DMBA Commercial

DMBA Focus Formulary This formulary lists prescription medication that may be covered by Deseret Choice Hawaii, Deseret Premier, Deseret Select, and

Deseret Value. For assistance finding a specific medication not on this list, please use the Formulary Lookup Tool or call Magellan

Customer Service at (800) 424-1799.

Tier Information

T1 Tier 1 drugs are low-cost preferred medications. This tier may include generic, single-source brand drugs, or multisource brand drugs. Cost sharing applies to Tier 1 drugs.

T2 Tier 2 drugs are moderate-cost preferred medications. This tier may include generic, single-source, or multi-source brand drugs. Cost sharing applies to Tier 2 drugs.

T3 Tier 3 drugs are non-preferred medications, and the plan does not cover any portion of the cost for Tier 3 drugs. However, Tier 3 drugs may be eligible for a network discount through contracted pharmacies. Because the plan does not pay for Tier 3 drugs, your out-of-pocket costs will be higher and many Tier 3 drugs have lower-cost options in Tier 1 or 2. This tier may include generic, single-source brand drugs, or multi-source brands drugs.

T4 Tier 4 drugs are high-cost specialty medications. This tier may include generic, single-source brand drugs, or multi-source brands drugs. Cost sharing applies to Tier 4 drugs.

Drug List Information

In this drug list, some medications are marked with a letter code that indicates potential coverage requirements or limits. Your

benefit plan determines how these medications may be covered.

PA Prior Authorization – You or your provider must get prior authorization before you fill your prescription, which ensures appropriate use of the selected drug. Without prior approval, the plan does not cover this drug.

QL Quantity Limit - There is a limit on the amount of this drug covered per prescription, or within a specific time period.

ST Step Therapy - In some cases, you may be required to try certain drugs to treat your medical condition

before you move up a “step” to other drug options. AL Age Limit - This drug may be covered only if you meet the minimum or maximum age.

GL Gender Limit - This drug is restricted for use by a single gender. C Custom - This drug has unique restrictions. Med PA Medical Pharmacy, Prior Authorization – This drug may be available on the medical benefit after prior

authorization.

Where differences exist between this formulary and your benefit plan documents, the benefit plan documents govern.

LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ANTICONVULSANTS

Anticonvulsants, Other

KEPPRA XR 3

levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mg tablet,500 mg/5 ml soln, 500 mg/5 ml vial, 750 mg tablet, 1,000 mgtablet, 1000 mg/10 ml)

1

levetiracetam er 1

ROWEEPRA 500 MG TABLET 1

ROWEEPRA XR 1

Calcium Channel Modifying Agents

CELONTIN 2 QL 120 / 30 days

ethosuximide (250 mg capsule, 250 mg/5 ml soln) 1

LYRICA (225 MG CAPSULE, 300 MG CAPSULE) 3 QL 60 / 30 days

LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MGCAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MGCAPSULE)

3 QL 90 / 30 days

LYRICA 20 MG/ML ORAL SOLUTION 3 QL 900 / 30 days

pregabalin (25 mg capsule, 50 mg capsule, 75 mg capsule, 100mg capsule, 150 mg capsule, 200 mg capsule, 225 mg capsule,300 mg capsule)

1 QL 90 / 30 days

pregabalin 20 mg/ml solution 1 QL 900 / 30 days

zonisamide 1

Gamma-aminobutyric Acid (GABA) Augmenting Agents

clobazam (10 mg tablet, 20 mg tablet) 1QL 2 / day

PA

clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25 mg odt, 0.5mg dis tablet, 0.5 mg odt, 0.5 mg tablet, 1 mg dis tablet, 1 mgodt, 1 mg tablet, 2 mg odt, 2 mg tablet)

1

clorazepate dipotassium 1

DIASTAT 2

DIASTAT ACUDIAL 2

PAGE 2 LAST UPDATED 01/2022

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PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

diazepam (2 mg tablet, 2.5 mg rectal gel sys, 5 mg tablet, 5mg/5 ml solution, 5 mg/ml oral conc, 10 mg rectal gel syst, 10mg tablet, 20 mg rectal gel syst)

1

divalproex sodium (dr 125 mg cap sprnk, dr 125 mg cp(sprnk),sod dr 125 mg tab, sod dr 250 mg tab, sod dr 500 mg tab)

1

divalproex sodium er 1

gabapentin (100 mg capsule, 250 mg/5 ml soln, 300 mgcapsule, 300 mg/6 ml soln, 400 mg capsule, 600 mg tablet, 800mg tablet)

1

GABITRIL 12 MG TABLET 3 QL 120 / 30 days

GABITRIL 16 MG TABLET 3 QL 90 / 30 days

GRALISE ER 300 MG TABLET 3 QL 30 / 30 days

GRALISE ER 600 MG TABLET 3 QL 90 / 30 days

lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oralconcent)

1

LORAZEPAM INTENSOL 1

ONFI (10 MG TABLET, 20 MG TABLET) 3 QL 60 / 30 days

phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elix, 20mg/5 ml soln, 30 mg tablet, 30 mg/7.5 ml sol, 32.4 mg tablet, 60mg tablet, 60 mg/15 ml soln, 64.8 mg tablet, 97.2 mg tablet, 100mg tablet)

1

primidone 1

SABRIL 500 MG POWDER PACKET 4QL 120 / 30 days

PA

SABRIL 500 MG TABLET 4QL 180 / 30 days

PA

tiagabine hcl (2 mg tablet, 4 mg tablet) 1

tiagabine hcl 12 mg tablet 1 QL 4 / day

tiagabine hcl 16 mg tablet 1 QL 3 / day

TRANXENE T-TAB 3

valproate sodium 1

valproic acid (250 mg capsule, 250 mg/5 ml soln, 500 mg/10 mlsol)

1



vigabatrin (500 mg powder packt, 500 mg tablet) 4QL 6 / day

PA

VIGADRONE 4QL 6 / day

PA

Glutamate Reducing Agents

felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 ml susp) 1

FELBATOL (400 MG TABLET, 600 MG TABLET) 3

LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET,25 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MGTABLET)

3

LAMICTAL (BLUE) 3

LAMICTAL (ORANGE) 3

LAMICTAL ODT (ODT 25 MG TABLET, ODT 100 MG TABLET,ODT 200 MG TABLET)

3

LAMICTAL ODT 50 MG TABLET 3 QL 30 / 30 days

LAMICTAL XR 3

LAMICTAL XR (BLUE) 2

LAMICTAL XR (GREEN) 2

LAMICTAL XR (ORANGE) 2

lamotrigine (5 mg disper tablet, 25 mg disper tab, 25 mg tablet,100 mg tablet, 150 mg tablet, 200 mg tablet)

1

lamotrigine (blue) 1

lamotrigine (green) 1

lamotrigine (orange) 1

lamotrigine er 1

lamotrigine odt (odt 25 mg tablet, odt 100 mg tablet, odt 200 mgtablet)

1

lamotrigine odt 50 mg tablet 1 QL 30 / 30 days

SUBVENITE 1

SUBVENITE (BLUE) 1

SUBVENITE (GREEN) 1

SUBVENITE (ORANGE) 1



topiramate (15 mg sprinkle cap, 25 mg sprinkle cap, 25 mgtablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)

1

Sodium Channel Agents

BANZEL (200 MG TABLET, 400 MG TABLET) 2 QL 240 / 30 days

carbamazepine (100 mg tab chew, 100 mg/5 ml susp, 200 mgtablet)

1

carbamazepine er (er 100 mg cap, er 200 mg cap, er 200 mgtablet, er 300 mg cap, er 400 mg tablet)

1

carbamazepine er 100 mg tablet 1 QL 180 / 30 days

CARBATROL 3

DILANTIN 30 MG CAPSULE 2 QL 30 / 30 days

DILANTIN-125 2 NTINarrowTherapeuticIndicator

EPITOL 1

fosphenytoin sodium 1

oxcarbazepine 300 mg/5 ml susp 1 QL 1200 / 30 days

oxcarbazepine (150 mg tablet, 300 mg tablet, 600 mg tablet) 1

PEGANONE 2

PHENYTEK 2

phenytoin (50 mg infatab chew, 50 mg tablet chew, 100 mg/4ml susp, 125 mg/5 ml susp)

1

phenytoin sodium (50 mg/ml ampul, 50 mg/ml vial, 100 mg/2 mlvial, 250 mg/5 ml vial)

1

phenytoin sodium extended 1

rufinamide (40 mg/ml suspension, 200 mg tablet, 400 mg tablet) 1 PA

TEGRETOL XR (200 MG TABLET, 400 MG TABLET) 3

TEGRETOL XR 100 MG TABLET 3 QL 180 / 30 days

TRILEPTAL 300 MG/5 ML SUSP 3 QL 1200 / 30 days

VIMPAT (100 MG TABLET, 150 MG TABLET, 200 MGTABLET)

2QL 60 / 30 days

PA



VIMPAT 50 MG TABLET 2QL 180 / 30 days

PA

VIMPAT (10 MG/ML SOLUTION, 200 MG/20 ML VIAL) 2QL 1200 / 30 days

PA

Analgesics

acetaminophen-codeine (acetamin-codein 300-30 mg/12.5,acetaminop-codeine 120-12 mg/5, acetaminophen-cod #2tablet, acetaminophen-cod #3 tablet, acetaminophen-cod #4tablet)

1

asa-butalb-caffeine-codeine 3

ASCOMP WITH CODEINE 1

BUPAP 3 QL 40 / 10 days

butalb-acetamin-caf-cod 50-325 1

butalbital compound-codeine 1

butalbital-acetaminophn 50-300 3


butalbital-acetaminophen-caffe 1

butalbital-asa-caffeine cap 1

carisoprodol-aspirin 1

carisoprodol-aspirin-codeine 1

diclofenac sodium-misoprostol 1

DUEXIS 3 QL 90 / 30 days

ENDOCET 1

ESGIC CAPSULE 3

hydrocodone-acetaminophen (hydrocodone-acetamin 2.5-108/5, hydrocodone-acetamin 5-217/10, hydrocodone-acetamin5-300 mg, hydrocodone-acetamin 5-325 mg, hydrocodone-acetamin 7.5-300, hydrocodone-acetamin 7.5-325,hydrocodone-acetamin 10-300 mg, hydrocodone-acetamin 10-325 mg, hydrocodone-acetamn 7.5-325/15)

1

hydrocodone-ibuprofen 1

ibuprofen-famotidine 1

LORCET 1



LORCET HD 1

LORCET PLUS 1

naproxen-esomeprazole mag 3 QL 2 / day

oxycodone hcl-aspirin 1

oxycodone hcl-ibuprofen 1

oxycodone-acetaminophen (oxycodone-acetaminophen 5-325,oxycodone-acetaminophen 10-325, oxycodone-acetaminophn2.5-325, oxycodone-acetaminophn 7.5-325)

1

pentazocine-naloxone hcl 1

tramadol hcl-acetaminophen 1

VANATOL LQ 1

VICODIN HP 1

VTOL LQ 1

ZEBUTAL 3

Nonsteroidal Anti-inflammatory Drugs

CAMBIA 3

CATAFLAM 1

CELEBREX 3 QL 60 / 30 days

celecoxib 1 QL 60 / 30 days

COMFORT PAC-IBUPROFEN 1

COMFORT PAC-MELOXICAM 3

COMFORT PAC-NAPROXEN 3

diclofenac epolamine 3 ST

diclofenac pot 50 mg tablet 1

diclofenac sodium (dr 25 mg tab, dr 50 mg tab, dr 75 mg tab, ec25 mg tab, ec 50 mg tab, ec 75 mg tab)

1

diclofenac sodium er 1

diflunisal 1

ec-naproxen 3

etodolac (200 mg capsule, 300 mg capsule, 400 mg tablet, 500mg tablet)

1



etodolac er 1

fenoprofen calcium (400 mg capsule, 600 mg tablet) 1

FLECTOR 3QL 60 / 30 days

ST

flurbiprofen 1

IBU 1

ibuprofen (100 mg/5 ml susp, 400 mg tablet, 600 mg tablet, 800mg tablet)

1

INDOCIN 25 MG/5 ML SUSPENSION 3

indomethacin (25 mg capsule, 50 mg capsule) 1

indomethacin er 1

ketoprofen (50 mg capsule, 75 mg capsule, er 200 mg capsule) 1

ketorolac 15.75 mg nasal spray 3 QL 5 / 5 days

ketorolac tromethamine (10 mg tablet, 15 mg/ml vial, 30 mg/mlvial, 60 mg/2 ml vial, 300 mg/10 ml vial)

1

meclofenamate sodium 1

mefenamic acid 1

meloxicam (7.5 mg tablet, 15 mg tablet) 1

nabumetone 1

NALFON (400 MG CAPSULE, 600 MG TABLET) 3

NAPRELAN CR 375 MG TABLET 3

NAPRELAN CR 500 MG TABLET 3 QL 60 / 30 days

NAPRELAN CR 750 MG TABLET 3 QL 30 / 30 days

naproxen (125 mg/5 ml suspen, 250 mg tablet, 375 mg tablet,dr 375 mg tablet, 500 mg kit, 500 mg tablet, dr 500 mg tablet)

1

naproxen sodium (275 mg tab, 550 mg tab) 1

naproxen sod cr 375 mg tablet 1

naproxen sod cr 500 mg tablet 1 QL 60 / 30 days

naproxen sod cr 750 mg tablet 1 QL 1 / day

naproxen sod er 375 mg tablet 1



naproxen sod er 500 mg tablet 1 QL 60 / 30 days

oxaprozin 1

piroxicam 1

SPRIX 3 QL 5 / 5 days

sulindac 1

tolmetin sodium (200 mg tab, 400 mg cap, 600 mg tab) 1

VOLTAREN-XR 3

Opioid Analgesics, Long-acting

CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 MGCAPSULE)

3 QL 30 / 30 days

DURAGESIC 25 MCG/HR PATCH 3

fentanyl (12 mcg/hr patch, 25 mcg/hr patch, 50 mcg/hr patch,75 mcg/hr patch, 100 mcg/hr patch)

1

hydromorphone er (er 8 mg tab, er 12 mg tab) 1 QL 1 / day

hydromorphone hcl er 16 mg tab 1 QL 180 / 30 days

KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 30MG CAPSULE, ER 50 MG CAPSULE, ER 60 MG CAPSULE,ER 80 MG CAPSULE, ER 100 MG CAPSULE, ER 200 MGCAPSULE)

3QL 60 / 30 days

ST

levorphanol 2 mg tablet 1

methadone hcl (5 mg/5 ml solution, hcl 5 mg tablet, 10 mg/5 mlsolution, 10 mg/ml oral conc, hcl 10 mg tablet, hcl 10 mg/mlsyringe, hcl 10 mg/ml vial, hcl 200 mg/20 ml vl)

1

METHADONE INTENSOL 1

morphine sulfate er (er 10 mg cap, er 20 mg cap, er 30 mg cap,er 50 mg cap, er 60 mg cap, er 80 mg cap, er 100 mg cap)

1 QL 2 / day

morphine sulfate er (er 45 mg cap, er 75 mg cap, er 90 mg cap,er 120 mg cap)

1 QL 1 / day

morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er 60 mgtablet, er 100 mg tablet, er 200 mg tablet)

1 QL 3 / day

MS CONTIN 3QL 3 / day

ST

NUCYNTA ER 3QL 2 / day

ST



oxycodone hcl er 1 QL 3 / day

OXYCONTIN (ER 10 MG TABLET, ER 15 MG TABLET, ER 20MG TABLET, ER 30 MG TABLET, ER 40 MG TABLET)

3 QL 120 / 30 days

OXYCONTIN ER 60 MG TABLET 3 QL 90 / 30 days

OXYCONTIN ER 80 MG TABLET 3 QL 60 / 30 days

oxymorphone hcl er 1 QL 2 / day

tramadol hcl er (er 100 mg capsule, er 200 mg capsule, er 300mg capsule)

1 QL 30 / 30 days

tramadol hcl er (er 100 mg tablet, er 200 mg tablet, er 300 mgtablet)

1

tramadol hcl er (er 100 mg tablet, er 200 mg tablet, er 300 mgtablet)

1 QL 1 / day

Opioid Analgesics, Short-acting

ACTIQ (200 MCG LOZENGE, 400 MCG LOZENGE, 1,600MCG LOZENGE)

3QL 120 / 30 days

PA

ACTIQ (600 MCG LOZENGE, 800 MCG LOZENGE, 1,200MCG LOZENGE)

3 QL 120 / 30 days

BENZEFOAM 1

butorphanol tartrate (1 mg/ml vial, 2 mg/ml vial, 4 mg/2 ml vial,10 mg/ml spray)

1

codeine sulfate 1

DEMEROL (25 MG/0.5 ML AMPUL, 100 MG/2 ML AMPUL) 3

fentanyl citrate (200 mcg, 400 mcg) 1QL 120 / 30 days

PA

fentanyl citrate (cit 1,200 mcg, cit 1,600 mcg, citrate 600 mcg,citrate 800 mcg)

4QL 120 / 30 days

PA

fentanyl citrate (100 mcg tb, 200 mcg tb, 400 mcg tb, 600 mcgtb, 800 mcg tb)

3 QL 6 / day

FENTORA 3 QL 180 / 30 days

hydromorphone hcl (1 mg/ml solution, hcl 1 mg/ml amp, 2 mgtablet, 2 mg/ml vial, hcl 2 mg/ml amp, 4 mg tablet, hcl 4 mg/mlamp, 5 mg/5 ml soln, 8 mg tablet, 10 mg/ml ampule, 10 mg/mlvial, 50 mg/5 ml amp, 50 mg/5 ml vial, 500 mg/50 ml vl)

1

hydromorphone 55 mg/55 ml-ns 1



LAZANDA 3QL 30 / 30 days

PA

meperidine hcl (25 mg/ml vial, 50 mg tablet, 50 mg/5 mlsolution, 50 mg/ml vial, 100 mg/ml vial)

1

morphine sulfate (5 mg/10 ml vial, 10 mg/10 ml vial, sulf 10mg/5 ml soln, sulf 20 mg/5 ml soln, sulfate 1 mg/ml vial, sulfateir 15 mg tab, 30 mg/30 ml pca vial, 30 mg/30 ml syringe, sulf100 mg/5 ml conc, sulfate ir 30 mg tab)

1

morphine sulfate-0.9% nacl (1 mg/ml-0.9% syr, 2 mg/2 ml-0.9%, 30 mg/30 ml-0.9%, 50 mg/50 ml-0.9%, 100mg/100ml-0.9%)

1

morphine sulfate-nacl (2 mg/2 syring, 50 mg/50 syrg) 1

nalbuphine hcl (10 mg/ml ampul, 20 mg/ml ampul, 100 mg/10ml vial, 200 mg/10 ml vial)

1

NUCYNTA 3 QL 180 / 30 days

oxycodone hcl ((ir) 5 mg cap, (ir) 5 mg tablet, (ir) 10 mg tab, (ir)15 mg tab, (ir) 20 mg tab, (ir) 30 mg tab, 100 mg/5 ml conc)

1

oxymorphone hcl 10 mg tablet 1 QL 12 / day

oxymorphone hcl 5 mg tablet 1 QL 2 / day

SUBSYS 3

tramadol hcl 50 mg tablet 1

Anesthetics

Local Anesthetics

DERMACINRX PRIZOPAK 1

GLYDO 1

lidocaine 5% patch 1

lidocaine hcl (0.5% vial, 1% 20 mg/2 ml, 1% 20 mg/2 ml vl, 1%300 mg/30 ml, 1% 50 mg/5 ml, 1% 50 mg/5 ml vl, 1% abboject,1% ampul, 1% syringe, 1% vial, 2% jel urojet ac, 2% jelly, 2%jelly uro-jet, 4% solution, 30 mg/3 ml syr, 100 mg/10 ml syr)

1

lidocaine hcl viscous 1

lidocaine-prilocaine 1

LIVIXIL PAK 1

PRIKAAN 1



PRIKAAN LITE 1

PRILOVIX PLUS 3

REGENECARE 3

RELADOR PAK 1

RELADOR PAK PLUS 1

XYLOCAINE 0.5% VIAL 3

XYLOCAINE-MPF (AMPUL, VIAL) 3

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

acamprosate calcium 1

ANTABUSE 3

disulfiram 1

VIVITROL 4

Opioid Dependence Treatments

buprenorphine (5 mcg/hr patch, 10 mcg/hr patch, 20 mcg/hrpatch)

1

buprenorphine hcl (2 mg tablet, 8 mg tablet) 1QL 90 / 30 days

ST

buprenorphine hcl (0.3 mg/ml crpjct, 0.3 mg/ml vial) 1

buprenorphine-nalox 2-0.5mg fm 3 QL 12 / day

buprenorphine-naloxone (4-1mg film, 12-3mg flm) 3 QL 3 / day

buprenorphine-nalox 2-0.5mg tb 1QL 12 / day

PA

buprenorphine-nalox 8-2 mg tab 1QL 90 / 30 days

PA

BUTRANS (5 MCG/HR PATCH, 10 MCG/HR PATCH, 20MCG/HR PATCH)

3 QL 4 / 28 days

SUBOXONE (4 MG-1 MG FILM, 8 MG-2 MG FILM, 12 MG-3MG FILM)

3 QL 90 / 30 days

SUBOXONE 2 MG-0.5 MG SL FILM 3 QL 12 / day



Opioid Reversal Agents

naloxone 2 mg/2 ml syringe 1

Smoking Cessation Agents

APLENZIN 3 QL 30 / 30 days

bupropion hcl 1

bupropion hcl sr 1

bupropion hcl xl 450 mg tablet 1 QL 1 / day

bupropion xl (150 mg tablet, 300 mg tablet) 1

CHANTIX STARTING MONTH BOX 2

CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MGTABLET)

2 QL 60 / 30 days

FORFIVO XL 3

NICOTROL 2 QL 600 / 30 days

NICOTROL NS 3

varenicline tartrate (0.5 mg tablet, 1 mg tablet) 1 QL 2 / day

WELLBUTRIN SR 150 MG TABLET 3

Antibacterials

Aminoglycosides

amikacin sulfate 1

GENTAK 1

gentamicin sulfate (0.1% cream, 0.1% ointment, 0.3% eye drop,10 mg/ml vial, 20 mg/2 ml vial, ped 20 mg/2 ml vial, 80 mg/2 mlvial, 800 mg/20 ml vial)

1

gentamicin sulfate in ns (70 mg/ns 50 ml pb, 90 mg/ns 100 mlpb, iso 100 mg/100 ml, iso 120 mg/100 ml, isoton 60 mg/50 ml,isoton 80 mg/100 ml, isoton 80 mg/50 ml)

1

HUMATIN 3

KITABIS PAK 4 PA

neomycin sulfate 1

paromomycin sulfate 1

streptomycin sulfate 1



TOBI 4 PA

TOBRADEX EYE OINTMENT 2

tobramycin (300 mg/5 ml ampule, pak 300 mg/5 ml) 4 PA

tobramycin 0.3% eye drop 1

tobramycin sulfate (1.2 gm vial, 1.2 gram/30 ml vial, 10 mg/mlvial, 40 mg/ml vial, 80 mg/2 ml vial, 1,200 mg/30 ml vial)

1

tobramycin sulfate in ns 1

TOBREX 0.3% EYE OINTMENT 2

colistimethate 1

neomycin-polymyxin b (40 mg/ml amp, 40 mg/ml vl) 1

SYNERCID 3

Antibacterials, Other

acetic acid 2% ear solution 1

ALTABAX 4

bacitracin (500 unit/gm ophth, 50,000 unit vial) 1

CENTANY AT 3

chloramphenicol sod succinate 1

CLEOCIN 100 MG VAGINAL OVULE 2QL 30 / 30 days

GL Female

CLINDACIN ETZ KIT 3

CLINDACIN ETZ 1% PLEDGET 1 QL 60 / 30 days

CLINDACIN P 1 QL 69 / 30 days

CLINDACIN PAC 3

CLINDAGEL 3

clindamycin (pediatric) 1

clindamycin hcl 1

clindamycin 2% vaginal cream 1 GL Female

clindamycin phosphate 1% foam 1 QL 50 / 30 days

clindamycin phosphate (ph gel, ph solution, phos pledget,phosp lotion)

1 QL 60 / 30 days



clindamycin phosphate 1% gel 3

clindamycin phosphate (9 g/60 ml vial, 300 mg/2 ml vl, 600mg/4 ml vl, 900 mg/6 ml vl)

1

clindamycin phosphate-d5w 1

CUBICIN 4

CUBICIN RF 4 QL 13 / 7 days

daptomycin 500 mg vial 4 QL 13 / 7 days

EVOCLIN 3

fosfomycin tromethamine 3

FURADANTIN 3

LINCOCIN 3

lincomycin hcl 1

linezolid 100 mg/5 ml susp 1

linezolid 600 mg tablet 1 QL 60 / 30 days

mafenide acetate 1

methenamine hippurate 1

methenamine mand 1 gm tablet 1

METROGEL (GEL, PUMP) 3

metronidazole 375 mg capsule 1 QL 180 / 30 days

metronidazole (0.75% cream, 0.75% lotion, top 1% gel pump,topical 0.75% gl, topical 1% gel, 250 mg tablet, 500 mg tablet,500 mg/100 ml)

1

metronidazole vaginal 0.75% gl 1 GL Female

mupirocin 2% cream 1 QL 2 / day

mupirocin 2% ointment 1

nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap, mcr 50 mgcap, mcr 100 mg cap)

1

nitrofurantoin mono-macro 1

polymyxin b sulfate 1

PRIMSOL 3

ROSADAN (CREAM, GEL) 1



ROSADAN (CREAM KIT, GEL KIT) 3

SULFAMYLON 8.5% CREAM 3

tigecycline 1

tinidazole 1 QL 120 / 30 days

trimethoprim 1

TYGACIL 3

vancomycin 1

vancomycin 1 gram/200 ml bag 3

vancomycin hcl (1 gm add-van vial, 1 gm vial, hcl 1g/200 mlbag, hcl 5 gm vial, hcl 10 gm vial, hcl 125 mg capsule, hcl 250mg capsule, 500 mg add-van vial, 500 mg vial, 750 mg add-vanvial, hcl 750 mg vial)

1

vancomycin hcl-0.9% nacl (vanco 1.25 gm/250 ml-0.9%, vanco500 mg/100 ml-0.9%, vanco 750 mg/150 ml-0.9%, vancomycin1 g/200ml-0.9%)

1

vancomycin-d5w 500 mg/100 ml 1

XIFAXAN 200 MG TABLET 2QL 9 / 3 days

PA

XIFAXAN 550 MG TABLET 2QL 42 / 14 days

PA

ZYVOX (100 MG/5 ML SUSPENSION, 600 MG TABLET) 3

Beta-lactam, Cephalosporins

cefaclor (250 mg capsule, 500 mg capsule) 1

cefaclor er 1

cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mg capsule, 500mg/5 ml susp)

1

cefazolin sodium (1 gm add-van vial, 1 gm vial, 10 gm vial, 20gm bulk vial, sod 100 gm bulk bag, sod 300 gm bulk bag, 500mg vial)

1

cefazolin 2 g/100 ml-0.9% nacl 1

cefazolin 1 g/50 ml-dextrose 1

cefazolin-d5w 1

cefdinir (125 mg/5 ml susp, 250 mg/5 ml susp, 300 mg capsule) 1



cefepime 2 gm injection 1

cefepime hcl 2 gram vial 1

cefepime-dextrose 2 gm/50 ml 1

cefixime 400 mg capsule 3

cefixime (100 mg/5 ml susp, 200 mg/5 ml susp) 1

cefotaxime sodium 1 gm vial 1

cefoxitin 10 gm vial 1

cefpodoxime proxetil (50 mg/5 ml susp, 100 mg tablet, 100mg/5 ml susp, 200 mg tablet)

1

cefprozil (125 mg/5 ml susp, 250 mg tablet, 250 mg/5 ml susp,500 mg tablet)

1

ceftazidime (1 gm piggyback, 1 gm vial, 2 gm piggyback, 2 gmvial, 6 gm vial)

1

ceftriaxone (1 gm add-vant vial, 1 gm piggyback, 1 gm vial, 1gm-d5w bag, 2 gm add vial, 2 gm piggyback, 2 gm vial, 2 gm-d5w bag, 10 gm vial, 100 gram bulk bag, 250 mg vial, 500 mgvial)

1

cefuroxime 1

cefuroxime sodium 1

cephalexin (125 mg/5 ml susp, 250 mg capsule, 250 mg tablet,250 mg/5 ml susp, 500 mg capsule, 500 mg tablet)

1

CLAFORAN 1 GM ADD-VANTAGE VL 3

MAXIPIME 2 GM ADD-VANTAGE VL 3

SUPRAX (100 MG TABLET CHEWABLE, 100 MG/5 MLSUSPENSION, 200 MG/5 ML SUSPENSION, 400 MGCAPSULE, 500 MG/5 ML SUSPENSION)

3

SUPRAX 200 MG TABLET CHEWABLE 3 QL 20 / 10 days

TAZICEF (1 GM ADD-VANTAGE VIAL, 1 GRAM VIAL, 2 GMADD-VANTAGE VIAL, 2 GRAM VIAL, 6 GRAM VIAL)

1

TEFLARO 3

Beta-lactam, Other

imipenem-cilastatin 500 mg vl 1

INVANZ 3

meropenem 1

meropenem-0.9% nacl 1



MERREM 3

Beta-lactam, Penicillins

amoxicillin (125 mg tab chew, 125 mg/5 ml susp, 200 mg/5 mlsusp, 250 mg capsule, 250 mg tab chew, 250 mg/5 ml susp,400 mg/5 ml susp, 500 mg capsule, 500 mg tablet, 875 mgtablet)

1

amoxicillin-clavulanate pot er 1

amoxicillin-clavulanate potass (200-28.5 mg tab chew, 200-28.5mg/5 ml sus, 250-125 mg tablet, 250-62.5 mg/5 ml sus, 400-57mg tab chew, 400-57 mg/5 ml susp, 500-125 mg tablet, 600-42.9 mg/5 ml sus, 875-125 mg tablet)

1

ampicillin sodium (1 gm add-vantage vl, 1 gm vial, 2 gm add-vantage vl, 2 gm vial, 10 gm bottle, 10 gm vial, 125 mg vial, 250mg vial, 500 mg vial)

1

ampicillin trihydrate 1

ampicillin-sulbactam (ampicillin-sulb 1.5 g add vial, ampicillin-sulb 3 gm add vial, ampicillin-sulbactam 1.5 gm vl, ampicillin-sulbactam 3 gm vial, ampicillin-sulbactam 15 gm vl)

1

BICILLIN C-R 3

BICILLIN L-A 1,200,000 UNITS 3 QL 2 / 28 days

dicloxacillin sodium 1

MOXATAG 3

nafcillin 1 gm/ 50 ml inj 1

nafcillin sodium (1 gm add-van vial, 1 gm vial, 10 gm bulk vial) 1

oxacillin 1

oxacillin sodium (1 gm add-vantage vl, 1 gm vial, 2 gm add-vantage vl, 2 gm vial, 10 gm vial)

1

penicillin g potassium 1

pen g 1.2 million unit/2 ml 1

penicillin g sodium 1

penicillin gk-iso-osm dextrose (pen g 2 million unit/50 ml, pen g3 million unit/50 ml)

1

penicillin v potassium (125 mg/5 ml soln, 250 mg tablet, 250mg/5 ml soln, 500 mg tablet)

1

piperacillin-tazobactam (piperacil-tazo 3.375 gm add vl,piperacil-tazobact 3.375 gm vl, piperacil-tazobact 13.5 gm vl,piperacil-tazobact 40.5 gram)

1



ZOSYN 3.375 GM/50 ML GALAXY 3

Macrolides

AZASITE 3

azithromycin 1 gm pwd packet 1 QL 2 / 30 days

azithromycin 100 mg/5 ml susp 1 QL 1/ 30 days

azithromycin 500 mg tablet 1 QL 6 / 30 days

azithromycin (200 mg/5 ml susp, 250 mg tablet, 500 mg add-van vl, 600 mg tablet, i.v. 500 mg vial)

1

clarithromycin (125 mg/5 ml sus, 250 mg tablet, 250 mg/5 mlsus, 500 mg tablet)

1

clarithromycin er 1

DIFICID 200 MG TABLET 2QL 20 / days

PA

E.E.S. 200 3 QL 200 / 10 days

E.E.S. 400 1

ERY 1

ERY-TAB 1 QL 90 / 30 days

ERYPED 200 3 QL 200 / 10 days

ERYTHROCIN STEARATE 1 QL 240 / 30 days

erythromycin (0.5% eye ointment, 2% gel, 250 mg filmtab, 500mg filmtab)

1

erythromycin 2% solution 1 QL 2 / day

erythromycin (dr 250 mg tablet, dr 333 mg tablet, dr 500 mgtablet)

1 QL 90 / 30 days

erythromycin 200 mg/5 ml susp 1 QL 200 / 10 days

erythromycin ethylsuccinate (400 mg/5 ml susp, es 400 mg tab) 1

Quinolones

AVELOX IV 3

BESIVANCE 2

CILOXAN 0.3% OINTMENT 2



CIPRO 10% SUSPENSION 3

ciprofloxacin 1

ciprofloxacin hcl (0.3% eye drop, hcl 100 mg tab, hcl 250 mgtab, hcl 500 mg tab, hcl 750 mg tab)

1

ciprofloxacin-d5w 1

gatifloxacin 1

levofloxacin (0.5% eye drops, 25 mg/ml solution, 250 mg tablet,500 mg tablet, 750 mg tablet)

1

MOXEZA 2

moxifloxacin 0.5% eye drops 1

moxifloxacin 400 mg/250 ml bag 3

moxifloxacin hcl 1 QL 30 / 30 days

ofloxacin (0.3% ear drops, 0.3% eye drops, 300 mg tablet, 400mg tablet)

1

ZYMAXID 3

Sulfonamides

BACTRIM DS 3

silver sulfadiazine 1

SSD 3

sulfacetamide sodium (eye drops, eye ointment, sod top susp,sodium lotn)

1

sulfadiazine 1

sulfamethoxazole-trimethoprim (ds tablet, iv vial, ss tablet,susp)

1

SULFATRIM 3

Tetracyclines

AVIDOXY 1

COREMINO 3

demeclocycline hcl 1

DOXY 100 1

doxycycline hyclate (50 mg cap, 100 mg cap, 100 mg tab, 100mg vl)

1



doxycycline hyclate (dr 75 mg tab, dr 100 mg tab, dr 150 mgtab)

1QL 60 / 30 days

ST

doxycycline mono 75 mg capsule 1 QL 60 / 30 days

doxycycline monohydrate (25 mg/5 ml susp, mono 50 mg cap,mono 50 mg tablet, mono 75 mg tablet, mono 100 mg cap,mono 100 mg tablet)

1

LYMEPAK 3

minocycline hcl (50 mg capsule, 75 mg capsule, 100 mgcapsule)

1

minocycline hcl er (er 45 mg tablet, er 90 mg tablet, er 135 mgtablet)

1QL 30 / 30 days

ST

minocycline hcl er (er 55 mg tablet, er 65 mg tablet, er 80 mgtablet, er 105 mg tablet, er 115 mg tablet)

3QL 1 / day

ST

MONDOXYNE NL 1

MONODOX 3

MORGIDOX 50 MG CAPSULE 1

MORGIDOX (1X100 MG KIT, 1X50 MG KIT, 2X100 MG KIT,100 MG CAPSULE)

3

SOLODYN 2 QL 30 / 30 days

VIBRAMYCIN (25 MG/5 ML SUSP, 50 MG/5 ML SYRUP, 100MG CAPSULE)

3

Antidementia Agents

Antidementia Agents, Other

ergoloid mesylates 1

Cholinesterase Inhibitors

ARICEPT (5 MG TABLET, 10 MG TABLET) 3

donepezil hcl 1

donepezil hcl odt 1

EXELON (9.5 MG/24HR PATCH, 13.3 MG/24HR PATCH) 3

EXELON 4.6 MG/24HR PATCH 3 QL 30 / 30 days

galantamine er 1



galantamine hbr 1

galantamine hydrobromide 1

rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 6mg capsule, 9.5 mg/24hr patch, 13.3 mg/24hr ptch)

1

rivastigmine 4.6 mg/24hr patch 1 QL 30 / 30 days

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

memantine 5-10 mg titration pk 1 QL 49 / 28 days

memantine hcl (2 mg/ml solution, 5 mg tablet, 10 mg tablet) 1

memantine hcl er 1

NAMENDA 5-10 MG TITRATION PK 3 QL 49 / 28 days

NAMENDA (5 MG TABLET, 10 MG TABLET) 3

NAMENDA XR TITRATION PACK 2 QL 30 / 30 days

NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MGCAPSULE, 28 MG CAPSULE)

3 QL 30 / 30 days

Antidepressants

chlordiazepoxide-amitriptyline 1

olanzapine-fluoxetine hcl 1 QL 1 / day

perphenazine-amitriptyline 1

Antidepressants, Other

ABILIFY 3 QL 45 / 30 days

aripiprazole 1 mg/ml solution 1 ST

aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mgtablet, 30 mg tablet)

1 QL 45 / 30 days

aripiprazole 20 mg tablet 1

aripiprazole odt 1

mirtazapine (15 mg odt, 15 mg tablet) 1 QL 2 / day

mirtazapine (7.5 mg tablet, 30 mg odt, 30 mg tablet, 45 mg odt,45 mg tablet)

1 QL 1 / day

quetiapine fumarate 1

quetiapine er 50 mg tablet 1 QL 1 / day



quetiapine fumarate er (er 150 mg tablet, er 200 mg tablet) 1 QL 30 / 30 days

quetiapine fumarate er (er 300 mg tablet, er 400 mg tablet) 1 QL 60 / 30 days

SEROQUEL (25 MG TABLET, 50 MG TABLET) 3 QL 6 / day

SEROQUEL 100 MG TABLET 3 QL 3 / day

SEROQUEL 200 MG TABLET 3 QL 1.5 / day



SEROQUEL XR (150 MG TABLET, 200 MG TABLET) 3 QL 30 / 30 days

SEROQUEL XR (300 MG TABLET, 400 MG TABLET) 3 QL 60 / 30 days

SEROQUEL XR 50 MG TABLET 3 QL 180 / 30 days

Monoamine Oxidase Inhibitors

EMSAM 3 QL 30 / 30 days

MARPLAN 3 QL 180 / 30 days

NARDIL 3

phenelzine sulfate 1

tranylcypromine sulfate 1

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

citalopram hbr (10 mg tablet, 10 mg/5 ml soln, 20 mg tablet, 20mg/10 ml sol, 40 mg tablet)

1

CYMBALTA (20 MG CAPSULE, 60 MG CAPSULE) 3 QL 60 / 30 days

CYMBALTA 30 MG CAPSULE 3 QL 90 / 30 days

desvenlafaxine er 1

desvenlafaxine succinate er (er 50 mg, er 100mg) 1

duloxetine hcl (dr 20 mg cap, dr 60 mg cap) 1 QL 60 / 30 days

duloxetine hcl dr 30 mg cap 1 QL 90 / 30 days

EFFEXOR XR (75 MG CAPSULE, 150 MG CAPSULE) 3

escitalopram oxalate 5 mg/5 ml 3



escitalopram oxalate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 QL 1 / day

fluoxetine dr 1

fluoxetine hcl (hcl 10 mg capsule, 20 mg/5 ml solution, hcl 20mg capsule, hcl 40 mg capsule)

1

fluvoxamine maleate 1

fluvoxamine maleate er 1

maprotiline hcl 1

nefazodone hcl 1

paroxetine cr 1

paroxetine er 1

paroxetine hcl (10 mg tablet, 10 mg/5 ml susp, 20 mg tablet, 30mg tablet, 40 mg tablet)

1

PAXIL 20 MG TABLET 3

PEXEVA 3 QL 1 / day

PRISTIQ (ER 50 MG TABLET, ER 100 MG TABLET) 3

sertraline hcl (20 mg/ml oral conc, hcl 25 mg tablet, hcl 50 mgtablet, hcl 100 mg tablet)

1

trazodone hcl 1

venlafaxine hcl 1

venlafaxine hcl er (er 37.5 mg cap, er 75 mg cap, er 150 mgcap)

1 QL 1 / day

VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL 30 / 30 days

Tricyclics

amitriptyline hcl 1

amoxapine 1

clomipramine hcl 1

desipramine hcl 1

doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mgcapsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150mg capsule)

1

imipramine hcl 1

imipramine pamoate 1



nortriptyline hcl (10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap) 1

protriptyline hcl 1

trimipramine maleate (25 mg cap, 50 mg cap) 1

trimipramine maleate 100 mg cp 3 QL 60 / 30 days

Antiemetics

Antiemetics, Other

chlorpromazine hcl (10 mg tablet, 25 mg tablet, 25 mg/ml amp,25 mg/ml ampule, 50 mg tablet, 50 mg/2 ml amp, 100 mgtablet, 200 mg tablet)

1

COMPRO 1

diphenhydramine 50 mg/ml vial 1

metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10 mg tablet,10 mg/10 ml sol, 10 mg/2 ml vial)

1

metoclopramide hcl odt 1

perphenazine 1

PHENADOZ 1

prochlorperazine 1

prochlorperazine edisylate 1

prochlorperazine maleate 1

promethazine hcl (6.25 mg/5 ml soln, 6.25 mg/5 ml syrp, 12.5mg suppos, 12.5 mg tablet, 25 mg suppository, 25 mg tablet, 25mg/ml ampul, 25 mg/ml vial, 50 mg suppository, 50 mg tablet,50 mg/ml ampul, 50 mg/ml vial)

1

PROMETHEGAN 1

scopolamine 1

TIGAN 100 MG/ML VIAL 3

TRANSDERM-SCOP 3

trimethobenzamide hcl 1

Emetogenic Therapy Adjuncts

ALOXI 2 M-PA Medical BenefitPA

aprepitant (40 mg capsule, 80 mg capsule, 125 mg capsule,125-80-80 mg pack)

1



dronabinol 1

EMEND (40 MG CAPSULE, 80 MG CAPSULE, TRIPACK) 3

granisetron hcl (0.1 mg/ml vial, 1 mg tablet, 1 mg/ml vial, 4mg/4 ml vial)

1

ondansetron hcl (4 mg/5 ml solution, hcl 4 mg tablet, hcl 4 mg/2ml amp, hcl 4 mg/2 ml vial, hcl 8 mg tablet, hcl 24 mg tablet, 40mg/20 ml vial)

1

ondansetron odt 1

palonosetron 0.25 mg/5 ml vial 1

PA

M-PA Medical BenefitPA

SANCUSO 2

ZOFRAN 4 MG TABLET 3

Antifungals

ABELCET 3

AMBISOME 3

amphotericin b 1

CANCIDAS 3

CICLODAN 8% SOLUTION 1

ciclopirox (0.77% cream, 0.77% gel, 0.77% topical susp, 1%shampoo, 8% solution, 8% treatment kit)

1

clotrimazole 10 mg troche 1

econazole nitrate 1

ERAXIS (WATER DILUENT) 3

EXTINA 3

fluconazole (10 mg/ml susp, 40 mg/ml susp, 50 mg tablet, 100mg tablet, 150 mg tablet, 200 mg tablet)

1

fluconazole-nacl (200 mg/100 ml, 400 mg/200 ml) 1

flucytosine 1

griseofulvin (125 mg/5 ml susp, micro 500 mg tab) 1

griseofulvin ultramicrosize 1

GYNAZOLE 1 1 GL Female

itraconazole 100 mg capsule 1 QL 120 / 30 days



itraconazole 10 mg/ml solution 3

ketoconazole 2% cream 1 QL 2 / day

ketoconazole 2% foam 1

ST

AL At least 12 yrsold

ketoconazole (2% shampoo, 200 mg tablet) 1

MENTAX 3

miconazole 3 200 mg vag supp 1 GL Female

MYCAMINE 3

naftifine hcl 1% gel 3

NAFTIN 1% GEL 3

NATACYN 2

NOXAFIL 40 MG/ML SUSPENSION 2

NYAMYC 1

nystatin 100,000 unit/gm powd 1 QL 1 / day

nystatin (100,000 unit/gm cream, 100,000 unit/gm oint, 100,000unit/ml susp, 500,000 unit oral tab, 500,000 unit/5 ml sus)

1

nystatin-triamcinolone (cream, ointm) 1

NYSTOP 1

ONMEL 3

terbinafine hcl 1

terconazole (0.4% cream, 0.8% cream, 80 mg suppository) 1 GL Female

VFEND 40 MG/ML SUSPENSION 3 QL 450 / 30 days

voriconazole 40 mg/ml susp 1 QL 450 / 30 days

voriconazole (50 mg tablet, 200 mg tablet, 200 mg vial) 1

Antigout Agents

allopurinol 1

allopurinol sodium 4 PA

colchicine 0.6 mg tablet 1 QL 120 / 30 days



COLCRYS 3 QL 120 / 30 days

febuxostat 1QL 30 / 30 days

ST

probenecid 1

probenecid-colchicine 1

ULORIC 3QL 30 / 30 days

ST

ZYLOPRIM 3

Antimigraine Agents

MIGERGOT 3 QL 0.8 / day

sumatriptan succ-naproxen sod 1 ST

TREXIMET 3QL 0.3 / day

PA

Ergot Alkaloids

dihydroergotamine mesylate (1 mg/ml amp, 4 mg/ml spry) 1

ERGOMAR 2 QL 20 / 30 days

BOTOX 100 UNIT VIAL 4 PA

Prophylactic

timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1

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

almotriptan malate 1 QL 9

AMERGE 3QL 0.3 / day

ST

eletriptan hbr 1 ST

FROVA 3QL 9 / 30 days

ST



frovatriptan succinate 1QL 9 / 30 days

ST

IMITREX 5 MG NASAL SPRAY 3

IMITREX (25 MG TABLET, 50 MG TABLET, 100 MG TABLET) 3 ST

MAXALT 3 ST

MAXALT MLT 3 ST

naratriptan hcl 1 QL 9 / 30 days

RELPAX 3QL 9 / 30 days

ST

rizatriptan (5 mg odt, 5 mg tablet, 10 mg odt, 10 mg tablet) 1 QL 12 / 30 days

sumatriptan 1

sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5 ml inject, 6mg/0.5 ml cart, 6 mg/0.5 ml inject, 6 mg/0.5 ml syrng, 6 mg/0.5ml vial)

1

sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mgtablet)

1 QL 9 / 30 days

zolmitriptan 5 mg nasal spray 3

zolmitriptan (2.5 mg tablet, 5 mg tablet) 1 QL 9 / 30 days

zolmitriptan odt 1 QL 9 / 30 days

ZOMIG (2.5 MG TABLET, 5 MG NASAL SPRAY, 5 MGTABLET)

3 ST

ZOMIG ZMT 3 ST

Antimyasthenic Agents

Parasympathomimetics

guanidine hcl 1

MESTINON 180 MG TIMESPAN 3 QL 60 / 30 days

pyridostigmine bromide (60 mg/5 ml soln, br 60 mg tablet) 1

pyridostigmine bromide er 1 QL 60 / 30 days



Antimycobacterials

PASER 3

Antimycobacterials, Other

dapsone (25 mg tablet, 100 mg tablet) 1

MYCOBUTIN 3 QL 180 / 90 days

rifabutin 1 QL 180 / 90 days

Antituberculars

CAPASTAT SULFATE 3

cycloserine 1

ethambutol hcl 1

isoniazid (50 mg/5 ml solution, 100 mg tablet, 100 mg/ml vial,300 mg tablet)

1

PRIFTIN 3

pyrazinamide 1

RIFADIN 150 MG CAPSULE 1

RIFAMATE 3

rifampin (150 mg capsule, 300 mg capsule, iv 600 mg vial) 1

RIFATER 3

SIRTURO 100 MG TABLET 3 QL 120 / 30 days

Antineoplastics

Alkylating Agents

ALKERAN 50 MG VIAL 3

busulfan 4 PA

BUSULFEX 4 PA

GLEOSTINE (10 MG CAPSULE, 40 MG CAPSULE) 4

LEUKERAN 2

MATULANE 2

melphalan hcl 1



Antiandrogens

abiraterone acetate 250 mg tab 4QL 4 / day

PA

bicalutamide 1

CASODEX 3

flutamide 1

nilutamide 4 QL 270 / 30 days

XTANDI 40 MG CAPSULE 4QL 120 / 30 days

PA

Antiangiogenic Agents

POMALYST 4 PA

REVLIMID (5 MG CAPSULE, 10 MG CAPSULE, 15 MGCAPSULE, 25 MG CAPSULE)

4QL 30 / 30 days

PA

THALOMID (150 MG CAPSULE, 200 MG CAPSULE) 4QL 60 / 30 days

PA

THALOMID (50 MG CAPSULE, 100 MG CAPSULE) 4QL 30 / 30 days

PA

Antiestrogens/Modifiers

EMCYT 2 QL 375 / 30 days

FARESTON 3 QL 30 / 30 days

SOLTAMOX 3

tamoxifen citrate 1 GL Female

toremifene citrate 1 QL 1 / day

Antimetabolites

DROXIA 2 QL 30 / 30 days

hydroxyurea 1

mercaptopurine 1



TABLOID 3

Antineoplastics, Other

fludarabine 50 mg vial 4

fludarabine 50 mg/2 ml vial 1

leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25 mg tab,50 mg vial, 100 mg vial, 200 mg vial, 350 mg vial, 500 mg vl)

1

mitoxantrone hcl 4

ZOLINZA 4QL 120 / 30 days

PA

Aromatase Inhibitors, 3rd Generation

anastrozole 1

ARIMIDEX 3

AROMASIN 3

exemestane 1

letrozole 1

Enzyme Inhibitors

ETOPOPHOS 3

etoposide (100 mg/5 ml vial, 500 mg/25 ml vial, 1,000 mg/50 mlvial)

4

HYCAMTIN 4 MG VIAL 4QL 2 / 7 days

PA

TOPOSAR 4

topotecan hcl (4 mg vial, 4 mg/4 ml vial) 4

topotecan hcl 1 mg/ml vial 4 PA

Molecular Target Inhibitors

AFINITOR 10 MG TABLET 4QL 30 / 30 days

PA

BOSULIF 100 MG TABLET 4QL 3 / day

PA



BOSULIF 500 MG TABLET 4QL 30 / 30 days

PA

CAPRELSA 4 PA

COMETRIQ 100 MG DAILY-DOSE PK 4QL 56 / 28 days

PA

COMETRIQ 140 MG DAILY-DOSE PK 4QL 112 / 28 days

PA

COMETRIQ 60 MG DAILY-DOSE PACK 4QL 84 / 28 days

PA

ERIVEDGE 4QL 30 / 30 days

PA

erlotinib hcl (100 mg tablet, 150 mg tablet) 4QL 1 / day

PA

erlotinib hcl 25 mg tablet 4QL 2 / day

PA

everolimus (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet) 4QL 30 / 30 days

PA

everolimus 10 mg tablet 4 QL 2 / day

ICLUSIG 15 MG TABLET 4QL 60 / 30 days

PA

ICLUSIG 45 MG TABLET 4QL 30 / 30 days

PA

imatinib mesylate 100 mg tab 4QL 3 / day

PA

imatinib mesylate 400 mg tab 4QL 2 / day

PA

INLYTA 1 MG TABLET 4QL 180 / 30 days

PA



INLYTA 5 MG TABLET 4QL 60 / 30 days

PA

JAKAFI 4QL 60 / 30 days

PA

lapatinib 4QL 180 / 30 days

PA

MEKINIST 4 PA

NEXAVAR 4QL 120 / 30 days

PA

SPRYCEL (50 MG TABLET, 70 MG TABLET, 80 MG TABLET,100 MG TABLET, 140 MG TABLET)

4QL 30 / 30 days

PA

SPRYCEL 20 MG TABLET 4QL 60 / 30 days

PA

STIVARGA 4QL 84 / 28 days

PA

sunitinib malate (12.5 mg cap, 25 mg capsule, 50 mg capsule) 4QL 90 / 30 days

PA

TAFINLAR 4QL 120 / 30 days

PA

TASIGNA (150 MG CAPSULE, 200 MG CAPSULE) 4QL 120 / 30 days

PA

VOTRIENT 4QL 120 / 30 days

PA

XALKORI 4 PA

ZELBORAF 4QL 240 / 30 days

PA

Monoclonal Antibodies

ARZERRA 100 MG/5 ML VIAL 4

PA




ABRAXANE 4

PA


ADRIAMYCIN (10 MG/5 ML VIAL, 20 MG/10 ML VIAL, 50MG/25 ML VIAL, 200 MG/100 ML VIAL)

1

ADRUCIL 1

ALIMTA 4

PA


azacitidine 4

BICNU 3

bleomycin sulfate 1

CAMPTOSAR 40 MG/2 ML VIAL 4

carboplatin (50 mg/5 ml vial, 150 mg vial, 150 mg/15 ml vial,450 mg/45 ml vial, 600 mg/60 ml vial)

1 PA

carmustine 3

cisplatin (50 mg/50 ml vial, 100 mg/100 ml vial, 200 mg/200 mlvial)

1

cladribine 1

clofarabine 4 PA

CLOLAR 4 PA

COSMEGEN 4

cytarabine 1

dacarbazine 1

DACOGEN 4

daunorubicin hcl (20 mg vial, 20 mg/4 ml vial, 50 mg/10 ml vial) 1

decitabine 4

dexrazoxane 1

DOCEFREZ 3

docetaxel (160 mg/16 ml vial, 160 mg/8 ml vial) 1 QL 1 / 21 days

docetaxel (20 mg/2 ml vial, 20 mg/ml vial, 80 mg/8 ml vial) 1 QL 3 / 21 days

docetaxel 80 mg/4 ml vial 4 QL 3 / 21 days



doxorubicin 20 mg/10 ml vial 1 QL 2 / 28 days

doxorubicin 50 mg/25 ml vial 1 QL 3 / 28 days

doxorubicin hcl (10 mg vial, 10 mg/5 ml vial, 50 mg vial, 150mg/75 ml vial, 200 mg/100 ml vial)

1

doxorubicin hcl liposome 4 QL 2 / 28 days

ELITEK 1.5 MG VIAL 4

ELITEK 7.5 MG VIAL 3

epirubicin hcl (50 mg/25 ml vial, hcl 50 mg vial, 200 mg/100 mlvial, hcl 200 mg vial)

1

ETHYOL 4

FASLODEX 3 QL 10 / 28 days

fluorouracil (1 gram/20 ml vial, 2.5 gram/50 ml vl, 5 gram/100 mlvl, 500 mg/10 ml vial)

1

FOLOTYN 4

PA


fulvestrant 3QL 0.36/day

PA

gemcitabine hcl (1 gram vial, 2 gram vial, 200 mg vial) 1

HALAVEN 3 M-PA Medical BenefitPA

idarubicin hcl 1

ifosfamide (1 gm vial, 1 gm/20 ml vial, 3 gm vial, 3 gm/60 mlvial)

1

irinotecan hcl (100 mg/5 ml vl, 500 mg/25 ml vl) 1

irinotecan hcl 40 mg/2 ml vial 4

ISTODAX 4

PA


LIPODOX 1

LIPODOX 50 1 QL 3 / 28 days

mesna 1

MESNEX 400 MG TABLET 2



mitomycin 4

MUTAMYCIN 4

nelarabine 4

NIPENT 4

oxaliplatin (100 mg vial, 100 mg/20 ml vial) 1 QL 3 / 14 days

oxaliplatin (50 mg vial, 50 mg/10 ml vial) 1 QL 1 / 14 days

paclitaxel 4

PERJETA 4

PA


PROLEUKIN 4

SYNRIBO 4

PA


TREANDA 4

PA


VELCADE 4

PA


VIDAZA 4

vinblastine sulfate 1

VINCASAR PFS 1

vincristine sulfate 1

vinorelbine tartrate 1

ZANOSAR 3

Retinoids

bexarotene 4 PA

PANRETIN 4 QL 60 / 30 days

TARGRETIN (1% GEL, 75 MG CAPSULE) 4 PA

tretinoin 10 mg capsule 1



Antiparasitics

Antihelminthics

albendazole 1 QL 4 / day

BILTRICIDE 3

ivermectin 0.5% lotion 1

ivermectin 3 mg tablet 1 PA

praziquantel 1

STROMECTOL 3

Antiprotozoals

ALINIA 100 MG/5 ML SUSPENSION 2

QL 60 / 3 days

AL At least 1 yrs old

PA

ALINIA 500 MG TABLET 2

QL 2 / day


PA

atovaquone 1

atovaquone-proguanil hcl 1

chloroquine phosphate 1

COARTEM 2 QL 6 / 30 days

hydroxychloroquine 200 mg tab 1 QL 2 / day

MALARONE 3

mefloquine hcl 1

MEPRON 3 QL 300 / 30 days

nitazoxanide 1 PA

PENTAM 300 3

pentamidine 300 mg vial 3

primaquine 1

quinine sulfate 1



Pediculicides/Scabicides

CROTAN 1

EURAX 10% CREAM 2

lindane 1

malathion 1

permethrin 1

spinosad 1

ULESFIA 2

Antiparkinson Agents

Anticholinergics

benztropine mesylate (mes 0.5 mg tab, mes 1 mg tablet, 2 mg/2ml ampule, 2 mg/2 ml vial, mes 2 mg tablet)

1

trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml soln, 5 mg tablet) 1

carbidopa-levodopa-entacapone 1

Antiparkinson Agents, Other

amantadine (50 mg/5 ml solution, 100 mg capsule, 100 mgtablet, 100 mg/10 ml soln)

1

COMTAN 3

entacapone 1

TASMAR 4

tolcapone 4

Dopamine Agonists

APOKYN 4 QL 45 / 30 days

bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) 1

MIRAPEX (0.25 MG TABLET, 0.5 MG TABLET, 0.75 MGTABLET)

3

MIRAPEX ER 3

NEUPRO 3

pramipexole dihydrochloride 1

pramipexole er (er 0.375 mg tablet, er 0.75 mg tablet, er 3.75mg tablet)

1



pramipexole er (er 1.5 mg tablet, er 2.25 mg tablet, er 3 mgtablet, er 4.5 mg tablet)

1 QL 30 / 30 days

ropinirole er 1

ropinirole hcl 1

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors

carbidopa 1 QL 90 / 30 days

carbidopa-levodopa (carbidopa-levo 10-100 mg odt, carbidopa-levo 25-100 mg odt, carbidopa-levo 25-250 mg odt, carbidopa-levodopa 10-100 tab, carbidopa-levodopa 25-100 tab,carbidopa-levodopa 25-250 tab)

1

carbidopa-levodopa er 1

LODOSYN 3 QL 90 / 30 days

Monoamine Oxidase B (MAO-B) Inhibitors

AZILECT 3

rasagiline mesylate 1

selegiline hcl (5 mg capsule, 5 mg tablet) 1

ZELAPAR 3

Antipsychotics

1st Generation/Typical

fluphenazine decanoate 1

fluphenazine hcl (2.5 mg/5 ml elix, 2.5 mg/ml vial, 5 mg/mlconc)

1

haloperidol 1

haloperidol decanoate (dec 50 mg/ml vial, dec 100 mg/ml amp,dec 100 mg/ml vial, dec 250 mg/5 ml vl, dec 500 mg/5 ml vl,decan 50 mg/ml amp)

1

haloperidol decanoate 100 1

haloperidol lactate (2 mg/ml conc, 5 mg/ml ampul, 5 mg/ml vial,10 mg/5 ml cup, 50 mg/10 ml vl)

1

loxapine 1

pimozide 1 mg tablet 1

pimozide 2 mg tablet 1 QL 90 / 90 days

thioridazine hcl 1



thiothixene 1

trifluoperazine hcl 1

2nd Generation/Atypical

asenapine maleate (5 mg tablet, 10 mg tablet) 1

FANAPT TITRATION PACK 3

FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MGTABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET)

3 QL 60 / 30 days

GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MGCAPSULE, 80 MG CAPSULE)

3 QL 2 / day

GEODON 20 MG/ML VIAL 3

INVEGA 3 QL 30 / 30 days

INVEGA SUSTENNA 117 MG/0.75 ML 4 QL 0.75 / 28 days

INVEGA SUSTENNA 156 MG/ML SYRG 4 QL 1 / 28 days




LATUDA (20 MG TABLET, 40 MG TABLET, 80 MG TABLET,120 MG TABLET)

2 QL 30 / 30 days

olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10 mgtablet, 15 mg tablet, 20 mg tablet)

1 QL 1 / day

olanzapine 10 mg vial 1

olanzapine odt 1 QL 1 / day

paliperidone er (er 1.5 mg tablet, er 3 mg tablet, er 9 mg tablet) 1

paliperidone er 6 mg tablet 1 QL 30 / 30 days

RISPERDAL 1 MG/ML SOLUTION 3 QL 16/day

RISPERDAL (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3 QL 8 / day

RISPERDAL 3 MG TABLET 3 QL 5 / day

RISPERDAL 4 MG TABLET 3 QL 4 / day

RISPERDAL CONSTA 4 QL 2 / 14 days



risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 1 mg/mlsolution, 2 mg tablet, 3 mg tablet, 4 mg tablet)

1

risperidone odt 1

SAPHRIS (5 MG TAB, 10 MG TAB) 3 QL 60 / 30 days

ziprasidone hcl 1

ziprasidone mesylate 3

ZYPREXA (2.5 MG TABLET, 5 MG TABLET) 3 QL 6 / day

ZYPREXA 10 MG TABLET 3 QL 3 / day



ZYPREXA 7.5 MG TABLET 3 QL 4 / day

Treatment-Resistant

clozapine 1

clozapine odt 1

CLOZARIL (50 MG TABLET, 100 MG TABLET) 3 QL 9 / day

CLOZARIL 200 MG TABLET 3 QL 4 / day

CLOZARIL 25 MG TABLET 3 QL 18 / day

Antispasticity Agents

baclofen (10 mg tablet, 20 mg tablet) 1

baclofen 10 mg/20 ml vial 3

COMFORT PAC-TIZANIDINE 3

dantrolene sodium (25 mg cap, 50 mg cap, 100 mg cap) 1

GABLOFEN (50 MCG/ML SYRINGE, 10,000 MCG/20 ML VIAL) 3

LIORESAL INTRATHECAL (0.05 MG/1 ML AMP, 10 MG/20 MLAMPULE, 10 MG/20 ML K)

3

tizanidine hcl (2 mg tablet, 4 mg tablet) 1

ZANAFLEX 6 MG CAPSULE 3



Antivirals

Anti-HIV Agents, Integrase Inhibitors (INSTI)

ISENTRESS (25 MG TABLET CHEW, 100 MG TABLETCHEW)

2

ISENTRESS 400 MG TABLET 2 QL 60 / 30 days

STRIBILD 4 QL 30 / 30 days

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

COMPLERA 4QL 30 / 30 days

ST

EDURANT 3 QL 60 / 30 days

efavirenz (50 mg capsule, 200 mg capsule, 600 mg tablet) 1

efavirenz-emtric-tenofov disop 3 QL 1 / day

etravirine 1

INTELENCE 100 MG TABLET 3

INTELENCE 200 MG TABLET 3 QL 60 / 30 days

nevirapine (50 mg/5 ml susp, 200 mg tablet) 1

nevirapine er 100 mg tablet 1

nevirapine er 400 mg tablet 1 QL 30 / 30 days

RESCRIPTOR 3

SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MGTABLET)

3

VIRAMUNE 50 MG/5 ML SUSP 3

VIRAMUNE XR 3 QL 30 / 30 days

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

abacavir (20 mg/ml solution, 300 mg tablet) 1

abacavir-lamivudine 4 QL 30 / 30 days

abacavir-lamivudine-zidovudine 4

didanosine 1

emtricitabine 3



emtricitabine-tenofv 200-300mg 4 QL 1 / day

EMTRIVA 200 MG CAPSULE 3 QL 30 / 30 days

EMTRIVA 10 MG/ML SOLUTION 3

EPIVIR 10 MG/ML ORAL SOLN 3

EPZICOM 4 PA

lamivudine (10 mg/ml oral soln, 150 mg tablet, 300 mg tablet) 1

lamivudine-zidovudine 1

RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE, 200MG/20 ML VIAL)

3

stavudine 1

tenofovir disoproxil fumarate 1

TRIZIVIR 3

VIDEX 2

VIDEX EC 3

ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 3

zidovudine (50 mg/5 ml syrup, 100 mg capsule, 300 mg tablet) 1

Anti-HIV Agents, Other

FUZEON 3

SELZENTRY (150 MG TABLET, 300 MG TABLET) 2

Anti-HIV Agents, Protease Inhibitors

APTIVUS 250 MG CAPSULE 3 QL 120 / 30 days

APTIVUS 100 MG/ML SOLUTION 3

atazanavir sulfate 1

CRIXIVAN 200 MG CAPSULE 2 QL 30 / 30 days

CRIXIVAN 400 MG CAPSULE 2 QL 120 / 30 days

fosamprenavir calcium 1

INVIRASE 3

KALETRA 80 MG-20 MG/ML SOLN 4 QL 160 / 30 days

KALETRA 100-25 MG TABLET 4 QL 30 / 30 days



KALETRA 200-50 MG TABLET 4 QL 60 / 30 days

LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 3

lopinavir-ritonavir 80-20mg/ml 4

lopinavir-ritonavr 100-25mg tb 4 QL 1 / day

lopinavir-ritonavr 200-50mg tb 4 QL 2 / day

NORVIR 80 MG/ML SOLUTION 2

NORVIR 100 MG TABLET 3 QL 90 / 30 days

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150MG TABLET)

2 PA

PREZISTA (600 MG TABLET, 800 MG TABLET) 2QL 60 / 30 days

PA

REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 MGCAPSULE)

3 QL 30 / 30 days

ritonavir 1 QL 3 / day

VIRACEPT 250 MG TABLET 3QL 30 / 30 days

PA

VIRACEPT 625 MG TABLET 3QL 60 / 30 days

PA

Anti-cytomegalovirus (CMV) Agents

cidofovir 1

foscarnet sodium (mg/250 ml bag, mg/250 ml bttl) 3

VALCYTE (50 MG/ML SOLUTION, 450 MG TABLET) 3

valganciclovir hcl 50 mg/ml 1

valganciclovir 450 mg tablet 1 QL 120 / 30 days

ZIRGAN 3

Anti-hepatitis B (HBV) Agents

adefovir dipivoxil 1

BARACLUDE 0.05 MG/ML SOLUTION 2 QL 600 / 30 days

BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 3



entecavir 1 QL 30 / 30 days

EPIVIR HBV 25 MG/5 ML SOLN 2

EPIVIR HBV 100 MG TABLET 3 QL 30 / 30 days

HEPSERA 3

INTRON A (18 MILLION UNIT/3 ML, 25 MILLION UNIT/2.5ML) 4 PA

lamivudine hbv 1 QL 30 / 30 days

PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) 4QL 4 / 28 days

PA

PEGINTRON 4 PA

RIBASPHERE (200 MG CAPSULE, 600 MG TABLET) 1

RIBASPHERE RIBAPAK 4

ribavirin (200 mg capsule, 200 mg tablet) 1

SYLATRON 4 PA

VIREAD POWDER 2

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MGTABLET)

2 QL 30 / 30 days

VIREAD 300 MG TABLET 3 QL 30 / 30 days

Anti-influenza Agents

oseltamivir phosphate (6 mg/ml suspension, phos 30 mgcapsule, phos 45 mg capsule, phos 75 mg capsule)

1 QL 1 fill / 30 days

RELENZA 2 QL 1 / 270 days

rimantadine hcl 1

TAMIFLU 6 MG/ML SUSPENSION 3 QL 60 / 270 days

Antihepatitis Agents

ribavirin 6 gm inhalation vial 1

VIRAZOLE 3

Antiherpetic Agents

acyclovir 5% cream 1 PA



acyclovir (5% ointment, 200 mg capsule, 200 mg/5 ml susp,400 mg tablet, 800 mg tablet)

1

acyclovir sodium (sodium 1 gm vial, 500 mg/10 ml vial, sodium500 mg vial, 1,000 mg/20 ml vial)

1

DENAVIR 3

famciclovir 1

trifluridine 1

valacyclovir 1

ZOVIRAX (5% OINTMENT, 200 MG/5 ML SUSP) 3

XERESE 3

Anxiolytics

Anxiolytics, Other

buspirone hcl 1

hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup, hcl 10 mgtablet, 25 mg/ml vial, hcl 25 mg tablet, 50 mg/25 ml syrup, 50mg/ml vial, hcl 50 mg tablet, 100 mg/2 ml vial, 500 mg/10 mlvial)

1

hydroxyzine pamoate 1

meprobamate 1

Benzodiazepines

alprazolam 1

alprazolam er 1

ALPRAZOLAM INTENSOL 1

alprazolam odt 1

alprazolam xr 1

chlordiazepoxide hcl 1

estazolam 1

oxazepam 1

triazolam 1



Bipolar Agents

Mood Stabilizers

lithium carbonate (150 mg cap, 300 mg cap, 300 mg tab, 600mg cap)

1

lithium carbonate er 1

Blood Glucose Regulators

Antidiabetic Agents

acarbose 1

alogliptin 1QL 30 / 30 days

ST

AVANDIA 2 MG TABLET 3 QL 30 / 30 days

AVANDIA 4 MG TABLET 3 QL 60 / 30 days

BYETTA 2QL 2.4 / 30 days

ST

colesevelam hcl 3.75 g packet 1 QL 1 / day

colesevelam 625 mg tablet 1 QL 6 / day

CYCLOSET 3

glimepiride 1

glipizide 1

glipizide er 1

glipizide xl 1

glyburide 1

glyburide micronized 1

INVOKANA 3QL 30 / 30 days

ST

JANUVIA 3QL 1 / 1 days

ST

metformin hcl 500 mg/5 ml soln 3

metformin hcl (500 mg tablet, 850 mg tablet, 1,000 mg tablet) 1



metformin hcl er 1

miglitol 1

nateglinide 1

NESINA 3QL 30 / 30 days

ST

ONGLYZA 3QL 30 / 30 days

ST

pioglitazone hcl 1

repaglinide 1

RIOMET 3

SYMLINPEN 120 2QL 10.8 / 30 days

PA

SYMLINPEN 60 2QL 6 / 30 days

PA

TRADJENTA 3QL 1 / day

ST

VICTOZA 2-PAK 2QL 6 / 30 days

ST

VICTOZA 3-PAK 2QL 6 / 20 days

ST

WELCHOL 3.75G PACKET 3 QL 30 / 30 days

WELCHOL 625 MG TABLET 3 QL 180 / 30 days

ACTOPLUS MET XR 3 QL 60 / 30 days

alogliptin-metformin 1QL 60 / 30 days

ST

alogliptin-pioglitazone 1QL 1 / 1 days

ST

glipizide-metformin 1



glyburide-metformin hcl 1

JANUMET 3QL 2 / 1 days

ST

JANUMET XR (50-1,000 MG TABLET, 100-1,000 MG TABLET) 3QL 1 / 1 days

ST

JANUMET XR 50-500 MG TABLET 3QL 60 / 30 days

ST

JENTADUETO 3QL 2 / day

ST

KAZANO 3QL 60 / 30 days

ST

KOMBIGLYZE XR (5-1,000 MG TAB, 5-500 MG TABLET) 3QL 1 / day

ST

KOMBIGLYZE XR 2.5-1,000 MG TAB 3QL 60 / 30 days

ST

OSENI 3QL 1 / 1 days

ST

pioglitazone-glimepiride 1

repaglinide-metformin hcl 1

Glycemic Agents

diazoxide 1 QL 3 / day

GLUCAGEN 1 MG HYPOKIT 3 ST

GLUCAGEN DIAGNOSTIC 1 MG VIAL 2

glucagon hcl 1

Insulins

HUMULIN R U-500 2QL 90 days

PA



insulin aspart 2QL 3 / day

ST

insulin aspart prot mix 70-30 (pn, vl) 2QL 2 / day

ST

LANTUS 2 QL 75 / 30 days

LANTUS SOLOSTAR 2 QL 75 / 30 days

LEVEMIR 2 QL 200 / 90 days

LEVEMIR FLEXTOUCH 2 QL 60 / 30 days

NOVOLIN 70-30 100 UNIT/ML VIAL 2 QL 180 / 90 days

NOVOLIN 70-30 FLEXPEN 2 QL 180 / 90 days

NOVOLIN N 100 UNIT/ML VIAL 2 QL 180 / 90 days

NOVOLIN N 100 UNIT/ML FLEXPEN 2 QL 180 / 90 days

NOVOLIN R 100 UNIT/ML VIAL 2 QL 180 / 90 days

NOVOLOG 2 QL 2 / day

NOVOLOG MIX 70-30 2 QL 3 / day

NOVOLOG MIX 70-30 FLEXPEN 2 QL 3 / day

Blood Products/Modifiers/Volume Expanders

Anticoagulants

COUMADIN 2

ELIQUIS 2.5 MG TABLET 2 QL 60 / 30 days

ELIQUIS 5 MG TABLET 2 QL 74 / 30 days

enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr, 60mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe, 120 mg/0.8ml syr, 150 mg/ml syringe, 300 mg/3 ml vial)

1

fondaparinux sodium 1

FRAGMIN (2,500 UNIT/0.2 ML SYR, 5,000 UNIT/0.2 ML SYR,7,500 UNIT/0.3 ML SYR, 10,000 UNIT/ML SYRINGE, 12,500UNIT/0.5 ML SYR, 15,000 UNIT/0.6 ML SYR, 18,000UNIT/0.72 ML)

4



FRAGMIN 95,000 UNIT/3.8 ML VL 1

heparin flush (hep-lock flush 100 unit/ml kit, heparin 1,000unit/10 (100/ml), heparin iv flush 100 units/ml)

1

heparin lock (lock flush 100 unit/ml, 500 unit/5 ml (100/ml)) 1

heparin sodium (sod 1,000 unit/ml vial, 5,000 unit/ml carpujct,sod 5,000 unit/ml vial, 10,000 unit/10 ml vial, sod 10,000 unit/mlvl, sod 20,000 unit/ml vl, 30,000 unit/30 ml vial, 40,000 unit/4 mlvial, 50,000 unit/10 ml vial, 50,000 unit/5 ml vial)

1

heparin sodium in 0.45% nacl 1

heparin-12,500 unit/250-1/2 ns 1

heparin 20,000 unit/500 ml-d5w 1

JANTOVEN 1

LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 MLSYRINGE, 60 MG/0.6 ML SYRINGE, 80 MG/0.8 ML SYRINGE,100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/MLSYRINGE, 300 MG/3 ML VIAL)

3

PRADAXA (75 MG CAPSULE, 150 MG CAPSULE) 2 QL 60 / 30 days

warfarin sodium 1

XARELTO (10 MG TABLET, 20 MG TABLET) 2 QL 30 / 30 days

XARELTO 15 MG TABLET 2 QL 30 / 15 days

Blood Formation Modifiers

anagrelide hcl 1

ARANESP (25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, 40MCG/0.4 ML SYRINGE, 40 MCG/ML VIAL, 60 MCG/0.3 MLSYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 ML SYRINGE, 100MCG/ML VIAL, 150 MCG/0.3 ML SYRINGE, 200 MCG/0.4 MLSYRINGE, 300 MCG/0.6 ML SYRINGE, 500 MCG/1 MLSYRINGE)

4

PA


EPOGEN 4

PA


LEUKINE 4QL 28 / 14 days

PA

MOZOBIL 4

PA




NEULASTA 4

PA


NEULASTA ONPRO 4

PA


NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480MCG/0.8 ML SYR)

4QL 3 / day

PA

PROCRIT 4

PA


PROMACTA (12.5 MG TABLET, 25 MG TABLET) 4QL 30 / 30 days

PA

PROMACTA 50 MG TABLET 4QL 60 / 30 days

PA

PROMACTA 75 MG TABLET 4 PA

argatroban 1

argatroban-0.9% nacl 1

argatroban-sodium chloride 1

Coagulants

CYKLOKAPRON (MG/10 ML AMP, MG/10 ML VL) 3

tranexamic acid (650 mg tablet, 1,000 mg/10 ml) 1

Platelet Modifying Agents

AGGRENOX 3

aspirin-dipyridamole er 1

BRILINTA 90 MG TABLET 2 QL 60 / 30 days

cilostazol 1

clopidogrel 1

dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1

EFFIENT 3 QL 30 / 30 days



prasugrel hcl 1 QL 1 / day

Cardiovascular Agents

Alpha-adrenergic Agonists

CATAPRES-TTS 1 3 QL 4 / 28 days



clonidine 1 QL 4 / 28 days

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1

clonidine hcl er 1 QL 120 / 30 days

guanfacine hcl 1

KAPVAY 3 QL 120 / 30 days

methyldopa 1

methyldopate hcl 1

midodrine hcl 1

Alpha-adrenergic Blocking Agents

DIBENZYLINE 4QL 360 / 30 days

PA

doxazosin mesylate 1

phenoxybenzamine hcl 4QL 360 / 30 days

PA

prazosin hcl 1

terazosin hcl 1

Angiotensin II Receptor Antagonists

ATACAND 3

BENICAR 3 QL 30 / 30 days

candesartan cilexetil 1

DIOVAN 3



EDARBI 3 QL 30 / 30 days

eprosartan mesylate 1

irbesartan 1 QL 30 / 30 days

losartan potassium 1

MICARDIS 3

olmesartan medoxomil 1 QL 30 / 30 days

telmisartan 1

valsartan 1

Angiotensin-converting Enzyme (ACE) Inhibitors

benazepril hcl 1

captopril 1

enalapril maleate (2.5 mg tab, 5 mg tablet, 10 mg tab, 20 mgtab)

1

fosinopril sodium 1

lisinopril 1

LOTENSIN 10 MG TABLET 3

moexipril hcl 1

perindopril erbumine 1

quinapril hcl 1

ramipril 1

trandolapril 1

Antiarrhythmics

amiodarone hcl (hcl 100 mg tablet, 150 mg/3 ml vial, hcl 200mg tablet, hcl 400 mg tablet, 450 mg/9 ml vial, 900 mg/18 mlvial)

1

disopyramide phosphate 1

dofetilide 1 QL 60 / 30 days

flecainide acetate 1

mexiletine hcl 1

MULTAQ 2 QL 60 / 30 days



NEXTERONE 3

PACERONE 200 MG TABLET 1

procainamide hcl (1 gram/10 ml vial, 1 gram/2 ml vial, 1,000mg/10 ml vl, 1,000 mg/2 ml vl)

1

propafenone hcl 1

propafenone hcl er 1

quinidine gluconate 1

quinidine sulfate 1

RYTHMOL SR 3

SORINE 1

sotalol 1

SOTALOL AF 1

sotalol hcl 1

TIKOSYN 3 QL 60 / 30 days

Beta-adrenergic Blocking Agents

acebutolol hcl 1

atenolol 1

betaxolol hcl (10 mg tablet, 20 mg tablet) 1

bisoprolol fumarate 1

carvedilol 1

carvedilol er 1

COREG CR 3 QL 30 / 30 days

INNOPRAN XL 120 MG CAPSULE 3

INNOPRAN XL 80 MG CAPSULE 3 QL 90 / 90 days

labetalol hcl (20 mg/4 ml vial, 100 mg tablet, 100 mg/20 ml vl,200 mg tablet, 200 mg/40 ml vl, 300 mg tablet)

1

metoprolol succinate 1

metoprolol tartrate (5 mg/5 ml carpuject, tart 5 mg/5 ml vial,tartrate 25 mg tab, tartrate 50 mg tab, tartrate 100 mg tab)

1

nadolol 1

nebivolol hcl 1



pindolol 1

propranolol hcl (1 mg/ml vial, 10 mg tablet, 20 mg tablet, 20mg/5 ml soln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet, 80mg tablet)

1

propranolol hcl er 1

TOPROL XL 3

Calcium Channel Blocking Agents

amlodipine besylate 1

CARDIZEM LA (180 MG TABLET, 240 MG TABLET, 300 MGTABLET, 360 MG TABLET, 420 MG TABLET)

3 QL 30 / 30 days

CARDIZEM LA 120 MG TABLET 2 QL 30 / 30 days

CARTIA XT 1

DILT-XR 1

diltiazem 12hr er 1

diltiazem 24hr er (24hr er 120 mg cap, 24hr er 180 mg cap,24hr er 240 mg cap, 24hr er 300 mg cap, 24hr er 420 mg cap)

1 QL 1 / day

diltiazem 24hr er 360 mg cap 1

diltiazem 24hr er (cd) 1

diltiazem 24hr er (la) 1

diltiazem 24hr er (xr) 1

diltiazem hcl (25 mg/5 ml vial, 30 mg tablet, 50 mg/10 ml vial,60 mg tablet, 90 mg tablet, 100 mg add-van vial, 120 mg tablet,125 mg/25 ml vial)

1

diltiazem-d5w 1

felodipine er 1

isradipine 1

MATZIM LA 1

nicardipine hcl (20 mg capsule, 25 mg/10 ml ampule, 25 mg/10ml vial, 30 mg capsule)

1

nifedipine 1

nifedipine er 1

nimodipine 1

SULAR 3



TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE, 240 MGCAPSULE, 300 MG CAPSULE)

1 QL 1 / day

TAZTIA XT 360 MG CAPSULE 1

TIADYLT ER (ER 120 MG CAPSULE, ER 180 MG CAPSULE,ER 240 MG CAPSULE, ER 300 MG CAPSULE, ER 420 MGCAPSULE)

1 QL 1 / day

TIADYLT ER 360 MG CAPSULE 1

verapamil er (er 120 mg capsule, er 120 mg tablet, er 180 mgcapsule, er 180 mg tablet, er 240 mg capsule, er 240 mg tablet)

1

verapamil er pm 1

verapamil hcl (5 mg/2 ml ampul, 5 mg/2 ml vial, 10 mg/4 mlsyringe, 10 mg/4 ml vial, 40 mg tablet, 80 mg tablet, 120 mgtablet)

1

verapamil sr 1

ALDACTAZIDE 50-50 TABLET 3 QL 240 / 30 days

amiloride-hydrochlorothiazide 1

amlodipine besylate-benazepril 1

amlodipine-atorvastatin 1 QL 30 / 30 days

amlodipine-olmesartan 1 QL 30 / 30 days

amlodipine-valsartan 1 QL 30 / 30 days

amlod-valsa-hctz 5-160-25 mg 1

amlodipine-valsartan-hctz (5-160-12.5 mg, 10-160-12.5mg, 10-160-25 mg, 10-320-25 mg)

1 QL 30 / 30 days

ATACAND HCT 3

atenolol-chlorthalidone 1

AZOR 3 QL 30 / 30 days

benazepril-hydrochlorothiazide 1

BENICAR HCT 3 QL 30 / 30 days

BIDIL 2 QL 90 / 30 days

bisoprolol-hydrochlorothiazide 1

candesartan-hydrochlorothiazid 1

captopril-hydrochlorothiazide 1



DEMSER 2 QL 120 / 30 days

DIOVAN HCT 3

EDARBYCLOR 3 QL 30 / 30 days

enalapril-hydrochlorothiazide 1

EXFORGE 3 QL 30 / 30 days

EXFORGE HCT 3QL 30 / 30 days

ST

ezetimibe-simvastatin 1 QL 1 / day

fosinopril-hydrochlorothiazide 1

irbesartan-hydrochlorothiazide 1

lisinopril-hydrochlorothiazide 1

losartan-hydrochlorothiazide 1

LOTREL (5-40 MG CAPSULE, 10-40 MG CAPSULE) 3

methyldopa-hydrochlorothiazide 1

metoprolol-hydrochlorothiazide 1

MICARDIS HCT 3

olmesartan-amlodipine-hctz 1 QL 30 / 30 days

olmesartan-hydrochlorothiazide 1 QL 30 / 30 days

propranolol-hydrochlorothiazid 1

quinapril-hydrochlorothiazide 1

spironolactone-hctz 1

TEKTURNA HCT (150-12.5 MG TAB, 150-25 MG TABLET,300-12.5 MG TAB)

3 QL 1 / day

TEKTURNA HCT 300-25 MG TABLET 3 QL 30 / 30 days

telmisartan-amlodipine (40-10, 40-5 mg) 1 QL 30 / 30 days

telmisartan-amlodipine (80-10, 80-5 mg) 1

telmisartan-hydrochlorothiazid 1

trandolapr-verapam er 4-240 mg 1 QL 30 / 30 days



trandolapril-verapamil er (er 1-240 mg, er 2-180 mg, er 2-240mg)

1

triamterene-hydrochlorothiazid (37.5-25 mg cp, 37.5-25 mg tb,75-50 mg tab)

1

TRIBENZOR (20-5-12.5 MG TABLET, 40-10-12.5 MG TABLET) 3

TRIBENZOR (40-10-25 MG TABLET, 40-5-12.5 MG TABLET,40-5-25 MG TABLET)

3 QL 30 / 30 days

TWYNSTA (40-10 MG TABLET, 40-5 MG TABLET) 3 QL 30 / 30 days

TWYNSTA (80-10 MG TABLET, 80-5 MG TABLET) 3

valsartan-hydrochlorothiazide 1

VYTORIN 3 QL 30 / 30 days

Cardiovascular Agents, Other

aliskiren 1 QL 1 / day

DIGITEK 1

DIGOX 1

digoxin (0.05 mg/ml solution, 0.125 mg tablet, 0.25 mg tablet,0.25 mg/ml syringe, 125 mcg tablet, 250 mcg tablet, 500 mcg/2ml ampule)

1

LANOXIN (125 MCG TABLET, 250 MCG TABLET, 500 MCG/2ML AMPULE)

3

pentoxifylline 1

RANEXA 3 QL 60 / 30 days

ranolazine er 1 QL 2 / day

VECAMYL 1

Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide 1

acetazolamide er 1

acetazolamide sodium 1

methazolamide 1

Diuretics, Loop

bumetanide (0.25 mg/ml vial, 0.5 mg tablet, 1 mg tablet, 1 mg/4ml vial, 2 mg tablet, 2.5 mg/10 ml vial)

1



EDECRIN 3QL 240 / 30 days

PA

ethacrynic acid 1 QL 240 / 30 days

furosemide (10 mg/ml solution, 20 mg tablet, 20 mg/2 ml vial,40 mg tablet, 40 mg/4 ml vial, 40 mg/5 ml soln, 80 mg tablet,100 mg/10 ml vial)

1

torsemide 1

Diuretics, Potassium-sparing

amiloride hcl 1

DYRENIUM 3 QL 30 / 30 days

eplerenone 1

spironolactone 1

triamterene 3 QL 30 / 30 days

Diuretics, Thiazide

chlorothiazide sodium 1

chlorthalidone 1

DIURIL 3

hydrochlorothiazide (12.5 mg cp, 12.5 mg tb, 25 mg tab, 50 mgtab)

1

indapamide 1

metolazone 1

Dyslipidemics, Fibric Acid Derivatives

fenofibrate (43 mg capsule, 48 mg tablet, 50 mg capsule, 54 mgtablet, 67 mg capsule, 134 mg capsule, 145 mg tablet, 160 mgtablet, 200 mg capsule)

1

fenofibric acid (35 mg tablet, dr 45 mg cap, 105 mg tablet, dr135 mg cap)

1

FENOGLIDE 3

FIBRICOR 3

gemfibrozil 1

LIPOFEN 3

TRILIPIX 3



Dyslipidemics, HMG CoA Reductase Inhibitors

ALTOPREV 3 QL 30 / 30 days

atorvastatin calcium 1 QL 30 / 30 days

CRESTOR 3 QL 30 / 30 days

fluvastatin er 1QL 30 / 30 days

ST

fluvastatin sodium 1QL 30 / 30 days

ST

LESCOL 3QL 1 / day

ST

LESCOL XL 3QL 30 / 30 days

ST

LIVALO 3

lovastatin 1 QL 30 / 30 days

pravastatin sodium 1 QL 30 / 30 days

rosuvastatin calcium 1 QL 30 / 30 days

simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mgtablet, 80 mg tablet)

1 QL 30 / 30 days

Dyslipidemics, Other

cholestyramine (packet, powder) 1

cholestyramine light powder 1 QL 478 / 28 days

cholestyramine light packet 1

COLESTID FLAVORED GRANULES 3

colestipol hcl (1 gm tablet, granules, granules packet) 1

ENDUR-ACIN ER 500 MG TABLET 1

ezetimibe 1 QL 30 / 30 days

icosapent ethyl 1

LOVAZA 3



niacin (er 500 mg caplet, er 500 mg tablet, er 1,000 mg tablet, tr500 mg caplet, tr 500 mg tablet)

1

niacin er 1

NIASPAN 3

omega-3 acid ethyl esters 1

PREVALITE POWDER 1 QL 478 / 28 days

PREVALITE PACKET 1

VASCEPA 1 GM CAPSULE 3

QL 120 / 30 days

B4G Brand ForGeneric

ZETIA 3

Vasodilators, Direct-acting Arterial

hydralazine hcl (10 mg tablet, 20 mg/ml vial, 25 mg tablet, 50mg tablet, 100 mg tablet)

1

minoxidil (2.5 mg tablet, 10 mg tablet) 1

Vasodilators, Direct-acting Arterial/Venous

DILATRATE-SR 2

isosorbide dinitrate (5 mg tab, 10 mg tab, 20 mg tab, 30 mg tab) 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

MINITRAN 1

NITRO-BID 2

NITRO-DUR 3

nitroglycerin (0.3 mg tablet sl, 0.4 mg tablet sl, 0.6 mg tablet sl,5 mg/ml vial, 400 mcg spray)

1

nitroglycerin patch 1

NITROLINGUAL 3

NITROSTAT 3

RECTIV 3 QL 60 / 30 days



Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

ADDERALL 15 MG TABLET 3 QL 3 / day

ADDERALL 30 MG TABLET 3 QL 2 / day

ADDERALL 7.5 MG TABLET 3

ADDERALL XR 3

dextroamphetamine 5 mg/5 ml 1

dextroamphetamine sulfate (5 mg tab, 10 mg tab) 1 QL 180 / 30 days

dextroamphetamine sulfate er 1 QL 120 / 30 days

dextroamphetamine-amphet er 1 QL 1 / day

dextroamp-amphetamine 5 mg tab 1 QL 180 / 30 days

dextroamphetamine-amphetamine (20 mg tab, 30 mg tab) 1 QL 2 / day

dextroamphetamine-amphetamine (dextroamp-amphetam 7.5mg tab, dextroamp-amphetam 12.5 mg tab, dextroamp-amphetamin 10 mg tab, dextroamp-amphetamin 15 mg tab)

1 QL 3 / day

VYVANSE (20 MG CAPSULE, 30 MG CAPSULE, 40 MGCAPSULE, 50 MG CAPSULE, 60 MG CAPSULE, 70 MGCAPSULE)

3

ZENZEDI (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET,10 MG TABLET)

3

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

atomoxetine hcl 1 QL 1 / day

CONCERTA 3

DAYTRANA 2QL 30 / 30 days

ST

dexmethylphenidate hcl 1 QL 60 / 30 days

dexmethylphenidate hcl er 1 QL 30 / 30 days

FOCALIN XR (5 MG CAPSULE, 15 MG CAPSULE, 20 MGCAPSULE, 25 MG CAPSULE, 30 MG CAPSULE, 35 MGCAPSULE, 40 MG CAPSULE)

3

FOCALIN XR 10 MG CAPSULE 3 QL 30 / 30 days



guanfacine hcl er 1 QL 1 / day

METADATE ER 1

methylphenidate er (er 18 mg tab, er 20 mg tab, er 27 mg tab,er 36 mg tab)

1QL 30 / 30 days

ST

methylphenidate er 54 mg tab 1QL 1 / day

ST

methylphenidate er (la) (20mg cp, 30mg cp, 40mg cp) 1 QL 30 / 30 days

methylphenidate er(la) 10mg cp 1 QL 1 / day

methylphenidate hcl (2.5 mg chew tb, 5 mg chew tab, 5 mg/5 mlsoln, 10 mg chew tab, 10 mg/5 ml sol)

1

methylphenidate hcl (5 mg tablet, 10 mg tablet, 20 mg tablet) 1 QL 90 / 30 days

methylphenidate hcl cd 1 QL 30 / 30 days

methylphenidate er(cd) 10mg cp 1 QL 1 / day

methylphenidate hcl er (cd) (20mg cp, 30mg cp, 40mg cp,50mg cp, 60mg cp)

1 QL 30 / 30 days

methylphenidate la (20 mg cap, 30 mg cap, 40 mg cap) 1 QL 30 / 30 days

methylphenidate la 10 mg cap 1 QL 1 / day

QUILLIVANT XR 3

RITALIN LA 10 MG CAPSULE 3

STRATTERA (10 MG CAPSULE, 18 MG CAPSULE, 25 MGCAPSULE, 40 MG CAPSULE)

3 QL 60 / 30 days

STRATTERA (60 MG CAPSULE, 80 MG CAPSULE, 100 MGCAPSULE)

3 QL 30 / 30 days

Central Nervous System Agents, Other

NUEDEXTA 2 PA

riluzole 1

tetrabenazine 4 PA

XENAZINE 4 PA



Fibromyalgia Agents

SAVELLA TITRATION PACK 3 QL 55 / 28 days

SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MGTABLET, 100 MG TABLET)

3 QL 60 / 30 days

Multiple Sclerosis Agents

AVONEX PREFILLED SYR 30 MCG KT 4QL 0.15 / day

PA

COPAXONE 20 MG/ML SYRINGE 4QL 30 / 28 days

PA

dimethyl fumarate 4QL 2 / day

PA

GILENYA 0.5 MG CAPSULE 4QL 30 / 30 days

PA

glatiramer 20 mg/ml syringe 4QL 1 / day

PA

Dental and Oral Agents

cevimeline hcl 1

chlorhexidine 0.12% rinse 1

doxycycline hyclate 20 mg tab 1

KEPIVANCE 4

ORALONE 1

PAROEX 1

PERIOGARD 1

pilocarpine hcl (1% eye drops, 2% eye drops, 4% eye drops, hcl5 mg tablet, hcl 7.5 mg tablet)

1

triamcinolone 0.1% paste 1

Dermatological Agents

ABSORICA (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE, 40 MG CAPSULE)

3QL 60 / 30 days

PA

ACANYA 3



ACCUTANE (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE)

1QL 2 / day

PA

ACCUTANE 40 MG CAPSULE 1QL 4 / day

PA

acitretin 1

ACZONE 5% GEL 3

adapalene (gel, gel pump) 1QL 45 / 30 days

PA

adapalene-bnzyl perox 0.1-2.5% 1 QL 45 / 30 days

AMNESTEEM (10 MG CAPSULE, 20 MG CAPSULE) 1QL 60 / 30 days

PA

AMNESTEEM 40 MG CAPSULE 1QL 120 / 30 days

PA

ATRALIN 3QL 45 / 30 days

PA

AVITA (CREAM, GEL) 3 PA

azelaic acid 1

AZELEX 2

BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP) 3

calcipotriene (cream, ointment, solution) 1

calcipotriene-betamethasone dp 1

calcitriol 3 mcg/g ointment 1

CARAC 3

CLARAVIS (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE)

1QL 60 / 30 days

PA

CLARAVIS 40 MG CAPSULE 1QL 120 / 30 days

PA

clind ph-benzoyl perox 1.2-5% 1 QL 45 / 30 days



clind ph-benzoyl pero 1.2-2.5% 3

clindamycin phos-tretinoin 1 QL 60/ 30 days

clindamycin-benzoyl peroxide (clindamycin-benzoyl,clindamycin-bnz pmp)

1 QL 50 / 30 days

clotrimazole-betamethasone crm 1

clotrimazole-betamethasone lot 1

ST


CONDYLOX 2

CORTISPORIN (CREAM, OINTMENT) 3

dapsone 5% gel 1

diclofenac sodium 1% gel 1

DIFFERIN (GEL, GEL PUMP) 3QL 45 / 30 days

PA

DOVONEX 3

doxycycline ir-dr 1 QL 30 / 30 days

ELIDEL 3

EPIDUO 3

erythromycin-benzoyl peroxide 1

fluorouracil (0.5% cream, 2% topical soln, 5% cream, 5%topical soln)

1

imiquimod 3.75% cream 1

QL 56 / 60 days


imiquimod 5% cream packet 1

imiquimod 3.75% cream pump 3

QL 0.25 / day


isotretinoin (10 mg capsule, 20 mg capsule, 30 mg capsule) 1QL 60 / 30 days

PA

isotretinoin 40 mg capsule 1QL 120 / 30 days

PA



methoxsalen 4

MYORISAN (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE)

1QL 60 / 30 days

PA

MYORISAN 40 MG CAPSULE 1QL 120 / 30 days

PA

NEUAC 1.2-5% KIT 3

NEUAC GEL 3 QL 45 / 30 days

ORACEA 3 QL 30 / 30 days

OXSORALEN-ULTRA 3

PICATO 2

pimecrolimus 1

podofilox 1

PROTOPIC 3

RETIN-A (0.01% GEL, 0.025% CREAM, 0.025% GEL, 0.05%CREAM, 0.1% CREAM)

3 PA

RETIN-A MICRO 3 PA

RETIN-A MICRO PUMP (PUMP 0.04% GEL, PUMP 0.1% GEL) 3QL 50 / 30 days

PA

SANTYL 3

selenium sulfide 2.5% lotion 1

SOLARAZE 3

SORILUX 3

STELARA 90 MG/ML SYRINGE 4QL 0.012 / day

PA

STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL) 4

QL 0.006 / day

PA


TACLONEX (0.005%-0.064% SUSPENS, OINTMENT) 3

tacrolimus (0.03% ointment, 0.1% ointment) 1



tazarotene 0.1% cream 1

TAZORAC 0.1% CREAM 3 PA

TAZORAC (0.05% CREAM, 0.05% GEL, 0.1% GEL) 3

TRETIN-X (0.025% CREAM COMB PCK, 0.05% COMBOPACK, 0.1% COMBO PACK)

3 PA

tretinoin (0.01% gel, 0.025% cream, 0.025% gel, 0.05% cream,0.05% gel, 0.1% cream)

1QL 45 / 30 days

PA

tretinoin 0.05% emollient crm 1QL 40 / 30 days

PA

tretinoin microsphere (gel 0.04%, gel 0.1%) 1QL 45 / 30 days

PA

tretinoin microsphere (gel 0.04% pump, gel 0.1% pump) 1QL 50 / 30 days

PA

UVADEX 3

VELTIN 3

VEREGEN 3

VOLTAREN 3

ZENATANE (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE)

1QL 60 / 30 days

PA

ZENATANE 40 MG CAPSULE 1QL 120 / 30 days

PA

ZIANA 3

ZYCLARA (CREAM, CREAM PUMP) 3

Enzyme Replacement/Modifiers

ALDURAZYME 4

PA


BUPHENYL (500 MG TABLET, POWDER) 3

CREON (DR 6,000 UNIT CAPSULE, DR 12,000 UNITCAPSULE, DR 24,000 UNIT CAPSULE)

2

CYSTADANE 4



CYSTAGON 4

CYSTARAN 4 PA

ELAPRASE 4

PA


ELELYSO 4

PA


FABRAZYME 35 MG VIAL 4

QL 2 / 12 days

PA


FABRAZYME 5 MG VIAL 4

QL 2 / 14 days

PA


LUMIZYME 4

PA


miglustat 4

NAGLAZYME 4

PA


nitisinone 10 mg capsule 4QL 420 / 30 days

PA


PA


PA

PANCREAZE (DR 4,200 UNIT CAP, DR 10,500 UNIT CAP, DR16,800 UNIT CAP, DR 21,000 UNIT CAP)

3 ST

RAVICTI 4 PA

sapropterin 100 mg powder pkt 4 PA



sodium phenylbutyrate (500mg tb, powder) 1

SUCRAID 4QL 236 / 23 days

PA

VPRIV 4

PA


ZAVESCA 4

ZENPEP (DR 5,000 UNIT CAPSULE, DR 10,000 UNITCAPSULE, DR 15,000 UNIT CAPSULE, DR 20,000 UNITCAPSULE)

2

Gastrointestinal Agents

Antispasmodics, Gastrointestinal

atropine sulfate (0.05 mg/ml syringe, 0.1 mg/ml syringe, 0.5mg/5 ml abboject, 0.5 mg/5 ml syringe, 1 mg/10 ml abboject, 1mg/10 ml syringe)

1

CUVPOSA 3

dicyclomine hcl (10 mg capsule, 10 mg/5 ml soln, 20 mg tablet,20 mg/2 ml ampul, 20 mg/2 ml vial)

1

glycopyrrolate (0.2 mg/ml vial, 0.4 mg/2 ml vl, 1 mg tablet, 1mg/5 ml soln, 1 mg/5 ml syrng, 1 mg/5 ml vial, 2 mg tablet, 4mg/20 ml vial)

1

glycopyrrolate 1 mg/5 ml-water 1

GLYRX-PF 0.4 MG/2 ML VIAL 3

methscopolamine bromide 1

COLYTE WITH FLAVOR PACKETS 3

CREON (DR 3,000 UNIT CAPSULE, DR 36,000 UNITCAPSULE)

2

GAVILYTE-C 1

GAVILYTE-G 1

GAVILYTE-N 1

GOLYTELY 2 QL 140 / day

lansoprazol-amoxicil-clarithro 1 QL 112 / 14 days

NULYTELY 2 QL 140 / day

NULYTELY WITH FLAVOR PACKS 2 QL 140 / day



OMECLAMOX-PAK COMBO PACK 3

OMECLAMOX-PAK DAILY CARD 3 QL 80 / 365 days

omeprazole-bicarb 40-1,100 cap 3

peg 3350-electrolyte 1 AL At least 49 yrsold

peg-3350 and electrolytes 1 AL At least 49 yrsold

PEG-PREP 1

PERTZYE (DR 8,000 UNIT CAPSULE, DR 16,000 UNITCAPSULE)

3 ST

PYLERA 3 QL 120 / 30 days

TRILYTE WITH FLAVOR PACKETS 1

VIOKACE 3 ST

ZENPEP (DR 3,000 UNIT CAPSULE, DR 25,000 UNITCAPSULE)

2

Gastrointestinal Agents, Other

diphenoxylate-atropine (diphenoxylat-atrop 2.5-0.025/5,diphenoxylate-atrop 2.5-0.025)

1

GATTEX 5 MG 30-VIAL KIT 4 PA

GATTEX 5 MG ONE-VIAL KIT 4QL 1 / 28 days

PA

loperamide 2 mg capsule 1

MOTOFEN 2

MYTESI 3

NORDITROPIN FLEXPRO 30 MG/3 ML 4 PA

RELISTOR 12 MG/0.6 ML VIAL 3QL 3.8 / day

PA

URSO 3

ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1

Histamine2 (H2) Receptor Antagonists

cimetidine (300 mg tablet, 300 mg/5 ml soln, 400 mg tablet, 400mg/6.67 ml soln, 800 mg tablet)

1



famotidine 20 mg piggyback 4

famotidine (20 mg/2 ml vial, 40 mg tablet, 40 mg/4 ml vial, 40mg/5 ml susp, 200 mg/20 ml vial, 500 mg/50 ml vial)

1

nizatidine (15 mg/ml solution, 150 mg capsule, 300 mg capsule) 1

PEPCID 20 MG TABLET 1

ranitidine hcl (15 mg/ml syrup, hcl 50 mg/2 ml vial, 150 mgcapsule, 150 mg/10 ml syrup, hcl 150 mg/6 ml vl, 300 mgcapsule, 300 mg tablet, 1,000 mg/40 ml vial)

1

ZANTAC (50 MG/2 ML VIAL, 150 MG/6 ML VIAL) 3

Irritable Bowel Syndrome Agents

alosetron hcl 4QL 60 / 30 days

PA

AMITIZA 3

QL 60 / 30 days

ST


LINZESS (145 MCG CAPSULE, 290 MCG CAPSULE) 2

QL 1 / day

ST


LOTRONEX 0.5 MG TABLET 3 QL 60 / 30 days

LOTRONEX 1 MG TABLET 3

lubiprostone 3

QL 2 / day

ST


Laxatives

CONSTULOSE 1

ENULOSE 1

GAVILAX 8.5 GRAM POWDER PACKET 1

GENERLAC 1

KRISTALOSE 10 GM PACKET 2

KRISTALOSE 20 GM PACKET 2 QL 60 / 20 days



lactulose 10 gm packet 1 QL 4 / day

lactulose (10 gm/15 ml solution, 20 gm/30 ml solution) 1

MOVIPREP 3

polyethylene glycol 3350 1 AL At least 49 yrsold

PREPOPIK 3

Protectants

CARAFATE 1 GM/10 ML SUSP 2

misoprostol 1

sucralfate (1 gm tablet, 1 gm/10 ml susp) 1

Proton Pump Inhibitors

ACIPHEX 3 QL 60 / 30 days

DEXILANT DR 30 MG CAPSULE 3 QL 30 / 30 days

DEXILANT DR 60 MG CAPSULE 3 QL 60 / 30 days

dexlansoprazole dr 30 mg cap 3 QL 1 / day

dexlansoprazole dr 60 mg cap 3 QL 2 / day

esomeprazole magnesium (dr 10 mg packet, dr 20 mg packet,dr 40 mg packet)

1 QL 1 / day

esomeprazole sodium 1

NEXIUM (DR 2.5 MG PACKET, DR 5 MG PACKET) 2

NEXIUM I.V. 3

omeprazole (dr 10 mg capsule, dr 20 mg capsule) 3

pantoprazole 40 mg suspension 3

pantoprazole sodium (sod dr 20 mg tab, sod dr 40 mg tab,sodium 40 mg vial)

1

PREVACID 15 MG SOLUTAB 3 QL 30 / 30 days

PREVACID 30 MG SOLUTAB 3 QL 60 / 30 days

PROTONIX 40 MG SUSPENSION 3

PROTONIX IV 3

rabeprazole sod dr 20 mg tab 1 QL 60 / 30 days



Genitourinary Agents

Antispasmodics, Urinary

darifenacin er 1

DETROL LA 3 QL 30 / 30 days

ENABLEX 3

flavoxate hcl 1

GELNIQUE 3QL 30 / 30 days

ST

MYRBETRIQ (ER 25 MG TABLET, ER 50 MG TABLET) 2

QL 30 / 30 days


oxybutynin chloride (5 mg tablet, 5 mg/5 ml syrup) 1

oxybutynin chloride er 1

OXYTROL 2

solifenacin succinate 1 QL 1 / day

tolterodine tartrate 1

tolterodine tart er 2 mg cap 1 QL 30 / 30 days

tolterodine tart er 4 mg cap 1

TOVIAZ 3 ST

trospium chloride 1

trospium chloride er 1

VESICARE 3 QL 30 / 30 days

Benign Prostatic Hypertrophy Agents

alfuzosin hcl er 1

AVODART 3 QL 30 / 30 days

CARDURA XL 3 QL 30 / 30 days

dutasteride 1 QL 30 / 30 days

finasteride 5 mg tablet 1



RAPAFLO 3 QL 30 / 30 days

silodosin 3 QL 1 / day

tamsulosin hcl 1

dutasteride-tamsulosin 1 QL 30 / 30 days

JALYN 3 QL 30 / 30 days

Genitourinary Agents, Other

bethanechol chloride 1

DEPEN 3 QL 120 / 30 days

ELMIRON 2 QL 120 / 30 days

penicillamine 250 mg tablet 3 QL 4 / day

Phosphate Binders

calcium acetate (667 mg capsule, 667 mg gelcap, 667 mgtablet)

1

FOSRENOL (500 MG TABLET CHEW, 750 MG TABLETCHEW, 1,000 MG TABLET CHEW)

3

lanthanum carbonate 1

PHOSLYRA 3

RENVELA (0.8 GM POWDER PACKET, 2.4 GM POWDERPACKET)

3

RENVELA 800 MG TABLET 3 QL 270 / 30 days

sevelamer carbonate (0.8 gm powder packet, 2.4 gm powderpacket, carbonate 800 mg tab)

1

sevelamer hcl 1

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

A-HYDROCORT 1

ALA-SCALP 3

alclometasone dipropionate (dipr oint, dipro crm) 1

amcinonide 0.1% cream 3

amcinonide 0.1% lotion 1

BESER 3



betamethasone diprop augmented (crm, gel, lot, oin) 1

betamethasone dipropionate (crm, lot, oint) 1

betamethasone valerate (va 0.1% cream, va 0.1% lotion, valer0.1% ointm, valer 0.12% foam)

1

budesonide er 3 QL 1 / day

CAPEX SHAMPOO 2

clobetasol emollient (emollient crm, emollnt foam) 1

clobetasol emulsion 1

clobetasol propionate (cream, gel, ointment, prop foam, propspray, shampoo, solution, topical lotn)

1

CLOBEX 0.05% SPRAY 3

clocortolone pivalate 3

CLODAN 0.05% KIT 3

CLODAN 0.05% SHAMPOO 1

CLODERM 3

COLOCORT 1

CORDRAN 4 MCG/SQ CM TAPE LARGE 2

CORMAX 1

CORTIFOAM 2 QL 28 / 14 days

cortisone acetate 1

DECADRON 3

DESONATE 3

desonide 0.05% gel 3

desonide (cream, lotion, ointment) 1

desoximetasone (0.05% cream, 0.05% gel, 0.05% ointment,0.25% cream, 0.25% ointment)

1

desoximetasone 0.25% spray 3

DESRX 1

dexamethasone (0.5 mg tablet, 0.5 mg/5 ml elx, 0.5 mg/5 ml liq,0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mgtablet, 6 mg tablet)

1

dexamethasone 13 day 1.5 mg tb 3



DEXAMETHASONE INTENSOL 1

DEXPAK 13 DAY 1.5 MG TABLET 3 QL 51 / 13 days

diflorasone diacetate (cream, ointment) 3

fludrocortisone acetate 1

fluocinolone acetonide (0.01% body oil, 0.01% cream, 0.01%scalp oil, 0.01% solution, 0.025% cream, 0.025% ointment)

1

fluocinolone acetonide oil 1

fluocinonide (0.05% cream, 0.05% gel, 0.05% ointment, 0.05%solution, 0.1% cream)

1

fluocinonide-e 1

fluticasone propionate (0.005% oint, 0.05% cream, 0.05%lotion)

1

halcinonide 3

halobetasol propionate (cream, ointmnt) 1

HALOG (CREAM, OINTMENT) 3

hydrocortisone (1% absorbase, 2.5% cream, 2.5% lotion, 2.5%ointment, 5 mg tablet, 10 mg tablet, 20 mg tablet, 100 mg/60ml)

1

hydrocortisone butyrate (hydrocort buty lipid crm, hydrocort butylipo cream, hydrocortisone butyr lotn)

3

hydrocortisone butyrate (buty cream, butyr oint, butyr soln) 1

hydrocortisone valerate (cream, ointmt) 1

KENALOG 3

LOCOID (CREAM, LOTION, SOLUTION) 3

LOCOID LIPOCREAM 3

methylprednisolone (4 mg dosepk, 4 mg tablet, 8 mg tab, 16 mgtab, 32 mg tab)

1

methylprednisolone acetate 1

methylprednisolone sodium succ (1 gm vl, 40 mg vl, 125 mg) 1

MILLIPRED 1

mometasone furoate (cream, oint, soln) 1

ORAPRED ODT 15 MG TABLET 3 QL 120 / 30 days

ORAPRED ODT 30 MG TABLET 3 QL 90 / 30 days



PANDEL 3

PEDIAPRED 3

prednicarbate (cream, ointment) 1

prednisolone 1

prednisolone odt 15 mg tablet 1 QL 120 / 30 days

prednisolone odt 30 mg tablet 1 QL 90 / 30 days

prednisolone sodium phosphate (5 mg/5 ml soln, 15 mg/5 mlsoln, sod ph 25 mg/5 ml)

1

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab dose pack, 5mg tablet, 5 mg/5 ml solution, 10 mg tab dose pack, 10 mgtablet, 20 mg tablet, 50 mg tablet)

1

PROCTO-MED HC 1

PROCTO-PAK 1

PROCTOSOL-HC 1

PROCTOZONE-HC 1

PSORCON 1

RAYOS 3

SCALACORT 1

SOLU-CORTEF (100 MG ACT-O-VIAL, 100 MG VIAL, 250 MGACT-O-VIAL, 500 MG ACT-O-VIAL, 1,000 MG ACT-O-VL)

3

SOLU-MEDROL (1 GRAM VIAL, 40 MG VIAL, 125 MG VIAL,500 MG VIAL, 1,000 MG VIAL, 2,000 MG VIAL)

3

SYNALAR TS 3

TOPICORT 0.25% SPRAY 3

triamcinolone 0.05% ointment 3

triamcinolone acetonide (0.025% cream, 0.025% lotion, 0.025%oint, 0.1% cream, 0.1% lotion, 0.1% ointment, 0.147 mg/gspray, 0.5% cream, 0.5% ointment)

1

TRIANEX 3

TRIDERM 1

TRITOCIN 1

UCERIS 9 MG ER TABLET 3 QL 30 / 30 days

VANOS 3



VERDESO 3

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

desmopressin acetate (0.01% solution, acetate 0.1 mg tb,acetate 0.2 mg tb, 10 mcg/0.1 ml spr)

1

INCRELEX 4 PA

NORDITROPIN FLEXPRO (5 MG/1.5, 10 MG/1.5, 15 MG/1.5) 4 PA

STIMATE 4 QL 2.5 / 30 days

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Androgens

ANDRODERM 3QL 1 / day

GL Male

ANDROGEL 1% (50 MG/5 G) PKT 3QL 5 / day

GL Male

danazol 1

METHITEST 2 GL Male

methyltestosterone 1 GL Male

TESTIM 3QL 300 / 30 days

GL Male

testosterone (1% (50 mg/5 g) pk, 12.5 mg/1.25 gram, 50 mg/5gram gel, 50 mg/5 gram pkt)

1QL 300 / 30 days

GL Male

testosterone enanthate 1 GL Male

TESTRED 3 GL Male

VOGELXO (12.5 MG/1.25 PUMP, 50 MG/5 GEL, 50 MG/5 GELPACKT)

3QL 300 / 30 days

GL Male

Estrogens

ALORA 3 GL Female

DEPO-ESTRADIOL 1 GL Female



DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 1MG GEL PACKET)

2QL 90 / 30 days

GL Female

DIVIGEL (0.75 MG GEL PACKET, 1.25 MG GEL PACKET) 2QL 3 / day

GL Female

DOTTI 1QL 0.29 / day

GL Female

ELESTRIN 3 GL Female

ESTRACE 0.01% CREAM 3 GL Female

ESTRACE 2 MG TABLET 1 GL Female

estradiol (0.01% cream, 0.5 mg tablet, 1 mg tablet, 2 mg tablet,10 mcg vaginal insrt)

1 GL Female

estradiol (once weekly) (0.025 mg patch(1/wk), 0.0375mgpatch(1/wk), 0.05 mg patch (1/wk), 0.075 mg patch(1/wk), 0.1mg patch (1/wk))

1QL 8 / 28 days

GL Female

estradiol 0.06 mg patch (1/wk) 1QL 12 / 28 days

GL Female

estradiol (twice weekly) (0.025 mg patch(2/wk), 0.0375mgpatch(2/wk), 0.05 mg patch (2/wk), 0.1 mg patch (2/wk))

1QL 8 / 28 days

GL Female

estradiol 0.075 mg patch(2/wk) 1QL 12 / 28 days

GL Female

estradiol valerate 1 GL Female

ESTRING 3QL 1 / 84 days

GL Female

EVAMIST 2QL 8.1 / 18 days

GL Female

FEMRING 3QL 1 / 84 days

GL Female

LYLLANA 1QL 0.29 / day

GL Female



MENEST (0.3 MG TABLET, 1.25 MG TABLET) 3QL 30 / 30 days

GL Female

MENEST (0.625 MG TABLET, 2.5 MG TABLET) 3 GL Female

MENOSTAR 3QL 4 / 28 days

GL Female

MINIVELLE (0.025 MG PATCH, 0.05 MG PATCH, 0.075 MGPATCH, 0.1 MG PATCH)

3 GL Female

PREMARIN (25 MG VIAL, VAGINAL CREAM-APPL) 2 GL Female

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MGTABLET, 0.9 MG TABLET, 1.25 MG TABLET)

2QL 30 / 30 days

GL Female

VAGIFEM 3QL 18 / 28 days

GL Female

VIVELLE-DOT 3 GL Female

YUVAFEM 1QL 18 / 28 days

GL Female

AFIRMELLE 3GL Female

PA

ALTAVERA 3QL 28 / 21 days

GL Female

ALYACEN 1-35 28 TABLET 3QL 28 / 21 days

GL Female

ALYACEN 7-7-7-28 TABLET 3 GL Female

AMABELZ 3 GL Female

AMETHIA 3QL 91 / 91 days

GL Female

AMETHIA LO 3QL 91 / 91 days

GL Female

AMETHYST 3 GL Female



APRI 3QL 28 / 28 days

GL Female

ARANELLE 3 GL Female

ASHLYNA 3QL 91 / 91 days

GL Female

AUBRA 3QL 28 / 28 days

GL Female

AUBRA EQ 3 GL Female

AUROVELA 3GL Female

PA

AUROVELA 24 FE 3GL Female

PA

AUROVELA FE 3GL Female

PA

AVIANE 3QL 28 / 28 days

GL Female

AYUNA 3GL Female

PA

AZURETTE 3QL 28 / 28 days

GL Female

BALZIVA 3QL 28 / 21 days

GL Female

BEKYREE 3QL 28 / 28 days

GL Female

BEYAZ 3 GL Female

BLISOVI 24 FE 3 GL Female

BLISOVI FE 3 GL Female



BRIELLYN 3QL 28 / 21 days

GL Female

CAMRESE 3QL 91 / 91 days

GL Female

CAMRESE LO 3QL 91 / 91 days

GL Female

CAZIANT 3QL 28 / 28 days

GL Female

CHARLOTTE 24 FE 3GL Female

PA

CHATEAL 3QL 28 / 21 days

GL Female

CHATEAL EQ 3 GL Female

CLIMARA PRO 3QL 12 / 28 days

GL Female

COMBIPATCH 2QL 8 / 28 days

GL Female

CRYSELLE 3QL 28 / 28 days

GL Female

CYCLAFEM 1-35-28 TABLET 3QL 28 / 21 days

GL Female

CYCLAFEM 7-7-7-28 TABLET 3 GL Female

CYRED 3QL 28 / 28 days

GL Female

CYRED EQ 3 GL Female

DASETTA 1-35-28 TABLET 3QL 28 / 21 days

GL Female

DASETTA 7/7/7-28 TABLET 3 GL Female



DAYSEE 3QL 91 / 91 days

GL Female

desogestr-eth estrad eth estra 3QL 28 / 28 days

GL Female

desogestrel-ethinyl estradiol 3 GL Female

DOLISHALE 1 GL Female

drosp-ee-levomef 3-0.02-0.451 3QL 28 / 28 days

GL Female

drosp-ee-levomef 3-0.03-0.451 3QL 1 / day

GL Female

drospirenone-ethinyl estradiol 3 GL Female

ELINEST 3QL 28 / 28 days

GL Female

ELURYNG 2

QL 4 / 84 days

GL Female

PA

EMOQUETTE 3QL 28 / 28 days

GL Female

ENPRESSE 3QL 28 / 28 days

GL Female

ENSKYCE 3 GL Female

ESTARYLLA 3 GL Female

estradiol-norethindrone acetat 1 GL Female

ESTROSTEP FE 3 GL Female

ethynodiol-eth estra 1mg-35mcg 3QL 1 / day

GL Female

ethynodiol-eth estra 1mg-50mcg 3 GL Female



etonogestrel-ethinyl estradiol 1

QL 4 / 84 days

GL Female

PA

FALMINA 3QL 28 / 28 days

GL Female

FEMYNOR 3 GL Female

FYAVOLV 1 MG-5 MCG TABLET 1 GL Female

GEMMILY 3 GL Female

GENERESS FE 3QL 28 / 28 days

GL Female

GIANVI 3 GL Female

HAILEY 3GL Female

PA

HAILEY 24 FE 3 GL Female

HAILEY FE 1GL Female

PA

ICLEVIA 3 GL Female

ISIBLOOM 3 GL Female

JAIMIESS 1

QL 91 days

GL Female

PA

JASMIEL 3 GL Female

JINTELI 1 GL Female

JOLESSA 3QL 91 / 91 days

GL Female

JULEBER 3 GL Female

JUNEL 3 GL Female



JUNEL FE 1 MG-20 MCG TABLET 3GL Female

PA

JUNEL FE 1.5 MG-30 MCG TABLET 3 GL Female

JUNEL FE 24 3 GL Female

KAITLIB FE 3 GL Female

KALLIGA 1GL Female

PA

KARIVA 3QL 28 / 28 days

GL Female

KELNOR 1-35 3 GL Female

KELNOR 1-50 3 GL Female

KURVELO 3QL 28 / 21 days

GL Female

LARIN 3 GL Female

LARIN 24 FE 3 GL Female

LARIN FE 3 GL Female

LARISSIA 3QL 28 / 28 days

GL Female

LAYOLIS FE 3 GL Female

LEENA 3 GL Female

LESSINA 3QL 28 / 28 days

GL Female

LEVONEST 3QL 28 / 28 days

GL Female

levonorg-eth estrad eth estrad (levono-e 0.15-0.03-0.01,levonor-e 0.1-0.02-0.01)

3QL 91 / 91 days

GL Female

levonor-eth estra 0.09-0.02 mg 3 GL Female



levonor-eth estrad 0.15-0.03 3QL 91 / 91 days

GL Female

levonorgestrel-eth estradiol (0.1-0.02 mg, triphasic) 3QL 28 / 28 days

GL Female

LEVORA-28 3QL 28 / 21 days

GL Female

LILLOW 3QL 1 / day

GL Female

LO LOESTRIN FE 3 GL Female

LO-ZUMANDIMINE 3GL Female

PA

LOESTRIN 3 GL Female

LOESTRIN FE 3 GL Female

LOJAIMIESS 1

QL 91 days

GL Female

PA

LOPREEZA 1 GL Female

LORYNA 3 GL Female

LOSEASONIQUE 3QL 91 / 91 days

GL Female

LOW-OGESTREL 3QL 28 / 28 days

GL Female

LUTERA 3QL 28 / 28 days

GL Female

MARLISSA 3QL 28 / 21 days

GL Female

MELODETTA 24 FE 3 GL Female

MERZEE 3 GL Female



MIBELAS 24 FE 3GL Female

PA

MICROGESTIN 3 GL Female

MICROGESTIN FE 3 GL Female

MILI 3 GL Female

MIMVEY 1 GL Female

MIRCETTE 3QL 28 / 28 days

GL Female

MONO-LINYAH 3 GL Female

NECON 3QL 28 / 28 days

GL Female

NIKKI 3 GL Female

noret-estr-fe 0.4-0.035(21)-75 3 GL Female

norethin-estra-fe 0.8-0.025 mg 3QL 28 / 28 days

GL Female

norethin-ee 1.5-0.03 mg(21) tb 1GL Female

PA

norethindron-ethinyl estradiol (norethin-eth 1 mg-5 mcg,norethind-eth 1-0.02 mg)

3 GL Female

norethindrone-e.estradiol-iron (1-0.02(21)-75 tab, 1-0.02(24)-75chw)

3 GL Female

noreth-ee-fe 1.5-0.03mg(21)-75 1

QL 28 / 28 days

GL Female

PA

norgestimate-ethinyl estradiol (0.18-0.215-0.25/0.025, 0.18-0.215-0.25/0.035)

3 GL Female

norgestimate-ethinyl estradiol (norg-ethin estra mg,norgestimate-ee mg)

1GL Female

PA

NORTREL (1-35 21 TABLET, 7-7-7-28 TABLET) 3 GL Female



NORTREL 0.5-35-28 TABLET 3QL 28 / 28 days

GL Female

NORTREL 1-35 28 TABLET 3QL 28 / 21 days

GL Female

NUVARING 3QL 4 / 84 days

GL Female

NYLIA 3 GL Female

NYMYO 3 GL Female

OCELLA 3 GL Female

OGESTREL 3 GL Female

ORSYTHIA 3QL 28 / 28 days

GL Female

ORTHO TRI-CYCLEN 3 GL Female

ORTHO-NOVUM 3 GL Female

oxandrolone 1

PHILITH 3QL 28 / 21 days

GL Female

PIMTREA 3QL 28 / 28 days

GL Female

PIRMELLA 1-35 28 TABLET 1QL 28 / 21 days

GL Female

PIRMELLA 7-7-7-28 TABLET 3 GL Female

PORTIA 3QL 28 / 21 days

GL Female

PREFEST 3 GL Female

PREMPHASE 2QL 28 / 28 days

GL Female



PREMPRO 2QL 28 / 28 days

GL Female

PREVIFEM 3 GL Female

RECLIPSEN 3QL 28 / 28 days

GL Female

SAFYRAL 3QL 28 / 30 days

GL Female

SEASONIQUE 3QL 91 / 91 days

GL Female

SETLAKIN 3 GL Female

SIMLIYA 3GL Female

PA

SIMPESSE 3

QL 91 days

GL Female

PA

SPRINTEC 3 GL Female

SRONYX 3QL 28 / 28 days

GL Female

SYEDA 3 GL Female

TARINA 24 FE 3GL Female

PA

TARINA FE 3 GL Female

TARINA FE 1-20 EQ 3 GL Female

TAYSOFY 1 GL Female

TAYTULLA 3 GL Female

TILIA FE 3 GL Female



TRI FEMYNOR 3GL Female

PA

TRI-ESTARYLLA 3 GL Female

TRI-LEGEST FE 3 GL Female

TRI-LINYAH 3 GL Female

TRI-LO-ESTARYLLA 3 GL Female

TRI-LO-MARZIA 3 GL Female

TRI-LO-MILI 3GL Female

PA

TRI-LO-SPRINTEC 3 GL Female

TRI-MILI 3 GL Female

TRI-NYMYO 3 GL Female

TRI-PREVIFEM 3 GL Female

TRI-SPRINTEC 3 GL Female

TRI-VYLIBRA 3 GL Female

TRI-VYLIBRA LO 3 GL Female

TRIVORA-28 3QL 28 / 28 days

GL Female

TYBLUME 1 GL Female

TYDEMY 3QL 1 / day

GL Female

VELIVET 3QL 28 / 28 days

GL Female

VIENVA 3QL 28 / 28 days

GL Female

VIORELE 3QL 28 / 28 days

GL Female



VOLNEA 1GL Female

PA

VYFEMLA 3QL 28 / 21 days

GL Female

VYLIBRA 3 GL Female

WERA 3 GL Female

WYMZYA FE 3QL 28 / 28 days

GL Female

YASMIN 28 3 GL Female

YAZ 3 GL Female

ZARAH 3 GL Female

ZOVIA 1-35 3 GL Female

ZOVIA 1-35E 3 GL Female

ZUMANDIMINE 3

QL 91 days

GL Female

PA

Progestins

CAMILA 3QL 28 / 28 days

GL Female

DEBLITANE 3QL 28 / 28 days

GL Female

DEPO-PROVERA (150 MG/ML SYRINGE, 150 MG/ML VIAL) 3 GL Female

DEPO-PROVERA 400 MG/ML VIAL 2 GL Female

DEPO-SUBQ PROVERA 104 3QL 0.65 / 90 days

GL Female

ENDOMETRIN 2QL 3 / day

GL Female



ERRIN 3QL 28 / 28 days

GL Female

HEATHER 3QL 28 / 28 days

GL Female

INCASSIA 3 GL Female

JENCYCLA 3QL 28 / 28 days

GL Female

LYLEQ 3 GL Female

LYZA 3QL 28 / 28 days

GL Female

medroxyprogesterone 150 mg/ml 3 GL Female

medroxyprogesterone acetate (2.5 mg tab, 5 mg tab, 10 mgtab)

1 GL Female

MEGACE ES 3

megestrol acetate (20 mg tablet, 40 mg tablet, acet 40 mg/mlsusp, acet 400 mg/10 ml, 625 mg/5 ml susp)

1

NORA-BE 3QL 28 / 28 days

GL Female

norethindrone 3QL 28 / 28 days

GL Female

norethindrone ac (lupaneta) 1 GL Female

norethindrone acetate 1 GL Female

NORLYDA 3GL Female

PA

ORTHO MICRONOR 3QL 28 / 28 days

GL Female

progesterone (100 mg capsule, 200 mg capsule) 1 GL Female

PROVERA 5 MG TABLET 3 GL Female



SHAROBEL 3QL 28 / 28 days

GL Female

TULANA 3 GL Female

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

EUTHYROX 1

LEVO-T 2

levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcgtablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcgtablet, 137 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcgtablet, 300 mcg tablet)

1

LEVOXYL 2

liothyronine sodium (5 mcg tab, 10 mcg/ml vl, 25 mcg tab, 50mcg tab)

1

SYNTHROID 3 ST

UNITHROID 2

Hormonal Agents, Suppressant (Adrenal)

LYSODREN 2

Hormonal Agents, Suppressant (Parathyroid)

cinacalcet hcl (30 mg tablet, 60 mg tablet) 4QL 2 / day

PA

cinacalcet hcl 90 mg tablet 4QL 4 / day

PA

Hormonal Agents, Suppressant (Pituitary)

cabergoline 1

ELIGARD (22.5 MG SYRINGE B, 22.5 MG SYRINGE KIT) 4 QL 1 / 84 days

ELIGARD (30 MG SYRINGE B, 30 MG SYRINGE KIT) 4 QL 1 / 112 days

ELIGARD (45 MG SYRINGE B, 45 MG SYRINGE KIT) 4 QL 1 / 168 days

ELIGARD (7.5 MG SYRINGE B, 7.5 MG SYRINGE KIT) 4 QL 1 / 28 days

FIRMAGON 120 MG VIAL 4

FIRMAGON 2 X 120 MG KIT 4 QL 6 / 28 days



FIRMAGON 80 MG KIT 4 QL 4 / 28 days

leuprolide acetate (14 mg/2.8 ml kt, 14 mg/2.8 ml vl) 4

LUPRON DEPOT (11.25 MG 3MO KIT, 22.5 MG 3MO KIT) 4 QL 1 / 84 days

LUPRON DEPOT (3.75 MG KIT, 7.5 MG KIT) 4 QL 1 / 28 days

LUPRON DEPOT 45 MG 6MO KIT 4 QL 1 / 168 days

LUPRON DEPOT-4 MONTH KIT 4 QL 1 / 112 days

LUPRON DEPO 11.25MG (LUPANETA) 4 QL 1 / 84 days

LUPRON DEPOT 3.75MG (LUPANETA) 4 QL 1 / 28 days

LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG KIT, 15 MGKIT)

4 QL 1 / 28 days

LUPRON DEPOT-PED (11.25 MG 3MO, 30 MG 3MO KIT) 4 QL 1 / 84 days

octreotide acetate (acet 0.05 mg/ml vl, acet 50 mcg/ml amp,acet 50 mcg/ml vial, acet 100 mcg/ml amp, acet 100 mcg/ml vl,acet 200 mcg/ml vl, acet 500 mcg/ml amp, acet 500 mcg/ml vl,1,000 mcg/5 ml vial, 1,000 mcg/ml vial, 5,000 mcg/5 ml vial)

1

SANDOSTATIN 3

SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL, 30 MGKT, 30 MG VL)

4

PA


SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 4

QL 1 / 28 days

PA


SIGNIFOR (0.6 MG/ML, 0.9 MG/ML) 3 PA

SIGNIFOR 0.3 MG/ML AMPULE 4 PA

SOMATULINE DEPOT 120 MG/0.5 ML 4 QL 0.5 / 28 days

SOMATULINE DEPOT 60 MG/0.2 ML 4

SOMATULINE DEPOT 90 MG/0.3 ML 4 QL 0.3 / 30 days

SOMAVERT (10 MG VIAL, 20 MG VIAL) 4QL 30 / 30 days

PA



SOMAVERT 15 MG VIAL 4 PA

SYNAREL 4

TRELSTAR (3.75 MG VIAL, 22.5 MG VIAL) 3

TRELSTAR 11.25 MG VIAL 3 QL 1 / 28 days

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

methimazole 1

propylthiouracil 1

Immunological Agents

Angioedema (HAE) Agents

CINRYZE 4 PA

FIRAZYR 4QL 9 / 28 days

PA

icatibant 4QL 9 / 28 days

PA

SAJAZIR 3QL 9 / 28 days

PA

Immune Suppressants

AZASAN 2 QL 30 / 30 days

azathioprine 50 mg tablet 1

azathioprine sodium 1

CELLCEPT (200 MG/ML ORAL SUSP, 500 MG VIAL) 3

CIMZIA (2X200 MG/ML SYRINGE KIT, 2X200MG/ML(X3)START KT, 200 MG VIAL KIT)

4

QL 3 / fill

PA


cyclosporine (25 mg capsule, 100 mg capsule, 250 mg/5 mlampul)

1

cyclosporine modified (25 mg, 50 mg, 100 mg, 100mg/ml) 1



ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/MLSYRINGE)

4QL 0.29 / day

PA

everolimus (0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet) 3

GENGRAF (25 MG CAPSULE, 100 MG CAPSULE) 2

GENGRAF 100 MG/ML SOLUTION 1

HUMIRA 4QL 0.22 / day

PA

HUMIRA PEN 4QL 0.22 / day

PA

HUMIRA PEN CROHN'S-UC-HS 4QL 0.22 / day

PA

HUMIRA PEN PSOR-UVEITS-ADOL HS 4QL 0.22 / day

PA

IMURAN 3 QL 1 / day

KINERET 4QL 10 / day

PA

methotrexate (1 gm vial, 2.5 mg tablet, 50 mg/2 ml vial, 250mg/10 ml vial)

1

methotrexate sodium 1

mycophenolate mofetil (200 mg/ml susp, 250 mg capsule, 500mg tablet, 500 mg vial)

1

mycophenolic acid 1 QL 240 / 30 days

MYFORTIC 3 QL 240 / 30 days

NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATINCAPSULE, 100 MG/ML SOLUTION)

3

ORENCIA (125 MG/ML SYRINGE, 250 MG VIAL) 4

QL 0.15 / day

PA


PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MGCAPSULE, 5 MG/ML AMPULE)

3

RAPAMUNE 1 MG/ML ORAL SOLN 2



RAPAMUNE (1 MG TABLET, 2 MG TABLET) 1

SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE) 3

SANDIMMUNE 100 MG/ML SOLN 2

SIMPONI 50 MG/0.5 ML SYRINGE 4QL 0.04 / day

PA

sirolimus (0.5 mg tablet, 1 mg tablet, 1 mg/ml solution, 2 mgtablet)

1

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 1

temsirolimus 4

PA


TORISEL 4

PA


TREXALL 3

XELJANZ 5 MG TABLET 4QL 2 / day

PA

ZORTRESS (0.25 MG TABLET, 0.5 MG TABLET, 0.75 MGTABLET)

3

Immunizing Agents, Passive

ATGAM 4 PA

GAMASTAN 4 PA

GAMASTAN S-D 4 PA

GAMMAGARD LIQUID 4

PA


GAMMAGARD S-D 4

PA


GAMMAKED 4

PA


GAMMAPLEX (5 GRAM/100 ML VIAL, 10 GRAM/200 ML VIAL,20 GRAM/400 ML VIAL)

4

PA




GAMUNEX-C 4

PA


PRIVIGEN 4

PA


THYMOGLOBULIN 2 PA

NULOJIX 4

Immunomodulators

ACTIMMUNE 4 PA

ARCALYST 4

ILARIS 4

PA


leflunomide 1

RIDAURA 2

Vaccines

ACTHIB 2

ADACEL TDAP VIAL 2

BOOSTRIX TDAP (SYRINGE, VIAL) 2

DAPTACEL DTAP 2

ENGERIX-B 20 MCG/ML SYRN 2

ENGERIX-B PEDIATRIC-ADOLESCENT 2

HAVRIX 720 UNIT/0.5 ML SYRINGE 2

HIBERIX 2

IMOVAX RABIES VACCINE 2

INFANRIX DTAP VIAL 2

IPOL VIAL 2

IXIARO 2

M-M-R II VACCINE 2

MENACTRA 2



MENVEO A-C-Y-W-135-DIP 2

PEDVAXHIB 2

PENTACEL ACTHIB COMPONENT 2

PROQUAD 2

RABAVERT 2

RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, 10MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML VIAL)

2

ROTATEQ 2

tdvax 1

TYPHIM VI (25 MCG/0.5 ML AL, 25 MCG/0.5 ML SYRNG) 2 QL 1 / days

VARIVAX VACCINE 2

YF-VAX 2

Inflammatory Bowel Disease Agents

Aminosalicylates

APRISO 2 QL 120 / 30 days

ASACOL HD 3QL 180 / 30 days

ST

balsalazide disodium 1

DELZICOL 3QL 6 / day

ST

DIPENTUM 3 QL 30 / 30 days

LIALDA 3QL 120 / 30 days

ST

mesalamine (4 gm/60 ml enema, 4 gm/60 ml kit) 1

mesalamine 1,000 mg supp 1 QL 1 / day

mesalamine 800 mg dr tablet 1 QL 180 / 30 days

mesalamine dr 1.2 gm tablet 1 QL 4 / day

mesalamine dr 1QL 6 / day

ST



mesalamine er 1 QL 4 / day

PENTASA 250 MG CAPSULE 3 QL 150 / 30 days

PENTASA 500 MG CAPSULE 3 QL 240 / 30 days

ROWASA 4 GM/60 ML ENEMA KIT 3

Sulfonamides

sulfasalazine 1

sulfasalazine dr 1

Local Anesthetics

SYNERA 3

Metabolic Bone Disease Agents

ACTONEL (5 MG TABLET, 35 MG TABLET) 3 QL 30 / 30 days

ACTONEL 150 MG TABLET 3 QL 1 / 28 days

alendronate sodium (sod 70 mg/75 ml, sodium 5 mg tablet,sodium 10 mg tab, sodium 35 mg tab, sodium 70 mg tab)

1

ATELVIA 3 QL 30 / 30 days

BINOSTO 3

calcitonin-salmon 200 units sp 1

calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml ampul,1 mcg/ml solution)

1

doxercalciferol (0.5 mcg cap, 1 mcg capsule, 2.5 mcg cap, 4mcg/2 ml vl)

1

etidronate disodium 1

FOSAMAX PLUS D 2

HECTOROL 3

ibandronate sodium 150 mg tab 1 QL 1 / 28 days

paricalcitol (1 mcg capsule, 2 mcg capsule) 1 QL 30 / 30 days

paricalcitol (2 mcg/ml vial, 4 mcg capsule, 5 mcg/ml vial, 10mcg/2 ml vial)

1

risedronate sodium (5 mg tablet, 30 mg tab, 35 mg tab) 1 QL 30 / 30 days

risedronate sodium 150 mg tab 1 QL 1 / 28 days



risedronate sodium dr 1 QL 30 / 30 days

XGEVA 4

QL 1.7 / 28 days

PA


ZEMPLAR (2 MCG/ML VIAL, 5 MCG/ML VIAL, 10 MCG/2 MLVIAL)

4

zoledronic acid (4 mg/100 ml, 4 mg/5 ml vial, 5 mg/100 ml) 4 QL 100 / 365 days

zoledronic acid 4 mg vial 4 QL 1 / 365 days

No USP Category

cromolyn 100 mg/5 ml oral conc 1

DYSPORT 4 PA

GASTROCROM 3

METHERGINE 1 QL 6 / day

methylergonovine 0.2 mg tablet 1 QL 6 / day

propantheline bromide 1

REGONOL 3

sterile water for irrigation 1

XEOMIN (50 UNIT VIAL, 100 UNIT VIAL) 4 PA

Ophthalmic Agents

AK-POLY-BAC 1

ALCAINE 1

bacitracin-polymyxin 1

BLEPHAMIDE 3

BLEPHAMIDE S.O.P. 2

COMBIGAN 3

COSOPT PF 3

dorzolamide-timolol 2%-0.5% 3

dorzolamide-timolol eye drops 1



LASTACAFT 3

MAXITROL EYE DROPS 1

NEO-POLYCIN 1

NEO-POLYCIN HC 1

neomycin-bacitracin-poly-hc 1

neomycin-bacitracin-polymyxin 1

neomycin-polymyxin-dexameth (neomyc-polym-dexamet ointm,neomyc-polym-dexameth drop)

1

neomycin-polymyxin-gramicidin 1

neomycin-poly-hc eye drops 1

POLYCIN 1

polymyxin b sul-trimethoprim 1

PRED-G (1% DROPS, S.O.P. OINTMENT) 3

proparacaine hcl 1

SIMBRINZA 2 QL 0.4 / day

sulfacetamide-prednisolone 1

TOBRADEX ST 3

tobramycin-dexamethasone 1

ZYLET 2

Ophthalmic Agents, Other

LACRISERT 2

RESTASIS 2

RESTASIS MULTIDOSE 2

Ophthalmic Anti-allergy Agents

ALOCRIL 3

ALOMIDE 3

azelastine hcl 0.05% drops 1

bepotastine besilate 1 QL 0.334 / day

BEPREVE 3

cromolyn 4% eye drops 1



epinastine hcl 1

olopatadine hcl (0.1% drops, 0.2% drop) 1

PATADAY 3

PATANOL 3

Ophthalmic Anti-inflammatories

ACUVAIL 3

ALREX 2

bromfenac sodium 1

dexamethasone 0.1% eye drop 1

diclofenac 0.1% eye drops 1

difluprednate 1

DUREZOL 3

FLAREX 3

fluorometholone 1

flurbiprofen sodium 1

FML FORTE 3

FML S.O.P. 3

ILEVRO 3

ketorolac tromethamine (0.4% solution, 0.5% solution) 1

LOTEMAX (EYE OINTMENT, OPHTHALMIC GEL) 2

LOTEMAX 0.5% EYE DROPS 3

loteprednol etabonate (etabonate drp, ophthalmc gel) 1

MAXIDEX 3

NEVANAC 3

PRED MILD 2

prednisolone ac 1% eye drop 1

prednisolone sod 1% eye drop 1

PROLENSA 3



Ophthalmic Antiglaucoma Agents

ALPHAGAN P 0.1% DROPS 2

ALPHAGAN P 0.15% EYE DROPS 3

apraclonidine hcl 1

AZOPT 3

betaxolol hcl 0.5% eye drop 1

BETIMOL 2

BETOPTIC S 2

brimonidine tartrate 1

brinzolamide 1

carteolol hcl 1

dorzolamide hcl 1

IOPIDINE 3

ISTALOL 3

levobunolol hcl 1

metipranolol 1

PHOSPHOLINE IODIDE 2

timolol maleate 0.5% eye drop 3

timolol maleate (0.25% gel-solution, 0.25% gfs gel-solution,maleate 0.25% eye drop, 0.5% eye drop, 0.5% gel-solution,0.5% gfs gel-solution, maleate 0.5% eye drops)

1

TIMOPTIC 3

TIMOPTIC 0.25% OCUDOSE DROP 3

TIMOPTIC-XE 3

Ophthalmic Prostaglandin and Prostamide Analogs

latanoprost 0.005% eye drops 1

LUMIGAN 2

TRAVATAN Z 3QL 0.167 / day

ST

travoprost 1



ZIOPTAN 3

Otic Agents

CIPRO HC 3

CIPRODEX 2

ciprofloxacin-dexamethasone 1 QL 0.257 / day

hydrocortisone-acetic acid 1

neomycin-polymyxin-hc ear susp 1

neomycin-polymyxin-hydrocort 1

Respiratory Tract/Pulmonary Agents

Anti-inflammatories, Inhaled Corticosteroids

ALVESCO 160 MCG INHALER 3QL 6.1 / 15 days

ST

ALVESCO 80 MCG INHALER 3QL 6.1 / 30 days

ST

ASMANEX (TWISTHALER 110 MCG #30, TWISTHALER 220MCG #30, TWISTHALR 220 MCG #120)

3QL 1 / 28 days

ST

ASMANEX TWISTHALER 220 MCG #60 3QL 2 / 28 days

ST

BECONASE AQ 3

budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp) 1 QL 120 / 30 days

budesonide 1 mg/2 ml inh susp 1 QL 180 / 30 days

FLOVENT 250 MCG DISKUS 2 QL 8 / day

FLOVENT DISKUS (50 MCG, 100 MCG) 2 QL 4 / day

FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 MCGINHALER)

2 QL 0.8 / day

FLOVENT HFA 44 MCG INHALER 2 QL 0.767 / day

flunisolide 1

NASONEX 3 QL 17 / 28 days



OMNARIS 3 QL 12.5 / 30 days

PULMICORT 3 QL 120 / 30 days

PULMICORT FLEXHALER 2 QL 0.07 / day

QNASL 3 QL 10.6 / 30 days

QVAR REDIHALER 40 MCG 2 QL 0.6 / day

QVAR REDIHALER 80 MCG 2 QL 0.87 / day

ZETONNA 3 QL 6.1 / 30 days

Antihistamines

azelastine hcl (0.1% (137 mcg) spry, 0.15% nasal spray) 1

carbinoxamine 4 mg/5 ml liquid 1

cetirizine hcl (1 mg/ml soln, 1 mg/ml syrup) 1

clemastine fum 2.68 mg tab 1

cyproheptadine hcl (2 mg/5 ml soln, 2 mg/5 ml syrup, 4 mgtablet, 4 mg/10 ml syrp)

1

desloratadine (2.5 mg odt, 5 mg odt, 5 mg tablet) 1

levocetirizine dihydrochloride (2.5 mg/5 ml sol, 5 mg tablet) 1

olopatadine 665 mcg nasal spry 1

PATANASE 3

Antileukotrienes

montelukast sodium (4 mg granules, 4 mg tab chew, 5 mg tabchew, 10 mg tablet)

1

zafirlukast 1

zileuton er 3

ZYFLO 3

Bronchodilators, Anticholinergic

ATROVENT HFA 2 QL 12.9 / 30 days

ipratropium bromide (br 0.02% soln, 0.03% spray, 0.06% spray) 1

SPIRIVA 2 QL 30 / 30 days



TUDORZA PRESSAIR 3QL 1 / 15 days

ST

Bronchodilators, Sympathomimetic

albuterol sulfate (sul 0.63 mg/3 ml sol, sul 1.25 mg/3 ml sol, 2.5mg/0.5 ml sol, sul 2.5 mg/3 ml soln, 5 mg/ml solution, 100mg/20 ml soln)

1

albuterol sulf 2 mg/5 ml syrup 1 QL 600 / 30 days

albuterol sulfate (er 4 mg tab, er 8 mg tab) 1 QL 60 / 30 days

albuterol sulfate 2 mg tab 1 QL 120 / 30 days

albuterol sulfate 4 mg tab 1 QL 240 / 30 days

albuterol sulfate hfa 1 QL 0.6 / day

ARCAPTA NEOHALER 3QL 30 / 30 days

ST

arformoterol tartrate 1 QL 120 / 30 days

BROVANA 3 QL 120 / 30 days

epinephrine (0.15 mg auto-injct, 0.3 mg auto-inject) 1 QL 4 / 365 days

EPIPEN 3QL 4 / 365 days

PA

EPIPEN 2-PAK 3QL 4 / 365 days

PA

formoterol fumarate 1 QL 120 / 30 days

levalbuterol concentrate 1

levalbuterol hcl 1

levalbuterol tartrate hfa 3 QL 0.5 / day

metaproterenol sulfate 1

PERFOROMIST 2 QL 120 / 30 days

SEREVENT DISKUS 2 QL 60 / 30 days

terbutaline sulfate (sulf 1 mg/ml vial, sulfate 2.5 mg tab, sulfate5 mg tab)

1



XOPENEX CONCENTRATE 3 QL 90 / 30 days

XOPENEX HFA 3 QL 0.5 / day

Cystic Fibrosis Agents

CAYSTON 4QL 84 / 28 days

PA

KALYDECO 150 MG TABLET 4QL 60 / 30 days

PA

TOBI PODHALER 4QL 224 / 28 days

PA

Mast Cell Stabilizers

cromolyn 20 mg/2 ml neb soln 1

Phosphodiesterase Inhibitors, Airways Disease

aminophylline 1

DALIRESP 250 MCG TABLET 3QL 1 / day

ST

DALIRESP 500 MCG TABLET 3QL 30 / 30 days

ST

ELIXOPHYLLIN 2

theophylline (80 mg/15 ml soln, er 400 mg tablet, er 600 mgtablet)

1

theophylline anhydrous 1

Pulmonary Antihypertensives

ADCIRCA 3 QL 60 / 30 days

ALYQ 3

ambrisentan 4QL 1 / day

PA

bosentan 4QL 2 / day

PA



LETAIRIS 4QL 30 / 30 days

PA

REMODULIN 4 PA

REVATIO (10 MG/12.5 ML VIAL, 20 MG TABLET) 4 PA

sildenafil 20 mg tablet 1QL 90 / 30 days

PA

sildenafil 10 mg/12.5 ml vial 4 PA

tadalafil 20 mg tablet 1 PA

treprostinil 4 PA

TYVASO 4QL 2.9 / 30 days

PA

TYVASO INSTITUTIONAL START KIT 4 PA

TYVASO REFILL KIT 4QL 2.9 / 30 days

PA

TYVASO STARTER KIT 4 PA

VENTAVIS 10 MCG/1 ML SOLUTION 4QL 30 / 6 days

PA

VENTAVIS 20 MCG/1 ML SOLUTION 4QL 30 / 12 days

PA

Respiratory Tract Agents, Other

acetylcysteine (10% vial, 20% vial) 1

ADVAIR DISKUS 2 QL 2 / day

ADVAIR HFA 2 QL 0.4 / day

ARALAST NP 4

PA


budesonide-formoterol fumarate 3QL 10.2 / 28 days

ST



DULERA (100 MCG INHALER, 200 MCG INHALER) 3QL 13 / 28 days

ST

fluticasone-salmeterol (100-50, 250-50, 500-50) 1 QL 2 / day

GLASSIA 4

PA


PROLASTIN C 4

PA


SYMBICORT 2 QL 10.2 / 28 days

WIXELA INHUB 1 QL 2 / day

ZEMAIRA 4

PA


CLARINEX-D 12 HOUR 3 QL 60 / 30 days

COMBIVENT RESPIMAT 2 QL 4 / 20 days

DYMISTA 3 QL 23 / 30 days

promethazine-phenylephrine 1

PULMOZYME 4 QL 150 / 30 days

SEMPREX-D 3 QL 120 / 30 days

Skeletal Muscle Relaxants

AMRIX 3 QL 30 / 30 days

carisoprodol 1

chlorzoxazone (375 mg tablet, 750 mg tablet) 3

chlorzoxazone 500 mg tablet 1

COMFORT PAC-CYCLOBENZAPRINE 3 QL 90 / 30 days

cyclobenzaprine hcl 1

cyclobenzaprine hcl er 3 QL 1 / day

FEXMID 3



LORZONE 375 MG TABLET 3

LORZONE 750 MG TABLET 3 QL 120 / 30 days

METAXALL 1

metaxalone 800 mg tablet 1

methocarbamol (500 mg tablet, 750 mg tablet) 1

orphenadrine citrate 1

orphenadrine citrate er 1

SKELAXIN 3

Sleep Disorder Agents

GABA Receptor Modulators

EDLUAR 3 QL 30 / 30 days

eszopiclone 1

flurazepam hcl 1

LUNESTA 3

temazepam 1

zaleplon 1 QL 1 / day

zolpidem tartrate (5 mg tablet, 10 mg tablet) 1

zolpidem tartrate er 1

ZOLPIMIST 3

Sleep Disorders, Other

armodafinil (50 mg tablet, 250 mg tablet) 1QL 30 / 30 days

PA

modafinil 1QL 30 / 30 days

PA

NUVIGIL (50 MG TABLET, 250 MG TABLET) 3

ramelteon 3 QL 30 / 30 days

ROZEREM 3 QL 30 / 30 days

SILENOR 3



XYREM 4QL 540 / 30 days

PA

Therapeutic Nutrients/Minerals/Electrolytes

Electrolyte/Mineral Modifiers

CHEMET 2

deferasirox (125 mg tb susp, 250 mg tb susp) 4 QL 100 / 30 days

deferasirox 500 mg tb for susp 4 QL 200 / 30 days

deferiprone 3

EXJADE (125 MG TABLET, 250 MG TABLET) 4QL 100 / 30 days

PA

EXJADE 500 MG TABLET 4QL 200 / 30 days

PA

FERRIPROX 500 MG TABLET 3

JYNARQUE 30 MG TABLET 4QL 2 / day

PA

KIONEX 1

sodium polystyrene sulfonate (sod polystyren 15 g/60 ml,sodium polystyrene powder)

1

SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMASUSP)

1

tolvaptan 15 mg tablet 4QL 3 / day

PA

tolvaptan 30 mg tablet 4QL 2 / day

PA

trientine hcl 3

Electrolyte/Mineral Replacement

carglumic acid 3

DILUENT FOR LEFAMULIN(XENLETA) 4

DILUENT FOR YF-VAX 1 DOSE VIAL 2

fluoride 1 mg tablet chewable 1



ISOLYTE S (IV OLN PH7.4, IV OLUTION-EXCEL) 3

K-TAB ER 20 MEQ TABLET 1

KLOR-CON 10 3

KLOR-CON 8 3

KLOR-CON M10 1

KLOR-CON M15 1

KLOR-CON M20 1

LIQUIVIDA HYDRATION KIT 3

LUDENT FLUORIDE 1 MG TAB CHEW 1

magnesium sulfate 50% syringe 1

MONOJECT 0.9% SODIUM CHLORIDE 1

MONOJECT PREFILL ADVANCED 1

MONOJECT SODIUM CHLORIDE FLUSH 1

normal saline flush 1

NORMOSOL-R 3

NORMOSOL-R PH 7.4 3

OSMOPREP 3

PHYSIOLYTE 3

PHYSIOSOL 3

PLASMA-LYTE 148 3

PLASMA-LYTE A PH 7.4 3

potassium chloride (2 meq/ml conc, er 8 meq capsule, er 8 meqtablet, 10 meq/100 ml sol, 10 meq/5 ml conc, 10 meq/50 ml sol,er 10 meq capsule, er 10 meq tablet, er 15 meq tablet, 20meq/10 ml conc, 20 meq/100 ml sol, 20 meq/50 ml sol, er 20meq tablet, 30 meq/100 ml sol, 40 meq/100 ml sol, 40 meq/20ml conc, 60 meq/30 ml conc)

1

potassium chloride-0.9% nacl (20 meq/1,000ml-ns, 40meq/1,000ml-ns)

1

potassium chloride-nacl 1

potassium citrate er (er 5 tab, er 10 tb) 1 QL 240 / 30 days

potassium citrate er 15 meq tb 1 QL 4 / day



sodium chloride (bacteriostatic saline vial, saline 0.45% soln-excel con, sodium chloride 0.45% soln, sodium chloride 0.9%(pwr inj), sodium chloride 0.9% 1,000 ml, sodium chloride 0.9%100 ml, sodium chloride 0.9% 250 ml, sodium chloride 0.9% 50ml, sodium chloride 0.9% 500 ml, sodium chloride 0.9%carpuject, sodium chloride 0.9% irrig, sodium chloride 0.9%irrig., sodium chloride 0.9% prcss sol, sodium chloride 0.9% sol-excel, sodium chloride 0.9% soln, sodium chloride 0.9%solution, sodium chloride 0.9% syringe, sodium chloride 0.9%vial, sodium chloride 0.9% zr syr, sodium chloride 3% iv soln,sodium chloride 5% iv soln, sodium chloride 50 meq/20 ml,sodium chloride 100 meq/40 ml)

1

sodium chloride-water 1

sodium fluoride 1 mg (2.2 mg) 1

UROCIT-K (SR 5 TABLET, SR 10 TABLET) 3 QL 240 / 30 days

UROCIT-K ER 15 MEQ TABLET 3 QL 120 / 30 days

AMINOSYN II (10% IV SOLUTION, 15% IV SOLUTION) 3

AMINOSYN II WITH ELECTROLYTES 3

AMINOSYN M 3

AMINOSYN 8.5%-ELECTROLYTES SOL 3

AMINOSYN-HBC 3

AMINOSYN-PF (7% IV SOLUTION, 10% IV SOLUTION) 3

CARNITOR SF 3

CLINIMIX (4.25%-10% SOLUTION, 4.25%-25% SOLUTION,4.25%-5% SOLUTION, 5%-15% SOLUTION, 5%-20%SOLUTION, 5%-25% SOLUTION)

3

CLINIMIX E (2.75%-5% SOLUTION, 4.25%-5% SOLUTION,5%-15% SOLUTION, 5%-20% SOLUTION, 5%-25%SOLUTION)

3

CLINISOL 2

dextrose 10%-0.2% nacl 1


dextrose 2.5%-0.45% nacl 1


dextrose 5%-0.2% nacl-kcl 1











dextrose 5%-1/2ns-kcl 1

dextrose 5%-ns-kcl 1

dextrose 5%-potassium chloride (20 meq/l in solution, 40 meqin solution)

1

dextrose in lactated ringers 1

dextrose in water (5%-water 100 ml, 5%-water 50 ml, 5%-wateriv soln, 5%-water vial, 10%-water iv solution)

1

fomepizole 1

glucose in water 1

HEPATAMINE 3

INTRALIPID 3

IONOSOL B WITH DEXTROSE 5% 3

IONOSOL MB-DEXTROSE 5% 3

ISOLYTE P WITH DEXTROSE 3

lactated ringers (injection, irrigation) 1

levocarnitine (1 g/10 ml soln, 330 mg tablet) 1

levocarnitine sf 3

NEPHRAMINE 3

NORMOSOL-M AND DEXTROSE 3

NORMOSOL-R AND DEXTROSE 3

PLENAMINE 1

potassium chloride in d5lr 1

PREMASOL (6% IV SOLUTION, 10% IV SOLUTION) 3

PROCALAMINE 3



PROSOL 3

ringers injection 1

ringers irrigation 1

SUPREP 3

TPN ELECTROLYTES 3

TPN ELECTROLYTES II 3

TRAVASOL 3

TROPHAMINE (6% IV SOLUTION, 10% IV SOLUTION) 3

Uncategorized

Unclassified

ABILIFY MAINTENA (ER 300 MG SYR, ER 300 MG VL, ER400 MG SYR, ER 400 MG VL)

4 ST

ABILIFY MYCITE (2 MG KIT, 2 MG MAINT KIT, 2 MG STARTKIT, 5 MG KIT, 5 MG MAINT KIT, 5 MG START KIT, 10 MGKIT, 10 MG MAINT KIT, 10 MG START KIT, 15 MG KIT, 15 MGMAINT KIT, 15 MG START KIT, 20 MG KIT, 20 MG MAINTKIT, 20 MG START KIT, 30 MG KIT, 30 MG MAINT KIT, 30 MGSTART KIT)

3

abiraterone 500 mg tablet 4QL 2 / day

PA

ABLYSINOL 3

ABSORICA (25 MG CAPSULE, 35 MG CAPSULE) 3 PA

ABSORICA LD 3 PA

ACCRUFER 3QL 2 / day

PA

accutrend cholesterol strip 3

ACD SOLUTION A 3

ACD-A 3

acetamn-caf-dihydrcodein 320.5 1

acetamin-caf-dihydrocodein 325 3 QL 6 / day

acetaminophen (1000mg/100ml bag, 1000mg/100ml vl) 1



acetic acid 0.25% irrig soln 1

acetylcysteine 6 gram/30 ml vl 1

ACIPHEX SPRINKLE DR 10 MG CAP 3

ACIPHEX SPRINKLE DR 5 MG CAP 3 QL 30 / 30 days

ACTEMRA (80 MG/4 ML VIAL, 162 MG/0.9 ML SYRINGE) 4QL 0.15 / day

PA

ACTEMRA 200 MG/10 ML VIAL 4

QL 0.36 / day

PA


ACTEMRA 400 MG/20 ML VIAL 4

QL 1.5 / day

PA


ACTEMRA ACTPEN 4QL 0.15 / day

PA

ACTHREL 3

ACTIVASE 3

acyclovir sodium-0.9% nacl 1

ACZONE 7.5% GEL PUMP 3

ADACEL TDAP SYRINGE 2

adapalene 0.1% swab 3 PA

adapalene 0.1% solution 1 PA

ADCETRIS 4

PA


ADDYI 3

ADEMPAS 4QL 90 / 30 days

PA

ADENOSCAN 3

adenosine (6 mg/2 ml syringe, 6 mg/2 ml vial, 12 mg/4 mlsyringe, 12 mg/4 ml vial, 60 mg/20 ml vial, 90 mg/30 ml vial)

1



adenovirus type 4 2

adenovirus type 4 and type 7 2

adenovirus type 7 2

ADHANSIA XR 3 QL 1 / day

ADLYXIN 10-20 MCG STARTER PACK 3QL 14 / 1 rx

ST

ADLYXIN 20 MCG MAINTENANCE PK 3QL 0.22 / day

ST

ADRENALIN 1 MG/ML VIAL 2

ADRENALIN CHLORIDE 3

ADREVIEW 3

ADULT ASPIRIN REGIMEN 1

ADULT LOW DOSE ASPIRIN EC 1 AL 45.0 to 79.0 yrsold

ADVATE 4C

Hemophiliadrugs will belimited toHemophiliaTreatmentCenters (HTCs)ONLY

PA

ADYNOVATE 4C


PA

ADYPHREN 1

ADYPHREN II 2

ADZENYS ER 3

ADZENYS XR-ODT 3

AEMCOLO 3



AFINITOR DISPERZ 4QL 30 / 30 days

PA

AFLURIA QUAD 2019-20 (3YR UP) 2

AFLURIA QUAD 2019-20 (6-35MO) 2

AFLURIA QUAD 2019-2020 2







AFSTYLA 4C


PA

AGGRASTAT (3.75 MG/15 ML VIAL, 5 MG/100 ML IV SOLN, 5MG/100 ML VIAL, 12.5 MG/250 ML)

3

AIMOVIG 140 MG/ML AUTOINJECTOR 2QL 0.04 / day

PA

AIMOVIG 70 MG/ML AUTOINJECTOR 2QL 2 / 30 days

PA

AJOVY AUTOINJECTOR 3QL 0.057 / day

PA

AJOVY SYRINGE 3QL 0.057 / day

PA

AK-FLUOR 3

AKLIEF 3 PA

AKTEN 3

AKYNZEO (235-0.25 MG VIAL, 300-0.5 MG CAPSULE) 3 QL 4 / 30 days



AKYNZEO 235-0.25 MG/20 ML VIAL 3

albumin (human) 1

ALBUMINEX 3

albustix reagent 2

alcohol,dehydrated (ampule, vial) 1

ALECENSA 4QL 240 / 30 days

PA

alfentanil hcl 1

ALIQOPA 4

PA


ALKERAN 2 MG TABLET 3 QL 70 / 30 days

ALKINDI SPRINKLE 3 PA

ALLZITAL 3

ALPHANATE 4C


PA

ALPHANINE SD (SD 500 UNIT VIAL, SD 1,500 UNIT VIAL) 4C


PA

ALPHANINE SD 1,000 UNIT VIAL 4C

Hemophiliadrugs will belimited toHemophiliatreatmentcenters (HCTs)ONLY

PA



ALPROLIX 4C


PA

alprostadil 3 PA

ALTACAINE 1

alternaria alternata 3

ALTRENO 3 PA

ALUNBRIG (30 MG TABLET, 90 MG TABLET, 90 MG-180 MGTAB PACK, 180 MG TABLET)

4 PA

alvimopan 1QL 15 / 8 days

PA

AMIDATE 40 MG/20 ML ABBOJECT 3

aminocaproic acid (0.25 gram/ml, 5 g/20 ml vl) 1

AMINOPROTECT 3

AMINOSYN (8.5% IV SOLUTION, 10% IV SOLUTION) 3

AMINOSYN 7%-ELECTROLYTE SOL 3

amiodarone 150 mg/3 ml syringe 1

amiodarone hcl-d5w (150 mg/100, 900 mg/500) 1

AMMONUL 3

amphetamine 1 QL 10 / day

amyl nitrite 1

AMYVID 3

AMZEEQ 3

ANA-LEX 1

ANADROL-50 3 QL 90 / 30 days

ANALPRAM HC 2.5%-1% LOTION 2

ANASPAZ 3



ANDROGEL (1% (25 MG/2.5 G) PKT, 1.62%(1.25G) GELPCKT)

3QL 2.5 / day

GL Male

ANDROGEL (1.62% GEL PUMP, 1.62%(2.5G) GEL PCKT) 3QL 5 / day

GL Male

ANGELIQ 3QL 28 / 21 days

GL Female

ANGIOMAX 3

ANIMI-3 3

ANORO ELLIPTA 2 QL 60 / 30 days

anticoag sodium citrate 4% sol 1

antivenin latrodectus mactans 1

antivenin micrurus fulvius 1

ANTIVERT 3

ANUCORT-HC 1

ANUSOL-HC 25 MG SUPPOSITORY 1

APADAZ 3 QL 12 / day

APEXICON E 2

APHEN 1

APTENSIO XR 3

APTIOM (200 MG TABLET, 400 MG TABLET, 600 MGTABLET)

2QL 30 / 30 days

PA

APTIOM 800 MG TABLET 2QL 60 / 30 days

PA

AQUA GLYCOLIC HC 3

AQUASOL A 3

AQUORAL 3 QL 40 / 30 days

ARAKODA 3

ARANESP (10 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL) 4

PA




ARAZLO 3 PA

ARIKAYCE 4 PA

ARISTADA 4

ARISTADA INITIO 4QL 1.60 / day

PA

ARISTOSPAN 3

armodafinil (150 mg tablet, 200 mg tablet) 1QL 30 / 30 days

PA

ARMONAIR DIGIHALER 3QL 1 / 28 days

ST

ARMOUR THYROID (120 MG TABLET, 180 MG TABLET, 240MG TABLET, 300 MG TABLET)

3QL 90 / 30 days

ST

ARMOUR THYROID (15 MG TABLET, 30 MG TABLET, 60 MGTABLET, 90 MG TABLET)

3QL 180 / 30 days

ST

ARNUITY ELLIPTA 100 MCG INH 2 QL 2 / day



arsenic trioxide 4 PA

ARTISS 3

ARZERRA 1,000 MG/50 ML VIAL 4

PA


ASCENIV 4

PA


ASCLERA 3

ascorbic acid 500 mg/ml vial 1

asenapine 2.5 mg tablet sl 1



ASMANEX TWISTHALER 220 MCG #14 3QL 1 / 28 days

ST

ASMANEX HFA (HFA 100 MCG INHALER, HFA 200 MCGINHALER)

3QL 13 / 30 days

ST

ASMANEX HFA 50 MCG INHALER 3QL 0.44 / day

ST

ASPARLAS 4

PA


ASPIR 81 1 AL 45.0 to 79.0 yrsold

ASPIR-LOW 1 AL 45.0 to 79.0 yrsold

aspirin (81 mg chewable tablet, 325 mg tablet, bayer 325 mgtablet, cvs 81 mg chewable tab, cvs 325 mg caplet, cvs 325 mgtablet, eq 81 mg chewable tab, eq 325 mg tablet, eql 81 mgchewable tab, eql 325 mg tablet, gnp 81 mg chewable tab, gnp325 mg tablet, gs 81 mg chewable tab, gs 325 mg tablet, hm 81mg chewable tab, hm 325 mg tablet, kro 81 mg chewable tab,kro 325 mg tablet, pub 81 mg chewable tab, pub 325 mg tablet,qc 81 mg chewable tab, qc 325 mg tablet, ra 81 mg chewabletab, ra 325 mg tablet, sm 81 mg chewable tab, sm 325 mgtablet)

1 AL 45.0 to 79.0 yrsold

ASPIRIN (BAYER 325 MG CAPLET, BAYER 325 MG TABLET,BAYER 500 MG CAPLET, BAYER 500 MG TABLET, 600 MGSUPPOSITORY)

1

aspirin ec (cvs ec 81 mg tablet, cvs ec 325 mg tablet, ec 81 mgtablet, ec 325 mg caplet, ec 325 mg tablet, eq ec 81 mg tablet,eq ec 325 mg tablet, eql ec 81 mg tablet, eql ec 325 mg tablet,gnp ec 81 mg tablet, gnp ec 325 mg tablet, gs ec 81 mg tablet,gs ec 325 mg tablet, hm ec 81 mg tablet, hm ec 325 mg tablet,kro ec 81 mg tablet, qc ec 81 mg tablet, qc ec 325 mg tablet, raec 81 mg tablet, ra ec 325 mg tablet, sm ec 81 mg tablet, sm ec325 mg tablet)

1 AL 45.0 to 79.0 yrsold

aspirin ec (ec 500 mg tablet, ec 650 mg tablet) 1

ASTAGRAF XL 3 QL 30 / 30 days

ASTERO 3

ASTRAZENECA COVID19 VAC(UNAPP) 2

ASTRINGYN 2 PA



ATOPADERM 3

ATOPICLAIR 3

atracurium besylate 1

ATRAPRO DERMAL SPRAY 3

ATROPEN 3

atropine sulfate (0.4 mg/ml vial, 1 mg/2.5 ml syringe, 1 mg/mlvial, 1% eye drops, 1% eye ointment, 2 mg/5 ml syringe, 8mg/20 ml vial)

1

ATRYN 1,750 UNIT VIAL 4

AUGMENTIN 125-31.25 MG/5 ML 2

aureobasidium 51,000 pnu/ml vl 3

AURYXIA 3 QL 360 / 30 days

AUSTEDO (6 MG TABLET, 9 MG TABLET) 4QL 2 / day

PA

AUSTEDO 12 MG TABLET 4 PA

AVAR CLEANSER 1

AVAR-E 1

AVAR-E GREEN 1

AVASTIN 4

PA


AVC 2 GL Female

AVEED 3QL 1 / 28 days

GL Male

AVIDOXY DK 3

AVITENE FLOUR 2 PA

AVITENE (SHEET 35MMX35MM, SHEET 70MMX35MM,SHEET 70MMX70MM)

3 PA

AVONEX PEN (PEN 30 MCG/0.5 ML, PEN 30 MCG/0.5 MLKIT)

4QL 0.15 / day

PA



AVSOLA 4

QL 10 / 30 days

PA

BSP Benefit ShiftProgram


AVYCAZ 3

AYVAKIT 4QL 1 / day

PA

AZESCO 3

AZSTARYS 3

aztreonam 1

b complex-folic acid 1

B-12 COMPLIANCE 1

b-complex tablet 1

b-complex with vitamin c (aplet, tablet) 1

BABY OIL 1

baclofen 5 mg tablet 1

baclofen (40 mg/20 ml vial, 20,000 mcg/20 ml vial) 3

BAFIERTAM 4QL 4 / day

PA

BAL IN OIL 3

BAL-CARE DHA 1

balanced b-complex 1

balanced salt 1

BALCOLTRA 3QL 1 / day

GL Female

balsam peru-castor oil 3

BALVERSA 3 MG TABLET 4QL 3 / day

PA




PA


PA

BAQSIMI 2

BAVENCIO 4

PA


BAXDELA (300 MG VIAL, 450 MG TABLET) 3

BEAU RX 3

BELBUCA (150 MCG FILM, 750 MCG FILM) 2QL 60 / 30 days

PA

BELBUCA (75 MCG FILM, 300 MCG FILM, 450 MCG FILM,600 MCG FILM, 900 MCG FILM)

2 PA

BELEODAQ 4

PA


belladonna-opium 1

BELRAPZO 4

PA


BELSOMRA 3QL 30 / 30 days

ST

BELVIQ 3

bendamustine hcl 4

PA


BENDEKA 4

PA


BENEFIX 4C


PA



BENLYSTA (120 MG VIAL, 200 MG/ML AUTOINJECT, 200MG/ML SYRINGE, 400 MG VIAL)

4 PA

BENZEPRO 6% FOAMING CLOTHS 1

benzhydrocodone-acetaminophen 1 QL 12 / day

benznidazole 2QL max 60 days

AL 2 to 12 yrs old

benzonatate 1

pr benzoyl peroxide 7% wash 1

benzphetamine hcl 1

BERINERT (500 UNIT KIT, 500 UNIT VIAL) 4 PA

BESPONSA 4

PA


betamethasone sod phos-acetate 1

BETHKIS 3

bevacizumab 2.5 mg/0.1 ml syrg 1

BEVESPI AEROSPHERE 3QL 10.7 / 30 days

ST

BEXSERO 2

BIJUVA 3 GL Female

BIKTARVY 4QL 1 / day

PA

bimatoprost 0.03% eye drops 1

BIOGLO 1

BIOTHRAX 2

bivalirudin (250 mg add-vant vl, 250 mg vial, rtu 250 mg/50 ml) 1

bivalirudin-0.9% nacl 1

BLANCHE 1

BLINCYTO (35 MCG VIAL, 35MCG VL W-STABILIZER) 4

PA




BLOXIVERZ 4

BONJESTA 3 QL 2 / day

bortezomib 4

PA


BOSULIF 400 MG TABLET 4QL 1 / day

PA

BOTOX 200 UNIT VIAL 4 PA

botulism antitoxin heptavalent 1

BP 10-1 1

BRAFTOVI 50 MG CAPSULE 4QL 4 / day

PA

BRAFTOVI 75 MG CAPSULE 4QL 6 / day

PA

BREO ELLIPTA 2 QL 60 / 30 days

BREVIBLOC (2,000 MG/100 ML BAG, 2,500 MG/250 ML BAG) 3

BREVITAL SODIUM 3

BREZTRI AEROSPHERE 2QL 0.36/day

ST

BRIGHT BEGINNINGS SOY 3

BRILINTA 60 MG TABLET 2 QL 60 / 30 days

BRISDELLE 3QL 1 / day

GL Female

BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 25 MGTABLET, 50 MG TABLET, 50 MG/5 ML VIAL, 75 MG TABLET,100 MG TABLET)

2 PA

BROMFED DM 1

brompheniramine-pseudoephed-dm 1

BROMSITE 3



BRONCHITOL 3QL 20 / day

PA

BRUKINSA 4 PA

BRYHALI 3

BSS PLUS 3

budesonide dr 1

budesonide ec 1

buffered aspirin 1

BUNAVAIL 3 QL 30 / 30 days

bupivacaine hcl (0.25% vial, 0.5% vial, 0.75% ampul, 0.75%vial)

1

bupivacaine hcl-0.9% nacl (0.0625%-0.9% nacl, 0.1%-0.9%nacl bag, 0.125%-0.9% nacl, 0.25%-0.9% nacl, 0.25%-nssyringe)

1

bupivacaine hcl-epinephrine 1

bupivacaine-dextrose 1

buprenorphine (7.5 mcg/hr patch, 15 mcg/hr patch) 1

buprenorphine hcl (75 mcg film, 150 mcg film, 300 mcg film,450 mcg film, 600 mcg film, 750 mcg film, 900 mcg film)

1 QL 2 / day

butalb-acetamin-caf-cod 50-300 1 QL 180 / 30 days


butalb-aspirin-caffe 50-325-40 1

BUTRANS (7.5 MCG/HR PATCH, 15 MCG/HR PATCH) 3 QL 4 / 28 days

BYDUREON BCISE 2QL 0.144 / day

ST

BYDUREON PEN 2QL 4 / 28 days

ST

BYFAVO 3

BYNFEZIA 4QL 0.6 / day

PA

C-NATE DHA 1



CABLIVI (11 MG KIT, 11 MG VIAL) 4 PA

CABOMETYX 4QL 30 / 30 days

PA

CADEAU DHA 3

CAFERGOT 3 QL 40 / 30 days

caffeine and sodium benzoate 1

caffeine citrate (60 mg/3 ml oral, 60 mg/3 ml vial) 1

calcium chloride (abboject, syringe, vial) 1

calcium disodium versenate 1

calcium gluconate (gluc 1,000 mg/10 ml vl, gluc 5,000 mg/50 mlvl, gluc 10,000 mg/100 ml, gluconate 10% vial)

1

calcium gluconate-0.9% nacl (1 g/100-0.9%, 1 g/110-0.9%) 1

calcium gluc 1,000mg/50ml-nacl 1

calcium-folic acid plus d 1

CALDOLOR (800 MG/200 ML BAG, 800 MG/8 ML VIAL) 3

CALQUENCE 4 PA

CAMPTOSAR 300 MG/15 ML VIAL 3

capecitabine 150 mg tablet 4QL 30 / 90 days

PA

capecitabine 500 mg tablet 4QL 140 / 14 days

PA

CAPHOSOL 3

CAPLYTA 3

CARBOCAINE (1% VIAL, 1.5% VIAL, 2% VIAL) 3

carboprost tromethamine (250 mcg/ml ampul, 250 mcg/ml vial) 3 PA

CARDENE I.V. (CARDENE-DEX 20 MG/200 ML SOLN,CARDENE-NACL 20 MG/200 ML SOLN, CARDENE-NACL 40MG/200 ML IV)

3

cardioplegia del nido formula 3

cardioplegia 36 meq k/500 ml 3



cardioplegic 1

CARDIOVID PLUS 3

CAROSPIR 2 PA

CATHFLO ACTIVASE 4

cefaclor (125 mg/5 ml susp, 250 mg/5 ml susp, 375 mg/5 mlsuspen)

1

cefazolin sodium-dextrose (2 g/100, 2 g/50) 1

cefazolin sodium-sterile water 1

cefditoren pivoxil 1

cefepime 1 gm injection 1

cefepime hcl 1 gm vial 1

cefepime-dextrose 1 gm/50 ml 1

cefotetan 1

cefotetan & dextrose 1

cefoxitin (1 gm vial, 2 gm vial) 1

cefoxitin sodium 1

cefuroxime sodium-0.9% nacl 1

CELLUGEL 3

CEM-UREA 1

CENTRATEX 1

cephalexin 750 mg capsule 1

CEPROTIN 4

CEQUA 3

CERDELGA 4 PA

CERENX 3

CERETEC (0.5 MG VIAL, INJECTION KIT) 3

CEREZYME 4

PA


CERVIDIL 3



CETACAINE 3

CETRAXAL 3

CETROTIDE 4

chemstrip micral 2

children's aspirin (81 mg chew tab, 81 mg tab chew) 1 AL 45.0 to 79.0 yrsold

sm child aspirin 81 mg chw tab 1

children's ferrous sulfate 1 AL 0.5 to 12.0 yrsold

CHILDREN'S IRON 1 AL 0.5 to 12.0 yrsold

chlordiazepoxide-clidinium 1

chlorpromazine hcl (30 mg/ml conc, 100 mg/ml conc) 1

CHOLBAM 3

chromium cl 40 mcg/10 ml vial 1

CIMDUO 4QL 1 / day

ST

CINQAIR 4

QL 3 / 28 days

PA


CINVANTI 2 PA

ciprofloxacin 0.2% otic soln 1

ciprofloxacin hcl-fluocinolone 1

cisatracurium besylate 1

cisplatin 50 mg vial 1

citrate phosphate dextrose 1

CLAFORAN 2 GM ADD-VANTAGE VL 3

clemastine 0.5 mg/5 ml syrup 1 AL At least 6 yrs old

CLENPIQ 3

clever choice holding chamber (chamber-med, chamber-sm) 2



CLEVIPREX 3

CLINDESSE 2 GL Female

CLINIMIX E 4.25%-10% SOLUTION 3

clobazam 2.5 mg/ml suspension 1QL 16/day

PA

CLOBETEX 3 PA

clomiphene citrate 1

clonidine hcl (1,000 mcg/10 ml vial, 5,000 mcg/10 ml vial) 1

COAGADEX 4 PA

coal tar 1

colchicine 0.6 mg capsule 1 QL 120 / 30 days

COMIRNATY 2

COMPLETE NATAL DHA 1

COMPLETENATE 1

CONCEPT DHA 3 QL 30 / 30 days

CONCEPT OB 3 QL 30 / 30 days

CONRAY 3

CONRAY-30 3

CONRAY-43 3

CONSENSI 3

COPAXONE 40 MG/ML SYRINGE 4QL 0.434 / day

PA

COPIKTRA 4QL 2 / day

PA

copper chloride 1

CORDRAN (CREAM, LOTION) 3

CORIFACT 3



CORLANOR 5 MG/5 ML ORAL SOLN 3QL 300 / 30 days

PA

CORLANOR (5 MG TABLET, 7.5 MG TABLET) 3QL 60 / 30 days

PA

CORTANE-B 3

CORVITA 1

CORVITA 150 1

cosyntropin 1

COTELLIC 4QL 63 / 21 days

PA

COTEMPLA XR-ODT 3

CRESEMBA 186 MG CAPSULE 2QL 60 / 30 days

PA

CRESEMBA 372 MG VIAL 2 PA

CRINONE 2 GL Female

CROFAB 2

CUPRIMINE 3 QL 120 / 30 days

CUROSURF 3

CUTAQUIG 4 PA

CUVITRU 4 PA

cyanocobalamin injection 1

CYANOKIT 3

CYCLOGYL 0.5% EYE DROPS 3

CYCLOMYDRIL 3

cyclopentolate hcl 1

cyclophosphamide 25 mg capsule 1 QL 150 / 30 days

cyclophosphamide 50 mg capsule 1 QL 60 / 30 days

cyclophosphamide (25 mg tablet, 50 mg tablet) 1



cyclophosphamide (1 gm vial, 1 gm/5 ml vl, 2 gm vial, 2 gm/10ml vl, 500 mg vial, 500 mg/2.5 ml)

4

CYRAMZA 4

PA


CYSTADROPS 4

CYSTO-CONRAY II 3

CYSTOGRAFIN 3

CYSTOGRAFIN-DILUTE 3

CYTOGAM 4 PA

CYTRA-2 1

CYTRA-3 1

CYTRA-K ORAL SOLUTION 1

D-PENAMINE 2 PA

DANTRIUM 20 MG VIAL 3

dantrolene sodium 20 mg vial 1

DANYELZA 4

QL 0.434 / day

PA


dapsone 7.5% gel pump 3

DARZALEX 4

PA


DATSCAN 3

DAURISMO 100 MG TABLET 4QL 1 / day

PA

DAURISMO 25 MG TABLET 4QL 2 / day

PA

DAYLOGIC ACNE TREATMENT 3

DAYVIGO 3 QL 1 / day



deferasirox (90 mg granule pkt, 180 mg granule pkt, 180 mgtablet, 360 mg granule pkt)

4 PA

deferasirox 360 mg tablet 4QL 150 / 30 days

PA

deferasirox 90 mg tablet 4QL 5 / 30 days

PA

deferoxamine mesylate 1

DEFINITY 3

DEFINITY RT 3

DELFLEX WITH 1.5% DEXTROSE 3



DELSTRIGO 3

DEMEROL (25 MG/ML CARPUJECT, 25 MG/ML SYRINGE, 50MG/ML CARPUJECT, 50 MG/ML SYRINGE, 75 MG/1.5 MLAMPUL, 75 MG/ML CARPUJECT, 100 MG/ML CARPUJECT)

3

DENTA 5000 PLUS 1

DENTAGEL 1

DERMAWERX SDS 1 PA

DERMAWERX SURGICAL PLUS PAK 1

DERMAZENE CREAM 1

DESCOVY 4 QL 30 / 30 days

desflurane 3

desvenlafaxine succnt er 25 mg 1

DEXABLISS 3

dexamethasone (6 1.5 mg tab, 10 1.5 mg tb) 3

dexamethasone sodium phosphate (4 mg/ml syringe, 4 mg/mlvial, 10 mg/ml syring, 10 mg/ml vial, 20 mg/5 ml vial, 100 mg/10ml vl, 120 mg/30 ml vl)

1

dexamethasone-0.9% nacl 1

dexcom 2

dexcom g4 ((ped) receiver kit, receiver kit, receiver-share (ped),receiver-share kit, transmitter kit)

2



dexcom g5 (receiver kit, transmitter kit) 2

dexcom g5-g4 sensor 2

dexcom g6 (receiver, sensor, transmitter) 2



dexrazoxane diluent-sodium lac 1

DEXTENZA 3

dextroamphetamine sulfate (15 mg tab, 20 mg tab, 30 mg tab) 1 QL 6 / day


dextrose 5%-electrolyte #48 1

d5w-kcl 30 meq/l iv solution 1

dextrose in ringers injection 1

dextrose in water (20%-water iv soln, 25%-water syringe, 30%-water iv soln, 40%-water iv soln, 50%-water abboject, 50%-water iv soln, 50%-water syringe, 50%-water vial, 70%-water ivsoln)

1

DIACOMIT (250 MG CAPSULE, 250 MG POWDER PACKET,500 MG CAPSULE, 500 MG POWDER PACKET)

4QL 2 / day

PA

DIALYVITE 2

DIALYVITE 800 WITH IRON 3

DIALYVITE ZINC 2

DIANEAL PD-2 W-2.5% DEXTROSE 3


DIANEAL WITH 1.5% DEXTROSE 3



diazepam (10 mg/2 ml carpuject, 10 mg/2 ml syringe, 50 mg/10ml vial)

1

DICLEGIS 3 QL 120 / 30 days

diclofenac pot 25 mg tablet 1

DIFICID 40 MG/ML SUSPENSION 2 PA



DIGIFAB 3

DILUENT FOR ACTHIB 2

diluent for artesunate 3

diluent for decitabine 4

diluent for epoprostenol 1

DILUENT FOR HIBERIX 2

DILUENT FOR IMOVAX 2

DILUENT FOR ISTODAX 4

DILUENT FOR IXEMPRA 4 PA

DILUENT FOR JEVTANA 4

DILUENT FOR MENHIBRIX 2

DILUENT FOR MENOMUNE (1 VL, 10) 2

DILUENT FOR NOVOSEVEN RT 4 PA

DILUENT FOR RABAVERT 2

DILUENT FOR ROTARIX 2

diluent for treprostinil 1

DILUENT FOR VIVITROL 4

DILUENT FOR YF-VAX 5 DOSE VIAL 2

DILUENT-MERCK LIVE VIRUS VACC 2

DILUTING MEDIUM FOR NOVOLOG 3

dimenhydrinate 50 mg/ml vial 1

diphenhydramine hcl (12.5 mg/5 ml, 25 mg/10 ml, 50 mg/mlcrpjt, 50 mg/ml syrng)

1

diphenhydramine-0.9% nacl 1

diphtheria-tetanus toxoids-ped 1

dipyridamole 5 mg/ml vial 1

DISCOVISC 3

DMSA 3

dobutamine hcl 1

dobutamine hcl-d5w 1



DOJOLVI 4 PA

DONNATAL TABLET 1

dopamine hcl 1

dopamine hcl in 5% dextrose 1

DOPTELET 3

DORAL 3

DORYX MPC 3

DOTAREM (2.5 MMOL/5 ML VIAL, 5 MMOL/10 ML VIAL, 7.5MMOL/15 ML VIAL, 10 MMOL/20 ML VIAL, 50 MMOL/100 MLVIAL)

3

DOVATO 4 QL 1 / day

doxapram hcl 1

doxycycline hyclate (50 mg tablet, hyclate 75 mg tab, hyclate150 mg tab)

3

doxycycline hyc dr 50 mg tab 1QL 60 / 30 days

ST

doxycycline hyc dr 80 mg tab 1 QL 2 / day

doxycycline mono 150 mg cap 1 QL 60 / 30 days

doxycycline mono 150 mg tablet 1

doxylamine succ-pyridoxine hcl 3

DRAXIMAGE DTPA 3

DRAXIMAGE MAA 3

DRAXIMAGE MDP-25 3

DRISDOL 3

DRIZALMA SPRINKLE 3

droperidol (5 mg/2 ml ampul, 5 mg/2 ml vial) 1

droxidopa 100 mg capsule 1 QL 18 / day



DRYSOL SOLUTION 3



DUAKLIR PRESSAIR 3QL 0.0333 / day

PA

DUAVEE 2QL 30 / 30 days

GL Female

DULERA 50 MCG-5 MCG INHALER 3QL 0.46 / day

ST

DUOBRII 3

DUODOTE 3

DUOPA 3

DUOVISC 3

DUPIXENT 200 MG/1.14 ML PEN 4QL 0.126 / day

PA

DUPIXENT 300 MG/2 ML PEN 4QL 0.15 / day

PA

DUPIXENT SYRINGE 4QL 0.15 / day

PA

DUZALLO 3

DVORAH 3 QL 10 / day

DXEVO 3

DYANAVEL XR 3

ED-SPAZ 1

efavirenz-lamivu-tenofov disop 4 QL 1 / day

EFFER-K 10 MEQ TABLET EFF 2

EFFER-K 20 MEQ TABLET EFF 2 QL 150 / 30 days

EFFER-K 25 MEQ TABLET EFF 1

EGATEN 2

EGRIFTA 3

EGRIFTA SV 3



ELASTIDERM 1

ELEPSIA XR 3

ELETONE 3

ELIQUIS DVT-PE TREAT START 5MG 2 QL 2.5 / day

ELLIOTTS B 3

ELOCTATE 4C


PA

EMEND 125 MG POWDER PACKET 2 QL 1 / 28 days

EMEND 150 MG VIAL 2 QL 1 / 7 days

EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/MLORAL SUSP, 30 MG TABLET, 36 MG TABLET)

4 PA

EMGALITY PEN 2QL 0.04 / day

PA

EMGALITY 120 MG/ML SYRINGE 2QL 0.04 / day

PA

EMGALITY SYRINGE (100 MG/ML SYR(1 OF 3), 300 MG (100MG X3SYR))

2QL 0.1 / day

PA

EMPAVELI 4 PA

EMPLICITI 4

PA


emtricitabine-tenofovir disop (100-150mg, 133-200mg, 167-250mg)

4

EMULSION SB TOPICAL TWIN PACK 1

EMVERM 1

enalapril 1 mg/ml oral soln 1

enalaprilat 1



ENBREL 25 MG/0.5 ML VIAL 4QL 0.29 / day

PA

ENBREL MINI 4QL 0.15 / day

PA

ENBREL SURECLICK 4QL 0.15 / day

PA

ENDARI 3

ENDO-AVITENE 3 PA

ENGERIX-B 20 MCG/ML VIAL 2

ENSTILAR 3

ENTOCORT EC 3

ENTRESTO 2 QL 60 / 30 days

ENTYVIO 4

QL 2 / 30 days

PA


ENVARSUS XR 3 QL 30 / 30 days

EOVIST 3

EPANED 3

EPCLUSA (150-37.5 MG PELLET PKT, 200 MG-50 MGTABLET, 200-50 MG PELLET PACK)

4QL 1 / day

PA

EPCLUSA 400 MG-100 MG TABLET 4QL 28 / 28 days

PA

ephedrine sulfate-0.9% nacl (10 mg/ml-0.9% nacl, 100mg/10ml-0.9%nacl)

1

ephedrine sulfate-0.9% nacl (25 mg/5, 50 mg/5) 1 DC ExcludedProducts

EPICERAM 3

epicoccum nigrum 1:20 vial 3

EPICYN 3



EPIDIOLEX 3

EPIDUO FORTE 2

EPIFOAM 3

epinephrine (0.1 mg/ml syringe, 1 mg/10 ml abbojct, 1 mg/mlampul, 30 mg/30 ml vial)

1

epinephrine convenience kit 1

epinephrine hcl-0.9% nacl (epineph 4 mg/250 ml-0.9% nacl,epineph 8 mg/250 ml-0.9% nacl, epinephrine 1 mg/250 ml-ns)

1

epinephrine hcl-d5w (1 mg/250, 2 mg/250, 5 mg/250, 8 mg/250) 1

epinephrine 2 mg/250 ml-ns 1 DC ExcludedProducts

epinephrine-0.9% nacl (epineph 0.1 mg/10 ml-0.9% nacl,epinephrine 4 mg/250 ml-ns, epinephrine 5 mg/250 ml-ns)

1

EPISIL 3

ERBITUX 4

PA


ergotamine-caffeine 1

ERLEADA 4QL 4 / day

PA

ERWINAZE 4

PA


erythromycin dr 250 mg cap 1

ESBRIET 267 MG CAPSULE 4QL 270 / 30 days

PA

ESBRIET (267 MG TABLET, 801 MG TABLET) 4 PA

esmolol hcl (100 mg/10 ml syrg, 100 mg/10 ml vial) 1

esmolol hcl-sodium chloride 1

ESPEROCT 4 PA

ESTROGEL 3 GL Female

estrogen-methyltestosterone 1 GL Female



ETHAMOLIN 3

ethyl chloride 1

etomidate 1

etoposide 50 mg capsule 1

EUCRISA 2 ST

EVEKEO 3

EVEKEO ODT 3

EVENITY 4

PA


EVENITY (2 SYRINGES) 4

PA


everolimus 1 mg tablet 4QL 2 / day

PA

everolimus (2 mg tab susp, 3 mg tab susp) 4 QL 1 / day

everolimus 5 mg tab for susp 4 QL 2 / day

EVICEL FIBRIN 2X1 ML SEALANT 2 PA

EVISTA 3

EVOTAZ 4 QL 30 / 30 days

EVRYSDI 4QL 6.66 / day

PA

EXPAREL 3

EXSERVAN 3

EXTRANEAL ICODEXTRIN DIALYSIS 3

EYSUVIS 3

EZALLOR SPRINKLE 3

FABIOR 3 PA

FARXIGA 2QL 30 / 30 days

ST



FARYDAK 4QL 6 / 21 days

PA

FASENRA 4QL 0.04 / day

PA

FASENRA PEN 4QL 0.04 / day

PA

FEIBA NF 4C


PA

FEMHRT 3QL 28 / 28 days

GL Female

fenoprofen 200 mg capsule 1

fentanyl (37.5 mcg/hr patch, 62.5 mcg/hr patch, 87.5 mcg/hrpatch)

1

fentanyl citrate (50 mcg/ml syringe, 100 mcg/2 ml ampul, 100mcg/2 ml vial, 250 mcg/5 ml ampul, 250 mcg/5 ml vial, citrate400 mcg/8 ml, 500 mcg/10 ml vial, 1,000 mcg/20 ml vial, 2,500mcg/50 ml bag, 2,500 mcg/50 ml syrng, 2,500 mcg/50 ml vial,2,750 mcg/55 ml syr, 2,750 mcg/55 ml syrng, 5,000 mcg/100 mlbag)

1

fentanyl 50 mcg/ml vial 3

fentanyl citrate-0.9% nacl (10 mcg/ml-0.9% nacl, 100mcg/10ml-0.9%nacl, 500 mcg/50ml-0.9%nacl, 550 mcg/55ml-0.9%nacl, 600 mcg/30ml-0.9%nacl, 750 mcg/30ml-0.9%nacl,1,000mcg/50-0.9% nacl, 1,250 mcg/25 ml-ns, 1,250 mcg/50-0.9%nacl, 2,000mcg/100-0.9%nacl, 5,000mcg/250-0.9%nacl)

1

fentanyl citrate-0.9% nacl (1 mg/100 ml-0.9% nacl,2.5mg/250ml-0.9% nacl, 1,000mcg/100-0.9%nacl,2,500mcg/250-0.9%nacl)

1 DC ExcludedProducts

fentanyl citrate-d5w (100 mcg/10, 300 mcg/30 syr, 2,500mcg/250)

1

fentanyl citrate-sterile water 1

fentanyl-bupivacaine-0.9% nacl (2 mcg-bup 0.0625%-ns, 2mcg-bupiv 0.1%-ns, 2 mcg-bupiv 0.125%-ns, 5 mcg-bupiv0.04%-ns, 10 mcg-bupiva 0.2%-ns)

1



fentanyl-ropivacaine-0.9% nacl (2 0.1%-ns, 2 0.125%-ns, 20.2%-ns)

1

FERAHEME 3

FEROCON 1

FERREX 150 FORTE 3

FERREX 150 FORTE PLUS 1

FERREX 28 1

FERRIPROX 100 MG/ML SOLUTION 3 PA

FERRIPROX 1,000 MG TABLET 3

FERRIPROX (2 TIMES A DAY) 3


FERROCITE PLUS 1

ferrous sulf 15 mg iron/ml drp 1 AL 0.5 to 12.0 yrsold

ferumoxytol 1

FETZIMA 20-40 MG TITRATION PAK 3

FETZIMA (ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80MG CAPSULE, ER 120 MG CAPSULE)

3 QL 30 / 30 days

FIBRYGA 4 PA

FINTEPLA 4QL 12 / day

PA

FIORICET WITH CODEINE 3 QL 180 / 30 days

FIRDAPSE 3

FIRVANQ 3

FLEBOGAMMA DIF 4

PA


flexichamber mask 3

FLOLIPID 3

floxuridine 1

FLUAD 2019-2020 2



FLUAD 2020-2021 2

FLUAD QUAD 2020-2021 2

FLUAD QUAD 2021-2022 2

FLUARIX QUAD 2019-2020 2



FLUBLOK QUAD 2019-2020 2



FLUCELVAX QUAD 2019-2020 (SYR, VIAL) 2



fluconazole-nacl 100 mg/50 ml 1

fludeoxyglucose f-18 3

FLULAVAL QUAD 2019-2020 (SYR, VIAL) 2

FLULAVAL QUAD 2020-2021 2


flumazenil 1

FLUMIST QUAD 2019-2020 2



fluorescein-benoxinate 3

fluorescein-proparacaine 1

FLUORESCITE 1

fluoride (0.25 mg tablet chew, 0.5 mg tablet chew) 1

FLUORIDEX SENSITIVITY RELIEF 2

FLUORITAB 0.5 MG TABLET CHEW 1

FLUOROPLEX 3

FLURA-DROPS 1

flurandrenolide (cream, lotion, ointment) 3



fluticasone-salmeterol (55-14, 113-14, 232-14) 1 QL 0.04 / day

FLUZONE HIGH-DOSE 2019-2020 2

FLUZONE HIGH-DOSE QUAD 2020-21 2


FLUZONE QUAD 2019-2020 (SYRINGE, VIAL) 2



FLUZONE QUAD PEDI 2019-2020 2

FOLBEE 1

FOLBEE PLUS 1

FOLBEE PLUS CZ 1

FOLBIC 1

folic acid (0.4 mg tablet, ra 0.4 mg tablet, 0.8 mg tablet, 1 mgtablet, 5 mg/ml vial, 20 mg capsule, 50 mg/10 ml vial, 400 mcgtablet, gnp 400 mcg tablet, 800 mcg capsule, 800 mcg tablet,cvs 800 mcg tablet, ra 800 mcg tablet, sm 400 mcg tablet, sv800 mcg tablet, 1,000 mcg tablet)

1

FOLIVANE-F 1

FOLIVANE-OB 1

FOLIVANE-PLUS 1

FOLIXAPURE 1

FOLLISTIM AQ 4 ST

FOLPLEX 2.2 1

FOLTRATE 2

FORTAVIT 3

FORTEO 4 QL 2.4 / 28 days

FORTESTA 3QL 120 / 30 days

GL Male

fosaprepitant dimeglumine 4 QL 2 / fill

FOSRENOL (750 MG POWDER PACKET, 1,000 MGPOWDER PACK)

2



FOTIVDA 4QL 0.767 / day

PA

FREAMINE HBC 3

FREAMINE III 3

freestyle freedom lite meter 2

freestyle insulinx (glucose sys, strip nfrs, test strip) 2

freestyle insulinx test strips 2

freestyle libre 14 day reader 2 QL max 1 per 365days

freestyle libre 14 day sensor 2 QL 0.08 / day

freestyle libre 2 reader 2 QL max 1 per 365days

freestyle libre 2 sensor 2 QL 0.072 / day

freestyle lite meter 2

freestyle lite test strip 2

freestyle test strips 2

FUL-GLO 1 MG OPTH STRIP 1

FULPHILA 4

PA


furosemide (40 mg/4 ml syringe, 100 mg/10 ml syring) 1

FUSILEV 3 M-PA Medical BenefitPA

FUSION PLUS 3

FYAVOLV 0.5 MG-2.5 MCG TABLET 1 GL Female

FYCOMPA 0.5 MG/ML ORAL SUSP 2 PA

FYCOMPA (2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8MG TABLET, 10 MG TABLET, 12 MG TABLET)

2QL 30 / 30 days

PA

GABLOFEN (10,000 MCG/20 ML SYRG, 20,000 MCG/20 MLSYRG, 20,000 MCG/20 ML VIAL, 40,000 MCG/20 ML SYRG,40,000 MCG/20 ML VIAL)

3



GADAVIST (1 MMOL/ML BULK VIAL, 7.5 MMOL/7.5 ML SYR,7.5 MMOL/7.5 ML VIAL, 10 MMOL/10 ML SYRINGE, 10MMOL/10 ML VIAL, 15 MMOL/15 ML SYRINGE, 15 MMOL/15ML VIAL)

3

GALAFOLD 4QL 0.5 / day

PA

GALZIN 3

GAMMAPLEX (5 GRAM/50 ML VIAL, 10 GRAM/100 ML VIAL,20 GRAM/200 ML VIAL)

4

PA


ganirelix acetate 4

GARDASIL 9 (9 SYRINGE, 9 VIAL) 2

GASTROGRAFIN 3

GASTROMARK 3

GAZYVA 4

PA


GEL-FLOW NT 3

GELCLAIR 3

gelfilm 2

GELFILM OPHTHALMIC 25X50MM 3

GELFOAM POWDER 2 PA

GELFOAM (DENTAL SPONGE SZ 4, 12-7MM SPONGE, SIZE50 SPONGE, SIZE 100 SPONGE, SIZE 200 SPONGE)

3 PA

GELFOAM COMPRESSED 3 PA

gemcitabine hcl (1 gram/26.3 ml vl, hcl 1 gram/10 ml, hcl 1.5gram/15 ml, 2 gram/52.6 ml vl, hcl 2 gram/20 ml, 200 mg/5.26ml vl, hcl 200 mg/2 ml vl)

1

GEMTESA 3

GENADUR KIT 3

isoton gentamicin 100 mg/50 ml 1

GENVOYA 4 QL 30 / 30 days



GILENYA 0.25 MG CAPSULE 4QL 1 / day

PA

GILOTRIF 4QL 30 / 30 days

PA

glatiramer 40 mg/ml syringe 4QL 0.434 / day

PA

GLEOSTINE 100 MG CAPSULE 4

GLIADEL 3

glutaraldehyde 1

glycine 1.5% irrigation 1

glycopyrrolate (0.2 mg/ml syrng, 0.4 mg/2 ml syr, 0.6 mg/3 mlsyr)

1

glycopyrrolate 0.4mg/2ml-water 1

glycopyrrolate-water 1

GLYXAMBI 2QL 30 / 30 days

ST

GOCOVRI 3

GONAL-F 4

GONAL-F RFF 4

GONAL-F RFF REDI-JECT 4

GONITRO 3

GRALISE 300-600 MG SAMPLE PACK 3

GRANIX (300 MCG/0.5 ML SAFE SYR, 300 MCG/0.5 MLSYRINGE, 300 MCG/ML VIAL)

4QL 4 / day

PA

GRANIX (480 MCG/0.8 ML SAFE SYR, 480 MCG/0.8 MLSYRINGE, 480 MCG/1.6 ML VIAL)

4QL 3 / day

PA

GREEN GLO 1

GVOKE HYPOPEN 1-PACK 2


GVOKE PFS 1-PACK SYRINGE 2




HAEGARDA 4 PA

halobetasol prop 0.05% foam 3

HALOG 0.1% SOLUTION 3

HARVONI (33.75-150 MG PELLET PK, 45-200 MG TABLET,90-400 MG TABLET)

4QL 1 / day

PA

HARVONI 45-200 MG PELLET PACKT 4QL 2 / day

PA

HAVRIX 1,440 UNITS/ML SYRINGE 2

HEMABATE 3

HEMANGEOL 3

HEMATINIC PLUS 1

HEMATINIC WITH FOLIC ACID 1

HEMATOGEN FA 1

HEMATOGEN FORTE 1

HEMAX 1

HEMETAB 1

HEMLIBRA 4 PA

HEMMOREX-HC 30 MG SUPPOSITORY 1

HEMOFIL M 4C


PA

HEPAGAM B 4 PA



heparin flush (iv flush 1 unit/ml syr, 2 unit/2 ml (1/ml) syr, 3unit/3 ml (1/ml) syr, 5 unit/5 ml (1/ml) syr, 10 unit/10 ml (1/ml),flush 10 units/ml syr, 20 units/2 ml (10/ml), 30 units/3 ml(10/ml), 50 units/5 ml (10/ml), 60 units/6 ml (10/ml), 200 unit/2ml (100/ml), 300 unit/3 ml (100/ml))

1

heparin lock (lock flush 10 units/ml, 100 unit/10 ml (10/ml)) 1

heparin sodium (2,000 unit/2 ml vial, sod 5,000 unit/0.5 ml, sod5,000 unit/ml syrg)

1

heparin 5,000 unit/1,000 ml-ns 1 DC ExcludedProducts

heparin sodium-0.9% nacl (1,000 unit/500 ml-ns, 2,000unit/1,000 ml-ns, 2,500 unit/5 ml-ns syr, 2,500 unit/500 ml-ns,4,000 unit/1,000 ml-ns, 5,000 unit/500 ml-ns, 6,000 unit/3 ml-nssyr)

1

HEPLISAV-B 2

HERCEPTIN 4

PA


hetastarch-0.9% nacl 1

HETLIOZ 3

HETLIOZ LQ 3

HEXTEND LACTATED ELECTROLYTE 3

HICON 4 PA

HIDEX 3

HIZENTRA (1 GRAM/5 ML SYRINGE, 1 GRAM/5 ML VIAL, 2GRAM/10 ML SYRINGE, 2 GRAM/10 ML VIAL, 4 GRAM/20 MLSYRINGE, 4 GRAM/20 ML VIAL, 10 GRAM/50 ML VIAL)

4 PA

HOMACTIN AA PLUS 15 PE 3

HORIZANT ER 300 MG TABLET 3

HORIZANT ER 600 MG TABLET 3 QL 60 / 30 days

HPR PLUS EMOLLIENT FOAM 3

HPR PLUS-MB HYDROGEL 3

HUMATE-P 4C


PA



HUMIRA(CF) 4QL 0.22 / day

PA

HUMIRA(CF) PEDIATRIC CROHN'S 4QL 0.22 / day

PA

HUMIRA(CF) PEN 4QL 0.22 / day

PA

HUMIRA(CF) PEN CROHN'S-UC-HS 4QL 0.22 / day

PA

HUMIRA(CF) PEN PEDIATRIC UC 4QL 0.22 / day

PA

HUMIRA(CF) PEN PSOR-UV-ADOL HS 4QL 0.22 / day

PA

HUMULIN R U-500 KWIKPEN 2QL 90 days

PA

HYCAMTIN 0.25 MG CAPSULE 4 QL 92 / 21 days

HYCAMTIN 1 MG CAPSULE 4 QL 23 / 21 days

HYCODAN 5 MG-1.5 MG TABLET 3 QL 6 / day

HYDRO 40 3

hydrocodone bitartrate er (er 10 mg capsule, er 15 mg capsule,er 20 mg capsule, er 30 mg capsule, er 40 mg capsule, er 50mg capsule)

3QL 2 / day

PA

hydrocodone bitartrate er (er 20 mg tablet, er 30 mg tablet, er40 mg tablet, er 60 mg tablet, er 100 mg tablet, er 120 mgtablet)

1 QL 1 / day

hydrocodone er 80 mg tablet 3 QL 1 / day

hydrocodone-acetaminophen (2.5-325, 10-325/15) 1

hydrocodone-chlorpheniramne er 1

hydrocodone-homatropine mbr (5-1.5, soln, syrup) 1

hydrocortisone acetate (25 mg, 30 mg) 1

hydrocortisone-iodoquinol 1



hydrocortisone-pramoxine (1%-1% crm, 2.5%-1% cm, 2.5-1%crm)

1

HYDROMET 1

hydromorphone hcl er 32 mg tab 1 QL 6 / day

hydromorphone hcl (0.5 mg/0.5 ml, 1 mg/ml carpujct, 1 mg/mlsyringe, 2 mg/ml carpujct, 2 mg/ml isecure, 2 mg/ml syringe, 3mg suppos, 4 mg/ml carpujct)

1

hydromorphone hcl-0.9% nacl (0.5 mg/ml-ns syr, 1 mg/ml-nssyrng, 2 mg/10 ml-ns, 5 mg/25 ml-ns, 6 mg/30 ml-ns, 10 mg/50ml-ns, 15 mg/30 ml-ns, 20 mg/100 ml-ns, 25 mg/50 ml-ns, 30mg/30 ml-ns, 50 mg/50 ml-ns)

1

hydromorphone hcl-d5w (0.5 mg/5, 3 mg/30) 1

hydroquinone (cream, tr cream) 1

hydroxocobalamin 1

hydroxychloroquine sulfate (100 mg tab, 300 mg tab, 400 mgtab)

1

hydroxyprogest 1,250 mg/5 ml 4 PA

hydroxyprogesterone caproate (hydroxyprogest 250 mg/ml vial,hydroxyprogesterone 1.25 g/5ml)

4GL Female

PA

HYLATOPICPLUS EMOLLIENT FOAM 3

HYLENEX 3

HYOPHEN 1

hyoscyamine sulfate (0.125 mg odt, 0.125 mg tab sl, 0.125mg/5 ml elix, 0.125 mg/ml drop, sulf 0.125 mg tab)

1

hyoscyamine sulfate er 1

hyoscyamine sulfate sr 1

HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML ELIXIR) 1

HYPERHEP B (NEONATAL SYRINGE, SYRINGE, VIAL) 3 PA

HYPERRHO S-D 4

HYPERTET S-D 2 PA

HYQVIA 4 PA

HYQVIA HY COMPONENT 4 PA

HYQVIA IG COMPONENT 4 PA



HYSINGLA ER 3 QL 1 / day

IBRANCE (75 MG CAPSULE, 75 MG TABLET, 100 MGCAPSULE, 100 MG TABLET, 125 MG CAPSULE, 125 MGTABLET)

4 PA

ibutilide fumarate 1

IC GREEN 3

ICAR-C PLUS 3

ICLUSIG 10 MG TABLET 4QL 2 / day

PA

ICLUSIG 30 MG TABLET 4QL 1 / day

PA

IDELVION 4C


PA

IDHIFA 4 PA

IFEREX 150 FORTE 1

ILUVIEN 3

IMBRUVICA 140 MG CAPSULE 4QL 120 / 30 days

PA

IMBRUVICA (70 MG CAPSULE, 140 MG TABLET, 280 MGTABLET, 420 MG TABLET, 560 MG TABLET)

4QL 1 / day

PA

imipenem-cilastatin 250 mg vl 1

IMLYGIC 4

PA


IMOGAM RABIES-HT 2 PA

IMPAVIDO 4 QL 90 / 30 days

IMPEKLO 3



IMPOYZ 3

INBRIJA 3

INCRUSE ELLIPTA 3QL 1 / day

ST

INDICLOR 3

INDIUM IN-111 DTPA 3

indium in-111 oxyquinoline 1

INDOCIN 50 MG SUPPOSITORY 3

indocyanine green 1

indomethacin 1 mg vial 1

INFANRIX DTAP SYRINGE 2

INFASURF 3

INFED 3

INFLECTRA 4

QL 0.5 / day

PA


INFUVITE ADULT 3

INFUVITE PEDIATRIC 3

INGREZZA (40 MG CAPSULE, 80 MG CAPSULE) 3

INGREZZA 60 MG CAPSULE 4

QL 1 / day


INGREZZA INITIATION PACK 3

INJECTAFER 3

INOVA 3

INOVA 4-1 3

INOVA 8-2 3

INQOVI 4QL 0.18 / day

PA



INREBIC 4QL 4 / day

PA

insulin aspart flexpen 2QL 3 / day

ST

insulin aspart penfill 2QL 2 / day

ST

insulin syringe (gnp insul syr 0.5 ml 31gx5/16", insulin syrin 0.5ml 31gx5/16", ulticare ins safety 1ml 29x1/2, ulticare safety 0.5ml 29gx1/2)

2

insulin syringe (syr 0.3ml 31gx1/4(1/2), syringe 0.3 ml 31gx1/4,syringe 0.5 ml 31gx1/4, syringe 1 ml 31gx1/4")

1

INTEGRA F 3

INTEGRA PLUS 1

INTELENCE 25 MG TABLET 3

INTRAROSA 3 GL Female

INTRON A (10 MILLION VIL, 18 MILLION VIL, 50 MILLIONVIL)

4 PA

INVEGA HAFYERA 4

INVEGA TRINZA 4

INVELTYS 3

INVOKAMET 3QL 60 / 30 days

ST

INVOKAMET XR 3QL 1 / 1 days

ST

IODOFLEX 3

IODOSORB 3

ipratropium-albuterol 1

IRESSA 4

irinotecan hcl 300 mg/15 ml vl 1 PA

ISENTRESS 100 MG POWDER PACKET 2

ISENTRESS HD 2



isoflurane 1

ISOPTO ATROPINE 3

ISOSOURCE 1.5 CAL 3

ISOSOURCE 1.5 CAL TUBE FEED 3

isosulfan blue 1

isotretinoin (25 mg capsule, 35 mg capsule) 1QL 2 / day

PA

ISOVUE-200 41% VIAL 3

ISOVUE-M 200 3

ISOVUE-M 300 3

isoxsuprine hcl 1

ISTURISA 1 MG TABLET 4QL 8 / day

PA


PA


PA

iv sol stabilizer for blincyto 4 PA

IXEMPRA 4 PA

IXINITY 4C


PA

JADENU 180 MG TABLET 4QL 11 / 30 days

PA

JANSSEN COVID-19 VACCINE (EUA) 2

JARDIANCE 2QL 30 / 30 days

ST



JATENZO 3

JEMPERLI 4

QL 0.5 / day

PA


JENTADUETO XR 2.5 MG-1,000 MG 3QL 2 / day

ST

JENTADUETO XR 5 MG-1,000 MG TB 3QL 1 / day

ST

JEVITY 1.2 CAL 3

JEVTANA 4

QL 0.15 / day

PA


JIVI 4C


PA

JORNAY PM 3 QL 1 / day

JUBLIA 3

JULUCA 4 QL 1 / day

JYNARQUE (15 MG-15 MG TABLET, 30 MG-15 MG TABLET,45 MG-15 MG TABLET, 60 MG-30 MG TABLET, 90 MG-30 MGTABLET)

4QL 2 / day

PA

K-PHOS NEUTRAL 1

K-PHOS ORIGINAL 3

KABIVEN 3

KADCYLA 4

PA




KADIAN ER 40 MG CAPSULE 3QL 60 / 30 days

ST

KALBITOR 4

PA


KALYDECO (50 MG GRANULES PACKET, 75 MGGRANULES PACKET)

4QL 60 / 30 days

PA

KALYDECO 25 MG GRANULES PACKET 4QL 2 / day

PA

KANJINTI 4

PA


KAPSPARGO SPRINKLE 3

KARBINAL ER 3 QL 1200 / 30 days

KATERZIA 3

KCENTRA 3

KENALOG-10 4

KENALOG-40 4

KENALOG-80 3

kendall 0.9% nacl with cap 1

KERYDIN 3 B4G Brand ForGeneric

KESIMPTA PEN 4QL 0.057 / day

PA

ketamine hcl (hcl 50 mg/ml syringe, 100 mg/2 ml syringe, 200mg/20 ml vial, 500 mg/10 ml vial, 500 mg/5 ml vial, 1,000 mg/10ml vial)

1

ketamine hcl-0.9% nacl (20 mg/2, 50 mg/5, 60 mg/20) 1

ketamine 50 mg/5 ml-water vial 1

keto-diastix reagent 2

KETOCAL 2.5:1 3

ketone test strip 2



ketoprofen 25 mg capsule 3

ketorolac tromethamine (15 mg/ml carpuject, 15 mg/ml isecuresyr, 15 mg/ml syringe, 30 mg/ml carpuject, 30 mg/ml isecuresyr, 30 mg/ml syringe, 60 mg/2 ml carpuject, 60 mg/2 mlsyringe)

1

KETOVIE 4:1 3

KEVEYIS 4QL 60 / 30 days

PA

KEVZARA (150 MG/1.14 ML PEN INJ, 150 MG/1.14 MLSYRINGE, 200 MG/1.14 ML PEN INJ, 200 MG/1.14 MLSYRINGE)

4QL 0.1 / day

PA

KEYTRUDA 4

PA


KINEVAC 3

KINRIX (TIP-LOK SYRINGE, VIAL) 2

KISQALI 4 PA

KISQALI FEMARA CO-PACK 4 PA

KLISYRI 2QL 5 / 5 days

PA

KLOR-CON 1 QL 180 / 90 days

KLOR-CON-EF 1

KOATE 4C


PA

KOGENATE FS 4C


PA



KOSELUGO 4QL 4 / day

PA

KOVALTRY 4C


PA

KRINTAFEL 3

KRYSTEXXA 3 M-PA Medical BenefitPA

KYNMOBI 3

KYPROLIS 4

PA


labetalol hcl (20 mg/4 ml crpjt, 20 mg/4 ml syrng) 1

LAMICTAL ODT (BLUE) 3

LAMICTAL ODT (GREEN) 3

LAMICTAL ODT (ORANGE) 3

lamotrigine odt (blue) 1

lamotrigine odt (green) 1

lamotrigine odt (orange) 1

LAMPIT 120 MG TABLET 3

QL 8 / day

AL Up to 18 yrs old

PA

LAMPIT 30 MG TABLET 3

QL 12 / day

AL Up to 18 yrs old

PA

LANOXIN (62.5 MCG TABLET, 187.5 MCG TABLET) 3

LATUDA 60 MG TABLET 2 QL 30 / 30 days

LDO PLUS 3



LENVIMA (14 MG DAILY, 20 MG DAILY) 4QL 60 / 30 days

PA

LENVIMA (4 MG CAPSULE, 12 MG DAILY DOSE) 4QL 1 / day

PA

LENVIMA (8 MG DAILY, 18 MG DAILY) 4 PA

LENVIMA 10 MG DAILY DOSE 4QL 30 / 30 days

PA

LENVIMA 24 MG DAILY DOSE 4QL 90 / 30 days

PA

leucovorin calcium (100 mg/10 ml vl, 500 mg/50 ml vl) 1

levetiracetam-nacl 1

levofloxacin (500 mg/20 ml vial, 750 mg/30 ml vial) 1

levofloxacin-d5w 1

levoleucovorin calcium (50 mg vial, 175 mg/17.5 ml, 250 mg/25ml vl)

1 M-PA Medical BenefitPA

levonorg 0.15mg-ee 20-25-30mcg 3QL 1 / day

GL Female

levothyroxine 3

levothyroxine sodium (100 mcg vial, 200 mcg vial, 500 mcg vial) 1

levothyroxine sodium (100 mcg/5 ml vl, 200 mcg/5 ml vl, 500mcg/5 ml vl)

3

LEVULAN 3

LEXETTE 3

LEXISCAN 3

LICART 3

LIDO-K 1



lidocaine hcl (hcl 1.5% ampul, hcl 2% 100 mg/5 ml, hcl 2% 40mg/2 ml, hcl 2% 40 mg/2 ml vl, hcl 2% abboject, hcl 2% ampul,hcl 2% luer-jet, hcl 2% syringe, hcl 2% vial, 3% cream, hcl 3%lotion, hcl 4% ampul, hcl 10 mg/ml syringe, 100 mg/5 ml (2%)syr, 200 mg/10 ml(2%) syr, hcl 200 mg/10 ml syr)

1

lidocaine hcl in 5% dextrose 1

lidocaine hcl in 7.5% dextrose 1

lidocaine hcl-epinephrine (0.5%-epi 1:200,000, 1%-epi1:100,000, 1.5%-epi 1:200,000, 2%-epi 1:100,000, 2%-epi1:200,000)

1

lidocaine-epinephrine 1

lidocaine-hydrocortisone (2-2% cream kit, 2.8-0.55% gel, 3-0.5% cream, 3-0.5% cream kit, 3-1% cream kit, 3-2.5% gel kit)

1

lidocaine-tetracaine 1

LIDOPIN 3% CREAM 1

linezolid-0.9% nacl 1

linezolid-d5w 1

LINZESS 72 MCG CAPSULE 2

QL 1 / day

ST


LIPOCHOL PLUS 3

LIQUID E-Z PAQUE 1

lite touch (syr 0.3 ml, syr 0.5 ml) 2

litetouch insulin syringe (ins 0.3 ml 31gx5/16", ins 0.5 ml31gx5/16", syr 0.5 ml 28gx1/2", syr 0.5 ml 29gx1/2", syrin 1 ml28gx1/2", syrin 1 ml 29gx1/2", syrin 1 ml 30gx5/16")

2

lithium 1

LMD 10% WITH 0.9% SOD CHLORIDE 1

LMD 10% WITH 5% DEXTROSE 1

lo-dose aspirin ec 1 AL 45.0 to 79.0 yrsold

LOFENA 3

lofric origo 3

LONHALA MAGNAIR REFILL 3 QL 2 / day



LONHALA MAGNAIR STARTER 3 QL 2 / day

LONSURF 15 MG-6.14 MG TABLET 4QL 2.15 / day

PA

LONSURF 20 MG-8.19 MG TABLET 4QL 3 / day

PA

lorazepam (2 mg/ml carpuject, 2 mg/ml syringe, 2 mg/ml vial, 4mg/ml carpuject, 4 mg/ml vial, 20 mg/10 ml vial, 40 mg/10 mlvial)

1

LORBRENA 100 MG TABLET 4QL 1 / day

PA

LORBRENA 25 MG TABLET 4QL 3 / day

PA

LOREEV XR 3

LORTAB 1

LOTEMAX SM 3

low dose aspirin ec 1 AL 45.0 to 79.0 yrsold

LUCEMYRA 4 PA

LUDENT FLUORIDE (0.25 MG TB CHW, 0.5 MG TB CHEW) 1

LUGOL'S 1

luliconazole 3

LUMAKRAS 4QL 8 / day

PA

LUPANETA PK 11.25-5 MG 3MO KIT 3 QL 1 / 84 days

LUPANETA PK 3.75-5 MG 1MO KIT 3

LUPKYNIS 4QL 6 / day

PA

LUZU 3

LYBALVI 3



LYNPARZA 4QL 4 / day

PA

LYRICA CR 3 QL 1 / day

LYSIPLEX PLUS TABLET 3

M-END PE 3

M-NATAL PLUS 2

M.V.I. ADULT 3

M.V.I. PEDIATRIC 3

magellan safety needle 2

MAGNEBIND 400 3

magnesium chl 200 mg/ml vial 1

magnesium sulfate (sulf 2 g/50 ml bag, sulf 4 g/100 ml bag, sulf4 g/50 ml bag, sulf 20 g/500 ml bag, sulf 40 g/1,000 ml, sulfate50% vial)

1

magnesium sulfate-0.9% nacl (2 gm/50, 3 g/150) 1

magnesium sulfate-d5w (1 gram/50 bag, sulf 1 g/100, 2gram/100, 2 gram/50, 4 gram/50 bag, 50 gram/500)

1

magnesium-lactated ringers (40 gram/1,000, 40 gram/500, 50gram/500)

1

MAGNEVIST (BULK VIAL, SYRINGE, VIAL) 3

MAKENA (250 MG/ML VIAL, 275 MG/1.1 ML AUTOINJCT,1,250 MG/5 ML VIAL)

4GL Female

PA

manganese chloride 1

manganese sulfate 1

mannitol (5% iv solution, 10% iv solution, 20% iv solution, 25%vial)

1

MAR-COF BP 3

MAR-COF CG 3

MARNATAL-F 2

MARQIBO 4

PA




MAVENCLAD 4QL 0.667 / day

PA

MAVYRET (50-20 MG PELLET PACKET, 100-40 MG TABLET) 4QL 3 / day

PA

MAXIPIME 1 GM ADD-VANTAGE VL 3

MAYZENT 0.25 MG STARTER PACK 4QL 2.5 / day

PA

MAYZENT 0.25 MG TABLET 4QL 120 / 30 days

PA

MAYZENT 2 MG TABLET 4QL 1 / day

PA

MB HYDROGEL 1

MD-76 R (R INFUSION BOTTLE, R VIAL) 3

MD-GASTROVIEW 1

me-naphos-mb-hyo 1 1

MEKTOVI 4QL 6 / day

PA

meloxicam (5 mg capsule, 10 mg capsule) 1 AL At least 18 yrsold

melphalan 3

MEMBRANEBLUE 3

MENQUADFI 2

meperidine 10 mg/ml cartrdge 1

meperidine hcl-0.9% nacl 1

MEPHYTON 3

mepivacaine hcl 3

metaxalone 400 mg tablet 1

methacholine cl inhal sol pack 3

methadone 40 mg tablet dispr 1

methadone hcl-0.9% nacl 1



METHADOSE 40 MG TABLET DISPR 1

methenamine mand 500 mg tablet 1

methocarbamol 1,000 mg/10 ml 1

methocel e 4 m (thocl 4 powdr, thocl 4 priupowdr) 3

methylene blue (ampul, vial) 1

methylergonovine maleate (0.2 mg/ml amp, 0.2 mg/ml vl) 1

methylphenidate er (er 10 mg cap, er 15 mg cap, er 20 mg cap,er 30 mg cap, er 40 mg cap, er 50 mg cap, er 60 mg cap, er 72mg tab)

1QL 1 / day

ST

methylphenidate er 10 mg tab 1QL 30 / 30 days

ST

methylphenidate la 60 mg cap 1

metoclopramide 10 mg/2 ml syr 1

METOPIRONE 3

metoprolol tartrate (37.5 mg tb, 75 mg tab) 1

MICRHOGAM ULTRA-FILTERED PLUS 4 PA

microair mesh nebulizer 3

midazolam hcl (hcl 1 mg/ml vial, 2 mg/2 ml carpuject, 2 mg/2 mlisecure, 2 mg/2 ml syringe, hcl 2 mg/2 ml vial, hcl 2 mg/mlsyrup, 5 mg/5 ml syringe, 5 mg/ml carpuject, 5 mg/ml isecuresyr, 5 mg/ml syringe, hcl 5 mg/5 ml vial, hcl 5 mg/ml vial, 10mg/2 ml syringe, hcl 10 mg/10 ml vial, hcl 10 mg/2 ml vial, hcl25 mg/5 ml vial, 40 mg/8 ml syringe, hcl 50 mg/10 ml vial, 125mg/25 ml syringe)

1

midazolam hcl-0.9% nacl (50 mg/50 ml-0.9%nacl,100mg/100ml-0.9%nacl, 125mg/125ml-0.9%nacl)

1

midazolam hcl-d5w 1

midazolam hcl-nacl 1

midazolam-0.9% nacl 1

MIFEPREX 3 GL Female

mifepristone 3 GL Female

milk of magnesia suspension 1

MILLIPRED DP 1



milrinone in 5% dextrose 1

milrinone lactate 1

MINOCIN 100 MG VIAL 3

MINOLIRA ER 3

MIOCHOL-E 3

MIOSTAT 3

MIRCERA 4

PA


MIRVASO (GEL, GEL PUMP) 3

MITIGARE 3 QL 120 / 30 days

MITOSOL 3

mixed vespid venom 1,650 mcg 2 DC ExcludedProducts

mixed vespid venom 3,900 mcg 2

MKO (MIDAZOLAM-KETAMINE-ONDAN) 3

MODERNA COVID-19 VACCINE (EUA) 2

molindone hcl 1

molnupiravir (eua) 2

MONONINE 4C


PA

MONSEL'S 2 PA

MORPHABOND ER 3QL 2 / day

ST



morphine sulfate (1 mg/2 ml syringe, 2 mg/ml carpuject, 2mg/ml isecure syr, 2 mg/ml syringe, 4 mg/ml carpuject, 4 mg/mlisecure syr, 4 mg/ml syringe, 5 mg/ml syringe, 5 mg/ml vial, sulf5 mg suppos, 8 mg/ml syringe, 10 mg/0.7 ml auto-inj, 10 mg/mlsyringe, sulf 10 mg suppos, sulf 20 mg suppos, sulf 30 mgsuppos, sulfate 4 mg/ml vial, sulfate 8 mg/ml vial, sulfate 10mg/ml vial, sulfate 25 mg/ml vial, sulfate 50 mg/ml vial, 300mg/20 ml vial)

1

morphine sulfate er 40 mg cap 1 QL 1 / day

morphine 150 mg/30 ml-0.9%nacl 3

morphine sulfate-0.9% nacl (0.5 mg/ml-0.9% nacl, 5 mg/5 ml-0.9% nacl, 60 mg/30 ml-0.9% nacl, 250 mg/50 ml-ns, 250mg/50ml-0.9% nacl, 275 mg/55 ml-0.9%nacl, 500mg/100ml-0.9% nacl)

1

MOTEGRITY 3

QL 1 / day

ST


MOVANTIK 2QL 1 / day

ST

moxifloxacin hcl-bss 1

mucor plumbeus 30,000 pnu/ml 3

MUCOSITISRX 3

MUGARD 4

MULPLETA 4QL 1 / day

PA

multi-vitamin w-fluoride-iron 1

MULTIGEN FOLIC 1

MULTIGEN PLUS 1

MULTIHANCE 3

MULTIHANCE MULTIPACK 3

MULTITRACE-4 1

MULTITRACE-5 1

multivitamin with fluoride (multivit-fluor 0.25 mg tab chw,multivit-fluor 0.5 mg tab chew, multivit-fluoride 1 mg tab chw)

1



multivitamin-iron-fluoride 1

MVASI 4

PA


MVC-FLUORIDE (0.25 MG TAB CHEW, 1 MG TAB CHEW) 2

MVC-FLUORIDE 0.5 MG TAB CHEW 1

MYALEPT 4 PA

MYCAPSSA 4QL 4 / day

PA

MYDAYIS 3

MYFERON-150 FORTE 1

MYLERAN 2

MYLOTARG 4

PA


MYNATAL 2

MYNATAL PLUS 1

MYNATAL-Z 1

MYNEPHROCAPS 1

MYOBLOC 4 PA

MYOVIEW 3

MYRBETRIQ ER 8 MG/ML SUSP 2 QL 30 / 30 days

MYXREDLIN 3

NABI-HB 4 PA

nafcillin 2 gm/ 100 ml inj 1

nafcillin sodium (2 gm add-vant vial, 2 gm vial) 1

NALOCET 3

naloxone 2 mg auto-injector 2 PA

naloxone hcl (0.4 mg/ml carpuject, 0.4 mg/ml vial, 4 mg/10 mlvial)

1



naltrexone hcl 1

NAMZARIC (14 MG CAPSULE, 28 MG CAPSULE) 3 QL 30 / 30 days

NAMZARIC (7 MG-10 MG CAPSULE, 21 MG-10 MGCAPSULE, TITRATION PACK)

3

NARCAN 2 QL 4 / 365 days

NAROPIN (0.2% 20 MG/10 ML AMP, 0.2% 20 MG/10 ML VIAL,0.2% 200 MG/100 ML BAG, 0.2% 200 MG/100 ML BTL, 0.2%40 MG/20 ML AMP, 0.2% 40 MG/20 ML VIAL, 0.2% 400MG/200 ML BAG, 0.2% 400 MG/200 ML BTL, 0.5% 1,000MG/200 ML, 0.5% 100 MG/20 ML AMP, 0.5% 100 MG/20 MLVIAL, 0.5% 150 MG/30 ML VIAL, 0.5% 500 MG/100 ML BTL,0.75% 150 MG/20 ML AMP, 0.75% 150 MG/20 ML VL, 1% 100MG/10 ML AMPULE, 1% 100 MG/10 ML VIAL, 1% 200 MG/20ML AMPULE, 1% 200 MG/20 ML VIAL)

3

NASCOBAL 3

NATAZIA 3QL 28 / 28 days

GL Female

NATESTO 3QL 3 / day

GL Male

NATPARA 3

NATURE-THROID 2

NAYZILAM 3 QL 10 / 30 days

NEBUSAL 6% VIAL 3

bd eclipse needle 18gx1 1/2" 2

NEO-SYNALAR 0.5%-0.025% CREAM 3

NEOSALUS (CREAM, FOAM, LOTION) 3

NEOSALUS CP 3

neostigmine methylsulfate (2 mg/2 ml syringe, 3 mg/3 mlsyringe, 4 mg/4 ml syringe, 5 mg/10 ml vial, 5 mg/5 ml syringe)

4

neostigmine 3 mg/3 ml-water 4

neostigmine 5 mg/5 ml-water 1

NERLYNX 4 PA

NESACAINE 3



NEUPOGEN 480 MCG/1.6 ML VIAL 4QL 3 / day

PA

NEURACEQ 3

NEURIN-SL 3

NEUTRASAL 3

NEWGEN 1

NEXLETOL 2QL 1 / day

PA

NEXLIZET 2QL 1 / day

PA

NEXTSTELLIS 3 GL Female

niacin (er 250 mg tablet, tr 250 mg tablet) 1

nicardipine 2.5 mg/ml syringe 1

nicardipine hcl-0.9% nacl (20mg/200ml-0.9%nacl, 40mg/200ml-0.9%nacl)

3

nicardipine 1 mg/10 ml-ns syrg 1

nicotine lozenge (4 mg mini lozenge, cvs 4 mg mini lozenge,gnp 4 mg mini lozenge, gs 4 mg mini lozenge, hm 4 mg minilozenge, kro 4 mg mini lozenge, ra 4 mg mini lozenge)

1

NINLARO 4QL 3 / 28 days

PA

NITHIODOTE 3

NITRO-TIME 1

nitroglycerin in d5w 1

NITYR 10 MG TABLET 4QL 20 / day

PA


PA


PA



NIVA-FOL 1

NIVA-PLUS 1

NIVATOPIC PLUS 1

NIVESTYM (300 MCG/0.5 ML SYRING, 300 MCG/ML VIAL,480 MCG/0.8 ML SYRING, 480 MCG/1.6 ML VIAL)

4QL 3 / day

PA

NOCDURNA 3

NOCTIVA 3

NOLIX (CREAM, LOTION) 3

norepinephr 8 mg/250-0.9% nacl 1

norepinephr 4 mg/250-0.9% nacl 1 DC ExcludedProducts

norepinephrine bitartrate (4 mg/4 ml ampul, 4 mg/4 ml vial) 1

norepinephrine bitartrate-d5w (4 mg/250, 8 mg/250) 1 DC ExcludedProducts

norethind-eth estrad 0.5-2.5 3QL 28 / 28 days

GL Female

NORGESIC FORTE 3

NORITATE 3

norm-ject tuberkulin syringe 2

NORMLGEL AG 1

nortriptyline 10 mg/5 ml soln 1

NORVIR 100 MG POWDER PACKET 2

NOURIANZ 4QL 1 / day

PA

NOVOEIGHT 4C


PA

NOVOLIN R 100 UNIT/ML FLEXPEN 2 QL 180 / 90 days



NOVOLOG 100 UNIT/ML FLEXPEN 2 QL 3 / day

RELION NOVOLOG U-100 FLEXPEN 2 QL 2 / day

NOVOLOG PENFILL 2 QL 3 / day

NOVOSEVEN RT 4C


PA

NOXAFIL DR 100 MG TABLET 2 QL 90 / 30 days

NOXAFIL 300 MG/16.7 ML VIAL 2

NP THYROID (15 MG TABLET, 30 MG TABLET, 60 MGTABLET, 90 MG TABLET)

2 QL 180 / 30 days

NP THYROID 120 MG TABLET 2

NPLATE (125 MCG VIAL, 250 MCG VIAL, 500 MCG VIAL) 4

PA


NU-DERM 1

NUBEQA 4QL 4 / day

PA

NUCALA 100 MG/ML AUTO-INJECTOR 4QL 0.4 / day

PA

NUCALA 100 MG/ML SYRINGE 4QL 1 / 30 days

PA

NUCALA 100 MG/ML POWDER VIAL 4

QL 1 / 28 days

PA


NULEV 1

NUMOISYN (LIQUID, LOZENGE) 3

NUPLAZID (10 MG TABLET, 34 MG CAPSULE) 2 ST



NURTEC ODT 2QL 0.54 / day

PA

NUVAIL 3 QL 15 / 30 days

NUVESSA 3 GL Female

NUVIGIL 150 MG TABLET 3

NUWIQ 4C


PA

NUZYRA (100 MG VIAL, 150 MG TABLET, 150 MG TABLET-7DAY, 150 MG-7 DAY WITH LOAD)

3

NYMALIZE (30 MG/10 ML SOLUTION, 30 MG/5 ML ORALSYRNG, 60 MG/10 ML ORAL SYRN, 60 MG/10 MLSOLUTION, 60 MG/20 ML SOLUTION)

3

NYVEPRIA 4

PA


O-CAL FA 2

O-CAL PRENATAL 2

OB COMPLETE PREMIER 2

OBIZUR 4C


PA

OBREDON 3

OCALIVA 4 PA

OCTAGAM 4

PA


OCTAPLAS (BLOOD A IV BAG, BLOOD AB IV BAG, BLOOD BIV BAG, BLOOD O IV BAG)

3



OCTREOSCAN 3

octreotide acet 50 mcg/ml syr 1 QL 90 / 30 days

octreotide acetate (100 mcg/ml syr, 500 mcg/ml syr) 1

OCUCOAT 1

ODACTRA 3

ODEFSEY 4 QL 30 / 30 days

ODOMZO 4QL 30 / 30 days

PA

OFEV 4QL 60 / 30 days

PA

OGIVRI 4

PA


OMNIPAQUE (140 MG/ML BOTTLE, 180 MG/ML VIAL, 240MG/ML BOTTLE, 240 MG/ML INFU BTL, 240 MG/ML VIAL,300 MG/ML BOTTLE, 300 MG/ML INFU BTL, 300 MG/MLPLUSPAK, 300 MG/ML PLUSPAK BT, 300 MG/ML VIAL, 350MG/ML INFU BTL, 350 MG/ML PLUSPAK)

3

OMNISCAN (287 MG/ML SYRINGE, 287 MG/ML VIAL) 3

ondansetron hcl 4 mg/2 ml syr 1

ondansetron hcl-0.9% nacl (8mg/50ml-0.9% nacl, 16mg/50ml-0.9%nacl)

1

ONEXTON (1.2%-3.75% GEL, GEL PUMP) 3

ONFI 2.5 MG/ML SUSPENSION 3 QL 240 / 15 days

ONGENTYS 3

ONIVYDE 4

PA


ONTRUZANT 4

PA


ONUREG 4QL 0.5 / day

PA



ONZETRA XSAIL 3 ST

OPDIVO (40 MG/4 ML VIAL, 100 MG/10 ML VIAL, 120 MG/12ML VIAL, 240 MG/24 ML VIAL)

4

PA


opium tincture 1

OPSUMIT 4QL 30 / 30 days

PA

OPTIRAY 300 (300 MG/ML) SYRN, 300 MG/ML) VIAL) 3



OPTISON 3

ORAPRED ODT 10 MG TABLET 3

ORAVIG 3

ORBACTIV 2

ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 MLSYRINGE)

4QL 0.15 / day

PA

ORENCIA CLICKJECT 4QL 0.15 / day

PA

ORENITRAM ER (ER 0.125 MG TABLET, ER 0.25 MGTABLET, ER 2.5 MG TABLET, ER 5 MG TABLET)

4 PA

ORENITRAM ER 1 MG TABLET 4QL 60 / 30 days

PA

ORFADIN (4 MG/ML SUSPENSION, 20 MG CAPSULE) 4 PA

ORGOVYX 4QL 1.25 / day

PA



ORIAHNN 3

QL 2 / day

GL Female


PA

ORILISSA 150 MG TABLET 2QL 1 / day

PA

ORILISSA 200 MG TABLET 2QL 2 / day

PA

ORKAMBI (100 MG-125 MG TABLET, 100-125 MG GRANULEPKT, 150-188 MG GRANULE PKT)

4 PA

ORKAMBI 200 MG-125 MG TABLET 4QL 112 / 28 days

PA

ORLADEYO 4QL 1 / day

PA

orphenadrine-aspirin-caffeine 3

ORPHENGESIC FORTE 3

ORTIKOS 3

OSCIMIN 1

OSCIMIN SL 1

OSCIMIN SR 1

OSMOLEX ER 3

OSPHENA 3QL 30 / 30 days

GL Female

OTEZLA (28 DAY STARTER PACK, 30 MG TABLET,STARTER PACK)

4QL 2 / day

PA

OTREXUP 3

OVACE PLUS 10% SHAMPOO 3

OVIDREL 3

OXBRYTA (300 MG TABLET FOR SUSP, 500 MG TABLET) 4 PA



OXERVATE 3

OXTELLAR XR 3

oxycodone hcl 5 mg/5 ml soln 1

oxycodone-acetaminophen (oxycodon-acetaminophen 7.5-300,oxycodone-acetaminoph 10-300/5)

1 QL 13 / day

oxycodone-acetaminophn 2.5-300 3 QL 12 / day

oxytocin 1

oxytocin-0.9% nacl (10 unit/500 ml-ns, 15 unit/250 ml-ns, 20unit/1,000 ml-ns, 30 unit/500 ml-ns)

1

oxytocin 30 unit/500 ml-d5lr 1

oxytocin 20 unit/1,000 ml-d5w 1

oxytocin-lactated ringers (10 unit/500, 15 unit/250, 30 unit/500) 1

OZEMPIC 0.25-0.5 MG/DOSE PEN 2QL 0.067 / day

ST

OZEMPIC 1 MG/DOSE (2 MG/1.5ML) 2QL 0.124 / day

ST

OZEMPIC 1 MG/DOSE (4 MG/3 ML) 2QL 0.15 / day

ST

OZOBAX 3

PADCEV 4

PA


palonosetron 0.25 mg/2 ml vial 1

PA


PALYNZIQ 10 MG/0.5 ML SYRINGE 4QL 0.5 / day

PA

PALYNZIQ 2.5 MG/0.5 ML SYRINGE 4QL 0.144 / day

PA

PALYNZIQ 20 MG/ML SYRINGE 4QL 1 / day

PA



PANCREAZE (DR 2,600 UNIT CAP, DR 37,000 UNIT CAP) 3 ST

pancuronium 10 mg/10 ml vial 1

PANHEMATIN 3

PANZYGA 4

PA


papaverine hcl 1 PA

paregoric 1

PAREMYD 3

paroxetine mesylate 3QL 1 / day

GL Female

PARSABIV 3

PAXLOVID (EUA) 2

PAZEO 3

PEDIARIX 2

PEDIASURE 1.5 WITH FIBER 3

PEDIASURE ENTERAL WITH FIBER 3 PA

PEDIASURE WITH FIBER 3 PA

pediatric comp-air compres neb 3

pediatric iron 1 AL 0.5 to 12.0 yrsold

PEMAZYRE 4QL 0.67 / day

PA



pen needle (gs pen needle 31g x 1/4", gs pen needle 31g x5/16", gs pen needle 31g x 5mm, gs pen needle 31g x 8mm, gspen needle 32g x 4mm, gs pen needle 32g x 6mm, kro penneedle 4mm x 32g, kro pen needle 5mm x 31g, pen needle4mm 32g, pen needle 5mm 31g, pen needle 31g 5mm, penneedle 31g x 1/4", pen needle 31g x 3/16", pen needle 31g x5/16", pen needle 32g 4mm, pen needle 32g x 1/4", pen needle32g x 3/16", pen needle 32g x 5/32", relion pen needle32gx5/32")

1

penicillamine 250 mg capsule 1 QL 4 / day

penicillin g 600,000 unit/1 ml 1

pen g k 1 million unit/50 ml 1

PENLEN 3

PENNSAID 2% SOLUTION PACKET 3

PENTACEL 2

PENTACEL DTAP-IPV COMPONENT 2

PERIKABIVEN 3

PERSERIS 4

PERTZYE (DR 4,000 UNIT CAPSULE, DR 24,000 UNITCAPSULE)

3 ST

PFIZER COVID (12Y UP) VAC(EUA) 2

PFIZER COVID (5-11Y) VAC (EUA) 2

PFIZER COVID-19 VACCINE (EUA) 2

phenazopyridine hcl 1

phendimetrazine tartrate 1

phendimetrazine tartrate er 1

phenobarbital sodium 1

PHENOHYTRO TABLET 1

phenol liquified 1

phentolamine mesylate 1

phenylephrine hcl (2.5% eye drop, 10 mg/ml vial, 10% eyedrops, 50 mg/5 ml vial, 100 mg/10 ml vl)

1

phenylephrine hcl-0.9% nacl (0.4 mg/10 ml-ns, 20 mg/250 ml-ns, 40 mg/250 ml-ns, 80 mg/250 ml-ns, 400 mcg/10 ml-ns)

1

phenylephrine hcl-0.9% nacl (0.5 mg/5 ml-ns, 500 mcg/5 ml-ns) 1 DC ExcludedProducts



phenytoin 50 mg/ml syringe 1

PHESGO 4

PA


PHEXXI 3 GL Female

PHOTOFRIN 3

PHYSICIANS EZ USE B-12 3

phytonadione (1 mg/0.5 ml syr, 5 mg tablet, 10 mg/ml ampul) 1

PIFELTRO 3

piperacillin-tazobactam (piperacil-tazo 2.25 gm add vl, piperacil-tazo 4.5 gm add vial, piperacil-tazobact 2.25 gm vl, piperacil-tazobact 4.5 gm vial)

1

PIQRAY 4QL 1 / day

PA

PKU EASY MICROTAB 3

PKU PERIFLEX JUNIOR PLUS 3

PLEGRIDY 4QL 1 / 28 days

PA

PLEGRIDY PEN 4QL 1 / 28 days

PA

PLENVU 3

PLEXION (CLEANSER, CREAM, LOTION) 3

PLIAGLIS 3

PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 2

PNV 29-1 1

PNV-DHA 1

PNV-OMEGA 1

PNV-SELECT 1

PODOCON-25 1

POLIVY (30 MG VIAL, 140 MG VIAL) 4QL 1 / day

PA



POLOCAINE 1% VIAL 1

POLOCAINE 2% VIAL 3

POLOCAINE-MPF 1

POLY-IRON 150 FORTE 1

POLY-VI-FLOR 0.25 MG DROPS 3 QL 50 / 30 days

POLY-VI-FLOR (0.25 MG TAB CHEW, 0.5 MG TAB CHEW, 1MG TAB CHEW)

3

POLY-VI-FLOR WITH IRON (0.25 MG, 0.5 MG) 3

PONTOCAINE 3

PONVORY (14-DAY STARTER PACK, 20 MG TABLET) 4QL 1 / day

PA

posaconazole 1 QL 3 / day

potass cit-sod cit-citric acid 1

potassium acetate 1

potassium chloride (10% (20 meq/15ml), 10% (40 meq/30ml),20% (40 meq/15ml))

1

potassium cl 20 meq packet 1 QL 180 / 90 days

potassium citrate-citric acid 1 QL 600 / 30 days

potassium cl-lidocaine-ns 1

potassium phosphate 1

potassium ph 15 mmol/250 ml-ns 1

pr benzoyl peroxide 1

PR CREAM 1

PR NATAL 400 1

PR NATAL 400 EC 1

PR NATAL 430 1

PR NATAL 430 EC 1

PRADAXA 110 MG CAPSULE 2 QL 60 / 30 days

pralidoxime chloride 1



PRALUENT PEN 4QL 2 / 28 days

PA

PRAMOSONE 2.5%-1% CREAM 3

PRAMOSONE (1% LOTION, 1%-1% CREAM, 2.5%-1%LOTION)

2

PRECEDEX (200 MCG/2 ML VIAL, 200 MCG/50 ML INJECT,400 MCG/100 ML INJECT)

3

precision xtr b-ketone strip 2

prednisolone ac-moxiflox-bromf 3

prednisolone odt 10 mg tablet 1

pregabalin er 1 QL 1 / day

PRENA1 PEARL 1

PRENA1 TRUE 1

PRENATA 3

PRENATABS FA 3

PRENATABS RX 3

prenatal low iron 1

prenatal plus (iron tablet, pnv multivit tab) 1

prenatal vitamin plus low iron 1

prenatal-u 1

PREPIDIL 3

PREPLUS 1

PRESTALIA 3

PRETAB 1

pretomanid 2

PREVIDENT 1.1% GEL 1

PREVIDENT 5000 DRY MOUTH 3

PREVIDENT 5000 ORTHO DEFENSE 3

PREVIDENT 5000 PLUS 3

PREVIDENT 5000 SENSITIVE 3

PREVNAR 13 2



PREVNAR 20 2

PREVYMIS (240 MG TABLET, 480 MG TABLET) 4QL 1 / day

PA

PREZCOBIX 4QL 30 / 30 days

PA

PRIALT 4 PA

PRILOSEC 3

PRISMASOL (B22GK 4/0, BGK 0/2.5, BGK 2/0, BGK 2/3.5,BGK 4/0/1.2, BGK 4/2.5, BK 0/0/1.2)

3

PRISTIQ ER 25 MG TABLET 3

pro comfort spacer with mask (spacer-adult, spacer-child) 3

PRO DNA COLLECTION 1

PRO DNA MEDICATED COLLECTION 1

procainamid 1,000 mg/10 ml syr 1

procare pediatric neb bear 2

procare pediatric nebulizer (dog, eagle) 3

procare spacer with adult mask 3

procare spacer with child mask 3

PROCTOFOAM-HC 2

PROCYSBI (DR 25 MG CAPSULE, DR 75 MG CAPSULE, DR75 MG GRANULE PKT, DR 300 MG GRANULE PKT)

3

PROFERRIN-FORTE 3

PROFILNINE 4

progesterone 500 mg/10 ml vial 1 GL Female

PROGRAF (0.2 MG GRANULE PACKET, 1 MG GRANULEPACKET)

3

PROHANCE (279.3 MG/ML SYRINGE, 279.3 MG/ML VIAL) 3

PROHANCE MULTIPACK 3

PROLATE 10 MG-300 MG/5 ML SOLN 3

QL 30 / day




PROLATE (5-300 MG TABLET, 7.5-300 MG TABLET, 10-300MG TABLET)

3 QL 13 / day

PROMACTA 12.5 MG SUSPEN PACKET 4QL 180 / 30 days

PA

PROMACTA 25 MG SUSPENSION PCKT 4QL 1 / day

PA

promethazine-codeine 1

promethazine-dm 1

promethazine-phenyleph-codeine 1

PROMISEB 3

propofol 1

PROSTIN E2 VAGINAL SUPPOSITORY 3

PROSTIN VR PEDIATRIC 4 PA

protamine sulfate 1

PROTECT IRON TABLET 3

PROVENGE 3 M-PA Medical BenefitPA

PROVIDA OB 3

PROVOCHOLINE 3

PULMOSAL 1

PUREVIT DUALFE PLUS 1

PURIXAN 3 QL 80 / 30 days

pyridostigmine br 30 mg tablet 1

pyridoxine 100 mg/ml vial 1

QBRELIS 3

QBREXZA 3

QDOLO 3

QL 80 / day


QELBREE (ER 150 MG CAPSULE, ER 200 MG CAPSULE) 2QL 2 / day

ST



QELBREE ER 100 MG CAPSULE 2QL 1 / day

ST

QINLOCK 4QL 3 / day

PA

QMIIZ ODT 3

QNASL CHILDREN 3

QSYMIA 3

QTERN 3QL 1 / day

ST

QUADRACEL DTAP-IPV 2

QUARTETTE 3QL 91 / 91 days

GL Female

quazepam 1

QUDEXY XR (100 MG CAPSULE, 150 MG CAPSULE, 200 MGCAPSULE)

3

QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE) 3 QL 30 / 30 days

QUELICIN 3

QUFLORA FE PED 0.25 MG/ML DROP 3

QUILLICHEW ER 3

QULIPTA 3

QUTENZA 4

R-GENE 10 3

R-NATAL OB 1

RADIAPLEXRX 3

RADIOGARDASE 2

raloxifene hcl 1QL 30 / 30 days

GL Female

RASUVO (7.5 MG/0.15 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML,17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5ML, 30 MG/0.6 ML)

3

RASUVO 10 MG/0.2 ML AUTOINJ 3 QL 0.8 / 28 days



RAYALDEE 3

READI-CAT 2 2% SUSPENSION 3

REBINYN 4C


PA

REBLOZYL 4

PA


RECOMBINATE 4C


PA

RECOTHROM 3 PA

REDITREX 10 MG/0.4 ML SYRINGE 3QL 0.067 / day

PA

REDITREX 12.5 MG/0.5 ML SYRING 3QL 0.08 / day

PA


PA


PA


PA


PA

REDITREX 25 MG/ML SYRINGE 3QL 0.15 / day

PA



REDITREX 7.5 MG/0.3 ML SYRINGE 3QL 0.05 / day

PA

RELAFEN DS 3

RELAGARD 1 GL Female

RELEXXII 3

RELISTOR 12 MG/0.6 ML SYRINGE 3QL 0.6 / day

PA

RELISTOR 8 MG/0.4 ML SYRINGE 3QL 0.4 / day

PA

RELISTOR 150 MG TABLET 3QL 90 / 30 days

PA

RELTONE 3

RENA-VITE RX 1

RENAL CAPS 1

RENFLEXIS 4

QL 10 / 30 days

PA


REPATHA PUSHTRONEX 4QL 3.5 / 28 days

PA

REPATHA SURECLICK 4QL 2 / 28 days

PA

REPATHA SYRINGE 4QL 2 / 28 days

PA

REQ49+ 3

RESECTISOL 3

RESPA A.R. 3

RETACRIT 4

PA




RETEVMO 40 MG CAPSULE 4QL 2 / day

PA

RETEVMO 80 MG CAPSULE 4QL 4 / day

PA

RETIN-A MICRO PUMP 0.06% GEL 3 PA

RETIN-A MICRO PUMP 0.08% GEL 3

RETISERT 4 QL 2 / 900 days

REVATIO 10 MG/ML ORAL SUSP 4QL 112 / 18 days

PA

REVLIMID (2.5 MG CAPSULE, 20 MG CAPSULE) 4QL 30 / 30 days

PA

REVONTO 1

REXULTI 3 QL 1 / 1 days

REYATAZ 50 MG POWDER PACKET 2

REYVOW 100 MG TABLET 3

QL 0.3 / day


PA

REYVOW 50 MG TABLET 3

QL 4 / 30 days


PA

RHOFADE 3

RHOGAM ULTRA-FILTERED PLUS 4 PA

RHOPHYLAC 4 PA

RHOPRESSA 3 QL 0.13 / day

RIASTAP 4

RIMSO-50 3

RINVOQ 4QL 1 / day

PA



RIOMET ER 3

RITUXAN 4

QL 16 / 30 days

PA


RITUXAN HYCELA 1,400 MG-23,400 4

QL 1.7 / day

PA


RITUXAN HYCELA 1,600 MG-26,800 4

QL 0.5 / day

PA


RIVELSA 3GL Female

PA

ROBAXIN 3

ROCKLATAN 3

rocuronium bromide (50 mg/5 ml syringe, 50 mg/5 ml vial, 100mg/10 ml syr, 100 mg/10 ml vial)

1

romidepsin 27.5 mg/5.5 ml vial 4

PA


ropivacaine hcl (0.2% 20 mg/10 ml, 0.2% 200 mg/100 ml, 0.2%40 mg/20 ml, 0.2% 400 mg/200 ml, hcl 0.5% syringe, 0.75%150 mg/20 ml, 1% 100 mg/10 ml vl, 1% 200 mg/20 ml vl, 50mg/10 ml syrng)

1

ropivacaine 2mg/ml-ns on-q pmp 3

ropivacaine hcl-0.9% nacl (0.1%-0.9%, 0.15%-0.9%, 0.2%-0.9%)

1

ROSANIL 1

ROSULA 10%-5% CLOTHS 1

rosuvastatin-ezetimibe 1 QL 1 / day

ROSZET 3

ROTARIX 2



ROZLYTREK 100 MG CAPSULE 4QL 5 / day

PA

ROZLYTREK 200 MG CAPSULE 4QL 3 / day

PA

RUBRACA 4 PA

RUCONEST 4QL 0.134 / day

PA

RUKOBIA 4

RUXIENCE 100 MG/10 ML VIAL 4

QL 4.3 / day

PA


RUXIENCE 500 MG/50 ML VIAL 4

QL 14.3 / day

PA


RUZURGI 4QL 1 / day

PA

RYANODEX 3

RYBELSUS 2QL 1 / day

ST

RYDAPT 4 PA

RYTARY (ER 23.75 MG-95 MG CAP, ER 48.75 MG-195 MGCAP)

3 QL 360 / 30 days

RYTARY (ER 36.25 MG-145 MG CAP, ER 61.25 MG-245 MGCAP)

3 QL 270 / 30 days

safety syringe-needle 2

salicylic acid (6% cream, 6% cream kit, 6% foam, 6% gel, 6%lotion, 26% liquid, 27.5% liquid)

1

SALIVAMAX 3

salsalate 1

SALVAX 3



SALVAX DUO PLUS 3

SANADERMRX 1 PA

SAPHRIS 2.5 MG TAB SUBLINGUAL 3 QL 60 / 30 days

sapropterin dihydrochloride (100 mg tablet, 500 mg powder pkt) 4 PA

SAVAYSA (30 MG TABLET, 60 MG TABLET) 3 QL 30 / 30 days

SAVAYSA 15 MG TABLET 3 QL 1 / day

SCALACORT DK 3

SCANDONEST PLAIN 3

SCLEROSOL 3

SE-NATAL 19 1

SE-NATAL-19 1

SE-TAN PLUS 1

SECUADO 3

SEEBRI NEOHALER 3QL 2 / day

ST

SEGLUROMET 3QL 2 / day

ST

SELECT-OB 2

SELECT-OB + DHA 2

selenium 400 mcg/10 ml vial 1

selenium sulfide 2.25% shampoo 1

SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75MG TABLET)

2

SENSORCAINE 1

SENSORCAINE WITH DEXTROSE 1

SENSORCAINE-EPINEPHRINE 1

SENSORCAINE-MPF (0.5% AMPUL, 0.5% VIAL, 0.75%AMPUL, 0.75% VIAL)

1

SENSORCAINE-MPF EPINEPHRINE (SENSORC MPF 0.75%-EPI, SENSORC-MPF 0.25%-EPI)

1



SERNIVO 3

SEVENFACT 4 PA

sevoflurane 1

SEYSARA 3

SF 1

SF 5000 PLUS 1

SHINGRIX 2 AL At least 50 yrsold

SHINGRIX ADJUVANT COMPONENT 2 AL At least 50 yrsold

SHINGRIX GE ANTIGEN COMPONENT 2 AL At least 50 yrsold

SIGNIFOR LAR (20 MG KIT, 20 MG VIAL) 4 PA

SIKLOS 3

sildenafil 10 mg/ml oral susp 4QL 112 / 18 days

PA

SILIKON 1000 3

SILIQ 4QL 0.22 / day

PA

silver nitrate 1

silver nitrate applicator 1

SIMPLY SLEEP 1

SIMPONI (50 MG/0.5 ML PEN INJEC, 100 MG/ML PENINJECTOR, 100 MG/ML SYRINGE)

4QL 0.04 / day

PA

SIMPONI ARIA 4

QL 1.5 / day

PA


SIMULECT 3

SINOGRAFIN 3

SIRTURO 20 MG TABLET 3



SITAVIG 3 QL 30 / 30 days

SITZMARKS 3

SIVEXTRO 200 MG TABLET 2QL 6 / 6 days

PA

SIVEXTRO 200 MG VIAL 2 PA

SKYRIZI 150 MG/ML SYRINGE 4QL 0.012 / day

PA

SKYRIZI 75 MG/0.83 ML SYRINGE 4QL 0.02 / day

PA

SKYRIZI (2 SYRINGES) KIT 4QL 0.012 / day

PA

SKYRIZI PEN 4QL 0.012 / day

PA

sod ferric gluconate complex 1

sodium acetate (40 meq/20 ml vl, 100 meq/50 ml, 200 meq/100ml)

1

sodium acetate 400 meq/100 ml 1

sodium bicarbonate (bicarb 4.2% abboject, bicarb 7.5%abboject, bicarb 8.4% abboject, bicarbonate 4.2% vial,bicarbonate 8.4% vial)

1

sodium bicarbonate-d5w 1

sodium bicarb 8.4%-water vial 1

sodium chloride (0.9% inhal vl, 3% vial, 4 meq/ml vl, 7% vial,10% vial, 120 meq/30 ml, 400 meq/100 ml)

1

sodium citrate 4% soln 1

sodium citrate 4% syringe 1 DC ExcludedProducts

sodium citrate-citric acid 1

sodium fluoride (0.2% rinse, 0.25 (0.55) mg, 0.5 mg(1.1 mg),0.5 mg/ml drop, 1.1% cream, 5000 ppm cream, 5000 ppmpaste)

1

SODIUM FLUORIDE 5000 DRY MOUTH 1



sodium fluoride enamel protect 1

sodium fluoride sensitive 1

sodium iodide i-131 3

sodium nitrite 1

sodium phenylacet-sod benzoate 1

sodium phosphate 1

sodium phos 15 mmol/250 ml-ns 1

sod sulfacetamide 10% shampoo 1

sodium sulfacetamide-sulfur (sod sulfac-sulfur 9.8-4.8% crm,sod sulfac-sulfur 9.8-4.8% lot, sod sulface-sulf 9.8-4.8% clsr,sod sulface-sulfur 9-4.5% wash, sod sulfacet-sulfur 10-2% clsr,sod sulfacet-sulfur 10-4% pad, sod sulfacetamide-sulfur lotn,sod sulfacetamide-sulfur susp, sodium sulfacet-sulfur wash,sulfacetamide-sulfur 10-2% crm, sulfacetamide-sulfur 10-5%crm)

1

sodium thiosulfate 1

sofosbuvir-velpatasvir 4QL 1 / day

PA

SOLIQUA 100-33 2QL 0.6 / day

ST

SOLOSEC 3

SOMAVERT (25 MG VIAL, 30 MG VIAL) 4 PA

SONAFINE 1

SOOLANTRA 3

sorbitol (3% irrig, 3.3% soln) 1

sorbitol-mannitol 1

SOTRADECOL 3

SOTYLIZE 3

SOVALDI 200 MG PELLET PACKET 4QL 2 / day

PA

SOVALDI (150 MG PELLET PACKET, 200 MG TABLET) 4QL 1 / day

PA



SOVALDI 400 MG TABLET 4QL 30 / 30 days

PA

space chamber 3

space chamber-large mask 3

space chamber-medium mask 3

space chamber-small mask 3

SPECTRACEF 3

SPIRIVA RESPIMAT 2 QL 4 / 30 days

SPRAVATO 4QL 8 / 28 days

PA

SPRAY AND STRETCH 3

SPRITAM 3

SSS 10-5 (CREAM, FOAM) 1

ST. JOSEPH ASPIRIN 1

ST. JOSEPH ASPIRIN EC 1

STEGLATRO 3QL 1 / day

ST

STEGLUJAN 3QL 1 / day

ST

STELARA 130 MG/26 ML VIAL 4

QL 1.86 / day

PA


sterile talc 1

sterile water (grifols factor) 1

sterile water (shire) 1

STERILE WATER DILUENT-CABLIVI 4 PA

sterile water for activase 1

sterile water for aralast np 1

sterile water for berinert 1



sterile water for gammagard 1

sterile water for humate-p 1

STERILE WATER FOR KCENTRA 3

sterile water for prolastin-c 1

sterile water for tnkase 1

sterile water for zemaira 1

STIOLTO RESPIMAT 2 QL 4 / 28 days

STRENSIQ 4 PA

STRIANT 3QL 2 / day

GL Male

STRIVERDI RESPIMAT 2 QL 0.144 / day

strong iodine 1

succinylcholine chloride (100 mg/5 ml, 140 mg/7 ml, 200 mg/10ml)

1

succinylcholine chloride-nacl (100 mg/5, 200 mg/10) 1

sufentanil citrate (50 mcg/ml ampul, 50 mcg/ml ampule, 50mcg/ml vial, 100 mcg/2 ml ampule, 100 mcg/2 ml vial, 250mcg/5 ml ampule, 250 mcg/5 ml vial)

1

SULFACLEANSE 8-4 1

sunitinib malate 37.5 mg cap 4QL 90 / 30 days

PA

super b complex 1

cvs super b-complex-vit c cplt 1

super vitamin b complex 1

SUPERVITE 3

SUPPRELIN LA 4

SUPRANE 3

SURE RESULT TAC PAK 1 PA

SURFAXIN 3

SURVANTA 3



SUSTOL 2

PA


SUTAB 3 QL 0.8 / day

SWABFLUSH 3

SYLVANT 4

PA


SYMDEKO 4QL 2 / day

PA

SYMJEPI 3

SYMPAZAN 3

SYMPROIC 2QL 1 / day

ST

SYMTUZA 4 QL 1 / day

SYNAGIS 4

PA


SYNDROS 3

SYNJARDY 2QL 60 / 30 days

ST

SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET,12.5-1,000 MG TAB)

2QL 2 / day

ST

SYNJARDY XR 25-1,000 MG TABLET 2QL 1 / day

ST

syringe (luer-lok 5 ml syringe, syringe glass 3 ml) 2

SYRINGE AVITENE 2 PA

syringe slip tip 2

syringe-needle 2



TABRECTA 4QL 4 / day

PA

TACHOSIL 3 PA

TAGRISSO 4QL 30 / 30 days

PA

TAKHZYRO 4QL 0.144 / day

PA

TALICIA 3 QL 12 / day

TALTZ AUTOINJECTOR 4QL 0.04 / day

PA

TALTZ AUTOINJECTOR (2 PACK) 4QL 0.04 / day

PA

TALTZ AUTOINJECTOR (3 PACK) 4QL 0.04 / day

PA

TALTZ SYRINGE 4QL 0.04 / day

PA

TALZENNA 4 PA

TANDEM PLUS 3

TAPERDEX 3

TARON FORTE 1

TARON-C DHA 1 QL 30 / 30 days

TASIGNA 50 MG CAPSULE 4QL 4 / day

PA

tavaborole 1

TAVALISSE 4 PA



tazarotene 0.1% foam 3

QL 1.667 / day

AL Up to 35 yrs old

PA

TAZVERIK 4 PA

tc99m mebrofenin prep 1

tc99m medronate prep 1

tc99m pyrophosphate prep 1

tc99m sestamibi prep 1

tc99m sulfur colloid prep 1

TEMIXYS 4 QL 1 / day

TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MGCAPSULE, 100 MG VIAL, 140 MG CAPSULE, 180 MGCAPSULE, 250 MG CAPSULE)

4QL 10 / 5 days

PA

temozolomide 4QL 10 / 5 days

PA

teniposide 4

TENIVAC (SYRINGE, VIAL) 2

TEPMETKO 4QL 2 / day

PA

teriparatide 4 QL 2.48 / 28 days

TERRELL 1

TESTONE CIK 3 GL Male

TESTOPEL 3 GL Male

testosterone ((2.5 g) pkt, gel pump) 1QL 5 / day

GL Male

testosterone 10 mg gel pump 1QL 120 / 30 days

GL Male

testosterone 1% (25mg/2.5g) pk 1QL 300 / 30 days

GL Male



testosterone 1.62%(1.25 g) pkt 1QL 2.5 / day

GL Male

testosterone 30 mg/1.5 ml pump 1 GL Male

TETCAINE 1

tetracaine hcl (0.5% eye drop, 0.5% steri-unit sol, 1% (20 mg/2ml) amp, 1% (20 mg/2 ml) vl)

1

tetracycline hcl 1

TEXACORT 3

THALITONE 1

thallous cl tl-201 37 mbq/ml 1

THAM 3

THEO-24 (ER 100 MG CAPSULE, ER 200 MG CAPSULE, ER400 MG CAPSULE)

3

THEO-24 ER 300 MG CAPSULE 3 QL 60 / 30 days

theophylline in 5% dextrose 1

thiamine 200 mg/2 ml vial 1

THIOLA 4 QL 360 / 30 days

THIOLA EC 4

THROMBATE III 3

THROMBI-GEL 3 PA

THROMBI-PAD 3 PA

THROMBIN-JMI (5,000 UNIT EPIST, 5,000 UNITS SYR, 5,000UNITS VIAL, 20,000 UNITS PUMP, 20,000 UNITS SYR,20,000 UNITS VIAL)

3 PA

THYQUIDITY 2NTI

NarrowTherapeuticIndicator

PA

THYROGEN 3

thyroid (15 mg tablet, 30 mg tablet, 60 mg tablet, 90 mg tablet,120 mg tablet)

2

TIBSOVO 4QL 2 / day

PA



TICOVAC 2

TIGLUTIK 3

tiopronin 4 PA

TIROSINT 3

TIROSINT-SOL 3

TIVICAY 10 MG TABLET 4 QL 5 / day

TIVICAY 25 MG TABLET 4 QL 2 / day

TIVICAY 50 MG TABLET 4 QL 30 / 30 days

TIVICAY PD 4 QL 10 / day

TIVORBEX 3

TNKASE 50 MG KIT 3

TOLAK 3

TOLSURA 3

topiramate er (er 50 mg capsule, er 100 mg capsule, er 150 mgcapsule, er 200 mg capsule)

1

topiramate er 25 mg capsule 1 QL 30 / 30 days

TOSYMRA 3

TOUJEO MAX SOLOSTAR 2 QL 0.934 / day

TOUJEO SOLOSTAR 2 QL 27 / 30 days

TOXICOLOGY SALIVA COLLECTION 1

TPOXX (NATIONAL STOCKPILE) 3

TRACLEER 32 MG TABLET FOR SUSP 4QL 2 / day

PA

tramadol hcl 100 mg tablet 1 QL 4 / day

tramadol hcl er 150 mg capsule 1

TRAZIMERA 4

PA


TRELEGY ELLIPTA 2 QL 2 / day



TREMFYA (100 MG/ML INJECTOR, 100 MG/ML SYRINGE) 4QL 0.04 / day

PA

TRESIBA 2 QL 75 / 30 days

TRESIBA FLEXTOUCH U-100 2 QL 75 / 30 days

TRESIBA FLEXTOUCH U-200 2 QL 45 / 30 days

TRETIN-X 0.075% CREAM 3 PA

TRETTEN 4

TREZIX 3

TRI-BUFFERED ASPIRIN 1

TRI-LUMA 3

TRI-VI-FLOR 3

tri-vitamin with fluoride 1

triacetin 1

triamcinolone acetonide (40 mg/ml vl, 40mg/ml vl, 50mg/5ml vl,200 mg/5 ml, 400 mg/10ml)

1

trichloroacetic acid (25%, 75%) 1

TRICITRASOL 3

TRICITRATES 1

TRICON 1

TRIESENCE 3

TRIGELS-F FORTE 1

TRIJARDY XR 2QL 2 / day

ST

TRIKAFTA 100-50-75 MG/150 MG 4 PA

TRIKAFTA 50-25-37.5 MG/75 MG 4QL 3 / day

PA

TRINATAL RX 1 1

TRINATE 3

TRINTELLIX 2 ST



TRIPHROCAPS 1

TRIPLE DYE 3

TRIPTODUR 4 PA

TRIUMEQ 4 QL 30 / 30 days

TRIVEEN-DUO DHA 1

TROKENDI XR 3 QL 30 / 30 days

tropicamide 1

TRUDHESA 3

TRULANCE 3

QL 1 / day

ST


TRULICITY (0.75 MG/0.5 ML PEN, 1.5 MG/0.5 ML PEN) 2QL 2 / 28 days

ST

TRULICITY (3 MG/0.5 ML PEN, 4.5 MG/0.5 ML PEN) 2QL 0.07 / day

ST

TRUMENBA 2

TRUSELTIQ (50 MG DAILY PK, 125 MG DAILY PK) 4QL 1.5 / day

PA

TRUSELTIQ 100 MG DAILY DOSE PK 4QL 0.75 / day

PA

TRUSELTIQ 75 MG DAILY DOSE PK 4QL 2.5 / day

PA

TRUST NATAL DHA 1

TRUVADA (100 MG-150 MG TABLET, 133 MG-200 MGTABLET, 167 MG-250 MG TABLET)

4 QL 30 / 30 days

TUKYSA 4QL 4 / day

PA

TURALIO 4QL 4 / day

PA



TUSSICAPS 10 MG-8 MG CAPSULE 2 QL 20 / 10 days

TUSSICAPS 5 MG-4 MG CAPSULE 2

TUXARIN ER 3 QL 2 / day

TUZISTRA XR 3 QL 600 / 30 days

TWINRIX 2

TWIRLA 3 GL Female

TYBOST 2

TYMLOS 3

UBRELVY 2QL 0.54 / day

PA

UDENYCA 4

PA


UKONIQ 4QL 4 / day

PA

ULTIVA 3

ultra-fine micro pen needle 2

ULTRAFOAM 2 PA

ULTRAVATE 3

ULTRAVIST 3

UMECTA 1

UNITUXIN 3 M-PA Medical BenefitPA

UPTRAVI (200 MCG TABLET, 200-800 TITRATION PACK, 400MCG TABLET, 600 MCG TABLET, 800 MCG TABLET, 1,000MCG TABLET, 1,200 MCG TABLET, 1,400 MCG TABLET,1,600 MCG TABLET)

3

URE-K 1

urea (35% foam, 39% cream, 40% cream, 45% cream, 45%nail gel, 47% cream, 50% cream, 50% nail stick)

1

URELLE 3

URETRON D-S 3



URIBEL 3 QL 120 / 30 days

UROGESIC-BLUE 3

UROQID-ACID NO.2 3

ursodiol (200 mg capsule, 400 mg capsule) 1

URYL 1

USTELL 1

UTIBRON NEOHALER 3QL 2 / day

ST

V-C FORTE 1

VALCHLOR 4 PA

valrubicin 4

VALSTAR 4

VALTOCO 2QL 10 / 30 days

PA

vancomycin hcl (1.5 gram/300 ml bag, 2 gram/400 ml bag) 3

vancomycin hcl (1.25 gram vial, 1.5 gram vial, 250 mg vial) 1

vancomycin hcl-0.9% nacl (1 gram/250, 1.5 gm/500, 1.75gm/500, 2 gram/500, 750 mg/250)

1

vancomycin hcl-d5w (1 gram/100, 1 gram/250, 1.5 gram/250) 1

VANTAS 4 QL 1 / 12 months

VAPRISOL-5% DEXTROSE 3

VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 ML VIAL,50 UNITS/ML SYRINGE, 50 UNITS/ML VIAL)

2

VARITHENA 3

VARIZIG 4 PA

VARUBI 180 MG DOSE(2X 90MG TB) 2

VARUBI 166.5 MG/92.5 ML VIAL 2 PA

VASCEPA 0.5 GM CAPSULE 3 B4G Brand ForGeneric

VASELINE WHITE PETROLEUM 1



VASOSTRICT 1

VAXCHORA VACCINE 2

VAXELIS (SYRINGE, VIAL) 2

VAXNEUVANCE 2

VECTIBIX 4

PA


vecuronium bromide 1

vecuronium bromide-water 1

VELETRI 4 PA

VELPHORO 3

VELTASSA 2 QL 30 / 30 days

VEMLIDY 3

VENCLEXTA (10 MG TAB (10MG X 2), 10 MG TABLET, 50MG TABLET)

4QL 30 / 30 days

PA

VENCLEXTA 100 MG TABLET 4QL 120 / 30 days

PA

VENCLEXTA STARTING PACK 4QL 42 / 30 days

PA

VENELEX OINTMENT 3

VENELEX OINTMENT PACKET 1

VENOFER 4

VERQUVO 2QL 1 / day

PA

VERSACLOZ 3 QL 20 / day

VERZENIO 4 PA

VESICARE LS 3 QL 300 / 30 days

VIBERZI 2QL 60 / 30 days

PA



VIC-FORTE 1

VIIBRYD 10-20 MG STARTER PACK 3 QL 30 / 30 days

VIMIZIM 4

PA


VIMPAT STARTER KIT 2QL 28 / 28 days

PA

VINATE ONE 1

VINATE-M 1

VIRT-C DHA 1

VIRT-CAPS 1

VIRT-GARD 1

VIRT-NATE DHA 1

VIRT-PHOS 250 NEUTRAL 1

VIRT-PN PLUS 1

VIRTRATE-2 1

VIRTRATE-3 1

VIRTRATE-K 1

VISCOAT 3

VISIONBLUE 3

VISIPAQUE (270 MG/ML BOTTLE, 270 MG/ML INFU BTL, 270MG/ML VIAL, 320 MG/ML BOTTLE, 320 MG/ML INFU BTL,320 MG/ML INFUS BTL, 320 MG/ML PLUSPAK, 320 MG/MLVIAL)

3

VISUDYNE 4

VITA-RESPA 3

VITAFOL GUMMIES 3

VITAFOL-OB+DHA 2

vitamin b12-folic acid 1

vitamin d2 1.25mg(50,000 unit) 1

vitamin k1 1



vit a,c,d-fluoride 0.25 mg/ml 1

VITRAKVI 100 MG CAPSULE 4QL 2 / day

PA

VITRAKVI 25 MG CAPSULE 4QL 6 / day

PA

VITRAKVI 20 MG/ML SOLUTION 4QL 10 / day

PA

VITRASE 3

VIVACAINE 1

VIZIMPRO 4QL 1 / day

PA

VOCABRIA 4QL 1 / day

PA

VORAXAZE 3

VOSEVI 4QL 1 / day

PA

VRAYLAR 1.5 MG-3 MG PACK 3 QL 1 / 1 days

VRAYLAR (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MGCAPSULE, 6 MG CAPSULE)

3 QL 30 / 30 days

VYNDAMAX 4QL 1 / day

PA

VYNDAQEL 4QL 4 / day

PA

VYVANSE (10 MG CAPSULE, 10 MG CHEWABLE TABLET,20 MG CHEWABLE TABLET, 30 MG CHEWABLE TABLET, 40MG CHEWABLE TABLET, 50 MG CHEWABLE TABLET, 60MG CHEWABLE TABLET)

3

VYXEOS 4

PA


VYZULTA 3



WAKIX 3

wasp venom protein 1 DC ExcludedProducts

water (bacteriostatic vial, for injection vial, sterile for injection) 1

WESTHROID 2

white-faced hornet venom 1 DC ExcludedProducts

WILATE 4C


PA

willis the whale compressr neb 2

WILZIN 3

WINLEVI 2QL 2 / day

PA

WINRHO SDF 4 PA

WP THYROID 3 ST

WYNZORA 3

XADAGO 3

XARELTO DVT-PE TREAT START 30D 2 QL 51 / 30 days

XARELTO 2.5 MG TABLET 2 QL 2 / day

XATMEP 2 PA

XCLAIR 3

XCOPRI (100 MG TABLET, 150 MG TABLET, 200 MGTABLET, 250 MG DAILY DOSE PACK, 350 MG DAILY DOSEPACK)

3

XELJANZ 1 MG/ML SOLUTION 4QL 20 / day

PA

XELJANZ 10 MG TABLET 4QL 2 / day

PA



XELJANZ XR 4QL 1 / day

PA

XELODA 150 MG TABLET 4QL 30 / 90 days

PA

XELODA 500 MG TABLET 4QL 140 / 14 days

PA

XELPROS 3

XEMBIFY 4 PA

XENICAL 2

XEOMIN 200 UNIT VIAL 4 PA

XEPI 3

XERMELO 4 PA

XEROSTOMIA RELIEF 3

XHANCE 3

XIAFLEX 3 QL 2 / 28 days

XIGDUO XR (5 MG-500 MG TABLET, 10 MG-1,000 MG TAB,10 MG-500 MG TABLET)

2QL 30 / 30 days

ST

XIGDUO XR 2.5 MG-1,000 MG TAB 2QL 2 / day

ST

XIGDUO XR 5 MG-1,000 MG TABLET 2QL 60 / 30 days

ST

XIIDRA 2 QL 0.2 / day

XOFIGO 3

XOFLUZA 3

XOLAIR 150 MG/ML SYRINGE 4

QL 0.15 / day

PA




XOLAIR 75 MG/0.5 ML SYRINGE 4

QL 0.04 / day

PA


XOLAIR 150 MG/1.2 ML POWDER VL 4

QL 0.22 / day

PA


XOLEGEL 3

XOSPATA 4QL 3 / day

PA

XPOVIO 100 MG ONCE WEEKLY DOSE 4QL 0.767 / day

PA


PA

XPOVIO 40 MG TWICE WEEKLY DOSE 4QL 0.574 / day

PA


PA


PA


PA


PA

XTAMPZA ER 3QL 60 / 30 days

ST

XTANDI 40 MG TABLET 4QL 4 / day

PA



XTANDI 80 MG TABLET 4QL 2 / day

PA

XULANE 3 GL Female

XYLOCAINE WITH EPINEPHRINE (1%-EPI, 2%-EPI) 3

XYLOCAINE-MPF 1%-EPI 1:200,000 3

XYNTHA 4C


PA

XYNTHA SOLOFUSE 4C


PA

XYOSTED 3 GL Male

XYWAV 4QL 18 / day

PA

yellow hornet venom protein 2 DC ExcludedProducts

YERVOY 4

PA


YONDELIS 4

PA


YONSA 4QL 4 / day

PA

YUPELRI 3

ZAFEMY 3 GL Female

ZALTRAP 4

PA




ZALVIT 3

ZARXIO 4QL 3 / day

PA

ZATEAN-PN DHA 1

ZATEAN-PN PLUS 1

ZEGALOGUE AUTOINJECTOR 2

ZEGALOGUE SYRINGE 2

ZEJULA 4 PA

ZELNORM 3

QL 2 / day

ST

AL Up to 65 yrs old

ZEMBRACE SYMTOUCH 3 ST

ZENPEP DR 40,000 UNIT CAPSULE 2

ZENZEDI (15 MG TABLET, 20 MG TABLET, 30 MG TABLET) 3

ZEPOSIA (0.23-0.46 MG START PCK, 0.23-0.46-0.92 MG KIT,0.92 MG CAPSULE)

4QL 1 / day

PA

ZERBAXA 3

ZERVIATE 2

ZEVALIN 3

ZIEXTENZO 4

PA


zinc chloride 1

zinc sulfate (10 mg/10 ml vial, 25 mg/5 ml vial) 1

ZINGIBER 1

ZIPSOR 3 QL 120 / 30 days

ZIRABEV 4

PA




ZOHYDRO ER 3QL 60 / 30 days

ST

ZOLADEX 10.8 MG IMPLANT SYRN 4 QL 1 / 84 days

ZOLADEX 3.6 MG IMPLANT SYRN 4 QL 1 / 28 days

zolmitriptan 2.5 mg nasal spry 3

ZOMIG 2.5 MG NASAL SPRAY 3 ST

ZONTIVITY 2QL 30 / 30 days

ST

ZORTRESS 1 MG TABLET 3

ZORVOLEX 18 MG CAPSULE 3

ZORVOLEX 35 MG CAPSULE 3 QL 30 / 10 days

ZOSYN (2.25 GM/50 ML BAG, 4.5 GM/100 ML BAG) 3

ZTLIDO 3

ZUBSOLV 3

ZUPLENZ 3

ZYCLARA 2.5% CREAM PUMP 3

ZYDELIG 4QL 60 / 30 days

PA

ZYKADIA 4QL 8 / day

PA

ZYNLONTA 4

QL 0.1 / day

PA


ZYNRELEF 3

ZYPITAMAG 3 QL 1 / day

ZYPREXA RELPREVV 4

ZYVOX 600 MG/300 ML-D5W 3


Index of covered drugsAA-HYDROCORT 77

abacavir 43

abacavir-lamivudine 43

abacavir-lamivudine-zidovudine 43

ABELCET 26

ABILIFY 22

ABILIFY MAINTENA 119

ABILIFY MYCITE 119

abiraterone acetate 31,119

ABLYSINOL 119

ABRAXANE 35

ABSORICA 66,119

ABSORICA LD 119

acamprosate calcium 12

ACANYA 66

acarbose 48

ACCRUFER 119

ACCUTANE 67

accutrend cholesterol 119

ACD SOLUTION A 119

ACD-A 119

acebutolol hcl 56

acetamin-caff-dihydrocodeine 119

acetaminophen 119

acetaminophen-codeine 6

acetazolamide 60

acetazolamide er 60

acetazolamide sodium 60

acetic acid 14,120

acetylcysteine 112,120

ACIPHEX 75

ACIPHEX SPRINKLE 120

acitretin 67

ACTEMRA 120

ACTEMRA ACTPEN 120

ACTHIB 101

ACTHREL 120

ACTIMMUNE 101

ACTIQ 10

ACTIVASE 120

ACTONEL 103

ACTOPLUS MET XR 49

ACUVAIL 106

acyclovir 46,47

acyclovir sodium 47

acyclovir sodium-0.9% nacl 120

ACZONE 67,120

ADACEL TDAP 101,120

adapalene 67,120

adapalene-benzoyl peroxide 67

ADCETRIS 120

ADCIRCA 111

ADDERALL 64

ADDERALL XR 64

ADDYI 120

adefovir dipivoxil 45

ADEMPAS 120

ADENOSCAN 120

adenosine 120

adenovirus type 4 121

adenovirus type 4 and type 7 121

adenovirus type 7 121

ADHANSIA XR 121

ADLYXIN 121

ADRENALIN 121

ADRENALIN CHLORIDE 121

ADREVIEW 121

ADRIAMYCIN 35

ADRUCIL 35

ADULT ASPIRIN REGIMEN 121

ADULT LOW DOSE ASPIRIN EC 121

ADVAIR DISKUS 112

ADVAIR HFA 112

ADVATE 121

ADYNOVATE 121

ADYPHREN 121

ADYPHREN II 121

ADZENYS ER 121

ADZENYS XR-ODT 121

AEMCOLO 121


AFINITOR 32

AFINITOR DISPERZ 122

AFIRMELLE 83


AFLURIA QUAD 2019-20 (6-35MO) 122




AFLURIA QUAD 2020-21 (6-35MO) 122



AFLURIA QUAD 2021-22 (6-35MO) 122

AFSTYLA 122

AGGRASTAT 122

AGGRENOX 53

AIMOVIG AUTOINJECTOR 122

AJOVY AUTOINJECTOR 122

AJOVY SYRINGE 122

AK-FLUOR 122

AK-POLY-BAC 104

AKLIEF 122

AKTEN 122

AKYNZEO 122,123

ALA-SCALP 77

albendazole 38

albumin (human) 123

ALBUMINEX 123

albustix reagent 123

albuterol sulfate 110

albuterol sulfate hfa 110

ALCAINE 104

alclometasone dipropionate 77

alcohol,dehydrated 123

ALDACTAZIDE 58

ALDURAZYME 70

ALECENSA 123

alendronate sodium 103

alfentanil hcl 123

alfuzosin hcl er 76

ALIMTA 35

ALINIA 38

ALIQOPA 123

aliskiren 60

ALKERAN 30,123

ALKINDI SPRINKLE 123

allopurinol 27

allopurinol sodium 27

ALLZITAL 123

almotriptan malate 28

ALOCRIL 105

alogliptin 48

alogliptin-metformin 49

alogliptin-pioglitazone 49

ALOMIDE 105

ALORA 81

alosetron hcl 74

ALOXI 25

ALPHAGAN P 107

ALPHANATE 123

ALPHANINE SD 123

alprazolam 47

alprazolam er 47

ALPRAZOLAM INTENSOL 47

alprazolam odt 47

alprazolam xr 47

ALPROLIX 124

alprostadil 124

ALREX 106

ALTABAX 14

ALTACAINE 124

ALTAVERA 83

alternaria alternata 124

ALTOPREV 62

ALTRENO 124

ALUNBRIG 124

ALVESCO 108

alvimopan 124

ALYACEN 83

ALYQ 111

AMABELZ 83

amantadine 39

AMBISOME 26


ambrisentan 111

amcinonide 77

AMERGE 28

AMETHIA 83

AMETHIA LO 83

AMETHYST 83

AMIDATE 124

amikacin sulfate 13

amiloride hcl 61

amiloride-hydrochlorothiazide 58

aminocaproic acid 124

aminophylline 111

AMINOPROTECT 124

AMINOSYN 124

AMINOSYN II 117

AMINOSYN II WITH ELECTROLYTES 117

AMINOSYN M 117

AMINOSYN WITH ELECTROLYTES 117,124

AMINOSYN-HBC 117

AMINOSYN-PF 117

amiodarone hcl 55,124

amiodarone hcl-d5w 124

AMITIZA 74

amitriptyline hcl 24

amlodipine besylate 57

amlodipine besylate-benazepril 58

amlodipine-atorvastatin 58

amlodipine-olmesartan 58

amlodipine-valsartan 58

amlodipine-valsartan-hctz 58

AMMONUL 124

AMNESTEEM 67

amoxapine 24

amoxicillin 18

amoxicillin-clavulanate pot er 18

amoxicillin-clavulanate potass 18

amphetamine 124

amphotericin b 26

ampicillin sodium 18

ampicillin trihydrate 18

ampicillin-sulbactam 18

AMRIX 113

amyl nitrite 124

AMYVID 124

AMZEEQ 124

ANA-LEX 124

ANADROL-50 124

anagrelide hcl 52

ANALPRAM HC 124

ANASPAZ 124

anastrozole 32

ANDRODERM 81

ANDROGEL 81,125

ANGELIQ 125

ANGIOMAX 125

ANIMI-3 125

ANORO ELLIPTA 125

ANTABUSE 12

anticoagulant sodium citrate 125

antivenin latrodectus mactans 125

antivenin micrurus fulvius 125

ANTIVERT 125

ANUCORT-HC 125

ANUSOL-HC 125

APADAZ 125

APEXICON E 125

APHEN 125

APLENZIN 13

APOKYN 39

apraclonidine hcl 107

aprepitant 25

APRI 84

APRISO 102

APTENSIO XR 125

APTIOM 125

APTIVUS 44

AQUA GLYCOLIC HC 125

AQUASOL A 125

AQUORAL 125

ARAKODA 125

ARALAST NP 112

ARANELLE 84


ARANESP 52,125

ARAZLO 126

ARCALYST 101

ARCAPTA NEOHALER 110

arformoterol tartrate 110

argatroban 53

argatroban-0.9% nacl 53

argatroban-sodium chloride 53

ARICEPT 21

ARIKAYCE 126

ARIMIDEX 32

aripiprazole 22

aripiprazole odt 22

ARISTADA 126

ARISTADA INITIO 126

ARISTOSPAN 126

armodafinil 114,126

ARMONAIR DIGIHALER 126

ARMOUR THYROID 126

ARNUITY ELLIPTA 126

AROMASIN 32

arsenic trioxide 126

ARTISS 126

ARZERRA 34,126

asa-butalb-caffeine-codeine 6

ASACOL HD 102

ASCENIV 126

ASCLERA 126

ASCOMP WITH CODEINE 6

ascorbic acid 126

asenapine maleate 41,126

ASHLYNA 84

ASMANEX 108,127

ASMANEX HFA 127

ASPARLAS 127

ASPIR 81 127

ASPIR-LOW 127

aspirin 127

ASPIRIN 127

aspirin ec 127

aspirin-dipyridamole er 53

ASTAGRAF XL 127

ASTERO 127

ASTRAZENECA COVID19 VAC(UNAPP) 127

ASTRINGYN 127

ATACAND 54

ATACAND HCT 58

atazanavir sulfate 44

ATELVIA 103

atenolol 56

atenolol-chlorthalidone 58

ATGAM 100

atomoxetine hcl 64

ATOPADERM 128

ATOPICLAIR 128

atorvastatin calcium 62

atovaquone 38

atovaquone-proguanil hcl 38

atracurium besylate 128

ATRALIN 67

ATRAPRO DERMAL SPRAY 128

ATROPEN 128

atropine sulfate 72,128

ATROVENT HFA 109

ATRYN 128

AUBRA 84

AUBRA EQ 84

AUGMENTIN 128

aureobasidium pullulans 128

AUROVELA 84

AUROVELA 24 FE 84

AUROVELA FE 84

AURYXIA 128

AUSTEDO 128

AVANDIA 48

AVAR 128

AVAR-E 128

AVAR-E GREEN 128

AVASTIN 128

AVC 128

AVEED 128

AVELOX IV 19


AVIANE 84

AVIDOXY 20

AVIDOXY DK 128

AVITA 67

AVITENE 128

AVODART 76

AVONEX 66

AVONEX PEN 128

AVSOLA 129

AVYCAZ 129

AYUNA 84

AYVAKIT 129

azacitidine 35

AZASAN 98

AZASITE 19

azathioprine 98

azathioprine sodium 98

azelaic acid 67

azelastine hcl 105,109

AZELEX 67

AZESCO 129

AZILECT 40

azithromycin 19

AZOPT 107

AZOR 58

AZSTARYS 129

aztreonam 129

AZURETTE 84

Bb complex-folic acid 129

B-12 COMPLIANCE 129

b-complex 129

b-complex with vitamin c 129

BABY OIL 129

bacitracin 14

bacitracin-polymyxin 104

baclofen 42,129

BACTRIM DS 20

BAFIERTAM 129

BAL IN OIL 129

BAL-CARE DHA 129

balanced b-complex 129

balanced salt 129

BALCOLTRA 129

balsalazide disodium 102

balsam peru-castor oil 129

BALVERSA 129,130

BALZIVA 84

BANZEL 5

BAQSIMI 130

BARACLUDE 45

BAVENCIO 130

BAXDELA 130

BEAU RX 130

BECONASE AQ 108

BEKYREE 84

BELBUCA 130

BELEODAQ 130

belladonna-opium 130

BELRAPZO 130

BELSOMRA 130

BELVIQ 130

benazepril hcl 55

benazepril-hydrochlorothiazide 58

bendamustine hcl 130

BENDEKA 130

BENEFIX 130

BENICAR 54

BENICAR HCT 58

BENLYSTA 131

BENZACLIN 67

BENZEFOAM 10

BENZEPRO 131

benzhydrocodone-acetaminophen 131

benznidazole 131

benzonatate 131

benzoyl peroxide 131

benzphetamine hcl 131

benztropine mesylate 39

bepotastine besilate 105

BEPREVE 105


BERINERT 131

BESER 77

BESIVANCE 19

BESPONSA 131

betamethasone diprop augmented 78

betamethasone dipropionate 78

betamethasone sod phos-acetate 131

betamethasone valerate 78

betaxolol hcl 56,107

bethanechol chloride 77

BETHKIS 131

BETIMOL 107

BETOPTIC S 107

bevacizumab 131

BEVESPI AEROSPHERE 131

bexarotene 37

BEXSERO 131

BEYAZ 84

bicalutamide 31

BICILLIN C-R 18

BICILLIN L-A 18

BICNU 35

BIDIL 58

BIJUVA 131

BIKTARVY 131

BILTRICIDE 38

bimatoprost 131

BINOSTO 103

BIOGLO 131

BIOTHRAX 131

bisoprolol fumarate 56

bisoprolol-hydrochlorothiazide 58

bivalirudin 131

bivalirudin-0.9% nacl 131

BLANCHE 131

bleomycin sulfate 35

BLEPHAMIDE 104

BLEPHAMIDE S.O.P. 104

BLINCYTO 131

BLISOVI 24 FE 84

BLISOVI FE 84

BLOXIVERZ 132

BONJESTA 132

BOOSTRIX TDAP 101

bortezomib 132

bosentan 111

BOSULIF 32,33,132

BOTOX 28,132

botulism antitoxin heptavalent 132

BP 10-1 132

BRAFTOVI 132

BREO ELLIPTA 132

BREVIBLOC 132

BREVITAL SODIUM 132

BREZTRI AEROSPHERE 132

BRIELLYN 85

BRIGHT BEGINNINGS SOY 132

BRILINTA 53,132

brimonidine tartrate 107

brinzolamide 107

BRISDELLE 132

BRIVIACT 132

BROMFED DM 132

bromfenac sodium 106

bromocriptine mesylate 39

brompheniramine-pseudoephed-dm 132

BROMSITE 132

BRONCHITOL 133

BROVANA 110

BRUKINSA 133

BRYHALI 133

BSS PLUS 133

budesonide 108

budesonide dr 133

budesonide ec 133

budesonide er 78

budesonide-formoterol fumarate 112

buffered aspirin 133

bumetanide 60

BUNAVAIL 133

BUPAP 6

BUPHENYL 70


bupivacaine hcl 133

bupivacaine hcl-0.9% nacl 133

bupivacaine hcl-epinephrine 133

bupivacaine-dextrose 133

buprenorphine 12,133

buprenorphine hcl 12,133

buprenorphine-naloxone 12

bupropion hcl 13

bupropion hcl sr 13

bupropion xl 13

buspirone hcl 47

busulfan 30

BUSULFEX 30

butalb-acetaminoph-caff-codein 6,133

butalbital compound-codeine 6

butalbital-acetaminophen 6,133

butalbital-acetaminophen-caffe 6

butalbital-aspirin-caffeine 6,133

butorphanol tartrate 10

BUTRANS 12,133

BYDUREON BCISE 133

BYDUREON PEN 133

BYETTA 48

BYFAVO 133

BYNFEZIA 133

CC-NATE DHA 133

cabergoline 96

CABLIVI 134

CABOMETYX 134

CADEAU DHA 134

CAFERGOT 134

caffeine and sodium benzoate 134

caffeine citrate 134

calcipotriene 67

calcipotriene-betamethasone dp 67

calcitonin-salmon 103

calcitriol 67,103

calcium acetate 77

calcium chloride 134

calcium disodium versenate 134

calcium gluconate 134

calcium gluconate-0.9% nacl 134

calcium gluconate-nacl 134

calcium-folic acid plus d 134

CALDOLOR 134

CALQUENCE 134

CAMBIA 7

CAMILA 94

CAMPTOSAR 35,134

CAMRESE 85

CAMRESE LO 85

CANCIDAS 26

candesartan cilexetil 54

candesartan-hydrochlorothiazid 58

CAPASTAT SULFATE 30

capecitabine 134

CAPEX SHAMPOO 78

CAPHOSOL 134

CAPLYTA 134

CAPRELSA 33

captopril 55

captopril-hydrochlorothiazide 58

CARAC 67

CARAFATE 75

carbamazepine 5

carbamazepine er 5

CARBATROL 5

carbidopa 40

carbidopa-levodopa 40

carbidopa-levodopa er 40

carbidopa-levodopa-entacapone 39

carbinoxamine maleate 109

CARBOCAINE 134

carboplatin 35

carboprost tromethamine 134

CARDENE I.V. 134

cardioplegia del nido formula 134

cardioplegia induction 4:1 134

cardioplegic 135

CARDIOVID PLUS 135


CARDIZEM LA 57

CARDURA XL 76

carglumic acid 115

carisoprodol 113

carisoprodol-aspirin 6

carisoprodol-aspirin-codeine 6

carmustine 35

CARNITOR SF 117

CAROSPIR 135

carteolol hcl 107

CARTIA XT 57

carvedilol 56

carvedilol er 56

CASODEX 31

CATAFLAM 7

CATAPRES-TTS 1 54

CATAPRES-TTS 2 54

CATAPRES-TTS 3 54

CATHFLO ACTIVASE 135

CAYSTON 111

CAZIANT 85

cefaclor 16,135

cefaclor er 16

cefadroxil 16

cefazolin sodium 16

cefazolin sodium-0.9% nacl 16

cefazolin sodium-dextrose 16,135

cefazolin sodium-sterile water 135

cefazolin-d5w 16

cefdinir 16

cefditoren pivoxil 135

cefepime 17,135

cefepime hcl 17,135

cefepime-dextrose 17,135

cefixime 17

cefotaxime sodium 17

cefotetan 135

cefotetan & dextrose 135

cefoxitin 17,135

cefoxitin sodium 135

cefpodoxime proxetil 17

cefprozil 17

ceftazidime 17

ceftriaxone 17

cefuroxime 17

cefuroxime sodium 17

cefuroxime sodium-0.9% nacl 135

CELEBREX 7

celecoxib 7

CELLCEPT 98

CELLUGEL 135

CELONTIN 2

CEM-UREA 135

CENTANY AT 14

CENTRATEX 135

cephalexin 17,135

CEPROTIN 135

CEQUA 135

CERDELGA 135

CERENX 135

CERETEC 135

CEREZYME 135

CERVIDIL 135

CETACAINE 136

cetirizine hcl 109

CETRAXAL 136

CETROTIDE 136

cevimeline hcl 66

CHANTIX 13

CHARLOTTE 24 FE 85

CHATEAL 85

CHATEAL EQ 85

CHEMET 115

chemstrip micral 136

children's aspirin 136

children's ferrous sulfate 136

CHILDREN'S IRON 136

chloramphenicol sod succinate 14

chlordiazepoxide hcl 47

chlordiazepoxide-amitriptyline 22

chlordiazepoxide-clidinium 136

chlorhexidine gluconate 66


chloroquine phosphate 38

chlorothiazide sodium 61

chlorpromazine hcl 25,136

chlorthalidone 61

chlorzoxazone 113

CHOLBAM 136

cholestyramine 62

cholestyramine light 62

chromium 136

CICLODAN 26

ciclopirox 26

cidofovir 45

cilostazol 53

CILOXAN 19

CIMDUO 136

cimetidine 73

CIMZIA 98

cinacalcet hcl 96

CINQAIR 136

CINRYZE 98

CINVANTI 136

CIPRO 20

CIPRO HC 108

CIPRODEX 108

ciprofloxacin 20

ciprofloxacin hcl 20,136

ciprofloxacin hcl-fluocinolone 136

ciprofloxacin-d5w 20

ciprofloxacin-dexamethasone 108

cisatracurium besylate 136

cisplatin 35,136

citalopram hbr 23

citrate phosphate dextrose 136

cladribine 35

CLAFORAN 17,136

CLARAVIS 67

CLARINEX-D 12 HOUR 113

clarithromycin 19

clarithromycin er 19

clemastine fumarate 109,136

CLENPIQ 136

CLEOCIN 14

clever choice holding chamber 136

CLEVIPREX 137

CLIMARA PRO 85

CLINDACIN ETZ 14

CLINDACIN P 14

CLINDACIN PAC 14

CLINDAGEL 14

clindamycin (pediatric) 14

clindamycin hcl 14

clindamycin phos-benzoyl perox 67,68

clindamycin phos-tretinoin 68

clindamycin phosphate 14,15

clindamycin phosphate-d5w 15

clindamycin-benzoyl peroxide 68

CLINDESSE 137

CLINIMIX 117

CLINIMIX E 117,137

CLINISOL 117

clobazam 2,137

clobetasol emollient 78

clobetasol emulsion 78

clobetasol propionate 78

CLOBETEX 137

CLOBEX 78

clocortolone pivalate 78

CLODAN 78

CLODERM 78

clofarabine 35

CLOLAR 35

clomiphene citrate 137

clomipramine hcl 24

clonazepam 2

clonidine 54

clonidine hcl 54,137

clonidine hcl er 54

clopidogrel 53

clorazepate dipotassium 2

clotrimazole 26

clotrimazole-betamethasone 68

clozapine 42


clozapine odt 42

CLOZARIL 42

COAGADEX 137

coal tar 137

COARTEM 38

codeine sulfate 10

colchicine 27,137

COLCRYS 28

colesevelam hcl 48

COLESTID 62

colestipol hcl 62

colistimethate 14

COLOCORT 78

COLYTE WITH FLAVOR PACKETS 72

COMBIGAN 104

COMBIPATCH 85

COMBIVENT RESPIMAT 113

COMETRIQ 33

COMFORT PAC-CYCLOBENZAPRINE 113

COMFORT PAC-IBUPROFEN 7

COMFORT PAC-MELOXICAM 7

COMFORT PAC-NAPROXEN 7

COMFORT PAC-TIZANIDINE 42

COMIRNATY 137

COMPLERA 43

COMPLETE NATAL DHA 137

COMPLETENATE 137

COMPRO 25

COMTAN 39

CONCEPT DHA 137

CONCEPT OB 137

CONCERTA 64

CONDYLOX 68

CONRAY 137

CONRAY-30 137

CONRAY-43 137

CONSENSI 137

CONSTULOSE 74

CONZIP 9

COPAXONE 66,137

COPIKTRA 137

copper chloride 137

CORDRAN 78,137

COREG CR 56

COREMINO 20

CORIFACT 137

CORLANOR 138

CORMAX 78

CORTANE-B 138

CORTIFOAM 78

cortisone acetate 78

CORTISPORIN 68

CORVITA 138

CORVITA 150 138

COSMEGEN 35

COSOPT PF 104

cosyntropin 138

COTELLIC 138

COTEMPLA XR-ODT 138

COUMADIN 51

CREON 70,72

CRESEMBA 138

CRESTOR 62

CRINONE 138

CRIXIVAN 44

CROFAB 138

cromolyn sodium 104,105,111

CROTAN 39

CRYSELLE 85

CUBICIN 15

CUBICIN RF 15

CUPRIMINE 138

CUROSURF 138

CUTAQUIG 138

CUVITRU 138

CUVPOSA 72

cyanocobalamin injection 138

CYANOKIT 138

CYCLAFEM 85

cyclobenzaprine hcl 113

cyclobenzaprine hcl er 113

CYCLOGYL 138


CYCLOMYDRIL 138

cyclopentolate hcl 138

cyclophosphamide 138,139

cycloserine 30

CYCLOSET 48

cyclosporine 98

cyclosporine modified 98

CYKLOKAPRON 53

CYMBALTA 23

cyproheptadine hcl 109

CYRAMZA 139

CYRED 85

CYRED EQ 85

CYSTADANE 70

CYSTADROPS 139

CYSTAGON 71

CYSTARAN 71

CYSTO-CONRAY II 139

CYSTOGRAFIN 139

CYSTOGRAFIN-DILUTE 139

cytarabine 35

CYTOGAM 139

CYTRA-2 139

CYTRA-3 139

CYTRA-K 139

DD-PENAMINE 139

dacarbazine 35

DACOGEN 35

DALIRESP 111

danazol 81

DANTRIUM 139

dantrolene sodium 42,139

DANYELZA 139

dapsone 30,68,139

DAPTACEL DTAP 101

daptomycin 15

darifenacin er 76

DARZALEX 139

DASETTA 85

DATSCAN 139

daunorubicin hcl 35

DAURISMO 139

DAYLOGIC ACNE TREATMENT 139

DAYSEE 86

DAYTRANA 64

DAYVIGO 139

DEBLITANE 94

DECADRON 78

decitabine 35

deferasirox 115,140

deferiprone 115

deferoxamine mesylate 140

DEFINITY 140

DEFINITY RT 140




DELSTRIGO 140

DELZICOL 102

demeclocycline hcl 20

DEMEROL 10,140

DEMSER 59

DENAVIR 47

DENTA 5000 PLUS 140

DENTAGEL 140

DEPEN 77

DEPO-ESTRADIOL 81

DEPO-PROVERA 94

DEPO-SUBQ PROVERA 104 94

DERMACINRX PRIZOPAK 11

DERMAWERX SDS 140

DERMAWERX SURGICAL PLUS PAK 140

DERMAZENE 140

DESCOVY 140

desflurane 140

desipramine hcl 24

desloratadine 109

desmopressin acetate 81

desogestr-eth estrad eth estra 86

desogestrel-ethinyl estradiol 86


DESONATE 78

desonide 78

desoximetasone 78

DESRX 78

desvenlafaxine er 23

desvenlafaxine succinate er 23,140

DETROL LA 76

DEXABLISS 140

dexamethasone 78,140

DEXAMETHASONE INTENSOL 79

dexamethasone sodium phosphate 106,140

dexamethasone-0.9% nacl 140

dexcom 140

dexcom g4 140

dexcom g5 141

dexcom g5-g4 sensor 141

dexcom g6 141

DEXILANT 75

dexlansoprazole dr 75

dexmethylphenidate hcl 64

dexmethylphenidate hcl er 64

DEXPAK 79,141

dexrazoxane 35

dexrazoxane diluent-sodium lac 141

DEXTENZA 141

dextroamphetamine sulfate 64,141

dextroamphetamine sulfate er 64

dextroamphetamine-amphet er 64

dextroamphetamine-amphetamine 64



dextrose 2.5%-0.45% nacl 117













dextrose 5%-electrolyte #48 141

dextrose 5%-ns-kcl 118

dextrose 5%-potassium chloride 118,141

dextrose in lactated ringers 118

dextrose in ringers injection 141

dextrose in water 118,141

DIACOMIT 141

DIALYVITE 141

DIALYVITE 800 WITH IRON 141

DIALYVITE ZINC 141






DIASTAT 2

DIASTAT ACUDIAL 2

diazepam 3,141

diazoxide 50

DIBENZYLINE 54

DICLEGIS 141

diclofenac epolamine 7

diclofenac potassium 7,141

diclofenac sodium 7,68,106

diclofenac sodium er 7

diclofenac sodium-misoprostol 6

dicloxacillin sodium 18

dicyclomine hcl 72

didanosine 43

DIFFERIN 68

DIFICID 19,141

diflorasone diacetate 79

diflunisal 7

difluprednate 106

DIGIFAB 142

DIGITEK 60

DIGOX 60

digoxin 60


dihydroergotamine mesylate 28

DILANTIN 5

DILANTIN-125 5

DILATRATE-SR 63

DILT-XR 57

diltiazem 12hr er 57

diltiazem 24hr er 57

diltiazem 24hr er (cd) 57

diltiazem 24hr er (la) 57

diltiazem 24hr er (xr) 57

diltiazem hcl 57

diltiazem-d5w 57

DILUENT FOR ACTHIB 142

diluent for artesunate 142

diluent for decitabine 142

diluent for epoprostenol 142

DILUENT FOR HIBERIX 142

DILUENT FOR IMOVAX 142

DILUENT FOR ISTODAX 142

DILUENT FOR IXEMPRA 142

DILUENT FOR JEVTANA 142

DILUENT FOR LEFAMULIN(XENLETA) 115

DILUENT FOR MENHIBRIX 142

DILUENT FOR MENOMUNE 142

DILUENT FOR NOVOSEVEN RT 142

DILUENT FOR RABAVERT 142

DILUENT FOR ROTARIX 142

diluent for treprostinil 142

DILUENT FOR VIVITROL 142

DILUENT FOR YF-VAX 115,142

DILUENT-MERCK LIVE VIRUS VACC 142

DILUTING MEDIUM FOR NOVOLOG 142

dimenhydrinate 142

dimethyl fumarate 66

DIOVAN 54

DIOVAN HCT 59

DIPENTUM 102

diphenhydramine hcl 25,142

diphenhydramine-0.9% nacl 142

diphenoxylate-atropine 73

diphtheria-tetanus toxoids-ped 142

dipyridamole 53,142

DISCOVISC 142

disopyramide phosphate 55

disulfiram 12

DIURIL 61

divalproex sodium 3

divalproex sodium er 3

DIVIGEL 82

DMSA 142

dobutamine hcl 142

dobutamine hcl-d5w 142

DOCEFREZ 35

docetaxel 35

dofetilide 55

DOJOLVI 143

DOLISHALE 86

donepezil hcl 21

donepezil hcl odt 21

DONNATAL 143

dopamine hcl 143

dopamine hcl in 5% dextrose 143

DOPTELET 143

DORAL 143

DORYX MPC 143

dorzolamide hcl 107

dorzolamide-timolol 104

DOTAREM 143

DOTTI 82

DOVATO 143

DOVONEX 68

doxapram hcl 143

doxazosin mesylate 54

doxepin hcl 24

doxercalciferol 103

doxorubicin hcl 36

doxorubicin hcl liposome 36

DOXY 100 20

doxycycline hyclate 20,21,66,143

doxycycline ir-dr 68

doxycycline monohydrate 21,143

doxylamine succ-pyridoxine hcl 143


DRAXIMAGE DTPA 143

DRAXIMAGE MAA 143

DRAXIMAGE MDP-25 143

DRISDOL 143

DRIZALMA SPRINKLE 143

dronabinol 26

droperidol 143

drospirenone-eth estra-levomef 86

drospirenone-ethinyl estradiol 86

DROXIA 31

droxidopa 143

DRYSOL 143

DUAKLIR PRESSAIR 144

DUAVEE 144

DUEXIS 6

DULERA 113,144

duloxetine hcl 23

DUOBRII 144

DUODOTE 144

DUOPA 144

DUOVISC 144

DUPIXENT PEN 144

DUPIXENT SYRINGE 144

DURAGESIC 9

DUREZOL 106

dutasteride 76

dutasteride-tamsulosin 77

DUZALLO 144

DVORAH 144

DXEVO 144

DYANAVEL XR 144

DYMISTA 113

DYRENIUM 61

DYSPORT 104

EE.E.S. 200 19

E.E.S. 400 19

ec-naproxen 7

econazole nitrate 26

ED-SPAZ 144

EDARBI 55

EDARBYCLOR 59

EDECRIN 61

EDLUAR 114

EDURANT 43

efavirenz 43

efavirenz-emtric-tenofov disop 43

efavirenz-lamivu-tenofov disop 144

EFFER-K 144

EFFEXOR XR 23

EFFIENT 53

EGATEN 144

EGRIFTA 144

EGRIFTA SV 144

ELAPRASE 71

ELASTIDERM 145

ELELYSO 71

ELEPSIA XR 145

ELESTRIN 82

ELETONE 145

eletriptan hbr 28

ELIDEL 68

ELIGARD 96

ELINEST 86

ELIQUIS 51,145

ELITEK 36

ELIXOPHYLLIN 111

ELLIOTTS B 145

ELMIRON 77

ELOCTATE 145

ELURYNG 86

EMCYT 31

EMEND 26,145

EMFLAZA 145

EMGALITY PEN 145

EMGALITY SYRINGE 145

EMOQUETTE 86

EMPAVELI 145

EMPLICITI 145

EMSAM 23

emtricitabine 43


emtricitabine-tenofovir disop 44,145

EMTRIVA 44

EMULSION SB 145

EMVERM 145

ENABLEX 76

enalapril maleate 55,145

enalapril-hydrochlorothiazide 59

enalaprilat 145

ENBREL 99,146

ENBREL MINI 146

ENBREL SURECLICK 146

ENDARI 146

ENDO-AVITENE 146

ENDOCET 6

ENDOMETRIN 94

ENDUR-ACIN 62

ENGERIX-B ADULT 101,146

ENGERIX-B PEDIATRIC-ADOLESCENT 101

enoxaparin sodium 51

ENPRESSE 86

ENSKYCE 86

ENSTILAR 146

entacapone 39

entecavir 46

ENTOCORT EC 146

ENTRESTO 146

ENTYVIO 146

ENULOSE 74

ENVARSUS XR 146

EOVIST 146

EPANED 146

EPCLUSA 146

ephedrine sulfate-0.9% nacl 146

EPICERAM 146

epicoccum nigrum 146

EPICYN 146

EPIDIOLEX 147

EPIDUO 68

EPIDUO FORTE 147

EPIFOAM 147

epinastine hcl 106

epinephrine 110,147

epinephrine convenience kit 147

epinephrine hcl-0.9% nacl 147

epinephrine hcl-d5w 147

epinephrine-0.9% nacl 147

EPIPEN 110

EPIPEN 2-PAK 110

epirubicin hcl 36

EPISIL 147

EPITOL 5

EPIVIR 44

EPIVIR HBV 46

eplerenone 61

EPOGEN 52

eprosartan mesylate 55

EPZICOM 44

ERAXIS (WATER DILUENT) 26

ERBITUX 147

ergoloid mesylates 21

ERGOMAR 28

ergotamine-caffeine 147

ERIVEDGE 33

ERLEADA 147

erlotinib hcl 33

ERRIN 95

ERWINAZE 147

ERY 19

ERY-TAB 19

ERYPED 200 19

ERYTHROCIN STEARATE 19

erythromycin 19,147

erythromycin ethylsuccinate 19

erythromycin-benzoyl peroxide 68

ESBRIET 147

escitalopram oxalate 23,24

ESGIC 6

esmolol hcl 147

esmolol hcl-sodium chloride 147

esomeprazole magnesium 75

esomeprazole sodium 75

ESPEROCT 147


ESTARYLLA 86

estazolam 47

ESTRACE 82

estradiol 82

estradiol (once weekly) 82

estradiol (twice weekly) 82

estradiol valerate 82

estradiol-norethindrone acetat 86

ESTRING 82

ESTROGEL 147

estrogen-methyltestosterone 147

ESTROSTEP FE 86

eszopiclone 114

ethacrynic acid 61

ethambutol hcl 30

ETHAMOLIN 148

ethosuximide 2

ethyl chloride 148

ethynodiol-ethinyl estradiol 86

ETHYOL 36

etidronate disodium 103

etodolac 7

etodolac er 8

etomidate 148

etonogestrel-ethinyl estradiol 87

ETOPOPHOS 32

etoposide 32,148

etravirine 43

EUCRISA 148

EURAX 39

EUTHYROX 96

EVAMIST 82

EVEKEO 148

EVEKEO ODT 148

EVENITY 148

EVENITY (2 SYRINGES) 148

everolimus 33,99,148

EVICEL 148

EVISTA 148

EVOCLIN 15

EVOTAZ 148

EVRYSDI 148

EXELON 21

exemestane 32

EXFORGE 59

EXFORGE HCT 59

EXJADE 115

EXPAREL 148

EXSERVAN 148

EXTINA 26

EXTRANEAL ICODEXTRIN DIALYSIS 148

EYSUVIS 148

EZALLOR SPRINKLE 148

ezetimibe 62

ezetimibe-simvastatin 59

FFABIOR 148

FABRAZYME 71

FALMINA 87

famciclovir 47

famotidine 74

FANAPT 41

FARESTON 31

FARXIGA 148

FARYDAK 149

FASENRA 149

FASENRA PEN 149

FASLODEX 36

febuxostat 28

FEIBA NF 149

felbamate 4

FELBATOL 4

felodipine er 57

FEMHRT 149

FEMRING 82

FEMYNOR 87

fenofibrate 61

fenofibric acid 61

FENOGLIDE 61

fenoprofen calcium 8,149

fentanyl 9,149


fentanyl citrate 10,149

fentanyl citrate-0.9% nacl 149

fentanyl citrate-d5w 149

fentanyl citrate-sterile water 149

fentanyl-bupivacaine-0.9% nacl 149

fentanyl-ropivacaine-0.9% nacl 150

FENTORA 10

FERAHEME 150

FEROCON 150

FERREX 150 FORTE 150

FERREX 150 FORTE PLUS 150

FERREX 28 150

FERRIPROX 115,150



FERROCITE PLUS 150

ferrous sulfate 150

ferumoxytol 150

FETZIMA 150

FEXMID 113

FIBRICOR 61

FIBRYGA 150

finasteride 76

FINTEPLA 150

FIORICET WITH CODEINE 150

FIRAZYR 98

FIRDAPSE 150

FIRMAGON 96,97

FIRVANQ 150

FLAREX 106

flavoxate hcl 76

FLEBOGAMMA DIF 150

flecainide acetate 55

FLECTOR 8

flexichamber mask 150

FLOLIPID 150

FLOVENT DISKUS 108

FLOVENT HFA 108

floxuridine 150

FLUAD 2019-2020 150

FLUAD 2020-2021 151

FLUAD QUAD 2020-2021 151

FLUAD QUAD 2021-2022 151







FLUCELVAX QUAD 2019-2020 151



fluconazole 26

fluconazole-nacl 26,151

flucytosine 26

fludarabine phosphate 32

fludeoxyglucose f-18 151

fludrocortisone acetate 79




flumazenil 151




flunisolide 108

fluocinolone acetonide 79

fluocinolone acetonide oil 79

fluocinonide 79

fluocinonide-e 79

fluorescein-benoxinate 151

fluorescein-proparacaine 151

FLUORESCITE 151

fluoride 115,151

FLUORIDEX SENSITIVITY RELIEF 151

FLUORITAB 151

fluorometholone 106

FLUOROPLEX 151

fluorouracil 36,68

fluoxetine dr 24

fluoxetine hcl 24

fluphenazine decanoate 40


fluphenazine hcl 40

FLURA-DROPS 151

flurandrenolide 151

flurazepam hcl 114

flurbiprofen 8

flurbiprofen sodium 106

flutamide 31

fluticasone propionate 79

fluticasone-salmeterol 113,152

fluvastatin er 62

fluvastatin sodium 62

fluvoxamine maleate 24

fluvoxamine maleate er 24

FLUZONE HIGH-DOSE 2019-2020 152



FLUZONE QUAD 2019-2020 152



FLUZONE QUAD PEDI 2019-2020 152

FML FORTE 106

FML S.O.P. 106

FOCALIN XR 64

FOLBEE 152

FOLBEE PLUS 152

FOLBEE PLUS CZ 152

FOLBIC 152

folic acid 152

FOLIVANE-F 152

FOLIVANE-OB 152

FOLIVANE-PLUS 152

FOLIXAPURE 152

FOLLISTIM AQ 152

FOLOTYN 36

FOLPLEX 2.2 152

FOLTRATE 152

fomepizole 118

fondaparinux sodium 51

FORFIVO XL 13

formoterol fumarate 110

FORTAVIT 152

FORTEO 152

FORTESTA 152

FOSAMAX PLUS D 103

fosamprenavir calcium 44

fosaprepitant dimeglumine 152

foscarnet sodium 45

fosfomycin tromethamine 15

fosinopril sodium 55

fosinopril-hydrochlorothiazide 59

fosphenytoin sodium 5

FOSRENOL 77,152

FOTIVDA 153

FRAGMIN 51,52

FREAMINE HBC 153

FREAMINE III 153

freestyle freedom lite 153

freestyle insulinx 153

freestyle insulinx test strips 153

freestyle libre 14 day reader 153

freestyle libre 14 day sensor 153

freestyle libre 2 reader 153

freestyle libre 2 sensor 153

freestyle lite meter 153

freestyle lite test strip 153

freestyle test strips 153

FROVA 28

frovatriptan succinate 29

FUL-GLO 153

FULPHILA 153

fulvestrant 36

FURADANTIN 15

furosemide 61,153

FUSILEV 153

FUSION PLUS 153

FUZEON 44

FYAVOLV 87,153

FYCOMPA 153

Ggabapentin 3

GABITRIL 3


GABLOFEN 42,153

GADAVIST 154

GALAFOLD 154

galantamine er 21

galantamine hbr 22

galantamine hydrobromide 22

GALZIN 154

GAMASTAN 100

GAMASTAN S-D 100

GAMMAGARD LIQUID 100

GAMMAGARD S-D 100

GAMMAKED 100

GAMMAPLEX 100,154

GAMUNEX-C 101

ganirelix acetate 154

GARDASIL 9 154

GASTROCROM 104

GASTROGRAFIN 154

GASTROMARK 154

gatifloxacin 20

GATTEX 73

GAVILAX 74

GAVILYTE-C 72

GAVILYTE-G 72

GAVILYTE-N 72

GAZYVA 154

GEL-FLOW NT 154

GELCLAIR 154

gelfilm 154

GELFILM 154

GELFOAM 154

GELFOAM COMPRESSED 154

GELNIQUE 76

gemcitabine hcl 36,154

gemfibrozil 61

GEMMILY 87

GEMTESA 154

GENADUR 154

GENERESS FE 87

GENERLAC 74

GENGRAF 99

GENTAK 13

gentamicin sulfate 13

gentamicin sulfate in ns 13,154

GENVOYA 154

GEODON 41

GIANVI 87

GILENYA 66,155

GILOTRIF 155

GLASSIA 113

glatiramer acetate 66,155

GLEOSTINE 30,155

GLIADEL 155

glimepiride 48

glipizide 48

glipizide er 48

glipizide xl 48

glipizide-metformin 49

GLUCAGEN 50

glucagon hcl 50

glucose in water 118

glutaraldehyde 155

glyburide 48

glyburide micronized 48

glyburide-metformin hcl 50

glycine 155

glycopyrrolate 72,155

glycopyrrolate-sterile water 72,155

glycopyrrolate-water 155

GLYDO 11

GLYRX-PF 72

GLYXAMBI 155

GOCOVRI 155

GOLYTELY 72

GONAL-F 155

GONAL-F RFF 155

GONAL-F RFF REDI-JECT 155

GONITRO 155

GRALISE 3,155

granisetron hcl 26

GRANIX 155

GREEN GLO 155


griseofulvin 26

griseofulvin ultramicrosize 26

guanfacine hcl 54

guanfacine hcl er 65

guanidine hcl 29





GYNAZOLE 1 26

HHAEGARDA 156

HAILEY 87

HAILEY 24 FE 87

HAILEY FE 87

HALAVEN 36

halcinonide 79

halobetasol propionate 79,156

HALOG 79,156

haloperidol 40

haloperidol decanoate 40

haloperidol decanoate 100 40

haloperidol lactate 40

HARVONI 156

HAVRIX 101,156

HEATHER 95

HECTOROL 103

HEMABATE 156

HEMANGEOL 156

HEMATINIC PLUS 156

HEMATINIC WITH FOLIC ACID 156

HEMATOGEN FA 156

HEMATOGEN FORTE 156

HEMAX 156

HEMETAB 156

HEMLIBRA 156

HEMMOREX-HC 156

HEMOFIL M 156

HEPAGAM B 156

heparin flush 52,157

heparin lock 52,157

heparin sodium 52,157

heparin sodium in 0.45% nacl 52

heparin sodium-0.45% nacl 52

heparin sodium-0.9% nacl 157

heparin sodium-d5w 52

HEPATAMINE 118

HEPLISAV-B 157

HEPSERA 46

HERCEPTIN 157

hetastarch-0.9% nacl 157

HETLIOZ 157

HETLIOZ LQ 157

HEXTEND LACTATED ELECTROLYTE 157

HIBERIX 101

HICON 157

HIDEX 157

HIZENTRA 157

HOMACTIN AA PLUS 15 PE 157

HORIZANT 157

HPR PLUS 157

HPR PLUS-MB HYDROGEL 157

HUMATE-P 157

HUMATIN 13

HUMIRA 99

HUMIRA PEN 99

HUMIRA PEN CROHN'S-UC-HS 99

HUMIRA PEN PSOR-UVEITS-ADOL HS 99

HUMIRA(CF) 158

HUMIRA(CF) PEDIATRIC CROHN'S 158

HUMIRA(CF) PEN 158

HUMIRA(CF) PEN CROHN'S-UC-HS 158

HUMIRA(CF) PEN PEDIATRIC UC 158

HUMIRA(CF) PEN PSOR-UV-ADOL HS 158

HUMULIN R U-500 50

HUMULIN R U-500 KWIKPEN 158

HYCAMTIN 32,158

HYCODAN 158

hydralazine hcl 63

HYDRO 40 158

hydrochlorothiazide 61


hydrocodone bitartrate er 158

hydrocodone-acetaminophen 6,158

hydrocodone-chlorpheniramne er 158

hydrocodone-homatropine mbr 158

hydrocodone-ibuprofen 6

hydrocortisone 79

hydrocortisone acetate 158

hydrocortisone butyrate 79

hydrocortisone valerate 79

hydrocortisone-acetic acid 108

hydrocortisone-iodoquinol 158

hydrocortisone-pramoxine 159

HYDROMET 159

hydromorphone er 9,159

hydromorphone hcl 10,159

hydromorphone hcl-0.9% nacl 10,159

hydromorphone hcl-d5w 159

hydroquinone 159

hydroxocobalamin 159

hydroxychloroquine sulfate 38,159

hydroxyprogesterone caproate 159

hydroxyurea 31

hydroxyzine hcl 47

hydroxyzine pamoate 47

HYLATOPICPLUS 159

HYLENEX 159

HYOPHEN 159

hyoscyamine sulfate 159

hyoscyamine sulfate er 159

hyoscyamine sulfate sr 159

HYOSYNE 159

HYPERHEP B 159

HYPERRHO S-D 159

HYPERTET S-D 159

HYQVIA 159

HYQVIA HY COMPONENT 159

HYQVIA IG COMPONENT 159

HYSINGLA ER 160

Iibandronate sodium 103

IBRANCE 160

IBU 8

ibuprofen 8

ibuprofen-famotidine 6

ibutilide fumarate 160

IC GREEN 160

ICAR-C PLUS 160

icatibant 98

ICLEVIA 87

ICLUSIG 33,160

icosapent ethyl 62

idarubicin hcl 36

IDELVION 160

IDHIFA 160

IFEREX 150 FORTE 160

ifosfamide 36

ILARIS 101

ILEVRO 106

ILUVIEN 160

imatinib mesylate 33

IMBRUVICA 160

imipenem-cilastatin sodium 17,160

imipramine hcl 24

imipramine pamoate 24

imiquimod 68

IMITREX 29

IMLYGIC 160

IMOGAM RABIES-HT 160

IMOVAX RABIES VACCINE 101

IMPAVIDO 160

IMPEKLO 160

IMPOYZ 161

IMURAN 99

INBRIJA 161

INCASSIA 95

INCRELEX 81

INCRUSE ELLIPTA 161

indapamide 61

INDICLOR 161

INDIUM IN-111 DTPA 161

indium in-111 oxyquinoline 161


INDOCIN 8,161

indocyanine green 161

indomethacin 8,161

indomethacin er 8

INFANRIX DTAP 101,161

INFASURF 161

INFED 161

INFLECTRA 161

INFUVITE ADULT 161

INFUVITE PEDIATRIC 161

INGREZZA 161

INGREZZA INITIATION PACK 161

INJECTAFER 161

INLYTA 33,34

INNOPRAN XL 56

INOVA 161

INOVA 4-1 161

INOVA 8-2 161

INQOVI 161

INREBIC 162

insulin aspart 51

insulin aspart flexpen 162

insulin aspart penfill 162

insulin aspart prot mix 70-30 51

insulin syringe 162

INTEGRA F 162

INTEGRA PLUS 162

INTELENCE 43,162

INTRALIPID 118

INTRAROSA 162

INTRON A 46,162

INVANZ 17

INVEGA 41

INVEGA HAFYERA 162

INVEGA SUSTENNA 41

INVEGA TRINZA 162

INVELTYS 162

INVIRASE 44

INVOKAMET 162

INVOKAMET XR 162

INVOKANA 48

IODOFLEX 162

IODOSORB 162

IONOSOL B WITH DEXTROSE 5% 118

IONOSOL MB-DEXTROSE 5% 118

IOPIDINE 107

IPOL 101

ipratropium bromide 109

ipratropium-albuterol 162

irbesartan 55

irbesartan-hydrochlorothiazide 59

IRESSA 162

irinotecan hcl 36,162

ISENTRESS 43,162

ISENTRESS HD 162

ISIBLOOM 87

isoflurane 163

ISOLYTE P WITH DEXTROSE 118

ISOLYTE S 116

isoniazid 30

ISOPTO ATROPINE 163

isosorbide dinitrate 63

isosorbide mononitrate 63

isosorbide mononitrate er 63

ISOSOURCE 1.5 CAL 163

ISOSOURCE 1.5 CAL TUBE FEED 163

isosulfan blue 163

isotretinoin 68,163

ISOVUE-200 163

ISOVUE-M 200 163

ISOVUE-M 300 163

isoxsuprine hcl 163

isradipine 57

ISTALOL 107

ISTODAX 36

ISTURISA 163

itraconazole 26,27

iv sol stabilizer for blincyto 163

ivermectin 38

IXEMPRA 163

IXIARO 101

IXINITY 163


JJADENU 163

JAIMIESS 87

JAKAFI 34

JALYN 77

JANSSEN COVID-19 VACCINE (EUA) 163

JANTOVEN 52

JANUMET 50

JANUMET XR 50

JANUVIA 48

JARDIANCE 163

JASMIEL 87

JATENZO 164

JEMPERLI 164

JENCYCLA 95

JENTADUETO 50

JENTADUETO XR 164

JEVITY 1.2 CAL 164

JEVTANA 164

JINTELI 87

JIVI 164

JOLESSA 87

JORNAY PM 164

JUBLIA 164

JULEBER 87

JULUCA 164

JUNEL 87

JUNEL FE 88

JUNEL FE 24 88

JYNARQUE 115,164

KK-PHOS NEUTRAL 164

K-PHOS ORIGINAL 164

K-TAB ER 116

KABIVEN 164

KADCYLA 164

KADIAN 9,165

KAITLIB FE 88

KALBITOR 165

KALETRA 44,45

KALLIGA 88

KALYDECO 111,165

KANJINTI 165

KAPSPARGO SPRINKLE 165

KAPVAY 54

KARBINAL ER 165

KARIVA 88

KATERZIA 165

KAZANO 50

KCENTRA 165

KELNOR 1-35 88

KELNOR 1-50 88

KENALOG 79

KENALOG-10 165

KENALOG-40 165

KENALOG-80 165

kendall 0.9% nacl with cap 165

KEPIVANCE 66

KEPPRA XR 2

KERYDIN 165

KESIMPTA PEN 165

ketamine hcl 165

ketamine hcl-0.9% nacl 165

ketamine hcl-water 165

keto-diastix reagent 165

KETOCAL 2.5:1 165

ketoconazole 27

ketone test strip 165

ketoprofen 8,166

ketorolac tromethamine 8,106,166

KETOVIE 4:1 166

KEVEYIS 166

KEVZARA 166

KEYTRUDA 166

KINERET 99

KINEVAC 166

KINRIX 166

KIONEX 115

KISQALI 166

KISQALI FEMARA CO-PACK 166


KITABIS PAK 13

KLISYRI 166

KLOR-CON 166

KLOR-CON 10 116

KLOR-CON 8 116

KLOR-CON M10 116

KLOR-CON M15 116

KLOR-CON M20 116

KLOR-CON-EF 166

KOATE 166

KOGENATE FS 166

KOMBIGLYZE XR 50

KOSELUGO 167

KOVALTRY 167

KRINTAFEL 167

KRISTALOSE 74

KRYSTEXXA 167

KURVELO 88

KYNMOBI 167

KYPROLIS 167

Llabetalol hcl 56,167

LACRISERT 105

lactated ringers 118

lactulose 75

LAMICTAL 4

LAMICTAL (BLUE) 4

LAMICTAL (ORANGE) 4

LAMICTAL ODT 4

LAMICTAL ODT (BLUE) 167

LAMICTAL ODT (GREEN) 167

LAMICTAL ODT (ORANGE) 167

LAMICTAL XR 4

LAMICTAL XR (BLUE) 4

LAMICTAL XR (GREEN) 4

LAMICTAL XR (ORANGE) 4

lamivudine 44

lamivudine hbv 46

lamivudine-zidovudine 44

lamotrigine 4

lamotrigine (blue) 4

lamotrigine (green) 4

lamotrigine (orange) 4

lamotrigine er 4

lamotrigine odt 4

lamotrigine odt (blue) 167

lamotrigine odt (green) 167

lamotrigine odt (orange) 167

LAMPIT 167

LANOXIN 60,167

lansoprazol-amoxicil-clarithro 72

lanthanum carbonate 77

LANTUS 51

LANTUS SOLOSTAR 51

lapatinib 34

LARIN 88

LARIN 24 FE 88

LARIN FE 88

LARISSIA 88

LASTACAFT 105

latanoprost 107

LATUDA 41,167

LAYOLIS FE 88

LAZANDA 11

LDO PLUS 167

LEENA 88

leflunomide 101

LENVIMA 168

LESCOL 62

LESCOL XL 62

LESSINA 88

LETAIRIS 112

letrozole 32

leucovorin calcium 32,168

LEUKERAN 30

LEUKINE 52

leuprolide acetate 97

levalbuterol concentrate 110

levalbuterol hcl 110

levalbuterol tartrate hfa 110

LEVEMIR 51


LEVEMIR FLEXTOUCH 51

levetiracetam 2

levetiracetam er 2

levetiracetam-nacl 168

LEVO-T 96

levobunolol hcl 107

levocarnitine 118

levocarnitine sf 118

levocetirizine dihydrochloride 109

levofloxacin 20,168

levofloxacin-d5w 168

levoleucovorin calcium 168

LEVONEST 88

levonorg-eth estrad eth estrad 88,168

levonorgestrel-eth estradiol 88,89

LEVORA-28 89

levorphanol tartrate 9

levothyroxine 168

levothyroxine sodium 96,168

LEVOXYL 96

LEVULAN 168

LEXETTE 168

LEXISCAN 168

LEXIVA 45

LIALDA 102

LICART 168

LIDO-K 168

lidocaine 11

lidocaine hcl 11,169

lidocaine hcl in 5% dextrose 169

lidocaine hcl in 7.5% dextrose 169

lidocaine hcl viscous 11

lidocaine hcl-epinephrine 169

lidocaine-epinephrine 169

lidocaine-hydrocortisone 169

lidocaine-prilocaine 11

lidocaine-tetracaine 169

LIDOPIN 169

LILLOW 89

LINCOCIN 15

lincomycin hcl 15

lindane 39

linezolid 15

linezolid-0.9% nacl 169

linezolid-d5w 169

LINZESS 74,169

LIORESAL INTRATHECAL 42

liothyronine sodium 96

LIPOCHOL PLUS 169

LIPODOX 36

LIPODOX 50 36

LIPOFEN 61

LIQUID E-Z PAQUE 169

LIQUIVIDA HYDRATION KIT 116

lisinopril 55

lisinopril-hydrochlorothiazide 59

lite touch 169

litetouch insulin syringe 169

lithium 169

lithium carbonate 48

lithium carbonate er 48

LIVALO 62

LIVIXIL PAK 11

LMD 10% WITH 0.9% SOD CHLORIDE 169

LMD 10% WITH 5% DEXTROSE 169

LO LOESTRIN FE 89

lo-dose aspirin ec 169

LO-ZUMANDIMINE 89

LOCOID 79

LOCOID LIPOCREAM 79

LODOSYN 40

LOESTRIN 89

LOESTRIN FE 89

LOFENA 169

lofric origo 169

LOJAIMIESS 89

LONHALA MAGNAIR REFILL 169

LONHALA MAGNAIR STARTER 170

LONSURF 170

loperamide 73

lopinavir-ritonavir 45

LOPREEZA 89


lorazepam 3,170

LORAZEPAM INTENSOL 3

LORBRENA 170

LORCET 6

LORCET HD 7

LORCET PLUS 7

LOREEV XR 170

LORTAB 170

LORYNA 89

LORZONE 114

losartan potassium 55

losartan-hydrochlorothiazide 59

LOSEASONIQUE 89

LOTEMAX 106

LOTEMAX SM 170

LOTENSIN 55

loteprednol etabonate 106

LOTREL 59

LOTRONEX 74

lovastatin 62

LOVAZA 62

LOVENOX 52

low dose aspirin ec 170

LOW-OGESTREL 89

loxapine 40

lubiprostone 74

LUCEMYRA 170

LUDENT FLUORIDE 116,170

LUGOL'S 170

luliconazole 170

LUMAKRAS 170

LUMIGAN 107

LUMIZYME 71

LUNESTA 114

LUPANETA PACK 170

LUPKYNIS 170

LUPRON DEPOT 97

LUPRON DEPOT (LUPANETA) 97

LUPRON DEPOT-PED 97

LUTERA 89

LUZU 170

LYBALVI 170

LYLEQ 95

LYLLANA 82

LYMEPAK 21

LYNPARZA 171

LYRICA 2

LYRICA CR 171

LYSIPLEX PLUS 171

LYSODREN 96

LYZA 95

MM-END PE 171

M-M-R II VACCINE 101

M-NATAL PLUS 171

M.V.I. ADULT 171

M.V.I. PEDIATRIC 171

mafenide acetate 15

magellan safety needle 171

MAGNEBIND 400 171

magnesium chloride 171

magnesium sulfate 116,171

magnesium sulfate-0.9% nacl 171

magnesium sulfate-d5w 171

magnesium-lactated ringers 171

MAGNEVIST 171

MAKENA 171

MALARONE 38

malathion 39

manganese chloride 171

manganese sulfate 171

mannitol 171

maprotiline hcl 24

MAR-COF BP 171

MAR-COF CG 171

MARLISSA 89

MARNATAL-F 171

MARPLAN 23

MARQIBO 171

MATULANE 30

MATZIM LA 57


MAVENCLAD 172

MAVYRET 172

MAXALT 29

MAXALT MLT 29

MAXIDEX 106

MAXIPIME 17,172

MAXITROL 105

MAYZENT 172

MB HYDROGEL 172

MD-76 R 172

MD-GASTROVIEW 172

me-naphos-mb-hyo 1 172

meclofenamate sodium 8

medroxyprogesterone acetate 95

mefenamic acid 8

mefloquine hcl 38

MEGACE ES 95

megestrol acetate 95

MEKINIST 34

MEKTOVI 172

MELODETTA 24 FE 89

meloxicam 8,172

melphalan 172

melphalan hcl 30

memantine hcl 22

memantine hcl er 22

MEMBRANEBLUE 172

MENACTRA 101

MENEST 83

MENOSTAR 83

MENQUADFI 172

MENTAX 27

MENVEO A-C-Y-W-135-DIP 102

meperidine hcl 11,172

meperidine hcl-0.9% nacl 172

MEPHYTON 172

mepivacaine hcl 172

meprobamate 47

MEPRON 38

mercaptopurine 31

meropenem 17

meropenem-0.9% nacl 17

MERREM 18

MERZEE 89

mesalamine 102

mesalamine dr 102

mesalamine er 103

mesna 36

MESNEX 36

MESTINON 29

METADATE ER 65

metaproterenol sulfate 110

METAXALL 114

metaxalone 114,172

metformin hcl 48

metformin hcl er 49

methacholine chloride 172

methadone hcl 9,172

methadone hcl-0.9% nacl 172

METHADONE INTENSOL 9

METHADOSE 173

methazolamide 60

methenamine hippurate 15

methenamine mandelate 15,173

METHERGINE 104

methimazole 98

METHITEST 81

methocarbamol 114,173

methocel e 4 m 173

methotrexate 99

methotrexate sodium 99

methoxsalen 69

methscopolamine bromide 72

methyldopa 54

methyldopa-hydrochlorothiazide 59

methyldopate hcl 54

methylene blue 173

methylergonovine maleate 104,173

methylphenidate er 65,173

methylphenidate er (la) 65

methylphenidate hcl 65

methylphenidate hcl cd 65


methylphenidate hcl er (cd) 65

methylphenidate la 65,173

methylprednisolone 79

methylprednisolone acetate 79

methylprednisolone sodium succ 79

methyltestosterone 81

metipranolol 107

metoclopramide hcl 25,173

metoclopramide hcl odt 25

metolazone 61

METOPIRONE 173

metoprolol succinate 56

metoprolol tartrate 56,173

metoprolol-hydrochlorothiazide 59

METROGEL 15

metronidazole 15

mexiletine hcl 55

MIBELAS 24 FE 90

MICARDIS 55

MICARDIS HCT 59

miconazole 3 27

MICRHOGAM ULTRA-FILTERED PLUS 173

microair mesh nebulizer 173

MICROGESTIN 90

MICROGESTIN FE 90

midazolam hcl 173

midazolam hcl-0.9% nacl 173

midazolam hcl-d5w 173

midazolam hcl-nacl 173

midazolam-0.9% nacl 173

midodrine hcl 54

MIFEPREX 173

mifepristone 173

MIGERGOT 28

miglitol 49

miglustat 71

MILI 90

milk of magnesia 173

MILLIPRED 79

MILLIPRED DP 173

milrinone in 5% dextrose 174

milrinone lactate 174

MIMVEY 90

MINITRAN 63

MINIVELLE 83

MINOCIN 174

minocycline hcl 21

minocycline hcl er 21

MINOLIRA ER 174

minoxidil 63

MIOCHOL-E 174

MIOSTAT 174

MIRAPEX 39

MIRAPEX ER 39

MIRCERA 174

MIRCETTE 90

mirtazapine 22

MIRVASO 174

misoprostol 75

MITIGARE 174

mitomycin 37

MITOSOL 174

mitoxantrone hcl 32

mixed vespid venom protein 174

MKO (MIDAZOLAM-KETAMINE-ONDAN) 174

modafinil 114

MODERNA COVID-19 VACCINE (EUA) 174

moexipril hcl 55

molindone hcl 174

molnupiravir (eua) 174

mometasone furoate 79

MONDOXYNE NL 21

MONO-LINYAH 90

MONODOX 21

MONOJECT 0.9% SODIUM CHLORIDE 116

MONOJECT PREFILL ADVANCED 116

MONOJECT SODIUM CHLORIDE FLUSH 116

MONONINE 174

MONSEL'S 174

montelukast sodium 109

MORGIDOX 21

MORPHABOND ER 174


morphine sulfate 11,175

morphine sulfate er 9,175

morphine sulfate-0.9% nacl 11,175

morphine sulfate-nacl 11

MOTEGRITY 175

MOTOFEN 73

MOVANTIK 175

MOVIPREP 75

MOXATAG 18

MOXEZA 20

moxifloxacin 20

moxifloxacin hcl 20

moxifloxacin hcl-bss 175

MOZOBIL 52

MS CONTIN 9

mucor plumbeus 175

MUCOSITISRX 175

MUGARD 175

MULPLETA 175

MULTAQ 55

multi-vitamin w-fluoride-iron 175

MULTIGEN FOLIC 175

MULTIGEN PLUS 175

MULTIHANCE 175

MULTIHANCE MULTIPACK 175

MULTITRACE-4 175

MULTITRACE-5 175

multivitamin with fluoride 175

multivitamin-iron-fluoride 176

mupirocin 15

MUTAMYCIN 37

MVASI 176

MVC-FLUORIDE 176

MYALEPT 176

MYCAMINE 27

MYCAPSSA 176

MYCOBUTIN 30

mycophenolate mofetil 99

mycophenolic acid 99

MYDAYIS 176

MYFERON-150 FORTE 176

MYFORTIC 99

MYLERAN 176

MYLOTARG 176

MYNATAL 176

MYNATAL PLUS 176

MYNATAL-Z 176

MYNEPHROCAPS 176

MYOBLOC 176

MYORISAN 69

MYOVIEW 176

MYRBETRIQ 76,176

MYTESI 73

MYXREDLIN 176

NNABI-HB 176

nabumetone 8

nadolol 56

nafcillin 18,176

nafcillin sodium 18,176

naftifine hcl 27

NAFTIN 27

NAGLAZYME 71

nalbuphine hcl 11

NALFON 8

NALOCET 176

naloxone hcl 13,176

naltrexone hcl 177

NAMENDA 22

NAMENDA XR 22

NAMZARIC 177

NAPRELAN 8

naproxen 8

naproxen sodium 8

naproxen sodium cr 8

naproxen sodium er 8,9

naproxen-esomeprazole mag 7

naratriptan hcl 29

NARCAN 177

NARDIL 23

NAROPIN 177


NASCOBAL 177

NASONEX 108

NATACYN 27

NATAZIA 177

nateglinide 49

NATESTO 177

NATPARA 177

NATURE-THROID 177

NAYZILAM 177

nebivolol hcl 56

NEBUSAL 177

NECON 90

needle 177

nefazodone hcl 24

nelarabine 37

NEO-POLYCIN 105

NEO-POLYCIN HC 105

NEO-SYNALAR 177

neomycin sulfate 13

neomycin-bacitracin-poly-hc 105

neomycin-bacitracin-polymyxin 105

neomycin-polymyxin b 14

neomycin-polymyxin-dexameth 105

neomycin-polymyxin-gramicidin 105

neomycin-polymyxin-hc 105,108

neomycin-polymyxin-hydrocort 108

NEORAL 99

NEOSALUS 177

NEOSALUS CP 177

neostigmine methylsulfate 177

neostigmine-sterile water 177

NEPHRAMINE 118

NERLYNX 177

NESACAINE 177

NESINA 49

NEUAC 69

NEULASTA 53

NEULASTA ONPRO 53

NEUPOGEN 53,178

NEUPRO 39

NEURACEQ 178

NEURIN-SL 178

NEUTRASAL 178

NEVANAC 106

nevirapine 43

nevirapine er 43

NEWGEN 178

NEXAVAR 34

NEXIUM 75

NEXIUM I.V. 75

NEXLETOL 178

NEXLIZET 178

NEXTERONE 56

NEXTSTELLIS 178

niacin 63,178

niacin er 63

NIASPAN 63

nicardipine hcl 57,178

nicardipine hcl-0.9% nacl 178

nicotine lozenge 178

NICOTROL 13

NICOTROL NS 13

nifedipine 57

nifedipine er 57

NIKKI 90

nilutamide 31

nimodipine 57

NINLARO 178

NIPENT 37

nitazoxanide 38

NITHIODOTE 178

nitisinone 71

NITRO-BID 63

NITRO-DUR 63

NITRO-TIME 178

nitrofurantoin 15

nitrofurantoin mono-macro 15

nitroglycerin 63

nitroglycerin in d5w 178

nitroglycerin patch 63

NITROLINGUAL 63

NITROSTAT 63


NITYR 178

NIVA-FOL 179

NIVA-PLUS 179

NIVATOPIC PLUS 179

NIVESTYM 179

nizatidine 74

NOCDURNA 179

NOCTIVA 179

NOLIX 179

NORA-BE 95

NORDITROPIN FLEXPRO 73,81

norepinephrine bitar-0.9% nacl 179

norepinephrine bitartrate 179

norepinephrine bitartrate-d5w 179

norethin-eth estra-ferrous fum 90

norethindron-ethinyl estradiol 90,179

norethindrone 95

norethindrone ac (lupaneta) 95

norethindrone acetate 95

norethindrone-e.estradiol-iron 90

NORGESIC FORTE 179

norgestimate-ethinyl estradiol 90

NORITATE 179

NORLYDA 95

norm-ject tuberkulin syringe 179

normal saline flush 116

NORMLGEL AG 179

NORMOSOL-M AND DEXTROSE 118

NORMOSOL-R 116

NORMOSOL-R AND DEXTROSE 118

NORMOSOL-R PH 7.4 116

NORTREL 90,91

nortriptyline hcl 25,179

NORVIR 45,179

NOURIANZ 179

NOVOEIGHT 179

NOVOLIN 70-30 51

NOVOLIN 70-30 FLEXPEN 51

NOVOLIN N 51

NOVOLIN N FLEXPEN 51

NOVOLIN R 51

NOVOLIN R FLEXPEN 179

NOVOLOG 51

NOVOLOG FLEXPEN 180

NOVOLOG MIX 70-30 51

NOVOLOG MIX 70-30 FLEXPEN 51

NOVOLOG PENFILL 180

NOVOSEVEN RT 180

NOXAFIL 27,180

NP THYROID 180

NPLATE 180

NU-DERM 180

NUBEQA 180

NUCALA 180

NUCYNTA 11

NUCYNTA ER 9

NUEDEXTA 65

NULEV 180

NULOJIX 101

NULYTELY 72

NULYTELY WITH FLAVOR PACKS 72

NUMOISYN 180

NUPLAZID 180

NURTEC ODT 181

NUVAIL 181

NUVARING 91

NUVESSA 181

NUVIGIL 114,181

NUWIQ 181

NUZYRA 181

NYAMYC 27

NYLIA 91

NYMALIZE 181

NYMYO 91

nystatin 27

nystatin-triamcinolone 27

NYSTOP 27

NYVEPRIA 181

OO-CAL FA 181

O-CAL PRENATAL 181


OB COMPLETE PREMIER 181

OBIZUR 181

OBREDON 181

OCALIVA 181

OCELLA 91

OCTAGAM 181

OCTAPLAS 181

OCTREOSCAN 182

octreotide acetate 97,182

OCUCOAT 182

ODACTRA 182

ODEFSEY 182

ODOMZO 182

OFEV 182

ofloxacin 20

OGESTREL 91

OGIVRI 182

olanzapine 41

olanzapine odt 41

olanzapine-fluoxetine hcl 22

olmesartan medoxomil 55

olmesartan-amlodipine-hctz 59

olmesartan-hydrochlorothiazide 59

olopatadine hcl 106,109

OMECLAMOX-PAK 73

omega-3 acid ethyl esters 63

omeprazole 75

omeprazole-sodium bicarbonate 73

OMNARIS 109

OMNIPAQUE 182

OMNISCAN 182

ondansetron hcl 26,182

ondansetron hcl-0.9% nacl 182

ondansetron odt 26

ONEXTON 182

ONFI 3,182

ONGENTYS 182

ONGLYZA 49

ONIVYDE 182

ONMEL 27

ONTRUZANT 182

ONUREG 182

ONZETRA XSAIL 183

OPDIVO 183

opium tincture 183

OPSUMIT 183

OPTIRAY 300 183

OPTIRAY 320 183

OPTIRAY 350 183

OPTISON 183

ORACEA 69

ORALONE 66

ORAPRED ODT 79,183

ORAVIG 183

ORBACTIV 183

ORENCIA 99,183

ORENCIA CLICKJECT 183

ORENITRAM ER 183

ORFADIN 183

ORGOVYX 183

ORIAHNN 184

ORILISSA 184

ORKAMBI 184

ORLADEYO 184

orphenadrine citrate 114

orphenadrine citrate er 114

orphenadrine-aspirin-caffeine 184

ORPHENGESIC FORTE 184

ORSYTHIA 91

ORTHO MICRONOR 95

ORTHO TRI-CYCLEN 91

ORTHO-NOVUM 91

ORTIKOS 184

OSCIMIN 184

OSCIMIN SL 184

OSCIMIN SR 184

oseltamivir phosphate 46

OSENI 50

OSMOLEX ER 184

OSMOPREP 116

OSPHENA 184

OTEZLA 184


OTREXUP 184

OVACE PLUS 184

OVIDREL 184

oxacillin 18

oxacillin sodium 18

oxaliplatin 37

oxandrolone 91

oxaprozin 9

oxazepam 47

OXBRYTA 184

oxcarbazepine 5

OXERVATE 185

OXSORALEN-ULTRA 69

OXTELLAR XR 185

oxybutynin chloride 76

oxybutynin chloride er 76

oxycodone hcl 11,185

oxycodone hcl er 10

oxycodone hcl-aspirin 7

oxycodone hcl-ibuprofen 7

oxycodone-acetaminophen 7,185

OXYCONTIN 10

oxymorphone hcl 11

oxymorphone hcl er 10

oxytocin 185

oxytocin-0.9% nacl 185

oxytocin-d5-lactated ringers 185

oxytocin-d5w 185

oxytocin-lactated ringers 185

OXYTROL 76

OZEMPIC 185

OZOBAX 185

PPACERONE 56

paclitaxel 37

PADCEV 185

paliperidone er 41

palonosetron hcl 26,185

PALYNZIQ 185

PANCREAZE 71,186

pancuronium bromide 186

PANDEL 80

PANHEMATIN 186

PANRETIN 37

pantoprazole sodium 75

PANZYGA 186

papaverine hcl 186

paregoric 186

PAREMYD 186

paricalcitol 103

PAROEX 66

paromomycin sulfate 13

paroxetine cr 24

paroxetine er 24

paroxetine hcl 24

paroxetine mesylate 186

PARSABIV 186

PASER 30

PATADAY 106

PATANASE 109

PATANOL 106

PAXIL 24

PAXLOVID (EUA) 186

PAZEO 186

PEDIAPRED 80

PEDIARIX 186

PEDIASURE 1.5 WITH FIBER 186

PEDIASURE ENTERAL WITH FIBER 186

PEDIASURE WITH FIBER 186

pediatric comp-air compres neb 186

pediatric iron 186

PEDVAXHIB 102

peg 3350-electrolyte 73

peg-3350 and electrolytes 73

PEG-PREP 73

PEGANONE 5

PEGASYS 46

PEGINTRON 46

PEMAZYRE 186

pen needle 187

penicillamine 77,187


penicillin g potassium 18

penicillin g procaine 18,187

penicillin g sodium 18

penicillin gk-iso-osm dextrose 18,187

penicillin v potassium 18

PENLEN 187

PENNSAID 187

PENTACEL 187

PENTACEL ACTHIB COMPONENT 102

PENTACEL DTAP-IPV COMPONENT 187

PENTAM 300 38

pentamidine isethionate 38

PENTASA 103

pentazocine-naloxone hcl 7

pentoxifylline 60

PEPCID 74

PERFOROMIST 110

PERIKABIVEN 187

perindopril erbumine 55

PERIOGARD 66

PERJETA 37

permethrin 39

perphenazine 25

perphenazine-amitriptyline 22

PERSERIS 187

PERTZYE 73,187

PEXEVA 24

PFIZER COVID (12Y UP) VAC(EUA) 187

PFIZER COVID (5-11Y) VAC (EUA) 187

PFIZER COVID-19 VACCINE (EUA) 187

PHENADOZ 25

phenazopyridine hcl 187

phendimetrazine tartrate 187

phendimetrazine tartrate er 187

phenelzine sulfate 23

phenobarbital 3

phenobarbital sodium 187

PHENOHYTRO 187

phenol 187

phenoxybenzamine hcl 54

phentolamine mesylate 187

phenylephrine hcl 187

phenylephrine hcl-0.9% nacl 187

PHENYTEK 5

phenytoin 5

phenytoin sodium 5,188

phenytoin sodium extended 5

PHESGO 188

PHEXXI 188

PHILITH 91

PHOSLYRA 77

PHOSPHOLINE IODIDE 107

PHOTOFRIN 188

PHYSICIANS EZ USE B-12 188

PHYSIOLYTE 116

PHYSIOSOL 116

phytonadione 188

PICATO 69

PIFELTRO 188

pilocarpine hcl 66

pimecrolimus 69

pimozide 40

PIMTREA 91

pindolol 57

pioglitazone hcl 49

pioglitazone-glimepiride 50

piperacillin-tazobactam 18,188

PIQRAY 188

PIRMELLA 91

piroxicam 9

PKU EASY 188

PKU PERIFLEX JUNIOR PLUS 188

PLASMA-LYTE 148 116

PLASMA-LYTE A PH 7.4 116

PLEGRIDY 188

PLEGRIDY PEN 188

PLENAMINE 118

PLENVU 188

PLEXION 188

PLIAGLIS 188

PNEUMOVAX 23 188

PNV 29-1 188


PNV-DHA 188

PNV-OMEGA 188

PNV-SELECT 188

PODOCON-25 188

podofilox 69

POLIVY 188

POLOCAINE 189

POLOCAINE-MPF 189

POLY-IRON 150 FORTE 189

POLY-VI-FLOR 189

POLY-VI-FLOR WITH IRON 189

POLYCIN 105

polyethylene glycol 3350 75

polymyxin b sul-trimethoprim 105

polymyxin b sulfate 15

POMALYST 31

PONTOCAINE 189

PONVORY 189

PORTIA 91

posaconazole 189

potass cit-sod cit-citric acid 189

potassium acetate 189

potassium chloride 116,189

potassium chloride in d5lr 118

potassium chloride-0.9% nacl 116

potassium chloride-nacl 116

potassium citrate er 116

potassium citrate-citric acid 189

potassium cl-lidocaine-ns 189

potassium phosphate 189

potassium phosphate-0.9% nacl 189

pr benzoyl peroxide 189

PR CREAM 189

PR NATAL 400 189

PR NATAL 400 EC 189

PR NATAL 430 189

PR NATAL 430 EC 189

PRADAXA 52,189

pralidoxime chloride 189

PRALUENT PEN 190

pramipexole dihydrochloride 39

pramipexole er 39,40

PRAMOSONE 190

prasugrel hcl 54

pravastatin sodium 62

praziquantel 38

prazosin hcl 54

PRECEDEX 190

precision xtra 190

PRED MILD 106

PRED-G 105

prednicarbate 80

prednisolone 80

prednisolone ac-moxiflox-bromf 190

prednisolone acetate 106

prednisolone sodium phos odt 80,190

prednisolone sodium phosphate 80,106

prednisone 80

PREFEST 91

pregabalin 2

pregabalin er 190

PREMARIN 83

PREMASOL 118

PREMPHASE 91

PREMPRO 92

PRENA1 PEARL 190

PRENA1 TRUE 190

PRENATA 190

PRENATABS FA 190

PRENATABS RX 190

prenatal low iron 190

prenatal plus 190

prenatal vitamin plus low iron 190

prenatal-u 190

PREPIDIL 190

PREPLUS 190

PREPOPIK 75

PRESTALIA 190

PRETAB 190

pretomanid 190

PREVACID 75

PREVALITE 63


PREVIDENT 190

PREVIDENT 5000 DRY MOUTH 190

PREVIDENT 5000 ORTHO DEFENSE 190

PREVIDENT 5000 PLUS 190

PREVIDENT 5000 SENSITIVE 190

PREVIFEM 92

PREVNAR 13 190

PREVNAR 20 191

PREVYMIS 191

PREZCOBIX 191

PREZISTA 45

PRIALT 191

PRIFTIN 30

PRIKAAN 11

PRIKAAN LITE 12

PRILOSEC 191

PRILOVIX PLUS 12

primaquine 38

primidone 3

PRIMSOL 15

PRISMASOL 191

PRISTIQ 24,191

PRIVIGEN 101

pro comfort spacer with mask 191

PRO DNA COLLECTION 191

PRO DNA MEDICATED COLLECTION 191

probenecid 28

probenecid-colchicine 28

procainamide hcl 56,191

PROCALAMINE 118

procare pediatric nebulizer 191

procare spacer with adult mask 191

procare spacer with child mask 191

prochlorperazine 25

prochlorperazine edisylate 25

prochlorperazine maleate 25

PROCRIT 53

PROCTO-MED HC 80

PROCTO-PAK 80

PROCTOFOAM-HC 191

PROCTOSOL-HC 80

PROCTOZONE-HC 80

PROCYSBI 191

PROFERRIN-FORTE 191

PROFILNINE 191

progesterone 95,191

PROGRAF 99,191

PROHANCE 191

PROHANCE MULTIPACK 191

PROLASTIN C 113

PROLATE 191,192

PROLENSA 106

PROLEUKIN 37

PROMACTA 53,192

promethazine hcl 25

promethazine-codeine 192

promethazine-dm 192

promethazine-phenyleph-codeine 192

promethazine-phenylephrine 113

PROMETHEGAN 25

PROMISEB 192

propafenone hcl 56

propafenone hcl er 56

propantheline bromide 104

proparacaine hcl 105

propofol 192

propranolol hcl 57

propranolol hcl er 57

propranolol-hydrochlorothiazid 59

propylthiouracil 98

PROQUAD 102

PROSOL 119

PROSTIN E2 VAGINAL SUPPOSITORY 192

PROSTIN VR PEDIATRIC 192

protamine sulfate 192

PROTECT IRON 192

PROTONIX 75

PROTONIX IV 75

PROTOPIC 69

protriptyline hcl 25

PROVENGE 192

PROVERA 95


PROVIDA OB 192

PROVOCHOLINE 192

PSORCON 80

PULMICORT 109

PULMICORT FLEXHALER 109

PULMOSAL 192

PULMOZYME 113

PUREVIT DUALFE PLUS 192

PURIXAN 192

PYLERA 73

pyrazinamide 30

pyridostigmine bromide 29,192

pyridostigmine bromide er 29

pyridoxine hcl 192

QQBRELIS 192

QBREXZA 192

QDOLO 192

QELBREE 192,193

QINLOCK 193

QMIIZ ODT 193

QNASL 109

QNASL CHILDREN 193

QSYMIA 193

QTERN 193

QUADRACEL DTAP-IPV 193

QUARTETTE 193

quazepam 193

QUDEXY XR 193

QUELICIN 193

quetiapine fumarate 22

quetiapine fumarate er 22,23

QUFLORA FE 193

QUILLICHEW ER 193

QUILLIVANT XR 65

quinapril hcl 55

quinapril-hydrochlorothiazide 59

quinidine gluconate 56

quinidine sulfate 56

quinine sulfate 38

QULIPTA 193

QUTENZA 193

QVAR REDIHALER 109

RR-GENE 10 193

R-NATAL OB 193

RABAVERT 102

rabeprazole sodium 75

RADIAPLEXRX 193

RADIOGARDASE 193

raloxifene hcl 193

ramelteon 114

ramipril 55

RANEXA 60

ranitidine hcl 74

ranolazine er 60

RAPAFLO 77

RAPAMUNE 99,100

rasagiline mesylate 40

RASUVO 193

RAVICTI 71

RAYALDEE 194

RAYOS 80

READI-CAT 2 194

REBINYN 194

REBLOZYL 194

RECLIPSEN 92

RECOMBINATE 194

RECOMBIVAX HB 102

RECOTHROM 194

RECTIV 63

REDITREX 194,195

REGENECARE 12

REGONOL 104

RELADOR PAK 12

RELADOR PAK PLUS 12

RELAFEN DS 195

RELAGARD 195

RELENZA 46

RELEXXII 195


RELISTOR 73,195

RELPAX 29

RELTONE 195

REMODULIN 112

RENA-VITE RX 195

RENAL CAPS 195

RENFLEXIS 195

RENVELA 77

repaglinide 49

repaglinide-metformin hcl 50

REPATHA PUSHTRONEX 195

REPATHA SURECLICK 195

REPATHA SYRINGE 195

REQ49+ 195

RESCRIPTOR 43

RESECTISOL 195

RESPA A.R. 195

RESTASIS 105

RESTASIS MULTIDOSE 105

RETACRIT 195

RETEVMO 196

RETIN-A 69

RETIN-A MICRO 69

RETIN-A MICRO PUMP 69,196

RETISERT 196

RETROVIR 44

REVATIO 112,196

REVLIMID 31,196

REVONTO 196

REXULTI 196

REYATAZ 45,196

REYVOW 196

RHOFADE 196

RHOGAM ULTRA-FILTERED PLUS 196

RHOPHYLAC 196

RHOPRESSA 196

RIASTAP 196

RIBASPHERE 46

RIBASPHERE RIBAPAK 46

ribavirin 46

RIDAURA 101

rifabutin 30

RIFADIN 30

RIFAMATE 30

rifampin 30

RIFATER 30

riluzole 65

rimantadine hcl 46

RIMSO-50 196

ringers injection 119

ringers irrigation 119

RINVOQ 196

RIOMET 49

RIOMET ER 197

risedronate sodium 103

risedronate sodium dr 104

RISPERDAL 41

RISPERDAL CONSTA 41

risperidone 42

risperidone odt 42

RITALIN LA 65

ritonavir 45

RITUXAN 197

RITUXAN HYCELA 197

rivastigmine 22

RIVELSA 197

rizatriptan 29

ROBAXIN 197

ROCKLATAN 197

rocuronium bromide 197

romidepsin 197

ropinirole er 40

ropinirole hcl 40

ropivacaine hcl 197

ropivacaine hcl-0.9% nacl 197

ROSADAN 15,16

ROSANIL 197

ROSULA 197

rosuvastatin calcium 62

rosuvastatin-ezetimibe 197

ROSZET 197

ROTARIX 197


ROTATEQ 102

ROWASA 103

ROWEEPRA 2

ROWEEPRA XR 2

ROZEREM 114

ROZLYTREK 198

RUBRACA 198

RUCONEST 198

rufinamide 5

RUKOBIA 198

RUXIENCE 198

RUZURGI 198

RYANODEX 198

RYBELSUS 198

RYDAPT 198

RYTARY 198

RYTHMOL SR 56

SSABRIL 3

safety syringe-needle 198

SAFYRAL 92

SAJAZIR 98

salicylic acid 198

SALIVAMAX 198

salsalate 198

SALVAX 198

SALVAX DUO PLUS 199

SANADERMRX 199

SANCUSO 26

SANDIMMUNE 100

SANDOSTATIN 97

SANDOSTATIN LAR DEPOT 97

SANTYL 69

SAPHRIS 42,199

sapropterin dihydrochloride 71,199

SAVAYSA 199

SAVELLA 66

SCALACORT 80

SCALACORT DK 199

SCANDONEST PLAIN 199

SCLEROSOL 199

scopolamine 25

SE-NATAL 19 199

SE-NATAL-19 199

SE-TAN PLUS 199

SEASONIQUE 92

SECUADO 199

SEEBRI NEOHALER 199

SEGLUROMET 199

SELECT-OB 199

SELECT-OB + DHA 199

selegiline hcl 40

selenium 199

selenium sulfide 69,199

SELZENTRY 44,199

SEMPREX-D 113

SENSORCAINE 199

SENSORCAINE WITH DEXTROSE 199

SENSORCAINE-EPINEPHRINE 199

SENSORCAINE-MPF 199

SENSORCAINE-MPF EPINEPHRINE 199

SEREVENT DISKUS 110

SERNIVO 200

SEROQUEL 23

SEROQUEL XR 23

sertraline hcl 24

SETLAKIN 92

sevelamer carbonate 77

sevelamer hcl 77

SEVENFACT 200

sevoflurane 200

SEYSARA 200

SF 200

SF 5000 PLUS 200

SHAROBEL 96

SHINGRIX 200

SHINGRIX ADJUVANT COMPONENT 200

SHINGRIX GE ANTIGEN COMPONENT 200

SIGNIFOR 97

SIGNIFOR LAR 200

SIKLOS 200


sildenafil citrate 112,200

SILENOR 114

SILIKON 1000 200

SILIQ 200

silodosin 77

silver nitrate 200

silver nitrate applicator 200

silver sulfadiazine 20

SIMBRINZA 105

SIMLIYA 92

SIMPESSE 92

SIMPLY SLEEP 200

SIMPONI 100,200

SIMPONI ARIA 200

SIMULECT 200

simvastatin 62

SINOGRAFIN 200

sirolimus 100

SIRTURO 30,200

SITAVIG 201

SITZMARKS 201

SIVEXTRO 201

SKELAXIN 114

SKYRIZI 201

SKYRIZI (2 SYRINGES) KIT 201

SKYRIZI PEN 201

sod ferric gluconate complex 201

sodium acetate 201

sodium bicarbonate 201

sodium bicarbonate-d5w 201

sodium bicarbonate-water 201

sodium chloride 117,201

sodium chloride-water 117

sodium citrate 201

sodium citrate-citric acid 201

sodium fluoride 117,201

SODIUM FLUORIDE 5000 DRY MOUTH 201

sodium fluoride enamel protect 202

sodium fluoride sensitive 202

sodium iodide i-131 202

sodium nitrite 202

sodium phenylacet-sod benzoate 202

sodium phenylbutyrate 72

sodium phosphate 202

sodium phosphate-0.9% nacl 202

sodium polystyrene sulfonate 115

sodium sulfacetamide 202

sodium sulfacetamide-sulfur 202

sodium thiosulfate 202

sofosbuvir-velpatasvir 202

SOLARAZE 69

solifenacin succinate 76

SOLIQUA 100-33 202

SOLODYN 21

SOLOSEC 202

SOLTAMOX 31

SOLU-CORTEF 80

SOLU-MEDROL 80

SOMATULINE DEPOT 97

SOMAVERT 97,98,202

SONAFINE 202

SOOLANTRA 202

sorbitol 202

sorbitol-mannitol 202

SORILUX 69

SORINE 56

sotalol 56

SOTALOL AF 56

sotalol hcl 56

SOTRADECOL 202

SOTYLIZE 202

SOVALDI 202,203

space chamber 203

space chamber-large mask 203

space chamber-medium mask 203

space chamber-small mask 203

SPECTRACEF 203

spinosad 39

SPIRIVA 109

SPIRIVA RESPIMAT 203

spironolactone 61

spironolactone-hctz 59


SPRAVATO 203

SPRAY AND STRETCH 203

SPRINTEC 92

SPRITAM 203

SPRIX 9

SPRYCEL 34

SPS 115

SRONYX 92

SSD 20

SSS 10-5 203

ST. JOSEPH ASPIRIN 203

ST. JOSEPH ASPIRIN EC 203

stavudine 44

STEGLATRO 203

STEGLUJAN 203

STELARA 69,203

sterile talc 203

sterile water (grifols factor) 203

sterile water (shire) 203

STERILE WATER DILUENT-CABLIVI 203

sterile water for activase 203

sterile water for aralast np 203

sterile water for berinert 203

sterile water for gammagard 204

sterile water for humate-p 204

STERILE WATER FOR KCENTRA 204

sterile water for prolastin-c 204

sterile water for tnkase 204

sterile water for zemaira 204

STIMATE 81

STIOLTO RESPIMAT 204

STIVARGA 34

STRATTERA 65

STRENSIQ 204

streptomycin sulfate 13

STRIANT 204

STRIBILD 43

STRIVERDI RESPIMAT 204

STROMECTOL 38

strong iodine 204

SUBOXONE 12

SUBSYS 11

SUBVENITE 4

SUBVENITE (BLUE) 4

SUBVENITE (GREEN) 4

SUBVENITE (ORANGE) 4

succinylcholine chloride 204

succinylcholine chloride-nacl 204

SUCRAID 72

sucralfate 75

sufentanil citrate 204

SULAR 57

sulfacetamide sodium 20

sulfacetamide-prednisolone 105

SULFACLEANSE 8-4 204

sulfadiazine 20

sulfamethoxazole-trimethoprim 20

SULFAMYLON 16

sulfasalazine 103

sulfasalazine dr 103

SULFATRIM 20

sulindac 9

sumatriptan 29

sumatriptan succ-naproxen sod 28

sumatriptan succinate 29

sunitinib malate 34,204

super b complex 204

super b complex-vitamin c 204

super vitamin b complex 204

SUPERVITE 204

SUPPRELIN LA 204

SUPRANE 204

SUPRAX 17

SUPREP 119

SURE RESULT TAC PAK 204

SURFAXIN 204

SURVANTA 204

SUSTIVA 43

SUSTOL 205

SUTAB 205

SWABFLUSH 205

SYEDA 92


SYLATRON 46

SYLVANT 205

SYMBICORT 113

SYMDEKO 205

SYMJEPI 205

SYMLINPEN 120 49

SYMLINPEN 60 49

SYMPAZAN 205

SYMPROIC 205

SYMTUZA 205

SYNAGIS 205

SYNALAR TS 80

SYNAREL 98

SYNDROS 205

SYNERA 103

SYNERCID 14

SYNJARDY 205

SYNJARDY XR 205

SYNRIBO 37

SYNTHROID 96

syringe 205

SYRINGE AVITENE 205

syringe slip tip 205

syringe-needle 205

TTABLOID 32

TABRECTA 206

TACHOSIL 206

TACLONEX 69

tacrolimus 69,100

tadalafil 112

TAFINLAR 34

TAGRISSO 206

TAKHZYRO 206

TALICIA 206

TALTZ AUTOINJECTOR 206

TALTZ AUTOINJECTOR (2 PACK) 206

TALTZ AUTOINJECTOR (3 PACK) 206

TALTZ SYRINGE 206

TALZENNA 206

TAMIFLU 46

tamoxifen citrate 31

tamsulosin hcl 77

TANDEM PLUS 206

TAPERDEX 206

TARGRETIN 37

TARINA 24 FE 92

TARINA FE 92

TARINA FE 1-20 EQ 92

TARON FORTE 206

TARON-C DHA 206

TASIGNA 34,206

TASMAR 39

tavaborole 206

TAVALISSE 206

TAYSOFY 92

TAYTULLA 92

tazarotene 70,207

TAZICEF 17

TAZORAC 70

TAZTIA XT 58

TAZVERIK 207

tc99m mebrofenin prep 207

tc99m medronate prep 207

tc99m pyrophosphate prep 207

tc99m sestamibi prep 207

tc99m sulfur colloid prep 207

tdvax 102

TEFLARO 17

TEGRETOL XR 5

TEKTURNA HCT 59

telmisartan 55

telmisartan-amlodipine 59

telmisartan-hydrochlorothiazid 59

temazepam 114

TEMIXYS 207

TEMODAR 207

temozolomide 207

temsirolimus 100

teniposide 207

TENIVAC 207


tenofovir disoproxil fumarate 44

TEPMETKO 207

terazosin hcl 54

terbinafine hcl 27

terbutaline sulfate 110

terconazole 27

teriparatide 207

TERRELL 207

TESTIM 81

TESTONE CIK 207

TESTOPEL 207

testosterone 81,207,208

testosterone enanthate 81

TESTRED 81

TETCAINE 208

tetrabenazine 65

tetracaine hcl 208

tetracycline hcl 208

TEXACORT 208

THALITONE 208

thallous chloride tl-201 208

THALOMID 31

THAM 208

THEO-24 208

theophylline 111

theophylline anhydrous 111

theophylline in 5% dextrose 208

thiamine hcl 208

THIOLA 208

THIOLA EC 208

thioridazine hcl 40

thiothixene 41

THROMBATE III 208

THROMBI-GEL 208

THROMBI-PAD 208

THROMBIN-JMI 208

THYMOGLOBULIN 101

THYQUIDITY 208

THYROGEN 208

thyroid 208

TIADYLT ER 58

tiagabine hcl 3

TIBSOVO 208

TICOVAC 209

TIGAN 25

tigecycline 16

TIGLUTIK 209

TIKOSYN 56

TILIA FE 92

timolol maleate 28,107

TIMOPTIC 107

TIMOPTIC OCUDOSE 107

TIMOPTIC-XE 107

tinidazole 16

tiopronin 209

TIROSINT 209

TIROSINT-SOL 209

TIVICAY 209

TIVICAY PD 209

TIVORBEX 209

tizanidine hcl 42

TNKASE 209

TOBI 14

TOBI PODHALER 111

TOBRADEX 14

TOBRADEX ST 105

tobramycin 14

tobramycin sulfate 14

tobramycin sulfate in ns 14

tobramycin-dexamethasone 105

TOBREX 14

TOLAK 209

tolcapone 39

tolmetin sodium 9

TOLSURA 209

tolterodine tartrate 76

tolterodine tartrate er 76

tolvaptan 115

TOPICORT 80

topiramate 5

topiramate er 209

TOPOSAR 32


topotecan hcl 32

TOPROL XL 57

toremifene citrate 31

TORISEL 100

torsemide 61

TOSYMRA 209

TOUJEO MAX SOLOSTAR 209

TOUJEO SOLOSTAR 209

TOVIAZ 76

TOXICOLOGY SALIVA COLLECTION 209

TPN ELECTROLYTES 119

TPN ELECTROLYTES II 119

TPOXX (NATIONAL STOCKPILE) 209

TRACLEER 209

TRADJENTA 49

tramadol hcl 11,209

tramadol hcl er 10,209

tramadol hcl-acetaminophen 7

trandolapril 55

trandolapril-verapamil er 59,60

tranexamic acid 53

TRANSDERM-SCOP 25

TRANXENE T-TAB 3

tranylcypromine sulfate 23

TRAVASOL 119

TRAVATAN Z 107

travoprost 107

TRAZIMERA 209

trazodone hcl 24

TREANDA 37

TRELEGY ELLIPTA 209

TRELSTAR 98

TREMFYA 210

treprostinil 112

TRESIBA 210

TRESIBA FLEXTOUCH U-100 210

TRESIBA FLEXTOUCH U-200 210

TRETIN-X 70,210

tretinoin 37,70

tretinoin microsphere 70

TRETTEN 210

TREXALL 100

TREXIMET 28

TREZIX 210

TRI FEMYNOR 93

TRI-BUFFERED ASPIRIN 210

TRI-ESTARYLLA 93

TRI-LEGEST FE 93

TRI-LINYAH 93

TRI-LO-ESTARYLLA 93

TRI-LO-MARZIA 93

TRI-LO-MILI 93

TRI-LO-SPRINTEC 93

TRI-LUMA 210

TRI-MILI 93

TRI-NYMYO 93

TRI-PREVIFEM 93

TRI-SPRINTEC 93

TRI-VI-FLOR 210

tri-vitamin with fluoride 210

TRI-VYLIBRA 93

TRI-VYLIBRA LO 93

triacetin 210

triamcinolone acetonide 66,80,210

triamterene 61

triamterene-hydrochlorothiazid 60

TRIANEX 80

triazolam 47

TRIBENZOR 60

trichloroacetic acid 210

TRICITRASOL 210

TRICITRATES 210

TRICON 210

TRIDERM 80

trientine hcl 115

TRIESENCE 210

trifluoperazine hcl 41

trifluridine 47

TRIGELS-F FORTE 210

trihexyphenidyl hcl 39

TRIJARDY XR 210

TRIKAFTA 210


TRILEPTAL 5

TRILIPIX 61

TRILYTE WITH FLAVOR PACKETS 73

trimethobenzamide hcl 25

trimethoprim 16

trimipramine maleate 25

TRINATAL RX 1 210

TRINATE 210

TRINTELLIX 210

TRIPHROCAPS 211

TRIPLE DYE 211

TRIPTODUR 211

TRITOCIN 80

TRIUMEQ 211

TRIVEEN-DUO DHA 211

TRIVORA-28 93

TRIZIVIR 44

TROKENDI XR 211

TROPHAMINE 119

tropicamide 211

trospium chloride 76

trospium chloride er 76

TRUDHESA 211

TRULANCE 211

TRULICITY 211

TRUMENBA 211

TRUSELTIQ 211

TRUST NATAL DHA 211

TRUVADA 211

TUDORZA PRESSAIR 110

TUKYSA 211

TULANA 96

TURALIO 211

TUSSICAPS 212

TUXARIN ER 212

TUZISTRA XR 212

TWINRIX 212

TWIRLA 212

TWYNSTA 60

TYBLUME 93

TYBOST 212

TYDEMY 93

TYGACIL 16

TYMLOS 212

TYPHIM VI 102

TYVASO 112

TYVASO INSTITUTIONAL START KIT 112

TYVASO REFILL KIT 112

TYVASO STARTER KIT 112

UUBRELVY 212

UCERIS 80

UDENYCA 212

UKONIQ 212

ULESFIA 39

ULORIC 28

ULTIVA 212

ultra-fine micro pen needle 212

ULTRAFOAM 212

ULTRAVATE 212

ULTRAVIST 212

UMECTA 212

UNITHROID 96

UNITUXIN 212

UPTRAVI 212

URE-K 212

urea 212

URELLE 212

URETRON D-S 212

URIBEL 213

UROCIT-K 117

UROGESIC-BLUE 213

UROQID-ACID NO.2 213

URSO 73

ursodiol 73,213

URYL 213

USTELL 213

UTIBRON NEOHALER 213

UVADEX 70


VV-C FORTE 213

VAGIFEM 83

valacyclovir 47

VALCHLOR 213

VALCYTE 45

valganciclovir hcl 45

valproate sodium 3

valproic acid 3

valrubicin 213

valsartan 55

valsartan-hydrochlorothiazide 60

VALSTAR 213

VALTOCO 213

VANATOL LQ 7

vancomycin 16

vancomycin hcl 16,213

vancomycin hcl-0.9% nacl 16,213

vancomycin hcl-d5w 16,213

VANOS 80

VANTAS 213

VAPRISOL-5% DEXTROSE 213

VAQTA 213

varenicline tartrate 13

VARITHENA 213

VARIVAX VACCINE 102

VARIZIG 213

VARUBI 213

VASCEPA 63,213

VASELINE WHITE PETROLEUM 213

VASOSTRICT 214

VAXCHORA VACCINE 214

VAXELIS 214

VAXNEUVANCE 214

VECAMYL 60

VECTIBIX 214

vecuronium bromide 214

vecuronium bromide-water 214

VELCADE 37

VELETRI 214

VELIVET 93

VELPHORO 214

VELTASSA 214

VELTIN 70

VEMLIDY 214

VENCLEXTA 214

VENCLEXTA STARTING PACK 214

VENELEX 214

venlafaxine hcl 24

venlafaxine hcl er 24

VENOFER 214

VENTAVIS 112

verapamil er 58

verapamil er pm 58

verapamil hcl 58

verapamil sr 58

VERDESO 81

VEREGEN 70

VERQUVO 214

VERSACLOZ 214

VERZENIO 214

VESICARE 76

VESICARE LS 214

VFEND 27

VIBERZI 214

VIBRAMYCIN 21

VIC-FORTE 215

VICODIN HP 7

VICTOZA 2-PAK 49

VICTOZA 3-PAK 49

VIDAZA 37

VIDEX 44

VIDEX EC 44

VIENVA 93

vigabatrin 4

VIGADRONE 4

VIIBRYD 24,215

VIMIZIM 215

VIMPAT 5,6,215

VINATE ONE 215

VINATE-M 215


vinblastine sulfate 37

VINCASAR PFS 37

vincristine sulfate 37

vinorelbine tartrate 37

VIOKACE 73

VIORELE 93

VIRACEPT 45

VIRAMUNE 43

VIRAMUNE XR 43

VIRAZOLE 46

VIREAD 46

VIRT-C DHA 215

VIRT-CAPS 215

VIRT-GARD 215

VIRT-NATE DHA 215

VIRT-PHOS 250 NEUTRAL 215

VIRT-PN PLUS 215

VIRTRATE-2 215

VIRTRATE-3 215

VIRTRATE-K 215

VISCOAT 215

VISIONBLUE 215

VISIPAQUE 215

VISUDYNE 215

VITA-RESPA 215

VITAFOL GUMMIES 215

VITAFOL-OB+DHA 215

vitamin b12-folic acid 215

vitamin d2 215

vitamin k1 215

vitamins a,c,d and fluoride 216

VITRAKVI 216

VITRASE 216

VIVACAINE 216

VIVELLE-DOT 83

VIVITROL 12

VIZIMPRO 216

VOCABRIA 216

VOGELXO 81

VOLNEA 94

VOLTAREN 70

VOLTAREN-XR 9

VORAXAZE 216

voriconazole 27

VOSEVI 216

VOTRIENT 34

VPRIV 72

VRAYLAR 216

VTOL LQ 7

VYFEMLA 94

VYLIBRA 94

VYNDAMAX 216

VYNDAQEL 216

VYTORIN 60

VYVANSE 64,216

VYXEOS 216

VYZULTA 216

WWAKIX 217

warfarin sodium 52

wasp venom protein 217

water 104,217

WELCHOL 49

WELLBUTRIN SR 13

WERA 94

WESTHROID 217

white-faced hornet venom 217

WILATE 217

willis the whale compressr neb 217

WILZIN 217

WINLEVI 217

WINRHO SDF 217

WIXELA INHUB 113

WP THYROID 217

WYMZYA FE 94

WYNZORA 217

XXADAGO 217

XALKORI 34

XARELTO 52,217


XATMEP 217

XCLAIR 217

XCOPRI 217

XELJANZ 100,217

XELJANZ XR 218

XELODA 218

XELPROS 218

XEMBIFY 218

XENAZINE 65

XENICAL 218

XEOMIN 104,218

XEPI 218

XERESE 47

XERMELO 218

XEROSTOMIA RELIEF 218

XGEVA 104

XHANCE 218

XIAFLEX 218

XIFAXAN 16

XIGDUO XR 218

XIIDRA 218

XOFIGO 218

XOFLUZA 218

XOLAIR 218,219

XOLEGEL 219

XOPENEX CONCENTRATE 111

XOPENEX HFA 111

XOSPATA 219

XPOVIO 219

XTAMPZA ER 219

XTANDI 31,219,220

XULANE 220

XYLOCAINE 12

XYLOCAINE WITH EPINEPHRINE 220

XYLOCAINE-MPF 12

XYLOCAINE-MPF WITH EPINEPHRINE 220

XYNTHA 220

XYNTHA SOLOFUSE 220

XYOSTED 220

XYREM 115

XYWAV 220

YYASMIN 28 94

YAZ 94

yellow hornet venom protein 220

YERVOY 220

YF-VAX 102

YONDELIS 220

YONSA 220

YUPELRI 220

YUVAFEM 83

ZZAFEMY 220

zafirlukast 109

zaleplon 114

ZALTRAP 220

ZALVIT 221

ZANAFLEX 42

ZANOSAR 37

ZANTAC 74

ZARAH 94

ZARXIO 221

ZATEAN-PN DHA 221

ZATEAN-PN PLUS 221

ZAVESCA 72

ZEBUTAL 7

ZEGALOGUE AUTOINJECTOR 221

ZEGALOGUE SYRINGE 221

ZEJULA 221

ZELAPAR 40

ZELBORAF 34

ZELNORM 221

ZEMAIRA 113

ZEMBRACE SYMTOUCH 221

ZEMPLAR 104

ZENATANE 70

ZENPEP 72,73,221

ZENZEDI 64,221

ZEPOSIA 221

ZERBAXA 221


ZERVIATE 221

ZETIA 63

ZETONNA 109

ZEVALIN 221

ZIAGEN 44

ZIANA 70

zidovudine 44

ZIEXTENZO 221

zileuton er 109

zinc chloride 221

zinc sulfate 221

ZINGIBER 221

ZIOPTAN 108

ziprasidone hcl 42

ziprasidone mesylate 42

ZIPSOR 221

ZIRABEV 221

ZIRGAN 45

ZOFRAN 26

ZOHYDRO ER 222

ZOLADEX 222

zoledronic acid 104

ZOLINZA 32

zolmitriptan 29,222

zolmitriptan odt 29

zolpidem tartrate 114

zolpidem tartrate er 114

ZOLPIMIST 114

ZOMIG 29,222

ZOMIG ZMT 29

zonisamide 2

ZONTIVITY 222

ZORTRESS 100,222

ZORVOLEX 222

ZOSYN 19,222

ZOVIA 1-35 94

ZOVIA 1-35E 94

ZOVIRAX 47

ZTLIDO 222

ZUBSOLV 222

ZUMANDIMINE 94

ZUPLENZ 222

ZYCLARA 70,222

ZYDELIG 222

ZYFLO 109

ZYKADIA 222

ZYLET 105

ZYLOPRIM 28

ZYMAXID 20

ZYNLONTA 222

ZYNRELEF 222

ZYPITAMAG 222

ZYPREXA 42

ZYPREXA RELPREVV 222

ZYVOX 16,222


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