Rx Drug Formulary - shared.portals.lumeris.io

Rx Drug FormularyMEDIC A RE A DVA NTAGE | 202 2

ESSENCE ADVANTAGE PLATINUM (HMO) bull ESSENCE ADVANTAGE GOLD (HMO)

This formulary was updated on 10052021 For more recent information or other questions please contact Essence Healthcare Customer Service at 1-855-996-8422 (TTY 711) from 8 am to 8 pm You may reach a messaging service on weekends from April 1 through September 30 and holidays Please leave a message and your call will be returned the next business day

Serving the California counties of Alameda San Mateo and Santa Clara

Essence Advantage (HMO)

2022 Formulary

(List of Covered Drugs)

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

Note to existing members This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take When this drug list (formulary) refers to ldquowerdquo ldquousrdquo or ldquoourrdquo it means Essence Advantage (HMO) When it refers to ldquoplanrdquo or ldquoour planrdquo it means Essence Advantage Platinum (HMO) and Essence Advantage Gold (HMO) This document includes a list of the drugs (formulary) for our plan which is current as of October 2021 For an updated formulary please contact us Our contact information along with the date we last updated the formulary appears on the front and back cover pages You must generally use network pharmacies to use your prescription drug benefit Benefits formulary pharmacy network andor copaymentscoinsurance may change on January 1 2023 and from time to time during the year

HPMS Approved Formulary File Submission ID 22306 Version Number 7

Y0027_22-219_C i

What is the Essence Advantage (HMO) Formulary A formulary is a list of covered drugs selected by our plan 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 We will generally cover the drugs listed in our formulary as long as the drug is medically necessary the prescription is filled at a plan network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage

Can the Formulary (drug list) change Most changes in drug coverage happen on January 1 but we may add or remove drugs on the Drug List during the year move them to different cost-sharing tiers or add new restrictions We must follow the 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 ldquoHow do I request an exception to the Essence Advantage (HMO) Formularyrdquo

Drugs removed from the market If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drugrsquos 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 both Or we may make changes based on new clinical guidelines If we remove drugs from our formulary or add prior authorization quantity limits andor 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 ldquoHow do I request an exception to the Essence Advantage (HMO) Formularyrdquo

ii

Changes that will not affect you if you are currently taking the drug Generally if you are taking a drug on our 2022 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2022 coverage year except as described above This means these drugs will remain available at the same cost sharing and with no new restrictions for those members taking them for the remainder of the coverage year You will not get direct notice this year about changes that do not affect you However on January 1 of the next year such changes would affect you and it is important to check the Drug List for the new benefit year for any changes to drugs The enclosed formulary is current as of October 2021 To get updated information about the drugs covered by our plan please contact us Our contact information appears on the front and back cover pages If we make other types of formulary changes than those listed above (non-maintenance changes) we will mail written notification to affected members in the form of Formulary Errata Sheets

How do I use the Formulary There are two ways to find your drug within the formulary

Medical Condition The formulary begins on page 1 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 ldquoCardiovascular Agentsrdquo If you know what your drug is used for look for the category name in the list that begins on page number 1 Then look under the category name for your drug

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 I-1 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 Our plan 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

iii

Prior Authorization We require you or your physician to get prior authorization for certain drugs This means that you will need to get approval from us before you fill your prescriptions If you donrsquot get approval we may not cover the drug

Quantity Limits For certain drugs we limit the amount of the drug that we will cover For example we provide eighteen per prescription for sumatriptan 50mg tablet This may be in addition to a standard one-month or three-month supply

Step Therapy In some cases we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition For example if Drug A and Drug B both treat your medical condition 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 out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1 You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site We have posted online documents that explain our prior authorization and step therapy restrictions You may also ask us to send you a copy Our contact information along with the date we last updated the formulary appears on the front and back cover pages

You can ask us 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 ldquoHow do I request an exception to the Essence Advantage formularyrdquo on page iv 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 Service and ask if your drug is covered

If you learn that our plan does not cover your drug you have two options

You can ask Customer Service for a list of similar drugs that are covered by our plan When you receive the list show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan

You can ask us 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 Essence Advantage (HMO Formulary You can ask us to make an exception to our coverage rules There are several types of exceptions that you can ask us to make

iv

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 cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier (Tier 5) or Tier 6 If approved this would lower the amount you must pay for your drug

You can ask us to waive coverage restrictions or limits on your drug For example for certain drugs we limit 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 we will only approve your request for an exception if the alternative drugs included on the planrsquos formulary the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition andor would cause you to have adverse medical effects You should contact us to ask us for an initial coverage decision for a formulary tiering or utilization restriction exception When you request a formulary tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request Generally we must make our decision within 72 hours of getting your prescriberrsquos 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 wersquoll 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 Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug Examples include beneficiaries who are entering a long-term care facility are discharged from a hospital to home or are ending a long-term care stay and returning to the community

v

For more information For more detailed information about your Essence Advantage prescription drug coverage please review your Evidence of Coverage and other plan materials If you have questions about Essence 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 day7 day a week TTY users should call 1-877-486-2048 Or visit httpwwwmedicaregov

Essence Advantage Formulary The formulary below provides coverage information about the drugs covered by Essence Advantage If you have trouble finding your drug in the list turn to the Index that begins on page I-1 The first column of the chart lists the drug name Brand name drugs are capitalized (eg HUMIRA) and generic drugs are listed in lower-case italics (eg warfarin) The information in the RequirementsLimits column tells you if Essence Advantage has any special requirements for coverage of your drug

List of Abbreviations

CB Capped benefit For drugs not normally covered in a Medicare Prescription Drug Plan we limit the amount of the drug that the plan will cover For example we provide six tablets per 30-day prescription for sildenafil

EX This prescription drug is not normally covered in a Medicare Prescription Drug Plan The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is the amount you pay does not help you qualify for catastrophic coverage) In addition if you are receiving extra help to pay for your prescriptions you will not get any extra help to pay for this drug

GC Gap Coverage We provide additional coverage of this prescription drug during the coverage gap Please refer to our Evidence of Coverage for more information about this coverage

LA Limited Access This prescription may be available only at certain pharmacies For more information consult your Provider Directory or call customer service at 1-855-996-8422 (TTY 711) from 8 am to 8 pm You may reach a messaging service on weekends from April 1 through September 30 and holidays Please leave a message and your call will be returned the next business day or visit wwwEverythingEssencecom

NDS Non-Extended Days Supply This drug can only be obtained for a one-month supply or less You cannot fill a prescription for more than a one-month supply

NM Non-Mail Order The prescription cannot be filled by a plan network mail order pharmacy

vii

PA Prior Authorization We require you or your physician to get prior authorization for certain drugs This means that you will need to get approval from Essence Advantage before you fill your prescriptions If you dont get approval the plan may not cover the drug

PA BvD Prior Authorization for Part B vs Part D Determination This prescription drug has a Part B versus D administrative prior authorization requirement You (or your physician) are required to get prior authorization from us to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug Without prior approval the plan may not cover this drug

PA NSO Prior Authorization New Starts Only If you are a new member or if you have not taken this drug before you or your physician are required to get prior authorization from Essence Advantage before you fill your prescription for this drug Without prior approval the plan may not cover this drug

QL Quantity Limit For certain drugs we limit the amount of the drug that the plan will cover For example we provide eighteen tablets per prescription for sumatriptan succinate This may be in addition to a standard one-month or three-month supply

SI Select Insulins which are part of the Insulin Savings Program and therefore will incur low consistent copays through the Coverage Gap phase See the Evidence of Coverage for more information regarding Select Insulins including full cost-sharing information

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

For information regarding copayment amounts andor coinsurance percentages refer to Chapter 6 Section 52and Section 54 in your Evidence of Coverage

viii

Table of Contents

Analgesics3Anesthetics 9Anti-AddictionSubstance Abuse Treatment Agents 9Antianxiety Agents 11Antibacterials 12Anticancer Agents 20Anticonvulsants37Antidementia Agents 42Antidepressants 43Antidiabetic Agents 46Antifungals51Antigout Agents 53Antihistamines53Anti-Infectives (Skin And Mucous Membrane)54Antimigraine Agents54Antimycobacterials55Antinausea Agents56Antiparasite Agents 57Antiparkinsonian Agents58Antipsychotic Agents60Antivirals (Systemic)66Blood ProductsModifiersVolume Expanders 72Caloric Agents76Cardiovascular Agents 78Central Nervous System Agents 91Contraceptives95Dental And Oral Agents 103Dermatological Agents 104Devices 110Enzyme ReplacementModifiers 148Eye Ear Nose Throat Agents 150Gastrointestinal Agents 154Genitourinary Agents 158Heavy Metal Antagonists 159Hormonal Agents StimulantReplacementModifying160Immunological Agents167

1

Inflammatory Bowel Disease Agents 177Metabolic Bone Disease Agents178Miscellaneous Therapeutic Agents180Ophthalmic Agents 182Replacement Preparations 183Respiratory Tract Agents 185Skeletal Muscle Relaxants 190Sleep Disorder Agents 191Vasodilating Agents191

2

Drug Name Drug Tier RequirementsLimits

AnalgesicsAnalgesics Miscellaneousacetaminophen-codeine oral solution120-12 mg5 ml

1 GC NDS QL (4500 per 30 days)

acetaminophen-codeine oral tablet300-15 mg 300-30 mg

2 NDS QL (360 per 30 days)

acetaminophen-codeine oral tablet300-60 mg


ascomp with codeine oral capsule30-50-325-40 mg

(codeine-butalbital-asa-caff)


buprenorphine hcl injection solution03 mgml

(Buprenex) 2

buprenorphine hcl injection syringe03 mgml

2

buprenorphine transdermal patch weekly 10 mcghour 15 mcghour 20 mcghour 5 mcghour 75 mcghour

(Butrans) 2 NDS QL (4 per 28 days)

butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg

(Fioricet with Codeine) 2 NDS QL (180 per 30 days)



butalbital-acetaminophen oral tablet50-325 mg

(Tencon) 2 QL (180 per 30 days)

butalbital-acetaminophen-caff oral capsule 50-325-40 mg

(Zebutal) 2 QL (180 per 30 days)

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

(Esgic) 2 QL (180 per 30 days)

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

2 QL (180 per 30 days)

butalbital-aspirin-caffeine oral tablet 50-325-40 mg


butorphanol nasal spraynon-aerosol10 mgml


codeine sulfate oral tablet 30 mg 60 mg


codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg

(Ascomp with Codeine)


endocet oral tablet 10-325 mg (oxycodone-acetaminophen)


You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document

3


endocet oral tablet 25-325 mg 5-325 mg

(oxycodone-acetaminophen)




fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 400 mcg 600 mcg 800 mcg

(Actiq) 5 PA NM NDS QL (120 per 30 days)

fentanyl citrate buccal lozenge on a handle 200 mcg

(Actiq) 2 PA NDS QL (120 per 30 days)

fentanyl transdermal patch 72 hour100 mcghr 12 mcghr 25 mcghr 50 mcghr 75 mcghr


hydrocodone-acetaminophen oral solution 75-325 mg15 ml


hydrocodone-acetaminophen oral tablet 10-300 mg

(Vicodin HP) 2 NDS QL (180 per 30 days)

hydrocodone-acetaminophen oral tablet 10-325 mg 75-300 mg 75-325 mg




hydrocodone-ibuprofen oral tablet10-200 mg 5-200 mg 75-200 mg


hydromorphone (pf) injection solution 10 (mgml) (5 ml) 10 mgml

2

hydromorphone oral liquid 1 mgml (Dilaudid) 2 NDS QL (1200 per 30 days)

hydromorphone oral tablet 2 mg 4 mg 8 mg

(Dilaudid) 2 NDS QL (180 per 30 days)

LAZANDA NASAL SPRAYNON-AEROSOL 100 MCGSPRAY 300 MCGSPRAY 400 MCGSPRAY

5 PA NM NDS QL (30 per 30 days)

methadone injection solution 10 mgml


methadone oral solution 10 mg5 ml 2 NDS QL (600 per 30 days)



4


methadone oral tablet 10 mg 2 NDS QL (120 per 30 days)


methadose oral tabletsoluble 40 mg (methadone) 2 NDS QL (30 per 30 days)

morphine concentrate oral solution100 mg5 ml (20 mgml)

2 PA NDS QL (180 per 30 days)

morphine oral solution 10 mg5 ml 2 NDS QL (700 per 30 days)

morphine oral solution 20 mg5 ml (4 mgml)


MORPHINE ORAL TABLET 15 MG




morphine oral tablet extended release 100 mg 200 mg 60 mg

(MS Contin) 2 NDS QL (60 per 30 days)

morphine oral tablet extended release 15 mg 30 mg


oxycodone oral capsule 5 mg 2 NDS QL (180 per 30 days)

oxycodone oral concentrate 20 mgml


oxycodone oral solution 5 mg5 ml 2 NDS QL (1300 per 30 days)

oxycodone oral tablet 10 mg 2 NDS QL (180 per 30 days)

oxycodone oral tablet 15 mg 30 mg (Roxicodone) 2 NDS QL (120 per 30 days)


oxycodone oral tablet 5 mg (Roxicodone) 2 NDS QL (180 per 30 days)

oxycodone oral tabletoral onlyextrel12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 60 mg 80 mg

(OxyContin) 3 NDS QL (60 per 30 days)

oxycodone-acetaminophen oral tablet 10-325 mg

(Endocet) 2 NDS QL (180 per 30 days)

oxycodone-acetaminophen oral tablet 25-325 mg 5-325 mg



5




oxycodone-aspirin oral tablet48355-325 mg


OXYCONTIN ORAL TABLETORAL ONLYEXTREL12 HR 10 MG 15 MG 20 MG 30 MG 40 MG 60 MG 80 MG

(oxycodone) 3 NDS QL (60 per 30 days)

oxymorphone oral tablet 10 mg 2 NDS QL (120 per 30 days)


oxymorphone oral tablet extended release 12 hr 10 mg 15 mg 20 mg 30 mg 40 mg 5 mg 75 mg


tencon oral tablet 50-325 mg (butalbital-acetaminophen)


tramadol oral tablet 50 mg (Ultram) 1 GC NDS QL (240 per 30 days)

tramadol-acetaminophen oral tablet375-325 mg

(Ultracet) 2 NDS QL (300 per 30 days)

vicodin hp oral tablet 10-300 mg (hydrocodone-acetaminophen)


XTAMPZA ER ORAL CAPSPRINKLER12HR(DONT CRUSH) 135 MG 18 MG 9 MG


XTAMPZA ER ORAL CAPSPRINKLER12HR(DONT CRUSH) 27 MG




zebutal oral capsule 50-325-40 mg (butalbital-acetaminophen-caff)


Nonsteroidal Anti-Inflammatory Agentscelecoxib oral capsule 100 mg 200 mg 400 mg 50 mg

(Celebrex) 2 QL (60 per 30 days)

diclofenac epolamine transdermal patch 12 hour 13

(Flector) 4 PA QL (60 per 30 days)


6


diclofenac potassium oral tablet 50 mg

(Cataflam) 2 QL (120 per 30 days)

diclofenac sodium oral tablet extended release 24 hr 100 mg


diclofenac sodium oral tabletdelayed release (drec) 25 mg






diclofenac sodium topical drops 15


diclofenac sodium topical gel 1 (Arthritis Pain (diclofenac))

2 QL (1000 per 30 days)

diclofenac sodium topical gel 3 2 PA QL (100 per 28 days)

diclofenac-misoprostol oral tabletirdelayed relbiphasic 50-200 mg-mcg

(Arthrotec 50) 2


(Arthrotec 75) 2

diflunisal oral tablet 500 mg 2

etodolac oral capsule 200 mg 300 mg

2

etodolac oral tablet 400 mg (Lodine) 2

etodolac oral tablet 500 mg 2

fenoprofen oral tablet 600 mg (Nalfon) 2

flurbiprofen oral tablet 100 mg 2

ibu oral tablet 400 mg 600 mg 800 mg

(ibuprofen) 1 GC

ibuprofen oral suspension 100 mg5 ml

(Childrens Advil) 2

ibuprofen oral tablet 400 mg 600 mg 800 mg

(IBU) 1 GC

ibuprofen-famotidine oral tablet800-266 mg

(Duexis) 2 PA QL (90 per 30 days)

indomethacin oral capsule 25 mg 1 GC QL (240 per 30 days)



7


indomethacin oral capsule extended release 75 mg


ketoprofen oral capsule 50 mg 75 mg

2

ketoprofen oral capsuleext rel pellets 24 hr 200 mg

2

ketorolac injection cartridge 15 mgml




ketorolac injection solution 15 mgml


ketorolac injection solution 30 mgml (1 ml)


ketorolac injection syringe 15 mgml 2 QL (40 per 30 days)


ketorolac intramuscular cartridge 60 mg2 ml


ketorolac intramuscular solution 60 mg2 ml


ketorolac intramuscular syringe 60 mg2 ml


ketorolac oral tablet 10 mg 2 QL (20 per 30 days)

mefenamic acid oral capsule 250 mg 2

meloxicam oral tablet 15 mg 75 mg (Mobic) 1 GC

nabumetone oral tablet 500 mg 750 mg

(Relafen) 2

naproxen oral tablet 250 mg 375 mg

1 GC

naproxen oral tablet 500 mg (Naprosyn) 1 GC

naproxen oral tabletdelayed release (drec) 375 mg 500 mg

(EC-Naprosyn) 2

naproxen-esomeprazole oral tabletirdelayed relbiphasic 375-20 mg

(Vimovo) 5 PA NM NDS QL (60 per 30 days)

PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 MGGRAM ACTUATION(2 )


piroxicam oral capsule 10 mg 20 mg

(Feldene) 2


8


sulindac oral tablet 150 mg 200 mg 2

tolmetin oral capsule 400 mg 2

tolmetin oral tablet 200 mg 600 mg 2

AnestheticsLocal Anestheticsglydo mucous membrane jelly in applicator 2

(lidocaine hcl) 2 QL (30 per 30 days)

lidocaine (pf) injection solution 15 mgml (15 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine-MPF) 1 GC

lidocaine (pf) injection solution 40 mgml (4 )

1 GC

lidocaine hcl 1 20 mg2 ml vl latex-free sdv pf 10 mgml (1 )


lidocaine hcl injection solution 10 mgml (1 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine) 1 GC

lidocaine hcl mucous membrane jelly2


lidocaine hcl mucous membrane solution 4 (40 mgml)

2 PA

lidocaine topical adhesive patchmedicated 5

(Lidoderm) 2 PA QL (90 per 30 days)

lidocaine topical ointment 5 2 PA QL (90 per 30 days)

lidocaine viscous mucous membrane solution 2

(lidocaine hcl) 2

lidocaine-prilocaine topical cream25-25

2 PA QL (30 per 30 days)

ZTLIDO TOPICAL ADHESIVE PATCHMEDICATED 18


Anti-AddictionSubstance Abuse Treatment AgentsAnti-AddictionSubstance Abuse Treatment Agentsacamprosate oral tabletdelayed release (drec) 333 mg

2

buprenorphine hcl sublingual tablet2 mg 8 mg



9


buprenorphine-naloxone sublingual film 12-3 mg

(Suboxone) 2 QL (60 per 30 days)

buprenorphine-naloxone sublingual film 2-05 mg 4-1 mg 8-2 mg


buprenorphine-naloxone sublingual tablet 2-05 mg 8-2 mg


bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg

2

CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG

(varenicline) 3 QL (336 per 365 days)

CHANTIX ORAL TABLET 05 MG 1 MG


CHANTIX STARTING MONTH BOX ORAL TABLETSDOSE PACK 05 MG (11)- 1 MG (42)

3

disulfiram oral tablet 250 mg 500 mg

2

KLOXXADO NASAL SPRAYNON-AEROSOL 8 MGACTUATION


LUCEMYRA ORAL TABLET 018 MG

5 NM NDS QL (228 per 14 days)

naloxone injection solution 04 mgml

2

naloxone injection syringe 04 mgml 1 mgml

2

naltrexone oral tablet 50 mg 2

NARCAN NASAL SPRAYNON-AEROSOL 4 MGACTUATION


NICOTROL INHALATION CARTRIDGE 10 MG

4 QL (1008 per 90 days)

SUBLOCADE SUBCUTANEOUS SOLUTION EXTENDED REL SYRINGE 100 MG05 ML





10


varenicline oral tablet 05 mg 1 mg 2 QL (336 per 365 days)

Antianxiety AgentsBenzodiazepinesalprazolam oral tablet 025 mg 05 mg 1 mg

(Xanax) 1 GC NDS QL (120 per 30 days)

alprazolam oral tablet 2 mg (Xanax) 1 GC NDS QL (150 per 30 days)

alprazolam oral tablet extended release 24 hr 05 mg 1 mg 2 mg

(Xanax XR) 2 NDS QL (120 per 30 days)

alprazolam oral tablet extended release 24 hr 3 mg


chlordiazepoxide hcl oral capsule 10 mg 25 mg 5 mg


clonazepam oral tablet 05 mg 1 mg (Klonopin) 1 GC NDS QL (90 per 30 days)

clonazepam oral tablet 2 mg (Klonopin) 1 GC NDS QL (300 per 30 days)

clonazepam oral tabletdisintegrating 0125 mg 025 mg 05 mg 1 mg


clonazepam oral tabletdisintegrating 2 mg


clorazepate dipotassium oral tablet15 mg 375 mg


clorazepate dipotassium oral tablet75 mg

(Tranxene T-Tab) 2 NDS QL (180 per 30 days)

diazepam injection solution 5 mgml 2 QL (10 per 28 days)

diazepam injection syringe 5 mgml 2 QL (10 per 28 days)

diazepam oral concentrate 5 mgml (Diazepam Intensol) 2 NDS QL (1200 per 30 days)

diazepam oral solution 5 mg5 ml (1 mgml)


diazepam oral tablet 10 mg 2 mg 5 mg

(Valium) 1 GC NDS QL (120 per 30 days)

estazolam oral tablet 1 mg 2 NDS QL (60 per 30 days)


flurazepam oral capsule 15 mg 2 NDS QL (60 per 30 days)


11



lorazepam 2 mgml oral concent 2 mgml

(Lorazepam Intensol) 2 NDS QL (150 per 30 days)

lorazepam injection solution 2 mgml 4 mgml

(Ativan) 1 GC QL (2 per 30 days)

lorazepam injection syringe 2 mgml 4 mgml

1 GC QL (2 per 30 days)

lorazepam intensol oral concentrate2 mgml

(lorazepam) 2 NDS QL (150 per 30 days)

lorazepam oral tablet 05 mg 1 mg (Ativan) 1 GC NDS QL (90 per 30 days)

lorazepam oral tablet 2 mg (Ativan) 1 GC NDS QL (150 per 30 days)

midazolam oral syrup 2 mgml 2 NDS QL (10 per 30 days)

oxazepam oral capsule 10 mg 15 mg 30 mg


temazepam oral capsule 15 mg 30 mg

(Restoril) 1 GC NDS QL (30 per 30 days)

triazolam oral tablet 0125 mg 2 NDS QL (120 per 30 days)

triazolam oral tablet 025 mg (Halcion) 2 NDS QL (60 per 30 days)

AntibacterialsAminoglycosidesgentamicin injection solution 20 mg2 ml 40 mgml

2

gentamicin sulfate (ped) (pf) injection solution 20 mg2 ml

2

gentamicin sulfate (pf) intravenous solution 100 mg10 ml 60 mg6 ml 80 mg8 ml

2

neomycin oral tablet 500 mg 2

streptomycin intramuscular recon soln 1 gram

5 NM NDS

TOBI PODHALER INHALATION CAPSULE WINHALATION DEVICE 28 MG



12


tobramycin in 0225 nacl inhalation solution for nebulization300 mg5 ml

(Tobi) 5 PA BvD NM NDS

tobramycin inhalation solution for nebulization 300 mg4 ml

(Bethkis) 5 PA BvD NM NDS

tobramycin sulfate injection solution40 mgml

2

Antibacterials Miscellaneousbacitracin intramuscular recon soln50000 unit

2

chloramphenicol sod succinate intravenous recon soln 1 gram

2

clindamycin hcl oral capsule 150 mg 300 mg 75 mg

(Cleocin HCl) 1 GC

clindamycin in 5 dextrose intravenous piggyback 300 mg50 ml

2

clindamycin pediatric oral recon soln 75 mg5 ml

(clindamycin palmitate hcl)

2

clindamycin phosphate injection solution 150 (mgml) (6 ml)

2

clindamycin phosphate injection solution 150 mgml

(Cleocin) 2

clindamycin phosphate intravenous solution 600 mg4 ml

2

colistin (colistimethate na) injection recon soln 150 mg

(Coly-Mycin M Parenteral)

5 PA BvD NM NDS

daptomycin intravenous recon soln500 mg

(Cubicin) 5 NM NDS

FIRVANQ ORAL RECON SOLN 25 MGML

4

linezolid 600 mg300 ml-09 nacl600 mg300 ml

2

linezolid in dextrose 5 intravenous piggyback 600 mg300 ml

(Zyvox) 2

linezolid oral suspension for reconstitution 100 mg5 ml

(Zyvox) 5 NM NDS

linezolid oral tablet 600 mg (Zyvox) 2

methenamine hippurate oral tablet 1 gram

(Hiprex) 2


13


metronidazole in nacl (iso-os) intravenous piggyback 500 mg100 ml

(Metro IV) 2

metronidazole oral tablet 250 mg 500 mg

1 GC

nitrofurantoin macrocrystal oral capsule 100 mg 25 mg 50 mg

(Macrodantin) 2 QL (120 per 30 days)

nitrofurantoin monohydm-cryst oral capsule 100 mg

(Macrobid) 2 QL (60 per 30 days)

polymyxin b sulfate injection recon soln 500000 unit

2

SYNERCID INTRAVENOUS RECON SOLN 500 MG

5 NM NDS

trimethoprim oral tablet 100 mg 1 GC

vancomycin intravenous recon soln1000 mg 10 gram 5 gram 500 mg 750 mg

2

vancomycin oral capsule 125 mg (Vancocin) 2 QL (56 per 14 days)


XIFAXAN ORAL TABLET 200 MG




Cephalosporinscefaclor oral capsule 250 mg 500 mg

2

cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml

2

cefaclor oral tablet extended release 12 hr 500 mg

2

cefadroxil oral capsule 500 mg 2

cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml

2

cefadroxil oral tablet 1 gram 2

cefazolin injection recon soln 1 gram 10 gram 500 mg

2

cefdinir oral capsule 300 mg 2


14


cefdinir oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

2

cefepime injection recon soln 1 gram 2 gram

2

cefixime oral capsule 400 mg (Suprax) 2

cefixime oral suspension for reconstitution 100 mg5 ml 200 mg5 ml

(Suprax) 2

cefotaxime injection recon soln 1 gram

2

cefoxitin 1 gm piggyback bag 1 gram50 ml

2

cefoxitin intravenous recon soln 1 gram

2

cefoxitin intravenous recon soln 10 gram 2 gram

2

cefpodoxime oral suspension for reconstitution 100 mg5 ml 50 mg5 ml

2

cefpodoxime oral tablet 100 mg 200 mg

2

cefprozil oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

2

cefprozil oral tablet 250 mg 500 mg 2

ceftazidime injection recon soln 1 gram 2 gram

(Fortaz) 2

ceftazidime injection recon soln 6 gram

(Tazicef) 2

ceftriaxone injection recon soln 1 gram 10 gram 2 gram 250 mg 500 mg

2

cefuroxime axetil oral tablet 250 mg 500 mg

2

cefuroxime sodium injection recon soln 750 mg

2

cefuroxime sodium intravenous recon soln 15 gram 75 gram

2

cephalexin oral capsule 250 mg 500 mg

1 GC


15


cephalexin oral capsule 750 mg (Keflex) 2

cephalexin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

2

cephalexin oral tablet 250 mg 500 mg

2

TEFLARO INTRAVENOUS RECON SOLN 400 MG 600 MG

5 NM NDS

Macrolidesazithromycin intravenous recon soln500 mg

(Zithromax) 2

azithromycin oral suspension for reconstitution 100 mg5 ml 200 mg5 ml

(Zithromax) 2

azithromycin oral tablet 250 mg (6 pack) 500 mg (3 pack)

1 GC

azithromycin oral tablet 250 mg 500 mg

(Zithromax) 1 GC

azithromycin oral tablet 600 mg 2

clarithromycin oral suspension for reconstitution 125 mg5 ml 250 mg5 ml

2

clarithromycin oral tablet 250 mg 500 mg

2

clarithromycin oral tablet extended release 24 hr 500 mg

2

DIFICID ORAL SUSPENSION FOR RECONSTITUTION 40 MGML


DIFICID ORAL TABLET 200 MG


erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml

(EES Granules) 2


(EryPed 400) 2

erythromycin oral tablet 250 mg 500 mg

2


16


Miscellaneous B-Lactam Antibioticsaztreonam injection recon soln 1 gram 2 gram

(Azactam) 2

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MGML

5 PA NM LA NDS

ertapenem injection recon soln 1 gram

(Invanz) 2

imipenem-cilastatin intravenous recon soln 250 mg

2


(Primaxin IV) 2

meropenem intravenous recon soln 1 gram

2

meropenem intravenous recon soln500 mg

2

meropenem-09 nacl 500 mg50500 mg50 ml

2

Penicillinsamoxicillin oral capsule 250 mg 500 mg

1 GC

amoxicillin oral suspension for reconstitution 125 mg5 ml 200 mg5 ml 250 mg5 ml 400 mg5 ml

1 GC

amoxicillin oral tablet 500 mg 875 mg

1 GC

amoxicillin oral tabletchewable 125 mg 250 mg

2

amoxicillin-pot clavulanate oral suspension for reconstitution 200-285 mg5 ml 400-57 mg5 ml

2

amoxicillin-pot clavulanate oral suspension for reconstitution 250-625 mg5 ml

(Augmentin) 2


(Augmentin ES-600) 2

amoxicillin-pot clavulanate oral tablet 250-125 mg

2

amoxicillin-pot clavulanate oral tablet 500-125 mg 875-125 mg

(Augmentin) 1 GC


17


amoxicillin-pot clavulanate oral tablet extended release 12 hr 1000-625 mg

(Augmentin XR) 2

amoxicillin-pot clavulanate oral tabletchewable 200-285 mg 400-57 mg

2

ampicillin oral capsule 250 mg 500 mg

2

ampicillin sodium injection recon soln 1 gram 10 gram 125 mg 2 gram 250 mg 500 mg

2

ampicillin-sulbactam injection recon soln 15 gram 15 gram 3 gram

(Unasyn) 2

BICILLIN L-A INTRAMUSCULAR SYRINGE 1200000 UNIT2 ML 2400000 UNIT4 ML 600000 UNITML

4

dicloxacillin oral capsule 250 mg 500 mg

2

nafcillin 1 gm 50 ml inj 1 gram50 ml

2


2

nafcillin injection recon soln 1 gram 2 gram

2

nafcillin injection recon soln 10 gram

5 NM NDS

penicillin g potassium injection recon soln 20 million unit

(Pfizerpen-G) 2

penicillin g procaine intramuscular syringe 12 million unit2 ml 600000 unitml

2

penicillin v potassium oral recon soln125 mg5 ml 250 mg5 ml

2

penicillin v potassium oral tablet 250 mg 500 mg

1 GC

pfizerpen-g injection recon soln 20 million unit

(penicillin g potassium) 2

piperacillin-tazobactam intravenous recon soln 225 gram 3375 gram 45 gram 405 gram

2


18


QuinolonesBAXDELA ORAL TABLET 450 MG


ciprofloxacin hcl 750 mg tab fc 750 mg

1 GC

ciprofloxacin hcl oral tablet 100 mg 2

ciprofloxacin hcl oral tablet 250 mg 500 mg

(Cipro) 1 GC

ciprofloxacin hcl oral tablet 750 mg 1 GC

ciprofloxacin in 5 dextrose intravenous piggyback 200 mg100 ml 400 mg200 ml

2

ciprofloxacin oral suspensionmicrocapsule recon 250 mg5 ml 500 mg5 ml

(Cipro) 2

levofloxacin in d5w intravenous piggyback 250 mg50 ml 500 mg100 ml 750 mg150 ml

2

levofloxacin intravenous solution 25 mgml

2

levofloxacin oral solution 250 mg10 ml

2

levofloxacin oral tablet 250 mg 500 mg 750 mg

1 GC

moxifloxacin oral tablet 400 mg 2Sulfonamidessulfadiazine oral tablet 500 mg 2

sulfamethoxazole-trimethoprim intravenous solution 400-80 mg5 ml

2

sulfamethoxazole-trimethoprim oral suspension 200-40 mg5 ml

(Sulfatrim) 2

sulfamethoxazole-trimethoprim oral tablet 400-80 mg

(Bactrim) 1 GC


(Bactrim DS) 1 GC

Tetracyclinesdemeclocycline oral tablet 150 mg 300 mg

2

doxy-100 intravenous recon soln 100 mg

(doxycycline hyclate) 2


19


doxycycline hyclate intravenous recon soln 100 mg

(Doxy-100) 2

doxycycline hyclate oral capsule 100 mg 50 mg

(Morgidox) 2

doxycycline hyclate oral tablet 100 mg

(LymePak) 2


2

doxycycline hyclate oral tabletdelayed release (drec) 100 mg 150 mg 75 mg

2

doxycycline hyclate oral tabletdelayed release (drec) 200 mg 50 mg

(Doryx) 2

doxycycline monohydrate oral capsule 100 mg

(Mondoxyne NL) 2 QL (60 per 30 days)


(Monodox) 2 QL (60 per 30 days)

doxycycline monohydrate oral suspension for reconstitution 25 mg5 ml

(Vibramycin) 2

doxycycline monohydrate oral tablet100 mg

(Avidoxy) 2 QL (60 per 30 days)


2

doxycycline monohydrate oral tablet50 mg 75 mg


minocycline oral capsule 100 mg 50 mg 75 mg

2

minocycline oral tablet 100 mg 50 mg 75 mg

2

mondoxyne nl oral capsule 100 mg 75 mg

(doxycycline monohydrate)


tetracycline oral capsule 250 mg 500 mg

2

tigecycline intravenous recon soln 50 mg

(Tygacil) 5 NM NDS

Anticancer AgentsAnticancer Agentsabiraterone oral tablet 250 mg (Zytiga) 5 PA NSO NM NDS

QL (120 per 30 days)


20


ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG

5 PA BvD NM NDS

ADCETRIS INTRAVENOUS RECON SOLN 50 MG

5 PA NSO NM NDS

adriamycin intravenous solution 10 mg5 ml 2 mgml 20 mg10 ml 50 mg25 ml

(doxorubicin) 2 PA BvD

adrucil intravenous solution 25 gram50 ml

(fluorouracil) 2 PA BvD

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG 3 MG 5 MG

(everolimus (antineoplastic))

5 PA NSO NM NDS QL (112 per 28 days)

AFINITOR ORAL TABLET 10 MG



ALECENSA ORAL CAPSULE 150 MG


ALIMTA INTRAVENOUS RECON SOLN 100 MG 500 MG

5 NM NDS

ALIQOPA INTRAVENOUS RECON SOLN 60 MG


ALUNBRIG ORAL TABLET 180 MG 90 MG


ALUNBRIG ORAL TABLET 30 MG


ALUNBRIG ORAL TABLETSDOSE PACK 90 MG (7)- 180 MG (23)

5 PA NSO NM NDS

anastrozole oral tablet 1 mg (Arimidex) 1 GC

arsenic trioxide intravenous solution1 mgml

5 NM NDS


(Trisenox) 5 NM NDS

ASPARLAS INTRAVENOUS SOLUTION 750 UNITML

5 PA NSO NM NDS

AVASTIN INTRAVENOUS SOLUTION 25 MGML

5 PA NSO NM NDS

AYVAKIT ORAL TABLET 100 MG 200 MG 25 MG 300 MG 50 MG



21


azacitidine injection recon soln 100 mg

(Vidaza) 5 NM NDS

BALVERSA ORAL TABLET 3 MG






BAVENCIO INTRAVENOUS SOLUTION 20 MGML

5 PA NSO NM NDS

BELEODAQ INTRAVENOUS RECON SOLN 500 MG

5 PA NSO NM NDS

BENDEKA INTRAVENOUS SOLUTION 25 MGML

(bendamustine) 5 PA NSO NM NDS

BESPONSA INTRAVENOUS RECON SOLN 09 MG (025 MGML INITIAL)

5 PA NSO NM NDS

bexarotene oral capsule 75 mg (Targretin) 5 PA NSO NM NDS

bicalutamide oral tablet 50 mg (Casodex) 2

BLENREP INTRAVENOUS RECON SOLN 100 MG

5 PA NSO NM NDS

bleomycin injection recon soln 15 unit 30 unit

2

BLINCYTO INTRAVENOUS KIT 35 MCG

5 PA NSO NM NDS

BORTEZOMIB INTRAVENOUS RECON SOLN 35 MG

5 PA NSO NM NDS

BOSULIF ORAL TABLET 100 MG


BOSULIF ORAL TABLET 400 MG 500 MG


BRAFTOVI ORAL CAPSULE 75 MG


BRUKINSA ORAL CAPSULE 80 MG


CABOMETYX ORAL TABLET 20 MG 60 MG


CABOMETYX ORAL TABLET 40 MG


CALQUENCE ORAL CAPSULE 100 MG



22


CAPRELSA ORAL TABLET 100 MG

(vandetanib) 5 PA NSO NM NDS QL (60 per 30 days)



carboplatin intravenous solution 10 mgml

(Paraplatin) 2

cladribine intravenous solution 10 mg10 ml

2 PA BvD

clofarabine intravenous solution 20 mg20 ml

(Clolar) 5 NM NDS

COMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1) 140 MGDAY(80 MG X1-20 MG X3) 60 MGDAY (20 MG X 3DAY)


COPIKTRA ORAL CAPSULE 15 MG 25 MG


COTELLIC ORAL TABLET 20 MG

5 PA NSO NM LA NDS QL (63 per 28 days)

cyclophosphamide intravenous recon soln 1 gram 2 gram 500 mg

5 PA BvD NM NDS

cyclophosphamide intravenous solution 200 mgml

5 PA BvD NM NDS

CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG 50 MG

4 PA BvD ST

cyclophosphamide oral tablet 25 mg 50 mg

3 PA BvD ST

CYRAMZA INTRAVENOUS SOLUTION 10 MGML

5 PA NSO NM NDS

DANYELZA INTRAVENOUS SOLUTION 4 MGML


DARZALEX FASPRO SUBCUTANEOUS SOLUTION 1800 MG-30000 UNIT15 ML

5 PA NSO NM NDS

DARZALEX INTRAVENOUS SOLUTION 20 MGML

5 PA NSO NM LA NDS

DAURISMO ORAL TABLET 100 MG





23


decitabine intravenous recon soln 50 mg

(Dacogen) 5 NM NDS

docetaxel intravenous solution 20 mg2 ml (10 mgml) 80 mg4 ml (20 mgml)

5 NM NDS

docetaxel intravenous solution 80 mg8 ml (10 mgml)

2

doxorubicin intravenous solution 10 mg5 ml 2 mgml 20 mg10 ml 50 mg25 ml

(Adriamycin) 2 PA BvD

doxorubicin peg-liposomal intravenous suspension 2 mgml

(Doxil) 5 PA BvD NM NDS

ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 225 MG

4


4


4

ELIGARD SUBCUTANEOUS SYRINGE 75 MG (1 MONTH)

4

EMCYT ORAL CAPSULE 140 MG

5 NM NDS

EMPLICITI INTRAVENOUS RECON SOLN 300 MG 400 MG

5 PA NSO NM NDS

ENHERTU INTRAVENOUS RECON SOLN 100 MG

5 PA NSO NM NDS

ERBITUX INTRAVENOUS SOLUTION 100 MG50 ML 200 MG100 ML

5 PA NSO NM NDS

ERIVEDGE ORAL CAPSULE 150 MG


ERLEADA ORAL TABLET 60 MG


erlotinib oral tablet 100 mg 25 mg (Tarceva) 5 PA NSO NM NDS QL (60 per 30 days)

erlotinib oral tablet 150 mg (Tarceva) 5 PA NSO NM NDS QL (90 per 30 days)


24


ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG

4

etoposide intravenous solution 20 mgml

(Toposar) 2

everolimus (antineoplastic) oral tablet 10 mg

(Afinitor) 5 PA NSO NM NDS QL (56 per 28 days)

everolimus (antineoplastic) oral tablet 25 mg 5 mg 75 mg


everolimus (antineoplastic) oral tablet for suspension 2 mg 3 mg 5 mg

(Afinitor Disperz) 5 PA NSO NM NDS QL (112 per 28 days)

exemestane oral tablet 25 mg (Aromasin) 2

EXKIVITY ORAL CAPSULE 40 MG


FARYDAK ORAL CAPSULE 10 MG 15 MG 20 MG

5 PA NSO NM NDS

floxuridine injection recon soln 05 gram

2 PA BvD

fluorouracil intravenous solution 1 gram20 ml 5 gram100 ml 500 mg10 ml

2 PA BvD

flutamide oral capsule 125 mg 2

FOTIVDA ORAL CAPSULE 089 MG 134 MG


fulvestrant intramuscular syringe250 mg5 ml

(Faslodex) 5 NM NDS

GAVRETO ORAL CAPSULE 100 MG


GAZYVA INTRAVENOUS SOLUTION 1000 MG40 ML

5 PA NSO NM NDS

gemcitabine intravenous recon soln 1 gram 200 mg

2 PA BvD

gemcitabine intravenous recon soln 2 gram

5 PA BvD NM NDS

gemcitabine intravenous solution 1 gram263 ml (38 mgml) 200 mg526 ml (38 mgml)

5 PA BvD NM NDS

gemcitabine intravenous solution 2 gram526 ml (38 mgml)

2 PA BvD

GILOTRIF ORAL TABLET 20 MG 30 MG 40 MG



25


HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10000 UNIT5 ML


HERCEPTIN INTRAVENOUS RECON SOLN 150 MG

5 PA NSO NM NDS

HERZUMA INTRAVENOUS RECON SOLN 150 MG 420 MG

5 PA NSO NM NDS

hydroxyurea oral capsule 500 mg (Hydrea) 2

IBRANCE ORAL CAPSULE 100 MG 125 MG 75 MG


IBRANCE ORAL TABLET 100 MG 125 MG 75 MG


ICLUSIG ORAL TABLET 10 MG 15 MG 30 MG 45 MG


IDHIFA ORAL TABLET 100 MG 50 MG


ifosfamide intravenous recon soln 1 gram

(Ifex) 2

ifosfamide intravenous solution 1 gram20 ml 3 gram60 ml

2

imatinib oral tablet 100 mg (Gleevec) 2 PA NSO QL (180 per 30 days)


IMBRUVICA ORAL CAPSULE 140 MG




IMBRUVICA ORAL TABLET 140 MG 280 MG 420 MG 560 MG


IMFINZI INTRAVENOUS SOLUTION 50 MGML

5 PA NSO NM NDS

IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFUML

4 PA NSO QL (4 per 365 days)




26


INFUGEM INTRAVENOUS PIGGYBACK 1200 MG120 ML (10 MGML) 1300 MG130 ML (10 MGML) 1400 MG140 ML (10 MGML) 1500 MG150 ML (10 MGML) 1600 MG160 ML (10 MGML) 1700 MG170 ML (10 MGML) 1800 MG180 ML (10 MGML) 1900 MG190 ML (10 MGML) 2000 MG200 ML (10 MGML) 2200 MG220 ML (10 MGML)

5 PA BvD NM NDS

INLYTA ORAL TABLET 1 MG 5 PA NSO NM NDS QL (180 per 30 days)


INQOVI ORAL TABLET 35-100 MG


INREBIC ORAL CAPSULE 100 MG


IRESSA ORAL TABLET 250 MG 5 PA NSO NM NDS QL (60 per 30 days)

irinotecan intravenous solution 100 mg5 ml 300 mg15 ml 40 mg2 ml

(Camptosar) 2

irinotecan intravenous solution 500 mg25 ml

2

IXEMPRA INTRAVENOUS RECON SOLN 15 MG 45 MG

5 NM NDS

JAKAFI ORAL TABLET 10 MG 15 MG 20 MG 25 MG 5 MG


JEMPERLI INTRAVENOUS SOLUTION 50 MGML

5 PA NSO NM NDS

KANJINTI INTRAVENOUS RECON SOLN 150 MG 420 MG

5 PA NSO NM NDS

KEYTRUDA INTRAVENOUS SOLUTION 25 MGML


KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG





27




KISQALI ORAL TABLET 200 MGDAY (200 MG X 1)






KOSELUGO ORAL CAPSULE 10 MG




KYPROLIS INTRAVENOUS RECON SOLN 10 MG 30 MG 60 MG

5 PA NSO NM NDS

lapatinib oral tablet 250 mg (Tykerb) 5 PA NSO NM NDS

LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 12 MGDAY (4 MG X 3) 14 MGDAY(10 MG X 1-4 MG X 1) 18 MGDAY (10 MG X 1-4 MG X2) 20 MGDAY (10 MG X 2) 24 MGDAY(10 MG X 2-4 MG X 1) 4 MG 8 MGDAY (4 MG X 2)

5 PA NSO NM NDS

letrozole oral tablet 25 mg (Femara) 1 GC

LEUKERAN ORAL TABLET 2 MG

5 NM NDS

leuprolide subcutaneous kit 1 mg02 ml

5 NM NDS

LIBTAYO INTRAVENOUS SOLUTION 50 MGML


LONSURF ORAL TABLET 15-614 MG




LORBRENA ORAL TABLET 100 MG





28


LUMAKRAS ORAL TABLET 120 MG


LUMOXITI INTRAVENOUS RECON SOLN 1 MG

5 PA NSO NM NDS

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 225 MG

5 NM NDS


5 NM NDS


5 NM NDS

LYNPARZA ORAL TABLET 100 MG 150 MG


LYSODREN ORAL TABLET 500 MG

5 NM NDS

MARQIBO INTRAVENOUS KIT 5 MG31 ML(016 MGML) FINAL

5 PA NSO NM NDS

MATULANE ORAL CAPSULE 50 MG

5 NM NDS

megestrol oral tablet 20 mg 40 mg 2

MEKINIST ORAL TABLET 05 MG




MEKTOVI ORAL TABLET 15 MG


melphalan hcl intravenous recon soln50 mg

(Alkeran (as HCl)) 5 NM NDS

mercaptopurine oral tablet 50 mg 2

methotrexate sodium (pf) injection recon soln 1 gram

2 PA BvD

methotrexate sodium (pf) injection solution 25 mgml

2 PA BvD

methotrexate sodium injection solution 25 mgml

2 PA BvD

methotrexate sodium oral tablet 25 mg

2 PA BvD ST


29


mitoxantrone intravenous concentrate 2 mgml

2

MONJUVI INTRAVENOUS RECON SOLN 200 MG

5 PA NSO NM NDS

MVASI INTRAVENOUS SOLUTION 25 MGML

5 PA NSO NM NDS

MYLOTARG INTRAVENOUS RECON SOLN 45 MG (1 MGML INITIAL CONC)

5 PA NSO NM NDS

NERLYNX ORAL TABLET 40 MG


NEXAVAR ORAL TABLET 200 MG


nilutamide oral tablet 150 mg (Nilandron) 5 NM NDS

NINLARO ORAL CAPSULE 23 MG 3 MG 4 MG


NUBEQA ORAL TABLET 300 MG


ODOMZO ORAL CAPSULE 200 MG

5 PA NSO NM LA NDS

OGIVRI INTRAVENOUS RECON SOLN 150 MG 420 MG

5 PA NSO NM NDS

ONCASPAR INJECTION SOLUTION 750 UNITML

5 PA NSO NM NDS

ONIVYDE INTRAVENOUS DISPERSION 43 MGML

5 NM NDS

ONTRUZANT INTRAVENOUS RECON SOLN 150 MG 420 MG

5 PA NSO NM NDS

ONUREG ORAL TABLET 200 MG 300 MG


OPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 120 MG12 ML 240 MG24 ML 40 MG4 ML

5 PA NSO NM NDS

oxaliplatin intravenous recon soln100 mg 50 mg

2

oxaliplatin intravenous solution 100 mg20 ml 200 mg40 ml 50 mg10 ml (5 mgml)

2

paclitaxel intravenous concentrate 6 mgml

2 PA BvD


30


PADCEV INTRAVENOUS RECON SOLN 20 MG 30 MG

5 PA NSO NM NDS

PEMAZYRE ORAL TABLET 135 MG 45 MG 9 MG


PEPAXTO INTRAVENOUS RECON SOLN 20 MG


PERJETA INTRAVENOUS SOLUTION 420 MG14 ML (30 MGML)

5 PA NSO NM NDS

PHESGO SUBCUTANEOUS SOLUTION 1200 MG-600MG- 30000 UNIT15ML


PHESGO SUBCUTANEOUS SOLUTION 600 MG-600 MG- 20000 UNIT10ML


PIQRAY ORAL TABLET 200 MGDAY (200 MG X 1)


PIQRAY ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 300 MGDAY (150 MG X 2)


POLIVY INTRAVENOUS RECON SOLN 140 MG 30 MG

5 PA NSO NM NDS

POMALYST ORAL CAPSULE 1 MG 2 MG 3 MG 4 MG


PORTRAZZA INTRAVENOUS SOLUTION 800 MG50 ML (16 MGML)


PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT

5 NM NDS

PURIXAN ORAL SUSPENSION 20 MGML

5 NM NDS

QINLOCK ORAL TABLET 50 MG


RETEVMO ORAL CAPSULE 40 MG




REVLIMID ORAL CAPSULE 10 MG 15 MG 25 MG 20 MG 25 MG 5 MG



31


RIABNI INTRAVENOUS SOLUTION 10 MGML

5 PA NSO NM NDS

RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG117 ML (120 MGML) 1600 MG134 ML (120 MGML)

5 PA NSO NM NDS

RITUXAN INTRAVENOUS CONCENTRATE 10 MGML

5 PA NSO NM NDS

ROZLYTREK ORAL CAPSULE 100 MG




RUBRACA ORAL TABLET 200 MG 250 MG 300 MG


RUXIENCE INTRAVENOUS SOLUTION 10 MGML

5 PA NSO NM NDS

RYBREVANT INTRAVENOUS SOLUTION 50 MGML

5 PA NSO NM NDS

RYDAPT ORAL CAPSULE 25 MG


SARCLISA INTRAVENOUS SOLUTION 20 MGML

5 PA NSO NM NDS

SCEMBLIX ORAL TABLET 20 MG 40 MG

5 PA NSO NM NDS

SOLTAMOX ORAL SOLUTION 20 MG10 ML

5 NM NDS

SPRYCEL ORAL TABLET 100 MG 140 MG 50 MG 70 MG 80 MG


SPRYCEL ORAL TABLET 20 MG


STIVARGA ORAL TABLET 40 MG


sunitinib oral capsule 125 mg 25 mg 375 mg 50 mg

(Sutent) 5 PA NSO NM NDS QL (30 per 30 days)

SYLVANT INTRAVENOUS RECON SOLN 100 MG 400 MG

5 PA NSO NM NDS

SYNRIBO SUBCUTANEOUS RECON SOLN 35 MG

5 PA NSO NM NDS

TABLOID ORAL TABLET 40 MG

(thioguanine) 4


32


TABRECTA ORAL TABLET 150 MG 200 MG


TAFINLAR ORAL CAPSULE 50 MG 75 MG


TAGRISSO ORAL TABLET 40 MG 80 MG


TALZENNA ORAL CAPSULE 025 MG




tamoxifen oral tablet 10 mg 20 mg 2

TARGRETIN TOPICAL GEL 1

5 PA NSO NM NDS

TASIGNA ORAL CAPSULE 150 MG 200 MG


TASIGNA ORAL CAPSULE 50 MG


TAZVERIK ORAL TABLET 200 MG


TECENTRIQ INTRAVENOUS SOLUTION 1200 MG20 ML (60 MGML) 840 MG14 ML (60 MGML)

5 PA NSO NM NDS

TEMODAR INTRAVENOUS RECON SOLN 100 MG

5 PA NSO NM NDS

temsirolimus intravenous recon soln30 mg3 ml (10 mgml) (first)

(Torisel) 5 PA BvD NM NDS QL (4 per 28 days)

TEPMETKO ORAL TABLET 225 MG


thiotepa injection recon soln 100 mg 15 mg

(Tepadina) 5 NM NDS

TIBSOVO ORAL TABLET 250 MG


TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG

4

TIVDAK INTRAVENOUS RECON SOLN 40 MG


toposar intravenous solution 20 mgml

(etoposide) 2


33


topotecan intravenous recon soln 4 mg

(Hycamtin) 5 NM NDS

topotecan intravenous solution 4 mg4 ml (1 mgml)

5 NM NDS

toremifene oral tablet 60 mg (Fareston) 5 NM NDS

TRAZIMERA INTRAVENOUS RECON SOLN 150 MG 420 MG

5 PA NSO NM NDS

TREANDA INTRAVENOUS RECON SOLN 100 MG 25 MG

5 PA NSO NM NDS

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG






tretinoin (antineoplastic) oral capsule 10 mg

5 NM NDS

TRODELVY INTRAVENOUS RECON SOLN 180 MG

5 PA NSO NM NDS

TRUSELTIQ ORAL CAPSULE 100 MGDAY (100 MG X 1) 125 MGDAY(100 MG X1-25MG X1) 50 MGDAY (25 MG X 2) 75 MGDAY (25 MG X 3)

5 PA NSO NM NDS

TRUXIMA INTRAVENOUS SOLUTION 10 MGML

5 PA NSO NM NDS

TUKYSA ORAL TABLET 150 MG




TURALIO ORAL CAPSULE 200 MG


UKONIQ ORAL TABLET 200 MG



34


UNITUXIN INTRAVENOUS SOLUTION 35 MGML

5 PA NSO NM NDS

valrubicin intravesical solution 40 mgml

(Valstar) 5 NM NDS

VECTIBIX INTRAVENOUS SOLUTION 100 MG5 ML (20 MGML) 400 MG20 ML (20 MGML)

5 PA NSO NM NDS

VELCADE INJECTION RECON SOLN 35 MG

5 PA NSO NM NDS

VENCLEXTA ORAL TABLET 10 MG

3 PA NSO LA QL (60 per 30 days)





VENCLEXTA STARTING PACK ORAL TABLETSDOSE PACK 10 MG-50 MG- 100 MG

5 PA NSO NM LA NDS

VERZENIO ORAL TABLET 100 MG 150 MG 200 MG 50 MG


vinblastine intravenous solution 1 mgml

2 PA BvD

vincasar pfs intravenous solution 1 mgml 2 mg2 ml

(vincristine) 2 PA BvD

vincristine intravenous solution 1 mgml 2 mg2 ml

(Vincasar PFS) 2 PA BvD

vinorelbine intravenous solution 10 mgml 50 mg5 ml

(Navelbine) 2

VITRAKVI ORAL CAPSULE 100 MG




VITRAKVI ORAL SOLUTION 20 MGML


VIZIMPRO ORAL TABLET 15 MG 30 MG 45 MG


VOTRIENT ORAL TABLET 200 MG



35


VYXEOS INTRAVENOUS RECON SOLN 44-100 MG

5 PA BvD NM NDS

WELIREG ORAL TABLET 40 MG


XALKORI ORAL CAPSULE 200 MG 250 MG


XATMEP ORAL SOLUTION 25 MGML

4 PA BvD ST

XOSPATA ORAL TABLET 40 MG


XPOVIO ORAL TABLET 100 MGWEEK (20 MG X 5)


XPOVIO ORAL TABLET 100 MGWEEK (50 MG X 2) 40 MGWEEK (20 MG X 2) 40MG TWICE WEEK (40 MG X 2) 80 MGWEEK (40 MG X 2)


XPOVIO ORAL TABLET 40 MGWEEK (40 MG X 1) 60 MGWEEK (60 MG X 1)


XPOVIO ORAL TABLET 40MG TWICE WEEK (80 MGWEEK) 80 MGWEEK (20 MG X 4)




XPOVIO ORAL TABLET 60MG TWICE WEEK (120 MGWEEK)




XTANDI ORAL CAPSULE 40 MG


XTANDI ORAL TABLET 40 MG 5 PA NSO NM NDS QL (120 per 30 days)


YERVOY INTRAVENOUS SOLUTION 200 MG40 ML (5 MGML) 50 MG10 ML (5 MGML)

5 PA NSO NM NDS

YONDELIS INTRAVENOUS RECON SOLN 1 MG

5 PA NSO NM NDS


36


YONSA ORAL TABLET 125 MG 5 PA NSO NM NDS QL (120 per 30 days)

ZALTRAP INTRAVENOUS SOLUTION 100 MG4 ML (25 MGML) 200 MG8 ML (25 MGML)

5 PA NSO NM NDS

ZEJULA ORAL CAPSULE 100 MG


ZELBORAF ORAL TABLET 240 MG


ZEPZELCA INTRAVENOUS RECON SOLN 4 MG

5 PA NSO NM NDS

ZIRABEV INTRAVENOUS SOLUTION 25 MGML

5 PA NSO NM NDS

ZOLADEX SUBCUTANEOUS IMPLANT 108 MG




ZOLINZA ORAL CAPSULE 100 MG

5 NM NDS

ZYDELIG ORAL TABLET 100 MG 150 MG


ZYKADIA ORAL TABLET 150 MG


ZYNLONTA INTRAVENOUS RECON SOLN 10 MG

5 PA NSO NM NDS

ZYTIGA ORAL TABLET 250 MG 500 MG

(abiraterone) 5 PA NSO NM NDS QL (120 per 30 days)

AnticonvulsantsAnticonvulsantsAPTIOM ORAL TABLET 200 MG 400 MG


APTIOM ORAL TABLET 600 MG 800 MG


BRIVIACT INTRAVENOUS SOLUTION 50 MG5 ML


BRIVIACT ORAL SOLUTION 10 MGML


BRIVIACT ORAL TABLET 10 MG 100 MG 25 MG 50 MG 75 MG



37


carbamazepine oral capsule er multiphase 12 hr 100 mg 200 mg 300 mg

(Carbatrol) 2

carbamazepine oral suspension 100 mg5 ml

(Tegretol) 2

carbamazepine oral tablet 200 mg (Epitol) 2

carbamazepine oral tablet extended release 12 hr 100 mg 200 mg 400 mg

(Tegretol XR) 2

carbamazepine oral tabletchewable100 mg

2

CELONTIN ORAL CAPSULE 300 MG

4

clobazam oral suspension 25 mgml (Onfi) 2 PA NSO QL (480 per 30 days)

clobazam oral tablet 10 mg 20 mg (Onfi) 2 PA NSO QL (60 per 30 days)

DIACOMIT ORAL CAPSULE 250 MG




DIACOMIT ORAL POWDER IN PACKET 250 MG




diazepam rectal kit 125-15-175-20 mg 5-75-10 mg

(Diastat AcuDial) 4

diazepam rectal kit 25 mg (Diastat) 4

DILANTIN ORAL CAPSULE 30 MG

4

divalproex oral capsule delayed rel sprinkle 125 mg

(Depakote Sprinkles) 2

divalproex oral tablet extended release 24 hr 250 mg 500 mg

(Depakote ER) 2

divalproex oral tabletdelayed release (drec) 125 mg 250 mg 500 mg

(Depakote) 2

EPIDIOLEX ORAL SOLUTION 100 MGML

5 PA NSO NM NDS

epitol oral tablet 200 mg (carbamazepine) 2

ethosuximide oral capsule 250 mg (Zarontin) 2


38


ethosuximide oral solution 250 mg5 ml

(Zarontin) 2

felbamate oral suspension 600 mg5 ml

(Felbatol) 2

felbamate oral tablet 400 mg 600 mg

(Felbatol) 2

FINTEPLA ORAL SOLUTION 22 MGML

5 PA NSO NM NDS

fosphenytoin injection solution 100 mg pe2 ml 500 mg pe10 ml

(Cerebyx) 2

FYCOMPA ORAL SUSPENSION 05 MGML


FYCOMPA ORAL TABLET 10 MG 12 MG 8 MG


FYCOMPA ORAL TABLET 2 MG


FYCOMPA ORAL TABLET 4 MG 6 MG


gabapentin oral capsule 100 mg 300 mg

(Neurontin) 1 GC QL (360 per 30 days)

gabapentin oral capsule 400 mg (Neurontin) 1 GC QL (270 per 30 days)

gabapentin oral solution 250 mg5 ml

(Neurontin) 2 QL (2160 per 30 days)

gabapentin oral tablet 600 mg (Neurontin) 2 QL (180 per 30 days)


lamotrigine oral tablet 100 mg 150 mg 200 mg 25 mg

(Subvenite) 1 GC

lamotrigine oral tablet disintegrating dose pk 25 mg (21) -50 mg (7)

(Lamictal ODT Starter (Blue))

2

lamotrigine oral tablet disintegrating dose pk 25 mg(14)-50 mg (14)-100 mg (7)

(Lamictal ODT Starter (Orange))

2


(Lamictal ODT Starter (Green))

2

lamotrigine oral tablet extended release 24hr 100 mg 200 mg 25 mg 250 mg 300 mg 50 mg

(Lamictal XR) 2


39


lamotrigine oral tablet chewable dispersible 25 mg 5 mg

(Lamictal) 2

lamotrigine oral tabletdisintegrating 100 mg 200 mg 25 mg 50 mg

(Lamictal ODT) 2

levetiracetam intravenous solution500 mg5 ml

(Keppra) 2

levetiracetam oral solution 100 mgml

(Keppra) 2

levetiracetam oral tablet 1000 mg 250 mg 500 mg 750 mg

(Keppra) 2

levetiracetam oral tablet extended release 24 hr 500 mg 750 mg

(Keppra XR) 2

NAYZILAM NASAL SPRAYNON-AEROSOL 5 MGSPRAY (01 ML)


oxcarbazepine oral suspension 300 mg5 ml (60 mgml)

(Trileptal) 2

oxcarbazepine oral tablet 150 mg 300 mg 600 mg

(Trileptal) 2

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG 300 MG

4

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG

5 NM NDS

phenobarbital oral elixir 20 mg5 ml (4 mgml)

2

phenobarbital oral tablet 100 mg 15 mg 162 mg 30 mg 324 mg 60 mg 648 mg 972 mg

2

phenytoin oral suspension 125 mg5 ml

(Dilantin-125) 2

phenytoin oral tabletchewable 50 mg

(Dilantin Infatabs) 2

phenytoin sodium extended oral capsule 100 mg

(Dilantin Extended) 2

phenytoin sodium extended oral capsule 200 mg 300 mg

(Phenytek) 2

phenytoin sodium intravenous solution 50 mgml

2


40


phenytoin sodium intravenous syringe 50 mgml

2

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

(Lyrica) 2 QL (90 per 30 days)

pregabalin oral capsule 225 mg 300 mg


pregabalin oral solution 20 mgml (Lyrica) 2 QL (900 per 30 days)

primidone oral tablet 250 mg 50 mg (Mysoline) 2

rufinamide oral suspension 40 mgml (Banzel) 5 NM NDS

rufinamide oral tablet 200 mg 400 mg

(Banzel) 5 NM NDS

SPRITAM ORAL TABLET FOR SUSPENSION 1000 MG

4 ST QL (60 per 30 days)

SPRITAM ORAL TABLET FOR SUSPENSION 250 MG 500 MG 750 MG


subvenite oral tablet 100 mg 150 mg 200 mg 25 mg

(lamotrigine) 1 GC

SYMPAZAN ORAL FILM 10 MG 20 MG


SYMPAZAN ORAL FILM 5 MG 4 PA NSO QL (60 per 30 days)

tiagabine oral tablet 12 mg 16 mg 2 mg 4 mg

(Gabitril) 2

topiramate oral capsule sprinkle 15 mg 25 mg

(Topamax) 2

topiramate oral tablet 100 mg 200 mg 25 mg 50 mg

(Topamax) 1 GC

valproate sodium intravenous solution 500 mg5 ml (100 mgml)

2

valproic acid (as sodium salt) oral solution 250 mg5 ml

2

valproic acid oral capsule 250 mg 2

VALTOCO NASAL SPRAYNON-AEROSOL 10 MGSPRAY (01 ML) 15 MG2 SPRAY (7501ML X 2) 20 MG2 SPRAY (10MG01ML X2) 5 MGSPRAY (01 ML)

4

vigabatrin oral powder in packet 500 mg

(Vigadrone) 5 PA NSO NM NDS QL (180 per 30 days)


41


vigabatrin oral tablet 500 mg (Sabril) 5 PA NSO NM NDS QL (180 per 30 days)

vigadrone oral powder in packet 500 mg

(vigabatrin) 5 PA NSO NM NDS QL (180 per 30 days)

VIMPAT INTRAVENOUS SOLUTION 200 MG20 ML


VIMPAT ORAL SOLUTION 10 MGML

3 QL (1200 per 30 days)

VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 50 MG


XCOPRI MAINTENANCE PACK ORAL TABLET 250 MGDAY (200 MG X1-50 MG X1) 250MGDAY(150 MG X1-100MG X1) 350 MGDAY (200 MG X1-150MG X1)


XCOPRI ORAL TABLET 100 MG 50 MG




XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14) 150 MG (14)- 200 MG (14) 50 MG (14)- 100 MG (14)

4

zonisamide oral capsule 100 mg 25 mg

(Zonegran) 2

zonisamide oral capsule 50 mg 2

Antidementia AgentsAntidementia Agentsdonepezil oral tablet 10 mg 5 mg (Aricept) 1 GC QL (30 per 30

days)

donepezil oral tablet 23 mg (Aricept) 2 QL (30 per 30 days)

donepezil oral tabletdisintegrating10 mg 5 mg


ergoloid oral tablet 1 mg 2

galantamine oral capsuleext rel pellets 24 hr 16 mg 24 mg 8 mg

(Razadyne ER) 2 QL (30 per 30 days)

galantamine oral solution 4 mgml 2 QL (200 per 30 days)

galantamine oral tablet 12 mg 4 mg 8 mg



42


memantine oral capsulesprinkleer 24hr 14 mg 21 mg 28 mg 7 mg

(Namenda XR) 2 ST QL (30 per 30 days)

memantine oral solution 2 mgml 2 QL (300 per 30 days)

memantine oral tablet 10 mg 5 mg (Namenda) 2 QL (60 per 30 days)

NAMZARIC ORAL CAPSPRINKLEER 24HR DOSE PACK 7142128 MG-10 MG

3 ST

NAMZARIC ORAL CAPSULESPRINKLEER 24HR 14-10 MG 21-10 MG 28-10 MG 7-10 MG


rivastigmine tartrate oral capsule15 mg 3 mg 45 mg 6 mg


rivastigmine transdermal patch 24 hour 133 mg24 hour 46 mg24 hour 95 mg24 hour

(Exelon Patch) 2 QL (30 per 30 days)

AntidepressantsAntidepressantsamitriptyline oral tablet 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg

2

amitriptyline-chlordiazepoxide oral tablet 125-5 mg 25-10 mg

2

amoxapine oral tablet 100 mg 150 mg 25 mg 50 mg

2

bupropion hcl oral tablet 100 mg 75 mg

2

bupropion hcl oral tablet extended release 24 hr 150 mg 300 mg

(Wellbutrin XL) 2

bupropion hcl oral tablet sustained-release 12 hr 100 mg 150 mg 200 mg

(Wellbutrin SR) 2

citalopram oral solution 10 mg5 ml 2 QL (600 per 30 days)

citalopram oral tablet 10 mg 20 mg 40 mg

(Celexa) 1 GC QL (30 per 30 days)

clomipramine oral capsule 25 mg 50 mg 75 mg

(Anafranil) 2

desipramine oral tablet 10 mg 25 mg

(Norpramin) 2

desipramine oral tablet 100 mg 150 mg 50 mg 75 mg

2


43


desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 25 mg 50 mg

(Pristiq) 2 QL (30 per 30 days)

doxepin oral capsule 10 mg 100 mg 150 mg 25 mg 50 mg 75 mg

2

doxepin oral concentrate 10 mgml 1 GC

DRIZALMA SPRINKLE ORAL CAPSULE DELAYED REL SPRINKLE 20 MG 30 MG 60 MG


DRIZALMA SPRINKLE ORAL CAPSULE DELAYED REL SPRINKLE 40 MG


duloxetine oral capsuledelayed release(drec) 20 mg 30 mg 60 mg

(Cymbalta) 2 QL (60 per 30 days)

duloxetine oral capsuledelayed release(drec) 40 mg


EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG24 HR 6 MG24 HR 9 MG24 HR

5 ST NM NDS QL (30 per 30 days)

escitalopram oxalate oral solution 5 mg5 ml

2

escitalopram oxalate oral tablet 10 mg 20 mg 5 mg

(Lexapro) 1 GC

FETZIMA ORAL CAPSULEEXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)

4 ST

FETZIMA ORAL CAPSULEEXTENDED RELEASE 24 HR 120 MG 20 MG 40 MG 80 MG


fluoxetine oral capsule 10 mg 20 mg 40 mg

(Prozac) 1 GC

fluoxetine oral solution 20 mg5 ml (4 mgml)

2

fluvoxamine oral tablet 100 mg 25 mg 50 mg

2

imipramine hcl oral tablet 10 mg 25 mg 50 mg

2


44


imipramine pamoate oral capsule100 mg 125 mg 150 mg 75 mg

2

maprotiline oral tablet 25 mg 50 mg 75 mg

2

MARPLAN ORAL TABLET 10 MG

4

mirtazapine oral tablet 15 mg 30 mg

(Remeron) 2


2

mirtazapine oral tabletdisintegrating 15 mg 30 mg 45 mg

(Remeron SolTab) 2

nefazodone oral tablet 100 mg 150 mg 200 mg 250 mg 50 mg

2

nortriptyline oral capsule 10 mg 25 mg 50 mg 75 mg

(Pamelor) 1 GC

nortriptyline oral solution 10 mg5 ml

2

paroxetine hcl oral suspension 10 mg5 ml

(Paxil) 2

paroxetine hcl oral tablet 10 mg 20 mg 30 mg 40 mg

(Paxil) 1 GC

paroxetine hcl oral tablet extended release 24 hr 125 mg 25 mg 375 mg

(Paxil CR) 2

PAXIL ORAL SUSPENSION 10 MG5 ML

(paroxetine hcl) 4

perphenazine-amitriptyline oral tablet 2-10 mg 2-25 mg 4-10 mg 4-25 mg 4-50 mg

2

phenelzine oral tablet 15 mg (Nardil) 2

protriptyline oral tablet 10 mg 5 mg 2

sertraline oral concentrate 20 mgml (Zoloft) 2

sertraline oral tablet 100 mg 25 mg 50 mg

(Zoloft) 1 GC

SPRAVATO NASAL SPRAYNON-AEROSOL 28 MG

4 PA NSO

SPRAVATO NASAL SPRAYNON-AEROSOL 56 MG (28 MG X 2) 84 MG (28 MG X 3)

5 PA NSO NM NDS


45


tranylcypromine oral tablet 10 mg (Parnate) 2

trazodone oral tablet 100 mg 150 mg 50 mg

1 GC

trazodone oral tablet 300 mg 2

trimipramine oral capsule 100 mg 25 mg 50 mg

2

TRINTELLIX ORAL TABLET 10 MG 20 MG 5 MG


venlafaxine oral capsuleextended release 24hr 150 mg

(Effexor XR) 2 QL (30 per 30 days)

venlafaxine oral capsuleextended release 24hr 375 mg 75 mg


venlafaxine oral tablet 100 mg 25 mg 375 mg 50 mg 75 mg

2

venlafaxine oral tablet extended release 24hr 150 mg 375 mg


venlafaxine oral tablet extended release 24hr 75 mg


VIIBRYD ORAL TABLET 10 MG 20 MG 40 MG


VIIBRYD ORAL TABLETSDOSE PACK 10 MG (7)- 20 MG (23)

3

ZULRESSO INTRAVENOUS SOLUTION 5 MGML

5 NM NDS

Antidiabetic AgentsAntidiabetic Agents Miscellaneousacarbose oral tablet 100 mg 25 mg 50 mg

(Precose) 2 QL (90 per 30 days)

FARXIGA ORAL TABLET 10 MG 5 MG


JARDIANCE ORAL TABLET 10 MG 25 MG


JENTADUETO ORAL TABLET 25-1000 MG 25-500 MG 25-850 MG


JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG



46




KORLYM ORAL TABLET 300 MG


metformin oral solution 500 mg5 ml (Riomet) 2 QL (765 per 30 days)

metformin oral tablet 1000 mg 6 GC QL (75 per 30 days)



metformin oral tablet extended release 24 hr 500 mg




miglitol oral tablet 100 mg 25 mg 50 mg


nateglinide oral tablet 120 mg 60 mg


OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML)


OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML)


pioglitazone oral tablet 15 mg 30 mg 45 mg

(Actos) 6 GC QL (30 per 30 days)

repaglinide oral tablet 05 mg 1 mg 6 GC QL (120 per 30 days)

repaglinide oral tablet 2 mg 6 GC QL (240 per 30 days)

repaglinide-metformin oral tablet 1-500 mg 2-500 mg


RYBELSUS ORAL TABLET 14 MG 3 MG 7 MG


SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2700 MCG27 ML



47




SYNJARDY ORAL TABLET 125-1000 MG 125-500 MG 5-1000 MG 5-500 MG


SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 25-1000 MG




TRADJENTA ORAL TABLET 5 MG


TRULICITY SUBCUTANEOUS PEN INJECTOR 075 MG05 ML 15 MG05 ML 3 MG05 ML 45 MG05 ML


VICTOZA SUBCUTANEOUS PEN INJECTOR 06 MG01 ML (18 MG3 ML)


XIGDUO XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 10-500 MG


XIGDUO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 5-1000 MG 5-500 MG


InsulinsFIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)

3 SI QL (30 per 28 days)

FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML (3 ML)


FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML


HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNITML



48


HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNITML (3 ML)


LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNITML

(insulin glargine) 3 SI QL (40 per 28 days)

NOVOLIN 7030 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML (70-30)


NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)


NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNITML


NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)


NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNITML


NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNITML (3 ML)

(insulin aspart u-100) 2 SI QL (30 per 28 days)

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNITML (70-30)

(insulin asp prt-insulin aspart)


NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNITML (70-30)




49


NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNITML


NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNITML


SOLIQUA 10033 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCGML


TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNITML (3 ML)


TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNITML (15 ML)


XULTOPHY 10036 SUBCUTANEOUS INSULIN PEN 100 UNIT-36 MG ML (3 ML)


Sulfonylureasglimepiride oral tablet 1 mg 2 mg (Amaryl) 6 GC QL (30 per 30

days)

glimepiride oral tablet 4 mg (Amaryl) 6 GC QL (60 per 30 days)

glipizide oral tablet 10 mg (Glucotrol) 6 GC QL (120 per 30 days)

glipizide oral tablet 5 mg 6 GC QL (60 per 30 days)

glipizide oral tablet extended release 24hr 10 mg

(Glucotrol XL) 6 GC QL (60 per 30 days)

glipizide oral tablet extended release 24hr 25 mg 5 mg


glipizide-metformin oral tablet 25-250 mg


glipizide-metformin oral tablet 25-500 mg 5-500 mg


glyburide micronized oral tablet 15 mg 3 mg 6 mg

(Glynase) 6 GC


50


glyburide oral tablet 125 mg 25 mg 5 mg

6 GC

glyburide-metformin oral tablet125-250 mg 25-500 mg 5-500 mg

6 GC

AntifungalsAntifungalsABELCET INTRAVENOUS SUSPENSION 5 MGML

4 PA BvD

AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG

5 PA BvD NM NDS

amphotericin b injection recon soln50 mg

2 PA BvD

caspofungin intravenous recon soln50 mg

(Cancidas) 5 NM NDS


(Cancidas) 2

ciclopirox topical cream 077 (Ciclodan) 2 QL (180 per 30 days)

ciclopirox topical gel 077 2 QL (300 per 30 days)

ciclopirox topical shampoo 1 (Loprox) 2

ciclopirox topical solution 8 (Ciclodan) 2 QL (198 per 30 days)

ciclopirox topical suspension 077 (Loprox (as olamine)) 2 QL (180 per 30 days)

clotrimazole mucous membrane troche 10 mg

2

clotrimazole topical cream 1 (Antifungal (clotrimazole))

2

clotrimazole topical solution 1 2

clotrimazole-betamethasone topical cream 1-005


clotrimazole-betamethasone topical lotion 1-005


econazole topical cream 1 2 QL (170 per 30 days)

fluconazole in nacl (iso-osm) intravenous piggyback 100 mg50 ml 200 mg100 ml 400 mg200 ml

2 PA BvD

fluconazole oral suspension for reconstitution 10 mgml 40 mgml

(Diflucan) 2

fluconazole oral tablet 100 mg 150 mg 200 mg 50 mg

(Diflucan) 2

flucytosine oral capsule 250 mg 500 mg

(Ancobon) 5 NM NDS


51


griseofulvin microsize oral suspension 125 mg5 ml

2

griseofulvin microsize oral tablet500 mg

2

griseofulvin ultramicrosize oral tablet 125 mg 250 mg

2

itraconazole oral capsule 100 mg (Sporanox) 2

itraconazole oral solution 10 mgml (Sporanox) 2 PA

ketoconazole oral tablet 200 mg 2

ketoconazole topical cream 2 2 QL (180 per 30 days)

ketoconazole topical shampoo 2 2 QL (360 per 30 days)

miconazole-3 vaginal suppository200 mg

2

NOXAFIL INTRAVENOUS SOLUTION 300 MG167 ML

5 NM NDS

NOXAFIL ORAL SUSPENSION 200 MG5 ML (40 MGML)

(posaconazole) 5 PA NM NDS

nyamyc topical powder 100000 unitgram

(nystatin) 2 QL (60 per 30 days)

nystatin oral suspension 100000 unitml


nystatin oral tablet 500000 unit 2

nystatin topical cream 100000 unitgram


nystatin topical ointment 100000 unitgram


nystatin topical powder 100000 unitgram

(Nyamyc) 2 QL (60 per 30 days)

nystatin-triamcinolone topical cream 100000-01 unitg-

2

nystatin-triamcinolone topical ointment 100000-01 unitgram-

2

nystop topical powder 100000 unitgram


posaconazole oral tabletdelayed release (drec) 100 mg

(Noxafil) 5 PA NM NDS

terbinafine hcl oral tablet 250 mg 1 GC

voriconazole intravenous recon soln200 mg

(Vfend IV) 5 PA BvD NM NDS


52


voriconazole oral suspension for reconstitution 200 mg5 ml (40 mgml)

(Vfend) 5 PA NM NDS

voriconazole oral tablet 200 mg 50 mg

(Vfend) 2

Antigout AgentsAntigout Agents Otherallopurinol oral tablet 100 mg (Zyloprim) 1 GC

allopurinol oral tablet 300 mg 1 GC

colchicine oral tablet 06 mg (Colcrys) 4 PA QL (120 per 30 days)

febuxostat oral tablet 40 mg 80 mg (Uloric) 2 ST QL (30 per 30 days)

MITIGARE ORAL CAPSULE 06 MG

(colchicine) 2 QL (60 per 30 days)

probenecid oral tablet 500 mg 2

probenecid-colchicine oral tablet500-05 mg

2

AntihistaminesAntihistaminescarbinoxamine maleate oral liquid 4 mg5 ml

2

carbinoxamine maleate oral tablet 4 mg

2

clemastine oral tablet 268 mg 2

cyproheptadine oral syrup 2 mg5 ml 2

cyproheptadine oral tablet 4 mg 2

diphenhydramine hcl injection solution 50 mgml

2

diphenhydramine hcl injection syringe 50 mgml

2

diphenhydramine hcl oral elixir 125 mg5 ml

(Diphen) 2

hydroxyzine hcl intramuscular solution 25 mgml 50 mgml

2

hydroxyzine hcl oral solution 10 mg5 ml

2

hydroxyzine hcl oral tablet 10 mg 25 mg 50 mg

1 GC

levocetirizine oral solution 25 mg5 ml

(Xyzal) 2


53


levocetirizine oral tablet 5 mg (24HR Allergy Relief) 1 GC

promethazine oral syrup 625 mg5 ml

2

Anti-Infectives (Skin And Mucous Membrane)Anti-Infectives (Skin And Mucous Membrane)clindamycin phosphate vaginal cream 2

(Cleocin) 2

metronidazole vaginal gel 075 (Metrogel Vaginal) 2

terconazole vaginal cream 04 08

2

terconazole vaginal suppository 80 mg

2

Antimigraine AgentsAntimigraine AgentsAIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MGML 70 MGML


dihydroergotamine injection solution1 mgml

(DHE45) 2 QL (24 per 28 days)

dihydroergotamine nasal spraynon-aerosol 05 mgpump act (4 mgml)

(Migranal) 5 NM NDS QL (8 per 28 days)

EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MGML


EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MGML


EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG3 ML (100 MGML X 3)


naratriptan oral tablet 1 mg 25 mg (Amerge) 2 QL (9 per 30 days)

rizatriptan oral tablet 10 mg (Maxalt) 2 QL (12 per 30 days)

rizatriptan oral tablet 5 mg 2 QL (12 per 30 days)

rizatriptan oral tabletdisintegrating10 mg

(Maxalt-MLT) 2 QL (12 per 30 days)




54


sumatriptan nasal spraynon-aerosol20 mgactuation

(Imitrex) 2 QL (12 per 30 days)



sumatriptan succinate oral tablet100 mg


sumatriptan succinate oral tablet 25 mg 50 mg


sumatriptan succinate subcutaneous cartridge 4 mg05 ml

(Imitrex STATdose Refill)





sumatriptan succinate subcutaneous pen injector 4 mg05 ml 6 mg05 ml

(Imitrex STATdose Pen)


sumatriptan succinate subcutaneous solution 6 mg05 ml


sumatriptan succinate subcutaneous syringe 6 mg05 ml


UBRELVY ORAL TABLET 100 MG 50 MG


zolmitriptan oral tablet 25 mg 5 mg

(Zomig) 2 QL (6 per 30 days)

zolmitriptan oral tabletdisintegrating 25 mg 5 mg


AntimycobacterialsAntimycobacterialsdapsone oral tablet 100 mg 25 mg 2

ethambutol oral tablet 100 mg 2

ethambutol oral tablet 400 mg (Myambutol) 2

isoniazid oral solution 50 mg5 ml 2

isoniazid oral tablet 100 mg 300 mg 1 GC

PRETOMANID ORAL TABLET 200 MG


PRIFTIN ORAL TABLET 150 MG

4

pyrazinamide oral tablet 500 mg 2

rifabutin oral capsule 150 mg (Mycobutin) 2

rifampin intravenous recon soln 600 mg

(Rifadin) 2


55


rifampin oral capsule 150 mg 300 mg

2

SIRTURO ORAL TABLET 100 MG 20 MG

5 PA NM NDS

TRECATOR ORAL TABLET 250 MG

4

Antinausea AgentsAntinausea AgentsAKYNZEO (FOSNETUPITANT) INTRAVENOUS RECON SOLN 235-025 MG

4

AKYNZEO (FOSNETUPITANT) INTRAVENOUS SOLUTION 235 MG-025 MG 20 ML

4

AKYNZEO (NETUPITANT) ORAL CAPSULE 300-05 MG

4 PA BvD

aprepitant oral capsule 125 mg 2 PA BvD QL (2 per 28 days)


aprepitant oral capsule 80 mg (Emend) 2 PA BvD QL (4 per 28 days)

aprepitant oral capsuledose pack125 mg (1)- 80 mg (2)

(Emend) 2 PA BvD QL (6 per 28 days)

compro rectal suppository 25 mg (prochlorperazine) 2

dimenhydrinate injection solution 50 mgml

2

dronabinol oral capsule 10 mg 25 mg 5 mg

(Marinol) 2 PA QL (60 per 30 days)

droperidol injection solution 25 mgml

2

EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG ML FINAL CONC)

4 PA BvD QL (6 per 28 days)

fosaprepitant intravenous recon soln150 mg

(Emend (fosaprepitant))


granisetron (pf) intravenous solution 1 mgml (1 ml) 100 mcgml

2

granisetron hcl intravenous solution1 mgml

2


56


granisetron hcl oral tablet 1 mg 2 PA BvD

meclizine oral tablet 125 mg 2

meclizine oral tablet 25 mg (Dramamine Less Drowsy)

2

ondansetron hcl (pf) injection solution 4 mg2 ml

1 GC

ondansetron hcl (pf) injection syringe 4 mg2 ml

1 GC

ondansetron hcl intravenous solution2 mgml

2

ondansetron hcl oral solution 4 mg5 ml

2 PA BvD

ondansetron hcl oral tablet 24 mg 8 mg

2 PA BvD

ondansetron hcl oral tablet 4 mg (Zofran) 2 PA BvD

ondansetron oral tabletdisintegrating 4 mg 8 mg

2 PA BvD

prochlorperazine edisylate injection solution 10 mg2 ml (5 mgml) 5 mgml

2

prochlorperazine maleate oral tablet10 mg 5 mg

(Compazine) 2

prochlorperazine rectal suppository25 mg

(Compro) 2

promethazine injection solution 25 mgml 50 mgml

(Phenergan) 2

promethazine oral tablet 125 mg 25 mg 50 mg

1 GC

promethazine rectal suppository125 mg 25 mg 50 mg

(Promethegan) 2

promethegan rectal suppository 125 mg 25 mg 50 mg

(promethazine) 2

scopolamine base transdermal patch 3 day 1 mg over 3 days

(Transderm-Scop) 2 QL (10 per 30 days)

SYNDROS ORAL SOLUTION 5 MGML


Antiparasite AgentsAntiparasite Agentsalbendazole oral tablet 200 mg (Albenza) 5 NM NDS

atovaquone oral suspension 750 mg5 ml

(Mepron) 2


57


atovaquone-proguanil oral tablet250-100 mg

(Malarone) 2


(Malarone Pediatric) 2

chloroquine phosphate oral tablet250 mg




COARTEM ORAL TABLET 20-120 MG

4

hydroxychloroquine oral tablet 200 mg

(Plaquenil) 2 QL (90 per 30 days)

IMPAVIDO ORAL CAPSULE 50 MG


ivermectin oral tablet 3 mg (Stromectol) 2

KRINTAFEL ORAL TABLET 150 MG

4

mefloquine oral tablet 250 mg 2

nitazoxanide oral tablet 500 mg (Alinia) 5 NM NDS

paromomycin oral capsule 250 mg (Humatin) 2

pentamidine inhalation recon soln300 mg

(Nebupent) 2 PA BvD

pentamidine injection recon soln 300 mg

(Pentam) 2

PRIMAQUINE ORAL TABLET 263 MG

4

pyrimethamine oral tablet 25 mg (Daraprim) 5 PA NM NDS

quinine sulfate oral capsule 324 mg (Qualaquin) 2 PA QL (42 per 7 days)

tinidazole oral tablet 250 mg 500 mg

2

Antiparkinsonian AgentsAntiparkinsonian Agentsamantadine hcl oral capsule 100 mg 2

amantadine hcl oral solution 50 mg5 ml

1 GC

amantadine hcl oral tablet 100 mg 2

APOKYN SUBCUTANEOUS CARTRIDGE 10 MGML


benztropine injection solution 1 mgml

(Cogentin) 2


58


benztropine oral tablet 05 mg 1 mg 2 mg

2

bromocriptine oral capsule 5 mg (Parlodel) 2

bromocriptine oral tablet 25 mg (Parlodel) 2

cabergoline oral tablet 05 mg 2

carbidopa oral tablet 25 mg (Lodosyn) 2

carbidopa-levodopa oral tablet 10-100 mg

(Sinemet) 2


(Dhivy) 2


2

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

2

carbidopa-levodopa oral tabletdisintegrating 10-100 mg 25-100 mg 25-250 mg

2

carbidopa-levodopa-entacapone oral tablet 125-50-200 mg

(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4

entacapone oral tablet 200 mg (Comtan) 2

INBRIJA INHALATION CAPSULE WINHALATION DEVICE 42 MG


KYNMOBI SUBLINGUAL FILM 10 MG 15 MG 20 MG 25 MG 30 MG


KYNMOBI SUBLINGUAL FILM 10-15-20-25-30 MG

5 PA NM NDS


59


NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG24 HOUR 2 MG24 HOUR 3 MG24 HOUR 4 MG24 HOUR 6 MG24 HOUR 8 MG24 HOUR


ONGENTYS ORAL CAPSULE 25 MG 50 MG


OSMOLEX ER ORAL TABLET IR - ER BIPHASIC 24HR 129 MG 193 MG 258 MG


OSMOLEX ER ORAL TABLET IR - ER BIPHASIC 24HR 322 MGDAY(129 MG X1-193MG X1)


pramipexole oral tablet 0125 mg 025 mg 05 mg 075 mg 1 mg 15 mg

(Mirapex) 1 GC

rasagiline oral tablet 05 mg 1 mg (Azilect) 2

ropinirole oral tablet 025 mg 05 mg 1 mg 2 mg 3 mg 4 mg 5 mg

2

ropinirole oral tablet extended release 24 hr 12 mg 2 mg 4 mg 6 mg 8 mg

2

selegiline hcl oral capsule 5 mg 2

selegiline hcl oral tablet 5 mg 2

trihexyphenidyl oral elixir 04 mgml

2

trihexyphenidyl oral tablet 2 mg 5 mg

1 GC

XADAGO ORAL TABLET 100 MG




Antipsychotic AgentsAntipsychotic Agentsaripiprazole oral solution 1 mgml 2 QL (900 per 30 days)

aripiprazole oral tablet 10 mg 15 mg 20 mg 30 mg 5 mg

(Abilify) 2 QL (30 per 30 days)

aripiprazole oral tablet 2 mg (Abilify) 2 QL (60 per 30 days)

aripiprazole oral tabletdisintegrating 10 mg



60




ARISTADA INITIO INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 675 MG24 ML


ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML








asenapine maleate sublingual tablet10 mg 25 mg 5 mg

(Saphris) 2 ST QL (60 per 30 days)

CAPLYTA ORAL CAPSULE 42 MG


chlorpromazine injection solution 25 mgml

2

chlorpromazine oral concentrate 100 mgml 30 mgml

2

chlorpromazine oral tablet 10 mg 100 mg 200 mg 25 mg 50 mg

2

clozapine oral tablet 100 mg (Clozaril) 2 QL (270 per 30 days)


clozapine oral tablet 25 mg 50 mg (Clozaril) 2 QL (90 per 30 days)

clozapine oral tabletdisintegrating100 mg 125 mg 25 mg


clozapine oral tabletdisintegrating150 mg





61


FANAPT ORAL TABLET 1 MG 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG


FANAPT ORAL TABLETSDOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)

4 ST

fluphenazine decanoate injection solution 25 mgml

2

fluphenazine hcl injection solution25 mgml

2

fluphenazine hcl oral concentrate 5 mgml

2

fluphenazine hcl oral elixir 25 mg5 ml

2

fluphenazine hcl oral tablet 1 mg 10 mg 25 mg 5 mg

2

haloperidol decanoate intramuscular solution 100 mgml

(Haldol Decanoate) 2

haloperidol decanoate intramuscular solution 100 mgml (1 ml)

2



haloperidol decanoate intramuscular solution 50 mgml(1ml)

2

haloperidol lactate injection solution5 mgml

2

haloperidol lactate intramuscular syringe 5 mgml

2

haloperidol lactate oral concentrate2 mgml

2

haloperidol oral tablet 05 mg 1 mg 10 mg 2 mg 20 mg 5 mg

2

INVEGA HAFYERA INTRAMUSCULAR SYRINGE 1092 MG35 ML




INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML



62


INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MGML








INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG0875 ML








LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG


LATUDA ORAL TABLET 80 MG


loxapine succinate oral capsule 10 mg 25 mg 5 mg 50 mg

2

LYBALVI ORAL TABLET 10-10 MG 15-10 MG 20-10 MG 5-10 MG


molindone oral tablet 10 mg 2 QL (240 per 30 days)



NUPLAZID ORAL CAPSULE 34 MG


NUPLAZID ORAL TABLET 10 MG



63


olanzapine intramuscular recon soln10 mg

(Zyprexa) 2 QL (30 per 30 days)

olanzapine oral tablet 10 mg 15 mg 25 mg 20 mg 5 mg 75 mg


olanzapine oral tabletdisintegrating10 mg 15 mg 20 mg 5 mg

(Zyprexa Zydis) 2 QL (30 per 30 days)

paliperidone oral tablet extended release 24hr 15 mg 3 mg 9 mg

(Invega) 2 QL (30 per 30 days)

paliperidone oral tablet extended release 24hr 6 mg


perphenazine oral tablet 16 mg 2 mg 4 mg 8 mg

2

PERSERIS ABDOMINAL SUBCUTANEOUS SUSPENSIONEXTENDED REL SYRING 120 MG 90 MG


pimozide oral tablet 1 mg 2 mg 2

quetiapine oral tablet 100 mg 200 mg 25 mg 50 mg

(Seroquel) 2 QL (90 per 30 days)

quetiapine oral tablet 300 mg 400 mg


quetiapine oral tablet extended release 24 hr 150 mg 200 mg 50 mg

(Seroquel XR) 2 QL (30 per 30 days)

quetiapine oral tablet extended release 24 hr 300 mg 400 mg


REXULTI ORAL TABLET 025 MG




REXULTI ORAL TABLET 1 MG 2 MG 3 MG 4 MG


RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML 25 MG2 ML





64


risperidone oral solution 1 mgml (Risperdal) 2 QL (480 per 30 days)

risperidone oral tablet 025 mg 2 QL (60 per 30 days)

risperidone oral tablet 05 mg 1 mg 2 mg 3 mg

(Risperdal) 2 QL (60 per 30 days)

risperidone oral tablet 4 mg (Risperdal) 2 QL (120 per 30 days)

risperidone oral tabletdisintegrating025 mg 05 mg 1 mg 2 mg


risperidone oral tabletdisintegrating3 mg 4 mg


SECUADO TRANSDERMAL PATCH 24 HOUR 38 MG24 HOUR 57 MG24 HOUR 76 MG24 HOUR


thioridazine oral tablet 10 mg 100 mg 25 mg 50 mg

2

thiothixene oral capsule 1 mg 10 mg 2 mg 5 mg

2

trifluoperazine oral tablet 1 mg 10 mg 2 mg 5 mg

2

VERSACLOZ ORAL SUSPENSION 50 MGML


VRAYLAR ORAL CAPSULE 15 MG 3 MG 45 MG 6 MG


VRAYLAR ORAL CAPSULEDOSE PACK 15 MG (1)- 3 MG (6)

4 ST

ziprasidone hcl oral capsule 20 mg 40 mg 60 mg 80 mg

(Geodon) 2 QL (60 per 30 days)

ziprasidone mesylate intramuscular recon soln 20 mgml (final conc)


ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG





65




Antivirals (Systemic)Antiretroviralsabacavir oral solution 20 mgml (Ziagen) 2

abacavir oral tablet 300 mg (Ziagen) 2

abacavir-lamivudine oral tablet 600-300 mg

(Epzicom) 2

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

(Trizivir) 5 NM NDS

APTIVUS (WITH VITAMIN E) ORAL SOLUTION 100 MGML

5 NM NDS

APTIVUS ORAL CAPSULE 250 MG

5 NM NDS

atazanavir oral capsule 150 mg 200 mg 300 mg

(Reyataz) 2

BIKTARVY ORAL TABLET 50-200-25 MG

5 NM NDS

CABENUVA INTRAMUSCULAR SUSPENSIONEXTENDED RELEASE 400 MG2 ML- 600 MG2 ML 600 MG3 ML- 900 MG3 ML

5 NM NDS

CIMDUO ORAL TABLET 300-300 MG

5 NM NDS

COMPLERA ORAL TABLET 200-25-300 MG

5 NM NDS

CRIXIVAN ORAL CAPSULE 200 MG

4

DELSTRIGO ORAL TABLET 100-300-300 MG

5 NM NDS

DESCOVY ORAL TABLET 200-25 MG

5 NM NDS

didanosine oral capsuledelayed release(drec) 250 mg 400 mg

2

DOVATO ORAL TABLET 50-300 MG

5 NM NDS


66


EDURANT ORAL TABLET 25 MG

5 NM NDS

efavirenz oral capsule 200 mg 50 mg

(Sustiva) 2

efavirenz oral tablet 600 mg (Sustiva) 2

efavirenz-emtricitabin-tenofov oral tablet 600-200-300 mg

(Atripla) 5 NM NDS

efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg

(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS

emtricitabine oral capsule 200 mg (Emtriva) 2

emtricitabine-tenofovir (tdf) oral tablet 100-150 mg 133-200 mg 167-250 mg 200-300 mg

(Truvada) 5 NM NDS

EMTRIVA ORAL SOLUTION 10 MGML

4

EPIVIR HBV ORAL SOLUTION 25 MG5 ML (5 MGML)

4

etravirine oral tablet 100 mg 200 mg

(Intelence) 5 NM NDS

EVOTAZ ORAL TABLET 300-150 MG

5 NM NDS

fosamprenavir oral tablet 700 mg (Lexiva) 2

FUZEON SUBCUTANEOUS RECON SOLN 90 MG

5 NM NDS

GENVOYA ORAL TABLET 150-150-200-10 MG

5 NM NDS

INTELENCE ORAL TABLET 25 MG

4

INVIRASE ORAL TABLET 500 MG

5 NM NDS

ISENTRESS HD ORAL TABLET 600 MG

5 NM NDS

ISENTRESS ORAL POWDER IN PACKET 100 MG

4

ISENTRESS ORAL TABLET 400 MG

5 NM NDS

ISENTRESS ORAL TABLETCHEWABLE 100 MG 25 MG

4


67


JULUCA ORAL TABLET 50-25 MG

5 NM NDS

lamivudine oral solution 10 mgml (Epivir) 2

lamivudine oral tablet 100 mg (Epivir HBV) 2

lamivudine oral tablet 150 mg 300 mg

(Epivir) 2

lamivudine-zidovudine oral tablet150-300 mg

(Combivir) 2

LEXIVA ORAL SUSPENSION 50 MGML

4

lopinavir-ritonavir oral solution 400-100 mg5 ml

(Kaletra) 2 QL (480 per 30 days)

lopinavir-ritonavir oral tablet 100-25 mg



(Kaletra) 5 NM NDS QL (120 per 30 days)

nevirapine oral suspension 50 mg5 ml

2

nevirapine oral tablet 200 mg 2

nevirapine oral tablet extended release 24 hr 100 mg

2


(Viramune XR) 2

NORVIR ORAL POWDER IN PACKET 100 MG

4

NORVIR ORAL SOLUTION 80 MGML

4

ODEFSEY ORAL TABLET 200-25-25 MG

5 NM NDS

PIFELTRO ORAL TABLET 100 MG

5 NM NDS

PREZCOBIX ORAL TABLET 800-150 MG-MG

5 NM NDS

PREZISTA ORAL SUSPENSION 100 MGML

5 NM NDS

PREZISTA ORAL TABLET 150 MG 600 MG 800 MG

5 NM NDS

PREZISTA ORAL TABLET 75 MG

4

RETROVIR INTRAVENOUS SOLUTION 10 MGML

4


68


REYATAZ ORAL POWDER IN PACKET 50 MG

5 NM NDS

ritonavir oral tablet 100 mg (Norvir) 2

RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HR 600 MG

5 NM NDS

SELZENTRY ORAL SOLUTION 20 MGML

4

SELZENTRY ORAL TABLET 150 MG 300 MG 75 MG

5 NM NDS

SELZENTRY ORAL TABLET 25 MG

3

stavudine oral capsule 15 mg 20 mg 30 mg 40 mg

2

STRIBILD ORAL TABLET 150-150-200-300 MG

5 NM NDS

SYMTUZA ORAL TABLET 800-150-200-10 MG

5 NM NDS

TEMIXYS ORAL TABLET 300-300 MG

5 NM NDS

tenofovir disoproxil fumarate oral tablet 300 mg

(Viread) 2

TIVICAY ORAL TABLET 10 MG

4

TIVICAY ORAL TABLET 25 MG 50 MG

5 NM NDS

TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG

4

TRIUMEQ ORAL TABLET 600-50-300 MG

5 NM NDS

TROGARZO INTRAVENOUS SOLUTION 200 MG133 ML (150 MGML)

5 NM NDS

VEMLIDY ORAL TABLET 25 MG


VIRACEPT ORAL TABLET 250 MG 625 MG

5 NM NDS

VIREAD ORAL POWDER 40 MGSCOOP (40 MGGRAM)

5 NM NDS

VIREAD ORAL TABLET 150 MG 200 MG 250 MG

5 NM NDS


69


VOCABRIA ORAL TABLET 30 MG

4

zidovudine oral capsule 100 mg (Retrovir) 2

zidovudine oral syrup 10 mgml (Retrovir) 2

zidovudine oral tablet 300 mg 2Antivirals Miscellaneousfoscarnet intravenous solution 24 mgml

(Foscavir) 2 PA BvD

oseltamivir oral capsule 30 mg (Tamiflu) 2 QL (84 per 180 days)



oseltamivir oral suspension for reconstitution 6 mgml

(Tamiflu) 2 QL (540 per 180 days)

PREVYMIS INTRAVENOUS SOLUTION 240 MG12 ML




PREVYMIS ORAL TABLET 240 MG 480 MG


RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MGACTUATION


rimantadine oral tablet 100 mg (Flumadine) 2

SYNAGIS INTRAMUSCULAR SOLUTION 100 MGML 50 MG05 ML

5 PA NM NDS

XOFLUZA ORAL TABLET 20 MG 40 MG


XOFLUZA ORAL TABLET 80 MG


Hcv AntiviralsEPCLUSA ORAL PELLETS IN PACKET 150-375 MG


EPCLUSA ORAL TABLET 200-50 MG



(sofosbuvir-velpatasvir)


HARVONI ORAL PELLETS IN PACKET 3375-150 MG





70


HARVONI ORAL TABLET 45-200 MG



(ledipasvir-sofosbuvir) 5 PA NM NDS QL (28 per 28 days)

MAVYRET ORAL TABLET 100-40 MG


VOSEVI ORAL TABLET 400-100-100 MG


InterferonsINTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) 18 MILLION UNIT (1 ML) 50 MILLION UNIT (1 ML)

5 PA NSO NM NDS

INTRON A INJECTION SOLUTION 10 MILLION UNITML 6 MILLION UNITML

5 PA NSO NM NDS

PEGASYS SUBCUTANEOUS SOLUTION 180 MCGML

5 NM NDS

PEGASYS SUBCUTANEOUS SYRINGE 180 MCG05 ML

5 NM NDS

PEGINTRON SUBCUTANEOUS KIT 50 MCG05 ML

5 NM NDS

Nucleosides And Nucleotidesacyclovir oral capsule 200 mg 2

acyclovir oral suspension 200 mg5 ml

(Zovirax) 2

acyclovir oral tablet 400 mg 800 mg 2

acyclovir sodium intravenous recon soln 1000 mg 500 mg

2 PA BvD

acyclovir sodium intravenous solution 50 mgml

2 PA BvD

adefovir oral tablet 10 mg (Hepsera) 2

cidofovir intravenous solution 75 mgml

5 NM NDS

entecavir oral tablet 05 mg 1 mg (Baraclude) 2

famciclovir oral tablet 125 mg 250 mg 500 mg

2


71


ganciclovir sodium intravenous recon soln 500 mg

(Cytovene) 5 PA BvD NM NDS

ganciclovir sodium intravenous solution 50 mgml

5 PA BvD NM NDS

ribavirin inhalation recon soln 6 gram

(Virazole) 5 PA BvD NM NDS

ribavirin oral capsule 200 mg 2

ribavirin oral tablet 200 mg 2

valacyclovir oral tablet 1 gram 500 mg

(Valtrex) 2

valganciclovir oral recon soln 50 mgml

(Valcyte) 5 NM NDS

valganciclovir oral tablet 450 mg (Valcyte) 2

VEKLURY INTRAVENOUS RECON SOLN 100 MG

(remdesivir) 5 PA BvD NM NDS

Blood ProductsModifiersVolume ExpandersAnticoagulantsELIQUIS DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 5 MG (74 TABS)

3

ELIQUIS ORAL TABLET 25 MG


ELIQUIS ORAL TABLET 5 MG 3 QL (74 per 30 days)

enoxaparin subcutaneous solution300 mg3 ml

(Lovenox) 2 QL (30 per 30 days)

enoxaparin subcutaneous syringe100 mgml 150 mgml


enoxaparin subcutaneous syringe120 mg08 ml 80 mg08 ml


enoxaparin subcutaneous syringe 30 mg03 ml






fondaparinux subcutaneous syringe10 mg08 ml

(Arixtra) 5 NM NDS QL (24 per 30 days)


72



(Arixtra) 2 QL (15 per 30 days)





heparin (porcine) injection cartridge5000 unitml (1 ml)

2

heparin (porcine) injection solution1000 unitml 10000 unitml 20000 unitml 5000 unitml

2

heparin (porcine) injection syringe5000 unitml

2

heparin porcine (pf) injection solution 1000 unitml

2

heparin porcine (pf) injection syringe 5000 unit05 ml

2

jantoven oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

(warfarin) 1 GC

warfarin oral tablet 1 mg 10 mg 2 mg 25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

(Jantoven) 1 GC

XARELTO DVT-PE TREAT 30D START ORAL TABLETSDOSE PACK 15 MG (42)- 20 MG (9)

3

XARELTO ORAL TABLET 10 MG 20 MG




Blood Formation ModifiersCINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)


DOPTELET (10 TAB PACK) ORAL TABLET 20 MG






FULPHILA SUBCUTANEOUS SYRINGE 6 MG06 ML

5 PA NM NDS


73


GRANIX SUBCUTANEOUS SOLUTION 300 MCGML 480 MCG16 ML

5 PA NM NDS

GRANIX SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML

5 PA NM NDS

HAEGARDA SUBCUTANEOUS RECON SOLN 2000 UNIT




LEUKINE INJECTION RECON SOLN 250 MCG

5 NM NDS

MOZOBIL SUBCUTANEOUS SOLUTION 24 MG12 ML (20 MGML)

5 NM NDS

MULPLETA ORAL TABLET 3 MG


NEULASTA SUBCUTANEOUS SYRINGE 6 MG06 ML

5 PA NM NDS

NIVESTYM INJECTION SOLUTION 300 MCGML 480 MCG16 ML

5 PA NM NDS

NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG05 ML 480 MCG08 ML

5 PA NM NDS

NPLATE SUBCUTANEOUS RECON SOLN 125 MCG 250 MCG 500 MCG

5 PA NM NDS

NYVEPRIA SUBCUTANEOUS SYRINGE 6 MG06 ML

5 PA NM NDS

ORLADEYO ORAL CAPSULE 110 MG 150 MG


PROMACTA ORAL POWDER IN PACKET 125 MG




PROMACTA ORAL TABLET 125 MG





74


PROMACTA ORAL TABLET 50 MG 75 MG


RETACRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNIT2 ML 20000 UNITML 3000 UNITML 4000 UNITML


RETACRIT INJECTION SOLUTION 40000 UNITML


UDENYCA SUBCUTANEOUS SYRINGE 6 MG06 ML

5 PA NM NDS

ZARXIO INJECTION SYRINGE 300 MCG05 ML 480 MCG08 ML

5 PA NM NDS

ZIEXTENZO SUBCUTANEOUS SYRINGE 6 MG06 ML

5 PA NM NDS

Hematologic Agents MiscellaneousADAKVEO INTRAVENOUS SOLUTION 10 MGML

5 PA NM NDS

anagrelide oral capsule 05 mg (Agrylin) 2

anagrelide oral capsule 1 mg 2

CABLIVI INJECTION KIT 11 MG


DROXIA ORAL CAPSULE 200 MG 300 MG 400 MG

4

GIVLAARI SUBCUTANEOUS SOLUTION 189 MGML

5 PA NM NDS

protamine intravenous solution 10 mgml

2

SIKLOS ORAL TABLET 1000 MG 100 MG

4 PA

TAVALISSE ORAL TABLET 100 MG 150 MG


tranexamic acid intravenous solution1000 mg10 ml (100 mgml)

(Cyklokapron) 2

tranexamic acid oral tablet 650 mg (Lysteda) 2 QL (30 per 30 days)Platelet-Aggregation Inhibitorsaspirin-dipyridamole oral capsule er multiphase 12 hr 25-200 mg


BRILINTA ORAL TABLET 60 MG 90 MG

3


75


cilostazol oral tablet 100 mg 50 mg 2

clopidogrel oral tablet 75 mg (Plavix) 1 GC

dipyridamole oral tablet 25 mg 50 mg 75 mg

2

pentoxifylline oral tablet extended release 400 mg

2

prasugrel oral tablet 10 mg 5 mg (Effient) 2 QL (30 per 30 days)

Caloric AgentsCaloric AgentsAMINOSYN II 15 INTRAVENOUS PARENTERAL SOLUTION 15

4 PA BvD

AMINOSYN-PF 7 (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7

4 PA BvD

CLINIMIX 5D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5

4 PA BvD

CLINIMIX 425D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 425

4 PA BvD

CLINIMIX 425D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 425

4 PA BvD

CLINIMIX 5-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5

4 PA BvD

CLINIMIX 6-D5W (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 6-5

4 PA BvD

CLINIMIX 8-D10W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 8-10

4 PA BvD


76



4 PA BvD

CLINIMIX E 275D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 275

4 PA BvD

CLINIMIX E 425D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 425

4 PA BvD


4 PA BvD

CLINIMIX E 5D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5

4 PA BvD


4 PA BvD

CLINIMIX E 8-D10W SULFITEFREE INTRAVENOUS PARENTERAL SOLUTION 8-10

4 PA BvD


4 PA BvD

dextrose 10 in water (d10w) intravenous parenteral solution 10

2 PA BvD

dextrose 5 in water (d5w) intravenous parenteral solution

4

dextrose 5 in water (d5w) intravenous piggyback 5

2

dextrose 5-water iv soln single use 1 GC

dextrose 5-water iv soln single use 2


77


HEPATAMINE 8 INTRAVENOUS PARENTERAL SOLUTION 8

4 PA BvD

INTRALIPID INTRAVENOUS EMULSION 20 30

4 PA BvD

NEPHRAMINE 54 INTRAVENOUS PARENTERAL SOLUTION 54

4 PA BvD

NUTRILIPID INTRAVENOUS EMULSION 20

4 PA BvD

PROCALAMINE 3 INTRAVENOUS PARENTERAL SOLUTION 3

4 PA BvD

PROSOL 20 INTRAVENOUS PARENTERAL SOLUTION

4 PA BvD

TRAVASOL 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD

TROPHAMINE 10 INTRAVENOUS PARENTERAL SOLUTION 10

4 PA BvD

Cardiovascular AgentsAlpha-Adrenergic Agentsclonidine hcl oral tablet 01 mg 02 mg 03 mg

1 GC

clonidine transdermal patch weekly01 mg24 hr

(Catapres-TTS-1) 2 QL (4 per 28 days)





doxazosin oral tablet 1 mg 2 mg 4 mg 8 mg

(Cardura) 2

droxidopa oral capsule 100 mg 200 mg 300 mg

(Northera) 5 PA NM NDS QL (180 per 30 days)

guanfacine oral tablet 1 mg 2 mg 2

methyldopa oral tablet 250 mg 500 mg

2


78


midodrine oral tablet 10 mg 25 mg 5 mg

2

phenylephrine hcl injection solution10 mgml

(Vazculep) 2

prazosin oral capsule 1 mg 2 mg 5 mg

(Minipress) 2

Angiotensin Ii Receptor Antagonistscandesartan oral tablet 16 mg 32 mg 4 mg 8 mg

(Atacand) 2

candesartan-hydrochlorothiazid oral tablet 16-125 mg 32-125 mg 32-25 mg

(Atacand HCT) 2

EDARBI ORAL TABLET 40 MG 80 MG

3

EDARBYCLOR ORAL TABLET 40-125 MG 40-25 MG

3

ENTRESTO ORAL TABLET 24-26 MG


ENTRESTO ORAL TABLET 49-51 MG 97-103 MG


eprosartan oral tablet 600 mg 2

irbesartan oral tablet 150 mg 300 mg 75 mg

(Avapro) 6 GC

irbesartan-hydrochlorothiazide oral tablet 150-125 mg 300-125 mg

(Avalide) 6 GC

losartan oral tablet 100 mg 25 mg 50 mg

(Cozaar) 6 GC

losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 50-125 mg

(Hyzaar) 6 GC

olmesartan oral tablet 20 mg 40 mg 5 mg

(Benicar) 6 GC

olmesartan-amlodipin-hcthiazid oral tablet 20-5-125 mg 40-10-125 mg 40-10-25 mg 40-5-125 mg 40-5-25 mg

(Tribenzor) 2

olmesartan-hydrochlorothiazide oral tablet 20-125 mg 40-125 mg 40-25 mg

(Benicar HCT) 6 GC

telmisartan oral tablet 20 mg 40 mg 80 mg

(Micardis) 6 GC


79


telmisartan-amlodipine oral tablet40-10 mg 40-5 mg 80-10 mg 80-5 mg

(Twynsta) 2

telmisartan-hydrochlorothiazid oral tablet 40-125 mg 80-125 mg 80-25 mg

(Micardis HCT) 2

valsartan oral tablet 160 mg 320 mg 40 mg 80 mg

(Diovan) 6 GC

valsartan-hydrochlorothiazide oral tablet 160-125 mg 160-25 mg 320-125 mg 320-25 mg 80-125 mg

(Diovan HCT) 6 GC

Angiotensin-Converting Enzyme Inhibitorsbenazepril oral tablet 10 mg 20 mg 40 mg

(Lotensin) 6 GC

benazepril oral tablet 5 mg 6 GC

benazepril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg

(Lotensin HCT) 6 GC

benazepril-hydrochlorothiazide oral tablet 5-625 mg

6 GC

captopril oral tablet 100 mg 125 mg 25 mg 50 mg

2

captopril-hydrochlorothiazide oral tablet 25-15 mg 25-25 mg 50-15 mg 50-25 mg

2

enalapril maleate oral solution 1 mgml

(Epaned) 2 ST QL (1200 per 30 days)

enalapril maleate oral tablet 10 mg 25 mg 20 mg 5 mg

(Vasotec) 6 GC

enalaprilat intravenous solution 125 mgml

2

enalapril-hydrochlorothiazide oral tablet 10-25 mg

(Vaseretic) 6 GC


6 GC

EPANED ORAL SOLUTION 1 MGML

(enalapril maleate) 4 ST QL (1200 per 30 days)

fosinopril oral tablet 10 mg 20 mg 40 mg

6 GC


80


fosinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg

2

lisinopril oral tablet 10 mg 25 mg 20 mg 30 mg 40 mg 5 mg

(Zestril) 6 GC

lisinopril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg

(Zestoretic) 6 GC

moexipril oral tablet 15 mg 75 mg 2

perindopril erbumine oral tablet 2 mg 4 mg 8 mg

6 GC

QBRELIS ORAL SOLUTION 1 MGML


quinapril oral tablet 10 mg 20 mg 40 mg 5 mg

(Accupril) 6 GC

quinapril-hydrochlorothiazide oral tablet 10-125 mg 20-125 mg 20-25 mg

(Accuretic) 6 GC

ramipril oral capsule 125 mg 10 mg 25 mg 5 mg

(Altace) 6 GC

trandolapril oral tablet 1 mg 2 mg 4 mg

6 GC

Antiarrhythmic Agentsamiodarone oral tablet 100 mg 400 mg

(Pacerone) 2

amiodarone oral tablet 200 mg (Pacerone) 1 GC

disopyramide phosphate oral capsule100 mg 150 mg

(Norpace) 2

dofetilide oral capsule 125 mcg 250 mcg 500 mcg

(Tikosyn) 2

flecainide oral tablet 100 mg 150 mg 50 mg

2



lidocaine (pf) intravenous syringe100 mg5 ml (2 ) 50 mg5 ml (1 )

1 GC

mexiletine oral capsule 150 mg 200 mg 250 mg

2

MULTAQ ORAL TABLET 400 MG

3

pacerone oral tablet 100 mg 400 mg (amiodarone) 2


81


pacerone oral tablet 200 mg (amiodarone) 1 GC

procainamide injection solution 100 mgml 500 mgml

2

procainamide intravenous syringe100 mgml

2

propafenone oral capsuleextended release 12 hr 225 mg 325 mg 425 mg

(Rythmol SR) 2

propafenone oral tablet 150 mg 225 mg 300 mg

2

quinidine gluconate oral tablet extended release 324 mg

2

quinidine sulfate oral tablet 200 mg 1 GC

quinidine sulfate oral tablet 300 mg 2Beta-Adrenergic Blocking Agentsacebutolol oral capsule 200 mg 400 mg

2

atenolol oral tablet 100 mg 25 mg 50 mg

(Tenormin) 1 GC

atenolol-chlorthalidone oral tablet100-25 mg

(Tenoretic 100) 2


(Tenoretic 50) 2

betaxolol oral tablet 10 mg 20 mg 2

bisoprolol fumarate oral tablet 10 mg 5 mg

2

bisoprolol-hydrochlorothiazide oral tablet 10-625 mg 25-625 mg 5-625 mg

(Ziac) 2

BYSTOLIC ORAL TABLET 10 MG 25 MG 20 MG 5 MG

(nebivolol) 3

carvedilol oral tablet 125 mg 25 mg 3125 mg 625 mg

(Coreg) 1 GC

labetalol intravenous solution 5 mgml

2

labetalol intravenous syringe 20 mg4 ml (5 mgml)

2

labetalol oral tablet 100 mg 200 mg 300 mg

2


82


metoprolol succinate oral tablet extended release 24 hr 100 mg 200 mg 25 mg 50 mg

(Toprol XL) 1 GC

metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg 100-50 mg 50-25 mg

2

metoprolol tartrate intravenous solution 5 mg5 ml

2

metoprolol tartrate oral tablet 100 mg 50 mg

(Lopressor) 1 GC

metoprolol tartrate oral tablet 25 mg

1 GC

nadolol oral tablet 20 mg 40 mg 80 mg

(Corgard) 2

nebivolol oral tablet 10 mg 25 mg 20 mg 5 mg

(Bystolic) 2

pindolol oral tablet 10 mg 5 mg 2

propranolol intravenous solution 1 mgml

2

propranolol oral capsuleextended release 24 hr 120 mg 160 mg 60 mg 80 mg

(Inderal LA) 2

propranolol oral solution 20 mg5 ml (4 mgml) 40 mg5 ml (8 mgml)

2

propranolol oral tablet 10 mg 20 mg 40 mg 60 mg 80 mg

2

propranolol-hydrochlorothiazid oral tablet 40-25 mg 80-25 mg

2

sorine oral tablet 120 mg 160 mg 240 mg 80 mg

(sotalol) 2

sotalol af oral tablet 120 mg 160 mg 80 mg

(sotalol) 2

sotalol oral tablet 120 mg 160 mg 240 mg 80 mg

(Sorine) 2

timolol maleate oral tablet 10 mg 20 mg 5 mg

2

Calcium-Channel Blocking Agentscartia xt oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg

(diltiazem hcl) 2


83


diltiazem 24h er(cd) 300 mg cp 300 mg

(Cartia XT) 2

diltiazem hcl intravenous solution 5 mgml

2

diltiazem hcl oral capsuleextended release 12 hr 120 mg 60 mg 90 mg

2

diltiazem hcl oral capsuleextended release 24 hr 360 mg

(Taztia XT) 2


(Tiadylt ER) 2

diltiazem hcl oral capsuleextended release 24hr 120 mg 180 mg 240 mg 300 mg

(Cartia XT) 2

diltiazem hcl oral tablet 120 mg 30 mg 60 mg

(Cardizem) 2

diltiazem hcl oral tablet 90 mg 2

dilt-xr oral capsuleextrel 24h degradable 120 mg 180 mg 240 mg

(diltiazem hcl) 2

matzim la oral tablet extended release 24 hr 180 mg 240 mg 300 mg 360 mg 420 mg

(diltiazem hcl) 2

taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg

(diltiazem hcl) 2

tiadylt er oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg 360 mg 420 mg

(diltiazem hcl) 2

verapamil intravenous syringe 25 mgml

2

verapamil oral capsule 24 hr er pellet ct 100 mg 200 mg 300 mg

(Verelan PM) 2

verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg

(Verelan) 2

verapamil oral capsuleext rel pellets 24 hr 360 mg

(Verelan) 4

verapamil oral tablet 120 mg 40 mg 80 mg

1 GC

verapamil oral tablet extended release 120 mg 180 mg 240 mg

(Calan SR) 2


84


Cardiovascular Agents MiscellaneousCORLANOR ORAL SOLUTION 5 MG5 ML


CORLANOR ORAL TABLET 5 MG 75 MG


digitek oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)

(digoxin) 2

digox oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)

(digoxin) 2

digoxin injection syringe 250 mcgml (025 mgml)

2

digoxin oral tablet 125 mcg (0125 mg) 250 mcg (025 mg)

(Digitek) 2

epinephrine injection auto-injector015 mg03 ml

(EpiPen Jr) 2 QL (4 per 30 days)




(Auvi-Q) 2 QL (4 per 30 days)

epinephrine injection solution 1 mgml

(Adrenalin) 1 GC

hydralazine injection solution 20 mgml

2

hydralazine oral tablet 10 mg 100 mg 25 mg 50 mg

2

icatibant subcutaneous syringe 30 mg3 ml

(Sajazir) 5 PA NM NDS QL (18 per 30 days)

metyrosine oral capsule 250 mg (Demser) 5 NM NDS

ranolazine oral tablet extended release 12 hr 1000 mg

(Ranexa) 2 QL (60 per 30 days)



sajazir subcutaneous syringe 30 mg3 ml

(icatibant) 5 PA NM NDS QL (18 per 30 days)

SYMJEPI INJECTION SYRINGE 015 MG03 ML



(epinephrine) 4 QL (4 per 30 days)

VYNDAMAX ORAL CAPSULE 61 MG



85


VYNDAQEL ORAL CAPSULE 20 MG


Dihydropyridinesamlodipine oral tablet 10 mg 25 mg 5 mg

(Norvasc) 1 GC

amlodipine-benazepril oral capsule10-20 mg 10-40 mg 5-10 mg 5-20 mg

(Lotrel) 6 GC

amlodipine-benazepril oral capsule25-10 mg 5-40 mg

6 GC

amlodipine-olmesartan oral tablet10-20 mg 10-40 mg 5-20 mg 5-40 mg

(Azor) 2

amlodipine-valsartan oral tablet 10-160 mg 10-320 mg 5-160 mg 5-320 mg

(Exforge) 6 GC

amlodipine-valsartan-hcthiazid oral tablet 10-160-125 mg 10-160-25 mg 10-320-25 mg 5-160-125 mg 5-160-25 mg

(Exforge HCT) 2

felodipine oral tablet extended release 24 hr 10 mg 25 mg 5 mg

2

isradipine oral capsule 25 mg 5 mg 2

KATERZIA ORAL SUSPENSION 1 MGML


nicardipine oral capsule 20 mg 30 mg

2

nifedipine oral capsule 10 mg 20 mg 2

nifedipine oral tablet extended release 24hr 30 mg 60 mg 90 mg

(Procardia XL) 2

nifedipine oral tablet extended release 30 mg 60 mg 90 mg

(Adalat CC) 2

Diureticsamiloride oral tablet 5 mg 2

amiloride-hydrochlorothiazide oral tablet 5-50 mg

2

bumetanide injection solution 025 mgml

2

bumetanide oral tablet 05 mg 1 mg 2 mg

2


86


chlorothiazide sodium intravenous recon soln 500 mg

(Diuril IV) 2

chlorthalidone oral tablet 25 mg 50 mg

2

furosemide injection solution 10 mgml

2

furosemide injection syringe 10 mgml

1 GC

furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)

2

furosemide oral tablet 20 mg 40 mg 80 mg

(Lasix) 1 GC

hydrochlorothiazide oral capsule125 mg

1 GC

hydrochlorothiazide oral tablet 125 mg 25 mg 50 mg

1 GC

indapamide oral tablet 125 mg 25 mg

1 GC

JYNARQUE ORAL TABLET 15 MG 30 MG


JYNARQUE ORAL TABLETS SEQUENTIAL 15 MG (AM) 15 MG (PM) 30 MG (AM) 15 MG (PM) 45 MG (AM) 15 MG (PM) 60 MG (AM) 30 MG (PM) 90 MG (AM) 30 MG (PM)


metolazone oral tablet 10 mg 25 mg 5 mg

2

spironolactone oral tablet 100 mg 25 mg 50 mg

(Aldactone) 1 GC

spironolacton-hydrochlorothiaz oral tablet 25-25 mg

(Aldactazide) 2

torsemide oral tablet 10 mg 100 mg 20 mg 5 mg

2

triamterene-hydrochlorothiazid oral capsule 375-25 mg

1 GC

triamterene-hydrochlorothiazid oral tablet 375-25 mg

(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


87


Dyslipidemicsamlodipine-atorvastatin oral tablet10-10 mg 5-10 mg

(Caduet) 2

amlodipine-atorvastatin oral tablet10-20 mg 10-40 mg 10-80 mg 5-20 mg 5-40 mg 5-80 mg

(Caduet) 2 QL (30 per 30 days)

amlodipine-atorvastatin oral tablet25-10 mg 25-20 mg 25-40 mg

2

atorvastatin oral tablet 10 mg 20 mg 40 mg 80 mg

(Lipitor) 6 GC QL (30 per 30 days)

cholestyramine (with sugar) oral powder in packet 4 gram

(Questran) 2

cholestyramine light oral powder in packet 4 gram

(cholestyramine-aspartame)

2

colesevelam oral powder in packet375 gram

(WelChol) 2

colesevelam oral tablet 625 mg (WelChol) 2

colestipol oral packet 5 gram (Colestid) 2

colestipol oral tablet 1 gram (Colestid) 2

EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 MG 20 MG 40 MG 5 MG


ezetimibe oral tablet 10 mg (Zetia) 2 QL (30 per 30 days)

ezetimibe-simvastatin oral tablet 10-10 mg

(Vytorin 10-10) 2 QL (30 per 30 days)







fenofibrate micronized oral capsule130 mg 134 mg 200 mg 43 mg 67 mg

2

fenofibrate nanocrystallized oral tablet 145 mg 48 mg

(Tricor) 2

fenofibrate oral tablet 160 mg 54 mg

2

fenofibric acid (choline) oral capsuledelayed release(drec) 135 mg 45 mg

(Trilipix) 2


88


fluvastatin oral capsule 20 mg 40 mg


gemfibrozil oral tablet 600 mg (Lopid) 1 GC

JUXTAPID ORAL CAPSULE 10 MG 30 MG 40 MG 60 MG


JUXTAPID ORAL CAPSULE 20 MG




LIVALO ORAL TABLET 1 MG 2 MG 4 MG


lovastatin oral tablet 10 mg 20 mg 40 mg

6 GC

NEXLETOL ORAL TABLET 180 MG


NEXLIZET ORAL TABLET 180-10 MG


niacin oral tablet 500 mg (Niacor) 2

niacin oral tablet extended release 24 hr 1000 mg 500 mg 750 mg

(Niaspan Extended-Release)

2

niacor oral tablet 500 mg (niacin) 2

omega-3 acid ethyl esters oral capsule 1 gram

(Lovaza) 2 QL (120 per 30 days)

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MGML 75 MGML


pravastatin oral tablet 10 mg 80 mg 6 GC

pravastatin oral tablet 20 mg 40 mg 6 GC QL (30 per 30 days)

prevalite oral powder in packet 4 gram


2

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG35 ML


REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MGML


REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MGML



89


rosuvastatin oral tablet 10 mg 20 mg 40 mg 5 mg

(Crestor) 6 GC QL (30 per 30 days)

simvastatin oral tablet 10 mg 20 mg 40 mg 80 mg

(Zocor) 6 GC QL (30 per 30 days)

simvastatin oral tablet 5 mg 6 GC QL (30 per 30 days)

VASCEPA ORAL CAPSULE 05 GRAM



(icosapent ethyl) 2 QL (120 per 30 days)

Renin-Angiotensin-Aldosterone System Inhibitorsaliskiren oral tablet 150 mg 300 mg (Tekturna) 2

CAROSPIR ORAL SUSPENSION 25 MG5 ML


eplerenone oral tablet 25 mg 50 mg (Inspra) 2VasodilatorsBIDIL ORAL TABLET 20-375 MG

3

isosorbide dinitrate oral tablet 10 mg 20 mg 30 mg

2

isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) 2

isosorbide mononitrate oral tablet10 mg 20 mg

2

isosorbide mononitrate oral tablet extended release 24 hr 120 mg 30 mg 60 mg

1 GC

minitran transdermal patch 24 hour01 mghr 02 mghr 04 mghr 06 mghr

(nitroglycerin) 2

minoxidil oral tablet 10 mg 25 mg 2

nitroglycerin intravenous solution 50 mg10 ml (5 mgml)

2

nitroglycerin sublingual tablet 03 mg 04 mg 06 mg

(Nitrostat) 2

nitroglycerin transdermal patch 24 hour 01 mghr 02 mghr 04 mghr 06 mghr

(Minitran) 2


90


Central Nervous System AgentsCentral Nervous System Agentsatomoxetine oral capsule 10 mg 18 mg 25 mg 40 mg

(Strattera) 2 QL (60 per 30 days)

atomoxetine oral capsule 100 mg 60 mg 80 mg


AUBAGIO ORAL TABLET 14 MG 7 MG


AUSTEDO ORAL TABLET 12 MG 9 MG


AUSTEDO ORAL TABLET 6 MG


AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG05 ML


AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG05 ML


BETASERON SUBCUTANEOUS KIT 03 MG


caffeine citrate intravenous solution60 mg3 ml (20 mgml)

(Cafcit) 2 PA BvD

caffeine citrate oral solution 60 mg3 ml (20 mgml)

2

clonidine hcl oral tablet extended release 12 hr 01 mg

(Kapvay) 2 QL (120 per 30 days)

COPAXONE SUBCUTANEOUS SYRINGE 20 MGML

(glatiramer) 5 PA NM NDS QL (30 per 30 days)



dalfampridine oral tablet extended release 12 hr 10 mg

(Ampyra) 2 PA QL (60 per 30 days)

dexmethylphenidate oral tablet 10 mg 25 mg 5 mg

(Focalin) 2 QL (60 per 30 days)

dextroamphetamine oral capsule extended release 10 mg 15 mg 5 mg

(Dexedrine Spansule) 2 QL (120 per 30 days)

dextroamphetamine oral tablet 10 mg

(Zenzedi) 2 QL (180 per 30 days)

dextroamphetamine oral tablet 15 mg 5 mg





91


dextroamphetamine-amphetamine oral capsuleextended release 24hr10 mg 15 mg 5 mg

(Adderall XR) 2 QL (30 per 30 days)



dextroamphetamine-amphetamine oral tablet 10 mg 125 mg 15 mg 20 mg 30 mg 5 mg 75 mg

(Adderall) 2 QL (60 per 30 days)

dimethyl fumarate oral capsuledelayed release(drec) 120 mg

(Tecfidera) 5 PA NM NDS QL (14 per 7 days)

dimethyl fumarate oral capsuledelayed release(drec) 120 mg (14)- 240 mg (46)

(Tecfidera) 5 PA NM NDS



ENSPRYNG SUBCUTANEOUS SYRINGE 120 MGML

5 PA NM NDS

flumazenil intravenous solution 01 mgml

2

GILENYA ORAL CAPSULE 025 MG 05 MG


glatiramer subcutaneous syringe 20 mgml

(Copaxone) 5 PA NM NDS QL (30 per 30 days)



glatopa subcutaneous syringe 20 mgml




guanfacine oral tablet extended release 24 hr 1 mg 2 mg 3 mg 4 mg

(Intuniv ER) 2 QL (30 per 30 days)

KESIMPTA PEN SUBCUTANEOUS PEN INJECTOR 20 MG04 ML


lithium carbonate oral capsule 150 mg 300 mg 600 mg

1 GC

lithium carbonate oral tablet 300 mg 2


92


lithium carbonate oral tablet extended release 300 mg

(Lithobid) 2


2

MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG

5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS

MAYZENT ORAL TABLET 025 MG




MAYZENT STARTER PACK ORAL TABLETSDOSE PACK 025 MG (12 TABS)

5 PA NM NDS

metadate er oral tablet extended release 20 mg

(methylphenidate hcl) 2 QL (90 per 30 days)

methylphenidate hcl oral capsule er biphasic 30-70 10 mg 20 mg 40 mg 50 mg 60 mg


methylphenidate hcl oral capsule er biphasic 30-70 30 mg


methylphenidate hcl oral capsuleer biphasic 50-50 10 mg 20 mg 40 mg

(Ritalin LA) 2 QL (30 per 30 days)

methylphenidate hcl oral capsuleer biphasic 50-50 30 mg




methylphenidate hcl oral solution 10 mg5 ml 5 mg5 ml

(Methylin) 2 QL (900 per 30 days)


93


methylphenidate hcl oral tablet 10 mg 20 mg 5 mg

(Ritalin) 2 QL (90 per 30 days)

methylphenidate hcl oral tablet extended release 10 mg



(Metadate ER) 2 QL (90 per 30 days)

methylphenidate hcl oral tablet extended release 24hr 18 mg (bx rating) 27 mg (bx rating) 54 mg (bx rating)


methylphenidate hcl oral tablet extended release 24hr 18 mg 27 mg 54 mg

(Concerta) 2 QL (30 per 30 days)

methylphenidate hcl oral tablet extended release 24hr 36 mg


methylphenidate hcl oral tablet extended release 24hr 36 mg (bx rating)


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG05 ML


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG05 ML- 94 MCG05 ML

5 PA NM NDS

PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG05 ML


PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG05 ML- 94 MCG05 ML

5 PA NM NDS

RADICAVA INTRAVENOUS SOLUTION 30 MG100 ML


riluzole oral tablet 50 mg (Rilutek) 2 QL (60 per 30 days)

SAVELLA ORAL TABLET 100 MG 125 MG 25 MG 50 MG


SAVELLA ORAL TABLETSDOSE PACK 125 MG (5)-25 MG(8)-50 MG(42)

3

tetrabenazine oral tablet 125 mg 25 mg

(Xenazine) 5 PA NM NDS QL (112 per 28 days)


94


VUMERITY ORAL CAPSULEDELAYED RELEASE(DREC) 231 MG


ContraceptivesContraceptivesafirmelle oral tablet 01-20 mg-mcg (levonorgestrel-ethinyl

estrad)2

altavera (28) oral tablet 015-003 mg

(levonorgestrel-ethinyl estrad)

2

alyacen 135 (28) oral tablet 1-35 mg-mcg

(norethindrone-ethin estradiol)

2

alyacen 777 (28) oral tablet050751 mg- 35 mcg

2

amethia oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)

(l norgesteestradiol-eestrad)


apri oral tablet 015-003 mg (desogestrel-ethinyl estradiol)

2

aranelle (28) oral tablet 05105-35 mg-mcg

2

ashlyna oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)



aubra eq oral tablet 01-20 mg-mcg (levonorgestrel-ethinyl estrad)

2

aurovela 1530 (21) oral tablet 15-30 mg-mcg

(norethindrone ac-eth estradiol)

2



2

aurovela 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)

(norethindrone-eestradiol-iron)

2

aurovela fe 1530 (28) oral tablet15 mg-30 mcg (21)75 mg (7)


2

aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg (21)75 mg (7)


1 GC

aviane oral tablet 01-20 mg-mcg (levonorgestrel-ethinyl estrad)

2

ayuna oral tablet 015-003 mg (levonorgestrel-ethinyl estrad)

2

azurette (28) oral tablet 015-002 mgx21 001 mg x 5

(desog-eestradioleestradiol)

2


95


balziva (28) oral tablet 04-35 mg-mcg

2

bekyree (28) oral tablet 015-002 mgx21 001 mg x 5


2

blisovi 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)


2

blisovi fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)


2



1 GC

briellyn oral tablet 04-35 mg-mcg 2

camila oral tablet 035 mg (norethindrone (contraceptive))

1 GC

caziant (28) oral tablet0112515-25 mg-mcg

2

chateal eq (28) oral tablet 015-003 mg


2

cryselle (28) oral tablet 03-30 mg-mcg

(norgestrel-ethinyl estradiol)

2

cyclafem 135 (28) oral tablet 1-35 mg-mcg


2

cyclafem 777 (28) oral tablet050751 mg- 35 mcg

2

cyred eq oral tablet 015-003 mg (desogestrel-ethinyl estradiol)

2

dasetta 135 (28) oral tablet 1-35 mg-mcg


2

dasetta 777 (28) oral tablet050751 mg- 35 mcg

2

daysee oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)



deblitane oral tablet 035 mg (norethindrone (contraceptive))

1 GC

desog-eestradioleestradiol oral tablet 015-002 mgx21 001 mg x 5

(Azurette (28)) 2

desogestrel-ethinyl estradiol oral tablet 015-003 mg

(Apri) 2

drospirenone-ethinyl estradiol oral tablet 3-002 mg

(Jasmiel (28)) 2


96



(Syeda) 2

elinest oral tablet 03-30 mg-mcg (norgestrel-ethinyl estradiol)

2

ELLA ORAL TABLET 30 MG 4 QL (6 per 365 days)

eluryng vaginal ring 012-0015 mg24 hr

(etonogestrel-ethinyl estradiol)


emoquette oral tablet 015-003 mg (desogestrel-ethinyl estradiol)

2

enpresse oral tablet 50-30 (6)75-40 (5)125-30(10)

(levonorg-eth estrad triphasic)

2

enskyce oral tablet 015-003 mg (desogestrel-ethinyl estradiol)

2

errin oral tablet 035 mg (norethindrone (contraceptive))

1 GC

estarylla oral tablet 025-35 mg-mcg (norgestimate-ethinyl estradiol)

2

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg

(Kelnor 135 (28)) 2


(Kelnor 1-50 (28)) 2

etonogestrel-ethinyl estradiol vaginal ring 012-0015 mg24 hr

(EluRyng) 4 QL (1 per 28 days)

falmina (28) oral tablet 01-20 mg-mcg


2

femynor oral tablet 025-35 mg-mcg (norgestimate-ethinyl estradiol)

1 GC

hailey 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)


2

hailey fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)


2



2

hailey oral tablet 15-30 mg-mcg (norethindrone ac-eth estradiol)

2

heather oral tablet 035 mg (norethindrone (contraceptive))

1 GC

iclevia oral tabletsdose pack3 month 015 mg-30 mcg (91)



incassia oral tablet 035 mg (norethindrone (contraceptive))

1 GC


97


introvale oral tabletsdose pack3 month 015 mg-30 mcg (91)



isibloom oral tablet 015-003 mg (desogestrel-ethinyl estradiol)

2

jaimiess oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)



jasmiel (28) oral tablet 3-002 mg (drospirenone-ethinyl estradiol)

2

jencycla oral tablet 035 mg (norethindrone (contraceptive))

1 GC

juleber oral tablet 015-003 mg (desogestrel-ethinyl estradiol)

2

junel 1530 (21) oral tablet 15-30 mg-mcg


2



2

junel fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)


2



1 GC

junel fe 24 oral tablet 1 mg-20 mcg (24)75 mg (4)


2

kalliga oral tablet 015-003 mg (desogestrel-ethinyl estradiol)

2

kariva (28) oral tablet 015-002 mgx21 001 mg x 5


2

kelnor 135 (28) oral tablet 1-35 mg-mcg

(ethynodiol diac-eth estradiol)

2

kelnor 1-50 (28) oral tablet 1-50 mg-mcg


2

kurvelo (28) oral tablet 015-003 mg


2

l norgesteestradiol-eestrad oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)

(LoJaimiess) 2 QL (91 per 84 days)


(Amethia) 2 QL (91 per 84 days)

larin 1530 (21) oral tablet 15-30 mg-mcg


2


98




2

larin 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)


2

larin fe 1530 (28) oral tablet 15 mg-30 mcg (21)75 mg (7)


2



1 GC

larissia oral tablet 01-20 mg-mcg (levonorgestrel-ethinyl estrad)

2

lessina oral tablet 01-20 mg-mcg (levonorgestrel-ethinyl estrad)

2

levonest (28) oral tablet 50-30 (6)75-40 (5)125-30(10)


2

levonorgestrel-ethinyl estrad oral tablet 01-20 mg-mcg

(Afirmelle) 2

levonorgestrel-ethinyl estrad oral tablet 015-003 mg

(Altavera (28)) 2

levonorgestrel-ethinyl estrad oral tabletsdose pack3 month 015 mg-30 mcg (91)

(Iclevia) 2 QL (91 per 84 days)

levonorg-eth estrad triphasic oral tablet 50-30 (6)75-40 (5)125-30(10)

(Enpresse) 2

levora-28 oral tablet 015-003 mg (levonorgestrel-ethinyl estrad)

2

lillow (28) oral tablet 015-003 mg (levonorgestrel-ethinyl estrad)

2

lojaimiess oral tabletsdose pack3 month 010 mg-20 mcg (84)10 mcg (7)



loryna (28) oral tablet 3-002 mg (drospirenone-ethinyl estradiol)

2

low-ogestrel (28) oral tablet 03-30 mg-mcg


2

lo-zumandimine (28) oral tablet 3-002 mg

(drospirenone-ethinyl estradiol)

2

lutera (28) oral tablet 01-20 mg-mcg


2

lyleq oral tablet 035 mg (norethindrone (contraceptive))

1 GC


99


lyza oral tablet 035 mg (norethindrone (contraceptive))

1 GC

marlissa (28) oral tablet 015-003 mg


2

microgestin fe 120 (28) oral tablet1 mg-20 mcg (21)75 mg (7)


1 GC

mili oral tablet 025-35 mg-mcg (norgestimate-ethinyl estradiol)

1 GC

mono-linyah oral tablet 025-35 mg-mcg

(norgestimate-ethinyl estradiol)

2

necon 0535 (28) oral tablet 05-35 mg-mcg

2

nikki (28) oral tablet 3-002 mg (drospirenone-ethinyl estradiol)

2

norethindrone (contraceptive) oral tablet 035 mg

(Camila) 1 GC

norethindrone ac-eth estradiol oral tablet 15-30 mg-mcg

(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2

norethindrone-eestradiol-iron oral capsule 1 mg-20 mcg (24)75 mg (4)

(Gemmily) 2

norethindrone-eestradiol-iron oral tablet 1 mg-20 mcg (21)75 mg (7)

(Aurovela Fe 1-20 (28)) 1 GC


(Aurovela Fe 1530 (28))

2

norgestimate-ethinyl estradiol oral tablet 0180215025 mg-25 mcg

(Tri-Lo-Estarylla) 2

norgestimate-ethinyl estradiol oral tablet 0180215025 mg-35 mcg (28)

(Tri-Estarylla) 2

norgestimate-ethinyl estradiol oral tablet 025-35 mg-mcg

(Femynor) 2

norlyda oral tablet 035 mg (norethindrone (contraceptive))

1 GC

nortrel 0535 (28) oral tablet 05-35 mg-mcg

2

nortrel 135 (21) oral tablet 1-35 mg-mcg (21)

2


100




2

nortrel 777 (28) oral tablet050751 mg- 35 mcg

2

nylia 777 (28) oral tablet050751 mg- 35 mcg

2

nymyo oral tablet 025-35 mg-mcg (norgestimate-ethinyl estradiol)

2

orsythia oral tablet 01-20 mg-mcg (levonorgestrel-ethinyl estrad)

2

philith oral tablet 04-35 mg-mcg 2

pimtrea (28) oral tablet 015-002 mgx21 001 mg x 5


2

pirmella oral tablet 050751 mg- 35 mcg

2

pirmella oral tablet 1-35 mg-mcg (norethindrone-ethin estradiol)

2

portia 28 oral tablet 015-003 mg (levonorgestrel-ethinyl estrad)

2

previfem oral tablet 025-35 mg-mcg (norgestimate-ethinyl estradiol)

1 GC

reclipsen (28) oral tablet 015-003 mg

(desogestrel-ethinyl estradiol)

2

setlakin oral tabletsdose pack3 month 015 mg-30 mcg (91)



sharobel oral tablet 035 mg (norethindrone (contraceptive))

1 GC

simliya (28) oral tablet 015-002 mgx21 001 mg x 5


2

simpesse oral tabletsdose pack3 month 015 mg-30 mcg (84)10 mcg (7)



SLYND ORAL TABLET 4 MG (28)

4

sprintec (28) oral tablet 025-35 mg-mcg


2

sronyx oral tablet 01-20 mg-mcg (levonorgestrel-ethinyl estrad)

2

syeda oral tablet 3-003 mg (drospirenone-ethinyl estradiol)

2


101


tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)


2

tarina fe 1-20 eq (28) oral tablet 1 mg-20 mcg (21)75 mg (7)


1 GC

tri femynor oral tablet0180215025 mg-35 mcg (28)


2

tri-estarylla oral tablet0180215025 mg-35 mcg (28)


1 GC

tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)

2

tri-linyah oral tablet 0180215025 mg-35 mcg (28)


2

tri-lo-estarylla oral tablet0180215025 mg-25 mcg


1 GC

tri-lo-marzia oral tablet0180215025 mg-25 mcg


1 GC

tri-lo-mili oral tablet 0180215025 mg-25 mcg


1 GC

tri-lo-sprintec oral tablet0180215025 mg-25 mcg


2

tri-mili oral tablet 0180215025 mg-35 mcg (28)


2

tri-nymyo oral tablet0180215025 mg-35 mcg (28)


2

tri-previfem (28) oral tablet0180215025 mg-35 mcg (28)


1 GC

tri-sprintec (28) oral tablet0180215025 mg-35 mcg (28)


2

trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)


2

tri-vylibra lo oral tablet0180215025 mg-25 mcg


1 GC

tri-vylibra oral tablet0180215025 mg-35 mcg (28)


2

tulana oral tablet 035 mg (norethindrone (contraceptive))

1 GC

tyblume oral tabletchewable 01 mg- 20 mcg

2

velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg

2


102


vestura (28) oral tablet 3-002 mg (drospirenone-ethinyl estradiol)

2

vienva oral tablet 01-20 mg-mcg (levonorgestrel-ethinyl estrad)

2

viorele (28) oral tablet 015-002 mgx21 001 mg x 5


2

volnea (28) oral tablet 015-002 mgx21 001 mg x 5


2

vyfemla (28) oral tablet 04-35 mg-mcg

2

vylibra oral tablet 025-35 mg-mcg (norgestimate-ethinyl estradiol)

2

wera (28) oral tablet 05-35 mg-mcg

2

xulane transdermal patch weekly150-35 mcg24 hr


zafemy transdermal patch weekly150-35 mcg24 hr


zarah oral tablet 3-003 mg (drospirenone-ethinyl estradiol)

2

zovia 1-35 (28) oral tablet 1-35 mg-mcg


2

zovia 1-35e tablet outer 1-35 mg-mcg


2

zumandimine (28) oral tablet 3-003 mg


2

Dental And Oral AgentsDental And Oral Agentscevimeline oral capsule 30 mg (Evoxac) 2

chlorhexidine gluconate mucous membrane mouthwash 012

(Paroex Oral Rinse) 1 GC

denta 5000 plus dental cream 11 (fluoride (sodium)) 1 GC

dentagel dental gel 11 (fluoride (sodium)) 1 GC

fluoride (sodium) dental solution02

(PreviDent) 1 GC

oralone dental paste 01 (triamcinolone acetonide)

2

paroex oral rinse mucous membrane mouthwash 012

(chlorhexidine gluconate)

1 GC

periogard mucous membrane mouthwash 012


1 GC


103


pilocarpine hcl oral tablet 5 mg 75 mg

(Salagen (pilocarpine)) 2

sf 5000 plus dental cream 11 (fluoride (sodium)) 1 GC

sodium fluoride-pot nitrate dental paste 11-5

(Fluoridex Sensitivity Relief)

1 GC

triamcinolone acetonide dental paste01

(Oralone) 2

Dermatological AgentsDermatological Agents Otheraccutane oral capsule 10 mg 20 mg 30 mg 40 mg

(isotretinoin) 2

acitretin oral capsule 10 mg 175 mg 25 mg

2

acyclovir topical cream 5 (Zovirax) 2 QL (5 per 4 days)

acyclovir topical ointment 5 (Zovirax) 2 QL (30 per 30 days)

ALCOHOL 70 SWABS (Alcohol Pads) 1 GC

ALCOHOL PADS TOPICAL PADS MEDICATED

(alcohol swabs) 1 GC

ALCOHOL PREP SWABS TOPICAL PADS MEDICATED


ammonium lactate topical cream 12

2

ammonium lactate topical lotion 12

(Skin Treatment) 2

BD SINGLE USE SWAB (alcohol swabs) 1 GC

calcipotriene scalp solution 0005 2 QL (120 per 30 days)

calcipotriene topical cream 0005 (Dovonex) 2 QL (120 per 30 days)

calcipotriene topical ointment 0005


CARETOUCH ALCOHOL 70 PREP PAD


CURITY ALCOHOL PREPS 2 PLYMEDIUM


DENAVIR TOPICAL CREAM 1

5 NM NDS

EASY COMFORT ALCOHOL 70 PAD


EASY TOUCH ALCOHOL 70 PADS GAMMA-STERILIZED


fluorouracil topical cream 05 (Carac) 5 NM NDS


104


fluorouracil topical cream 5 (Efudex) 2

fluorouracil topical solution 2 5

2

HEB INCONTROL ALCOHOL 70 PADS


imiquimod topical cream in packet 5

(Aldara) 2 QL (24 per 30 days)

IV ANTISEPTIC WIPES (alcohol swabs) 1 GC

KENDALL ALCOHOL 70 PREP PAD


methoxsalen oral capsuleliqd-filledrapid rel 10 mg

5 NM NDS

PANRETIN TOPICAL GEL 01


podofilox topical solution 05 2

PRO COMFORT ALCOHOL 70 PADS


PURE COMFORT ALCOHOL 70 PADS


RA ISOPROPYL ALCOHOL 70 WIPES


REGRANEX TOPICAL GEL 001


SANTYL TOPICAL OINTMENT 250 UNITGRAM


SURE COMFORT ALCOHOL PREP PADS


SURE-PREP ALCOHOL PREP PADS


TRUE COMFORT ALCOHOL 70 PADS


TRUE COMFORT PRO ALCOHOL PADS


ULTILET ALCOHOL STERL SWAB


VALCHLOR TOPICAL GEL 0016

5 NM NDS

VEREGEN TOPICAL OINTMENT 15

5 NM NDS

WEBCOL ALCOHOL PREPS 20SLARGE



105


zenatane oral capsule 10 mg 20 mg 30 mg 40 mg

(isotretinoin) 2

Dermatological Antibacterialsclindamycin phosphate topical foam1

(Evoclin) 2 QL (100 per 30 days)

clindamycin phosphate topical solution 1

(Cleocin T) 2 QL (180 per 30 days)

clindamycin phosphate topical swab1

(Clindacin ETZ) 2

clindamycin-benzoyl peroxide topical gel 12 (1 base) -5

(Neuac) 2

clindamycin-benzoyl peroxide topical gel 1-5

(Benzaclin) 2

ery pads topical swab 2 (erythromycin with ethanol)

2

erythromycin with ethanol topical gel 2

(Erygel) 2 QL (180 per 30 days)

erythromycin with ethanol topical solution 2


erythromycin-benzoyl peroxide topical gel 3-5

(Benzamycin) 2

gentamicin topical cream 01 2 QL (120 per 30 days)

gentamicin topical ointment 01 2 QL (120 per 30 days)

metronidazole topical cream 075 (Rosadan) 2

metronidazole topical gel 075 (Rosadan) 2

metronidazole topical gel 1 (Metrogel) 2

metronidazole topical lotion 075 (MetroLotion) 2

mupirocin topical ointment 2 (Centany) 1 GC QL (220 per 30 days)

neomycin-polymyxin b gu irrigation solution 40 mg-200000 unitml

2

rosadan topical cream 075 (metronidazole) 2

selenium sulfide topical lotion 25 2

silver sulfadiazine topical cream 1 (SSD) 2

ssd topical cream 1 (silver sulfadiazine) 4

sulfacetamide sodium (acne) topical suspension 10

(Klaron) 2

Dermatological Anti-Inflammatory Agentsala-cort topical cream 1 (hydrocortisone) 1 GC


106


ala-scalp topical lotion 2 2

alclometasone topical cream 005 2

alclometasone topical ointment 005

2

betamethasone dipropionate topical cream 005

2

betamethasone dipropionate topical lotion 005

2

betamethasone dipropionate topical ointment 005

2

betamethasone valerate topical cream 01

2

betamethasone valerate topical foam012

(Luxiq) 2

betamethasone valerate topical lotion 01

2

betamethasone valerate topical ointment 01

2

betamethasone augmented topical cream 005

2

betamethasone augmented topical gel 005

2

betamethasone augmented topical lotion 005

2

betamethasone augmented topical ointment 005

(Diprolene (augmented))

2

clobetasol scalp solution 005 2

clobetasol topical cream 005 2

clobetasol topical foam 005 (Olux) 2

clobetasol topical gel 005 2

clobetasol topical lotion 005 (Clobex) 2

clobetasol topical ointment 005 (Temovate) 2

clobetasol topical shampoo 005 (Clobex) 2

clobetasol-emollient topical cream005

2

clobetasol-emollient topical foam005

(Olux-E) 2

desonide topical cream 005 (DesOwen) 2

desonide topical lotion 005 (DesOwen) 2

desonide topical ointment 005 2


107


desoximetasone topical cream 005 025

(Topicort) 2 QL (120 per 30 days)

desoximetasone topical gel 005 (Topicort) 2 QL (120 per 30 days)

desoximetasone topical ointment005 025


diflorasone topical ointment 005 2 QL (180 per 30 days)

EUCRISA TOPICAL OINTMENT 2

3

fluocinolone topical cream 001 2

fluocinolone topical cream 0025 (Synalar) 2

fluocinolone topical ointment 0025

(Synalar) 2

fluocinonide topical cream 005 2

fluocinonide topical gel 005 2

fluocinonide topical ointment 005 2

fluocinonide topical solution 005 2

fluocinonide-e topical cream 005 (fluocinonide-emollient)

2

fluticasone propionate topical cream005

2

fluticasone propionate topical ointment 0005

2

halobetasol propionate topical cream 005

2

halobetasol propionate topical ointment 005

2

hydrocortisone 25 cream 25 1 GC

hydrocortisone butyrate topical cream 01


hydrocortisone butyrate topical lotion 01

(Locoid) 2 QL (236 per 30 days)

hydrocortisone butyrate topical ointment 01


hydrocortisone butyrate topical solution 01


hydrocortisone topical cream 1 (Ala-Cort) 1 GC

hydrocortisone topical cream with perineal applicator 25

(Procto-Med HC) 1 GC

hydrocortisone topical lotion 25 2

hydrocortisone topical ointment 1 (Anti-Itch (HC)) 1 GC


108


hydrocortisone topical ointment 25

1 GC

hydrocortisone valerate topical cream 02

2

hydrocortisone valerate topical ointment 02

2

mometasone topical cream 01 2

mometasone topical ointment 01 2

mometasone topical solution 01 2

pimecrolimus topical cream 1 (Elidel) 2 QL (100 per 30 days)

prednicarbate topical ointment 01

2

procto-med hc topical cream with perineal applicator 25

(hydrocortisone) 2

procto-pak topical cream with perineal applicator 1

(hydrocortisone) 2

proctosol hc topical cream with perineal applicator 25

(hydrocortisone) 2

proctozone-hc topical cream with perineal applicator 25

(hydrocortisone) 2

tacrolimus topical ointment 003 01

(Protopic) 2 QL (100 per 30 days)

triamcinolone acetonide topical cream 0025

1 GC

triamcinolone acetonide topical cream 01 05

(Triderm) 1 GC

triamcinolone acetonide topical lotion 0025 01

2

triamcinolone acetonide topical ointment 0025

1 GC


(Trianex) 2

triamcinolone acetonide topical ointment 01 05

2

Dermatological Retinoidsadapalene topical cream 01 (Differin) 2

adapalene topical gel 01 (Differin) 2

ALTRENO TOPICAL LOTION 005

4 PA

tazarotene topical cream 01 (Tazorac) 2


109


TAZORAC TOPICAL CREAM 005

4

tretinoin topical cream 0025 (Avita) 2 PA

tretinoin topical cream 005 01

(Retin-A) 2 PA

tretinoin topical gel 001 (Retin-A) 2 PA

tretinoin topical gel 0025 (Avita) 2 PA

tretinoin topical gel 005 (Atralin) 2 PAScabicides And Pediculicidesmalathion topical lotion 05 (Ovide) 2

permethrin topical cream 5 (Elimite) 2

DevicesDevices1ST TIER UNIFINE PENTP 5MM 31G 31 GAUGE X 316

(pen needle diabetic) 2

1ST TIER UNIFINE PNTIP 4MM 32G 32 GAUGE X 532




1ST TIER UNIFINE PNTIP 8MM 31G STRLSINGLE-USESHRT 31 GAUGE X 516


1ST TIER UNIFINE PNTP 29GX12 29 GAUGE X 12






ABOUTTIME PEN NEEDLE 30G X 8MM 30 GAUGE X 516








ADVOCATE INS 03 ML 30GX516 03 ML 30 GAUGE X 516

(insulin syringe-needle u-100)

2


110




2



2



2



2

ADVOCATE INS SYR 03 ML 29GX12 03 ML 29 GAUGE X 12


2



2



2



2

ADVOCATE PEN NDL 127MM 29G 29 GAUGE X 12


ADVOCATE PEN NEEDLE 4MM 33G 33 GAUGE X 532


ADVOCATE PEN NEEDLES 5MM 31G 31 GAUGE X 316




ASSURE ID DUO-SHIELD 30GX316 30 GAUGE X 316

2


2

ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 12

2

ASSURE ID PEN NEEDLE 30GX316 30 GAUGE X 316

2


111



2


2

ASSURE ID SYR 05 ML 29GX12 (RX) 05 ML 29 GAUGE X 12

2

ASSURE ID SYR 05 ML 31GX1564 05 ML 31 GAUGE X 1564

2


2

BD AUTOSHIELD DUO NDL 5MMX30G 30 GAUGE X 316

2

BD ECLIPSE 30GX12 SYRINGE 1 ML 30 GAUGE X 12


2

BD INS SYR 03 ML 8MMX31G(12) 03 ML 31 GAUGE X 516

2

BD INS SYRINGE 12 ML 6MMX31G (ONLY FOR 500 UNITML INSULIN) 12 ML 31 GAUGE X 1564

2

BD INS SYRN UF 1 ML 127MMX30G NOT FOR RETAIL SALE 1 ML 30 GAUGE X 12


2

BD INSULIN SYR 05 ML 29GX12 05 ML 29 GAUGE X 12


2

BD INSULIN SYR 1 ML 25GX1 1 ML 25 X 1

2



2


2

BD INSULIN SYR 1 ML 27GX58 MICRO-FINE 1 ML 27 GAUGE X 58

2


112


BD INSULIN SYR 1 ML 28GX12 (OTC) 1 ML 28 GAUGE X 12

(Comfort EZ Insulin Syringe)

2

BD INSULIN SYRINGE 1 ML WO NEEDLE 1 ML

(insulin syringe needleless)

2

BD LUER-LOK SYRINGE 1 ML 1 ML

(BD Insulin Syringe Slip Tip)

2

BD NANO 2 GEN PEN NDL 32GX4MM 32 GAUGE X 532


BD SAFETGLD INS 03 ML 13MMX29G 03 ML 29 GAUGE X 12


2



2



2



2

BD SAFETYGLD INS 1 ML 13MMX29G 1 ML 29 GAUGE X 12


2

BD SAFETYGLID INS 1 ML 6MMX31G 1 ML 31 GAUGE X 1564

2

BD SAFETYGLIDE SYRINGE 27GX58 1 ML 27 GAUGE X 58

2

BD SAFTYGLD INS 03 ML 6MMX31G 03 ML 31 GAUGE X 1564

2


2

BD UF MICRO PEN NEEDLE 6MMX32G 32 GAUGE X 14


BD UF MINI PEN NEEDLE 5MMX31G 31 GAUGE X 316


BD UF NANO PEN NEEDLE 4MMX32G 32 GAUGE X 532



113


BD UF ORIG PEN NDL 127MMX29G 29 GAUGE X 12


BD UF SHORT PEN NEEDLE 8MMX31G 31 GAUGE X 516


BD VEO INS 03 ML 6MMX31G (12) 03 ML 31 GAUGE X 1564

2

BD VEO INS SYRING 1 ML 6MMX31G 1 ML 31 GAUGE X 1564


2

BD VEO INS SYRN 03 ML 6MMX31G 03 ML 31 GAUGE X 1564


2



2

BORDERED GAUZE 2X2 2 X 2

(gauze bandage) 1 GC

CAREFINE PEN NEEDLE 127MM 29G 29 GAUGE X 12










CAREFINE PEN NEEDLES 6MM 32G 32 GAUGE X 14




CAREONE SYR 03 ML 31GX516 SHORT HRI 03 ML 31 GAUGE X 516

(Advocate Syringes) 2

CARETOUCH PEN NEEDLE 29G 12MM 29 GAUGE X 12


CARETOUCH PEN NEEDLE 31GX14 31 GAUGE X 14





114








CARETOUCH SYR 03 ML 31GX516 03 ML 31 GAUGE X 516


2



2



2

CARETOUCH SYR 1 ML 28GX516 1 ML 28 X 516

2


2



2



2

CLICKFINE 31G X 516 NEEDLES 8MM UNIVERSAL 31 GAUGE X 516


CLICKFINE PEN NEEDLE 32GX532 32GX4MM STERILE 32 GAUGE X 532


CLICKFINE UNIVERSAL 31G X 14 6MM STORE BRAND 31 GAUGE X 14


COMFORT EZ INS 03 ML 30GX12 03 ML 30 GAUGE X 12


2



2


115




2

COMFORT EZ INSULIN SYR 03 ML 03 ML 31 GAUGE X 516


2

COMFORT EZ INSULIN SYR 05 ML 05 ML 30 GAUGE X 516 05 ML 31 GAUGE X 516


2

COMFORT EZ PEN NEEDLE 12MM 29G 29 GAUGE X 12


COMFORT EZ PEN NEEDLES 4MM 32G SINGLE USE MICRO 32 GAUGE X 532


COMFORT EZ PEN NEEDLES 4MM 33G SINGLE USEMICROHRI 33 GAUGE X 532


COMFORT EZ PEN NEEDLES 5MM 31G LATEX-FREE MINI 31 GAUGE X 316


COMFORT EZ PEN NEEDLES 5MM 32G SINGLE USEMINIHRI 32 GAUGE X 316


COMFORT EZ PEN NEEDLES 5MM 33G 33 GAUGE X 316

2

COMFORT EZ PEN NEEDLES 6MM 31G LATEX-FREE 31 GAUGE X 14


COMFORT EZ PEN NEEDLES 6MM 32G SINGLE USE HRI 32 GAUGE X 14



2

COMFORT EZ PEN NEEDLES 8MM 31G LATEX-FREE SHORT 31 GAUGE X 516



2


2


116


COMFORT EZ SYR 03 ML 29GX12 03 ML 29 GAUGE X 12


2



2



2



2



2



2



2



2

COMFORT POINT PEN NDL 31GX13 31 GAUGE X 13

2


2

COMFORT TOUCH PEN NDL 31G 4MM 31 GAUGE X 532

2












117





2


2

COMFORT TOUCH PEN NDL 33GX4MM 33 GAUGE X 532



2

CURAD GAUZE PADS 2 X 2 2 X 2


CURITY GAUZE SPONGES (12 PLY)-200BAG 2 X 2

1 GC

CURITY GUAZE PADS 1S(12 PLY) 2 X 2


DERMACEA 2X2 GAUZE 12 PLY USP TYPE VII 2 X 2


DERMACEA GAUZE 2X2 SPONGE 8 PLY LATEX-FREE 2 X 2

1 GC

DERMACEA NON-WOVEN 2X2 SPNGE 2 X 2

1 GC

DROPLET 05 ML 29GX125MM(12) 05 ML 29 GAUGE X 12

2


2

DROPLET INS 03 ML 29GX125MM 03 ML 29 GAUGE X 12


2



2

DROPLET INS 05 ML 30GX6MM(12) 05ML 30 GAUGE X 1564

2

DROPLET INS 05 ML 30GX8MM(12) 05 ML 30 GAUGE X 516

2


118



2


2

DROPLET INS SYR 03 ML 30GX6MM 03 ML 30 GAUGE X 1564

2



2



2



2



2



2


2



2



2



2

DROPLET MICRON 34G X 964 34 GAUGE X 964

2

DROPLET PEN NEEDLE 29GX12 29 GAUGE X 12



2


119















2



DROPSAFE PEN NEEDLE 31GX14 31 GAUGE X 14

2


2

DRUG MART ULTRA COMFORT SYR 03 ML 29 GAUGE X 12 03 ML 31 GAUGE X 516


2

DRUG MART ULTRA COMFORT SYR 05ML 05 ML 31 GAUGE X 516


2

DRUG MART ULTRA COMFORT SYR 1ML 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 516


2

EASY COMFORT 03 ML SYRINGE 03 ML 30 GAUGE X 516


2

EASY COMFORT 05 ML 30GX12 05 ML 30 GAUGE X 12


2



2


120



2



2



2


2

EASY COMFORT INSULIN 1 ML SYR 1 ML 30 GAUGE X 516


2

EASY COMFORT PEN NDL 31GX14 31 GAUGE X 14








EASY COMFORT PEN NDL 33G 4MM 33 GAUGE X 532



2


2

EASY COMFORT SYR 1 ML 30GX12 1 ML 30 GAUGE X 12


2

EASY GLIDE INS 03 ML 31GX6MM 03 ML 31 GAUGE X 1564


2



2



2


121


EASY GLIDE PEN NEEDLE 4MM 33G 33 GAUGE X 532


EASY TOUCH 03 ML SYR 30GX12 03 ML 30 GAUGE X 12


2



2


2



2


2



2


2


2

EASY TOUCH FLIPLOK 1 ML 27GX05 1 ML 27 GAUGE X 12

2

EASY TOUCH INSULIN 1 ML 29GX12 1 ML 29 GAUGE X 12

2


2

EASY TOUCH INSULIN SYR 03 ML 03 ML 30 GAUGE X 516 03 ML 31 GAUGE X 516


2



2



2


122


EASY TOUCH INSULIN SYR 1 ML RETRACTABLE 1 ML 30 GAUGE X 12


2

EASY TOUCH INSULN 1 ML 29GX12 1 ML 29 GAUGE X 12

2


2


2


2


2


2

EASY TOUCH LUER LOK INSUL 1 ML 1 ML


2

EASY TOUCH PEN NEEDLE 29GX12 29 GAUGE X 12
















EASY TOUCH SAF PEN NDL 29G 5MM 29 GAUGE X 316

2


123



2


2


2

EASY TOUCH SYR 05 ML 28G 127MM 12 ML 28 GAUGE X 12


2



2


2



2



2

EASY TOUCH UNI-SLIP SYR 1 ML 1 ML


2

EASYTOUCH SAF PEN NDL 30G 6MM 30 GAUGE X 14

2

EQL INSULIN 03 ML SYRINGE SHORT NEEDLE 03 ML 30

(Ultra Comfort Insulin Syringe)

2

EQL INSULIN 05 ML SYRINGE SHORT NEEDLE 12 ML 30 GAUGE

(Lite Touch Insulin Syringe)

2

EQL INSULIN 1 ML SYRINGE SHORT NEEDLE 1 ML 30 GAUGE X 716


2

EXEL INSULIN SYRINGE 27G-1 ML 1 ML 27 GAUGE X 12


2

FIFTY50 INS 05 ML 31GX516 SHORT NEEDLE 05 ML 31 GAUGE X 516


FIFTY50 INS SYR 1 ML 31GX516 SHORT NEEDLE 1 ML 31 GAUGE X 516



124


FIFTY50 PEN 31G X 316 NEEDLE (OTC) 31 GAUGE X 316


FIFTY50 PEN NEEDLE 32G X 14 32 GAUGE X 14

(BD Ultra-Fine Micro Pen Needle)

2

FP INSULIN 1 ML SYRINGE 1 ML 28 GAUGE


2

FREESTYLE PREC 05 ML 30GX516 05 ML 30 GAUGE X 516


2



2



2



2

GAUZE PAD TOPICAL BANDAGE 2 X 2


GNP ULT C 03 ML 29GX12 (12) 03 ML 29 GAUGE X 12

2

GNP ULTRA COMFORT 05 ML SYR 12 ML 29 12 ML 30 GAUGE


2

GNP ULTRA COMFORT 1 ML SYRINGE 1 ML 28 GAUGE 1 ML 30 GAUGE X 716


2

GNP ULTRA COMFORT 1 ML SYRINGE 1 ML 29 GAUGE

2

GNP ULTRA COMFORT 310 ML SYR 03 ML 30


2

HEALTHWISE INS 03 ML 30GX516 03 ML 30 GAUGE X 516


2



2


125




2



2



2



2

HEALTHWISE PEN NEEDLE 31G 5MM 31 GAUGE X 316






HEALTHY ACCENTS PENTIP 4MM 32G 32 GAUGE X 532








HEALTHY ACCENTS PENTP 12MM 29G 29 GAUGE X 12

2

INCONTROL PEN NEEDLE 12MM 29G 29 GAUGE X 12










INSULIN SYR 03 ML 30GX516 03 ML 30 GAUGE X 516



126


INSULIN SYR 03 ML 31GX14(12) 03 ML 31 GAUGE X 14

(UltiCare Insuln Syr(half unit))

2

INSULIN SYRIN 03 ML 30GX12 SHORT NEEDLE 03 ML 30 GAUGE X 12


2

INSULIN SYRIN 05 ML 28GX12 12 ML 28 GAUGE X 12


2

INSULIN SYRIN 05 ML 30GX12 SHORT NEEDLE (OTC) 05 ML 30 GAUGE X 12


2



INSULIN SYRING 05 ML 27GX12 12 ML 27 GAUGE X 12

(Easy Touch Insulin Syringe)

2

INSULIN SYRINGE 03 ML 03 ML 29 GAUGE


2

INSULIN SYRINGE 03 ML 31GX14 03 ML 31 GAUGE X 14

(Sure Comfort Insulin Syringe)

2

INSULIN SYRINGE 05 ML 12 ML 29


2



2


2

INSULIN SYRINGE 1 ML 30GX12 (RX) 1 ML 30 GAUGE X 12

(BD Eclipse Luer-Lok) 2

INSULIN SYRINGE 1 ML 30GX516 SHORT NEEDLE (OTC) 1 ML 30 GAUGE X 516




2

INSULIN SYRINGE-NEEDLE U-100 SYRINGE 03 ML 29 GAUGE

(Ultilet Insulin Syringe) 2


127


INSULIN SYRINGE-NEEDLE U-100 SYRINGE 1 ML 29 GAUGE X 12




2

INSUPEN 30G ULTRAFIN NEEDLE 30 GAUGE X 516


INSUPEN 31G ULTRAFIN NEEDLE 31 GAUGE X 14 31 GAUGE X 516


INSUPEN 32G 6MM PEN NEEDLE 32 GAUGE X 14



2

INSUPEN PEN NEEDLE 29GX12MM 29 GAUGE X 12


INSUPEN PEN NEEDLE 31GX316 31 GAUGE X 316






KRO PEN NEEDLE 4MM X 33G 33 GAUGE X 532

(Advocate Pen Needle) 2

LISCO SPONGES 100BAG 2 X 2

1 GC

LITE TOUCH 31GX14 PEN NEEDLE 31 GAUGE X 14


LITE TOUCH INSULIN 05 ML SYR 12 ML 28 GAUGE 12 ML 29 12 ML 30 GAUGE


2

LITE TOUCH INSULIN 1 ML SYR 1 ML 28 GAUGE 1 ML 30 GAUGE X 716


2

LITE TOUCH INSULIN 1 ML SYR 1 ML 29 GAUGE

2

LITE TOUCH INSULIN SYR 1 ML 1 ML 31 GAUGE X 516


2

LITE TOUCH PEN NEEDLE 29G 29 GAUGE X 12



128


LITE TOUCH PEN NEEDLE 31G 31 GAUGE X 316 31 GAUGE X 516


LITETOUCH INS 03 ML 29GX12 03 ML 29 GAUGE X 12


2



2



2



2

LITETOUCH SYR 05 ML 28GX12 12 ML 28 GAUGE X 12


2



2



2

LITETOUCH SYRIN 1 ML 28GX12 1 ML 28 GAUGE X 12


2



2



2

MAGELLAN INSUL SYRINGE 03 ML 03 ML 30 X 516

2

MAGELLAN INSUL SYRINGE 05 ML 05 ML 30 GAUGE X 516

2

MAGELLAN INSULIN SYR 03 ML 03 ML 29 X 12

2

MAGELLAN INSULIN SYR 05 ML 05 ML 29 GAUGE X 12

2


129


MAGELLAN INSULIN SYRINGE 1 ML 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 516

2

MAXICOMFORT II PEN NDL 31GX6MM 31 GAUGE X 14


MAXICOMFORT INS 05 ML 27GX12 12 ML 27 GAUGE X 12


2

MAXI-COMFORT INS 05 ML 28G 12 ML 28 GAUGE X 12


2



2

MAXI-COMFORT INS 1 ML 28GX12 1 ML 28 GAUGE X 12


2

MAXICOMFORT PEN NDL 29G X 5MM 29 GAUGE X 316

2


2

MICRODOT PEN NEEDLE 31GX6MM 31 GAUGE X 14






MINI ULTRA-THIN II PEN NDL 31G LATEX-FREESTERILE 31 GAUGE X 316


MONOJECT 05 ML SYRN 28GX12 12 ML 28 GAUGE


2

MONOJECT 1 ML SYRN 27X12 1 ML 27 GAUGE X 12


2

MONOJECT 1 ML SYRN 28GX12 (OTC) 1 ML 28 GAUGE X 12


2

MONOJECT INSUL SYR U100 (OTC) 03 ML 29 GAUGE X 12


2


130


MONOJECT INSUL SYR U100 5ML29GX12 (OTC) 05 ML 29 GAUGE X 12


2

MONOJECT INSUL SYR U100 05 ML CONVERTS TO 29G (OTC) 12 ML 28 GAUGE X 12


2

MONOJECT INSUL SYR U100 1 ML 1 ML 25 GAUGE X 58


2

MONOJECT INSUL SYR U100 1 ML 3S 29GX12 (OTC) 1 ML 29 GAUGE X 12


2

MONOJECT INSUL SYR U100 1 ML WO NEEDLE (OTC) 1 ML

(insulin syringes (disposable))

2

MONOJECT INSULIN SYR 03 ML (OTC) 03 ML 30 GAUGE X 516


2

MONOJECT INSULIN SYR 03 ML 03 ML 30 GAUGE X 516


2



2



2

MONOJECT INSULIN SYR 1 ML 3S (OTC) 1 ML 30 GAUGE X 516


2

MONOJECT INSULIN SYR U-100 05 ML 29 GAUGE X 12


2

MONOJECT INSULIN SYR U-100 29 GAUGE X 12

2

MONOJECT SYRINGE 03 ML 03 ML 31 GAUGE X 516


2



2



2

NOVOFINE 30 NEEDLE 30 GAUGE X 13

2

NOVOFINE 32G NEEDLES 32 GAUGE X 14



131


NOVOFINE PLUS PEN NDL 32GX16 32 GAUGE X 16

2

NOVOTWIST NEEDLE 32G 5MM 32 GAUGE X 15

2

OMNIPOD DASH 5 PACK POD SUBCUTANEOUS CARTRIDGE

3

OMNIPOD DASH PDM KIT 3 QL (1 per 365 days)

OMNIPOD INSULIN MANAGEMENT


OMNIPOD INSULIN REFILL SUBCUTANEOUS CARTRIDGE

3

PC UNIFINE PENTIPS 8MM NEEDLE SHORT 31 GAUGE X 516


PEN NEEDLE 30G X 516 30 GAUGE X 516


PEN NEEDLE 30G X 8MM 30 GAUGE X 516

(AboutTime Pen Needle)

2


(CareFine Pen Needle) 2

PEN NEEDLE 32G X 532 4MM 32 GAUGE X 532

(1st Tier Unifine Pentips)

2

PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12

(1st Tier Unifine Pentips Plus)

2

PEN NEEDLES 12MM 29G 29GX12MMSTRL 29 GAUGE X 12


PEN NEEDLES 4MM 32G 32 GAUGE X 532


PEN NEEDLES 6MM 31G 31GX6MM STRL 31 GAUGE X 14


2

PEN NEEDLES 8MM 31G 31GX8MMSTRLSHORT (OTC) 31 GAUGE X 516


PENTIPS PEN NEEDLE 29GX12 29 GAUGE X 12



132


PENTIPS PEN NEEDLE 31GX316 MINI 5MM 31 GAUGE X 316


PENTIPS PEN NEEDLE 31GX516 SHORT 8MM 31 GAUGE X 516


PENTIPS PEN NEEDLE 32GX532 4MM 32 GAUGE X 532


PENTIPS PEN NEEDLE 6MM 31G 31 GAUGE X 14


PIP PEN NEEDLE 31G X 5MM 31 GAUGE X 316




PREVENT PEN NEEDLE 31GX14 31 GAUGE X 14

2


2

PRO COMFORT 05 ML 30GX12 05 ML 30 GAUGE X 12


2



2



2



2



2



2

PRO COMFORT PEN NDL 31GX516 31 GAUGE X 516


PRO COMFORT PEN NDL 32G X 14 32 GAUGE X 14



133


PRO COMFORT PEN NDL 4MM 32G 32 GAUGE X 532




PRODIGY INS SYR 1 ML 28GX12 1 ML 28 GAUGE X 12


2

PRODIGY SYRNG 05 ML 31GX516 05 ML 31 GAUGE X 516


2

PRODIGY SYRNGE 03 ML 31GX516 03 ML 31 GAUGE X 516


2

PURE COMFORT PEN NDL 32G 4MM 32 GAUGE X 532







2

RELI ON 31G X 14 NEEDLES 31 GAUGE X 14


RELION INS SYR 03 ML 31GX6MM 03 ML 31 GAUGE X 1564

(BD Veo Insulin Syringe UF)

2



2

RELION INS SYR 1 ML 31GX1564 1 ML 31 GAUGE X 1564


2

RELI-ON INSULIN 05 ML SYR 12 ML 29


2

RELI-ON INSULIN 1 ML SYR 1 ML 29 GAUGE X 716

2

RELION MINI PEN 31G X 14 NDL 31 GAUGE X 14


RELION PEN NEEDLE 31G 6MM 31 GAUGE X 1564

2


134


RELION PEN NEEDLES 32GX532 32 GAUGE X 532


SAFESNAP INS SYR UNITS-100 03 ML 30GX51610X10LF 03 ML 30 GAUGE X 516

2


2


2


2


2

SAFETY PEN NEEDLE 5MM X 31G 31 GAUGE X 316

2

SECURESAFE PEN NDL 30GX516 OUTER 30 GAUGE X 516

2

SM STERILE PADS 2 X 2 2X2 STERILE 2 X 2


SM ULT CFT 03 ML 31GX516(12) 03 ML 31 GAUGE X 516

2

SURE CMFT SFTY PEN NDL 31G 6MM 31 GAUGE X 14

2


2

NEEDLES INSULIN DISP SAFETY


2

SURE COMFORT 05 ML SYRINGE 05 ML 30 GAUGE X 12 05 ML 30 GAUGE X 516 05 ML 31 GAUGE X 516 12 ML 28 GAUGE X 12


2


135


SURE COMFORT 1 ML SYRINGE 1 ML 28 GAUGE X 12 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 12 1 ML 30 GAUGE X 516 1 ML 31 GAUGE X 516


2

SURE COMFORT 310 ML SYRINGE 03 ML 29 GAUGE X 12 03 ML 30 GAUGE X 12 03 ML 30 GAUGE X 516


2

SURE COMFORT 310 ML SYRINGE INSULIN SYRINGE 03 ML 31 GAUGE X 516


2

SURE COMFORT 30G PEN NEEDLE 30 GAUGE X 516




SURE COMFORT INS 03 ML 31GX14 03 ML 31 GAUGE X 14


2



2



2

SURE COMFORT PEN NDL 29GX12 127MM 29 GAUGE X 12


SURE COMFORT PEN NDL 31GX316 31 GAUGE X 316






SURE-FINE PEN NEEDLES 127MM 29 GAUGE X 12







136


SURE-JECT INSU SYR U100 03 ML 03 ML 29 GAUGE X 12 03 ML 30 GAUGE X 516


2

SURE-JECT INSU SYR U100 05 ML 05 ML 29 GAUGE X 12 05 ML 30 GAUGE X 516 12 ML 28 GAUGE X 12


2

SURE-JECT INSU SYR U100 1 ML 1 ML 28 GAUGE X 12


2

SURE-JECT INSUL SYR U100 1 ML 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 516


2

SURE-JECT INSULIN SYRINGE 1 ML 1 ML 31 GAUGE X 516


2

TECHLITE 03 ML 29GX12MM (12) 03 ML 29 GAUGE X 12

2


2


2


2


2


2


2


2


2


2

TECHLITE INS SYR 1 ML 29GX12MM 1 ML 29 GAUGE X 12


2



2


137




2



2



2

TECHLITE PEN NEEDLE 29GX12 29 GAUGE X 12



2










2



TERUMO INS SYR 03 ML 29GX12 03 ML 29 GAUGE X 12


TERUMO INS SYRINGE U100-1 ML 1 ML 27 GAUGE X 12 1 ML 28 GAUGE X 12 1 ML 29 GAUGE X 12


2

TERUMO INS SYRINGE U100-1 ML 1 ML 30 GAUGE X 38

(Thinpro Insulin Syringe)

2

TERUMO INS SYRINGE U100-12 ML 12 ML 30 X 38


2



2


138


TERUMO INS SYRNG U100-12 ML 05 ML 29 GAUGE X 12 12 ML 27 GAUGE X 12 12 ML 28 GAUGE X 12


2

THINPRO INS SYRIN U100-03 ML 03 ML 29 GAUGE X 12 03 ML 30 X 38


2

THINPRO INS SYRIN U100-03 ML 03 ML 31 X 38

2

THINPRO INS SYRIN U100-05 ML 05 ML 29 GAUGE X 12 12 ML 28 GAUGE X 12 12 ML 30 X 38


2


2

THINPRO INS SYRIN U100-1 ML 1 ML 28 GAUGE X 12 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 38


2


2

TOPCARE CLICKFINE 31G X 14 31 GAUGE X 14




TOPCARE ULTRA COMFORT SYRINGE 03 ML 29 GAUGE X 12 03 ML 30 GAUGE X 516 03 ML 31 GAUGE X 516 05 ML 29 GAUGE X 12 05 ML 30 GAUGE X 516 05 ML 31 GAUGE X 516 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 516 1 ML 31 GAUGE X 516


2

TRUE CMFRT PRO 05 ML 30G 516 05 ML 30 GAUGE X 516


2



2


2


139


TRUE COMFORT 05 ML 31GX516 05 ML 31 GAUGE X 516


2



2

TRUE COMFORT PEN NDL 31G 8MM 31 GAUGE X 516


TRUE COMFORT PEN NDL 31GX5MM 31 GAUGE X 316








TRUE COMFORT PRO 1 ML 30G 12 1 ML 30 GAUGE X 12


2



2



2


2

TRUE COMFRT PRO 05 ML 30G 12 05 ML 30 GAUGE X 12


2

TRUEPLUS PEN NEEDLE 29GX12 29 GAUGE X 12


TRUEPLUS PEN NEEDLE 31G X 14 31 GAUGE X 14









140


TRUEPLUS SYR 03 ML 29GX12 03 ML 29 GAUGE X 12


2



2



2



2



2



2



2



2



2



2



2

ULT CFT 03 ML 30GX516 (12) 03 ML 30 GAUGE X 516

2

ULTICAR INS 03 ML 31GX14(12) 03 ML 31 GAUGE X 14

(insulin syrndl u100 half mark)

2

ULTICARE INS 03 ML 31GX14 03 ML 31 GAUGE X 14


2



2


141




2

ULTICARE INS SYR 1 ML 30GX12 30GX12 1 ML 30 GAUGE X 12


2

ULTICARE PEN NEEDLE 31GX316 31 GAUGE X 316


ULTICARE PEN NEEDLE 6MM 31G 31 GAUGE X 14




ULTICARE PEN NEEDLES 12MM 29G 29 GAUGE X 12


ULTICARE PEN NEEDLES 4MM 32G MICRO 32GX4MM 32 GAUGE X 532




ULTICARE SAFE PEN NDL 5MM 30G 30 GAUGE X 316

2


2

ULTICARE SAFETY 05 ML 29GX12 LATEXFREE (RX) 05 ML 29 GAUGE X 12


ULTICARE SYR 03 ML 30GX12 LATEX FREE 03 ML 30 GAUGE X 12


2

ULTICARE SYR 03 ML 31GX516 LATEX FREESHORT NDL 03 ML 31 GAUGE X 516


2



2



2


142




2

ULTIGUARD SAFE 1 ML 30G 127MM 1 ML 30 X 12

2

ULTIGUARD SAFE PACK 29G 127MM 29 GAUGE X 12

2


2

ULTIGUARD SAFE03 ML 30G 127MM 03 ML 30 X 12

2


2

ULTIGUARD SAFEPACK 1 ML 31G 8MM 1 ML 31 X 516

2

ULTIGUARD SAFEPACK 31G 5MM 31 GAUGE X 316

2


2


2


2

ULTIGUARD SAFEPK 03 ML 31G 8MM 03 ML 31 X 516

2


2

ULTILET INSULIN SYRINGE 03 ML 03 ML 29 GAUGE X 12 03 ML 30 GAUGE X 516 03 ML 31 GAUGE X 516


2



2



2


143


ULTILET PEN NEEDLE 29 GAUGE

2

ULTILET PEN NEEDLE 4MM 32G 32 GAUGE X 532


ULTRA COMFORT 03 ML SYRINGE 03 ML 30 GAUGE X 516


2

ULTRA COMFORT 05 ML 28GX12 CONVERTS TO 29G 12 ML 28 GAUGE X 12


2

ULTRA COMFORT 05 ML 29GX12 05 ML 29 GAUGE X 12


2

ULTRA COMFORT 05 ML SYRINGE 12 ML 28 GAUGE


2



2



2

ULTRA FLO 03 ML 30G 12 (12) 03 ML 30 GAUGE X 12

2

ULTRA FLO 03 ML 30G 516(12) 03 ML 30 GAUGE X 516

2


2

ULTRA FLO PEN NEEDLE 31G 5MM 31 GAUGE X 316








ULTRA FLO PEN NEEDLES 12MM 29G 29 GAUGE X 12



144


ULTRA FLO SYR 03 ML 29GX12 03 ML 29 GAUGE X 12


2

ULTRA FLO SYR 03 ML 30G 516 03 ML 30 GAUGE X 516


2



2



2

ULTRA THIN PEN NDL 32G X 4MM 32 GAUGE X 532


ULTRACARE INS 03 ML 30GX516 03 ML 30 GAUGE X 516


2



2



2



2



2

ULTRACARE INS 1 ML 30G X 516 1 ML 30 GAUGE X 516


2



2



2

ULTRACARE PEN NEEDLE 31GX14 31 GAUGE X 14









145








ULTRA-THIN II 1 ML 31GX516 1 ML 31 GAUGE X 516


2

ULTRA-THIN II INS 03 ML 29G 03 ML 29 GAUGE X 12


2



2



2



2



2



2

ULTRA-THIN II INS SYR 1 ML 29G 1 ML 29 GAUGE X 12


2



2

ULTRA-THIN II PEN NDL 29GX12 29 GAUGE X 12




UNIFINE PEN NEEDLE 32G 4MM 32 GAUGE X 532


UNIFINE PENTIPS 12MM 29G 29GX12MM STRL 29 GAUGE X 12


UNIFINE PENTIPS 31GX316 31GX5MMSTRLMINI 31 GAUGE X 316


UNIFINE PENTIPS 32GX14 32 GAUGE X 14



146


UNIFINE PENTIPS 32GX532 32GX4MM STRL NANO 32 GAUGE X 532




UNIFINE PENTIPS 6MM 31G 31 GAUGE X 14


UNIFINE PENTIPS MAX 30GX316 30 GAUGE X 316

2

UNIFINE PENTIPS NEEDLES 29G 29 GAUGE

2

UNIFINE PENTIPS PLUS 29GX12 12MM 29 GAUGE X 12


UNIFINE PENTIPS PLUS 30GX316 30 GAUGE X 316

2

UNIFINE PENTIPS PLUS 31GX14 ULTRA SHORT 6MM 31 GAUGE X 14


UNIFINE PENTIPS PLUS 31GX316 MINI 31 GAUGE X 316


UNIFINE PENTIPS PLUS 31GX516 SHORT 31 GAUGE X 516






UNIFINE SAFECONTROL 30GX316 30 GAUGE X 316

2


2

VANISHPOINT 05 ML 30GX12 SY LATEX-FREE OUTER 05 ML 30 GAUGE X 12


2

VANISHPOINT INS 1 ML 30GX316 1 ML 30 GAUGE X 316

2


147


VANISHPOINT U-100 29X12 SYR 1 ML 29 GAUGE X 12


2

VERIFINE PEN NEEDLE 31G X 6MM 31 GAUGE X 14








VERSALON ALL PURPOSE SPONGE 25SN-STERILE3PLY 2 X 2

1 GC

V-GO 20 DEVICE 3

V-GO 30 DEVICE 3

V-GO 40 DEVICE 3

Enzyme ReplacementModifiersEnzyme ReplacementModifiersALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML

5 NM NDS

CERDELGA ORAL CAPSULE 84 MG

5 PA NM NDS

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5 NM NDS

CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT

3

ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML

5 NM NDS

ELITEK INTRAVENOUS RECON SOLN 15 MG 75 MG

5 NM NDS

FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG

5 PA NM NDS

GALAFOLD ORAL CAPSULE 123 MG



148


KANUMA INTRAVENOUS SOLUTION 2 MGML

5 PA NM NDS

KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML

5 PA BvD NM NDS

MEPSEVII INTRAVENOUS SOLUTION 2 MGML

5 PA NM NDS

miglustat oral capsule 100 mg (Zavesca) 5 PA NM NDS QL (90 per 30 days)

NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML

5 NM NDS

nitisinone oral capsule 10 mg 2 mg 5 mg

(Orfadin) 5 PA NM NDS

NITYR ORAL TABLET 10 MG 2 MG 5 MG

5 PA NM NDS

ORFADIN ORAL CAPSULE 20 MG

5 PA NM NDS

ORFADIN ORAL SUSPENSION 4 MGML

5 PA NM NDS

PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML

5 PA NM NDS

PULMOZYME INHALATION SOLUTION 1 MGML

5 PA BvD NM NDS

REVCOVI INTRAMUSCULAR SOLUTION 24 MG15 ML (16 MGML)

5 PA NM NDS

sapropterin oral tabletsoluble 100 mg

(Kuvan) 5 NM NDS

STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML

5 PA NM LA NDS

VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)

5 PA NM NDS

VPRIV INTRAVENOUS RECON SOLN 400 UNIT

5 NM NDS


149


ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 25000-79000- 105000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT

3

Eye Ear Nose Throat AgentsEye Ear Nose Throat Agents Miscellaneousalcaine ophthalmic (eye) drops 05

(proparacaine) 2

apraclonidine ophthalmic (eye) drops 05

2

atropine ophthalmic (eye) drops 1

(Isopto Atropine) 4

azelastine nasal aerosolspray 137 mcg (01 )


azelastine nasal spraynon-aerosol2055 mcg (015 )


azelastine ophthalmic (eye) drops005

2

bepotastine besilate ophthalmic (eye) drops 15

(Bepreve) 2 ST

cromolyn ophthalmic (eye) drops 4

2

cyclopentolate ophthalmic (eye) drops 05 1 2

(Cyclogyl) 2

CYSTADROPS OPHTHALMIC (EYE) DROPS 037


CYSTARAN OPHTHALMIC (EYE) DROPS 044


epinastine ophthalmic (eye) drops005

2

ipratropium bromide nasal spraynon-aerosol 21 mcg (003 )





150


olopatadine nasal spraynon-aerosol06

(Patanase) 2 QL (305 per 30 days)

olopatadine ophthalmic (eye) drops01

(Eye Allergy Itch-Redness Rlf)

2


(Eye Allergy Itch Relief)

2

proparacaine ophthalmic (eye) drops 05

(Alcaine) 2

TEPEZZA INTRAVENOUS RECON SOLN 500 MG

5 PA NM NDS

Eye Ear Nose Throat Anti-Infectives Agentsacetic acid otic (ear) solution 2 2

bacitracin ophthalmic (eye) ointment 500 unitgram

2

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram

(Polycin) 2

bleph-10 ophthalmic (eye) drops 10

(sulfacetamide sodium) 2

ciprofloxacin hcl ophthalmic (eye) drops 03

(Ciloxan) 2

ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01

(Ciprodex) 2 QL (75 per 7 days)

erythromycin ophthalmic (eye) ointment 5 mggram (05 )


gatifloxacin ophthalmic (eye) drops05

(Zymaxid) 2

gentak ophthalmic (eye) ointment03 (3 mggram)

(gentamicin) 2

gentamicin ophthalmic (eye) drops03

1 GC

hydrocortisone-acetic acid otic (ear) drops 1-2

2

levofloxacin ophthalmic (eye) drops05

2

moxifloxacin ophthalmic (eye) drops 05

(Vigamox) 2

NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5

4


151


neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1

(Neo-Polycin HC) 2

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg

(Neo-Polycin) 2

neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension35mgml-10000 unitml-01

(Maxitrol) 2

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01

(Maxitrol) 2

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml

2

neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml

2

neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-

2

neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-

2

neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1

(neomycin-bacitracin-poly-hc)

2

neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg

(neomycin-bacitracin-polymyxin)

2

ofloxacin ophthalmic (eye) drops03

(Ocuflox) 2

ofloxacin otic (ear) drops 03 2

polycin ophthalmic (eye) ointment500-10000 unitgram

(bacitracin-polymyxin b)

2

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml

(Polytrim) 1 GC

sulfacetamide sodium ophthalmic (eye) drops 10

(Bleph-10) 2


152


sulfacetamide sodium ophthalmic (eye) ointment 10

2

sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )

2

tobramycin ophthalmic (eye) drops03

(Tobrex) 2

tobramycin-dexamethasone ophthalmic (eye) dropssuspension03-01

(TobraDex) 2

trifluridine ophthalmic (eye) drops1

2

ZIRGAN OPHTHALMIC (EYE) GEL 015

4

ZYLET OPHTHALMIC (EYE) DROPSSUSPENSION 03-05

3

Eye Ear Nose Throat Anti-Inflammatory AgentsALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02

3 ST

bromfenac ophthalmic (eye) drops009

2

BROMSITE OPHTHALMIC (EYE) DROPS 0075

3

dexamethasone sodium phosphate ophthalmic (eye) drops 01

2

diclofenac sodium ophthalmic (eye) drops 01

2

difluprednate ophthalmic (eye) drops 005

(Durezol) 2

DUREZOL OPHTHALMIC (EYE) DROPS 005

(difluprednate) 3

EYSUVIS OPHTHALMIC (EYE) DROPSSUSPENSION 025


flunisolide nasal spraynon-aerosol25 mcg (0025 )


fluocinolone acetonide oil otic (ear) drops 001

(DermOtic Oil) 2

fluorometholone ophthalmic (eye) dropssuspension 01

(FML Liquifilm) 4


153


flurbiprofen sodium ophthalmic (eye) drops 003

2

fluticasone propionate nasal spraysuspension 50 mcgactuation

(24 Hour Allergy Relief)


ILEVRO OPHTHALMIC (EYE) DROPSSUSPENSION 03

3

INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1

3

ketorolac ophthalmic (eye) drops05

(Acular) 2 QL (10 per 25 days)

LOTEMAX OPHTHALMIC (EYE) OINTMENT 05

3

LOTEMAX SM OPHTHALMIC (EYE) DROPSGEL 038

3

loteprednol etabonate ophthalmic (eye) dropsgel 05

(Lotemax) 2

loteprednol etabonate ophthalmic (eye) dropssuspension 05

(Lotemax) 2

mometasone nasal spraynon-aerosol50 mcgactuation

(Nasonex) 2 QL (34 per 30 days)

prednisolone acetate ophthalmic (eye) dropssuspension 1

(Pred Forte) 4

prednisolone sodium phosphate ophthalmic (eye) drops 1

2

PROLENSA OPHTHALMIC (EYE) DROPS 007

3

RESTASIS MULTIDOSE 005 EYE PF 005


RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005


XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCGACTUATION


XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5


Gastrointestinal AgentsAntiulcer Agents And Acid Suppressantsamoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg

2


154


cimetidine hcl oral solution 300 mg5 ml

2

cimetidine oral tablet 200 mg (Acid Reducer (cimetidine))

2

cimetidine oral tablet 300 mg 400 mg 800 mg

2

esomeprazole magnesium oral capsuledelayed release(drec) 20 mg

(Nexium) 2 QL (30 per 30 days)



esomeprazole sodium intravenous recon soln 20 mg

2


(Nexium IV) 2

famotidine (pf) intravenous solution20 mg2 ml

1 GC

famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg50 ml

2

famotidine intravenous solution 10 mgml

2

famotidine oral suspension 40 mg5 ml (8 mgml)

2

famotidine oral tablet 20 mg (Acid Controller) 1 GC

famotidine oral tablet 40 mg (Pepcid) 1 GC

lansoprazole oral capsuledelayed release(drec) 15 mg

(Prevacid 24Hr) 2 QL (30 per 30 days)


(Prevacid) 2 QL (60 per 30 days)

misoprostol oral tablet 100 mcg 200 mcg

(Cytotec) 2

nizatidine oral capsule 150 mg 300 mg

2

nizatidine oral solution 150 mg10 ml

2

omeprazole oral capsuledelayed release(drec) 10 mg 40 mg

1 GC

omeprazole oral capsuledelayed release(drec) 20 mg

1 GC


155


omeprazole-sodium bicarbonate oral capsule 20-11 mg-gram 40-11 mg-gram

(Zegerid) 2 ST QL (30 per 30 days)

pantoprazole intravenous recon soln40 mg

(Protonix) 2

pantoprazole oral tabletdelayed release (drec) 20 mg

(Protonix) 1 GC QL (30 per 30 days)



rabeprazole oral tabletdelayed release (drec) 20 mg

(AcipHex) 2 QL (30 per 30 days)

sucralfate oral tablet 1 gram (Carafate) 2Gastrointestinal Agents OtherCARBAGLU ORAL TABLET DISPERSIBLE 200 MG

5 NM NDS

constulose oral solution 10 gram15 ml

(lactulose) 2

cromolyn oral concentrate 100 mg5 ml

(Gastrocrom) 2

dicyclomine oral capsule 10 mg 2

dicyclomine oral solution 10 mg5 ml 2

dicyclomine oral tablet 20 mg 2

diphenoxylate-atropine oral liquid25-0025 mg5 ml

2

diphenoxylate-atropine oral tablet25-0025 mg

(Lomotil) 2

enulose oral solution 10 gram15 ml (lactulose) 2

GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG

5 PA NM NDS

generlac oral solution 10 gram15 ml (lactulose) 2

glycopyrrolate oral tablet 1 mg 2 mg

2

kionex (with sorbitol) oral suspension 15-193 gram60 ml

2

lactulose oral solution 10 gram15 ml

(Constulose) 2

LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG


LOKELMA ORAL POWDER IN PACKET 10 GRAM



156




loperamide oral capsule 2 mg (Anti-Diarrheal (loperamide))

2

lubiprostone oral capsule 24 mcg 8 mcg

(Amitiza) 3 QL (60 per 30 days)

methscopolamine oral tablet 25 mg 5 mg

2

metoclopramide hcl injection solution 5 mgml

2

metoclopramide hcl injection syringe5 mgml

2

metoclopramide hcl oral solution 5 mg5 ml

2

metoclopramide hcl oral tablet 10 mg 5 mg

(Reglan) 1 GC

MOVANTIK ORAL TABLET 125 MG 25 MG


OCALIVA ORAL TABLET 10 MG 5 MG


propantheline oral tablet 15 mg 2

RAVICTI ORAL LIQUID 11 GRAMML

5 PA NM NDS

RELISTOR ORAL TABLET 150 MG


RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML


RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML




sodium phenylbutyrate oral tablet500 mg

(Buphenyl) 5 NM NDS

sodium polystyrene (sorb free) oral suspension 15 gram60 ml

2

sodium polystyrene sulfonate oral powder

2

sps (with sorbitol) oral suspension15-20 gram60 ml

2

ursodiol oral capsule 300 mg 2

ursodiol oral tablet 250 mg (URSO 250) 2


157


ursodiol oral tablet 500 mg (URSO Forte) 2

XERMELO ORAL TABLET 250 MG


LaxativesCLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML

3

gavilyte-c oral recon soln 240-2272-672 -584 gram

(peg 3350-electrolytes) 2

gavilyte-g oral recon soln 236-2274-674 -586 gram


gavilyte-n oral recon soln 420 gram (peg-electrolyte soln) 2

SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM

3

trilyte with flavor packets oral recon soln 420 gram

(peg-electrolyte soln) 2

Phosphate Binderscalcium acetate(phosphat bind) oral capsule 667 mg

2

calcium acetate(phosphat bind) oral tablet 667 mg

2

lanthanum oral tabletchewable1000 mg 500 mg 750 mg

(Fosrenol) 5 NM NDS

PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)5 ML

4

sevelamer carbonate oral powder in packet 08 gram 24 gram

(Renvela) 5 NM NDS

sevelamer carbonate oral tablet 800 mg

(Renvela) 2

sevelamer hcl oral tablet 400 mg 2

sevelamer hcl oral tablet 800 mg (Renagel) 2

VELPHORO ORAL TABLETCHEWABLE 500 MG

3

Genitourinary AgentsAntispasmodics Urinarybethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg

2

flavoxate oral tablet 100 mg 2


158


MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG

3

oxybutynin chloride oral syrup 5 mg5 ml

2

oxybutynin chloride oral tablet 5 mg 2

oxybutynin chloride oral tablet extended release 24hr 10 mg 5 mg

(Ditropan XL) 2

oxybutynin chloride oral tablet extended release 24hr 15 mg

2

tolterodine oral capsuleextended release 24hr 2 mg 4 mg

(Detrol LA) 2

tolterodine oral tablet 1 mg 2 mg (Detrol) 2

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG 8 MG

3

trospium oral capsuleextended release 24hr 60 mg

2

trospium oral tablet 20 mg 2Genitourinary Agents Miscellaneousalfuzosin oral tablet extended release 24 hr 10 mg

(Uroxatral) 1 GC QL (30 per 30 days)

dutasteride oral capsule 05 mg (Avodart) 2

dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg

(Jalyn) 2

finasteride oral tablet 5 mg (Proscar) 1 GC

tamsulosin oral capsule 04 mg (Flomax) 1 GC

terazosin oral capsule 1 mg 10 mg 2 mg 5 mg

1 GC

THIOLA EC ORAL TABLETDELAYED RELEASE (DREC) 100 MG 300 MG

5 PA NM NDS

tiopronin oral tablet 100 mg (Thiola) 5 NM NDS

Heavy Metal AntagonistsHeavy Metal Antagonistsclovique oral capsule 250 mg (trientine) 5 PA NM NDS QL

(240 per 30 days)

deferasirox oral granules in packet180 mg 360 mg 90 mg

(Jadenu Sprinkle) 5 PA NM NDS

deferasirox oral tablet 180 mg 360 mg

(Jadenu) 5 PA NM NDS


159


deferasirox oral tablet 90 mg (Jadenu) 2 PA

deferasirox oral tablet dispersible125 mg

(Exjade) 2 PA

deferasirox oral tablet dispersible250 mg 500 mg

(Exjade) 5 PA NM NDS

deferiprone oral tablet 500 mg (Ferriprox) 5 PA NM NDS

deferoxamine injection recon soln 2 gram

2 PA

deferoxamine injection recon soln500 mg

(Desferal) 2 PA

FERRIPROX 1000 MG TAB(2XDAY) 1000 MG

5 PA NM NDS

FERRIPROX ORAL SOLUTION 100 MGML

5 PA NM NDS

FERRIPROX ORAL TABLET 1000 MG

5 PA NM NDS

penicillamine oral capsule 250 mg (Cuprimine) 5 PA NM NDS

penicillamine oral tablet 250 mg (Depen Titratabs) 5 PA NM NDS

trientine oral capsule 250 mg (Syprine) 5 PA NM NDS QL (240 per 30 days)

Hormonal Agents StimulantReplacementModifyingAndrogensANADROL-50 ORAL TABLET 50 MG

5 PA NM NDS

danazol oral capsule 100 mg 200 mg 50 mg

2

oxandrolone oral tablet 10 mg 25 mg

(Oxandrin) 2

testosterone cypionate intramuscular oil 100 mgml 200 mgml

(Depo-Testosterone) 2 PA

testosterone cypionate intramuscular oil 200 mgml (1 ml)

2 PA

testosterone enanthate intramuscular oil 200 mgml


testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )

(Vogelxo) 2 PA QL (300 per 30 days)


160


testosterone transdermal gel in metered-dose pump 2025 mg125 gram (162 )

(AndroGel) 2 PA QL (150 per 30 days)

testosterone transdermal gel in packet 1 (25 mg25gram) 1 (50 mg5 gram)


testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)


XYOSTED SUBCUTANEOUS AUTO-INJECTOR 100 MG05 ML 50 MG05 ML 75 MG05 ML


Estrogens And Antiestrogensamabelz oral tablet 05-01 mg 1-05 mg

(estradiol-norethindrone acet)

2

dotti transdermal patch semiweekly0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr

(estradiol) 2 QL (8 per 28 days)

DUAVEE ORAL TABLET 045-20 MG

3

estradiol oral tablet 05 mg 1 mg 2 mg

(Estrace) 1 GC

estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr

(Dotti) 2 QL (8 per 28 days)

estradiol transdermal patch weekly0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr

(Climara) 2 QL (4 per 28 days)

estradiol vaginal cream 001 (01 mggram)

(Estrace) 2

estradiol vaginal tablet 10 mcg (Yuvafem) 2 QL (18 per 28 days)

estradiol valerate intramuscular oil20 mgml 40 mgml

(Delestrogen) 2

estradiol-norethindrone acet oral tablet 05-01 mg

(Amabelz) 2

FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR



161


fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg


2

jinteli oral tablet 1-5 mg-mcg (norethindrone ac-eth estradiol)

2

lyllana transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr


mimvey oral tablet 1-05 mg (estradiol-norethindrone acet)

2

norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg

(Fyavolv) 2

PREMARIN INJECTION RECON SOLN 25 MG

3

PREMARIN ORAL TABLET 03 MG 045 MG 09 MG

3

PREMARIN ORAL TABLET 0625 MG 125 MG

(conjugated estrogens) 3

PREMARIN VAGINAL CREAM 0625 MGGRAM

3

PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)

3

PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG

3

raloxifene oral tablet 60 mg (Evista) 2

yuvafem vaginal tablet 10 mcg (estradiol) 2 QL (18 per 28 days)GlucocorticoidsMineralocorticoidsa-hydrocort injection recon soln 100 mg

2

betamethasone acetsod phos injection suspension 6 mgml

(Celestone Soluspan) 2

dexamethasone 05 mg5 ml liq 05 mg5 ml

2

dexamethasone oral elixir 05 mg5 ml

2

dexamethasone oral tablet 05 mg 075 mg 4 mg 6 mg

(Decadron) 2

dexamethasone oral tablet 1 mg 15 mg 2 mg

2


162


dexamethasone sodium phos (pf) injection solution 10 mgml

1 GC

dexamethasone sodium phos (pf) injection syringe 10 mgml

1 GC

dexamethasone sodium phosphate injection solution 10 mgml 4 mgml

1 GC

dexamethasone sodium phosphate injection syringe 4 mgml

1 GC

EMFLAZA ORAL SUSPENSION 2275 MGML


EMFLAZA ORAL TABLET 18 MG


EMFLAZA ORAL TABLET 30 MG 36 MG 6 MG


fludrocortisone oral tablet 01 mg 2

HEMADY ORAL TABLET 20 MG

4

hydrocortisone oral tablet 10 mg 20 mg 5 mg

(Cortef) 2

methylprednisolone acetate injection suspension 40 mgml 80 mgml

(Depo-Medrol) 2

methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg

(Medrol) 2

methylprednisolone oral tabletsdose pack 4 mg

(Medrol (Pak)) 2

methylprednisolone sodium succ injection recon soln 125 mg 40 mg

2

methylprednisolone sodium succ intravenous recon soln 1000 mg 500 mg

(Solu-Medrol) 2

prednisolone 15 mg5 ml soln af df15 mg5 ml (3 mgml)

2 PA BvD

prednisolone oral solution 15 mg5 ml

2 PA BvD

prednisolone sodium phosphate oral solution 25 mg5 ml (5 mgml)

2 PA BvD

prednisolone sodium phosphate oral solution 5 mg base5 ml (67 mg5 ml)

(Pediapred) 2 PA BvD

prednisone oral solution 5 mg5 ml 2 PA BvD


163


prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg

1 PA BvD GC

prednisone oral tabletsdose pack 10 mg 10 mg (48 pack) 5 mg 5 mg (48 pack)

2

SOLU-CORTEF ACT-O-VIAL (PF) INJECTION RECON SOLN 1000 MG8 ML 100 MG2 ML 250 MG2 ML 500 MG4 ML

4

triamcinolone acetonide injection suspension 40 mgml

(Kenalog) 2

PituitaryACTHAR INJECTION GEL 80 UNITML


BYNFEZIA SUBCUTANEOUS PEN INJECTOR 2500 MCGML

5 NM NDS

desmopressin injection solution 4 mcgml

(DDAVP) 2

desmopressin nasal spray with pump10 mcgspray (01 ml)

2

desmopressin oral tablet 01 mg 02 mg

(DDAVP) 2

EGRIFTA SUBCUTANEOUS RECON SOLN 2 MG


EGRIFTA SV SUBCUTANEOUS RECON SOLN 2 MG


INCRELEX SUBCUTANEOUS SOLUTION 10 MGML

5 NM NDS


5 NM NDS

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG 75 MG

5 NM NDS

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

5 NM NDS

LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG

5 NM NDS


164


MYCAPSSA ORAL CAPSULEDELAYED RELEASE(DREC) 20 MG


NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG15 ML (67 MGML) 15 MG15 ML (10 MGML) 30 MG3 ML (10 MGML) 5 MG15 ML (33 MGML)

5 PA NM NDS

octreotide acetate injection solution1000 mcgml 200 mcgml

2

octreotide acetate injection solution100 mcgml 50 mcgml 500 mcgml

(Sandostatin) 2

octreotide acetate injection syringe100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)

2

ORGOVYX ORAL TABLET 120 MG

5 PA NSO NM NDS

ORILISSA ORAL TABLET 150 MG




SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 10 MG 20 MG 30 MG

5 NM NDS

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG

5 PA NM NDS

SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)


SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML





165




SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG

5 PA NM NDS

SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)


SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML

5 NM NDS

TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 225 MG


ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG

5 PA NM NDS

Progestinshydroxyprogesterone cap(ppres) intramuscular oil 250 mgml

(Makena) 5 NM NDS

medroxyprogesterone intramuscular suspension 150 mgml

(Depo-Provera) 2 QL (1 per 84 days)

medroxyprogesterone intramuscular syringe 150 mgml


medroxyprogesterone oral tablet 10 mg 25 mg 5 mg

(Provera) 1 GC

megestrol oral suspension 400 mg10 ml (40 mgml)

2

norethindrone acetate oral tablet 5 mg

(Aygestin) 2

progesterone intramuscular oil 50 mgml

2

progesterone micronized oral capsule 100 mg 200 mg

(Prometrium) 2

Thyroid And Antithyroid Agentslevothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg

(Euthyrox) 1 GC

levothyroxine oral tablet 300 mcg (Levo-T) 1 GC


166


liothyronine oral tablet 25 mcg 5 mcg 50 mcg

(Cytomel) 2

methimazole oral tablet 10 mg 5 mg 1 GC

propylthiouracil oral tablet 50 mg 2

Immunological AgentsImmunological AgentsACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML

5 PA NM NDS

ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)

5 PA NM NDS

ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML

5 PA NM NDS

ARCALYST SUBCUTANEOUS RECON SOLN 220 MG

5 NM NDS

AVSOLA INTRAVENOUS RECON SOLN 100 MG

5 PA NM NDS

azathioprine oral tablet 50 mg (Imuran) 2 PA BvD

azathioprine sodium injection recon soln 100 mg

2 PA BvD

BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG

5 PA NM NDS

BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML


BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML


CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)

5 PA NM NDS

CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)

5 PA NM NDS

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML

5 PA NM NDS


167


COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML

5 PA NM NDS

COSENTYX SUBCUTANEOUS SYRINGE 75 MG05 ML

5 PA NM NDS

cyclosporine intravenous solution250 mg5 ml

(Sandimmune) 2 PA BvD

cyclosporine modified oral capsule100 mg 25 mg

(Gengraf) 2 PA BvD

cyclosporine modified oral capsule50 mg

2 PA BvD

cyclosporine modified oral solution100 mgml

(Gengraf) 2 PA BvD

cyclosporine oral capsule 100 mg 25 mg


DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 100 MG067 ML

5 PA NM NDS

ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)

5 PA NM NDS

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)

5 PA NM NDS

ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML

5 PA NM NDS

ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)

5 PA NM NDS

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)

5 PA NM NDS

everolimus (immunosuppressive) oral tablet 025 mg

(Zortress) 2 PA BvD

everolimus (immunosuppressive) oral tablet 05 mg 075 mg

(Zortress) 5 PA BvD NM NDS

FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5

5 PA BvD NM NDS

GAMIFANT INTRAVENOUS SOLUTION 5 MGML

5 PA NM NDS


168


GAMMAGARD LIQUID INJECTION SOLUTION 10

5 PA BvD NM NDS

GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM

5 PA BvD NM NDS

GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5

5 PA BvD NM NDS

GAMMAPLEX INTRAVENOUS SOLUTION 10 10 (100 ML) 10 (200 ML)

5 PA BvD NM NDS

GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )

5 PA BvD NM NDS

gengraf oral capsule 100 mg 25 mg (cyclosporine modified) 2 PA BvD

gengraf oral solution 100 mgml (cyclosporine modified) 2 PA BvD

HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML

5 PA NM NDS

HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML

5 PA NM NDS

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML

5 PA NM NDS

HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML

5 PA NM NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML

5 PA NM NDS

HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML

5 PA NM NDS


169


HUMIRA(CF) PEN PEDIATRIC UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML

5 PA NM NDS

HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML

5 PA NM NDS

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML 80 MG08 ML

5 PA NM NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML

5 PA NM NDS

HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )

5 PA BvD NM NDS

ILARIS (PF) SUBCUTANEOUS RECON SOLN 150 MGML

5 PA NM NDS

ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML

5 PA NM NDS

ILUMYA SUBCUTANEOUS SYRINGE 100 MGML

5 PA NM NDS

INFLECTRA INTRAVENOUS RECON SOLN 100 MG

5 PA NM NDS

KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML

5 PA NM NDS

KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML

5 PA NM NDS

KINERET SUBCUTANEOUS SYRINGE 100 MG067 ML

5 PA NM NDS

leflunomide oral tablet 10 mg 20 mg (Arava) 2

mycophenolate mofetil (hcl) intravenous recon soln 500 mg

(CellCept Intravenous) 2 PA BvD

mycophenolate mofetil oral capsule250 mg

(CellCept) 2 PA BvD


170


mycophenolate mofetil oral suspension for reconstitution 200 mgml

(CellCept) 5 PA BvD NM NDS

mycophenolate mofetil oral tablet500 mg

(CellCept) 2 PA BvD

NULOJIX INTRAVENOUS RECON SOLN 250 MG

5 PA BvD NM NDS

OCTAGAM INTRAVENOUS SOLUTION 10 5

5 PA BvD NM NDS

OLUMIANT ORAL TABLET 1 MG 2 MG

5 PA NM NDS

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG

5 PA NM NDS

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML

5 PA NM NDS

ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML

5 PA NM NDS

OTEZLA ORAL TABLET 30 MG 5 PA NM NDS

OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47) 10 MG (4)-20 MG (4)-30 MG(19)

5 PA NM NDS

PRIVIGEN INTRAVENOUS SOLUTION 10

5 PA BvD NM NDS

PROGRAF INTRAVENOUS SOLUTION 5 MGML

4 PA BvD

PROGRAF ORAL GRANULES IN PACKET 02 MG 1 MG

4 PA BvD ST

RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG02 ML 125 MG025 ML 15 MG03 ML 175 MG035 ML 20 MG04 ML 225 MG045 ML 25 MG05 ML 30 MG06 ML 75 MG015 ML

3

REMICADE INTRAVENOUS RECON SOLN 100 MG

(infliximab) 5 PA NM NDS


171


RENFLEXIS INTRAVENOUS RECON SOLN 100 MG

5 PA NM NDS

REZUROCK ORAL TABLET 200 MG

5 PA NSO NM NDS

RIDAURA ORAL CAPSULE 3 MG

5 NM NDS

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG

5 PA NM NDS

sirolimus oral solution 1 mgml (Rapamune) 5 PA BvD NM NDS

sirolimus oral tablet 05 mg 1 mg (Rapamune) 2 PA BvD

sirolimus oral tablet 2 mg (Rapamune) 5 PA BvD NM NDS

SKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MGML

5 PA NM NDS

SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML 75 MG083 ML

5 PA NM NDS

SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)

5 PA NM NDS

STELARA INTRAVENOUS SOLUTION 130 MG26 ML

5 PA NM NDS

STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML

5 PA NM NDS

STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML

5 PA NM NDS

tacrolimus oral capsule 05 mg 1 mg 5 mg

(Prograf) 2 PA BvD

TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML

5 PA NM NDS

TALTZ SYRINGE (2 PACK) SUBCUTANEOUS SYRINGE 80 MGML

5 PA NM NDS


5 PA NM NDS


172


TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML

5 PA NM NDS

TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML

5 PA NM NDS

TREMFYA SUBCUTANEOUS SYRINGE 100 MGML

5 PA NM NDS

TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML

5 PA NM LA NDS

XELJANZ ORAL SOLUTION 1 MGML

5 PA NM NDS

XELJANZ ORAL TABLET 10 MG 5 MG

5 PA NM NDS

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG

5 PA NM NDS

ZORTRESS ORAL TABLET 1 MG

(everolimus (immunosuppressive))

5 PA BvD NM NDS

VaccinesACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML

3

ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML

3

ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML

3

BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG

3

BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML

3


173


BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML

3

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML

3

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML

3

DENGVAXIA (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP45-6 CCID5005 ML


ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML

3 PA BvD

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML

3 PA BvD

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML

3 PA BvD

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML


GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML


HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML

3

HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML

3

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT

3 PA BvD


174


INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF05ML

3

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML

3

IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML

3

IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML

3

KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF05 ML

3

KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML

3

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML

3

MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML

3

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML

3

M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML

3

PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML

3

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML

3

PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML

3


175


PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005

3

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML

3

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT

3 PA BvD

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML

3 PA BvD

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML

3 PA BvD

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50ML

3

ROTATEQ VACCINE ORAL SOLUTION 2 ML

3

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML


TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML

(tetanus-diphtheria toxoids-td)

3

TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML

3

TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML

3


176


TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML

3

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML

3

TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML

3

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML

3

TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML

(typhoid vi polysacch vaccine)

3

VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML

3

VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML

3

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML


YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML

3

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML


Inflammatory Bowel Disease AgentsInflammatory Bowel Disease Agentsalosetron oral tablet 05 mg (Lotronex) 2


177


alosetron oral tablet 1 mg (Lotronex) 5 NM NDS

balsalazide oral capsule 750 mg (Colazal) 2

budesonide oral capsuledelayedextendrelease 3 mg

(Entocort EC) 2

DIPENTUM ORAL CAPSULE 250 MG

5 ST NM NDS

hydrocortisone rectal enema 100 mg60 ml

(Cortenema) 4

mesalamine oral capsule (with del rel tablets) 400 mg

(Delzicol) 2

mesalamine oral capsuleextended release 24hr 0375 gram

(Apriso) 2

mesalamine oral tabletdelayed release (drec) 12 gram

(Lialda) 2

mesalamine oral tabletdelayed release (drec) 800 mg

(Asacol HD) 2

mesalamine rectal suppository 1000 mg

(Canasa) 2

sulfasalazine oral tablet 500 mg (Azulfidine) 2

sulfasalazine oral tabletdelayed release (drec) 500 mg

(Azulfidine EN-tabs) 4

UCERIS RECTAL FOAM 2 MGACTUATION

3

Metabolic Bone Disease AgentsMetabolic Bone Disease Agentsalendronate oral solution 70 mg75 ml


alendronate oral tablet 10 mg 5 mg 1 GC QL (30 per 30 days)

alendronate oral tablet 35 mg 1 GC QL (4 per 28 days)

alendronate oral tablet 70 mg (Fosamax) 1 GC QL (4 per 28 days)

calcitonin (salmon) injection solution 200 unitml

(Miacalcin) 5 NM NDS

calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation


calcitriol intravenous solution 1 mcgml

2

calcitriol oral capsule 025 mcg 05 mcg

(Rocaltrol) 2

calcitriol oral solution 1 mcgml (Rocaltrol) 2


178


cinacalcet oral tablet 30 mg (Sensipar) 2 QL (60 per 30 days)

cinacalcet oral tablet 60 mg (Sensipar) 5 NM NDS QL (60 per 30 days)


doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg

2

EVENITY SUBCUTANEOUS SYRINGE 105 MG117 ML 210MG234ML ( 105MG117MLX2)


ibandronate intravenous solution 3 mg3 ml


ibandronate intravenous syringe 3 mg3 ml


ibandronate oral tablet 150 mg (Boniva) 2 QL (1 per 28 days)

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE


pamidronate intravenous recon soln30 mg 90 mg

2

pamidronate intravenous solution 30 mg10 ml (3 mgml) 60 mg10 ml (6 mgml) 90 mg10 ml (9 mgml)

2

paricalcitol oral capsule 1 mcg 2 mcg

(Zemplar) 2

paricalcitol oral capsule 4 mcg 2

PROLIA SUBCUTANEOUS SYRINGE 60 MGML


RAYALDEE ORAL CAPSULEEXTENDED RELEASE 24 HR 30 MCG


risedronate oral tablet 150 mg (Actonel) 2 QL (1 per 28 days)

risedronate oral tablet 30 mg 5 mg 2 QL (30 per 30 days)


risedronate oral tablet 35 mg (12 pack) 35 mg (4 pack)


risedronate oral tabletdelayed release (drec) 35 mg

(Atelvia) 2 QL (4 per 28 days)


179


TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)


XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)

5 PA NM NDS

zoledronic acid intravenous recon soln 4 mg

2

zoledronic acid intravenous solution4 mg5 ml

2

zoledronic acid-mannitol-water intravenous piggyback 5 mg100 ml

(Reclast) 2 QL (100 per 300 days)

Miscellaneous Therapeutic AgentsMiscellaneous Therapeutic AgentsACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML

5 PA NM NDS

buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg

2

CYSTADANE ORAL POWDER 1 GRAM17 ML

5 NM NDS

dexrazoxane hcl intravenous recon soln 250 mg 500 mg

5 NM NDS

diazoxide oral suspension 50 mgml (Proglycem) 2

ELMIRON ORAL CAPSULE 100 MG


ENDARI ORAL POWDER IN PACKET 5 GRAM


EVRYSDI ORAL RECON SOLN 075 MGML

5 PA NM NDS

EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML

5 PA NM LA NDS

fomepizole intravenous solution 1 gramml

5 NM NDS

GVOKE HYPOPEN 2-PACK SUBCUTANEOUS AUTO-INJECTOR 05 MG01 ML 1 MG02 ML

3


180


GVOKE PFS 1-PACK SYRINGE SUBCUTANEOUS SYRINGE 05 MG01 ML 1 MG02 ML

3

hydroxyzine pamoate oral capsule100 mg

2

hydroxyzine pamoate oral capsule25 mg 50 mg

(Vistaril) 1 GC

KEVEYIS ORAL TABLET 50 MG


leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg

2

leucovorin calcium injection solution10 mgml

2

leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg

2

levocarnitine (with sugar) oral solution 100 mgml

(Carnitor) 2

levocarnitine oral tablet 330 mg (Carnitor) 4

levoleucovorin calcium intravenous recon soln 50 mg

(Fusilev) 5 NM NDS

mesna intravenous solution 100 mgml

(Mesnex) 2

MESNEX ORAL TABLET 400 MG

5 NM NDS

OXLUMO SUBCUTANEOUS SOLUTION 945 MG05 ML

5 PA NM NDS

pyridostigmine bromide oral syrup60 mg5 ml

(Mestinon) 2

pyridostigmine bromide oral tablet30 mg

2


(Mestinon) 2

pyridostigmine bromide oral tablet extended release 180 mg

(Mestinon Timespan) 2

RECTIV RECTAL OINTMENT 04 (WW)


TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)



181


THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG


TOTECT INTRAVENOUS RECON SOLN 500 MG

5 NM NDS

TYBOST ORAL TABLET 150 MG


VISTOGARD ORAL GRANULES IN PACKET 10 GRAM


XURIDEN ORAL GRANULES IN PACKET 2 GRAM


Ophthalmic AgentsAntiglaucoma Agentsacetazolamide oral capsule extended release 500 mg

2

acetazolamide oral tablet 125 mg 250 mg

2

acetazolamide sodium injection recon soln 500 mg

2

ALPHAGAN P OPHTHALMIC (EYE) DROPS 01

3

AZOPT OPHTHALMIC (EYE) DROPSSUSPENSION 1

(brinzolamide) 2

betaxolol ophthalmic (eye) drops05

2

bimatoprost ophthalmic (eye) drops003


brimonidine ophthalmic (eye) drops015

(Alphagan P) 4


1 GC

carteolol ophthalmic (eye) drops 1

2

COMBIGAN OPHTHALMIC (EYE) DROPS 02-05

3

dorzolamide ophthalmic (eye) drops2

(Trusopt) 2

dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml

(Cosopt) 2


182


latanoprost ophthalmic (eye) drops0005

(Xalatan) 1 GC QL (25 per 25 days)

levobunolol ophthalmic (eye) drops05

1 GC

LUMIGAN OPHTHALMIC (EYE) DROPS 001


methazolamide oral tablet 25 mg 50 mg

2

metipranolol ophthalmic (eye) drops 03

2

pilocarpine hcl ophthalmic (eye) drops 1 2

(Isopto Carpine) 2

pilocarpine hcl ophthalmic (eye) drops 4

2

RHOPRESSA OPHTHALMIC (EYE) DROPS 002


ROCKLATAN OPHTHALMIC (EYE) DROPS 002-0005


SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02

3

timolol maleate ophthalmic (eye) drops 025 05

(Timoptic) 1 GC

timolol maleate ophthalmic (eye) gel forming solution 025 05

(Timoptic-XE) 4

travoprost ophthalmic (eye) drops0004

(Travatan Z) 2 QL (25 per 25 days)

VYZULTA OPHTHALMIC (EYE) DROPS 0024


XELPROS OPHTHALMIC (EYE) DROPS EMULSION 0005


ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE 00015


Replacement PreparationsReplacement Preparationscalcium chloride intravenous syringe100 mgml (10 )

2

d5 and 09 sodium chloride intravenous parenteral solution

4


183


d5 -045 sodium chloride intravenous parenteral solution

4

ISOLYTE S IV SOLUTION-EXCEL SINGLE USE

4

ISOLYTE S PH 74 INTRAVENOUS PARENTERAL SOLUTION

4

ISOLYTE-P IN 5 DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5

4

klor-con m10 oral tableter particlescrystals 10 meq

(potassium chloride) 2





magnesium sulfate in d5w intravenous piggyback 1 gram100 ml

2

magnesium sulfate in water intravenous parenteral solution 20 gram500 ml (4 ) 40 gram1000 ml (4 )

2 PA BvD

magnesium sulfate in water intravenous piggyback 2 gram50 ml (4 ) 4 gram100 ml (4 ) 4 gram50 ml (8 )

2 PA BvD

magnesium sulfate injection syringe4 meqml

2 PA BvD

NORMOSOL-M IN 5 DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

4

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION

4

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION

4

potassium chloride intravenous solution 2 meqml

1 PA BvD GC


184


potassium chloride intravenous solution 2 meqml (20 ml)

2 PA BvD

potassium chloride oral capsule extended release 10 meq 8 meq

2

potassium chloride oral liquid 20 meq15 ml 40 meq15 ml

2

potassium chloride oral tablet extended release 10 meq 20 meq 8 meq

(K-Tab) 2

potassium chloride oral tableter particlescrystals 10 meq

(Klor-Con M10) 2


(Klor-Con M15) 2


(Klor-Con M20) 2

potassium chloride-045 nacl intravenous parenteral solution 20 meql

2

potassium citrate oral tablet extended release 10 meq (1080 mg)

(Urocit-K 10) 2

potassium citrate oral tablet extended release 15 meq

(Urocit-K 15) 2


(Urocit-K 5) 2

sodium chloride 045 intravenous parenteral solution 045

2

sodium chloride 09 intravenous parenteral solution

2

sodium chloride 09 intravenous piggyback

2

sodium chloride 09 solution viaflex single use

4

Respiratory Tract AgentsAnti-Inflammatories Inhaled CorticosteroidsADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCGDOSE 250-50 MCGDOSE 500-50 MCGDOSE

(fluticasone propion-salmeterol)



185


ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION


ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION 50 MCGACTUATION


BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE 200-25 MCGDOSE


budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml

(Pulmicort) 2 PA BvD QL (120 per 30 days)

budesonide inhalation suspension for nebulization 1 mg2 ml


FLOVENT 100 MCG DISKUS 100 MCGACTUATION




FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION


FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION


FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION







186


SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION

(budesonide-formoterol)


Antileukotrienesmontelukast oral tablet 10 mg (Singulair) 1 GC

montelukast oral tabletchewable 4 mg 5 mg

(Singulair) 1 GC

zafirlukast oral tablet 10 mg 20 mg (Accolate) 2Bronchodilatorsalbuterol 5 mgml solution 5 mgml 2 PA BvD QL (120 per

30 days)

albuterol sulfate inhalation hfa aerosol inhaler 90 mcgactuation

(ProAir HFA) 2 QL (17 per 30 days)

albuterol sulfate inhalation hfa aerosol inhaler 90 mcgactuation (nda020503)




albuterol sulfate inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 )


albuterol sulfate inhalation solution for nebulization 25 mg05 ml


albuterol sulfate oral syrup 2 mg5 ml

2

albuterol sulfate oral tablet 2 mg 4 mg

2

albuterol sulfate oral tablet extended release 12 hr 4 mg 8 mg

2

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION


ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION



187


BREZTRI AEROSPHERE INHALATION HFA AEROSOL INHALER 160-9-48 MCGACTUATION


COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION


elixophyllin oral elixir 80 mg15 ml (theophylline) 2

ipratropium bromide inhalation solution 002


ipratropium-albuterol inhalation solution for nebulization 05 mg-3 mg(25 mg base)3 ml


metaproterenol oral syrup 10 mg5 ml

1 GC

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCGACTUATION


SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE


SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION 25 MCGACTUATION


SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG


STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION


terbutaline oral tablet 25 mg 5 mg 2

terbutaline subcutaneous solution 1 mgml

5 NM NDS

theophylline oral solution 80 mg15 ml

2

theophylline oral tablet extended release 12 hr 300 mg 450 mg

2


188



2

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG


Respiratory Tract Agents Otheracetylcysteine intravenous solution200 mgml (20 )

(Acetadote) 2

acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )

2 PA BvD

BRONCHITOL INHALATION CAPSULE WINHALATION DEVICE 40 MG


CINQAIR INTRAVENOUS SOLUTION 10 MGML

5 PA NM NDS

cromolyn inhalation solution for nebulization 20 mg2 ml

2 PA BvD

DALIRESP ORAL TABLET 250 MCG




ESBRIET ORAL CAPSULE 267 MG


ESBRIET ORAL TABLET 267 MG




FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML


FASENRA SUBCUTANEOUS SYRINGE 30 MGML


KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG


KALYDECO ORAL TABLET 150 MG


NUCALA SUBCUTANEOUS AUTO-INJECTOR 100 MGML

5 PA NM LA NDS QL (3 per 28 days)


189


NUCALA SUBCUTANEOUS RECON SOLN 100 MG


NUCALA SUBCUTANEOUS SYRINGE 100 MGML


OFEV ORAL CAPSULE 100 MG 150 MG


ORKAMBI ORAL GRANULES IN PACKET 100-125 MG 150-188 MG


ORKAMBI ORAL TABLET 100-125 MG 200-125 MG


PROLASTIN C 1000 MG20 ML VL PRICEONE MGLFSUV 1000 MG (+-)20 ML

5 PA BvD NM NDS

PROLASTIN-C INTRAVENOUS RECON SOLN 1000 MG

5 PA BvD NM NDS

SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)


TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N) 50-25-375 MG (D)75 MG (N)


XOLAIR SUBCUTANEOUS RECON SOLN 150 MG

5 PA NM NDS

XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML

5 PA NM NDS

Skeletal Muscle RelaxantsSkeletal Muscle Relaxantsbaclofen oral tablet 10 mg 20 mg 5 mg

2

chlorzoxazone oral tablet 250 mg 5 NM NDS QL (120 per 30 days)

chlorzoxazone oral tablet 500 mg 2

cyclobenzaprine oral tablet 10 mg 5 mg

1 GC

dantrolene oral capsule 100 mg 2

dantrolene oral capsule 25 mg 50 mg

(Dantrium) 2


190


methocarbamol oral tablet 500 mg 750 mg

2

revonto intravenous recon soln 20 mg

(dantrolene) 2

tizanidine oral tablet 2 mg 2

tizanidine oral tablet 4 mg (Zanaflex) 2

Sleep Disorder AgentsSleep Disorder Agentsarmodafinil oral tablet 150 mg 200 mg 250 mg 50 mg

(Nuvigil) 2 PA QL (30 per 30 days)

BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG


eszopiclone oral tablet 1 mg 2 mg 3 mg

(Lunesta) 2 QL (30 per 30 days)

HETLIOZ LQ ORAL SUSPENSION 4 MGML


HETLIOZ ORAL CAPSULE 20 MG


SUNOSI ORAL TABLET 150 MG 75 MG


XYREM ORAL SOLUTION 500 MGML


zaleplon oral capsule 10 mg 5 mg 2 QL (30 per 30 days)

zolpidem oral tablet 10 mg 5 mg (Ambien) 1 GC QL (30 per 30 days)

zolpidem oral tabletext release multiphase 125 mg 625 mg

(Ambien CR) 2 QL (30 per 30 days)

Vasodilating AgentsVasodilating AgentsADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG


alyq oral tablet 20 mg (tadalafil (pulm hypertension))


ambrisentan oral tablet 10 mg 5 mg (Letairis) 5 PA NM NDS QL (30 per 30 days)

epoprostenol (glycine) intravenous recon soln 05 mg 15 mg

(Flolan) 5 PA NM NDS

OPSUMIT ORAL TABLET 10 MG



191


sildenafil (pulmhypertension) intravenous solution 10 mg125 ml

(Revatio) 5 PA NM NDS QL (375 per 1 day)

sildenafil (pulmhypertension) oral tablet 20 mg

(Revatio) 2 PA QL (90 per 30 days)

sildenafil oral tablet 100 mg 25 mg 50 mg

(Viagra) 2 EX CB (6 EA per 30 days)

tadalafil (pulm hypertension) oral tablet 20 mg

(Alyq) 2 PA QL (60 per 30 days)

tadalafil oral tablet 25 mg 5 mg (Cialis) 2 PA QL (30 per 30 days)

TRACLEER ORAL TABLET 125 MG 625 MG

(bosentan) 5 PA NM LA NDS QL (60 per 30 days)

TRACLEER ORAL TABLET FOR SUSPENSION 32 MG


treprostinil sodium injection solution1 mgml 10 mgml 25 mgml 5 mgml

(Remodulin) 5 PA NM NDS

TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)

5 PA NM NDS

UPTRAVI INTRAVENOUS RECON SOLN 1800 MCG


UPTRAVI ORAL TABLET 1000 MCG 1200 MCG 1400 MCG 1600 MCG 400 MCG 600 MCG 800 MCG


UPTRAVI ORAL TABLET 200 MCG


UPTRAVI ORAL TABLETSDOSE PACK 200 MCG (140)- 800 MCG (60)

5 PA NM NDS


192

INDEX

1ST TIER UNIFINE PENTIPS 1101ST TIER UNIFINE PENTIPS PLUS110abacavir 66abacavir-lamivudine 66abacavir-lamivudine-zidovudine 66ABELCET 51abiraterone 20ABOUTTIME PEN NEEDLE 110ABRAXANE21acamprosate 9acarbose 46accutane 104acebutolol 82acetaminophen-codeine 3acetazolamide 182acetazolamide sodium 182acetic acid 151acetylcysteine 189acitretin 104ACTEMRA 167ACTEMRA ACTPEN167ACTHAR 164ACTHIB (PF) 173ACTIMMUNE 180acyclovir 71 104acyclovir sodium 71ADACEL(TDAP ADOLESNADULT)(PF) 173ADAKVEO 75adapalene 109ADCETRIS 21adefovir 71ADEMPAS 191adriamycin 21

adrucil 21ADVAIR DISKUS 185ADVAIR HFA 186ADVOCATE PEN NEEDLE 111ADVOCATE SYRINGES 110 111AFINITOR21AFINITOR DISPERZ 21afirmelle 95a-hydrocort 162AIMOVIG AUTOINJECTOR 54AKYNZEO (FOSNETUPITANT)56AKYNZEO (NETUPITANT) 56ala-cort 106ala-scalp 107albendazole 57albuterol sulfate 187alcaine 150alclometasone 107ALCOHOL PADS 104ALCOHOL PREP PADS 105ALCOHOL PREP SWABS 104ALCOHOL SWABS 104ALCOHOL WIPES 105ALDURAZYME148ALECENSA 21alendronate 178alfuzosin 159ALIMTA 21ALIQOPA21aliskiren 90allopurinol 53alosetron 177 178ALPHAGAN P182

alprazolam 11ALREX153altavera (28) 95ALTRENO 109ALUNBRIG21alyacen 135 (28) 95alyacen 777 (28) 95alyq 191amabelz 161amantadine hcl 58AMBISOME51ambrisentan 191amethia 95amiloride 86amiloride-hydrochlorothiazide 86AMINOSYN II 15 76AMINOSYN-PF 7 (SULFITE-FREE)76amiodarone 81amitriptyline 43amitriptyline-chlordiazepoxide 43amlodipine 86amlodipine-atorvastatin 88amlodipine-benazepril 86amlodipine-olmesartan 86amlodipine-valsartan 86amlodipine-valsartan-hcthiazid 86ammonium lactate 104amoxapine 43amoxicil-clarithromy-lansopraz 154amoxicillin 17amoxicillin-pot clavulanate 17 18amphotericin b 51ampicillin 18ampicillin sodium 18ampicillin-sulbactam 18ANADROL-50 160

I-1

anagrelide 75anastrozole 21ANORO ELLIPTA 187APOKYN 58apraclonidine 150aprepitant 56apri 95APTIOM37APTIVUS 66APTIVUS (WITH VITAMIN E) 66aranelle (28) 95ARCALYST 167aripiprazole 60 61ARISTADA61ARISTADA INITIO 61armodafinil 191ARNUITY ELLIPTA 186arsenic trioxide 21ascomp with codeine 3asenapine maleate 61ashlyna 95ASPARLAS21aspirin-dipyridamole 75ASSURE ID DUO-SHIELD 111ASSURE ID INSULIN SAFETY111 112ASSURE ID PEN NEEDLE 111 112atazanavir 66atenolol 82atenolol-chlorthalidone 82atomoxetine 91atorvastatin 88atovaquone 57atovaquone-proguanil 58atropine 150ATROVENT HFA 187AUBAGIO91aubra eq 95

aurovela 1530 (21) 95aurovela 120 (21) 95aurovela 24 fe 95aurovela fe 1530 (28) 95aurovela fe 1-20 (28) 95AUSTEDO 91AVASTIN21aviane 95AVONEX 91AVSOLA 167ayuna 95AYVAKIT21azacitidine 22azathioprine 167azathioprine sodium 167azelastine 150azithromycin 16AZOPT 182aztreonam 17azurette (28) 95bacitracin 13 151bacitracin-polymyxin b 151baclofen 190balsalazide 178BALVERSA 22balziva (28) 96BAVENCIO22BAXDELA 19BCG VACCINE LIVE (PF) 173BD ALCOHOL SWABS104BD AUTOSHIELD DUO PEN NEEDLE112BD ECLIPSE LUER-LOK112BD INSULIN SYRINGE112BD INSULIN SYRINGE (HALF UNIT) 112BD INSULIN SYRINGE SLIP TIP 113BD INSULIN SYRINGE U-500112

BD INSULIN SYRINGE ULTRA-FINE112BD NANO 2ND GEN PEN NEEDLE 113BD SAFETYGLIDE INSULIN SYRINGE112 113BD SAFETYGLIDE SYRINGE 113BD ULTRA-FINE MICRO PEN NEEDLE113BD ULTRA-FINE MINI PEN NEEDLE113BD ULTRA-FINE NANO PEN NEEDLE113BD ULTRA-FINE ORIG PEN NEEDLE114BD ULTRA-FINE SHORT PEN NEEDLE114BD VEO INSULIN SYR (HALF UNIT) 114BD VEO INSULIN SYRINGE UF 114bekyree (28) 96BELEODAQ22BELSOMRA191benazepril 80benazepril-hydrochlorothiazide 80BENDEKA22BENLYSTA167benztropine 58 59bepotastine besilate 150BESPONSA 22betamethasone acetsod phos 162betamethasone dipropionate 107betamethasone valerate 107betamethasone augmented 107BETASERON91betaxolol 82 182bethanechol chloride 158bexarotene 22

I-2

BEXSERO 173bicalutamide 22BICILLIN L-A 18BIDIL 90BIKTARVY 66bimatoprost 182bisoprolol fumarate 82bisoprolol-hydrochlorothiazide 82BLENREP 22bleomycin 22bleph-10 151BLINCYTO22blisovi 24 fe 96blisovi fe 1530 (28) 96blisovi fe 120 (28) 96BOOSTRIX TDAP174BORDERED GAUZE 114BORTEZOMIB 22BOSULIF 22BRAFTOVI 22BREO ELLIPTA 186BREZTRI AEROSPHERE 188briellyn 96BRILINTA 75brimonidine 182BRIVIACT 37bromfenac 153bromocriptine 59BROMSITE 153BRONCHITOL 189BRUKINSA 22budesonide 178 186bumetanide 86buprenorphine 3buprenorphine hcl 3 9buprenorphine-naloxone 10bupropion hcl 43bupropion hcl (smoking deter) 10buspirone 180butalbital-acetaminop-caf-cod 3

butalbital-acetaminophen 3butalbital-acetaminophen-caff 3butalbital-aspirin-caffeine 3butorphanol 3BYNFEZIA 164BYSTOLIC82CABENUVA 66cabergoline 59CABLIVI 75CABOMETYX 22caffeine citrate 91calcipotriene 104calcitonin (salmon) 178calcitriol 178calcium acetate(phosphat bind) 158calcium chloride 183CALQUENCE22camila 96candesartan 79candesartan-hydrochlorothiazid 79CAPLYTA61CAPRELSA23captopril 80captopril-hydrochlorothiazide 80CARBAGLU 156carbamazepine 38carbidopa 59carbidopa-levodopa 59carbidopa-levodopa-entacapone 59carbinoxamine maleate 53carboplatin 23CAREFINE PEN NEEDLE 114CARETOUCH ALCOHOL PREP PAD 104CARETOUCH INSULIN SYRINGE 115

CARETOUCH PEN NEEDLE114 115CAROSPIR 90carteolol 182cartia xt 83carvedilol 82caspofungin 51CAYSTON 17caziant (28) 96cefaclor 14cefadroxil 14cefazolin 14cefdinir 14 15cefepime 15cefixime 15cefotaxime 15cefoxitin 15cefoxitin in dextrose iso-osm 15cefpodoxime 15cefprozil 15ceftazidime 15ceftriaxone 15cefuroxime axetil 15cefuroxime sodium 15celecoxib 6CELONTIN38cephalexin 15 16CERDELGA 148CEREZYME 148cevimeline 103CHANTIX10CHANTIX CONTINUING MONTH BOX10CHANTIX STARTING MONTH BOX10chateal eq (28) 96chloramphenicol sod succinate 13chlordiazepoxide hcl 11chlorhexidine gluconate 103chloroquine phosphate 58

I-3

chlorothiazide sodium 87chlorpromazine 61chlorthalidone 87chlorzoxazone 190cholestyramine (with sugar) 88cholestyramine light 88ciclopirox 51cidofovir 71cilostazol 76CIMDUO 66cimetidine 155cimetidine hcl 155CIMZIA167CIMZIA POWDER FOR RECONST167cinacalcet 179CINQAIR 189CINRYZE 73ciprofloxacin 19ciprofloxacin hcl 19 151ciprofloxacin in 5 dextrose 19ciprofloxacin-dexamethasone 151citalopram 43cladribine 23clarithromycin 16clemastine 53CLENPIQ 158CLICKFINE PEN NEEDLE 115clindamycin hcl 13clindamycin in 5 dextrose 13clindamycin pediatric 13clindamycin phosphate 13 54 106clindamycin-benzoyl peroxide 106CLINIMIX 5D15W SULFITE FREE76CLINIMIX 425D10W SULF FREE76CLINIMIX 425D5W SULFIT FREE 76

CLINIMIX 5-D20W(SULFITE-FREE) 76CLINIMIX 6-D5W (SULFITE-FREE)76CLINIMIX 8-D10W(SULFITE-FREE) 76CLINIMIX 8-D14W(SULFITE-FREE) 77CLINIMIX E 275D5W SULF FREE77CLINIMIX E 425D10W SUL FREE 77CLINIMIX E 425D5W SULF FREE77CLINIMIX E 5D15W SULFIT FREE 77CLINIMIX E 5D20W SULFIT FREE 77CLINIMIX E 8-D10W SULFITEFREE 77CLINIMIX E 8-D14W SULFITEFREE 77clobazam 38clobetasol 107clobetasol-emollient 107clofarabine 23clomipramine 43clonazepam 11clonidine 78clonidine hcl 78 91clopidogrel 76clorazepate dipotassium 11clotrimazole 51clotrimazole-betamethasone 51clovique 159clozapine 61COARTEM 58codeine sulfate 3codeine-butalbital-asa-caff 3colchicine 53

colesevelam 88colestipol 88colistin (colistimethate na) 13COMBIGAN 182COMBIVENT RESPIMAT188COMETRIQ23COMFORT EZ INSULIN SYRINGE115 116 117COMFORT EZ PEN NEEDLES 116COMFORT TOUCH PEN NEEDLE117 118COMPLERA 66compro 56constulose 156COPAXONE 91COPIKTRA23CORLANOR85COSENTYX 168COSENTYX (2 SYRINGES) 167COSENTYX PEN (2 PENS) 168COTELLIC23CREON 148CRIXIVAN 66cromolyn 150 156 189cryselle (28) 96CURAD GAUZE PAD 118CURITY ALCOHOL SWABS 104CURITY GAUZE 118cyclafem 135 (28) 96cyclafem 777 (28) 96cyclobenzaprine 190cyclopentolate 150cyclophosphamide 23CYCLOPHOSPHAMIDE23cyclosporine 168cyclosporine modified 168cyproheptadine 53

I-4

CYRAMZA23cyred eq 96CYSTADANE 180CYSTADROPS 150CYSTARAN150d5 and 09 sodium chloride 183d5 -045 sodium chloride 184dalfampridine 91DALIRESP189danazol 160dantrolene 190DANYELZA 23dapsone 55DAPTACEL (DTAP PEDIATRIC) (PF) 174daptomycin 13DARZALEX 23DARZALEX FASPRO 23dasetta 135 (28) 96dasetta 777 (28) 96DAURISMO 23daysee 96deblitane 96decitabine 24deferasirox 159 160deferiprone 160deferoxamine 160DELSTRIGO 66demeclocycline 19DENAVIR104DENGVAXIA (PF)174denta 5000 plus 103dentagel 103DERMACEA 118DERMACEA NON-WOVEN118DESCOVY 66desipramine 43desmopressin 164

desog-eestradioleestradiol 96desogestrel-ethinyl estradiol 96desonide 107desoximetasone 108desvenlafaxine succinate 44dexamethasone 162dexamethasone sodium phos (pf) 163dexamethasone sodium phosphate 153 163dexmethylphenidate 91dexrazoxane hcl 180dextroamphetamine 91dextroamphetamine-amphetamine 92dextrose 10 in water (d10w) 77dextrose 5 in water (d5w) 77DIACOMIT38diazepam 11 38diazoxide 180diclofenac epolamine 6diclofenac potassium 7diclofenac sodium 7 153diclofenac-misoprostol 7dicloxacillin 18dicyclomine 156didanosine 66DIFICID16diflorasone 108diflunisal 7difluprednate 153digitek 85digox 85digoxin 85dihydroergotamine 54DILANTIN 38diltiazem hcl 84dilt-xr 84dimenhydrinate 56dimethyl fumarate 92

DIPENTUM178diphenhydramine hcl 53diphenoxylate-atropine 156dipyridamole 76disopyramide phosphate 81disulfiram 10divalproex 38docetaxel 24dofetilide 81donepezil 42DOPTELET (10 TAB PACK) 73DOPTELET (15 TAB PACK) 73DOPTELET (30 TAB PACK) 73dorzolamide 182dorzolamide-timolol 182dotti 161DOVATO 66doxazosin 78doxepin 44doxercalciferol 179doxorubicin 24doxorubicin peg-liposomal 24doxy-100 19doxycycline hyclate 20doxycycline monohydrate 20DRIZALMA SPRINKLE 44dronabinol 56droperidol 56DROPLET INSULIN SYR(HALF UNIT)118 119DROPLET INSULIN SYRINGE 118 119DROPLET MICRON PEN NEEDLE 119DROPLET PEN NEEDLE 119 120DROPSAFE PEN NEEDLE 120drospirenone-ethinyl estradiol96 97DROXIA 75

I-5

droxidopa 78DUAVEE161duloxetine 44DUPIXENT SYRINGE 168DUREZOL 153dutasteride 159dutasteride-tamsulosin 159EASY COMFORT ALCOHOL PAD 104EASY COMFORT INSULIN SYRINGE120 121EASY COMFORT PEN NEEDLES 121EASY GLIDE INSULIN SYRINGE 121EASY GLIDE PEN NEEDLE 122EASY TOUCH 123EASY TOUCH ALCOHOL PREP PADS 104EASY TOUCH FLIPLOCK INSULIN123EASY TOUCH FLIPLOCK SYRINGE 122EASY TOUCH INSULIN SAFETY SYR 122EASY TOUCH INSULIN SYRINGE122 123 124EASY TOUCH LUER LOCK INSULIN123EASY TOUCH PEN NEEDLE 123EASY TOUCH SAFETY PEN NEEDLE 123 124EASY TOUCH SHEATHLOCK INSULIN 122 123EASY TOUCH UNI-SLIP 124econazole 51EDARBI 79

EDARBYCLOR79EDURANT 67efavirenz 67efavirenz-emtricitabin-tenofov 67efavirenz-lamivu-tenofov disop 67EGRIFTA164EGRIFTA SV 164ELAPRASE 148ELIGARD24ELIGARD (3 MONTH)24ELIGARD (4 MONTH)24ELIGARD (6 MONTH)24elinest 97ELIQUIS 72ELIQUIS DVT-PE TREAT 30D START72ELITEK148elixophyllin 188ELLA97ELMIRON 180eluryng 97EMCYT 24EMEND 56EMFLAZA 163EMGALITY PEN 54EMGALITY SYRINGE 54emoquette 97EMPLICITI24EMSAM 44emtricitabine 67emtricitabine-tenofovir (tdf) 67EMTRIVA67enalapril maleate 80enalaprilat 80enalapril-hydrochlorothiazide 80ENBREL 168ENBREL MINI 168ENBREL SURECLICK168ENDARI180endocet 3 4

ENGERIX-B (PF) 174ENGERIX-B PEDIATRIC (PF) 174ENHERTU24enoxaparin 72enpresse 97enskyce 97ENSPRYNG 92entacapone 59entecavir 71ENTRESTO 79enulose 156EPANED 80EPCLUSA 70EPIDIOLEX38epinastine 150epinephrine 85epitol 38EPIVIR HBV67eplerenone 90epoprostenol (glycine) 191eprosartan 79ERBITUX 24ergoloid 42ERIVEDGE24ERLEADA 24erlotinib 24errin 97ertapenem 17ery pads 106erythromycin 16 151erythromycin ethylsuccinate 16erythromycin with ethanol 106erythromycin-benzoyl peroxide 106ESBRIET 189escitalopram oxalate 44esomeprazole magnesium 155esomeprazole sodium 155estarylla 97

I-6

estazolam 11estradiol 161estradiol valerate 161estradiol-norethindrone acet 161eszopiclone 191ethambutol 55ethosuximide 38 39ethynodiol diac-eth estradiol 97etodolac 7etonogestrel-ethinyl estradiol 97ETOPOPHOS 25etoposide 25etravirine 67EUCRISA108EVENITY179everolimus (antineoplastic) 25everolimus (immunosuppressive) 168EVOTAZ 67EVRYSDI180EXEL INSULIN124exemestane 25EXKIVITY25EXONDYS-51 180EYSUVIS153EZALLOR SPRINKLE 88ezetimibe 88ezetimibe-simvastatin 88FABRAZYME 148falmina (28) 97famciclovir 71famotidine 155famotidine (pf) 155famotidine (pf)-nacl (iso-os) 155FANAPT 62FARXIGA46FARYDAK 25FASENRA189FASENRA PEN 189febuxostat 53

felbamate 39felodipine 86FEMRING 161femynor 97fenofibrate 88fenofibrate micronized 88fenofibrate nanocrystallized 88fenofibric acid (choline) 88fenoprofen 7fentanyl 4fentanyl citrate 4FERRIPROX 160FERRIPROX (2 TIMES A DAY) 160FETZIMA 44FIASP FLEXTOUCH U-100 INSULIN48FIASP PENFILL U-100 INSULIN48FIASP U-100 INSULIN48finasteride 159FINTEPLA39FIRVANQ13flavoxate 158FLEBOGAMMA DIF168flecainide 81FLOVENT DISKUS 186FLOVENT HFA186floxuridine 25fluconazole 51fluconazole in nacl (iso-osm) 51flucytosine 51fludrocortisone 163flumazenil 92flunisolide 153fluocinolone 108fluocinolone acetonide oil 153fluocinonide 108fluocinonide-e 108fluoride (sodium) 103

fluorometholone 153fluorouracil 25 104 105fluoxetine 44fluphenazine decanoate 62fluphenazine hcl 62flurazepam 11 12flurbiprofen 7flurbiprofen sodium 154flutamide 25fluticasone propionate 108 154fluvastatin 89fluvoxamine 44fomepizole 180fondaparinux 72 73fosamprenavir 67fosaprepitant 56foscarnet 70fosinopril 80fosinopril-hydrochlorothiazide 81fosphenytoin 39FOTIVDA 25FREESTYLE PRECISION125FULPHILA 73fulvestrant 25furosemide 87FUZEON67fyavolv 162FYCOMPA 39gabapentin 39GALAFOLD 148galantamine 42GAMIFANT 168GAMMAGARD LIQUID 169GAMMAGARD S-D (IGA lt 1 MCGML)169GAMMAPLEX 169GAMMAPLEX (WITH SORBITOL)169GAMUNEX-C 169ganciclovir sodium 72

I-7

GARDASIL 9 (PF)174gatifloxacin 151GATTEX 30-VIAL156GAUZE PAD 125gavilyte-c 158gavilyte-g 158gavilyte-n 158GAVRETO25GAZYVA 25gemcitabine 25gemfibrozil 89generlac 156gengraf 169gentak 151gentamicin 12 106 151gentamicin sulfate (ped) (pf) 12gentamicin sulfate (pf) 12GENVOYA 67GILENYA92GILOTRIF 25GIVLAARI 75glatiramer 92glatopa 92glimepiride 50glipizide 50glipizide-metformin 50glyburide 51glyburide micronized 50glyburide-metformin 51glycopyrrolate 156glydo 9granisetron (pf) 56granisetron hcl 56 57GRANIX 74griseofulvin microsize 52griseofulvin ultramicrosize 52guanfacine 78 92GVOKE HYPOPEN 2-PACK 180

GVOKE PFS 1-PACK SYRINGE 181HAEGARDA 74hailey 97hailey 24 fe 97hailey fe 1530 (28) 97hailey fe 120 (28) 97halobetasol propionate 108haloperidol 62haloperidol decanoate 62haloperidol lactate 62HARVONI70 71HAVRIX (PF) 174HEALTHWISE INSULIN SYRINGE 125 126HEALTHWISE PEN NEEDLE 126HEALTHY ACCENTS UNIFINE PENTIP126heather 97HEMADY 163heparin (porcine) 73heparin porcine (pf) 73HEPATAMINE 878HERCEPTIN 26HERCEPTIN HYLECTA26HERZUMA26HETLIOZ 191HETLIOZ LQ191HIBERIX (PF)174HUMIRA 169HUMIRA PEN169HUMIRA PEN CROHNS-UC-HS START169HUMIRA PEN PSOR-UVEITS-ADOL HS169HUMIRA(CF)170HUMIRA(CF) PEDI CROHNS STARTER169HUMIRA(CF) PEN 170

HUMIRA(CF) PEN CROHNS-UC-HS 169HUMIRA(CF) PEN PEDIATRIC UC 170HUMIRA(CF) PEN PSOR-UV-ADOL HS 170HUMULIN R U-500 (CONC) INSULIN 48HUMULIN R U-500 (CONC) KWIKPEN49hydralazine 85hydrochlorothiazide 87hydrocodone-acetaminophen 4hydrocodone-ibuprofen 4hydrocortisone 108 109 163 178hydrocortisone butyrate 108hydrocortisone valerate 109hydrocortisone-acetic acid 151hydromorphone 4hydromorphone (pf) 4hydroxychloroquine 58hydroxyprogesterone cap(ppres) 166hydroxyurea 26hydroxyzine hcl 53hydroxyzine pamoate 181HYQVIA170ibandronate 179IBRANCE 26ibu 7ibuprofen 7ibuprofen-famotidine 7icatibant 85iclevia 97ICLUSIG 26IDHIFA26ifosfamide 26ILARIS (PF) 170ILEVRO 154ILUMYA170

I-8

imatinib 26IMBRUVICA 26IMFINZI 26imipenem-cilastatin 17imipramine hcl 44imipramine pamoate 45imiquimod 105IMLYGIC26IMOVAX RABIES VACCINE (PF) 174IMPAVIDO58INBRIJA 59incassia 97INCONTROL ALCOHOL PADS 105INCONTROL PEN NEEDLE 126INCRELEX 164indapamide 87indomethacin 7 8INFANRIX (DTAP) (PF) 175INFLECTRA170INFUGEM27INLYTA 27INQOVI27INREBIC27INSULIN SYRNDL U100 HALF MARK 127INSULIN SYRINGE 113INSULIN SYRINGE MICROFINE 112INSULIN SYRINGE NEEDLELESS 113INSULIN SYRINGE-NEEDLE U-100113 114 124 125 126 127 128 134 138 142INSUPEN128INTELENCE67INTRALIPID78

INTRON A71introvale 98INVEGA HAFYERA 62INVEGA SUSTENNA 62 63INVEGA TRINZA63INVELTYS154INVIRASE 67IPOL 175ipratropium bromide 150 188ipratropium-albuterol 188irbesartan 79irbesartan-hydrochlorothiazide 79IRESSA 27irinotecan 27ISENTRESS 67ISENTRESS HD 67isibloom 98ISOLYTE S PH 74184ISOLYTE-P IN 5 DEXTROSE 184ISOLYTE-S 184isoniazid 55isosorbide dinitrate 90isosorbide mononitrate 90isradipine 86itraconazole 52IV PREP WIPES105ivermectin 58IXEMPRA27IXIARO (PF)175jaimiess 98JAKAFI27jantoven 73JARDIANCE 46jasmiel (28) 98JEMPERLI27jencycla 98JENTADUETO46JENTADUETO XR46 47jinteli 162

juleber 98JULUCA 68junel 1530 (21) 98junel 120 (21) 98junel fe 1530 (28) 98junel fe 120 (28) 98junel fe 24 98JUXTAPID89JYNARQUE 87kalliga 98KALYDECO 189KANJINTI 27KANUMA149kariva (28) 98KATERZIA86kelnor 135 (28) 98kelnor 1-50 (28) 98KESIMPTA PEN 92ketoconazole 52ketoprofen 8ketorolac 8 154KEVEYIS 181KEVZARA 170KEYTRUDA 27KINERET 170KINRIX (PF) 175kionex (with sorbitol) 156KISQALI 28KISQALI FEMARA CO-PACK27 28klor-con m10 184klor-con m15 184klor-con m20 184KLOXXADO 10KORLYM 47KOSELUGO 28KRINTAFEL 58KRYSTEXXA 149kurvelo (28) 98KYNMOBI59

I-9

KYPROLIS 28l norgesteestradiol-eestrad 98labetalol 82lactulose 156lamivudine 68lamivudine-zidovudine 68lamotrigine 39 40lansoprazole 155lanthanum 158LANTUS SOLOSTAR U-100 INSULIN49LANTUS U-100 INSULIN 49lapatinib 28larin 1530 (21) 98larin 120 (21) 99larin 24 fe 99larin fe 1530 (28) 99larin fe 120 (28) 99larissia 99latanoprost 183LATUDA 63LAZANDA 4leflunomide 170LENVIMA 28lessina 99letrozole 28leucovorin calcium 181LEUKERAN28LEUKINE 74leuprolide 28levetiracetam 40levobunolol 183levocarnitine 181levocarnitine (with sugar) 181levocetirizine 53 54levofloxacin 19 151levofloxacin in d5w 19levoleucovorin calcium 181levonest (28) 99levonorgestrel-ethinyl estrad 99

levonorg-eth estrad triphasic 99levora-28 99levothyroxine 166LEXIVA 68LIBTAYO28lidocaine 9lidocaine (pf) 9 81lidocaine hcl 9lidocaine viscous 9lidocaine-prilocaine 9lillow (28) 99linezolid 13linezolid in dextrose 5 13linezolid-09 sodium chloride 13LINZESS 156liothyronine 167LISCO128lisinopril 81lisinopril-hydrochlorothiazide 81LITE TOUCH INSULIN PEN NEEDLES 128 129LITE TOUCH INSULIN SYRINGE 128 129lithium carbonate 92 93LIVALO 89lojaimiess 99LOKELMA 156 157LONSURF 28loperamide 157lopinavir-ritonavir 68lorazepam 12lorazepam intensol 12LORBRENA 28loryna (28) 99losartan 79losartan-hydrochlorothiazide 79LOTEMAX154LOTEMAX SM 154loteprednol etabonate 154lovastatin 89

low-ogestrel (28) 99loxapine succinate 63lo-zumandimine (28) 99lubiprostone 157LUCEMYRA 10LUMAKRAS 29LUMIGAN183LUMOXITI29LUPRON DEPOT164LUPRON DEPOT (3 MONTH) 29 164LUPRON DEPOT (4 MONTH)29LUPRON DEPOT (6 MONTH)29LUPRON DEPOT-PED164LUPRON DEPOT-PED (3 MONTH)164lutera (28) 99LYBALVI63lyleq 99lyllana 162LYNPARZA 29LYSODREN 29lyza 100MAGELLAN INSULIN SAFETY SYRNG129 130MAGELLAN SYRINGE129magnesium sulfate 184magnesium sulfate in d5w 184magnesium sulfate in water 184malathion 110maprotiline 45marlissa (28) 100MARPLAN 45MARQIBO 29MATULANE 29matzim la 84MAVENCLAD (10 TABLET PACK) 93

I-10

MAVENCLAD (4 TABLET PACK) 93MAVENCLAD (5 TABLET PACK) 93MAVENCLAD (6 TABLET PACK) 93MAVENCLAD (7 TABLET PACK) 93MAVENCLAD (8 TABLET PACK) 93MAVENCLAD (9 TABLET PACK) 93MAVYRET 71MAXICOMFORT II PEN NEEDLE 130MAXICOMFORT INSULIN SYRINGE 130MAXI-COMFORT INSULIN SYRINGE 130MAXICOMFORT SAFETY PEN NEEDLE130MAYZENT 93MAYZENT STARTER PACK 93meclizine 57medroxyprogesterone 166mefenamic acid 8mefloquine 58megestrol 29 166MEKINIST 29MEKTOVI 29meloxicam 8melphalan hcl 29memantine 43MENACTRA (PF) 175MENQUADFI (PF) 175MENVEO A-C-Y-W-135-DIP (PF) 175MEPSEVII149mercaptopurine 29

meropenem 17meropenem-09 sodium chloride 17mesalamine 178mesna 181MESNEX181metadate er 93metaproterenol 188metformin 47methadone 4 5methadose 5methazolamide 183methenamine hippurate 13methimazole 167methocarbamol 191methotrexate sodium 29methotrexate sodium (pf) 29methoxsalen 105methscopolamine 157methyldopa 78methylphenidate hcl 93 94methylprednisolone 163methylprednisolone acetate 163methylprednisolone sodium succ 163metipranolol 183metoclopramide hcl 157metolazone 87metoprolol succinate 83metoprolol ta-hydrochlorothiaz 83metoprolol tartrate 83metronidazole 14 54 106metronidazole in nacl (iso-os) 14metyrosine 85mexiletine 81miconazole-3 52MICRODOT INSULIN PEN NEEDLE 130microgestin fe 120 (28) 100midazolam 12

midodrine 79miglitol 47miglustat 149mili 100mimvey 162MINI ULTRA-THIN II 130minitran 90minocycline 20minoxidil 90mirtazapine 45misoprostol 155MITIGARE53mitoxantrone 30M-M-R II (PF)175moexipril 81molindone 63mometasone 109 154mondoxyne nl 20MONJUVI30MONOJECT INSULIN SAFETY SYRING131MONOJECT INSULIN SYRINGE 130 131MONOJECT SYRINGE 130MONOJECT ULTRA COMFORT INSULIN 144mono-linyah 100montelukast 187morphine 5MORPHINE 5morphine concentrate 5MOVANTIK 157moxifloxacin 19 151MOZOBIL74MULPLETA 74MULTAQ81mupirocin 106MVASI 30MYCAPSSA 165mycophenolate mofetil 170 171

I-11

mycophenolate mofetil (hcl) 170MYLOTARG 30MYRBETRIQ 159nabumetone 8nadolol 83nafcillin 18nafcillin in dextrose iso-osm 18NAGLAZYME149naloxone 10naltrexone 10NAMZARIC 43naproxen 8naproxen-esomeprazole 8naratriptan 54NARCAN10NATACYN 151nateglinide 47NATPARA 179NAYZILAM 40nebivolol 83necon 0535 (28) 100nefazodone 45neomycin 12neomycin-bacitracin-poly-hc 152neomycin-bacitracin-polymyxin 152neomycin-polymyxin b gu 106neomycin-polymyxin b-dexameth 152neomycin-polymyxin-gramicidin 152neomycin-polymyxin-hc 152neo-polycin 152neo-polycin hc 152NEPHRAMINE 54 78NERLYNX 30NEULASTA74NEUPRO60nevirapine 68NEXAVAR 30

NEXLETOL 89NEXLIZET 89niacin 89niacor 89nicardipine 86NICOTROL 10nifedipine 86nikki (28) 100nilutamide 30NINLARO30nitazoxanide 58nitisinone 149nitrofurantoin macrocrystal 14nitrofurantoin monohydm-cryst 14nitroglycerin 90NITYR149NIVESTYM 74nizatidine 155NORDITROPIN FLEXPRO 165norethindrone (contraceptive) 100norethindrone acetate 166norethindrone ac-eth estradiol 100 162norethindrone-eestradiol-iron 100norgestimate-ethinyl estradiol 100norlyda 100NORMOSOL-M IN 5 DEXTROSE 184nortrel 0535 (28) 100nortrel 135 (21) 100nortrel 135 (28) 101nortrel 777 (28) 101nortriptyline 45NORVIR 68NOVOFINE 30131NOVOFINE 32131NOVOFINE PLUS132

NOVOLIN 7030 U-100 INSULIN49NOVOLIN 70-30 FLEXPEN U-100 49NOVOLIN N FLEXPEN49NOVOLIN N NPH U-100 INSULIN49NOVOLIN R FLEXPEN 49NOVOLIN R REGULAR U-100 INSULN49NOVOLOG FLEXPEN U-100 INSULIN 49NOVOLOG MIX 70-30 U-100 INSULN49NOVOLOG MIX 70-30FLEXPEN U-10049NOVOLOG PENFILL U-100 INSULIN50NOVOLOG U-100 INSULIN ASPART50NOVOTWIST132NOXAFIL 52NPLATE74NUBEQA 30NUCALA189 190NULOJIX171NUPLAZID 63NUTRILIPID78nyamyc 52nylia 777 (28) 101nymyo 101nystatin 52nystatin-triamcinolone 52nystop 52NYVEPRIA74OCALIVA 157OCTAGAM171octreotide acetate 165ODEFSEY68ODOMZO 30

I-12

OFEV190ofloxacin 152OGIVRI30olanzapine 64olmesartan 79olmesartan-amlodipin-hcthiazid 79olmesartan-hydrochlorothiazide 79olopatadine 151OLUMIANT 171omega-3 acid ethyl esters 89omeprazole 155omeprazole-sodium bicarbonate 156OMNIPOD VGO132OMNIPOD DASH PDM KIT 132OMNIPOD INSULIN MANAGEMENT132OMNIPOD INSULIN REFILL 132ONCASPAR30ondansetron 57ondansetron hcl 57ondansetron hcl (pf) 57ONGENTYS 60ONIVYDE30ONTRUZANT 30ONUREG30OPDIVO 30OPSUMIT 191oralone 103ORENCIA 171ORENCIA (WITH MALTOSE) 171ORENCIA CLICKJECT171ORFADIN149ORGOVYX 165ORILISSA 165

ORKAMBI 190ORLADEYO74orsythia 101oseltamivir 70OSMOLEX ER60OTEZLA171OTEZLA STARTER171oxaliplatin 30oxandrolone 160oxazepam 12oxcarbazepine 40OXLUMO 181OXTELLAR XR 40oxybutynin chloride 159oxycodone 5oxycodone-acetaminophen 5 6oxycodone-aspirin 6OXYCONTIN6oxymorphone 6OZEMPIC 47pacerone 81 82paclitaxel 30PADCEV 31paliperidone 64PALYNZIQ 149pamidronate 179PANRETIN105pantoprazole 156paricalcitol 179paroex oral rinse 103paromomycin 58paroxetine hcl 45PAXIL 45PEDIARIX (PF) 175PEDVAX HIB (PF) 175PEGASYS71PEGINTRON71PEMAZYRE 31PEN NEEDLE125 132 134

PEN NEEDLE DIABETIC117 125 128 132 134penicillamine 160penicillin g potassium 18penicillin g procaine 18penicillin v potassium 18PENNSAID8PENTACEL (PF) 175pentamidine 58PENTIPS132 133pentoxifylline 76PEPAXTO 31perindopril erbumine 81periogard 103PERJETA 31permethrin 110perphenazine 64perphenazine-amitriptyline 45PERSERIS64pfizerpen-g 18phenelzine 45phenobarbital 40phenylephrine hcl 79phenytoin 40phenytoin sodium 40 41phenytoin sodium extended 40PHESGO 31philith 101PHOSLYRA 158PIFELTRO68pilocarpine hcl 104 183pimecrolimus 109pimozide 64pimtrea (28) 101pindolol 83pioglitazone 47PIP PEN NEEDLE133piperacillin-tazobactam 18PIQRAY 31pirmella 101

I-13

piroxicam 8PLASMA-LYTE 148 184PLASMA-LYTE A184PLEGRIDY94podofilox 105POLIVY31polycin 152polymyxin b sulfate 14polymyxin b sulf-trimethoprim152POMALYST31portia 28 101PORTRAZZA 31posaconazole 52potassium chloride 184 185potassium chloride-045 nacl 185potassium citrate 185PRALUENT PEN 89pramipexole 60prasugrel 76pravastatin 89prazosin 79prednicarbate 109prednisolone 163prednisolone acetate 154prednisolone sodium phosphate 154 163prednisone 163 164pregabalin 41PREMARIN162PREMPHASE 162PREMPRO 162PRETOMANID 55prevalite 89PREVENT DROPSAFE PEN NEEDLE133previfem 101PREVYMIS70PREZCOBIX68PREZISTA 68

PRIFTIN 55PRIMAQUINE 58primidone 41PRIVIGEN 171PRO COMFORT ALCOHOL PADS 105PRO COMFORT INSULIN SYRINGE 133PRO COMFORT PEN NEEDLE133 134PROAIR RESPICLICK 188probenecid 53probenecid-colchicine 53procainamide 82PROCALAMINE 378prochlorperazine 57prochlorperazine edisylate 57prochlorperazine maleate 57procto-med hc 109procto-pak 109proctosol hc 109proctozone-hc 109PRODIGY INSULIN SYRINGE 134progesterone 166progesterone micronized 166PROGRAF 171PROLASTIN-C 190PROLENSA 154PROLEUKIN31PROLIA179PROMACTA 74 75promethazine 54 57promethegan 57propafenone 82propantheline 157proparacaine 151propranolol 83propranolol-hydrochlorothiazid 83propylthiouracil 167

PROQUAD (PF) 176PROSOL 20 78protamine 75protriptyline 45PULMOZYME149PURE COMFORT ALCOHOL PADS 105PURE COMFORT PEN NEEDLE 134PURIXAN31pyrazinamide 55pyridostigmine bromide 181pyrimethamine 58QBRELIS 81QINLOCK31QUADRACEL (PF) 176quetiapine 64quinapril 81quinapril-hydrochlorothiazide 81quinidine gluconate 82quinidine sulfate 82quinine sulfate 58RABAVERT (PF)176rabeprazole 156RADICAVA94raloxifene 162ramipril 81ranolazine 85rasagiline 60RASUVO (PF)171RAVICTI157RAYALDEE 179reclipsen (28) 101RECOMBIVAX HB (PF) 176RECTIV181REGRANEX105RELENZA DISKHALER 70RELION NEEDLES 134RELION PEN NEEDLES135RELISTOR157

I-14

REMICADE171RENFLEXIS 172repaglinide 47repaglinide-metformin 47REPATHA PUSHTRONEX89REPATHA SURECLICK89REPATHA SYRINGE89RESTASIS 154RESTASIS MULTIDOSE154RETACRIT 75RETEVMO31RETROVIR68REVCOVI149REVLIMID 31revonto 191REXULTI 64REYATAZ 69REZUROCK 172RHOPRESSA 183RIABNI 32ribavirin 72RIDAURA 172rifabutin 55rifampin 55 56riluzole 94rimantadine 70RINVOQ172risedronate 179RISPERDAL CONSTA 64risperidone 65ritonavir 69RITUXAN32RITUXAN HYCELA 32rivastigmine 43rivastigmine tartrate 43rizatriptan 54ROCKLATAN 183ropinirole 60rosadan 106rosuvastatin 90

ROTARIX 176ROTATEQ VACCINE176ROZLYTREK32RUBRACA 32rufinamide 41RUKOBIA69RUXIENCE 32RYBELSUS47RYBREVANT32RYDAPT32SAFESNAP INSULIN SYRINGE 135SAFETY PEN NEEDLE135sajazir 85SANDOSTATIN LAR DEPOT 165SANTYL 105sapropterin 149SARCLISA32SAVELLA 94SCEMBLIX 32scopolamine base 57SECUADO 65SECURESAFE PEN NEEDLE 135selegiline hcl 60selenium sulfide 106SELZENTRY 69SEREVENT DISKUS 188SEROSTIM 165sertraline 45setlakin 101sevelamer carbonate 158sevelamer hcl 158sf 5000 plus 104sharobel 101SHINGRIX (PF) 176SIGNIFOR 165SIKLOS 75sildenafil 192

sildenafil (pulmhypertension) 192silver sulfadiazine 106SIMBRINZA 183simliya (28) 101simpesse 101simvastatin 90sirolimus 172SIRTURO56SKYRIZI 172SLYND101sodium chloride 045 185sodium chloride 09 185sodium fluoride-pot nitrate 104sodium phenylbutyrate 157sodium polystyrene (sorb free) 157sodium polystyrene sulfonate 157SOLIQUA 10033 50SOLTAMOX 32SOLU-CORTEF ACT-O-VIAL (PF)164SOMATULINE DEPOT 165 166SOMAVERT 166sorine 83sotalol 83sotalol af 83SPIRIVA RESPIMAT188SPIRIVA WITH HANDIHALER 188spironolactone 87spironolacton-hydrochlorothiaz 87SPRAVATO 45sprintec (28) 101SPRITAM41SPRYCEL 32sps (with sorbitol) 157sronyx 101ssd 106stavudine 69

I-15

STELARA 172STERILE PADS 135STIOLTO RESPIMAT188STIVARGA32STRENSIQ 149streptomycin 12STRIBILD69SUBLOCADE 10subvenite 41sucralfate 156sulfacetamide sodium 152 153sulfacetamide sodium (acne) 106sulfacetamide-prednisolone 153sulfadiazine 19sulfamethoxazole-trimethoprim 19sulfasalazine 178sulindac 9sumatriptan 55sumatriptan succinate 55sunitinib 32SUNOSI191SUPPRELIN LA 166SUPREP BOWEL PREP KIT 158SURE COMFORT ALCOHOL PREP PADS 105SURE COMFORT INS SYR U-100135SURE COMFORT INSULIN SYRINGE135 136SURE COMFORT PEN NEEDLE 136SURE COMFORT SAFETY PEN NEEDLE135SURE-FINE PEN NEEDLES 136SURE-JECT INSULIN SYRINGE 137

SURE-PREP ALCOHOL PREP PADS 105syeda 101SYLVANT32SYMBICORT 187SYMDEKO 190SYMJEPI85SYMLINPEN 120 47SYMLINPEN 60 48SYMPAZAN 41SYMTUZA69SYNAGIS70SYNAREL166SYNDROS 57SYNERCID14SYNJARDY48SYNJARDY XR 48SYNRIBO32TABLOID 32TABRECTA 33tacrolimus 109 172tadalafil 192tadalafil (pulm hypertension) 192TAFINLAR33TAGRISSO 33TAKHZYRO181TALTZ AUTOINJECTOR 172TALTZ SYRINGE173TALTZ SYRINGE (2 PACK) 172TALTZ SYRINGE (3 PACK) 172TALZENNA 33tamoxifen 33tamsulosin 159TARGRETIN33tarina 24 fe 102tarina fe 1-20 eq (28) 102TASIGNA 33TAVALISSE75

tazarotene 109TAZORAC 110taztia xt 84TAZVERIK33TDVAX 176TECENTRIQ 33TECHLITE INSULIN SYRINGE 137 138TECHLITE INSULN SYR(HALF UNIT) 137TECHLITE PEN NEEDLE 138TEFLARO16telmisartan 79telmisartan-amlodipine 80telmisartan-hydrochlorothiazid 80temazepam 12TEMIXYS 69TEMODAR33temsirolimus 33tencon 6TENIVAC (PF)176tenofovir disoproxil fumarate 69TEPEZZA151TEPMETKO 33terazosin 159terbinafine hcl 52terbutaline 188terconazole 54TERUMO INSULIN SYRINGE 138 139testosterone 160 161testosterone cypionate 160testosterone enanthate 160TETANUSDIPHTHERIA TOX PED(PF) 177tetrabenazine 94tetracycline 20THALOMID 182theophylline 188 189

I-16

THINPRO INSULIN SYRINGE 139THIOLA EC 159thioridazine 65thiotepa 33thiothixene 65tiadylt er 84tiagabine 41TIBSOVO 33TICE BCG 33tigecycline 20timolol maleate 83 183tinidazole 58tiopronin 159TIVDAK33TIVICAY69TIVICAY PD69tizanidine 191TOBI PODHALER 12tobramycin 13 153tobramycin in 0225 nacl 13tobramycin sulfate 13tobramycin-dexamethasone 153tolmetin 9tolterodine 159TOPCARE CLICKFINE 139TOPCARE ULTRA COMFORT 139topiramate 41toposar 33topotecan 34toremifene 34torsemide 87TOTECT182TOUJEO MAX U-300 SOLOSTAR50TOUJEO SOLOSTAR U-300 INSULIN50TOVIAZ 159TRACLEER 192

TRADJENTA 48tramadol 6tramadol-acetaminophen 6trandolapril 81tranexamic acid 75tranylcypromine 46TRAVASOL 10 78travoprost 183TRAZIMERA 34trazodone 46TREANDA 34TRECATOR56TRELEGY ELLIPTA 189TRELSTAR34TREMFYA173treprostinil sodium 192tretinoin 110tretinoin (antineoplastic) 34tri femynor 102triamcinolone acetonide104 109 164triamterene-hydrochlorothiazid 87triazolam 12trientine 160tri-estarylla 102trifluoperazine 65trifluridine 153trihexyphenidyl 60TRIKAFTA190tri-legest fe 102tri-linyah 102tri-lo-estarylla 102tri-lo-marzia 102tri-lo-mili 102tri-lo-sprintec 102trilyte with flavor packets 158trimethoprim 14tri-mili 102trimipramine 46TRINTELLIX 46

tri-nymyo 102tri-previfem (28) 102TRIPTODUR 166tri-sprintec (28) 102TRIUMEQ 69trivora (28) 102tri-vylibra 102tri-vylibra lo 102TRODELVY 34TROGARZO69TROPHAMINE 10 78trospium 159TRUE COMFORT ALCOHOL PADS 105TRUE COMFORT INSULIN SYRINGE 140TRUE COMFORT PEN NEEDLE 140TRUE COMFORT PRO ALCOHOL PADS 105TRUE COMFORT PRO INS SYRINGE 139 140TRUEPLUS INSULIN 141TRUEPLUS PEN NEEDLE 140TRULICITY 48TRUMENBA 177TRUSELTIQ 34TRUXIMA34TUKYSA34tulana 102TURALIO 34TWINRIX (PF) 177tyblume 102TYBOST 182TYMLOS180TYPHIM VI177TYSABRI 173TYVASO 192UBRELVY 55UCERIS178

I-17

UDENYCA 75UKONIQ34ULTICARE142 143ULTICARE INSULIN SYRINGE 141 142ULTICARE INSULN SYR(HALF UNIT) 141ULTICARE PEN NEEDLE 142ULTICARE SAFETY PEN NEEDLE 142ULTIGUARD SAFEPACK-INSULIN SYR 143ULTIGUARD SAFEPACK-PEN NEEDLE143ULTILET ALCOHOL SWAB 105ULTILET INSULIN SYRINGE 127 143ULTILET PEN NEEDLE144ULTRA CMFT INS SYR (HALF UNIT) 125 135 141ULTRA COMFORT INSULIN SYRINGE120 125 144ULTRA FLO INSUL SYR(HALF UNIT) 144ULTRA FLO INSULIN SYRINGE 145ULTRA FLO PEN NEEDLE 144ULTRA THIN PEN NEEDLE 145ULTRACARE INSULIN SYRINGE 145ULTRACARE PEN NEEDLE145 146ULTRA-THIN II (SHORT) INS SYR 146ULTRA-THIN II (SHORT) PEN NDL 146

ULTRA-THIN II INS PEN NEEDLES 146ULTRA-THIN II INSULIN SYRINGE 146UNIFINE PEN NEEDLE146UNIFINE PENTIPS132 146 147UNIFINE PENTIPS MAXFLOW 147UNIFINE PENTIPS PLUS147UNIFINE PENTIPS PLUS MAXFLOW 147UNIFINE SAFECONTROL147UNITUXIN35UPTRAVI192ursodiol 157 158valacyclovir 72VALCHLOR 105valganciclovir 72valproate sodium 41valproic acid 41valproic acid (as sodium salt) 41valrubicin 35valsartan 80valsartan-hydrochlorothiazide 80VALTOCO 41vancomycin 14VANISHPOINT INSULIN SYRINGE 147VANISHPOINT SYRINGE 147 148VAQTA (PF) 177varenicline 11VARIVAX (PF) 177VASCEPA 90VECTIBIX35VEKLURY72VELCADE 35velivet triphasic regimen (28) 102VELPHORO158

VEMLIDY 69VENCLEXTA 35VENCLEXTA STARTING PACK 35venlafaxine 46verapamil 84VEREGEN 105VERIFINE PEN NEEDLE148VERSACLOZ65VERSALON 148VERZENIO35vestura (28) 103V-GO 20148V-GO 30148V-GO 40148vicodin hp 6VICTOZA48vienva 103vigabatrin 41 42vigadrone 42VIIBRYD 46VIMIZIM 149VIMPAT42vinblastine 35vincasar pfs 35vincristine 35vinorelbine 35viorele (28) 103VIRACEPT 69VIREAD69VISTOGARD 182VITRAKVI35VIZIMPRO 35VOCABRIA 70volnea (28) 103voriconazole 52 53VOSEVI 71VOTRIENT35VPRIV 149VRAYLAR65

I-18

VUMERITY95vyfemla (28) 103vylibra 103VYNDAMAX 85VYNDAQEL86VYXEOS 36VYZULTA 183warfarin 73WEBCOL105WELIREG36wera (28) 103XADAGO60XALKORI36XARELTO 73XARELTO DVT-PE TREAT 30D START73XATMEP36XCOPRI 42XCOPRI MAINTENANCE PACK 42XCOPRI TITRATION PACK 42XELJANZ 173XELJANZ XR173XELPROS 183XERMELO158XGEVA 180XHANCE 154XIFAXAN14XIGDUO XR 48XIIDRA154XOFLUZA 70XOLAIR190XOSPATA36XPOVIO 36XTAMPZA ER 6XTANDI 36xulane 103XULTOPHY 10036 50XURIDEN 182

XYOSTED161XYREM191YERVOY36YF-VAX (PF) 177YONDELIS36YONSA 37yuvafem 162zafemy 103zafirlukast 187zaleplon 191ZALTRAP37zarah 103ZARXIO75zebutal 6ZEJULA 37ZELBORAF 37zenatane 106ZENPEP 150ZEPZELCA 37zidovudine 70ZIEXTENZO75ZIOPTAN (PF)183ziprasidone hcl 65ziprasidone mesylate 65ZIRABEV37ZIRGAN153ZOLADEX 37zoledronic acid 180zoledronic acid-mannitol-water 180ZOLINZA 37zolmitriptan 55zolpidem 191zonisamide 42ZORBTIVE166ZORTRESS 173ZOSTAVAX (PF) 177zovia 135e (28) 103zovia 1-35 (28) 103ZTLIDO 9

ZULRESSO46zumandimine (28) 103ZYDELIG 37ZYKADIA37ZYLET 153ZYNLONTA 37ZYPREXA RELPREVV 65 66ZYTIGA 37

I-19


Toll-free 1-855-996-8422TTY users dial 7118 am to 8 pm seven days a week

PO Box 5904Troy MI 48007 wwwEssenceHealthcarecom

Y0027_22-219_C

Essence Advantage (HMO)

2022 Formulary

(List of Covered Drugs)

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

Note to existing members This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take When this drug list (formulary) refers to ldquowerdquo ldquousrdquo or ldquoourrdquo it means Essence Advantage (HMO) When it refers to ldquoplanrdquo or ldquoour planrdquo it means Essence Advantage Platinum (HMO) and Essence Advantage Gold (HMO) This document includes a list of the drugs (formulary) for our plan which is current as of October 2021 For an updated formulary please contact us Our contact information along with the date we last updated the formulary appears on the front and back cover pages You must generally use network pharmacies to use your prescription drug benefit Benefits formulary pharmacy network andor copaymentscoinsurance may change on January 1 2023 and from time to time during the year

HPMS Approved Formulary File Submission ID 22306 Version Number 7

Y0027_22-219_C i








ii







iii











iv








v










vii








viii

Table of Contents


1


2












(Buprenex) 2


2



























3
























2











4

































5
































6















2 QL (1000 per 30 days)



(Arthrotec 50) 2


(Arthrotec 75) 2



2






(ibuprofen) 1 GC


(Childrens Advil) 2


(IBU) 1 GC






7





2


2





















(Relafen) 2


1 GC



(EC-Naprosyn) 2






(Feldene) 2


8










1 GC




(Xylocaine) 1 GC




2 PA





(lidocaine hcl) 2






2




9









2






3


2






2


2





4 QL (1008 per 90 days)






10

































11





















2


2


2



5 NM NDS




12







2


2


2


(Cleocin HCl) 1 GC


2



2


2


(Cleocin) 2


2



5 PA BvD NM NDS


(Cubicin) 5 NM NDS


4


2


(Zyvox) 2


(Zyvox) 5 NM NDS



(Hiprex) 2


13



(Metro IV) 2


1 GC






2


5 NM NDS



2








2


2


2



2



2



14



2


2



(Suprax) 2


2


2


2


2


2


2


2



(Fortaz) 2


(Tazicef) 2


2


2


2


2


1 GC


15




2


2


5 NM NDS


(Zithromax) 2


(Zithromax) 2


1 GC


(Zithromax) 1 GC



2


2


2






(EES Granules) 2


(EryPed 400) 2


2


16



(Azactam) 2


5 PA NM LA NDS


(Invanz) 2


2


(Primaxin IV) 2


2


2


2


1 GC


1 GC


1 GC


2


2


(Augmentin) 2




2


(Augmentin) 1 GC


17



(Augmentin XR) 2


2


2


2


(Unasyn) 2


4


2


2


2


2


5 NM NDS


(Pfizerpen-G) 2


2


2


1 GC




2


18





1 GC



(Cipro) 1 GC



2


(Cipro) 2


2


2


2


1 GC



2


(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


2




19



(Doxy-100) 2


(Morgidox) 2


(LymePak) 2


2


2


(Doryx) 2






(Vibramycin) 2




2




2


2





2


(Tygacil) 5 NM NDS




20



5 PA BvD NM NDS


5 PA NSO NM NDS














5 NM NDS








5 PA NSO NM NDS



5 NM NDS


(Trisenox) 5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS




21



(Vidaza) 5 NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS




5 PA NSO NM NDS


2


5 PA NSO NM NDS


5 PA NSO NM NDS
















22







(Paraplatin) 2


2 PA BvD


(Clolar) 5 NM NDS








5 PA BvD NM NDS


5 PA BvD NM NDS


4 PA BvD ST


3 PA BvD ST


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM LA NDS






23



(Dacogen) 5 NM NDS


5 NM NDS


2






4


4


4


4


5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








24



4


(Toposar) 2











5 PA NSO NM NDS


2 PA BvD


2 PA BvD





(Faslodex) 5 NM NDS




5 PA NSO NM NDS


2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD




25





5 PA NSO NM NDS


5 PA NSO NM NDS











(Ifex) 2


2










5 PA NSO NM NDS






26



5 PA BvD NM NDS









(Camptosar) 2


2


5 NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS








27















5 PA NSO NM NDS



5 PA NSO NM NDS



5 NM NDS


5 NM NDS












28





5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS




5 NM NDS


5 PA NSO NM NDS


5 NM NDS












2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


29



2


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS











5 PA NSO NM LA NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


2


2


2 PA BvD


30



5 PA NSO NM NDS






5 PA NSO NM NDS










5 PA NSO NM NDS






5 NM NDS


5 NM NDS










31



5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS


(thioguanine) 4


32














5 PA NSO NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS






(Tepadina) 5 NM NDS




4




(etoposide) 2


33



(Hycamtin) 5 NM NDS


5 NM NDS



5 PA NSO NM NDS


5 PA NSO NM NDS








5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS










34



5 PA NSO NM NDS


(Valstar) 5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM LA NDS




2 PA BvD






(Navelbine) 2












35



5 PA BvD NM NDS






4 PA BvD ST






















5 PA NSO NM NDS


5 PA NSO NM NDS


36




5 PA NSO NM NDS






5 PA NSO NM NDS


5 PA NSO NM NDS






5 NM NDS






5 PA NSO NM NDS














37



(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4












(Diastat AcuDial) 4



4




(Depakote ER) 2


(Depakote) 2


5 PA NSO NM NDS




38



(Zarontin) 2


(Felbatol) 2


(Felbatol) 2


5 PA NSO NM NDS


(Cerebyx) 2

















(Subvenite) 1 GC



2



2



2


(Lamictal XR) 2


39



(Lamictal) 2


(Lamictal ODT) 2


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




(Trileptal) 2


(Trileptal) 2


4


5 NM NDS


2


2


(Dilantin-125) 2






(Phenytek) 2


2


40



2









(Banzel) 5 NM NDS






(lamotrigine) 1 GC





(Gabitril) 2


(Topamax) 2


(Topamax) 1 GC


2


2



4




41








3 QL (1200 per 30 days)










4


(Zonegran) 2



days)











42







3 ST








2


2


2


2


(Wellbutrin XL) 2


(Wellbutrin SR) 2





(Anafranil) 2


(Norpramin) 2


2


43





2













2


(Lexapro) 1 GC


4 ST




(Prozac) 1 GC


2


2


2


44



2


2


4


(Remeron) 2


2


(Remeron SolTab) 2


2


(Pamelor) 1 GC


2


(Paxil) 2


(Paxil) 1 GC


(Paxil CR) 2


(paroxetine hcl) 4


2





(Zoloft) 1 GC


4 PA NSO


5 PA NSO NM NDS


45




1 GC



2








2








3


5 NM NDS












46

































47





























48





























49















days)













(Glynase) 6 GC


50



6 GC


6 GC


4 PA BvD


5 PA BvD NM NDS


2 PA BvD


(Cancidas) 5 NM NDS


(Cancidas) 2







2


2








2 PA BvD


(Diflucan) 2


(Diflucan) 2


(Ancobon) 5 NM NDS


51



2


2


2







2


5 NM NDS















2


2









52



(Vfend) 5 PA NM NDS


(Vfend) 2









2


2


2





2


2


(Diphen) 2


2


2


1 GC


(Xyzal) 2


53




2


(Cleocin) 2



2


2





















54





































4




(Rifadin) 2


55



2


5 PA NM NDS


4


4


4


4 PA BvD








2




2







2


2


56





2


1 GC


1 GC


2


2 PA BvD


2 PA BvD



2 PA BvD


2


(Compazine) 2


(Compro) 2


(Phenergan) 2


1 GC


(Promethegan) 2


(promethazine) 2







(Mepron) 2


57



(Malarone) 2








4







4





(Nebupent) 2 PA BvD


(Pentam) 2


4




2



1 GC





(Cogentin) 2


58



2






(Sinemet) 2


(Dhivy) 2


2


2


2


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4







5 PA NM NDS


59











(Mirapex) 1 GC



2


2




2


1 GC












60



















2


2


2











61





4 ST


2


2


2


2


2




2




2


2


2


2


2








62























2











63













2























64














2


2


2






4 ST










65







(Epzicom) 2


(Trizivir) 5 NM NDS


5 NM NDS


5 NM NDS


(Reyataz) 2


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


2


5 NM NDS


66



5 NM NDS


(Sustiva) 2



(Atripla) 5 NM NDS


(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS



(Truvada) 5 NM NDS


4


4




5 NM NDS



5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


4


5 NM NDS


4


67



5 NM NDS




(Epivir) 2


(Combivir) 2


4








2



2


(Viramune XR) 2


4


4


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


4


68



5 NM NDS



5 NM NDS


4


5 NM NDS


3


2


5 NM NDS


5 NM NDS


5 NM NDS


(Viread) 2


4


5 NM NDS


4


5 NM NDS


5 NM NDS




5 NM NDS


5 NM NDS


5 NM NDS


69



4




(Foscavir) 2 PA BvD
















5 PA NM NDS

















70











5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS



(Zovirax) 2



2 PA BvD


2 PA BvD



5 NM NDS



2


71





5 PA BvD NM NDS






(Valtrex) 2


(Valcyte) 5 NM NDS





3



















72









2


2


2


2


2


(warfarin) 1 GC


(Jantoven) 1 GC


3














5 PA NM NDS


73



5 PA NM NDS


5 PA NM NDS






5 NM NDS


5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS












74









5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






4


5 PA NM NDS


2


4 PA




(Cyklokapron) 2




3


75





2


2



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


76



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


2 PA BvD


4


2




77



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


1 GC








(Cardura) 2





2


78



2


(Vazculep) 2


(Minipress) 2


(Atacand) 2


(Atacand HCT) 2


3


3







(Avapro) 6 GC


(Avalide) 6 GC


(Cozaar) 6 GC


(Hyzaar) 6 GC


(Benicar) 6 GC


(Tribenzor) 2


(Benicar HCT) 6 GC


(Micardis) 6 GC


79



(Twynsta) 2


(Micardis HCT) 2


(Diovan) 6 GC


(Diovan HCT) 6 GC


(Lotensin) 6 GC



(Lotensin HCT) 6 GC


6 GC


2


2




(Vasotec) 6 GC


2


(Vaseretic) 6 GC


6 GC




6 GC


80



2


(Zestril) 6 GC


(Zestoretic) 6 GC



6 GC




(Accupril) 6 GC


(Accuretic) 6 GC


(Altace) 6 GC


6 GC


(Pacerone) 2



(Norpace) 2


(Tikosyn) 2


2




1 GC


2


3



81




2


2


(Rythmol SR) 2


2


2



2


(Tenormin) 1 GC


(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 2


(nebivolol) 3


(Coreg) 1 GC


2


2


2


82



(Toprol XL) 1 GC


2


2


(Lopressor) 1 GC


1 GC


(Corgard) 2


(Bystolic) 2



2


(Inderal LA) 2


2


2


2


(sotalol) 2


(sotalol) 2


(Sorine) 2


2


(diltiazem hcl) 2


83



(Cartia XT) 2


2


2


(Taztia XT) 2


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



(diltiazem hcl) 2


(diltiazem hcl) 2


(diltiazem hcl) 2


(diltiazem hcl) 2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


(Calan SR) 2


84







(digoxin) 2


(digoxin) 2


2


(Digitek) 2








(Adrenalin) 1 GC


2


2

















85





(Norvasc) 1 GC


(Lotrel) 6 GC


6 GC


(Azor) 2


(Exforge) 6 GC


(Exforge HCT) 2


2





2



(Procardia XL) 2


(Adalat CC) 2



2


2


2


86



(Diuril IV) 2


2


2


1 GC


2


(Lasix) 1 GC


1 GC


1 GC


1 GC






2


(Aldactone) 1 GC


(Aldactazide) 2


2


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


87



(Caduet) 2




2




(Questran) 2



2


(WelChol) 2
















2


(Tricor) 2


2


(Trilipix) 2


88














6 GC








2










2








89















3


2



2


1 GC


(nitroglycerin) 2



2


(Nitrostat) 2


(Minitran) 2


90



















(Cafcit) 2 PA BvD


2




















91















5 PA NM NDS


2
















1 GC



92



(Lithobid) 2


2


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






5 PA NM NDS
















93



















5 PA NM NDS




5 PA NM NDS







3




94





estrad)2



2



2


2





2


2





2



2



2



2



2



1 GC


2


2



2


95



2



2



2



2



1 GC



1 GC


2



2



2



2


2


2



2


2





1 GC


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


96



(Syeda) 2


2






2



2


2


1 GC


2


(Kelnor 135 (28)) 2


(Kelnor 1-50 (28)) 2





2


1 GC



2



2



2


2


1 GC





1 GC


97






2





2


1 GC


2



2



2



2



1 GC



2


2



2



2



2



2







2


98




2



2



2



1 GC


2


2



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2


2


2





2



2



2



2


1 GC


99



1 GC



2



1 GC


1 GC



2


2


2


(Camila) 1 GC


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2


(Gemmily) 2





2




(Tri-Estarylla) 2


(Femynor) 2


1 GC


2


2


100




2


2


2


2


2




2


2


2


2


1 GC



2





1 GC



2





4



2


2


2


101




2



1 GC



2



1 GC


2



2



1 GC



1 GC



1 GC



2



2



2



1 GC



2



2



1 GC



2


1 GC


2


2


102



2


2



2



2


2


2


2






2



2



2



2







(PreviDent) 1 GC


2



1 GC



1 GC


103







1 GC


(Oralone) 2


(isotretinoin) 2


2









2


(Skin Treatment) 2











5 NM NDS







104




2









5 NM NDS

























5 NM NDS


5 NM NDS




105



(isotretinoin) 2






(Clindacin ETZ) 2


(Neuac) 2


(Benzaclin) 2


2






(Benzamycin) 2









2






(Klaron) 2



106





2


2


2


2


2


(Luxiq) 2


2


2


2


2


2



2









2


(Olux-E) 2





107









3




(Synalar) 2






2


2


2


2


2
















108



1 GC


2


2






2


(hydrocortisone) 2


(hydrocortisone) 2


(hydrocortisone) 2


(hydrocortisone) 2




1 GC


(Triderm) 1 GC


2


1 GC


(Trianex) 2


2




4 PA



109



4



(Retin-A) 2 PA





























2


110




2



2



2



2



2



2



2



2










2


2


2


2


111



2


2


2


2


2


2



2


2


2



2



2


2



2


2


2


112




2



2



2





2



2



2



2



2


2


2


2


2








113







2



2



2



2


























114










2



2



2


2


2



2



2









2



2


115




2



2



2












2






2




2


2


116




2



2



2



2



2



2



2



2


2


2


2












117





2


2




2




1 GC






1 GC


1 GC


2


2



2



2


2


2


118



2


2


2



2



2



2



2



2


2



2



2



2


2




2


119















2




2


2



2



2



2



2



2



2


120



2



2



2


2



2












2


2



2



2



2



2


121






2



2


2



2


2



2


2


2


2


2


2



2



2



2


122




2


2


2


2


2


2


2



2


















2


123



2


2


2



2



2


2



2



2



2


2



2



2



2



2






124






2



2



2



2



2



2




2



2



2


2



2



2



2


125




2



2



2



2
















2














126




2



2



2



2





2



2



2



2



2


2







2




127






2








2












1 GC





2



2


2



2




128






2



2



2



2



2



2



2



2



2



2


2


2


2


2


129



2





2



2



2



2


2


2











2



2



2



2


130




2



2



2



2



2



2



2



2



2



2



2


2



2



2



2


2




131



2


2


3





3







2





2



2







2






132















2


2



2



2



2



2



2



2






133








2



2



2








2





2



2



2



2


2




2


134





2


2


2


2


2


2


2




2


2


2



2



2


135




2



2



2







2



2



2
















136




2



2



2



2



2


2


2


2


2


2


2


2


2


2


2



2



2


137




2



2



2




2










2







2



2



2



2


138




2



2


2



2


2



2


2







2



2



2


2


139




2



2













2



2



2


2



2












140




2



2



2



2



2



2



2



2



2



2



2


2



2



2



2


141




2



2














2


2





2



2



2



2


142




2


2


2


2


2


2


2


2


2


2


2


2


2



2



2



2


143



2





2



2



2



2



2



2


2


2


2












144




2



2



2



2





2



2



2



2



2



2



2



2










145










2



2



2



2



2



2



2



2



2














146









2


2




2












2


2



2


2


147




2










1 GC

V-GO 20 DEVICE 3

V-GO 30 DEVICE 3

V-GO 40 DEVICE 3


5 NM NDS


5 PA NM NDS


5 NM NDS


3


5 NM NDS


5 NM NDS


5 PA NM NDS




148



5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS



5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


(Kuvan) 5 NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 NM NDS


149



3


(proparacaine) 2


2


(Isopto Atropine) 4






2


(Bepreve) 2 ST


2


(Cyclogyl) 2






2






150






2



2


(Alcaine) 2


5 PA NM NDS



2


(Polycin) 2




(Ciloxan) 2






(Zymaxid) 2


(gentamicin) 2


1 GC


2


2


(Vigamox) 2


4


151



(Neo-Polycin HC) 2


(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2



2



2


(Ocuflox) 2




2


(Polytrim) 1 GC


(Bleph-10) 2


152



2


2


(Tobrex) 2


(TobraDex) 2


2


4


3


3 ST


2


3


2


2


(Durezol) 2


(difluprednate) 3






(DermOtic Oil) 2


(FML Liquifilm) 4


153



2





3


3




3


3


(Lotemax) 2


(Lotemax) 2




(Pred Forte) 4


2


3










2


154



2


2


2






2


(Nexium IV) 2


1 GC


2


2


2








(Cytotec) 2


2


2


1 GC


1 GC


155





(Protonix) 2








5 NM NDS


(lactulose) 2


(Gastrocrom) 2





2


(Lomotil) 2



5 PA NM NDS



2


2


(Constulose) 2






156





2




2


2


2


2


(Reglan) 1 GC







5 PA NM NDS










(Buphenyl) 5 NM NDS


2


2


2




157






3







3




2


2


(Fosrenol) 5 NM NDS


4


(Renvela) 5 NM NDS


(Renvela) 2




3


2



158



3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


2





(Jalyn) 2




1 GC


5 PA NM NDS



(240 per 30 days)






159




(Exjade) 2 PA





2 PA


(Desferal) 2 PA


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


2


(Oxandrin) 2




2 PA






160












2




3


(Estrace) 1 GC






(Estrace) 2



(Delestrogen) 2


(Amabelz) 2




161




2


2




2


(Fyavolv) 2


3


3




3


3


3



2




2


2


(Decadron) 2


2


162



1 GC


1 GC


1 GC


1 GC









4


(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





163



1 PA BvD GC


2


4


(Kenalog) 2




5 NM NDS


(DDAVP) 2


2


(DDAVP) 2






5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


164





5 PA NM NDS


2


(Sandostatin) 2


2


5 PA NSO NM NDS






5 NM NDS


5 PA NM NDS








165





5 PA NM NDS




5 NM NDS




5 PA NM NDS


(Makena) 5 NM NDS






(Provera) 1 GC


2


(Aygestin) 2


2


(Prometrium) 2


(Euthyrox) 1 GC



166



(Cytomel) 2




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS



2 PA BvD


5 PA NM NDS






5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


167



5 PA NM NDS


5 PA NM NDS




(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Zortress) 2 PA BvD




5 PA BvD NM NDS


5 PA NM NDS


168



5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


169



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





(CellCept) 2 PA BvD


170





(CellCept) 2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA NM NDS


5 PA BvD NM NDS


4 PA BvD


4 PA BvD ST


3




171



5 PA NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NM NDS





5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Prograf) 2 PA BvD


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


172



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA BvD NM NDS


3


3


3


3


3


173



3


3


3




3 PA BvD


3 PA BvD


3 PA BvD






3


3


3 PA BvD


174



3


3


3


3


3


3


3


3


3


3


3


3


3


175



3


3


3 PA BvD


3 PA BvD


3 PA BvD


3


3





3


3


3


176



3


3


3


3



3


3


3




3





177





(Entocort EC) 2


5 ST NM NDS


(Cortenema) 4


(Delzicol) 2


(Apriso) 2


(Lialda) 2


(Asacol HD) 2


(Canasa) 2





3











2


(Rocaltrol) 2



178






2











2


2


(Zemplar) 2














179





5 PA NM NDS


2


2




5 PA NM NDS


2


5 NM NDS


5 NM NDS







5 PA NM NDS


5 PA NM LA NDS


5 NM NDS


3


180



3


2


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



(Fusilev) 5 NM NDS


(Mesnex) 2


5 NM NDS


5 PA NM NDS


(Mestinon) 2


2


(Mestinon) 2








181





5 NM NDS








2


2


2


3


(brinzolamide) 2


2




(Alphagan P) 4


1 GC


2


3


(Trusopt) 2


(Cosopt) 2


182





1 GC




2


2


(Isopto Carpine) 2


2






3


(Timoptic) 1 GC


(Timoptic-XE) 4










2


4


183



4


4


4


4








2


2 PA BvD


2 PA BvD


2 PA BvD


4


4


4


1 PA BvD GC


184



2 PA BvD


2


2


(K-Tab) 2


(Klor-Con M10) 2


(Klor-Con M15) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


2


2


2


4





185



























186







(Singulair) 1 GC


30 days)












2


2


2






187












1 GC













5 NM NDS


2


2


188



2




(Acetadote) 2


2 PA BvD




5 PA NM NDS


2 PA BvD






















189













5 PA BvD NM NDS


5 PA BvD NM NDS






5 PA NM NDS


5 PA NM NDS


2




1 GC



(Dantrium) 2


190



2


(dantrolene) 2































191


















5 PA NM NDS








5 PA NM NDS


192

INDEX




I-1




I-2




I-3




I-4




I-5




I-6




I-7




I-8




I-9




I-10




I-11




I-12




I-13




I-14




I-15




I-16




I-17




I-18




I-19




Y0027_22-219_C








ii







iii











iv








v










vii








viii

Table of Contents


1


2












(Buprenex) 2


2



























3
























2











4

































5
































6















2 QL (1000 per 30 days)



(Arthrotec 50) 2


(Arthrotec 75) 2



2






(ibuprofen) 1 GC


(Childrens Advil) 2


(IBU) 1 GC






7





2


2





















(Relafen) 2


1 GC



(EC-Naprosyn) 2






(Feldene) 2


8










1 GC




(Xylocaine) 1 GC




2 PA





(lidocaine hcl) 2






2




9









2






3


2






2


2





4 QL (1008 per 90 days)






10

































11





















2


2


2



5 NM NDS




12







2


2


2


(Cleocin HCl) 1 GC


2



2


2


(Cleocin) 2


2



5 PA BvD NM NDS


(Cubicin) 5 NM NDS


4


2


(Zyvox) 2


(Zyvox) 5 NM NDS



(Hiprex) 2


13



(Metro IV) 2


1 GC






2


5 NM NDS



2








2


2


2



2



2



14



2


2



(Suprax) 2


2


2


2


2


2


2


2



(Fortaz) 2


(Tazicef) 2


2


2


2


2


1 GC


15




2


2


5 NM NDS


(Zithromax) 2


(Zithromax) 2


1 GC


(Zithromax) 1 GC



2


2


2






(EES Granules) 2


(EryPed 400) 2


2


16



(Azactam) 2


5 PA NM LA NDS


(Invanz) 2


2


(Primaxin IV) 2


2


2


2


1 GC


1 GC


1 GC


2


2


(Augmentin) 2




2


(Augmentin) 1 GC


17



(Augmentin XR) 2


2


2


2


(Unasyn) 2


4


2


2


2


2


5 NM NDS


(Pfizerpen-G) 2


2


2


1 GC




2


18





1 GC



(Cipro) 1 GC



2


(Cipro) 2


2


2


2


1 GC



2


(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


2




19



(Doxy-100) 2


(Morgidox) 2


(LymePak) 2


2


2


(Doryx) 2






(Vibramycin) 2




2




2


2





2


(Tygacil) 5 NM NDS




20



5 PA BvD NM NDS


5 PA NSO NM NDS














5 NM NDS








5 PA NSO NM NDS



5 NM NDS


(Trisenox) 5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS




21



(Vidaza) 5 NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS




5 PA NSO NM NDS


2


5 PA NSO NM NDS


5 PA NSO NM NDS
















22







(Paraplatin) 2


2 PA BvD


(Clolar) 5 NM NDS








5 PA BvD NM NDS


5 PA BvD NM NDS


4 PA BvD ST


3 PA BvD ST


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM LA NDS






23



(Dacogen) 5 NM NDS


5 NM NDS


2






4


4


4


4


5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








24



4


(Toposar) 2











5 PA NSO NM NDS


2 PA BvD


2 PA BvD





(Faslodex) 5 NM NDS




5 PA NSO NM NDS


2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD




25





5 PA NSO NM NDS


5 PA NSO NM NDS











(Ifex) 2


2










5 PA NSO NM NDS






26



5 PA BvD NM NDS









(Camptosar) 2


2


5 NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS








27















5 PA NSO NM NDS



5 PA NSO NM NDS



5 NM NDS


5 NM NDS












28





5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS




5 NM NDS


5 PA NSO NM NDS


5 NM NDS












2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


29



2


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS











5 PA NSO NM LA NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


2


2


2 PA BvD


30



5 PA NSO NM NDS






5 PA NSO NM NDS










5 PA NSO NM NDS






5 NM NDS


5 NM NDS










31



5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS


(thioguanine) 4


32














5 PA NSO NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS






(Tepadina) 5 NM NDS




4




(etoposide) 2


33



(Hycamtin) 5 NM NDS


5 NM NDS



5 PA NSO NM NDS


5 PA NSO NM NDS








5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS










34



5 PA NSO NM NDS


(Valstar) 5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM LA NDS




2 PA BvD






(Navelbine) 2












35



5 PA BvD NM NDS






4 PA BvD ST






















5 PA NSO NM NDS


5 PA NSO NM NDS


36




5 PA NSO NM NDS






5 PA NSO NM NDS


5 PA NSO NM NDS






5 NM NDS






5 PA NSO NM NDS














37



(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4












(Diastat AcuDial) 4



4




(Depakote ER) 2


(Depakote) 2


5 PA NSO NM NDS




38



(Zarontin) 2


(Felbatol) 2


(Felbatol) 2


5 PA NSO NM NDS


(Cerebyx) 2

















(Subvenite) 1 GC



2



2



2


(Lamictal XR) 2


39



(Lamictal) 2


(Lamictal ODT) 2


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




(Trileptal) 2


(Trileptal) 2


4


5 NM NDS


2


2


(Dilantin-125) 2






(Phenytek) 2


2


40



2









(Banzel) 5 NM NDS






(lamotrigine) 1 GC





(Gabitril) 2


(Topamax) 2


(Topamax) 1 GC


2


2



4




41








3 QL (1200 per 30 days)










4


(Zonegran) 2



days)











42







3 ST








2


2


2


2


(Wellbutrin XL) 2


(Wellbutrin SR) 2





(Anafranil) 2


(Norpramin) 2


2


43





2













2


(Lexapro) 1 GC


4 ST




(Prozac) 1 GC


2


2


2


44



2


2


4


(Remeron) 2


2


(Remeron SolTab) 2


2


(Pamelor) 1 GC


2


(Paxil) 2


(Paxil) 1 GC


(Paxil CR) 2


(paroxetine hcl) 4


2





(Zoloft) 1 GC


4 PA NSO


5 PA NSO NM NDS


45




1 GC



2








2








3


5 NM NDS












46

































47





























48





























49















days)













(Glynase) 6 GC


50



6 GC


6 GC


4 PA BvD


5 PA BvD NM NDS


2 PA BvD


(Cancidas) 5 NM NDS


(Cancidas) 2







2


2








2 PA BvD


(Diflucan) 2


(Diflucan) 2


(Ancobon) 5 NM NDS


51



2


2


2







2


5 NM NDS















2


2









52



(Vfend) 5 PA NM NDS


(Vfend) 2









2


2


2





2


2


(Diphen) 2


2


2


1 GC


(Xyzal) 2


53




2


(Cleocin) 2



2


2





















54





































4




(Rifadin) 2


55



2


5 PA NM NDS


4


4


4


4 PA BvD








2




2







2


2


56





2


1 GC


1 GC


2


2 PA BvD


2 PA BvD



2 PA BvD


2


(Compazine) 2


(Compro) 2


(Phenergan) 2


1 GC


(Promethegan) 2


(promethazine) 2







(Mepron) 2


57



(Malarone) 2








4







4





(Nebupent) 2 PA BvD


(Pentam) 2


4




2



1 GC





(Cogentin) 2


58



2






(Sinemet) 2


(Dhivy) 2


2


2


2


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4







5 PA NM NDS


59











(Mirapex) 1 GC



2


2




2


1 GC












60



















2


2


2











61





4 ST


2


2


2


2


2




2




2


2


2


2


2








62























2











63













2























64














2


2


2






4 ST










65







(Epzicom) 2


(Trizivir) 5 NM NDS


5 NM NDS


5 NM NDS


(Reyataz) 2


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


2


5 NM NDS


66



5 NM NDS


(Sustiva) 2



(Atripla) 5 NM NDS


(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS



(Truvada) 5 NM NDS


4


4




5 NM NDS



5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


4


5 NM NDS


4


67



5 NM NDS




(Epivir) 2


(Combivir) 2


4








2



2


(Viramune XR) 2


4


4


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


4


68



5 NM NDS



5 NM NDS


4


5 NM NDS


3


2


5 NM NDS


5 NM NDS


5 NM NDS


(Viread) 2


4


5 NM NDS


4


5 NM NDS


5 NM NDS




5 NM NDS


5 NM NDS


5 NM NDS


69



4




(Foscavir) 2 PA BvD
















5 PA NM NDS

















70











5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS



(Zovirax) 2



2 PA BvD


2 PA BvD



5 NM NDS



2


71





5 PA BvD NM NDS






(Valtrex) 2


(Valcyte) 5 NM NDS





3



















72









2


2


2


2


2


(warfarin) 1 GC


(Jantoven) 1 GC


3














5 PA NM NDS


73



5 PA NM NDS


5 PA NM NDS






5 NM NDS


5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS












74









5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






4


5 PA NM NDS


2


4 PA




(Cyklokapron) 2




3


75





2


2



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


76



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


2 PA BvD


4


2




77



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


1 GC








(Cardura) 2





2


78



2


(Vazculep) 2


(Minipress) 2


(Atacand) 2


(Atacand HCT) 2


3


3







(Avapro) 6 GC


(Avalide) 6 GC


(Cozaar) 6 GC


(Hyzaar) 6 GC


(Benicar) 6 GC


(Tribenzor) 2


(Benicar HCT) 6 GC


(Micardis) 6 GC


79



(Twynsta) 2


(Micardis HCT) 2


(Diovan) 6 GC


(Diovan HCT) 6 GC


(Lotensin) 6 GC



(Lotensin HCT) 6 GC


6 GC


2


2




(Vasotec) 6 GC


2


(Vaseretic) 6 GC


6 GC




6 GC


80



2


(Zestril) 6 GC


(Zestoretic) 6 GC



6 GC




(Accupril) 6 GC


(Accuretic) 6 GC


(Altace) 6 GC


6 GC


(Pacerone) 2



(Norpace) 2


(Tikosyn) 2


2




1 GC


2


3



81




2


2


(Rythmol SR) 2


2


2



2


(Tenormin) 1 GC


(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 2


(nebivolol) 3


(Coreg) 1 GC


2


2


2


82



(Toprol XL) 1 GC


2


2


(Lopressor) 1 GC


1 GC


(Corgard) 2


(Bystolic) 2



2


(Inderal LA) 2


2


2


2


(sotalol) 2


(sotalol) 2


(Sorine) 2


2


(diltiazem hcl) 2


83



(Cartia XT) 2


2


2


(Taztia XT) 2


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



(diltiazem hcl) 2


(diltiazem hcl) 2


(diltiazem hcl) 2


(diltiazem hcl) 2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


(Calan SR) 2


84







(digoxin) 2


(digoxin) 2


2


(Digitek) 2








(Adrenalin) 1 GC


2


2

















85





(Norvasc) 1 GC


(Lotrel) 6 GC


6 GC


(Azor) 2


(Exforge) 6 GC


(Exforge HCT) 2


2





2



(Procardia XL) 2


(Adalat CC) 2



2


2


2


86



(Diuril IV) 2


2


2


1 GC


2


(Lasix) 1 GC


1 GC


1 GC


1 GC






2


(Aldactone) 1 GC


(Aldactazide) 2


2


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


87



(Caduet) 2




2




(Questran) 2



2


(WelChol) 2
















2


(Tricor) 2


2


(Trilipix) 2


88














6 GC








2










2








89















3


2



2


1 GC


(nitroglycerin) 2



2


(Nitrostat) 2


(Minitran) 2


90



















(Cafcit) 2 PA BvD


2




















91















5 PA NM NDS


2
















1 GC



92



(Lithobid) 2


2


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






5 PA NM NDS
















93



















5 PA NM NDS




5 PA NM NDS







3




94





estrad)2



2



2


2





2


2





2



2



2



2



2



1 GC


2


2



2


95



2



2



2



2



1 GC



1 GC


2



2



2



2


2


2



2


2





1 GC


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


96



(Syeda) 2


2






2



2


2


1 GC


2


(Kelnor 135 (28)) 2


(Kelnor 1-50 (28)) 2





2


1 GC



2



2



2


2


1 GC





1 GC


97






2





2


1 GC


2



2



2



2



1 GC



2


2



2



2



2



2







2


98




2



2



2



1 GC


2


2



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2


2


2





2



2



2



2


1 GC


99



1 GC



2



1 GC


1 GC



2


2


2


(Camila) 1 GC


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2


(Gemmily) 2





2




(Tri-Estarylla) 2


(Femynor) 2


1 GC


2


2


100




2


2


2


2


2




2


2


2


2


1 GC



2





1 GC



2





4



2


2


2


101




2



1 GC



2



1 GC


2



2



1 GC



1 GC



1 GC



2



2



2



1 GC



2



2



1 GC



2


1 GC


2


2


102



2


2



2



2


2


2


2






2



2



2



2







(PreviDent) 1 GC


2



1 GC



1 GC


103







1 GC


(Oralone) 2


(isotretinoin) 2


2









2


(Skin Treatment) 2











5 NM NDS







104




2









5 NM NDS

























5 NM NDS


5 NM NDS




105



(isotretinoin) 2






(Clindacin ETZ) 2


(Neuac) 2


(Benzaclin) 2


2






(Benzamycin) 2









2






(Klaron) 2



106





2


2


2


2


2


(Luxiq) 2


2


2


2


2


2



2









2


(Olux-E) 2





107









3




(Synalar) 2






2


2


2


2


2
















108



1 GC


2


2






2


(hydrocortisone) 2


(hydrocortisone) 2


(hydrocortisone) 2


(hydrocortisone) 2




1 GC


(Triderm) 1 GC


2


1 GC


(Trianex) 2


2




4 PA



109



4



(Retin-A) 2 PA





























2


110




2



2



2



2



2



2



2



2










2


2


2


2


111



2


2


2


2


2


2



2


2


2



2



2


2



2


2


2


112




2



2



2





2



2



2



2



2


2


2


2


2








113







2



2



2



2


























114










2



2



2


2


2



2



2









2



2


115




2



2



2












2






2




2


2


116




2



2



2



2



2



2



2



2


2


2


2












117





2


2




2




1 GC






1 GC


1 GC


2


2



2



2


2


2


118



2


2


2



2



2



2



2



2


2



2



2



2


2




2


119















2




2


2



2



2



2



2



2



2


120



2



2



2


2



2












2


2



2



2



2



2


121






2



2


2



2


2



2


2


2


2


2


2



2



2



2


122




2


2


2


2


2


2


2



2


















2


123



2


2


2



2



2


2



2



2



2


2



2



2



2



2






124






2



2



2



2



2



2




2



2



2


2



2



2



2


125




2



2



2



2
















2














126




2



2



2



2





2



2



2



2



2


2







2




127






2








2












1 GC





2



2


2



2




128






2



2



2



2



2



2



2



2



2



2


2


2


2


2


129



2





2



2



2



2


2


2











2



2



2



2


130




2



2



2



2



2



2



2



2



2



2



2


2



2



2



2


2




131



2


2


3





3







2





2



2







2






132















2


2



2



2



2



2



2



2






133








2



2



2








2





2



2



2



2


2




2


134





2


2


2


2


2


2


2




2


2


2



2



2


135




2



2



2







2



2



2
















136




2



2



2



2



2


2


2


2


2


2


2


2


2


2


2



2



2


137




2



2



2




2










2







2



2



2



2


138




2



2


2



2


2



2


2







2



2



2


2


139




2



2













2



2



2


2



2












140




2



2



2



2



2



2



2



2



2



2



2


2



2



2



2


141




2



2














2


2





2



2



2



2


142




2


2


2


2


2


2


2


2


2


2


2


2


2



2



2



2


143



2





2



2



2



2



2



2


2


2


2












144




2



2



2



2





2



2



2



2



2



2



2



2










145










2



2



2



2



2



2



2



2



2














146









2


2




2












2


2



2


2


147




2










1 GC

V-GO 20 DEVICE 3

V-GO 30 DEVICE 3

V-GO 40 DEVICE 3


5 NM NDS


5 PA NM NDS


5 NM NDS


3


5 NM NDS


5 NM NDS


5 PA NM NDS




148



5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS



5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


(Kuvan) 5 NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 NM NDS


149



3


(proparacaine) 2


2


(Isopto Atropine) 4






2


(Bepreve) 2 ST


2


(Cyclogyl) 2






2






150






2



2


(Alcaine) 2


5 PA NM NDS



2


(Polycin) 2




(Ciloxan) 2






(Zymaxid) 2


(gentamicin) 2


1 GC


2


2


(Vigamox) 2


4


151



(Neo-Polycin HC) 2


(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2



2



2


(Ocuflox) 2




2


(Polytrim) 1 GC


(Bleph-10) 2


152



2


2


(Tobrex) 2


(TobraDex) 2


2


4


3


3 ST


2


3


2


2


(Durezol) 2


(difluprednate) 3






(DermOtic Oil) 2


(FML Liquifilm) 4


153



2





3


3




3


3


(Lotemax) 2


(Lotemax) 2




(Pred Forte) 4


2


3










2


154



2


2


2






2


(Nexium IV) 2


1 GC


2


2


2








(Cytotec) 2


2


2


1 GC


1 GC


155





(Protonix) 2








5 NM NDS


(lactulose) 2


(Gastrocrom) 2





2


(Lomotil) 2



5 PA NM NDS



2


2


(Constulose) 2






156





2




2


2


2


2


(Reglan) 1 GC







5 PA NM NDS










(Buphenyl) 5 NM NDS


2


2


2




157






3







3




2


2


(Fosrenol) 5 NM NDS


4


(Renvela) 5 NM NDS


(Renvela) 2




3


2



158



3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


2





(Jalyn) 2




1 GC


5 PA NM NDS



(240 per 30 days)






159




(Exjade) 2 PA





2 PA


(Desferal) 2 PA


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


2


(Oxandrin) 2




2 PA






160












2




3


(Estrace) 1 GC






(Estrace) 2



(Delestrogen) 2


(Amabelz) 2




161




2


2




2


(Fyavolv) 2


3


3




3


3


3



2




2


2


(Decadron) 2


2


162



1 GC


1 GC


1 GC


1 GC









4


(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





163



1 PA BvD GC


2


4


(Kenalog) 2




5 NM NDS


(DDAVP) 2


2


(DDAVP) 2






5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


164





5 PA NM NDS


2


(Sandostatin) 2


2


5 PA NSO NM NDS






5 NM NDS


5 PA NM NDS








165





5 PA NM NDS




5 NM NDS




5 PA NM NDS


(Makena) 5 NM NDS






(Provera) 1 GC


2


(Aygestin) 2


2


(Prometrium) 2


(Euthyrox) 1 GC



166



(Cytomel) 2




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS



2 PA BvD


5 PA NM NDS






5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


167



5 PA NM NDS


5 PA NM NDS




(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Zortress) 2 PA BvD




5 PA BvD NM NDS


5 PA NM NDS


168



5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


169



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





(CellCept) 2 PA BvD


170





(CellCept) 2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA NM NDS


5 PA BvD NM NDS


4 PA BvD


4 PA BvD ST


3




171



5 PA NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NM NDS





5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Prograf) 2 PA BvD


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


172



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA BvD NM NDS


3


3


3


3


3


173



3


3


3




3 PA BvD


3 PA BvD


3 PA BvD






3


3


3 PA BvD


174



3


3


3


3


3


3


3


3


3


3


3


3


3


175



3


3


3 PA BvD


3 PA BvD


3 PA BvD


3


3





3


3


3


176



3


3


3


3



3


3


3




3





177





(Entocort EC) 2


5 ST NM NDS


(Cortenema) 4


(Delzicol) 2


(Apriso) 2


(Lialda) 2


(Asacol HD) 2


(Canasa) 2





3











2


(Rocaltrol) 2



178






2











2


2


(Zemplar) 2














179





5 PA NM NDS


2


2




5 PA NM NDS


2


5 NM NDS


5 NM NDS







5 PA NM NDS


5 PA NM LA NDS


5 NM NDS


3


180



3


2


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



(Fusilev) 5 NM NDS


(Mesnex) 2


5 NM NDS


5 PA NM NDS


(Mestinon) 2


2


(Mestinon) 2








181





5 NM NDS








2


2


2


3


(brinzolamide) 2


2




(Alphagan P) 4


1 GC


2


3


(Trusopt) 2


(Cosopt) 2


182





1 GC




2


2


(Isopto Carpine) 2


2






3


(Timoptic) 1 GC


(Timoptic-XE) 4










2


4


183



4


4


4


4








2


2 PA BvD


2 PA BvD


2 PA BvD


4


4


4


1 PA BvD GC


184



2 PA BvD


2


2


(K-Tab) 2


(Klor-Con M10) 2


(Klor-Con M15) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


2


2


2


4





185



























186







(Singulair) 1 GC


30 days)












2


2


2






187












1 GC













5 NM NDS


2


2


188



2




(Acetadote) 2


2 PA BvD




5 PA NM NDS


2 PA BvD






















189













5 PA BvD NM NDS


5 PA BvD NM NDS






5 PA NM NDS


5 PA NM NDS


2




1 GC



(Dantrium) 2


190



2


(dantrolene) 2































191


















5 PA NM NDS








5 PA NM NDS


192

INDEX




I-1




I-2




I-3




I-4




I-5




I-6




I-7




I-8




I-9




I-10




I-11




I-12




I-13




I-14




I-15




I-16




I-17




I-18




I-19




Y0027_22-219_C







iii











iv








v










vii








viii

Table of Contents


1


2












(Buprenex) 2


2



























3
























2











4

































5
































6















2 QL (1000 per 30 days)



(Arthrotec 50) 2


(Arthrotec 75) 2



2






(ibuprofen) 1 GC


(Childrens Advil) 2


(IBU) 1 GC






7





2


2





















(Relafen) 2


1 GC



(EC-Naprosyn) 2






(Feldene) 2


8










1 GC




(Xylocaine) 1 GC




2 PA





(lidocaine hcl) 2






2




9









2






3


2






2


2





4 QL (1008 per 90 days)






10

































11





















2


2


2



5 NM NDS




12







2


2


2


(Cleocin HCl) 1 GC


2



2


2


(Cleocin) 2


2



5 PA BvD NM NDS


(Cubicin) 5 NM NDS


4


2


(Zyvox) 2


(Zyvox) 5 NM NDS



(Hiprex) 2


13



(Metro IV) 2


1 GC






2


5 NM NDS



2








2


2


2



2



2



14



2


2



(Suprax) 2


2


2


2


2


2


2


2



(Fortaz) 2


(Tazicef) 2


2


2


2


2


1 GC


15




2


2


5 NM NDS


(Zithromax) 2


(Zithromax) 2


1 GC


(Zithromax) 1 GC



2


2


2






(EES Granules) 2


(EryPed 400) 2


2


16



(Azactam) 2


5 PA NM LA NDS


(Invanz) 2


2


(Primaxin IV) 2


2


2


2


1 GC


1 GC


1 GC


2


2


(Augmentin) 2




2


(Augmentin) 1 GC


17



(Augmentin XR) 2


2


2


2


(Unasyn) 2


4


2


2


2


2


5 NM NDS


(Pfizerpen-G) 2


2


2


1 GC




2


18





1 GC



(Cipro) 1 GC



2


(Cipro) 2


2


2


2


1 GC



2


(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


2




19



(Doxy-100) 2


(Morgidox) 2


(LymePak) 2


2


2


(Doryx) 2






(Vibramycin) 2




2




2


2





2


(Tygacil) 5 NM NDS




20



5 PA BvD NM NDS


5 PA NSO NM NDS














5 NM NDS








5 PA NSO NM NDS



5 NM NDS


(Trisenox) 5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS




21



(Vidaza) 5 NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS




5 PA NSO NM NDS


2


5 PA NSO NM NDS


5 PA NSO NM NDS
















22







(Paraplatin) 2


2 PA BvD


(Clolar) 5 NM NDS








5 PA BvD NM NDS


5 PA BvD NM NDS


4 PA BvD ST


3 PA BvD ST


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM LA NDS






23



(Dacogen) 5 NM NDS


5 NM NDS


2






4


4


4


4


5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








24



4


(Toposar) 2











5 PA NSO NM NDS


2 PA BvD


2 PA BvD





(Faslodex) 5 NM NDS




5 PA NSO NM NDS


2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD




25





5 PA NSO NM NDS


5 PA NSO NM NDS











(Ifex) 2


2










5 PA NSO NM NDS






26



5 PA BvD NM NDS









(Camptosar) 2


2


5 NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS








27















5 PA NSO NM NDS



5 PA NSO NM NDS



5 NM NDS


5 NM NDS












28





5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS




5 NM NDS


5 PA NSO NM NDS


5 NM NDS












2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


29



2


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS











5 PA NSO NM LA NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


2


2


2 PA BvD


30



5 PA NSO NM NDS






5 PA NSO NM NDS










5 PA NSO NM NDS






5 NM NDS


5 NM NDS










31



5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS


(thioguanine) 4


32














5 PA NSO NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS






(Tepadina) 5 NM NDS




4




(etoposide) 2


33



(Hycamtin) 5 NM NDS


5 NM NDS



5 PA NSO NM NDS


5 PA NSO NM NDS








5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS










34



5 PA NSO NM NDS


(Valstar) 5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM LA NDS




2 PA BvD






(Navelbine) 2












35



5 PA BvD NM NDS






4 PA BvD ST






















5 PA NSO NM NDS


5 PA NSO NM NDS


36




5 PA NSO NM NDS






5 PA NSO NM NDS


5 PA NSO NM NDS






5 NM NDS






5 PA NSO NM NDS














37



(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4












(Diastat AcuDial) 4



4




(Depakote ER) 2


(Depakote) 2


5 PA NSO NM NDS




38



(Zarontin) 2


(Felbatol) 2


(Felbatol) 2


5 PA NSO NM NDS


(Cerebyx) 2

















(Subvenite) 1 GC



2



2



2


(Lamictal XR) 2


39



(Lamictal) 2


(Lamictal ODT) 2


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




(Trileptal) 2


(Trileptal) 2


4


5 NM NDS


2


2


(Dilantin-125) 2






(Phenytek) 2


2


40



2









(Banzel) 5 NM NDS






(lamotrigine) 1 GC





(Gabitril) 2


(Topamax) 2


(Topamax) 1 GC


2


2



4




41








3 QL (1200 per 30 days)










4


(Zonegran) 2



days)











42







3 ST








2


2


2


2


(Wellbutrin XL) 2


(Wellbutrin SR) 2





(Anafranil) 2


(Norpramin) 2


2


43





2













2


(Lexapro) 1 GC


4 ST




(Prozac) 1 GC


2


2


2


44



2


2


4


(Remeron) 2


2


(Remeron SolTab) 2


2


(Pamelor) 1 GC


2


(Paxil) 2


(Paxil) 1 GC


(Paxil CR) 2


(paroxetine hcl) 4


2





(Zoloft) 1 GC


4 PA NSO


5 PA NSO NM NDS


45




1 GC



2








2








3


5 NM NDS












46

































47





























48





























49















days)













(Glynase) 6 GC


50



6 GC


6 GC


4 PA BvD


5 PA BvD NM NDS


2 PA BvD


(Cancidas) 5 NM NDS


(Cancidas) 2







2


2








2 PA BvD


(Diflucan) 2


(Diflucan) 2


(Ancobon) 5 NM NDS


51



2


2


2







2


5 NM NDS















2


2









52



(Vfend) 5 PA NM NDS


(Vfend) 2









2


2


2





2


2


(Diphen) 2


2


2


1 GC


(Xyzal) 2


53




2


(Cleocin) 2



2


2





















54





































4




(Rifadin) 2


55



2


5 PA NM NDS


4


4


4


4 PA BvD








2




2







2


2


56





2


1 GC


1 GC


2


2 PA BvD


2 PA BvD



2 PA BvD


2


(Compazine) 2


(Compro) 2


(Phenergan) 2


1 GC


(Promethegan) 2


(promethazine) 2







(Mepron) 2


57



(Malarone) 2








4







4





(Nebupent) 2 PA BvD


(Pentam) 2


4




2



1 GC





(Cogentin) 2


58



2






(Sinemet) 2


(Dhivy) 2


2


2


2


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4







5 PA NM NDS


59











(Mirapex) 1 GC



2


2




2


1 GC












60



















2


2


2











61





4 ST


2


2


2


2


2




2




2


2


2


2


2








62























2











63













2























64














2


2


2






4 ST










65







(Epzicom) 2


(Trizivir) 5 NM NDS


5 NM NDS


5 NM NDS


(Reyataz) 2


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


2


5 NM NDS


66



5 NM NDS


(Sustiva) 2



(Atripla) 5 NM NDS


(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS



(Truvada) 5 NM NDS


4


4




5 NM NDS



5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


4


5 NM NDS


4


67



5 NM NDS




(Epivir) 2


(Combivir) 2


4








2



2


(Viramune XR) 2


4


4


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


4


68



5 NM NDS



5 NM NDS


4


5 NM NDS


3


2


5 NM NDS


5 NM NDS


5 NM NDS


(Viread) 2


4


5 NM NDS


4


5 NM NDS


5 NM NDS




5 NM NDS


5 NM NDS


5 NM NDS


69



4




(Foscavir) 2 PA BvD
















5 PA NM NDS

















70











5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS



(Zovirax) 2



2 PA BvD


2 PA BvD



5 NM NDS



2


71





5 PA BvD NM NDS






(Valtrex) 2


(Valcyte) 5 NM NDS





3



















72









2


2


2


2


2


(warfarin) 1 GC


(Jantoven) 1 GC


3














5 PA NM NDS


73



5 PA NM NDS


5 PA NM NDS






5 NM NDS


5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS












74









5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






4


5 PA NM NDS


2


4 PA




(Cyklokapron) 2




3


75





2


2



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


76



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


2 PA BvD


4


2




77



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


1 GC








(Cardura) 2





2


78



2


(Vazculep) 2


(Minipress) 2


(Atacand) 2


(Atacand HCT) 2


3


3







(Avapro) 6 GC


(Avalide) 6 GC


(Cozaar) 6 GC


(Hyzaar) 6 GC


(Benicar) 6 GC


(Tribenzor) 2


(Benicar HCT) 6 GC


(Micardis) 6 GC


79



(Twynsta) 2


(Micardis HCT) 2


(Diovan) 6 GC


(Diovan HCT) 6 GC


(Lotensin) 6 GC



(Lotensin HCT) 6 GC


6 GC


2


2




(Vasotec) 6 GC


2


(Vaseretic) 6 GC


6 GC




6 GC


80



2


(Zestril) 6 GC


(Zestoretic) 6 GC



6 GC




(Accupril) 6 GC


(Accuretic) 6 GC


(Altace) 6 GC


6 GC


(Pacerone) 2



(Norpace) 2


(Tikosyn) 2


2




1 GC


2


3



81




2


2


(Rythmol SR) 2


2


2



2


(Tenormin) 1 GC


(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 2


(nebivolol) 3


(Coreg) 1 GC


2


2


2


82



(Toprol XL) 1 GC


2


2


(Lopressor) 1 GC


1 GC


(Corgard) 2


(Bystolic) 2



2


(Inderal LA) 2


2


2


2


(sotalol) 2


(sotalol) 2


(Sorine) 2


2


(diltiazem hcl) 2


83



(Cartia XT) 2


2


2


(Taztia XT) 2


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



(diltiazem hcl) 2


(diltiazem hcl) 2


(diltiazem hcl) 2


(diltiazem hcl) 2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


(Calan SR) 2


84







(digoxin) 2


(digoxin) 2


2


(Digitek) 2








(Adrenalin) 1 GC


2


2

















85





(Norvasc) 1 GC


(Lotrel) 6 GC


6 GC


(Azor) 2


(Exforge) 6 GC


(Exforge HCT) 2


2





2



(Procardia XL) 2


(Adalat CC) 2



2


2


2


86



(Diuril IV) 2


2


2


1 GC


2


(Lasix) 1 GC


1 GC


1 GC


1 GC






2


(Aldactone) 1 GC


(Aldactazide) 2


2


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


87



(Caduet) 2




2




(Questran) 2



2


(WelChol) 2
















2


(Tricor) 2


2


(Trilipix) 2


88














6 GC








2










2








89















3


2



2


1 GC


(nitroglycerin) 2



2


(Nitrostat) 2


(Minitran) 2


90



















(Cafcit) 2 PA BvD


2




















91















5 PA NM NDS


2
















1 GC



92



(Lithobid) 2


2


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






5 PA NM NDS
















93



















5 PA NM NDS




5 PA NM NDS







3




94





estrad)2



2



2


2





2


2





2



2



2



2



2



1 GC


2


2



2


95



2



2



2



2



1 GC



1 GC


2



2



2



2


2


2



2


2





1 GC


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


96



(Syeda) 2


2






2



2


2


1 GC


2


(Kelnor 135 (28)) 2


(Kelnor 1-50 (28)) 2





2


1 GC



2



2



2


2


1 GC





1 GC


97






2





2


1 GC


2



2



2



2



1 GC



2


2



2



2



2



2







2


98




2



2



2



1 GC


2


2



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2


2


2





2



2



2



2


1 GC


99



1 GC



2



1 GC


1 GC



2


2


2


(Camila) 1 GC


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2


(Gemmily) 2





2




(Tri-Estarylla) 2


(Femynor) 2


1 GC


2


2


100




2


2


2


2


2




2


2


2


2


1 GC



2





1 GC



2





4



2


2


2


101




2



1 GC



2



1 GC


2



2



1 GC



1 GC



1 GC



2



2



2



1 GC



2



2



1 GC



2


1 GC


2


2


102



2


2



2



2


2


2


2






2



2



2



2







(PreviDent) 1 GC


2



1 GC



1 GC


103







1 GC


(Oralone) 2


(isotretinoin) 2


2









2


(Skin Treatment) 2











5 NM NDS







104




2









5 NM NDS

























5 NM NDS


5 NM NDS




105



(isotretinoin) 2






(Clindacin ETZ) 2


(Neuac) 2


(Benzaclin) 2


2






(Benzamycin) 2









2






(Klaron) 2



106





2


2


2


2


2


(Luxiq) 2


2


2


2


2


2



2









2


(Olux-E) 2





107









3




(Synalar) 2






2


2


2


2


2
















108



1 GC


2


2






2


(hydrocortisone) 2


(hydrocortisone) 2


(hydrocortisone) 2


(hydrocortisone) 2




1 GC


(Triderm) 1 GC


2


1 GC


(Trianex) 2


2




4 PA



109



4



(Retin-A) 2 PA





























2


110




2



2



2



2



2



2



2



2










2


2


2


2


111



2


2


2


2


2


2



2


2


2



2



2


2



2


2


2


112




2



2



2





2



2



2



2



2


2


2


2


2








113







2



2



2



2


























114










2



2



2


2


2



2



2









2



2


115




2



2



2












2






2




2


2


116




2



2



2



2



2



2



2



2


2


2


2












117





2


2




2




1 GC






1 GC


1 GC


2


2



2



2


2


2


118



2


2


2



2



2



2



2



2


2



2



2



2


2




2


119















2




2


2



2



2



2



2



2



2


120



2



2



2


2



2












2


2



2



2



2



2


121






2



2


2



2


2



2


2


2


2


2


2



2



2



2


122




2


2


2


2


2


2


2



2


















2


123



2


2


2



2



2


2



2



2



2


2



2



2



2



2






124






2



2



2



2



2



2




2



2



2


2



2



2



2


125




2



2



2



2
















2














126




2



2



2



2





2



2



2



2



2


2







2




127






2








2












1 GC





2



2


2



2




128






2



2



2



2



2



2



2



2



2



2


2


2


2


2


129



2





2



2



2



2


2


2











2



2



2



2


130




2



2



2



2



2



2



2



2



2



2



2


2



2



2



2


2




131



2


2


3





3







2





2



2







2






132















2


2



2



2



2



2



2



2






133








2



2



2








2





2



2



2



2


2




2


134





2


2


2


2


2


2


2




2


2


2



2



2


135




2



2



2







2



2



2
















136




2



2



2



2



2


2


2


2


2


2


2


2


2


2


2



2



2


137




2



2



2




2










2







2



2



2



2


138




2



2


2



2


2



2


2







2



2



2


2


139




2



2













2



2



2


2



2












140




2



2



2



2



2



2



2



2



2



2



2


2



2



2



2


141




2



2














2


2





2



2



2



2


142




2


2


2


2


2


2


2


2


2


2


2


2


2



2



2



2


143



2





2



2



2



2



2



2


2


2


2












144




2



2



2



2





2



2



2



2



2



2



2



2










145










2



2



2



2



2



2



2



2



2














146









2


2




2












2


2



2


2


147




2










1 GC

V-GO 20 DEVICE 3

V-GO 30 DEVICE 3

V-GO 40 DEVICE 3


5 NM NDS


5 PA NM NDS


5 NM NDS


3


5 NM NDS


5 NM NDS


5 PA NM NDS




148



5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS



5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


(Kuvan) 5 NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 NM NDS


149



3


(proparacaine) 2


2


(Isopto Atropine) 4






2


(Bepreve) 2 ST


2


(Cyclogyl) 2






2






150






2



2


(Alcaine) 2


5 PA NM NDS



2


(Polycin) 2




(Ciloxan) 2






(Zymaxid) 2


(gentamicin) 2


1 GC


2


2


(Vigamox) 2


4


151



(Neo-Polycin HC) 2


(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2



2



2


(Ocuflox) 2




2


(Polytrim) 1 GC


(Bleph-10) 2


152



2


2


(Tobrex) 2


(TobraDex) 2


2


4


3


3 ST


2


3


2


2


(Durezol) 2


(difluprednate) 3






(DermOtic Oil) 2


(FML Liquifilm) 4


153



2





3


3




3


3


(Lotemax) 2


(Lotemax) 2




(Pred Forte) 4


2


3










2


154



2


2


2






2


(Nexium IV) 2


1 GC


2


2


2








(Cytotec) 2


2


2


1 GC


1 GC


155





(Protonix) 2








5 NM NDS


(lactulose) 2


(Gastrocrom) 2





2


(Lomotil) 2



5 PA NM NDS



2


2


(Constulose) 2






156





2




2


2


2


2


(Reglan) 1 GC







5 PA NM NDS










(Buphenyl) 5 NM NDS


2


2


2




157






3







3




2


2


(Fosrenol) 5 NM NDS


4


(Renvela) 5 NM NDS


(Renvela) 2




3


2



158



3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


2





(Jalyn) 2




1 GC


5 PA NM NDS



(240 per 30 days)






159




(Exjade) 2 PA





2 PA


(Desferal) 2 PA


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


2


(Oxandrin) 2




2 PA






160












2




3


(Estrace) 1 GC






(Estrace) 2



(Delestrogen) 2


(Amabelz) 2




161




2


2




2


(Fyavolv) 2


3


3




3


3


3



2




2


2


(Decadron) 2


2


162



1 GC


1 GC


1 GC


1 GC









4


(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





163



1 PA BvD GC


2


4


(Kenalog) 2




5 NM NDS


(DDAVP) 2


2


(DDAVP) 2






5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


164





5 PA NM NDS


2


(Sandostatin) 2


2


5 PA NSO NM NDS






5 NM NDS


5 PA NM NDS








165





5 PA NM NDS




5 NM NDS




5 PA NM NDS


(Makena) 5 NM NDS






(Provera) 1 GC


2


(Aygestin) 2


2


(Prometrium) 2


(Euthyrox) 1 GC



166



(Cytomel) 2




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS



2 PA BvD


5 PA NM NDS






5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


167



5 PA NM NDS


5 PA NM NDS




(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Zortress) 2 PA BvD




5 PA BvD NM NDS


5 PA NM NDS


168



5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


169



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





(CellCept) 2 PA BvD


170





(CellCept) 2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA NM NDS


5 PA BvD NM NDS


4 PA BvD


4 PA BvD ST


3




171



5 PA NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NM NDS





5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Prograf) 2 PA BvD


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


172



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA BvD NM NDS


3


3


3


3


3


173



3


3


3




3 PA BvD


3 PA BvD


3 PA BvD






3


3


3 PA BvD


174



3


3


3


3


3


3


3


3


3


3


3


3


3


175



3


3


3 PA BvD


3 PA BvD


3 PA BvD


3


3





3


3


3


176



3


3


3


3



3


3


3




3





177





(Entocort EC) 2


5 ST NM NDS


(Cortenema) 4


(Delzicol) 2


(Apriso) 2


(Lialda) 2


(Asacol HD) 2


(Canasa) 2





3











2


(Rocaltrol) 2



178






2











2


2


(Zemplar) 2














179





5 PA NM NDS


2


2




5 PA NM NDS


2


5 NM NDS


5 NM NDS







5 PA NM NDS


5 PA NM LA NDS


5 NM NDS


3


180



3


2


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



(Fusilev) 5 NM NDS


(Mesnex) 2


5 NM NDS


5 PA NM NDS


(Mestinon) 2


2


(Mestinon) 2








181





5 NM NDS








2


2


2


3


(brinzolamide) 2


2




(Alphagan P) 4


1 GC


2


3


(Trusopt) 2


(Cosopt) 2


182





1 GC




2


2


(Isopto Carpine) 2


2






3


(Timoptic) 1 GC


(Timoptic-XE) 4










2


4


183



4


4


4


4








2


2 PA BvD


2 PA BvD


2 PA BvD


4


4


4


1 PA BvD GC


184



2 PA BvD


2


2


(K-Tab) 2


(Klor-Con M10) 2


(Klor-Con M15) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


2


2


2


4





185



























186







(Singulair) 1 GC


30 days)












2


2


2






187












1 GC













5 NM NDS


2


2


188



2




(Acetadote) 2


2 PA BvD




5 PA NM NDS


2 PA BvD






















189













5 PA BvD NM NDS


5 PA BvD NM NDS






5 PA NM NDS


5 PA NM NDS


2




1 GC



(Dantrium) 2


190



2


(dantrolene) 2































191


















5 PA NM NDS








5 PA NM NDS


192

INDEX




I-1




I-2




I-3




I-4




I-5




I-6




I-7




I-8




I-9




I-10




I-11




I-12




I-13




I-14




I-15




I-16




I-17




I-18




I-19




Y0027_22-219_C











iv








v










vii








viii

Table of Contents


1


2












(Buprenex) 2


2



























3
























2











4

































5
































6















2 QL (1000 per 30 days)



(Arthrotec 50) 2


(Arthrotec 75) 2



2






(ibuprofen) 1 GC


(Childrens Advil) 2


(IBU) 1 GC






7





2


2





















(Relafen) 2


1 GC



(EC-Naprosyn) 2






(Feldene) 2


8










1 GC




(Xylocaine) 1 GC




2 PA





(lidocaine hcl) 2






2




9









2






3


2






2


2





4 QL (1008 per 90 days)






10

































11





















2


2


2



5 NM NDS




12







2


2


2


(Cleocin HCl) 1 GC


2



2


2


(Cleocin) 2


2



5 PA BvD NM NDS


(Cubicin) 5 NM NDS


4


2


(Zyvox) 2


(Zyvox) 5 NM NDS



(Hiprex) 2


13



(Metro IV) 2


1 GC






2


5 NM NDS



2








2


2


2



2



2



14



2


2



(Suprax) 2


2


2


2


2


2


2


2



(Fortaz) 2


(Tazicef) 2


2


2


2


2


1 GC


15




2


2


5 NM NDS


(Zithromax) 2


(Zithromax) 2


1 GC


(Zithromax) 1 GC



2


2


2






(EES Granules) 2


(EryPed 400) 2


2


16



(Azactam) 2


5 PA NM LA NDS


(Invanz) 2


2


(Primaxin IV) 2


2


2


2


1 GC


1 GC


1 GC


2


2


(Augmentin) 2




2


(Augmentin) 1 GC


17



(Augmentin XR) 2


2


2


2


(Unasyn) 2


4


2


2


2


2


5 NM NDS


(Pfizerpen-G) 2


2


2


1 GC




2


18





1 GC



(Cipro) 1 GC



2


(Cipro) 2


2


2


2


1 GC



2


(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


2




19



(Doxy-100) 2


(Morgidox) 2


(LymePak) 2


2


2


(Doryx) 2






(Vibramycin) 2




2




2


2





2


(Tygacil) 5 NM NDS




20



5 PA BvD NM NDS


5 PA NSO NM NDS














5 NM NDS








5 PA NSO NM NDS



5 NM NDS


(Trisenox) 5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS




21



(Vidaza) 5 NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS




5 PA NSO NM NDS


2


5 PA NSO NM NDS


5 PA NSO NM NDS
















22







(Paraplatin) 2


2 PA BvD


(Clolar) 5 NM NDS








5 PA BvD NM NDS


5 PA BvD NM NDS


4 PA BvD ST


3 PA BvD ST


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM LA NDS






23



(Dacogen) 5 NM NDS


5 NM NDS


2






4


4


4


4


5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








24



4


(Toposar) 2











5 PA NSO NM NDS


2 PA BvD


2 PA BvD





(Faslodex) 5 NM NDS




5 PA NSO NM NDS


2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD




25





5 PA NSO NM NDS


5 PA NSO NM NDS











(Ifex) 2


2










5 PA NSO NM NDS






26



5 PA BvD NM NDS









(Camptosar) 2


2


5 NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS








27















5 PA NSO NM NDS



5 PA NSO NM NDS



5 NM NDS


5 NM NDS












28





5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS




5 NM NDS


5 PA NSO NM NDS


5 NM NDS












2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


29



2


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS











5 PA NSO NM LA NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


2


2


2 PA BvD


30



5 PA NSO NM NDS






5 PA NSO NM NDS










5 PA NSO NM NDS






5 NM NDS


5 NM NDS










31



5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS


(thioguanine) 4


32














5 PA NSO NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS






(Tepadina) 5 NM NDS




4




(etoposide) 2


33



(Hycamtin) 5 NM NDS


5 NM NDS



5 PA NSO NM NDS


5 PA NSO NM NDS








5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS










34



5 PA NSO NM NDS


(Valstar) 5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM LA NDS




2 PA BvD






(Navelbine) 2












35



5 PA BvD NM NDS






4 PA BvD ST






















5 PA NSO NM NDS


5 PA NSO NM NDS


36




5 PA NSO NM NDS






5 PA NSO NM NDS


5 PA NSO NM NDS






5 NM NDS






5 PA NSO NM NDS














37



(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4












(Diastat AcuDial) 4



4




(Depakote ER) 2


(Depakote) 2


5 PA NSO NM NDS




38



(Zarontin) 2


(Felbatol) 2


(Felbatol) 2


5 PA NSO NM NDS


(Cerebyx) 2

















(Subvenite) 1 GC



2



2



2


(Lamictal XR) 2


39



(Lamictal) 2


(Lamictal ODT) 2


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




(Trileptal) 2


(Trileptal) 2


4


5 NM NDS


2


2


(Dilantin-125) 2






(Phenytek) 2


2


40



2









(Banzel) 5 NM NDS






(lamotrigine) 1 GC





(Gabitril) 2


(Topamax) 2


(Topamax) 1 GC


2


2



4




41








3 QL (1200 per 30 days)










4


(Zonegran) 2



days)











42







3 ST








2


2


2


2


(Wellbutrin XL) 2


(Wellbutrin SR) 2





(Anafranil) 2


(Norpramin) 2


2


43





2













2


(Lexapro) 1 GC


4 ST




(Prozac) 1 GC


2


2


2


44



2


2


4


(Remeron) 2


2


(Remeron SolTab) 2


2


(Pamelor) 1 GC


2


(Paxil) 2


(Paxil) 1 GC


(Paxil CR) 2


(paroxetine hcl) 4


2





(Zoloft) 1 GC


4 PA NSO


5 PA NSO NM NDS


45




1 GC



2








2








3


5 NM NDS












46

































47





























48





























49















days)













(Glynase) 6 GC


50



6 GC


6 GC


4 PA BvD


5 PA BvD NM NDS


2 PA BvD


(Cancidas) 5 NM NDS


(Cancidas) 2







2


2








2 PA BvD


(Diflucan) 2


(Diflucan) 2


(Ancobon) 5 NM NDS


51



2


2


2







2


5 NM NDS















2


2









52



(Vfend) 5 PA NM NDS


(Vfend) 2









2


2


2





2


2


(Diphen) 2


2


2


1 GC


(Xyzal) 2


53




2


(Cleocin) 2



2


2





















54





































4




(Rifadin) 2


55



2


5 PA NM NDS


4


4


4


4 PA BvD








2




2







2


2


56





2


1 GC


1 GC


2


2 PA BvD


2 PA BvD



2 PA BvD


2


(Compazine) 2


(Compro) 2


(Phenergan) 2


1 GC


(Promethegan) 2


(promethazine) 2







(Mepron) 2


57



(Malarone) 2








4







4





(Nebupent) 2 PA BvD


(Pentam) 2


4




2



1 GC





(Cogentin) 2


58



2






(Sinemet) 2


(Dhivy) 2


2


2


2


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4







5 PA NM NDS


59











(Mirapex) 1 GC



2


2




2


1 GC












60



















2


2


2











61





4 ST


2


2


2


2


2




2




2


2


2


2


2








62























2











63













2























64














2


2


2






4 ST










65







(Epzicom) 2


(Trizivir) 5 NM NDS


5 NM NDS


5 NM NDS


(Reyataz) 2


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


2


5 NM NDS


66



5 NM NDS


(Sustiva) 2



(Atripla) 5 NM NDS


(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS



(Truvada) 5 NM NDS


4


4




5 NM NDS



5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


4


5 NM NDS


4


67



5 NM NDS




(Epivir) 2


(Combivir) 2


4








2



2


(Viramune XR) 2


4


4


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


4


68



5 NM NDS



5 NM NDS


4


5 NM NDS


3


2


5 NM NDS


5 NM NDS


5 NM NDS


(Viread) 2


4


5 NM NDS


4


5 NM NDS


5 NM NDS




5 NM NDS


5 NM NDS


5 NM NDS


69



4




(Foscavir) 2 PA BvD
















5 PA NM NDS

















70











5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS



(Zovirax) 2



2 PA BvD


2 PA BvD



5 NM NDS



2


71





5 PA BvD NM NDS






(Valtrex) 2


(Valcyte) 5 NM NDS





3



















72









2


2


2


2


2


(warfarin) 1 GC


(Jantoven) 1 GC


3














5 PA NM NDS


73



5 PA NM NDS


5 PA NM NDS






5 NM NDS


5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS












74









5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






4


5 PA NM NDS


2


4 PA




(Cyklokapron) 2




3


75





2


2



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


76



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


2 PA BvD


4


2




77



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


1 GC








(Cardura) 2





2


78



2


(Vazculep) 2


(Minipress) 2


(Atacand) 2


(Atacand HCT) 2


3


3







(Avapro) 6 GC


(Avalide) 6 GC


(Cozaar) 6 GC


(Hyzaar) 6 GC


(Benicar) 6 GC


(Tribenzor) 2


(Benicar HCT) 6 GC


(Micardis) 6 GC


79



(Twynsta) 2


(Micardis HCT) 2


(Diovan) 6 GC


(Diovan HCT) 6 GC


(Lotensin) 6 GC



(Lotensin HCT) 6 GC


6 GC


2


2




(Vasotec) 6 GC


2


(Vaseretic) 6 GC


6 GC




6 GC


80



2


(Zestril) 6 GC


(Zestoretic) 6 GC



6 GC




(Accupril) 6 GC


(Accuretic) 6 GC


(Altace) 6 GC


6 GC


(Pacerone) 2



(Norpace) 2


(Tikosyn) 2


2




1 GC


2


3



81




2


2


(Rythmol SR) 2


2


2



2


(Tenormin) 1 GC


(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 2


(nebivolol) 3


(Coreg) 1 GC


2


2


2


82



(Toprol XL) 1 GC


2


2


(Lopressor) 1 GC


1 GC


(Corgard) 2


(Bystolic) 2



2


(Inderal LA) 2


2


2


2


(sotalol) 2


(sotalol) 2


(Sorine) 2


2


(diltiazem hcl) 2


83



(Cartia XT) 2


2


2


(Taztia XT) 2


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



(diltiazem hcl) 2


(diltiazem hcl) 2


(diltiazem hcl) 2


(diltiazem hcl) 2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


(Calan SR) 2


84







(digoxin) 2


(digoxin) 2


2


(Digitek) 2








(Adrenalin) 1 GC


2


2

















85





(Norvasc) 1 GC


(Lotrel) 6 GC


6 GC


(Azor) 2


(Exforge) 6 GC


(Exforge HCT) 2


2





2



(Procardia XL) 2


(Adalat CC) 2



2


2


2


86



(Diuril IV) 2


2


2


1 GC


2


(Lasix) 1 GC


1 GC


1 GC


1 GC






2


(Aldactone) 1 GC


(Aldactazide) 2


2


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


87



(Caduet) 2




2




(Questran) 2



2


(WelChol) 2
















2


(Tricor) 2


2


(Trilipix) 2


88














6 GC








2










2








89















3


2



2


1 GC


(nitroglycerin) 2



2


(Nitrostat) 2


(Minitran) 2


90



















(Cafcit) 2 PA BvD


2




















91















5 PA NM NDS


2
















1 GC



92



(Lithobid) 2


2


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






5 PA NM NDS
















93



















5 PA NM NDS




5 PA NM NDS







3




94





estrad)2



2



2


2





2


2





2



2



2



2



2



1 GC


2


2



2


95



2



2



2



2



1 GC



1 GC


2



2



2



2


2


2



2


2





1 GC


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


96



(Syeda) 2


2






2



2


2


1 GC


2


(Kelnor 135 (28)) 2


(Kelnor 1-50 (28)) 2





2


1 GC



2



2



2


2


1 GC





1 GC


97






2





2


1 GC


2



2



2



2



1 GC



2


2



2



2



2



2







2


98




2



2



2



1 GC


2


2



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2


2


2





2



2



2



2


1 GC


99



1 GC



2



1 GC


1 GC



2


2


2


(Camila) 1 GC


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2


(Gemmily) 2





2




(Tri-Estarylla) 2


(Femynor) 2


1 GC


2


2


100




2


2


2


2


2




2


2


2


2


1 GC



2





1 GC



2





4



2


2


2


101




2



1 GC



2



1 GC


2



2



1 GC



1 GC



1 GC



2



2



2



1 GC



2



2



1 GC



2


1 GC


2


2


102



2


2



2



2


2


2


2






2



2



2



2







(PreviDent) 1 GC


2



1 GC



1 GC


103







1 GC


(Oralone) 2


(isotretinoin) 2


2









2


(Skin Treatment) 2











5 NM NDS







104




2









5 NM NDS

























5 NM NDS


5 NM NDS




105



(isotretinoin) 2






(Clindacin ETZ) 2


(Neuac) 2


(Benzaclin) 2


2






(Benzamycin) 2









2






(Klaron) 2



106





2


2


2


2


2


(Luxiq) 2


2


2


2


2


2



2









2


(Olux-E) 2





107









3




(Synalar) 2






2


2


2


2


2
















108



1 GC


2


2






2


(hydrocortisone) 2


(hydrocortisone) 2


(hydrocortisone) 2


(hydrocortisone) 2




1 GC


(Triderm) 1 GC


2


1 GC


(Trianex) 2


2




4 PA



109



4



(Retin-A) 2 PA





























2


110




2



2



2



2



2



2



2



2










2


2


2


2


111



2


2


2


2


2


2



2


2


2



2



2


2



2


2


2


112




2



2



2





2



2



2



2



2


2


2


2


2








113







2



2



2



2


























114










2



2



2


2


2



2



2









2



2


115




2



2



2












2






2




2


2


116




2



2



2



2



2



2



2



2


2


2


2












117





2


2




2




1 GC






1 GC


1 GC


2


2



2



2


2


2


118



2


2


2



2



2



2



2



2


2



2



2



2


2




2


119















2




2


2



2



2



2



2



2



2


120



2



2



2


2



2












2


2



2



2



2



2


121






2



2


2



2


2



2


2


2


2


2


2



2



2



2


122




2


2


2


2


2


2


2



2


















2


123



2


2


2



2



2


2



2



2



2


2



2



2



2



2






124






2



2



2



2



2



2




2



2



2


2



2



2



2


125




2



2



2



2
















2














126




2



2



2



2





2



2



2



2



2


2







2




127






2








2












1 GC





2



2


2



2




128






2



2



2



2



2



2



2



2



2



2


2


2


2


2


129



2





2



2



2



2


2


2











2



2



2



2


130




2



2



2



2



2



2



2



2



2



2



2


2



2



2



2


2




131



2


2


3





3







2





2



2







2






132















2


2



2



2



2



2



2



2






133








2



2



2








2





2



2



2



2


2




2


134





2


2


2


2


2


2


2




2


2


2



2



2


135




2



2



2







2



2



2
















136




2



2



2



2



2


2


2


2


2


2


2


2


2


2


2



2



2


137




2



2



2




2










2







2



2



2



2


138




2



2


2



2


2



2


2







2



2



2


2


139




2



2













2



2



2


2



2












140




2



2



2



2



2



2



2



2



2



2



2


2



2



2



2


141




2



2














2


2





2



2



2



2


142




2


2


2


2


2


2


2


2


2


2


2


2


2



2



2



2


143



2





2



2



2



2



2



2


2


2


2












144




2



2



2



2





2



2



2



2



2



2



2



2










145










2



2



2



2



2



2



2



2



2














146









2


2




2












2


2



2


2


147




2










1 GC

V-GO 20 DEVICE 3

V-GO 30 DEVICE 3

V-GO 40 DEVICE 3


5 NM NDS


5 PA NM NDS


5 NM NDS


3


5 NM NDS


5 NM NDS


5 PA NM NDS




148



5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS



5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


(Kuvan) 5 NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 NM NDS


149



3


(proparacaine) 2


2


(Isopto Atropine) 4






2


(Bepreve) 2 ST


2


(Cyclogyl) 2






2






150






2



2


(Alcaine) 2


5 PA NM NDS



2


(Polycin) 2




(Ciloxan) 2






(Zymaxid) 2


(gentamicin) 2


1 GC


2


2


(Vigamox) 2


4


151



(Neo-Polycin HC) 2


(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2



2



2


(Ocuflox) 2




2


(Polytrim) 1 GC


(Bleph-10) 2


152



2


2


(Tobrex) 2


(TobraDex) 2


2


4


3


3 ST


2


3


2


2


(Durezol) 2


(difluprednate) 3






(DermOtic Oil) 2


(FML Liquifilm) 4


153



2





3


3




3


3


(Lotemax) 2


(Lotemax) 2




(Pred Forte) 4


2


3










2


154



2


2


2






2


(Nexium IV) 2


1 GC


2


2


2








(Cytotec) 2


2


2


1 GC


1 GC


155





(Protonix) 2








5 NM NDS


(lactulose) 2


(Gastrocrom) 2





2


(Lomotil) 2



5 PA NM NDS



2


2


(Constulose) 2






156





2




2


2


2


2


(Reglan) 1 GC







5 PA NM NDS










(Buphenyl) 5 NM NDS


2


2


2




157






3







3




2


2


(Fosrenol) 5 NM NDS


4


(Renvela) 5 NM NDS


(Renvela) 2




3


2



158



3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


2





(Jalyn) 2




1 GC


5 PA NM NDS



(240 per 30 days)






159




(Exjade) 2 PA





2 PA


(Desferal) 2 PA


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


2


(Oxandrin) 2




2 PA






160












2




3


(Estrace) 1 GC






(Estrace) 2



(Delestrogen) 2


(Amabelz) 2




161




2


2




2


(Fyavolv) 2


3


3




3


3


3



2




2


2


(Decadron) 2


2


162



1 GC


1 GC


1 GC


1 GC









4


(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





163



1 PA BvD GC


2


4


(Kenalog) 2




5 NM NDS


(DDAVP) 2


2


(DDAVP) 2






5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


164





5 PA NM NDS


2


(Sandostatin) 2


2


5 PA NSO NM NDS






5 NM NDS


5 PA NM NDS








165





5 PA NM NDS




5 NM NDS




5 PA NM NDS


(Makena) 5 NM NDS






(Provera) 1 GC


2


(Aygestin) 2


2


(Prometrium) 2


(Euthyrox) 1 GC



166



(Cytomel) 2




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS



2 PA BvD


5 PA NM NDS






5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


167



5 PA NM NDS


5 PA NM NDS




(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Zortress) 2 PA BvD




5 PA BvD NM NDS


5 PA NM NDS


168



5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


169



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





(CellCept) 2 PA BvD


170





(CellCept) 2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA NM NDS


5 PA BvD NM NDS


4 PA BvD


4 PA BvD ST


3




171



5 PA NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NM NDS





5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Prograf) 2 PA BvD


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


172



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA BvD NM NDS


3


3


3


3


3


173



3


3


3




3 PA BvD


3 PA BvD


3 PA BvD






3


3


3 PA BvD


174



3


3


3


3


3


3


3


3


3


3


3


3


3


175



3


3


3 PA BvD


3 PA BvD


3 PA BvD


3


3





3


3


3


176



3


3


3


3



3


3


3




3





177





(Entocort EC) 2


5 ST NM NDS


(Cortenema) 4


(Delzicol) 2


(Apriso) 2


(Lialda) 2


(Asacol HD) 2


(Canasa) 2





3











2


(Rocaltrol) 2



178






2











2


2


(Zemplar) 2














179





5 PA NM NDS


2


2




5 PA NM NDS


2


5 NM NDS


5 NM NDS







5 PA NM NDS


5 PA NM LA NDS


5 NM NDS


3


180



3


2


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



(Fusilev) 5 NM NDS


(Mesnex) 2


5 NM NDS


5 PA NM NDS


(Mestinon) 2


2


(Mestinon) 2








181





5 NM NDS








2


2


2


3


(brinzolamide) 2


2




(Alphagan P) 4


1 GC


2


3


(Trusopt) 2


(Cosopt) 2


182





1 GC




2


2


(Isopto Carpine) 2


2






3


(Timoptic) 1 GC


(Timoptic-XE) 4










2


4


183



4


4


4


4








2


2 PA BvD


2 PA BvD


2 PA BvD


4


4


4


1 PA BvD GC


184



2 PA BvD


2


2


(K-Tab) 2


(Klor-Con M10) 2


(Klor-Con M15) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


2


2


2


4





185



























186







(Singulair) 1 GC


30 days)












2


2


2






187












1 GC













5 NM NDS


2


2


188



2




(Acetadote) 2


2 PA BvD




5 PA NM NDS


2 PA BvD






















189













5 PA BvD NM NDS


5 PA BvD NM NDS






5 PA NM NDS


5 PA NM NDS


2




1 GC



(Dantrium) 2


190



2


(dantrolene) 2































191


















5 PA NM NDS








5 PA NM NDS


192

INDEX




I-1




I-2




I-3




I-4




I-5




I-6




I-7




I-8




I-9




I-10




I-11




I-12




I-13




I-14




I-15




I-16




I-17




I-18




I-19




Y0027_22-219_C








v










vii








viii

Table of Contents


1


2












(Buprenex) 2


2



























3
























2











4

































5
































6















2 QL (1000 per 30 days)



(Arthrotec 50) 2


(Arthrotec 75) 2



2






(ibuprofen) 1 GC


(Childrens Advil) 2


(IBU) 1 GC






7





2


2





















(Relafen) 2


1 GC



(EC-Naprosyn) 2






(Feldene) 2


8










1 GC




(Xylocaine) 1 GC




2 PA





(lidocaine hcl) 2






2




9









2






3


2






2


2





4 QL (1008 per 90 days)






10

































11





















2


2


2



5 NM NDS




12







2


2


2


(Cleocin HCl) 1 GC


2



2


2


(Cleocin) 2


2



5 PA BvD NM NDS


(Cubicin) 5 NM NDS


4


2


(Zyvox) 2


(Zyvox) 5 NM NDS



(Hiprex) 2


13



(Metro IV) 2


1 GC






2


5 NM NDS



2








2


2


2



2



2



14



2


2



(Suprax) 2


2


2


2


2


2


2


2



(Fortaz) 2


(Tazicef) 2


2


2


2


2


1 GC


15




2


2


5 NM NDS


(Zithromax) 2


(Zithromax) 2


1 GC


(Zithromax) 1 GC



2


2


2






(EES Granules) 2


(EryPed 400) 2


2


16



(Azactam) 2


5 PA NM LA NDS


(Invanz) 2


2


(Primaxin IV) 2


2


2


2


1 GC


1 GC


1 GC


2


2


(Augmentin) 2




2


(Augmentin) 1 GC


17



(Augmentin XR) 2


2


2


2


(Unasyn) 2


4


2


2


2


2


5 NM NDS


(Pfizerpen-G) 2


2


2


1 GC




2


18





1 GC



(Cipro) 1 GC



2


(Cipro) 2


2


2


2


1 GC



2


(Sulfatrim) 2


(Bactrim) 1 GC


(Bactrim DS) 1 GC


2




19



(Doxy-100) 2


(Morgidox) 2


(LymePak) 2


2


2


(Doryx) 2






(Vibramycin) 2




2




2


2





2


(Tygacil) 5 NM NDS




20



5 PA BvD NM NDS


5 PA NSO NM NDS














5 NM NDS








5 PA NSO NM NDS



5 NM NDS


(Trisenox) 5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS




21



(Vidaza) 5 NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS




5 PA NSO NM NDS


2


5 PA NSO NM NDS


5 PA NSO NM NDS
















22







(Paraplatin) 2


2 PA BvD


(Clolar) 5 NM NDS








5 PA BvD NM NDS


5 PA BvD NM NDS


4 PA BvD ST


3 PA BvD ST


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM LA NDS






23



(Dacogen) 5 NM NDS


5 NM NDS


2






4


4


4


4


5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








24



4


(Toposar) 2











5 PA NSO NM NDS


2 PA BvD


2 PA BvD





(Faslodex) 5 NM NDS




5 PA NSO NM NDS


2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


2 PA BvD




25





5 PA NSO NM NDS


5 PA NSO NM NDS











(Ifex) 2


2










5 PA NSO NM NDS






26



5 PA BvD NM NDS









(Camptosar) 2


2


5 NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS








27















5 PA NSO NM NDS



5 PA NSO NM NDS



5 NM NDS


5 NM NDS












28





5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS




5 NM NDS


5 PA NSO NM NDS


5 NM NDS












2 PA BvD


2 PA BvD


2 PA BvD


2 PA BvD ST


29



2


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS











5 PA NSO NM LA NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


2


2


2 PA BvD


30



5 PA NSO NM NDS






5 PA NSO NM NDS










5 PA NSO NM NDS






5 NM NDS


5 NM NDS










31



5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS




5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS










5 PA NSO NM NDS


5 PA NSO NM NDS


(thioguanine) 4


32














5 PA NSO NM NDS








5 PA NSO NM NDS


5 PA NSO NM NDS






(Tepadina) 5 NM NDS




4




(etoposide) 2


33



(Hycamtin) 5 NM NDS


5 NM NDS



5 PA NSO NM NDS


5 PA NSO NM NDS








5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS










34



5 PA NSO NM NDS


(Valstar) 5 NM NDS


5 PA NSO NM NDS


5 PA NSO NM NDS








5 PA NSO NM LA NDS




2 PA BvD






(Navelbine) 2












35



5 PA BvD NM NDS






4 PA BvD ST






















5 PA NSO NM NDS


5 PA NSO NM NDS


36




5 PA NSO NM NDS






5 PA NSO NM NDS


5 PA NSO NM NDS






5 NM NDS






5 PA NSO NM NDS














37



(Carbatrol) 2


(Tegretol) 2



(Tegretol XR) 2


2


4












(Diastat AcuDial) 4



4




(Depakote ER) 2


(Depakote) 2


5 PA NSO NM NDS




38



(Zarontin) 2


(Felbatol) 2


(Felbatol) 2


5 PA NSO NM NDS


(Cerebyx) 2

















(Subvenite) 1 GC



2



2



2


(Lamictal XR) 2


39



(Lamictal) 2


(Lamictal ODT) 2


(Keppra) 2


(Keppra) 2


(Keppra) 2


(Keppra XR) 2




(Trileptal) 2


(Trileptal) 2


4


5 NM NDS


2


2


(Dilantin-125) 2






(Phenytek) 2


2


40



2









(Banzel) 5 NM NDS






(lamotrigine) 1 GC





(Gabitril) 2


(Topamax) 2


(Topamax) 1 GC


2


2



4




41








3 QL (1200 per 30 days)










4


(Zonegran) 2



days)











42







3 ST








2


2


2


2


(Wellbutrin XL) 2


(Wellbutrin SR) 2





(Anafranil) 2


(Norpramin) 2


2


43





2













2


(Lexapro) 1 GC


4 ST




(Prozac) 1 GC


2


2


2


44



2


2


4


(Remeron) 2


2


(Remeron SolTab) 2


2


(Pamelor) 1 GC


2


(Paxil) 2


(Paxil) 1 GC


(Paxil CR) 2


(paroxetine hcl) 4


2





(Zoloft) 1 GC


4 PA NSO


5 PA NSO NM NDS


45




1 GC



2








2








3


5 NM NDS












46

































47





























48





























49















days)













(Glynase) 6 GC


50



6 GC


6 GC


4 PA BvD


5 PA BvD NM NDS


2 PA BvD


(Cancidas) 5 NM NDS


(Cancidas) 2







2


2








2 PA BvD


(Diflucan) 2


(Diflucan) 2


(Ancobon) 5 NM NDS


51



2


2


2







2


5 NM NDS















2


2









52



(Vfend) 5 PA NM NDS


(Vfend) 2









2


2


2





2


2


(Diphen) 2


2


2


1 GC


(Xyzal) 2


53




2


(Cleocin) 2



2


2





















54





































4




(Rifadin) 2


55



2


5 PA NM NDS


4


4


4


4 PA BvD








2




2







2


2


56





2


1 GC


1 GC


2


2 PA BvD


2 PA BvD



2 PA BvD


2


(Compazine) 2


(Compro) 2


(Phenergan) 2


1 GC


(Promethegan) 2


(promethazine) 2







(Mepron) 2


57



(Malarone) 2








4







4





(Nebupent) 2 PA BvD


(Pentam) 2


4




2



1 GC





(Cogentin) 2


58



2






(Sinemet) 2


(Dhivy) 2


2


2


2


(Stalevo 50) 4


(Stalevo 75) 4


(Stalevo 100) 4


(Stalevo 125) 4


(Stalevo 150) 4


(Stalevo 200) 4







5 PA NM NDS


59











(Mirapex) 1 GC



2


2




2


1 GC












60



















2


2


2











61





4 ST


2


2


2


2


2




2




2


2


2


2


2








62























2











63













2























64














2


2


2






4 ST










65







(Epzicom) 2


(Trizivir) 5 NM NDS


5 NM NDS


5 NM NDS


(Reyataz) 2


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


2


5 NM NDS


66



5 NM NDS


(Sustiva) 2



(Atripla) 5 NM NDS


(Symfi Lo) 5 NM NDS


(Symfi) 5 NM NDS



(Truvada) 5 NM NDS


4


4




5 NM NDS



5 NM NDS


5 NM NDS


4


5 NM NDS


5 NM NDS


4


5 NM NDS


4


67



5 NM NDS




(Epivir) 2


(Combivir) 2


4








2



2


(Viramune XR) 2


4


4


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


4


4


68



5 NM NDS



5 NM NDS


4


5 NM NDS


3


2


5 NM NDS


5 NM NDS


5 NM NDS


(Viread) 2


4


5 NM NDS


4


5 NM NDS


5 NM NDS




5 NM NDS


5 NM NDS


5 NM NDS


69



4




(Foscavir) 2 PA BvD
















5 PA NM NDS

















70











5 PA NSO NM NDS


5 PA NSO NM NDS


5 NM NDS


5 NM NDS


5 NM NDS



(Zovirax) 2



2 PA BvD


2 PA BvD



5 NM NDS



2


71





5 PA BvD NM NDS






(Valtrex) 2


(Valcyte) 5 NM NDS





3



















72









2


2


2


2


2


(warfarin) 1 GC


(Jantoven) 1 GC


3














5 PA NM NDS


73



5 PA NM NDS


5 PA NM NDS






5 NM NDS


5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS












74









5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






4


5 PA NM NDS


2


4 PA




(Cyklokapron) 2




3


75





2


2



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


76



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


2 PA BvD


4


2




77



4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


4 PA BvD


1 GC








(Cardura) 2





2


78



2


(Vazculep) 2


(Minipress) 2


(Atacand) 2


(Atacand HCT) 2


3


3







(Avapro) 6 GC


(Avalide) 6 GC


(Cozaar) 6 GC


(Hyzaar) 6 GC


(Benicar) 6 GC


(Tribenzor) 2


(Benicar HCT) 6 GC


(Micardis) 6 GC


79



(Twynsta) 2


(Micardis HCT) 2


(Diovan) 6 GC


(Diovan HCT) 6 GC


(Lotensin) 6 GC



(Lotensin HCT) 6 GC


6 GC


2


2




(Vasotec) 6 GC


2


(Vaseretic) 6 GC


6 GC




6 GC


80



2


(Zestril) 6 GC


(Zestoretic) 6 GC



6 GC




(Accupril) 6 GC


(Accuretic) 6 GC


(Altace) 6 GC


6 GC


(Pacerone) 2



(Norpace) 2


(Tikosyn) 2


2




1 GC


2


3



81




2


2


(Rythmol SR) 2


2


2



2


(Tenormin) 1 GC


(Tenoretic 100) 2


(Tenoretic 50) 2



2


(Ziac) 2


(nebivolol) 3


(Coreg) 1 GC


2


2


2


82



(Toprol XL) 1 GC


2


2


(Lopressor) 1 GC


1 GC


(Corgard) 2


(Bystolic) 2



2


(Inderal LA) 2


2


2


2


(sotalol) 2


(sotalol) 2


(Sorine) 2


2


(diltiazem hcl) 2


83



(Cartia XT) 2


2


2


(Taztia XT) 2


(Tiadylt ER) 2


(Cartia XT) 2


(Cardizem) 2



(diltiazem hcl) 2


(diltiazem hcl) 2


(diltiazem hcl) 2


(diltiazem hcl) 2


2


(Verelan PM) 2


(Verelan) 2


(Verelan) 4


1 GC


(Calan SR) 2


84







(digoxin) 2


(digoxin) 2


2


(Digitek) 2








(Adrenalin) 1 GC


2


2

















85





(Norvasc) 1 GC


(Lotrel) 6 GC


6 GC


(Azor) 2


(Exforge) 6 GC


(Exforge HCT) 2


2





2



(Procardia XL) 2


(Adalat CC) 2



2


2


2


86



(Diuril IV) 2


2


2


1 GC


2


(Lasix) 1 GC


1 GC


1 GC


1 GC






2


(Aldactone) 1 GC


(Aldactazide) 2


2


1 GC


(Maxzide-25mg) 1 GC


(Maxzide) 1 GC


87



(Caduet) 2




2




(Questran) 2



2


(WelChol) 2
















2


(Tricor) 2


2


(Trilipix) 2


88














6 GC








2










2








89















3


2



2


1 GC


(nitroglycerin) 2



2


(Nitrostat) 2


(Minitran) 2


90



















(Cafcit) 2 PA BvD


2




















91















5 PA NM NDS


2
















1 GC



92



(Lithobid) 2


2


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS






5 PA NM NDS
















93



















5 PA NM NDS




5 PA NM NDS







3




94





estrad)2



2



2


2





2


2





2



2



2



2



2



1 GC


2


2



2


95



2



2



2



2



1 GC



1 GC


2



2



2



2


2


2



2


2





1 GC


(Azurette (28)) 2


(Apri) 2


(Jasmiel (28)) 2


96



(Syeda) 2


2






2



2


2


1 GC


2


(Kelnor 135 (28)) 2


(Kelnor 1-50 (28)) 2





2


1 GC



2



2



2


2


1 GC





1 GC


97






2





2


1 GC


2



2



2



2



1 GC



2


2



2



2



2



2







2


98




2



2



2



1 GC


2


2



2


(Afirmelle) 2


(Altavera (28)) 2




(Enpresse) 2


2


2





2



2



2



2


1 GC


99



1 GC



2



1 GC


1 GC



2


2


2


(Camila) 1 GC


(Aurovela 1530 (21)) 2


(Aurovela 120 (21)) 2


(Gemmily) 2





2




(Tri-Estarylla) 2


(Femynor) 2


1 GC


2


2


100




2


2


2


2


2




2


2


2


2


1 GC



2





1 GC



2





4



2


2


2


101




2



1 GC



2



1 GC


2



2



1 GC



1 GC



1 GC



2



2



2



1 GC



2



2



1 GC



2


1 GC


2


2


102



2


2



2



2


2


2


2






2



2



2



2







(PreviDent) 1 GC


2



1 GC



1 GC


103







1 GC


(Oralone) 2


(isotretinoin) 2


2









2


(Skin Treatment) 2











5 NM NDS







104




2









5 NM NDS

























5 NM NDS


5 NM NDS




105



(isotretinoin) 2






(Clindacin ETZ) 2


(Neuac) 2


(Benzaclin) 2


2






(Benzamycin) 2









2






(Klaron) 2



106





2


2


2


2


2


(Luxiq) 2


2


2


2


2


2



2









2


(Olux-E) 2





107









3




(Synalar) 2






2


2


2


2


2
















108



1 GC


2


2






2


(hydrocortisone) 2


(hydrocortisone) 2


(hydrocortisone) 2


(hydrocortisone) 2




1 GC


(Triderm) 1 GC


2


1 GC


(Trianex) 2


2




4 PA



109



4



(Retin-A) 2 PA





























2


110




2



2



2



2



2



2



2



2










2


2


2


2


111



2


2


2


2


2


2



2


2


2



2



2


2



2


2


2


112




2



2



2





2



2



2



2



2


2


2


2


2








113







2



2



2



2


























114










2



2



2


2


2



2



2









2



2


115




2



2



2












2






2




2


2


116




2



2



2



2



2



2



2



2


2


2


2












117





2


2




2




1 GC






1 GC


1 GC


2


2



2



2


2


2


118



2


2


2



2



2



2



2



2


2



2



2



2


2




2


119















2




2


2



2



2



2



2



2



2


120



2



2



2


2



2












2


2



2



2



2



2


121






2



2


2



2


2



2


2


2


2


2


2



2



2



2


122




2


2


2


2


2


2


2



2


















2


123



2


2


2



2



2


2



2



2



2


2



2



2



2



2






124






2



2



2



2



2



2




2



2



2


2



2



2



2


125




2



2



2



2
















2














126




2



2



2



2





2



2



2



2



2


2







2




127






2








2












1 GC





2



2


2



2




128






2



2



2



2



2



2



2



2



2



2


2


2


2


2


129



2





2



2



2



2


2


2











2



2



2



2


130




2



2



2



2



2



2



2



2



2



2



2


2



2



2



2


2




131



2


2


3





3







2





2



2







2






132















2


2



2



2



2



2



2



2






133








2



2



2








2





2



2



2



2


2




2


134





2


2


2


2


2


2


2




2


2


2



2



2


135




2



2



2







2



2



2
















136




2



2



2



2



2


2


2


2


2


2


2


2


2


2


2



2



2


137




2



2



2




2










2







2



2



2



2


138




2



2


2



2


2



2


2







2



2



2


2


139




2



2













2



2



2


2



2












140




2



2



2



2



2



2



2



2



2



2



2


2



2



2



2


141




2



2














2


2





2



2



2



2


142




2


2


2


2


2


2


2


2


2


2


2


2


2



2



2



2


143



2





2



2



2



2



2



2


2


2


2












144




2



2



2



2





2



2



2



2



2



2



2



2










145










2



2



2



2



2



2



2



2



2














146









2


2




2












2


2



2


2


147




2










1 GC

V-GO 20 DEVICE 3

V-GO 30 DEVICE 3

V-GO 40 DEVICE 3


5 NM NDS


5 PA NM NDS


5 NM NDS


3


5 NM NDS


5 NM NDS


5 PA NM NDS




148



5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS



5 NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


(Kuvan) 5 NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 NM NDS


149



3


(proparacaine) 2


2


(Isopto Atropine) 4






2


(Bepreve) 2 ST


2


(Cyclogyl) 2






2






150






2



2


(Alcaine) 2


5 PA NM NDS



2


(Polycin) 2




(Ciloxan) 2






(Zymaxid) 2


(gentamicin) 2


1 GC


2


2


(Vigamox) 2


4


151



(Neo-Polycin HC) 2


(Neo-Polycin) 2


(Maxitrol) 2


(Maxitrol) 2


2


2


2


2



2



2


(Ocuflox) 2




2


(Polytrim) 1 GC


(Bleph-10) 2


152



2


2


(Tobrex) 2


(TobraDex) 2


2


4


3


3 ST


2


3


2


2


(Durezol) 2


(difluprednate) 3






(DermOtic Oil) 2


(FML Liquifilm) 4


153



2





3


3




3


3


(Lotemax) 2


(Lotemax) 2




(Pred Forte) 4


2


3










2


154



2


2


2






2


(Nexium IV) 2


1 GC


2


2


2








(Cytotec) 2


2


2


1 GC


1 GC


155





(Protonix) 2








5 NM NDS


(lactulose) 2


(Gastrocrom) 2





2


(Lomotil) 2



5 PA NM NDS



2


2


(Constulose) 2






156





2




2


2


2


2


(Reglan) 1 GC







5 PA NM NDS










(Buphenyl) 5 NM NDS


2


2


2




157






3







3




2


2


(Fosrenol) 5 NM NDS


4


(Renvela) 5 NM NDS


(Renvela) 2




3


2



158



3


2



(Ditropan XL) 2


2


(Detrol LA) 2



3


2





(Jalyn) 2




1 GC


5 PA NM NDS



(240 per 30 days)






159




(Exjade) 2 PA





2 PA


(Desferal) 2 PA


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





5 PA NM NDS


2


(Oxandrin) 2




2 PA






160












2




3


(Estrace) 1 GC






(Estrace) 2



(Delestrogen) 2


(Amabelz) 2




161




2


2




2


(Fyavolv) 2


3


3




3


3


3



2




2


2


(Decadron) 2


2


162



1 GC


1 GC


1 GC


1 GC









4


(Cortef) 2


(Depo-Medrol) 2


(Medrol) 2


(Medrol (Pak)) 2


2


(Solu-Medrol) 2


2 PA BvD


2 PA BvD


2 PA BvD





163



1 PA BvD GC


2


4


(Kenalog) 2




5 NM NDS


(DDAVP) 2


2


(DDAVP) 2






5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


5 NM NDS


164





5 PA NM NDS


2


(Sandostatin) 2


2


5 PA NSO NM NDS






5 NM NDS


5 PA NM NDS








165





5 PA NM NDS




5 NM NDS




5 PA NM NDS


(Makena) 5 NM NDS






(Provera) 1 GC


2


(Aygestin) 2


2


(Prometrium) 2


(Euthyrox) 1 GC



166



(Cytomel) 2




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 NM NDS


5 PA NM NDS



2 PA BvD


5 PA NM NDS






5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


167



5 PA NM NDS


5 PA NM NDS




(Gengraf) 2 PA BvD


2 PA BvD


(Gengraf) 2 PA BvD




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Zortress) 2 PA BvD




5 PA BvD NM NDS


5 PA NM NDS


168



5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA BvD NM NDS




5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


169



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS





(CellCept) 2 PA BvD


170





(CellCept) 2 PA BvD


5 PA BvD NM NDS


5 PA BvD NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA NM NDS


5 PA BvD NM NDS


4 PA BvD


4 PA BvD ST


3




171



5 PA NM NDS


5 PA NSO NM NDS


5 NM NDS


5 PA NM NDS





5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


(Prograf) 2 PA BvD


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


172



5 PA NM NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM LA NDS


5 PA NM NDS


5 PA NM NDS


5 PA NM NDS



5 PA BvD NM NDS


3


3


3


3


3


173



3


3


3




3 PA BvD


3 PA BvD


3 PA BvD






3


3


3 PA BvD


174



3


3


3


3


3


3


3


3


3


3


3


3


3


175



3


3


3 PA BvD


3 PA BvD


3 PA BvD


3


3





3


3


3


176



3


3


3


3



3


3


3




3





177





(Entocort EC) 2


5 ST NM NDS


(Cortenema) 4


(Delzicol) 2


(Apriso) 2


(Lialda) 2


(Asacol HD) 2


(Canasa) 2





3











2


(Rocaltrol) 2



178






2











2


2


(Zemplar) 2














179





5 PA NM NDS


2


2




5 PA NM NDS


2


5 NM NDS


5 NM NDS







5 PA NM NDS


5 PA NM LA NDS


5 NM NDS


3


180



3


2


(Vistaril) 1 GC




2


2


2


(Carnitor) 2



(Fusilev) 5 NM NDS


(Mesnex) 2


5 NM NDS


5 PA NM NDS


(Mestinon) 2


2


(Mestinon) 2








181





5 NM NDS








2


2


2


3


(brinzolamide) 2


2




(Alphagan P) 4


1 GC


2


3


(Trusopt) 2


(Cosopt) 2


182





1 GC




2


2


(Isopto Carpine) 2


2






3


(Timoptic) 1 GC


(Timoptic-XE) 4










2


4


183



4


4


4


4








2


2 PA BvD


2 PA BvD


2 PA BvD


4


4


4


1 PA BvD GC


184



2 PA BvD


2


2


(K-Tab) 2


(Klor-Con M10) 2


(Klor-Con M15) 2


(Klor-Con M20) 2


2


(Urocit-K 10) 2


(Urocit-K 15) 2


(Urocit-K 5) 2


2


2


2


4





185



























186







(Singulair) 1 GC


30 days)












2


2


2






187












1 GC













5 NM NDS


2


2


188



2




(Acetadote) 2


2 PA BvD




5 PA NM NDS


2 PA BvD






















189













5 PA BvD NM NDS


5 PA BvD NM NDS






5 PA NM NDS


5 PA NM NDS


2




1 GC



(Dantrium) 2


190



2


(dantrolene) 2































191


















5 PA NM NDS








5 PA NM NDS


192

INDEX




I-1




I-2




I-3




I-4




I-5




I-6




I-7




I-8




I-9




I-10




I-11




I-12




I-13




I-14




I-15




I-16




I-17




I-18




I-19




Y0027_22-219_C

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