopa oral tablet dispersible Generic

carbidopa-levodopa-entacapone oral tablet Generic

chlordiazepoxide hcl oral capsule Generic

clonazepam oral tablet Generic

clonidine hcl er oral tablet extended release 12 hour


clorazepate dipotassium oral tablet Generic


dalfampridine er oral tablet extended release 12 hour

Generic PA; SP; QL (60 EA per 30 days)

dantrolene sodium oral capsule Generic

DAYTRANA TRANSDERMAL PATCH Brand PA; QL (30 patches per 30 days)

DEXEDRINE ORAL TABLET BrandPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)

dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg


dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 35 mg


dexmethylphenidate hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (60 EA per 30 days)

dextroamphetamine sulfate er oral capsule extended release 24 hour


dextroamphetamine sulfate oral solution GenericPA; ¥ (PA applies to members 25 and older); QL (1200 mL per 30 days)

dextroamphetamine sulfate oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)

DIAZEPAM INTENSOL ORAL CONCENTRATE Generic

diazepam oral concentrate Generic


49

Drug Status Notesdiazepam oral solution Generic

diazepam oral tablet Generic

diazepam rectal gel Generic QL (1 System per 1 Rx)


DILANTIN ORAL CAPSULE 30 MG BrandPA; ¥ (PA applies to members 6 years and under)

diphenhydramine hcl oral capsule 25 mg Brand

diphenhydramine hcl oral capsule 50 mg Generic

diphenhydramine hcl oral elixir Brand


Generic


Generic


donepezil hcl oral tablet 10 mg, 5 mg Generic

donepezil hcl oral tablet dispersible Generic

DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE Brand PA; QL (240 ML per 30 days)

DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP

EDLUAR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)


EMFLAZA ORAL SUSPENSION Brand PA; QL (26 ML per 30 days)

EMFLAZA ORAL TABLET Brand PA; QL (30 EA per 30 days)

entacapone oral tablet Generic


EPITOL ORAL TABLET Generic

ergoloid mesylates oral tablet Generic

estazolam oral tablet 1 mg Generic

eszopiclone oral tablet Generic PA; QL (30 EA per 30 days)

ethosuximide oral capsule Generic

ethosuximide oral solution Generic

EXONDYS 51 INTRAVENOUS SOLUTION Medical Benefit PA

EXTAVIA SUBCUTANEOUS KIT Brand


50

Drug Status Notesflurazepam hcl oral capsule Generic


FYCOMPA ORAL SUSPENSION Brand PA

FYCOMPA ORAL TABLET Brand PA

gabapentin oral capsule Generic

gabapentin oral solution 250 mg/5ml Generic

gabapentin oral tablet Generic

galantamine hydrobromide er oral capsule extended release 24 hour

Generic

galantamine hydrobromide oral solution Generic

galantamine hydrobromide oral tablet Generic


MB/RX PA


generlac oral solution Generic

GILENYA ORAL CAPSULE 0.5 MG Brand PA

glatiramer acetate subcutaneous solution prefilled syringe

Generic SP

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML Generic

GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA

GRALISE ORAL TABLET Brand PA; QL (90 EA per 30 days)

GRALISE STARTER ORAL Brand PA

guanfacine hcl er oral tablet extended release 24 hour

Generic PA


HETLIOZ ORAL CAPSULE Brand PA; QL (30 EA per 30 days)

HORIZANT ORAL TABLET EXTENDED RELEASE Brand PA; QL (60 EA per 30 days)

hydroxyzine hcl oral syrup Generic

hydroxyzine hcl oral tablet Generic

hydroxyzine pamoate oral capsule Generic

INCRELEX SUBCUTANEOUS SOLUTION Brand PA; SP

INGREZZA ORAL CAPSULE Brand PA


51

Drug Status NotesKEVEYIS ORAL TABLET Brand PA



lamotrigine er oral tablet extended release 24 hour


lamotrigine odt oral tablet dispersible Generic

lamotrigine oral kit 25 & 50 & 100 mg, 25 (21)-50 (7) mg, 50 (42)-100(14) mg

Generic

lamotrigine oral tablet 100 mg, 150 mg Generic QL (90 EA per 30 days)

lamotrigine oral tablet 200 mg Generic

lamotrigine oral tablet 25 mg Generic QL (180 EA per 30 days)

lamotrigine oral tablet chewable Generic QL (180 EA per 30 days)

lamotrigine oral tablet dispersible Generic

lamotrigine starter kit-blue oral kit Generic

lamotrigine starter kit-green oral kit Generic

lamotrigine starter kit-orange oral kit Generic

lamotrigine titration oral kit Generic

LEMTRADA INTRAVENOUS SOLUTION Medical Benefit PA

levetiracetam er oral tablet extended release 24 hour 500 mg




levetiracetam oral solution Generic

levetiracetam oral tablet Generic

lidocaine external patch 5 % Generic





memantine hcl oral solution Generic

memantine hcl oral tablet Generic



52

Drug Status Notes

methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 40 mg, 50 mg, 60 mg


methylphenidate hcl er (cd) oral capsule extended release 30 mg


methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 60 mg




methylphenidate hcl er (la) oral capsule extended release 24 hour 30 mg


methylphenidate hcl er oral tablet extended release 10 mg, 20 mg


methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg


methylphenidate hcl er oral tablet extended release 24 hour


methylphenidate hcl er oral tablet extended release 36 mg


methylphenidate hcl oral solution GenericPA; ¥ (PA applies to members 25 and older); QL (900 mL per 30 days)

methylphenidate hcl oral tablet GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)

methylphenidate hcl oral tablet chewable GenericPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)


modafinil oral tablet Generic PA; QL (30 EA per 30 days)

MYOBLOC INTRAMUSCULAR SOLUTION Medical Benefit PA; SP



53

Drug Status NotesNEUPRO TRANSDERMAL PATCH 24 HOUR Brand PA; QL (30 EA per 30 days)



NUPLAZID ORAL CAPSULE Brand PA; SP; QL (30 EA per 30 days)

NUPLAZID ORAL TABLET BrandPA; SP; QL (60 Tablets per 30 days)

OCREVUS INTRAVENOUS SOLUTION Medical Benefit PA




ONFI ORAL SUSPENSION Brand PA

ONFI ORAL TABLET 10 MG, 20 MG Brand PA; QL (60 EA per 30 days)

oxazepam oral capsule Generic

oxcarbazepine oral suspension Generic

oxcarbazepine oral tablet Generic

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG


OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 MG Brand PA; QL (120 EA per 30 days)

PEGANONE ORAL TABLET Brand PA

PHENYTOIN INFATABS ORAL TABLET CHEWABLE Generic

phenytoin oral suspension 125 mg/5ml Generic

phenytoin oral tablet chewable Generic

phenytoin sodium extended oral capsule Generic

pimozide oral tablet Generic PA

pramipexole dihydrochloride er oral tablet extended release 24 hour

Generic

pramipexole dihydrochloride oral tablet Generic


Generic

propranolol hcl oral solution Generic



54

Drug Status Notespyridostigmine bromide er oral tablet extended release

Generic


QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED Brand PA; QL (360 mL per 30 days)

RADICAVA INTRAVENOUS SOLUTION Medical Benefit PA

rasagiline mesylate oral tablet Generic

REBIF REBIDOSE SUBCUTANEOUS SOLUTION Brand SP

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION Brand SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

Brand SP

REBIF SUBCUTANEOUS SOLUTION Brand SP

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION Brand SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

Brand SP

riluzole oral tablet Generic

rivastigmine tartrate oral capsule Generic

rivastigmine transdermal patch 24 hour Generic



ropinirole hcl er oral tablet extended release 24 hour

Generic

ropinirole hcl oral tablet Generic

ROZEREM ORAL TABLET Brand PA; QL (30 EA per 30 days)

SABRIL ORAL TABLET Brand PA; SP; QL (180 EA per 30 days)

selegiline hcl oral capsule Generic

selegiline hcl oral tablet Generic


55

Drug Status NotesSIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 30 MG

Medical Benefit PA



SPINRAZA INTRATHECAL SOLUTION Medical Benefit PA

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE Brand PA; QL (60 EA per 30 days)





sumatriptan succinate subcutaneous solution 6 mg/0.5ml






TECFIDERA ORAL Brand PA; SP; QL (60 EA per 30 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE Brand PA; SP; QL (60 EA per 30 days)

temazepam oral capsule Generic

tetrabenazine oral tablet 12.5 mg Brand PA; SP; QL (240 EA per 30 days)

tetrabenazine oral tablet 25 mg Brand PA; SP; QL (120 EA per 30 days)

tiagabine hcl oral tablet 2 mg, 4 mg Generic

tolcapone oral tablet Generic PA; QL (180 EA per 30 days)











56

Drug Status Notestrientine hcl oral capsule Generic PA

trihexyphenidyl hcl oral elixir Generic

trihexyphenidyl hcl oral tablet Generic



TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG Brand PA; QL (60 EA per 30 days)

TYSABRI INTRAVENOUS CONCENTRATE Medical Benefit PA; SP; QL (1 vial per 28 days)

valproic acid oral capsule Generic

valproic acid oral solution Generic

valproic acid oral syrup Generic

vigabatrin oral packet Generic PA; QL (180 EA per 30 days)

VIMPAT ORAL SOLUTION Brand PA; QL (1200 ML per 30 days)

VIMPAT ORAL TABLET Brand PA; QL (60 EA per 30 days)

VYVANSE ORAL CAPSULE Brand PA; QL (30 EA per 30 days)

XADAGO ORAL TABLET Brand PA


XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP



XYREM ORAL SOLUTION Brand PA

zaleplon oral capsule Generic QL (30 EA per 30 days)

ZELAPAR ORAL TABLET DISPERSIBLE Brand PA; QL (60 EA per 30 days)

ZENZEDI ORAL TABLET 10 MG, 5 MG BrandPA; ¥ (PA applies to members 25 and older); QL (90 EA per 30 days)

ZINBRYTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand

PA; SP; QL (1 Injection per 30 days)



zolpidem tartrate er oral tablet extended release Generic PA; QL (30 EA per 30 days)

zolpidem tartrate oral tablet Generic QL (30 EA per 30 days)

zolpidem tartrate sublingual tablet sublingual Generic PA; QL (30 EA per 30 days)


57

Drug Status Notes


zonisamide oral capsule Generic


DISORDER OF NERVOUS SYSTEM



amantadine hcl oral capsule Generic







APTIOM ORAL TABLET Brand PA







AUBAGIO ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)


AVONEX INTRAMUSCULAR KIT Brand SP

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT Brand SP

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT Brand SP


BELSOMRA ORAL TABLET Brand PA

benztropine mesylate oral tablet Generic

BETASERON SUBCUTANEOUS KIT Brand SP


58

Drug Status NotesBETASERON SUBCUTANEOUS SOLUTION RECONSTITUTED Brand SP


BRIVIACT ORAL SOLUTION Brand PA

BRIVIACT ORAL TABLET Brand PA





Generic


Generic





carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

Generic

carbidopa-levodopa oral tablet Generic

carbidopa-levodopa oral tablet dispersible Generic

carbidopa-levodopa-entacapone oral tablet Generic













59

Drug Status Notesdexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg











diazepam oral solution Generic


diazepam rectal gel Generic QL (1 System per 1 Rx)


DILANTIN ORAL CAPSULE 30 MG BrandPA; ¥ (PA applies to members 6 years and under)





Generic


Generic






60

Drug Status NotesDYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP

EDLUAR SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (30 EA per 30 days)




entacapone oral tablet Generic




estazolam oral tablet 1 mg Generic

eszopiclone oral tablet Generic PA; QL (30 EA per 30 days)

ethosuximide oral capsule Generic

ethosuximide oral solution Generic


EXTAVIA SUBCUTANEOUS KIT Brand

flurazepam hcl oral capsule Generic








Generic




MB/RX PA



GILENYA ORAL CAPSULE 0.5 MG Brand PA


61

Drug Status Notesglatiramer acetate subcutaneous solution prefilled syringe

Generic SP

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML Generic

GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA




Generic PA


HETLIOZ ORAL CAPSULE Brand PA; QL (30 EA per 30 days)

HORIZANT ORAL TABLET EXTENDED RELEASE Brand PA; QL (60 EA per 30 days)









lamotrigine er oral tablet extended release 24 hour




Generic











62

Drug Status NotesLEMTRADA INTRAVENOUS SOLUTION Medical Benefit PA






























63

Drug Status Notes












NEUPRO TRANSDERMAL PATCH 24 HOUR Brand PA; QL (30 EA per 30 days)





OCREVUS INTRAVENOUS SOLUTION Medical Benefit PA







oxcarbazepine oral suspension Generic

oxcarbazepine oral tablet Generic


64

Drug Status NotesOXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG


OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 MG Brand PA; QL (120 EA per 30 days)


PHENYTOIN INFATABS ORAL TABLET CHEWABLE Generic

phenytoin oral suspension 125 mg/5ml Generic

phenytoin oral tablet chewable Generic

phenytoin sodium extended oral capsule Generic



Generic

pramipexole dihydrochloride oral tablet Generic


Generic




Generic





REBIF REBIDOSE SUBCUTANEOUS SOLUTION Brand SP

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION Brand SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

Brand SP

REBIF SUBCUTANEOUS SOLUTION Brand SP


65

Drug Status NotesREBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION Brand SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

Brand SP






ropinirole hcl er oral tablet extended release 24 hour

Generic

ropinirole hcl oral tablet Generic

ROZEREM ORAL TABLET Brand PA; QL (30 EA per 30 days)


selegiline hcl oral capsule Generic

selegiline hcl oral tablet Generic

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 30 MG

Medical Benefit PA



SPINRAZA INTRATHECAL SOLUTION Medical Benefit PA











66

Drug Status Notessumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml


TECFIDERA ORAL Brand PA; SP; QL (60 EA per 30 days)

TECFIDERA ORAL CAPSULE DELAYED RELEASE Brand PA; SP; QL (60 EA per 30 days)

temazepam oral capsule Generic



tiagabine hcl oral tablet 2 mg, 4 mg Generic












trihexyphenidyl hcl oral elixir Generic

trihexyphenidyl hcl oral tablet Generic





valproic acid oral capsule Generic

valproic acid oral solution Generic

valproic acid oral syrup Generic


VIMPAT ORAL SOLUTION Brand PA; QL (1200 ML per 30 days)

VIMPAT ORAL TABLET Brand PA; QL (60 EA per 30 days)


XADAGO ORAL TABLET Brand PA


67

Drug Status NotesXARELTO ORAL TABLET 2.5 MG Brand PA; QL (60 EA per 30 days)





zaleplon oral capsule Generic QL (30 EA per 30 days)

ZELAPAR ORAL TABLET DISPERSIBLE Brand PA; QL (60 EA per 30 days)


ZINBRYTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand

PA; SP; QL (1 Injection per 30 days)



zolpidem tartrate er oral tablet extended release Generic PA; QL (30 EA per 30 days)

zolpidem tartrate oral tablet Generic QL (30 EA per 30 days)

zolpidem tartrate sublingual tablet sublingual Generic PA; QL (30 EA per 30 days)


zonisamide oral capsule Generic


DISORDER OF REPRODUCTIVE SYSTEM


alendronate sodium oral tablet 10 mg, 5 mg Generic QL (30 EA per 30 days)


ALTAVERA ORAL TABLET Generic

alyacen 1/35 oral tablet Generic

alyacen 7/7/7 oral tablet Generic

AMETHIA LO ORAL TABLET Generic

AMETHIA ORAL TABLET Generic

AMETHYST ORAL TABLET Generic

ANDRODERM TRANSDERMAL PATCH 24 HOUR Brand PA


68

Drug Status NotesANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)

Brand PA

ANDROXY ORAL TABLET Brand PA

APRI ORAL TABLET Generic

ARANELLE ORAL TABLET Generic

ASHLYNA ORAL TABLET Generic

AUBRA ORAL TABLET Generic

AVIANE ORAL TABLET Generic

AZURETTE ORAL TABLET Generic

BALZIVA ORAL TABLET Generic

BEKYREE ORAL TABLET Generic

BLISOVI 24 FE ORAL TABLET Generic

BLISOVI FE 1.5/30 ORAL TABLET Generic

BLISOVI FE 1/20 ORAL TABLET Generic

briellyn oral tablet Generic

calcitonin (salmon) nasal solution Generic

CAMILA ORAL TABLET Generic

CAMRESE LO ORAL TABLET Generic

CAMRESE ORAL TABLET Generic

CAZIANT ORAL TABLET Generic

CHATEAL ORAL TABLET Generic


clomiphene citrate oral tablet Generic PA

CRINONE VAGINAL GEL 8 % Brand PA

CRYSELLE-28 ORAL TABLET Generic

CYCLAFEM 1/35 ORAL TABLET Generic

CYCLAFEM 7/7/7 ORAL TABLET Generic

CYRED ORAL TABLET Generic

danazol oral capsule Generic

DASETTA 1/35 ORAL TABLET Generic

DASETTA 7/7/7 ORAL TABLET Generic

DAYSEE ORAL TABLET Generic

DEBLITANE ORAL TABLET Generic


69

Drug Status Notesdesogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

$0

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

Generic

drospiren-eth estrad-levomefol oral tablet 3-0.03-0.451 mg

Generic

drospirenone-ethinyl estradiol oral tablet Generic

DUAVEE ORAL TABLET Brand PA

ELINEST ORAL TABLET Generic

ELLA ORAL TABLET Brand

EMOQUETTE ORAL TABLET Generic

ENPRESSE-28 ORAL TABLET Generic

ENSKYCE ORAL TABLET 0.15-30 MG-MCG Generic

ERRIN ORAL TABLET Generic

ESTARYLLA ORAL TABLET Generic

estradiol oral tablet Generic

estradiol transdermal patch twice weekly Generic

estradiol transdermal patch weekly Generic

estropipate oral tablet Generic

exemestane oral tablet Generic

FALMINA ORAL TABLET Generic

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML Brand PA; SP; QL (1 vial per 30 days)

FOSAMAX PLUS D ORAL TABLET Brand PA; QL (4 EA per 28 days)

GIANVI ORAL TABLET Generic

GILDAGIA ORAL TABLET Generic

GILDESS 1.5/30 ORAL TABLET Generic

GILDESS 1/20 ORAL TABLET Generic

GILDESS 24 FE ORAL TABLET Generic

GILDESS FE 1.5/30 ORAL TABLET Generic

GILDESS FE 1/20 ORAL TABLET Generic

HEATHER ORAL TABLET Generic




70

Drug Status Notesibandronate sodium oral tablet Generic PA; QL (1 EA per 28 days)


INTROVALE ORAL TABLET Generic

JENCYCLA ORAL TABLET Generic

JOLESSA ORAL TABLET Generic

JOLIVETTE ORAL TABLET Generic

JULEBER ORAL TABLET Generic

JUNEL 1.5/30 ORAL TABLET Generic

JUNEL 1/20 ORAL TABLET Generic

JUNEL FE 1.5/30 ORAL TABLET Generic

JUNEL FE 1/20 ORAL TABLET Generic

JUNEL FE 24 ORAL TABLET Generic

KAITLIB FE ORAL TABLET CHEWABLE Generic

KARIVA ORAL TABLET Generic

KELNOR 1/35 ORAL TABLET Generic

KIMIDESS ORAL TABLET Generic

KURVELO ORAL TABLET Generic

LARIN 1.5/30 ORAL TABLET Generic

LARIN 1/20 ORAL TABLET Generic

LARIN 24 FE ORAL TABLET Generic

LARIN FE 1.5/30 ORAL TABLET Generic

LARIN FE 1/20 ORAL TABLET Generic

LAYOLIS FE ORAL TABLET CHEWABLE Generic

LEENA ORAL TABLET Generic

LESSINA ORAL TABLET Generic

letrozole oral tablet Generic

LEVONEST ORAL TABLET Generic

levonorgest-eth estrad 91-day oral tablet Generic

levonorgestrel oral tablet 1.5 mg Generic

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

Generic

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

$0

levonorg-eth estrad triphasic oral tablet Generic


71

Drug Status NotesLEVORA 0.15/30 (28) ORAL TABLET Generic

LO LOESTRIN FE ORAL TABLET Generic

LOMEDIA 24 FE ORAL TABLET Generic

LORYNA ORAL TABLET Generic

LOW-OGESTREL ORAL TABLET Generic



LUTERA ORAL TABLET Generic

LYZA ORAL TABLET Generic

marlissa oral tablet Generic


mefenamic acid oral capsule Generic PA


methitest oral tablet Brand PA

methyltestosterone oral capsule Generic


MIACALCIN INJECTION SOLUTION Brand


MICROGESTIN 1.5/30 ORAL TABLET Generic

MICROGESTIN 1/20 ORAL TABLET Generic

MICROGESTIN 24 FE ORAL TABLET Generic

MICROGESTIN FE 1.5/30 ORAL TABLET Generic

MICROGESTIN FE 1/20 ORAL TABLET Generic

MONO-LINYAH ORAL TABLET Generic

MONONESSA ORAL TABLET Generic

MY WAY ORAL TABLET Generic

MYZILRA ORAL TABLET Generic


NECON 0.5/35 (28) ORAL TABLET Generic

NECON 1/35 (28) ORAL TABLET Generic




72

Drug Status NotesNECON 7/7/7 ORAL TABLET Generic

NEXT CHOICE ONE DOSE ORAL TABLET Generic

NIKKI ORAL TABLET Generic

NORA-BE ORAL TABLET Generic

norethin ace-eth estrad-fe oral tablet Generic

norethin ace-eth estrad-fe oral tablet chewable Generic


norethindrone acet-ethinyl est oral tablet Generic

norethindrone oral tablet Generic

norethindrone-eth estradiol oral tablet Generic

norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg

Generic

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

Generic

norgestim-eth estrad triphasic oral tablet Generic

NORTREL 0.5/35 (28) ORAL TABLET Generic

NORTREL 1/35 (21) ORAL TABLET Generic

NORTREL 1/35 (28) ORAL TABLET Generic

NORTREL 7/7/7 ORAL TABLET Generic

NUVARING VAGINAL RING Brand

OCELLA ORAL TABLET Generic

OGESTREL ORAL TABLET Generic

ORSYTHIA ORAL TABLET Generic


PHILITH ORAL TABLET Generic

PIMTREA ORAL TABLET Generic

PIRMELLA 1/35 ORAL TABLET Generic

PIRMELLA 7/7/7 ORAL TABLET Generic

PORTIA-28 ORAL TABLET Generic

PREMARIN ORAL TABLET Brand




PREVIFEM ORAL TABLET Generic


73

Drug Status Notesprogesterone intramuscular oil Generic PA

progesterone micronized oral capsule Generic

PROLIA SUBCUTANEOUS SOLUTION Medical BenefitPA; SP; QL (1 syringe per 180 days)

QUASENSE ORAL TABLET Generic

raloxifene hcl oral tablet Generic

RECLIPSEN ORAL TABLET Generic




risedronate sodium oral tablet delayed release Generic PA; QL (4 EA per 28 days)

SETLAKIN ORAL TABLET Generic

SHAROBEL ORAL TABLET Generic


SOLTAMOX ORAL SOLUTION Brand

SPRINTEC 28 ORAL TABLET Generic

SRONYX ORAL TABLET Generic

STRIANT BUCCAL Brand PA

SYEDA ORAL TABLET Generic

SYNAREL NASAL SOLUTION Brand PA

tadalafil oral tablet 5 mg Generic PA; QL (30 EA per 30 days)

tamoxifen citrate oral tablet Generic

TARINA FE 1/20 ORAL TABLET Generic



TESTOPEL IMPLANT PELLET Brand PA

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

Generic PA

testosterone enanthate intramuscular solution Generic PA

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

Generic PA

testosterone transdermal solution Generic PA

TILIA FE ORAL TABLET Generic



74

Drug Status Notestranexamic acid oral tablet Generic PA

TRI-ESTARYLLA ORAL TABLET Generic

TRI-LEGEST FE ORAL TABLET Generic

TRI-LINYAH ORAL TABLET Generic

TRI-LO-ESTARYLLA ORAL TABLET Generic

TRI-LO-MARZIA ORAL TABLET Generic

TRI-LO-SPRINTEC ORAL TABLET Generic

TRINESSA (28) ORAL TABLET Generic

TRINESSA LO ORAL TABLET Generic

TRI-PREVIFEM ORAL TABLET Generic

TRI-SPRINTEC ORAL TABLET Generic

TRIVORA (28) ORAL TABLET Generic

TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA; QL (2 ML per 30 days)


VELIVET ORAL TABLET Generic

VESTURA ORAL TABLET Generic

VIENVA ORAL TABLET Generic

viorele oral tablet Generic

VYFEMLA ORAL TABLET Generic

WERA ORAL TABLET Generic

WYMZYA FE ORAL TABLET CHEWABLE Generic

XIAFLEX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA

XULANE TRANSDERMAL PATCH WEEKLY Generic

ZARAH ORAL TABLET Generic

ZENCHENT FE ORAL TABLET CHEWABLE Generic

ZENCHENT ORAL TABLET Generic


ZOVIA 1/35E (28) ORAL TABLET Generic

ZOVIA 1/50E (28) ORAL TABLET Generic


75

Drug Status NotesDISORDER OF RESPIRATORY SYSTEM


acetylcysteine inhalation solution Generic





Brand PA



Generic






Brand PA





Brand


Brand


Brand


Brand


76


Brand














chlorpromazine hcl oral tablet Generic





clotrimazole mouth/throat lozenge Generic

clotrimazole mouth/throat troche Generic









77

Drug Status NotesDUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML Brand PA; SP; QL (2 ML per 28 days)







ESBRIET ORAL CAPSULE Brand SP; QL (270 EA per 30 days)






Brand





Generic





Generic


Generic





78

Drug Status NotesINCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand







levalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml

Generic




lidocaine external ointment Generic QL (50 GM per 30 days)










NOXAFIL ORAL TABLET DELAYED RELEASE Brand PA








79

Drug Status NotesORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG Brand PA; SP




PASER ORAL PACKET Brand PA



PRIFTIN ORAL TABLET Brand PA



Brand PA


promethazine vc/codeine oral syrup Generic







Brand









80

Drug Status NotesREVATIO ORAL SUSPENSION RECONSTITUTED Brand PA; SP




Brand



SIRTURO ORAL TABLET Brand PA


Brand


SYMBICORT INHALATION AEROSOL160-4.5 MCG/ACT Brand PA




SYNAGIS INTRAMUSCULAR SOLUTION Medical Benefit PA; SP


terbutaline sulfate oral tablet Generic


Generic


Generic








81

Drug Status NotesTUSSIGON ORAL TABLET Generic
















DISORDER OF THE DIGESTIVE SYSTEM

ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE Brand PA

adefovir dipivoxil oral tablet Generic


AKYNZEO ORAL CAPSULE Brand PA; QL (1 EA per 1 Fill)

alosetron hcl oral tablet Generic

AMITIZA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)

amoxicill-clarithro-lansopraz oral Generic

ANZEMET ORAL TABLET 100 MG Brand PA; QL (10 EA per 1 fill)


APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand

balsalazide disodium oral capsule Generic

BARACLUDE ORAL SOLUTION Brand


82

Drug Status NotesBONJESTA ORAL TABLET EXTENDED RELEASE Brand PA

budesonide er oral tablet extended release 24 hour

Generic PA

budesonide oral capsule delayed release particles Generic

CANTIL ORAL TABLET Brand PA

CARAFATE ORAL SUSPENSION BrandPA; ¥ (PA applies to members 12 years and older)

CESAMET ORAL CAPSULE Brand PA


chlordiazepoxide-clidinium oral capsule Generic

chlorhexidine gluconate mouth/throat solution Generic

CHOLBAM ORAL CAPSULE Brand PA

cimetidine hcl oral solution Generic

cimetidine oral tablet Generic





CLINPRO 5000 DENTAL PASTE Generic

COLOCORT RECTAL ENEMA Generic

COMPRO RECTAL SUPPOSITORY Generic


CREON ORAL CAPSULE DELAYED RELEASE PARTICLES Brand




DAKLINZA ORAL TABLET Brand PA; SP

DENAVIR EXTERNAL CREAM Brand PA; QL (5 GM per 1 Fill)

DENTA 5000 PLUS DENTAL CREAM Generic

DENTAGEL DENTAL GEL Generic

DEXILANT ORAL CAPSULE DELAYED RELEASE 60 MG Brand PA


83

Drug Status NotesDICLEGIS ORAL TABLET DELAYED RELEASE Brand PA

dicyclomine hcl oral capsule Generic

dicyclomine hcl oral solution Generic

dicyclomine hcl oral tablet Generic

DIFICID ORAL TABLET Brand PA; QL (20 EA per 1 Fill)

dimenhydrinate oral tablet Generic

DIPENTUM ORAL CAPSULE Brand

diphenoxylate-atropine oral liquid Generic

diphenoxylate-atropine oral tablet Generic


EMEND ORAL CAPSULE Brand PA; QL (6 EA per 1 Rx)

EMEND ORAL SUSPENSION RECONSTITUTED Brand PA; QL (3 Units per 7 days)

entecavir oral tablet Generic

ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP


EPCLUSA ORAL TABLET Brand PA; SP; # (Genotypes 2-6)

famotidine oral suspension reconstituted Generic

famotidine oral tablet 20 mg, 40 mg Generic

FLUOR-A-DAY ORAL SOLUTION Generic

FLUORIDEX DAILY DEFENSE DENTAL GEL Generic

FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE Generic

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP Generic

GAMASTAN S/D INTRAMUSCULAR INJECTABLE Medical Benefit PA; SP



GATTEX SUBCUTANEOUS KIT Brand SP; QL (1 Kit per 1 day)

GAVILYTE-C ORAL SOLUTION RECONSTITUTED Generic


84

Drug Status NotesGAVILYTE-G ORAL SOLUTION RECONSTITUTED Generic

GAVILYTE-H ORAL KIT Generic




GIAZO ORAL TABLET Brand PA

granisetron hcl oral tablet Generic QL (14 EA per 1 Fill)

HARVONI ORAL TABLET Brand PA; SP









Generic

hydrocortisone ace-pramoxine rectal cream Generic


hydrocortisone rectal enema Generic


ivermectin oral tablet Generic



lamivudine oral tablet 100 mg Generic

lansoprazole oral capsule delayed release Generic PA

lansoprazole oral tablet dispersible Generic PA; ¥ (Age Limit: Max 2 years)

LINZESS ORAL CAPSULE Brand PA; QL (30 EA per 30 days)


85

Drug Status NotesLONSURF ORAL TABLET Brand PA; SP

loperamide hcl oral capsule Generic

MAVYRET ORAL TABLET Brand PA; SP

mesalamine oral tablet delayed release 1.2 gm GenericPA; STPA; QL (120 EA per 30 days)

mesalamine oral tablet delayed release 800 mg Generic

mesalamine rectal enema Generic

methscopolamine bromide oral tablet Generic PA


Generic


misoprostol oral tablet Generic

MOVANTIK ORAL TABLET Brand PA





Generic

multi-vitamin/fluoride oral tablet chewable 0.5 mg

Brand



Generic


neomycin sulfate oral tablet Generic

NEXIUM ORAL PACKET Brand PA

nizatidine oral capsule Generic

nizatidine oral solution Generic

NUTRESTORE ORAL PACKET Brand PA

OCALIVA ORAL TABLET BrandPA; SP; QL (30 TABS per 30 days)




OLYSIO ORAL CAPSULE Brand PA; SP

omeprazole oral capsule delayed release Generic


86

Drug Status Notesomeprazole-sodium bicarbonate oral packet Generic PA

ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml

Generic

ondansetron hcl oral solution Generic QL (105 ML per 1 Fill)

ondansetron hcl oral tablet Generic QL (21 EA per 1 Fill)

ondansetron oral tablet dispersible Generic QL (21 EA per 1 Fill)

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT

Brand

paregoric oral tincture Generic

PAROEX MOUTH/THROAT SOLUTION Generic

paromomycin sulfate oral capsule Generic

peg 3350/electrolytes oral solution reconstituted Generic

peg 3350-kcl-na bicarb-nacl oral solution reconstituted

Generic

peg-3350/electrolytes oral solution reconstituted Generic

PENTASA ORAL CAPSULE EXTENDED RELEASE Brand

PERIOGARD MOUTH/THROAT SOLUTION Generic

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES Brand

PHENERGAN RECTAL SUPPOSITORY12.5 MG Generic


polyethylene glycol 3350 oral powder Generic

pramcort rectal cream Generic

praziquantel oral tablet Generic

PRILOSEC ORAL PACKET Brand PA

prochlorperazine edisylate injection solution Generic

prochlorperazine maleate oral tablet Generic

prochlorperazine rectal suppository Generic


promethazine hcl oral solution Generic

promethazine hcl oral syrup Generic

promethazine hcl oral tablet Generic


87

Drug Status Notespromethazine hcl rectal suppository Generic

rabeprazole sodium oral tablet delayed release Generic PA




RELISTOR ORAL TABLET Brand PA; QL (90 Tablets per 30 days)

RELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6ML, 8 MG/0.4ML Brand PA



RIBASPHERE ORAL CAPSULE Generic QL (210 EA per 30 days)

RIBASPHERE ORAL TABLET 200 MG Generic QL (210 EA per 30 days)

ribavirin oral capsule Generic

ribavirin oral tablet 200 mg Generic

SANCUSO TRANSDERMAL PATCH Brand PA

sf 5000 plus dental cream Generic

sf dental gel Generic

sodium fluoride oral solution Generic

sodium fluoride oral tablet chewable Generic

SOVALDI ORAL TABLET Brand PA; SP


STELARA INTRAVENOUS SOLUTION Medical BenefitPA; SP; ¥ (1 Fill per life of plan); QL (4 VIALS per 1 Fill)

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand


sucralfate oral tablet Generic

sulfasalazine oral tablet Generic


SYMPROIC ORAL TABLET Brand PA



TECHNIVIE ORAL TABLET Brand PA; SP



88

Drug Status Notestinidazole oral tablet Generic


TRILYTE ORAL SOLUTION RECONSTITUTED Generic

trimethobenzamide hcl oral capsule Generic




UCERIS RECTAL FOAM Brand PA

ursodiol oral capsule Generic

ursodiol oral tablet Generic

VARUBI ORAL TABLET BrandPA; ¥ (Max of 6 tablets per 30 days); QL (2 Tablets per 1 Fill)

VIBERZI ORAL TABLET Brand PA

VIEKIRA PAK ORAL TABLET THERAPY PACK Brand PA; SP

VIEKIRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP



VOSEVI ORAL TABLET Brand PA; SP



XERMELO ORAL TABLET Brand PA



ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 40000-136000 UNIT, 5000-24000 UNIT

Brand

ZEPATIER ORAL TABLET Brand PA; SP

ZINPLAVA INTRAVENOUS SOLUTION Medical Benefit PA



89

Drug Status NotesDISORDER OF THE ENDOCRINE GLANDS

acarbose oral tablet Generic

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA

ADLYXIN STARTER PACK SUBCUTANEOUS PEN-INJECTOR KIT Brand PA

ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA





alogliptin-pioglitazone oral tablet Generic PA; QL (30 EA per 30 days)

ANDRODERM TRANSDERMAL PATCH 24 HOUR Brand PA

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%)

Brand PA

ANDROXY ORAL TABLET Brand PA


AVANDAMET ORAL TABLET 2-1000 MG Brand PA

AVANDIA ORAL TABLET Brand PA



BYDUREON SUBCUTANEOUS PEN-INJECTOR Brand PA

BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER Brand PA





cabergoline oral tablet Generic


90

Drug Status Notescalcitonin (salmon) nasal solution Generic




chlorpropamide oral tablet Generic


CRINONE VAGINAL GEL 8 % Brand PA

desmopressin ace rhinal tube nasal solution Generic

desmopressin ace spray refrig nasal solution Generic


desmopressin acetate spray nasal solution Generic

dexamethasone oral elixir Generic

dexamethasone oral solution Generic

dexamethasone oral tablet Generic




estradiol transdermal patch weekly Generic

estropipate oral tablet Generic


fludrocortisone acetate oral tablet Generic



glimepiride oral tablet Generic

glipizide er oral tablet extended release 24 hour Generic

glipizide oral tablet Generic

glipizide xl oral tablet extended release 24 hour Generic

glipizide-metformin hcl oral tablet Generic

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED Brand

GLUCAGON EMERGENCY INJECTION KIT Brand

glyburide micronized oral tablet Generic

glyburide oral tablet Generic


91

Drug Status Notesglyburide-metformin oral tablet Generic

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION Brand

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

Brand




ibandronate sodium oral tablet Generic PA; QL (1 EA per 28 days)



INVOKAMET ORAL TABLET BrandPA; STPA; QL (60 EA per 30 days)

INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand

PA; STPA; QL (60 Tablets per 30 days)



KORLYM ORAL TABLET Brand PA


LEVO-T ORAL TABLET Generic

levothyroxine sodium oral tablet Generic

liothyronine sodium oral tablet Generic

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT Medical Benefit PA

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT Medical Benefit PA






Generic PA

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg

Generic PA


92

Drug Status Notesmetformin hcl er oral tablet extended release 24 hour

Generic

metformin hcl oral tablet Generic

methimazole oral tablet Generic

methitest oral tablet Brand PA




Generic



Generic



miglitol oral tablet Generic

nateglinide oral tablet Generic

NATPARA SUBCUTANEOUS CARTRIDGE BrandPA; SP; QL (2 Cartridges per 21 days)









paricalcitol oral capsule Generic PA

pioglitazone hcl oral tablet Generic

pioglitazone hcl-glimepiride oral tablet Generic

pioglitazone hcl-metformin hcl oral tablet Generic




Generic


93

Drug Status Notesprednisolone sodium phosphate oral tablet dispersible

Generic

PREMARIN ORAL TABLET Brand






propylthiouracil oral tablet Generic











Medical Benefit PA

SIGNIFOR SUBCUTANEOUS SOLUTION Brand PA; QL (60 ML per 30 days)


STRIANT BUCCAL Brand PA



SYNAREL NASAL SOLUTION Brand PA

TANZEUM SUBCUTANEOUS PEN-INJECTOR Brand PA

TESTOPEL IMPLANT PELLET Brand PA


94

Drug Status Notestestosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

Generic PA

testosterone enanthate intramuscular solution Generic PA

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

Generic PA


tolazamide oral tablet Generic

tolbutamide oral tablet Generic

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA


UNITHROID ORAL TABLET 137 MCG Generic

UNITHROID ORAL TABLET 50 MCG, 75 MCG, 88 MCG Brand

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand PA

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA


EAR PROBLEM

ACETASOL HC OTIC SOLUTION Generic

acetic acid otic solution Generic

acetic acid-aluminum acetate otic solution Generic


CIPRO HC OTIC SUSPENSION Brand PA

CIPRODEX OTIC SUSPENSION Brand PA

dexamethasone sodium phosphate ophthalmic solution

Generic

fluocinolone acetonide otic oil Generic

hydrocortisone-acetic acid otic solution Generic


neomycin-polymyxin-hc otic solution Generic

neomycin-polymyxin-hc otic suspension Generic


95

Drug Status Notesofloxacin otic solution Generic

EYE DISORDER


ALOCRIL OPHTHALMIC SOLUTION Brand PA

ALPHAGAN P OPHTHALMIC SOLUTION0.1 % Brand PA


azelastine hcl ophthalmic solution Generic PA

AZOPT OPHTHALMIC SUSPENSION Brand PA

bacitracin ophthalmic ointment Generic

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

Generic

BEPREVE OPHTHALMIC SOLUTION Brand PA

betaxolol hcl ophthalmic solution Generic

bimatoprost ophthalmic solution Generic PA

brimonidine tartrate ophthalmic solution 0.15 % Generic PA

bromfenac sodium (once-daily) ophthalmic solution

Generic

bromfenac sodium ophthalmic solution Generic

carteolol hcl ophthalmic solution Generic


COMBIGAN OPHTHALMIC SOLUTION Brand PA

cromolyn sodium ophthalmic solution Generic

cyclopentolate hcl ophthalmic solution 0.5 % Generic QL (15 ML per 30 days)

cyclopentolate hcl ophthalmic solution 1 %, 2 % Generic QL (2 ML per 30 days)


Generic

diclofenac sodium ophthalmic solution Generic

dorzolamide hcl ophthalmic solution Generic

dorzolamide hcl-timolol mal ophthalmic solution Generic

EMADINE OPHTHALMIC SOLUTION Brand PA

epinastine hcl ophthalmic solution Generic PA

erythromycin ophthalmic ointment Generic

fluorometholone ophthalmic suspension Generic

flurbiprofen sodium ophthalmic solution Generic


96

Drug Status NotesGAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED


HOMATROPAIRE OPHTHALMIC SOLUTION Generic

homatropine hbr ophthalmic solution Generic

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML


HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML


HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML


ketorolac tromethamine ophthalmic solution Generic

ketotifen fumarate ophthalmic solution Generic

LASTACAFT OPHTHALMIC SOLUTION Brand PA

latanoprost ophthalmic solution Generic

levobunolol hcl ophthalmic solution 0.5 % Generic

LUMIGAN OPHTHALMIC SOLUTION 0.01 % Brand PA

methazolamide oral tablet Generic

metipranolol ophthalmic solution Generic

naphazoline hcl ophthalmic solution Generic

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

Generic

neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

Generic

NEO-POLYCIN OPHTHALMIC OINTMENT Generic

olopatadine hcl ophthalmic solution Generic PA

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

Generic


polymyxin b-trimethoprim ophthalmic solution Generic

polyvinyl alcohol ophthalmic solution Generic


97

Drug Status Notesprednisolone acetate ophthalmic suspension Generic

proparacaine hcl ophthalmic solution Generic

RESCULA OPHTHALMIC SOLUTION Brand PA

RESTASIS OPHTHALMIC EMULSION Brand PA; QL (60 EA per 30 days)

RHOPRESSA OPHTHALMIC SOLUTION Brand PA

SIMBRINZA OPHTHALMIC SUSPENSION Brand PA

sulfacetamide sodium ophthalmic ointment Generic

sulfacetamide sodium ophthalmic solution Generic

sulfacetamide-prednisolone ophthalmic solution Generic

timolol maleate ophthalmic gel forming solution Generic

timolol maleate ophthalmic solution 0.25 %, 0.5 %

Generic

tobramycin-dexamethasone ophthalmic suspension

Generic

TRAVATAN Z OPHTHALMIC SOLUTION Brand PA

trifluridine ophthalmic solution Generic

tropicamide ophthalmic solution Generic

VYZULTA OPHTHALMIC SOLUTION Brand PA


ZIOPTAN OPHTHALMIC SOLUTION Brand PA

ZIRGAN OPHTHALMIC GEL Brand PA

FEVER




INFECTION


abacavir sulfate oral tablet Generic



acyclovir external ointment Generic


ALFERON N INJECTION SOLUTION Medical Benefit PA


98

Drug Status Notesamantadine hcl oral capsule Generic




APTIVUS ORAL CAPSULE Brand

APTIVUS ORAL SOLUTION Brand


atovaquone-proguanil hcl oral tablet Generic

ATRIPLA ORAL TABLET Brand


bacitracin ophthalmic ointment Generic

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

Generic



benznidazole oral tablet Brand


BIKTARVY ORAL TABLET Brand





chloroquine phosphate oral tablet Generic

CICLODAN EXTERNAL CREAM Generic

CICLODAN EXTERNAL SOLUTION Generic

ciclopirox external gel Generic

ciclopirox external solution Brand

ciclopirox olamine external cream Generic

ciclopirox olamine external suspension Generic PA

CIMDUO ORAL TABLET Brand

CIPRODEX OTIC SUSPENSION Brand PA




99

Drug Status Notesclemastine fumarate oral tablet 2.68 mg Generic


clotrimazole anti-fungal external cream Generic

clotrimazole external cream Generic

clotrimazole external solution Generic



clotrimazole-betamethasone external cream Generic

clotrimazole-betamethasone external lotion Generic

COARTEM ORAL TABLET Brand QL (24 EA per 30 days)

COMPLERA ORAL TABLET Brand

CRESEMBA ORAL CAPSULE Brand PA

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Brand




dapsone oral tablet Brand


DESCOVY ORAL TABLET Brand


didanosine oral capsule delayed release Generic



econazole nitrate external cream Generic

ECOZA EXTERNAL FOAM Brand PA

EDURANT ORAL TABLET Brand




EMTRIVA ORAL CAPSULE Brand

EMTRIVA ORAL SOLUTION Brand



100

Drug Status NotesEPCLUSA ORAL TABLET Brand PA; SP; # (Genotypes 2-6)


erythromycin ophthalmic ointment Generic

EVOTAZ ORAL TABLET Brand

EXELDERM EXTERNAL CREAM Brand PA

EXELDERM EXTERNAL SOLUTION Brand PA




FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED Brand SP





gentamicin sulfate external cream Generic

gentamicin sulfate external ointment Generic

GENVOYA ORAL TABLET Brand



griseofulvin microsize oral suspension Generic

griseofulvin microsize oral tablet Generic

griseofulvin ultramicrosize oral tablet Generic


Generic



Generic




imiquimod external cream Generic

IMPAVIDO ORAL CAPSULE Brand

INTELENCE ORAL TABLET Brand


101

Drug Status NotesINVIRASE ORAL CAPSULE Brand

INVIRASE ORAL TABLET Brand


ISENTRESS HD ORAL TABLET Brand QL (60 EA per 30 days)

ISENTRESS ORAL PACKET Brand QL (60 EA per 30 days)

ISENTRESS ORAL TABLET Brand

ISENTRESS ORAL TABLET CHEWABLE Brand

isoniazid oral syrup Generic

isoniazid oral tablet Generic


JUBLIA EXTERNAL SOLUTION Brand PA

JULUCA ORAL TABLET Brand

KALETRA ORAL SOLUTION Brand

KALETRA ORAL TABLET Brand

ketoconazole external cream Generic

ketoconazole external shampoo Generic

LAMISIL ORAL PACKET BrandPA; ¥ (Max of 6 weeks); QL (2 Packets per 1 day)



lamivudine oral tablet 150 mg, 300 mg Brand

lamivudine-zidovudine oral tablet Brand



LEXIVA ORAL SUSPENSION Brand


lindane external lotion Generic

lindane external shampoo Generic

luliconazole external cream Generic PA


malathion external lotion Generic


mefloquine hcl oral tablet Generic


102

Drug Status Notesmegestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 mg/5ml

Generic

methenamine hippurate oral tablet Generic

methenamine mandelate oral tablet Generic







mupirocin calcium external cream Generic PA

mupirocin external ointment Generic

naftifine hcl external cream Generic PA

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

Generic

neomycin-polymyxin-hc ophthalmic suspension3.5-10000-1

Generic

NEO-POLYCIN OPHTHALMIC OINTMENT Generic

nevirapine er oral tablet extended release 24 hour Generic

nevirapine oral suspension Generic

nevirapine oral tablet Generic


NORVIR ORAL CAPSULE Brand

NORVIR ORAL PACKET Brand

NORVIR ORAL SOLUTION Brand



NYAMYC EXTERNAL POWDER Generic

nystatin external cream Generic

nystatin external ointment Generic

nystatin external powder Generic

nystatin mouth/throat suspension Generic


103

Drug Status Notesnystatin oral powder Generic

nystatin oral tablet Generic

nystatin-triamcinolone external cream Generic

nystatin-triamcinolone external ointment Generic

NYSTOP EXTERNAL POWDER Generic


ODEFSEY ORAL TABLET Brand




oseltamivir phosphate oral capsule 30 mg Generic¥ (Max of 2 fills per year); QL (20 EA per 1 Fill)

oseltamivir phosphate oral capsule 45 mg, 75 mg Generic¥ (Max of 2 fills per year); QL (10 EA per 1 Fill)

oseltamivir phosphate oral suspension reconstituted

Generic¥ (Max of 2 fills per year); QL (180 ML per 1 Fill)

oxiconazole nitrate external cream Generic PA

OXISTAT EXTERNAL LOTION Brand PA


paromomycin sulfate oral capsule Generic


PERIOGARD MOUTH/THROAT SOLUTION Generic

permethrin external cream Generic


podofilox external solution Generic





PREZCOBIX ORAL TABLET Brand

PREZISTA ORAL SUSPENSION Brand

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG Brand


104

Drug Status NotesPRIFTIN ORAL TABLET Brand PA










RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand¥ (Max of 2 fills per year); QL (20 Blisters per 1 Rx)

RESCRIPTOR ORAL TABLET Brand

REYATAZ ORAL PACKET Brand





rimantadine hcl oral tablet Generic


SELZENTRY ORAL SOLUTION Brand QL (1800 ML per 30 days)

SELZENTRY ORAL TABLET Brand



silver sulfadiazine external cream Generic


SKLICE EXTERNAL LOTION BrandPA; STPA; QL (117 GM per 1 day)



spinosad external suspension BrandPA; STPA; QL (120 ML per 1 Fill)


105

Drug Status NotesSSD EXTERNAL CREAM Generic

stavudine oral capsule Brand

stavudine oral solution reconstituted Brand

STRIBILD ORAL TABLET Brand



SYMFI LO ORAL TABLET Brand

SYMFI ORAL TABLET Brand

SYMTUZA ORAL TABLET Brand








TIVICAY ORAL TABLET Brand




Generic

TRECATOR ORAL TABLET Brand PA



TRIUMEQ ORAL TABLET Brand

TRUVADA ORAL TABLET 200-300 MG Brand


TYBOST ORAL TABLET Brand

ULESFIA EXTERNAL LOTION Brand PA; QL (12 Bottles per 1 Rx)



VEREGEN EXTERNAL OINTMENT Brand PA

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM Brand


106

Drug Status NotesVIEKIRA PAK ORAL TABLET THERAPY PACK Brand PA; SP


VIRACEPT ORAL TABLET Brand








zidovudine oral capsule Brand

zidovudine oral syrup Brand

zidovudine oral tablet Brand




INFLAMMATION OF THE SEROUS MEMBRANES IN THE BODY


INFLAMMATORY DISORDER









107

Drug Status NotesADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE



Brand PA


alclometasone dipropionate external cream Generic

alclometasone dipropionate external ointment Generic




MB/RX PA; SP


amcinonide external cream Generic PA

amcinonide external lotion Generic PA

amcinonide external ointment Generic PA



Brand PA

APEXICON E EXTERNAL CREAM Brand PA

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand




Brand


Brand


Brand


108


Brand


Brand





balsalazide disodium oral capsule Generic








betamethasone dipropionate aug external cream Generic

betamethasone dipropionate aug external gel Generic

betamethasone dipropionate aug external lotion Generic

betamethasone dipropionate aug external ointment

Generic

betamethasone dipropionate external cream Generic

betamethasone dipropionate external lotion Generic

betamethasone dipropionate external ointment Generic

betamethasone valerate external cream Generic

betamethasone valerate external lotion Generic

betamethasone valerate external ointment Generic



Generic


109

Drug Status Notesbromfenac sodium ophthalmic solution Generic

budesonide er oral tablet extended release 24 hour

Generic PA



budesonide oral capsule delayed release particles Generic

CAPEX EXTERNAL SHAMPOO Brand PA

CARAFATE ORAL SUSPENSION BrandPA; ¥ (PA applies to members 12 years and older)







chlordiazepoxide-clidinium oral capsule Generic

choline-mag trisalicylate oral liquid Generic



ciclopirox external shampoo Brand PA



cimetidine hcl oral solution Generic

cimetidine oral tablet 300 mg, 400 mg, 800 mg Generic










110

Drug Status Notesclobetasol propionate e external cream Generic

clobetasol propionate external cream Generic PA

clobetasol propionate external foam Generic

clobetasol propionate external gel Generic PA

clobetasol propionate external lotion Generic

clobetasol propionate external ointment Generic PA

clocortolone pivalate external cream Generic PA

clocortolone pivalate pump external cream Generic PA










COLOCORT RECTAL ENEMA Generic

CORDRAN EXTERNAL TAPE Brand PA
















111

Drug Status NotesDALIRESP ORAL TABLET Brand PA; STPA


desonide external cream Generic PA

desonide external lotion Generic PA

desonide external ointment Generic PA

desoximetasone external cream 0.05 % Generic PA

desoximetasone external cream 0.25 % Generic

desoximetasone external gel Generic

desoximetasone external ointment 0.05 % Generic PA

desoximetasone external ointment 0.25 % Generic


Generic

diclofenac potassium oral tablet Generic


Generic


diclofenac sodium transdermal gel 1 % Generic STPA

diclofenac sodium transdermal solution Generic PA


diflorasone diacetate external cream Generic PA

diflorasone diacetate external ointment Generic PA

DIPENTUM ORAL CAPSULE Brand








ELIDEL EXTERNAL CREAM Brand PA




112

Drug Status NotesEMFLAZA ORAL TABLET Brand PA; QL (30 EA per 30 days)













ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA; SP

EPCLUSA ORAL TABLET Brand PA; SP; # (Genotypes 2-6)



etodolac oral capsule Generic

etodolac oral tablet Generic

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE Medical Benefit PA; SP





FINACEA EXTERNAL FOAM Brand PA; QL (50 GM per 1 Rx)

FINACEA EXTERNAL GEL Brand PA; QL (50 GM per 1 Rx)


Brand



fluocinolone acetonide body external oil Generic

fluocinolone acetonide external cream Generic


113

Drug Status Notesfluocinolone acetonide external ointment Generic

fluocinolone acetonide external solution Generic


fluocinolone acetonide scalp external oil Generic

fluocinonide external cream 0.05 % Generic QL (60 GM per 30 days)

fluocinonide external cream 0.1 % Generic PA; QL (120 GM per 30 days)

fluocinonide external gel Generic QL (60 GM per 30 days)

fluocinonide external ointment Generic QL (60 GM per 30 days)

fluocinonide external solution Generic QL (60 ML per 30 days)

fluorometholone ophthalmic suspension Generic

flurandrenolide external cream Generic PA

flurandrenolide external lotion Generic PA

flurandrenolide external ointment Generic PA


fluticasone propionate external cream Generic

fluticasone propionate external lotion Generic

fluticasone propionate external ointment Generic



Generic




MB/RX PA





Medical Benefit PA



114

Drug Status NotesGAMUNEX-C INJECTION SOLUTION Medical Benefit PA; SP

GIAZO ORAL TABLET Brand PA


Generic


halobetasol propionate external cream Generic PA

halobetasol propionate external ointment Generic PA

HALOG EXTERNAL CREAM Brand PA

HALOG EXTERNAL OINTMENT Brand PA



HOMATROPAIRE OPHTHALMIC SOLUTION Generic

homatropine hbr ophthalmic solution Generic


MB/RX PA; SP








Generic




Generic


hydrocortisone butyrate external cream Generic PA


115

Drug Status Noteshydrocortisone butyrate external ointment Generic PA

hydrocortisone butyrate external solution Generic PA

hydrocortisone external cream 1 %, 2.5 % Generic

hydrocortisone external lotion Generic

hydrocortisone external ointment 1 %, 2.5 % Generic


hydrocortisone rectal cream Generic

hydrocortisone rectal enema Generic

hydrocortisone valerate external cream Generic

hydrocortisone valerate external ointment Generic



ibuprofen oral suspension Generic

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




Brand







ketoconazole external foam Generic


KETODAN EXTERNAL FOAM Generic


Generic

ketoprofen oral capsule Generic




116

Drug Status NotesKEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (2.28 ML per 30 days)






lansoprazole oral capsule delayed release Generic PA

lansoprazole oral tablet dispersible Generic PA; ¥ (Age Limit: Max 2 years)







meclofenamate sodium oral capsule Generic





mesalamine rectal enema Generic





Generic

metronidazole external cream Generic

metronidazole external gel 0.75 % Generic

metronidazole external gel 1 % Generic PA

metronidazole external lotion Generic

MIRVASO EXTERNAL GEL Brand PA


117

Drug Status Notesmometasone furoate external cream Generic

mometasone furoate external ointment Generic

mometasone furoate external solution Generic










naproxen dr oral tablet delayed release Generic

naproxen oral suspension Generic

naproxen oral tablet Generic

naproxen sodium oral tablet Generic

nizatidine oral capsule Generic

nizatidine oral solution Generic

NORITATE EXTERNAL CREAM Brand PA













118

Drug Status NotesOCTAGAM INTRAVENOUS SOLUTION 10 GM/100ML, 2 GM/20ML, 20 GM/200ML, 5 GM/50ML






omeprazole oral capsule delayed release Generic










OTEZLA ORAL TABLET Brand PA; SP; QL (60 EA per 30 days)

OTEZLA ORAL TABLET THERAPY PACK Brand PA; SP; QL (60 EA per 30 days)






PENNSAID TRANSDERMAL SOLUTION 2 % Brand PA

PENTASA ORAL CAPSULE EXTENDED RELEASE Brand





119

Drug Status Notespiroxicam oral capsule Generic



prednicarbate external cream Generic

prednisolone acetate ophthalmic suspension Generic




Generic


Generic


PRILOSEC ORAL PACKET Brand PA



PROCTO-PAK RECTAL CREAM Generic

PROCTOSOL HC RECTAL CREAM Generic

PROCTOZONE-HC RECTAL CREAM Generic









Brand


Generic






120

Drug Status NotesQVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED Brand QL (10.6 GM per 30 days)














SAVELLA ORAL TABLET Brand STPA; QL (60 EA per 30 days)

SAVELLA TITRATION PACK ORAL Brand STPA; QL (60 EA per 30 days)

selenium sulfide external lotion Generic

selenium sulfide external shampoo 2.25 % Generic

selenium sulf-pyrithione-urea external shampoo Generic



Brand








SOOLANTRA EXTERNAL CREAM Brand PA


121

Drug Status NotesSOVALDI ORAL TABLET Brand PA; SP


Brand





sucralfate oral tablet Generic



sulfacetamide-prednisolone ophthalmic solution Generic

sulfasalazine oral tablet Generic


sulindac oral tablet Generic





SYNALAR (CREAM) EXTERNAL KIT Brand PA

SYNALAR (OINTMENT) EXTERNAL KIT Brand PA

tacrolimus external ointment Generic PA

TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand

PA; SP; ¥ (One 80 mg auto-injector/syringe per 28 days); QL (1 Injection per 28 days)

TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand






122

Drug Status Notestheophylline er oral tablet extended release 12 hour

Generic


Generic





Generic




triamcinolone acetonide external aerosol solution Generic PA

triamcinolone acetonide external cream Generic

triamcinolone acetonide external lotion Generic

triamcinolone acetonide external ointment Generic





UCERIS RECTAL FOAM Brand PA



VIEKIRA PAK ORAL TABLET THERAPY PACK Brand PA; SP







MB/RX PA; SP




123

Drug Status NotesXELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; SP; QL (30 EA per 30 days)








INJURY TO A MUCOUS MEMBRANE









doxycycline hyclate oral tablet 20 mg Generic









nystatin mouth/throat suspension Generic

nystatin oral powder Generic

nystatin oral tablet Generic





124

Drug Status NotesPERIOGARD MOUTH/THROAT SOLUTION Generic








triamcinolone acetonide mouth/throat paste Generic


LUNG DISEASE







Brand PA



Generic






Brand PA





125


Brand


Brand


Brand


Brand


Brand



















126

Drug Status Notesepoprostenol sodium intravenous solution reconstituted 0.5 mg




ESBRIET ORAL CAPSULE Brand SP; QL (270 EA per 30 days)






Brand



Generic





Generic


Generic





Brand







127

Drug Status Noteslevalbuterol hcl inhalation nebulization solution0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml

Generic

























Brand PA




128

Drug Status Notespromethazine-dm oral syrup Generic



Brand









Brand





Brand









129

Drug Status Notesterbutaline sulfate oral tablet Generic


Generic


Generic




















MAJOR TRAUMATIC INJURY

CIDALEAZE EXTERNAL CREAM Generic

FLECTOR TRANSDERMAL PATCH BrandPA; ¥ (Max of 3 months); QL (60 Patches per 30 days)

lidocaine hcl external cream 3 % Generic

lidocaine hcl external lotion Generic



130

Drug Status Notessilver sulfadiazine external cream Generic

SSD EXTERNAL CREAM Generic

MARGINAL ZONE LYMPHOMA



MUSCLE OR BONE DISORDER









alendronate sodium oral tablet 40 mg Generic QL (1 EA per 6 Months)










BRINEURA SOLUTION Medical Benefit PA

calcitonin (salmon) nasal solution Generic





131

Drug Status Notescarbamazepine oral tablet Generic


carisoprodol oral tablet 350 mg Generic

carisoprodol-aspirin oral tablet Generic


chlorzoxazone oral tablet 500 mg Generic

choline-mag trisalicylate oral liquid Generic




















cyclobenzaprine hcl oral tablet 10 mg, 5 mg Generic





Generic PA



132

Drug Status Notes

















Generic




duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg

Generic STPA; QL (60 EA per 30 days)

duloxetine hcl oral capsule delayed release particles 30 mg





133

Drug Status NotesDYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP















etidronate disodium oral tablet Generic




EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE Medical Benefit PA; SP


FLECTOR TRANSDERMAL PATCH BrandPA; ¥ (Max of 3 months); QL (60 Patches per 30 days)







MB/RX PA


GELNIQUE TRANSDERMAL GEL Brand PA


134

Drug Status NotesGLYDO EXTERNAL GEL Generic


Generic PA









ibandronate sodium oral tablet Generic PA; QL (1 EA per 28 days)









Generic








135

Drug Status Noteslamotrigine odt oral tablet dispersible Generic


Generic

















metaxalone oral tablet 800 mg Generic STPA; QL (120 EA per 30 days)


methocarbamol oral tablet Generic











136

Drug Status Notes
















MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA


naproxen dr oral tablet delayed release Generic










137

Drug Status NotesORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR Brand PA; SP; QL (4 ML per 28 days)






orphenadrine citrate er oral tablet extended release 12 hour

Generic




oxybutynin chloride er oral tablet extended release 24 hour

Generic

oxybutynin chloride oral syrup Generic

oxybutynin chloride oral tablet Generic

OXYTROL TRANSDERMAL PATCH TWICE WEEKLY Brand PA











Generic





138

Drug Status Notesraloxifene hcl oral tablet Generic





risedronate sodium oral tablet 30 mg, 5 mg Generic PA; QL (30 EA per 30 days)









Medical Benefit PA













sulindac oral tablet Generic


139

Drug Status Notes







tizanidine hcl oral tablet Generic




Generic

tolterodine tartrate oral tablet Generic

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA



trospium chloride er oral capsule extended release 24 hour

Generic

trospium chloride oral tablet Generic


VESICARE ORAL TABLET 10 MG Generic PA

VESICARE ORAL TABLET 5 MG Brand PA








XIAFLEX INJECTION SOLUTION RECONSTITUTED Medical Benefit PA



140

Drug Status Notes



NEUROPSYCHIATRIC DISORDER

Abilify Maintena Intramuscular Prefilled Syringe MB/RX PA

Abilify Maintena Intramuscular Suspension Reconstituted ER

MB/RX PA

acamprosate calcium oral tablet delayed release Generic QL (180 EA per 30 days)

alprazolam er oral tablet extended release 24 hour

Generic

alprazolam oral tablet Generic

alprazolam oral tablet dispersible Generic

alprazolam xr oral tablet extended release 24 hour

Generic

amoxapine oral tablet Generic




aripiprazole oral solution Generic PA; QL (750 ML per 30 days)

aripiprazole oral tablet Generic PA; QL (30 EA per 30 days)

aripiprazole oral tablet dispersible Generic PA; QL (30 EA per 30 days)

Aristada Initio Intramuscular Prefilled Syringe MB/RX PA

Aristada Intramuscular Prefilled Syringe MB/RX PA

ASCOMP-CODEINE ORAL CAPSULE Generic QL (180 EA per 30 days)



BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 6.3-1 MG Brand

PA; ¥ (Max of 32 mg/day for the first 6 months); QL (30 EA per 30 days)

BUNAVAIL BUCCAL FILM 4.2-0.7 MG BrandPA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)

buprenorphine hcl sublingual tablet sublingual Generic PA


141

Drug Status Notes

buprenorphine hcl-naloxone hcl sublingual film GenericPA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg

Generic¥ (Max of 32 mg/day for the first 6 months); QL (90 EA per 30 days)

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg

Generic¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)

bupropion hcl er (smoking det) oral tablet extended release 12 hour

Generic

bupropion hcl er (sr) oral tablet extended release 12 hour

Generic

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

Generic

bupropion hcl oral tablet Generic

buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg

Generic

buspirone hcl oral tablet 30 mg Generic PA

butalbital-acetaminophen oral tablet 50-325 mg Generic QL (180 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-325-40 mg


butalbital-apap-caffeine oral tablet 50-325-40 mg Generic QL (180 EA per 30 days)

butalbital-asa-caff-codeine oral capsule Generic QL (180 EA per 30 days)

butalbital-aspirin-caffeine oral capsule Generic QL (180 EA per 30 days)


Generic


Generic


CHANTIX CONTINUING MONTH PAK ORAL TABLET Brand PA; QL (60 EA per 30 days)

CHANTIX ORAL TABLET Brand PA; QL (60 EA per 30 days)

CHANTIX STARTING MONTH PAK ORAL TABLET Brand PA; QL (60 EA per 30 days)



citalopram hydrobromide oral solution Generic

citalopram hydrobromide oral tablet Generic


142

Drug Status Notesclomipramine hcl oral capsule Generic





clozapine oral tablet Generic

clozapine oral tablet dispersible Generic QL (60 EA per 30 days)


desipramine hcl oral tablet Generic

desvenlafaxine er oral tablet extended release 24 hour

Generic PA; STPA

desvenlafaxine fumarate er oral tablet extended release 24 hour

Brand PA; STPA
















143

Drug Status Notesdisulfiram oral tablet Generic


Generic


Generic




doxepin hcl oral capsule Generic

doxepin hcl oral concentrate Generic

drospirenone-ethinyl estradiol oral tablet 3-0.02 mg

Generic






EMSAM TRANSDERMAL PATCH 24 HOUR Brand PA; QL (30 EA per 30 days)

eq nicotine mouth/throat lozenge Generic

eq nicotine polacrilex mouth/throat gum Generic

eq nicotine polacrilex mouth/throat lozenge Generic

eq nicotine step 3 transdermal patch 24 hour Generic

eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr

Generic

eql nicotine polacrilex mouth/throat gum Generic

eql nicotine polacrilex mouth/throat lozenge Generic

eql nicotine transdermal patch 24 hour Generic


escitalopram oxalate oral solution Generic

escitalopram oxalate oral tablet Generic

FANAPT ORAL TABLET Brand PA; QL (60 EA per 30 days)

FANAPT TITRATION PACK ORAL TABLET Brand PA

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)


144

Drug Status NotesFETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK Brand PA; QL (28 EA per 28 days)

fluoxetine hcl (pmdd) oral capsule Generic PA

fluoxetine hcl (pmdd) oral tablet Generic PA

fluoxetine hcl oral capsule Generic

fluoxetine hcl oral solution Generic

fluoxetine hcl oral tablet 10 mg, 20 mg Generic PA

fluphenazine decanoate injection solution Generic

fluphenazine hcl oral concentrate Generic

fluphenazine hcl oral elixir Generic

fluphenazine hcl oral tablet Generic

fluvoxamine maleate er oral capsule extended release 24 hour


fluvoxamine maleate oral tablet Generic


Generic




gnp nicotine mini mouth/throat lozenge Generic

gnp nicotine polacrilex mouth/throat gum Generic

gnp nicotine polacrilex mouth/throat lozenge Generic


Generic PA

haloperidol decanoate intramuscular solution100 mg/ml, 50 mg/ml

Generic

haloperidol lactate injection solution 5 mg/ml Generic

haloperidol lactate oral concentrate Generic

haloperidol oral tablet Generic

hm nicotine polacrilex mouth/throat gum Generic

hm nicotine polacrilex mouth/throat lozenge Generic

hm nicotine transdermal patch 24 hour 21 mg/24hr, 7 mg/24hr

Generic




145

Drug Status Noteshydroxyzine pamoate oral capsule Generic

imipramine hcl oral tablet Generic

imipramine pamoate oral capsule Generic PA

Invega Sustenna Intramuscular Suspension MB/RXPA; ¥ (2 vials for first month); QL (1 vial per 30 days)

Invega Trinza Intramuscular Suspension MB/RX PA



Generic










LATUDA ORAL TABLET Brand PA; QL (30 EA per 30 days)

lithium carbonate er oral tablet extended release Generic

lithium carbonate oral capsule Generic

lithium carbonate oral tablet Generic

lithium oral solution Generic

LORAZEPAM INTENSOL ORAL CONCENTRATE Generic

lorazepam oral concentrate Generic

lorazepam oral tablet Generic


loxapine succinate oral capsule Generic

maprotiline hcl oral tablet Generic



meprobamate oral tablet Generic PA

METHADONE HCL INTENSOL ORAL CONCENTRATE Generic QL (6 ML per 1 day)


146

Drug Status Notesmethadone hcl oral concentrate Generic QL (6 ML per 1 day)

methadone hcl oral solution 10 mg/5ml Generic QL (30 ML per 1 day)


methadone hcl oral tablet 10 mg Generic QL (6 EA per 1 day)
























147

Drug Status Notes


mirtazapine oral tablet Generic

mirtazapine oral tablet dispersible Generic

naltrexone hcl oral tablet Generic

nefazodone hcl oral tablet Generic

NICORELIEF MOUTH/THROAT GUM Generic

nicotine mini mouth/throat lozenge Generic

nicotine polacrilex mouth/throat gum Generic

nicotine polacrilex mouth/throat lozenge Generic

nicotine step 1 transdermal patch 24 hour Generic



nicotine transdermal patch 24 hour Generic

NICOTROL INHALATION INHALER Brand PA

NICOTROL NS NASAL SOLUTION Brand PA


nortriptyline hcl oral capsule Generic

nortriptyline hcl oral solution Generic

NUEDEXTA ORAL CAPSULE Brand PA



olanzapine oral tablet Generic QL (30 EA per 30 days)

olanzapine oral tablet dispersible Generic QL (30 EA per 30 days)

olanzapine-fluoxetine hcl oral capsule Generic PA; QL (30 EA per 30 days)

OLEPTRO ORAL TABLET EXTENDED RELEASE 24 HOUR Brand PA; STPA


paliperidone er oral tablet extended release 24 hour


paroxetine hcl er oral tablet extended release 24 hour


paroxetine hcl oral tablet Generic


148

Drug Status Notesperphenazine oral tablet Generic

phenelzine sulfate oral tablet Generic


PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 50 MG Brand STPA

PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT Medical Benefit PA

protriptyline hcl oral tablet Generic PA

quetiapine fumarate er oral tablet extended release 24 hour

Generic PA

quetiapine fumarate oral tablet Generic QL (90 EA per 30 days)


ra mini nicotine mouth/throat lozenge Generic

ra nicotine mouth/throat gum Generic

ra nicotine polacrilex mouth/throat gum Generic

ra nicotine polacrilex mouth/throat lozenge Generic

ra nicotine transdermal patch 24 hour Generic

REXULTI ORAL TABLET Brand PA; QL (30 EA per 30 days)

RisperDAL Consta Intramuscular Suspension Reconstituted

MB/RX PA; QL (2 injections per 28 days)

RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE Generic

risperidone oral solution Generic

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg


risperidone oral tablet 4 mg Generic

risperidone oral tablet dispersible Generic



SAPHRIS SUBLINGUAL TABLET SUBLINGUAL Brand PA; QL (60 EA per 30 days)

sertraline hcl oral concentrate Generic

sertraline hcl oral tablet Generic

SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Medical Benefit PA


149

Drug Status Notes

SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG Brand


SUBOXONE SUBLINGUAL FILM 2-0.5 MG BrandPA; ¥ (Max of 32 mg/day for the first 6 months); QL (90 EA per 30 days)



tgt nicotine mouth/throat gum 4 mg Generic

tgt nicotine polacrilex mouth/throat gum Generic

tgt nicotine polacrilex mouth/throat lozenge Generic

tgt nicotine step one transdermal patch 24 hour Generic

tgt nicotine step three transdermal patch 24 hour Generic

tgt nicotine step two transdermal patch 24 hour Generic

thioridazine hcl oral tablet Generic

thiothixene oral capsule Generic

tranylcypromine sulfate oral tablet Generic

trazodone hcl oral tablet Generic

trifluoperazine hcl oral tablet Generic

trimipramine maleate oral capsule Generic PA

TRINTELLIX ORAL TABLET Brand PA; QL (30 EA per 30 days)

venlafaxine hcl er oral capsule extended release 24 hour

Generic

venlafaxine hcl er oral tablet extended release 24 hour

Generic STPA

venlafaxine hcl oral tablet Generic


VIIBRYD ORAL TABLET Brand PA; QL (30 EA per 30 days)

VIIBRYD STARTER PACK ORAL KIT Brand PA

VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED Medical Benefit PA

VRAYLAR ORAL CAPSULE Brand PA

VRAYLAR ORAL CAPSULE THERAPY PACK Brand PA



150

Drug Status Notes


ziprasidone hcl oral capsule Generic QL (60 EA per 30 days)

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG

BrandPA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG, 8.6-2.1 MG Brand


ZyPREXA Relprevv Intramuscular Suspension Reconstituted 210 MG, 300 MG

MB/RX PA; QL (2 vials per 28 days)

ZyPREXA Relprevv Intramuscular Suspension Reconstituted 405 MG

MB/RX PA; QL (1 vial per 28 days)

NOT FEELING WELL


NUTRITIONAL DISORDER





cyanocobalamin injection solution Generic

ergocalciferol oral capsule Generic

folbee oral tablet Generic




levocarnitine oral tablet Generic


Generic


multi vitamin/minerals oral tablet Generic




Generic


151

Drug Status Notesmulti-vitamin/fluoride oral tablet chewable 0.5 mg

Brand

mynephrocaps oral capsule Generic


RENAL ORAL CAPSULE Generic




vitamin d (ergocalciferol) oral capsule 50000 unit Generic


OTHER OVER-THE-COUNTER DRUGS

ACCU-CHEK SAFE-T PRO LANCETS Brand

ACCU-CHEK SOFT TOUCH LANCETS Brand

ACCU-CHEK SOFTCLIX LANCETS Brand

AT LAST LANCETS Brand

BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 29G X 1/2" 2 ML, U-100 1 ML

Brand

BD INSULIN SYRINGE MICROFINE Brand

BD INSULIN SYRINGE U/F 30G X 1/2" 1 ML Brand

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML

Brand

BD LANCET ULTRAFINE 33G Brand

BD SAFETY-LOK INSULIN SYRINGE Brand

BD SYRINGE SLIP TIP 3 ML Brand

CLEANLET LANCETS 28G Brand


comfort lancets Brand

cytra-2 oral solution Generic

daily multi oral tablet Brand


152

Drug Status Notesdiphenhydramine hcl oral capsule 25 mg Brand

eq nicotine mouth/throat gum 4 mg Generic



eq nicotine transdermal patch 24 hour 7 mg/24hr Generic

EZ-LETS LANCETS 26G Brand

FINGERSTIX LANCETS Brand

FREESTYLE INSULINX TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

FREESTYLE LANCETS Brand

FREESTYLE LITE TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

FREESTYLE PRECISION NEO TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

FREESTYLE TEST IN VITRO STRIP $0 QL (150 strips per 30 days)

GENTLE-LET GP LANCETS Brand

GENTLE-LET LANCETS Brand

GLUCOSOURCE LANCETS Brand

gnp lancets Brand

gnp ultra com insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml

Brand

HAEMOLANCE LOW FLOW LANCETS Brand

hm nicotine transdermal patch 24 hour 7 mg/24hr Generic

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Brand

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION Brand

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR Brand

HUMULIN N SUBCUTANEOUS SUSPENSION Brand

HUMULIN R INJECTION SOLUTION Brand

HY-VEE LANCETS Brand

hy-vee thin lancets Brand


153

Drug Status Notesinsulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Brand

insulin syringe 29g x 1/2" 1 ml, 30g x 5/16" 1 ml Brand

insulin syringe/needle Brand

kinney lancets Brand

kinney thin lancets Brand

kinray insulin syringe 29g x 1/2" 0.5 ml Brand

lancets Brand

lancets thin Brand


LIFESCAN UNISTIK II LANCETS Brand

lite touch lancets Brand

longs lancets thin Brand

MEDISENSE THIN LANCETS Brand

MEIJER LANCETS Brand

MICROTAINER SAFETY FLOW LANCET Brand

MONOJECT FILTER ASPIRATOR Brand

MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 30G X 5/16" 1 ML, U-100 1 ML

Brand

MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML Brand

MONOJECT PHARMACY TRAY 20 ML , 3 ML , 35 ML , 6 ML , 60 ML Brand

MONOJECT PISTON SYRINGE Brand

MONOJECT SAFETY SYRINGE/SHIELD 12 ML , 20G X 1-1/2" 12 ML, 21G X 1" 3 ML, 21G X 1-1/2" 3 ML, 3 ML

Brand


154

Drug Status NotesMONOJECT SYRINGE 12 ML , 18G X 1" 12 ML, 20G X 1" 3 ML, 20G X 1-1/2" 12 ML, 20G X 1-1/2" 3 ML, 20G X 1-1/2" 6 ML, 20G X 3/4" 3 ML, 21G X 1" 12 ML, 21G X 1" 3 ML, 21G X 1" 6 ML, 21G X 1-1/2" 12 ML, 21G X 1-1/2" 3 ML, 21G X 1-1/2" 6 ML, 22G X 1" 3 ML, 22G X 1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 1" 3 ML, 25G X 1-1/4" 3 ML, 25G X 5/8" 3 ML, 27G X 1-1/4" 3 ML, 3 ML

Brand

MONOJECT SYRINGE CATH TIP Brand

MONOJECT SYRINGE ECC LUER 35 ML Brand

MONOJECT SYRINGE LUER LOCK Brand

MONOJECT SYRINGE REG LUER 12 ML , 20 ML , 3 ML , 35 ML , 6 ML Brand

MONOJECT TB SAFETY SYRINGE 28G X 1/2" 1 ML Brand

MONOJECT TB SYRINGE 25G X 5/8" 1 ML, 26G X 3/8" 1 ML, 28G X 1/2" 1 ML Brand

MONOJECT ULTRA COMFORT SYRINGE28G X 1/2" 0.5 ML Brand

MONOLET LANCETS Brand

MULTI COMPLETE ORAL CAPSULE Generic

n-acetyl-l-cysteine oral capsule Generic

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION Brand

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION Brand

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION Brand

NOVOLIN N SUBCUTANEOUS SUSPENSION Brand

NOVOLIN R INJECTION SOLUTION Brand

NOVOLIN R RELION INJECTION SOLUTION Brand

ONETOUCH CLUB LANCETS FINE PT Brand

ONETOUCH FINEPOINT LANCETS Brand

ONETOUCH LANCETS Brand

ONETOUCH ULTRASOFT LANCETS Brand


155

Drug Status NotesPRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML

Brand

PRECISION THIN LANCETS Brand

PRECISION THINS GP LANCETS Brand

PRECISION ULTRA LANCET Brand

PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP $0 QL (150 strips per 30 days)

preferred plus lancets colored Brand

preferred plus lancets thin Brand

prenatal 19 oral tablet Generic

prenatal 19 oral tablet chewable Generic

PSS SELECT GP LANCETS Brand

PSS SELECT SAFETY LANCETS Brand

qc nicotine polacrilex mouth/throat gum Generic

reality lancets Brand

reality trigger lancets Brand

sb lancets thin Brand

sb lancets ultra thin Brand

sr nicotine mouth/throat gum Generic

super thin lancets Brand

sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml

Brand

SURELITE LANCETS Brand

tb syringe 1 ml Brand

TECHLITE LANCETS Brand

tgt nicotine mouth/throat gum Generic

THINLETS GP LANCETS Brand

THINLETS LANCET Brand

topco insulin syringe Brand

ULTILET CLASSIC LANCETS Brand

ULTILET LANCETS Brand

ULTRA-THIN II AUTO LANCET Brand


156

Drug Status NotesULTRA-THIN II LANCETS Brand

UNILET COMFORTOUCH LANCET Brand

UNILET G.P. LANCET Brand

UNILET G.P. SUPERLITE LANCET Brand

UNILET LANCET Brand

UNILET SUPERLITE LANCET Brand

UNISTIK 1 Brand

VITALET PRO LANCETS Brand

VITALET PRO PLUS LANCETS Brand

W&F LANCETS 26G Brand

W&F LANCETS COLORED 21G Brand

weight loss daily multi oral tablet Generic

OTHER PRESCRIPTION DRUGS




acamprosate calcium oral tablet delayed release Generic QL (180 EA per 30 days)

acetaminophen-codeine oral tablet Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)

acetazolamide er oral capsule extended release 12 hour

Generic


acitretin oral capsule Generic QL (60 EA per 30 days)



acyclovir oral capsule Generic

acyclovir oral suspension Generic

acyclovir oral tablet Generic



ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand

ADMELOG SUBCUTANEOUS SOLUTION Brand

ALBENZA ORAL TABLET Brand


157

Drug Status NotesALECENSA ORAL CAPSULE Brand PA; SP

ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED Medical Benefit PA




alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 25-30 mg, 25-45 mg


ALOMIDE OPHTHALMIC SOLUTION Brand PA

alosetron hcl oral tablet 0.5 mg Generic

Alphanate Intravenous Solution Reconstituted MB/RX PA; SP

ALUNBRIG ORAL TABLET Brand PA; SP

ALUNBRIG ORAL TABLET THERAPY PACK Brand PA; SP

amiodarone hcl oral tablet 100 mg Generic

amitriptyline hcl oral tablet Generic

amlodipine besylate-valsartan oral tablet Generic PA; QL (30 EA per 30 days)

amlodipine-olmesartan oral tablet Generic PA

amlodipine-valsartan-hctz oral tablet Generic PA; QL (30 EA per 30 days)


amoxicillin oral capsule Generic

amoxicillin oral suspension reconstituted Generic

amoxicillin oral tablet Generic

amoxicillin oral tablet chewable 125 mg, 250 mg Generic

amoxicillin-pot clavulanate er oral tablet extended release 12 hour

Generic

amoxicillin-pot clavulanate oral suspension reconstituted

Generic

amoxicillin-pot clavulanate oral tablet Generic

amoxicillin-pot clavulanate oral tablet chewable Generic

amphetamine-dextroamphetamine oral tablet 12.5 mg, 15 mg, 7.5 mg


ampicillin oral capsule Generic

ampicillin oral suspension reconstituted Generic

anastrozole oral tablet Generic


158

Drug Status NotesANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED

Brand PA

ANTARA ORAL CAPSULE 30 MG, 90 MG Brand PA; QL (30 EA per 30 days)

antipyrine-benzocaine otic solution 5.4-1.4 %, 54-14 mg/ml

Generic

APIDRA INJECTION SOLUTION Brand

APIDRA OPTICLIK SUBCUTANEOUS SOLUTION Brand

APIDRA OPTICLIK SUBCUTANEOUS SOLUTION CARTRIDGE Brand

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand

APTIOM ORAL TABLET Brand PA

aripiprazole oral tablet 2 mg Generic PA; QL (30 EA per 30 days)

aripiprazole oral tablet dispersible Generic PA; QL (30 EA per 30 days)





atovaquone oral suspension Generic

AUBRA ORAL TABLET Generic


AVAR CLEANSER EXTERNAL EMULSION Generic

azithromycin oral packet Generic

azithromycin oral suspension reconstituted Generic

azithromycin oral tablet 250 mg, 500 mg, 600 mg Generic

bacitra-neomycin-polymyxin-hc ophthalmic ointment

Generic

BANZEL ORAL SUSPENSION Brand PA

BANZEL ORAL TABLET Brand PA

BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand

BAXDELA ORAL TABLET Brand PA

benzphetamine hcl oral tablet 25 mg Generic PA

bexarotene oral capsule Generic


159

Drug Status Notesbicalutamide oral tablet Generic

bimatoprost ophthalmic solution Generic PA

BOSULIF ORAL TABLET 100 MG Brand PA; SP; QL (120 EA per 30 days)

BOSULIF ORAL TABLET 500 MG Brand PA; SP; QL (30 EA per 30 days)

bp multinatal plus oral tablet chewable Generic

BRAFTOVI ORAL CAPSULE Brand PA

BRINTELLIX ORAL TABLET Brand PA; QL (30 EA per 30 days)


Generic

budesonide inhalation suspension 1 mg/2ml Generic

buprenorphine hcl-naloxone hcl sublingual film GenericPA; ¥ (Max of 32 mg/day for the first 6 months); QL (60 EA per 30 days)

buprenorphine transdermal patch weekly 10 mcg/hr, 20 mcg/hr, 5 mcg/hr



CABOMETYX ORAL TABLET Brand PA; SP

calcipotriene-betameth diprop external ointment Generic PA

CALQUENCE ORAL CAPSULE Brand PA

capecitabine oral tablet Generic

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

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

carbamazepine er oral tablet extended release 12 hour 100 mg

Generic


carvedilol phosphate er oral capsule extended release 24 hour

GenericPA; STPA; QL (30 EA per 30 days)

cefaclor oral capsule Generic

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

Generic

cefadroxil oral capsule Generic

cefadroxil oral suspension reconstituted Generic

cefadroxil oral tablet Generic

cefdinir oral capsule Generic

cefdinir oral suspension reconstituted Generic

cefditoren pivoxil oral tablet 200 mg Generic


160

Drug Status Notescefixime oral suspension reconstituted Generic

cefpodoxime proxetil oral suspension reconstituted

Generic

cefpodoxime proxetil oral tablet Generic

cefprozil oral suspension reconstituted Generic

cefprozil oral tablet Generic

ceftibuten oral capsule Generic

CEFTIN ORAL SUSPENSION RECONSTITUTED Brand PA

cefuroxime axetil oral tablet Generic


cephalexin oral capsule Generic

cephalexin oral suspension reconstituted Generic

cephalexin oral tablet Generic

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 200 UNIT Medical Benefit PA

CEROVEL EXTERNAL LOTION Generic

chlorthalidone oral tablet 100 mg Generic

choline & mag trisalicylate oral tablet 1000 mg Generic

ciprofloxacin hcl ophthalmic solution Generic

ciprofloxacin hcl oral tablet Generic

ciprofloxacin oral suspension reconstituted Generic

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour

Generic

clarithromycin er oral tablet extended release 24 hour

Generic

clarithromycin oral suspension reconstituted Generic

clarithromycin oral tablet Generic

clindamycin hcl oral capsule Generic

clindamycin palmitate hcl oral solution reconstituted

Generic

clobetasol propionate external liquid Generic PA






161

Drug Status Notesclozapine oral tablet dispersible 150 mg, 200 mg Generic QL (60 EA per 30 days)

colesevelam hcl oral tablet Generic PA

COMETRIQ (100 MG DAILY DOSE) ORAL KIT Brand PA



CORTISPORIN-TC OTIC SUSPENSION Brand PA

COTELLIC ORAL TABLET Brand PA; SP

cyclopentolate hcl ophthalmic solution 0.5 % Generic QL (15 ML per 30 days)

cyclophosphamide oral capsule Generic

cycloserine oral capsule Generic




Generic PA

demeclocycline hcl oral tablet Generic PA

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

$0

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

Generic






diazepam oral solution 5 mg/5ml Generic

diclofenac sodium oral tablet delayed release Generic


diclofenac sodium transdermal gel 3 % Generic¥ (Max of 90 days per year); QL (200 GM per 30 days)


dicloxacillin sodium oral capsule Generic

dicyclomine hcl oral solution Generic


162

Drug Status Notesdiltiazem hcl er coated beads oral tablet extended release 24 hour

Generic PA


dorzolamide hcl ophthalmic solution Generic

dorzolamide hcl-timolol mal ophthalmic solution Generic

doxepin hcl external cream Generic QL (45 grams per 1 Fill)


doxycycline hyclate oral capsule Generic

doxycycline hyclate oral tablet 100 mg Generic

doxycycline monohydrate oral capsule 100 mg, 50 mg

Generic

doxycycline monohydrate oral suspension reconstituted

Generic

doxycycline monohydrate oral tablet 100 mg, 50 mg

Generic

drospiren-eth estrad-levomefol oral tablet 3-0.03-0.451 mg

Generic


Generic








DYSPORT (GLABELLAR LINES) INTRAMUSCULAR SOLUTION RECONSTITUTED


E.E.S. 400 ORAL TABLET Generic






ERLEADA ORAL TABLET Brand PA; SP


163

Drug Status NotesERYPED 400 ORAL SUSPENSION RECONSTITUTED Generic

ERY-TAB ORAL TABLET DELAYED RELEASE Generic

ERYTHROCIN STEARATE ORAL TABLET250 MG Generic

erythromycin base oral capsule delayed release particles

Generic

erythromycin base oral tablet Generic

erythromycin ethylsuccinate oral suspension reconstituted

Generic

erythromycin ethylsuccinate oral tablet Generic

est estrogens-methyltest hs oral tablet Generic

est estrogens-methyltest oral tablet Generic


estradiol-norethindrone acet oral tablet Generic


ethambutol hcl oral tablet Generic

etoposide oral capsule Generic

ezetimibe oral tablet Generic PA; QL (30 EA per 30 days)

ezetimibe-simvastatin oral tablet Generic PA; QL (30 EA per 30 days)

FABIOR EXTERNAL FOAM Brand PA

famciclovir oral tablet Generic

FARESTON ORAL TABLET Brand


felbamate oral suspension Generic PA

felbamate oral tablet Generic PA

fenofibrate oral capsule 150 mg, 50 mg Generic PA; QL (30 EA per 30 days)

fenofibrate oral tablet 120 mg, 40 mg Generic PA; QL (30 EA per 30 days)

fenofibric acid oral capsule delayed release Generic PA; QL (30 EA per 30 days)

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR Brand PA; QL (30 EA per 30 days)

FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK Brand PA; QL (28 EA per 28 days)

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand


164

Drug Status NotesFIASP SUBCUTANEOUS SOLUTION Brand

FIRST-LANSOPRAZOLE ORAL SUSPENSION Brand

PA; ¥ (PA applies to members 14 and older (No PA required for members 0-13 years of age))

FIRST-OMEPRAZOLE ORAL SUSPENSION Brand

PA; ¥ (PA applies to members 14 and older (No PA required for members 0-13 years of age))

FIRVANQ ORAL SOLUTION RECONSTITUTED Brand PA; QL (2 Bottles per 10 days)

fluconazole oral suspension reconstituted Generic

fluconazole oral tablet Generic

flucytosine oral capsule Generic PA


FLUORIDEX ENHANCED WHITENING DENTAL GEL Generic

fluoxetine hcl (pmdd) oral tablet Generic PA


flurandrenolide external lotion Generic PA

flutamide oral capsule Generic

fluvastatin sodium er oral tablet extended release 24 hour





gatifloxacin ophthalmic solution Generic

gentamicin sulfate ophthalmic ointment Generic

gentamicin sulfate ophthalmic solution Generic

GILOTRIF ORAL TABLET Brand PA

GLEOSTINE ORAL CAPSULE 5 MG Brand

glycopyrrolate oral tablet 1 mg, 2 mg Generic



Hemofil M Intravenous Solution Reconstituted 1000 UNIT, 1700 UNIT, 1701-2000 UNIT, 250 UNIT, 500 UNIT, 801-1700 UNIT

MB/RX PA; SP

heparin sodium (porcine) injection solution 2500 unit/ml

Generic


165

Drug Status NotesHEXALEN ORAL CAPSULE Brand

Hizentra Subcutaneous Solution 10 GM/50ML MB/RX PA; SP

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

Brand

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Brand

HUMALOG MIX 50/50 PEN SUBCUTANEOUS SUSPENSION Brand

HUMALOG MIX 50/50 PEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Brand

HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION Brand

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Brand

HUMALOG MIX 75/25 PEN SUBCUTANEOUS SUSPENSION Brand

HUMALOG MIX 75/25 PEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Brand

HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION Brand

HUMALOG PEN SUBCUTANEOUS SOLUTION Brand

HUMALOG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand

HUMALOG SUBCUTANEOUS SOLUTION Brand


MB/RX PA; SP

HYCAMTIN ORAL CAPSULE 0.25 MG Brand PA; SP; QL (15 EA per 21 days)

HYCAMTIN ORAL CAPSULE 1 MG Brand PA; SP; QL (25 EA per 21 days)

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml

Generic QL (480 ML per 1 day)



166

Drug Status NotesHYDROXYprogesterone Caproate Intramuscular Oil


HYOPHEN ORAL TABLET Generic

hyoscyamine sulfate er oral tablet extended release 12 hour

Generic

hyoscyamine sulfate oral elixir Generic

hyoscyamine sulfate oral solution Generic

hyoscyamine sulfate oral tablet Generic

hyoscyamine sulfate oral tablet dispersible Generic

hyoscyamine sulfate sublingual tablet sublingual Generic

hyosyne oral elixir Generic

hyosyne oral solution Generic

IBRANCE ORAL CAPSULE Brand PA; SP

ICLUSIG ORAL TABLET Brand PA

IDHIFA ORAL TABLET Brand PA; QL (30 EA per 30 days)

ILARIS (150MG DELIVERED) SUBCUTANEOUS SOLUTION RECONSTITUTED


imatinib mesylate oral tablet 100 mg Generic

imatinib mesylate oral tablet 400 mg Brand

IMBRUVICA ORAL TABLET 140 MG Brand PA

INLYTA ORAL TABLET Brand PA; SP

IRESSA ORAL TABLET Brand PA

isometheptene-dichloral-apap oral capsule Generic QL (300 EA per 30 days)

isotretinoin oral capsule Generic PA

itraconazole oral capsule Generic


ketoconazole oral tablet Generic

KISQALI 200 DOSE ORAL TABLET Brand PA



Kogenate FS Intravenous Kit MB/RX PA; SP

KUVAN ORAL PACKET 100 MG Brand PA; SP




167

Drug Status NotesLARIN FE 1.5/30 ORAL TABLET Generic

LARIN FE 1/20 ORAL TABLET Generic

latanoprost ophthalmic solution Generic

LATRIX EXTERNAL SUSPENSION Generic

LATUDA ORAL TABLET 60 MG Brand PA; QL (30 EA per 30 days)

LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK Brand PA







levofloxacin ophthalmic solution Generic

levofloxacin oral solution Generic

levofloxacin oral tablet Generic

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg

Generic

levonorgestrel oral tablet 1.5 mg Generic

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

$0

levonorg-eth estrad triphasic oral tablet Generic


linezolid oral suspension reconstituted Generic QL (840 ML per 14 days)

linezolid oral tablet Generic QL (28 EA per 14 days)

LOMEDIA 24 FE ORAL TABLET Generic

lomustine oral capsule Generic

LUPRON INJECTION KIT Medical Benefit PA

LUPRON SUBCUTANEOUS SOLUTION Medical Benefit PA

LYNPARZA ORAL CAPSULE Brand PA

LYNPARZA ORAL TABLET Brand PA


168

Drug Status NotesLYSODREN ORAL TABLET Brand

LYZA ORAL TABLET Generic

MATULANE ORAL CAPSULE Brand

me/naphos/mb/hyo1 oral tablet Generic

megestrol acetate oral suspension 625 mg/5ml Generic

megestrol acetate oral tablet Generic

MEKINIST ORAL TABLET Brand PA; SP

MEKTOVI ORAL TABLET Brand PA

melphalan oral tablet Generic



meperidine hcl oral tablet 100 mg Generic QL (12 EA per 1 day)

mercaptopurine oral tablet Generic




Generic PA

methoxsalen rapid oral capsule Generic





metronidazole oral capsule Generic

metronidazole oral tablet Generic

miglitol oral tablet Generic

minocycline hcl oral capsule Generic



Monoclate-P Intravenous Kit 1500 UNIT, 250 UNIT, 500 UNIT

MB/RX PA; SP

MONOJECT CONTROL SYRINGE Brand


169

Drug Status NotesMONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML

Brand

MONOJECT SAFETY SYRINGE/SHIELD21G X 1-1/2" 12 ML, 22G X 1-1/2" 3 ML Brand

MONOJECT SYRINGE 22G X 1-1/2" 12 ML, 22G X 1-1/2" 6 ML, 3 ML , 6 ML Brand

MONOJECT SYRINGE LUER LOCK 6 ML , 60 ML Brand

MONOJECT SYRINGE REG LUER 12 ML Brand

Mononine Intravenous Solution Reconstituted MB/RX PA; SP

morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 90 mg

Generic PA; QL (2 EA per 1 day)

morphine sulfate er beads oral capsule extended release 24 hour 30 mg








morphine sulfate er oral capsule extended release 24 hour 10 mg




moxifloxacin hcl oral tablet Generic



multivitamin/fluoride oral tablet chewable 0.25-0.3 mg, 0.5-0.3 mg, 1-0.3 mg

Generic


Generic


MYLERAN ORAL TABLET Brand


neomycin-polymyxin-dexameth ophthalmic ointment

Generic


170

Drug Status Notesneomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

Generic

neomycin-polymyxin-hc otic solution 1 % Generic

NEO-POLYCIN HC OPHTHALMIC OINTMENT Generic

NERLYNX ORAL TABLET Brand PA

nevirapine er oral tablet extended release 24 hour400 mg

Generic

NEXAVAR ORAL TABLET Brand PA; SP; QL (120 EA per 30 days)

niacin er (antihyperlipidemic) oral tablet extended release

Generic

NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG Generic

nilutamide oral tablet Generic

nitrofurantoin macrocrystal oral capsule Generic

nitrofurantoin monohyd macro oral capsule Generic

nitrofurantoin oral suspension Generic

NODOLOR ORAL CAPSULE Generic QL (300 EA per 30 days)

norethin ace-eth estrad-fe oral tablet Generic

norethin ace-eth estrad-fe oral tablet chewable Generic

norethindrone acet-ethinyl est oral tablet Generic


norethin-eth estradiol-fe oral tablet chewable 0.8-25 mg-mcg

Generic

norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-25 mcg

Generic

norgestrel-ethinyl estradiol oral tablet Generic

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

Brand

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION Brand

NOVOLOG SUBCUTANEOUS SOLUTION Brand

NovoSeven Intravenous Solution Reconstituted MB/RX PA; SP


171

Drug Status NotesNOXAFIL ORAL TABLET DELAYED RELEASE Brand PA

np thyroid oral tablet 15 mg, 30 mg, 60 mg, 90 mg

Generic

ofloxacin ophthalmic solution Generic

ofloxacin oral tablet 400 mg Generic

olmesartan medoxomil oral tablet Generic STPA

olmesartan medoxomil-hctz oral tablet Generic STPA



OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION Brand PA




opium oral tincture Generic


oseltamivir phosphate oral capsule 30 mg Generic¥ (Max of 2 fills per year); QL (20 EA per 1 Fill)

oseltamivir phosphate oral capsule 45 mg, 75 mg Generic¥ (Max of 2 fills per year); QL (10 EA per 1 Fill)

oseltamivir phosphate oral suspension reconstituted

Generic¥ (Max of 2 fills per year); QL (180 ML per 1 Fill)

otic care otic solution Generic


oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 20 mg, 40 mg, 80 mg


oxycodone-acetaminophen oral solution Generic¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG Brand PA; QL (90 EA per 30 days)

paliperidone er oral tablet extended release 24 hour


PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT

Brand

pantoprazole sodium oral tablet delayed release Generic


172

Drug Status Notesparicalcitol oral capsule Generic PA


penicillin g procaine intramuscular suspension Generic

penicillin v potassium oral solution reconstituted Generic

penicillin v potassium oral tablet Generic


phenobarbital oral elixir Generic

phenobarbital oral solution Generic

phenobarbital oral tablet Generic

PHENOHYTRO ORAL TABLET Generic



phenylephrine-guaifenesin oral liquid Generic

PHOS-FLUR DENTAL GEL Generic

PHOSPHASAL ORAL TABLET Generic

phytonadione oral tablet Generic

pimozide oral tablet 2 mg Generic PA

PIMTREA ORAL TABLET Generic

PIRMELLA 7/7/7 ORAL TABLET Generic

POMALYST ORAL CAPSULE Brand PA; SP

potassium chloride er oral tablet extended release20 meq

Generic

potassium chloride oral packet Generic

potassium citrate er oral tablet extended release Generic


Generic




Generic

prednisone oral solution Generic

prednisone oral tablet Generic

prednisone oral tablet therapy pack Generic

premium lidocaine external ointment Generic QL (50 GM per 30 days)


173

Drug Status Notesprimidone oral tablet Generic



progesterone micronized transdermal cream Generic

promethazine hcl rectal suppository 50 mg Generic


PROTONIX ORAL PACKET Brand PA

PURIXAN ORAL SUSPENSION Brand

pyrazinamide oral tablet Generic


Generic

quetiapine fumarate er oral tablet extended release 24 hour

Generic PA

quinine sulfate oral capsule Generic PA




REA LO 40 EXTERNAL CREAM Generic

REA LO 40 EXTERNAL LOTION Generic

REMEVEN EXTERNAL CREAM Generic



REVLIMID ORAL CAPSULE Brand PA; SP

rifabutin oral capsule Generic

rifampin oral capsule Generic


risedronate sodium oral tablet 30 mg, 5 mg Generic PA; QL (30 EA per 30 days)



RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE Generic


rivastigmine transdermal patch 24 hour 4.6 mg/24hr, 9.5 mg/24hr

Generic

Rixubis Intravenous Solution Reconstituted MB/RX PA; SP


174

Drug Status NotesROSANIL CLEANSER EXTERNAL EMULSION Generic

rosuvastatin calcium oral tablet Generic PA; QL (30 EA per 30 days)

RUBRACA ORAL TABLET 200 MG, 300 MG Brand PA; SP; QL (120 EA per 30 days)

RUBRACA ORAL TABLET 250 MG Brand PA; QL (120 EA per 30 days)

RYDAPT ORAL CAPSULE Brand PA




SIVEXTRO ORAL TABLET Brand PA; QL (6 EA per 365 days)

sodium fluoride oral tablet 2.2 (1 f) mg Generic

sodium polystyrene sulfonate oral powder Generic


SPRYCEL ORAL TABLET 100 MG, 140 MG Brand PA; SP; QL (30 EA per 30 days)

SPRYCEL ORAL TABLET 20 MG, 50 MG, 70 MG, 80 MG Brand PA; SP; QL (60 EA per 30 days)

STIVARGA ORAL TABLET Brand PA; SP; QL (84 EA per 28 days)

sulfacetamide sodium-sulfur external emulsion Generic

sulfacetamide sodium-sulfur external lotion 10-5 %

Generic

sulfamethoxazole-trimethoprim oral suspension200-40 mg/5ml

Generic

sulfamethoxazole-trimethoprim oral tablet Generic


SUPRAX ORAL CAPSULE Brand PA

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML Brand PA

SUPRAX ORAL TABLET CHEWABLE Brand PA

SUTENT ORAL CAPSULE Brand PA; SP

TABLOID ORAL TABLET Brand



tadalafil oral tablet 5 mg Generic PA; QL (30 EA per 30 days)

TAFINLAR ORAL CAPSULE Brand PA; SP


175

Drug Status NotesTAGRISSO ORAL TABLET 40 MG Brand PA; QL (30 Tablets per 30 days)

TAGRISSO ORAL TABLET 80 MG Brand PA

TARCEVA ORAL TABLET 100 MG, 150 MG Brand SP; QL (30 EA per 30 days)

TARCEVA ORAL TABLET 25 MG Brand SP; QL (90 EA per 30 days)

TASIGNA ORAL CAPSULE Brand PA; SP


telmisartan-hctz oral tablet Generic PA

temozolomide oral capsule Generic


terbinafine hcl oral tablet Generic¥ (Max of 90 tablets per 365 days); QL (30 EA per 30 days)

testosterone transdermal gel 10 mg/act (2%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

Generic PA




tetracycline hcl oral capsule Generic

TIBSOVO ORAL TABLET Brand PA

TIVICAY ORAL TABLET 50 MG Brand


tobramycin ophthalmic solution Generic



Generic

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR Brand

tretinoin external gel 0.05 % Generic PA; Age Limit (Max 26 Years)

tretinoin oral capsule Generic



TRI-LO-SPRINTEC ORAL TABLET Generic


trimethoprim oral tablet Generic


176

Drug Status NotesTROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG



TYKERB ORAL TABLET Brand PA; SP; QL (180 EA per 30 days)

UNITHROID DIRECT ORAL TABLET Generic

UNITHROID ORAL TABLET 137 MCG Generic

urea external cream 40 %, 50 % Generic

urea external lotion 40 % Generic

urea external suspension Generic

urea nail film external suspension Generic

urea-c40 external lotion Generic

ure-k external cream Generic

URIMAR-T ORAL TABLET Generic

UROLET MB ORAL TABLET Generic

UROPHEN MB ORAL TABLET Generic

URYL ORAL TABLET Generic

valacyclovir hcl oral tablet Generic

valganciclovir hcl oral solution reconstituted Generic

valganciclovir hcl oral tablet Generic

valsartan oral tablet Generic STPA

vancomycin hcl oral capsule Generic QL (40 EA per 10 days)

VENCLEXTA ORAL TABLET Brand PA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK Brand PA

VERZENIO ORAL TABLET Brand PA; SP


voriconazole oral suspension reconstituted Generic PA

voriconazole oral tablet Generic PA; QL (180 EA per 30 days)

VOTRIENT ORAL TABLET Brand PA; SP; QL (120 EA per 30 days)

VYFEMLA ORAL TABLET Generic

Wilate Intravenous Solution Reconstituted MB/RX PA; SP

XALKORI ORAL CAPSULE Brand PA; SP

XTANDI ORAL CAPSULE Brand PA; SP; QL (120 EA per 30 days)


177

Drug Status NotesYONSA ORAL TABLET Brand PA

ZEJULA ORAL CAPSULE Brand PA

ZELBORAF ORAL TABLET Brand PA; SP

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000-51000 UNIT, 20000-68000 UNIT, 25000 UNIT, 3000-10000 UNIT, 5000 UNIT

Brand

ZOMIG NASAL SOLUTION 2.5 MG BrandPA; STPA; QL (6 Units per 30 days)

ZOVIRAX EXTERNAL CREAM Brand PA; QL (5 GM per 1 Rx)

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


ZYDELIG ORAL TABLET Brand PA

ZYKADIA ORAL CAPSULE Brand PA; SP

ZYTIGA ORAL TABLET 250 MG Brand PA; SP; QL (120 EA per 30 days)

OVERDOSE


AMITIZA ORAL CAPSULE Brand PA; QL (60 EA per 30 days)

EVZIO INJECTION SOLUTION AUTO-INJECTOR Brand

PA; ¥ (Max of 4 units per 30 days); QL (2 Units per 1 Rx)

FERRIPROX ORAL SOLUTION Brand PA

FERRIPROX ORAL TABLET Brand PA




MOVANTIK ORAL TABLET Brand PA

naloxone hcl injection solution 0.4 mg/ml Generic

NARCAN NASAL LIQUID Brand¥ (1 kit(box) per RX, 2 kits(boxes) per 30 days); QL (1 Kit per 1 RX)

RELISTOR ORAL TABLET Brand PA; QL (90 Tablets per 30 days)

RELISTOR SUBCUTANEOUS SOLUTION12 MG/0.6ML, 8 MG/0.4ML Brand PA

SYMPROIC ORAL TABLET Brand PA


VISTOGARD ORAL PACKET Brand QL (20 EA per 30 days)


178

Drug Status NotesPAIN

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL Brand PA

acetaminophen-codeine #2 oral tablet Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)



acetaminophen-codeine oral solution Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)

acetaminophen-codeine oral tablet Generic¥ (Max of 4 g of acetaminophen or 360 mg of codeine)


amlodipine besylate oral tablet Generic

ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT Brand PA

ASCOMP-CODEINE ORAL CAPSULE Generic QL (180 EA per 30 days)

atenolol oral tablet Generic

BELBUCA BUCCAL FILM Brand PA; QL (60 Films per 30 days)




Generic


buprenorphine transdermal patch weekly Generic PA; QL (4 EA per 28 days)

butalbital-acetaminophen oral tablet 50-325 mg Generic QL (180 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-325-40 mg


butalbital-apap-caffeine oral tablet 50-325-40 mg Generic QL (180 EA per 30 days)

butalbital-asa-caff-codeine oral capsule Generic QL (180 EA per 30 days)


butorphanol tartrate injection solution Generic

butorphanol tartrate nasal solution Generic

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG Brand PA


179

Drug Status NotesCIDALEAZE EXTERNAL CREAM Generic


cimetidine oral tablet 200 mg Generic

clopidogrel bisulfate oral tablet Generic

codeine sulfate oral tablet Generic QL (360 mg per 1 day)



diflunisal oral tablet Generic


diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

Generic

diltiazem hcl er beads oral capsule extended release 24 hour

Generic

diltiazem hcl er coated beads oral capsule extended release 24 hour

Generic

diltiazem hcl er coated beads oral tablet extended release 24 hour

Generic PA

diltiazem hcl er oral capsule extended release 12 hour

Generic

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

Generic

diltiazem hcl oral tablet Generic


Generic


Generic







EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG Brand PA; QL (2 EA per 1 day)

EMBEDA ORAL CAPSULE EXTENDED RELEASE 20-0.8 MG Brand PA; QL (12 EA per 1 day)


180

Drug Status NotesEMBEDA ORAL CAPSULE EXTENDED RELEASE 30-1.2 MG Brand PA; QL (8 EA per 1 day)

EMBEDA ORAL CAPSULE EXTENDED RELEASE 50-2 MG, 60-2.4 MG Brand PA; QL (4 EA per 1 day)

EMBEDA ORAL CAPSULE EXTENDED RELEASE 80-3.2 MG Brand PA; QL (3 EA per 1 day)



eplerenone oral tablet Generic PA; QL (60 EA per 30 days)



famotidine oral suspension reconstituted Generic

famotidine oral tablet 20 mg, 40 mg Generic

fenoprofen calcium oral tablet Generic

fentanyl citrate buccal lozenge on a handle Generic PA; QL (120 EA per 30 days)

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr


fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr


FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG Brand PA; QL (4 EA per 1 day)

flavoxate hcl oral tablet Generic








hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml


hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Generic QL (12 EA per 1 day)

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



181

Drug Status Noteshydromorphone hcl er oral tablet er 24 hour abuse-deterrent

Generic PA; QL (64 mg per 1 day)

hydromorphone hcl oral liquid Generic QL (120 mg per 1 day)

hydromorphone hcl oral tablet Generic QL (120 mg per 1 day)

hydromorphone hcl rectal suppository Generic

IBUDONE ORAL TABLET Generic QL (5 EA per 1 day)




isosorbide dinitrate er oral tablet extended release

Generic

isosorbide dinitrate oral tablet Generic

isosorbide mononitrate er oral tablet extended release 24 hour

Generic

isosorbide mononitrate oral tablet Generic

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG Brand PA; QL (1 EA per 1 day)


ketorolac tromethamine injection solution 15 mg/ml, 30 mg/ml

Generic¥ (Max of 5 days per Rx); QL (120 MG per 1 day)

ketorolac tromethamine intramuscular solution60 mg/2ml

Generic¥ (Max of 5 days per Rx); QL (120 mg per 1 day)


ketorolac tromethamine oral tablet Generic QL (20 EA per 30 days)






MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR Generic PA


mefenamic acid oral capsule Generic PA

meperidine hcl oral solution Generic QL (120 ML per 1 day)

meperidine hcl oral tablet 100 mg Generic QL (12 EA per 1 day)


182

Drug Status Notesmeperidine hcl oral tablet 50 mg Generic QL (24 EA per 1 day)

METHADONE HCL INTENSOL ORAL CONCENTRATE Generic QL (6 ML per 1 day)

methadone hcl oral concentrate Generic QL (6 ML per 1 day)





metoprolol succinate er oral tablet extended release 24 hour

Generic

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

Generic

metoprolol tartrate oral tablet 37.5 mg, 75 mg Brand PA


MORPHABOND ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT Brand PA; QL (60 EA per 30 days)

morphine sulfate (concentrate) oral solution 100 mg/5ml


morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 90 mg





















183

Drug Status Notesmorphine sulfate er oral capsule extended release 24 hour 50 mg, 60 mg




morphine sulfate er oral tablet extended release100 mg










morphine sulfate oral solution 10 mg/5ml Generic QL (120 ML per 1 day)

morphine sulfate oral solution 20 mg/5ml Generic QL (60 ML per 1 day)

morphine sulfate oral tablet 15 mg Generic QL (16 EA per 1 day)

morphine sulfate oral tablet 30 mg Generic QL (8 EA per 1 day)

nadolol oral tablet 20 mg, 40 mg, 80 mg Generic





nicardipine hcl oral capsule Generic

nifedipine er oral tablet extended release 24 hour Generic

nifedipine er osmotic release oral tablet extended release 24 hour

Generic

nifedipine oral capsule Generic

nitroglycerin sublingual tablet sublingual Generic

nitroglycerin transdermal patch 24 hour Generic

nitroglycerin translingual aerosol solution Generic

nitroglycerin translingual solution Generic


NUCYNTA ORAL TABLET Brand PA


184

Drug Status NotesOPANA ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT Brand PA; QL (80 mg per 1 day)


oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg


oxycodone hcl er oral tablet er 12 hour abuse-deterrent 15 mg

Brand QL (90 EA per 30 days)

oxycodone hcl oral capsule Generic QL (160 mg per 1 day)

oxycodone hcl oral concentrate 100 mg/5ml Generic QL (160 mg per 1 day)

oxycodone hcl oral solution Generic

oxycodone hcl oral tablet Generic QL (160 mg per 1 day)

oxycodone-acetaminophen oral solution Generic¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Generic¥ (Max of 4 g of acetaminophen or 160 mg of oxycodone )

oxycodone-aspirin oral tablet 4.8355-325 mg Generic

oxycodone-ibuprofen oral tablet Generic PA

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG Brand PA; QL (90 EA per 30 days)

oxymorphone hcl er oral tablet extended release 12 hour

Generic PA; QL (80 mg per 1 day)

oxymorphone hcl oral tablet Generic PA; QL (80 mg per 1 day)


perindopril erbumine oral tablet Generic

phenazopyridine hcl oral tablet 100 mg, 200 mg Generic







promethazine hcl rectal suppository Generic


Generic


185

Drug Status Notespropranolol hcl oral solution 40 mg/5ml Generic


RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR Brand PA; QL (60 EA per 30 days)





SPRIX NASAL SOLUTION BrandPA; ¥ (Max of 5 days per Rx); QL (4 units per 1 day)












timolol maleate oral tablet Generic










tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 300 mg

Generic PA

tramadol hcl er oral tablet extended release 24 hour


tramadol hcl oral tablet Generic QL (240 EA per 30 days)


186

Drug Status Notestramadol-acetaminophen oral tablet Generic QL (240 EA per 30 days)

trandolapril oral tablet Generic






ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT Brand PA; QL (120 mg per 1 day)





PATIENT DEMOGRAPHICS

bupropion hcl er (smoking det) oral tablet extended release 12 hour

Generic

CHANTIX CONTINUING MONTH PAK ORAL TABLET Brand PA; QL (60 EA per 30 days)

CHANTIX ORAL TABLET Brand PA; QL (60 EA per 30 days)

CHANTIX STARTING MONTH PAK ORAL TABLET Brand PA; QL (60 EA per 30 days)

eq nicotine mouth/throat lozenge Generic

eq nicotine polacrilex mouth/throat gum Generic



eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr

Generic

eql nicotine polacrilex mouth/throat gum Generic

eql nicotine polacrilex mouth/throat lozenge Generic

eql nicotine transdermal patch 24 hour Generic

gnp nicotine mini mouth/throat lozenge Generic

gnp nicotine polacrilex mouth/throat gum Generic

gnp nicotine polacrilex mouth/throat lozenge Generic


187

Drug Status Noteshm nicotine polacrilex mouth/throat gum Generic

hm nicotine polacrilex mouth/throat lozenge Generic

hm nicotine transdermal patch 24 hour 21 mg/24hr, 7 mg/24hr

Generic

NICORELIEF MOUTH/THROAT GUM Generic

nicotine mini mouth/throat lozenge Generic

nicotine polacrilex mouth/throat gum Generic

nicotine polacrilex mouth/throat lozenge Generic




nicotine transdermal patch 24 hour Generic

NICOTROL INHALATION INHALER Brand PA

NICOTROL NS NASAL SOLUTION Brand PA

ra mini nicotine mouth/throat lozenge Generic

ra nicotine mouth/throat gum Generic

ra nicotine polacrilex mouth/throat gum Generic

ra nicotine polacrilex mouth/throat lozenge Generic

ra nicotine transdermal patch 24 hour Generic

tgt nicotine mouth/throat gum 4 mg Generic

tgt nicotine polacrilex mouth/throat gum Generic

tgt nicotine polacrilex mouth/throat lozenge Generic

tgt nicotine step one transdermal patch 24 hour Generic

tgt nicotine step three transdermal patch 24 hour Generic

tgt nicotine step two transdermal patch 24 hour Generic

PREGNANCY

BONJESTA ORAL TABLET EXTENDED RELEASE Brand PA


DICLEGIS ORAL TABLET DELAYED RELEASE Brand PA

ELITE-OB ORAL TABLET Generic



INATAL ADVANCE ORAL TABLET Generic


188

Drug Status Notes

Makena Intramuscular Oil MB/RXSingle Dose Vial Only; QL (1 ML per 7 days)

Makena Subcutaneous Solution Auto-Injector MB/RX QL (2 ML per 7 days)

methylergonovine maleate oral tablet Generic

prenatabs fa oral tablet Generic

prenatal 19 oral tablet Generic

prenatal 19 oral tablet chewable Generic

prenatal oral tablet 27-0.8 mg Generic

TRINATE ORAL TABLET Generic

PROCEDURE


MB/RX PA; SP








Generic







Generic








FERRIPROX ORAL SOLUTION Brand PA


189

Drug Status NotesFERRIPROX ORAL TABLET Brand PA




GAVILYTE-C ORAL SOLUTION RECONSTITUTED Generic

GAVILYTE-G ORAL SOLUTION RECONSTITUTED Generic





Brand

heparin sodium (porcine) injection solution10000 unit/ml, 20000 unit/ml, 5000 unit/ml

Generic


MB/RX PA; SP

















lidocaine hcl external solution Generic


190

Drug Status Noteslidocaine viscous mouth/throat solution Generic

lidocaine-prilocaine external cream Generic

lidocaine-prilocaine external kit Generic

liothyronine sodium oral tablet Generic



Generic








Generic


peg 3350/electrolytes oral solution reconstituted Generic

peg 3350-kcl-na bicarb-nacl oral solution reconstituted

Generic

peg-3350/electrolytes oral solution reconstituted Generic



Generic












191

Drug Status Notesproparacaine hcl ophthalmic solution Generic


Generic















MB/RX PA; SP







REACTION DUE TO AN ALLERGEN

ADRENACLICK INJECTION SOLUTION AUTO-INJECTOR Brand PA; QL (2 EA per 1 Fill)


AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 MG/0.1ML Brand PA; QL (2 EA per 1 Fill)





192

Drug Status NotesBEPREVE OPHTHALMIC SOLUTION Brand PA


















epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.3 mg/0.3ml

Generic QL (2 EA per 1 Fill)

EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR Brand PA; QL (2 EA per 1 Fill)

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR Brand PA; QL (2 EA per 1 Fill)




Generic








193

Drug Status Notesmontelukast sodium oral packet Generic




















RECENT OPERATION


MB/RX PA; SP





Generic





194

Drug Status Notescyclosporine modified oral solution Generic



Generic










Brand


MB/RX PA; SP















lidocaine hcl external solution Generic

lidocaine viscous mouth/throat solution Generic

lidocaine-prilocaine external cream Generic

lidocaine-prilocaine external kit Generic


195

Drug Status Notesmycophenolate mofetil oral capsule Generic


Generic






Generic




Generic








proparacaine hcl ophthalmic solution Generic











MB/RX PA; SP



196

Drug Status NotesZORTRESS ORAL TABLET Brand SP

SKIN CONDITION

ABSORICA ORAL CAPSULE Brand PA

acitretin oral capsule Generic QL (60 EA per 30 days)

acne medication 5 external gel Generic

acyclovir external ointment Generic

ACZONE EXTERNAL GEL 7.5 % Brand PA; QL (60 GM per 30 days)

adapalene external cream Generic STPA

adapalene external gel Generic STPA

adapalene external lotion Generic STPA

alclometasone dipropionate external cream Generic

alclometasone dipropionate external ointment Generic


ALTRENO EXTERNAL LOTION Brand PA

amcinonide external cream Generic PA

amcinonide external lotion Generic PA

amcinonide external ointment Generic PA

ammonium lactate external cream Generic

ammonium lactate external lotion Generic

AMNESTEEM ORAL CAPSULE Generic PA

APEXICON E EXTERNAL CREAM Brand PA

AVITA EXTERNAL CREAM Generic PA; Age Limit (Max 26 Years)

AVITA EXTERNAL GEL Generic PA; Age Limit (Max 26 Years)

AZELEX EXTERNAL CREAM Brand PA; QL (30 grams per 1 fill)




benzoyl peroxide external gel 10 %, 2.5 %, 5 % Generic

benzoyl peroxide wash external liquid Generic

benzoyl peroxide-erythromycin external gel Generic QL (23 GM per 30 days)


betamethasone dipropionate aug external cream Generic


197

Drug Status Notesbetamethasone dipropionate aug external gel Generic

betamethasone dipropionate aug external lotion Generic

betamethasone dipropionate aug external ointment

Generic

betamethasone dipropionate external cream Generic

betamethasone dipropionate external lotion Generic

betamethasone dipropionate external ointment Generic

betamethasone valerate external cream Generic

betamethasone valerate external foam Generic

betamethasone valerate external lotion Generic

betamethasone valerate external ointment Generic



bp foaming wash external liquid Generic

bp wash external liquid 10 %, 2.5 %, 5 % Generic

bpo external gel Brand PA

calcipotriene external cream Generic

calcipotriene external ointment Generic

calcipotriene external solution Generic

calcipotriene-betameth diprop external ointment Generic PA

CALCITRENE EXTERNAL OINTMENT Generic

calcitriol external ointment Generic

CAPEX EXTERNAL SHAMPOO Brand PA




CICLODAN EXTERNAL SOLUTION Generic


ciclopirox external shampoo Brand PA

ciclopirox external solution Brand





198

Drug Status NotesCIMZIA PREFILLED SUBCUTANEOUS KIT Brand PA; SP; QL (2 EA per 28 days)




CLARAVIS ORAL CAPSULE GenericPA; ¥ (Max of 5 months); QL (60 EA per 30 days)


clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-5 %

Generic PA; QL (50 GM per 30 days)

clindamycin phosphate external foam Generic PA

clindamycin phosphate external gel Generic

clindamycin phosphate external lotion Generic

clindamycin phosphate external solution Generic

clobetasol propionate e external cream Generic

clobetasol propionate external cream Generic PA

clobetasol propionate external foam Generic

clobetasol propionate external gel Generic PA

clobetasol propionate external liquid Generic PA

clobetasol propionate external lotion Generic

clobetasol propionate external ointment Generic PA

clobetasol propionate external shampoo Generic

clobetasol propionate external solution Generic PA








CORDRAN EXTERNAL TAPE Brand PA




199

Drug Status NotesCOSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR








dapsone external gel Generic PA; QL (60 GM per 30 days)

dapsone oral tablet Brand


desonide external cream Generic PA

desonide external lotion Generic PA

desonide external ointment Generic PA

desoximetasone external cream 0.05 % Generic PA

desoximetasone external cream 0.25 % Generic

desoximetasone external gel Generic

desoximetasone external ointment 0.05 % Generic PA

desoximetasone external ointment 0.25 % Generic

diclofenac sodium transdermal gel 3 % Generic¥ (Max of 90 days per year); QL (200 GM per 30 days)

diflorasone diacetate external cream Generic PA

diflorasone diacetate external ointment Generic PA


Generic


DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED Medical Benefit PA; SP



ELIDEL EXTERNAL CREAM Brand PA



200

Drug Status NotesENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML Brand










ERIVEDGE ORAL CAPSULE Brand PA; SP

erythromycin external gel Generic

erythromycin external solution Generic



FABIOR EXTERNAL FOAM Brand PA


FINACEA EXTERNAL FOAM Brand PA; QL (50 GM per 1 Rx)

FINACEA EXTERNAL GEL Brand PA; QL (50 GM per 1 Rx)


fluocinolone acetonide body external oil Generic

fluocinolone acetonide external cream Generic

fluocinolone acetonide external ointment Generic

fluocinolone acetonide external solution Generic


fluocinolone acetonide scalp external oil Generic

fluocinonide external cream 0.05 % Generic QL (60 GM per 30 days)


fluocinonide external gel Generic QL (60 GM per 30 days)

fluocinonide external ointment Generic QL (60 GM per 30 days)

fluocinonide external solution Generic QL (60 ML per 30 days)

fluorouracil external cream Generic

fluorouracil external solution Generic



201

Drug Status Notesflurandrenolide external lotion Generic PA

flurandrenolide external ointment Generic PA

fluticasone propionate external cream Generic

fluticasone propionate external lotion Generic

fluticasone propionate external ointment Generic



gentamicin sulfate external cream Generic

gentamicin sulfate external ointment Generic


griseofulvin microsize oral suspension Generic

griseofulvin microsize oral tablet Generic

griseofulvin ultramicrosize oral tablet Generic

halobetasol propionate external cream Generic PA

halobetasol propionate external ointment Generic PA

HALOG EXTERNAL CREAM Brand PA

HALOG EXTERNAL OINTMENT Brand PA








Generic

hydrocortisone butyrate external cream Generic PA

hydrocortisone butyrate external ointment Generic PA

hydrocortisone butyrate external solution Generic PA

hydrocortisone external cream 1 %, 2.5 % Generic


202

Drug Status Noteshydrocortisone external lotion Generic

hydrocortisone external ointment 1 %, 2.5 % Generic


hydrocortisone valerate external cream Generic

hydrocortisone valerate external ointment Generic


hydroxyurea oral capsule Generic


imiquimod pump external cream Generic PA; QL (7.5 GM per 14 days)

IMPAVIDO ORAL CAPSULE Brand


isotretinoin oral capsule Generic PA



ketoconazole external foam Generic


KETODAN EXTERNAL FOAM Generic







lindane external lotion Generic

lindane external shampoo Generic



malathion external lotion Generic


methoxsalen rapid oral capsule Generic

metronidazole external cream Generic

metronidazole external gel 0.75 % Generic


203

Drug Status Notesmetronidazole external gel 1 % Generic PA

metronidazole external lotion Generic


mometasone furoate external cream Generic

mometasone furoate external ointment Generic

mometasone furoate external solution Generic



MYORISAN ORAL CAPSULE Generic PA


NEUAC EXTERNAL GEL Brand PA


NORITATE EXTERNAL CREAM Brand PA








ODOMZO ORAL CAPSULE Brand PA













204

Drug Status Notespermethrin external cream Generic

PICATO EXTERNAL GEL Brand PA; QL (1 Box per 1 Rx)


prednicarbate external cream Generic

PROCTO-PAK RECTAL CREAM Generic





RETIN-A MICRO PUMP EXTERNAL GEL0.08 % Brand PA; Age Limit (Max 26 Years)



selenium sulfide external shampoo 2.25 % Generic

selenium sulf-pyrithione-urea external shampoo Generic

SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; SP; QL (3 ML per 28 days)


SOOLANTRA EXTERNAL CREAM Brand PA

spinosad external suspension BrandPA; STPA; QL (120 ML per 1 Fill)




sulfacetamide sodium (acne) external lotion Generic

sulfacetamide sodium external suspension Generic

SYNALAR (CREAM) EXTERNAL KIT Brand PA

SYNALAR (OINTMENT) EXTERNAL KIT Brand PA

TACLONEX EXTERNAL SUSPENSION Brand PA



205

Drug Status Notes





TAZORAC EXTERNAL CREAM Brand PA; STPA

TAZORAC EXTERNAL GEL Brand PA; STPA

TILIA FE ORAL TABLET Generic

TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Brand PA; SP; QL (1 ML per 54 days)

tretinoin external cream GenericPA; ^ (Preferred Product); Age Limit (Max 26 Years)

tretinoin external gel 0.01 %, 0.025 % GenericPA; ^ (Preferred Product); Age Limit (Max 26 Years)

tretinoin external gel 0.05 % Generic PA; Age Limit (Max 26 Years)

tretinoin microsphere external gel Generic PA; Age Limit (Max 26 Years)

tretinoin microsphere pump external gel Generic PA; Age Limit (Max 26 Years)



triamcinolone acetonide external cream Generic

triamcinolone acetonide external lotion Generic

triamcinolone acetonide external ointment Generic

TRI-LEGEST FE ORAL TABLET Generic

ULESFIA EXTERNAL LOTION Brand PA; QL (12 Bottles per 1 Rx)







ZENATANE ORAL CAPSULE 10 MG, 20 MG, 30 MG Generic PA

ZENATANE ORAL CAPSULE 40 MG Brand PA


206

Drug Status NotesZOLINZA ORAL CAPSULE Brand PA; SP

ZYCLARA EXTERNAL CREAM Brand PA; QL (28 EA per 14 days)

ZYCLARA PUMP EXTERNAL CREAM 2.5 % Brand PA; QL (7.5 GM per 14 days)

SLOW DRUG ELIMINATION BY KIDNEY


TACHYARRHYTHMIA

amiodarone hcl oral tablet Generic

DIGITEK ORAL TABLET Generic

DIGOX ORAL TABLET Generic

digoxin oral solution Generic

digoxin oral tablet Generic



flecainide acetate oral tablet Generic


propafenone hcl er oral capsule extended release 12 hour

Generic

propafenone hcl oral tablet Generic


Generic




sotalol hcl (af) oral tablet 120 mg, 80 mg Generic

sotalol hcl oral tablet Generic





TUMOR

ABSTRAL SUBLINGUAL TABLET SUBLINGUAL Brand PA



207

Drug Status NotesAFINITOR ORAL TABLET Brand PA; SP; QL (30 EA per 30 days)

AKYNZEO ORAL CAPSULE Brand PA; QL (1 EA per 1 Fill)

alfuzosin hcl er oral tablet extended release 24 hour

Generic










CESAMET ORAL CAPSULE Brand PA

DEMSER ORAL CAPSULE Brand





ELIGARD SUBCUTANEOUS KIT Medical Benefit PA; SP

EMCYT ORAL CAPSULE Brand


EMEND ORAL SUSPENSION RECONSTITUTED Brand PA; QL (3 Units per 7 days)


Brand SP



ERIVEDGE ORAL CAPSULE Brand PA; SP


208

Drug Status Notesexemestane oral tablet Generic


FARYDAK ORAL CAPSULE Brand PA; SP

fentanyl citrate buccal lozenge on a handle Generic PA; QL (120 EA per 30 days)

FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG Brand PA; QL (4 EA per 1 day)

finasteride oral tablet 5 mg Generic

fluorouracil external cream 5 % Generic

fluorouracil external solution 5 % Generic


granisetron hcl oral tablet Generic QL (14 EA per 1 Fill)





hydroxyurea oral capsule Generic





letrozole oral tablet Generic

LEUKERAN ORAL TABLET Brand


LONSURF ORAL TABLET Brand PA; SP







209

Drug Status NotesNEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT Brand SP; QL (0.6 ML per 14 days)






NINLARO ORAL CAPSULE Brand PA; SP




ODOMZO ORAL CAPSULE Brand PA


Generic

ondansetron hcl oral solution Generic QL (105 ML per 1 Fill)

ondansetron hcl oral tablet Generic QL (21 EA per 1 Fill)

ondansetron oral tablet dispersible Generic QL (21 EA per 1 Fill)





Brand SP




RAPAFLO ORAL CAPSULE Brand PA


SANCUSO TRANSDERMAL PATCH Brand PA

SOLTAMOX ORAL SOLUTION Brand


tamoxifen citrate oral tablet Generic

tamsulosin hcl oral capsule Generic


210

Drug Status Notesterazosin hcl oral capsule Generic

THALOMID ORAL CAPSULE Brand SP

VARUBI ORAL TABLET BrandPA; ¥ (Max of 6 tablets per 30 days); QL (2 Tablets per 1 Fill)


XERMELO ORAL TABLET Brand PA



ZOLADEX SUBCUTANEOUS IMPLANT10.8 MG Medical Benefit PA; QL (1 EA per 84 days)


ZOLINZA ORAL CAPSULE Brand PA; SP


211


212

Indexabacavir sulfate ............ 17, 98, 157abacavir sulfate-lamivudine.......................................17, 98, 157abacavir-lamivudine-zidovudine.......................................17, 98, 157Abilify Maintena.......................141ABSORICA ............................. 197ABSTRAL ....................... 179, 207acamprosate calcium ........ 141, 157acarbose ................................25, 90ACCU-CHEK SAFE-T PRO LANCETS ............................... 152ACCU-CHEK SOFT TOUCH LANCETS ............................... 152ACCU-CHEK SOFTCLIX LANCETS ............................... 152acebutolol hcl ..............................34acetaminophen-codeine .... 157, 179acetaminophen-codeine #2 ....... 179acetaminophen-codeine #3 ....... 179acetaminophen-codeine #4 ....... 179ACETASOL HC ....................... 95acetazolamide ......... 25, 76, 96, 125acetazolamide er .......................157acetic acid ...................................95acetic acid-aluminum acetate ..... 95acetylcysteine .............. 76, 125, 178ACIPHEX SPRINKLE.....................................82, 107, 157acitretin .............................157, 197acne medication 5 ..................... 197ACTEMRA ..14, 17, 107, 131, 157ACTIMMUNE .............. 3, 17, 131ACTOPLUS MET XR ........25, 90acyclovir ......................98, 157, 197ACZONE ................................. 197adapalene ..................................197adefovir dipivoxil .. 82, 98, 107, 157ADEMPAS ...3, 8, 34, 76, 125, 157ADLYXIN ............................25, 90ADLYXIN STARTER PACK...............................................25, 90ADMELOG ............................. 157ADMELOG SOLOSTAR ...... 157ADRENACLICK .................... 192ADVAIR DISKUS 8, 76, 108, 125

ADVAIR HFA .......8, 76, 108, 125Advate...........................................3Adynovate.....................................3AFINITOR ............ 43, 68, 82, 208AFINITOR DISPERZ 47, 58, 207Afstyla...........................................3AKYNZEO ........................ 82, 208ALBENZA ............................... 157albuterol sulfate .............. 8, 76, 125albuterol sulfate er ..........8, 76, 125alclometasone dipropionate...........................................108, 197ALECENSA .............................158alendronate sodium 26, 68, 90, 131ALFERON N .............98, 108, 197alfuzosin hcl er ....................44, 208ALIQOPA ................................158ALLI ...........................................26allopurinol .................... 26, 44, 208almotriptan malate.........................34, 47, 58, 158, 179ALOCRIL ..........96, 108, 124, 192alogliptin benzoate ........26, 90, 158alogliptin-metformin hcl.......................................26, 90, 158alogliptin-pioglitazone ..26, 90, 158ALOMIDE ...............................158alosetron hcl ....................... 82, 158ALPHAGAN P .......................... 96Alphanate..................................158Alphanate/VWF Complex/Human...................3, 17, 34, 108, 189, 194AlphaNine SD...............................3alprazolam ................................ 141alprazolam er ............................141alprazolam xr ............................141Alprolix.........................................3ALTAVERA ..............................68ALTRENO ...............................197ALUNBRIG .............................158ALVESCO ............. 8, 76, 108, 125alyacen 1/35 ................................68alyacen 7/7/7 ...............................68amantadine hcl ................47, 58, 99amcinonide ........................108, 197

AMETHIA .................................68AMETHIA LO .......................... 68AMETHYST ............................. 68amiloride hcl .........................26, 34amiloride-hydrochlorothiazide ... 34aminocaproic acid ...... 34, 189, 194amiodarone hcl ........... 34, 158, 207AMITIZA .......................... 82, 178amitriptyline hcl ........................158amlodipine besy-benazepril hcl .. 34amlodipine besylate ............ 34, 179amlodipine besylate-valsartan.............................................34, 158amlodipine-atorvastatin...................................26, 34, 47, 58amlodipine-olmesartan ....... 34, 158amlodipine-valsartan-hctz .. 34, 158ammonium lactate .....................197AMNESTEEM ........................ 197amoxapine .................................141amoxicill-clarithro-lansopraz...............................82, 99, 108, 158amoxicillin ................................ 158amoxicillin-pot clavulanate ...... 158amoxicillin-pot clavulanate er ..158amphetamine-dextroamphet er...............................47, 58, 131, 141amphetamine-dextroamphetamine.......................47, 58, 131, 141, 158ampicillin .................................. 158ANADROL-50 .......................3, 17anagrelide hcl ................. 3, 34, 208anastrozole ................................158ANDRODERM ....................68, 90ANDROGEL ....................... 69, 90ANDROXY ..........................69, 90ANORO ELLIPTA.........................8, 76, 108, 125, 159ANTARA ........................... 26, 159antipyrine-benzocaine ...............159ANZEMET ........................ 82, 208APEXICON E ................. 108, 197APIDRA ...................................159APIDRA OPTICLIK ..............159APIDRA SOLOSTAR ............ 159


213

APRI ...........................................69APRISO ............................. 82, 108APTIOM ......................48, 58, 159APTIVUS .......................17, 18, 99ARANELLE .............................. 69ARANESP (ALBUMIN FREE) ............................ 3, 44, 208ARCALYST .......... 18, 26, 95, 108ARCAPTA NEOHALER.................................8, 76, 108, 125aripiprazole .......................141, 159Aristada.....................................141Aristada Initio........................... 141armodafinil ............. 48, 58, 76, 125ARYMO ER ............................ 179ASCOMP-CODEINE ..... 141, 179ASHLYNA .................................69ASMANEX 120 METERED DOSES ................... 8, 76, 108, 126ASMANEX 14 METERED DOSES ................... 9, 76, 108, 126ASMANEX 30 METERED DOSES ................... 9, 76, 108, 126ASMANEX 60 METERED DOSES ................... 9, 76, 109, 126ASMANEX 7 METERED DOSES ................... 9, 77, 109, 126ASMANEX HFA ...9, 77, 109, 126aspirin-dipyridamole er.....................3, 35, 48, 58, 159, 189AT LAST LANCETS ............. 152atazanavir sulfate ..........18, 99, 159atenolol ............................... 35, 179atenolol-chlorthalidone .............. 35atomoxetine hcl.......................48, 58, 131, 141, 159atorvastatin calcium ................... 26atovaquone ................................159atovaquone-proguanil hcl ...........99ATRIPLA ............................ 18, 99atropine sulfate ....... 48, 58, 96, 131ATROVENT HFA ........ 9, 77, 126AUBAGIO ........................... 48, 58AUBRA .............................. 69, 159AURYXIA.........3, 7, 26, 44, 90, 131, 151, 159AUSTEDO ........... 48, 58, 131, 141

AUVI-Q ....................................192AVANDAMET ....................26, 90AVANDIA ............................26, 90AVAR CLEANSER ................ 159AVIANE .....................................69AVITA ..................................... 197AVONEX ............................. 48, 58AVONEX PEN .................... 48, 58AVONEX PREFILLED ..... 48, 58azathioprine.........14, 18, 44, 109, 131, 189, 194azelastine hcl.......9, 12, 77, 96, 99, 109, 124, 192AZELEX ..................................197azithromycin ............................. 159AZOPT .......................................96AZURETTE .............................. 69bacitracin ..............................96, 99bacitracin-polymyxin b ......... 96, 99bacitra-neomycin-polymyxin-hc159baclofen .........................48, 58, 131balsalazide disodium .......... 82, 109BALZIVA .................................. 69BANZEL ..................................159BARACLUDE ............. 82, 99, 109BASAGLAR KWIKPEN ....... 159BAXDELA ...............................159BD INSULIN SYRINGE ........152BD INSULIN SYRINGE MICROFINE ...........................152BD INSULIN SYRINGE U/F 152BD INSULIN SYRINGE ULTRAFINE ...........................152BD LANCET ULTRAFINE 33G ........................................... 152BD SAFETY-LOK INSULIN SYRINGE ................................ 152BD SYRINGE SLIP TIP ........ 152Bebulin..........................................3BECONASE AQ.............9, 13, 77, 99, 109, 124, 192BEKYREE .................................69BELBUCA ............................... 179BELSOMRA ....................... 48, 58BELVIQ .....................................26BELVIQ XR .............................. 26benazepril hcl ..............................35

benazepril-hydrochlorothiazide ..35BeneFIX........................................3BENLYSTA .........14, 18, 109, 197benznidazole ............................... 99benzonatate ..... 13, 77, 99, 109, 126benzoyl peroxide ....................... 197benzoyl peroxide wash ..............197benzoyl peroxide-erythromycin .197benzphetamine hcl ...............26, 159benztropine mesylate .............48, 58BEPREVE ......... 96, 109, 124, 193Berinert................. 18, 26, 193, 197betamethasone dipropionate...........................................109, 198betamethasone dipropionate aug ............................ 109, 197, 198betamethasone valerate .... 109, 198BETASERON ................48, 58, 59betaxolol hcl ..........................35, 96bethanechol chloride ...................44BEVYXXA .......3, 35, 77, 126, 189bexarotene .................159, 198, 208bicalutamide ............................. 160BIDIL ......................................... 35BIKTARVY .........................18, 99bimatoprost ......................... 96, 160bisoprolol fumarate .................... 35bisoprolol-hydrochlorothiazide .. 35BIVIGAM ..................................18BLISOVI 24 FE .........................69BLISOVI FE 1.5/30 .................. 69BLISOVI FE 1/20 ..................... 69BONJESTA ....................... 83, 188BOSULIF .................................160BOTOX ..........35, 48, 59, 179, 198bp foaming wash ....................... 198bp multinatal plus ..................... 160bp wash ..................................... 198bpo ............................................ 198BRAFTOVI ............................. 160BREO ELLIPTA .. 9, 77, 109, 126briellyn ........................................69BRILINTA .....3, 35, 179, 189, 194brimonidine tartrate ....................96BRINEURA ....................... 26, 131BRINTELLIX ......................... 160BRIVIACT .......................... 48, 59


214

bromfenac sodium.....................96, 110, 179, 189, 194bromfenac sodium (once-daily).............96, 109, 160, 179, 189, 194bromocriptine mesylate ...48, 59, 90budesonide9, 13, 77, 83, 99, 110, 126, 160, 193budesonide er ......................83, 110bumetanide ............................26, 35BUNAVAIL ............................. 141buprenorphine ...................160, 179buprenorphine hcl .....................141buprenorphine hcl-naloxone hcl...........................................142, 160bupropion hcl ............................142bupropion hcl er (smoking det)...........................................142, 187bupropion hcl er (sr) .................142bupropion hcl er (xl) .................142buspirone hcl ............................ 142butalbital-acetaminophen . 142, 179butalbital-apap-caffeine ... 142, 179butalbital-asa-caff-codeine...........................................142, 179butalbital-aspirin-caffeine...................................142, 160, 179butorphanol tartrate ................. 179BYDUREON ....................... 26, 90BYETTA 10 MCG PEN ..... 26, 90BYETTA 5 MCG PEN ....... 26, 90BYSTOLIC ................................35cabergoline ................................. 90CABOMETYX ........................160caffeine citrate.................48, 59, 77, 126, 151, 188calcipotriene ............................. 198calcipotriene-betameth diprop...........................................160, 198calcitonin (salmon) ....... 69, 91, 131CALCITRENE ........................198calcitriol ..............................26, 198calcium acetate (phos binder).....................7, 27, 44, 91, 131, 151CALQUENCE .........................160CAMILA ....................................69CAMRESE ................................ 69CAMRESE LO ..........................69

candesartan cilexetil ...................35CANTIL .....................................83capecitabine ..............................160CAPEX .............................110, 198CAPRELSA .............................160captopril ....................27, 35, 44, 91captopril-hydrochlorothiazide ....35CARAFATE ...................... 83, 110CARBAGLU ............................. 27carbamazepine.......................48, 59, 131, 132, 142carbamazepine er ..48, 59, 142, 160carbidopa ......................48, 59, 160carbidopa-levodopa ..............49, 59carbidopa-levodopa er ..........49, 59carbidopa-levodopa-entacapone...............................................49, 59CARDIZEM LA ................35, 179CARIMUNE NF ......3, 18, 35, 110carisoprodol ..............................132carisoprodol-aspirin ................. 132carteolol hcl ................................ 96carvedilol .................................... 35carvedilol phosphate er ...... 35, 160CAYSTON ...............9, 27, 77, 126CAZIANT ..................................69cefaclor ..................................... 160cefadroxil .................................. 160cefdinir ......................................160cefditoren pivoxil ...................... 160cefixime ..................................... 161cefpodoxime proxetil .................161cefprozil .................................... 161ceftibuten ...................................161CEFTIN ................................... 161cefuroxime axetil .......................161celecoxib ....... 14, 18, 110, 132, 161cephalexin ................................. 161CERDELGA ..............................27CEREZYME ..................... 27, 161CEROVEL ...............................161CESAMET .........................83, 208cetirizine hcl...........13, 27, 77, 99, 110, 193, 198cevimeline hcl ... 14, 18, 83, 96, 110CHANTIX ....................... 142, 187

CHANTIX CONTINUING MONTH PAK ................. 142, 187CHANTIX STARTING MONTH PAK ................. 142, 187CHATEAL .................................69chlordiazepoxide hcl .....49, 59, 142chlordiazepoxide-clidinium 83, 110chlorhexidine gluconate83, 99, 124chloroquine phosphate ................99chlorothiazide ............................. 27chlorpromazine hcl ..... 77, 126, 142chlorpropamide .....................27, 91chlorthalidone .....................27, 161chlorzoxazone ........................... 132CHOLBAM ......................... 27, 83cholestyramine ............................27cholestyramine light ....................27choline & mag trisalicylate ...... 161choline-mag trisalicylate .. 110, 132CICLODAN ...............99, 110, 198ciclopirox .................... 99, 110, 198ciclopirox olamine ...... 99, 110, 198CIDALEAZE...................130, 180, 189, 194, 198cilostazol ..................... 35, 132, 180CIMDUO ............................. 18, 99cimetidine ....................83, 110, 180cimetidine hcl ......................83, 110CIMZIA . 14, 18, 83, 110, 132, 199CIMZIA PREFILLED.................14, 18, 83, 110, 132, 199CIMZIA STARTER KIT.................14, 18, 83, 110, 132, 199CINQAIR ...............9, 77, 110, 126Cinryze........................................27CIPRO HC ................................ 95CIPRODEX ......................... 95, 99ciprofloxacin ............................. 161ciprofloxacin hcl ....................... 161ciprofloxacin-ciproflox hcl er ... 161citalopram hydrobromide ......... 142CLARAVIS ............................. 199CLARINEX ... 13, 77, 99, 110, 193CLARINEX-D 12 HOUR.....................9, 13, 77, 99, 110, 193clarithromycin ...........................161clarithromycin er ...................... 161


215

CLEANLET LANCETS 28G 152clemastine fumarate...............13, 77, 100, 110, 193, 199clindamycin hcl .........................161clindamycin palmitate hcl .........161clindamycin phos-benzoyl perox...................................................199clindamycin phosphate...............................44, 69, 100, 199CLINPRO 5000 .........................83clobetasol propionate111, 161, 199clobetasol propionate e .....111, 199clocortolone pivalate 111, 161, 199clocortolone pivalate pump...................................111, 161, 199clomiphene citrate .......................69clomipramine hcl ...................... 143clonazepam ........... 49, 59, 132, 143clonidine hcl ................................35clonidine hcl er.......................49, 59, 132, 143, 161clopidogrel bisulfate ........... 35, 180clorazepate dipotassium49, 59, 143CLORPRES ...............................35clotrimazole 77, 100, 111, 124, 199clotrimazole anti-fungal...........................100, 111, 152, 199clotrimazole-betamethasone...................................100, 111, 199clozapine ........................... 143, 162Coagadex...................................... 3COARTEM ............................. 100codeine sulfate .......................... 180colchicine ....................27, 111, 132colchicine-probenecid .27, 111, 132colesevelam hcl ................... 27, 162colestipol hcl ...............................27COLOCORT ..................... 83, 111COMBIGAN ............................. 96COMBIVENT RESPIMAT.........................................9, 77, 126COMETRIQ (100 MG DAILY DOSE) ........................ 162COMETRIQ (140 MG DAILY DOSE) ........................ 162COMETRIQ (60 MG DAILY DOSE) ...................................... 162

comfort lancets ..........................152COMPLERA ..................... 18, 100COMPRO .................................. 83constulose ................. 27, 49, 59, 83CONTRAVE ............................. 27CORDRAN ......................111, 199Corifact......................................... 3CORLANOR ............................. 35cortisone acetate ...........18, 91, 111CORTISPORIN-TC ............... 162COSENTYX 15, 19, 111, 132, 200COSENTYX 300 DOSE.......................15, 18, 111, 132, 199COSENTYX SENSOREADY 300 DOSE .... 15, 18, 111, 132, 200COSENTYX SENSOREADY PEN .............. 15, 18, 111, 132, 200COTELLIC ............................. 162CREON ......................................83CRESEMBA ............................100CRINONE ........................... 69, 91CRIXIVAN ........................19, 100cromolyn sodium.....9, 19, 77, 96, 111, 124, 126, 193CRYSELLE-28 ......................... 69CRYSVITA ........... 7, 27, 132, 151Cuvitru........................................ 19cyanocobalamin ....................7, 151CYCLAFEM 1/35 ..................... 69CYCLAFEM 7/7/7 .................... 69cyclobenzaprine hcl .................. 132cyclopentolate hcl ............... 96, 162cyclophosphamide .....................162cycloserine ................................ 162cyclosporine ....19, 44, 83, 189, 195cyclosporine modified.................19, 44, 83, 189, 194, 195cyproheptadine hcl...............13, 77, 100, 111, 193, 200CYRED ...................................... 69CYSTAGON ..............................27cytra-2 .......................................152daily multi ................................. 152DAKLINZA ...............83, 100, 111dalfampridine er ... 49, 59, 132, 162DALIRESP ............ 9, 77, 112, 126danazol ..................................27, 69

dantrolene sodium .. 49, 59, 98, 132dapsone ............................. 100, 200darifenacin hydrobromide er.....................................44, 132, 162DASETTA 1/35 ......................... 69DASETTA 7/7/7 ........................ 69DAYSEE .................................... 69DAYTRANA ........49, 59, 132, 143DEBLITANE .............................69demeclocycline hcl ....................162DEMSER ........................... 35, 208DENAVIR ..................83, 100, 200DENTA 5000 PLUS .................. 83DENTAGEL ..............................83DESCOVY .........................19, 100desipramine hcl .........................143desloratadine 13, 77, 100, 112, 193desmopressin ace rhinal tube27, 91desmopressin ace spray refrig...............................................27, 91desmopressin acetate ...... 27, 44, 91desmopressin acetate spray .. 27, 91desogestrel-ethinyl estradiol.............................................70, 162desonide ............................ 112, 200desoximetasone ................. 112, 200desvenlafaxine er ...................... 143desvenlafaxine fumarate er .......143dexamethasone ............................91dexamethasone sodium phosphate ......95, 96, 112, 189, 195DEXEDRINE ...... 49, 59, 133, 143DEXILANT ............................... 83dexmethylphenidate hcl...............................49, 60, 133, 143dexmethylphenidate hcl er.......................49, 60, 133, 143, 162dextroamphetamine sulfate...............................49, 60, 133, 143dextroamphetamine sulfate er...............................49, 60, 133, 143diazepam . 49, 50, 60, 133, 143, 162DIAZEPAM INTENSOL...............................49, 60, 133, 143DICLEGIS .........................84, 188diclofenac potassium 112, 133, 180


216

diclofenac sodium96, 112, 133, 162, 180, 189, 195, 200diclofenac sodium er...............................15, 19, 112, 133dicloxacillin sodium ..................162dicyclomine hcl ................... 84, 162didanosine ...........................19, 100diethylpropion hcl .......................28diethylpropion hcl er ...................28DIFICID .....................84, 100, 112diflorasone diacetate ........ 112, 200diflunisal ................................... 180DIGITEK ...........................35, 207DIGOX ...............................36, 207digoxin ................................ 36, 207dihydroergotamine mesylate.................................36, 50, 60, 180DILANTIN .......................... 50, 60diltiazem cd .........................36, 180diltiazem hcl ........................36, 180diltiazem hcl er ................... 36, 180diltiazem hcl er beads ......... 36, 180diltiazem hcl er coated beads.....................................36, 163, 180dimenhydrinate ........................... 84DIPENTUM .......................84, 112diphenhydramine hcl...............................50, 60, 153, 193diphenoxylate-atropine ............... 84dipyridamole ................................. 4disopyramide phosphate ............. 36disulfiram ..................................144divalproex sodium.........................36, 50, 60, 144, 180divalproex sodium er.........................36, 50, 60, 144, 180dofetilide ............. 36, 163, 189, 207donepezil hcl ................. 50, 60, 144DOPTELET .................................4dorzolamide hcl .................. 96, 163dorzolamide hcl-timolol mal.............................................96, 163doxazosin mesylate ....... 36, 44, 208doxepin hcl ........................144, 163doxercalciferol ......44, 91, 163, 189doxycycline hyclate ........... 124, 163

doxycycline monohydrate ......... 163dronabinol .......19, 28, 84, 100, 208drospiren-eth estrad-levomefol.............................................70, 163drospirenone-ethinyl estradiol.............................70, 144, 163, 200DROXIA ...................................... 4DUAVEE ............. 70, 91, 133, 163DULERA ............... 9, 77, 112, 126duloxetine hcl ....133, 144, 163, 180DUPIXENT ... 9, 78, 112, 126, 200dutasteride .................. 44, 163, 208dutasteride-tamsulosin hcl.....................................44, 163, 208DUZALLO .................28, 112, 133DYANAVEL XR .50, 60, 133, 144DYSPORT ........... 50, 61, 134, 200DYSPORT (GLABELLAR LINES) ..................................... 163E.E.S. 400 .................................163econazole nitrate .......100, 112, 200ECOZA ............ 100, 112, 163, 200EDARBI .....................................36EDLUAR ............................. 50, 61EDURANT .........................19, 100efavirenz ......................19, 100, 163EGRIFTA ...... 15, 19, 28, 100, 112ELELYSO ................................. 28eletriptan hydrobromide.........................36, 50, 61, 163, 180ELIDEL ........................... 112, 200ELIGARD ..........................44, 208ELINEST ................................... 70ELIQUIS ..4, 36, 78, 126, 189, 207ELITE-OB ............................... 188ELLA ......................................... 70Eloctate......................................... 4EMADINE ......... 96, 112, 124, 193EMBEDA .........................180, 181EMCYT ............................. 44, 208EMEND ............. 84, 189, 195, 208EMFLAZA .. 50, 61, 112, 113, 134EMOQUETTE .......................... 70EMSAM ................................... 144EMTRIVA ......................... 19, 100enalapril maleate ........................ 36enalapril-hydrochlorothiazide ....36

ENBREL ......15, 19, 113, 134, 201ENBREL MINI.......................15, 19, 113, 134, 200ENBREL SURECLICK.......................15, 19, 113, 134, 201ENDARI .......................................4enoxaparin sodium ..4, 36, 181, 189ENPRESSE-28 .......................... 70ENSKYCE ................................. 70entacapone ............................50, 61entecavir ..............84, 100, 113, 163ENTRESTO ...............................36ENTYVIO ..........................84, 113enulose ...................... 28, 50, 61, 84EPCLUSA ..................84, 101, 113epinastine hcl ...... 96, 113, 124, 193epinephrine ............................... 193epinephrine hcl ........... 36, 101, 193EPIPEN 2-PAK .......................193EPIPEN JR 2-PAK ................. 193EPITOL ....................... 50, 61, 134eplerenone ...........................36, 181EPOGEN ................. 4, 44, 45, 208epoprostenol sodium .9, 37, 78, 127eprosartan mesylate ....................37eq nicotine .................144, 153, 187eq nicotine polacrilex144, 153, 187eq nicotine step 3 ...... 144, 153, 187eql nicotine ........................144, 187eql nicotine polacrilex ...... 144, 187ergocalciferol ........................7, 151ergoloid mesylates ........ 50, 61, 144ERIVEDGE ..................... 201, 208ERLEADA ...............................163ERRIN ....................................... 70ERYPED 400 ...........................164ERY-TAB ................................ 164ERYTHROCIN STEARATE 164erythromycin ............... 96, 101, 201erythromycin base .....................164erythromycin ethylsuccinate ..... 164ESBRIET ..................... 10, 78, 127escitalopram oxalate .................144est estrogens-methyltest ............ 164est estrogens-methyltest hs ........164ESTARYLLA ............................70estazolam .............................. 50, 61


217

estradiol ........................ 70, 91, 164estradiol-norethindrone acet .... 164estropipate ............................ 70, 91eszopiclone ............................50, 61ethacrynic acid28, 37, 78, 127, 164ethambutol hcl .......................... 164ethosuximide ......................... 50, 61etidronate disodium ............ 28, 134etodolac .....................113, 134, 181etodolac er ............ 15, 19, 113, 134etoposide ................................... 164EUFLEXXA .................... 113, 134EVOTAZ ........................... 19, 101EVZIO ..................................... 178EXELDERM ........... 101, 113, 201exemestane .......................... 70, 209EXONDYS 51 ......50, 61, 113, 134EXTAVIA ............................50, 61ezetimibe ............................. 28, 164ezetimibe-simvastatin ..........28, 164EZ-LETS LANCETS 26G ..... 153FABIOR ...........................164, 201FABRAZYME .....28, 45, 201, 209FALMINA ................................. 70famciclovir ................................ 164famotidine ........................... 84, 181FANAPT .................................. 144FANAPT TITRATION PACK ....................................... 144FARESTON .............................164FARXIGA ....................28, 91, 164FARYDAK .......................... 4, 209FASENRA ........... 10, 78, 113, 127Feiba....................................... 4, 37felbamate ...................................164felodipine er ................................ 37fenofibrate ...........................28, 164fenofibrate micronized ................ 28fenofibric acid .....................28, 164fenoprofen calcium ................... 181fentanyl ..................................... 181fentanyl citrate .................. 181, 209FENTORA .......................181, 209FERRIPROX ...........178, 189, 190FETZIMA ........................144, 164FETZIMA TITRATION 145, 164FIASP .......................................165

FIASP FLEXTOUCH ............ 164FINACEA ........................ 113, 201finasteride ........................... 45, 209FINGERSTIX LANCETS ......153FIRAZYR ............ 19, 28, 193, 201FIRST-LANSOPRAZOLE .... 165FIRST-OMEPRAZOLE ........ 165FIRVANQ ................................165flavoxate hcl ........................45, 181FLEBOGAMMA DIF .............. 20flecainide acetate ................ 37, 207FLECTOR ....................... 130, 134FLOLAN ................10, 37, 78, 127flolipid .........................................28FLOVENT DISKUS...............................10, 78, 113, 127FLOVENT HFA ..10, 78, 113, 127fluconazole ................................165flucytosine ................................. 165fludrocortisone acetate ............... 91flunisolide ..... 13, 78, 101, 113, 193fluocinolone acetonide.............................95, 113, 114, 201fluocinolone acetonide body...........................................113, 201fluocinolone acetonide scalp...........................................114, 201fluocinonide .............. 114, 165, 201FLUOR-A-DAY ........................ 84FLUORIDEX DAILY DEFENSE ..................................84FLUORIDEX ENHANCED WHITENING ..........................165FLUORIDEX SENSITIVITY RELIEF ..................................... 84fluorometholone ..................96, 114fluorouracil ....................... 201, 209fluoxetine hcl .............................145fluoxetine hcl (pmdd) ........ 145, 165fluphenazine decanoate .............145fluphenazine hcl ........................ 145FLURA-DROPS ........................84flurandrenolide . 114, 165, 201, 202flurazepam hcl ...................... 51, 61flurbiprofen ........... 15, 20, 114, 134flurbiprofen sodium .... 96, 190, 195flutamide ................................... 165

fluticasone propionate.................10, 13, 78, 101, 114, 202fluticasone-salmeterol...............................10, 78, 114, 127fluvastatin sodium .......................28fluvastatin sodium er ...........28, 165fluvoxamine maleate ................. 145fluvoxamine maleate er .............145folbee .....................................7, 151folic acid ........................... 4, 7, 151fondaparinux sodium.................................4, 37, 190, 195FORADIL AEROLIZER...............................10, 78, 114, 127FORTEO ..................... 70, 91, 134FOSAMAX PLUS D ... 70, 91, 134fosamprenavir calcium20, 101, 165fosinopril sodium ........................ 37fosinopril sodium-hctz ................ 37FREESTYLE INSULINX TEST ........................................ 153FREESTYLE LANCETS .......153FREESTYLE LITE TEST .....153FREESTYLE PRECISION NEO TEST .............................. 153FREESTYLE TEST ............... 153frovatriptan succinate.........................37, 51, 61, 165, 181FULPHILA ....................4, 20, 209furosemide ...............28, 37, 78, 127FUZEON ............................20, 101FYCOMPA ..........51, 61, 134, 165gabapentin ............ 51, 61, 101, 181galantamine hydrobromide.......................................51, 61, 145galantamine hydrobromide er.......................................51, 61, 145GAMASTAN S/D ......84, 101, 114Gammagard.....20, 51, 61, 114, 134GAMMAGARD S/D LESS IGA.4, 20, 37, 84, 97, 98, 114, 124, 202GAMMAKED ......... 4, 20, 37, 114GAMMAPLEX ....... 4, 20, 37, 114GAMUNEX-C ......... 4, 20, 37, 115gatifloxacin ............................... 165GATTEX ................... 84, 190, 195


218

GAVILYTE-C ...................84, 190GAVILYTE-G ...................85, 190GAVILYTE-H ...........................85GELNIQUE .......................45, 134gemfibrozil .................................. 28generlac .................... 29, 51, 61, 85GENGRAF .... 20, 45, 85, 190, 195gentamicin sulfate .....101, 165, 202GENTLE-LET GP LANCETS ............................... 153GENTLE-LET LANCETS .... 153GENVOYA ........................20, 101GIANVI ..................... 70, 145, 202GIAZO ............................... 85, 115GILDAGIA ................................70GILDESS 1.5/30 ........................70GILDESS 1/20 ...........................70GILDESS 24 FE ........................70GILDESS FE 1.5/30 ..................70GILDESS FE 1/20 .....................70GILENYA ............................51, 61GILOTRIF .............................. 165glatiramer acetate .................51, 62GLATOPA ...........................51, 62GLEOSTINE ...........................165glimepiride ............................29, 91glipizide .................................29, 91glipizide er ............................ 29, 91glipizide xl .............................29, 91glipizide-metformin hcl .........29, 91GLUCAGEN HYPOKIT ... 29, 91GLUCAGON EMERGENCY...............................................29, 91GLUCOSOURCE LANCETS...................................................153glyburide ............................... 29, 91glyburide micronized ............ 29, 91glyburide-metformin ............. 29, 92glycopyrrolate ...........................165GLYDO.......45, 78, 127, 135, 181, 190, 195gnp lancets ................................ 153gnp nicotine mini .............. 145, 187gnp nicotine polacrilex ..... 145, 187gnp ultra com insulin syringe ... 153GOCOVRI ...........................51, 62GRALISE ............ 51, 62, 101, 181

GRALISE STARTER...............................51, 62, 101, 181granisetron hcl ....................85, 209GRANIX ................ 4, 20, 165, 209griseofulvin microsize .......101, 202griseofulvin ultramicrosize...........................................101, 202guaifenesin er13, 78, 101, 115, 127guanfacine hcl .............................37guanfacine hcl er .. 51, 62, 135, 145guanidine hcl .. 20, 51, 62, 115, 135HAEGARDA ............................. 29HAEMOLANCE LOW FLOW LANCETS .................. 153halobetasol propionate ..... 115, 202HALOG ........................... 115, 202haloperidol ................................145haloperidol decanoate .............. 145haloperidol lactate ....................145HARVONI ................. 85, 101, 115HEATHER ................................ 70Helixate FS................................... 4HEMLIBRA .......................... 4, 37HEMMOREX-HC ...... 37, 85, 115Hemofil M............................ 4, 165heparin (porcine) in nacl.....................................37, 190, 195heparin sodium (porcine).................................5, 37, 165, 190HETLIOZ ............................51, 62HEXALEN ...............................166Hizentra...............................20, 166hm nicotine ................145, 153, 188hm nicotine polacrilex ...... 145, 188HOMATROPAIRE .......... 97, 115homatropine hbr ................. 97, 115HORIZANT .........................51, 62HUMALOG .............................166HUMALOG KWIKPEN ........ 166HUMALOG MIX 50/50 ......... 166HUMALOG MIX 50/50 KWIKPEN ...............................166HUMALOG MIX 50/50 PEN 166HUMALOG MIX 75/25 ......... 166HUMALOG MIX 75/25 KWIKPEN ...............................166HUMALOG MIX 75/25 PEN 166

HUMALOG PEN ....................166Humate-P...........5, 20, 37, 115, 166, 190, 195HUMIRA16, 21, 85, 115, 135, 202HUMIRA PEDIATRIC CROHNS START...........15, 20, 85, 97, 115, 135, 202HUMIRA PEN.................15, 21, 85, 115, 135, 202HUMIRA PEN-CD/UC/HS STARTER...........15, 21, 85, 97, 115, 135, 202HUMIRA PEN-PS/UV/ADOL HS START...........15, 21, 85, 97, 115, 135, 202HUMULIN 70/30 .................... 153HUMULIN 70/30 KWIKPEN 153HUMULIN N ...........................153HUMULIN N KWIKPEN ......153HUMULIN R ...........................153HUMULIN R U-500 (CONCENTRATED) ..........29, 92HUMULIN R U-500 KWIKPEN ...........................29, 92HYCAMTIN ............................166hydralazine hcl ............................37hydrochlorothiazide ....................38hydrocod polst-cpm polst er...............13, 78, 101, 115, 127, 193hydrocodone-acetaminophen...........................................166, 181hydrocodone-homatropine.......................13, 78, 101, 115, 127hydrocodone-ibuprofen .............181hydrocortisone.........21, 85, 92, 116, 166, 202, 203hydrocortisone ace-pramoxine...............................38, 85, 115, 202hydrocortisone acetate ..38, 85, 115hydrocortisone butyrate...................................115, 116, 202hydrocortisone valerate .... 116, 203hydrocortisone-acetic acid ......... 95hydromet ....... 13, 78, 101, 116, 127hydromorphone hcl ...................182hydromorphone hcl er ...............182


219

hydroxychloroquine sulfate.......................16, 21, 116, 135, 203HYDROXYprogesterone Caproate...........38, 45, 70, 92, 167, 188, 209hydroxyurea ...................... 203, 209hydroxyzine hcl.......................51, 62, 145, 190, 195hydroxyzine pamoate.......................51, 62, 146, 190, 195HYOPHEN .............................. 167hyoscyamine sulfate .................. 167hyoscyamine sulfate er ..............167hyosyne ......................................167Hyqvia.........................................21HY-VEE LANCETS ...............153hy-vee thin lancets .................... 153ibandronate sodium ...... 71, 92, 135IBRANCE ................................167IBUDONE ................................182ibuprofen ...................116, 135, 182ICLUSIG ................................. 167Idelvion......................................... 5IDHIFA ....................................167ILARIS ...........21, 29, 95, 116, 135ILARIS (150MG DELIVERED) ......................... 167imatinib mesylate ...................... 167IMBRUVICA ...... 5, 131, 167, 209imipramine hcl .................... 45, 146imipramine pamoate ................. 146imiquimod ......... 101, 116, 203, 209imiquimod pump ....................... 203IMPAVIDO ..................... 101, 203INATAL ADVANCE ..............188INCRELEX ................... 51, 62, 92INCRUSE ELLIPTA...............................10, 79, 116, 127indapamide ........................... 29, 38indomethacin ...............29, 116, 135indomethacin er .......... 29, 116, 135INFLECTRA.................16, 21, 85, 116, 135, 203INGREZZA ................. 51, 62, 135INLYTA ...................................167insulin syringe ...........................154insulin syringe/needle ............... 154

INTELENCE .....................21, 101INTRAROSA 45, 71, 92, 124, 182INTROVALE ............................ 71Invega Sustenna........................ 146Invega Trinza............................ 146INVIRASE .........................21, 102INVOKAMET .....................29, 92INVOKAMET XR .............. 29, 92INVOKANA ........................ 29, 92ipratropium bromide.........10, 13, 79, 102, 116, 127, 193ipratropium-albuterol ... 10, 79, 127IPRIVASK .............5, 38, 190, 195irbesartan ....................................38irbesartan-hydrochlorothiazide ..38IRESSA ....................................167ISENTRESS ...................... 21, 102ISENTRESS HD ............... 21, 102isometheptene-dichloral-apap .. 167isoniazid ....................................102isosorbide dinitrate .............38, 182isosorbide dinitrate er .........38, 182isosorbide mononitrate ....... 38, 182isosorbide mononitrate er ...38, 182isotretinoin ........................167, 203isradipine .................................... 38itraconazole .............................. 167ivermectin ....................85, 102, 167Ixinity............................................5JADENU ...................... 5, 178, 190JADENU SPRINKLE .5, 178, 190JAKAFI ......................... 5, 38, 209JENCYCLA ...............................71JOLESSA ...................................71JOLIVETTE ............................. 71JUBLIA ....................102, 116, 203JULEBER ..................................71JULUCA ............................ 21, 102JUNEL 1.5/30 ............................ 71JUNEL 1/20 ............................... 71JUNEL FE 1.5/30 ...................... 71JUNEL FE 1/20 ......................... 71JUNEL FE 24 ............................ 71JUXTAPID ................................ 29JYNARQUE .............................. 45KADIAN .................................. 182KAITLIB FE ............................. 71

KALETRA .........................21, 102KALYDECO ......... 10, 29, 79, 127KANUMA ..................................29KARIVA .................................... 71KELNOR 1/35 ...........................71ketoconazole ......102, 116, 167, 203KETODAN ...................... 116, 203ketoprofen ................. 116, 135, 182ketoprofen er .........16, 21, 116, 135ketorolac tromethamine.....................97, 116, 182, 190, 195ketotifen fumarate97, 116, 124, 193KEVEYIS .............. 29, 52, 62, 135KEVZARA .......... 16, 21, 117, 135KIMIDESS ................................ 71KINERET ............16, 21, 117, 135kinney lancets ............................154kinney thin lancets .................... 154kinray insulin syringe ............... 154KIONEX .............................. 29, 30KISQALI 200 DOSE .............. 167KISQALI 400 DOSE .............. 167KISQALI 600 DOSE .............. 167Koate.............................................5Koate-DVI.................................... 5Kogenate FS..........................5, 167Kogenate FS Bio-Set.................... 5KORLYM ............................30, 92Kovaltry........................................ 5KRYSTEXXA ........... 30, 117, 135KURVELO ................................ 71KUVAN ..............................30, 167KYNAMRO ...............................30labetalol hcl ................................ 38lactulose ....................30, 52, 62, 85lactulose encephalopathy...................................30, 52, 62, 85LAMISIL ................. 102, 117, 203lamivudine .....21, 85, 102, 117, 167lamivudine-zidovudine ........21, 102lamotrigine ............52, 62, 136, 146lamotrigine er ....................... 52, 62lamotrigine odt ......52, 62, 136, 146lamotrigine starter kit-blue...............................52, 62, 136, 146


220

lamotrigine starter kit-green...............................52, 62, 136, 146lamotrigine starter kit-orange...............................52, 62, 136, 146lamotrigine titration...............................52, 62, 136, 146lancets ....................................... 154lancets thin ................................154lansoprazole ........................85, 117LARIN 1.5/30 ............................ 71LARIN 1/20 ............................... 71LARIN 24 FE ............................ 71LARIN FE 1.5/30 .............. 71, 168LARIN FE 1/20 ................. 71, 168LASTACAFT .... 97, 117, 124, 193latanoprost ..........................97, 168LATRIX ...................................168LATUDA ......................... 146, 168LAYOLIS FE ............................ 71LEENA .......................................71leflunomide ........... 16, 21, 117, 136LEMTRADA ....................... 52, 63LENVIMA 10 MG DAILY DOSE ....................................... 168LENVIMA 12 MG DAILY DOSE ....................................... 168LENVIMA 14 MG DAILY DOSE ....................................... 168LENVIMA 20 MG DAILY DOSE ....................................... 168LENVIMA 24 MG DAILY DOSE ....................................... 168LENVIMA 4 MG DAILY DOSE ....................................... 168LESSINA ................................... 71LETAIRIS ............. 10, 38, 79, 127letrozole .............................. 71, 209leucovorin calcium ....5, 7, 151, 178LEUKERAN ........................5, 209leuprolide acetate ......... 45, 92, 209levalbuterol hcl ............. 10, 79, 128levalbuterol tartrate...............................10, 79, 128, 168levetiracetam .................52, 63, 136levetiracetam er .................... 52, 63levobunolol hcl ............................97levocarnitine ................. 7, 151, 154

levocetirizine dihydrochloride.........13, 30, 79, 102, 117, 193, 203levofloxacin ...............................168LEVONEST ...............................71levonorgest-eth estrad 91-day.............................................71, 168levonorgestrel ..................... 71, 168levonorgestrel-ethinyl estrad.............................................71, 168levonorg-eth estrad triphasic.............................................71, 168LEVORA 0.15/30 (28) .............. 72LEVO-T ..................................... 92levothyroxine sodium .................. 92LEXIVA .............................22, 102lidocaine52, 63, 79, 102, 128, 168, 182, 190, 195, 203lidocaine hcl45, 79, 128, 130, 136, 182, 190, 195, 203lidocaine viscous ...............191, 195lidocaine-prilocaine ..........191, 195LIFESCAN UNISTIK II LANCETS ............................... 154lindane .............................. 102, 203linezolid .....................................168LINZESS ................................... 85liothyronine sodium ............ 92, 191lisinopril ......................................38lisinopril-hydrochlorothiazide ....38lite touch lancets ....................... 154lithium ....................................... 146lithium carbonate ......................146lithium carbonate er ................. 146LIVALO .....................................30LO LOESTRIN FE ...................72LOMEDIA 24 FE ..............72, 168lomustine ...................................168longs lancets thin ...................... 154LONSURF ......................... 86, 209loperamide hcl ............................ 86lorazepam ................................. 146LORAZEPAM INTENSOL ...146LORYNA ................... 72, 146, 203losartan potassium ......................38losartan potassium-hctz .............. 38

lovastatin .....................................30LOW-OGESTREL ................... 72loxapine succinate .....................146luliconazole ...............102, 117, 203LUMIGAN .................................97LUPRON ................................. 168LUPRON DEPOT (1-MONTH) ........... 5, 38, 45, 72, 209LUPRON DEPOT (3-MONTH) ........... 5, 38, 45, 72, 209LUPRON DEPOT (4-MONTH) ........................... 45, 209LUPRON DEPOT (6-MONTH) ........................... 45, 209LUPRON DEPOT-PED (1-MONTH) ................................... 92LUPRON DEPOT-PED (3-MONTH) ................................... 92LUTERA ....................................72LYNPARZA ............................ 168LYRICA ...................30, 52, 63, 92LYRICA CR...................30, 52, 63, 92, 102, 182LYSODREN ............................ 169LYZA ................................. 72, 169Makena......................................189malathion .......................... 102, 203maprotiline hcl ..........................146marlissa .......................................72MATULANE ........................... 169MATZIM LA .................... 38, 182MAVYRET ................86, 102, 117me/naphos/mb/hyo1 .................. 169meclizine hcl ................... 38, 52, 63meclofenamate sodium...................................117, 136, 182MEDISENSE THIN LANCETS ............................... 154medroxyprogesterone acetate...................................38, 45, 72, 92mefenamic acid ................... 72, 182mefloquine hcl ...........................102megestrol acetate...................7, 22, 30, 103, 151, 169MEIJER LANCETS ...............154MEKINIST ..............................169MEKTOVI ...............................169


221

meloxicam ............. 16, 22, 117, 136melphalan ................................. 169memantine hcl .......52, 63, 146, 169meperidine hcl ...........169, 182, 183meprobamate ............................ 146mercaptopurine .........................169mesalamine ................. 86, 117, 169MESNEX ............... 38, 45, 72, 209metaproterenol sulfate .. 10, 79, 128metaxalone ................................136metformin hcl ........................ 30, 93metformin hcl er ....................30, 93metformin hcl er (mod) . 30, 92, 169metformin hcl er (osm) ..........30, 92methadone hcl ...................147, 183METHADONE HCL INTENSOL ......................146, 183methamphetamine hcl.........................30, 52, 63, 136, 147methazolamide ............................ 97methenamine hippurate .......45, 103methenamine mandelate ..... 45, 103methimazole ................................ 93methitest ................................72, 93methocarbamol ......................... 136methotrexate ..16, 22, 117, 136, 203methoxsalen rapid .............169, 203methscopolamine bromide .......... 86methyclothiazide ......................... 30methyldopa ..................................39methyldopa-hydrochlorothiazide ....................39methylergonovine maleate .. 39, 189methylphenidate hcl...............53, 64, 137, 147, 148, 169methylphenidate hcl er.........................53, 63, 64, 137, 147methylphenidate hcl er (cd)...............................53, 63, 136, 147methylphenidate hcl er (la)...............53, 63, 136, 137, 147, 169methylprednisolone .......22, 93, 117methylprednisolone sodium succ.......................................22, 93, 117methyltestosterone ........ 72, 93, 169metipranolol ................................97metoclopramide hcl .........30, 86, 93

metolazone ............................ 30, 45metoprolol succinate er ...... 39, 183metoprolol tartrate ..............39, 183metoprolol-hydrochlorothiazide . 39metronidazole.......45, 72, 103, 117, 169, 203, 204mexiletine hcl .............................. 39MIACALCIN .............. 72, 93, 137miconazole 3 ................. 45, 72, 103MICROGESTIN 1.5/30 ............72MICROGESTIN 1/20 ...............72MICROGESTIN 24 FE ............72MICROGESTIN FE 1.5/30 ......72MICROGESTIN FE 1/20 .........72micronized colestipol hcl ............ 30MICROTAINER SAFETY FLOW LANCET .................... 154midodrine hcl .............................. 39MIGERGOT ......... 39, 53, 64, 183miglitol ..........................31, 93, 169minocycline hcl ......................... 169minoxidil ..................................... 39mirtazapine ............................... 148MIRVASO ............... 117, 169, 204misoprostol ................................. 86modafinil ................. 53, 64, 79, 128moexipril hcl ............................... 39moexipril-hydrochlorothiazide ... 39mometasone furoate.......13, 79, 103, 118, 169, 193, 204Monoclate-P..........................5, 169MONOJECT CONTROL SYRINGE ................................ 169MONOJECT FILTER ASPIRATOR ...........................154MONOJECT INSULIN SYRINGE ........................ 154, 170MONOJECT PHARMACY TRAY ....................................... 154MONOJECT PISTON SYRINGE ................................ 154MONOJECT SAFETY SYRINGE/SHIELD ........154, 170MONOJECT SYRINGE 155, 170MONOJECT SYRINGE CATH TIP ............................... 155

MONOJECT SYRINGE ECC LUER ....................................... 155MONOJECT SYRINGE LUER LOCK .................. 155, 170MONOJECT SYRINGE REG LUER ............................... 155, 170MONOJECT TB SAFETY SYRINGE ................................ 155MONOJECT TB SYRINGE ..155MONOJECT ULTRA COMFORT SYRINGE .......... 155MONOLET LANCETS ..........155MONO-LINYAH ...................... 72MONONESSA ...........................72Mononine..............................5, 170montelukast sodium.........10, 13, 79, 103, 118, 128, 194MORPHABOND ER .............. 183morphine sulfate ....................... 184morphine sulfate (concentrate) .183morphine sulfate er ... 170, 183, 184morphine sulfate er beads .170, 183MOVANTIK ..................... 86, 178moxifloxacin hcl ........................170MULTI COMPLETE .............155multi vitamin/fluoride ..... 7, 86, 151multi vitamin/minerals .......... 7, 151multi-vit/fluoride ..... 7, 86, 151, 170multi-vit/fluoride/iron.................................7, 86, 151, 170multivitamin/fluoride.................................7, 86, 151, 170multi-vitamin/fluoride ..... 8, 86, 152mupirocin ..................103, 118, 204mupirocin calcium .... 103, 118, 204MY WAY ...................................72MYALEPT ............ 16, 22, 31, 118mycophenolate mofetil...........22, 45, 46, 86, 170, 191, 196mycophenolic acid.......................22, 46, 170, 191, 196MYLERAN ..............................170mynephrocaps ....................... 8, 152MYOBLOC ................. 53, 64, 137MYORISAN ............................ 204MYRBETRIQ ................... 46, 137MYZILRA ................................. 72


222

nabumetone ...........16, 22, 118, 137n-acetyl-l-cysteine .....................155nadolol ................................ 39, 184nadolol-bendroflumethiazide ......39naftifine hcl ....... 103, 118, 170, 204naloxone hcl ..............................178naltrexone hcl ........................... 148naphazoline hcl ...........................97naproxen ................... 118, 137, 184naproxen dr .......................118, 137naproxen sodium .......118, 137, 184naratriptan hcl ........ 39, 53, 64, 184NARCAN ................................. 178NATAZIA ......................39, 46, 72nateglinide ............................ 31, 93NATPARA ...........................31, 93NECON 0.5/35 (28) ................... 72NECON 1/35 (28) ...................... 72NECON 1/50 (28) ...................... 72NECON 10/11 (28) .................... 72NECON 7/7/7 .............................73nefazodone hcl .......................... 148neomycin sulfate ......... 86, 191, 196neomycin-polymyxin-dexameth...........................................170, 171neomycin-polymyxin-gramicidin.............................................97, 103neomycin-polymyxin-hc...............................95, 97, 103, 171NEO-POLYCIN ................97, 103NEO-POLYCIN HC ...............171NERLYNX ...............................171NEUAC .................................... 204NEULASTA ...........5, 22, 191, 210NEULASTA ONPRO.................................5, 22, 191, 210NEUPOGEN ..................5, 22, 210NEUPRO ............................. 54, 64nevirapine ........................... 22, 103nevirapine er ...............22, 103, 171NEXAVAR .............................. 171NEXIUM ....................................86NEXT CHOICE ONE DOSE .. 73niacin er ...................................... 31niacin er (antihyperlipidemic).............................................31, 171NIACOR .................................... 31

nicardipine hcl .................... 39, 184NICORELIEF ................. 148, 188nicotine ............................. 148, 188nicotine mini ..................... 148, 188nicotine polacrilex ............ 148, 188nicotine step 1 ................... 148, 188nicotine step 2 ................... 148, 188nicotine step 3 ................... 148, 188NICOTROL .....................148, 188NICOTROL NS .............. 148, 188NIFEDIAC CC ........................171nifedipine ............................ 39, 184nifedipine er ........................ 39, 184nifedipine er osmotic release.............................................39, 184NIKKI ........................ 73, 148, 204nilutamide ................................. 171nimodipine .............. 39, 54, 64, 130NINLARO ........................... 6, 210nisoldipine er .............................. 39nitrofurantoin ............................171nitrofurantoin macrocrystal ......171nitrofurantoin monohyd macro .171nitroglycerin ....................... 39, 184NITYR ....................................... 31nizatidine .............................86, 118NODOLOR ..............................171NORA-BE ..................................73NORDITROPIN FLEXPRO.....................8, 22, 31, 93, 103, 152norethin ace-eth estrad-fe ...73, 171norethindrone ............................. 73norethindrone acetate...................................39, 46, 73, 93norethindrone acet-ethinyl est.............................................73, 171norethindrone-eth estradiol...............................73, 93, 137, 171norethin-eth estradiol-fe ..... 73, 171norgestimate-eth estradiol .......... 73norgestim-eth estrad triphasic.............................................73, 171norgestrel-ethinyl estradiol ...... 171NORITATE ..................... 118, 204NORTHERA ............................. 39NORTREL 0.5/35 (28) ..............73NORTREL 1/35 (21) .................73

NORTREL 1/35 (28) .................73NORTREL 7/7/7 ....................... 73nortriptyline hcl ........................ 148NORVIR ............................ 22, 103Novoeight..................................... 6NOVOLIN 70/30 ..................... 155NOVOLIN 70/30 RELION .... 155NOVOLIN N ........................... 155NOVOLIN N RELION ...........155NOVOLIN R ........................... 155NOVOLIN R RELION ...........155NOVOLOG ............................. 171NOVOLOG FLEXPEN ..........171NOVOLOG MIX 70/30 .......... 171NOVOLOG MIX 70/30 FLEXPEN ................................171NovoSeven................................171NovoSeven RT........................6, 39NOXAFIL.22, 23, 79, 103, 118, 124, 128, 172np thyroid ..................................172NUCALA10, 40, 79, 118, 128, 194NUCYNTA .............................. 184NUCYNTA ER 31, 54, 64, 93, 184NUEDEXTA ............................148NUPLAZID ................. 54, 64, 148NUTRESTORE .........86, 191, 196NUVARING .............................. 73Nuwiq........................................... 6NYAMYC ................ 103, 118, 204nystatin ......103, 104, 118, 124, 204nystatin-triamcinolone...................................104, 118, 204NYSTOP .................. 104, 118, 204Obizur....................... 6, 23, 40, 118OCALIVA ................................. 86OCELLA ................................... 73OCREVUS ...........................54, 64OCTAGAM ............. 6, 23, 40, 119octreotide acetate.............31, 54, 64, 86, 93, 137, 210ODACTRA .. 13, 79, 104, 119, 194ODEFSEY ......................... 23, 104ODOMZO ........................204, 210OFEV ........................... 10, 79, 128ofloxacin ............................. 96, 172OGESTREL .............................. 73


223

olanzapine .................................148olanzapine-fluoxetine hcl ..........148OLEPTRO ...............................148olmesartan medoxomil ........40, 172olmesartan medoxomil-hctz 40, 172olopatadine hcl.....................97, 119, 124, 172, 194OLUMIANT ........16, 23, 119, 137OLYSIO .............86, 104, 119, 172omeprazole ..........................86, 119OMEPRAZOLE+SYRSPEND SF ALKA ............................. 172omeprazole-sodium bicarbonate...............................40, 87, 119, 172OMNARIS.................10, 13, 79, 104, 119, 194ondansetron ........................ 87, 210ondansetron hcl .. 87, 191, 196, 210ONETOUCH CLUB LANCETS FINE PT ...............155ONETOUCH FINEPOINT LANCETS ............................... 155ONETOUCH LANCETS ....... 155ONETOUCH ULTRASOFT LANCETS ............................... 155ONFI ............................ 54, 64, 172OPANA ER ..............................185opium ........................................ 172OPSUMIT ......11, 40, 79, 128, 172ORALAIR.................11, 13, 79, 104, 119, 194ORENCIA ... 16, 23, 119, 138, 204ORENCIA CLICKJECT.......................16, 23, 119, 138, 204ORENITRAM ....... 11, 40, 80, 128ORFADIN ..................................31ORKAMBI ............ 11, 31, 80, 128orphenadrine citrate er .............138ORSYTHIA ............................... 73oseltamivir phosphate .......104, 172OSPHENA ..... 46, 73, 93, 124, 185OTEZLA ..................119, 138, 204otic care .................................... 172oxandrolone ................................ 31oxaprozin .............. 16, 23, 119, 138oxazepam ...................... 54, 64, 148oxcarbazepine ....................... 54, 64

oxiconazole nitrate...........................104, 119, 172, 204OXISTAT ................ 104, 119, 204OXTELLAR XR ................. 54, 65oxybutynin chloride .............46, 138oxybutynin chloride er ........ 46, 138oxycodone hcl ........................... 185oxycodone hcl er ............... 172, 185oxycodone-acetaminophen172, 185oxycodone-aspirin .....................185oxycodone-ibuprofen 185, 191, 196OXYCONTIN ................. 172, 185oxymorphone hcl .......................185oxymorphone hcl er .................. 185OXYTROL ........................ 46, 138paliperidone er ..................148, 172PALYNZIQ ............................... 31PANCREAZE ................... 87, 172PANRETIN . 16, 23, 119, 204, 210pantoprazole sodium .................172paregoric .....................................87paricalcitol ....................46, 93, 173PAROEX ................... 87, 104, 124paromomycin sulfate ...........87, 104paroxetine hcl ........................... 148paroxetine hcl er ....................... 148PASER ............... 80, 104, 119, 128peg 3350/electrolytes .......... 87, 191peg 3350-kcl-na bicarb-nacl.............................................87, 191peg-3350/electrolytes ..........87, 191PEGANONE ........54, 65, 138, 173penicillin g procaine ................. 173penicillin v potassium ............... 173PENNSAID ..............119, 138, 173PENTASA ..........................87, 119pentoxifylline er .......... 40, 138, 185PERFOROMIST .11, 80, 119, 128perindopril erbumine .......... 40, 185PERIOGARD ............87, 104, 125permethrin .........................104, 205perphenazine .............................149PERTZYE ................................. 87phenazopyridine hcl ............46, 185phendimetrazine tartrate ............ 31phendimetrazine tartrate er ........ 31phenelzine sulfate ......................149

PHENERGAN ...87, 185, 191, 196phenobarbital ............................173PHENOHYTRO ..................... 173phenoxybenzamine hcl 40, 173, 210phentermine hcl ...........................31phenyleph-promethazine-cod...............13, 80, 104, 119, 128, 173phenylephrine-guaifenesin ........173phenytoin ...............................54, 65PHENYTOIN INFATABS .54, 65phenytoin sodium extended ...54, 65PHILITH ................................... 73PHOS-FLUR ........................... 173PHOSPHA 250 NEUTRAL ..... 31PHOSPHASAL ....................... 173phytonadione .........................6, 173PICATO ...................................205pilocarpine hcl...16, 23, 87, 97, 119, 191, 196, 210pimozide ........54, 65, 138, 149, 173PIMTREA ......................... 73, 173pindolol ....................................... 40pioglitazone hcl .....................31, 93pioglitazone hcl-glimepiride .32, 93pioglitazone hcl-metformin hcl...............................................32, 93PIRMELLA 1/35 .......................73PIRMELLA 7/7/7 ..............73, 173piroxicam .............. 16, 23, 120, 138podofilox ................... 104, 120, 205polyethylene glycol 3350 ............ 87polymyxin b-trimethoprim.............................97, 104, 120, 125polyvinyl alcohol .........................97POMALYST ............................173PORTIA-28 ............................... 73pot bicarb-pot chloride ............... 32potassium bicarbonate ................32potassium chloride ..............32, 173potassium chloride crys er ..........32potassium chloride er ......... 32, 173potassium citrate er .................. 173PRADAXA .............6, 40, 191, 207PRALUENT ........................ 32, 40pramcort ............................... 40, 87pramipexole dihydrochloride54, 65


224

pramipexole dihydrochloride er.......................................54, 65, 173prasugrel hcl.................6, 40, 173, 185, 191, 196pravastatin sodium ......................32praziquantel ................ 87, 104, 173prazosin hcl .................................40PRECISION SURE-DOSE SYRINGE ................................ 156PRECISION THIN LANCETS ............................... 156PRECISION THINS GP LANCETS ............................... 156PRECISION ULTRA LANCET ..................................156PRECISION XTRA BLOOD GLUCOSE ...............................156prednicarbate ....................120, 205prednisolone ................. 23, 93, 120prednisolone acetate ...........98, 120prednisolone sodium phosphate.........................23, 93, 94, 120, 173prednisone .................................173preferred plus lancets colored .. 156preferred plus lancets thin ........ 156PREMARIN .. 46, 73, 94, 125, 185premium lidocaine .................... 173PREMPHASE ....... 46, 73, 94, 125PREMPRO ............ 46, 73, 94, 125prenatabs fa .............................. 189prenatal .....................................189prenatal 19 ........................156, 189PREVIFEM ............................... 73PREVYMIS ....... 23, 104, 191, 196PREZCOBIX .....................23, 104PREZISTA ........................ 23, 104PRIFTIN ............80, 105, 120, 128PRILOSEC ........................87, 120primidone ..................................174PRISTIQ ..................................149PRIVIGEN .............. 6, 23, 40, 120PROAIR HFA ............. 11, 80, 128PROAIR RESPICLICK.......................................11, 80, 128probenecid .. 32, 120, 138, 191, 207PROBUPHINE IMPLANT KIT ........................................... 149

prochlorperazine .........................87prochlorperazine edisylate ......... 87prochlorperazine maleate ...........87PROCRIT ......................6, 46, 210PROCTO-PAK ............... 120, 205PROCTOSOL HC .. 120, 174, 205PROCTOZONE-HC...................................120, 174, 205Profilnine...................................... 6Profilnine SD................................ 6progesterone ............. 40, 46, 74, 94progesterone micronized .....74, 174PROLIA .......................74, 94, 138PROMACTA.....................6, 23, 40, 87, 105, 120promethazine hcl...............87, 88, 174, 185, 191, 196promethazine vc plain.......................13, 80, 105, 120, 194promethazine vc/codeine.......................14, 80, 105, 120, 128promethazine-codeine...............14, 80, 105, 120, 128, 194promethazine-dm...............14, 80, 105, 120, 129, 194promethazine-phenylephrine...............14, 80, 105, 120, 174, 194propafenone hcl .................. 40, 207propafenone hcl er ..............40, 207proparacaine hcl .........98, 192, 196propranolol hcl.........................40, 54, 65, 138, 186propranolol hcl er ...40, 54, 65, 185propranolol-hctz ......................... 40propylthiouracil .......................... 94PROTONIX .............................174protriptyline hcl ........................ 149PROVENTIL HFA ..... 11, 80, 129pseudoephedrine hcl...............................14, 80, 105, 120PSS SELECT GP LANCETS 156PSS SELECT SAFETY LANCETS ............................... 156PULMICORT FLEXHALER...............................11, 80, 120, 129PULMOZYME ..... 11, 32, 80, 129PURIXAN ................................174

pyrazinamide .............................174pyridostigmine bromide.........................23, 55, 65, 120, 138pyridostigmine bromide er.................23, 55, 65, 120, 138, 174qc nicotine polacrilex ................156QNASL .........14, 80, 105, 120, 194QNASL CHILDRENS.......................14, 80, 105, 120, 194QSYMIA ....................................32QUASENSE ...............................74quetiapine fumarate .................. 149quetiapine fumarate er ......149, 174QUILLIVANT XR...............................55, 65, 138, 149quinapril hcl ................................40quinapril-hydrochlorothiazide ....41quinidine gluconate er 41, 192, 207quinidine sulfate ..........41, 192, 207quinidine sulfate er ..... 41, 192, 207quinine sulfate ...........................174QVAR ...................11, 80, 120, 129QVAR REDIHALER...............................11, 80, 121, 129ra mini nicotine .................149, 188ra nicotine .........................149, 188ra nicotine polacrilex ........149, 188rabeprazole sodium .... 88, 121, 174RADICAVA .................55, 65, 138raloxifene hcl 74, 94, 139, 174, 210ramipril ....................................... 41RANEXA ........................... 41, 186ranitidine hcl .................41, 88, 121RAPAFLO ......................... 46, 210RAPAMUNE.................24, 46, 80, 129, 192, 196rasagiline mesylate ....... 55, 65, 174RAVICTI ................................... 32REA LO 40 .............................. 174reality lancets ............................156reality trigger lancets ............... 156REBIF ............................ 55, 65, 66REBIF REBIDOSE ............ 55, 65REBIF REBIDOSE TITRATION PACK ........... 55, 65


225

REBIF TITRATION PACK...............................................55, 66Rebinyn.........................................6RECLIPSEN ............................. 74Recombinate................................. 6RELENZA DISKHALER ...... 105RELISTOR ........................88, 178REMEVEN ..............................174REMICADE.................16, 24, 88, 121, 139, 205REMODULIN ....... 11, 41, 80, 129RENAL ................................ 8, 152RENFLEXIS.................17, 24, 88, 121, 139, 205repaglinide ....................32, 94, 174repaglinide-metformin hcl.......................................32, 94, 174REPATHA ...........................32, 41REPATHA PUSHTRONEX SYSTEM ..............................32, 41REPATHA SURECLICK .. 32, 41RESCRIPTOR .................. 24, 105RESCULA ................................. 98reserpine ..................................... 41RESTASIS ................. 98, 121, 125RETIN-A MICRO PUMP ......205REVATIO ..............11, 41, 81, 129REVLIMID ............................. 174REXULTI ................................ 149REYATAZ .........................24, 105RHOPRESSA ............................98RIBASPHERE .......... 88, 105, 121ribavirin ...................... 88, 105, 121rifabutin .................................... 174rifampin .....................................174riluzole .......................... 55, 66, 139rimantadine hcl .........................105risedronate sodium.........................32, 74, 94, 139, 174RisperDAL Consta....................149risperidone ................................149RISPERIDONE M-TAB 149, 174ritonavir ...................... 24, 105, 174RITUXAN ....17, 24, 121, 139, 210rivastigmine .......... 55, 66, 149, 174rivastigmine tartrate ..... 55, 66, 149Rixubis..................................6, 174

rizatriptan benzoate 41, 55, 66, 186ropinirole hcl ........................ 55, 66ropinirole hcl er ....................55, 66ROSANIL CLEANSER ......... 175rosuvastatin calcium ...........32, 175ROZEREM ..........................55, 66RUBRACA .............................. 175Ruconest............... 24, 32, 194, 205RYDAPT ..................................175SABRIL ....................... 55, 66, 139salsalate ................ 17, 24, 121, 139SANCUSO ......................... 88, 210SAPHRIS ................................. 149SAVAYSA ....... 6, 41, 81, 129, 207SAVELLA ............... 121, 139, 186SAVELLA TITRATION PACK ....................... 121, 139, 186SAXENDA ................................. 32sb lancets thin ........................... 156sb lancets ultra thin .................. 156selegiline hcl ......................... 55, 66selenium sulfide ........ 121, 175, 205selenium sulf-pyrithione-urea...........................................121, 205SELZENTRY .................... 24, 105SEMPREX-D.......................14, 81, 105, 121, 194SENSIPAR ...................46, 94, 192SEREVENT DISKUS...............................11, 81, 121, 129SEROSTIM8, 24, 32, 94, 105, 152sertraline hcl .............................149SETLAKIN ................................74sf ..................................................88sf 5000 plus ................................. 88SHAROBEL .............................. 74SIGNIFOR .................................94SIGNIFOR LAR...........................33, 56, 66, 94, 139SIKLOS ....................................... 6sildenafil citrate ...... 11, 41, 81, 129SILIQ ....................................... 205silver sulfadiazine...........................105, 131, 192, 196SIMBRINZA ............................. 98SIMPONI .............17, 24, 121, 139

SIMPONI ARIA...............17, 24, 121, 139, 175, 205simvastatin .................................. 33sirolimus.........24, 46, 81, 129, 175, 192, 196SIRTURO .......... 81, 105, 121, 129SIVEXTRO ............................. 175SKLICE ................................... 105sodium fluoride ................... 88, 175sodium polystyrene sulfonate.............................................33, 175SOLIRIS...6, 24, 33, 41, 46, 56, 66, 121, 139SOLOSEC ................... 46, 74, 105SOLTAMOX ..................... 74, 210SOMAVERT ... 33, 56, 66, 94, 139SOOLANTRA ................. 121, 205sotalol hcl ............................41, 207sotalol hcl (af) .....................41, 207SOVALDI .......... 88, 105, 122, 175spinosad ............................ 105, 205SPINRAZA ..........................56, 66SPIRIVA RESPIMAT...............................11, 81, 122, 129spironolactone ........ 33, 41, 88, 107spironolactone-hctz ...............33, 41SPRINTEC 28 ........................... 74SPRITAM ....................56, 66, 139SPRIX ...................... 186, 192, 196SPRYCEL ................................175SPS ............................................. 33sr nicotine ................................. 156SRONYX ................................... 74SSD ................... 106, 131, 192, 196stavudine ............................. 24, 106STELARA ......... 88, 122, 139, 205STIVARGA ............................. 175STRENSIQ ................................ 33STRIANT .............................74, 94STRIBILD ......................... 24, 106STRIVERDI RESPIMAT...............................11, 81, 122, 129SUBLOCADE ......................... 149SUBOXONE ............................150sucralfate ............................ 88, 122


226

sulfacetamide sodium.....................98, 106, 122, 125, 205sulfacetamide sodium (acne) .... 205sulfacetamide sodium-sulfur .....175sulfacetamide-prednisolone 98, 122sulfamethoxazole-trimethoprim 175sulfasalazine.................17, 24, 88, 122, 139, 175sulindac .............................122, 139sumatriptan ............. 41, 56, 66, 186sumatriptan succinate.....................41, 42, 56, 66, 67, 186sumatriptan succinate refill.................................41, 56, 66, 186super thin lancets ......................156SUPRAX .................................. 175SUPRENZA ...............................33sure comfort insulin syringe ..... 156SURELITE LANCETS .......... 156SUTENT .................................. 175SYEDA .......................................74SYMBICORT ......12, 81, 122, 129SYMDEKO ............12, 33, 81, 129SYMFI ............................... 24, 106SYMFI LO .........................24, 106SYMLINPEN 120 ............... 33, 94SYMLINPEN 60 ................. 33, 94SYMPROIC .......................88, 178SYMTUZA ........................ 24, 106SYNAGIS ...........81, 106, 122, 129SYNALAR (CREAM) .... 122, 205SYNALAR (OINTMENT)...........................................122, 205SYNAREL ........................... 74, 94SYNDROS ..... 24, 33, 88, 106, 210TABLOID ................................175TACLONEX ............................205tacrolimus.24, 46, 88, 122, 175, 192, 196, 205tadalafil ...............................74, 175tadalafil (pah) . 12, 42, 81, 129, 175TAFINLAR ............................. 175TAGRISSO ..............................176TALTZ .....................122, 140, 206tamoxifen citrate ................. 74, 210tamsulosin hcl ..................... 47, 210TANZEUM ..........................33, 94

TARCEVA ...............................176TARINA FE 1/20 ...................... 74TASIGNA ................................ 176TAVALISSE ............6, 24, 42, 122TAZORAC .............................. 206tb syringe 1 ml .......................... 156TECFIDERA .......................56, 67TECHLITE LANCETS ..........156TECHNIVIE ............. 88, 106, 122TEKTURNA ..............................42TEKTURNA HCT .................... 42telmisartan .................. 42, 176, 186telmisartan-hctz .................. 42, 176temazepam ............................ 56, 67temozolomide ............................ 176tenofovir disoproxil fumarate.......................24, 88, 106, 122, 176terazosin hcl ..................42, 47, 211terbinafine hcl ...........................176terbutaline sulfate ......... 12, 81, 130terconazole ....................47, 74, 106TESTOPEL ......................... 74, 94testosterone ................... 74, 95, 176testosterone cypionate ...........74, 95testosterone enanthate .......... 74, 95tetrabenazine .56, 67, 140, 150, 176tetracycline hcl ..........................176tgt nicotine ................ 150, 156, 188tgt nicotine polacrilex ....... 150, 188tgt nicotine step one .......... 150, 188tgt nicotine step three ........150, 188tgt nicotine step two .......... 150, 188THALOMID ........................6, 211theophylline ...........12, 81, 123, 130theophylline er ...... 12, 81, 123, 130THINLETS GP LANCETS ... 156THINLETS LANCET ............ 156thioridazine hcl ......................... 150thiothixene .................................150tiagabine hcl ......................... 56, 67TIBSOVO ................................ 176TILIA FE ...........................74, 206timolol maleate ............. 42, 98, 186tinidazole .................47, 74, 89, 106TIVICAY ................... 24, 106, 176tizanidine hcl .............................140

TOBI PODHALER.................12, 33, 81, 106, 123, 130tobramycin.........12, 33, 81, 106, 123, 130, 176tobramycin-dexamethasone.....................................98, 106, 123tolazamide .............................33, 95tolbutamide ........................... 33, 95tolcapone .......................56, 67, 176tolmetin sodium .....17, 25, 123, 140tolterodine tartrate ..............47, 140tolterodine tartrate er . 47, 140, 176topco insulin syringe .................156topiramate ...............42, 56, 67, 186topiramate er .......... 42, 56, 67, 186torsemide ...............................33, 42TOVIAZ .............................47, 140TRACLEER .......... 12, 42, 81, 130tramadol hcl ..............................186tramadol hcl er ......................... 186tramadol hcl er (biphasic) ........ 186tramadol-acetaminophen ..........187trandolapril .........................42, 187trandolapril-verapamil hcl er ..... 42tranexamic acid ...............42, 47, 75tranylcypromine sulfate ............ 150TRAVATAN Z .......................... 98trazodone hcl ............................ 150TRECATOR ............................106TREMFYA .............................. 206TRESIBA FLEXTOUCH ...... 176tretinoin .............................176, 206tretinoin microsphere ................206tretinoin microsphere pump ......206Tretten...........................................6TREXALL ... 17, 25, 123, 140, 206triamcinolone acetonide14, 81, 106, 123, 125, 176, 194, 206triamterene-hctz ....................33, 42trientine hcl...........33, 57, 67, 89, 140, 176, 178TRI-ESTARYLLA ................... 75trifluoperazine hcl .....................150trifluridine ...........98, 106, 123, 125trihexyphenidyl hcl ................57, 67TRI-LEGEST FE ..............75, 206TRI-LINYAH ............................75


227

TRI-LO-ESTARYLLA ............ 75TRI-LO-MARZIA .................... 75TRI-LO-SPRINTEC .........75, 176TRILYTE .................. 89, 176, 192trimethobenzamide hcl 89, 192, 196trimethoprim ............................. 176trimipramine maleate ................150TRINATE ................................ 189TRINESSA (28) .........................75TRINESSA LO ..........................75TRINTELLIX ......................... 150TRI-PREVIFEM .......................75TRI-SPRINTEC ........................75TRIUMEQ .........................25, 106tri-vit/fluoride/iron ..........8, 89, 152tri-vitamin/fluoride ......... 8, 89, 152TRIVORA (28) ..........................75TROKENDI XR...................42, 43, 57, 67, 177, 187tropicamide ................................. 98trospium chloride ................47, 140trospium chloride er ........... 47, 140TRULICITY ........................33, 95TRUVADA ........................ 25, 106TUSSIGON ..14, 82, 106, 123, 130TYBOST ............................ 25, 106TYKERB ................................. 177TYMLOS ..................... 75, 95, 140TYSABRI ...............57, 67, 89, 123Tyvaso.....................12, 43, 82, 130Tyvaso Refill .......... 12, 43, 82, 130Tyvaso Starter.........12, 43, 82, 130UCERIS ............................. 89, 123ULESFIA ......................... 106, 206ULTILET CLASSIC LANCETS ............................... 156ULTILET LANCETS .............156ULTRA-THIN II AUTO LANCET ..................................156ULTRA-THIN II LANCETS .157UNILET COMFORTOUCH LANCET ..................................157UNILET G.P. LANCET .........157UNILET G.P. SUPERLITE LANCET ..................................157UNILET LANCET ................. 157

UNILET SUPERLITE LANCET ..................................157UNISTIK 1 .............................. 157UNITHROID .....................95, 177UNITHROID DIRECT .......... 177UPTRAVI .............. 12, 43, 82, 130urea ........................................... 177urea nail film .............................177urea-c40 ....................................177ure-k ..........................................177URIMAR-T ..............................177UROLET MB .......................... 177UROPHEN MB .......................177ursodiol ....................................... 89URYL ....................................... 177valacyclovir hcl .........................177valganciclovir hcl ..................... 177valproic acid ......................... 57, 67valsartan ............................. 43, 177valsartan-hydrochlorothiazide ... 43vancomycin hcl ......................... 177VANDAZOLE .............47, 75, 106VARUBI .............................89, 211VELETRI .............. 12, 43, 82, 130VELIVET .................................. 75VELTASSA ............................... 33VENCLEXTA ......................... 177VENCLEXTA STARTING PACK ....................................... 177venlafaxine hcl .......................... 150venlafaxine hcl er ......................150Ventavis.................. 12, 43, 82, 130VENTOLIN HFA ........12, 82, 130VERAMYST14, 82, 106, 123, 194verapamil hcl .............. 43, 187, 207verapamil hcl er ..........................43VEREGEN ...............106, 123, 206VERZENIO ............................. 177VESICARE ........................47, 140VESTURA ................. 75, 150, 206VIBERZI ................................... 89VICTOZA ............................34, 95VIDEX ............................... 25, 106VIEKIRA PAK ......... 89, 107, 123VIEKIRA XR ............ 89, 107, 123VIENVA .....................................75vigabatrin ..............57, 67, 140, 177

VIIBRYD ................................. 150VIIBRYD STARTER PACK .150VIMPAT .............................. 57, 67viorele ......................................... 75VIRACEPT ....................... 25, 107VIREAD ...............25, 89, 107, 123VISTOGARD .......................... 178VITALET PRO LANCETS ... 157VITALET PRO PLUS LANCETS ............................... 157vitamin d (ergocalciferol) ..... 8, 152VIVITROL .............................. 150Vonvendi.................6, 43, 192, 196voriconazole ..............................177VOSEVI ..................... 89, 107, 123VOTRIENT ............................. 177VPRIV ........................................34VRAYLAR .............................. 150VYFEMLA ........................ 75, 177VYVANSE ........... 57, 67, 140, 150VYZULTA .................................98W&F LANCETS 26G .............157W&F LANCETS COLORED 21G ........................................... 157warfarin sodium ......................7, 43weight loss daily multi .............. 157WERA ........................................75Wilate 7, 25, 43, 123, 177, 192, 196WYMZYA FE ........................... 75XADAGO .............................57, 67XALKORI ............................... 177XARELTO7, 43, 57, 68, 82, 130, 187, 192, 207XARELTO STARTER PACK...................7, 43, 82, 130, 192, 207XATMEP ............. 7, 123, 140, 211XELJANZ.................17, 25, 89, 123, 140, 206XELJANZ XR.................17, 25, 89, 124, 140, 206XENICAL ..................................34XEOMIN ....... 57, 68, 98, 140, 206XERMELO ........................89, 211XGEVA ......................34, 140, 211XIAFLEX .......................... 75, 140XIFAXAN ........34, 57, 68, 89, 107XIGDUO XR ....................... 34, 95


228

XOLAIR.........12, 34, 82, 124, 130, 194, 206XTANDI ...................................177XULANE ................................... 75XURIDEN ..................................34Xyntha...........................................7Xyntha Solofuse............................7XYREM ....................... 57, 68, 140YONSA .................................... 178zafirlukast ............. 12, 82, 124, 130zaleplon .................................57, 68ZARAH ......................................75ZARXIO ........................ 7, 25, 211ZEJULA ...................................178ZELAPAR ........................... 57, 68ZELBORAF ............................ 178ZENATANE ............................ 206ZENCHENT ..............................75ZENCHENT FE ........................75ZENPEP .............................89, 178ZENZEDI ............ 57, 68, 141, 151ZEPATIER ................89, 107, 124ZETONNA.................12, 14, 82, 107, 124, 194zidovudine ........................... 25, 107ZINBRYTA ......................... 57, 68ZINPLAVA ............... 89, 107, 124ZIOPTAN .................................. 98ziprasidone hcl ..........................151ZIRGAN .................... 98, 107, 124ZOHYDRO ER ....................... 187ZOLADEX ...................47, 75, 211ZOLINZA ........................207, 211zolmitriptan .............43, 57, 68, 187zolpidem tartrate ...................57, 68zolpidem tartrate er .............. 57, 68ZOMIG .......... 43, 58, 68, 178, 187zonisamide ............................ 58, 68ZONTIVITY.............7, 43, 58, 68, 187, 192, 196ZORBTIVE8, 25, 34, 95, 107, 152ZORTRESS ... 25, 47, 89, 192, 197ZOVIA 1/35E (28) .....................75ZOVIA 1/50E (28) .....................75ZOVIRAX ............................... 178ZUBSOLV ....................... 151, 178ZURAMPIC .............. 34, 124, 141

ZYCLARA ...............................207ZYCLARA PUMP .................. 207ZYDELIG ................................178ZYKADIA ............................... 178ZYPITAMAG ........................... 34ZyPREXA Relprevv................. 151ZYTIGA ...................................178


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