Reliance 2020 V15 Comprehensive Member Formulary · Reliance Medicare Advantage considers these...

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Reliance Medicare Advantage

2020 Comprehensive Formulary

(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File Submission ID 20311, Version Number 15

This formulary was updated on 6/1/2020. For more recent information or other

questions, please contact Reliance Medicare Advantage Customer Services at 844-705-

7498 or, for TTY users, 711. Our hours of operation are 24 hours a day, 7 days a week.

You can also visit our website at www.RelianceMedicareAdvantage.org.

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When this drug list (formulary) refers to “we,” “us”, or “our,” it means Reliance

Medicare Advantage. When it refers to “plan” or “our plan,” it means 2020 Reliance

Medicare Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of

July 1 2020. For an updated formulary, please contact us. Our contact information, along

with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit.

Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on

January 1, 2020, and from time to time during the year.

What is the Reliance Medicare Advantage Comprehensive Formulary?

A formulary is a list of covered drugs selected by Reliance Medicare Advantage in

consultation with a team of health care providers, which represents the prescription

therapies believed to be a necessary part of a quality treatment program. Reliance

Medicare Advantage will generally cover the drugs listed in our formulary as long as the

drug is medically necessary, the prescription is filled at a Reliance Medicare Advantage

network pharmacy, and other plan rules are followed. For more information on how to

fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?

Most changes in drug coverage happen on January 1, but we may add or remove drugs on

the Drug List during the year, move them to different cost-sharing tiers, or add new

restrictions. We must follow Medicare rules in making these changes.

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

coverage changes during the year:

New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the

same or lower cost sharing tier and with the same or fewer restrictions. Also,

when adding the new generic drug, we may decide to keep the brand name drug

on our Drug List, but immediately move it to a different cost-sharing tier or add

new restrictions. If you are currently taking that brand name drug, we may not tell

you in advance before we make that change, but we will later provide you with

information about the specific change(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice

we provide you will also include information on how to request an

exception, and you can also find information in the section below entitled

“How do I request an exception to the Reliance Medicare Advantage

Formulary?”

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Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug

from the market, we will immediately remove the drug from our formulary and

provide notice to members who take the drug.

Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market

to replace a brand name drug currently on the formulary or add new restrictions to

the brand name drug or move it to a different cost-sharing tier. Or we may make

changes based on new clinical guidelines. If we remove drugs from our

formulary, or add prior authorization, quantity limits and/or step therapy

restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify

affected members of the change at least 30 days before the change becomes

effective, or at the time the member requests a refill of the drug, at which time the

member will receive a 30-day supply of the drug.

o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The

notice we provide you will also include information on how to request an

exception, and you can also find information in the section below entitled

“How do I request an exception to the Reliance Medicare Advantage

Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if

you are taking a drug on our 2020 formulary that was covered at the beginning of the

year, we will not discontinue or reduce coverage of the drug during the 2020 coverage

year except as described above. This means these drugs will remain available at the same

cost-sharing and with no new restrictions for those members taking them for the

remainder of the coverage year.

The enclosed formulary is current as of July 1, 2020. To get updated information about

the drugs covered by Reliance Medicare Advantage, please contact us. Our contact

information appears on the front and back cover pages.

How do I use the Formulary?

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

Medical Condition

The formulary begins on page 9. The drugs in this formulary are grouped into

categories depending on the type of medical conditions that they are used to treat. For

example, drugs used to treat a heart condition are listed under the category,

“Cardiovascular Agents.” If you know what your drug is used for, look for the

category name in the list that begins on page 9. Then look under the category name

for your drug.

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Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the

Index that begins on page 116. The Index provides an alphabetical list of all of the

drugs included in this document. Both brand name drugs and generic drugs are listed

in the Index. Look in the Index and find your drug. Next to your drug, you will see

the page number where you can find coverage information. Turn to the page listed in

the Index and find the name of your drug in the first column of the list.

What are generic drugs?

Reliance Medicare Advantage covers both brand name drugs and generic drugs. A

generic drug is approved by the FDA as having the same active ingredient as the

brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?

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

requirements and limits may include:

Prior Authorization: Reliance Medicare Advantage requires you [or your physician] to get prior authorization for certain drugs. This means that you will

need to get approval from Reliance Medicare Advantage before you fill your

prescriptions. If you don’t get approval, Reliance Medicare Advantage may not

cover the drug.

Quantity Limits: For certain drugs, Reliance Medicare Advantage limits the amount of the drug that Reliance Medicare Advantage will cover. For example,

Reliance Medicare Advantage provides 90 units per prescription for LYRICA

CAPS. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Reliance Medicare Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug

for that condition. For example, if Drug A and Drug B both treat your medical

condition, Reliance Medicare Advantage may not cover Drug B unless you try

Drug A first. If Drug A does not work for you, Reliance Medicare Advantage

will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the

formulary that begins on page 9. You can also get more information about the

restrictions applied to specific covered drugs by visiting our Web site. We have posted on

line documents that explain our prior authorization and step therapy restrictions. You

may also ask us to send you a copy. Our contact information, along with the date we last

updated the formulary, appears on the front and back cover pages.

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You can ask Reliance Medicare Advantage to make an exception to these restrictions or

limits or for a list of other, similar drugs that may treat your health condition. See the

section, “How do I request an exception to the Reliance Medicare Advantage’s

formulary?” on page 5 for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first

contact Customer Services and ask if your drug is covered.

If you learn that Reliance Medicare Advantage does not cover your drug, you have two

options:

You can ask Member Services for a list of similar drugs that are covered by Reliance Medicare Advantage. When you receive the list, show it to your doctor

and ask him or her to prescribe a similar drug that is covered by Reliance

Medicare Advantage.

You can ask Reliance Medicare Advantage to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Reliance Medicare Advantage

Formulary?

You can ask Reliance Medicare Advantage to make an exception to our coverage rules.

There are several types of exceptions that you can ask us to make.

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

able to ask us to provide the drug at a lower cost-sharing level.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Reliance Medicare Advantage limits the amount of the

drug that we will cover. If your drug has a quantity limit, you can ask us to waive

the limit and cover a greater amount.

Generally, Reliance Medicare Advantage will only approve your request for an exception

if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or

additional utilization restrictions would not be as effective in treating your condition

and/or would cause you to have adverse medical effects.

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You should contact us to ask us for an initial coverage decision for a formulary, or

utilization restriction exception. When you request a formulary or utilization

restriction exception you should submit a statement from your prescriber or

physician supporting your request. Generally, we must make our decision within 72

hours of getting your prescriber’s supporting statement. You can request an expedited

(fast) exception if you or your doctor believe that your health could be seriously harmed

by waiting up to 72 hours for a decision. If your request to expedite is granted, we must

give you a decision no later than 24 hours after we get a supporting statement from your

doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs

or requesting an exception?

As a new or continuing member in our plan you may be taking drugs that are not on our

formulary. Or, you may be taking a drug that is on our formulary but your ability to get it

is limited. For example, you may need a prior authorization from us before you can fill

your prescription. You should talk to your doctor to decide if you should switch to an

appropriate drug that we cover or request a formulary exception so that we will cover the

drug you take. While you talk to your doctor to determine the right course of action for

you, we may cover your drug in certain cases during the first 90 days you are a member

of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is

limited, we will cover a temporary 30-day supply. If your prescription is written for fewer

days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After

your first 30-day supply, we will not pay for these drugs, even if you have been a

member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our

formulary or if your ability to get your drugs is limited, but you are past the first 90 days

of membership in our plan, we will cover a 31-day emergency supply of that drug while

you pursue a formulary exception.

Reliance Medicare Advantage LEVEL-OF-CARE CHANGE transition policy:

Reliance Medicare Advantage provides transition fills for enrollees who experience a

transition characterized as a level-of-care change from one treatment setting to another.

Examples of level-of-care changes where a transition may apply include:

1. Enrollees who are discharged from a hospital to a home setting (i.e., assisted living, LTC, or private home) accompanied by a list of medications that may not

always consider the formulary of the enrollee’s plan due to the short-term nature

of the hospital visit

2. Enrollees who end their Skilled Nursing Facility (SNF) Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their

Part D plan formulary

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3. Enrollees who give up hospice status to revert to standard Medicare Part A and B benefits

4. Enrollees who end an LTC facility stay and return to the community 5. Enrollees who are discharged from psychiatric hospitals with drug regimens that

are highly individualized

Reliance Medicare Advantage considers these unplanned transitions and applies the

transition fill process as required.

Reliance Medicare Advantage understands that while Part A provides reimbursement for

“a limited supply” to facilitate enrollee discharge, the enrollee is entitled to a full

outpatient supply in order to continue therapy once this limited supply is exhausted. This

is particularly true for enrollees using a mail-order pharmacy or home infusion therapy,

or for those residing in rural areas where obtaining a continuing supply of drugs may

involve certain delays.

Reliance Medicare Advantage ensures that enrollees are able to receive their outpatient

Part D prescriptions in advance of discharge from a Part A stay through this transition

process.

For more information

For more detailed information about your Reliance Medicare Advantage prescription

drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Reliance Medicare Advantage, please contact us. Our contact

information, along with the date we last updated the formulary, appears on the front and

back cover pages.

If you have general questions about Medicare prescription drug coverage, please call

Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY

users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Reliance Medicare Advantage’s Formulary

The comprehensive formulary below provides coverage information about the drugs

covered by Reliance Medicare Advantage. If you have trouble finding your drug in the

list, turn to the Index that begins on page 116.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,

NAMENDA) and generic drugs are listed in lower-case italics (e.g., amoxicillin).

The information in the Requirements/Limits column tells you if Reliance Medicare

Advantage has any special requirements for coverage of your drug.

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Requirements/Limits Helpful Tips

B/D

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

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

PA

Prior Authorization. Our plan requires you or your physician to get prior authorization for certain drugs. This means you will need to get approval from Reliance Medicare Advantage before you fill your prescriptions. If you do not get approval, your drug may not be covered.

QL Quantity Limit. For certain drugs, our plan limits the amount of the drug that will be covered.

ST

Step Therapy. In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

You can find information on what the symbols and abbreviations on this table mean by going to page 8

Formulary ID 20311, Version 15, Effective Date: 7/1/2020

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Drug Name Drug Tier Requirements/Limits

Analgesics

Analgesics

butalbital-acetaminophen oral capsule

4 PA

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

4 PA

butalbital-apap-caffeine oral capsule

4 PA

capacet oral capsule 50-325-40 mg

4 PA

esgic oral capsule 4 PA

marten-tab oral tablet 50-325 mg

4 PA

phrenilin forte oral capsule 50-300-40 mg

4 PA

tencon oral tablet 4 PA

zebutal oral capsule 4 PA

Nonsteroidal Anti-inflammatory Drugs

celecoxib oral capsule 2 QL (60 EA per 30 days)

diclofenac potassium oral tablet

4

diclofenac sodium er oral tablet extended release 24 hour

4

diclofenac sodium oral tablet delayed release

4

diclofenac sodium transdermal gel 1 %

2 QL (1000 GM per 30 days)

diclofenac sodium transdermal gel 3 %

4

diclofenac-misoprostol oral tablet delayed release

4

diflunisal oral tablet 2

etodolac er oral tablet extended release 24 hour

2


etodolac oral capsule 2

etodolac oral tablet 2

fenoprofen calcium oral capsule 400 mg

4

fenoprofen calcium oral tablet

4

flurbiprofen oral tablet 2

ibu oral tablet 600 mg, 800 mg

1

ibuprofen oral suspension

2

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

indomethacin er oral capsule extended release

4

indomethacin oral capsule 25 mg, 50 mg

4

INDOMETHACIN SODIUM INTRAVENOUS SOLUTION RECONSTITUTED

4

ketoprofen er oral capsule extended release 24 hour

4

ketoprofen oral capsule 2

ketorolac tromethamine injection solution

4

ketorolac tromethamine intramuscular solution

4

ketorolac tromethamine nasal solution 15.75 mg/spray

5 QL (5 EA per 30 days)

ketorolac tromethamine oral tablet


meclofenamate sodium oral capsule

4

mefenamic acid oral capsule

4

meloxicam oral tablet 1

nabumetone oral tablet 2



10


naproxen dr oral tablet delayed release

2

naproxen oral suspension

2

naproxen oral tablet 1

naproxen sodium er oral tablet extended release 24 hour 375 mg

2

naproxen sodium oral tablet 275 mg, 550 mg

2

naproxen-esomeprazole oral tablet delayed release

5 PA; QL (60 EA per 30 days)

oxaprozin oral tablet 2

piroxicam oral capsule 2

profeno oral tablet 600 mg

4

SPRIX NASAL SOLUTION


sulindac oral tablet 1

tolmetin sodium oral capsule

4

tolmetin sodium oral tablet

4

Opioid Analgesics, Long-acting

ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT 15 MG

4 ST; NDS

ARYMO ER ORAL TABLET EXTENDED RELEASE ABUSE-DETERRENT 30 MG, 60 MG

5 ST; NDS

buprenorphine hcl injection solution

5

buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr

3 QL (4 EA per 28 days); NDS


buprenorphine transdermal patch weekly 7.5 mcg/hr


BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR


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

3 NDS

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 75 mcg/hr

4 NDS

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

5 NDS

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12 mg, 8 mg

4 NDS

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 16 mg

4

hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 32 mg

5 NDS

INFUMORPH 200 INJECTION SOLUTION

4 NDS

INFUMORPH 500 INJECTION SOLUTION

4 NDS

levorphanol tartrate oral tablet

5 NDS

methadone hcl injection solution

4 NDS

methadone hcl intensol oral concentrate

2 NDS

methadone hcl oral concentrate

2 NDS



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methadone hcl oral solution

2 NDS

methadone hcl oral tablet

2 NDS

methadose oral concentrate 10 mg/ml

2 NDS

methadose sugar-free oral concentrate

2 NDS

mitigo injection solution 2 NDS

morphine sulfate er beads oral capsule extended release 24 hour

4 NDS

morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg

4 NDS

morphine sulfate er oral capsule extended release 24 hour 100 mg

5 NDS

morphine sulfate er oral capsule extended release 24 hour 40 mg

4

morphine sulfate er oral tablet extended release

2 NDS

oxymorphone hcl er oral tablet extended release 12 hour

4 NDS

tramadol hcl er (biphasic) oral tablet extended release 24 hour

4 NDS

tramadol hcl er oral tablet extended release 24 hour

4 NDS

XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT

3 NDS

Opioid Analgesics, Short-acting


ABSTRAL SUBLINGUAL TABLET SUBLINGUAL

5 PA; NDS

acetaminophen-codeine #2 oral tablet

2 NDS


2 NDS


2 NDS

acetaminophen-codeine oral solution

1 NDS

acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg

2 NDS

ascomp-codeine oral capsule

4 PA; NDS

butalbital-apap-caff-cod oral capsule

4 PA; NDS

butalbital-asa-caff-codeine oral capsule

4 PA; NDS

butorphanol tartrate injection solution

4 NDS

butorphanol tartrate nasal solution

2 NDS

CODEINE SULFATE ORAL TABLET 15 MG

2 NDS

codeine sulfate oral tablet 30 mg, 60 mg

2 NDS

DURAMORPH INJECTION SOLUTION

2 NDS

endocet oral tablet 2 NDS

fentanyl citrate (pf) injection solution 100 mcg/2ml, 1000 mcg/20ml, 250 mcg/5ml, 2500 mcg/50ml, 500 mcg/10ml

4 B/D; NDS

fentanyl citrate (pf) injection solution 50 mcg/ml

4 B/D



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fentanyl citrate (pf) injection solution cartridge

4 B/D; NDS

fentanyl citrate buccal lozenge on a handle

5 PA; NDS

fentanyl citrate buccal tablet

5 PA

hydrocodone-acetaminophen oral solution 10-325 mg/15ml

5

hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml

2 NDS

hydrocodone-acetaminophen oral tablet 10-300 mg

4 NDS

hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

2 NDS

hydrocodone-ibuprofen oral tablet

2 NDS

hydromorphone hcl injection solution 1 mg/ml

2

hydromorphone hcl injection solution 2 mg/ml, 4 mg/ml

2 NDS

hydromorphone hcl oral liquid

2 NDS

hydromorphone hcl oral tablet

2 NDS

hydromorphone hcl pf injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml

2

hydromorphone hcl pf injection solution 10 mg/ml, 50 mg/5ml

2 NDS


ibudone oral tablet 5-200 mg

2 NDS

LAZANDA NASAL SOLUTION

5 PA; NDS

lorcet hd oral tablet 2 NDS

lorcet oral tablet 2 NDS

lorcet plus oral tablet 2 NDS

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

2 NDS

morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml, 2 mg/ml

2 NDS

morphine sulfate (pf) injection solution 10 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml

2 B/D; NDS

morphine sulfate (pf) intravenous solution 10 mg/ml, 4 mg/ml

2

morphine sulfate (pf) intravenous solution 2 mg/ml, 8 mg/ml

2 NDS

morphine sulfate injection solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml

2 NDS

morphine sulfate intravenous solution 1 mg/ml, 150 mg/30ml

2 B/D; NDS

morphine sulfate oral solution

2 NDS

MORPHINE SULFATE ORAL TABLET

2 NDS

nalbuphine hcl injection solution

4 NDS

OXAYDO ORAL TABLET ABUSE-DETERRENT

5 NDS

oxycodone hcl oral capsule

2 NDS



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oxycodone hcl oral concentrate 100 mg/5ml

4 NDS

oxycodone hcl oral solution

2 NDS

oxycodone hcl oral tablet

2 NDS

oxycodone-acetaminophen oral solution 5-325 mg/5ml

2 NDS

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

2 NDS

OXYCODONE-ACETAMINOPHEN ORAL TABLET 2.5-300 MG

5

oxycodone-aspirin oral tablet

2 NDS

oxycodone-ibuprofen oral tablet 5-400 mg

2 NDS

oxymorphone hcl oral tablet

2 NDS

pentazocine-naloxone hcl oral tablet

4 NDS

primlev oral tablet 10-300 mg

5 NDS

primlev oral tablet 5-300 mg, 7.5-300 mg

4 NDS

prolate oral tablet 10-300 mg

5

prolate oral tablet 5-300 mg, 7.5-300 mg

4

ROXYBOND ORAL TABLET ABUSE-DETERRENT 15 MG, 30 MG, 5 MG

5 NDS

tramadol hcl oral tablet 100 mg

2

tramadol hcl oral tablet 50 mg

1 NDS


tramadol-acetaminophen oral tablet

2 NDS

verdrocet oral tablet 2.5-325 mg

2 NDS

vicodin es oral tablet 7.5-300 mg

2 NDS

vicodin hp oral tablet 10-300 mg

4 NDS

vicodin oral tablet 5-300 mg

2 NDS

xylon oral tablet 10-200 mg

2 NDS

Anesthetics

Local Anesthetics

7t lido external gel 2 PA; QL (30 GM per 30 days)

bupivacaine fisiopharma injection solution 2.5 mg/ml

4

bupivacaine hcl (pf) injection solution 0.25 %

4

chloroprocaine hcl (pf) injection solution

4

glydo external prefilled syringe

2 PA; QL (30 ML per 30 days)

lidocaine external ointment

4 PA; QL (150 GM per 30 days)

lidocaine external patch 5 %

4 PA

lidocaine hcl (pf) injection solution

2

lidocaine hcl external gel 2 %


lidocaine hcl external solution


lidocaine hcl injection solution

2



14


lidocaine hcl urethral/mucosal external gel


lidocaine hcl urethral/mucosal external prefilled syringe


lidocaine in dextrose solution

4

lidocaine-prilocaine external cream


lidocaine-tetracaine external cream 7-7 %


PLIAGLIS EXTERNAL CREAM


polocaine injection solution

4

polocaine-mpf injection solution

4

premium lidocaine external ointment


sensorcaine-mpf injection solution 0.25 %

4

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

acamprosate calcium oral tablet delayed release

2

disulfiram oral tablet 2

VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED

5

Opioid Dependence Treatments

buprenorphine hcl sublingual tablet sublingual

2


buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 4-1 mg


buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg


buprenorphine hcl-naloxone hcl sublingual film 8-2 mg


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


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


LUCEMYRA ORAL TABLET


naltrexone hcl oral tablet

2

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


SUBOXONE SUBLINGUAL FILM 2-0.5 MG


Opioid Reversal Agents

naloxone hcl injection solution

2

naloxone hcl injection solution cartridge

2

naloxone hcl injection solution prefilled syringe

2

NARCAN NASAL LIQUID

3

Smoking Cessation Agents

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




15


CHANTIX CONTINUING MONTH PAK ORAL TABLET


CHANTIX ORAL TABLET


CHANTIX STARTING MONTH PAK ORAL TABLET


NICOTROL INHALATION INHALER


NICOTROL NS NASAL SOLUTION

3 QL (360 ML per 365 days)

Antibacterials

Aminoglycosides

amikacin sulfate injection solution

2

gentak ophthalmic ointment

2

gentamicin in saline intravenous solution

2

gentamicin sulfate external cream

2

gentamicin sulfate external ointment

2

gentamicin sulfate injection solution

2

gentamicin sulfate intravenous solution 10 mg/ml

2

gentamicin sulfate ophthalmic solution

1

neomycin sulfate oral tablet

2

neomycin-polymyxin b gu irrigation solution

2

paromomycin sulfate oral capsule

4

streptomycin sulfate intramuscular solution reconstituted

4

tobramycin ophthalmic solution

1


tobramycin sulfate injection solution

2

tobramycin sulfate injection solution reconstituted

2

TOBREX OPHTHALMIC OINTMENT

4

Antibacterials, Other

ALTABAX EXTERNAL OINTMENT

4

baciim intramuscular solution reconstituted

2

bacitracin intramuscular solution reconstituted

2

bacitracin ophthalmic ointment

2

BACTROBAN NASAL NASAL OINTMENT 2 %

4

chloramphenicol sod succinate intravenous solution reconstituted

4

CLEOCIN VAGINAL SUPPOSITORY

4

clindacin etz external swab

2

clindacin-p external swab

2

clindamycin hcl oral capsule

2

clindamycin palmitate hcl oral solution reconstituted

2

clindamycin phosphate external foam

4

clindamycin phosphate external gel

2

clindamycin phosphate external lotion

2

clindamycin phosphate external solution

2



16


clindamycin phosphate external swab

2

clindamycin phosphate in d5w intravenous solution

2

clindamycin phosphate in nacl intravenous solution

2

clindamycin phosphate injection solution

2

clindamycin phosphate intravenous solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml

2

clindamycin phosphate vaginal cream

2

CLINDESSE VAGINAL CREAM

4

colistimethate sodium (cba) injection solution reconstituted

4

CORTISPORIN EXTERNAL CREAM

4

CORTISPORIN EXTERNAL OINTMENT

4

DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED

5

DAPTOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG

5

daptomycin intravenous solution reconstituted 500 mg

5

IMPAVIDO ORAL CAPSULE

5

lincomycin hcl injection solution

2


LINEZOLID IN SODIUM CHLORIDE INTRAVENOUS SOLUTION

5

linezolid intravenous solution

5

linezolid oral suspension reconstituted


linezolid oral tablet 4 QL (56 EA per 28 days)

mafenide acetate external packet

4

methenamine hippurate oral tablet

2

METRONIDAZOLE IN NACL INTRAVENOUS SOLUTION 500-0.74 MG/100ML-%

4

metronidazole in nacl intravenous solution 500-0.79 mg/100ml-%

2

metronidazole intravenous solution 5 mg/ml

2

metronidazole oral capsule

2

metronidazole oral tablet

2

metronidazole vaginal gel

2

MONUROL ORAL PACKET

4

mupirocin calcium external cream

4

mupirocin external ointment

2

nitrofurantoin macrocrystal oral capsule

4

nitrofurantoin monohydrate macrocrystals oral capsule

2



17


nitrofurantoin oral suspension

4

ORBACTIV INTRAVENOUS SOLUTION RECONSTITUTED

5

polymyxin b sulfate injection solution reconstituted

2

PRIMSOL ORAL SOLUTION

4

silver sulfadiazine external cream

2

SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED


SIVEXTRO ORAL TABLET


SSD EXTERNAL CREAM

2

SULFAMYLON EXTERNAL CREAM

4

SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED

5

tigecycline intravenous solution reconstituted

5

trimethoprim oral tablet 1

TRIMPEX ORAL SOLUTION 50 MG/5ML

4

vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, 500-5 mg/100ml-%, 750-5 mg/150ml-%

2

vancomycin hcl intravenous solution reconstituted 1 gm, 1.25 gm, 1.5 gm, 10 gm, 100 gm, 5 gm, 500 mg, 5000 mg, 750 mg

2


VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

2

vancomycin hcl oral capsule 125 mg


vancomycin hcl oral capsule 250 mg


vancomycin hcl oral solution reconstituted

4

VANDAZOLE VAGINAL GEL

2

VIBATIV INTRAVENOUS SOLUTION RECONSTITUTED

4

XENLETA INTRAVENOUS SOLUTION

5

XENLETA ORAL TABLET

5

XIFAXAN ORAL TABLET

5 PA

Beta-lactam, Cephalosporins

AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED

5

cefaclor er oral tablet extended release 12 hour

4

cefaclor oral capsule 4

cefaclor oral suspension reconstituted

4

cefadroxil oral capsule 2

cefadroxil oral suspension reconstituted

2

cefadroxil oral tablet 2



18


cefazolin sodium injection solution reconstituted

2

cefazolin sodium intravenous solution reconstituted

2

cefazolin sodium-dextrose intravenous solution

2

cefazolin sodium-dextrose intravenous solution reconstituted

2

cefdinir oral capsule 2

cefdinir oral suspension reconstituted

2

cefditoren pivoxil oral tablet

4

cefepime hcl injection solution reconstituted

2

cefepime hcl intravenous solution

2

cefepime-dextrose intravenous solution reconstituted

2

cefixime oral capsule 3

cefixime oral suspension reconstituted

4

cefotaxime sodium injection solution reconstituted

2

cefotetan disodium injection solution reconstituted

2

cefotetan disodium-dextrose intravenous solution reconstituted

2

cefoxitin sodium injection solution reconstituted

2

cefoxitin sodium intravenous solution reconstituted

2


cefoxitin sodium-dextrose intravenous solution reconstituted

2

cefpodoxime proxetil oral suspension reconstituted

2

cefpodoxime proxetil oral tablet

2

cefprozil oral suspension reconstituted

2

cefprozil oral tablet 2

ceftazidime and dextrose intravenous solution reconstituted

2

ceftazidime injection solution reconstituted

2

ceftibuten oral capsule 400 mg

2

ceftibuten oral suspension reconstituted 180 mg/5ml

2

ceftriaxone sodium in dextrose intravenous solution

2

ceftriaxone sodium injection solution reconstituted

2

ceftriaxone sodium intravenous solution reconstituted

2

ceftriaxone sodium-dextrose intravenous solution reconstituted

2

cefuroxime axetil oral tablet

2

cefuroxime sodium injection solution reconstituted

2

cefuroxime sodium intravenous solution reconstituted

2



19


cephalexin oral capsule 1

cephalexin oral suspension reconstituted

2

cephalexin oral tablet 2

FETROJA INTRAVENOUS SOLUTION RECONSTITUTED

5

SUPRAX ORAL CAPSULE

3

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

5

suprax oral tablet chewable

3

tazicef injection solution reconstituted

2

tazicef intravenous solution reconstituted

2

TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED

5

zinacef in sterile water intravenous solution 1.5 gm

2

zinacef intravenous solution reconstituted 750 mg

2

Beta-lactam, Other

azactam in dextrose intravenous solution 1 gm/50ml

4

AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION 2 GM/50ML

4

AZACTAM INJECTION SOLUTION RECONSTITUTED

4


aztreonam injection solution reconstituted 1 gm

4

aztreonam injection solution reconstituted 2 gm

5

DORIPENEM INTRAVENOUS SOLUTION RECONSTITUTED 250 MG, 500 MG

4

ertapenem sodium injection solution reconstituted

4

imipenem-cilastatin intravenous solution reconstituted

2

INVANZ INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

4

meropenem intravenous solution reconstituted

2

meropenem-sodium chloride intravenous solution reconstituted 1 gm/50ml

5

meropenem-sodium chloride intravenous solution reconstituted 500 mg/50ml

2

VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED

4

Beta-lactam, Penicillins

amoxicillin oral capsule 1

amoxicillin oral suspension reconstituted

1

amoxicillin oral tablet 1



20


amoxicillin oral tablet chewable

1

amoxicillin-potassium clavulanate er oral tablet extended release 12 hour

4

amoxicillin-potassium clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

2

amoxicillin-potassium clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

1

amoxicillin-potassium clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

2

ampicillin oral capsule 1

ampicillin sodium injection solution reconstituted

2

ampicillin sodium intravenous solution reconstituted

2

ampicillin-sulbactam sodium injection solution reconstituted

2

ampicillin-sulbactam sodium intravenous solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm

2

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML

5

BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION

4


BICILLIN C-R INTRAMUSCULAR SUSPENSION

4

BICILLIN L-A INTRAMUSCULAR SUSPENSION

4

dicloxacillin sodium oral capsule

2

nafcillin sodium in dextrose intravenous solution

5

nafcillin sodium injection solution reconstituted 1 gm, 2 gm

4

nafcillin sodium intravenous solution reconstituted 1 gm

4

nafcillin sodium intravenous solution reconstituted 10 gm, 2 gm

5

OXACILLIN SODIUM IN DEXTROSE INTRAVENOUS SOLUTION

4

oxacillin sodium injection solution reconstituted

4

oxacillin sodium intravenous solution reconstituted

4

PENICILLIN G POT IN DEXTROSE INTRAVENOUS SOLUTION

4

penicillin g potassium injection solution reconstituted

2

penicillin g sodium injection solution reconstituted

5

penicillin v potassium oral solution reconstituted

1



21


penicillin v potassium oral tablet

1

pfizerpen injection solution reconstituted 5000000 unit

2

piperacillin sod-tazobactam so intravenous solution reconstituted

2

ZOSYN INTRAVENOUS SOLUTION

4

Macrolides

azithromycin intravenous solution reconstituted

2

AZITHROMYCIN ORAL PACKET

2

azithromycin oral suspension reconstituted

2

azithromycin oral tablet 1

clarithromycin er oral tablet extended release 24 hour

2

clarithromycin oral suspension reconstituted

2

clarithromycin oral tablet

2

DIFICID ORAL TABLET 5

ery external pad 2

ERYPED 400 ORAL SUSPENSION RECONSTITUTED

5

ery-tab oral tablet delayed release

3

erythrocin lactobionate intravenous solution reconstituted

4

erythrocin stearate oral tablet

4


erythromycin base oral capsule delayed release particles

4

erythromycin base oral tablet

4

erythromycin base oral tablet delayed release

2

erythromycin ethylsuccinate oral suspension reconstituted

4

erythromycin ethylsuccinate oral tablet

4

erythromycin external gel

2

erythromycin external pad 2 %

2

erythromycin external solution

2

erythromycin ophthalmic ointment

1

erythromycin stearate oral tablet

4

PCE ORAL TABLET DELAYED RELEASE 333 MG, 500 MG

4

ZMAX ORAL SUSPENSION RECONSTITUTED 2 GM

4

Quinolones

BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED

5

BAXDELA ORAL TABLET

5

BESIVANCE OPHTHALMIC SUSPENSION

4

CILOXAN OPHTHALMIC OINTMENT

4



22


ciprofloxacin hcl ophthalmic solution

1

ciprofloxacin hcl oral tablet

1

CIPROFLOXACIN HCL OTIC SOLUTION

2

ciprofloxacin in d5w intravenous solution

2

ciprofloxacin intravenous solution 200 mg/20ml, 400 mg/40ml

2

ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%)

2

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg, 500 mg

2

gatifloxacin ophthalmic solution

2

levofloxacin in d5w intravenous solution

2

levofloxacin intravenous solution

4

levofloxacin ophthalmic solution

2

levofloxacin oral solution

4

levofloxacin oral tablet 2

moxifloxacin hcl in nacl intravenous solution

4

MOXIFLOXACIN HCL INTRAVENOUS SOLUTION

4

moxifloxacin hcl ophthalmic solution

2

moxifloxacin hcl oral tablet

4

ofloxacin ophthalmic solution

2


ofloxacin oral tablet 2

ofloxacin otic solution 2

Sulfonamides

sulfacetamide sodium (acne) external lotion

4

sulfacetamide sodium ophthalmic ointment

2

sulfacetamide sodium ophthalmic solution

2

sulfadiazine oral tablet 4

sulfamethoxazole-trimethoprim intravenous solution

2

sulfamethoxazole-trimethoprim oral suspension

2

sulfamethoxazole-trimethoprim oral tablet

1

sulfatrim pediatric oral suspension

2

Tetracyclines

coremino oral tablet extended release 24 hour

2

demeclocycline hcl oral tablet

2

DORYX MPC ORAL TABLET DELAYED RELEASE

4

doxy 100 intravenous solution reconstituted

4

doxycycline hyclate intravenous solution reconstituted

4

doxycycline hyclate oral capsule

2

doxycycline hyclate oral tablet 100 mg, 20 mg, 75 mg

2

doxycycline hyclate oral tablet 150 mg, 50 mg

4



23


doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg

4

DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG

5

doxycycline monohydrate oral capsule

2

doxycycline monohydrate oral suspension reconstituted

2

doxycycline monohydrate oral tablet

2

MINOCIN INTRAVENOUS SOLUTION RECONSTITUTED

5

minocycline hcl er oral tablet extended release 24 hour 105 mg, 115 mg, 55 mg, 65 mg, 80 mg

5

minocycline hcl er oral tablet extended release 24 hour 135 mg, 45 mg, 90 mg

2

minocycline hcl oral capsule

2

minocycline hcl oral tablet

2

mondoxyne nl oral capsule

2

morgidox oral capsule 2

NUZYRA INTRAVENOUS SOLUTION RECONSTITUTED

5

NUZYRA ORAL TABLET

5

okebo oral capsule 2


SEYSARA ORAL TABLET

5

soloxide oral tablet delayed release 150 mg

4

tetracycline hcl oral capsule

4

VIBRAMYCIN ORAL SYRUP

4

Anticonvulsants

Anticonvulsants, Other

APTIOM ORAL TABLET

5

BRIVIACT INTRAVENOUS SOLUTION

5 PA

BRIVIACT ORAL SOLUTION

5 PA

BRIVIACT ORAL TABLET

5 PA

EPIDIOLEX ORAL SOLUTION

5 PA

FYCOMPA ORAL SUSPENSION

4

FYCOMPA ORAL TABLET 10 MG, 12 MG, 4 MG, 6 MG

5

FYCOMPA ORAL TABLET 2 MG, 8 MG

4

levetiracetam er oral tablet extended release 24 hour

2

levetiracetam in nacl solution 1000 mg/100ml intravenous

4

LEVETIRACETAM IN NACL SOLUTION 1000 MG/100ML INTRAVENOUS

4


4



24



4


4


4

levetiracetam intravenous solution

4

levetiracetam oral solution

2

levetiracetam oral tablet 1

NAYZILAM NASAL SOLUTION

5

roweepra oral tablet 1

roweepra xr oral tablet extended release 24 hour

2

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE

4

XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK

5 PA

XCOPRI (350 MG DAILY DOSE) ORAL TABLET THERAPY PACK

5 PA

XCOPRI ORAL TABLET

5 PA

XCOPRI ORAL TABLET THERAPY PACK 14 X 12.5 MG & 14 X 25 MG

4 PA


XCOPRI ORAL TABLET THERAPY PACK 14 X 150 MG & 14 X200 MG, 14 X 50 MG & 14 X100 MG

5 PA

Calcium Channel Modifying Agents

CELONTIN ORAL CAPSULE

4

ethosuximide oral capsule

2

ethosuximide oral solution

2

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 50 MG, 75 MG


LYRICA ORAL CAPSULE 300 MG


LYRICA ORAL SOLUTION


pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 50 mg, 75 mg


pregabalin oral capsule 300 mg


pregabalin oral solution 2 QL (900 ML per 30 days)

zonisamide oral capsule 2

Gamma-aminobutyric Acid (GABA) Augmenting Agents

clobazam oral suspension

5

clobazam oral tablet 10 mg

4

clobazam oral tablet 20 mg

5

clonazepam oral tablet 0.5 mg, 1 mg


clonazepam oral tablet 2 mg




25


clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg


clonazepam oral tablet dispersible 2 mg


DIACOMIT ORAL CAPSULE

5 PA

DIACOMIT ORAL PACKET

5 PA

DIASTAT ACUDIAL RECTAL GEL

4

DIASTAT PEDIATRIC RECTAL GEL

4

diazepam rectal gel 4

divalproex sodium er oral tablet extended release 24 hour

2

divalproex sodium oral capsule delayed release sprinkle

2

divalproex sodium oral tablet delayed release

2

gabapentin oral capsule 100 mg, 300 mg


gabapentin oral capsule 400 mg


gabapentin oral solution 250 mg/5ml


gabapentin oral tablet 600 mg


gabapentin oral tablet 800 mg


phenobarbital oral elixir 4 PA

phenobarbital oral tablet 4 PA

phenobarbital sodium injection solution

2 PA

primidone oral tablet 2

SABRIL ORAL TABLET 5 PA

SYMPAZAN ORAL FILM

5

tiagabine hcl oral tablet 4


valproate sodium intravenous solution 100 mg/ml

2

valproic acid oral capsule

2

valproic acid oral solution

2

VALTOCO 10 MG DOSE NASAL LIQUID


VALTOCO 15 MG DOSE NASAL LIQUID THERAPY PACK


VALTOCO 20 MG DOSE NASAL LIQUID THERAPY PACK


VALTOCO 5 MG DOSE NASAL LIQUID


vigabatrin oral packet 5 PA

vigabatrin oral tablet 5 PA

vigadrone oral packet 5 PA

Glutamate Reducing Agents

felbamate oral suspension

5

felbamate oral tablet 4

lamotrigine er oral tablet extended release 24 hour

4

lamotrigine oral kit 21 x 25 mg & 7 x 50 mg, 25 & 50 & 100 mg

4

lamotrigine oral kit 42 x 50 mg & 14x100 mg

5

lamotrigine oral tablet 1

lamotrigine oral tablet chewable

2

lamotrigine oral tablet dispersible

4

lamotrigine starter kit-blue oral kit

2

lamotrigine starter kit-green oral kit

4



26


lamotrigine starter kit-orange oral kit

2

subvenite oral tablet 1

subvenite starter kit-blue oral kit

2

subvenite starter kit-green oral kit

4

subvenite starter kit-orange oral kit

2

topiramate er oral capsule er 24 hour sprinkle

4

topiramate oral capsule sprinkle

2

topiramate oral tablet 1

Sodium Channel Agents

BANZEL ORAL SUSPENSION

5

BANZEL ORAL TABLET

5

carbamazepine er oral capsule extended release 12 hour

2

carbamazepine er oral tablet extended release 12 hour

2

carbamazepine oral suspension

2

carbamazepine oral tablet

2

carbamazepine oral tablet chewable

1

CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR

4

dilantin infatabs oral tablet chewable

4

dilantin oral capsule 4

DILANTIN ORAL SUSPENSION

4

epitol oral tablet 2


fosphenytoin sodium injection solution

2

oxcarbazepine oral suspension

4

oxcarbazepine oral tablet

2

PEGANONE ORAL TABLET

4

phenytek oral capsule 4

phenytoin infatabs oral tablet chewable

2

phenytoin oral suspension

2

phenytoin oral tablet chewable

2

phenytoin sodium extended oral capsule

2

phenytoin sodium injection solution

2

TEGRETOL ORAL SUSPENSION

4

TEGRETOL ORAL TABLET

4

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR

4

VIMPAT INTRAVENOUS SOLUTION

4

VIMPAT ORAL SOLUTION

4

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG

5

VIMPAT ORAL TABLET 50 MG

4

Antidementia Agents

Antidementia Agents, Other

ergoloid mesylates oral tablet

2



27


Cholinesterase Inhibitors

donepezil hcl oral tablet 10 mg, 5 mg

1

donepezil hcl oral tablet 23 mg

4

donepezil hcl oral tablet dispersible

1

galantamine hydrobromide er oral capsule extended release 24 hour

2

galantamine hydrobromide oral solution

4

galantamine hydrobromide oral tablet

2

rivastigmine tartrate oral capsule

2

rivastigmine transdermal patch 24 hour

4

N-methyl-D-aspartate (NMDA) Receptor Antagonist

memantine hcl er oral capsule extended release 24 hour


memantine hcl oral solution 2 mg/ml

4

memantine hcl oral tablet 10 mg, 5 mg

2

MEMANTINE HCL ORAL TABLET 28 X 5 MG & 21 X 10 MG

4

Antidepressants

Antidepressants, Other

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR

5 ST; QL (30 EA per 30 days)


bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg


bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg


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


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


bupropion hcl oral tablet 2

mirtazapine oral tablet 2

mirtazapine oral tablet dispersible

2

SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY PACK

5 PA

SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY PACK

5 PA

Monoamine Oxidase Inhibitors

EMSAM TRANSDERMAL PATCH 24 HOUR


MARPLAN ORAL TABLET

4

phenelzine sulfate oral tablet

2

tranylcypromine sulfate oral tablet

4

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor



28


citalopram hydrobromide oral solution

2

citalopram hydrobromide oral tablet

1

desvenlafaxine er oral tablet extended release 24 hour 100 mg


desvenlafaxine er oral tablet extended release 24 hour 50 mg


DESVENLAFAXINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG


DESVENLAFAXINE FUMARATE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG


desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg


desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg, 50 mg


DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE SPRINKLE 20 MG, 60 MG


DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE SPRINKLE 30 MG, 40 MG


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


duloxetine hcl oral capsule delayed release particles 30 mg, 40 mg



escitalopram oxalate oral solution

1

escitalopram oxalate oral tablet

1

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR


FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK


fluoxetine hcl (pmdd) oral capsule 10 mg, 20 mg

2

fluoxetine hcl oral capsule

1

fluoxetine hcl oral capsule delayed release


fluoxetine hcl oral solution

2

fluoxetine hcl oral tablet 2

fluvoxamine maleate er oral capsule extended release 24 hour


fluvoxamine maleate oral tablet

2

maprotiline hcl oral tablet

2

nefazodone hcl oral tablet

4

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg


olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg


paroxetine hcl er oral tablet extended release 24 hour

4

paroxetine hcl oral tablet

4

paroxetine mesylate oral capsule




29


PAXIL ORAL SUSPENSION

4

PEXEVA ORAL TABLET 10 MG, 20 MG, 40 MG


PEXEVA ORAL TABLET 30 MG


sertraline hcl oral concentrate

2

sertraline hcl oral tablet 1

trazodone hcl oral tablet 2

TRINTELLIX ORAL TABLET


venlafaxine hcl er oral capsule extended release 24 hour

2

venlafaxine hcl er oral tablet extended release 24 hour

4

venlafaxine hcl oral tablet

2

VIIBRYD ORAL TABLET


VIIBRYD STARTER PACK ORAL KIT


Tricyclics

amitriptyline hcl oral tablet

4 PA

amoxapine oral tablet 4

chlordiazepoxide-amitriptyline oral tablet

4 PA

clomipramine hcl oral capsule

4

desipramine hcl oral tablet

4

doxepin hcl oral capsule 4 PA

doxepin hcl oral concentrate

4 PA

imipramine hcl oral tablet

4


imipramine pamoate oral capsule

4

nortriptyline hcl oral capsule

2

nortriptyline hcl oral solution

2

perphenazine-amitriptyline oral tablet

4 PA

protriptyline hcl oral tablet

2

trimipramine maleate oral capsule

4

Antiemetics

Antiemetics, Other

AKYNZEO ORAL CAPSULE

4 B/D; QL (2 EA per 30 days)

compro rectal suppository

2

doxylamine-pyridoxine oral tablet delayed release


droperidol injection solution

2

meclizine hcl oral tablet 4

phenadoz rectal suppository 12.5 mg, 25 mg

4 PA

phenergan rectal suppository 12.5 mg, 25 mg, 50 mg

4 PA

prochlorperazine edisylate injection solution 10 mg/2ml

4

prochlorperazine maleate oral tablet

1

prochlorperazine rectal suppository

2

promethazine hcl injection solution

4 PA

promethazine hcl oral syrup

3 PA



30


promethazine hcl oral tablet

4 PA

promethazine hcl rectal suppository

4 PA

promethegan rectal suppository

4 PA

scopolamine transdermal patch 72 hour

4

trimethobenzamide hcl oral capsule

4 B/D

Emetogenic Therapy Adjuncts

ANZEMET ORAL TABLET 100 MG


ANZEMET ORAL TABLET 50 MG


aprepitant oral capsule 125 mg




aprepitant oral capsule 80 & 125 mg




CINVANTI INTRAVENOUS EMULSION

4

dronabinol oral capsule 4 PA; QL (60 EA per 30 days)

EMEND ORAL SUSPENSION RECONSTITUTED


FOSAPREPITANT DIMEGLUMINE INTRAVENOUS SOLUTION RECONSTITUTED

4

granisetron hcl intravenous solution

2

granisetron hcl oral tablet



ondansetron hcl injection solution

2

ondansetron hcl oral solution

4 B/D; QL (450 ML per 30 days)

ondansetron hcl oral tablet 24 mg


ondansetron hcl oral tablet 4 mg, 8 mg

1 B/D

ondansetron odt oral tablet dispersible

1 B/D

palonosetron hcl intravenous solution

2

palonosetron hcl intravenous solution prefilled syringe

2

SANCUSO TRANSDERMAL PATCH


SYNDROS ORAL SOLUTION


Antifungals

Antifungals

ABELCET INTRAVENOUS SUSPENSION

5 B/D

AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED

5 B/D

AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG, 50 MG

5 B/D

amphotericin b intravenous solution reconstituted

4 B/D

caspofungin acetate intravenous solution reconstituted

5



31


ciclodan external cream 0.77 %

2

ciclodan external solution

2 PA

ciclopirox external gel 2

ciclopirox external shampoo

2

ciclopirox external solution

2 PA

ciclopirox olamine external cream

2

ciclopirox olamine external suspension

2

clotrimazole external cream

1

clotrimazole external solution

2

clotrimazole mouth/throat lozenge

2

clotrimazole-betamethasone external cream

1

clotrimazole-betamethasone external lotion

2

CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED

5

CRESEMBA ORAL CAPSULE

5

econazole nitrate external cream

2

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

4


EXELDERM EXTERNAL CREAM

4

EXELDERM EXTERNAL SOLUTION

4

fluconazole in dextrose intravenous solution 200 mg/100ml, 400 mg/200ml

2

fluconazole in sodium chloride intravenous solution

2

fluconazole oral suspension reconstituted

2

fluconazole oral tablet 2

flucytosine oral capsule 5

griseofulvin microsize oral suspension

2

griseofulvin microsize oral tablet

4

griseofulvin ultramicrosize oral tablet

4

gynazole-1 vaginal cream

4

itraconazole oral capsule

4 PA

itraconazole oral solution

5 PA

JUBLIA EXTERNAL SOLUTION

4

ketoconazole external cream

2

ketoconazole external foam

4

ketoconazole external shampoo

1

ketoconazole oral tablet 2

ketodan external foam 4

MENTAX EXTERNAL CREAM

4



32


micafungin sodium intravenous solution reconstituted

5

miconazole 3 vaginal suppository

2

MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED

5

naftifine hcl external cream

4

naftifine hcl external gel 2

NAFTIN EXTERNAL GEL

4

NATACYN OPHTHALMIC SUSPENSION

4

NOXAFIL INTRAVENOUS SOLUTION

5

NOXAFIL ORAL SUSPENSION

5

NOXAFIL ORAL TABLET DELAYED RELEASE

5

nyamyc external powder

2

nyata external powder 100000 unit/gm

2

nystatin external cream 1

nystatin external ointment

2

nystatin external powder

2

nystatin mouth/throat suspension

1

nystatin oral tablet 2

nystatin-triamcinolone external cream

2

nystatin-triamcinolone external ointment

2

nystop external powder 2


ONMEL ORAL TABLET 200 MG

5 PA

oxiconazole nitrate external cream

4

OXISTAT EXTERNAL LOTION

4

posaconazole oral tablet delayed release

5

sulconazole nitrate external cream

2

sulconazole nitrate external solution

2

terbinafine hcl oral tablet


terconazole vaginal cream

2

terconazole vaginal suppository

2

TOLSURA ORAL CAPSULE

5 PA

voriconazole intravenous solution reconstituted

5

voriconazole oral suspension reconstituted

5

voriconazole oral tablet 5

Antigout Agents

Antigout Agents

allopurinol oral tablet 1

allopurinol sodium intravenous solution reconstituted

4

COLCHICINE ORAL CAPSULE

3

colchicine oral tablet 3

colchicine-probenecid oral tablet

2

febuxostat oral tablet 2

GLOPERBA ORAL SOLUTION

4 ST



33


KRYSTEXXA INTRAVENOUS SOLUTION

5 PA

probenecid oral tablet 2

ULORIC ORAL TABLET

3 ST

Anti-inflammatory Agents

Glucocorticoids

hydrocortisone (perianal) external cream

2

procto-med hc external cream

2

procto-pak external cream

2

proctosol hc external cream

2

proctozone-hc external cream

2

triamcinolone acetonide external aerosol solution

4

Antimigraine Agents

Antimigraine Agents

REYVOW ORAL TABLET


UBRELVY ORAL TABLET 50 MG


Ergot Alkaloids

dihydroergotamine mesylate injection solution

5

dihydroergotamine mesylate nasal solution


ERGOMAR SUBLINGUAL TABLET SUBLINGUAL

3

ergotamine-caffeine oral tablet

2

migergot rectal suppository

5


Prophylactic

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML


AIMOVIG 4 PA; QL (2 ML per 30 days)

EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE


EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR


EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE


NURTEC ORAL TABLET DISPERSIBLE


timolol maleate oral tablet

2

UBRELVY ORAL TABLET 100 MG


Serotonin (5-HT) 1b/1d Receptor Agonists

almotriptan malate oral tablet


eletriptan hydrobromide oral tablet


frovatriptan succinate oral tablet


naratriptan hcl oral tablet


rizatriptan benzoate oral tablet


rizatriptan benzoate oral tablet dispersible


sumatriptan nasal solution




34


sumatriptan succinate oral tablet


SUMATRIPTAN SUCCINATE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE


sumatriptan succinate subcutaneous solution


sumatriptan succinate subcutaneous solution auto-injector


sumatriptan succinate subcutaneous solution prefilled syringe


sumatriptan-naproxen sodium oral tablet


TOSYMRA NASAL SOLUTION


zolmitriptan oral tablet 2 QL (12 EA per 30 days)

zolmitriptan oral tablet dispersible 2.5 mg


zolmitriptan oral tablet dispersible 5 mg


Antimyasthenic Agents

Parasympathomimetics

GUANIDINE HCL ORAL TABLET

4

MESTINON ORAL SOLUTION

5

pyridostigmine bromide er oral tablet extended release

4

pyridostigmine bromide oral solution

5

pyridostigmine bromide oral tablet 60 mg

2

REGONOL INTRAVENOUS SOLUTION

4


Antimycobacterials

Antimycobacterials, Other

dapsone oral tablet 2

rifabutin oral capsule 4

Antituberculars

CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED

4

cycloserine oral capsule 4

ethambutol hcl oral tablet

2

isoniazid injection solution

4

isoniazid oral syrup 2

isoniazid oral tablet 1

paser oral packet 4

PRIFTIN ORAL TABLET

4

pyrazinamide oral tablet 2

rifampin intravenous solution reconstituted

4

rifampin oral capsule 2

RIFATER ORAL TABLET

4

SIRTURO ORAL TABLET

5

TRECATOR ORAL TABLET

4

Antineoplastics

Alkylating Agents

BELRAPZO INTRAVENOUS SOLUTION

5

bendamustine hcl intravenous solution

5

BENDEKA INTRAVENOUS SOLUTION

5



35


BICNU INTRAVENOUS SOLUTION RECONSTITUTED

5

busulfan intravenous solution

5

carboplatin intravenous solution

2

carmustine intravenous solution reconstituted

5

cisplatin intravenous solution

2

cyclophosphamide injection solution reconstituted

5

cyclophosphamide oral capsule

2 B/D

dacarbazine intravenous solution reconstituted

2

EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED

5

GLEOSTINE ORAL CAPSULE

4

HEXALEN ORAL CAPSULE 50 MG

5

ifosfamide intravenous solution

4

ifosfamide intravenous solution reconstituted 1 gm

4

IFOSFAMIDE INTRAVENOUS SOLUTION RECONSTITUTED 3 GM

4

KISQALI FEMARA (400 MG DOSE) ORAL TABLET THERAPY PACK

5 PA


KISQALI FEMARA (600 MG DOSE) ORAL TABLET THERAPY PACK

5 PA

KISQALI FEMARA(200 MG DOSE) ORAL TABLET THERAPY PACK

5 PA

LEUKERAN ORAL TABLET

5

MATULANE ORAL CAPSULE

5

melphalan hcl intravenous solution reconstituted

5

MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG

5

oxaliplatin intravenous solution

4

oxaliplatin intravenous solution reconstituted

5

paraplatin intravenous solution

2

TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED

5

TEPADINA INJECTION SOLUTION RECONSTITUTED 100 MG

5

thiotepa injection solution reconstituted

5

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED

5

VALCHLOR EXTERNAL GEL

5 PA



36


YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED

5

ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED

5

Antiandrogens

abiraterone acetate oral tablet

5 PA

bicalutamide oral tablet 2

ERLEADA ORAL TABLET

5 PA

flutamide oral capsule 2

nilutamide oral tablet 5

NUBEQA ORAL TABLET

5 PA

XTANDI ORAL CAPSULE

5 PA

YONSA ORAL TABLET 5 PA

ZYTIGA ORAL TABLET 500 MG

5 PA

Antiangiogenic Agents

POMALYST ORAL CAPSULE

5 PA

QINLOCK ORAL TABLET

5 PA

REVLIMID ORAL CAPSULE

5 PA

TABRECTA ORAL TABLET 150 MG

5 PA

TABRECTA ORAL TABLET 200 MG


THALOMID ORAL CAPSULE

5 PA

Antiestrogens/Modifiers

EMCYT ORAL CAPSULE

5


FASLODEX INTRAMUSCULAR SOLUTION

5

fulvestrant intramuscular solution

5

SOLTAMOX ORAL SOLUTION

5

tamoxifen citrate oral tablet

2

toremifene citrate oral tablet

5

Antimetabolites

adrucil intravenous solution 2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml

2 B/D

ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED

5

ARRANON INTRAVENOUS SOLUTION

5

cladribine intravenous solution

5 B/D

clofarabine intravenous solution

5

cytarabine (pf) injection solution

2 B/D

cytarabine injection solution

2 B/D

DROXIA ORAL CAPSULE

4

floxuridine injection solution reconstituted

5 B/D

FLUOROPLEX EXTERNAL CREAM

5

fluorouracil external cream 0.5 %

5

fluorouracil external cream 5 %

2

fluorouracil external solution

2



37


fluorouracil intravenous solution

2 B/D

FOLOTYN INTRAVENOUS SOLUTION

5 PA

gemcitabine hcl intravenous solution

5

gemcitabine hcl intravenous solution reconstituted 1 gm, 200 mg

4

gemcitabine hcl intravenous solution reconstituted 2 gm

5

hydroxyurea oral capsule

2

INFUGEM INTRAVENOUS SOLUTION

5

LONSURF ORAL TABLET

5 PA

mercaptopurine oral tablet

2

NIPENT INTRAVENOUS SOLUTION RECONSTITUTED

5

PURIXAN ORAL SUSPENSION

5

SIKLOS ORAL TABLET 100 MG

4 PA

SIKLOS ORAL TABLET 1000 MG

5 PA

TABLOID ORAL TABLET

4

VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED

5 PA

Antineoplastics, Other

ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED

5


adriamycin intravenous solution

2 B/D

adriamycin intravenous solution reconstituted

2 B/D

amifostine intravenous solution reconstituted 500 mg

5

arsenic trioxide intravenous solution 10 mg/10ml

4

arsenic trioxide intravenous solution 12 mg/6ml

5

ASPARLAS INTRAVENOUS SOLUTION

5

azacitidine injection suspension reconstituted

5

BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

bleomycin sulfate injection solution reconstituted

2 B/D

BORTEZOMIB INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

BRAFTOVI ORAL CAPSULE

5 PA

CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED

5

COPIKTRA ORAL CAPSULE

5 PA

COTELLIC ORAL TABLET

5 PA

dactinomycin intravenous solution reconstituted

5



38


daunorubicin hcl intravenous solution 20 mg/4ml

4

daunorubicin hcl intravenous solution 50 mg/10ml

2

DAURISMO ORAL TABLET

5 PA

decitabine intravenous solution reconstituted

5 PA

dexrazoxane hcl intravenous solution reconstituted

5

DOCEFREZ INTRAVENOUS SOLUTION RECONSTITUTED 20 MG

5

docetaxel intravenous concentrate 160 mg/8ml, 20 mg/ml, 80 mg/4ml

5

DOCETAXEL INTRAVENOUS CONCENTRATE 200 MG/10ML

5

docetaxel intravenous solution

5

doxorubicin hcl intravenous solution

2 B/D

doxorubicin hcl intravenous solution reconstituted 10 mg, 50 mg

2 B/D

doxorubicin hcl liposomal intravenous injectable

5

ELZONRIS INTRAVENOUS SOLUTION

5 PA

epirubicin hcl intravenous solution

2


ERWINAZE INJECTION SOLUTION RECONSTITUTED

5

FARYDAK ORAL CAPSULE

5 PA

fludarabine phosphate intravenous solution reconstituted

4

HALAVEN INTRAVENOUS SOLUTION

5 PA

IBRANCE ORAL CAPSULE

5 PA

IBRANCE ORAL TABLET

5 PA

idarubicin hcl intravenous solution

5

INREBIC ORAL CAPSULE

5 PA

ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED

5 PA

IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED

5

JEVTANA INTRAVENOUS SOLUTION

5 PA

KISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK

5 PA


5 PA


5 PA

leucovorin calcium injection solution 100 mg/10ml

2 B/D



39


leucovorin calcium injection solution 500 mg/50ml

2

leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 350 mg, 50 mg

2

leucovorin calcium injection solution reconstituted 500 mg

4

leucovorin calcium oral tablet

2

levoleucovorin calcium intravenous solution 175 mg/17.5ml

5

LEVOLEUCOVORIN CALCIUM INTRAVENOUS SOLUTION RECONSTITUTED 175 MG

5

levoleucovorin calcium intravenous solution reconstituted 50 mg

5

levoleucovorin calcium pf intravenous solution

5

lipodox 50 intravenous injectable 2 mg/ml

5

LORBRENA ORAL TABLET

5 PA

LYNPARZA ORAL CAPSULE 50 MG

5 PA

LYNPARZA ORAL TABLET

5 PA

MARQIBO INTRAVENOUS SUSPENSION

5

MEKTOVI ORAL TABLET

5 PA

mitomycin intravenous solution reconstituted

5

mitoxantrone hcl intravenous concentrate

2 PA


mutamycin intravenous solution reconstituted

5

NERLYNX ORAL TABLET


NINLARO ORAL CAPSULE

5 PA

ONCASPAR INJECTION SOLUTION

5

paclitaxel intravenous concentrate

2

PEMAZYRE ORAL TABLET


PIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK

5 PA


5 PA


5 PA

PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED

5

RETEVMO ORAL CAPSULE

5 PA

ROMIDEPSIN INTRAVENOUS SOLUTION

5 PA

romidepsin intravenous solution reconstituted

5 PA

ROZLYTREK ORAL CAPSULE

5 PA

RYDAPT ORAL CAPSULE

5 PA

SYLATRON SUBCUTANEOUS KIT

5 PA



40


SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED

5 PA

TALZENNA ORAL CAPSULE

5 PA

TAZVERIK ORAL TABLET

5 PA

TENIPOSIDE INTRAVENOUS SOLUTION

5

THERACYS INTRAVESICAL SUSPENSION RECONSTITUTED 81 MG/VIAL

5

TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED

4

TRISENOX INTRAVENOUS SOLUTION

5

TUKYSA ORAL TABLET

5 PA

valrubicin intravesical solution

5

VALSTAR INTRAVESICAL SOLUTION

5

VELCADE INJECTION SOLUTION RECONSTITUTED

Date post:	08-Jul-2020
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