Page 1
PMAP MnCare MSC+ SNBC_010518_1 DHS Approved (01102018) U7483 (01/18)
Specialty Pharmacy Drug List Specialty medicines are usually prescribed by doctors who treat chronic and complex disease. These medications usually require a higher degree of management, are high in cost and are generally not stocked at retail pharmacies. Fairview Specialty Pharmacy is the exclusive network provider of specialty drugs for UCare State Public Program (Medicaid) members. Phone: 612-672-5260 or 1-800-595-7140 (toll free). A Fairview pharmacist is available 24 hours a day. Fax: 1-866-347-4939. The list below applies to State Public Programs and is updated regularly. Drugs with a Non-Formulary status may be covered under your medical benefit. Please go to ucare.org to review coverage criteria.
F = Formulary, NF = Non-Formulary
DRUG FORMULARY STATUS
ABRAXANE 100 MG VIAL NF
ACTEMRA 162 MG/0.9 ML SYRINGE
NF
ACTEMRA 200 MG/10 ML VIAL NF
ACTEMRA 400 MG/20 ML VIAL NF
ACTEMRA 80 MG/4 ML VIAL NF
ACTIMMUNE 100 MCG/0.5 ML VIAL
NF
ADCETRIS 50 MG VIAL NF
ADCIRCA 20 MG TABLET NF
ADEFOVIR DIPIVOXIL 10 MG TAB
F
ADVATE 1,201-1,800 UNIT VIAL
F
ADVATE 1,801-2,400 UNIT VIAL
F
ADVATE 2,401-3,600 UNIT VIAL
F
ADVATE 200-400 UNIT VIAL F
ADVATE 3,601-4,800 UNIT VIAL
F
ADVATE 401-800 UNIT VIAL F
ADVATE 801-1,200 UNIT VIAL F
DRUG FORMULARY STATUS
AFINITOR 10 MG TABLET F
AFINITOR 2.5 MG TABLET F
AFINITOR 5 MG TABLET F
AFINITOR 7.5 MG TABLET F
AFINITOR DISPERZ 2 MG TABLET
F
AFINITOR DISPERZ 3 MG TABLET
F
AFINITOR DISPERZ 5 MG TABLET
F
AFSTYLA 1,000 UNIT VIAL F
AFSTYLA 1,500 UNIT RANGE VIAL
F
AFSTYLA 2,000 UNIT VIAL F
AFSTYLA 2,500 UNIT RANGE VIAL
F
AFSTYLA 250 UNIT VIAL F
AFSTYLA 3,000 UNIT VIAL F
AFSTYLA 500 UNIT VIAL F
ALDURAZYME 2.9 MG/5 ML VIAL
NF
ALECENSA 150 MG CAPSULE F
Page 2
DRUG FORMULARY STATUS
ALFERON N 5 MILLION UNITS VIAL
NF
ALIMTA 100 MG VIAL NF
ALIMTA 500 MG VIAL NF
ALKERAN 2 MG TABLET NF
ALKERAN 50 MG VIAL NF
ALPHANATE 1,000-400 UNIT VIAL
F
ALPHANATE 1,500-600 UNIT VIAL
F
ALPHANATE 2,000-800 UNIT VIAL
NF
ALPHANATE 250-100 UNIT VIAL
F
ALPHANATE 500-200 UNIT VIAL
F
ALPHANINE SD 1,000 UNITS VIAL
NF
ALPHANINE SD 1,500 UNITS VIAL
NF
ALPHANINE SD 500 UNITS VIAL
NF
ARALAST NP 1,000 MG VIAL NF
ARALAST NP 500 MG VIAL NF
ARANESP 10 MCG/0.4 ML SYRINGE
F
ARANESP 100 MCG/0.5 ML SYRINGE
F
ARANESP 100 MCG/ML VIAL F
ARANESP 150 MCG/0.3 ML SYRINGE
F
ARANESP 150 MCG/0.75 ML VIAL
F
ARANESP 200 MCG/0.4 ML SYRINGE
F
ARANESP 200 MCG/ML VIAL F
ARANESP 25 MCG/0.42 ML SYRING
F
ARANESP 25 MCG/ML VIAL F
DRUG FORMULARY STATUS
ARANESP 300 MCG/0.6 ML SYRINGE
F
ARANESP 300 MCG/ML VIAL F
ARANESP 40 MCG/0.4 ML SYRINGE
F
ARANESP 40 MCG/ML VIAL F
ARANESP 500 MCG/1 ML SYRINGE
F
ARANESP 60 MCG/0.3 ML SYRINGE
F
ARANESP 60 MCG/ML VIAL F
ARIXTRA 10 MG/0.8 ML SYRINGE
NF
ARIXTRA 2.5 MG/0.5 ML SYRINGE
NF
ARIXTRA 5 MG/0.4 ML SYRINGE
NF
ARIXTRA 7.5 MG/0.6 ML SYRINGE
NF
ARRANON 250 MG/50 ML VIAL NF
ARZERRA 1,000 MG/50 ML VIAL
NF
ARZERRA 100 MG/5 ML VIAL NF
ASTAGRAF XL 0.5 MG CAPSULE
NF
ASTAGRAF XL 1 MG CAPSULE NF
ASTAGRAF XL 5 MG CAPSULE NF
ATGAM 50 MG/ML AMPUL F
AVASTIN 100 MG/4 ML VIAL NF
AVASTIN 400 MG/16 ML VIAL NF
AVONEX 30 MCG VIAL KIT F
AVONEX PEN 30 MCG/0.5 ML KIT
F
AVONEX PREFILLED SYR 30 MCG
F
AVONEX PREFILLED SYR 30 MCG KT
F
Page 3
DRUG FORMULARY STATUS
BARACLUDE 0.05 MG/ML SOLUTION
F
BARACLUDE 0.5 MG TABLET NF
BARACLUDE 1 MG TABLET NF
BCG (TICE STRAIN) VIAL NF
BCG VACCINE (TICE STRAIN) VIAL
NF
BEBULIN 200-1,200 UNITS VIAL
NF
BENEFIX 1,000 UNIT RANGE NF
BENEFIX 2,000 UNIT RANGE NF
BENEFIX 250 UNIT RANGE NF
BENEFIX 3,000 UNIT RANGE NF
BENEFIX 500 UNIT RANGE NF
BENLYSTA 120 MG VIAL NF
BENLYSTA 200 MG/ML AUTOINJECT
NF
BENLYSTA 200 MG/ML SYRINGE
NF
BENLYSTA 400 MG VIAL NF
BERINERT 500 UNIT KIT NF
BETASERON 0.3 MG KIT F
BETHKIS 300 MG/4 ML AMPULE
NF
BICNU 100 MG VIAL NF
BIVIGAM LIQUID 10% VIAL NF
BOTOX 100 UNITS VIAL NF
BOTOX 200 UNITS VIAL NF
BOTOX COSMETIC 100 UNITS VIAL
NF
BOTOX COSMETIC 50 UNITS VIAL
NF
BRAVELLE 75 UNIT VIAL NF
BUSULFEX 60 MG/10 ML VIAL NF
CALCIUM FOLINATE 10 MG/ML VIAL
F
DRUG FORMULARY STATUS
CALCIUM FOLINATE POWDER NF
CAMPTOSAR 100 MG/5 ML VIAL
NF
CAMPTOSAR 300 MG/15 ML VIAL
NF
CAMPTOSAR 40 MG/2 ML VIAL
NF
CAPECITABINE 150 MG TABLET
F
CAPECITABINE 500 MG TABLET
F
CARIMUNE NF 12 GM VIAL NF
CARIMUNE NF 6 GM VIAL NF
CELLCEPT 200 MG/ML ORAL SUSP
NF
CELLCEPT 250 MG CAPSULE NF
CELLCEPT 500 MG TABLET NF
CELLCEPT 500 MG VIAL NF
CEREZYME 400 UNITS VIAL NF
CETROTIDE 0.25 MG KIT NF
CIMZIA 200 MG VIAL KIT NF
CIMZIA 200 MG/ML STARTER KIT
NF
CIMZIA 200 MG/ML SYRINGE KIT
NF
CLOLAR 20 MG/20 ML VIAL NF
COPAXONE 20 MG/ML SYRINGE
NF
COPAXONE 40 MG/ML SYRINGE
F
COPEGUS 200 MG TABLET NF
COSENTYX 150 MG/ML PEN INJECT
F
COSENTYX 150 MG/ML SYRINGE
F
COSENTYX 300 MG DOSE-2 PENS
F
Page 4
DRUG FORMULARY STATUS
COSENTYX 300 MG DOSE-2 SYRINGE
F
COSMEGEN 0.5 MG VIAL NF
CYTOGAM 2.5 GM/50 ML VIAL NF
DACOGEN 50 MG VIAL NF
DAKLINZA 30 MG TABLET NF
DAKLINZA 60 MG TABLET NF
DAKLINZA 90 MG TABLET NF
DAUNOXOME 50 MG (2 MG/ML) VIAL
NF
DDAVP 0.01% NASAL SPRAY NF
DDAVP 0.1 MG TABLET NF
DDAVP 0.2 MG TABLET NF
DDAVP 10 MCG/0.1 ML SOLUTION
NF
DDAVP 4 MCG/ML AMPUL NF
DDAVP 4 MCG/ML VIAL NF
DEPOCYT 50 MG/5 ML VIAL NF
DESFERAL 2 GRAM VIAL NF
DESFERAL MESYLATE 500 MG VL
NF
DOCEFREZ 20 MG VIAL NF
DOCEFREZ 80 MG VIAL NF
DOXIL 2 MG/ML VIAL NF
DUPIXENT 300 MG/2 ML SAFE SYRG
F
DYSPORT 300 UNIT VIAL NF
DYSPORT 500 UNITS VIAL NF
ELAPRASE 6 MG/3 ML VIAL NF
ELIGARD 22.5 MG SYRINGE KIT
NF
ELIGARD 30 MG SYRINGE KIT NF
ELIGARD 45 MG SYRINGE KIT NF
ELIGARD 7.5 MG SYRINGE KIT NF
DRUG FORMULARY STATUS
ELITEK 1.5 MG VIAL NF
ELITEK 7.5 MG VIAL NF
ELLENCE 2 MG/ML VIAL NF
ELOCTATE 1,000 UNIT NOMINAL
F
ELOCTATE 1,500 UNIT NOMINAL
F
ELOCTATE 2,000 UNIT NOMINAL
F
ELOCTATE 250 UNIT NOMINAL
F
ELOCTATE 3,000 UNIT NOMINAL
F
ELOCTATE 4,000 UNIT NOMINAL
F
ELOCTATE 5,000 UNIT NOMINAL
F
ELOCTATE 500 UNIT NOMINAL
F
ELOCTATE 6,000 UNIT NOMINAL
F
ELOCTATE 750 UNIT NOMINAL
F
ELOXATIN 100 MG/20 ML VIAL NF
ELOXATIN 50 MG/10 ML VIAL NF
ELSPAR 10,000 UNITS VIAL NF
ENBREL 25 MG KIT F
ENBREL 25 MG/0.5 ML SYRINGE
F
ENBREL 50 MG/ML MINI CARTRIDGE
F
ENBREL 50 MG/ML SURECLICK SYR
F
ENBREL 50 MG/ML SYRINGE F
ENTECAVIR 0.5 MG TABLET F
ENTECAVIR 1 MG TABLET F
ENTYVIO 300 MG VIAL NF
Page 5
DRUG FORMULARY STATUS
ENVARSUS XR 0.75 MG TABLET
NF
ENVARSUS XR 1 MG TABLET NF
ENVARSUS XR 4 MG TABLET NF
EPCLUSA 400 MG-100 MG TABLET
NF
EPIVIR HBV 100 MG TABLET NF
EPIVIR HBV 25 MG/5 ML SOLN F
EPOGEN 10,000 UNITS/ML VIAL
F
EPOGEN 2,000 UNITS/ML VIAL F
EPOGEN 20,000 UNITS/2 ML VIAL
F
EPOGEN 20,000 UNITS/ML VIAL
F
EPOGEN 3,000 UNITS/ML VIAL F
EPOGEN 4,000 UNITS/ML VIAL F
ERBITUX 100 MG/50 ML VIAL NF
ERBITUX 200 MG/100 ML VIAL NF
ESBRIET 267 MG CAPSULE F
ESBRIET 267 MG TABLET F
ESBRIET 801 MG TABLET F
ETOPOPHOS 100 MG VIAL NF
EUFLEXXA 20 MG/2 ML SYRINGE
F
EVOMELA 50 MG VIAL NF
EXJADE 125 MG TABLET F
EXJADE 250 MG TABLET F
EXJADE 500 MG TABLET F
EXTAVIA 0.3 MG KIT F
EXTAVIA 0.3 MG VIAL NF
FABRAZYME 35 MG VIAL F
FABRAZYME 5 MG VIAL F
FASLODEX 250 MG/5 ML SYRINGE
F
DRUG FORMULARY STATUS
FEIBA NF 1,000 UNIT (NOMINAL)
F
FEIBA NF 1,750-3,250 UNIT VIAL
F
FEIBA NF 2,500 UNIT (NOMINAL)
F
FEIBA NF 400-650 UNIT VIAL F
FEIBA NF 500 UNIT (NOMINAL)
F
FIRAZYR 30 MG/3 ML SYRINGE
F
FIRMAGON 2 X 120 MG KIT F
FIRMAGON 2 X 120 MG VIALS F
FIRMAGON 80 MG KIT F
FIRMAGON 80 MG VIAL F
FLEBOGAMMA DIF 10% VIAL NF
FLEBOGAMMA DIF 5% VIAL NF
FLOXURIDINE 500 MG VIAL F
FLOXURIDINE POWDER NF
FOLLISTIM AQ 150 UNIT VIAL NF
FOLLISTIM AQ 300 UNIT CARTRIDG
NF
FOLLISTIM AQ 600 UNIT CARTRIDG
NF
FOLLISTIM AQ 75 UNIT VIAL NF
FOLLISTIM AQ 900 UNIT CARTRIDG
NF
FOLOTYN 20 MG/ML VIAL NF
FOLOTYN 40 MG/2 ML VIAL NF
FORTEO 600 MCG/2.4 ML PEN INJ
F
FRAGMIN 10,000 UNITS/ML SYRING
NF
FRAGMIN 12,500 UNITS/0.5 ML NF
FRAGMIN 15,000 UNITS/0.6 ML NF
FRAGMIN 18,000 UNITS/0.72 ML
NF
Page 6
DRUG FORMULARY STATUS
FRAGMIN 2,500 UNITS/0.2 ML SYR
NF
FRAGMIN 25,000 UNITS/ML VIAL
NF
FRAGMIN 5,000 UNITS/0.2 ML SYR
NF
FRAGMIN 7,500 UNITS/0.3 ML SYR
NF
FRAGMIN 95,000 UNITS/3.8 ML VL
NF
FUZEON 90 MG VIAL F
GAMASTAN S-D VIAL F
GAMMAGARD LIQUID 10% VIAL
F
GAMMAGARD S-D 10 G (IGA<1) SOL
F
GAMMAGARD S-D 5 G (IGA<1) SOLN
F
GAMMAKED 1 GRAM/10 ML VIAL
NF
GAMMAKED 10 GRAM/100 ML VIAL
NF
GAMMAKED 2.5 GRAM/25 ML VIAL
NF
GAMMAKED 20 GRAM/200 ML VIAL
NF
GAMMAKED 5 GRAM/50 ML VIAL
NF
GAMMAPLEX 10 GRAM/100 ML VIAL
NF
GAMMAPLEX 10 GRAM/200 ML VIAL
F
GAMMAPLEX 2.5 GRAM/50 ML VIAL
F
GAMMAPLEX 20 GRAM/200 ML VIAL
NF
GAMMAPLEX 20 GRAM/400 ML VIAL
F
GAMMAPLEX 5 GRAM/100 ML VIAL
F
DRUG FORMULARY STATUS
GAMMAPLEX 5 GRAM/50 ML VIAL
NF
GAMUNEX-C 1 GRAM/10 ML VIAL
F
GAMUNEX-C 10 GRAM/100 ML VIAL
F
GAMUNEX-C 2.5 GRAM/25 ML VIAL
F
GAMUNEX-C 20 GRAM/200 ML VIAL
F
GAMUNEX-C 40 GRAM/400 ML VIAL
NF
GAMUNEX-C 5 GRAM/50 ML VIAL
F
GANIRELIX ACET 250 MCG/0.5 ML
NF
GAZYVA 1,000 MG/40 ML VIAL NF
GEL-ONE 30 MG/3 ML SYRINGE
NF
GEMZAR 1 GRAM VIAL NF
GEMZAR 200 MG VIAL NF
GENOTROPIN 12 MG CARTRIDGE
F
GENOTROPIN 5 MG CARTRIDGE
F
GENOTROPIN MINIQUICK 0.2 MG
F
GENOTROPIN MINIQUICK 0.4 MG
F
GENOTROPIN MINIQUICK 0.6 MG
F
GENOTROPIN MINIQUICK 0.8 MG
F
GENOTROPIN MINIQUICK 1 MG
F
GENOTROPIN MINIQUICK 1.2 MG
F
GENOTROPIN MINIQUICK 1.4 MG
F
GENOTROPIN MINIQUICK 1.6 MG
F
Page 7
DRUG FORMULARY STATUS
GENOTROPIN MINIQUICK 1.8 MG
F
GENOTROPIN MINIQUICK 2 MG
F
GILENYA 0.5 MG CAPSULE F
GLATIRAMER 20 MG/ML SYRINGE
F
GLATIRAMER 40 MG/ML SYRINGE
F
GLATOPA 20 MG/ML SYRINGE F
GLEEVEC 100 MG TABLET NF
GLEEVEC 400 MG TABLET NF
GONAL-F 1,050 UNITS VIAL NF
GONAL-F 450 UNITS VIAL NF
GONAL-F RFF 75 UNITS VIAL NF
GONAL-F RFF REDI-JECT 300 UNIT
NF
GONAL-F RFF REDI-JECT 450 UNIT
NF
GONAL-F RFF REDI-JECT 900 UNIT
NF
GRANIX 300 MCG/0.5 ML SAFE SYR
NF
GRANIX 300 MCG/0.5 ML SYRINGE
NF
GRANIX 480 MCG/0.8 ML SAFE SYR
NF
GRANIX 480 MCG/0.8 ML SYRINGE
NF
HALAVEN 1 MG/2 ML VIAL NF
HARVONI 90-400 MG TABLET NF
HELIXATE FS 1,000 UNIT VIAL F
HELIXATE FS 2,000 UNIT VIAL F
HELIXATE FS 250 UNIT VIAL F
HELIXATE FS 3,000 UNITS VIAL
F
HELIXATE FS 500 UNIT VIAL F
DRUG FORMULARY STATUS
HEMOFIL M 1,000 UNIT NOMINAL
NF
HEMOFIL M 1,700 UNIT NOMINAL
NF
HEMOFIL M 250 UNIT NOMINAL
NF
HEMOFIL M 500 UNIT NOMINAL
NF
HEPSERA 10 MG TABLET NF
HERCEPTIN 150 MG VIAL NF
HERCEPTIN 440 MG VIAL NF
HIZENTRA 1 GRAM/5 ML VIAL F
HIZENTRA 10 GRAM/50 ML VIAL
F
HIZENTRA 2 GRAM/10 ML VIAL
F
HIZENTRA 4 GRAM/20 ML VIAL
F
HP ACTHAR GEL 80 UNIT/ML VIAL
NF
HUMATE-P 1,200 UNIT VWF:RCO
NF
HUMATE-P 2,400 UNIT VWF:RCO
NF
HUMATE-P 600 UNIT VWF:RCO NF
HUMATROPE 12 MG CARTRIDGE
F
HUMATROPE 24 MG CARTRIDGE
F
HUMATROPE 5 MG VIAL F
HUMATROPE 6 MG CARTRIDGE
F
HUMIRA 10 MG/0.2 ML SYRINGE
F
HUMIRA 20 MG/0.4 ML SYRINGE
F
HUMIRA 40 MG/0.8 ML PEN F
HUMIRA 40 MG/0.8 ML SYRINGE
F
Page 8
DRUG FORMULARY STATUS
HUMIRA PEDIATRIC CROHN'S START
F
HUMIRA PEN CROHN-UC-HS STARTER
F
HUMIRA PEN PSORIASIS-UVEITIS
F
HYALGAN 20 MG/2 ML SYRINGE
NF
HYALGAN 20 MG/2 ML VIAL NF
HYCAMTIN 0.25 MG CAPSULE NF
HYCAMTIN 1 MG CAPSULE NF
HYCAMTIN 4 MG VIAL NF
HYPERHEP B S-D NEONATAL SYRIN.
F
HYPERHEP B S-D SYRINGE F
HYPERHEP B S-D VIAL F
HYPERRAB S-D 150 UNITS/ML VIAL
F
HYPERRHO S-D 1500 UNITS SYR
F
HYPERRHO S-D 250 UNITS SYRINGE
F
HYQVIA 10 GM-800 UNIT PACK
NF
HYQVIA 2.5 GM-200 UNIT PACK
NF
HYQVIA 20 GM-1,600 UNIT PACK
NF
HYQVIA 30 GM-2,400 UNIT PACK
NF
HYQVIA 5 GM-400 UNIT PACK NF
IDAMYCIN PFS 1 MG/ML VIAL NF
IDELVION 1,000 UNIT VIAL F
IDELVION 2,000 UNIT VIAL F
IDELVION 250 UNIT VIAL F
IDELVION 500 UNIT VIAL F
IFEX 1 GM VIAL NF
DRUG FORMULARY STATUS
IFEX 3 GM VIAL NF
IMATINIB MESYLATE 100 MG TAB
F
IMATINIB MESYLATE 400 MG TAB
F
IMFINZI 120 MG/2.4 ML VIAL F
IMFINZI 500 MG/10 ML VIAL F
IMOGAM RABIES-HT 150 UNIT/ML
NF
INCIVEK 375 MG TABLET F
INFLECTRA 100 MG VIAL NF
INTRON A 10 MILLION UNITS VIAL
F
INTRON A 18 MILLION UNIT/3 ML
F
INTRON A 18 MILLION UNITS VIAL
F
INTRON A 25 MILLION UNIT/2.5ML
F
INTRON A 50 MILLION UNITS VIAL
F
IPRIVASK 15 MG VIAL NF
IRESSA 250 MG TABLET F
ISTODAX 10 MG KIT NF
IXEMPRA 15 MG KIT NF
IXEMPRA 45 MG KIT NF
IXINITY 1,000 UNIT RANGE F
IXINITY 1,000 UNIT RANGE-2 VLS
F
IXINITY 1,000 UNIT VIAL F
IXINITY 1,000 UNIT VIAL -2 VLS
F
IXINITY 1,500 UNIT RANGE F
IXINITY 1,500 UNIT RANGE-2 VLS
F
IXINITY 1,500 UNIT VIAL F
Page 9
DRUG FORMULARY STATUS
IXINITY 1,500 UNIT VIAL -2 VLS
F
IXINITY 2,000 UNIT RANGE F
IXINITY 250 UNIT RANGE F
IXINITY 3,000 UNIT RANGE F
IXINITY 500 UNIT RANGE F
IXINITY 500 UNIT VIAL F
JADENU 180 MG TABLET NF
JADENU 360 MG TABLET NF
JADENU 90 MG TABLET NF
JAKAFI 10 MG TABLET F
JAKAFI 15 MG TABLET F
JAKAFI 20 MG TABLET F
JAKAFI 25 MG TABLET F
JAKAFI 5 MG TABLET F
JEVTANA 60 MG/1.5 ML KIT NF
KADCYLA 100 MG VIAL F
KADCYLA 160 MG VIAL F
KALYDECO 150 MG TABLET F
KALYDECO 50 MG GRANULES PACKET
NF
KALYDECO 75 MG GRANULES PACKET
NF
KANUMA 20 MG/10 ML VIAL NF
KEVZARA 150 MG/1.14 ML SYRINGE
NF
KEVZARA 200 MG/1.14 ML SYRINGE
NF
KISQALI 200 MG DAILY DOSE NF
KISQALI 400 MG DAILY DOSE NF
KISQALI 600 MG DAILY DOSE NF
KITABIS PAK 300 MG/5 ML NF
KOATE 1,000 UNIT VIAL NF
KOATE 250 UNIT VIAL NF
DRUG FORMULARY STATUS
KOATE 500 UNIT VIAL NF
KOATE-DVI 1,000 UNIT VIAL NF
KOATE-DVI 250 UNIT VIAL NF
KOATE-DVI 500 UNIT VIAL NF
KOGENATE FS 1,000 UNIT-BIOSET
NF
KOGENATE FS 1,000 UNITS VIAL
NF
KOGENATE FS 2,000 UNIT VIAL
NF
KOGENATE FS 2,000 UNIT-BIOSET
NF
KOGENATE FS 250 UNIT VIAL NF
KOGENATE FS 250 UNIT VL-BIOSET
NF
KOGENATE FS 3,000 UNIT-BIOSET
NF
KOGENATE FS 3,000 UNITS VIAL
NF
KOGENATE FS 500 UNIT VIAL NF
KOGENATE FS 500 UNIT VL-BIOSET
NF
KOVALTRY 1,000 UNIT KIT F
KOVALTRY 1,000 UNIT VIAL F
KOVALTRY 2,000 UNIT KIT F
KOVALTRY 2,000 UNIT VIAL F
KOVALTRY 250 UNIT KIT F
KOVALTRY 250 UNIT VIAL F
KOVALTRY 3,000 UNIT KIT F
KOVALTRY 3,000 UNIT VIAL F
KOVALTRY 500 UNIT KIT F
KOVALTRY 500 UNIT VIAL F
KRYSTEXXA 8 MG/ML VIAL F
KUVAN 100 MG POWDER PACKET
NF
KUVAN 100 MG TABLET NF
Page 10
DRUG FORMULARY STATUS
KUVAN 500 MG POWDER PACKET
NF
KYPROLIS 30 MG VIAL NF
KYPROLIS 60 MG VIAL NF
LEUKINE 250 MCG VIAL F
LOVENOX 100 MG/ML SYRINGE
NF
LOVENOX 120 MG/0.8 ML SYRINGE
NF
LOVENOX 150 MG/ML SYRINGE
NF
LOVENOX 30 MG/0.3 ML SYRINGE
NF
LOVENOX 300 MG/3 ML VIAL NF
LOVENOX 40 MG/0.4 ML SYRINGE
NF
LOVENOX 60 MG/0.6 ML SYRINGE
NF
LOVENOX 80 MG/0.8 ML SYRINGE
NF
LUMIZYME 50 MG VIAL F
LUPANETA PK 11.25-5 MG 3MO KIT
NF
LUPANETA PK 3.75-5 MG 1MO KIT
NF
LUPRON DEPOT 11.25 MG 3MO KIT
F
LUPRON DEPOT 22.5 MG 3MO KIT
F
LUPRON DEPOT 3.75 MG KIT F
LUPRON DEPOT 45 MG 6MO KIT
NF
LUPRON DEPOT 7.5 MG KIT F
LUPRON DEPOT-4 MONTH KIT F
LUPRON DEPOT-PED 11.25 MG 3MO
NF
LUPRON DEPOT-PED 11.25 MG KIT
F
DRUG FORMULARY STATUS
LUPRON DEPOT-PED 15 MG KIT
F
LUPRON DEPOT-PED 30 MG 3MO KIT
NF
LUPRON DEPOT-PED 7.5 MG KIT
F
LYNPARZA 100 MG TABLET F
LYNPARZA 150 MG TABLET F
LYNPARZA 50 MG CAPSULE F
MAKENA 1,250 MG/5 ML VIAL F
MAKENA 250 MG/ML VIAL F
MAVYRET 100-40 MG TABLET F
MEKINIST 0.5 MG TABLET F
MEKINIST 2 MG TABLET F
MENOPUR 75 UNIT VIAL NF
MESNEX 1 GRAM/10 ML VIAL NF
MESNEX 400 MG TABLET F
MODERIBA 200 MG TABLET NF
MODERIBA 200-400 MG DOSEPACK
NF
MODERIBA 400-400 MG DOSEPACK
NF
MODERIBA 600-400 MG DOSEPACK
NF
MODERIBA 600-600 MG DOSEPACK
NF
MONOCLATE-P 1,000 UNIT KIT NF
MONOCLATE-P 1,500 UNIT KIT NF
MONOCLATE-P 250 UNIT KIT NF
MONOCLATE-P 500AHFU KIT NF
MONONINE 1,000 UNIT VIAL NF
MONOVISC 88 MG/4 ML SYRINGE
NF
MOZOBIL 24 MG/1.2 ML VIAL F
MUGARD ORAL WOUND RINSE
NF
Page 11
DRUG FORMULARY STATUS
MUSTARGEN 10 MG VIAL NF
MYCOPHENOLIC ACID DR 180 MG TB
F
MYCOPHENOLIC ACID DR 360 MG TB
F
MYFORTIC 180 MG TABLET NF
MYFORTIC 360 MG TABLET NF
MYOBLOC 10,000 UNITS/2 ML VIAL
NF
MYOBLOC 2,500 UNIT/0.5 ML VIAL
NF
MYOBLOC 5,000 UNITS/1 ML VIAL
NF
MYOZYME 50 MG VIAL F
NABI-HB VIAL NF
NAGLAZYME 5 MG/5 ML VIAL NF
NAVELBINE 10 MG/ML VIAL NF
NAVELBINE 50 MG/5 ML VIAL NF
NEBUPENT 300 MG INHAL POWDER
F
NEORAL 100 MG GELATIN CAPSULE
F
NEORAL 100 MG/ML SOLUTION
F
NEORAL 25 MG GELATIN CAPSULE
F
NEULASTA 6 MG/0.6 ML SYRINGE
F
NEULASTA ONPRO 6 MG/0.6 ML KIT
F
NEUMEGA 5 MG VIAL F
NEUPOGEN 300 MCG/0.5 ML SYR
F
NEUPOGEN 300 MCG/ML VIAL F
NEUPOGEN 480 MCG/0.8 ML SYR
F
NEUPOGEN 480 MCG/1.6 ML VIAL
F
DRUG FORMULARY STATUS
NEXPLANON 68 MG IMPLANT F
NINLARO 2.3 MG CAPSULE F
NINLARO 3 MG CAPSULE F
NINLARO 4 MG CAPSULE F
NIPENT 10 MG VIAL NF
NORDITROPIN FLEXPRO 10 MG/1.5
NF
NORDITROPIN FLEXPRO 15 MG/1.5
NF
NORDITROPIN FLEXPRO 30 MG/3 ML
NF
NORDITROPIN FLEXPRO 5 MG/1.5
NF
NORDITROPIN NORDIFLEX 30 MG/3
NF
NOVOSEVEN RT 1 MG VIAL NF
NOVOSEVEN RT 2 MG VIAL NF
NOVOSEVEN RT 5 MG VIAL NF
NOVOSEVEN RT 8 MG VIAL NF
NPLATE 250 MCG VIAL NF
NPLATE 500 MCG VIAL NF
NULOJIX 250 MG VIAL NF
NUTROPIN AQ 20 MG/2ML PEN CART
F
NUTROPIN AQ NUSPIN 10 INJECTOR
F
NUTROPIN AQ NUSPIN 20 INJECTOR
F
NUTROPIN AQ NUSPIN 5 INJECTOR
F
NUTROPIN AQ PEN CARTRIDGE
F
NUWIQ 1,000 UNIT VIAL F
NUWIQ 1,000 UNIT VIAL PACK F
NUWIQ 2,000 UNIT VIAL F
NUWIQ 2,000 UNIT VIAL PACK F
Page 12
DRUG FORMULARY STATUS
NUWIQ 2,500 UNIT VIAL F
NUWIQ 2,500 UNIT VIAL PACK F
NUWIQ 250 UNIT VIAL F
NUWIQ 250 UNIT VIAL PACK F
NUWIQ 3,000 UNIT VIAL F
NUWIQ 3,000 UNIT VIAL PACK F
NUWIQ 4,000 UNIT VIAL F
NUWIQ 4,000 UNIT VIAL PACK F
NUWIQ 500 UNIT VIAL F
NUWIQ 500 UNIT VIAL PACK F
OCTAGAM 10% VIAL NF
OCTAGAM 5% VIAL NF
OCTREOTIDE 1,000 MCG/5 ML VIAL
F
OCTREOTIDE 1,000 MCG/ML VIAL
F
OCTREOTIDE 5,000 MCG/5 ML VIAL
F
OCTREOTIDE ACET 0.05 MG/ML VL
F
OCTREOTIDE ACET 100 MCG/ML AMP
F
OCTREOTIDE ACET 100 MCG/ML SYR
F
OCTREOTIDE ACET 100 MCG/ML VL
F
OCTREOTIDE ACET 200 MCG/ML VL
F
OCTREOTIDE ACET 50 MCG/ML AMP
F
OCTREOTIDE ACET 50 MCG/ML SYR
F
OCTREOTIDE ACET 50 MCG/ML VIAL
F
OCTREOTIDE ACET 500 MCG/ML AMP
F
OCTREOTIDE ACET 500 MCG/ML SYR
F
DRUG FORMULARY STATUS
OCTREOTIDE ACET 500 MCG/ML VL
F
ODOMZO 200 MG CAPSULE NF
OLYSIO 150 MG CAPSULE NF
OMNITROPE 10 MG/1.5 ML CRTG
NF
OMNITROPE 5 MG/1.5 ML CRTG
NF
OMNITROPE 5.8 MG VIAL NF
ONCASPAR 3,750 UNIT/5 ML VIAL
NF
ONCASPAR 750 UNIT/ML VIAL NF
ORAFATE 1 GM/10 ML PASTE NF
ORENCIA 125 MG/ML SYRINGE
F
ORENCIA 250 MG VIAL F
ORENCIA 50 MG/0.4 ML SYRINGE
F
ORENCIA 87.5 MG/0.7 ML SYRINGE
F
ORENCIA CLICKJECT 125 MG/ML
F
ORKAMBI 100 MG-125 MG TABLET
F
ORKAMBI 200 MG-125 MG TABLET
F
ORTHOVISC 15 MG/ML SYRINGE
NF
OTEZLA 28 DAY STARTER PACK
F
OTEZLA 30 MG TABLET F
OTEZLA STARTER PACK F
OVIDREL 250 MCG/0.5 ML SYRG
NF
PEGASYS 180 MCG/0.5 ML SYRINGE
F
PEGASYS 180 MCG/ML VIAL F
PEGASYS PROCLICK 135 MCG/0.5
F
Page 13
DRUG FORMULARY STATUS
PEGASYS PROCLICK 180 MCG/0.5
F
PEGINTRON 120 MCG KIT NF
PEGINTRON 150 MCG KIT NF
PEGINTRON 50 MCG KIT NF
PEGINTRON 80 MCG KIT NF
PEGINTRON REDIPEN 120 MCG
NF
PEGINTRON REDIPEN 120 MCG 4PK
NF
PEGINTRON REDIPEN 150 MCG
NF
PEGINTRON REDIPEN 150 MCG 4PK
NF
PEGINTRON REDIPEN 50 MCG NF
PEGINTRON REDIPEN 50 MCG 4PK
NF
PEGINTRON REDIPEN 80 MCG NF
PEGINTRON REDIPEN 80 MCG 4PK
NF
PERJETA 420 MG/14 ML VIAL NF
PHOTOFRIN 75 MG VIAL NF
PLEGRIDY 125 MCG/0.5 ML PEN
F
PLEGRIDY 125 MCG/0.5 ML SYRING
F
PLEGRIDY PEN INJ STARTER PACK
F
PLEGRIDY SYRINGE STARTER PACK
F
PRALUENT 150 MG/ML PEN F
PRALUENT 75 MG/ML PEN F
PREGNYL 10,000 UNITS VIAL NF
PRIALT 100 MCG/ML VIAL NF
PRIALT 25 MCG/ML VIAL NF
PRIVIGEN 10% VIAL F
DRUG FORMULARY STATUS
PROCRIT 10,000 UNITS/ML VIAL
F
PROCRIT 2,000 UNITS/ML VIAL F
PROCRIT 20,000 UNITS/ML VIAL
F
PROCRIT 3,000 UNITS/ML VIAL F
PROCRIT 4,000 UNITS/ML VIAL F
PROCRIT 40,000 UNITS/ML VIAL
F
PROFILNINE 1,000 UNITS VIAL NF
PROFILNINE 1,500 UNITS VIAL NF
PROFILNINE 500 UNITS VIAL NF
PROGRAF 0.5 MG CAPSULE NF
PROGRAF 1 MG CAPSULE NF
PROGRAF 5 MG CAPSULE NF
PROGRAF 5 MG/ML AMPULE NF
PROLEUKIN 22 MILLION UNIT VIAL
F
PROLIA 60 MG/ML SYRINGE F
PROMACTA 12.5 MG TABLET F
PROMACTA 25 MG TABLET F
PROMACTA 50 MG TABLET F
PROMACTA 75 MG TABLET F
PROTHELIAL 1 GM/10 ML PASTE
NF
PROVISC 10 MG/ML DISP SYRNG
NF
PULMOZYME 1 MG/ML AMPUL
F
RAPAMUNE 0.5 MG TABLET NF
RAPAMUNE 1 MG TABLET NF
RAPAMUNE 1 MG/ML ORAL SOLN
F
RAPAMUNE 2 MG TABLET NF
RAVICTI 1.1 GRAM/ML LIQUID F
Page 14
DRUG FORMULARY STATUS
REBETOL 200 MG CAPSULE NF
REBETOL 40 MG/ML SOLUTION
NF
REBIF 22 MCG/0.5 ML SYRINGE
F
REBIF 44 MCG/0.5 ML SYRINGE
F
REBIF REBIDOSE 22 MCG/0.5 ML
F
REBIF REBIDOSE 44 MCG/0.5 ML
F
REBIF REBIDOSE TITRATION PACK
F
REBIF TITRATION PACK F
RECLAST 5 MG/100 ML SOLUTION
NF
RECOMBINATE 1,241-1,800 UNIT V
F
RECOMBINATE 1,801-2,400 UNIT V
F
RECOMBINATE 220-400 UNIT VIAL
F
RECOMBINATE 401-800 UNIT VIAL
F
RECOMBINATE 801-1,240 UNIT VL
F
REMICADE 100 MG VIAL NF
REPATHA 140 MG/ML SURECLICK
F
REVATIO 10 MG/12.5 ML VIAL NF
REVATIO 10 MG/ML ORAL SUSP
NF
REVATIO 20 MG TABLET NF
RHOGAM ULTRA-FILTERED PLUS SYR
NF
RHOPHYLAC 300 MCG/2 ML SYRINGE
NF
RIBASPHERE 200 MG CAPSULE
F
RIBASPHERE 200 MG TABLET F
DRUG FORMULARY STATUS
RIBASPHERE 400 MG TABLET F
RIBASPHERE 600 MG TABLET F
RIBASPHERE RIBAPAK 200-400 MG
F
RIBASPHERE RIBAPAK 400-400 MG
F
RIBASPHERE RIBAPAK 600-400 MG
F
RIBASPHERE RIBAPAK 600-600 MG
F
RIBATAB 400-400 MG DOSEPACK
NF
RIBATAB 400-600 MG DOSEPACK
NF
RIBATAB 600-600 MG DOSEPACK
NF
RIBAVIRIN 200 MG CAPSULE F
RIBAVIRIN 200 MG TABLET F
RIBAVIRIN 6 GM INHALATION VIAL
NF
RILUTEK 50 MG TABLET NF
RITUXAN 10 MG/ML VIAL NF
RIXUBIS 1,000 UNIT NOMINAL NF
RIXUBIS 2,000 UNIT NOMINAL NF
RIXUBIS 250 UNIT NOMINAL NF
RIXUBIS 3,000 UNIT NOMINAL NF
RIXUBIS 500 UNIT NOMINAL NF
RYDAPT 25 MG CAPSULE F
SAIZEN 5 MG VIAL NF
SAIZEN 8.8 MG CLICK.EASY CARTG
NF
SAIZEN 8.8 MG VIAL NF
SANDIMMUNE 100 MG CAPSULE
F
SANDIMMUNE 100 MG/ML SOLN
NF
Page 15
DRUG FORMULARY STATUS
SANDIMMUNE 25 MG CAPSULE
F
SANDIMMUNE 50 MG/ML AMPUL
NF
SANDOSTATIN 0.05 MG/ML AMPUL
NF
SANDOSTATIN 0.1 MG/ML AMPUL
NF
SANDOSTATIN 0.2 MG/ML VIAL
NF
SANDOSTATIN 0.5 MG/ML AMPUL
NF
SANDOSTATIN 1 MG/ML VIAL NF
SANDOSTATIN LAR 10 MG KIT NF
SANDOSTATIN LAR 20 MG KIT NF
SANDOSTATIN LAR 30 MG KIT NF
SANDOSTATIN LAR DEPOT 10 MG KT
NF
SANDOSTATIN LAR DEPOT 10 MG VL
NF
SANDOSTATIN LAR DEPOT 20 MG KT
NF
SANDOSTATIN LAR DEPOT 20 MG VL
NF
SANDOSTATIN LAR DEPOT 30 MG KT
NF
SANDOSTATIN LAR DEPOT 30 MG VL
NF
SENSIPAR 30 MG TABLET F
SENSIPAR 60 MG TABLET F
SENSIPAR 90 MG TABLET F
SILDENAFIL 10 MG/12.5 ML VIAL
F
SILDENAFIL 20 MG TABLET F
SILDENAFIL CITRATE POWDER
NF
SILIQ 210 MG/1.5 ML SYRINGE NF
SIMPONI 100 MG/ML PEN INJECTOR
NF
DRUG FORMULARY STATUS
SIMPONI 100 MG/ML SYRINGE NF
SIMPONI 50 MG/0.5 ML PEN INJEC
NF
SIMPONI 50 MG/0.5 ML SYRINGE
NF
SIMPONI ARIA 50 MG/4 ML VIAL
NF
SIMULECT 10 MG VIAL NF
SIMULECT 20 MG VIAL NF
SOLIRIS 300 MG/30 ML VIAL NF
SOMATULINE DEPOT 120 MG/0.5 ML
F
SOMATULINE DEPOT 60 MG/0.2 ML
F
SOMATULINE DEPOT 90 MG/0.3 ML
F
SOVALDI 400 MG TABLET NF
SPRYCEL 100 MG TABLET F
SPRYCEL 140 MG TABLET F
SPRYCEL 20 MG TABLET F
SPRYCEL 50 MG TABLET F
SPRYCEL 70 MG TABLET F
SPRYCEL 80 MG TABLET F
STELARA 130 MG/26 ML VIAL NF
STELARA 45 MG/0.5 ML SYRINGE
F
STELARA 45 MG/0.5 ML VIAL F
STELARA 90 MG/ML SYRINGE F
SUPPRELIN LA 50 MG KIT NF
SYLATRON 200 MCG 4-PACK F
SYLATRON 200 MCG KIT F
SYLATRON 300 MCG 4-PACK F
SYLATRON 300 MCG KIT F
SYLATRON 600 MCG KIT F
SYLVANT 100 MG VIAL F
Page 16
DRUG FORMULARY STATUS
SYLVANT 400 MG VIAL F
SYNRIBO 3.5 MG/ML VIAL NF
SYNVISC SYRINGE F
SYNVISC-ONE SYRINGE F
TAFINLAR 50 MG CAPSULE F
TAFINLAR 75 MG CAPSULE F
TARCEVA 100 MG TABLET F
TARCEVA 150 MG TABLET F
TARCEVA 25 MG TABLET F
TASIGNA 150 MG CAPSULE F
TASIGNA 200 MG CAPSULE F
TAXOTERE 20 MG/ML VIAL NF
TAXOTERE 80 MG/4 ML VIAL NF
TECENTRIQ 1,200 MG/20 ML VIAL
F
TECFIDERA DR 120 MG CAPSULE
F
TECFIDERA DR 240 MG CAPSULE
F
TECFIDERA STARTER PACK F
TECHNIVIE DOSE PACK NF
TEMODAR 100 MG CAPSULE NF
TEMODAR 100 MG VIAL F
TEMODAR 140 MG CAPSULE NF
TEMODAR 180 MG CAPSULE NF
TEMODAR 20 MG CAPSULE NF
TEMODAR 250 MG CAPSULE NF
TEMODAR 5 MG CAPSULE NF
TEMOZOLOMIDE 100 MG CAPSULE
F
TEMOZOLOMIDE 140 MG CAPSULE
F
TEMOZOLOMIDE 180 MG CAPSULE
F
DRUG FORMULARY STATUS
TEMOZOLOMIDE 20 MG CAPSULE
F
TEMOZOLOMIDE 250 MG CAPSULE
F
TEMOZOLOMIDE 5 MG CAPSULE
F
TENIPOSIDE 50 MG/5 ML AMPULE
NF
TETRABENAZINE 12.5 MG TABLET
F
TETRABENAZINE 25 MG TABLET
F
THERACYS 81 MG VIAL NF
THYMOGLOBULIN 25 MG VIAL
NF
THYROGEN 1.1 MG VIAL F
THYROGEN 1.1 MG VIAL W-DILUENT
F
TOBI 300 MG/5 ML SOLUTION NF
TOBI PODHALER 28 MG INHALE CAP
NF
TOBRAMYCIN 300 MG/5 ML AMPULE
F
TOBRAMYCIN PAK 300 MG/5 ML
NF
TORISEL 25 MG KIT NF
TOTECT 500 MG VIAL NF
TREANDA 100 MG VIAL NF
TREANDA 180 MG/2 ML VIAL NF
TREANDA 25 MG VIAL NF
TREANDA 45 MG/0.5 ML VIAL NF
TRELSTAR 11.25 MG SYRINGE NF
TRELSTAR 11.25 MG VIAL NF
TRELSTAR 22.5 MG SYRINGE NF
TRELSTAR 22.5 MG VIAL NF
TRELSTAR 3.75 MG SYRINGE NF
TRELSTAR 3.75 MG VIAL NF
Page 17
DRUG FORMULARY STATUS
TREMFYA 100 MG/ML SYRINGE
NF
TRETTEN 2,500 UNIT VIAL F
TRISENOX 10 MG/10 ML AMPULE
F
TYKERB 250 MG TABLET F
TYMLOS 80 MCG DOSE PEN INJECTR
NF
TYZEKA 600 MG TABLET F
VALSTAR 40 MG/ML VIAL NF
VANTAS 50 MG KIT NF
VECTIBIX 100 MG/5 ML VIAL F
VECTIBIX 400 MG/20 ML VIAL F
VELCADE 3.5 MG VIAL F
VELTASSA 16.8 GM POWDER PACKET
F
VELTASSA 25.2 GM POWDER PACKET
F
VELTASSA 8.4 GM POWDER PACKET
F
VEMLIDY 25 MG TABLET F
VERZENIO 100 MG TABLET NF
VERZENIO 150 MG TABLET NF
VERZENIO 200 MG TABLET NF
VERZENIO 50 MG TABLET NF
VIDAZA 100 MG VIAL NF
VIEKIRA PAK NF
VIMIZIM 5 MG/5 ML VIAL F
VIREAD 150 MG TABLET F
VIREAD 200 MG TABLET F
VIREAD 250 MG TABLET F
VIREAD 300 MG TABLET F
VIREAD POWDER F
VIVITROL 380 MG VIAL + DILUENT
NF
DRUG FORMULARY STATUS
VOSEVI 400-100-100 MG TABLET
F
VOTRIENT 200 MG TABLET F
VPRIV 400 UNITS VIAL F
WILATE 1,000-1,000 UNIT VIAL NF
WILATE 450-450 UNIT VIAL NF
WILATE 500-500 UNIT VIAL NF
WILATE 900-900 UNIT VIAL NF
WINRHO SDF 1,500 UNIT VIAL F
WINRHO SDF 15,000 UNIT VIAL
F
WINRHO SDF 2,500 UNIT VIAL F
WINRHO SDF 5,000 UNIT VIAL F
XELJANZ 5 MG TABLET F
XELJANZ XR 11 MG TABLET F
XELODA 150 MG TABLET NF
XELODA 500 MG TABLET NF
XEOMIN 100 UNIT VIAL NF
XEOMIN 200 UNIT VIAL NF
XEOMIN 50 UNIT VIAL NF
XGEVA 120 MG/1.7 ML VIAL F
XOLAIR 150 MG VIAL F
XYNTHA 1,000 UNIT KIT F
XYNTHA 2,000 UNIT KIT F
XYNTHA 250 UNIT KIT F
XYNTHA 500 UNIT KIT F
XYNTHA SOLOFUSE 1,000 UNIT KIT
F
XYNTHA SOLOFUSE 2,000 UNIT KIT
F
XYNTHA SOLOFUSE 250 UNIT KIT
F
XYNTHA SOLOFUSE 3,000 UNIT KIT
F
Page 18
DRUG FORMULARY STATUS
XYNTHA SOLOFUSE 500 UNIT KIT
F
ZALTRAP 100 MG/4 ML VIAL NF
ZALTRAP 200 MG/8 ML VIAL NF
ZANOSAR 1 GM POWDER VIAL
NF
ZARXIO 300 MCG/0.5 ML SYRINGE
F
ZARXIO 480 MCG/0.8 ML SYRINGE
F
ZELBORAF 240 MG TABLET F
ZEPATIER 50-100 MG TABLET NF
ZINECARD 250 MG VIAL NF
ZINECARD 500 MG VIAL NF
ZOLADEX 10.8 MG IMPLANT SYRN
NF
ZOLADEX 3.6 MG IMPLANT SYRN
NF
ZOLEDRONIC ACID 4 MG VIAL NF
DRUG FORMULARY STATUS
ZOLEDRONIC ACID 4 MG/100 ML
NF
ZOLEDRONIC ACID 4 MG/5 ML VIAL
NF
ZOLEDRONIC ACID 5 MG/100 ML
NF
ZOLINZA 100 MG CAPSULE F
ZOMACTON 10 MG VIAL NF
ZOMACTON 5 MG VIAL NF
ZOMETA 4 MG/100 ML INJECTION
NF
ZOMETA 4 MG/5 ML VIAL NF
ZORBTIVE 8.8 MG VIAL F
ZORTRESS 0.25 MG TABLET F
ZORTRESS 0.5 MG TABLET F
ZORTRESS 0.75 MG TABLET F
ZYKADIA 150 MG CAPSULE F
ZYTIGA 250 MG TABLET F
ZYTIGA 500 MG TABLET F
