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QUALIFIED HEALTH PLAN FORMULARY Effective January 2021
Provided by Elixir
Introduction
The Total Health Care (THC) Qualified Health Plan Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management. Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications.
Notice
The information contained in this formulary is provided by THC & Elixir, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information.
How to Read the Formulary All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. Any drug not found in this Formulary listing shall be considered a non-formulary drug.
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Tier Guidelines
The Certificate of Coverage provided upon enrollment has specific information regarding co-payments, co-insurance, annual deductible requirements and maximum out of pocket limits associated with the corresponding pharmacy benefit.
Prescribing Guidelines
Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include:
Prior Authorization Required (PA)
Drug requires prior authorization through a specific physician request process.
Over the Counter Drugs (OTC)
Drug coverage is available for drugs that are available OTC with an authorized prescription from your provider.
Specialty Drugs (SP)
Drug requires processing through THC’s contracted specialty pharmacy, Elixir Specialty Pharmacy.
Quantity Limit (QL) Drug coverage may be limited to specific quantities per prescription and/or time period.
Age Limit (AL) Drug coverage may depend on patient age.
Gender Restriction (GR)
Drug coverage may depend on patient gender.
Step Therapy Required (ST)
Drug coverage requires that an alternative or trial of another drug be used before the medication is covered.
Custom (C) Drug coverage has unique restrictions.
Generic Tier 1
Preferred Brand Tier 2
Non-Preferred Brand Non- Preferred Generic
Tier 3
Specialty Tier 4
Preventive Tier 5 $0 co-pay at in-network pharmacies
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Saving on Out-Of-Pocket Costs Total Health Care has designed its prescription drug plan to encourage the use of generic and preferred brand name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses (such as coinsurance and co-payments) or not receiving coverage at all. Members may also pay less for generic drugs or they may be asked to pay the cost difference between brand name drugs and their generic alternatives, which are preferred by the plan.
Benefit Coverage and Limitations
This formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments, coinsurance or a lack of coverage, which are not reflected in the THC Qualified Health Plan Formulary. Members should contact Total Health Care at 1-800-826-2862 if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. Preventive Medications
Total Health Care covers certain preventive services for $0 co-pay when delivered by in-network pharmacies. These drugs are indicated on the THC Qualified Health Plan Formulary under Drug Tier 5. Examples of preventive medications include aspirin, contraceptives, iron supplementations, smoking cessation products and Vitamin D drugs. These drugs are available with standard drug coverage recommendations and are only available for certain populations. Prior Authorization (PA) Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at www.THCmi.com. You may also request a form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should be faxed to 1-866-422-9119. Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC’s website has a contact link where members can contact THC’s Pharmacy Department to ask for an exception request. Non-Formulary Agents Drugs not located on the Total Health Care Qualified Health Plan Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by the health professional depending on specific coverage parameters. Review for non-formulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review:
• The patient has failed an appropriate trial of formulary or preferred agents. • The use of preferred or formulary agent is contraindicated in the patient.
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• The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety.
If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions
The member’s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are not limited to:
• OTC medications or their equivalents unless otherwise specified in the Formulary listing. • Drug products used for cosmetic purposes. • Drug products for sexual dysfunction. • Experimental drug products, or any drug product used in an experimental manner. • Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).
Mandated Generic Substitution
Total Health Care advocates the use of cost-effective generic drugs where FDA-approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted in lowercase lettering wherever an FDA-approved generic drug product is available. If a member or physician requests a brand name product in lieu of an approved generic, the member, based upon their coverage, will be required to pay the difference in cost between the brand/non-preferred brand and the generic drug, plus the brand/non-preferred brand copay.
Total Health Care Pharmacy and Therapeutics (P&T) Committee
Total Health Care’s Pharmacy & Therapeutics Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel.
Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutics Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC’s drug criteria by calling the Pharmacy Department at 1-800-826-2862.
Diabetic Testing Supplies
Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer,
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and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at 1-844-236-7933.
Specialty Bio-Pharmaceutical Pharmacy Program
Total Health Care works with Elixir Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Elixir Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to Elixir at 1-866-422-9119 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at www.THCmi.com. Once the order is received, Elixir obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Elixir Specialty Pharmacy. Then, Elixir Specialty Pharmacy staff ships the medication directly to the physician's office or the patient’s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty Bio-Pharmaceutical Pharmacy program, please contact Elixir at 1-844-222-5584 or Elixir Specialty Pharmacy at 1-877-437-9012.
Contact Information
The Total Health Care Qualified Health Plan Formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at 1-800-826-2862. Medication Limitations Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days’ supply limitation, and/or a limitation on the duration of therapy. Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit. Gender Restrictions Gender restrictions are indicated with a “GR” on the formulary and require the member to be a specific gender for coverage. Step Therapy Criteria
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Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled. Step Therapy Criteria
Therapy Class First Line Second Line Step Therapy Criteria
Aminosalicylic Acid Derivative Agents
APRISO, DELZICOL
PENTASA, mesalamine DR
Prior use of APRISO or mesalamine DR in the last 90 days.
Angiotensin Receptor Blocker and Calcium Channel Blocker
amlodipine-valsartan
amlodipine-olmesartan
Prior use of amlodipine-valsartan in the last 90 days.
Antidiabetic Agents – DPP4
alogliptin, alogliptin-metformin alogliptin- pioglitazone
JANUVIA, JANUMET, JANUMET XR, ONGLYZA, TRADJENTA
Prior use of alogliptin, alogliptin-metformin, or alogliptin-pioglitazone in the last 90 days.
Antidiabetic Agents – SGLT-2
INVOKANA, INVOKAMET, INVOKAMET XR, JARDIANCE, SYNJARDY, SYNJARDY XR
FARXIGA, XIGDUO XR
Prior use of TWO of the following: INVOKANA, INVOKAMET, JARDIANCE, SYNJARDY in the last 180 days.
Antiemetic Agents ondansetron, granisetron
ANZEMET, aprepitant
Prior use of ondansetron AND granisetron in the last 90 days.
Antiglaucoma Agents latanoprost, bimatoprost, travoprost
LUMIGAN, TRAVATAN-Z, ZIOPTAN
Prior use of TWO of the following: latanoprost, bimatoprost or travoprost in the last 90 days.
Antimigraine sumatriptan, rizatriptan, naratriptan, zolmitriptan
almotriptan, eletriptan, frovatriptan
Prior use of TWO of the following: sumatriptan, rizatriptan, zolmitriptan, naratriptan in the last 90 days.
Anti-Parkinson's Agents – MAO-B inhibitors
selegiline tablet EMSAM Prior use of selegiline tablet in the last 90 days.
Anti-Parkinson's Agents
ropinirole immediate-release, pramipexole immediate-release
ropinirole extended-release, pramipexole extended-release
Prior use of ropinirole immediate-release AND pramipexole immediate-release in the last 90 days.
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Anti-platelet Agents clopidogrel prasugrel Prior use of clopidogrel in the last 90 days.
Antipsychotics quetiapine IR, olanzapine, risperidone, ziprasidone
quetiapine ER
Prior use for 30 days of quetiapine IR, olanzapine, risperidone, or ziprasidone
Beta2 Agonist (nebulizer)
albuterol nebulizer solution
levalbuterol nebulizer solution
Prior use of albuterol nebulizer solution in the last 90 days.
Coreg CR carvedilol IR carvedilol ER Prior use of carvedilol IR in the last 90 days.
HMG-CoA Reductase Inhibitor
atorvastatin, simvastatin, rosuvastatin
LIVALO, ezetimibe-simvastatin
Prior use of TWO of the following: atorvastatin, rosuvastatin, simvastatin in the last 90 days.
Hypnotic Agents temazepam, zaleplon, zolpidem IR, zolpidem ER, eszopiclone
ramelteon, BELSOMRA
Prior use of TWO of the following: temazepam, zaleplon, zolpidem, zolpidem ER, eszopiclone in the last 90 days.
Nasal Corticosteroids flunisolide fluticasone, NASACORT OTC, budesonide OTC
azelastine, BECONASE AQ, mometasone, QNASL
Prior use of TWO of the following: flunisolide, fluticasone, NASACORT OTC or budesonide OTC nasal in the last 180 days.
Pediculicides malathion 0.5% NATROBA Prior use of malathion 0.5% within the last 90 days.
Pleuromutilin Antibiotic
mupirocin ALTABAX Prior use of mupirocin in the last 90 days.
Propranolol ER propranolol IR propranolol ER Prior use of propranolol IR in the last 90 days.
Retinoic Acid Derivatives
tretinoin 0.025%, tretinoin 0.05%, tretinoin 0.1%, tretinoin 0.01%, DIFFERIN OTC 0.1% GEL
tretinoin 0.04% gel adapalene-benz peroxide gel, clindamycin-tretinoin
Prior use of tretinoin 0.025%, tretinoin 0.05%, tretinoin 0.01%, tretinoin 0.1%, or DIFFERIN OTC 0.1% GEL in the last 90 days.
Topical Scalp Corticosteroids
ketoconazole 2% shampoo
CAPEX SHAMPOO
Prior use of ketoconazole 2% shampoo in the last 90 days.
Topical Corticosteroids
clobetasol, desonide, betamethasone,
calcipotriene -betamethasone
Prior use of TWO of the following: clobetasol, desonide, betamethasone, flucinolone,
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flucinolone, flucinonide, hydrocortisone, triamcinolone
flucinonide, hydrocortisone, or triamcinolone in the last 90 days.
Urinary Antispasmodics
oxybutynin, oxybutynin ER, OXYTROL OTC, oxybutynin syrup
tolterodine, tolterodine ER, trospium, trospium ER, darifenacin, solifenacin, TOVIAZ
Prior use of OXYTROL OTC, oxybutynin, oxybutynin ER, or oxybutynin syrup in the last 90 days.
Vascepa omega-3-acid icosapent ethyl Prior use of omega-3 acid capsule in the last 90 days.
Vyvanse amphetamine ER VYVANSE Prior use of amphetamine ER capsule in the last 90 days.
*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of Elixir. The presence of a medication on this formulary list does not guarantee coverage.
CURRENT AS OF 1/1/2021
lowercase italics = Generic drugsUPPERCASE BOLD = Brand name drugs
StatusT1 = Covered
NotesAL = Age LimitGR-F = Female OnlyGR-M = Male OnlyPA = Prior AuthorizationQL = Quantity LimitST = Step Therapy
Drug Status Notes
*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg
T2QL (30 EA per 30 days); AL (Min 6 Years)
amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg, 25 mg, 30 mg
T2QL (60 EA per 30 days); AL (Min 6 Years)
amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg
T1QL (120 EA per 30 days); AL (Min 6 Years)
amphetamine-dextroamphetamine oral tablet 20 mg, 5 mg, 7.5 mg
T1QL (90 EA per 30 days); AL (Min 6 Years)
amphetamine-dextroamphetamine oral tablet 30 mg
T1QL (60 EA per 30 days); AL (Min 6 Years)
armodafinil oral tablet 150 mg, 250 mg T1 QL (30 EA per 30 days)
armodafinil tablet 200 mg oral 200 mg T3 PA
armodafinil tablet 50 mg oral 50 mg T3 PA
atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg
T1QL (60 EA per 30 days); AL (Min 6 Years)
atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg
T1QL (30 EA per 30 days); AL (Min 6 Years)
caffeine citrate solution 20 mg/ml oral 20 mg/ml T1
caffeine citrate solution 60 mg/3ml intravenous60 mg/3ml
T1
caffeine-sodium benzoate solution 125-125 mg/ml injection 125-125 mg/ml
T1
DAYTRANA PATCH 10 MG/9HR TRANSDERMAL 10 MG/9HR T3
PA; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
DAYTRANA PATCH 15 MG/9HR TRANSDERMAL 15 MG/9HR T3
PA; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
DAYTRANA PATCH 20 MG/9HR TRANSDERMAL 20 MG/9HR T3
PA; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
DAYTRANA PATCH 30 MG/9HR TRANSDERMAL 30 MG/9HR T3
PA; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg
T1QL (30 EA per 30 days); AL (Min 4 Years)
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Drug Status Notes
dexmethylphenidate hcl oral tablet 10 mg, 5 mg T1QL (150 EA per 30 days); AL (Min 6 Years)
dexmethylphenidate hcl oral tablet 2.5 mg T1QL (90 EA per 30 days); AL (Min 6 Years)
dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg
T1
dextroamphetamine sulfate oral tablet 10 mg T1 QL (180 EA per 30 days)
dextroamphetamine sulfate oral tablet 5 mg T1 QL (360 EA per 30 days)
diethylpropion hcl er tablet extended release 24 hour 75 mg oral 75 mg
T1
diethylpropion hcl tablet 25 mg oral 25 mg T1
DOPRAM INTRAVENOUS SOLUTION 20 MG/ML T1
guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg
T1 QL (60 EA per 30 days)
methamphetamine hcl tablet 5 mg oral 5 mg T1AL (Min 6 Years and Max 17 Years)
methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg
T1QL (30 EA per 30 days); AL (Min 4 Years)
methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg
T1QL (30 EA per 30 days); AL (Min 4 Years and Max 10 Years)
methylphenidate hcl er oral tablet extended release 10 mg
T1QL (300 EA per 30 days); AL (Min 4 Years)
methylphenidate hcl er oral tablet extended release 20 mg
T1QL (150 EA per 30 days); AL (Min 4 Years)
methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg
T1QL (30 EA per 30 days); AL (Min 4 Years and Max 10 Years)
methylphenidate hcl er oral tablet extended release 24 hour 36 mg, 54 mg
T1QL (60 EA per 30 days); AL (Min 4 Years and Max 10 Years)
methylphenidate hcl oral solution 5 mg/5ml T1QL (600 ML per 30 days); AL (Min 4 Years and Max 10 Years)
methylphenidate hcl oral tablet 10 mg T1QL (300 EA per 30 days); AL (Min 4 Years)
methylphenidate hcl oral tablet 20 mg T1QL (150 EA per 30 days); AL (Min 4 Years)
methylphenidate hcl oral tablet 5 mg T1QL (600 EA per 30 days); AL (Min 4 Years)
methylphenidate hcl solution 10 mg/5ml oral 10 mg/5ml
T1PA; AL (Min 6 Years and Max 17 Years)
modafinil tablet 100 mg oral 100 mg T1 PA
modafinil tablet 200 mg oral 200 mg T1 PA
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Drug Status Notesphendimetrazine tartrate er capsule extended release 24 hour 105 mg oral 105 mg
T1
phendimetrazine tartrate tablet 35 mg oral 35 mg T1
phentermine hcl capsule 15 mg oral 15 mg T1
phentermine hcl capsule 30 mg oral 30 mg T1
phentermine hcl capsule 37.5 mg oral 37.5 mg T1
phentermine hcl tablet 37.5 mg oral 37.5 mg T1
VYVANSE CAPSULE 10 MG ORAL 10 MG T3ST; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
VYVANSE CAPSULE 20 MG ORAL 20 MG T3ST; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
VYVANSE CAPSULE 30 MG ORAL 30 MG T3ST; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
VYVANSE CAPSULE 40 MG ORAL 40 MG T3ST; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
VYVANSE CAPSULE 50 MG ORAL 50 MG T3ST; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
VYVANSE CAPSULE 60 MG ORAL 60 MG T3ST; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
VYVANSE CAPSULE 70 MG ORAL 70 MG T3ST; QL (30 EA per 30 days); AL (Min 6 Years and Max 17 Years)
*Aminoglycosides*neomycin sulfate tablet 500 mg oral 500 mg T1
paromomycin sulfate capsule 250 mg oral 250 mg T4 PA
tobramycin nebulization solution 300 mg/5ml inhalation 300 mg/5ml
T4 PA
*Analgesics - Anti-Inflammatory*ARCALYST SOLUTION RECONSTITUTED 220 MG SUBCUTANEOUS 220 MG T4 PA
celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg
T1 QL (60 EA per 30 days)
diclofenac potassium tablet 50 mg oral 50 mg T1
diclofenac sodium er tablet extended release 24 hour 100 mg oral 100 mg
T1
diclofenac sodium tablet delayed release 25 mg oral 25 mg
T1
diclofenac sodium tablet delayed release 50 mg oral 50 mg
T1
diclofenac sodium tablet delayed release 75 mg oral 75 mg
T1
diclofenac-misoprostol tablet delayed release 50-0.2 mg oral 50-0.2 mg
T3
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Drug Status Notesdiclofenac-misoprostol tablet delayed release 75-0.2 mg oral 75-0.2 mg
T3
ENBREL SOLUTION PREFILLED SYRINGE 50 MG/ML SUBCUTANEOUS 50 MG/ML
T4 PA
ENBREL SOLUTION RECONSTITUTED 25 MG SUBCUTANEOUS 25 MG T4 PA
ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML T4 PA
ENBREL SURECLICK SOLUTION AUTO-INJECTOR 50 MG/ML SUBCUTANEOUS 50 MG/ML
T4 PA
etodolac capsule 200 mg oral 200 mg T1
etodolac capsule 300 mg oral 300 mg T1
etodolac er tablet extended release 24 hour 400 mg oral 400 mg
T1
etodolac er tablet extended release 24 hour 500 mg oral 500 mg
T1
etodolac er tablet extended release 24 hour 600 mg oral 600 mg
T1
etodolac tablet 400 mg oral 400 mg T1
etodolac tablet 500 mg oral 500 mg T1
flurbiprofen tablet 100 mg oral 100 mg T1
flurbiprofen tablet 50 mg oral 50 mg T1
HUMIRA PEN PEN-INJECTOR KIT 40 MG/0.8ML SUBCUTANEOUS 40 MG/0.8ML T4 PA
HUMIRA PREFILLED SYRINGE KIT 20 MG/0.4ML SUBCUTANEOUS 20 MG/0.4ML T4 PA
HUMIRA PREFILLED SYRINGE KIT 40 MG/0.8ML SUBCUTANEOUS 40 MG/0.8ML T4 PA
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML T4 PA
IBU TABLET 400 MG ORAL 400 MG T1
ibuprofen oral suspension 100 mg/5ml T1
ibuprofen tablet 600 mg oral 600 mg T1
ibuprofen tablet 800 mg oral 800 mg T1
indomethacin capsule 25 mg oral 25 mg T1 AL (Max 64 Years)
indomethacin capsule 50 mg oral 50 mg T1 AL (Max 64 Years)
indomethacin er capsule extended release 75 mg oral 75 mg
T1 AL (Max 64 Years)
ketoprofen er capsule extended release 24 hour 200 mg oral 200 mg
T1 QL (30 EA per 30 days)
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Drug Status Notesketorolac tromethamine tablet 10 mg oral 10 mg T1 QL (20 EA per 5 days)
KINERET SOLUTION PREFILLED SYRINGE 100 MG/0.67ML SUBCUTANEOUS 100 MG/0.67ML
T4 PA
leflunomide tablet 10 mg oral 10 mg T1
leflunomide tablet 20 mg oral 20 mg T1
meclofenamate sodium capsule 100 mg oral 100 mg
T3
meclofenamate sodium capsule 50 mg oral 50 mg T3
meloxicam tablet 15 mg oral 15 mg T1
meloxicam tablet 7.5 mg oral 7.5 mg T1
nabumetone tablet 500 mg oral 500 mg T1 QL (120 EA per 30 days)
nabumetone tablet 750 mg oral 750 mg T1 QL (60 EA per 30 days)
naproxen sodium tablet 275 mg oral 275 mg T3
naproxen sodium tablet 550 mg oral 550 mg T3
naproxen suspension 125 mg/5ml oral 125 mg/5ml
T1QL (300 ML per 30 days); AL (Max 12 Years)
naproxen tablet 250 mg oral 250 mg T1
naproxen tablet 375 mg oral 375 mg T1
naproxen tablet 500 mg oral 500 mg T1
naproxen tablet delayed release 375 mg oral 375 mg
T1
naproxen tablet delayed release 500 mg oral 500 mg
T1
oxaprozin tablet 600 mg oral 600 mg T3
piroxicam capsule 10 mg oral 10 mg T1
piroxicam capsule 20 mg oral 20 mg T1
RIDAURA CAPSULE 3 MG ORAL 3 MG T4 PA
RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 MG T4 PA
sulindac tablet 150 mg oral 150 mg T1
sulindac tablet 200 mg oral 200 mg T1
tolmetin sodium capsule 400 mg oral 400 mg T1
tolmetin sodium tablet 600 mg oral 600 mg T3
XELJANZ TABLET 5 MG ORAL 5 MG T4 PA
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG T4 PA
*Analgesics - Nonnarcotic*
aspirin 81 oral tablet chewable 81 mg T5QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years)
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Drug Status Notesaspirin ec low dose oral tablet delayed release 81 mg
T5QL (60 EA per 30 days); AL (Min 40 Years and Max 79 Years)
aspirin ec oral tablet delayed release 325 mg T5QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)
aspirin oral tablet 325 mg T5QL (30 EA per 30 days); AL (Min 40 Years and Max 79 Years)
BAC TABLET 50-325-40 MG ORAL 50-325-40 MG T1
butalbital-acetaminophen oral tablet 50-325 mg T1
butalbital-apap-caffeine capsule 50-300-40 mg oral 50-300-40 mg
T1
butalbital-apap-caffeine capsule 50-325-40 mg oral 50-325-40 mg
T3
butalbital-aspirin-caffeine capsule 50-325-40 mg oral 50-325-40 mg
T1
diflunisal tablet 500 mg oral 500 mg T1
salsalate tablet 500 mg oral 500 mg T1
salsalate tablet 750 mg oral 750 mg T1
*Analgesics - Opioid*acetaminophen-codeine #2 tablet 300-15 mg oral300-15 mg
T1 QL (390 EA per 30 days)
acetaminophen-codeine #3 tablet 300-30 mg oral300-30 mg
T1 QL (390 EA per 30 days)
acetaminophen-codeine #4 tablet 300-60 mg oral300-60 mg
T1 QL (390 EA per 30 days)
acetaminophen-codeine solution 120-12 mg/5ml oral 120-12 mg/5ml
T1
buprenorphine hcl solution 0.3 mg/ml injection0.3 mg/ml
T3 PA
buprenorphine hcl tablet sublingual 2 mg sublingual 2 mg
T3 PA
buprenorphine hcl tablet sublingual 8 mg sublingual 8 mg
T3 PA
buprenorphine hcl-naloxone hcl sublingual film12-3 mg
T3 PA; QL (30 EA per 30 days)
buprenorphine hcl-naloxone hcl sublingual film2-0.5 mg, 4-1 mg
T3 PA; QL (90 EA per 30 days)
buprenorphine hcl-naloxone hcl sublingual film8-2 mg
T3 PA; QL (60 EA per 30 days)
buprenorphine hcl-naloxone hcl tablet sublingual 2-0.5 mg sublingual 2-0.5 mg
T3 PA; QL (90 EA per 30 days)
buprenorphine hcl-naloxone hcl tablet sublingual 8-2 mg sublingual 8-2 mg
T3 PA; QL (90 EA per 30 days)
6
Drug Status Notesbuprenorphine transdermal patch weekly 10 mcg/hr, 20 mcg/hr, 5 mcg/hr
T3 PA
butalbital-apap-caff-cod capsule 50-325-40-30 mg oral 50-325-40-30 mg
T1
butalbital-asa-caff-codeine capsule 50-325-40-30 mg oral 50-325-40-30 mg
T1
butorphanol tartrate solution 1 mg/ml injection 1 mg/ml
T3
butorphanol tartrate solution 10 mg/ml nasal 10 mg/ml
T3
butorphanol tartrate solution 2 mg/ml injection 2 mg/ml
T3
codeine sulfate tablet 15 mg oral 15 mg T1
codeine sulfate tablet 30 mg oral 30 mg T1
EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG
T3 PA
ENDOCET TABLET 5-325 MG ORAL 5-325 MG T1 QL (360 EA per 30 days)
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
T1 QL (10 EA per 30 days)
hydrocodone-acetaminophen solution 7.5-325 mg/15ml oral 7.5-325 mg/15ml
T1
hydrocodone-acetaminophen tablet 10-325 mg oral 10-325 mg
T1 QL (180 EA per 30 days)
hydrocodone-acetaminophen tablet 5-325 mg oral5-325 mg
T1 QL (180 EA per 30 days)
hydrocodone-acetaminophen tablet 7.5-325 mg oral 7.5-325 mg
T1 QL (180 EA per 30 days)
hydrocodone-ibuprofen oral tablet 10-200 mg T3 PA
hydrocodone-ibuprofen tablet 5-200 mg oral 5-200 mg
T2 QL (180 EA per 30 days)
hydrocodone-ibuprofen tablet 7.5-200 mg oral7.5-200 mg
T2 QL (180 EA per 30 days)
hydromorphone hcl er tablet extended release 24 hour 12 mg oral 12 mg
T3 PA
hydromorphone hcl er tablet extended release 24 hour 16 mg oral 16 mg
T3 PA
hydromorphone hcl er tablet extended release 24 hour 32 mg oral 32 mg
T3 PA
hydromorphone hcl er tablet extended release 24 hour 8 mg oral 8 mg
T3 PA
hydromorphone hcl liquid 1 mg/ml oral 1 mg/ml T3
7
Drug Status Noteshydromorphone hcl suppository 3 mg rectal 3 mg T3
hydromorphone hcl tablet 2 mg oral 2 mg T1 QL (240 EA per 30 days)
hydromorphone hcl tablet 4 mg oral 4 mg T1 QL (240 EA per 30 days)
hydromorphone hcl tablet 8 mg oral 8 mg T1 QL (240 EA per 30 days)
levorphanol tartrate tablet 2 mg oral 2 mg T1
meperidine hcl solution 100 mg/ml injection 100 mg/ml
T3
meperidine hcl solution 25 mg/ml injection 25 mg/ml
T3
meperidine hcl solution 50 mg/5ml oral 50 mg/5ml
T1
meperidine hcl solution 50 mg/ml injection 50 mg/ml
T3
meperidine hcl tablet 100 mg oral 100 mg T1
meperidine hcl tablet 50 mg oral 50 mg T1
METHADONE HCL INTENSOL CONCENTRATE 10 MG/ML ORAL 10 MG/ML
T1
methadone hcl solution 10 mg/5ml oral 10 mg/5ml
T1
methadone hcl solution 10 mg/ml injection 10 mg/ml
T3
methadone hcl solution 5 mg/5ml oral 5 mg/5ml T1
methadone hcl tablet 10 mg oral 10 mg T1 QL (240 EA per 30 days)
methadone hcl tablet 5 mg oral 5 mg T1
METHADOSE TABLET SOLUBLE 40 MG ORAL 40 MG T1
morphine sulfate (concentrate) solution 100 mg/5ml oral 100 mg/5ml
T1
morphine sulfate (pf) solution 0.5 mg/ml injection0.5 mg/ml
T3
morphine sulfate (pf) solution 1 mg/ml injection 1 mg/ml
T3
morphine sulfate (pf) solution 10 mg/ml intravenous 10 mg/ml
T3
morphine sulfate (pf) solution 2 mg/ml intravenous 2 mg/ml
T3
morphine sulfate (pf) solution 4 mg/ml intravenous 4 mg/ml
T3
morphine sulfate (pf) solution 8 mg/ml intravenous 8 mg/ml
T3
8
Drug Status Notesmorphine sulfate device 10 mg/0.7ml intramuscular 10 mg/0.7ml
T3
morphine sulfate er tablet extended release 100 mg oral 100 mg
T1 QL (90 EA per 30 days)
morphine sulfate er tablet extended release 15 mg oral 15 mg
T1 QL (90 EA per 30 days)
morphine sulfate er tablet extended release 30 mg oral 30 mg
T1 QL (90 EA per 30 days)
morphine sulfate er tablet extended release 60 mg oral 60 mg
T1 QL (90 EA per 30 days)
morphine sulfate oral tablet 15 mg T1 QL (180 EA per 30 days)
morphine sulfate solution 10 mg/5ml oral 10 mg/5ml
T1
morphine sulfate solution 20 mg/5ml oral 20 mg/5ml
T1
morphine sulfate suppository 10 mg rectal 10 mg T3
morphine sulfate suppository 20 mg rectal 20 mg T3
morphine sulfate suppository 30 mg rectal 30 mg T3
morphine sulfate suppository 5 mg rectal 5 mg T3
morphine sulfate tablet 30 mg oral 30 mg T1 QL (180 EA per 30 days)
nalbuphine hcl solution 10 mg/ml injection 10 mg/ml
T3
nalbuphine hcl solution 20 mg/ml injection 20 mg/ml
T3
NUCYNTA ER TABLET EXTENDED RELEASE 12 HOUR 100 MG ORAL 100 MG T3 PA
NUCYNTA ER TABLET EXTENDED RELEASE 12 HOUR 150 MG ORAL 150 MG T3 PA
NUCYNTA ER TABLET EXTENDED RELEASE 12 HOUR 200 MG ORAL 200 MG T3 PA
NUCYNTA ER TABLET EXTENDED RELEASE 12 HOUR 250 MG ORAL 250 MG T3 PA
NUCYNTA ER TABLET EXTENDED RELEASE 12 HOUR 50 MG ORAL 50 MG T3 PA
OXAYDO TABLET 7.5 MG ORAL 7.5 MG T3 PA; QL (180 EA per 30 days)
oxycodone hcl capsule 5 mg oral 5 mg T3 QL (180 EA per 30 days)
oxycodone hcl concentrate 100 mg/5ml oral 100 mg/5ml
T3
oxycodone hcl oral tablet 5 mg T3 PA; QL (180 EA per 30 days)
oxycodone hcl solution 5 mg/5ml oral 5 mg/5ml T1
oxycodone hcl tablet 10 mg oral 10 mg T1 QL (180 EA per 30 days)
oxycodone hcl tablet 15 mg oral 15 mg T1 QL (180 EA per 30 days)
9
Drug Status Notesoxycodone hcl tablet 20 mg oral 20 mg T1 QL (180 EA per 30 days)
oxycodone hcl tablet 30 mg oral 30 mg T1 QL (180 EA per 30 days)
oxycodone-acetaminophen tablet 10-325 mg oral10-325 mg
T1 QL (180 EA per 30 days)
oxycodone-acetaminophen tablet 2.5-325 mg oral2.5-325 mg
T1
oxycodone-acetaminophen tablet 7.5-325 mg oral7.5-325 mg
T1 QL (180 EA per 30 days)
oxycodone-aspirin tablet 4.8355-325 mg oral4.8355-325 mg
T1
oxymorphone hcl er tablet extended release 12 hour 10 mg oral 10 mg
T3 PA
oxymorphone hcl er tablet extended release 12 hour 15 mg oral 15 mg
T3 PA
oxymorphone hcl er tablet extended release 12 hour 20 mg oral 20 mg
T3 PA
oxymorphone hcl er tablet extended release 12 hour 30 mg oral 30 mg
T3 PA
oxymorphone hcl er tablet extended release 12 hour 40 mg oral 40 mg
T3 PA
oxymorphone hcl er tablet extended release 12 hour 5 mg oral 5 mg
T3 PA
oxymorphone hcl er tablet extended release 12 hour 7.5 mg oral 7.5 mg
T3 PA
pentazocine-naloxone hcl tablet 50-0.5 mg oral50-0.5 mg
T1
tramadol hcl er (biphasic) tablet extended release 24 hour 300 mg oral 300 mg
T3 QL (30 EA per 30 days)
tramadol hcl er capsule extended release 24 hour 150 mg oral 150 mg
T3 QL (30 EA per 30 days)
tramadol hcl er tablet extended release 24 hour 100 mg oral 100 mg
T3 QL (30 EA per 30 days)
tramadol hcl er tablet extended release 24 hour 200 mg oral 200 mg
T3 QL (30 EA per 30 days)
tramadol hcl tablet 50 mg oral 50 mg T1 QL (240 EA per 30 days)
tramadol-acetaminophen tablet 37.5-325 mg oral37.5-325 mg
T1
*Androgens-Anabolic*ANADROL-50 TABLET 50 MG ORAL 50 MG T4 PA
ANDRODERM PATCH 24 HOUR 2 MG/24HR TRANSDERMAL 2 MG/24HR T3 PA
10
Drug Status NotesANDRODERM PATCH 24 HOUR 4 MG/24HR TRANSDERMAL 4 MG/24HR T3 PA
methitest tablet 10 mg oral 10 mg T3
oxandrolone tablet 10 mg oral 10 mg T3 PA
oxandrolone tablet 2.5 mg oral 2.5 mg T3 PA
testosterone cypionate solution 100 mg/ml intramuscular 100 mg/ml
T1 GR-M
testosterone cypionate solution 200 mg/ml intramuscular 200 mg/ml
T1 GR-M
testosterone enanthate intramuscular solution200 mg/ml
T1 GR-M
testosterone gel 25 mg/2.5gm (1%) transdermal25 mg/2.5gm (1%)
T3 PA
testosterone solution 30 mg/act transdermal 30 mg/act
T3 PA
testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%)
T3 PA
testosterone transdermal gel 50 mg/5gm (1%) T3
*Anorectal And Related Products*ANALPRAM-HC LOTION 2.5-1 % EXTERNAL 2.5-1 % T3
COLOCORT ENEMA 100 MG/60ML RECTAL 100 MG/60ML T1
CORTIFOAM FOAM 10 % EXTERNAL 10 % T3 PA
lidocaine-hydrocortisone ace gel 2.8-0.55 % rectal 2.8-0.55 %
T3
lidocaine-hydrocortisone ace kit 2-2 % rectal 2-2 %
T3 PA
lidocaine-hydrocortisone ace kit 3-0.5 % rectal 3-0.5 %
T1
lidocaine-hydrocortisone ace kit 3-1 % rectal 3-1 %
T1
lidocaine-hydrocortisone ace kit 3-2.5 % rectal 3-2.5 %
T1
PROCTOFOAM HC FOAM 1-1 % EXTERNAL 1-1 % T3
PROCTOZONE-HC CREAM 2.5 % EXTERNAL 2.5 % T1
RECTIV OINTMENT 0.4 % RECTAL 0.4 % T3
11
Drug Status Notes
*Antacids*magnesium oxide oral tablet 400 mg T1
sodium bicarbonate oral tablet 650 mg T1
*Anthelmintics*albendazole oral tablet 200 mg T3 PA
ivermectin tablet 3 mg oral 3 mg T3 QL (10 EA per 30 days)
reeses pinworm medicine suspension 144 (50 base) mg/ml oral 144 (50 base) mg/ml
T1
*Antianginal Agents*DILATRATE-SR CAPSULE EXTENDED RELEASE 40 MG ORAL 40 MG T3
isosorbide dinitrate oral tablet 30 mg T1
isosorbide dinitrate tablet 10 mg oral 10 mg T1
isosorbide dinitrate tablet 20 mg oral 20 mg T1
isosorbide dinitrate tablet 5 mg oral 5 mg T1
isosorbide mononitrate er tablet extended release 24 hour 120 mg oral 120 mg
T1
isosorbide mononitrate er tablet extended release 24 hour 30 mg oral 30 mg
T1
isosorbide mononitrate er tablet extended release 24 hour 60 mg oral 60 mg
T1
isosorbide mononitrate tablet 10 mg oral 10 mg T1
isosorbide mononitrate tablet 20 mg oral 20 mg T1
NITRO-BID OINTMENT 2 % TRANSDERMAL 2 % T3
NITRO-DUR PATCH 24 HOUR 0.3 MG/HR TRANSDERMAL 0.3 MG/HR T3
NITRO-DUR PATCH 24 HOUR 0.8 MG/HR TRANSDERMAL 0.8 MG/HR T3
nitroglycerin er capsule extended release 2.5 mg oral 2.5 mg
T1
nitroglycerin patch 24 hour 0.1 mg/hr transdermal 0.1 mg/hr
T1
nitroglycerin patch 24 hour 0.2 mg/hr transdermal 0.2 mg/hr
T1
nitroglycerin patch 24 hour 0.4 mg/hr transdermal 0.4 mg/hr
T1
nitroglycerin patch 24 hour 0.6 mg/hr transdermal 0.6 mg/hr
T1
nitroglycerin solution 0.4 mg/spray translingual0.4 mg/spray
T3
12
Drug Status Notesnitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg
T1
NITRO-TIME CAPSULE EXTENDED RELEASE 6.5 MG ORAL 6.5 MG T1
NITRO-TIME CAPSULE EXTENDED RELEASE 9 MG ORAL 9 MG T1
RANEXA TABLET EXTENDED RELEASE 12 HOUR 1000 MG ORAL 1000 MG T3 PA
RANEXA TABLET EXTENDED RELEASE 12 HOUR 500 MG ORAL 500 MG T3 PA
*Antianxiety Agents*alprazolam er tablet extended release 24 hour 1 mg oral 1 mg
T3 AL (Max 64 Years)
alprazolam er tablet extended release 24 hour 2 mg oral 2 mg
T3 AL (Max 64 Years)
alprazolam tablet 0.25 mg oral 0.25 mg T1 AL (Max 64 Years)
alprazolam tablet 0.5 mg oral 0.5 mg T1 AL (Max 64 Years)
alprazolam tablet 1 mg oral 1 mg T1 AL (Max 64 Years)
alprazolam tablet 2 mg oral 2 mg T1 AL (Max 64 Years)
alprazolam tablet dispersible 0.25 mg oral 0.25 mg
T3 AL (Max 64 Years)
alprazolam tablet dispersible 0.5 mg oral 0.5 mg T3 AL (Max 64 Years)
alprazolam tablet dispersible 1 mg oral 1 mg T3 AL (Max 64 Years)
alprazolam tablet dispersible 2 mg oral 2 mg T3 AL (Max 64 Years)
alprazolam xr tablet extended release 24 hour 0.5 mg oral 0.5 mg
T3 AL (Max 64 Years)
alprazolam xr tablet extended release 24 hour 3 mg oral 3 mg
T3 AL (Max 64 Years)
buspirone hcl tablet 10 mg oral 10 mg T1
buspirone hcl tablet 15 mg oral 15 mg T1
buspirone hcl tablet 30 mg oral 30 mg T1
buspirone hcl tablet 5 mg oral 5 mg T1
buspirone hcl tablet 7.5 mg oral 7.5 mg T1
chlordiazepoxide hcl capsule 10 mg oral 10 mg T1 AL (Max 64 Years)
chlordiazepoxide hcl capsule 25 mg oral 25 mg T1 AL (Max 64 Years)
chlordiazepoxide hcl capsule 5 mg oral 5 mg T1 AL (Max 64 Years)
clorazepate dipotassium tablet 15 mg oral 15 mg T1 AL (Max 64 Years)
clorazepate dipotassium tablet 3.75 mg oral 3.75 mg
T1 AL (Max 64 Years)
clorazepate dipotassium tablet 7.5 mg oral 7.5 mg T1 AL (Max 64 Years)
diazepam solution 5 mg/5ml oral 5 mg/5ml T1 AL (Max 64 Years)
13
Drug Status Notesdiazepam solution 5 mg/ml injection 5 mg/ml T1 AL (Max 64 Years)
diazepam tablet 10 mg oral 10 mg T1 AL (Max 64 Years)
diazepam tablet 2 mg oral 2 mg T1 AL (Max 64 Years)
diazepam tablet 5 mg oral 5 mg T1 AL (Max 64 Years)
droperidol injection solution 2.5 mg/ml T1
hydroxyzine hcl solution 25 mg/ml intramuscular25 mg/ml
T1 AL (Max 64 Years)
hydroxyzine hcl solution 50 mg/ml intramuscular50 mg/ml
T1 AL (Max 64 Years)
hydroxyzine hcl syrup 10 mg/5ml oral 10 mg/5ml T1 AL (Max 64 Years)
hydroxyzine hcl tablet 10 mg oral 10 mg T1 AL (Max 64 Years)
hydroxyzine hcl tablet 25 mg oral 25 mg T1 AL (Max 64 Years)
hydroxyzine hcl tablet 50 mg oral 50 mg T1 AL (Max 64 Years)
hydroxyzine pamoate capsule 100 mg oral 100 mg
T1 AL (Max 64 Years)
hydroxyzine pamoate capsule 25 mg oral 25 mg T1 AL (Max 64 Years)
hydroxyzine pamoate capsule 50 mg oral 50 mg T1 AL (Max 64 Years)
LORAZEPAM INTENSOL CONCENTRATE 2 MG/ML ORAL 2 MG/ML T1
lorazepam solution 2 mg/ml injection 2 mg/ml T1
lorazepam solution 4 mg/ml injection 4 mg/ml T1
lorazepam tablet 0.5 mg oral 0.5 mg T1
lorazepam tablet 1 mg oral 1 mg T1
lorazepam tablet 2 mg oral 2 mg T1
meprobamate tablet 200 mg oral 200 mg T1 AL (Max 64 Years)
meprobamate tablet 400 mg oral 400 mg T1 AL (Max 64 Years)
oxazepam capsule 10 mg oral 10 mg T1
oxazepam oral capsule 15 mg, 30 mg T1
*Antiarrhythmics*amiodarone hcl tablet 200 mg oral 200 mg T1
disopyramide phosphate capsule 100 mg oral 100 mg
T1
disopyramide phosphate capsule 150 mg oral 150 mg
T1
dofetilide capsule 125 mcg oral 125 mcg T3
dofetilide capsule 250 mcg oral 250 mcg T3
dofetilide capsule 500 mcg oral 500 mcg T3
flecainide acetate tablet 100 mg oral 100 mg T1
flecainide acetate tablet 150 mg oral 150 mg T1
flecainide acetate tablet 50 mg oral 50 mg T1
14
Drug Status Notesmexiletine hcl capsule 150 mg oral 150 mg T1
mexiletine hcl capsule 200 mg oral 200 mg T1
mexiletine hcl capsule 250 mg oral 250 mg T1
MULTAQ TABLET 400 MG ORAL 400 MG T3 PA
NORPACE CR CAPSULE EXTENDED RELEASE 12 HOUR 100 MG ORAL 100 MG T3
PACERONE TABLET 400 MG ORAL 400 MG T1
propafenone hcl er capsule extended release 12 hour 225 mg oral 225 mg
T3
propafenone hcl er capsule extended release 12 hour 325 mg oral 325 mg
T3
propafenone hcl er capsule extended release 12 hour 425 mg oral 425 mg
T3
propafenone hcl tablet 150 mg oral 150 mg T1
propafenone hcl tablet 225 mg oral 225 mg T1
propafenone hcl tablet 300 mg oral 300 mg T1
quinidine gluconate er tablet extended release 324 mg oral 324 mg
T1
quinidine sulfate tablet 200 mg oral 200 mg T1
quinidine sulfate tablet 300 mg oral 300 mg T1
*Antiasthmatic And Bronchodilator Agents*ADVAIR HFA AEROSOL 115-21 MCG/ACT INHALATION 115-21 MCG/ACT T2 QL (12 GM per 30 days)
ADVAIR HFA AEROSOL 230-21 MCG/ACT INHALATION 230-21 MCG/ACT T2 QL (12 GM per 30 days)
ADVAIR HFA AEROSOL 45-21 MCG/ACT INHALATION 45-21 MCG/ACT T2 QL (12 GM per 30 days)
albuterol sulfate er tablet extended release 12 hour 4 mg oral 4 mg
T1
albuterol sulfate er tablet extended release 12 hour 8 mg oral 8 mg
T1
albuterol sulfate nebulization solution (2.5 mg/3ml) 0.083% inhalation (2.5 mg/3ml) 0.083%
T1
albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation (5 mg/ml) 0.5%
T1
albuterol sulfate nebulization solution 0.63 mg/3ml inhalation 0.63 mg/3ml
T1
albuterol sulfate nebulization solution 1.25 mg/3ml inhalation 1.25 mg/3ml
T1
albuterol sulfate syrup 2 mg/5ml oral 2 mg/5ml T1
15
Drug Status NotesANORO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH INHALATION 62.5-25 MCG/INH
T2
ARCAPTA NEOHALER CAPSULE 75 MCG INHALATION 75 MCG T3 PA; QL (30 EA per 30 days)
ARNUITY ELLIPTA AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT INHALATION 100 MCG/ACT
T2 QL (30 EA per 30 days)
ARNUITY ELLIPTA AEROSOL POWDER BREATH ACTIVATED 200 MCG/ACT INHALATION 200 MCG/ACT
T2 QL (30 EA per 30 days)
ASMANEX (120 METERED DOSES) AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH INHALATION220 MCG/INH
T2 QL (1 EA per 30 days)
ASMANEX (7 METERED DOSES) AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH INHALATION110 MCG/INH
T2 QL (1 EA per 30 days)
ASMANEX HFA INHALATION AEROSOL100 MCG/ACT T2 QL (13 GM per 1 day)
ASMANEX HFA INHALATION AEROSOL200 MCG/ACT T2 QL (13 GM per 30 days)
ATROVENT HFA AEROSOL SOLUTION 17 MCG/ACT INHALATION 17 MCG/ACT T3 QL (12.9 GM per 30 days)
BREO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH INHALATION 100-25 MCG/INH
T2 QL (60 EA per 30 days)
BREO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 200-25 MCG/INH INHALATION 200-25 MCG/INH
T2 QL (60 EA per 30 days)
BROVANA NEBULIZATION SOLUTION 15 MCG/2ML INHALATION 15 MCG/2ML T3 PA; QL (120 ML per 30 days)
budesonide suspension 0.25 mg/2ml inhalation0.25 mg/2ml
T1QL (120 ML per 30 days); AL (Max 6 Years)
budesonide suspension 0.5 mg/2ml inhalation 0.5 mg/2ml
T1QL (120 ML per 30 days); AL (Max 6 Years)
budesonide suspension 1 mg/2ml inhalation 1 mg/2ml
T3QL (120 ML per 30 days); AL (Max 6 Years)
COMBIVENT RESPIMAT AEROSOL SOLUTION 20-100 MCG/ACT INHALATION 20-100 MCG/ACT
T3 QL (4 GM per 30 days)
DALIRESP TABLET 500 MCG ORAL 500 MCG T2 QL (30 EA per 30 days)
16
Drug Status NotesDULERA AEROSOL 100-5 MCG/ACT INHALATION 100-5 MCG/ACT T3 QL (13 GM per 30 days)
DULERA AEROSOL 200-5 MCG/ACT INHALATION 200-5 MCG/ACT T3 QL (13 GM per 30 days)
ELIXOPHYLLIN ELIXIR 80 MG/15ML ORAL 80 MG/15ML T2
FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 30 MG/ML T4 PA
FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST INHALATION 100 MCG/BLIST
T2 QL (60 EA per 30 days)
FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST INHALATION 250 MCG/BLIST
T2 QL (60 EA per 30 days)
FLOVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 50 MCG/BLIST INHALATION 50 MCG/BLIST
T2 QL (60 EA per 30 days)
FLOVENT HFA AEROSOL 110 MCG/ACT INHALATION 110 MCG/ACT T2 QL (12 GM per 30 days)
FLOVENT HFA AEROSOL 220 MCG/ACT INHALATION 220 MCG/ACT T2 QL (12 GM per 30 days)
FLOVENT HFA AEROSOL 44 MCG/ACT INHALATION 44 MCG/ACT T2 QL (10.6 GM per 30 days)
fluticasone-salmeterol aerosol powder breath activated 113-14 mcg/act inhalation 113-14 mcg/act
T1 QL (1 EA per 30 days)
fluticasone-salmeterol aerosol powder breath activated 232-14 mcg/act inhalation 232-14 mcg/act
T1 QL (1 EA per 30 days)
fluticasone-salmeterol aerosol powder breath activated 55-14 mcg/act inhalation 55-14 mcg/act
T1 QL (1 EA per 30 days)
fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose
T2 QL (60 EA per 30 days)
INCRUSE ELLIPTA AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH INHALATION 62.5 MCG/INH
T3 QL (30 EA per 30 days)
ipratropium bromide solution 0.02 % inhalation0.02 %
T1
ipratropium-albuterol solution 0.5-2.5 (3) mg/3ml inhalation 0.5-2.5 (3) mg/3ml
T1
levalbuterol hcl nebulization solution 0.31 mg/3ml inhalation 0.31 mg/3ml
T1 ST
levalbuterol hcl nebulization solution 0.63 mg/3ml inhalation 0.63 mg/3ml
T1 ST
17
Drug Status Noteslevalbuterol hcl nebulization solution 1.25 mg/0.5ml inhalation 1.25 mg/0.5ml
T1 ST
levalbuterol tartrate aerosol 45 mcg/act inhalation 45 mcg/act
T3 QL (15 GM per 30 days)
metaproterenol sulfate syrup 10 mg/5ml oral 10 mg/5ml
T1
montelukast sodium packet 4 mg oral 4 mg T1
montelukast sodium tablet 10 mg oral 10 mg T1
montelukast sodium tablet chewable 4 mg oral 4 mg
T1
montelukast sodium tablet chewable 5 mg oral 5 mg
T1
PERFOROMIST NEBULIZATION SOLUTION 20 MCG/2ML INHALATION 20 MCG/2ML
T3 PA; QL (120 ML per 30 days)
PROAIR RESPICLICK AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT
T3 QL (1 EA per 30 days)
PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT INHALATION 180 MCG/ACT
T3 QL (1 EA per 30 days)
PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 90 MCG/ACT INHALATION 90 MCG/ACT
T3 QL (1 EA per 30 days)
QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT
T3 QL (10.6 GM per 30 days)
SEREVENT DISKUS AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE INHALATION 50 MCG/DOSE
T2 QL (60 EA per 30 days)
SPIRIVA HANDIHALER CAPSULE 18 MCG INHALATION 18 MCG T2 QL (30 EA per 30 days)
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT
T2 QL (4 GM per 30 days)
STRIVERDI RESPIMAT AEROSOL SOLUTION 2.5 MCG/ACT INHALATION2.5 MCG/ACT
T2 QL (4 GM per 30 days)
terbutaline sulfate solution 1 mg/ml injection 1 mg/ml
T1
terbutaline sulfate tablet 2.5 mg oral 2.5 mg T1
terbutaline sulfate tablet 5 mg oral 5 mg T1
18
Drug Status Notestheophylline er tablet extended release 12 hour 300 mg oral 300 mg
T1
theophylline er tablet extended release 12 hour 450 mg oral 450 mg
T1
theophylline er tablet extended release 24 hour 400 mg oral 400 mg
T1
theophylline er tablet extended release 24 hour 600 mg oral 600 mg
T1
theophylline solution 80 mg/15ml oral 80 mg/15ml
T1
TUDORZA PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT INHALATION 400 MCG/ACT
T3 QL (1 EA per 30 days)
VENTOLIN HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT
T2 QL (36 GM per 28 days)
WIXELA INHUB INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE
T2 QL (60 EA per 30 days)
XOLAIR SOLUTION RECONSTITUTED 150 MG SUBCUTANEOUS 150 MG T4 PA
zafirlukast tablet 10 mg oral 10 mg T3
zafirlukast tablet 20 mg oral 20 mg T3
zileuton er tablet extended release 12 hour 600 mg oral 600 mg
T4 PA
ZYFLO TABLET 600 MG ORAL 600 MG T4 PA
*Anticoagulants*ELIQUIS DVT/PE STARTER PACK ORAL TABLET 5 MG T2 QL (60 EA per 30 days)
ELIQUIS ORAL TABLET 2.5 MG, 5 MG T2 QL (60 EA per 30 days)
enoxaparin sodium injection solution 300 mg/3ml T3 PA
enoxaparin sodium solution 100 mg/ml subcutaneous 100 mg/ml
T3PA; Cover For 7 days supply per 30 days, requiring PA thereafter
enoxaparin sodium solution 120 mg/0.8ml subcutaneous 120 mg/0.8ml
T3PA; Cover For 7 days supply per 30 days, requiring PA thereafter
enoxaparin sodium solution 150 mg/ml subcutaneous 150 mg/ml
T3PA; Cover For 7 days supply per 30 days, requiring PA thereafter
enoxaparin sodium solution 30 mg/0.3ml subcutaneous 30 mg/0.3ml
T3PA; Cover For 7 days supply per 30 days, requiring PA thereafter
enoxaparin sodium solution 40 mg/0.4ml subcutaneous 40 mg/0.4ml
T3PA; Cover For 7 days supply per 30 days, requiring PA thereafter
19
Drug Status Notesenoxaparin sodium solution 60 mg/0.6ml subcutaneous 60 mg/0.6ml
T3PA; Cover For 7 days supply per 30 days, requiring PA thereafter
enoxaparin sodium solution 80 mg/0.8ml subcutaneous 80 mg/0.8ml
T3PA; Cover For 7 days supply per 30 days, requiring PA thereafter
fondaparinux sodium solution 10 mg/0.8ml subcutaneous 10 mg/0.8ml
T4 PA
fondaparinux sodium solution 2.5 mg/0.5ml subcutaneous 2.5 mg/0.5ml
T4 PA
fondaparinux sodium solution 5 mg/0.4ml subcutaneous 5 mg/0.4ml
T4 PA
fondaparinux sodium solution 7.5 mg/0.6ml subcutaneous 7.5 mg/0.6ml
T4 PA
FRAGMIN SOLUTION 10000 UNIT/ML SUBCUTANEOUS 10000 UNIT/ML T4 PA
FRAGMIN SOLUTION 12500 UNIT/0.5ML SUBCUTANEOUS 12500 UNIT/0.5ML T4 PA
FRAGMIN SOLUTION 15000 UNIT/0.6ML SUBCUTANEOUS 15000 UNIT/0.6ML T4 PA
FRAGMIN SOLUTION 18000 UNT/0.72ML SUBCUTANEOUS 18000 UNT/0.72ML T4 PA
FRAGMIN SOLUTION 2500 UNIT/0.2ML SUBCUTANEOUS 2500 UNIT/0.2ML T4 PA
FRAGMIN SOLUTION 5000 UNIT/0.2ML SUBCUTANEOUS 5000 UNIT/0.2ML T4 PA
FRAGMIN SOLUTION 7500 UNIT/0.3ML SUBCUTANEOUS 7500 UNIT/0.3ML T4 PA
heparin lock flush solution 10 unit/ml intravenous10 unit/ml
T1
heparin sod (porcine) in d5w solution 100 unit/ml intravenous 100 unit/ml
T1
heparin sodium (porcine) pf solution 5000 unit/0.5ml injection 5000 unit/0.5ml
T1
heparin sodium (porcine) solution 1000 unit/ml injection 1000 unit/ml
T1
heparin sodium (porcine) solution 10000 unit/ml injection 10000 unit/ml
T1
heparin sodium (porcine) solution 20000 unit/ml injection 20000 unit/ml
T1
heparin sodium (porcine) solution 5000 unit/ml injection 5000 unit/ml
T1
heparin sodium lock flush solution 100 unit/ml intravenous 100 unit/ml
T1
PRADAXA CAPSULE 150 MG ORAL 150 MG T3 PA
20
Drug Status NotesPRADAXA CAPSULE 75 MG ORAL 75 MG T3 PA
warfarin sodium tablet 1 mg oral 1 mg T1
warfarin sodium tablet 10 mg oral 10 mg T1
warfarin sodium tablet 2 mg oral 2 mg T1
warfarin sodium tablet 2.5 mg oral 2.5 mg T1
warfarin sodium tablet 3 mg oral 3 mg T1
warfarin sodium tablet 4 mg oral 4 mg T1
warfarin sodium tablet 5 mg oral 5 mg T1
warfarin sodium tablet 6 mg oral 6 mg T1
warfarin sodium tablet 7.5 mg oral 7.5 mg T1
XARELTO ORAL TABLET 2.5 MG T2 QL (60 EA per 30 days)
XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG T2 QL (51 EA per 365 days)
XARELTO TABLET 10 MG ORAL 10 MG T2 QL (30 EA per 30 days)
XARELTO TABLET 15 MG ORAL 15 MG T2 QL (60 EA per 30 days)
XARELTO TABLET 20 MG ORAL 20 MG T2 QL (30 EA per 30 days)
*Anticonvulsants*APTIOM TABLET 200 MG ORAL 200 MG T3 PA
APTIOM TABLET 400 MG ORAL 400 MG T3 PA
APTIOM TABLET 600 MG ORAL 600 MG T3 PA
APTIOM TABLET 800 MG ORAL 800 MG T3 PA
carbamazepine er capsule extended release 12 hour 100 mg oral 100 mg
T1
carbamazepine er capsule extended release 12 hour 200 mg oral 200 mg
T1
carbamazepine er capsule extended release 12 hour 300 mg oral 300 mg
T1
carbamazepine er tablet extended release 12 hour 100 mg oral 100 mg
T1
carbamazepine er tablet extended release 12 hour 200 mg oral 200 mg
T1
carbamazepine er tablet extended release 12 hour 400 mg oral 400 mg
T1
carbamazepine suspension 100 mg/5ml oral 100 mg/5ml
T1
carbamazepine tablet 200 mg oral 200 mg T1
carbamazepine tablet chewable 100 mg oral 100 mg
T1
CELONTIN CAPSULE 300 MG ORAL 300 MG T2
21
Drug Status Notesclobazam oral suspension 2.5 mg/ml T3 PA
clobazam oral tablet 10 mg, 20 mg T3 PA
clonazepam tablet 0.5 mg oral 0.5 mg T1
clonazepam tablet 1 mg oral 1 mg T1
clonazepam tablet 2 mg oral 2 mg T1
clonazepam tablet dispersible 0.125 mg oral0.125 mg
T1
clonazepam tablet dispersible 0.25 mg oral 0.25 mg
T1
clonazepam tablet dispersible 0.5 mg oral 0.5 mg T1
clonazepam tablet dispersible 1 mg oral 1 mg T1
clonazepam tablet dispersible 2 mg oral 2 mg T1
DILANTIN CAPSULE 30 MG ORAL 30 MG T2
DILANTIN ORAL CAPSULE 100 MG T2
divalproex sodium capsule delayed release sprinkle 125 mg oral 125 mg
T1
divalproex sodium er tablet extended release 24 hour 250 mg oral 250 mg
T1
divalproex sodium er tablet extended release 24 hour 500 mg oral 500 mg
T1
divalproex sodium tablet delayed release 125 mg oral 125 mg
T1
divalproex sodium tablet delayed release 250 mg oral 250 mg
T1
divalproex sodium tablet delayed release 500 mg oral 500 mg
T1
ethosuximide capsule 250 mg oral 250 mg T1
ethosuximide solution 250 mg/5ml oral 250 mg/5ml
T3
felbamate suspension 600 mg/5ml oral 600 mg/5ml
T4
felbamate tablet 400 mg oral 400 mg T3
felbamate tablet 600 mg oral 600 mg T3
FYCOMPA TABLET 10 MG ORAL 10 MG T3 PA
FYCOMPA TABLET 12 MG ORAL 12 MG T3 PA
FYCOMPA TABLET 2 MG ORAL 2 MG T3 PA
FYCOMPA TABLET 4 MG ORAL 4 MG T3 PA
FYCOMPA TABLET 6 MG ORAL 6 MG T3 PA
FYCOMPA TABLET 8 MG ORAL 8 MG T3 PA
gabapentin capsule 100 mg oral 100 mg T1
gabapentin capsule 300 mg oral 300 mg T1
22
Drug Status Notesgabapentin capsule 400 mg oral 400 mg T1
gabapentin solution 250 mg/5ml oral 250 mg/5ml T1
gabapentin tablet 600 mg oral 600 mg T1
gabapentin tablet 800 mg oral 800 mg T1
GABITRIL ORAL TABLET 12 MG T3
LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 100 MG, 42 X 50 MG & 14X100 MG
T3
lamotrigine er tablet extended release 24 hour 100 mg oral 100 mg
T3
lamotrigine er tablet extended release 24 hour 200 mg oral 200 mg
T3
lamotrigine er tablet extended release 24 hour 25 mg oral 25 mg
T3
lamotrigine er tablet extended release 24 hour 250 mg oral 250 mg
T3
lamotrigine er tablet extended release 24 hour 300 mg oral 300 mg
T3
lamotrigine er tablet extended release 24 hour 50 mg oral 50 mg
T3
lamotrigine tablet 100 mg oral 100 mg T1
lamotrigine tablet 150 mg oral 150 mg T1
lamotrigine tablet 200 mg oral 200 mg T1
lamotrigine tablet 25 mg oral 25 mg T1
lamotrigine tablet chewable 25 mg oral 25 mg T1
lamotrigine tablet chewable 5 mg oral 5 mg T1
levetiracetam er tablet extended release 24 hour 500 mg oral 500 mg
T3
levetiracetam er tablet extended release 24 hour 750 mg oral 750 mg
T3
levetiracetam solution 100 mg/ml oral 100 mg/ml T1
levetiracetam solution 500 mg/5ml intravenous500 mg/5ml
T1
levetiracetam tablet 1000 mg oral 1000 mg T1 QL (90 EA per 30 days)
levetiracetam tablet 250 mg oral 250 mg T1 QL (360 EA per 30 days)
levetiracetam tablet 500 mg oral 500 mg T1 QL (180 EA per 30 days)
levetiracetam tablet 750 mg oral 750 mg T1 QL (120 EA per 30 days)
LYRICA SOLUTION 20 MG/ML ORAL 20 MG/ML T3 PA
oxcarbazepine suspension 300 mg/5ml oral 300 mg/5ml
T1
23
Drug Status Notesoxcarbazepine tablet 150 mg oral 150 mg T1
oxcarbazepine tablet 300 mg oral 300 mg T1
oxcarbazepine tablet 600 mg oral 600 mg T1
PEGANONE TABLET 250 MG ORAL 250 MG T3
phenytoin sodium extended capsule 200 mg oral200 mg
T1
phenytoin sodium extended capsule 300 mg oral300 mg
T1
phenytoin sodium extended oral capsule 100 mg T1
phenytoin sodium solution 50 mg/ml injection 50 mg/ml
T1
phenytoin suspension 125 mg/5ml oral 125 mg/5ml
T1
phenytoin tablet chewable 50 mg oral 50 mg T1
pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 50 mg, 75 mg
T1 QL (90 EA per 30 days)
pregabalin oral capsule 300 mg T1 QL (60 EA per 30 days)
primidone tablet 250 mg oral 250 mg T1
primidone tablet 50 mg oral 50 mg T1
rufinamide oral suspension 40 mg/ml T3
tiagabine hcl oral tablet 12 mg, 16 mg T3
tiagabine hcl tablet 2 mg oral 2 mg T3
tiagabine hcl tablet 4 mg oral 4 mg T3
topiramate capsule sprinkle 15 mg oral 15 mg T1
topiramate capsule sprinkle 25 mg oral 25 mg T1
topiramate tablet 100 mg oral 100 mg T1
topiramate tablet 200 mg oral 200 mg T1
topiramate tablet 25 mg oral 25 mg T1
topiramate tablet 50 mg oral 50 mg T1
valproic acid capsule 250 mg oral 250 mg T1
valproic acid solution 250 mg/5ml oral 250 mg/5ml
T1
vigabatrin oral packet 500 mg T4 PA
VIMPAT TABLET 100 MG ORAL 100 MG T3 PA
VIMPAT TABLET 150 MG ORAL 150 MG T3 PA
VIMPAT TABLET 200 MG ORAL 200 MG T3 PA
VIMPAT TABLET 50 MG ORAL 50 MG T3 PA
zonisamide capsule 100 mg oral 100 mg T1 QL (180 EA per 30 days)
zonisamide capsule 25 mg oral 25 mg T1 QL (360 EA per 30 days)
24
Drug Status Noteszonisamide capsule 50 mg oral 50 mg T1 QL (360 EA per 30 days)
*Antidepressants*amitriptyline hcl tablet 10 mg oral 10 mg T1 AL (Max 64 Years)
amitriptyline hcl tablet 100 mg oral 100 mg T1 AL (Max 64 Years)
amitriptyline hcl tablet 150 mg oral 150 mg T1 AL (Max 64 Years)
amitriptyline hcl tablet 25 mg oral 25 mg T1 AL (Max 64 Years)
amitriptyline hcl tablet 50 mg oral 50 mg T1 AL (Max 64 Years)
amitriptyline hcl tablet 75 mg oral 75 mg T1 AL (Max 64 Years)
amoxapine tablet 100 mg oral 100 mg T1 AL (Max 64 Years)
amoxapine tablet 150 mg oral 150 mg T1 AL (Max 64 Years)
amoxapine tablet 25 mg oral 25 mg T1 AL (Max 64 Years)
amoxapine tablet 50 mg oral 50 mg T1 AL (Max 64 Years)
bupropion hcl er (sr) tablet extended release 12 hour 100 mg oral 100 mg
T1
bupropion hcl er (sr) tablet extended release 12 hour 150 mg oral 150 mg
T1
bupropion hcl er (sr) tablet extended release 12 hour 200 mg oral 200 mg
T1
bupropion hcl er (xl) tablet extended release 24 hour 150 mg oral 150 mg
T1
bupropion hcl er (xl) tablet extended release 24 hour 300 mg oral 300 mg
T1
bupropion hcl tablet 100 mg oral 100 mg T1
bupropion hcl tablet 75 mg oral 75 mg T1
citalopram hydrobromide solution 10 mg/5ml oral 10 mg/5ml
T1
citalopram hydrobromide tablet 10 mg oral 10 mg
T1
citalopram hydrobromide tablet 20 mg oral 20 mg
T1
citalopram hydrobromide tablet 40 mg oral 40 mg
T1 QL (30 EA per 30 days)
clomipramine hcl capsule 25 mg oral 25 mg T3 AL (Max 64 Years)
clomipramine hcl capsule 50 mg oral 50 mg T3 AL (Max 64 Years)
clomipramine hcl capsule 75 mg oral 75 mg T3 AL (Max 64 Years)
desipramine hcl tablet 10 mg oral 10 mg T3 QL (60 EA per 30 days)
desipramine hcl tablet 100 mg oral 100 mg T3 QL (60 EA per 30 days)
desipramine hcl tablet 150 mg oral 150 mg T3 QL (60 EA per 30 days)
desipramine hcl tablet 25 mg oral 25 mg T3 QL (60 EA per 30 days)
desipramine hcl tablet 50 mg oral 50 mg T3 QL (60 EA per 30 days)
25
Drug Status Notesdesipramine hcl tablet 75 mg oral 75 mg T3 QL (60 EA per 30 days)
desvenlafaxine er tablet extended release 24 hour 100 mg oral 100 mg
T3 QL (30 EA per 30 days)
desvenlafaxine er tablet extended release 24 hour 50 mg oral 50 mg
T3 QL (30 EA per 30 days)
desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg
T3 QL (30 EA per 30 days)
desvenlafaxine succinate er tablet extended release 24 hour 100 mg oral 100 mg
T3 QL (30 EA per 30 days)
desvenlafaxine succinate er tablet extended release 24 hour 50 mg oral 50 mg
T3 QL (30 EA per 30 days)
doxepin hcl capsule 10 mg oral 10 mg T1 AL (Max 64 Years)
doxepin hcl capsule 100 mg oral 100 mg T1 AL (Max 64 Years)
doxepin hcl capsule 25 mg oral 25 mg T1 AL (Max 64 Years)
doxepin hcl capsule 50 mg oral 50 mg T1 AL (Max 64 Years)
doxepin hcl capsule 75 mg oral 75 mg T1 AL (Max 64 Years)
doxepin hcl concentrate 10 mg/ml oral 10 mg/ml T1 AL (Max 64 Years)
doxepin hcl oral capsule 150 mg T1
duloxetine hcl capsule delayed release particles 20 mg oral 20 mg
T1 QL (60 EA per 30 days)
duloxetine hcl capsule delayed release particles 30 mg oral 30 mg
T1 QL (30 EA per 30 days)
duloxetine hcl capsule delayed release particles 60 mg oral 60 mg
T1 QL (30 EA per 30 days)
EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL 12 MG/24HR T3 ST; QL (30 EA per 30 days)
EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL 6 MG/24HR T3 ST; QL (30 EA per 30 days)
EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL 9 MG/24HR T3 ST; QL (30 EA per 30 days)
escitalopram oxalate solution 5 mg/5ml oral 5 mg/5ml
T1
escitalopram oxalate tablet 10 mg oral 10 mg T1 QL (45 EA per 30 days)
escitalopram oxalate tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days)
escitalopram oxalate tablet 5 mg oral 5 mg T1 QL (45 EA per 30 days)
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL 120 MG T3 PA
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 20 MG ORAL 20 MG T3 PA
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 40 MG ORAL 40 MG T3 PA
26
Drug Status NotesFETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 80 MG ORAL 80 MG T3 PA
fluoxetine hcl capsule 10 mg oral 10 mg T1
fluoxetine hcl capsule 20 mg oral 20 mg T1
fluoxetine hcl capsule 40 mg oral 40 mg T1
fluoxetine hcl capsule delayed release 90 mg oral90 mg
T1 QL (4 EA per 28 days)
fluoxetine hcl solution 20 mg/5ml oral 20 mg/5ml T1
fluvoxamine maleate tablet 100 mg oral 100 mg T1
fluvoxamine maleate tablet 25 mg oral 25 mg T1
fluvoxamine maleate tablet 50 mg oral 50 mg T1
imipramine hcl tablet 10 mg oral 10 mg T1 AL (Max 64 Years)
imipramine hcl tablet 25 mg oral 25 mg T1 AL (Max 64 Years)
imipramine hcl tablet 50 mg oral 50 mg T1 AL (Max 64 Years)
imipramine pamoate capsule 100 mg oral 100 mg T3 AL (Max 64 Years)
imipramine pamoate capsule 125 mg oral 125 mg T3 AL (Max 64 Years)
imipramine pamoate capsule 150 mg oral 150 mg T3 AL (Max 64 Years)
imipramine pamoate capsule 75 mg oral 75 mg T3 AL (Max 64 Years)
maprotiline hcl tablet 25 mg oral 25 mg T1
maprotiline hcl tablet 50 mg oral 50 mg T1
maprotiline hcl tablet 75 mg oral 75 mg T1
MARPLAN TABLET 10 MG ORAL 10 MG T3
mirtazapine tablet 15 mg oral 15 mg T1 AL (Max 64 Years)
mirtazapine tablet 30 mg oral 30 mg T1 AL (Max 64 Years)
mirtazapine tablet 45 mg oral 45 mg T1 AL (Max 64 Years)
mirtazapine tablet 7.5 mg oral 7.5 mg T1 AL (Max 64 Years)
mirtazapine tablet dispersible 15 mg oral 15 mg T3 AL (Max 64 Years)
mirtazapine tablet dispersible 30 mg oral 30 mg T3 AL (Max 64 Years)
mirtazapine tablet dispersible 45 mg oral 45 mg T3 AL (Max 64 Years)
nefazodone hcl tablet 100 mg oral 100 mg T1
nefazodone hcl tablet 150 mg oral 150 mg T1
nefazodone hcl tablet 200 mg oral 200 mg T1
nefazodone hcl tablet 250 mg oral 250 mg T1
nefazodone hcl tablet 50 mg oral 50 mg T1
nortriptyline hcl capsule 10 mg oral 10 mg T1
nortriptyline hcl capsule 25 mg oral 25 mg T1
nortriptyline hcl capsule 50 mg oral 50 mg T1
nortriptyline hcl capsule 75 mg oral 75 mg T1
27
Drug Status Notesnortriptyline hcl solution 10 mg/5ml oral 10 mg/5ml
T1
paroxetine hcl er tablet extended release 24 hour 12.5 mg oral 12.5 mg
T3
paroxetine hcl er tablet extended release 24 hour 25 mg oral 25 mg
T3
paroxetine hcl er tablet extended release 24 hour 37.5 mg oral 37.5 mg
T3
paroxetine hcl tablet 10 mg oral 10 mg T1
paroxetine hcl tablet 20 mg oral 20 mg T1
paroxetine hcl tablet 30 mg oral 30 mg T1
paroxetine hcl tablet 40 mg oral 40 mg T1
phenelzine sulfate tablet 15 mg oral 15 mg T1
protriptyline hcl tablet 10 mg oral 10 mg T1
protriptyline hcl tablet 5 mg oral 5 mg T1
sertraline hcl concentrate 20 mg/ml oral 20 mg/ml
T1
sertraline hcl tablet 100 mg oral 100 mg T1
sertraline hcl tablet 25 mg oral 25 mg T1
sertraline hcl tablet 50 mg oral 50 mg T1
tranylcypromine sulfate tablet 10 mg oral 10 mg T3
trazodone hcl tablet 100 mg oral 100 mg T1
trazodone hcl tablet 150 mg oral 150 mg T1
trazodone hcl tablet 50 mg oral 50 mg T1
trimipramine maleate capsule 100 mg oral 100 mg
T1
trimipramine maleate capsule 25 mg oral 25 mg T1
trimipramine maleate capsule 50 mg oral 50 mg T1
venlafaxine hcl er capsule extended release 24 hour 150 mg oral 150 mg
T1
venlafaxine hcl er capsule extended release 24 hour 37.5 mg oral 37.5 mg
T1
venlafaxine hcl er capsule extended release 24 hour 75 mg oral 75 mg
T1
venlafaxine hcl tablet 100 mg oral 100 mg T1
venlafaxine hcl tablet 25 mg oral 25 mg T1
venlafaxine hcl tablet 37.5 mg oral 37.5 mg T1
venlafaxine hcl tablet 50 mg oral 50 mg T1
venlafaxine hcl tablet 75 mg oral 75 mg T1
VIIBRYD TABLET 10 MG ORAL 10 MG T3 PA
28
Drug Status NotesVIIBRYD TABLET 20 MG ORAL 20 MG T3 PA
VIIBRYD TABLET 40 MG ORAL 40 MG T3 PA
*Antidiabetics*acarbose tablet 100 mg oral 100 mg T1
acarbose tablet 25 mg oral 25 mg T1
acarbose tablet 50 mg oral 50 mg T1
alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg
T2 QL (30 EA per 30 days)
alogliptin-metformin hcl oral tablet 12.5-1000 mg T2 QL (60 EA per 30 days)
alogliptin-metformin hcl oral tablet 12.5-500 mg T2 QL (30 EA per 30 days)
alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg
T2 QL (30 EA per 30 days)
AVANDIA TABLET 2 MG ORAL 2 MG T3
BYETTA 10 MCG PEN SOLUTION PEN-INJECTOR 10 MCG/0.04ML SUBCUTANEOUS 10 MCG/0.04ML
T3 PA; QL (2.4 ML per 30 days)
BYETTA 5 MCG PEN SOLUTION PEN-INJECTOR 5 MCG/0.02ML SUBCUTANEOUS 5 MCG/0.02ML
T3 PA; QL (1.2 ML per 30 days)
CYCLOSET TABLET 0.8 MG ORAL 0.8 MG T3
FARXIGA TABLET 5 MG ORAL 5 MG T3 ST; QL (30 EA per 30 days)
FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML T2
FIASP PENFILL SOLUTION CARTRIDGE 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML
T2
FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML T2
glimepiride tablet 1 mg oral 1 mg T1
glimepiride tablet 2 mg oral 2 mg T1
glimepiride tablet 4 mg oral 4 mg T1
glipizide er tablet extended release 24 hour 10 mg oral 10 mg
T1 QL (60 EA per 30 days)
glipizide er tablet extended release 24 hour 2.5 mg oral 2.5 mg
T1 QL (60 EA per 30 days)
glipizide er tablet extended release 24 hour 5 mg oral 5 mg
T1 QL (60 EA per 30 days)
glipizide tablet 10 mg oral 10 mg T1
glipizide tablet 5 mg oral 5 mg T1
glipizide-metformin hcl tablet 2.5-250 mg oral2.5-250 mg
T1
29
Drug Status Notesglipizide-metformin hcl tablet 2.5-500 mg oral2.5-500 mg
T1
glipizide-metformin hcl tablet 5-500 mg oral 5-500 mg
T1
GLUCAGEN HYPOKIT SOLUTION RECONSTITUTED 1 MG INJECTION 1 MG T2 QL (2 EA per 30 days)
glucagon emergency kit 1 mg injection 1 mg T3 QL (2 EA per 30 days)
glyburide micronized tablet 1.5 mg oral 1.5 mg T1
glyburide micronized tablet 3 mg oral 3 mg T1
glyburide micronized tablet 6 mg oral 6 mg T1
glyburide tablet 1.25 mg oral 1.25 mg T1
glyburide tablet 2.5 mg oral 2.5 mg T1
glyburide tablet 5 mg oral 5 mg T1
glyburide-metformin tablet 1.25-250 mg oral1.25-250 mg
T1
glyburide-metformin tablet 2.5-500 mg oral 2.5-500 mg
T1
glyburide-metformin tablet 5-500 mg oral 5-500 mg
T1
goodsense glucose tablet chewable 4-6 gm-mg oral 4-6 gm-mg
T1
HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML T2 QL (20 ML per 30 days)
INVOKAMET TABLET 150-1000 MG ORAL150-1000 MG T2 QL (60 EA per 30 days)
INVOKAMET TABLET 150-500 MG ORAL150-500 MG T2 QL (60 EA per 30 days)
INVOKAMET TABLET 50-1000 MG ORAL50-1000 MG T2 QL (60 EA per 30 days)
INVOKAMET TABLET 50-500 MG ORAL50-500 MG T2 QL (60 EA per 30 days)
INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG ORAL150-1000 MG
T2 QL (60 EA per 30 days)
INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR 150-500 MG ORAL 150-500 MG
T2 QL (60 EA per 30 days)
INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR 50-1000 MG ORAL 50-1000 MG
T2 QL (60 EA per 30 days)
INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR 50-500 MG ORAL 50-500 MG
T2 QL (60 EA per 30 days)
30
Drug Status NotesINVOKANA TABLET 100 MG ORAL 100 MG T2 QL (30 EA per 30 days)
INVOKANA TABLET 300 MG ORAL 300 MG T2 QL (30 EA per 30 days)
JANUMET ORAL TABLET 50-1000 MG, 50-500 MG T2 ST; QL (60 EA per 30 days)
JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG
T2 ST; QL (30 EA per 30 days)
JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG T2 ST; QL (30 EA per 30 days)
JARDIANCE TABLET 10 MG ORAL 10 MG T2 QL (30 EA per 30 days)
JARDIANCE TABLET 25 MG ORAL 25 MG T2 QL (30 EA per 30 days)
LANTUS SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML
T2
LANTUS SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T2
LEVEMIR FLEXTOUCH SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML
T2
LEVEMIR SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T2
metformin hcl er tablet extended release 24 hour 500 mg oral 500 mg
T1
metformin hcl er tablet extended release 24 hour 750 mg oral 750 mg
T1
metformin hcl tablet 1000 mg oral 1000 mg T1
metformin hcl tablet 500 mg oral 500 mg T1
metformin hcl tablet 850 mg oral 850 mg T1
miglitol tablet 25 mg oral 25 mg T3
nateglinide tablet 120 mg oral 120 mg T1
nateglinide tablet 60 mg oral 60 mg T1
NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML
T2
NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML
T2
NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS (70-30) 100 UNIT/ML
T2
31
Drug Status NotesNOVOLIN N FLEXPEN SUSPENSION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML
T2
NOVOLIN N RELION SUSPENSION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T2
NOVOLIN N SUSPENSION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T2
NOVOLIN R FLEXPEN SOLUTION PEN-INJECTOR 100 UNIT/ML INJECTION 100 UNIT/ML
T2
NOVOLIN R RELION SOLUTION 100 UNIT/ML INJECTION 100 UNIT/ML T2
NOVOLIN R SOLUTION 100 UNIT/ML INJECTION 100 UNIT/ML T2
NOVOLOG FLEXPEN SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML
T2
NOVOLOG MIX 70/30 FLEXPEN SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML SUBCUTANEOUS (70-30) 100 UNIT/ML
T2
NOVOLOG MIX 70/30 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS (70-30) 100 UNIT/ML
T2
NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML T2
NOVOLOG SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T2
ONGLYZA TABLET 2.5 MG ORAL 2.5 MG T3 ST; QL (30 EA per 30 days)
ONGLYZA TABLET 5 MG ORAL 5 MG T3 ST; QL (30 EA per 30 days)
OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML
T2 QL (1.5 ML per 30 days)
OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML T2 QL (3 ML per 30 days)
pioglitazone hcl tablet 15 mg oral 15 mg T1 QL (30 EA per 30 days)
pioglitazone hcl tablet 30 mg oral 30 mg T1 QL (30 EA per 30 days)
pioglitazone hcl tablet 45 mg oral 45 mg T1 QL (30 EA per 30 days)
pioglitazone hcl-glimepiride tablet 30-2 mg oral30-2 mg
T3
pioglitazone hcl-glimepiride tablet 30-4 mg oral30-4 mg
T3
pioglitazone hcl-metformin hcl tablet 15-500 mg oral 15-500 mg
T3
32
Drug Status Notespioglitazone hcl-metformin hcl tablet 15-850 mg oral 15-850 mg
T3
repaglinide tablet 0.5 mg oral 0.5 mg T1
repaglinide tablet 1 mg oral 1 mg T1
repaglinide tablet 2 mg oral 2 mg T1
RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG T2 QL (30 EA per 30 days)
SYMLINPEN 120 SOLUTION PEN-INJECTOR 2700 MCG/2.7ML SUBCUTANEOUS 2700 MCG/2.7ML
T3 PA
SYMLINPEN 60 SOLUTION PEN-INJECTOR 1500 MCG/1.5ML SUBCUTANEOUS 1500 MCG/1.5ML
T3 PA
SYNJARDY TABLET 12.5-1000 MG ORAL12.5-1000 MG T2 QL (60 EA per 30 days)
SYNJARDY TABLET 12.5-500 MG ORAL12.5-500 MG T2 QL (60 EA per 30 days)
SYNJARDY TABLET 5-1000 MG ORAL 5-1000 MG T2 QL (60 EA per 30 days)
SYNJARDY TABLET 5-500 MG ORAL 5-500 MG T2 QL (60 EA per 30 days)
SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG ORAL 10-1000 MG
T2 QL (60 EA per 30 days)
SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG ORAL12.5-1000 MG
T2 QL (60 EA per 30 days)
SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 25-1000 MG ORAL 25-1000 MG
T2 QL (60 EA per 30 days)
SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG ORAL 5-1000 MG
T2 QL (60 EA per 30 days)
tolbutamide tablet 500 mg oral 500 mg T1
TOUJEO SOLOSTAR SOLUTION PEN-INJECTOR 300 UNIT/ML SUBCUTANEOUS300 UNIT/ML
T2
TRADJENTA TABLET 5 MG ORAL 5 MG T3 ST; QL (30 EA per 30 days)
TRESIBA FLEXTOUCH SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS100 UNIT/ML
T2
TRESIBA FLEXTOUCH SOLUTION PEN-INJECTOR 200 UNIT/ML SUBCUTANEOUS200 UNIT/ML
T2
33
Drug Status NotesTRESIBA SOLUTION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML T2
TRULICITY SOLUTION PEN-INJECTOR 0.75 MG/0.5ML SUBCUTANEOUS 0.75 MG/0.5ML
T3 PA; QL (2 ML per 28 days)
TRULICITY SOLUTION PEN-INJECTOR 1.5 MG/0.5ML SUBCUTANEOUS 1.5 MG/0.5ML
T3 PA; QL (2 ML per 28 days)
VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS 18 MG/3ML T2 QL (9 ML per 30 days)
XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG ORAL 10-1000 MG
T3 ST; QL (30 EA per 30 days)
XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 10-500 MG ORAL 10-500 MG
T3 ST; QL (30 EA per 30 days)
XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG ORAL 5-1000 MG
T3 ST; QL (30 EA per 30 days)
XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR 5-500 MG ORAL 5-500 MG
T3 ST; QL (30 EA per 30 days)
*Antidiarrheal/Probiotic Agents*diphenoxylate-atropine liquid 2.5-0.025 mg/5ml oral 2.5-0.025 mg/5ml
T1
diphenoxylate-atropine tablet 2.5-0.025 mg oral2.5-0.025 mg
T1
loperamide hcl oral capsule 2 mg T1
loperamide hcl oral liquid 1 mg/5ml T1
loperamide hcl oral tablet 2 mg T1
MOTOFEN TABLET 1-0.025 MG ORAL 1-0.025 MG T3 PA
*Antidotes And Specific Antagonists*acetylcysteine solution 200 mg/ml intravenous200 mg/ml
T1
CHEMET CAPSULE 100 MG ORAL 100 MG T3
deferasirox oral tablet 180 mg T4 PA
deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg
T4 PA
deferiprone oral tablet 500 mg T4 PA
deferoxamine mesylate solution reconstituted 2 gm injection 2 gm
T1
JADENU TABLET 360 MG ORAL 360 MG T4 PA
34
Drug Status NotesJADENU TABLET 90 MG ORAL 90 MG T4 PA
naloxone hcl solution 0.4 mg/ml injection 0.4 mg/ml
T1 QL (2 ML per 90 days)
naloxone hcl solution prefilled syringe 2 mg/2ml injection 2 mg/2ml
T2 QL (2 ML per 90 days)
naltrexone hcl tablet 50 mg oral 50 mg T1
NARCAN NASAL LIQUID 4 MG/0.1ML T1
pentetate calcium trisodium solution 200 mg/ml combination 200 mg/ml
T1
pentetate zinc trisodium solution 200 mg/ml combination 200 mg/ml
T1
physostigmine salicylate solution 1 mg/ml injection 1 mg/ml
T1
RADIOGARDASE CAPSULE 0.5 GM ORAL0.5 GM T3 PA
VIVITROL SUSPENSION RECONSTITUTED 380 MG INTRAMUSCULAR 380 MG
T4 PA
*Antiemetics*AKYNZEO CAPSULE 300-0.5 MG ORAL300-0.5 MG T4 PA
ANZEMET TABLET 100 MG ORAL 100 MG T3 ST
ANZEMET TABLET 50 MG ORAL 50 MG T3 ST
aprepitant capsule 125 mg oral 125 mg T3 ST
aprepitant capsule 80 mg oral 80 mg T3 ST
dimenhydrinate solution 50 mg/ml injection 50 mg/ml
T3
dronabinol capsule 10 mg oral 10 mg T4 PA
dronabinol capsule 2.5 mg oral 2.5 mg T3 PA
dronabinol capsule 5 mg oral 5 mg T3 PA
granisetron hcl tablet 1 mg oral 1 mg T3 QL (10 EA per 30 days)
meclizine hcl oral tablet 25 mg T1
meclizine hcl tablet 12.5 mg oral (rx) 12.5 mg T1
ondansetron hcl solution 4 mg/5ml oral 4 mg/5ml T1 QL (50 ML per 30 days)
ondansetron hcl tablet 24 mg oral 24 mg T1 QL (5 EA per 30 days)
ondansetron hcl tablet 4 mg oral 4 mg T1 QL (15 EA per 30 days)
ondansetron hcl tablet 8 mg oral 8 mg T1 QL (15 EA per 30 days)
ondansetron oral tablet dispersible 4 mg, 8 mg T1 QL (15 EA per 30 days)
trimethobenzamide hcl capsule 300 mg oral 300 mg
T1
35
Drug Status Notes
*Antifungals*CRESEMBA CAPSULE 186 MG ORAL 186 MG T4 PA
fluconazole suspension reconstituted 10 mg/ml oral 10 mg/ml
T1 QL (105 ML per 30 days)
fluconazole suspension reconstituted 40 mg/ml oral 40 mg/ml
T1 QL (105 ML per 30 days)
fluconazole tablet 100 mg oral 100 mg T1 QL (30 EA per 30 days)
fluconazole tablet 150 mg oral 150 mg T1 QL (30 EA per 30 days)
fluconazole tablet 200 mg oral 200 mg T1 QL (30 EA per 30 days)
fluconazole tablet 50 mg oral 50 mg T1 QL (30 EA per 30 days)
flucytosine capsule 250 mg oral 250 mg T4 PA
flucytosine capsule 500 mg oral 500 mg T4 PA
griseofulvin microsize suspension 125 mg/5ml oral 125 mg/5ml
T3
griseofulvin microsize tablet 500 mg oral 500 mg T3
griseofulvin ultramicrosize tablet 125 mg oral125 mg
T3
griseofulvin ultramicrosize tablet 250 mg oral250 mg
T3
itraconazole oral capsule 100 mg T4 PA
ketoconazole tablet 200 mg oral 200 mg T1
nystatin tablet 500000 unit oral 500000 unit T1
terbinafine hcl tablet 250 mg oral 250 mg T1
voriconazole tablet 200 mg oral 200 mg T4 PA
voriconazole tablet 50 mg oral 50 mg T4 PA
*Antihistamines*carbinoxamine maleate tablet 4 mg oral 4 mg T1 AL (Max 64 Years)
cetirizine hcl oral tablet 10 mg T1 QL (30 EA per 30 days)
cetirizine hcl tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days)
cyproheptadine hcl syrup 2 mg/5ml oral 2 mg/5ml T1 AL (Max 64 Years)
cyproheptadine hcl tablet 4 mg oral 4 mg T1 AL (Max 64 Years)
diphenhydramine hcl elixir 12.5 mg/5ml oral (rx)12.5 mg/5ml
T1 AL (Max 64 Years)
diphenhydramine hcl solution 50 mg/ml injection50 mg/ml
T1 AL (Max 64 Years)
fexofenadine hcl oral tablet 180 mg T1 QL (30 EA per 30 days)
fexofenadine hcl oral tablet 60 mg T1 QL (60 EA per 30 days)
kp diphenhydramine hcl capsule 50 mg oral 50 mg
T1 AL (Max 64 Years)
36
Drug Status Noteslevocetirizine dihydrochloride tablet 5 mg oral (rx) 5 mg
T1 QL (30 EA per 30 days)
loratadine childrens oral syrup 5 mg/5ml T1QL (300 ML per 30 days); AL (Max 12 Years)
loratadine oral tablet 10 mg T1 QL (30 EA per 30 days)
promethazine hcl solution 25 mg/ml injection 25 mg/ml
T1 AL (Max 64 Years)
promethazine hcl solution 50 mg/ml injection 50 mg/ml
T1 AL (Max 64 Years)
promethazine hcl syrup 6.25 mg/5ml oral 6.25 mg/5ml
T1 AL (Max 64 Years)
promethazine hcl tablet 12.5 mg oral 12.5 mg T1 AL (Max 64 Years)
promethazine hcl tablet 25 mg oral 25 mg T1 AL (Max 64 Years)
promethazine hcl tablet 50 mg oral 50 mg T1 AL (Max 64 Years)
PROMETHEGAN SUPPOSITORY 12.5 MG RECTAL 12.5 MG T1
QL (12 EA per 30 days); AL (Max 64 Years)
PROMETHEGAN SUPPOSITORY 25 MG RECTAL 25 MG T1
QL (12 EA per 30 days); AL (Max 64 Years)
PROMETHEGAN SUPPOSITORY 50 MG RECTAL 50 MG T1
QL (12 EA per 30 days); AL (Max 64 Years)
*Antihyperlipidemics*atorvastatin calcium tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days)
atorvastatin calcium tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days)
atorvastatin calcium tablet 40 mg oral 40 mg T1 QL (30 EA per 30 days)
atorvastatin calcium tablet 80 mg oral 80 mg T1 QL (30 EA per 30 days)
colesevelam hcl oral packet 3.75 gm T3 PA
colesevelam hcl oral tablet 625 mg T3 PA
colestipol hcl granules 5 gm oral 5 gm T1
colestipol hcl tablet 1 gm oral 1 gm T1
ezetimibe tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days)
ezetimibe-simvastatin tablet 10-10 mg oral 10-10 mg
T3 ST; QL (30 EA per 30 days)
ezetimibe-simvastatin tablet 10-20 mg oral 10-20 mg
T3 ST; QL (30 EA per 30 days)
ezetimibe-simvastatin tablet 10-40 mg oral 10-40 mg
T3 ST; QL (30 EA per 30 days)
ezetimibe-simvastatin tablet 10-80 mg oral 10-80 mg
T3 ST; QL (30 EA per 30 days)
fenofibrate micronized capsule 134 mg oral 134 mg
T1
37
Drug Status Notesfenofibrate micronized capsule 200 mg oral 200 mg
T1
fenofibrate micronized capsule 43 mg oral 43 mg T1
fenofibrate micronized capsule 67 mg oral 67 mg T1
fenofibrate tablet 145 mg oral 145 mg T1
fenofibrate tablet 160 mg oral 160 mg T1
fenofibrate tablet 48 mg oral 48 mg T1
fenofibrate tablet 54 mg oral 54 mg T1
fenofibric acid capsule delayed release 135 mg oral 135 mg
T3
fenofibric acid capsule delayed release 45 mg oral 45 mg
T3
FIBRICOR TABLET 105 MG ORAL 105 MG T1
FIBRICOR TABLET 35 MG ORAL 35 MG T1
fluvastatin sodium capsule 20 mg oral 20 mg T3
fluvastatin sodium capsule 40 mg oral 40 mg T3
gemfibrozil tablet 600 mg oral 600 mg T1
icosapent ethyl oral capsule 1 gm T3 ST; QL (120 EA per 30 days)
LIVALO TABLET 1 MG ORAL 1 MG T3 ST; QL (30 EA per 30 days)
LIVALO TABLET 2 MG ORAL 2 MG T3 ST; QL (30 EA per 30 days)
LIVALO TABLET 4 MG ORAL 4 MG T3 ST; QL (30 EA per 30 days)
lovastatin tablet 10 mg oral 10 mg T1
lovastatin tablet 20 mg oral 20 mg T1
lovastatin tablet 40 mg oral 40 mg T1
niacin er (antihyperlipidemic) tablet extended release 1000 mg oral 1000 mg
T3
niacin er (antihyperlipidemic) tablet extended release 500 mg oral 500 mg
T3
niacin er (antihyperlipidemic) tablet extended release 750 mg oral 750 mg
T3
NIACOR TABLET 500 MG ORAL 500 MG T1
omega-3-acid ethyl esters capsule 1 gm oral 1 gm T3 QL (120 EA per 30 days)
PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML, 75 MG/ML T2 PA; QL (2 ML per 28 days)
pravastatin sodium tablet 10 mg oral 10 mg T1
pravastatin sodium tablet 20 mg oral 20 mg T1
pravastatin sodium tablet 40 mg oral 40 mg T1
pravastatin sodium tablet 80 mg oral 80 mg T1
PREVALITE PACKET 4 GM ORAL 4 GM T1 QL (60 EA per 30 days)
38
Drug Status NotesPREVALITE POWDER 4 GM/DOSE ORAL4 GM/DOSE T1 QL (239.4 GM per 30 days)
REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE420 MG/3.5ML
T2 PA; QL (3.5 ML per 30 days)
REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML T2 PA; QL (2 ML per 28 days)
REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML T2 PA; QL (2 ML per 28 days)
rosuvastatin calcium tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days)
rosuvastatin calcium tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days)
rosuvastatin calcium tablet 40 mg oral 40 mg T1 QL (30 EA per 30 days)
rosuvastatin calcium tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days)
simvastatin tablet 10 mg oral 10 mg T1
simvastatin tablet 20 mg oral 20 mg T1
simvastatin tablet 40 mg oral 40 mg T1
simvastatin tablet 5 mg oral 5 mg T1
simvastatin tablet 80 mg oral 80 mg T1 QL (30 EA per 30 days)
*Antihypertensives*aliskiren fumarate oral tablet 150 mg, 300 mg T3
amlodipine besy-benazepril hcl capsule 10-20 mg oral 10-20 mg
T1
amlodipine besy-benazepril hcl capsule 10-40 mg oral 10-40 mg
T1
amlodipine besy-benazepril hcl capsule 2.5-10 mg oral 2.5-10 mg
T1
amlodipine besy-benazepril hcl capsule 5-10 mg oral 5-10 mg
T1
amlodipine besy-benazepril hcl capsule 5-20 mg oral 5-20 mg
T1
amlodipine besy-benazepril hcl capsule 5-40 mg oral 5-40 mg
T1
amlodipine besylate-valsartan tablet 10-160 mg oral 10-160 mg
T1
amlodipine besylate-valsartan tablet 10-320 mg oral 10-320 mg
T1
amlodipine besylate-valsartan tablet 5-160 mg oral 5-160 mg
T1
amlodipine besylate-valsartan tablet 5-320 mg oral 5-320 mg
T1
amlodipine-olmesartan tablet 10-20 mg oral 10-20 mg
T3 ST
39
Drug Status Notesamlodipine-olmesartan tablet 10-40 mg oral 10-40 mg
T3 ST
amlodipine-olmesartan tablet 5-20 mg oral 5-20 mg
T3 ST
amlodipine-olmesartan tablet 5-40 mg oral 5-40 mg
T3 ST
atenolol-chlorthalidone tablet 100-25 mg oral100-25 mg
T1
atenolol-chlorthalidone tablet 50-25 mg oral 50-25 mg
T1
benazepril hcl tablet 10 mg oral 10 mg T1
benazepril hcl tablet 20 mg oral 20 mg T1
benazepril hcl tablet 40 mg oral 40 mg T1
benazepril hcl tablet 5 mg oral 5 mg T1
benazepril-hydrochlorothiazide tablet 10-12.5 mg oral 10-12.5 mg
T1
benazepril-hydrochlorothiazide tablet 20-12.5 mg oral 20-12.5 mg
T1
benazepril-hydrochlorothiazide tablet 20-25 mg oral 20-25 mg
T1
benazepril-hydrochlorothiazide tablet 5-6.25 mg oral 5-6.25 mg
T1
bisoprolol-hydrochlorothiazide tablet 10-6.25 mg oral 10-6.25 mg
T1
bisoprolol-hydrochlorothiazide tablet 2.5-6.25 mg oral 2.5-6.25 mg
T1
bisoprolol-hydrochlorothiazide tablet 5-6.25 mg oral 5-6.25 mg
T1
candesartan cilexetil tablet 16 mg oral 16 mg T3 QL (30 EA per 30 days)
candesartan cilexetil tablet 32 mg oral 32 mg T3 QL (30 EA per 30 days)
candesartan cilexetil-hctz tablet 16-12.5 mg oral16-12.5 mg
T3 QL (30 EA per 30 days)
candesartan cilexetil-hctz tablet 32-12.5 mg oral32-12.5 mg
T3 QL (30 EA per 30 days)
candesartan cilexetil-hctz tablet 32-25 mg oral32-25 mg
T3 QL (30 EA per 30 days)
captopril tablet 100 mg oral 100 mg T1
captopril tablet 12.5 mg oral 12.5 mg T1
captopril tablet 25 mg oral 25 mg T1
captopril tablet 50 mg oral 50 mg T1
captopril-hydrochlorothiazide tablet 25-15 mg oral 25-15 mg
T1
40
Drug Status Notescaptopril-hydrochlorothiazide tablet 25-25 mg oral 25-25 mg
T1
captopril-hydrochlorothiazide tablet 50-15 mg oral 50-15 mg
T1
captopril-hydrochlorothiazide tablet 50-25 mg oral 50-25 mg
T1
clonidine hcl tablet 0.1 mg oral 0.1 mg T1
clonidine hcl tablet 0.2 mg oral 0.2 mg T1
clonidine hcl tablet 0.3 mg oral 0.3 mg T1
clonidine patch weekly 0.1 mg/24hr transdermal0.1 mg/24hr
T3
clonidine patch weekly 0.2 mg/24hr transdermal0.2 mg/24hr
T3
clonidine patch weekly 0.3 mg/24hr transdermal0.3 mg/24hr
T3
doxazosin mesylate tablet 1 mg oral 1 mg T1 AL (Max 64 Years)
doxazosin mesylate tablet 2 mg oral 2 mg T1 AL (Max 64 Years)
doxazosin mesylate tablet 4 mg oral 4 mg T1 AL (Max 64 Years)
doxazosin mesylate tablet 8 mg oral 8 mg T1 AL (Max 64 Years)
EDARBI TABLET 40 MG ORAL 40 MG T3 PA
EDARBI TABLET 80 MG ORAL 80 MG T3 PA
enalapril maleate tablet 10 mg oral 10 mg T1
enalapril maleate tablet 2.5 mg oral 2.5 mg T1
enalapril maleate tablet 20 mg oral 20 mg T1
enalapril maleate tablet 5 mg oral 5 mg T1
enalapril-hydrochlorothiazide tablet 10-25 mg oral 10-25 mg
T1
enalapril-hydrochlorothiazide tablet 5-12.5 mg oral 5-12.5 mg
T1
eplerenone tablet 25 mg oral 25 mg T3
eplerenone tablet 50 mg oral 50 mg T3
fosinopril sodium tablet 10 mg oral 10 mg T1
fosinopril sodium tablet 20 mg oral 20 mg T1
fosinopril sodium tablet 40 mg oral 40 mg T1
fosinopril sodium-hctz tablet 10-12.5 mg oral 10-12.5 mg
T1
fosinopril sodium-hctz tablet 20-12.5 mg oral 20-12.5 mg
T1
guanfacine hcl tablet 1 mg oral 1 mg T1
guanfacine hcl tablet 2 mg oral 2 mg T1
hydralazine hcl tablet 10 mg oral 10 mg T1
41
Drug Status Noteshydralazine hcl tablet 100 mg oral 100 mg T1
hydralazine hcl tablet 25 mg oral 25 mg T1
hydralazine hcl tablet 50 mg oral 50 mg T1
irbesartan tablet 150 mg oral 150 mg T1 QL (30 EA per 30 days)
irbesartan tablet 300 mg oral 300 mg T1 QL (30 EA per 30 days)
irbesartan tablet 75 mg oral 75 mg T1 QL (30 EA per 30 days)
irbesartan-hydrochlorothiazide tablet 150-12.5 mg oral 150-12.5 mg
T1
irbesartan-hydrochlorothiazide tablet 300-12.5 mg oral 300-12.5 mg
T1
lisinopril tablet 10 mg oral 10 mg T1
lisinopril tablet 2.5 mg oral 2.5 mg T1
lisinopril tablet 20 mg oral 20 mg T1
lisinopril tablet 30 mg oral 30 mg T1
lisinopril tablet 40 mg oral 40 mg T1
lisinopril tablet 5 mg oral 5 mg T1
lisinopril-hydrochlorothiazide tablet 10-12.5 mg oral 10-12.5 mg
T1
lisinopril-hydrochlorothiazide tablet 20-12.5 mg oral 20-12.5 mg
T1
lisinopril-hydrochlorothiazide tablet 20-25 mg oral 20-25 mg
T1
losartan potassium tablet 100 mg oral 100 mg T1
losartan potassium tablet 25 mg oral 25 mg T1 QL (30 EA per 30 days)
losartan potassium tablet 50 mg oral 50 mg T1 QL (30 EA per 30 days)
losartan potassium-hctz tablet 100-12.5 mg oral100-12.5 mg
T1
losartan potassium-hctz tablet 100-25 mg oral100-25 mg
T1
losartan potassium-hctz tablet 50-12.5 mg oral50-12.5 mg
T1
methyldopa tablet 250 mg oral 250 mg T1
methyldopa tablet 500 mg oral 500 mg T1
metoprolol-hydrochlorothiazide tablet 100-25 mg oral 100-25 mg
T1
metoprolol-hydrochlorothiazide tablet 100-50 mg oral 100-50 mg
T1
metoprolol-hydrochlorothiazide tablet 50-25 mg oral 50-25 mg
T1
minoxidil tablet 10 mg oral 10 mg T1
minoxidil tablet 2.5 mg oral 2.5 mg T1
42
Drug Status Notesmoexipril hcl tablet 15 mg oral 15 mg T1
moexipril hcl tablet 7.5 mg oral 7.5 mg T1
olmesartan medoxomil tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days)
olmesartan medoxomil tablet 40 mg oral 40 mg T1 QL (30 EA per 30 days)
olmesartan medoxomil tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days)
olmesartan medoxomil-hctz tablet 20-12.5 mg oral 20-12.5 mg
T1 QL (30 EA per 30 days)
olmesartan medoxomil-hctz tablet 40-12.5 mg oral 40-12.5 mg
T1 QL (30 EA per 30 days)
olmesartan medoxomil-hctz tablet 40-25 mg oral40-25 mg
T1 QL (30 EA per 30 days)
perindopril erbumine tablet 2 mg oral 2 mg T1
perindopril erbumine tablet 4 mg oral 4 mg T1
perindopril erbumine tablet 8 mg oral 8 mg T1
phenoxybenzamine hcl capsule 10 mg oral 10 mg T3 PA
prazosin hcl capsule 1 mg oral 1 mg T1
prazosin hcl capsule 2 mg oral 2 mg T1
prazosin hcl capsule 5 mg oral 5 mg T1
propranolol-hctz tablet 40-25 mg oral 40-25 mg T1
propranolol-hctz tablet 80-25 mg oral 80-25 mg T1
quinapril hcl tablet 10 mg oral 10 mg T1
quinapril hcl tablet 20 mg oral 20 mg T1
quinapril hcl tablet 40 mg oral 40 mg T1
quinapril hcl tablet 5 mg oral 5 mg T1
quinapril-hydrochlorothiazide tablet 10-12.5 mg oral 10-12.5 mg
T1
quinapril-hydrochlorothiazide tablet 20-12.5 mg oral 20-12.5 mg
T1
quinapril-hydrochlorothiazide tablet 20-25 mg oral 20-25 mg
T1
ramipril capsule 1.25 mg oral 1.25 mg T1
ramipril capsule 10 mg oral 10 mg T1
ramipril capsule 2.5 mg oral 2.5 mg T1
ramipril capsule 5 mg oral 5 mg T1
TEKTURNA HCT TABLET 150-12.5 MG ORAL 150-12.5 MG T3
TEKTURNA HCT TABLET 150-25 MG ORAL 150-25 MG T3
TEKTURNA HCT TABLET 300-12.5 MG ORAL 300-12.5 MG T3
43
Drug Status NotesTEKTURNA HCT TABLET 300-25 MG ORAL 300-25 MG T3
telmisartan tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days)
telmisartan tablet 40 mg oral 40 mg T1 QL (30 EA per 30 days)
telmisartan tablet 80 mg oral 80 mg T1 QL (30 EA per 30 days)
telmisartan-hctz tablet 40-12.5 mg oral 40-12.5 mg
T3 QL (30 EA per 30 days)
telmisartan-hctz tablet 80-12.5 mg oral 80-12.5 mg
T3 QL (30 EA per 30 days)
telmisartan-hctz tablet 80-25 mg oral 80-25 mg T3 QL (30 EA per 30 days)
terazosin hcl capsule 1 mg oral 1 mg T1 AL (Max 64 Years)
terazosin hcl capsule 10 mg oral 10 mg T1 AL (Max 64 Years)
terazosin hcl capsule 2 mg oral 2 mg T1 AL (Max 64 Years)
terazosin hcl capsule 5 mg oral 5 mg T1 AL (Max 64 Years)
trandolapril tablet 1 mg oral 1 mg T1 QL (30 EA per 30 days)
trandolapril tablet 2 mg oral 2 mg T1 QL (30 EA per 30 days)
trandolapril tablet 4 mg oral 4 mg T1 QL (30 EA per 30 days)
trandolapril-verapamil hcl er tablet extended release 1-240 mg oral 1-240 mg
T3 QL (30 EA per 30 days)
trandolapril-verapamil hcl er tablet extended release 2-180 mg oral 2-180 mg
T3 QL (30 EA per 30 days)
trandolapril-verapamil hcl er tablet extended release 2-240 mg oral 2-240 mg
T3 QL (30 EA per 30 days)
trandolapril-verapamil hcl er tablet extended release 4-240 mg oral 4-240 mg
T3 QL (30 EA per 30 days)
valsartan tablet 160 mg oral 160 mg T1 QL (60 EA per 30 days)
valsartan tablet 320 mg oral 320 mg T1 QL (30 EA per 30 days)
valsartan tablet 40 mg oral 40 mg T1 QL (60 EA per 30 days)
valsartan tablet 80 mg oral 80 mg T1 QL (60 EA per 30 days)
valsartan-hydrochlorothiazide tablet 160-12.5 mg oral 160-12.5 mg
T1
valsartan-hydrochlorothiazide tablet 160-25 mg oral 160-25 mg
T1
valsartan-hydrochlorothiazide tablet 320-12.5 mg oral 320-12.5 mg
T1
valsartan-hydrochlorothiazide tablet 320-25 mg oral 320-25 mg
T1
valsartan-hydrochlorothiazide tablet 80-12.5 mg oral 80-12.5 mg
T1
44
Drug Status Notes
*Anti-Infective Agents - Misc.*ALINIA SUSPENSION RECONSTITUTED 100 MG/5ML ORAL 100 MG/5ML T4 PA
ALINIA TABLET 500 MG ORAL 500 MG T4 PA
atovaquone suspension 750 mg/5ml oral 750 mg/5ml
T3
clindamycin hcl capsule 150 mg oral 150 mg T1
clindamycin hcl capsule 300 mg oral 300 mg T1
clindamycin hcl capsule 75 mg oral 75 mg T1
clindamycin palmitate hcl solution reconstituted 75 mg/5ml oral 75 mg/5ml
T1
dapsone tablet 100 mg oral 100 mg T1
dapsone tablet 25 mg oral 25 mg T1
HYOPHEN ORAL TABLET 81.6 MG T1
linezolid solution 600 mg/300ml intravenous 600 mg/300ml
T3
linezolid suspension reconstituted 100 mg/5ml oral 100 mg/5ml
T3 AL (Max 12 Years)
linezolid tablet 600 mg oral 600 mg T3 QL (28 EA per 14 days)
MACROBID ORAL CAPSULE 100 MG T1
methenamine hippurate oral tablet 1 gm T1
methenamine mandelate oral tablet 0.5 gm T1
metronidazole capsule 375 mg oral 375 mg T1
metronidazole tablet 250 mg oral 250 mg T1
metronidazole tablet 500 mg oral 500 mg T1
MONUROL ORAL PACKET 3 GM T3
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
T1
nitrofurantoin monohyd macro capsule 100 mg oral 100 mg
T1
nitrofurantoin oral suspension 25 mg/5ml T3
pentamidine isethionate injection solution reconstituted 300 mg
T3
PHOSPHASAL ORAL TABLET 81.6 MG T1
SIVEXTRO TABLET 200 MG ORAL 200 MG T3 PA
sulfamethoxazole-trimethoprim suspension 200-40 mg/5ml oral 200-40 mg/5ml
T1
sulfamethoxazole-trimethoprim tablet 400-80 mg oral 400-80 mg
T1
sulfamethoxazole-trimethoprim tablet 800-160 mg oral 800-160 mg
T1
45
Drug Status Notestinidazole tablet 250 mg oral 250 mg T3
tinidazole tablet 500 mg oral 500 mg T3
trimethoprim tablet 100 mg oral 100 mg T1
URIMAR-T ORAL TABLET 120 MG T1
USTELL ORAL CAPSULE 120 MG T1
vancomycin hcl in dextrose intravenous solution1-5 gm/200ml-%
T1
vancomycin hcl intravenous solution reconstituted1 gm, 500 mg, 750 mg
T1
vancomycin hcl intravenous solution reconstituted10 gm
T3
XIFAXAN TABLET 200 MG ORAL 200 MG T4 PA
XIFAXAN TABLET 550 MG ORAL 550 MG T4 PA
*Antimalarials*atovaquone-proguanil hcl tablet 250-100 mg oral250-100 mg
T1 QL (30 EA per 30 days)
atovaquone-proguanil hcl tablet 62.5-25 mg oral62.5-25 mg
T1 QL (30 EA per 30 days)
chloroquine phosphate tablet 250 mg oral 250 mg T1
chloroquine phosphate tablet 500 mg oral 500 mg T1
COARTEM ORAL TABLET 20-120 MG T3
DARAPRIM TABLET 25 MG ORAL 25 MG T4 PA
hydroxychloroquine sulfate tablet 200 mg oral200 mg
T1
mefloquine hcl tablet 250 mg oral 250 mg T1
primaquine phosphate tablet 26.3 mg oral 26.3 mg
T1
quinine sulfate capsule 324 mg oral 324 mg T1
*Antimyasthenic/Cholinergic Agents*MESTINON SOLUTION 60 MG/5ML ORAL60 MG/5ML T2 PA
pyridostigmine bromide er tablet extended release 180 mg oral 180 mg
T2 PA
pyridostigmine bromide oral solution 60 mg/5ml T2 PA
pyridostigmine bromide tablet 60 mg oral 60 mg T1
*Antimycobacterial Agents*cycloserine capsule 250 mg oral 250 mg T3 PA
ethambutol hcl tablet 100 mg oral 100 mg T1
ethambutol hcl tablet 400 mg oral 400 mg T1
isoniazid syrup 50 mg/5ml oral 50 mg/5ml T1
46
Drug Status Notesisoniazid tablet 100 mg oral 100 mg T1
isoniazid tablet 300 mg oral 300 mg T1
PRIFTIN ORAL TABLET 150 MG T2
pyrazinamide tablet 500 mg oral 500 mg T3
rifabutin capsule 150 mg oral 150 mg T2 PA
rifampin capsule 150 mg oral 150 mg T1
rifampin capsule 300 mg oral 300 mg T1
*Antineoplastics And Adjunctive Therapies*abiraterone acetate oral tablet 250 mg T4 PA
ACTIMMUNE SOLUTION 2000000 UNIT/0.5ML SUBCUTANEOUS 2000000 UNIT/0.5ML
T4 PA
AFINITOR TABLET 10 MG ORAL 10 MG T4 PA
anastrozole tablet 1 mg oral 1 mg T1
bexarotene capsule 75 mg oral 75 mg T4 PA
bicalutamide tablet 50 mg oral 50 mg T1
BOSULIF TABLET 100 MG ORAL 100 MG T4 PA
BOSULIF TABLET 500 MG ORAL 500 MG T4 PA
capecitabine tablet 150 mg oral 150 mg T4 PA
capecitabine tablet 500 mg oral 500 mg T4 PA
CAPRELSA TABLET 100 MG ORAL 100 MG T4 PA
CAPRELSA TABLET 300 MG ORAL 300 MG T4 PA
COMETRIQ (100 MG DAILY DOSE) KIT 80 & 20 MG ORAL 80 & 20 MG T4 PA
COMETRIQ (140 MG DAILY DOSE) KIT 3 X 20 MG & 80 MG ORAL 3 X 20 MG & 80 MG
T4 PA
COMETRIQ (60 MG DAILY DOSE) KIT 20 MG ORAL 20 MG T4 PA
cyclophosphamide oral capsule 25 mg, 50 mg T3 PA
DEPO-PROVERA SUSPENSION 400 MG/ML INTRAMUSCULAR 400 MG/ML T3
ELIGARD KIT 22.5 MG SUBCUTANEOUS22.5 MG T4 PA
ELIGARD KIT 30 MG SUBCUTANEOUS 30 MG T4 PA
ELIGARD KIT 45 MG SUBCUTANEOUS 45 MG T4 PA
47
Drug Status NotesELIGARD KIT 7.5 MG SUBCUTANEOUS7.5 MG T4 PA
EMCYT CAPSULE 140 MG ORAL 140 MG T3
ERIVEDGE CAPSULE 150 MG ORAL 150 MG T4 PA
everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg T4 PA
exemestane tablet 25 mg oral 25 mg T3
FARYDAK CAPSULE 10 MG ORAL 10 MG T4 PA
FARYDAK CAPSULE 20 MG ORAL 20 MG T4 PA
FASLODEX SOLUTION 250 MG/5ML INTRAMUSCULAR 250 MG/5ML T4 PA
FIRMAGON (240 MG DOSE) SOLUTION RECONSTITUTED 120 MG/VIAL SUBCUTANEOUS 120 MG/VIAL
T4 PA
FIRMAGON SOLUTION RECONSTITUTED 80 MG SUBCUTANEOUS 80 MG T4 PA
flutamide capsule 125 mg oral 125 mg T3
GILOTRIF TABLET 20 MG ORAL 20 MG T4 PA
GILOTRIF TABLET 30 MG ORAL 30 MG T4 PA
GILOTRIF TABLET 40 MG ORAL 40 MG T4 PA
GLEOSTINE CAPSULE 10 MG ORAL 10 MG T4 PA
GLEOSTINE CAPSULE 100 MG ORAL 100 MG T4 PA
GLEOSTINE CAPSULE 40 MG ORAL 40 MG T4 PA
hydroxyprogesterone caproate solution 1.25 gm/5ml intramuscular 1.25 gm/5ml
T4 PA; GR-F
hydroxyurea capsule 500 mg oral 500 mg T1
IBRANCE CAPSULE 100 MG ORAL 100 MG T4 PA
IBRANCE CAPSULE 125 MG ORAL 125 MG T4 PA
IBRANCE CAPSULE 75 MG ORAL 75 MG T4 PA
IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG T4 PA
ICLUSIG TABLET 15 MG ORAL 15 MG T4 PA
ICLUSIG TABLET 45 MG ORAL 45 MG T4 PA
imatinib mesylate tablet 100 mg oral 100 mg T4 PA
imatinib mesylate tablet 400 mg oral 400 mg T4 PA
IMBRUVICA CAPSULE 140 MG ORAL 140 MG T4 PA
INLYTA TABLET 1 MG ORAL 1 MG T4 PA
48
Drug Status NotesINLYTA TABLET 5 MG ORAL 5 MG T4 PA
INTRON A SOLUTION 6000000 UNIT/ML INJECTION 6000000 UNIT/ML T4 PA
INTRON A SOLUTION RECONSTITUTED 10000000 UNIT INJECTION 10000000 UNIT T4 PA
INTRON A SOLUTION RECONSTITUTED 18000000 UNIT INJECTION 18000000 UNIT T4 PA
INTRON A SOLUTION RECONSTITUTED 50000000 UNIT INJECTION 50000000 UNIT T4 PA
JAKAFI TABLET 10 MG ORAL 10 MG T4 PA
JAKAFI TABLET 15 MG ORAL 15 MG T4 PA
JAKAFI TABLET 20 MG ORAL 20 MG T4 PA
JAKAFI TABLET 25 MG ORAL 25 MG T4 PA
JAKAFI TABLET 5 MG ORAL 5 MG T4 PA
KYPROLIS SOLUTION RECONSTITUTED 60 MG INTRAVENOUS 60 MG T4 PA
lapatinib ditosylate oral tablet 250 mg T4 PA
letrozole tablet 2.5 mg oral 2.5 mg T1GR-F; QL (30 EA per 30 days); AL (Min 18 Years)
leucovorin calcium tablet 10 mg oral 10 mg T1
leucovorin calcium tablet 15 mg oral 15 mg T1
leucovorin calcium tablet 25 mg oral 25 mg T1
leucovorin calcium tablet 5 mg oral 5 mg T1
LEUKERAN TABLET 2 MG ORAL 2 MG T4 PA
leuprolide acetate kit 1 mg/0.2ml injection 1 mg/0.2ml
T4 PA
LUPRON DEPOT (1-MONTH) KIT 3.75 MG INTRAMUSCULAR 3.75 MG T4 PA
LUPRON DEPOT (1-MONTH) KIT 7.5 MG INTRAMUSCULAR 7.5 MG T4 PA
LUPRON DEPOT (3-MONTH) KIT 11.25 MG INTRAMUSCULAR 11.25 MG T4 PA
LUPRON DEPOT (3-MONTH) KIT 22.5 MG INTRAMUSCULAR 22.5 MG T4 PA
LUPRON DEPOT (4-MONTH) KIT 30 MG INTRAMUSCULAR 30 MG T4 PA
LUPRON DEPOT (6-MONTH) KIT 45 MG INTRAMUSCULAR 45 MG T4 PA
LYSODREN ORAL TABLET 500 MG T3 PA
MATULANE CAPSULE 50 MG ORAL 50 MG T4 PA
49
Drug Status Notesmegestrol acetate suspension 400 mg/10ml oral400 mg/10ml
T1
megestrol acetate tablet 20 mg oral 20 mg T1
megestrol acetate tablet 40 mg oral 40 mg T1
MEKINIST TABLET 0.5 MG ORAL 0.5 MG T4 PA
MEKINIST TABLET 2 MG ORAL 2 MG T4 PA
mercaptopurine tablet 50 mg oral 50 mg T1
MESNEX TABLET 400 MG ORAL 400 MG T4 PA
methotrexate sodium (pf) injection solution 50 mg/2ml
T1
methotrexate sodium injection solution 50 mg/2ml T1
methotrexate sodium solution reconstituted 1 gm injection 1 gm
T1
methotrexate tablet 2.5 mg oral 2.5 mg T1
MYLERAN TABLET 2 MG ORAL 2 MG T4 PA
NEXAVAR TABLET 200 MG ORAL 200 MG T4 PA
ODOMZO CAPSULE 200 MG ORAL 200 MG T4 PA
POMALYST CAPSULE 1 MG ORAL 1 MG T4 PA
POMALYST CAPSULE 2 MG ORAL 2 MG T4 PA
POMALYST CAPSULE 3 MG ORAL 3 MG T4 PA
POMALYST CAPSULE 4 MG ORAL 4 MG T4 PA
SPRYCEL TABLET 100 MG ORAL 100 MG T4 PA
SPRYCEL TABLET 140 MG ORAL 140 MG T4 PA
SPRYCEL TABLET 20 MG ORAL 20 MG T4 PA
SPRYCEL TABLET 50 MG ORAL 50 MG T4 PA
SPRYCEL TABLET 70 MG ORAL 70 MG T4 PA
SPRYCEL TABLET 80 MG ORAL 80 MG T4 PA
STIVARGA TABLET 40 MG ORAL 40 MG T4 PA
SUTENT CAPSULE 12.5 MG ORAL 12.5 MG T4 PA
SUTENT CAPSULE 25 MG ORAL 25 MG T4 PA
SUTENT CAPSULE 50 MG ORAL 50 MG T4 PA
TABLOID TABLET 40 MG ORAL 40 MG T4 PA
TAFINLAR CAPSULE 50 MG ORAL 50 MG T4 PA
TAFINLAR CAPSULE 75 MG ORAL 75 MG T4 PA
tamoxifen citrate tablet 10 mg oral 10 mg T5
tamoxifen citrate tablet 20 mg oral 20 mg T5
TARCEVA TABLET 100 MG ORAL 100 MG T4 PA
TARCEVA TABLET 150 MG ORAL 150 MG T4 PA
50
Drug Status NotesTARCEVA TABLET 25 MG ORAL 25 MG T4 PA
TASIGNA CAPSULE 150 MG ORAL 150 MG T4 PA
TASIGNA CAPSULE 200 MG ORAL 200 MG T4 PA
TASIGNA ORAL CAPSULE 50 MG T4 PA
toremifene citrate oral tablet 60 mg T4 PA
TRELSTAR MIXJECT SUSPENSION RECONSTITUTED 22.5 MG INTRAMUSCULAR 22.5 MG
T4 PA
tretinoin capsule 10 mg oral 10 mg T4 PA
TREXALL TABLET 10 MG ORAL 10 MG T3 PA
TREXALL TABLET 15 MG ORAL 15 MG T3 PA
TREXALL TABLET 5 MG ORAL 5 MG T3 PA
TREXALL TABLET 7.5 MG ORAL 7.5 MG T3 PA
VALSTAR SOLUTION 40 MG/ML INTRAVESICAL 40 MG/ML T4 PA
VANTAS KIT 50 MG SUBCUTANEOUS 50 MG T4 PA
VOTRIENT TABLET 200 MG ORAL 200 MG T4 PA
XALKORI CAPSULE 200 MG ORAL 200 MG T4 PA
XALKORI CAPSULE 250 MG ORAL 250 MG T4 PA
ZOLADEX IMPLANT 10.8 MG SUBCUTANEOUS 10.8 MG T3 PA
ZOLADEX IMPLANT 3.6 MG SUBCUTANEOUS 3.6 MG T3 PA
ZOLINZA CAPSULE 100 MG ORAL 100 MG T4 PA
ZYDELIG TABLET 100 MG ORAL 100 MG T4 PA
ZYDELIG TABLET 150 MG ORAL 150 MG T4 PA
*Antiparkinson And Related Therapy Agents*amantadine hcl capsule 100 mg oral 100 mg T1
amantadine hcl syrup 50 mg/5ml oral 50 mg/5ml T1
amantadine hcl tablet 100 mg oral 100 mg T1
benztropine mesylate solution 1 mg/ml injection 1 mg/ml
T3
benztropine mesylate tablet 0.5 mg oral 0.5 mg T1 AL (Max 64 Years)
benztropine mesylate tablet 1 mg oral 1 mg T1 AL (Max 64 Years)
benztropine mesylate tablet 2 mg oral 2 mg T1 AL (Max 64 Years)
bromocriptine mesylate capsule 5 mg oral 5 mg T3
51
Drug Status Notesbromocriptine mesylate tablet 2.5 mg oral 2.5 mg T1
carbidopa tablet 25 mg oral 25 mg T3
carbidopa-levodopa er tablet extended release 25-100 mg oral 25-100 mg
T1
carbidopa-levodopa er tablet extended release 50-200 mg oral 50-200 mg
T1
carbidopa-levodopa tablet 10-100 mg oral 10-100 mg
T1
carbidopa-levodopa tablet 25-100 mg oral 25-100 mg
T1
carbidopa-levodopa tablet 25-250 mg oral 25-250 mg
T1
carbidopa-levodopa tablet dispersible 10-100 mg oral 10-100 mg
T1
carbidopa-levodopa tablet dispersible 25-100 mg oral 25-100 mg
T1
carbidopa-levodopa tablet dispersible 25-250 mg oral 25-250 mg
T1
entacapone tablet 200 mg oral 200 mg T3
NEUPRO PATCH 24 HOUR 1 MG/24HR TRANSDERMAL 1 MG/24HR T3 PA
NEUPRO PATCH 24 HOUR 2 MG/24HR TRANSDERMAL 2 MG/24HR T3 PA
NEUPRO PATCH 24 HOUR 3 MG/24HR TRANSDERMAL 3 MG/24HR T3 PA
NEUPRO PATCH 24 HOUR 4 MG/24HR TRANSDERMAL 4 MG/24HR T3 PA
NEUPRO PATCH 24 HOUR 6 MG/24HR TRANSDERMAL 6 MG/24HR T3 PA
NEUPRO PATCH 24 HOUR 8 MG/24HR TRANSDERMAL 8 MG/24HR T3 PA
pramipexole dihydrochloride er tablet extended release 24 hour 0.375 mg oral 0.375 mg
T3 ST; QL (30 EA per 30 days)
pramipexole dihydrochloride er tablet extended release 24 hour 0.75 mg oral 0.75 mg
T3 ST; QL (30 EA per 30 days)
pramipexole dihydrochloride er tablet extended release 24 hour 1.5 mg oral 1.5 mg
T3 ST; QL (30 EA per 30 days)
pramipexole dihydrochloride er tablet extended release 24 hour 2.25 mg oral 2.25 mg
T3 ST; QL (30 EA per 30 days)
pramipexole dihydrochloride er tablet extended release 24 hour 3 mg oral 3 mg
T3 ST; QL (30 EA per 30 days)
pramipexole dihydrochloride er tablet extended release 24 hour 3.75 mg oral 3.75 mg
T3 ST; QL (30 EA per 30 days)
52
Drug Status Notespramipexole dihydrochloride er tablet extended release 24 hour 4.5 mg oral 4.5 mg
T3 ST; QL (30 EA per 30 days)
pramipexole dihydrochloride tablet 0.125 mg oral0.125 mg
T1
pramipexole dihydrochloride tablet 0.25 mg oral0.25 mg
T1
pramipexole dihydrochloride tablet 0.5 mg oral0.5 mg
T1
pramipexole dihydrochloride tablet 0.75 mg oral0.75 mg
T1
pramipexole dihydrochloride tablet 1 mg oral 1 mg
T1
pramipexole dihydrochloride tablet 1.5 mg oral1.5 mg
T1
rasagiline mesylate tablet 0.5 mg oral 0.5 mg T3
rasagiline mesylate tablet 1 mg oral 1 mg T3
ropinirole hcl er tablet extended release 24 hour 12 mg oral 12 mg
T2 ST; QL (30 EA per 30 days)
ropinirole hcl er tablet extended release 24 hour 2 mg oral 2 mg
T2 ST; QL (30 EA per 30 days)
ropinirole hcl er tablet extended release 24 hour 4 mg oral 4 mg
T2 ST; QL (30 EA per 30 days)
ropinirole hcl er tablet extended release 24 hour 6 mg oral 6 mg
T2 ST; QL (30 EA per 30 days)
ropinirole hcl er tablet extended release 24 hour 8 mg oral 8 mg
T2 ST; QL (30 EA per 30 days)
ropinirole hcl tablet 0.25 mg oral 0.25 mg T1
ropinirole hcl tablet 0.5 mg oral 0.5 mg T1
ropinirole hcl tablet 1 mg oral 1 mg T1
ropinirole hcl tablet 2 mg oral 2 mg T1
ropinirole hcl tablet 3 mg oral 3 mg T1
ropinirole hcl tablet 4 mg oral 4 mg T1
ropinirole hcl tablet 5 mg oral 5 mg T1
selegiline hcl capsule 5 mg oral 5 mg T1
selegiline hcl tablet 5 mg oral 5 mg T1
tolcapone tablet 100 mg oral 100 mg T4 PA
trihexyphenidyl hcl oral tablet 5 mg T1
*Antipsychotics/Antimanic Agents*ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG T4 PA
aripiprazole solution 1 mg/ml oral 1 mg/ml T3 PA
53
Drug Status Notesaripiprazole tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days)
aripiprazole tablet 15 mg oral 15 mg T1 QL (30 EA per 30 days)
aripiprazole tablet 2 mg oral 2 mg T1 QL (30 EA per 30 days)
aripiprazole tablet 20 mg oral 20 mg T1 QL (30 EA per 30 days)
aripiprazole tablet 30 mg oral 30 mg T1 QL (30 EA per 30 days)
aripiprazole tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days)
aripiprazole tablet dispersible 10 mg oral 10 mg T3 PA
aripiprazole tablet dispersible 15 mg oral 15 mg T3 PA
chlorpromazine hcl tablet 10 mg oral 10 mg T1
chlorpromazine hcl tablet 100 mg oral 100 mg T1
chlorpromazine hcl tablet 200 mg oral 200 mg T1
chlorpromazine hcl tablet 25 mg oral 25 mg T1
chlorpromazine hcl tablet 50 mg oral 50 mg T1
clozapine oral tablet dispersible 12.5 mg T3
clozapine tablet 100 mg oral 100 mg T1
clozapine tablet 200 mg oral 200 mg T1
clozapine tablet 25 mg oral 25 mg T1
clozapine tablet 50 mg oral 50 mg T1
clozapine tablet dispersible 100 mg oral 100 mg T3
clozapine tablet dispersible 25 mg oral 25 mg T3
FANAPT TABLET 1 MG ORAL 1 MG T4 PA
FANAPT TABLET 10 MG ORAL 10 MG T4 PA
FANAPT TABLET 12 MG ORAL 12 MG T4 PA
FANAPT TABLET 2 MG ORAL 2 MG T4 PA
FANAPT TABLET 4 MG ORAL 4 MG T4 PA
FANAPT TABLET 6 MG ORAL 6 MG T4 PA
FANAPT TABLET 8 MG ORAL 8 MG T4 PA
fluphenazine decanoate solution 25 mg/ml injection 25 mg/ml
T3
fluphenazine hcl concentrate 5 mg/ml oral 5 mg/ml
T3
fluphenazine hcl elixir 2.5 mg/5ml oral 2.5 mg/5ml
T1
fluphenazine hcl solution 2.5 mg/ml injection 2.5 mg/ml
T3
fluphenazine hcl tablet 1 mg oral 1 mg T1
fluphenazine hcl tablet 10 mg oral 10 mg T1
fluphenazine hcl tablet 2.5 mg oral 2.5 mg T1
fluphenazine hcl tablet 5 mg oral 5 mg T1
54
Drug Status Noteshaloperidol decanoate solution 100 mg/ml intramuscular 100 mg/ml
T1
haloperidol decanoate solution 50 mg/ml intramuscular 50 mg/ml
T1
haloperidol lactate concentrate 2 mg/ml oral 2 mg/ml
T1
haloperidol lactate solution 5 mg/ml injection 5 mg/ml
T1
haloperidol tablet 0.5 mg oral 0.5 mg T1
haloperidol tablet 1 mg oral 1 mg T1
haloperidol tablet 10 mg oral 10 mg T1
haloperidol tablet 2 mg oral 2 mg T1
haloperidol tablet 20 mg oral 20 mg T1
haloperidol tablet 5 mg oral 5 mg T1
LATUDA TABLET 120 MG ORAL 120 MG T3 PA
LATUDA TABLET 20 MG ORAL 20 MG T3 PA
LATUDA TABLET 40 MG ORAL 40 MG T3 PA
LATUDA TABLET 80 MG ORAL 80 MG T3 PA
lithium carbonate capsule 150 mg oral 150 mg T1
lithium carbonate capsule 300 mg oral 300 mg T1
lithium carbonate capsule 600 mg oral 600 mg T1
lithium carbonate er tablet extended release 300 mg oral 300 mg
T1
lithium carbonate er tablet extended release 450 mg oral 450 mg
T1
lithium carbonate tablet 300 mg oral 300 mg T1
lithium solution 8 meq/5ml oral 8 meq/5ml T1
loxapine succinate capsule 10 mg oral 10 mg T1
loxapine succinate capsule 25 mg oral 25 mg T1
loxapine succinate capsule 5 mg oral 5 mg T1
loxapine succinate capsule 50 mg oral 50 mg T1
olanzapine solution reconstituted 10 mg intramuscular 10 mg
T2
olanzapine tablet 10 mg oral 10 mg T1
olanzapine tablet 15 mg oral 15 mg T1
olanzapine tablet 2.5 mg oral 2.5 mg T1
olanzapine tablet 20 mg oral 20 mg T1
olanzapine tablet 5 mg oral 5 mg T1
olanzapine tablet 7.5 mg oral 7.5 mg T1
olanzapine tablet dispersible 10 mg oral 10 mg T2
55
Drug Status Notesolanzapine tablet dispersible 15 mg oral 15 mg T2
olanzapine tablet dispersible 20 mg oral 20 mg T2
olanzapine tablet dispersible 5 mg oral 5 mg T2
paliperidone er tablet extended release 24 hour 1.5 mg oral 1.5 mg
T4 PA
paliperidone er tablet extended release 24 hour 3 mg oral 3 mg
T4 PA
paliperidone er tablet extended release 24 hour 6 mg oral 6 mg
T4 PA
paliperidone er tablet extended release 24 hour 9 mg oral 9 mg
T4 PA
perphenazine tablet 16 mg oral 16 mg T1
perphenazine tablet 2 mg oral 2 mg T1
perphenazine tablet 4 mg oral 4 mg T1
perphenazine tablet 8 mg oral 8 mg T1
prochlorperazine maleate tablet 10 mg oral 10 mg
T1
prochlorperazine maleate tablet 5 mg oral 5 mg T1
prochlorperazine suppository 25 mg rectal 25 mg T1
quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 200 mg, 50 mg
T2 ST; QL (30 EA per 30 days)
quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg
T2 ST; QL (60 EA per 30 days)
quetiapine fumarate tablet 100 mg oral 100 mg T1
quetiapine fumarate tablet 200 mg oral 200 mg T1
quetiapine fumarate tablet 25 mg oral 25 mg T1
quetiapine fumarate tablet 300 mg oral 300 mg T1
quetiapine fumarate tablet 400 mg oral 400 mg T1
quetiapine fumarate tablet 50 mg oral 50 mg T1
REXULTI TABLET 0.25 MG ORAL 0.25 MG T4 PA
REXULTI TABLET 0.5 MG ORAL 0.5 MG T4 PA
REXULTI TABLET 1 MG ORAL 1 MG T4 PA
REXULTI TABLET 2 MG ORAL 2 MG T4 PA
REXULTI TABLET 3 MG ORAL 3 MG T4 PA
REXULTI TABLET 4 MG ORAL 4 MG T4 PA
risperidone solution 1 mg/ml oral 1 mg/ml T3
risperidone tablet 0.25 mg oral 0.25 mg T1
risperidone tablet 0.5 mg oral 0.5 mg T1
risperidone tablet 1 mg oral 1 mg T1
risperidone tablet 2 mg oral 2 mg T1
56
Drug Status Notesrisperidone tablet 3 mg oral 3 mg T1
risperidone tablet 4 mg oral 4 mg T1
risperidone tablet dispersible 0.25 mg oral 0.25 mg
T3
risperidone tablet dispersible 1 mg oral 1 mg T3
risperidone tablet dispersible 2 mg oral 2 mg T3
risperidone tablet dispersible 4 mg oral 4 mg T3
SAPHRIS TABLET SUBLINGUAL 10 MG SUBLINGUAL 10 MG T3 PA
SAPHRIS TABLET SUBLINGUAL 5 MG SUBLINGUAL 5 MG T3 PA
thioridazine hcl tablet 10 mg oral 10 mg T2
thioridazine hcl tablet 100 mg oral 100 mg T2
thioridazine hcl tablet 25 mg oral 25 mg T2
thioridazine hcl tablet 50 mg oral 50 mg T2
thiothixene capsule 1 mg oral 1 mg T1
thiothixene capsule 10 mg oral 10 mg T1
thiothixene capsule 2 mg oral 2 mg T1
thiothixene capsule 5 mg oral 5 mg T1
trifluoperazine hcl tablet 1 mg oral 1 mg T1
trifluoperazine hcl tablet 10 mg oral 10 mg T1
trifluoperazine hcl tablet 2 mg oral 2 mg T1
trifluoperazine hcl tablet 5 mg oral 5 mg T1
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg
T1
*Antiseptics & Disinfectants*chlorhexidine gluconate solution 20 % 20 % T3
*Antivirals*abacavir sulfate oral solution 20 mg/ml T4 QL (900 ML per 30 days)
abacavir sulfate tablet 300 mg oral 300 mg T3 QL (60 EA per 30 days)
abacavir sulfate-lamivudine tablet 600-300 mg oral 600-300 mg
T4 QL (30 EA per 30 days)
abacavir-lamivudine-zidovudine tablet 300-150-300 mg oral 300-150-300 mg
T4 QL (60 EA per 30 days)
acyclovir capsule 200 mg oral 200 mg T1
acyclovir suspension 200 mg/5ml oral 200 mg/5ml
T1 AL (Max 12 Years)
acyclovir tablet 400 mg oral 400 mg T1
acyclovir tablet 800 mg oral 800 mg T1
adefovir dipivoxil tablet 10 mg oral 10 mg T4 PA
57
Drug Status NotesAPTIVUS CAPSULE 250 MG ORAL 250 MG T4 QL (120 EA per 30 days)
APTIVUS SOLUTION 100 MG/ML ORAL100 MG/ML T4 QL (300 ML per 30 days)
atazanavir sulfate oral capsule 300 mg T4 QL (30 EA per 30 days)
BARACLUDE SOLUTION 0.05 MG/ML ORAL 0.05 MG/ML T4 PA
BIKTARVY ORAL TABLET 50-200-25 MG T4 QL (30 EA per 30 days)
COMPLERA TABLET 200-25-300 MG ORAL 200-25-300 MG T4 QL (30 EA per 30 days)
CRIXIVAN CAPSULE 200 MG ORAL 200 MG T4 QL (360 EA per 30 days)
CRIXIVAN CAPSULE 400 MG ORAL 400 MG T4 QL (180 EA per 30 days)
DESCOVY ORAL TABLET 200-25 MG T4 QL (30 EA per 30 days)
didanosine capsule delayed release 200 mg oral200 mg
T3 QL (60 EA per 30 days)
didanosine capsule delayed release 250 mg oral250 mg
T3 QL (30 EA per 30 days)
didanosine capsule delayed release 400 mg oral400 mg
T3 QL (30 EA per 30 days)
EDURANT TABLET 25 MG ORAL 25 MG T4 QL (30 EA per 30 days)
efavirenz oral capsule 200 mg T4 QL (90 EA per 30 days)
efavirenz oral capsule 50 mg T4 QL (360 EA per 30 days)
efavirenz oral tablet 600 mg T4 QL (30 EA per 30 days)
efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg
T4 QL (30 EA per 30 days)
efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg
T1 QL (30 EA per 30 days)
efavirenz-lamivudine-tenofovir oral tablet 600-300-300 mg
T4
emtricitabine oral capsule 200 mg T4
emtricitabine-tenofovir df oral tablet 200-300 mg T4 QL (30 EA per 30 days)
EMTRIVA SOLUTION 10 MG/ML ORAL 10 MG/ML T4
EPIVIR HBV SOLUTION 5 MG/ML ORAL 5 MG/ML T3 QL (1800 ML per 30 days)
EVOTAZ TABLET 300-150 MG ORAL 300-150 MG T4 QL (30 EA per 30 days)
famciclovir tablet 125 mg oral 125 mg T3 QL (90 EA per 30 days)
famciclovir tablet 250 mg oral 250 mg T3 QL (90 EA per 30 days)
famciclovir tablet 500 mg oral 500 mg T3 QL (90 EA per 30 days)
fosamprenavir calcium oral tablet 700 mg T4 QL (120 EA per 30 days)
58
Drug Status NotesFUZEON SOLUTION RECONSTITUTED 90 MG SUBCUTANEOUS 90 MG T4 QL (60 EA per 30 days)
GENVOYA ORAL TABLET 150-150-200-10 MG T4 QL (30 EA per 30 days)
INTELENCE TABLET 100 MG ORAL 100 MG T4 QL (120 EA per 30 days)
INTELENCE TABLET 200 MG ORAL 200 MG T4 QL (60 EA per 30 days)
INTELENCE TABLET 25 MG ORAL 25 MG T4 QL (480 EA per 30 days)
INVIRASE TABLET 500 MG ORAL 500 MG T4 QL (120 EA per 30 days)
ISENTRESS TABLET 400 MG ORAL 400 MG T4 QL (60 EA per 30 days)
ISENTRESS TABLET CHEWABLE 100 MG ORAL 100 MG T4 QL (60 EA per 30 days)
ISENTRESS TABLET CHEWABLE 25 MG ORAL 25 MG T4 QL (60 EA per 30 days)
KALETRA TABLET 100-25 MG ORAL 100-25 MG T4 QL (360 EA per 30 days)
KALETRA TABLET 200-50 MG ORAL 200-50 MG T4 QL (180 EA per 30 days)
lamivudine solution 10 mg/ml oral 10 mg/ml T3 QL (900 ML per 30 days)
lamivudine tablet 100 mg oral 100 mg T2 QL (90 EA per 30 days)
lamivudine tablet 150 mg oral 150 mg T3 QL (60 EA per 30 days)
lamivudine tablet 300 mg oral 300 mg T3 QL (30 EA per 30 days)
lamivudine-zidovudine tablet 150-300 mg oral150-300 mg
T4 QL (60 EA per 30 days)
LEXIVA SUSPENSION 50 MG/ML ORAL 50 MG/ML T4 QL (180 ML per 30 days)
lopinavir-ritonavir solution 400-100 mg/5ml oral400-100 mg/5ml
T4 QL (450 ML per 30 days)
MAVYRET ORAL TABLET 100-40 MG T4 PA
nevirapine er tablet extended release 24 hour 400 mg oral 400 mg
T2 QL (30 EA per 30 days)
nevirapine tablet 200 mg oral 200 mg T1 QL (60 EA per 30 days)
NORVIR SOLUTION 80 MG/ML ORAL 80 MG/ML T4 QL (450 ML per 30 days)
oseltamivir phosphate capsule 30 mg oral 30 mg T1 QL (10 EA per 10 days)
oseltamivir phosphate capsule 45 mg oral 45 mg T1 QL (10 EA per 10 days)
oseltamivir phosphate capsule 75 mg oral 75 mg T1 QL (10 EA per 10 days)
oseltamivir phosphate oral suspension reconstituted 6 mg/ml
T1 QL (120 ML per 10 days)
59
Drug Status NotesPEGASYS SOLUTION 180 MCG/ML SUBCUTANEOUS 180 MCG/ML T4 PA
PEGINTRON KIT 50 MCG/0.5ML SUBCUTANEOUS 50 MCG/0.5ML T4 PA
PREZCOBIX TABLET 800-150 MG ORAL800-150 MG T4 QL (30 EA per 30 days)
PREZISTA SUSPENSION 100 MG/ML ORAL 100 MG/ML T4 QL (480 ML per 30 days)
PREZISTA TABLET 150 MG ORAL 150 MG T4 QL (240 EA per 30 days)
PREZISTA TABLET 600 MG ORAL 600 MG T4 QL (60 EA per 30 days)
PREZISTA TABLET 75 MG ORAL 75 MG T4 QL (480 EA per 30 days)
PREZISTA TABLET 800 MG ORAL 800 MG T4 QL (30 EA per 30 days)
RELENZA DISKHALER AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER INHALATION 5 MG/BLISTER
T2 PA; QL (20 EA per 5 days)
REYATAZ CAPSULE 150 MG ORAL 150 MG T4 QL (60 EA per 30 days)
REYATAZ CAPSULE 200 MG ORAL 200 MG T4 QL (60 EA per 30 days)
REYATAZ CAPSULE 300 MG ORAL 300 MG T4 QL (30 EA per 30 days)
ribavirin capsule 200 mg oral 200 mg T4 PA
rimantadine hcl tablet 100 mg oral 100 mg T1
ritonavir oral tablet 100 mg T4 QL (360 EA per 30 days)
SELZENTRY TABLET 150 MG ORAL 150 MG T4 QL (120 EA per 30 days)
SELZENTRY TABLET 300 MG ORAL 300 MG T4 QL (120 EA per 30 days)
sofosbuvir-velpatasvir tablet 400-100 mg oral400-100 mg
T4 PA; QL (28 EA per 28 days)
stavudine capsule 15 mg oral 15 mg T1 QL (60 EA per 30 days)
stavudine capsule 20 mg oral 20 mg T1 QL (60 EA per 30 days)
stavudine capsule 30 mg oral 30 mg T1 QL (60 EA per 30 days)
stavudine capsule 40 mg oral 40 mg T1 QL (60 EA per 30 days)
STRIBILD TABLET 150-150-200-300 MG ORAL 150-150-200-300 MG T4 QL (30 EA per 30 days)
tenofovir disoproxil fumarate oral tablet 300 mg T4 QL (30 EA per 30 days)
TIVICAY TABLET 50 MG ORAL 50 MG T4 QL (30 EA per 30 days)
TRIUMEQ TABLET 600-50-300 MG ORAL600-50-300 MG T4 QL (30 EA per 30 days)
60
Drug Status NotesTRUVADA TABLET 100-150 MG ORAL 100-150 MG T4 QL (30 EA per 30 days)
TRUVADA TABLET 133-200 MG ORAL 133-200 MG T4 QL (30 EA per 30 days)
TRUVADA TABLET 167-250 MG ORAL 167-250 MG T4 QL (30 EA per 30 days)
valacyclovir hcl tablet 1 gm oral 1 gm T1
valacyclovir hcl tablet 500 mg oral 500 mg T1
valganciclovir hcl solution reconstituted 50 mg/ml oral 50 mg/ml
T4 PA
valganciclovir hcl tablet 450 mg oral 450 mg T4 PA
VIRACEPT TABLET 250 MG ORAL 250 MG T4 QL (300 EA per 30 days)
VIRACEPT TABLET 625 MG ORAL 625 MG T4 QL (120 EA per 30 days)
VIRAMUNE SUSPENSION 50 MG/5ML ORAL 50 MG/5ML T2 QL (1200 ML per 30 days)
VIREAD TABLET 150 MG ORAL 150 MG T4 QL (30 EA per 30 days)
VIREAD TABLET 200 MG ORAL 200 MG T4 QL (30 EA per 30 days)
VIREAD TABLET 250 MG ORAL 250 MG T4 QL (30 EA per 30 days)
ZEPATIER TABLET 50-100 MG ORAL 50-100 MG T4 PA
zidovudine capsule 100 mg oral 100 mg T1 QL (180 EA per 30 days)
zidovudine syrup 50 mg/5ml oral 50 mg/5ml T1 QL (1800 ML per 30 days)
zidovudine tablet 300 mg oral 300 mg T1 QL (60 EA per 30 days)
*Beta Blockers*acebutolol hcl capsule 200 mg oral 200 mg T1
acebutolol hcl capsule 400 mg oral 400 mg T1
atenolol tablet 100 mg oral 100 mg T1
atenolol tablet 25 mg oral 25 mg T1
atenolol tablet 50 mg oral 50 mg T1
betaxolol hcl tablet 10 mg oral 10 mg T1
betaxolol hcl tablet 20 mg oral 20 mg T1
bisoprolol fumarate tablet 10 mg oral 10 mg T1
bisoprolol fumarate tablet 5 mg oral 5 mg T1
BYSTOLIC TABLET 10 MG ORAL 10 MG T3
BYSTOLIC TABLET 2.5 MG ORAL 2.5 MG T3
BYSTOLIC TABLET 20 MG ORAL 20 MG T3
BYSTOLIC TABLET 5 MG ORAL 5 MG T3
carvedilol phosphate er oral capsule extended release 24 hour 10 mg, 20 mg, 40 mg, 80 mg
T3 ST
carvedilol tablet 12.5 mg oral 12.5 mg T1
61
Drug Status Notescarvedilol tablet 25 mg oral 25 mg T1
carvedilol tablet 3.125 mg oral 3.125 mg T1
carvedilol tablet 6.25 mg oral 6.25 mg T1
labetalol hcl tablet 100 mg oral 100 mg T1
labetalol hcl tablet 200 mg oral 200 mg T1
labetalol hcl tablet 300 mg oral 300 mg T1
metoprolol succinate er tablet extended release 24 hour 100 mg oral 100 mg
T1 QL (45 EA per 30 days)
metoprolol succinate er tablet extended release 24 hour 200 mg oral 200 mg
T1 QL (60 EA per 30 days)
metoprolol succinate er tablet extended release 24 hour 25 mg oral 25 mg
T1 QL (45 EA per 30 days)
metoprolol succinate er tablet extended release 24 hour 50 mg oral 50 mg
T1 QL (45 EA per 30 days)
metoprolol tartrate tablet 100 mg oral 100 mg T1
metoprolol tartrate tablet 25 mg oral 25 mg T1
metoprolol tartrate tablet 50 mg oral 50 mg T1
nadolol tablet 20 mg oral 20 mg T1
nadolol tablet 40 mg oral 40 mg T1
nadolol tablet 80 mg oral 80 mg T1
pindolol tablet 10 mg oral 10 mg T1
pindolol tablet 5 mg oral 5 mg T1
propranolol hcl er capsule extended release 24 hour 120 mg oral 120 mg
T1 ST
propranolol hcl er capsule extended release 24 hour 160 mg oral 160 mg
T1 ST
propranolol hcl er capsule extended release 24 hour 60 mg oral 60 mg
T1 ST
propranolol hcl er capsule extended release 24 hour 80 mg oral 80 mg
T1 ST
propranolol hcl solution 20 mg/5ml oral 20 mg/5ml
T1
propranolol hcl solution 40 mg/5ml oral 40 mg/5ml
T1
propranolol hcl tablet 10 mg oral 10 mg T1
propranolol hcl tablet 20 mg oral 20 mg T1
propranolol hcl tablet 40 mg oral 40 mg T1
propranolol hcl tablet 60 mg oral 60 mg T1
propranolol hcl tablet 80 mg oral 80 mg T1
sotalol hcl (af) tablet 120 mg oral 120 mg T1
sotalol hcl (af) tablet 160 mg oral 160 mg T1
62
Drug Status Notessotalol hcl (af) tablet 80 mg oral 80 mg T1
sotalol hcl tablet 120 mg oral 120 mg T1
sotalol hcl tablet 160 mg oral 160 mg T1
sotalol hcl tablet 240 mg oral 240 mg T1
sotalol hcl tablet 80 mg oral 80 mg T1
timolol maleate tablet 10 mg oral 10 mg T1
timolol maleate tablet 20 mg oral 20 mg T1
timolol maleate tablet 5 mg oral 5 mg T1
*Calcium Channel Blockers*AFEDITAB CR TABLET EXTENDED RELEASE 24 HOUR 30 MG ORAL 30 MG T1 QL (30 EA per 30 days)
amlodipine besylate tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days)
amlodipine besylate tablet 2.5 mg oral 2.5 mg T1 QL (30 EA per 30 days)
amlodipine besylate tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days)
CARTIA XT CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL 120 MG T1 QL (30 EA per 30 days)
CARTIA XT CAPSULE EXTENDED RELEASE 24 HOUR 180 MG ORAL 180 MG T1 QL (30 EA per 30 days)
CARTIA XT CAPSULE EXTENDED RELEASE 24 HOUR 240 MG ORAL 240 MG T1 QL (30 EA per 30 days)
CARTIA XT CAPSULE EXTENDED RELEASE 24 HOUR 300 MG ORAL 300 MG T1 QL (30 EA per 30 days)
diltiazem hcl er beads capsule extended release 24 hour 420 mg oral 420 mg
T1 QL (30 EA per 30 days)
diltiazem hcl er beads oral capsule extended release 24 hour 360 mg
T1 QL (30 EA per 30 days)
diltiazem hcl er capsule extended release 12 hour 120 mg oral 120 mg
T1 QL (60 EA per 30 days)
diltiazem hcl er capsule extended release 12 hour 60 mg oral 60 mg
T1 QL (60 EA per 30 days)
diltiazem hcl er capsule extended release 12 hour 90 mg oral 90 mg
T1 QL (60 EA per 30 days)
diltiazem hcl er capsule extended release 24 hour 120 mg oral 120 mg
T1 QL (120 EA per 30 days)
diltiazem hcl tablet 120 mg oral 120 mg T1
diltiazem hcl tablet 30 mg oral 30 mg T1
diltiazem hcl tablet 60 mg oral 60 mg T1
diltiazem hcl tablet 90 mg oral 90 mg T1
dilt-xr capsule extended release 24 hour 240 mg oral 240 mg
T1 QL (30 EA per 30 days)
63
Drug Status Notesfelodipine er tablet extended release 24 hour 10 mg oral 10 mg
T1 QL (30 EA per 30 days)
felodipine er tablet extended release 24 hour 2.5 mg oral 2.5 mg
T1 QL (30 EA per 30 days)
felodipine er tablet extended release 24 hour 5 mg oral 5 mg
T1 QL (30 EA per 30 days)
isradipine capsule 2.5 mg oral 2.5 mg T1
isradipine capsule 5 mg oral 5 mg T1
nicardipine hcl capsule 20 mg oral 20 mg T1
nicardipine hcl capsule 30 mg oral 30 mg T1
nifedipine capsule 10 mg oral 10 mg T1
nifedipine capsule 20 mg oral 20 mg T1
nifedipine er osmotic release tablet extended release 24 hour 30 mg oral 30 mg
T1 QL (30 EA per 30 days)
nifedipine er osmotic release tablet extended release 24 hour 60 mg oral 60 mg
T1 QL (30 EA per 30 days)
nifedipine er osmotic release tablet extended release 24 hour 90 mg oral 90 mg
T1 QL (30 EA per 30 days)
nifedipine er tablet extended release 24 hour 60 mg oral 60 mg
T1 QL (30 EA per 30 days)
nimodipine capsule 30 mg oral 30 mg T3
nisoldipine er tablet extended release 24 hour 17 mg oral 17 mg
T3
nisoldipine er tablet extended release 24 hour 20 mg oral 20 mg
T1
nisoldipine er tablet extended release 24 hour 25.5 mg oral 25.5 mg
T1
nisoldipine er tablet extended release 24 hour 30 mg oral 30 mg
T1
nisoldipine er tablet extended release 24 hour 34 mg oral 34 mg
T3
nisoldipine er tablet extended release 24 hour 40 mg oral 40 mg
T1
nisoldipine er tablet extended release 24 hour 8.5 mg oral 8.5 mg
T3
TAZTIA XT CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL 120 MG T1 QL (30 EA per 30 days)
TAZTIA XT CAPSULE EXTENDED RELEASE 24 HOUR 180 MG ORAL 180 MG T1 QL (30 EA per 30 days)
TAZTIA XT CAPSULE EXTENDED RELEASE 24 HOUR 240 MG ORAL 240 MG T1 QL (30 EA per 30 days)
TAZTIA XT CAPSULE EXTENDED RELEASE 24 HOUR 300 MG ORAL 300 MG T1 QL (30 EA per 30 days)
64
Drug Status Notesverapamil hcl er capsule extended release 24 hour 100 mg oral 100 mg
T1 QL (30 EA per 30 days)
verapamil hcl er capsule extended release 24 hour 120 mg oral 120 mg
T1 QL (30 EA per 30 days)
verapamil hcl er capsule extended release 24 hour 180 mg oral 180 mg
T1 QL (60 EA per 30 days)
verapamil hcl er capsule extended release 24 hour 200 mg oral 200 mg
T1 QL (30 EA per 30 days)
verapamil hcl er capsule extended release 24 hour 240 mg oral 240 mg
T1 QL (30 EA per 30 days)
verapamil hcl er capsule extended release 24 hour 300 mg oral 300 mg
T1 QL (30 EA per 30 days)
verapamil hcl er capsule extended release 24 hour 360 mg oral 360 mg
T1 QL (30 EA per 30 days)
verapamil hcl er tablet extended release 120 mg oral 120 mg
T1 QL (30 EA per 30 days)
verapamil hcl er tablet extended release 180 mg oral 180 mg
T1 QL (30 EA per 30 days)
verapamil hcl er tablet extended release 240 mg oral 240 mg
T1 QL (30 EA per 30 days)
verapamil hcl tablet 120 mg oral 120 mg T1
verapamil hcl tablet 40 mg oral 40 mg T1
verapamil hcl tablet 80 mg oral 80 mg T1
*Cardiotonics*digoxin solution 0.05 mg/ml oral 0.05 mg/ml T1
digoxin tablet 125 mcg oral 125 mcg T1
digoxin tablet 250 mcg oral 250 mcg T1
*Cardiovascular Agents - Misc.*ADCIRCA TABLET 20 MG ORAL 20 MG T4 PA
ADEMPAS TABLET 0.5 MG ORAL 0.5 MG T4 PA
ADEMPAS TABLET 1 MG ORAL 1 MG T4 PA
ADEMPAS TABLET 1.5 MG ORAL 1.5 MG T4 PA
ADEMPAS TABLET 2 MG ORAL 2 MG T4 PA
ADEMPAS TABLET 2.5 MG ORAL 2.5 MG T4 PA
ambrisentan oral tablet 10 mg, 5 mg T4 PA
CORLANOR ORAL TABLET 5 MG, 7.5 MG T3 PA
OPSUMIT TABLET 10 MG ORAL 10 MG T4 PA
sildenafil citrate tablet 20 mg oral 20 mg T1 PA
tadalafil oral tablet 2.5 mg, 5 mg T3 PA
TRACLEER TABLET 125 MG ORAL 125 MG T4 PA
65
Drug Status NotesTRACLEER TABLET 62.5 MG ORAL 62.5 MG T4 PA
TYVASO STARTER SOLUTION 0.6 MG/ML INHALATION 0.6 MG/ML T4 PA
UPTRAVI TABLET 1000 MCG ORAL 1000 MCG T4 PA
UPTRAVI TABLET 1200 MCG ORAL 1200 MCG T4 PA
UPTRAVI TABLET 1400 MCG ORAL 1400 MCG T4 PA
UPTRAVI TABLET 1600 MCG ORAL 1600 MCG T4 PA
UPTRAVI TABLET 200 MCG ORAL 200 MCG T4 PA
UPTRAVI TABLET 400 MCG ORAL 400 MCG T4 PA
UPTRAVI TABLET 600 MCG ORAL 600 MCG T4 PA
UPTRAVI TABLET 800 MCG ORAL 800 MCG T4 PA
VENTAVIS SOLUTION 10 MCG/ML INHALATION 10 MCG/ML T4 PA
VENTAVIS SOLUTION 20 MCG/ML INHALATION 20 MCG/ML T4 PA
*Cephalosporins*cefaclor capsule 250 mg oral 250 mg T1
cefaclor capsule 500 mg oral 500 mg T1
cefaclor suspension reconstituted 125 mg/5ml oral 125 mg/5ml
T1
cefaclor suspension reconstituted 250 mg/5ml oral 250 mg/5ml
T1
cefaclor suspension reconstituted 375 mg/5ml oral 375 mg/5ml
T1
cefadroxil capsule 500 mg oral 500 mg T1
cefadroxil suspension reconstituted 250 mg/5ml oral 250 mg/5ml
T1
cefadroxil suspension reconstituted 500 mg/5ml oral 500 mg/5ml
T1
cefadroxil tablet 1 gm oral 1 gm T1
cefdinir capsule 300 mg oral 300 mg T1
cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml
T1
66
Drug Status Notescefditoren pivoxil tablet 400 mg oral 400 mg T2
cefpodoxime proxetil suspension reconstituted 100 mg/5ml oral 100 mg/5ml
T1
cefpodoxime proxetil suspension reconstituted 50 mg/5ml oral 50 mg/5ml
T1
cefpodoxime proxetil tablet 100 mg oral 100 mg T1
cefpodoxime proxetil tablet 200 mg oral 200 mg T1
cefprozil suspension reconstituted 125 mg/5ml oral 125 mg/5ml
T1
cefprozil suspension reconstituted 250 mg/5ml oral 250 mg/5ml
T1
cefprozil tablet 250 mg oral 250 mg T1
cefprozil tablet 500 mg oral 500 mg T1
cefuroxime axetil tablet 250 mg oral 250 mg T1
cefuroxime axetil tablet 500 mg oral 500 mg T1
cephalexin capsule 250 mg oral 250 mg T1
cephalexin capsule 500 mg oral 500 mg T1
cephalexin suspension reconstituted 125 mg/5ml oral 125 mg/5ml
T1
cephalexin suspension reconstituted 250 mg/5ml oral 250 mg/5ml
T1
cephalexin tablet 250 mg oral 250 mg T1
cephalexin tablet 500 mg oral 500 mg T1
SUPRAX SUSPENSION RECONSTITUTED 500 MG/5ML ORAL 500 MG/5ML T3
*Chemicals*coal tar solution T1
iodine strong (lugol's) solution (otc) T1
*Contraceptives*ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG T5 QL (28 EA per 28 days)
BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) T5 PA; QL (28 EA per 21 days)
BALZIVA ORAL TABLET 0.4-35 MG-MCG T5 GR-F; QL (28 EA per 21 days)
DEPO-SUBQ PROVERA 104 SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML SUBCUTANEOUS 104 MG/0.65ML
T3 GR-F; QL (1 ML per 90 days)
desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)
T5 PA; QL (28 EA per 21 days)
desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg
T5 QL (28 EA per 21 days)
67
Drug Status Notesdrospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg
T5 PA; QL (28 EA per 21 days)
drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg
T5 QL (28 EA per 21 days)
ELLA TABLET 30 MG ORAL 30 MG T5 GR-F; QL (1 EA per 30 days)
ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg
T5 QL (28 EA per 21 days)
GIANVI ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days)
JASMIEL ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days)
JUNEL 1.5/30 TABLET 1.5-30 MG-MCG ORAL 1.5-30 MG-MCG T5 GR-F; QL (21 EA per 21 days)
JUNEL FE 1.5/30 TABLET 1.5-30 MG-MCG ORAL 1.5-30 MG-MCG T5 GR-F; QL (28 EA per 21 days)
levonorgest-eth est & eth est oral tablet 42-21-21-7 days
T5 PA; QL (91 EA per 91 days)
levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg
T5 PA; QL (91 EA per 91 days)
levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg
T5 QL (91 EA per 91 days)
levonorgest-eth estrad 91-day tablet 0.1-0.02 & 0.01 mg oral 0.1-0.02 & 0.01 mg
T5 GR-F; QL (91 EA per 91 days)
levonorgestrel tablet 1.5 mg oral (otc) 1.5 mg T5 GR-F; QL (1 EA per 30 days)
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg
T5 QL (28 EA per 21 days)
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg
T5 QL (60 EA per 30 days)
LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG T5 PA; QL (28 EA per 21 days)
LORYNA ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days)
LOW-OGESTREL TABLET 0.3-30 MG-MCG ORAL 0.3-30 MG-MCG T5 GR-F; QL (28 EA per 21 days)
LO-ZUMANDIMINE ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days)
medroxyprogesterone acetate suspension 150 mg/ml intramuscular 150 mg/ml
T5 GR-F; QL (1 ML per 90 days)
NIKKI ORAL TABLET 3-0.02 MG T5 PA; QL (28 EA per 21 days)
norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg
T5 QL (28 EA per 21 days)
norethin ace-eth estrad-fe oral tablet chewable 1-20 mg-mcg(24)
T5 PA; QL (28 EA per 21 days)
norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg
T5 QL (21 EA per 21 days)
norethindrone oral tablet 0.35 mg T5 GR-F; QL (28 EA per 21 days)
68
Drug Status Notesnorethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, 0.8-25 mg-mcg
T5 PA; QL (28 EA per 21 days)
norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg
T5 QL (28 EA per 21 days)
norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-35 mcg
T5 QL (28 EA per 21 days)
NORTREL 0.5/35 (28) TABLET 0.5-35 MG-MCG ORAL 0.5-35 MG-MCG T5 GR-F; QL (28 EA per 21 days)
NORTREL 1/35 (28) TABLET 1-35 MG-MCG ORAL 1-35 MG-MCG T5 GR-F; QL (28 EA per 21 days)
NORTREL 7/7/7 TABLET 0.5/0.75/1-35 MG-MCG ORAL 0.5/0.75/1-35 MG-MCG T5 GR-F; QL (28 EA per 21 days)
NUVARING RING 0.12-0.015 MG/24HR VAGINAL 0.12-0.015 MG/24HR T5 PA; GR-F
OCELLA ORAL TABLET 3-0.03 MG T5 PA; QL (28 EA per 21 days)
SLYND ORAL TABLET 4 MG T5 PA; QL (28 EA per 21 days)
SYEDA ORAL TABLET 3-0.03 MG T5 PA; QL (28 EA per 21 days)
TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24) T5 PA; QL (28 EA per 21 days)
TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG T5 PA; QL (28 EA per 21 days)
TRI-LO-SPRINTEC ORAL TABLET0.18/0.215/0.25 MG-25 MCG T5 GR-F; QL (28 EA per 21 days)
TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 MCG/24HR T5 PA; QL (3 EA per 28 days)
VELIVET TABLET 0.1/0.125/0.15 -0.025 MG ORAL 0.1/0.125/0.15 -0.025 MG T5 GR-F; QL (28 EA per 21 days)
XULANE PATCH WEEKLY 150-35 MCG/24HR TRANSDERMAL 150-35 MCG/24HR
T5 PA; GR-F
ZARAH ORAL TABLET 3-0.03 MG T5 PA; QL (28 EA per 21 days)
ZOVIA 1/35E (28) TABLET 1-35 MG-MCG ORAL 1-35 MG-MCG T5 GR-F; QL (28 EA per 28 days)
ZUMANDIMINE ORAL TABLET 3-0.03 MG T5 PA; QL (28 EA per 21 days)
*Corticosteroids*betamethasone sod phos & acet suspension 6 (3-3) mg/ml injection 6 (3-3) mg/ml
T1
budesonide oral capsule delayed release particles3 mg
T3
cortisone acetate tablet 25 mg oral 25 mg T1
DEPO-MEDROL SUSPENSION 20 MG/ML INJECTION 20 MG/ML T3
69
Drug Status NotesDEXAMETHASONE INTENSOL CONCENTRATE 1 MG/ML ORAL 1 MG/ML T3
dexamethasone oral solution 0.5 mg/5ml T1
dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg (35), 1.5 mg (51)
T3
dexamethasone sodium phosphate solution 10 mg/ml injection 10 mg/ml
T1
dexamethasone sodium phosphate solution 120 mg/30ml injection 120 mg/30ml
T1
dexamethasone tablet 0.5 mg oral 0.5 mg T1
dexamethasone tablet 0.75 mg oral 0.75 mg T1
dexamethasone tablet 1 mg oral 1 mg T1
dexamethasone tablet 1.5 mg oral 1.5 mg T1
dexamethasone tablet 2 mg oral 2 mg T1
dexamethasone tablet 4 mg oral 4 mg T1
dexamethasone tablet 6 mg oral 6 mg T1
fludrocortisone acetate tablet 0.1 mg oral 0.1 mg T1
hydrocortisone tablet 10 mg oral 10 mg T1
hydrocortisone tablet 20 mg oral 20 mg T1
hydrocortisone tablet 5 mg oral 5 mg T1
methylprednisolone tablet 16 mg oral 16 mg T1
methylprednisolone tablet 32 mg oral 32 mg T1
methylprednisolone tablet 4 mg oral 4 mg T1
methylprednisolone tablet 8 mg oral 8 mg T1
methylprednisolone tablet therapy pack 4 mg oral4 mg
T1
MILLIPRED TABLET 5 MG ORAL 5 MG T3
prednisolone sodium phosphate solution 15 mg/5ml oral 15 mg/5ml
T1
prednisolone sodium phosphate solution 25 mg/5ml oral 25 mg/5ml
T1
prednisolone sodium phosphate solution 6.7 (5 base) mg/5ml oral 6.7 (5 base) mg/5ml
T1
PREDNISONE INTENSOL CONCENTRATE 5 MG/ML ORAL 5 MG/ML T3
prednisone solution 5 mg/5ml oral 5 mg/5ml T1
prednisone tablet 1 mg oral 1 mg T1
prednisone tablet 10 mg oral 10 mg T1
prednisone tablet 2.5 mg oral 2.5 mg T1
prednisone tablet 20 mg oral 20 mg T1
70
Drug Status Notesprednisone tablet 5 mg oral 5 mg T1
prednisone tablet 50 mg oral 50 mg T1
prednisone tablet therapy pack 5 mg (48) oral 5 mg (48)
T1
*Cough/Cold/Allergy*acetylcysteine solution 10 % inhalation 10 % T1
acetylcysteine solution 20 % inhalation 20 % T1
benzonatate capsule 100 mg oral 100 mg T1
benzonatate capsule 200 mg oral 200 mg T1
BROMFED DM SYRUP 30-2-10 MG/5ML ORAL 30-2-10 MG/5ML T1
hydrocod polst-cpm polst er suspension extended release 10-8 mg/5ml oral 10-8 mg/5ml
T1
hydrocodone-homatropine syrup 5-1.5 mg/5ml oral 5-1.5 mg/5ml
T1
promethazine vc/codeine syrup 6.25-5-10 mg/5ml oral 6.25-5-10 mg/5ml
T1
promethazine-codeine solution 6.25-10 mg/5ml oral 6.25-10 mg/5ml
T1
promethazine-dm syrup 6.25-15 mg/5ml oral6.25-15 mg/5ml
T1
sodium chloride nebulization solution 0.9 % inhalation (rx) 0.9 %
T1
sodium chloride nebulization solution 10 % inhalation 10 %
T1
sodium chloride nebulization solution 3 % inhalation 3 %
T1
sodium chloride nebulization solution 7 % inhalation 7 %
T1
*Dermatologicals*acitretin oral capsule 10 mg, 17.5 mg, 25 mg T3 PA
acne treatment gel 10 % external 10 % T1
acyclovir external ointment 5 % T3 PA
adapalene external gel 0.1 % T1 QL (45 GM per 30 days)
adapalene-benzoyl peroxide gel 0.1-2.5 % external 0.1-2.5 %
T3ST; QL (45 GM per 30 days); AL (Max 28 Years)
alclometasone dipropionate cream 0.05 % external 0.05 %
T1
alclometasone dipropionate ointment 0.05 % external 0.05 %
T1
ALTABAX OINTMENT 1 % EXTERNAL 1 % T3 ST
71
Drug Status Notesamcinonide cream 0.1 % external 0.1 % T3
amcinonide lotion 0.1 % external 0.1 % T3
amcinonide ointment 0.1 % external 0.1 % T3
ammonium lactate external cream 12 % T1 QL (385 GM per 30 days)
ammonium lactate external lotion 12 % T1 QL (500 G4M per 30 days)
ANECREAM CREAM 4 % EXTERNAL 4 % T1 QL (90 GM per 30 days)
ASPERCREME LIDOCAINE EXTERNAL PATCH 4 % T1 QL (30 EA per 30 days)
ASPERCREME W/LIDOCAINE CREAM 4 % EXTERNAL 4 % T1 QL (90 GM per 30 days)
AVITA GEL 0.025 % EXTERNAL 0.025 % T1QL (45 GM per 30 days); AL (Max 28 Years)
BASIS OVERNIGHT EXTERNAL CREAM T1
BENZEPRO FOAM 5.3 % EXTERNAL 5.3 % T3
BENZEPRO SHORT CONTACT FOAM 9.8 % EXTERNAL 9.8 % T3
benzoyl peroxide-erythromycin gel 5-3 % external5-3 %
T1
betamethasone dipropionate aug cream 0.05 % external 0.05 %
T1 QL (100 GM per 30 days)
betamethasone dipropionate aug external gel 0.05 %
T1 QL (100 GM per 30 days)
betamethasone dipropionate aug lotion 0.05 % external 0.05 %
T1 QL (120 ML per 30 days)
betamethasone dipropionate aug ointment 0.05 % external 0.05 %
T1 QL (100 GM per 30 days)
betamethasone dipropionate cream 0.05 % external 0.05 %
T1 QL (90 GM per 30 days)
betamethasone dipropionate lotion 0.05 % external 0.05 %
T1 QL (120 ML per 30 days)
betamethasone dipropionate ointment 0.05 % external 0.05 %
T1 QL (90 GM per 30 days)
betamethasone valerate cream 0.1 % external 0.1 %
T1 QL (90 GM per 30 days)
betamethasone valerate foam 0.12 % external0.12 %
T3
betamethasone valerate lotion 0.1 % external 0.1 %
T1 QL (120 ML per 30 days)
betamethasone valerate ointment 0.1 % external0.1 %
T1 QL (90 GM per 30 days)
calcipotriene cream 0.005 % external 0.005 % T3
calcipotriene solution 0.005 % external 0.005 % T3
72
Drug Status Notescalcipotriene-betameth diprop ointment 0.005-0.064 % external 0.005-0.064 %
T3 ST; QL (60 GM per 30 days)
CALCITRENE OINTMENT 0.005 % EXTERNAL 0.005 % T3
CAPEX SHAMPOO 0.01 % EXTERNAL 0.01 % T3 ST; QL (120 ML per 30 days)
CEM-UREA SOLUTION 45 % EXTERNAL45 % T3
ciclopirox solution 8 % external 8 % T1
CLINDACIN PAC KIT 1 % EXTERNAL 1 % T1
clindamycin phos-benzoyl perox external gel 1.2-5 %
T1 QL (45 GM per 30 days)
clindamycin phos-benzoyl perox gel 1-5 % external 1-5 %
T3
clindamycin phosphate external swab 1 % T1 QL (60 EA per 30 days)
clindamycin phosphate foam 1 % external 1 % T3
clindamycin phosphate lotion 1 % external 1 % T1
clindamycin phosphate solution 1 % external 1 % T1
clobetasol propionate e cream 0.05 % external0.05 %
T1 QL (120 GM per 30 days)
clobetasol propionate external cream 0.05 % T1
clobetasol propionate gel 0.05 % external 0.05 % T1 QL (120 GM per 30 days)
clobetasol propionate lotion 0.05 % external 0.05 %
T3
clobetasol propionate ointment 0.05 % external0.05 %
T3 QL (120 GM per 30 days)
clobetasol propionate shampoo 0.05 % external0.05 %
T3
clobetasol propionate solution 0.05 % external0.05 %
T1 QL (100 ML per 30 days)
CLODERM CREAM 0.1 % EXTERNAL 0.1 % T3
clotrimazole external cream 1 % T1 QL (50 GM per 30 days)
clotrimazole external solution 1 % T1
clotrimazole-betamethasone cream 1-0.05 % external 1-0.05 %
T1 QL (90 GM per 30 days)
clotrimazole-betamethasone lotion 1-0.05 % external 1-0.05 %
T3 QL (60 ML per 30 days)
CONDYLOX GEL 0.5 % EXTERNAL 0.5 % T3 PA
CORDRAN LOTION 0.05 % EXTERNAL0.05 % T3 PA
73
Drug Status NotesCORTISPORIN CREAM 3.5-10000-0.5 EXTERNAL 3.5-10000-0.5 T1
CORTISPORIN OINTMENT 1 % EXTERNAL 1 % T3
COSENTYX (300 MG DOSE) SOLUTION PREFILLED SYRINGE 150 MG/ML SUBCUTANEOUS 150 MG/ML
T4 PA
COSENTYX SENSOREADY PEN SOLUTION AUTO-INJECTOR 150 MG/ML SUBCUTANEOUS 150 MG/ML
T4 PA
CROTAN EXTERNAL LOTION 10 % T2 PA
DENAVIR EXTERNAL CREAM 1 % T3 PA
desonide cream 0.05 % external 0.05 % T3 QL (120 GM per 30 days)
desonide lotion 0.05 % external 0.05 % T3
desonide ointment 0.05 % external 0.05 % T1 QL (120 GM per 30 days)
desoximetasone cream 0.05 % external 0.05 % T1 QL (200 GM per 30 days)
desoximetasone cream 0.25 % external 0.25 % T1 QL (200 GM per 30 days)
desoximetasone gel 0.05 % external 0.05 % T1 QL (120 GM per 30 days)
desoximetasone ointment 0.05 % external 0.05 % T3 QL (120 GM per 30 days)
desoximetasone ointment 0.25 % external 0.25 % T1 QL (200 GM per 30 days)
diclofenac sodium gel 1 % external (rx) 1 % T1 QL (200 GM per 30 days)
DIFFERIN EXTERNAL GEL 0.1 % T1 QL (45 GM per 30 days)
diflorasone diacetate external cream 0.05 % T3 PA; QL (120 GM per 30 days)
diflorasone diacetate external ointment 0.05 % T3 PA; QL (120 GM per 30 days)
docosanol external cream 10 % T1
DRITHO-CREME HP EXTERNAL CREAM1 % T3 PA
DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 MG/2ML T4 PA
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML T4 PA
econazole nitrate cream 1 % external 1 % T1 QL (85 GM per 30 days)
ERTACZO CREAM 2 % EXTERNAL 2 % T3
erythromycin gel 2 % external 2 % T1
erythromycin solution 2 % external 2 % T1
ethyl chloride aerosol external T1
EUCERIN EXTERNAL CREAM T1
EXELDERM CREAM 1 % EXTERNAL 1 % T3 QL (30 GM per 30 days)
EXELDERM SOLUTION 1 % EXTERNAL 1 % T3 QL (30 ML per 30 days)
74
Drug Status NotesEXODERM LOTION 25-1 % EXTERNAL25-1 % T1
FINACEA GEL 15 % EXTERNAL 15 % T3 PA
finasteride tablet 1 mg oral 1 mg T1
fluocinolone acetonide body external oil 0.01 % T1 QL (128.28 ML per 30 days)
fluocinolone acetonide cream 0.01 % external0.01 %
T1 QL (120 GM per 30 days)
fluocinolone acetonide cream 0.025 % external0.025 %
T1 QL (120 GM per 30 days)
fluocinolone acetonide ointment 0.025 % external0.025 %
T1 QL (120 GM per 30 days)
fluocinolone acetonide scalp external oil 0.01 % T1 QL (128.28 ML per 30 days)
fluocinolone acetonide solution 0.01 % external0.01 %
T3 QL (120 ML per 30 days)
fluocinonide emulsified base cream 0.05 % external 0.05 %
T1 QL (120 GM per 30 days)
fluocinonide gel 0.05 % external 0.05 % T1 QL (120 GM per 30 days)
fluocinonide ointment 0.05 % external 0.05 % T1 QL (120 GM per 30 days)
fluocinonide solution 0.05 % external 0.05 % T1 QL (120 ML per 30 days)
fluorouracil cream 5 % external 5 % T3
fluorouracil solution 2 % external 2 % T1
fluorouracil solution 5 % external 5 % T1
flurandrenolide cream 0.05 % external 0.05 % T3 PA
flurandrenolide lotion 0.05 % external 0.05 % T3 PA
fluticasone propionate cream 0.05 % external0.05 %
T1 QL (120 GM per 30 days)
fluticasone propionate lotion 0.05 % external0.05 %
T3
fluticasone propionate ointment 0.005 % external0.005 %
T1 QL (120 GM per 30 days)
gentamicin sulfate cream 0.1 % external 0.1 % T1
gentamicin sulfate ointment 0.1 % external 0.1 % T1
halobetasol propionate cream 0.05 % external0.05 %
T1 QL (100 GM per 30 days)
halobetasol propionate ointment 0.05 % external0.05 %
T1 QL (100 GM per 30 days)
HALOG CREAM 0.1 % EXTERNAL 0.1 % T3 QL (100 GM per 30 days)
HALOG OINTMENT 0.1 % EXTERNAL 0.1 % T3 QL (100 GM per 30 days)
hydrocortisone butyr lipo base cream 0.1 % external 0.1 %
T1
75
Drug Status Noteshydrocortisone butyrate ointment 0.1 % external0.1 %
T1
hydrocortisone butyrate solution 0.1 % external0.1 %
T1
hydrocortisone cream 1 % external (otc) 1 % T1 QL (120 GM per 30 days)
hydrocortisone cream 2.5 % external 2.5 % T3 QL (90 GM per 30 days)
hydrocortisone external lotion 1 % T1 QL (240 GM per 30 days)
hydrocortisone external ointment 1 % T1 QL (90 GM per 30 days)
hydrocortisone lotion 2.5 % external 2.5 % T1 QL (120 ML per 30 days)
hydrocortisone ointment 2.5 % external 2.5 % T1 QL (90 GM per 30 days)
hydrocortisone valerate cream 0.2 % external 0.2 %
T1 QL (120 GM per 30 days)
hydrocortisone valerate ointment 0.2 % external0.2 %
T1 QL (120 GM per 30 days)
hydroquinone external cream 4 % T1
imiquimod cream 5 % external 5 % T3 QL (12 EA per 28 days)
ketoconazole cream 2 % external 2 % T1
ketoconazole shampoo 2 % external 2 % T1
lactic acid e cream 10-3500 %-unt/30gm external (rx) 10-3500 %-unt/30gm
T1 PA
lactic acid external lotion 10 % T1
lidocaine cream 4 % external 4 % T1 QL (90 GM per 30 days)
lidocaine hcl external cream 3 % T1 QL (85 GM per 30 days)
lidocaine hcl lotion 3 % external 3 % T1 QL (100 ML per 30 days)
lidocaine hcl solution 4 % external 4 % T1 QL (100 ML per 30 days)
lidocaine patch 5 % external 5 % T3 PA
lidocaine-prilocaine cream 2.5-2.5 % external2.5-2.5 %
T1
lindane shampoo 1 % external 1 % T3
LMX 4 CREAM 4 % EXTERNAL 4 % T1 QL (90 GM per 30 days)
mafenide acetate packet 5 % external 5 % T3
malathion external lotion 0.5 % T2
MENTAX CREAM 1 % EXTERNAL 1 % T3
methoxsalen rapid capsule 10 mg oral 10 mg T3 PA
metronidazole external cream 0.75 % T1
metronidazole external gel 0.75 % T1
metronidazole lotion 0.75 % external 0.75 % T1
miconazole nitrate external cream 2 % T1
MIRVASO GEL 0.33 % EXTERNAL 0.33 % T3 PA
mometasone furoate cream 0.1 % external 0.1 % T1
76
Drug Status Notesmometasone furoate ointment 0.1 % external 0.1 %
T1
mometasone furoate solution 0.1 % external 0.1 %
T1
mupirocin ointment 2 % external 2 % T1
naftifine hcl external gel 1 % T3 PA; QL (60 GM per 30 days)
NATROBA SUSPENSION 0.9 % EXTERNAL0.9 % T3 ST; QL (120 ML per 30 days)
NYAMYC EXTERNAL POWDER 100000 UNIT/GM T1
nystatin cream 100000 unit/gm external 100000 unit/gm
T1
nystatin external powder 100000 unit/gm T1
nystatin ointment 100000 unit/gm external100000 unit/gm
T1
nystatin-triamcinolone cream 100000-0.1 unit/gm-% external 100000-0.1 unit/gm-%
T3
nystatin-triamcinolone ointment 100000-0.1 unit/gm-% external 100000-0.1 unit/gm-%
T1
NYSTOP EXTERNAL POWDER 100000 UNIT/GM T1
oxiconazole nitrate cream 1 % external 1 % T3
permethrin cream 5 % external 5 % T1 QL (120 GM per 30 days)
pimecrolimus external cream 1 % T3 PA; QL (100 GM per 30 days)
podocon solution 25 % external 25 % T3
podofilox solution 0.5 % external 0.5 % T1
PR BENZOYL PEROXIDE WASH LIQUID 7 % EXTERNAL 7 % T3
prednicarbate cream 0.1 % external 0.1 % T1 QL (120 GM per 30 days)
prednicarbate ointment 0.1 % external 0.1 % T1 QL (120 GM per 30 days)
pyrogallic acid ointment 25-2 % external 25-2 % T1
REGRANEX GEL 0.01 % EXTERNAL 0.01 % T4 PA
ROSADAN KIT 0.75 % (CREAM) EXTERNAL 0.75 % (CREAM) T3
ROSADAN KIT 0.75 % (GEL) EXTERNAL0.75 % (GEL) T3
salicylic acid cream 6 % external 6 % T1
salicylic acid external solution 26 % T1
salicylic acid foam 6 % external 6 % T3
salicylic acid gel 6 % external 6 % T1
77
Drug Status Notessalicylic acid lotion 6 % external 6 % T1
salicylic acid shampoo 6 % external 6 % T1
salicylic acid wart remover liquid 27.5 % external27.5 %
T1
SANTYL OINTMENT 250 UNIT/GM EXTERNAL 250 UNIT/GM T3
selenium sulfide lotion 2.5 % external 2.5 % T1
silver nitrate solution 0.5 % external 0.5 % T1
silver nitrate solution 10 % external 10 % T1
silver nitrate solution 25 % external 25 % T1
silver nitrate solution 50 % external 50 % T1
SKLICE LOTION 0.5 % EXTERNAL 0.5 % T3 PA
SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE KIT 75 MG/0.83ML T4 PA
SSD CREAM 1 % EXTERNAL 1 % T1 QL (85 GM per 30 days)
STELARA SOLUTION PREFILLED SYRINGE 45 MG/0.5ML SUBCUTANEOUS45 MG/0.5ML
T4 PA
sulfacetamide sodium (acne) lotion 10 % external10 %
T3
sulfacetamide sodium liquid 10 % external 10 % T3
sulfacetamide sodium-sulfur external lotion 10-5 %
T3
SULFAMYLON CREAM 85 MG/GM EXTERNAL 85 MG/GM T3 QL (56.7 GM per 30 days)
SYNALAR (CREAM) KIT 0.025 % EXTERNAL 0.025 % T3
SYNALAR (OINTMENT) KIT 0.025 % EXTERNAL 0.025 % T3
TACLONEX SUSPENSION 0.005-0.064 % EXTERNAL 0.005-0.064 % T3 ST; QL (60 GM per 30 days)
tacrolimus ointment 0.03 % external 0.03 % T3
tacrolimus ointment 0.1 % external 0.1 % T3
tazarotene external cream 0.1 % T3 PA
TAZORAC EXTERNAL CREAM 0.05 % T3 PA
TAZORAC EXTERNAL GEL 0.05 %, 0.1 % T3 PA
tretinoin cream 0.025 % external 0.025 % T1QL (45 GM per 30 days); AL (Max 28 Years)
tretinoin cream 0.05 % external 0.05 % T1QL (45 GM per 30 days); AL (Max 28 Years)
tretinoin cream 0.1 % external 0.1 % T1QL (45 GM per 30 days); AL (Max 28 Years)
78
Drug Status Notes
tretinoin gel 0.01 % external 0.01 % T1QL (45 GM per 30 days); AL (Max 28 Years)
tretinoin microsphere gel 0.04 % external 0.04 % T3ST; QL (20 GM per 30 days); AL (Max 28 Years)
triamcinolone acetonide aerosol solution 0.147 mg/gm external 0.147 mg/gm
T3 PA
triamcinolone acetonide cream 0.025 % external0.025 %
T1 QL (160 GM per 30 days)
triamcinolone acetonide cream 0.1 % external 0.1 %
T1 QL (160 GM per 30 days)
triamcinolone acetonide cream 0.5 % external 0.5 %
T1 QL (60 GM per 30 days)
triamcinolone acetonide lotion 0.025 % external0.025 %
T1 QL (120 ML per 30 days)
triamcinolone acetonide lotion 0.1 % external 0.1 %
T1 QL (120 ML per 30 days)
triamcinolone acetonide ointment 0.025 % external 0.025 %
T1 QL (160 GM per 30 days)
triamcinolone acetonide ointment 0.1 % external0.1 %
T1 QL (160 GM per 30 days)
triamcinolone acetonide ointment 0.5 % external0.5 %
T1 QL (60 GM per 30 days)
UMECTA MOUSSE FOAM 40 % EXTERNAL 40 % T3
urea cream 39 % external 39 % T3
urea cream 40 % external 40 % T1
urea cream 45 % external 45 % T3
urea nail gel 45 % external 45 % T3
urea-c40 lotion 40 % external 40 % T3
VECTICAL OINTMENT 3 MCG/GM EXTERNAL 3 MCG/GM T3 PA
VELTIN GEL 1.2-0.025 % EXTERNAL 1.2-0.025 % T3
ST; QL (30 GM per 30 days); AL (Max 28 Years)
VEREGEN OINTMENT 15 % EXTERNAL15 % T3 PA
*Diagnostic Products*GLUCOCARD EXPRESSION TEST IN VITRO STRIP T1
GLUCOCARD VITAL TEST IN VITRO STRIP T1
ketone test in vitro strip T1
79
Drug Status Notes
*Digestive Aids*CREON CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT ORAL 12000 UNIT T2
CREON CAPSULE DELAYED RELEASE PARTICLES 24000-76000 UNIT ORAL24000-76000 UNIT
T2
CREON CAPSULE DELAYED RELEASE PARTICLES 3000-9500 UNIT ORAL 3000-9500 UNIT
T2
CREON CAPSULE DELAYED RELEASE PARTICLES 36000 UNIT ORAL 36000 UNIT T2
CREON CAPSULE DELAYED RELEASE PARTICLES 6000 UNIT ORAL 6000 UNIT T2
ZENPEP CAPSULE DELAYED RELEASE PARTICLES 25000-79000 UNIT ORAL25000-79000 UNIT
T2
*Diuretics*acetazolamide er capsule extended release 12 hour 500 mg oral 500 mg
T1 QL (60 EA per 30 days)
acetazolamide tablet 125 mg oral 125 mg T1
acetazolamide tablet 250 mg oral 250 mg T1
amiloride hcl tablet 5 mg oral 5 mg T1
amiloride-hydrochlorothiazide tablet 5-50 mg oral 5-50 mg
T1
bumetanide solution 0.25 mg/ml injection 0.25 mg/ml
T1
bumetanide tablet 0.5 mg oral 0.5 mg T1
bumetanide tablet 1 mg oral 1 mg T1
bumetanide tablet 2 mg oral 2 mg T1
CAROSPIR ORAL SUSPENSION 25 MG/5ML T1 AL (Max 12 Years)
chlorothiazide tablet 250 mg oral 250 mg T1
chlorothiazide tablet 500 mg oral 500 mg T1
chlorthalidone tablet 25 mg oral 25 mg T1
chlorthalidone tablet 50 mg oral 50 mg T1
ethacrynic acid tablet 25 mg oral 25 mg T3
furosemide solution 10 mg/ml oral 10 mg/ml T1
furosemide solution 8 mg/ml oral 8 mg/ml T1
furosemide tablet 20 mg oral 20 mg T1
furosemide tablet 40 mg oral 40 mg T1
furosemide tablet 80 mg oral 80 mg T1
80
Drug Status Noteshydrochlorothiazide capsule 12.5 mg oral 12.5 mg
T1
hydrochlorothiazide tablet 12.5 mg oral 12.5 mg T1
hydrochlorothiazide tablet 25 mg oral 25 mg T1
hydrochlorothiazide tablet 50 mg oral 50 mg T1
indapamide tablet 1.25 mg oral 1.25 mg T1
indapamide tablet 2.5 mg oral 2.5 mg T1
methazolamide tablet 25 mg oral 25 mg T3
methazolamide tablet 50 mg oral 50 mg T3
metolazone tablet 10 mg oral 10 mg T1
metolazone tablet 2.5 mg oral 2.5 mg T1
metolazone tablet 5 mg oral 5 mg T1
spironolactone tablet 100 mg oral 100 mg T1
spironolactone tablet 25 mg oral 25 mg T1
spironolactone tablet 50 mg oral 50 mg T1
spironolactone-hctz tablet 25-25 mg oral 25-25 mg
T1
torsemide tablet 10 mg oral 10 mg T1
torsemide tablet 100 mg oral 100 mg T1
torsemide tablet 20 mg oral 20 mg T1
torsemide tablet 5 mg oral 5 mg T1
triamterene oral capsule 100 mg T3
triamterene-hctz capsule 37.5-25 mg oral 37.5-25 mg
T1
triamterene-hctz tablet 37.5-25 mg oral 37.5-25 mg
T1
triamterene-hctz tablet 75-50 mg oral 75-50 mg T1
*Endocrine And Metabolic Agents - Misc.*alendronate sodium tablet 10 mg oral 10 mg T1 QL (30 EA per 30 days)
alendronate sodium tablet 35 mg oral 35 mg T1 QL (4 EA per 28 days)
alendronate sodium tablet 5 mg oral 5 mg T1 QL (30 EA per 30 days)
alendronate sodium tablet 70 mg oral 70 mg T1 QL (4 EA per 28 days)
cabergoline tablet 0.5 mg oral 0.5 mg T1
calcitonin (salmon) solution 200 unit/act nasal200 unit/act
T1
calcitriol capsule 0.25 mcg oral 0.25 mcg T1
calcitriol capsule 0.5 mcg oral 0.5 mcg T1
calcitriol solution 1 mcg/ml oral 1 mcg/ml T3
81
Drug Status Noteschorionic gonadotropin solution reconstituted 10000 unit intramuscular 10000 unit
T4 PA
CYSTADANE POWDER ORAL T4 PA
DDAVP RHINAL TUBE NASAL SOLUTION0.01 % T1
desmopressin ace spray refrig solution 0.01 % nasal 0.01 %
T3
desmopressin acetate solution 4 mcg/ml injection4 mcg/ml
T4 PA
desmopressin acetate spray nasal solution 0.01 % T1
desmopressin acetate tablet 0.1 mg oral 0.1 mg T1
desmopressin acetate tablet 0.2 mg oral 0.2 mg T1
doxercalciferol capsule 0.5 mcg oral 0.5 mcg T3 PA
doxercalciferol capsule 1 mcg oral 1 mcg T3 PA
doxercalciferol capsule 2.5 mcg oral 2.5 mcg T3 PA
FORTEO SOLUTION PEN-INJECTOR 600 MCG/2.4ML SUBCUTANEOUS 600 MCG/2.4ML
T4 PA
FOSAMAX PLUS D TABLET 70-2800 MG-UNIT ORAL 70-2800 MG-UNIT T3 PA
FOSAMAX PLUS D TABLET 70-5600 MG-UNIT ORAL 70-5600 MG-UNIT T3 PA
ganirelix acetate solution prefilled syringe 250 mcg/0.5ml subcutaneous 250 mcg/0.5ml
T4 PA
GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 0.2 MG SUBCUTANEOUS 0.2 MG
T4 PA
GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 0.4 MG SUBCUTANEOUS 0.4 MG
T4 PA
GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 0.6 MG SUBCUTANEOUS 0.6 MG
T4 PA
GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 0.8 MG SUBCUTANEOUS 0.8 MG
T4 PA
GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1 MG SUBCUTANEOUS1 MG
T4 PA
GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1.2 MG SUBCUTANEOUS 1.2 MG
T4 PA
82
Drug Status NotesGENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1.4 MG SUBCUTANEOUS 1.4 MG
T4 PA
GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1.6 MG SUBCUTANEOUS 1.6 MG
T4 PA
GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 1.8 MG SUBCUTANEOUS 1.8 MG
T4 PA
GENOTROPIN MINIQUICK SOLUTION RECONSTITUTED 2 MG SUBCUTANEOUS2 MG
T4 PA
GENOTROPIN SOLUTION RECONSTITUTED 12 MG SUBCUTANEOUS 12 MG
T4 PA
GENOTROPIN SOLUTION RECONSTITUTED 5 MG SUBCUTANEOUS5 MG
T4 PA
GONAL-F RFF REDIJECT SOLUTION 300 UNIT/0.5ML SUBCUTANEOUS 300 UNIT/0.5ML
T4 PA
GONAL-F RFF REDIJECT SOLUTION 450 UNT/0.75ML SUBCUTANEOUS 450 UNT/0.75ML
T4 PA
GONAL-F RFF REDIJECT SOLUTION 900 UNIT/1.5ML SUBCUTANEOUS 900 UNIT/1.5ML
T4 PA
ibandronate sodium tablet 150 mg oral 150 mg T1 QL (1 EA per 28 days)
INCRELEX SOLUTION 40 MG/4ML SUBCUTANEOUS 40 MG/4ML T4 PA
levocarnitine oral tablet 330 mg T3
levocarnitine solution 1 gm/10ml oral 1 gm/10ml T3
MIACALCIN SOLUTION 200 UNIT/ML INJECTION 200 UNIT/ML T4
nitisinone oral capsule 10 mg, 2 mg, 5 mg T4 PA
octreotide acetate solution 100 mcg/ml injection100 mcg/ml
T4 PA
octreotide acetate solution 1000 mcg/ml injection1000 mcg/ml
T4 PA
octreotide acetate solution 200 mcg/ml injection200 mcg/ml
T4 PA
octreotide acetate solution 50 mcg/ml injection 50 mcg/ml
T4 PA
83
Drug Status Notesoctreotide acetate solution 500 mcg/ml injection500 mcg/ml
T4 PA
OSPHENA TABLET 60 MG ORAL 60 MG T3 QL (30 EA per 30 days)
paricalcitol capsule 1 mcg oral 1 mcg T3 PA
paricalcitol capsule 2 mcg oral 2 mcg T3 PA
paricalcitol capsule 4 mcg oral 4 mcg T3 PA
raloxifene hcl tablet 60 mg oral 60 mg T5 PA
risedronate sodium tablet 150 mg oral 150 mg T3 QL (1 EA per 28 days)
risedronate sodium tablet 30 mg oral 30 mg T3 QL (30 EA per 30 days)
risedronate sodium tablet 35 mg oral 35 mg T3 QL (4 EA per 28 days)
risedronate sodium tablet 5 mg oral 5 mg T3 QL (30 EA per 30 days)
SAMSCA TABLET 15 MG ORAL 15 MG T4 PA
SANDOSTATIN LAR DEPOT KIT 10 MG INTRAMUSCULAR 10 MG T4 PA
SANDOSTATIN LAR DEPOT KIT 20 MG INTRAMUSCULAR 20 MG T4 PA
SANDOSTATIN LAR DEPOT KIT 30 MG INTRAMUSCULAR 30 MG T4 PA
sapropterin dihydrochloride oral tablet soluble100 mg
T4 PA
SENSIPAR TABLET 30 MG ORAL 30 MG T4 PA
SENSIPAR TABLET 60 MG ORAL 60 MG T4 PA
SENSIPAR TABLET 90 MG ORAL 90 MG T4 PA
SIGNIFOR LAR SUSPENSION RECONSTITUTED ER 20 MG INTRAMUSCULAR 20 MG
T4 PA
SIGNIFOR LAR SUSPENSION RECONSTITUTED ER 40 MG INTRAMUSCULAR 40 MG
T4 PA
SIGNIFOR LAR SUSPENSION RECONSTITUTED ER 60 MG INTRAMUSCULAR 60 MG
T4 PA
SIGNIFOR SOLUTION 0.3 MG/ML SUBCUTANEOUS 0.3 MG/ML T4 PA
SIGNIFOR SOLUTION 0.6 MG/ML SUBCUTANEOUS 0.6 MG/ML T4 PA
SIGNIFOR SOLUTION 0.9 MG/ML SUBCUTANEOUS 0.9 MG/ML T4 PA
SOMATULINE DEPOT SOLUTION 120 MG/0.5ML SUBCUTANEOUS 120 MG/0.5ML
T4 PA
84
Drug Status NotesSOMATULINE DEPOT SOLUTION 60 MG/0.2ML SUBCUTANEOUS 60 MG/0.2ML T4 PA
SOMATULINE DEPOT SOLUTION 90 MG/0.3ML SUBCUTANEOUS 90 MG/0.3ML T4 PA
SOMAVERT SOLUTION RECONSTITUTED 10 MG SUBCUTANEOUS 10 MG
T4 PA
SOMAVERT SOLUTION RECONSTITUTED 15 MG SUBCUTANEOUS 15 MG
T4 PA
SOMAVERT SOLUTION RECONSTITUTED 20 MG SUBCUTANEOUS 20 MG
T4 PA
STIMATE SOLUTION 1.5 MG/ML NASAL1.5 MG/ML T4 PA
tolvaptan oral tablet 30 mg T4 PA
*Estrogens*COMBIPATCH PATCH TWICE WEEKLY 0.05-0.14 MG/DAY TRANSDERMAL 0.05-0.14 MG/DAY
T3
COMBIPATCH PATCH TWICE WEEKLY 0.05-0.25 MG/DAY TRANSDERMAL 0.05-0.25 MG/DAY
T3
DUAVEE TABLET 0.45-20 MG ORAL 0.45-20 MG T3 GR-F; QL (30 EA per 30 days)
estradiol patch twice weekly 0.025 mg/24hr transdermal 0.025 mg/24hr
T2 GR-F; QL (8 EA per 28 days)
estradiol patch twice weekly 0.0375 mg/24hr transdermal 0.0375 mg/24hr
T2 GR-F; QL (8 EA per 28 days)
estradiol patch twice weekly 0.05 mg/24hr transdermal 0.05 mg/24hr
T2 GR-F; QL (8 EA per 28 days)
estradiol patch twice weekly 0.075 mg/24hr transdermal 0.075 mg/24hr
T2 GR-F; QL (8 EA per 28 days)
estradiol patch twice weekly 0.1 mg/24hr transdermal 0.1 mg/24hr
T2 GR-F; QL (8 EA per 28 days)
estradiol patch weekly 0.025 mg/24hr transdermal 0.025 mg/24hr
T1 GR-F; QL (4 EA per 28 days)
estradiol patch weekly 0.0375 mg/24hr transdermal 0.0375 mg/24hr
T1 GR-F; QL (4 EA per 28 days)
estradiol patch weekly 0.05 mg/24hr transdermal0.05 mg/24hr
T1 GR-F; QL (4 EA per 28 days)
estradiol patch weekly 0.06 mg/24hr transdermal0.06 mg/24hr
T1 GR-F; QL (4 EA per 28 days)
85
Drug Status Notesestradiol patch weekly 0.075 mg/24hr transdermal 0.075 mg/24hr
T1 GR-F; QL (4 EA per 28 days)
estradiol patch weekly 0.1 mg/24hr transdermal0.1 mg/24hr
T1 GR-F; QL (4 EA per 28 days)
estradiol tablet 0.5 mg oral 0.5 mg T1 GR-F
estradiol tablet 1 mg oral 1 mg T1 GR-F
estradiol tablet 2 mg oral 2 mg T1 GR-F
estradiol valerate oil 20 mg/ml intramuscular 20 mg/ml
T1 GR-F
estradiol valerate oil 40 mg/ml intramuscular 40 mg/ml
T1 GR-F
estradiol-norethindrone acet tablet 0.5-0.1 mg oral 0.5-0.1 mg
T1
estradiol-norethindrone acet tablet 1-0.5 mg oral1-0.5 mg
T1
ESTROGEL GEL 0.75 MG/1.25 GM (0.06%) TRANSDERMAL 0.75 MG/1.25 GM (0.06%) T3 GR-F
EVAMIST SOLUTION 1.53 MG/SPRAY TRANSDERMAL 1.53 MG/SPRAY T3 GR-F
JINTELI TABLET 1-5 MG-MCG ORAL 1-5 MG-MCG T1 GR-F; QL (28 EA per 28 days)
MENEST TABLET 0.3 MG ORAL 0.3 MG T3 GR-F
MENEST TABLET 0.625 MG ORAL 0.625 MG T3 GR-F
MENEST TABLET 1.25 MG ORAL 1.25 MG T3 GR-F
norethindrone-eth estradiol tablet 0.5-2.5 mg-mcg oral 0.5-2.5 mg-mcg
T1 GR-F; QL (28 EA per 28 days)
PREMARIN TABLET 0.3 MG ORAL 0.3 MG T3 GR-F
PREMARIN TABLET 0.45 MG ORAL 0.45 MG T3 GR-F
PREMARIN TABLET 0.625 MG ORAL 0.625 MG T3 GR-F
PREMARIN TABLET 0.9 MG ORAL 0.9 MG T3 GR-F
PREMARIN TABLET 1.25 MG ORAL 1.25 MG T3 GR-F
PREMPHASE TABLET 0.625-5 MG ORAL0.625-5 MG T3 GR-F
PREMPRO TABLET 0.3-1.5 MG ORAL 0.3-1.5 MG T3 GR-F
PREMPRO TABLET 0.45-1.5 MG ORAL0.45-1.5 MG T3 GR-F
PREMPRO TABLET 0.625-2.5 MG ORAL0.625-2.5 MG T3 GR-F
86
Drug Status NotesPREMPRO TABLET 0.625-5 MG ORAL0.625-5 MG T3 GR-F
*Fluoroquinolones*CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%), 500 MG/5ML (10%)
T3
ciprofloxacin hcl tablet 100 mg oral 100 mg T1
ciprofloxacin hcl tablet 250 mg oral 250 mg T1
ciprofloxacin hcl tablet 500 mg oral 500 mg T1
ciprofloxacin hcl tablet 750 mg oral 750 mg T1
levofloxacin tablet 250 mg oral 250 mg T1
levofloxacin tablet 500 mg oral 500 mg T1
levofloxacin tablet 750 mg oral 750 mg T1
moxifloxacin hcl tablet 400 mg oral 400 mg T3
ofloxacin tablet 400 mg oral 400 mg T1
*Gastrointestinal Agents - Misc.*alosetron hcl oral tablet 0.5 mg, 1 mg T3 PA
AMITIZA CAPSULE 24 MCG ORAL 24 MCG T3 PA
AMITIZA CAPSULE 8 MCG ORAL 8 MCG T3 PA
APRISO CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM ORAL 0.375 GM T3 QL (120 EA per 30 days)
balsalazide disodium capsule 750 mg oral 750 mg T1
calcium acetate (phos binder) capsule 667 mg oral 667 mg
T1
CALPHRON TABLET 667 MG ORAL 667 MG T1
cromolyn sodium oral concentrate 100 mg/5ml T3
DIPENTUM CAPSULE 250 MG ORAL 250 MG T3 PA
generlac solution 10 gm/15ml oral 10 gm/15ml T1
lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg
T3 PA
LINZESS CAPSULE 145 MCG ORAL 145 MCG T3 PA
LINZESS CAPSULE 290 MCG ORAL 290 MCG T3 PA
mesalamine enema 4 gm rectal 4 gm T3 QL (1680 ML per 28 days)
mesalamine oral capsule delayed release 400 mg T3 QL (180 EA per 30 days)
mesalamine oral tablet delayed release 1.2 gm T3 QL (60 EA per 30 days)
mesalamine rectal suppository 1000 mg T4 PA
87
Drug Status Notesmesalamine tablet delayed release 800 mg oral800 mg
T3 ST; QL (180 EA per 30 days)
metoclopramide hcl solution 10 mg/10ml oral 10 mg/10ml
T1
metoclopramide hcl tablet 10 mg oral 10 mg T1
metoclopramide hcl tablet 5 mg oral 5 mg T1
PENTASA CAPSULE EXTENDED RELEASE 250 MG ORAL 250 MG T3 ST; QL (240 EA per 30 days)
PENTASA CAPSULE EXTENDED RELEASE 500 MG ORAL 500 MG T3 ST; QL (240 EA per 30 days)
PHOSLYRA SOLUTION 667 MG/5ML ORAL 667 MG/5ML T3 PA
RENVELA PACKET 0.8 GM ORAL 0.8 GM T3 PA
sevelamer carbonate oral tablet 800 mg T3 PA
sevelamer carbonate packet 2.4 gm oral 2.4 gm T3 PA
sevelamer hcl oral tablet 800 mg T3 PA
sulfasalazine tablet 500 mg oral 500 mg T1
sulfasalazine tablet delayed release 500 mg oral500 mg
T1
ursodiol capsule 300 mg oral 300 mg T3
ursodiol tablet 250 mg oral 250 mg T3
ursodiol tablet 500 mg oral 500 mg T3
VELPHORO TABLET CHEWABLE 500 MG ORAL 500 MG T3 PA
*Genitourinary Agents - Miscellaneous*acetic acid solution 0.25 % irrigation 0.25 % T1
alfuzosin hcl er tablet extended release 24 hour 10 mg oral 10 mg
T3
aminoacetic acid solution 1.5 % irrigation 1.5 % T1
ARGYLE STERILE SALINE SOLUTION 0.9 % IRRIGATION 0.9 % T1
CARDURA XL TABLET EXTENDED RELEASE 24 HOUR 4 MG ORAL 4 MG T3
CYTRA-3 SYRUP 550-500-334 MG/5ML ORAL 550-500-334 MG/5ML T1
ELMIRON ORAL CAPSULE 100 MG T3
finasteride tablet 5 mg oral 5 mg T1
neomycin-polymyxin b gu solution 40-200000 irrigation 40-200000
T1
phenazopyridine hcl oral tablet 200 mg T1
phenazopyridine hcl tablet 100 mg oral 100 mg T1
88
Drug Status Notespotassium citrate er tablet extended release 10 meq (1080 mg) oral 10 meq (1080 mg)
T1
potassium citrate er tablet extended release 15 meq (1620 mg) oral 15 meq (1620 mg)
T3
potassium citrate er tablet extended release 5 meq (540 mg) oral 5 meq (540 mg)
T1
potassium citrate-citric acid solution 1100-334 mg/5ml oral 1100-334 mg/5ml
T1
silodosin oral capsule 4 mg, 8 mg T3
sod citrate-citric acid solution 500-334 mg/5ml oral 500-334 mg/5ml
T1
sorbitol solution 3 % irrigation 3 % T1
sorbitol solution 3.3 % irrigation 3.3 % T1
sorbitol-mannitol solution 2.7-0.54 gm/100ml irrigation 2.7-0.54 gm/100ml
T1
tamsulosin hcl capsule 0.4 mg oral 0.4 mg T1 QL (60 EA per 30 days)
*Gout Agents*allopurinol tablet 100 mg oral 100 mg T1
allopurinol tablet 300 mg oral 300 mg T1
colchicine oral capsule 0.6 mg T3 QL (60 EA per 30 days)
colchicine oral tablet 0.6 mg T2 QL (60 EA per 30 days)
colchicine-probenecid oral tablet 0.5-500 mg T1
probenecid tablet 500 mg oral 500 mg T1
ULORIC TABLET 40 MG ORAL 40 MG T3 PA
ULORIC TABLET 80 MG ORAL 80 MG T3 PA
*Hematological Agents - Misc.*anagrelide hcl capsule 0.5 mg oral 0.5 mg T1
anagrelide hcl capsule 1 mg oral 1 mg T1
aspirin-dipyridamole er capsule extended release 12 hour 25-200 mg oral 25-200 mg
T3
BERINERT KIT 500 UNIT INTRAVENOUS500 UNIT T4 PA
BRILINTA TABLET 60 MG ORAL 60 MG T2 QL (60 EA per 30 days)
BRILINTA TABLET 90 MG ORAL 90 MG T2 QL (60 EA per 30 days)
CEPROTIN SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS 1000 UNIT T4 PA
cilostazol tablet 100 mg oral 100 mg T1
cilostazol tablet 50 mg oral 50 mg T1
clopidogrel bisulfate tablet 300 mg oral 300 mg T1 QL (30 EA per 30 days)
clopidogrel bisulfate tablet 75 mg oral 75 mg T1 QL (30 EA per 30 days)
89
Drug Status Notesdipyridamole tablet 25 mg oral 25 mg T1
dipyridamole tablet 50 mg oral 50 mg T1
dipyridamole tablet 75 mg oral 75 mg T1
FIRAZYR SOLUTION 30 MG/3ML SUBCUTANEOUS 30 MG/3ML T4 PA
KALBITOR SOLUTION 10 MG/ML SUBCUTANEOUS 10 MG/ML T4 PA
pentoxifylline er tablet extended release 400 mg oral 400 mg
T1 QL (90 EA per 30 days)
prasugrel hcl oral tablet 10 mg, 5 mg T3 ST; QL (30 EA per 30 days)
ZONTIVITY TABLET 2.08 MG ORAL 2.08 MG T3 QL (30 EA per 30 days)
*Hematopoietic Agents*ARANESP (ALBUMIN FREE) SOLUTION 100 MCG/ML INJECTION 100 MCG/ML T4 PA
ARANESP (ALBUMIN FREE) SOLUTION 200 MCG/ML INJECTION 200 MCG/ML T4 PA
ARANESP (ALBUMIN FREE) SOLUTION 25 MCG/ML INJECTION 25 MCG/ML T4 PA
ARANESP (ALBUMIN FREE) SOLUTION 300 MCG/ML INJECTION 300 MCG/ML T4 PA
ARANESP (ALBUMIN FREE) SOLUTION 40 MCG/ML INJECTION 40 MCG/ML T4 PA
ARANESP (ALBUMIN FREE) SOLUTION 60 MCG/ML INJECTION 60 MCG/ML T4 PA
ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML INJECTION 100 MCG/0.5ML
T4 PA
ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 150 MCG/0.3ML INJECTION 150 MCG/0.3ML
T4 PA
ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 200 MCG/0.4ML INJECTION 200 MCG/0.4ML
T4 PA
ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 25 MCG/0.42ML INJECTION 25 MCG/0.42ML
T4 PA
ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 300 MCG/0.6ML INJECTION 300 MCG/0.6ML
T4 PA
ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 40 MCG/0.4ML INJECTION 40 MCG/0.4ML
T4 PA
90
Drug Status NotesARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 500 MCG/ML INJECTION 500 MCG/ML
T4 PA
ARANESP (ALBUMIN FREE) SOLUTION PREFILLED SYRINGE 60 MCG/0.3ML INJECTION 60 MCG/0.3ML
T4 PA
b-6 folic acid capsule 8.333-100-1 mg oral 8.333-100-1 mg
T1
cyanocobalamin solution 1000 mcg/ml injection1000 mcg/ml
T1
DROXIA CAPSULE 200 MG ORAL 200 MG T2
DROXIA CAPSULE 300 MG ORAL 300 MG T2
DROXIA CAPSULE 400 MG ORAL 400 MG T2
EPOGEN SOLUTION 10000 UNIT/ML INJECTION 10000 UNIT/ML T4 PA
EPOGEN SOLUTION 2000 UNIT/ML INJECTION 2000 UNIT/ML T4 PA
EPOGEN SOLUTION 20000 UNIT/ML INJECTION 20000 UNIT/ML T4 PA
EPOGEN SOLUTION 3000 UNIT/ML INJECTION 3000 UNIT/ML T4 PA
EPOGEN SOLUTION 4000 UNIT/ML INJECTION 4000 UNIT/ML T4 PA
fe tabs tablet delayed release 325 (65 fe) mg oral325 (65 fe) mg
T5
ferotrinsic capsule oral T1
ferraplus 90 tablet 90-1 mg oral 90-1 mg T1
ferrous sulfate elixir 220 (44 fe) mg/5ml oral 220 (44 fe) mg/5ml
T5
folic acid injection solution 5 mg/ml T1
folic acid oral tablet 1 mg, 800 mcg T5 QL (30 EA per 30 days)
folic acid tablet 400 mcg oral 400 mcg T5 QL (30 EA per 30 days)
hematinic/folic acid tablet 324-1 mg oral 324-1 mg
T1
HEMATOGEN FA CAPSULE 200-250-0.01-1 MG ORAL 200-250-0.01-1 MG T1
HEMATOGEN FORTE CAPSULE 460-60-0.01-1 MG ORAL (RX) 460-60-0.01-1 MG T1
iron 27 tablet 240 (27 fe) mg oral 240 (27 fe) mg T5
iron tablet 325 (65 fe) mg oral 325 (65 fe) mg T5
LEUKINE SOLUTION RECONSTITUTED 250 MCG INJECTION 250 MCG T4 PA
91
Drug Status NotesNEULASTA SOLUTION PREFILLED SYRINGE 6 MG/0.6ML SUBCUTANEOUS 6 MG/0.6ML
T4 PA
poly-iron 150 forte capsule 150-25-1 mg-mcg-mg oral 150-25-1 mg-mcg-mg
T1
PROCRIT SOLUTION 10000 UNIT/ML INJECTION 10000 UNIT/ML T4 PA
PROCRIT SOLUTION 2000 UNIT/ML INJECTION 2000 UNIT/ML T4 PA
PROCRIT SOLUTION 20000 UNIT/ML INJECTION 20000 UNIT/ML T4 PA
PROCRIT SOLUTION 3000 UNIT/ML INJECTION 3000 UNIT/ML T4 PA
PROCRIT SOLUTION 4000 UNIT/ML INJECTION 4000 UNIT/ML T4 PA
PROCRIT SOLUTION 40000 UNIT/ML INJECTION 40000 UNIT/ML T4 PA
PROMACTA TABLET 12.5 MG ORAL 12.5 MG T3 PA
PROMACTA TABLET 25 MG ORAL 25 MG T3 PA
PROMACTA TABLET 50 MG ORAL 50 MG T3 PA
PROMACTA TABLET 75 MG ORAL 75 MG T3 PA
RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML
T4 PA
ZARXIO SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML INJECTION 300 MCG/0.5ML
T4 PA
ZARXIO SOLUTION PREFILLED SYRINGE 480 MCG/0.8ML INJECTION 480 MCG/0.8ML
T4 PA
*Hemostatics*aminocaproic acid oral tablet 1000 mg, 500 mg T3
*Hypnotics/Sedatives/Sleep Disorder Agents*BELSOMRA TABLET 10 MG ORAL 10 MG T3 ST; QL (30 EA per 30 days)
BELSOMRA TABLET 15 MG ORAL 15 MG T3 ST; QL (30 EA per 30 days)
BELSOMRA TABLET 20 MG ORAL 20 MG T3 ST; QL (30 EA per 30 days)
BELSOMRA TABLET 5 MG ORAL 5 MG T3 ST; QL (30 EA per 30 days)
estazolam tablet 1 mg oral 1 mg T1
estazolam tablet 2 mg oral 2 mg T1
92
Drug Status Notes
eszopiclone tablet 1 mg oral 1 mg T1QL (30 EA per 30 days); AL (Max 64 Years)
eszopiclone tablet 2 mg oral 2 mg T1QL (30 EA per 30 days); AL (Max 64 Years)
eszopiclone tablet 3 mg oral 3 mg T1QL (30 EA per 30 days); AL (Max 64 Years)
flurazepam hcl capsule 15 mg oral 15 mg T1 AL (Max 64 Years)
flurazepam hcl capsule 30 mg oral 30 mg T1 AL (Max 64 Years)
HETLIOZ CAPSULE 20 MG ORAL 20 MG T4 PA
phenobarbital elixir 20 mg/5ml oral 20 mg/5ml T1
phenobarbital tablet 100 mg oral 100 mg T1
phenobarbital tablet 15 mg oral 15 mg T1
phenobarbital tablet 16.2 mg oral 16.2 mg T1
phenobarbital tablet 30 mg oral 30 mg T1
phenobarbital tablet 32.4 mg oral 32.4 mg T1
phenobarbital tablet 60 mg oral 60 mg T1
phenobarbital tablet 64.8 mg oral 64.8 mg T1
phenobarbital tablet 97.2 mg oral 97.2 mg T1
ROZEREM TABLET 8 MG ORAL 8 MG T3 ST; QL (30 EA per 30 days)
temazepam capsule 15 mg oral 15 mg T1
temazepam capsule 22.5 mg oral 22.5 mg T3
temazepam capsule 30 mg oral 30 mg T1
temazepam capsule 7.5 mg oral 7.5 mg T3
zaleplon capsule 10 mg oral 10 mg T1QL (30 EA per 30 days); AL (Max 64 Years)
zaleplon capsule 5 mg oral 5 mg T1QL (30 EA per 30 days); AL (Max 64 Years)
zolpidem tartrate er oral tablet extended release12.5 mg, 6.25 mg
T1QL (30 EA per 30 days); AL (Min 18 Years)
zolpidem tartrate tablet 10 mg oral 10 mg T1QL (30 EA per 30 days); AL (Max 64 Years)
zolpidem tartrate tablet 5 mg oral 5 mg T1QL (30 EA per 30 days); AL (Max 64 Years)
*Laxatives*GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM T5 QL (4000 ML per 365 days)
GAVILYTE-G SOLUTION RECONSTITUTED 236 GM ORAL 236 GM T1
GAVILYTE-N WITH FLAVOR PACK SOLUTION RECONSTITUTED 420 GM ORAL 420 GM
T1
93
Drug Status NotesGOLYTELY SOLUTION RECONSTITUTED 227.1 GM ORAL 227.1 GM T1 QL (1 EA per 365 days)
KRISTALOSE PACKET 20 GM ORAL 20 GM T3 PA
lactulose oral packet 10 gm T3 PA
lactulose solution 10 gm/15ml oral 10 gm/15ml T1
OSMOPREP TABLET 1.102-0.398 GM ORAL 1.102-0.398 GM T3
peg-3350/electrolytes/ascorbat oral solution reconstituted 100 gm
T3
polyethylene glycol 3350 oral powder 17 gm/scoop
T1
SUPREP BOWEL PREP KIT SOLUTION 17.5-3.13-1.6 GM/177ML ORAL 17.5-3.13-1.6 GM/177ML
T3
*Macrolides*azithromycin oral tablet 500 mg T1 QL (6 EA per 30 days)
azithromycin packet 1 gm oral 1 gm T1 QL (2 EA per 30 days)
azithromycin suspension reconstituted 100 mg/5ml oral 100 mg/5ml
T1
azithromycin suspension reconstituted 200 mg/5ml oral 200 mg/5ml
T1
azithromycin tablet 250 mg oral 250 mg T1 QL (6 EA per 5 days)
azithromycin tablet 600 mg oral 600 mg T1 QL (60 EA per 30 days)
clarithromycin er tablet extended release 24 hour 500 mg oral 500 mg
T1
clarithromycin suspension reconstituted 125 mg/5ml oral 125 mg/5ml
T1
clarithromycin suspension reconstituted 250 mg/5ml oral 250 mg/5ml
T1
clarithromycin tablet 250 mg oral 250 mg T1
clarithromycin tablet 500 mg oral 500 mg T1
DIFICID TABLET 200 MG ORAL 200 MG T3 PA
ERYTHROCIN STEARATE TABLET 250 MG ORAL 250 MG T3
erythromycin base capsule delayed release particles 250 mg oral 250 mg
T3
erythromycin base oral tablet delayed release 333 mg
T3
erythromycin base tablet 250 mg oral 250 mg T3
erythromycin base tablet 500 mg oral 500 mg T3
94
Drug Status Noteserythromycin ethylsuccinate tablet 400 mg oral400 mg
T3
*Medical Devices And Supplies*BD INSULIN SYRINGE 25G X 1" 1 ML T1 QL (200 EA per 30 days)
BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM T1 QL (200 EA per 30 days)
BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.5 ML T1 QL (200 EA per 30 days)
BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML, 31G X 15/64" 1 ML T1 QL (200 EA per 30 days)
COMFORT EZ PEN NEEDLES 32G X 5 MM T1 QL (200 EA per 30 days)
FREESTYLE LIBRE SENSOR SYSTEM T1
insulin syringe 28g x 1/2" 0.5 ml 28g x 1/2" 0.5 ml
T1 QL (200 EA per 30 days)
insulin syringe 28g x 1/2" 1 ml 28g x 1/2" 1 ml T1 QL (200 EA per 30 days)
insulin syringe 29g x 1/2" 0.5 ml 29g x 1/2" 0.5 ml
T1 QL (200 EA per 30 days)
insulin syringe 29g x 1/2" 1 ml 29g x 1/2" 1 ml T1 QL (200 EA per 30 days)
insupen pen needles 29g x 12mm 29g x 12mm T1 QL (200 EA per 30 days)
MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML 29G X 1/2" 0.3 ML T1 QL (200 EA per 30 days)
OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM T5
ONETOUCH VERIO SOLUTION IN VITRO T1 QL (1 EA per 365 days)
pen needles 31g x 6 mm 31g x 6 mm T1 QL (200 EA per 30 days)
pen needles 31g x 8 mm 31g x 8 mm T1 QL (200 EA per 30 days)
pen needles 32g x 4 mm 32g x 4 mm T1 QL (200 EA per 30 days)
pen needles 32g x 6 mm 32g x 6 mm T1 QL (200 EA per 30 days)
TECHLITE PEN NEEDLES 31G X 5 MM31G X 5 MM T1 QL (200 EA per 30 days)
ULTILET INSULIN SYRINGE 30G X 1/2" 0.5 ML 30G X 1/2" 0.5 ML T1 QL (200 EA per 30 days)
ULTILET INSULIN SYRINGE 30G X 1/2" 1 ML 30G X 1/2" 1 ML T1 QL (200 EA per 30 days)
ULTILET INSULIN SYRINGE 30G X 5/16" 0.3 ML 30G X 5/16" 0.3 ML T1 QL (200 EA per 30 days)
ULTILET INSULIN SYRINGE 30G X 5/16" 0.5 ML 30G X 5/16" 0.5 ML T1 QL (200 EA per 30 days)
ULTILET INSULIN SYRINGE 30G X 5/16" 1 ML 30G X 5/16" 1 ML T1 QL (200 EA per 30 days)
ULTILET INSULIN SYRINGE 31G X 5/16" 0.3 ML 31G X 5/16" 0.3 ML T1 QL (200 EA per 30 days)
95
Drug Status NotesULTILET INSULIN SYRINGE 31G X 5/16" 1 ML 31G X 5/16" 1 ML T1 QL (200 EA per 30 days)
ULTILET INSULIN SYRINGE SHORT 30G X 1/2" 0.3 ML 30G X 1/2" 0.3 ML T1 QL (200 EA per 30 days)
ULTILET INSULIN SYRINGE SHORT 31G X 5/16" 0.5 ML 31G X 5/16" 0.5 ML T1 QL (200 EA per 30 days)
*Migraine Products*almotriptan malate tablet 12.5 mg oral 12.5 mg T3 ST; QL (9 EA per 30 days)
almotriptan malate tablet 6.25 mg oral 6.25 mg T3 ST; QL (9 EA per 30 days)
eletriptan hydrobromide tablet 20 mg oral 20 mg T3 ST; QL (9 EA per 30 days)
eletriptan hydrobromide tablet 40 mg oral 40 mg T3 ST; QL (9 EA per 30 days)
ergotamine-caffeine oral tablet 1-100 mg T3 QL (40 EA per 28 days)
frovatriptan succinate tablet 2.5 mg oral 2.5 mg T3 ST; QL (9 EA per 30 days)
naratriptan hcl tablet 1 mg oral 1 mg T2 QL (9 EA per 30 days)
naratriptan hcl tablet 2.5 mg oral 2.5 mg T2 QL (9 EA per 30 days)
RELPAX TABLET 20 MG ORAL 20 MG T3 ST; QL (9 EA per 30 days)
rizatriptan benzoate tablet 10 mg oral 10 mg T1 QL (12 EA per 30 days)
rizatriptan benzoate tablet 5 mg oral 5 mg T1 QL (12 EA per 30 days)
rizatriptan benzoate tablet dispersible 10 mg oral10 mg
T1 QL (12 EA per 30 days)
rizatriptan benzoate tablet dispersible 5 mg oral 5 mg
T1 QL (12 EA per 30 days)
sumatriptan solution 20 mg/act nasal 20 mg/act T3
sumatriptan solution 5 mg/act nasal 5 mg/act T3
sumatriptan succinate solution 6 mg/0.5ml subcutaneous 6 mg/0.5ml
T3 PA; QL (10 ML per 30 days)
sumatriptan succinate solution auto-injector 6 mg/0.5ml subcutaneous 6 mg/0.5ml
T3 PA; QL (10 ML per 30 days)
sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml
T4 PA
sumatriptan succinate tablet 100 mg oral 100 mg T1 QL (9 EA per 30 days)
sumatriptan succinate tablet 25 mg oral 25 mg T1 QL (9 EA per 30 days)
sumatriptan succinate tablet 50 mg oral 50 mg T1 QL (9 EA per 30 days)
zolmitriptan tablet 2.5 mg oral 2.5 mg T1 QL (6 EA per 30 days)
zolmitriptan tablet 5 mg oral 5 mg T1 QL (6 EA per 30 days)
zolmitriptan tablet dispersible 2.5 mg oral 2.5 mg T1 QL (6 EA per 30 days)
zolmitriptan tablet dispersible 5 mg oral 5 mg T1 QL (6 EA per 30 days)
*Minerals & Electrolytes*EFFER-K TABLET EFFERVESCENT 10 MEQ ORAL 10 MEQ T3
96
Drug Status NotesEFFER-K TABLET EFFERVESCENT 20 MEQ ORAL 20 MEQ T3
fluoritab tablet chewable 1.1 (0.5 f) mg oral 1.1 (0.5 f) mg
T5
iodine strong solution 5 % oral 5 % T1
KLOR-CON M15 TABLET EXTENDED RELEASE 15 MEQ ORAL 15 MEQ T3
K-PRIME TABLET EFFERVESCENT 25 MEQ ORAL 25 MEQ T1
MONOJECT SODIUM CHLORIDE FLUSH SOLUTION 0.9 % INTRAVENOUS 0.9 % T3
PHOSPHO-TRIN 250 NEUTRAL TABLET 155-852-130 MG ORAL 155-852-130 MG T1
pot bicarb-pot chloride oral tablet effervescent 25 meq
T1
potassium chloride crys er tablet extended release 10 meq oral 10 meq
T1
potassium chloride crys er tablet extended release 20 meq oral 20 meq
T1
potassium chloride er capsule extended release 10 meq oral 10 meq
T1
potassium chloride er capsule extended release 8 meq oral 8 meq
T1
potassium chloride er oral tablet extended release20 meq
T1
potassium chloride er tablet extended release 10 meq oral 10 meq
T1
potassium chloride er tablet extended release 8 meq oral 8 meq
T1
potassium chloride packet 20 meq oral 20 meq T3
sodium chloride solution 0.9 % intravenous 0.9 % T3
sodium fluoride solution 1.1 (0.5 f) mg/ml oral 1.1 (0.5 f) mg/ml
T5
sodium fluoride tablet chewable 2.2 (1 f) mg oral2.2 (1 f) mg
T5
zinc sulfate capsule 220 (50 zn) mg oral (otc) 220 (50 zn) mg
T1
*Miscellaneous Therapeutic Classes*alprostadil solution 500 mcg/ml injection 500 mcg/ml
T1
AZASAN TABLET 100 MG ORAL 100 MG T3 PA
AZASAN TABLET 75 MG ORAL 75 MG T3 PA
97
Drug Status Notesazathioprine tablet 50 mg oral 50 mg T1
CUPRIMINE CAPSULE 250 MG ORAL 250 MG T4 PA
cyclosporine capsule 100 mg oral 100 mg T3
cyclosporine capsule 25 mg oral 25 mg T3
cyclosporine modified capsule 100 mg oral 100 mg
T3
cyclosporine modified capsule 25 mg oral 25 mg T1
everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg T4 PA
GENGRAF SOLUTION 100 MG/ML ORAL100 MG/ML T3
mycophenolate mofetil capsule 250 mg oral 250 mg
T1
mycophenolate mofetil suspension reconstituted 200 mg/ml oral 200 mg/ml
T4
mycophenolate mofetil tablet 500 mg oral 500 mg T1
mycophenolate sodium tablet delayed release 180 mg oral 180 mg
T3 PA
mycophenolate sodium tablet delayed release 360 mg oral 360 mg
T3 PA
penicillamine oral tablet 250 mg T4
RAPAMUNE SOLUTION 1 MG/ML ORAL 1 MG/ML T4 PA
REVLIMID CAPSULE 10 MG ORAL 10 MG T4 PA
REVLIMID CAPSULE 15 MG ORAL 15 MG T4 PA
REVLIMID CAPSULE 2.5 MG ORAL 2.5 MG T4 PA
REVLIMID CAPSULE 20 MG ORAL 20 MG T4 PA
REVLIMID CAPSULE 25 MG ORAL 25 MG T4 PA
REVLIMID CAPSULE 5 MG ORAL 5 MG T4 PA
SANDIMMUNE SOLUTION 100 MG/ML ORAL 100 MG/ML T4 PA
sirolimus tablet 0.5 mg oral 0.5 mg T4 PA
sodium polystyrene sulfonate powder oral T1
SPS SUSPENSION 15 GM/60ML ORAL 15 GM/60ML T1
sterile water for irrigation irrigation solution T1
SYPRINE CAPSULE 250 MG ORAL 250 MG T4
tacrolimus capsule 0.5 mg oral 0.5 mg T1
tacrolimus capsule 1 mg oral 1 mg T1
tacrolimus capsule 5 mg oral 5 mg T3
98
Drug Status NotesTHALOMID CAPSULE 100 MG ORAL 100 MG T4 PA
THALOMID CAPSULE 150 MG ORAL 150 MG T4 PA
THALOMID CAPSULE 200 MG ORAL 200 MG T4 PA
THALOMID CAPSULE 50 MG ORAL 50 MG T4 PA
ZORTRESS TABLET 0.75 MG ORAL 0.75 MG T4 PA
*Mouth/Throat/Dental Agents*cevimeline hcl capsule 30 mg oral 30 mg T3 PA
chlorhexidine gluconate solution 0.12 % mouth/throat 0.12 %
T1
FLUORIDEX DAILY RENEWAL CONCENTRATE 0.63 % MOUTH/THROAT0.63 %
T1
FLUORIDEX PASTE 1.1 % DENTAL 1.1 % T1
lidocaine hcl solution 4 % mouth/throat 4 % T1 QL (100 ML per 30 days)
nystatin suspension 100000 unit/ml mouth/throat100000 unit/ml
T1
ORAVIG TABLET 50 MG BUCCAL 50 MG T4 PA
pilocarpine hcl tablet 5 mg oral 5 mg T1
pilocarpine hcl tablet 7.5 mg oral 7.5 mg T1
sf 5000 plus cream 1.1 % dental 1.1 % T1
sf dental gel 1.1 % T1
triamcinolone acetonide paste 0.1 % mouth/throat0.1 %
T3 QL (5 GM per 30 days)
*Multivitamins*multivitamin/fluoride solution 0.25 mg/ml oral0.25 mg/ml
T1
prenatal tablet 27-0.8 mg oral (otc) 27-0.8 mg T5
TARON-PREX CAPSULE 30-1.2-265 MG ORAL 30-1.2-265 MG T1
thrivite 19 tablet 1 mg oral 1 mg T5
vitamins acd-fluoride solution 0.25 mg/ml oral0.25 mg/ml
T1
*Musculoskeletal Therapy Agents*baclofen tablet 10 mg oral 10 mg T1
baclofen tablet 20 mg oral 20 mg T1
carisoprodol tablet 350 mg oral 350 mg T1
99
Drug Status Noteschlorzoxazone oral tablet 375 mg T3
chlorzoxazone tablet 500 mg oral 500 mg T1 AL (Max 64 Years)
cyclobenzaprine hcl tablet 10 mg oral 10 mg T1 AL (Max 64 Years)
cyclobenzaprine hcl tablet 5 mg oral 5 mg T1 AL (Max 64 Years)
dantrolene sodium capsule 100 mg oral 100 mg T1
dantrolene sodium capsule 25 mg oral 25 mg T1
dantrolene sodium capsule 50 mg oral 50 mg T1
metaxalone tablet 800 mg oral 800 mg T3 PA; AL (Max 64 Years)
methocarbamol tablet 500 mg oral 500 mg T1 AL (Max 64 Years)
methocarbamol tablet 750 mg oral 750 mg T1 AL (Max 64 Years)
orphenadrine citrate er tablet extended release 12 hour 100 mg oral 100 mg
T1 AL (Max 64 Years)
tizanidine hcl capsule 2 mg oral 2 mg T3 QL (90 EA per 30 days)
tizanidine hcl capsule 4 mg oral 4 mg T3 QL (90 EA per 30 days)
tizanidine hcl capsule 6 mg oral 6 mg T3 QL (90 EA per 30 days)
tizanidine hcl tablet 2 mg oral 2 mg T1 QL (90 EA per 30 days)
tizanidine hcl tablet 4 mg oral 4 mg T1 QL (90 EA per 30 days)
*Nasal Agents - Systemic And Topical*allergy spray 24 hour aerosol 55 mcg/act nasal55 mcg/act
T1 QL (16.9 ML per 30 days)
azelastine hcl solution 0.1 % nasal 0.1 % T1
azelastine hcl solution 0.15 % nasal 0.15 % T3 ST
BECONASE AQ SUSPENSION 42 MCG/SPRAY NASAL 42 MCG/SPRAY T3 ST
cvs nasal allergy spray aerosol 55 mcg/act nasal55 mcg/act
T1 QL (16.9 ML per 30 days)
eq nasal allergy aerosol 55 mcg/act nasal 55 mcg/act
T1 QL (16.9 ML per 30 days)
FLONASE SENSIMIST SUSPENSION 27.5 MCG/SPRAY NASAL 27.5 MCG/SPRAY T1 QL (15.8 ML per 30 days)
flunisolide solution 25 mcg/act (0.025%) nasal 25 mcg/act (0.025%)
T1 QL (50 ML per 30 days)
fluticasone propionate nasal suspension 50 mcg/act
T1 QL (16 GM per 30 days)
gnp 24 hour nasal allergy aerosol 55 mcg/act nasal 55 mcg/act
T1 QL (16.9 ML per 30 days)
goodsense nasal allergy spray aerosol 55 mcg/act nasal 55 mcg/act
T1 QL (16.9 ML per 30 days)
ipratropium bromide solution 0.03 % nasal 0.03 %
T1 QL (30 ML per 30 days)
100
Drug Status Notesipratropium bromide solution 0.06 % nasal 0.06 %
T1 QL (15 ML per 30 days)
mometasone furoate suspension 50 mcg/act nasal50 mcg/act
T3 ST
nasal allergy 24 hour aerosol 55 mcg/act nasal55 mcg/act
T1 QL (16.9 ML per 30 days)
QNASL AEROSOL SOLUTION 80 MCG/ACT NASAL 80 MCG/ACT T3 ST
ra nasal allergy aerosol 55 mcg/act nasal 55 mcg/act
T1 QL (16.9 ML per 30 days)
triamcinolone acetonide aerosol 55 mcg/act nasal (otc) 55 mcg/act
T1 QL (16.9 GM per 30 days)
triamcinolone acetonide aerosol 55 mcg/act nasal (rx) 55 mcg/act
T1 QL (16.9 GM per 30 days)
*Neuromuscular Agents*riluzole oral tablet 50 mg T1
*Nutrients*nac capsule 600 mg oral 600 mg T1
*Ophthalmic Agents*ACUVAIL SOLUTION 0.45 % OPHTHALMIC 0.45 % T3
ALOCRIL SOLUTION 2 % OPHTHALMIC2 % T3 PA
ALOMIDE SOLUTION 0.1 % OPHTHALMIC 0.1 % T3 PA
ALPHAGAN P SOLUTION 0.1 % OPHTHALMIC 0.1 % T3
ALTACAINE SOLUTION 0.5 % OPHTHALMIC 0.5 % T1
apraclonidine hcl solution 0.5 % ophthalmic 0.5 %
T3
atropine sulfate ointment 1 % ophthalmic 1 % T1
atropine sulfate solution 1 % ophthalmic 1 % T1
AZASITE SOLUTION 1 % OPHTHALMIC 1 % T3 PA
azelastine hcl solution 0.05 % ophthalmic 0.05 % T1 QL (6 ML per 30 days)
AZOPT SUSPENSION 1 % OPHTHALMIC 1 % T3 QL (15 ML per 30 days)
bacitracin ointment 500 unit/gm ophthalmic 500 unit/gm
T1
bacitracin-polymyxin b ointment 500-10000 unit/gm ophthalmic 500-10000 unit/gm
T1
101
Drug Status Notesbacitra-neomycin-polymyxin-hc ointment 1 % ophthalmic 1 %
T1
balanced salt solution intraocular T1
BEPREVE SOLUTION 1.5 % OPHTHALMIC 1.5 % T3 PA
BESIVANCE SUSPENSION 0.6 % OPHTHALMIC 0.6 % T3
betaxolol hcl solution 0.5 % ophthalmic 0.5 % T1
BETOPTIC-S SUSPENSION 0.25 % OPHTHALMIC 0.25 % T2 PA
bimatoprost ophthalmic solution 0.03 % T1 QL (5 ML per 30 days)
BLEPHAMIDE S.O.P. OINTMENT 10-0.2 % OPHTHALMIC 10-0.2 % T2
brimonidine tartrate solution 0.15 % ophthalmic0.15 %
T3
brimonidine tartrate solution 0.2 % ophthalmic0.2 %
T1
bromfenac sodium (once-daily) solution 0.09 % ophthalmic 0.09 %
T3
carteolol hcl solution 1 % ophthalmic 1 % T1
CILOXAN OINTMENT 0.3 % OPHTHALMIC 0.3 % T3
ciprofloxacin hcl solution 0.3 % ophthalmic 0.3 %
T1
COMBIGAN SOLUTION 0.2-0.5 % OPHTHALMIC 0.2-0.5 % T3
cromolyn sodium solution 4 % ophthalmic 4 % T1
cvs sodium chloride ointment 5 % ophthalmic 5 % T1
cyclopentolate hcl solution 1 % ophthalmic 1 % T1
cyclopentolate hcl solution 2 % ophthalmic 2 % T1
CYSTARAN SOLUTION 0.44 % OPHTHALMIC 0.44 % T4
dexamethasone sodium phosphate solution 0.1 % ophthalmic 0.1 %
T1
diclofenac sodium solution 0.1 % ophthalmic 0.1 %
T1
dorzolamide hcl solution 2 % ophthalmic 2 % T1
dorzolamide hcl-timolol mal solution 22.3-6.8 mg/ml ophthalmic 22.3-6.8 mg/ml
T1
DUREZOL EMULSION 0.05 % OPHTHALMIC 0.05 % T3
epinastine hcl solution 0.05 % ophthalmic 0.05 % T3
102
Drug Status Noteserythromycin ointment 5 mg/gm ophthalmic 5 mg/gm
T1
eye allergy relief ophthalmic solution 0.025-0.3 % T1
FLAREX SUSPENSION 0.1 % OPHTHALMIC 0.1 % T3
FLUCAINE SOLUTION 0.25-0.5 % OPHTHALMIC 0.25-0.5 % T1
fluorometholone suspension 0.1 % ophthalmic 0.1 %
T1
flurbiprofen sodium solution 0.03 % ophthalmic0.03 %
T1
FML OINTMENT 0.1 % OPHTHALMIC 0.1 % T2
gatifloxacin solution 0.5 % ophthalmic 0.5 % T3
GENTAK OPHTHALMIC OINTMENT 0.3 % T1
gentamicin sulfate solution 0.3 % ophthalmic 0.3 %
T1
HOMATROPAIRE OPHTHALMIC SOLUTION 5 % T1
IOPIDINE SOLUTION 1 % OPHTHALMIC1 % T3
ketorolac tromethamine solution 0.4 % ophthalmic 0.4 %
T1
ketorolac tromethamine solution 0.5 % ophthalmic 0.5 %
T1
LACRISERT INSERT 5 MG OPHTHALMIC5 MG T3 PA
LASTACAFT SOLUTION 0.25 % OPHTHALMIC 0.25 % T3 PA
latanoprost solution 0.005 % ophthalmic 0.005 % T1 QL (5 ML per 30 days)
levobunolol hcl solution 0.5 % ophthalmic 0.5 % T1
levofloxacin ophthalmic solution 0.5 % T1
LOTEMAX OINTMENT 0.5 % OPHTHALMIC 0.5 % T3
LOTEMAX SUSPENSION 0.5 % OPHTHALMIC 0.5 % T3
LUMIGAN SOLUTION 0.01 % OPHTHALMIC 0.01 % T3 ST; QL (7.5 ML per 30 days)
moxifloxacin hcl (2x day) ophthalmic solution 0.5 %
T3
moxifloxacin hcl solution 0.5 % ophthalmic 0.5 % T3
103
Drug Status NotesNATACYN SUSPENSION 5 % OPHTHALMIC 5 % T3 PA
neomycin-bacitracin zn-polymyx ointment 5-400-10000 ophthalmic 5-400-10000
T1
neomycin-polymyxin-dexameth ointment 3.5-10000-0.1 ophthalmic 3.5-10000-0.1
T1
neomycin-polymyxin-dexameth suspension 3.5-10000-0.1 ophthalmic 3.5-10000-0.1
T1
neomycin-polymyxin-gramicidin solution 1.75-10000-.025 ophthalmic 1.75-10000-.025
T1
neomycin-polymyxin-hc suspension 3.5-10000-1 ophthalmic 3.5-10000-1
T1
NEVANAC SUSPENSION 0.1 % OPHTHALMIC 0.1 % T3
ofloxacin solution 0.3 % ophthalmic 0.3 % T1
olopatadine hcl solution 0.1 % ophthalmic (rx)0.1 %
T1
olopatadine hcl solution 0.2 % ophthalmic (rx)0.2 %
T3 PA
PHOSPHOLINE IODIDE SOLUTION RECONSTITUTED 0.125 % OPHTHALMIC0.125 %
T2 PA
pilocarpine hcl solution 1 % ophthalmic 1 % T1
pilocarpine hcl solution 2 % ophthalmic 2 % T1
pilocarpine hcl solution 4 % ophthalmic 4 % T1
polymyxin b-trimethoprim solution 10000-0.1 unit/ml-% ophthalmic 10000-0.1 unit/ml-%
T1
PRED MILD SUSPENSION 0.12 % OPHTHALMIC 0.12 % T2
prednisolone acetate ophthalmic suspension 1 % T1
prednisolone sodium phosphate solution 1 % ophthalmic 1 %
T1
proparacaine hcl solution 0.5 % ophthalmic 0.5 %
T1
SIMBRINZA SUSPENSION 1-0.2 % OPHTHALMIC 1-0.2 % T3 QL (8 ML per 30 days)
sodium chloride (hypertonic) ophthalmic solution5 %
T1
sulfacetamide sodium solution 10 % ophthalmic10 %
T1
sulfacetamide-prednisolone solution 10-0.23 % ophthalmic 10-0.23 %
T1
104
Drug Status Notestimolol maleate gel forming solution 0.25 % ophthalmic 0.25 %
T3
timolol maleate gel forming solution 0.5 % ophthalmic 0.5 %
T3
timolol maleate solution 0.25 % ophthalmic 0.25 %
T1
timolol maleate solution 0.5 % ophthalmic 0.5 % T1
TOBRADEX OINTMENT 0.3-0.1 % OPHTHALMIC 0.3-0.1 % T3 QL (3.5 GM per 30 days)
TOBRADEX ST SUSPENSION 0.3-0.05 % OPHTHALMIC 0.3-0.05 % T2 QL (5 ML per 30 days)
tobramycin solution 0.3 % ophthalmic 0.3 % T1
tobramycin-dexamethasone suspension 0.3-0.1 % ophthalmic 0.3-0.1 %
T1 QL (5 ML per 30 days)
TOBREX OINTMENT 0.3 % OPHTHALMIC0.3 % T2
travoprost (bak free) ophthalmic solution 0.004 % T3 ST; QL (5 ML per 30 days)
trifluridine solution 1 % ophthalmic 1 % T3
tropicamide solution 0.5 % ophthalmic 0.5 % T1
tropicamide solution 1 % ophthalmic 1 % T1
ZIOPTAN SOLUTION 0.0015 % OPHTHALMIC 0.0015 % T3 ST; QL (30 EA per 30 days)
ZIRGAN GEL 0.15 % OPHTHALMIC 0.15 % T3
*Otic Agents*ACETASOL HC SOLUTION 2-1 % OTIC 2-1 % T3
acetic acid solution 2 % otic 2 % T1
CIPRO HC SUSPENSION 0.2-1 % OTIC 0.2-1 % T3 PA
ciprofloxacin-dexamethasone otic suspension 0.3-0.1 %
T3
fluocinolone acetonide oil 0.01 % otic 0.01 % T3
neomycin-polymyxin-hc solution 3.5-10000-1 otic3.5-10000-1
T1
neomycin-polymyxin-hc suspension 3.5-10000-1 otic 3.5-10000-1
T1
ofloxacin solution 0.3 % otic 0.3 % T1
*Oxytocics*methylergonovine maleate oral tablet 0.2 mg T2
105
Drug Status Notes
*Passive Immunizing And Treatment Agents*HYPERRHO S/D SOLUTION PREFILLED SYRINGE 1500 UNIT INTRAMUSCULAR1500 UNIT
T2 GR-F
HYQVIA KIT 2.5 GM/25ML SUBCUTANEOUS 2.5 GM/25ML T4 PA
HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML
T4 PA
SYNAGIS SOLUTION 100 MG/ML INTRAMUSCULAR 100 MG/ML T4 PA
SYNAGIS SOLUTION 50 MG/0.5ML INTRAMUSCULAR 50 MG/0.5ML T4 PA
*Penicillins*amoxicillin capsule 250 mg oral 250 mg T1
amoxicillin capsule 500 mg oral 500 mg T1
amoxicillin suspension reconstituted 125 mg/5ml oral 125 mg/5ml
T1
amoxicillin suspension reconstituted 200 mg/5ml oral 200 mg/5ml
T1
amoxicillin suspension reconstituted 250 mg/5ml oral 250 mg/5ml
T1
amoxicillin suspension reconstituted 400 mg/5ml oral 400 mg/5ml
T1
amoxicillin tablet 500 mg oral 500 mg T1
amoxicillin tablet 875 mg oral 875 mg T1
amoxicillin tablet chewable 125 mg oral 125 mg T1
amoxicillin tablet chewable 250 mg oral 250 mg T1
amoxicillin-pot clavulanate er tablet extended release 12 hour 1000-62.5 mg oral 1000-62.5 mg
T3
amoxicillin-pot clavulanate suspension reconstituted 200-28.5 mg/5ml oral 200-28.5 mg/5ml
T1
amoxicillin-pot clavulanate suspension reconstituted 400-57 mg/5ml oral 400-57 mg/5ml
T1
amoxicillin-pot clavulanate suspension reconstituted 600-42.9 mg/5ml oral 600-42.9 mg/5ml
T1
amoxicillin-pot clavulanate tablet 250-125 mg oral 250-125 mg
T1 QL (28 EA per 14 days)
amoxicillin-pot clavulanate tablet 500-125 mg oral 500-125 mg
T1 QL (28 EA per 14 days)
106
Drug Status Notesamoxicillin-pot clavulanate tablet 875-125 mg oral 875-125 mg
T1 QL (28 EA per 14 days)
amoxicillin-pot clavulanate tablet chewable 200-28.5 mg oral 200-28.5 mg
T1
amoxicillin-pot clavulanate tablet chewable 400-57 mg oral 400-57 mg
T1
ampicillin capsule 500 mg oral 500 mg T1
BICILLIN L-A SUSPENSION 1200000 UNIT/2ML INTRAMUSCULAR 1200000 UNIT/2ML
T4 PA
BICILLIN L-A SUSPENSION 600000 UNIT/ML INTRAMUSCULAR 600000 UNIT/ML
T4 PA
dicloxacillin sodium capsule 250 mg oral 250 mg T1
dicloxacillin sodium capsule 500 mg oral 500 mg T1
penicillin v potassium solution reconstituted 125 mg/5ml oral 125 mg/5ml
T1
penicillin v potassium solution reconstituted 250 mg/5ml oral 250 mg/5ml
T1
penicillin v potassium tablet 250 mg oral 250 mg T1
penicillin v potassium tablet 500 mg oral 500 mg T1
*Pharmaceutical Adjuvants*cherry oral syrup T1
flavor sweet oral syrup T1
ORA-BLEND ORAL SUSPENSION T1
ORA-PLUS ORAL LIQUID T1
ORA-SWEET ORAL SYRUP T1
simple syrup oral syrup T1
*Progestins*hydroxyprogesterone caproate intramuscular oil250 mg/ml
T4 PA; GR-F
medroxyprogesterone acetate tablet 10 mg oral10 mg
T1
medroxyprogesterone acetate tablet 2.5 mg oral2.5 mg
T1
medroxyprogesterone acetate tablet 5 mg oral 5 mg
T1
norethindrone acetate tablet 5 mg oral 5 mg T1
progesterone micronized oral capsule 100 mg, 200 mg
T2 GR-F
107
Drug Status Notes
*Psychotherapeutic And Neurological Agents - Misc.*acamprosate calcium oral tablet delayed release333 mg
T1
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG T4 PA
AUBAGIO TABLET 14 MG ORAL 14 MG T4 PA
AUBAGIO TABLET 7 MG ORAL 7 MG T4 PA
AVONEX PEN AUTO-INJECTOR KIT 30 MCG/0.5ML INTRAMUSCULAR 30 MCG/0.5ML
T4 PA
AVONEX PREFILLED PREFILLED SYRINGE KIT 30 MCG/0.5ML INTRAMUSCULAR 30 MCG/0.5ML
T4 PA
bupropion hcl er (smoking det) tablet extended release 12 hour 150 mg oral 150 mg
T5
CHANTIX ORAL TABLET 0.5 MG, 1 MG T5 QL (60 EA per 30 days)
CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 T5 QL (60 EA per 30 days)
chlordiazepoxide-amitriptyline tablet 10-25 mg oral 10-25 mg
T1
chlordiazepoxide-amitriptyline tablet 5-12.5 mg oral 5-12.5 mg
T1
dalfampridine er oral tablet extended release 12 hour 10 mg
T4 PA
dimethyl fumarate oral capsule delayed release120 mg, 240 mg
T4 PA
disulfiram tablet 250 mg oral 250 mg T1
disulfiram tablet 500 mg oral 500 mg T1
donepezil hcl tablet 10 mg oral 10 mg T1
donepezil hcl tablet 23 mg oral 23 mg T3
donepezil hcl tablet 5 mg oral 5 mg T1
donepezil hcl tablet dispersible 10 mg oral 10 mg T1
donepezil hcl tablet dispersible 5 mg oral 5 mg T1
ergoloid mesylates tablet 1 mg oral 1 mg T3 PA
galantamine hydrobromide er capsule extended release 24 hour 16 mg oral 16 mg
T3
galantamine hydrobromide er capsule extended release 24 hour 24 mg oral 24 mg
T3
galantamine hydrobromide er capsule extended release 24 hour 8 mg oral 8 mg
T3
108
Drug Status Notesgalantamine hydrobromide tablet 12 mg oral 12 mg
T1
galantamine hydrobromide tablet 4 mg oral 4 mg T1
galantamine hydrobromide tablet 8 mg oral 8 mg T1
GILENYA CAPSULE 0.5 MG ORAL 0.5 MG T4 PA
glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml
T4 PA
GLATOPA SOLUTION PREFILLED SYRINGE 20 MG/ML SUBCUTANEOUS 20 MG/ML
T4 PA
MAYZENT ORAL TABLET 0.25 MG, 2 MG T4 PA
memantine hcl solution 2 mg/ml oral 2 mg/ml T3 PA
memantine hcl tablet 10 mg oral 10 mg T1 QL (60 EA per 30 days)
memantine hcl tablet 28 x 5 mg & 21 x 10 mg oral28 x 5 mg & 21 x 10 mg
T1 QL (49 EA per 365 days)
memantine hcl tablet 5 mg oral 5 mg T1 QL (60 EA per 30 days)
NICORETTE MOUTH/THROAT LOZENGE4 MG T5 QL (270 EA per 30 days)
nicotine mini mouth/throat lozenge 2 mg T5 QL (270 EA per 30 days)
nicotine polacrilex mouth/throat gum 2 mg, 4 mg T5 QL (810 EA per 365 days)
nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, 7 mg/24hr
T5 QL (90 EA per 365 days)
NICOTROL INHALATION INHALER 10 MG T5 QL (168 EA per 30 days)
NUEDEXTA CAPSULE 20-10 MG ORAL 20-10 MG T4 PA
olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg
T3 PA
perphenazine-amitriptyline tablet 2-10 mg oral 2-10 mg
T1
perphenazine-amitriptyline tablet 2-25 mg oral 2-25 mg
T1
perphenazine-amitriptyline tablet 4-10 mg oral 4-10 mg
T1
perphenazine-amitriptyline tablet 4-25 mg oral 4-25 mg
T1
perphenazine-amitriptyline tablet 4-50 mg oral 4-50 mg
T1
pimozide tablet 1 mg oral 1 mg T3 PA
pimozide tablet 2 mg oral 2 mg T3 PA
rivastigmine patch 24 hour 13.3 mg/24hr transdermal 13.3 mg/24hr
T3 PA
109
Drug Status Notesrivastigmine patch 24 hour 4.6 mg/24hr transdermal 4.6 mg/24hr
T3 PA
rivastigmine patch 24 hour 9.5 mg/24hr transdermal 9.5 mg/24hr
T3 PA
rivastigmine tartrate capsule 1.5 mg oral 1.5 mg T3
rivastigmine tartrate capsule 3 mg oral 3 mg T3
rivastigmine tartrate capsule 4.5 mg oral 4.5 mg T3
rivastigmine tartrate capsule 6 mg oral 6 mg T3
SAVELLA TABLET 100 MG ORAL 100 MG T3 PA
SAVELLA TABLET 12.5 MG ORAL 12.5 MG T3 PA
SAVELLA TABLET 25 MG ORAL 25 MG T3 PA
SAVELLA TABLET 50 MG ORAL 50 MG T3 PA
tetrabenazine tablet 12.5 mg oral 12.5 mg T4 PA
tetrabenazine tablet 25 mg oral 25 mg T4 PA
XYREM SOLUTION 500 MG/ML ORAL 500 MG/ML T4 PA
*Respiratory Agents - Misc.*ESBRIET CAPSULE 267 MG ORAL 267 MG T4 PA
KALYDECO TABLET 150 MG ORAL 150 MG T4 PA
OFEV CAPSULE 100 MG ORAL 100 MG T4 PA
OFEV CAPSULE 150 MG ORAL 150 MG T4 PA
PULMOZYME SOLUTION 1 MG/ML INHALATION 1 MG/ML T4 PA; QL (60 ML per 30 days)
*Sulfonamides*sulfadiazine tablet 500 mg oral 500 mg T3
*Tetracyclines*demeclocycline hcl tablet 150 mg oral 150 mg T3
demeclocycline hcl tablet 300 mg oral 300 mg T3
doxycycline hyclate capsule 100 mg oral 100 mg T1
doxycycline hyclate capsule 50 mg oral 50 mg T1
doxycycline hyclate tablet 100 mg oral 100 mg T1
doxycycline hyclate tablet 20 mg oral 20 mg T1
doxycycline monohydrate capsule 150 mg oral150 mg
T3
doxycycline monohydrate oral capsule 75 mg T3 PA
doxycycline monohydrate suspension reconstituted 25 mg/5ml oral 25 mg/5ml
T1
doxycycline monohydrate tablet 100 mg oral 100 mg
T1
110
Drug Status Notesdoxycycline monohydrate tablet 150 mg oral 150 mg
T3
doxycycline monohydrate tablet 50 mg oral 50 mg T1
doxycycline monohydrate tablet 75 mg oral 75 mg T1
minocycline hcl capsule 100 mg oral 100 mg T1
minocycline hcl capsule 50 mg oral 50 mg T1
minocycline hcl capsule 75 mg oral 75 mg T1
tetracycline hcl capsule 250 mg oral 250 mg T3
tetracycline hcl capsule 500 mg oral 500 mg T3
*Thyroid Agents*ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, 300 MG, 90 MG T1
levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
T1
liothyronine sodium tablet 25 mcg oral 25 mcg T1
liothyronine sodium tablet 5 mcg oral 5 mcg T1
liothyronine sodium tablet 50 mcg oral 50 mcg T1
methimazole tablet 10 mg oral 10 mg T1
methimazole tablet 5 mg oral 5 mg T1
NATURE-THROID ORAL TABLET 113.75 MG, 146.25 MG, 16.25 MG, 162.5 MG, 260 MG, 325 MG, 48.75 MG, 81.25 MG, 97.5 MG
T1
NATURE-THROID TABLET 130 MG ORAL130 MG T1
NATURE-THROID TABLET 195 MG ORAL195 MG T1
NATURE-THROID TABLET 32.5 MG ORAL32.5 MG T1
np thyroid oral tablet 120 mg, 15 mg, 30 mg T1
propylthiouracil tablet 50 mg oral 50 mg T1
SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG
T2
WESTHROID TABLET 65 MG ORAL 65 MG T1
*Ulcer Drugs/Antispasmodics/Anticholinergics*belladonna alkaloids-opium suppository 16.2-30 mg rectal 16.2-30 mg
T3QL (12 EA per 30 days); AL (Max 64 Years)
111
Drug Status Notesbelladonna alkaloids-opium suppository 16.2-60 mg rectal 16.2-60 mg
T3QL (12 EA per 30 days); AL (Max 64 Years)
CARAFATE ORAL SUSPENSION 1 GM/10ML T3
cimetidine hcl solution 300 mg/5ml oral 300 mg/5ml
T1
cimetidine oral tablet 200 mg T1
cimetidine tablet 300 mg oral 300 mg T1
cimetidine tablet 400 mg oral 400 mg T1
cimetidine tablet 800 mg oral 800 mg T1
dicyclomine hcl capsule 10 mg oral 10 mg T1 AL (Max 64 Years)
dicyclomine hcl solution 10 mg/5ml oral 10 mg/5ml
T1 AL (Max 64 Years)
dicyclomine hcl tablet 20 mg oral 20 mg T1 AL (Max 64 Years)
famotidine oral tablet 20 mg T1
famotidine suspension reconstituted 40 mg/5ml oral 40 mg/5ml
T1 AL (Max 12 Years)
famotidine tablet 40 mg oral 40 mg T1
FIRST-LANSOPRAZOLE SUSPENSION 3 MG/ML ORAL 3 MG/ML T1 QL (150 ML per 30 days)
glycopyrrolate tablet 1 mg oral 1 mg T1
glycopyrrolate tablet 2 mg oral 2 mg T1
hyoscyamine sulfate sl tablet sublingual 0.125 mg sublingual 0.125 mg
T1 AL (Max 64 Years)
hyoscyamine sulfate tablet 0.125 mg oral 0.125 mg
T1 AL (Max 64 Years)
hyoscyamine sulfate tablet dispersible 0.125 mg oral 0.125 mg
T1 AL (Max 64 Years)
hyosyne elixir 0.125 mg/5ml oral 0.125 mg/5ml T1 AL (Max 64 Years)
hyosyne solution 0.125 mg/ml oral 0.125 mg/ml T1 AL (Max 64 Years)
lansoprazole capsule delayed release 30 mg oral30 mg
T2 QL (30 EA per 30 days)
lansoprazole oral capsule delayed release 15 mg T1 QL (60 EA per 30 days)
methscopolamine bromide oral tablet 2.5 mg, 5 mg
T3 AL (Max 64 Years)
misoprostol tablet 100 mcg oral 100 mcg T1
misoprostol tablet 200 mcg oral 200 mcg T1
nizatidine capsule 150 mg oral 150 mg T1
nizatidine capsule 300 mg oral 300 mg T1
nizatidine solution 15 mg/ml oral 15 mg/ml T1
112
Drug Status Notesomeprazole capsule delayed release 10 mg oral10 mg
T1 QL (60 EA per 30 days)
omeprazole capsule delayed release 20 mg oral (rx) 20 mg
T1 QL (60 EA per 30 days)
omeprazole capsule delayed release 40 mg oral40 mg
T1 QL (60 EA per 30 days)
pantoprazole sodium tablet delayed release 20 mg oral 20 mg
T1 QL (60 EA per 30 days)
pantoprazole sodium tablet delayed release 40 mg oral 40 mg
T1 QL (60 EA per 30 days)
propantheline bromide tablet 15 mg oral 15 mg T1
rabeprazole sodium tablet delayed release 20 mg oral 20 mg
T1 QL (30 EA per 30 days)
sucralfate tablet 1 gm oral 1 gm T1
SYMAX DUOTAB TABLET EXTENDED RELEASE 0.375 MG ORAL 0.375 MG T1 AL (Max 64 Years)
SYMAX-SR TABLET EXTENDED RELEASE 12 HOUR 0.375 MG ORAL 0.375 MG
T1 AL (Max 64 Years)
*Urinary Anti-Infectives*urin ds oral tablet T1
*Urinary Antispasmodics*bethanechol chloride tablet 10 mg oral 10 mg T1
bethanechol chloride tablet 25 mg oral 25 mg T1
bethanechol chloride tablet 5 mg oral 5 mg T1
bethanechol chloride tablet 50 mg oral 50 mg T1
darifenacin hydrobromide er tablet extended release 24 hour 15 mg oral 15 mg
T2 ST
darifenacin hydrobromide er tablet extended release 24 hour 7.5 mg oral 7.5 mg
T2 ST
flavoxate hcl tablet 100 mg oral 100 mg T1
oxybutynin chloride er oral tablet extended release 24 hour 5 mg
T1
oxybutynin chloride er tablet extended release 24 hour 10 mg oral 10 mg
T1
oxybutynin chloride er tablet extended release 24 hour 15 mg oral 15 mg
T1
oxybutynin chloride oral syrup 5 mg/5ml T1
oxybutynin chloride tablet 5 mg oral 5 mg T1
OXYTROL FOR WOMEN PATCH TWICE WEEKLY 3.9 MG/24HR TRANSDERMAL3.9 MG/24HR
T1
113
Drug Status Notessolifenacin succinate oral tablet 10 mg, 5 mg T3 ST
tolterodine tartrate er capsule extended release 24 hour 2 mg oral 2 mg
T2 ST
tolterodine tartrate er capsule extended release 24 hour 4 mg oral 4 mg
T2 ST
tolterodine tartrate tablet 1 mg oral 1 mg T1 ST
tolterodine tartrate tablet 2 mg oral 2 mg T1 ST
TOVIAZ TABLET EXTENDED RELEASE 24 HOUR 4 MG ORAL 4 MG T2 ST
TOVIAZ TABLET EXTENDED RELEASE 24 HOUR 8 MG ORAL 8 MG T2 ST
trospium chloride er capsule extended release 24 hour 60 mg oral 60 mg
T1 ST
trospium chloride tablet 20 mg oral 20 mg T1 ST
VESICARE TABLET 10 MG ORAL 10 MG T3 ST
VESICARE TABLET 5 MG ORAL 5 MG T3 ST
*Vaccines*AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION T5
QL (0.5 ML per 365 days); AL (Min 6 Months)
AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML
T5QL (0.25 ML per 365 days); AL (Min 6 Months and Max 35 Months)
AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML
T5QL (0.5 ML per 365 days); AL (Min 3 Years)
FLUAD INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML T5
QL (0.5 ML per 365 days); AL (Min 65 Years)
FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE0.5 ML
T5QL (0.5 ML per 365 days); AL (Min 65 Years)
FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML
T5QL (0.5 ML per 365 days); AL (Min 6 Months)
FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION T5
QL (0.5 ML per 365 days); AL (Min 6 Months)
FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 0.5 ML T5
QL (0.5 ML per 365 days); AL (Min 3 Years)
FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML
T5QL (0.5 ML per 365 days); AL (Min 3 Years)
SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML
T5QL (2 EA per 1 lifetime); AL (Min 50 Years)
114
Drug Status Notes
*Vaginal And Related Products*CLEOCIN SUPPOSITORY 100 MG VAGINAL 100 MG T3
clindamycin phosphate cream 2 % vaginal 2 % T1
clotrimazole vaginal cream 1 % T1 QL (50 GM per 30 days)
CRINONE GEL 4 % VAGINAL 4 % T4 PA
CRINONE GEL 8 % VAGINAL 8 % T4 PA
ENDOMETRIN INSERT 100 MG VAGINAL100 MG T3 PA
estradiol tablet 10 mcg vaginal 10 mcg T3 GR-F
estradiol vaginal cream 0.1 mg/gm T2
ESTRING RING 2 MG VAGINAL 2 MG T3
FIRST-PROGESTERONE VGS SUPPOSITORY 100 MG VAGINAL 100 MG T2 GR-F; QL (30 EA per 30 days)
FIRST-PROGESTERONE VGS SUPPOSITORY 200 MG VAGINAL 200 MG T2 GR-F; QL (30 EA per 30 days)
GYNAZOLE-1 CREAM 2 % VAGINAL 2 % T3
metronidazole vaginal gel 0.75 % T1
miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm)
T1
miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm)
T1
terconazole cream 0.4 % vaginal 0.4 % T1
terconazole vaginal cream 0.8 % T1
terconazole vaginal suppository 80 mg T1
*Vasopressors*ADRENALIN SOLUTION 1 MG/ML INJECTION 1 MG/ML T1 QL (2 ML per 90 days)
epinephrine solution auto-injector 0.15 mg/0.15ml injection 0.15 mg/0.15ml
T1 QL (2 EA per 30 days)
epinephrine solution auto-injector 0.15 mg/0.3ml injection 0.15 mg/0.3ml
T1 QL (2 EA per 30 days)
epinephrine solution auto-injector 0.3 mg/0.3ml injection 0.3 mg/0.3ml
T1 QL (2 EA per 30 days)
midodrine hcl tablet 10 mg oral 10 mg T1
midodrine hcl tablet 2.5 mg oral 2.5 mg T1
midodrine hcl tablet 5 mg oral 5 mg T1
SYMJEPI SOLUTION PREFILLED SYRINGE 0.15 MG/0.3ML INJECTION 0.15 MG/0.3ML
T1 QL (2 EA per 30 days)
115
Drug Status Notes
*Vitamins*ascorbic acid solution 500 mg/ml injection 500 mg/ml
T1
niacin oral tablet 500 mg T1
phytonadione oral tablet 5 mg T2 PA
pyridoxine hcl solution 100 mg/ml injection 100 mg/ml
T3
REPLESTA CHILDRENS WAFER 350 MCG (14000 UT) ORAL 350 MCG (14000 UT) T5
THERA-D 4000 TABLET 100 MCG (4000 UT) ORAL 100 MCG (4000 UT) T5
vitamin d (cholecalciferol) oral capsule 25 mcg (1000 ut)
T5 QL (60 EA per 30 days)
vitamin d (ergocalciferol) capsule 1.25 mg (50000 ut) oral 1.25 mg (50000 ut)
T1
vitamin d oral capsule 50 mcg (2000 ut) T5 QL (60 EA per 30 days)
vitamin d3 capsule 250 mcg (10000 ut) oral 250 mcg (10000 ut)
T5 QL (60 EA per 30 days)
vitamin d3 oral capsule 1.25 mg (50000 ut) T2 QL (4 EA per 28 days)
vitamin d3 oral capsule 10 mcg (400 unit), 125 mcg (5000 ut)
T5 QL (60 EA per 30 days)
vitamin d3 tablet 10 mcg (400 unit) oral 10 mcg (400 unit)
T5
vitamin d3 tablet 125 mcg (5000 ut) oral 125 mcg (5000 ut)
T5
vitamin d3 tablet 25 mcg (1000 ut) oral 25 mcg (1000 ut)
T5
vitamin d3 tablet 50 mcg (2000 ut) oral 50 mcg (2000 ut)
T5
vitamin d3 tablet chewable 25 mcg (1000 ut) oral25 mcg (1000 ut)
T5
116
Indexabacavir sulfate .......................... 57abacavir sulfate-lamivudine ....... 57abacavir-lamivudine-zidovudine 57ABILIFY MAINTENA ............ 53abiraterone acetate .....................47acamprosate calcium ................ 108acarbose ......................................29acebutolol hcl ..............................61acetaminophen-codeine ................ 6acetaminophen-codeine #2 ........... 6acetaminophen-codeine #3 ........... 6acetaminophen-codeine #4 ........... 6ACETASOL HC ..................... 105acetazolamide ............................. 80acetazolamide er .........................80acetic acid ...........................88, 105acetylcysteine ........................ 34, 71acitretin .......................................71acne treatment .............................71ACTIMMUNE .......................... 47ACUVAIL ................................101acyclovir ................................57, 71adapalene ....................................71adapalene-benzoyl peroxide ....... 71ADCIRCA ..................................65adefovir dipivoxil ........................ 57ADEMPAS .................................65ADRENALIN .......................... 115ADVAIR HFA ...........................15AFEDITAB CR .........................63AFINITOR ................................ 47AFLURIA QUADRIVALENT...................................................114AKYNZEO ................................ 35albendazole ................................. 12albuterol sulfate .......................... 15albuterol sulfate er ......................15alclometasone dipropionate ........71alendronate sodium .................... 81alfuzosin hcl er ............................88ALINIA ......................................45aliskiren fumarate .......................39allergy spray 24 hour ................100allopurinol .................................. 89almotriptan malate ......................96ALOCRIL ................................101alogliptin benzoate ......................29alogliptin-metformin hcl ............. 29alogliptin-pioglitazone ................29ALOMIDE ...............................101alosetron hcl ............................... 87
ALPHAGAN P ........................ 101alprazolam .................................. 13alprazolam er ..............................13alprazolam xr ..............................13alprostadil ...................................97ALTABAX .................................71ALTACAINE .......................... 101amantadine hcl ............................51ambrisentan ................................ 65amcinonide ..................................72amiloride hcl ...............................80amiloride-hydrochlorothiazide ... 80aminoacetic acid .........................88aminocaproic acid ...................... 92amiodarone hcl ........................... 14AMITIZA .................................. 87amitriptyline hcl ..........................25amlodipine besy-benazepril hcl .. 39amlodipine besylate .................... 63amlodipine besylate-valsartan ....39amlodipine-olmesartan ......... 39, 40ammonium lactate .......................72amoxapine ...................................25amoxicillin ................................ 106amoxicillin-pot clavulanate...........................................106, 107amoxicillin-pot clavulanate er ..106amphetamine-dextroamphet er ..... 1amphetamine-dextroamphetamine .......................1ampicillin .................................. 107AMPYRA .................................108ANADROL-50 ...........................10anagrelide hcl ............................. 89ANALPRAM-HC ......................11anastrozole ..................................47ANDRODERM ....................10, 11ANECREAM .............................72ANORO ELLIPTA ...................16ANZEMET ................................ 35apraclonidine hcl ...................... 101aprepitant ....................................35APRISO ..................................... 87APTIOM ....................................21APTIVUS ...................................58ARANELLE .............................. 67ARANESP (ALBUMIN FREE) .................................. 90, 91ARCALYST ................................ 3ARCAPTA NEOHALER .........16ARGYLE STERILE SALINE . 88
aripiprazole ...........................53, 54armodafinil ................................... 1ARMOUR THYROID ............111ARNUITY ELLIPTA ............... 16ascorbic acid .............................116ASMANEX (120 METERED DOSES) ......................................16ASMANEX (7 METERED DOSES) ......................................16ASMANEX HFA .......................16ASPERCREME LIDOCAINE 72ASPERCREME W/LIDOCAINE ........................ 72aspirin ........................................... 6aspirin 81 ...................................... 5aspirin ec ...................................... 6aspirin ec low dose ....................... 6aspirin-dipyridamole er .............. 89atazanavir sulfate ........................58atenolol ....................................... 61atenolol-chlorthalidone .............. 40atomoxetine hcl .............................1atorvastatin calcium ................... 37atovaquone ..................................45atovaquone-proguanil hcl ...........46atropine sulfate ......................... 101ATROVENT HFA .................... 16AUBAGIO ............................... 108AVANDIA ..................................29AVITA ....................................... 72AVONEX PEN ........................ 108AVONEX PREFILLED ......... 108AZASAN ....................................97AZASITE .................................101azathioprine ................................ 98azelastine hcl .................... 100, 101azithromycin ............................... 94AZOPT .....................................101b-6 folic acid ............................... 91BAC ..............................................6bacitracin ..................................101bacitracin-polymyxin b ............. 101bacitra-neomycin-polymyxin-hc102baclofen .......................................99balanced salt .............................102BALCOLTRA ........................... 67balsalazide disodium .................. 87BALZIVA .................................. 67BARACLUDE ........................... 58BASIS OVERNIGHT ...............72BD INSULIN SYRINGE ..........95
117
BD PEN NEEDLE ORIGINAL U/F ........................ 95BD SAFETYGLIDE INSULIN SYRINGE ................ 95BD VEO INSULIN SYRINGE U/F ..............................................95BECONASE AQ ..................... 100belladonna alkaloids-opium...........................................111, 112BELSOMRA ............................. 92benazepril hcl ..............................40benazepril-hydrochlorothiazide ..40BENZEPRO .............................. 72BENZEPRO SHORT CONTACT ................................ 72benzonatate ................................. 71benzoyl peroxide-erythromycin ...72benztropine mesylate ...................51BEPREVE ............................... 102BERINERT ............................... 89BESIVANCE ........................... 102betamethasone dipropionate .......72betamethasone dipropionate aug .............................................. 72betamethasone sod phos & acet ..69betamethasone valerate .............. 72betaxolol hcl ........................61, 102bethanechol chloride .................113BETOPTIC-S .......................... 102bexarotene ...................................47bicalutamide ............................... 47BICILLIN L-A ........................ 107BIKTARVY ...............................58bimatoprost ............................... 102bisoprolol fumarate .................... 61bisoprolol-hydrochlorothiazide .. 40BLEPHAMIDE S.O.P. ........... 102BOSULIF ...................................47BREO ELLIPTA ...................... 16BRILINTA .................................89brimonidine tartrate ..................102BROMFED DM ........................ 71bromfenac sodium (once-daily) 102bromocriptine mesylate .........51, 52BROVANA ................................ 16budesonide ............................ 16, 69bumetanide ..................................80buprenorphine ...............................7buprenorphine hcl .........................6buprenorphine hcl-naloxone hcl ...6bupropion hcl ..............................25bupropion hcl er (smoking det) .108
bupropion hcl er (sr) ...................25bupropion hcl er (xl) ...................25buspirone hcl .............................. 13butalbital-acetaminophen ............. 6butalbital-apap-caff-cod ............... 7butalbital-apap-caffeine ............... 6butalbital-asa-caff-codeine ...........7butalbital-aspirin-caffeine ............ 6butorphanol tartrate ..................... 7BYETTA 10 MCG PEN ........... 29BYETTA 5 MCG PEN ............. 29BYSTOLIC ................................61cabergoline ................................. 81caffeine citrate .............................. 1caffeine-sodium benzoate ..............1calcipotriene ............................... 72calcipotriene-betameth diprop ....73calcitonin (salmon) ..................... 81CALCITRENE ..........................73calcitriol ......................................81calcium acetate (phos binder) .....87CALPHRON ............................. 87candesartan cilexetil ...................40candesartan cilexetil-hctz ........... 40capecitabine ................................47CAPEX .......................................73CAPRELSA ...............................47captopril ......................................40captopril-hydrochlorothiazide...............................................40, 41CARAFATE ............................ 112carbamazepine ............................21carbamazepine er ........................21carbidopa ....................................52carbidopa-levodopa ....................52carbidopa-levodopa er ................52carbinoxamine maleate ...............36CARDURA XL ..........................88carisoprodol ................................99CAROSPIR ............................... 80carteolol hcl .............................. 102CARTIA XT .............................. 63carvedilol .............................. 61, 62carvedilol phosphate er .............. 61cefaclor ....................................... 66cefadroxil .................................... 66cefdinir ........................................66cefditoren pivoxil ........................ 67cefpodoxime proxetil ...................67cefprozil ...................................... 67cefuroxime axetil .........................67celecoxib ....................................... 3
CELONTIN ............................... 21CEM-UREA .............................. 73cephalexin ................................... 67CEPROTIN ............................... 89cetirizine hcl ................................36cevimeline hcl ............................. 99CHANTIX ............................... 108CHANTIX STARTING MONTH PAK ......................... 108CHEMET ...................................34cherry ........................................107chlordiazepoxide hcl ...................13chlordiazepoxide-amitriptyline .108chlorhexidine gluconate ........57, 99chloroquine phosphate ................46chlorothiazide ............................. 80chlorpromazine hcl ..................... 54chlorthalidone .............................80chlorzoxazone ........................... 100chorionic gonadotropin .............. 82ciclopirox .................................... 73cilostazol ..................................... 89CILOXAN ............................... 102cimetidine ..................................112cimetidine hcl ............................112CIPRO ....................................... 87CIPRO HC .............................. 105ciprofloxacin hcl ................. 87, 102ciprofloxacin-dexamethasone ... 105citalopram hydrobromide ........... 25clarithromycin .............................94clarithromycin er ........................ 94CLEOCIN ................................115CLINDACIN PAC .................... 73clindamycin hcl ...........................45clindamycin palmitate hcl ...........45clindamycin phos-benzoyl perox .73clindamycin phosphate ....... 73, 115clobazam ..................................... 22clobetasol propionate ................. 73clobetasol propionate e ...............73CLODERM ............................... 73clomipramine hcl ........................ 25clonazepam ................................. 22clonidine ..................................... 41clonidine hcl ................................41clopidogrel bisulfate ................... 89clorazepate dipotassium ............. 13clotrimazole ........................ 73, 115clotrimazole-betamethasone ....... 73clozapine ..................................... 54coal tar ........................................67
118
COARTEM ............................... 46codeine sulfate .............................. 7colchicine ....................................89colchicine-probenecid .................89colesevelam hcl ........................... 37colestipol hcl ...............................37COLOCORT ............................. 11COMBIGAN ........................... 102COMBIPATCH ........................ 85COMBIVENT RESPIMAT ..... 16COMETRIQ (100 MG DAILY DOSE) .......................... 47COMETRIQ (140 MG DAILY DOSE) .......................... 47COMETRIQ (60 MG DAILY DOSE) ........................................ 47COMFORT EZ PEN NEEDLES ..................................95COMPLERA ............................. 58CONDYLOX ............................. 73CORDRAN ................................73CORLANOR ............................. 65CORTIFOAM ........................... 11cortisone acetate .........................69CORTISPORIN ........................ 74COSENTYX (300 MG DOSE) .74COSENTYX SENSOREADY PEN ............................................ 74CREON ......................................80CRESEMBA ..............................36CRINONE ............................... 115CRIXIVAN ................................58cromolyn sodium .................87, 102CROTAN ................................... 74CUPRIMINE .............................98cvs nasal allergy spray ............. 100cvs sodium chloride .................. 102cyanocobalamin ..........................91cyclobenzaprine hcl .................. 100cyclopentolate hcl ..................... 102cyclophosphamide .......................47cycloserine .................................. 46CYCLOSET .............................. 29cyclosporine ................................98cyclosporine modified .................98cyproheptadine hcl ......................36CYSTADANE ........................... 82CYSTARAN ............................ 102CYTRA-3 ...................................88dalfampridine er ....................... 108DALIRESP ................................ 16dantrolene sodium .................... 100
dapsone ....................................... 45DARAPRIM .............................. 46darifenacin hydrobromide er ....113DAYTRANA ................................1DDAVP RHINAL TUBE ......... 82deferasirox .................................. 34deferiprone ..................................34deferoxamine mesylate ................34demeclocycline hcl ....................110DENAVIR ..................................74DEPO-MEDROL ......................69DEPO-PROVERA .................... 47DEPO-SUBQ PROVERA 104 . 67DESCOVY .................................58desipramine hcl .....................25, 26desmopressin ace spray refrig .... 82desmopressin acetate .................. 82desmopressin acetate spray ........ 82desogestrel-ethinyl estradiol .......67desonide ...................................... 74desoximetasone ........................... 74desvenlafaxine er ........................ 26desvenlafaxine succinate er ........ 26dexamethasone ............................70DEXAMETHASONE INTENSOL ................................70dexamethasone sodium phosphate ............................70, 102dexmethylphenidate hcl .................2dexmethylphenidate hcl er ............ 1dextroamphetamine sulfate ...........2dextroamphetamine sulfate er .......2diazepam ............................... 13, 14diclofenac potassium .................... 3diclofenac sodium ........... 3, 74, 102diclofenac sodium er .....................3diclofenac-misoprostol ............. 3, 4dicloxacillin sodium ..................107dicyclomine hcl ......................... 112didanosine ...................................58diethylpropion hcl .........................2diethylpropion hcl er .....................2DIFFERIN ................................. 74DIFICID .....................................94diflorasone diacetate .................. 74diflunisal ....................................... 6digoxin ........................................ 65DILANTIN ................................ 22DILATRATE-SR ...................... 12diltiazem hcl ................................63diltiazem hcl er ........................... 63diltiazem hcl er beads ................. 63
dilt-xr .......................................... 63dimenhydrinate ........................... 35dimethyl fumarate ..................... 108DIPENTUM ...............................87diphenhydramine hcl ...................36diphenoxylate-atropine ............... 34dipyridamole ............................... 90disopyramide phosphate ............. 14disulfiram ..................................108divalproex sodium .......................22divalproex sodium er .................. 22docosanol ....................................74dofetilide ..................................... 14donepezil hcl ............................. 108DOPRAM .................................... 2dorzolamide hcl ........................ 102dorzolamide hcl-timolol mal .....102doxazosin mesylate ..................... 41doxepin hcl ..................................26doxercalciferol ............................82doxycycline hyclate ................... 110doxycycline monohydrate . 110, 111DRITHO-CREME HP ............. 74dronabinol ...................................35droperidol ................................... 14drospiren-eth estrad-levomefol ...68drospirenone-ethinyl estradiol ....68DROXIA .................................... 91DUAVEE ................................... 85DULERA ................................... 17duloxetine hcl ..............................26DUPIXENT ............................... 74DUREZOL ...............................102econazole nitrate .........................74EDARBI .....................................41EDURANT .................................58efavirenz ......................................58efavirenz-emtricitab-tenofovir .... 58efavirenz-lamivudine-tenofovir ...58EFFER-K .............................96, 97eletriptan hydrobromide ............. 96ELIGARD ............................47, 48ELIQUIS ....................................19ELIQUIS DVT/PE STARTER PACK ..................... 19ELIXOPHYLLIN ..................... 17ELLA ......................................... 68ELMIRON .................................88EMBEDA .....................................7EMCYT ..................................... 48EMSAM ..................................... 26emtricitabine ............................... 58
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emtricitabine-tenofovir df ........... 58EMTRIVA ................................. 58enalapril maleate ........................ 41enalapril-hydrochlorothiazide ....41ENBREL ......................................4ENBREL SURECLICK ............. 4ENDOCET ...................................7ENDOMETRIN ...................... 115enoxaparin sodium ................19, 20entacapone ..................................52epinastine hcl ............................ 102epinephrine ............................... 115EPIVIR HBV .............................58eplerenone ...................................41EPOGEN ................................... 91eq nasal allergy .........................100ergoloid mesylates .................... 108ergotamine-caffeine .................... 96ERIVEDGE ............................... 48ERTACZO .................................74ERYTHROCIN STEARATE .. 94erythromycin ....................... 74, 103erythromycin base .......................94erythromycin ethylsuccinate ....... 95ESBRIET ................................. 110escitalopram oxalate ...................26estazolam .................................... 92estradiol ........................ 85, 86, 115estradiol valerate ........................ 86estradiol-norethindrone acet ...... 86ESTRING ................................ 115ESTROGEL .............................. 86eszopiclone ..................................93ethacrynic acid ............................80ethambutol hcl ............................ 46ethosuximide ............................... 22ethyl chloride .............................. 74ethynodiol diac-eth estradiol ...... 68etodolac .........................................4etodolac er .................................... 4EUCERIN ..................................74EVAMIST ..................................86everolimus .............................48, 98EVOTAZ ................................... 58EXELDERM ............................. 74exemestane .................................. 48EXODERM ............................... 75eye allergy relief ....................... 103ezetimibe ..................................... 37ezetimibe-simvastatin ..................37famciclovir .................................. 58famotidine ................................. 112
FANAPT .................................... 54FARXIGA ..................................29FARYDAK ................................ 48FASENRA ................................. 17FASLODEX ...............................48fe tabs ..........................................91felbamate .....................................22felodipine er ................................ 64fenofibrate ...................................38fenofibrate micronized .......... 37, 38fenofibric acid .............................38fentanyl ......................................... 7ferotrinsic ....................................91ferraplus 90 .................................91ferrous sulfate ............................. 91FETZIMA ............................26, 27fexofenadine hcl .......................... 36FIASP .........................................29FIASP FLEXTOUCH .............. 29FIASP PENFILL ...................... 29FIBRICOR ................................ 38FINACEA .................................. 75finasteride ............................. 75, 88FIRAZYR .................................. 90FIRMAGON ..............................48FIRMAGON (240 MG DOSE) 48FIRST-LANSOPRAZOLE .... 112FIRST-PROGESTERONE VGS .......................................... 115FLAREX ..................................103flavor sweet ...............................107flavoxate hcl ..............................113flecainide acetate ........................ 14FLONASE SENSIMIST .........100FLOVENT DISKUS ................. 17FLOVENT HFA ........................17FLUAD .....................................114FLUAD QUADRIVALENT ...114FLUARIX QUADRIVALENT...................................................114FLUCAINE ............................. 103fluconazole ..................................36flucytosine ................................... 36fludrocortisone acetate ............... 70flunisolide ................................. 100fluocinolone acetonide ........75, 105fluocinolone acetonide body ....... 75fluocinolone acetonide scalp ...... 75fluocinonide ................................ 75fluocinonide emulsified base .......75FLUORIDEX ............................ 99
FLUORIDEX DAILY RENEWAL ................................99fluoritab ...................................... 97fluorometholone ........................103fluorouracil ................................. 75fluoxetine hcl ...............................27fluphenazine decanoate ...............54fluphenazine hcl .......................... 54flurandrenolide ........................... 75flurazepam hcl ............................ 93flurbiprofen ................................... 4flurbiprofen sodium .................. 103flutamide ..................................... 48fluticasone propionate ........ 75, 100fluticasone-salmeterol .................17fluvastatin sodium .......................38fluvoxamine maleate ................... 27FLUZONE QUADRIVALENT ................. 114FML ......................................... 103folic acid ..................................... 91fondaparinux sodium .................. 20FORTEO ................................... 82FOSAMAX PLUS D ................. 82fosamprenavir calcium ............... 58fosinopril sodium ........................ 41fosinopril sodium-hctz ................ 41FRAGMIN .................................20FREESTYLE LIBRE SENSOR SYSTEM ...................95frovatriptan succinate .................96furosemide ...................................80FUZEON ....................................59FYCOMPA ................................22gabapentin ............................ 22, 23GABITRIL ................................ 23galantamine hydrobromide .......109galantamine hydrobromide er .. 108ganirelix acetate ......................... 82gatifloxacin ............................... 103GAVILYTE-C ...........................93GAVILYTE-G ...........................93GAVILYTE-N WITH FLAVOR PACK ....................... 93gemfibrozil .................................. 38generlac ...................................... 87GENGRAF ................................ 98GENOTROPIN ......................... 83GENOTROPIN MINIQUICK...............................................82, 83GENTAK ................................. 103gentamicin sulfate ...............75, 103
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GENVOYA ................................59GIANVI ..................................... 68GILENYA ................................109GILOTRIF ................................ 48glatiramer acetate .....................109GLATOPA ...............................109GLEOSTINE .............................48glimepiride ..................................29glipizide .......................................29glipizide er .................................. 29glipizide-metformin hcl .........29, 30GLUCAGEN HYPOKIT ......... 30glucagon emergency ................... 30GLUCOCARD EXPRESSION TEST ................79GLUCOCARD VITAL TEST . 79glyburide ..................................... 30glyburide micronized .................. 30glyburide-metformin ................... 30glycopyrrolate ...........................112gnp 24 hour nasal allergy .........100GOLYTELY ..............................94GONAL-F RFF REDIJECT ....83goodsense glucose .......................30goodsense nasal allergy spray ..100granisetron hcl ............................35griseofulvin microsize .................36griseofulvin ultramicrosize ......... 36guanfacine hcl .............................41guanfacine hcl er .......................... 2GYNAZOLE-1 ........................ 115halobetasol propionate ............... 75HALOG ..................................... 75haloperidol ..................................55haloperidol decanoate ................ 55haloperidol lactate ......................55hematinic/folic acid .................... 91HEMATOGEN FA ................... 91HEMATOGEN FORTE ...........91heparin lock flush ....................... 20heparin sod (porcine) in d5w ......20heparin sodium (porcine) ............20heparin sodium (porcine) pf ....... 20heparin sodium lock flush ...........20HETLIOZ ..................................93HOMATROPAIRE ................ 103HUMIRA ..................................... 4HUMIRA PEN ............................ 4HUMULIN R U-500 (CONCENTRATED) ................30hydralazine hcl ......................41, 42hydrochlorothiazide ....................81
hydrocod polst-cpm polst er ....... 71hydrocodone-acetaminophen ........7hydrocodone-homatropine ..........71hydrocodone-ibuprofen .................7hydrocortisone ...................... 70, 76hydrocortisone butyr lipo base ... 75hydrocortisone butyrate ..............76hydrocortisone valerate .............. 76hydromorphone hcl ...................7, 8hydromorphone hcl er ...................7hydroquinone .............................. 76hydroxychloroquine sulfate .........46hydroxyprogesterone caproate.............................................48, 107hydroxyurea ................................ 48hydroxyzine hcl ........................... 14hydroxyzine pamoate .................. 14HYOPHEN ................................ 45hyoscyamine sulfate .................. 112hyoscyamine sulfate sl .............. 112hyosyne ......................................112HYPERRHO S/D .................... 106HYQVIA ..................................106ibandronate sodium .................... 83IBRANCE ..................................48IBU ............................................... 4ibuprofen .......................................4ICLUSIG ................................... 48icosapent ethyl ............................ 38imatinib mesylate ........................ 48IMBRUVICA ............................ 48imipramine hcl ............................ 27imipramine pamoate ................... 27imiquimod ................................... 76INCRELEX ............................... 83INCRUSE ELLIPTA ................17indapamide ................................. 81indomethacin .................................4indomethacin er ............................ 4INLYTA ...............................48, 49insulin syringe .............................95insupen pen needles .................... 95INTELENCE .............................59INTRON A ................................ 49INVIRASE .................................59INVOKAMET ...........................30INVOKAMET XR .................... 30INVOKANA .............................. 31iodine strong ............................... 97iodine strong (lugol's) .................67IOPIDINE ................................103ipratropium bromide ...17, 100, 101
ipratropium-albuterol ................. 17irbesartan ....................................42irbesartan-hydrochlorothiazide ..42iron ..............................................91iron 27 .........................................91ISENTRESS .............................. 59isoniazid ................................46, 47isosorbide dinitrate .....................12isosorbide mononitrate ............... 12isosorbide mononitrate er ...........12isradipine .................................... 64itraconazole ................................ 36ivermectin ....................................12JADENU .............................. 34, 35JAKAFI ..................................... 49JANUMET .................................31JANUMET XR ..........................31JANUVIA .................................. 31JARDIANCE .............................31JASMIEL ...................................68JINTELI .................................... 86JUNEL 1.5/30 ............................ 68JUNEL FE 1.5/30 ...................... 68KALBITOR ...............................90KALETRA .................................59KALYDECO ........................... 110ketoconazole ..........................36, 76ketone test ................................... 79ketoprofen er .................................4ketorolac tromethamine ........ 5, 103KINERET ....................................5KLOR-CON M15 ......................97kp diphenhydramine hcl ..............36K-PRIME ...................................97KRISTALOSE .......................... 94KYPROLIS ............................... 49labetalol hcl ................................ 62LACRISERT ........................... 103lactic acid ....................................76lactic acid e .................................76lactulose ......................................94LAMICTAL ODT .....................23lamivudine ...................................59lamivudine-zidovudine ................59lamotrigine ..................................23lamotrigine er ............................. 23lansoprazole ..............................112lanthanum carbonate .................. 87LANTUS .................................... 31LANTUS SOLOSTAR ............. 31lapatinib ditosylate ..................... 49LASTACAFT .......................... 103
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latanoprost ................................103LATUDA ................................... 55leflunomide ................................... 5letrozole ...................................... 49leucovorin calcium ......................49LEUKERAN ..............................49LEUKINE ..................................91leuprolide acetate ....................... 49levalbuterol hcl ..................... 17, 18levalbuterol tartrate ....................18LEVEMIR ................................. 31LEVEMIR FLEXTOUCH .......31levetiracetam ...............................23levetiracetam er .......................... 23levobunolol hcl ..........................103levocarnitine ............................... 83levocetirizine dihydrochloride .... 37levofloxacin .........................87, 103levonorgest-eth est & eth est .......68levonorgest-eth estrad 91-day .... 68levonorgestrel ............................. 68levonorgestrel-ethinyl estrad ...... 68levorphanol tartrate ......................8levothyroxine sodium ................ 111LEXIVA .....................................59lidocaine ..................................... 76lidocaine hcl ..........................76, 99lidocaine-hydrocortisone ace ..... 11lidocaine-prilocaine ....................76lindane ........................................ 76linezolid .......................................45LINZESS ................................... 87liothyronine sodium .................. 111lisinopril ......................................42lisinopril-hydrochlorothiazide ....42lithium ......................................... 55lithium carbonate ........................55lithium carbonate er ................... 55LIVALO .....................................38LMX 4 ........................................ 76LO LOESTRIN FE ...................68loperamide hcl ............................ 34lopinavir-ritonavir ...................... 59loratadine ....................................37loratadine childrens ....................37lorazepam ................................... 14LORAZEPAM INTENSOL .....14LORYNA ................................... 68losartan potassium ......................42losartan potassium-hctz .............. 42LOTEMAX ..............................103lovastatin .....................................38
LOW-OGESTREL ................... 68loxapine succinate .......................55LO-ZUMANDIMINE ...............68LUMIGAN ...............................103LUPRON DEPOT (1-MONTH) ................................... 49LUPRON DEPOT (3-MONTH) ................................... 49LUPRON DEPOT (4-MONTH) ................................... 49LUPRON DEPOT (6-MONTH) ................................... 49LYRICA .....................................23LYSODREN .............................. 49MACROBID ..............................45mafenide acetate ......................... 76MAGELLAN INSULIN SAFETY SYR ............................95magnesium oxide .........................12malathion .................................... 76maprotiline hcl ............................27MARPLAN ................................27MATULANE ............................. 49MAVYRET ................................59MAYZENT ..............................109meclizine hcl ............................... 35meclofenamate sodium ..................5medroxyprogesterone acetate.............................................68, 107mefloquine hcl .............................46megestrol acetate ........................ 50MEKINIST ................................50meloxicam ..................................... 5memantine hcl ...........................109MENEST ................................... 86MENTAX ...................................76meperidine hcl ...............................8meprobamate .............................. 14mercaptopurine ...........................50mesalamine ........................... 87, 88MESNEX ................................... 50MESTINON ...............................46metaproterenol sulfate ................ 18metaxalone ................................100metformin hcl .............................. 31metformin hcl er ..........................31methadone hcl ...............................8METHADONE HCL INTENSOL ..................................8METHADOSE ............................ 8methamphetamine hcl ................... 2methazolamide ............................ 81
methenamine hippurate ...............45methenamine mandelate ............. 45methimazole .............................. 111methitest ......................................11methocarbamol ......................... 100methotrexate ................................50methotrexate sodium ...................50methotrexate sodium (pf) ............ 50methoxsalen rapid .......................76methscopolamine bromide ........ 112methyldopa ..................................42methylergonovine maleate ........ 105methylphenidate hcl ...................... 2methylphenidate hcl er ..................2methylphenidate hcl er (cd) .......... 2methylphenidate hcl er (la) ...........2methylprednisolone .....................70metoclopramide hcl .....................88metolazone .................................. 81metoprolol succinate er .............. 62metoprolol tartrate ......................62metoprolol-hydrochlorothiazide . 42metronidazole ............... 45, 76, 115mexiletine hcl .............................. 15MIACALCIN ............................ 83miconazole 3 applicator ........... 115miconazole 3 combo pack .........115miconazole nitrate ...................... 76midodrine hcl ............................ 115miglitol ........................................31MILLIPRED ............................. 70minocycline hcl ......................... 111minoxidil ..................................... 42mirtazapine ................................. 27MIRVASO ................................. 76misoprostol ............................... 112modafinil ....................................... 2moexipril hcl ............................... 43mometasone furoate ......76, 77, 101MONOJECT SODIUM CHLORIDE FLUSH ................ 97montelukast sodium .................... 18MONUROL ............................... 45morphine sulfate ........................... 9morphine sulfate (concentrate) .....8morphine sulfate (pf) .....................8morphine sulfate er ....................... 9MOTOFEN ................................34moxifloxacin hcl ..................87, 103moxifloxacin hcl (2x day) ..........103MULTAQ .................................. 15multivitamin/fluoride .................. 99
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mupirocin ....................................77mycophenolate mofetil ................ 98mycophenolate sodium ................98MYLERAN ................................50nabumetone ...................................5nac .............................................101nadolol ........................................ 62naftifine hcl ................................. 77nalbuphine hcl .............................. 9naloxone hcl ................................35naltrexone hcl ............................. 35naproxen ....................................... 5naproxen sodium ...........................5naratriptan hcl ............................ 96NARCAN ................................... 35nasal allergy 24 hour ................101NATACYN .............................. 104nateglinide .................................. 31NATROBA ................................ 77NATURE-THROID ................111nefazodone hcl ............................ 27neomycin sulfate ........................... 3neomycin-bacitracin zn-polymyx ..................................... 104neomycin-polymyxin b gu ........... 88neomycin-polymyxin-dexameth .104neomycin-polymyxin-gramicidin...................................................104neomycin-polymyxin-hc .... 104, 105NEULASTA ...............................92NEUPRO ................................... 52NEVANAC .............................. 104nevirapine ................................... 59nevirapine er ...............................59NEXAVAR ................................ 50niacin ........................................ 116niacin er (antihyperlipidemic) .... 38NIACOR .................................... 38nicardipine hcl ............................ 64NICORETTE .......................... 109nicotine ..................................... 109nicotine mini ............................. 109nicotine polacrilex .................... 109NICOTROL .............................109nifedipine .................................... 64nifedipine er ................................ 64nifedipine er osmotic release ...... 64NIKKI ........................................ 68nimodipine .................................. 64nisoldipine er .............................. 64nitisinone .....................................83NITRO-BID ...............................12
NITRO-DUR ............................. 12nitrofurantoin ..............................45nitrofurantoin macrocrystal ........45nitrofurantoin monohyd macro ...45nitroglycerin ......................... 12, 13nitroglycerin er ........................... 12NITRO-TIME ........................... 13nizatidine ...................................112norethin ace-eth estrad-fe ...........68norethindrone ............................. 68norethindrone acetate ...............107norethindrone acet-ethinyl est .... 68norethindrone-eth estradiol ........ 86norethin-eth estradiol-fe ............. 69norgestimate-eth estradiol .......... 69norgestim-eth estrad triphasic ....69NORPACE CR ..........................15NORTREL 0.5/35 (28) ..............69NORTREL 1/35 (28) .................69NORTREL 7/7/7 ....................... 69nortriptyline hcl .................... 27, 28NORVIR .................................... 59NOVOLIN 70/30 ....................... 31NOVOLIN 70/30 FLEXPEN ... 31NOVOLIN 70/30 FLEXPEN RELION .....................................31NOVOLIN N ............................. 32NOVOLIN N FLEXPEN ..........32NOVOLIN N RELION .............32NOVOLIN R ............................. 32NOVOLIN R FLEXPEN ..........32NOVOLIN R RELION .............32NOVOLOG ............................... 32NOVOLOG FLEXPEN ............32NOVOLOG MIX 70/30 ............ 32NOVOLOG MIX 70/30 FLEXPEN ..................................32NOVOLOG PENFILL ............. 32np thyroid ..................................111NUCYNTA ER ............................9NUEDEXTA ............................109NUVARING .............................. 69NYAMYC .................................. 77nystatin ............................36, 77, 99nystatin-triamcinolone ................77NYSTOP .................................... 77OCELLA ................................... 69octreotide acetate ..................83, 84ODOMZO ..................................50OFEV ....................................... 110ofloxacin ..................... 87, 104, 105olanzapine .............................55, 56
olanzapine-fluoxetine hcl ..........109olmesartan medoxomil ................43olmesartan medoxomil-hctz ........ 43olopatadine hcl ......................... 104omega-3-acid ethyl esters ........... 38omeprazole ................................113OMNIFLEX DIAPHRAGM ....95ondansetron ................................ 35ondansetron hcl .......................... 35ONETOUCH VERIO ...............95ONGLYZA ................................ 32OPSUMIT ..................................65ORA-BLEND .......................... 107ORA-PLUS ..............................107ORA-SWEET ..........................107ORAVIG ....................................99orphenadrine citrate er .............100oseltamivir phosphate .................59OSMOPREP ..............................94OSPHENA ................................. 84oxandrolone ................................ 11oxaprozin ...................................... 5OXAYDO .....................................9oxazepam .................................... 14oxcarbazepine ....................... 23, 24oxiconazole nitrate ......................77oxybutynin chloride ...................113oxybutynin chloride er .............. 113oxycodone hcl ......................... 9, 10oxycodone-acetaminophen ..........10oxycodone-aspirin .......................10oxymorphone hcl er .................... 10OXYTROL FOR WOMEN ... 113OZEMPIC (0.25 OR 0.5 MG/DOSE) ................................ 32OZEMPIC (1 MG/DOSE) ........32PACERONE ..............................15paliperidone er ............................56pantoprazole sodium .................113paricalcitol ..................................84paromomycin sulfate .....................3paroxetine hcl ............................. 28paroxetine hcl er ......................... 28peg-3350/electrolytes/ascorbat ...94PEGANONE ..............................24PEGASYS ..................................60PEGINTRON ............................ 60pen needles ..................................95penicillamine ...............................98penicillin v potassium ............... 107pentamidine isethionate .............. 45PENTASA ..................................88
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pentazocine-naloxone hcl ........... 10pentetate calcium trisodium ........35pentetate zinc trisodium ..............35pentoxifylline er .......................... 90PERFOROMIST .......................18perindopril erbumine .................. 43permethrin ...................................77perphenazine ...............................56perphenazine-amitriptyline .......109phenazopyridine hcl ....................88phendimetrazine tartrate .............. 3phendimetrazine tartrate er .......... 3phenelzine sulfate ........................28phenobarbital ..............................93phenoxybenzamine hcl ................ 43phentermine hcl .............................3phenytoin .....................................24phenytoin sodium ........................ 24phenytoin sodium extended .........24PHOSLYRA .............................. 88PHOSPHASAL ......................... 45PHOSPHOLINE IODIDE ..... 104PHOSPHO-TRIN 250 NEUTRAL .................................97physostigmine salicylate ............. 35phytonadione .............................116pilocarpine hcl .................... 99, 104pimecrolimus ...............................77pimozide ....................................109pindolol ....................................... 62pioglitazone hcl ...........................32pioglitazone hcl-glimepiride .......32pioglitazone hcl-metformin hcl...............................................32, 33piroxicam ...................................... 5podocon .......................................77podofilox ..................................... 77polyethylene glycol 3350 ............ 94poly-iron 150 forte ......................92polymyxin b-trimethoprim .........104POMALYST ..............................50pot bicarb-pot chloride ............... 97potassium chloride ......................97potassium chloride crys er ..........97potassium chloride er ................. 97potassium citrate er .................... 89potassium citrate-citric acid ....... 89PR BENZOYL PEROXIDE WASH ........................................ 77PRADAXA ...........................20, 21PRALUENT .............................. 38pramipexole dihydrochloride ......53
pramipexole dihydrochloride er...............................................52, 53prasugrel hcl ...............................90pravastatin sodium ......................38prazosin hcl .................................43PRED MILD ............................104prednicarbate ..............................77prednisolone acetate .................104prednisolone sodium phosphate.............................................70, 104prednisone .............................70, 71PREDNISONE INTENSOL .... 70pregabalin ...................................24PREMARIN .............................. 86PREMPHASE ........................... 86PREMPRO .......................... 86, 87prenatal .......................................99PREVALITE ....................... 38, 39PREZCOBIX .............................60PREZISTA ................................ 60PRIFTIN ....................................47primaquine phosphate ................ 46primidone ....................................24PROAIR RESPICLICK ...........18probenecid .................................. 89prochlorperazine .........................56prochlorperazine maleate ...........56PROCRIT ..................................92PROCTOFOAM HC ................ 11PROCTOZONE-HC .................11progesterone micronized ...........107PROMACTA .............................92promethazine hcl .........................37promethazine vc/codeine .............71promethazine-codeine .................71promethazine-dm ........................ 71PROMETHEGAN .................... 37propafenone hcl .......................... 15propafenone hcl er ......................15propantheline bromide ..............113proparacaine hcl .......................104propranolol hcl ........................... 62propranolol hcl er .......................62propranolol-hctz ......................... 43propylthiouracil ........................ 111protriptyline hcl .......................... 28PULMICORT FLEXHALER ..18PULMOZYME ....................... 110pyrazinamide ...............................47pyridostigmine bromide .............. 46pyridostigmine bromide er ..........46pyridoxine hcl ........................... 116
pyrogallic acid ............................ 77QNASL .....................................101quetiapine fumarate .................... 56quetiapine fumarate er ................56quinapril hcl ................................43quinapril-hydrochlorothiazide ....43quinidine gluconate er ................ 15quinidine sulfate ..........................15quinine sulfate .............................46QVAR REDIHALER ............... 18ra nasal allergy .........................101rabeprazole sodium .................. 113RADIOGARDASE ................... 35raloxifene hcl .............................. 84ramipril ....................................... 43RANEXA ................................... 13RAPAMUNE ............................. 98rasagiline mesylate ..................... 53RECTIV .....................................11reeses pinworm medicine ............12REGRANEX ............................. 77RELENZA DISKHALER ........ 60RELPAX ....................................96RENVELA .................................88repaglinide ..................................33REPATHA .................................39REPATHA PUSHTRONEX SYSTEM ....................................39REPATHA SURECLICK ........ 39REPLESTA CHILDRENS .... 116RETACRIT ............................... 92REVLIMID ............................... 98REXULTI .................................. 56REYATAZ .................................60ribavirin ...................................... 60RIDAURA ....................................5rifabutin ...................................... 47rifampin .......................................47riluzole ...................................... 101rimantadine hcl ...........................60RINVOQ ......................................5risedronate sodium ..................... 84risperidone ............................56, 57ritonavir ...................................... 60rivastigmine ...................... 109, 110rivastigmine tartrate ................. 110rizatriptan benzoate .................... 96ropinirole hcl .............................. 53ropinirole hcl er ..........................53ROSADAN .................................77rosuvastatin calcium ...................39ROZEREM ................................93
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rufinamide ...................................24RYBELSUS ............................... 33salicylic acid ......................... 77, 78salicylic acid wart remover .........78salsalate ........................................ 6SAMSCA ................................... 84SANDIMMUNE ........................98SANDOSTATIN LAR DEPOT .......................................84SANTYL .................................... 78SAPHRIS ................................... 57sapropterin dihydrochloride .......84SAVELLA ............................... 110selegiline hcl ............................... 53selenium sulfide .......................... 78SELZENTRY ............................ 60SENSIPAR .................................84SEREVENT DISKUS ...............18sertraline hcl ...............................28sevelamer carbonate ................... 88sevelamer hcl .............................. 88sf ..................................................99sf 5000 plus ................................. 99SHINGRIX .............................. 114SIGNIFOR .................................84SIGNIFOR LAR ....................... 84sildenafil citrate .......................... 65silodosin ......................................89silver nitrate ................................78SIMBRINZA ........................... 104simple syrup .............................. 107simvastatin .................................. 39sirolimus ..................................... 98SIVEXTRO ............................... 45SKLICE ..................................... 78SKYRIZI (150 MG DOSE) ...... 78SLYND .......................................69sod citrate-citric acid ..................89sodium bicarbonate .................... 12sodium chloride .................... 71, 97sodium chloride (hypertonic) ....104sodium fluoride ........................... 97sodium polystyrene sulfonate ......98sofosbuvir-velpatasvir .................60solifenacin succinate .................114SOMATULINE DEPOT .... 84, 85SOMAVERT ............................. 85sorbitol ........................................89sorbitol-mannitol ........................ 89sotalol hcl ....................................63sotalol hcl (af) .......................62, 63SPIRIVA HANDIHALER ....... 18
SPIRIVA RESPIMAT ..............18spironolactone ............................ 81spironolactone-hctz .....................81SPRYCEL ..................................50SPS ............................................. 98SSD ............................................. 78stavudine ..................................... 60STELARA ................................. 78sterile water for irrigation .......... 98STIMATE ..................................85STIVARGA ............................... 50STRIBILD ................................. 60STRIVERDI RESPIMAT ........ 18sucralfate .................................. 113sulfacetamide sodium ..........78, 104sulfacetamide sodium (acne) ...... 78sulfacetamide sodium-sulfur .......78sulfacetamide-prednisolone ......104sulfadiazine ............................... 110sulfamethoxazole-trimethoprim .. 45SULFAMYLON ........................78sulfasalazine ............................... 88sulindac .........................................5sumatriptan ................................. 96sumatriptan succinate .................96SUPRAX .................................... 67SUPREP BOWEL PREP KIT .94SUTENT .................................... 50SYEDA .......................................69SYMAX DUOTAB ..................113SYMAX-SR ............................. 113SYMJEPI .................................115SYMLINPEN 120 ..................... 33SYMLINPEN 60 ....................... 33SYNAGIS .................................106SYNALAR (CREAM) .............. 78SYNALAR (OINTMENT) ....... 78SYNJARDY ...............................33SYNJARDY XR ........................ 33SYNTHROID .......................... 111SYPRINE ...................................98TABLOID ..................................50TACLONEX ..............................78tacrolimus ............................. 78, 98tadalafil .......................................65TAFINLAR ............................... 50tamoxifen citrate ......................... 50tamsulosin hcl ............................. 89TARCEVA ...........................50, 51TARON-PREX ..........................99TASIGNA .................................. 51TAYTULLA .............................. 69
tazarotene ................................... 78TAZORAC ................................ 78TAZTIA XT .............................. 64TECHLITE PEN NEEDLES ...95TEKTURNA HCT .............. 43, 44telmisartan .................................. 44telmisartan-hctz .......................... 44temazepam .................................. 93tenofovir disoproxil fumarate ..... 60terazosin hcl ................................44terbinafine hcl .............................36terbutaline sulfate ....................... 18terconazole ................................115testosterone ................................. 11testosterone cypionate .................11testosterone enanthate ................ 11tetrabenazine .............................110tetracycline hcl ..........................111THALOMID ..............................99theophylline .................................19theophylline er ............................ 19THERA-D 4000 .......................116thioridazine hcl ........................... 57thiothixene ...................................57thrivite 19 ....................................99tiagabine hcl ............................... 24timolol maleate ................... 63, 105tinidazole .....................................46TIVICAY ................................... 60tizanidine hcl .............................100TOBRADEX ............................105TOBRADEX ST ......................105tobramycin ............................ 3, 105tobramycin-dexamethasone ...... 105TOBREX ................................. 105tolbutamide ................................. 33tolcapone .....................................53tolmetin sodium .............................5tolterodine tartrate ....................114tolterodine tartrate er ............... 114tolvaptan ..................................... 85topiramate ...................................24toremifene citrate ........................51torsemide .....................................81TOUJEO SOLOSTAR ............. 33TOVIAZ ...................................114TRACLEER ........................ 65, 66TRADJENTA ............................33tramadol hcl ................................10tramadol hcl er ........................... 10tramadol hcl er (biphasic) .......... 10tramadol-acetaminophen ............10
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trandolapril .................................44trandolapril-verapamil hcl er ..... 44tranylcypromine sulfate .............. 28travoprost (bak free) ................. 105trazodone hcl .............................. 28TRELSTAR MIXJECT ........... 51TRESIBA ...................................34TRESIBA FLEXTOUCH ........ 33tretinoin ...........................51, 78, 79tretinoin microsphere ..................79TREXALL ................................. 51triamcinolone acetonide79, 99, 101triamterene ..................................81triamterene-hctz ..........................81trifluoperazine hcl .......................57trifluridine .................................105trihexyphenidyl hcl ......................53TRI-LEGEST FE ......................69TRI-LO-SPRINTEC .................69trimethobenzamide hcl ................35trimethoprim ............................... 46trimipramine maleate ..................28TRIUMEQ .................................60tropicamide ............................... 105trospium chloride ......................114trospium chloride er ................. 114TRULICITY ..............................34TRUVADA ................................ 61TUDORZA PRESSAIR ............19TWIRLA ....................................69TYVASO STARTER ................66ULORIC .................................... 89ULTILET INSULIN SYRINGE ............................ 95, 96ULTILET INSULIN SYRINGE SHORT ................... 96UMECTA MOUSSE .................79UPTRAVI .................................. 66urea ............................................. 79urea nail ......................................79urea-c40 ......................................79URIMAR-T ................................46urin ds ....................................... 113ursodiol ....................................... 88USTELL .....................................46valacyclovir hcl ...........................61valganciclovir hcl ....................... 61valproic acid ............................... 24valsartan ..................................... 44valsartan-hydrochlorothiazide ... 44VALSTAR ................................. 51vancomycin hcl ........................... 46
vancomycin hcl in dextrose .........46VANTAS ....................................51VECTICAL ............................... 79VELIVET .................................. 69VELPHORO ............................. 88VELTIN ..................................... 79venlafaxine hcl ............................ 28venlafaxine hcl er ........................28VENTAVIS ................................66VENTOLIN HFA ......................19verapamil hcl .............................. 65verapamil hcl er ..........................65VEREGEN .................................79VESICARE ..............................114VICTOZA ..................................34vigabatrin ....................................24VIIBRYD ............................. 28, 29VIMPAT .................................... 24VIRACEPT ............................... 61VIRAMUNE ..............................61VIREAD .....................................61vitamin d ................................... 116vitamin d (cholecalciferol) ........116vitamin d (ergocalciferol) ......... 116vitamin d3 ................................. 116vitamins acd-fluoride .................. 99VIVITROL ................................ 35voriconazole ................................36VOTRIENT ............................... 51VYVANSE ................................... 3warfarin sodium ..........................21WESTHROID ......................... 111WIXELA INHUB ......................19XALKORI ................................. 51XARELTO .................................21XARELTO STARTER PACK 21XELJANZ ....................................5XELJANZ XR .............................5XIFAXAN ..................................46XIGDUO XR ............................. 34XOLAIR .................................... 19XULANE ................................... 69XYREM ................................... 110zafirlukast ................................... 19zaleplon .......................................93ZARAH ......................................69ZARXIO .................................... 92ZENPEP .....................................80ZEPATIER ................................61zidovudine ................................... 61zileuton er ................................... 19zinc sulfate .................................. 97
ZIOPTAN ................................ 105ziprasidone hcl ............................57ZIRGAN .................................. 105ZOLADEX .................................51ZOLINZA ..................................51zolmitriptan .................................96zolpidem tartrate .........................93zolpidem tartrate er .................... 93zonisamide ............................ 24, 25ZONTIVITY ............................. 90ZORTRESS ............................... 99ZOVIA 1/35E (28) .....................69ZUMANDIMINE ......................69ZYDELIG ..................................51ZYFLO .......................................19
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