Commercial Formulary

Kaiser Permanente Insurance Company (KPIC)Point-of-Service (POS) Drug Formulary

For California Point-of-Service (POS) Grandfathered Plans Effective October 1, 2018 - December 31, 2018 This document contains information regarding the drugs that are covered when you participate in our Point-of-Service (POS) Health Insurance Plan(s) and use a MedImpact pharmacy. If you belong to our POS plan and you intend to fill your prescriptions at a Kaiser Permanente pharmacy, please visit kp.org/formulary for details on the drugs covered through your HMO Tier benefit. Please note that this formulary does not have a specialty drug tier. If you are on a POS plan with a specialty drug tier, please see the Kaiser Permanente POS Formulary with Specialty Drug Tier.For help with this Formulary, please call MedImpact 24 hours a day, 7 days a week, at 1-800-788-2949 or 711 (TTY). Access to the most current version of the Formulary can be obtained by visiting kp.org/kpic/ca/formulary. For help in your preferred language, please see page 13 in this document. How to Use This DocumentThis document is a list of the approved prescription medications covered under your POS Health Insurance Plan. All drugs are listed by their generic names and the most common proprietary (brand) name. The Formulary may be accessed by using the index, either by the generic name (in italics) or the proprietary name (in CAPITAL letters) or by the therapeutic drug category. This document applies only to outpatient prescription drugs provided to you through a retail pharmacy within the MedImpact network. This document does not apply to medications used in the doctor’s office or in the hospital. The drugs in this formulary are grouped into categories depending on the type of medical condition that they are used to treat. Look under the category name in alphabetical order by generic name for your drug. For all drugs within the Drug Formulary table, the tier level is denoted throughout the document using the following symbols (refer to tablebelow). Tier Definition:Symbol Guideline Description

T1 & T5* Tier 1 & Tier 5 Preferred Generic Medications

T2 & T4T2 & T4

Tier 2 & Tier 4 Preferred Brand Medications

T3 Tier 3 Non-Preferred Generic and Brand Medications

T6** Tier 6 Self-Injectable Medications - NOT COVERED

*In addition to preferred generic medications, Tier 5 also contains some brand medications.**Self-Injectable Medications are not covered.

KPIC POS GF Page 1 of 195

Tier Benefit DesignThe Formulary may be applied to a tier benefit design, where the insured shares the cost of prescription drug therapy based on the drug’s tier and copay or coinsurance. In most instances, generically available drugs will be covered in a separate lower tier (lower copay), and branded drugs listed on the Formulary will be covered under a higher tier (higher copay). Maintaining and Updating the FormularyThe MedImpact Healthcare Systems Pharmacy and Therapeutics (P&T) and Formulary Committees provide physicians and pharmacists with a method to evaluate the safety, efficacy and competitive prices for commercially available drug products. The MedImpact P&T and Formulary Committees meet quarterly and more often as warranted to ensure clinical relevancy of the Formulary. The Formulary is updated by the MedImpact P&T and Formulary Committees using a structured approach to the drug selection process to ensure continuing patient access to rational drug therapies. The MedImpact P&T and Formulary Committees use the following criteria in the evaluation of drug selection for the Formulary:• Drug safety profile• Drug efficacy• Comparison of relevant therapeutic benefits to current formulary agents of similar use, and to minimize therapeutic duplication where possible

• Lower costs relative to comparable therapies What medications are covered?Your prescription drug benefit will generally cover prescribed generic and brand-name drugs listed on the Formulary as long as the drug is medically necessary, the prescription is filled by a MedImpact network pharmacy provider, and other coverage rules are followed. Over-the-counter (OTC) medications are not generally covered. Certain preventive OTC medications are covered when prescribed by a physician, such as aspirin, iron supplementation and vitamin D. Durable medical equipment, prescribed by a physician to treat diabetes or to assist with inhalation devices, is also covered. This may include insulin syringes, insulin needles, and inhaler spacers. Elective coverage of preventive drugs at no cost. Additionally, if your plan covers preventive drugs at no cost (because your group elected to include preventive-care benefits required under the Affordable Care Act in their grandfathered plan), then the drugs identified in the table below are covered at no cost share regardless of the drug tier indicated on the Formulary. All medications in the list are covered with no cost if the insured has a prescription from his or her doctor. However, some medications are only covered at no cost for patients who meet the criteria listed in the table below. Preventive medications covered at the pharmacy at no cost with elective coverage:Drug Coverage Criteria required for coverage

Aspirin Generics Only Requires prescription*.

Fluoride Generics Only Children between 6 months and 6 years of age.

Folic Acid (0.4mg, 0.8mg) Generics Only Requires prescription*.

Iron Generics OnlyChildren between 6 months and 12 months of age, requires prescription*.

Birth control, implants** Nexplanon N/A

Xulane transdermal patch contraceptive

Generics Only N/A

Nuvaring contraceptive Brand N/A

Birth control, barrier methods Brands and generics Requires prescription*.


Drug Coverage Criteria required for coverage

Birth control, oral tablets

Generics, Lo Loestrin FE, Minastrin 24 FE, Safyral, Natazia, Quartette and Taytulla

N/A

Birth control, injections** Depo-Provera N/A

Birth control, intrauterine devices**

Liletta, Mirena, Skyla and Copper IUDs

N/A

Tamoxifen Generics OnlyCovered at no cost when used for breast cancer prevention.

Raloxifene Generics OnlyCovered at no cost when used for breast cancer prevention.Requires previous trial of tamoxifen.

Emergency ContraceptivesLevonorgestrel - 1.5mg & Ella

Requires prescription*.

Smoking Cessation Brand and genericsAdults 18 years and older, requires prescription*.Quantity and Step Edits may apply.

Influenza Virus Vaccines BrandNeed insurance card for processing and in-store administration required. This does not require a prescription. Age edits may apply.

Colonoscopy Prep supplies Brand and generics Adults 50-75 years old, requires prescription*.

Statins

Low to moderate intensity statins

• Atorvastatin 10-20mg• Flolipid 20 mg/5mL, 40 mg/5mL

• Fluvastatin 20-40mg• Fluvastatin ER 80mg • Lovastatin 10-40mg• Lovastatin ER 20- 40mg

• Pitavastatin 1-4mg• Pravastatin 10-80mg• Rosuvastatin 5-10mg• Simvastatin 5-40mg• Zypitamag 1-4 mg

For qualifying adults for the primary prevention of cardiovascular disease (CVD)

*OTC medications require a prescription in order to be covered at no cost.**Injectable contraceptive formulations or implants such as Depo-Provera or IUDs may be covered under the medical benefit at this time (you are able to receive the medication free at no charge during a visit with a doctor or nurse).


What is a generic drug?A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Under your POS Plan, you will pay different copay or coinsurance for preferred generic drugs and non-preferred generic drugs. Preferred drugs cost you less than non-preferred drugs. What is a brand-name drug?Brand-name drugs are usually manufactured and sold by the drug company that originally researched and developed the drug. When the patent on a brand-name drug expires, other drug companies may manufacture and sell an FDA- approved generic version of the drug with the same active ingredient(s) at lower prices. Under your POS Plan, you will pay a different copay or coinsurance for preferred brand drugs and non-preferred brand drugs. Preferred drugs cost you less than non-preferred drugs. If you request a brand-name drug when a generic drug is prescribed, you may be responsible for paying the brand-name copay plus the difference in cost between the generic drug and the brand-name drug. Please see your Certificate of Insurance for details. What drugs are not covered?• Self-administered injectable drugs (refer to Tier 6 for details). • Over-the-counter (OTC) medications or their equivalents, except for those OTC medications included in this Formulary.

• Any drug product used for cosmetic purposes.• Experimental drug products or any drug product used in an experimental manner. Refer to your Certificate of

Insurance for additional information.• Replacement of lost or stolen medication.• Medications administered by a clinician unless otherwise specified in the Formulary listing.• Foreign-sourced drugs or drugs not approved by the United States Food & Drug Administration, except in certain cases of drug shortage, when allowed under the individual's pharmacy benefit.

How do I request an exception for a drug that is not on the Formulary?You can request an exception to obtain coverage of a drug that is not on the Formulary by calling MedImpact at 1-800-788-2949. Upon receipt of your exception request, MedImpact will notify you within 72 hours for non-urgent requests and within 24 hours if urgent circumstances exist, of the request approval or other outcome. (Urgent circumstances exist when an insured is suffering from a health condition that may seriously jeopardize the insured’s life, health or ability to regain maximum function or when you are using a drug while undergoing a current course of treatment.) If a standard exception request is granted, coverage of the non-formulary drug will be granted for the duration of the prescription, including refills. If an exception based on urgent circumstances is granted, coverage of the non-formulary drug will be granted for the duration of the urgency. Are there any restrictions on the drugs covered on the Formulary?Yes, for certain agents with the Formulary, a recommended prescribing guideline may apply. These are denoted throughout the document using the following symbols (refer to table below).


Guideline Symbol Table:Symbol Guidelines Description

AGE Age Edit Coverage depends on patient age.

PAPrior Authorization

Requires a prior authorization based on specific clinical criteria.See “What is a Prior Authorization?” below for additional information.

QL Quantity LimitCoverage is limited to specific quantities per prescription and/or time period. Prior authorization is required for quantities exceeding the restriction.

ST Step TherapyCoverage depends on previous use of another drug.Prior authorization may be required.See “What is Step Therapy?” below for additional information.

What is a Prior Authorization?A prior authorization (“PA”) is a technique that is used to encourage safe and competitively priced medication use. Many drugs have multiple indications so PAs are placed on drugs to make sure the drug is appropriate and safe for the insured. How does the program work?Drugs marked with a PA mean that your prescriber must first show that you have a medically necessary need for that particular drug. This means that to receive coverage your prescriber will need to work with MedImpact to receive pre-approval of the drug. Prior authorized drugs have specific clinical criteria that you must meet in order to obtain coverage. Refer to Requirements / Limits column in the Formulary for drugs that require a PA. Upon receipt of your prior authorization request, MedImpact will notify the licensed prescribing provider within 72 hours for non-urgent requests and within 24 hours if urgent circumstances exist of the request approval or other outcome. If MedImpact fails to respond within 72 hours for non-urgent requests and within 24 hours if urgent circumstances exist from receipt of a request form from a licensed prescribing provider, the request shall be deemed to have been approved. If you are not satisfied with the outcome, you can request a waiver by calling MedImpact at 1-800-788-2949. What is Step Therapy?Selected prescription drugs require step therapy. The step therapy program encourages safe and competitively priced medication use. Under this program, a “step” approach is required to receive coverage for certain high-cost medications. This means that to receive coverage you may need to first try a proven, lower cost medication before using a more costly treatment. How does the program work? The step therapy program requires that you have a prescription history for a “first-line” medication before your benefit plan will cover a “second-line” medication. A first-line medication is recognized as safe and effective in treating a specific medical condition, as well as keeping costs down. A second-line medication is a less- preferred or sometimes more costly treatment option. Refer to Step Therapy Edits in the Index section at the end of the Formulary for a complete list of medications requiring step therapy and their criteria. When possible, your doctor should prescribe a first-line medication appropriate for your condition. If your doctor determines that a first-line drug is not appropriate for you or is not effective for you, your prescription drug benefit will cover a second-line drug when certain conditions are met. When possible, your doctor should prescribe a first-line medication appropriate for your condition. If your doctor determines that a first-line drug is not appropriate for you or is not effective for you, your prescription drug benefit will cover a second-line drug when certain conditions are met. Prior authorization may be required. Upon receipt of your request for a second-line drug, MedImpact will notify the licensed prescribing provider within 72 hours for non-urgent requests and within 24 hours if exigent circumstances exist of the request approval or other outcome. If you are not satisfied with the outcome, you can request a waiver by calling MedImpact at 1-800-788-2949.


What drugs are eligible to be mailed from the mail-order pharmacy?This drug formulary only applies to drugs obtained at a MedImpact retail pharmacy. There is no mail-order pharmacy coverage available through MedImpact. Mail-order pharmacy coverage is provided under the HMO tier of the POS Plan through Kaiser Permanente mail-order pharmacy. Please see your Evidence of Coverage or visit kp.org/formulary for details of this benefit. Benefit Coverage and LimitationsThis printed Formulary does not provide information regarding the specific coverage and limitations you may be subject to. Specific benefit inclusions, exclusions, and out-of-pocket costs are not reflected in the Formulary. The Formulary applies only to outpatient drugs provided to you, and does not apply to medications used in an inpatient setting. For specific questions regarding your coverage, please call KPIC Customer Service at 1-800-788-0710. Kaiser Foundation Health Plan, Inc. (KFHP), underwrites the HMO tier of the Kaiser Permanente POS Plan and Kaiser Permanente Insurance Company (KPIC), a subsidiary of KFHP, underwrites the participating and non-participating tiers of the Kaiser Permanente POS Plan.








Nondiscrimination Notice

Kaiser Permanente Insurance Company (KPIC) does not discriminate based on race, color, national origin, ancestry,

religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.

Language assistance services are available from our Member Services Contact Center 24 hours a day, seven days a week

(except closed holidays). We can provide no cost aids and services to people with disabilities to communicate effectively

with us, such as: qualified sign language interpreters and written information in other formats; large print, audio, and

accessible electronic formats. We also provide no cost language services to people whose primary language is not

English, such as: qualified interpreters and information written in other languages. To request these services, please call

1-800-464-4000 (TTY users call 711).

If you believe that KPIC failed to provide these services or there is a concern of discrimination based on race, color,

national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability you can

file a complaint by phone or mail with the KPIC Civil Rights Coordinator. If you need help filing a grievance, the KPIC

Civil Rights Coordinator is able to help you.

KPIC Civil Rights Coordinator

Grievance 1557

5855 Copley Drive, Suite 250

San Diego, CA 92111 1-888-251-7052

You may also contact the California Department of Insurance regarding your complaint.

By Phone:

California Department of Insurance

1-800-927-HELP

(1-800-927-4357)

TDD: 1-800-482-4TDD

(1-800-482-4833)

By Mail:

California Department of Insurance

Consumer Communications Bureau

300 S. Spring Street

Los Angeles, CA 90013

Electronically:

www.insurance.ca.gov

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights

if there is a concern of discrimination based on race, color, national origin, age, disability, or sex. You can file the

complaint electronically through the Office for Civil Rights Complaint Portal, available at

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200

Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697

(TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

KPIC-ND18-010-CA (3/2018)




Drug Name Tier Requirements/Limits

ALLERGY2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS

DESLORATADINE/PSEUDOEPHEDRINE CLARINEX-D 12HOUR 3 ST, QL: 2 IN 1 DAY

fexofenadine/pseudoephedrineALLEGRA-D 24HOUR (180-240MG)(TAB ER 24H)

1

PSEUDOEPHEDRINE HCL/ACRIVAS SEMPREX-D 3ALLERGENIC EXTRACTS, THERAPEUTICS

GR POL-ORC/SW VER/RYE/KENT/TIM ORALAIR (100 IR)(TAB SUBL) 2 PA

GR POL-ORC/SW VER/RYE/KENT/TIM ORALAIR (100-300IR) (TAB SUBL) 3 PA

GR POL-ORC/SW VER/RYE/KENT/TIM ORALAIR (300 IR)(TAB SUBL) 2 PA

GRASS POLLEN-TIMOTHY, STANDARD GRASTEK 2 PAMITE,D.FARINAE-D.PTERONYSSINUS ODACTRA 2 PAWEED POLLEN-SHORT RAGWEED RAGWITEK 2 PA

ANTIHISTAMINES - 1ST GENERATIONcarbinoxamine maleate CLISTIN 1 AGE: >= 2 YEARS

CARBINOXAMINE MALEATE KARBINAL ER 3 ST, AGE: >= 2 YEARS, QL: 960mLIN 30 DAYS

carbinoxamine maleate PALGIC 1 AGE: >= 2 YEARS

carbinoxamine maleate RYVENT 1 ST, AGE: >= 2 YEARS, QL: 4 IN 1DAY

clemastine fumarate TAVIST 1cyproheptadine hcl PERIACTIN 1hydroxyzine hcl ATARAX 1hydroxyzine pamoate VISTARIL 1promethazine hcl PHENERGAN 1promethazine hcl PHENERGAN VC 1

ANTIHISTAMINES - 2ND GENERATION

cetirizine hcl ZYRTEC (1 MG/ML)(SOLUTION) 1

desloratadine CLARINEX (2.5 MG)(TAB RAPDIS) 1 ST, QL: 1 IN 1 DAY

DESLORATADINE CLARINEX (2.5MG/5ML) (SYRUP) 3 ST, QL: 10mL IN 1 DAY

desloratadine CLARINEX (5 MG)(TAB RAPDIS) 1 ST, QL: 1 IN 1 DAY

desloratadine CLARINEX (5 MG)(TABLET) 1 QL: 1 IN 1 DAY

levocetirizine dihydrochlorideXYZAL (2.5MG/5ML)(SOLUTION)

1 ST, QL: 10mL IN 1 DAY

levocetirizine dihydrochloride XYZAL (5 MG)(TABLET) 1

NASAL ANTIHISTAMINEazelastine hcl ASTELIN 1 QL: 60mL IN 30 DAYSazelastine hcl ASTEPRO 1 ST, QL: 60mL IN 30 DAYSolopatadine hcl PATANASE 1 ST, QL: 30.5gm IN 30 DAYS

NASAL ANTIHISTAMINE & ANTI-INFLAM. STEROID COMB.AZELAS/FLUTICASONE/SOD CHLORID TICALAST 3AZELASTINE/FLUTICASONE DYMISTA 3 ST, QL: 23gm IN 30 DAYS

NASAL ANTI-INFLAMMATORY STEROIDSBECLOMETHASONE DIPROPIONATE BECONASE AQ 3 ST, QL: 25gm IN 30 DAYSBECLOMETHASONE DIPROPIONATE QNASL 2 ST, QL: 8.7gm IN 30 DAYSBECLOMETHASONE DIPROPIONATE QNASL CHILDREN 2 ST, QL: 4.9gm IN 30 DAYS


Drug Name Tier Requirements/LimitsCICLESONIDE OMNARIS 3 ST, QL: 5gm IN 12 DAYSCICLESONIDE ZETONNA 3 ST, QL: 6.1gm IN 30 DAYSflunisolide NASALIDE 1 QL: 25mL IN 30 DAYSfluticasone propionate FLONASE 1 QL: 16gm IN 30 DAYSFLUTICASONE PROPIONATE XHANCE 3 ST, QL: 32mL IN 30 DAYSFLUTICASONE/SOD CHL/SOD BICARB TICANASE 3FLUTICASONE/SOD CHL/SOD BICARB TICASPRAY 3mometasone furoate NASONEX 1 QL: 17gm IN 30 DAYSMOMETASONE FUROATE SINUVA 3 PA

ANTIEMESIS/ANTIVERTIGOANTIEMETIC/ANTIVERTIGO AGENTS

aprepitant EMEND (125 MG)(CAPSULE) 1 QL: 1 IN 21 DAYS

APREPITANT EMEND (125 MG)(SUSP RECON) 2 QL: 3 IN 21 DAYS

aprepitant EMEND (125MG-80MG) (CAP DS PK) 1 QL: 3 IN 21 DAYS



DOLASETRON MESYLATE ANZEMET (100 MG)(TABLET) 3 ST, QL: 4 PER FILL

DOLASETRON MESYLATE ANZEMET (50 MG)(TABLET) 3 ST, QL: 8 PER FILL

DOXYLAMINE SUCCINATE/VIT B6 BONJESTA 3 QL: 2 IN 1 DAYDOXYLAMINE SUCCINATE/VIT B6 DICLEGIS 3 QL: 4 IN 1 DAYdronabinol MARINOL 1 ST, QL: 2 IN 1 DAYDRONABINOL SYNDROS 3 ST, QL: 60mL IN 30 DAYSGRANISETRON SANCUSO 3 ST, QL: 1 IN 7 DAYSgranisetron hcl KYTRIL 1 ST, QL: 8 IN 30 DAYSmeclizine hcl (12.5 mg) (tablet) 1meclizine hcl (25 mg) (tablet) 1NABILONE CESAMET 3 ST, QL: 6 IN 1 DAYNETUPITANT/PALONOSETRON HCL AKYNZEO 2 QL: 1 IN 28 DAYSondansetron ZOFRAN ODT 1

ONDANSETRON ZUPLENZ (4 MG)(FILM) 3 ST, QL: 2 IN 3 DAYS

ONDANSETRON ZUPLENZ (8 MG)(FILM) 3 ST, QL: 1 IN 3 DAYS

ondansetron hcl (24 mg) (tablet) 1ondansetron hcl (4 mg) (tablet) 1ondansetron hcl (4 mg/5 ml) (solution) 1 QL: 50mL IN 15 DAYSondansetron hcl (8 mg) (tablet) 1prochlorperazine COMPAZINE 1prochlorperazine maleate COMPAZINE 1promethazine hcl PHENERGAN 1ROLAPITANT HCL VARUBI 3 QL: 2 IN 14 DAYS

scopolamineTRANSDERM-SCOP(1 MG/3 DAY)(PATCH TD 3)

1

SCOPOLAMINETRANSDERM-SCOP(1 MG/3 DAY)(PATCH TD 3)

3

trimethobenzamide hcl TIGAN 1

ASTHMA AND COPD5-LIPOXYGENASE INHIBITORS

ZILEUTON ZYFLO 3 ST, QL: 4 IN 1 DAY


Drug Name Tier Requirements/Limitszileuton ZYFLO CR 1 ST, QL: 2 IN 1 DAY

ANTICHOLINERGIC, ORALLY INHALED SHORT ACTINGipratropium bromide ATROVENT 1IPRATROPIUM BROMIDE ATROVENT HFA 2 QL: 25.8gm IN 30 DAYS

ANTICHOLINERGICS, ORALLY INHALED LONG ACTING

ACLIDINIUM BROMIDE TUDORZAPRESSAIR 3 ST, QL: 1 IN 30 DAYS

GLYCOPYRROL/NEBULIZER/ACCESSOR LONHALAMAGNAIR STARTER 3 QL: 60mL IN 30 DAYS

GLYCOPYRROLATE SEEBRI NEOHALER 3 ST, QL: 60 IN 30 DAYS

GLYCOPYRROLATE/NEB.ACCESSORIES LONHALAMAGNAIR REFILL 3 QL: 60mL IN 30 DAYS

TIOTROPIUM BROMIDE SPIRIVA 2 QL: 30 IN 30 DAYSTIOTROPIUM BROMIDE SPIRIVA RESPIMAT 2 QL: 4gm IN 30 DAYSUMECLIDINIUM BROMIDE INCRUSE ELLIPTA 3 ST, QL: 30 IN 30 DAYS

BETA-ADRENERGIC AGENTSalbuterol sulfate 1metaproterenol sulfate ALUPENT 1terbutaline sulfate 1

BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTINGalbuterol sulfate 1ALBUTEROL SULFATE PROAIR HFA 2

ALBUTEROL SULFATE PROAIRRESPICLICK 2

ALBUTEROL SULFATE PROVENTIL HFA 3

ALBUTEROL SULFATEVENTOLIN HFA (90MCG) (HFA AERAD)

2

levalbuterol hcl XOPENEX 1

levalbuterol hcl XOPENEXCONCENTRATE 1

levalbuterol tartrate XOPENEX HFA 1BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTING

INDACATEROL MALEATE ARCAPTANEOHALER 3 ST, QL: 1 IN 1 DAY

OLODATEROL HCL STRIVERDIRESPIMAT 2 QL: 4gm IN 30 DAYS

BETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTINGARFORMOTEROL TARTRATE BROVANA 3 QL: 120mL IN 30 DAYSFORMOTEROL FUMARATE PERFOROMIST 2 QL: 120mL IN 30 DAYSSALMETEROL XINAFOATE SEREVENT DISKUS 2 QL: 60 IN 30 DAYS

BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS

GLYCOPYRROLATE/FORMOTEROL FUM BEVESPIAEROSPHERE 3 ST, QL: 10.7gm IN 30 DAYS

INDACATEROL/GLYCOPYRROLATE UTIBRONNEOHALER 3 ST, QL: 60 IN 30 DAYS

IPRATROPIUM/ALBUTEROL SULFATE COMBIVENTRESPIMAT 2

ipratropium/albuterol sulfate DUONEB 1TIOTROPIUM BR/OLODATEROL HCL STIOLTO RESPIMAT 2 QL: 4gm IN 30 DAYSUMECLIDINIUM BRM/VILANTEROL TR ANORO ELLIPTA 2 QL: 60 IN 30 DAYS

BETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONSBUDESONIDE/FORMOTEROL FUMARATE SYMBICORT 2 QL: 10.2gm IN 30 DAYSFLUTICASONE/SALMETEROL ADVAIR DISKUS 2 QL: 60 IN 30 DAYSFLUTICASONE/SALMETEROL ADVAIR HFA 2 QL: 12gm IN 30 DAYS

fluticasone/salmeterol AIRDUORESPICLICK 3 QL: 1 IN 30 DAYS

FLUTICASONE/VILANTEROL BREO ELLIPTA 2 QL: 60 IN 30 DAYS


Drug Name Tier Requirements/LimitsMOMETASONE/FORMOTEROL DULERA 2 QL: 13gm IN 30 DAYS

BETA-ADRENERGIC-ANTICHOLINERGIC-GLUCOCORT, INHALEDFLUTICASONE/UMECLIDIN/VILANTER TRELEGY ELLIPTA 2 QL: 60 IN 30 DAYS

GLUCOCORTICOIDS, ORALLY INHALEDBECLOMETHASONE DIPROPIONATE QVAR REDIHALER 2 QL: 21.2gm IN 30 DAYS

budesonidePULMICORT(0.25MG/2ML)(AMPUL-NEB)

1 QL: 120mL IN 30 DAYS

budesonidePULMICORT (0.5MG/2ML) (AMPUL-NEB)


budesonidePULMICORT (1MG/2 ML) (AMPUL-NEB)


BUDESONIDE PULMICORTFLEXHALER 3 ST, QL: 1 IN 30 DAYS

CICLESONIDE ALVESCO 3 ST, QL: 12.2gm IN 30 DAYSFLUNISOLIDE AEROSPAN 3 ST, QL: 17.8gm IN 30 DAYSFLUTICASONE FUROATE ARNUITY ELLIPTA 2 QL: 30 IN 30 DAYS

FLUTICASONE PROPIONATE ARMONAIRRESPICLICK 3 ST, QL: 1 IN 30 DAYS

FLUTICASONE PROPIONATEFLOVENT DISKUS(100 MCG) (BLSTW/DEV)

2 QL: 60 IN 30 DAYS


2 QL: 120 IN 30 DAYS


2 QL: 60 IN 30 DAYS

FLUTICASONE PROPIONATEFLOVENT HFA (110MCG) (AERW/ADAP)

2 QL: 12gm IN 30 DAYS


2 QL: 24gm IN 30 DAYS


2 QL: 21.2gm IN 30 DAYS

MOMETASONE FUROATE ASMANEX 3 ST, QL: 1 IN 30 DAYSMOMETASONE FUROATE ASMANEX HFA 3 ST, QL: 13gm IN 30 DAYS

LEUKOTRIENE RECEPTOR ANTAGONISTSmontelukast sodium SINGULAIR 1zafirlukast ACCOLATE 1

MAST CELL STABILIZERScromolyn sodium GASTROCROM 1

MAST CELL STABILIZERS, ORALLY INHALEDcromolyn sodium 1

PHOSPHODIESTERASE-4 (PDE4) INHIBITORSROFLUMILAST DALIRESP 2 ST, QL: 1 IN 1 DAY

RESPIRATORY AIDS,DEVICES,EQUIPMENT

COMPRESSOR, FOR NEBULIZER DEVILBISSCOMPACT 3

COMPRESSOR, FOR NEBULIZER DEVILBISS PULMO-AIDE 3

COMPRESSOR, FOR NEBULIZER DEVILBISSPULMOMATE 3

COMPRESSOR, FOR NEBULIZER EBASECONTROLLER 3


Drug Name Tier Requirements/LimitsCOMPRESSOR, FOR NEBULIZER PULMO-AIDE 3

COMPRESSOR, FOR NEBULIZERSUNRISECOMPRESSOR-NEBULIZER

3

INHALER, ASSIST DEVICES ACE AEROSOLCLOUD ENHANCER 3

INHALER, ASSIST DEVICES AEROCHAMBERMINI 3

INHALER, ASSIST DEVICES AEROCHAMBERMV 3

INHALER, ASSIST DEVICES AEROCHAMBERPLUS FLOW-VU 3

INHALER, ASSIST DEVICES AEROCHAMBERWITH FLOWSIGNAL 3

INHALER, ASSIST DEVICES AEROCHAMBER Z-STAT PLUS 3

INHALER, ASSIST DEVICES AEROTRACH PLUS 3INHALER, ASSIST DEVICES AEROVENT PLUS 3INHALER, ASSIST DEVICES BREATHERITE 3INHALER, ASSIST DEVICES BREATHRITE 3

INHALER, ASSIST DEVICES COMPACT SPACECHAMBER 3

INHALER, ASSIST DEVICES COMPACT SPACECHAMBER PLUS 3

INHALER, ASSIST DEVICES EASIVENT 3INHALER, ASSIST DEVICES E-Z SPACER 3INHALER, ASSIST DEVICES FLEXICHAMBER 3INHALER, ASSIST DEVICES INSPIRACHAMBER 3INHALER, ASSIST DEVICES LITEAIRE 3INHALER, ASSIST DEVICES MICROCHAMBER 3INHALER, ASSIST DEVICES MICROSPACER 3

INHALER, ASSIST DEVICES OPTICHAMBERDIAMOND 3

INHALER, ASSIST DEVICES POCKET CHAMBER 3INHALER, ASSIST DEVICES PRIMEAIRE 3INHALER, ASSIST DEVICES PROCHAMBER 3INHALER, ASSIST DEVICES RITEFLO 3

INHALER, ASSIST DEVICES SPACE CHAMBERPLUS 3

INHALER, ASSIST DEVICES VORTEX 3

INHALER,ASSIST DEV,SMALL MASK AEROCHAMBERPLUS FLOW-VU 3

INHALER,ASSIST DEV,SMALL MASK AEROCHAMBER Z-STAT PLUS 3

INHALER,ASSIST DEV,SMALL MASKBREATHERITESPACER-INFANTMASK

3

INHALER,ASSIST DEV,SMALL MASKBREATHERITESPACER-NEONATEMSK

3

INHALER,ASSIST DEV,SMALL MASKBREATHERITESPACER-SM CHLDMSK

3

INHALER,ASSIST DEV,SMALL MASKCLEVER CHOICEHOLDINGCHAMBER

3

INHALER,ASSIST DEV,SMALL MASK COMPACT SPACECHAMBER 3

INHALER,ASSIST DEV,SMALL MASK INSPIRACHAMBER 3



INHALER,ASSIST DEV,SMALL MASK OPTICHAMBERDIAMOND 3

INHALER,ASSIST DEV,SMALL MASKVORTEX HOLDINGCHAMBER-TODDLER

3

INHALER,ASSIST DEV,SMALL MASK VORTEX VHCLADYBUG MASK 3

INHALER,ASSIST DEVICE,ACCESORY EASIVENT 3

INHALER,ASSIST DEVICE,ACCESORY FLEXICHAMBERMASK 3

INHALER,ASSIST DEVICE,ACCESORY LITETOUCH 3INHALER,ASSIST DEVICE,ACCESORY OPTICHAMBER 3INHALER,ASSIST DEVICE,ACCESORY SILICONE MASK 3

INHALER,ASSIST DEVICE,LG MASK AEROCHAMBERPLUS FLOW-VU 3

INHALER,ASSIST DEVICE,LG MASK AEROCHAMBER Z-STAT PLUS 3

INHALER,ASSIST DEVICE,LG MASKBREATHERITESPACER-ADULTMASK

3

INHALER,ASSIST DEVICE,LG MASKCLEVER CHOICEHOLDINGCHAMBER

3

INHALER,ASSIST DEVICE,LG MASK COMPACT SPACECHAMBER 3

INHALER,ASSIST DEVICE,LG MASK INSPIRACHAMBER 3

INHALER,ASSIST DEVICE,LG MASK OPTICHAMBERDIAMOND 3

INHALER,ASSIST DEVICE,MED MASK AEROCHAMBERPLUS FLOW-VU 3

INHALER,ASSIST DEVICE,MED MASK AEROCHAMBER Z-STAT PLUS 3

INHALER,ASSIST DEVICE,MED MASKBREATHERITESPACER-LG CHLDMSK

3

INHALER,ASSIST DEVICE,MED MASKCLEVER CHOICEHOLDINGCHAMBER

3

INHALER,ASSIST DEVICE,MED MASK COMPACT SPACECHAMBER 3

INHALER,ASSIST DEVICE,MED MASK INSPIRACHAMBER 3

INHALER,ASSIST DEVICE,MED MASK OPTICHAMBERDIAMOND 3

INHALER,ASSIST DEVICE,MED MASK VORTEX HOLDINGCHAMBER-CHILD 3

INHALER,ASSIST DEVICE,MED MASK VORTEX VHC FROGMASK 3

MUCUS CLEARING DEVICE AEROBIKA 3MUCUS CLEARING DEVICE QUAKE 3NASAL EXHALATION RESISTANC.DEV PROVENT 3NEBULIZER AEROECLIPSE II 3

NEBULIZER AERONEB GONEBULIZER 3

NEBULIZER AIRS DISPOSABLENEBULIZER 3

NEBULIZER ALTERANEBULIZER 3

NEBULIZER BABY NEBULIZER 3



NEBULIZERDEVILBISSDISPOSABLENEBULIZER

3

NEBULIZER ERAPIDNEBULIZER 3

NEBULIZER LC D NEBULIZERSET 3

NEBULIZER LC PLUS 3

NEBULIZERLC PLUSNEBULIZER-PEDMASK

3

NEBULIZER LC SPRINTNEBULIZER 3

NEBULIZER LC STAR 3NEBULIZER MICRO AIR 3

NEBULIZER MINI PLUSNEBULIZER 3

NEBULIZER PARI LC SPRINTSINUS 3

NEBULIZER PRODIGY MINI-MIST 3

NEBULIZER SIDESTREAM 3

NEBULIZER SIDESTREAMNEBULIZER 3

NEBULIZER SIDESTREAM PLUS 3NEBULIZER SINUSTAR 3

NEBULIZER SOOTHENEB MESHNEBULIZER 3

NEBULIZER TRUNEBNEBULIZER 3

NEBULIZER VIXONENEBULIZER 3

NEBULIZER AND COMPRESSOR CLEVER CHOICENEBULIZER 3

NEBULIZER AND COMPRESSOR CLEVER CHOICEWHISPER AIRE PED 3

NEBULIZER AND COMPRESSORCOMP-AIRNEBULIZERCOMPRESSOR

3

NEBULIZER AND COMPRESSORDEVILBISSPULMONEB LTCOMP-NEB

3

NEBULIZER AND COMPRESSOR DEVILBISSTRAVELER 3

NEBULIZER AND COMPRESSOR HOME NEBULIZERPLUS SIDESTREAM 3

NEBULIZER AND COMPRESSOR INNOSPIREDELUXE 3

NEBULIZER AND COMPRESSOR INNOSPIREELEGANCE 3

NEBULIZER AND COMPRESSOR INNOSPIREESSENCE 3

NEBULIZER AND COMPRESSOR INNOSPIRE MINI 3

NEBULIZER AND COMPRESSOR MY MDI PORTABLENEBULISER 3

NEBULIZER AND COMPRESSOROMBRACOMPRESSORSYSTEM

3

NEBULIZER AND COMPRESSOR PARI SINUSAEROSOL SYSTEM 3



NEBULIZER AND COMPRESSORPEDIATRICDINOSAURNEBULIZER

3

NEBULIZER AND COMPRESSOR PEDIATRIC DOGNEBULIZER 3

NEBULIZER AND COMPRESSOR PEDIATRIC FROGNEBULIZER 3

NEBULIZER AND COMPRESSORPORTABLENEBULIZERSYSTEM

3

NEBULIZER AND COMPRESSOR PRONEB ULTRA II 3

NEBULIZER AND COMPRESSORPULMONEB LTCOMPRESSORNEBUL

3

NEBULIZER AND COMPRESSOR SAMI THE SEAL 3NEBULIZER AND COMPRESSOR SINUSTAR 3

NEBULIZER AND COMPRESSORSOOTHENEBCOMPRESSORNEBULIZER

3

NEBULIZER AND COMPRESSOR TREK S COMBOPACK 3

NEBULIZER AND COMPRESSOR TREK S COMPACTCOMPRESSOR 3

NEBULIZER AND COMPRESSOR VIOS AEROSOLDELIVERY SYSTEM 3

NEBULIZER AND COMPRESSORWILLIS THEWHALECOMPRESSR NEB

3

PEAK FLOW METER AIRZONE PEAKFLOW METER 6

PEAK FLOW METER ASTHMA CHECK 6

PEAK FLOW METER IN-CHECK NASALWITH MASK 6

PEAK FLOW METER IN-CHECK ORAL 6

PEAK FLOW METER MICROLIFE PEAKFLOW 6

PEAK FLOW METERMINI-WRIGHTPEAK FLOWMETER

6

PEAK FLOW METER PEAK-AIR 6PEAK FLOW METER PERSONAL BEST 6PEAK FLOW METER PIKO 1 6PEAK FLOW METER POCKET PEAK 6

PEAK FLOW METER TRUZONE PEAKFLOW METER 6

PEAK FLOW METER/INH ASSIT DEVAEROGEARASTHMA ACTIONKIT

6

PEAK FLOW METER/INH ASSIT DEV ASTHMAPACKCHILDREN'S 6

SPIROMETER/DRUG DELIVERY ADAPT MISTASSIST KIT 3SPIROMETERS AND ACCESSORIES MISTASSIST 3SPIROMETERS AND ACCESSORIES PFLEX TRAINER 3SPIROMETERS AND ACCESSORIES THRESHOLD IMT 3SPIROMETERS AND ACCESSORIES THRESHOLD PEP 3

XANTHINEScaffeine citrate CAFCIT 1theophylline anhydrous ELIXOPHYLLIN 1theophylline anhydrous SLO-PHYLLIN 1THEOPHYLLINE ANHYDROUS THEO-24 2


Drug Name Tier Requirements/Limitstheophylline anhydrous THEO-DUR 1theophylline anhydrous UNIPHYL 1

AUTONOMIC NERVOUS SYSTEM DISORDERSALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS

memantine hcl NAMENDA (10 MG)(TABLET) 1 QL: 2 IN 1 DAY

memantine hclNAMENDA (2MG/ML)(SOLUTION)


memantine hcl NAMENDA (5 MG)(TABLET) 1 QL: 2 IN 1 DAY

memantine hcl NAMENDA (5 MG-10 MG) (TAB DS PK) 1 QL: 49 IN 28 DAYS

memantine hcl NAMENDA XR (14MG) (CAP SPR 24) 1 QL: 1 IN 1 DAY




MEMANTINE HCLNAMENDA XR (7-14-21-28) (CAP24DSPK)

2 QL: 28 IN 28 DAYS

ALZHEIMER'S THX,NMDA RECEPT ANTAG & CHOLINES INHIB

MEMANTINE HCL/DONEPEZIL HCL NAMZARIC (14MG-10MG) (CAP SPR 24) 2 ST, QL: 1 IN 1 DAY

MEMANTINE HCL/DONEPEZIL HCL NAMZARIC (21 MG-10MG) (CAP SPR 24) 2 ST, QL: 1 IN 1 DAY

MEMANTINE HCL/DONEPEZIL HCL NAMZARIC (28 MG-10MG) (CAP SPR 24) 2 ST, QL: 1 IN 1 DAY

MEMANTINE HCL/DONEPEZIL HCLNAMZARIC (7 MG-10 MG) (CAP SPR24)

2 ST, QL: 1 IN 1 DAY

MEMANTINE HCL/DONEPEZIL HCLNAMZARIC (7-10/14-10) (CAP24DSPK)

2 ST, QL: 28 IN 28 DAYS

CHOLINESTERASE INHIBITORSdonepezil hcl ARICEPT 1donepezil hcl ARICEPT ODT 1

galantamine hbr RAZADYNE (12 MG)(TABLET) 1 QL: 2 IN 1 DAY


galantamine hbrRAZADYNE (4MG/ML)(SOLUTION)



galantamine hbr RAZADYNE ER 1 QL: 1 IN 1 DAY

pyridostigmine bromide MESTINON (180MG) (TABLET ER) 1

pyridostigmine bromide MESTINON (60 MG)(TABLET) 1

PYRIDOSTIGMINE BROMIDE MESTINON (60MG/5 ML) (SYRUP) 2

rivastigmine EXELON 1 QL: 1 IN 1 DAYrivastigmine tartrate EXELON 1



BEHAVIORAL HEALTH - ANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS

mirtazapine 1MAOIS - NON-SELECTIVE & IRREVERSIBLE

ISOCARBOXAZID MARPLAN 3phenelzine sulfate NARDIL 1tranylcypromine sulfate PARNATE 1

NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS)BUPROPION HBR APLENZIN 3 ST, QL: 1 IN 1 DAYBUPROPION HCL FORFIVO XL 3 ST, QL: 1 IN 1 DAYbupropion hcl WELLBUTRIN 1bupropion hcl WELLBUTRIN SR 1bupropion hcl WELLBUTRIN XL 1

SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)citalopram hydrobromide CELEXA 1escitalopram oxalate LEXAPRO 1fluoxetine hcl 1fluoxetine hcl PROZAC 1fluoxetine hcl PROZAC WEEKLY 1FLUOXETINE HCL SARAFEM 3fluvoxamine maleate LUVOX 1fluvoxamine maleate LUVOX CR 1 ST, QL: 2 IN 1 DAY

paroxetine hcl PAXIL (10 MG)(TABLET) 1

PAROXETINE HCL PAXIL (10 MG/5 ML)(ORAL SUSP) 2




paroxetine hcl PAXIL CR 1paroxetine mesylate BRISDELLE 1 ST, QL: 1 IN 1 DAYPAROXETINE MESYLATE PEXEVA 3 ST, QL: 1 IN 1 DAYsertraline hcl ZOLOFT 1

SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS)nefazodone hcl SERZONE 1trazodone hcl DESYREL 1

SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)DESVENLAFAXINE ER 2 ST, QL: 1 IN 1 DAYdesvenlafaxine KHEDEZLA 1 ST, QL: 1 IN 1 DAYDESVENLAFAXINE FUMARATE ER 3 ST, QL: 1 IN 1 DAYdesvenlafaxine succinate PRISTIQ 1 QL: 1 IN 1 DAYduloxetine hcl (20 mg) (capsule dr) 1 QL: 2 IN 1 DAYduloxetine hcl (30 mg) (capsule dr) 1 QL: 2 IN 1 DAYduloxetine hcl (40 mg) (capsule dr) 1 ST, QL: 1 IN 1 DAYduloxetine hcl (60 mg) (capsule dr) 1 QL: 2 IN 1 DAYLEVOMILNACIPRAN HCL FETZIMA 2 ST, QL: 1 IN 1 DAYvenlafaxine hcl EFFEXOR 1venlafaxine hcl EFFEXOR XR 1venlafaxine hcl er 1

SSRI & 5HT1A PARTIAL AGONIST ANTIDEPRESSANTVILAZODONE HCL VIIBRYD 2 ST, QL: 1 IN 1 DAY

SSRI & SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANTVORTIOXETINE HYDROBROMIDE TRINTELLIX 2 ST, QL: 1 IN 1 DAY


Drug Name Tier Requirements/LimitsTRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS

amitriptyline/chlordiazepoxide LIMBITROL 1amitriptyline/chlordiazepoxide LIMBITROL DS 1

TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNSperphenazine/amitriptyline hcl ETRAFON-A 1perphenazine/amitriptyline hcl TRIAVIL 2-10 1perphenazine/amitriptyline hcl TRIAVIL 2-25 1perphenazine/amitriptyline hcl TRIAVIL 4-25 1perphenazine/amitriptyline hcl TRIAVIL 4-50 1

TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIBamitriptyline hcl ELAVIL 1amoxapine ASENDIN 1clomipramine hcl ANAFRANIL 1desipramine hcl NORPRAMIN 1doxepin hcl SINEQUAN 1imipramine hcl TOFRANIL 1imipramine pamoate TOFRANIL-PM 1maprotiline hcl LUDIOMIL 1nortriptyline hcl PAMELOR 1protriptyline hcl VIVACTIL 1trimipramine maleate SURMONTIL 1

BEHAVIORAL HEALTH - OTHERADRENERGICS, AROMATIC, NON-CATECHOLAMINE

AMPHETAMINE ADZENYS ER 3 ST, QL: 450mL IN 30 DAYSAMPHETAMINE ADZENYS XR-ODT 3 ST, QL: 1 IN 1 DAYAMPHETAMINE DYANAVEL XR 3 ST, QL: 240mL IN 30 DAYSAMPHETAMINE SULFATE EVEKEO 3 PA

dextroamphetamine sulfate DEXEDRINE (10MG) (CAPSULE ER) 1 QL: 2 IN 1 DAY

dextroamphetamine sulfate DEXEDRINE (10MG) (TABLET) 1 QL: 6 IN 1 DAY

dextroamphetamine sulfate DEXEDRINE (15MG) (CAPSULE ER) 1 QL: 4 IN 1 DAY

dextroamphetamine sulfate DEXEDRINE (5 MG)(CAPSULE ER) 1 QL: 2 IN 1 DAY

dextroamphetamine sulfate DEXEDRINE (5 MG)(TABLET) 1 QL: 3 IN 1 DAY

dextroamphetamine sulfate PROCENTRA 1 QL: 1800mL IN 30 DAYS

DEXTROAMPHETAMINE SULFATE ZENZEDI (15 MG)(TABLET) 3 ST, QL: 3 IN 1 DAY

DEXTROAMPHETAMINE SULFATE ZENZEDI (2.5 MG)(TABLET) 3 ST, QL: 3 IN 1 DAY



DEXTROAMPHETAMINE SULFATE ZENZEDI (7.5 MG)(TABLET) 3 ST, QL: 3 IN 1 DAY

dextroamphetamine/amphetamine ADDERALL 1 QL: 2 IN 1 DAY

DEXTROAMPHETAMINE/AMPHETAMINE ADDERALL XR (10MG) (CAP ER 24H) 1 QL: 1 IN 1 DAY








DEXTROAMPHETAMINE/AMPHETAMINE MYDAYIS 3 ST, QL: 1 IN 1 DAYLISDEXAMFETAMINE DIMESYLATE VYVANSE 2 ST, QL: 1 IN 1 DAYmethamphetamine hcl DESOXYN 1 QL: 5 IN 1 DAY

ANTI-ALCOHOLIC PREPARATIONSacamprosate calcium CAMPRAL 1disulfiram ANTABUSE 1

ANTI-ANXIETY - BENZODIAZEPINESalprazolam 1ALPRAZOLAM INTENSOL 2chlordiazepoxide hcl 1clorazepate dipotassium 1diazepam 1lorazepam 1oxazepam 1

ANTI-ANXIETY DRUGSbuspirone hcl BUSPAR 1meprobamate 1

ANTI-MANIA DRUGSCARBAMAZEPINE EQUETRO 3lithium carbonate 1lithium citrate 1

ANTI-NARCOLEPSY & ANTI-CATAPLEXY,SEDATIVE-TYPE AGTSODIUM OXYBATE XYREM 4 PA

ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINESpimozide ORAP 1

ANTIPSYCHOTIC-ATYPICAL,D3/D2 PARTIAL AG-5HT MIXED

CARIPRAZINE HCL VRAYLAR (1.5 MG)(CAPSULE) 2 ST, QL: 1 IN 1 DAY

CARIPRAZINE HCL VRAYLAR (1.5 MG-3MG) (CAP DS PK) 2 ST, QL: 7 IN 28 DAYS

CARIPRAZINE HCL VRAYLAR (3 MG)(CAPSULE) 2 ST, QL: 1 IN 1 DAY

CARIPRAZINE HCL VRAYLAR (4.5 MG)(CAPSULE) 2 ST, QL: 1 IN 1 DAY

CARIPRAZINE HCL VRAYLAR (6 MG)(CAPSULE) 2 ST, QL: 1 IN 1 DAY

ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED

aripiprazole ABILIFY (1 MG/ML)(SOLUTION) 1 ST, QL: 30mL IN 1 DAY

aripiprazole ABILIFY (10 MG)(TABLET) 1 QL: 1 IN 1 DAY






aripiprazoleABILIFY DISCMELT(10 MG) (TABRAPDIS)




aripiprazoleABILIFY DISCMELT(15 MG) (TABRAPDIS)


BREXPIPRAZOLE REXULTI 2 ST, QL: 1 IN 1 DAYANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS

LOXAPINE ADASUVE 4loxapine succinate LOXITANE 1

ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAGASENAPINE MALEATE SAPHRIS 2 ST, QL: 2 IN 1 DAYclozapine 1 QL: 3 IN 1 DAYclozapine CLOZARIL 1 QL: 3 IN 1 DAYclozapine FAZACLO 1 ST, QL: 3 IN 1 DAYCLOZAPINE VERSACLOZ 3 ST, QL: 18mL IN 1 DAY

ILOPERIDONE FANAPT (1 MG)(TABLET) 3 ST, QL: 2 IN 1 DAY



ILOPERIDONE FANAPT (1-2-4-6MG) (TAB DS PK) 3 ST, QL: 8 IN 28 DAYS





LURASIDONE HCL LATUDA (120 MG)(TABLET) 2 ST, QL: 1 IN 1 DAY





olanzapine ZYPREXA 1 QL: 1 IN 1 DAYolanzapine ZYPREXA ZYDIS 1 QL: 1 IN 1 DAY

paliperidone INVEGA (1.5 MG)(TAB ER 24) 1 ST, QL: 1 IN 1 DAY

paliperidone INVEGA (3 MG)(TAB ER 24) 1 ST, QL: 1 IN 1 DAY



quetiapine fumarate SEROQUEL 1 QL: 3 IN 1 DAY

quetiapine fumarate SEROQUEL XR (150MG) (TAB ER 24H) 1 QL: 1 IN 1 DAY







QUETIAPINE FUMARATESEROQUEL XR (50-200-300)(TAB24HDSPK)

3

risperidone (0.25 mg) (tab rapdis) 1 QL: 2 IN 1 DAYrisperidone (0.25 mg) (tablet) 1 QL: 2 IN 1 DAYrisperidone (0.5 mg) (tab rapdis) 1 QL: 2 IN 1 DAYrisperidone (0.5 mg) (tablet) 1 QL: 2 IN 1 DAYrisperidone (1 mg) (tab rapdis) 1 QL: 2 IN 1 DAYrisperidone (1 mg) (tablet) 1 QL: 2 IN 1 DAYrisperidone (1 mg/ml) (solution) 1 QL: 8mL IN 1 DAYrisperidone (2 mg) (tab rapdis) 1 QL: 2 IN 1 DAYrisperidone (2 mg) (tablet) 1 QL: 2 IN 1 DAYrisperidone (3 mg) (tab rapdis) 1 QL: 2 IN 1 DAYrisperidone (3 mg) (tablet) 1 QL: 2 IN 1 DAYrisperidone (4 mg) (tab rapdis) 1 QL: 2 IN 1 DAYrisperidone (4 mg) (tablet) 1 QL: 2 IN 1 DAYziprasidone hcl GEODON 1 QL: 2 IN 1 DAY

ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENESthiothixene NAVANE 1

ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONEShaloperidol HALDOL 1haloperidol lactate 1

ANTI-PSYCHOTICS,PHENOTHIAZINESchlorpromazine hcl THORAZINE 1fluphenazine hcl PROLIXIN 1perphenazine TRILAFON 1thioridazine hcl MELLARIL 1trifluoperazine hcl STELAZINE 1

BARBITURATESBUTABARBITAL SODIUM BUTISOL SODIUM 3phenobarbital 1SECOBARBITAL SODIUM SECONAL SODIUM 3

HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTSRAMELTEON ROZEREM 3 ST, QL: 1 IN 1 DAYTASIMELTEON HETLIOZ 4 PA

MONOAMINE OXIDASE(MAO) INHIBITORSSELEGILINE EMSAM 3 QL: 1 IN 1 DAY

NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS

armodafinil NUVIGIL (150 MG)(TABLET) 1 QL: 1 IN 1 DAY




modafinil PROVIGIL 1 QL: 2 IN 1 DAYNARCOTIC ANTAGONISTS

NALOXONE HCL EVZIO 3 QL: 0.8mL IN 365 DAYS

naloxone hcl NARCAN (0.4MG/ML) (SYRINGE) 3

naloxone hcl NARCAN (1 MG/ML)(SYRINGE) 3

NALOXONE HCL NARCAN (4 MG)(SPRAY) 2 QL: 4 IN 30 DAYS

naltrexone hcl REVIA 1


Drug Name Tier Requirements/LimitsSEDATIVE-HYPNOTICS - BENZODIAZEPINES

estazolam 1flurazepam hcl 1midazolam hcl 1quazepam DORAL 1temazepam RESTORIL 1triazolam 1

SEDATIVE-HYPNOTICS,NON-BARBITURATEDOXEPIN HCL SILENOR 2 ST, QL: 1 IN 1 DAYeszopiclone LUNESTA 1 QL: 1 IN 1 DAYmidazolam/ketamine/ondansetron 1SUVOREXANT BELSOMRA 2 ST, QL: 1 IN 1 DAYzaleplon SONATA 1 QL: 1 IN 1 DAYzolpidem tartrate AMBIEN 1 QL: 1 IN 1 DAYzolpidem tartrate AMBIEN CR 1 QL: 1 IN 1 DAYZOLPIDEM TARTRATE EDLUAR 3 ST, QL: 1 IN 1 DAYzolpidem tartrate INTERMEZZO 1 ST, QL: 1 IN 1 DAYZOLPIDEM TARTRATE ZOLPIMIST 3 ST, QL: 7.7mL IN 30 DAYS

SELECTIVE SEROTONIN 5-HT2A INVERSE AGONISTS (SSIA)PIMAVANSERIN TARTRATE NUPLAZID 4 PA

SSRI &ANTIPSYCH,ATYP,DOPAMINE&SEROTONIN ANTAG COMBolanzapine/fluoxetine hcl SYMBYAX 1 QL: 1 IN 1 DAY

TX FOR ADHD - SELECTIVE ALPHA-2A RECEPTOR AGONISTclonidine hcl KAPVAY 1 QL: 4 IN 1 DAYguanfacine hcl INTUNIV 1 QL: 1 IN 1 DAY

TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSYdexmethylphenidate hcl FOCALIN 1 QL: 2 IN 1 DAYdexmethylphenidate hcl FOCALIN XR 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAY

METHYLPHENIDATECOTEMPLA XR-ODT (17.3 MG) (TABRAP BP)






METHYLPHENIDATE DAYTRANA 3 ST, QL: 1 IN 1 DAY

METHYLPHENIDATE HCL APTENSIO XR 3 ST, AGE: <= 18 YEARS, QL: 1 IN 1DAY

METHYLPHENIDATE HCL CONCERTA (18 MG)(TAB ER 24) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAY




methylphenidate hcl (10 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (10 mg) (cpbp 50-50) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (10 mg) (tab chew) 1 QL: 3 IN 1 DAYmethylphenidate hcl (10 mg) (tablet er) 1 AGE: <= 18 YEARS, QL: 3 IN 1 DAYmethylphenidate hcl (10 mg) (tablet) 1 QL: 3 IN 1 DAYmethylphenidate hcl (10 mg/5 ml) (solution) 1methylphenidate hcl (18 mg) (tab er 24) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (2.5 mg) (tab chew) 1 QL: 3 IN 1 DAYmethylphenidate hcl (20 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (20 mg) (cpbp 50-50) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAY


Drug Name Tier Requirements/Limitsmethylphenidate hcl (20 mg) (tablet er) 1 AGE: <= 18 YEARS, QL: 3 IN 1 DAYmethylphenidate hcl (20 mg) (tablet) 1 QL: 3 IN 1 DAYmethylphenidate hcl (27 mg) (tab er 24) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (30 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 2 IN 1 DAYmethylphenidate hcl (30 mg) (cpbp 50-50) 1 AGE: <= 18 YEARS, QL: 2 IN 1 DAYmethylphenidate hcl (36 mg) (tab er 24) 1 AGE: <= 18 YEARS, QL: 2 IN 1 DAYmethylphenidate hcl (40 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (40 mg) (cpbp 50-50) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (5 mg) (tab chew) 1 QL: 3 IN 1 DAYmethylphenidate hcl (5 mg) (tablet) 1 QL: 3 IN 1 DAYmethylphenidate hcl (5 mg/5 ml) (solution) 1methylphenidate hcl (50 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (54 mg) (tab er 24) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (60 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (60 mg) (cpbp 50-50) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (72 mg) (tab er 24) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAY

METHYLPHENIDATE HCLQUILLICHEW ER(20 MG) (TABCBP24H)






METHYLPHENIDATE HCLQUILLIVANT XR (5MG/ML) (SU ERRC24)

2 ST, QL: 10mL IN 1 DAY, 150mLBOTTLE







METHYLPHENIDATE HCL RELEXXII 3 AGE: <= 18 YEARS, QL: 1 IN 1 DAYTX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE

atomoxetine hcl STRATTERA (10MG) (CAPSULE) 1 QL: 2 IN 1 DAY







CARDIOVASCULAR DISEASE - ARRHYTHMIAANTIARRHYTHMICS

amiodarone hcl CORDARONE 1disopyramide phosphate NORPACE 1DISOPYRAMIDE PHOSPHATE NORPACE CR 2dofetilide TIKOSYN 1


Drug Name Tier Requirements/LimitsDRONEDARONE HCL MULTAQ 2flecainide acetate TAMBOCOR 1mexiletine hcl MEXITIL 1propafenone hcl RYTHMOL 1propafenone hcl RYTHMOL SR 1quinidine gluconate 1quinidine sulfate 1

CARDIOVASCULAR DISEASE - CARDIAC STIMULANTADRENERGIC AGENTS,CATECHOLAMINES

epinephrine 1DIGITALIS GLYCOSIDES

DIGOXIN 2

digoxin LANOXIN (125MCG) (TABLET) 1

DIGOXIN LANOXIN (187.5MCG) (TABLET) 3

digoxin LANOXIN (250MCG) (TABLET) 1

DIGOXIN LANOXIN (62.5MCG) (TABLET) 3

CARDIOVASCULAR DISEASE - HYPERTENSIONACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION

amlodipine besylate/benazepril LOTREL 1PERINDOPRIL ARG/AMLODIPINE BES PRESTALIA 3 ST, QL: 1 IN 1 DAYtrandolapril/verapamil hcl 1

ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETICbenazepril/hydrochlorothiazide LOTENSIN HCT 1captopril/hydrochlorothiazide CAPOZIDE 1enalapril/hydrochlorothiazide VASERETIC 1fosinopril/hydrochlorothiazide MONOPRIL-HCT 1lisinopril/hydrochlorothiazide ZESTORETIC 1moexipril/hydrochlorothiazide UNIRETIC 1quinapril/hydrochlorothiazide ACCURETIC 1

ALPHA/BETA-ADRENERGIC BLOCKING AGENTScarvedilol COREG 1carvedilol phosphate COREG CR 1labetalol hcl TRANDATE 1

ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate CARDURA 1DOXAZOSIN MESYLATE CARDURA XL 3phenoxybenzamine hcl DIBENZYLINE 4 PAprazosin hcl MINIPRESS 1terazosin hcl HYTRIN 1

ANGIOTEN.RECEPTR ANTAG./CAL.CHANL BLKR/THIAZIDE CBamlodipine/valsartan/hcthiazid EXFORGE HCT 1olmesartan/amlodipin/hcthiazid TRIBENZOR 1

ANGIOTENSIN II RECEPTOR BLOCKER-BETA BLOCKER COMB.NEBIVOLOL HCL/VALSARTAN BYVALSON 2

ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMBAZILSARTAN MED/CHLORTHALIDONE EDARBYCLOR 2 STcandesartan/hydrochlorothiazid ATACAND HCT 1irbesartan/hydrochlorothiazide AVALIDE 1losartan/hydrochlorothiazide HYZAAR 1olmesartan/hydrochlorothiazide BENICAR HCT 1telmisartan/hydrochlorothiazid MICARDIS HCT 1VALSARTAN/HYDROCHLOROTHIAZIDE DIOVAN HCT 2


Drug Name Tier Requirements/Limitsvalsartan/hydrochlorothiazide 1

ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKRamlodipine bes/olmesartan med AZOR 1amlodipine besylate/valsartan EXFORGE 1telmisartan/amlodipine TWYNSTA 1

ANTIHYPERTENSIVES, ACE INHIBITORSbenazepril hcl LOTENSIN 1captopril CAPOTEN 1

ENALAPRIL MALEATE EPANED 3 ST, AGE: < 12 YEARS, QL: 1200mLIN 30 DAYS

enalapril maleate VASOTEC 1fosinopril sodium MONOPRIL 1lisinopril PRINIVIL 1

LISINOPRIL QBRELIS 3 ST, AGE: < 12 YEARS, QL: 1200mLIN 30 DAYS

lisinopril ZESTRIL 1moexipril hcl UNIVASC 1perindopril erbumine ACEON 1quinapril hcl ACCUPRIL 1ramipril ALTACE 1trandolapril MAVIK 1

ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONISTAZILSARTAN MEDOXOMIL EDARBI 2 STcandesartan cilexetil ATACAND 1eprosartan mesylate TEVETEN 1irbesartan AVAPRO 1losartan potassium COZAAR 1olmesartan medoxomil BENICAR 1telmisartan MICARDIS 1VALSARTAN DIOVAN 2valsartan 1

ANTIHYPERTENSIVES, GANGLIONIC BLOCKERSMECAMYLAMINE HCL VECAMYL 3 PA

ANTIHYPERTENSIVES, MISCELLANEOUSMETYROSINE DEMSER 3

ANTIHYPERTENSIVES, SYMPATHOLYTICclonidine CATAPRES-TTS 1 1clonidine CATAPRES-TTS 2 1clonidine CATAPRES-TTS 3 1clonidine hcl CATAPRES 1

clonidine hcl/chlorthalidoneCOMBIPRES(0.1MG-15MG)(TABLET)

1

clonidine hcl/chlorthalidone COMBIPRES (0.2-15MG) (TABLET) 1

clonidine hcl/chlorthalidoneCOMBIPRES(0.3MG-15MG)(TABLET)

3

guanfacine hcl TENEX 1methyldopa ALDOMET 1methyldopa/hydrochlorothiazide ALDORIL 15 1methyldopa/hydrochlorothiazide ALDORIL 25 1

ANTIHYPERTENSIVES, VASODILATORShydralazine hcl APRESOLINE 1minoxidil LONITEN 1

BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl SECTRAL 1


Drug Name Tier Requirements/Limitsatenolol TENORMIN 1betaxolol hcl KERLONE 1bisoprolol fumarate ZEBETA 1

METOPROLOL SUCCINATE KAPSPARGOSPRINKLE 3

metoprolol succinate TOPROL XL 1metoprolol tartrate 1nadolol CORGARD 1NEBIVOLOL HCL BYSTOLIC 2PENBUTOLOL SULFATE LEVATOL 3pindolol VISKEN 1

PROPRANOLOL HCL HEMANGEOL 3 ST, AGE: < 1 YEAR, QL: 360mL IN30 DAYS

propranolol hcl INDERAL 1propranolol hcl INDERAL LA 1PROPRANOLOL HCL INDERAL XL 3 STPROPRANOLOL HCL INNOPRAN XL 3 STsotalol hcl 1

SOTALOL HCLSOTYLIZE (5MG/ML)(SOLUTION)

3 ST, QL: 8 BOTTLES IN 30 DAYS

timolol maleate BLOCADREN 1BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATED

atenolol/chlorthalidone TENORETIC 100 1atenolol/chlorthalidone TENORETIC 50 1bisoprolol/hydrochlorothiazide ZIAC 1

metoprolol su/hydrochlorothiazDUTOPROL (100-12.5MG) (TAB ER24H)

1 QL: 2 IN 1 DAY

METOPROLOL SU/HYDROCHLOROTHIAZDUTOPROL (100-12.5MG) (TAB ER24H)

3 QL: 2 IN 1 DAY

metoprolol su/hydrochlorothiaz DUTOPROL (25-12.5MG) (TAB ER 24H) 1 QL: 1 IN 1 DAY

METOPROLOL SU/HYDROCHLOROTHIAZ DUTOPROL (25-12.5MG) (TAB ER 24H) 3 QL: 1 IN 1 DAY

metoprolol su/hydrochlorothiaz DUTOPROL (50-12.5MG) (TAB ER 24H) 1 QL: 1 IN 1 DAY

METOPROLOL SU/HYDROCHLOROTHIAZ DUTOPROL (50-12.5MG) (TAB ER 24H) 3 QL: 1 IN 1 DAY

metoprolol/hydrochlorothiazide LOPRESSOR HCT 1nadolol/bendroflumethiazide CORZIDE 1propranolol/hydrochlorothiazid INDERIDE-40/25 1propranolol/hydrochlorothiazid INDERIDE-80/25 1

CALCIUM CHANNEL BLOCKING AGENTSamlodipine besylate NORVASC 1diltiazem hcl CARDIZEM 1diltiazem hcl CARDIZEM CD 1

DILTIAZEM HCL CARDIZEM LA (120MG) (TAB ER 24H) 3

diltiazem hcl CARDIZEM LA (180MG) (TAB ER 24H) 1







diltiazem hcl CARDIZEM SR 1diltiazem hcl DILACOR XR 1diltiazem hcl TIAZAC 1felodipine PLENDIL 1isradipine DYNACIRC 1nicardipine hcl 1nifedipine ADALAT CC 1nifedipine PROCARDIA 1

nifedipine PROCARDIA XL (30MG) (TAB ER 24) 1


nifedipine PROCARDIA XL (60MG) (TABLET ER) 3


nifedipine PROCARDIA XL (90MG) (TABLET ER) 3

nimodipine NIMOTOP 1NIMODIPINE NYMALIZE 4 PAnisoldipine SULAR 1verapamil hcl CALAN 1verapamil hcl CALAN SR 1verapamil hcl VERELAN 1verapamil hcl VERELAN PM 1

LOOP DIURETICSbumetanide BUMEX 1ethacrynic acid EDECRIN 1furosemide LASIX 1torsemide DEMADEX 1

OSMOTIC DIURETICSMANNITOL RESECTISOL 3

POTASSIUM SPARING DIURETICSamiloride hcl MIDAMOR 1eplerenone INSPRA 1spironolactone ALDACTONE 1SPIRONOLACTONE CAROSPIR 3 ST, QL: 600mL IN 30 DAYSTRIAMTERENE DYRENIUM 3

POTASSIUM SPARING DIURETICS IN COMBINATIONamiloride/hydrochlorothiazide MODURETIC 5-50 1

spironolact/hydrochlorothiazidALDACTAZIDE (25MG-25MG)(TABLET)

1

SPIRONOLACT/HYDROCHLOROTHIAZIDALDACTAZIDE (50MG-50MG)(TABLET)

3

triamterene/hydrochlorothiazid DYAZIDE 1triamterene/hydrochlorothiazid MAXZIDE 1triamterene/hydrochlorothiazid MAXZIDE-25 MG 1

PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATORRIOCIGUAT ADEMPAS 4 PA

PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIB

SILDENAFIL CITRATEREVATIO (10MG/ML) (SUSPRECON)

4 PA



sildenafil citrate REVATIO (20 MG)(TABLET) 1 PA

tadalafil ADCIRCA 4 PAPULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST

AMBRISENTAN LETAIRIS 4 PABOSENTAN TRACLEER 4 PAMACITENTAN OPSUMIT 4 PA

PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPEILOPROST TROMETHAMINE VENTAVIS 4 PASELEXIPAG UPTRAVI 4 PATREPROSTINIL TYVASO 4 PATREPROSTINIL DIOLAMINE ORENITRAM ER 4 PATREPROSTINIL SODIUM REMODULIN 4 PA

TREPROSTINIL/NEB ACCESSORIES TYVASO REFILLKIT 4 PA

TREPROSTINIL/NEBULIZER/ACCESORTYVASOINSTITUTIONALSTART KIT

4 PA

TREPROSTINIL/NEBULIZER/ACCESOR TYVASO STARTERKIT 4 PA

RENIN INHIBITOR, DIRECTALISKIREN HEMIFUMARATE TEKTURNA 3 PA

RENIN INHIBITOR, DIRECT/THIAZIDE DIURETIC COMBALISKIREN/HYDROCHLOROTHIAZIDE TEKTURNA HCT 3 PA

THIAZIDE AND RELATED DIURETICS

chlorothiazide DIURIL (250 MG)(TABLET) 1

CHLOROTHIAZIDEDIURIL (250MG/5ML) (ORALSUSP)

3

chlorothiazide DIURIL (500 MG)(TABLET) 1

chlorthalidone HYGROTON 1hydrochlorothiazide 1indapamide LOZOL 1methyclothiazide 1metolazone ZAROXOLYN 1

VASODILATORS, COMBINATIONISOSORBIDE DINIT/HYDRALAZINE BIDIL 2

CARDIOVASCULAR DISEASE - LIPID IRREGULARITYANTIHYPERLIP.HMG COA REDUCT INHIB&CHOLEST.AB.INHIB

ezetimibe/simvastatin VYTORIN (10 MG-10MG) (TABLET) 1 QL: 1 IN 1 DAY



ezetimibe/simvastatin VYTORIN (10 MG-80MG) (TABLET) 1 ST, QL: 1 IN 1 DAY

ANTIHYPERLIPIDEMIC - APO B-100 SYNTHESIS INHIBITORMIPOMERSEN SODIUM KYNAMRO 4 PA

ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS

atorvastatin calcium LIPITOR (10 MG)(TABLET) 5

AGE: $0 COPAY IF AGE 40-75YEARS AND NO HISTORY OFCARDIOVASCULAR DISEASEPREVENTION MEDICATIONS IN120 DAYS, QL: 1 IN 1 DAY



atorvastatin calcium LIPITOR (20 MG)(TABLET) 5


atorvastatin calcium LIPITOR (40 MG)(TABLET) 1 QL: 1 IN 1 DAY

atorvastatin calcium LIPITOR (80 MG)(TABLET) 1 QL: 1 IN 1 DAY

fluvastatin sodium LESCOL 5

ST, AGE: $0 COPAY IF AGE 40-75YEARS AND NO HISTORY OFCARDIOVASCULAR DISEASEPREVENTION MEDICATIONS IN120 DAYS, QL: 2 IN 1 DAY

fluvastatin sodium LESCOL XL 5


LOVASTATIN ALTOPREV 5


lovastatin MEVACOR 5


PITAVASTATIN CALCIUM LIVALO 5


PITAVASTATIN MAGNESIUM ZYPITAMAG 5


pravastatin sodium PRAVACHOL 5


rosuvastatin calcium CRESTOR (10 MG)(TABLET) 5


rosuvastatin calcium CRESTOR (20 MG)(TABLET) 1 QL: 1 IN 1 DAY

rosuvastatin calcium CRESTOR (40 MG)(TABLET) 1 QL: 1 IN 1 DAY

rosuvastatin calcium CRESTOR (5 MG)(TABLET) 5


SIMVASTATIN FLOLIPID 5PA, AGE: $0 COPAY IF AGE 40-75YEARS AND NO HISTORY OFCARDIOVASCULAR DISEASE


Drug Name Tier Requirements/LimitsPREVENTION MEDICATIONS IN120 DAYS

simvastatin ZOCOR (10 MG)(TABLET) 5








simvastatin ZOCOR (80 MG)(TABLET) 1 ST, QL: 1 IN 1 DAY

ANTIHYPERLIPIDEMIC - MTP INHIBITORLOMITAPIDE MESYLATE JUXTAPID 4 PA

ANTIHYPERLIPIDEMIC - PCSK9 INHIBITORSALIROCUMAB PRALUENT PEN 4 PA

EVOLOCUMAB REPATHAPUSHTRONEX 4 PA

EVOLOCUMAB REPATHASURECLICK 4 PA

EVOLOCUMAB REPATHA SYRINGE 4 PABILE SALT SEQUESTRANTS

cholestyramine (with sugar) QUESTRAN 1cholestyramine/aspartame QUESTRAN LIGHT 1

colesevelam hcl WELCHOL (3.75 G)(POWD PACK) 1

COLESEVELAM HCL WELCHOL (625 MG)(TABLET) 1

colestipol hcl COLESTID (1 G)(TABLET) 1

colestipol hcl COLESTID (5 G)(GRANULES) 1

colestipol hcl COLESTID (5 G)(PACKET) 1

COLESTIPOL HCL COLESTID (7.5 G)(PACKET) 3

LIPOTROPICSezetimibe ZETIA 1 QL: 1 IN 1 DAYfenofibrate FENOGLIDE 1fenofibrate LIPOFEN 1fenofibrate LOFIBRA 1fenofibrate nanocrystallized TRICOR 1FENOFIBRATE NANOCRYSTALLIZED TRIGLIDE 2 ST

fenofibrate,micronized ANTARA (130 MG)(CAPSULE) 1

FENOFIBRATE,MICRONIZED ANTARA (30 MG)(CAPSULE) 3 ST



fenofibrate,micronized ANTARA (43 MG)(CAPSULE) 1

FENOFIBRATE,MICRONIZED ANTARA (90 MG)(CAPSULE) 3 ST

fenofibrate,micronized LOFIBRA 1fenofibric acid FIBRICOR 1fenofibric acid (choline) TRILIPIX 1gemfibrozil LOPID 1

ICOSAPENT ETHYL VASCEPA (0.5GRAM) (CAPSULE) 2 QL: 8 IN 1 DAY

ICOSAPENT ETHYL VASCEPA (1 G)(CAPSULE) 2 QL: 4 IN 1 DAY

METHIONINE/INOSI/CHOL/FOLIC AC LIPOCHOL PLUS 3niacin NIACOR 1niacin NIASPAN 1 STomega-3 acid ethyl esters LOVAZA 1 QL: 4 IN 1 DAY

CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTSADRENERGIC VASOPRESSOR AGENTS

DROXIDOPA NORTHERA 4 PAmidodrine hcl PROAMATINE 1

ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)SACUBITRIL/VALSARTAN ENTRESTO 2 QL: 2 IN 1 DAY

ANTIANGINAL & ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMIC

RANOLAZINE RANEXA (1000 MG)(TAB ER 12H) 2 QL: 2 IN 1 DAY

RANOLAZINE RANEXA (500 MG)(TAB ER 12H) 2 QL: 4 IN 1 DAY

ANTIANGINAL, HEART RATE REDUCING, I(F) INHIBITORIVABRADINE HCL CORLANOR 2 PA, QL: 2 IN 1 DAY

ANTIHYPERLIP - HMG-COA&CALCIUM CHANNEL BLOCKER CBamlodipine/atorvastatin CADUET 1 QL: 1 IN 1 DAY

CARDIOVASCULAR DISEASE - VASODILATIONVASODILATORS,CORONARY

amyl nitrite 1ISOSORBIDE DINITRATE DILATRATE-SR 3isosorbide dinitrate ISOCHRON 1

isosorbide dinitrate ISORDIL (10 MG)(TABLET) 1



ISOSORBIDE DINITRATE ISORDIL (40 MG)(TABLET) 2

isosorbide dinitrate ISORDILTITRADOSE 1

isosorbide mononitrate IMDUR 1isosorbide mononitrate MONOKET 1NITROGLYCERIN GONITRO 3 STNITROGLYCERIN NITRO-BID 2

nitroglycerinNITRO-DUR(0.1MG/HR) (PATCHTD24)

1


1



NITROGLYCERINNITRO-DUR (0.3MG/HR) (PATCHTD24)

2


1


1

NITROGLYCERINNITRO-DUR(0.8MG/HR) (PATCHTD24)

2

nitroglycerin NITROLINGUAL 1NITROGLYCERIN NITROMIST 3nitroglycerin NITROSTAT 1nitroglycerin NITRO-TIME 1

VASODILATORS,PERIPHERALergoloid mesylates HYDERGINE 1isoxsuprine hcl 1papaverine hcl 1

CONTRACEPTION/OXYTOCICSCONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC

ETONOGESTREL/ETHINYL ESTRADIOL NUVARING 5CONTRACEPTIVES,IMPLANTABLE

ETONOGESTREL NEXPLANON 5CONTRACEPTIVES,INJECTABLE

medroxyprogesterone acetate DEPO-PROVERA 5

MEDROXYPROGESTERONE ACETATE DEPO-SUBQPROVERA 104 5

CONTRACEPTIVES,INTRAVAGINALnonoxynol 9 CONCEPTROL 5nonoxynol 9 DELFEN 5NONOXYNOL 9 GYNOL II 5

NONOXYNOL 9TODAYCONTRACEPTIVESPONGE

5

NONOXYNOL 9 VCF 5CONTRACEPTIVES,ORAL

desog-e.estradiol/e.estradiol MIRCETTE 5desogestrel-ethinyl estradiol CYCLESSA 5desogestrel-ethinyl estradiol DESOGEN 5desogestrel-ethinyl estradiol ORTHO-CEPT 5drospir/eth estra/levomefol ca BEYAZ 5drospir/eth estra/levomefol ca SAFYRAL 5ESTRADIOL VALERATE/DIENOGEST NATAZIA 5ethinyl estradiol/drospirenone YASMIN 28 5ethinyl estradiol/drospirenone YAZ 5ethynodiol d-ethinyl estradiol DEMULEN 5ethynodiol d-ethinyl estradiol DEMULEN 1-50-21 5LEVONORGEST/ETH.ESTRADIOL/IRON BALCOLTRA 5 QL: 28 IN 28 DAYSlevonorgestrel PLAN B ONE-STEP 5levonorgestrel TAKE ACTION 5levonorgestrel-ethin estradiol (0.1-0.02mg) (tablet) 5levonorgestrel-ethin estradiol (0.15-0.03) (tablet) 5levonorgestrel-ethin estradiol (0.15-0.03) (tbdspk 3mo) 5levonorgestrel-ethin estradiol (6-5-10) (tablet) 5levonorgestrel-ethin estradiol (90-20 mcg) (tablet) 5


Drug Name Tier Requirements/Limitsl-norgest/e.estradiol-e.estrad LOSEASONIQUE 5l-norgest/e.estradiol-e.estrad QUARTETTE 5l-norgest/e.estradiol-e.estrad SEASONIQUE 5noreth-ethinyl estradiol/iron FEMCON FE 5noreth-ethinyl estradiol/iron GENERESS FE 5norethindrone NOR-Q-D 5norethindrone ORTHO MICRONOR 5norethindrone ac-eth estradiol LOESTRIN 5norethindrone-e.estradiol-iron ESTROSTEP FE 5NORETHINDRONE-E.ESTRADIOL-IRON LO LOESTRIN FE 5norethindrone-e.estradiol-iron LOESTRIN 24 FE 5norethindrone-e.estradiol-iron LOESTRIN FE 5norethindrone-e.estradiol-iron MINASTRIN 24 FE 5NORETHINDRONE-E.ESTRADIOL-IRON TAYTULLA 5norethindrone-ethinyl estrad MODICON 5norethindrone-ethinyl estrad ORTHO-NOVUM 5norethindrone-ethinyl estrad OVCON-35 5norethindrone-ethinyl estrad TRI-NORINYL 5

norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN 5

norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO 5

norgestimate-ethinyl estradiol ORTHO-CYCLEN 5norgestrel-ethinyl estradiol LO-OVRAL-28 5norgestrel-ethinyl estradiol LO-OVRAL-8 5norgestrel-ethinyl estradiol OVRAL 5ULIPRISTAL ACETATE ELLA 5

CONTRACEPTIVES,TRANSDERMALnorelgestromin/ethin.estradiol ORTHO EVRA 5

DIAPHRAGMS/CERVICAL CAPCERVICAL CAP FEMCAP 5DIAPHRAGMS, CONTOURED CAYA CONTOURED 5

DIAPHRAGMS, WIDE SEAL WIDE SEALDIAPHRAGM 5

OXYTOCICSDINOPROSTONE CERVIDIL 3DINOPROSTONE PREPIDIL 3

DINOPROSTONEPROSTIN E2VAGINALSUPPOSITORY

3

methylergonovine maleate 1

COUGH AND COLD1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS

chlorpheniramine/phenylephrine (1mg-2mg/ml)(drops) 1

phenylephrine hcl/prometh hcl PHENERGAN VC 1phenylephrine hcl/prometh hcl PHEN-TUSS AD 1

1ST GEN ANTIHIST-DECONGEST-ANTICHOLINERGIC COMBpseudoephed/chlor-mal/bell alk 1

ANTITUSSIVES,NON-NARCOTICbenzonatate TESSALON 1benzonatate TESSALON PERLE 1benzonatate ZONATUSS 1

NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESTbromphenira/pseudoephed/codein 1 AGE: >= 12 YEARSBROMPHENIRAMINE/P-EPH/CODEINE M-END PE 3 AGE: >= 12 YEARSBROMPHENIRAMINE/P-EPH/CODEINE POLY-TUSSIN AC 3 AGE: >= 12 YEARS


Drug Name Tier Requirements/LimitsCHLORPHEN/PSEUDOEPHED/CODEINE ZODRYL DAC 25 3 AGE: >= 12 YEARSCHLORPHEN/PSEUDOEPHED/CODEINE ZODRYL DAC 30 3 AGE: >= 12 YEARSCHLORPHEN/PSEUDOEPHED/CODEINE ZODRYL DAC 35 3 AGE: >= 12 YEARSCHLORPHEN/PSEUDOEPHED/CODEINE ZODRYL DAC 40 3 AGE: >= 12 YEARSCHLORPHEN/PSEUDOEPHED/CODEINE ZODRYL DAC 50 3 AGE: >= 12 YEARSCHLORPHEN/PSEUDOEPHED/CODEINE ZODRYL DAC 60 3 AGE: >= 12 YEARSCHLORPHEN/PSEUDOEPHED/CODEINE ZODRYL DAC 80 3 AGE: >= 12 YEARSCHLORPHENIRAMINE/PE/CODEINE CAPCOF 3 AGE: >= 12 YEARSDEXCHLORPHEN/PHENYLEPH/CODEINE PRO-RED AC 3 AGE: >= 12 YEARShydrocodone/cpm/pseudoephed 1 AGE: >= 18 YEARS

promethazine/phenyleph/codeine PENTAZINE VCWITH CODEINE 1 AGE: >= 18 YEARS

promethazine/phenyleph/codeine PHENERGAN VCWITH CODEINE 1 AGE: >= 18 YEARS

TRIPROLIDINE/PHENYLEPH/CODEINE HISTEX-AC 3 AGE: >= 12 YEARSNARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMB

PSEUDOEPHED/CODEINE/GUAIFEN CODITUSSIN DAC 3 AGE: >= 12 YEARSpseudoephed/codeine/guaifen TUSNEL C 1 AGE: >= 12 YEARSPSEUDOEPHED/CODEINE/GUAIFEN ZODRYL DEC 25 3 AGE: >= 12 YEARSPSEUDOEPHED/CODEINE/GUAIFEN ZODRYL DEC 30 3 AGE: >= 12 YEARSPSEUDOEPHED/CODEINE/GUAIFEN ZODRYL DEC 35 3 AGE: >= 12 YEARSPSEUDOEPHED/CODEINE/GUAIFEN ZODRYL DEC 40 3 AGE: >= 12 YEARSPSEUDOEPHED/CODEINE/GUAIFEN ZODRYL DEC 50 3 AGE: >= 12 YEARSPSEUDOEPHED/CODEINE/GUAIFEN ZODRYL DEC 60 3 AGE: >= 12 YEARSPSEUDOEPHED/CODEINE/GUAIFEN ZODRYL DEC 80 3 AGE: >= 12 YEARS

NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINECHLORPHENIRAMINE/CODEINE PHOS ZODRYL AC 25 3 AGE: >= 12 YEARSCHLORPHENIRAMINE/CODEINE PHOS ZODRYL AC 30 3 AGE: >= 12 YEARSCHLORPHENIRAMINE/CODEINE PHOS ZODRYL AC 35 3 AGE: >= 12 YEARSCHLORPHENIRAMINE/CODEINE PHOS ZODRYL AC 40 3 AGE: >= 12 YEARSCHLORPHENIRAMINE/CODEINE PHOS ZODRYL AC 50 3 AGE: >= 12 YEARSCHLORPHENIRAMINE/CODEINE PHOS ZODRYL AC 60 3 AGE: >= 12 YEARSCHLORPHENIRAMINE/CODEINE PHOS ZODRYL AC 80 3 AGE: >= 12 YEARSCHLORPHENIRAMINE/CODEINE PHOS Z-TUSS AC 3 AGE: >= 12 YEARS

CODEINE POLI/CHLORPHENIR POLIS TUZISTRA XR 3 ST, AGE: >= 18 YEARS, QL: 200mLIN 10 DAYS

HYDROCODONE/CHLORPHEN P-STIREX TUSSICAPS 3 AGE: >= 18 YEARShydrocodone/chlorphen p-stirex TUSSIONEX 1 AGE: >= 18 YEARSHYDROCODONE/CHLORPHENIRAMINE VITUZ 3 AGE: >= 18 YEARS

promethazine hcl/codeine PHENERGAN WITHCODEINE 1 AGE: >= 18 YEARS

NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMB.hydrocodone bit/homatrop me-br (5 mg-1.5mg)(tablet) 1 AGE: >= 18 YEARS

hydrocodone bit/homatrop me-br (5-1.5 mg/5) (syrup) 3 AGE: >= 18 YEARSNARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION

codeine phosphate/guaifenesin (10-100mg/5) (liquid)(otc) 1 AGE: >= 12 YEARS

codeine phosphate/guaifenesin (10-200mg/5) (liquid)(otc) 1 AGE: >= 12 YEARS

codeine phosphate/guaifenesin (20-200/10) (liquid)(otc) 3 AGE: >= 12 YEARS

codeine phosphate/guaifenesin (7.5-225/5) (liquid)(otc) 1 AGE: >= 12 YEARS

codeine phosphate/guaifenesin (8-200 mg/5) (liquid)(otc) 1 AGE: >= 12 YEARS

GUAIFENESIN/HYDROCODONE OBREDON 3 ST, AGE: >= 18 YEARS, QL: 600mLIN 10 DAYS


Drug Name Tier Requirements/LimitsNON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST

brompheniramine/pseudoephed/dm (2-30-10/5) (syrup) 1chlorpheniramine/phenyleph/dm (1-2-3mg/ml) (drops) 1

NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB.promethazine/dextromethorphan PHEN TUSS DM 1

NOSE PREPARATIONS, VASOCONSTRICTORS (RX)

EPINEPHRINE HCL ADRENALINCHLORIDE 3

TETRAHYDROZOLINE HCL TYZINE 3

DERMATOLOGY - ACNEACNE AGENTS,SYSTEMIC

ISOTRETINOIN ABSORICA 3 STisotretinoin 1

ACNE AGENTS,TOPICALadapalene/benzoyl peroxide EPIDUO 1 ST, AGE: <= 25 YEARSADAPALENE/BENZOYL PEROXIDE EPIDUO FORTE 2 ST, AGE: <= 25 YEARSAZELAIC ACID AZELEX 3clindamycin phos/benzoyl perox ACANYA 1 STclindamycin phos/benzoyl perox BENZACLIN 1clindamycin phos/benzoyl perox DUAC 1CLINDAMYCIN PHOS/BENZOYL PEROX ONEXTON 2 STCLINDAMYCIN/BENZOYL/EMOL CMB94 NEUAC 3

clindamycin/tretinoin VELTIN (1.2-0.025%)(GEL (GRAM)) 1

clindamycin/tretinoin ZIANA (1.2-0.025%)(GEL (GRAM)) 1

dapsone ACZONE (5 %) (GEL(GRAM)) 1

DAPSONE ACZONE (7.5 %)(GEL W/PUMP) 3

sulfacetamide sodium KLARON 1ANTICORROSIVE AGENTS

BUTYLATED HYDROXYTOLUENE(BHT) 3KERATOLYTIC-GLUCOCORTICOID COMBINATIONS

BENZOYL PEROXIDE/HYDROCORTISON VANOXIDE-HC 2ROSACEA AGENTS, TOPICAL

AZELAIC ACID FINACEA 2BRIMONIDINE TARTRATE MIRVASO 3IVERMECTIN SOOLANTRA 3 STmetronidazole METROCREAM 1metronidazole METROGEL 1metronidazole METROLOTION 1METRONIDAZOLE NORITATE 3 STmetronidazole ROSADAN 1METRONIDAZOLE/SKIN CLEANSER 23 ROSADAN 3OXYMETAZOLINE HCL RHOFADE 3

TOPICAL PREPARATIONS,ANTIBACTERIALSCADEXOMER IODINE IODOFLEX 3CADEXOMER IODINE IODOSORB 3CLIOQUINOL/HYDROCORTISONE ALA-QUIN 3

hydrocortisone/iodoquin/aloe 2ALCORTIN A (2 %-1%-1%) (GEL(GRAM))

1

HYDROCORTISONE/IODOQUIN/ALOE 2ALCORTIN A (2 %-1%-1%) (GELPACKET)

3

hydrocortisone/iodoquinol DERMAZENE 1


Drug Name Tier Requirements/Limitshydrocortisone/iodoquinol/aloe VYTONE 1iodine/potassium iodide (5%-10%) (solution) 1IODOQUINOL/ALOE P-SACCHARIDE 1 QUINJA 3SILVER SILVRSTAT 3SILVER CARBONATE NORMLGEL AG 3silver nitrate 1

VITAMIN A DERIVATIVESADAPALENE 3 AGE: <= 25 YEARSadapalene DIFFERIN 1 AGE: <= 25 YEARSADAPALENE PLIXDA 3 AGE: <= 25 YEARStretinoin ATRALIN 1 AGE: <= 25 YEARStretinoin RETIN-A 1 AGE: <= 25 YEARSTRETINOIN TRETIN-X 3 AGE: <= 25 YEARStretinoin microspheres RETIN-A MICRO 1 AGE: <= 25 YEARS

tretinoin microspheresRETIN-A MICROPUMP (0.04 %) (GELW/PUMP)

1 AGE: <= 25 YEARS

TRETINOIN MICROSPHERESRETIN-A MICROPUMP (0.06 %) (GELW/PUMP)

3 ST, AGE: <= 25 YEARS

TRETINOIN MICROSPHERESRETIN-A MICROPUMP (0.08 %) (GELW/PUMP)

3 ST, AGE: <= 25 YEARS

tretinoin microspheresRETIN-A MICROPUMP (0.1 %) (GELW/PUMP)

1 AGE: <= 25 YEARS

TRETINOIN/EMOL 9/SKIN CLEANSR1 TRETIN-X 3 AGE: <= 25 YEARSVITAMIN A DERIVATIVES, TOPICAL ACNE AGENTS

TAZAROTENE FABIOR 2 AGE: >= 12 YEARS

DERMATOLOGY - ANTIINFECTIVETOPICAL ANTIBIOTICS

CLINDAMYCIN PHOS/SKIN CLNSR 19 CLINDACIN ETZ 3CLINDAMYCIN PHOS/SKIN CLNSR 19 CLINDACIN PAC 3clindamycin phosphate CLEOCIN T 1clindamycin phosphate CLINDACIN ETZ 1clindamycin phosphate CLINDACIN P 1CLINDAMYCIN PHOSPHATE CLINDAGEL 3 STclindamycin phosphate EVOCLIN 1erythromycin base in ethanol 1ERYTHROMYCIN/BENZOYL PEROXIDE AKTIPAK 2erythromycin/benzoyl peroxide BENZAMYCIN 1gentamicin sulfate 1mupirocin BACTROBAN 1mupirocin CENTANY 1MUPIROCIN CENTANY AT 3mupirocin calcium BACTROBAN 1

TOPICAL ANTIFUNGAL/ANTIINFLAMMATORY,STERIOD AGENT

CLOTRIMAZOLE/BETAMETH DIP/ZINC DERMACINRXTHERAZOLE PAK 3

clotrimazole/betamethasone dip LOTRISONE 1TOPICAL ANTIFUNGALS

BUTENAFINE HCL MENTAX 3ciclopirox CICLODAN 1ciclopirox LOPROX 1ciclopirox PENLAC 1ciclopirox olamine CICLODAN 1ciclopirox olamine LOPROX 1CICLOPIROX/SKIN CLEANSER NO.28 CICLODAN 3


Drug Name Tier Requirements/LimitsCICLOPIROX/SKIN CLEANSER NO.40 LOPROX 3ciclopirox/urea/camph/men/euc CICLODAN 1clotrimazole (1 %) (cream (g)) 1clotrimazole (1 %) (solution) 1ECONAZOLE NITRATE ECOZA 3econazole nitrate SPECTAZOLE 1EFINACONAZOLE JUBLIA 3 PAgentian violet/brgreen/proflav 1ketoconazole EXTINA 1ketoconazole NIZORAL 1KETOCONAZOLE XOLEGEL 3luliconazole LUZU 1 ST, QL: 60gm IN 28 DAYSMICONAZOLE NITRATE/ZINC OX/PET VUSION 3

naftifine hcl NAFTIN (1 %)(CREAM (G)) 1

NAFTIFINE HCL NAFTIN (1 %) (GEL(GRAM)) 2

naftifine hcl NAFTIN (2 %)(CREAM (G)) 1

NAFTIFINE HCL NAFTIN (2 %) (GEL(GRAM)) 3

nystatin MYCOSTATIN 1nystatin NYAMYC 1nystatin NYSTEX 1nystatin NYSTOP 1nystatin/triamcin (100000-0.1) (cream (g)) 1nystatin/triamcin (100000-0.1) (oint. (g)) 1

oxiconazole nitrate OXISTAT (1 %)(CREAM (G)) 1

OXICONAZOLE NITRATE OXISTAT (1 %)(LOTION) 3

SERTACONAZOLE NITRATE ERTACZO 3sodium thiosulfate/sal acid VERSICLEAR 1SULCONAZOLE NITRATE EXELDERM 2TAVABOROLE KERYDIN 3 PA

TOPICAL ANTIPARASITICSBENZYL ALCOHOL ULESFIA 3CROTAMITON CROTAN 2CROTAMITON EURAX 2IVERMECTIN SKLICE 3lindane KWELL 1malathion OVIDE 1permethrin (5 %) (cream (g)) 1spinosad NATROBA 1

TOPICAL ANTIVIRALS

ACYCLOVIR ZOVIRAX (5 %)(CREAM (G)) 2

acyclovir ZOVIRAX (5 %)(OINT. (G)) 1

PENCICLOVIR DENAVIR 3TOPICAL ANTIVIRALS/ANTIINFLAMMATORY, STEROID AGENT

ACYCLOVIR/HYDROCORTISONE XERESE 3 ST, QL: 10gm IN 365 DAYSTOPICAL GENITAL WART-HPV TREATMENT AGENTS

SINECATECHINS VEREGEN 3 STTOPICAL PLEUROMUTILIN DERIVATIVES

RETAPAMULIN ALTABAX 3


Drug Name Tier Requirements/LimitsTOPICAL SULFONAMIDES

mafenide acetate SULFAMYLON (50G) (PACKET) 1

MAFENIDE ACETATE SULFAMYLON (8.5%) (CREAM (G)) 3

silver sulfadiazine SILVADENE 1silver sulfadiazine THERMAZENE 1sulfacetamide sod/sulfur/urea 1

sulfacetamide sodium/sulfur AVAR (10-5%(W/W))(CLEANSER) 1

SULFACETAMIDE SODIUM/SULFUR AVAR (9.5 %-5 %)(FOAM) 3

SULFACETAMIDE SODIUM/SULFUR AVAR (9.5 %-5 %)(MED. PAD) 3

sulfacetamide sodium/sulfur AVAR LS (10 %-2 %)(CLEANSER) 1

SULFACETAMIDE SODIUM/SULFUR AVAR LS (10 %-2 %)(FOAM) 3

SULFACETAMIDE SODIUM/SULFUR AVAR LS (10 %-2 %)(MED. PAD) 3

sulfacetamide sodium/sulfur AVAR-E 1sulfacetamide sodium/sulfur AVAR-E GREEN 1sulfacetamide sodium/sulfur AVAR-E LS 3sulfacetamide sodium/sulfur BP 10-1 1sulfacetamide sodium/sulfur CLARIFOAM EF 1

sulfacetamide sodium/sulfur PLEXION (10-5%(W/W)) (LOTION) 1

sulfacetamide sodium/sulfur PLEXION (9.8%-4.8%) (CLEANSER) 1

sulfacetamide sodium/sulfur PLEXION (9.8%-4.8%) (CREAM (G)) 1

sulfacetamide sodium/sulfur PLEXION (9.8%-4.8%) (LOTION) 1

SULFACETAMIDE SODIUM/SULFUR PLEXION (9.8%-4.8%) (MED. PAD) 3

sulfacetamide sodium/sulfur PLEXION TS 1SULFACETAMIDE SODIUM/SULFUR ROSANIL 3

SULFACETAMIDE SODIUM/SULFUR ROSULA (10 %-4.5%) (CLEANSER) 3

sulfacetamide sodium/sulfur ROSULA (10 %-5 %)(MED. PAD) 1

sulfacetamide sodium/sulfurSODIUMSULFACETAMIDE-SULFUR

1

sulfacetamide sodium/sulfur SULFACET-R 1sulfacetamide sodium/sulfur SUMADAN 1sulfacetamide sodium/sulfur SUMAXIN 1sulfacetamide sodium/sulfur SUMAXIN TS 1sulfacetamide sodium/sulfur ZENCIA 1sulfacetamide/sulfur/cleansr23 PLEXION 1SULFACETAMIDE/SULFUR/CLEANSR23 SUMADAN 3SULFACETAMIDE/SULFUR/CLEANSR23 SUMAXIN CP 3sulfact sod/sulur/avob/otn/oct SUMADAN XLT 1

DERMATOLOGY - ANTIINFLAMMATORYTOP. ANTI-INFLAM.,PHOSPHODIESTERASE-4 (PDE4) INHIB

CRISABOROLE EUCRISA 2 STTOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDAL

NEOMYC/BACIT/POLYMYX/HYDROCORT CORTISPORIN 2


Drug Name Tier Requirements/LimitsNEOMYCIN SULFATE/FLUOCINOLONE NEO-SYNALAR 3 STNEOMYCIN/FLUOCINOLONE/EMOLL 65 NEO-SYNALAR 3 STNEOMYCIN/POLYMYXIN B/HYDROCORT CORTISPORIN 2

TOPICAL ANTI-INFLAMMATORY STEROIDALalclometasone dipropionate ACLOVATE 1amcinonide CYCLOCORT 1betamethasone dipropionate DIPROLENE 1BETAMETHASONE DIPROPIONATE SERNIVO 3 STbetamethasone valerate LUXIQ 1betamethasone valerate VALISONE 1betamethasone/propylene glyc DIPROLENE 1betamethasone/propylene glyc DIPROLENE AF 1clobetasol propionate CLOBEX 1clobetasol propionate CLODAN 1CLOBETASOL PROPIONATE IMPOYZ 3 STclobetasol propionate OLUX 1clobetasol propionate TEMOVATE 1clobetasol propionate/emoll OLUX-E 1clobetasol propionate/emoll TEMOVATE E 1

clobetasol propionate/emoll TEMOVATEEMOLLIENT 1

CLOBETASOL/SKIN CLEANSER NO.28 CLODAN 3clocortolone pivalate CLODERM 1DESONIDE DESONATE 3desonide 1desonide DESOWEN 1DESONIDE VERDESO 3

desoximetasone TOPICORT (0.05 %)(CREAM (G)) 1

desoximetasone TOPICORT (0.05 %)(GEL (GRAM)) 1

desoximetasone TOPICORT (0.05 %)(OINT. (G)) 1

desoximetasone TOPICORT (0.25 %)(CREAM (G)) 1

desoximetasone TOPICORT (0.25 %)(OINT. (G)) 1

desoximetasone TOPICORT (0.25 %)(SPRAY) 1 ST

diflorasone diacetate APEXICON 1diflorasone diacetate PSORCON 1DIFLORASONE DIACETATE/EMOLL APEXICON E 2FLUOCINOLONE ACETONIDE CAPEX SHAMPOO 3

fluocinolone acetonide DERMA-SMOOTHE-FS 1

fluocinolone acetonide SYNALAR 1FLUOCINOLONE/EMOL COMB NO.65 SYNALAR 3

fluocinolone/shower cap DERMA-SMOOTHE-FS 1

FLUOCINOLONE/SKIN CLNSR10/TAPE XILAPAK 3FLUOCINOLONE/SKIN CLNSR28 SYNALAR TS 3FLUOCINOLONE/UREA/SILICONE,ADH NOXIPAK 3fluocinonide LIDEX 1fluocinonide VANOS 1fluocinonide/emollient base LIDEX-E 1

FLURANDRENOLIDE CORDRAN (0.025 %)(CREAM (G)) 3

flurandrenolide CORDRAN (0.05 %)(CREAM (G)) 1



flurandrenolide CORDRAN (0.05 %)(LOTION) 1

flurandrenolide CORDRAN (0.05 %)(OINT. (G)) 1

FLURANDRENOLIDECORDRAN(4MCG/SQ CM)(MED. TAPE)

3 ST, QL: 2 IN 30 DAYS

flurandrenolide NOLIX 1fluticasone propionate CUTIVATE 1HALCINONIDE HALOG 3

halobetasol propionate ULTRAVATE (0.05 %)(CREAM (G)) 1

HALOBETASOL PROPIONATE ULTRAVATE (0.05 %)(LOTION) 3

halobetasol propionate ULTRAVATE (0.05 %)(OINT. (G)) 1

HALOBETASOL/LACTIC ACID ULTRAVATE X 3hydrocort/min oil/petrolat,wht 1HYDROCORT/SAL ACID/SULF/SHAMP1 SCALACORT DK 2hydrocortisone (1 %) (cream (g)) 1hydrocortisone (1 %) (crm/pe app) 3hydrocortisone (1 %) (oint. (g)) 1hydrocortisone (2 %) (lotion) 1hydrocortisone (2.5 %) (cream (g)) 1hydrocortisone (2.5 %) (crm/pe app) 1hydrocortisone (2.5 %) (kit) 3hydrocortisone (2.5 %) (lotion) 1hydrocortisone (2.5 %) (oint. (g)) 1HYDROCORTISONE TEXACORT 2HYDROCORTISONE ACET/ALOE VERA NUCORT 3HYDROCORTISONE ACETATE MICORT-HC 3hydrocortisone butyrate LOCOID 1

hydrocortisone butyrate/emoll LOCOIDLIPOCREAM 3

HYDROCORTISONE PROBUTATE PANDEL 2hydrocortisone valerate 1

HYDROCORTISONE/SKIN CLEANSER25 AQUA GLYCOLICHC 3

HYDROCORTISONE/SKIN CLEANSER35 DERMASORB HC 3mometasone furoate ELOCON 1prednicarbate DERMATOP 1

TRIAMCINOLONE ACETON/SILICONES DERMACINRXSILAZONE 3

TRIAMCINOLONE ACETON/SILICONES SILAZONE-II 3triamcinolone acetonide 1

triamcinolone/dimeth/silicone DERMACINRXSILAPAK 1 ST, QL: 1 IN 30 DAYS

triamcinolone/dimeth/silicone DERMAWERX SDS 1 ST, QL: 1 IN 30 DAYStriamcinolone/dimeth/silicone NUTRIARX 1 ST, QL: 1 IN 30 DAYS

triamcinolone/dimeth/silicone SURE RESULT TACPAK 1 ST, QL: 1 IN 30 DAYS

TRIAMCINOLONE/DIMETH/SILICONE WHYTEDERMTDPAK 3

TRIAMCINOLONE/DIMETH/SILICONE WHYTEDERMTRILASIL PAK 3

TRIAMCINOLONE/EMOLLIENT COMB86 DERMASORB TA 3TOPICAL ANTI-INFLAMMATORY, NSAIDS

DICLOFEN SOD/KINESIOLOGY TAPE DICLO GEL-XRYLIX SHEET 3


Drug Name Tier Requirements/LimitsDICLOFEN SOD/KINESIOLOGY TAPE LEXIXRYL 3DICLOFEN SOD/KINESIOLOGY TAPE XRYLIX 3DICLOFENAC EPOLAMINE FLECTOR 3DICLOFENAC SODIUM DICLO GEL 3DICLOFENAC SODIUM DICLOFONO 3DICLOFENAC SODIUM DICLOZOR 3

diclofenac sodium PENNSAID (1.5 %)(DROPS) 1

DICLOFENAC SODIUMPENNSAID(20MG/G(2%)) (SOLMD PMP)

3 ST

diclofenac sodium VOLTAREN 1DICLOFENAC SODIUM VOPAC MDS 3DICLOFENAC SODIUM/CAPSAICIN DICLOPAK 3DICLOFENAC SODIUM/CAPSAICIN NUDICLO 3DICLOFENAC SODIUM/MENTHOL DITHOL 3

DICLOFENAC/CAPSICUM OLEORESIN DERMACINRXLEXITRAL 3

DICLOFENAC/CAPSICUM OLEORESIN DICLOTRAL 3

DICLOFENAC/CAPSICUM OLEORESIN SURE RESULT DSSPREMIUM PACK 3

DICLOFENAC/CAPSICUM OLEORESIN XELITRAL 3DICLOFENAC/ME-SALIC/MENTH/CAMP INFLAMMA-K 3DICLOFENAC/MET SALICYL/MENTHOL DICLOPR 3KETOPROFEN FROTEK 3

DERMATOLOGY - ANTIPRURITIC DRUGSANTIPRURITICS,TOPICAL

doxepin hcl PRUDOXIN 1 STdoxepin hcl ZONALON 1 STE101/NAMG FL/NA PH/NACL/HA-NAH ALEVICYN PLUS 3NA MG FL/NA PHO/NACL/HA/NA HYP LEVICYN 3NA MG FL/NA PHO/NACL/HA/NA HYP SP ANTIPRURITIC 3

DERMATOLOGY - MISCELLANEOUSANTIPERSPIRANTS

ALUMINUM CHLORIDE DRYSOL 2ANTISEBORRHEIC AGENTS

EMOLLIENT COMBINATION NO.43 PROMISEB 3emollient combination no.85 1

EMOLLIENT NO43/SKIN CLEANSER27 PROMISEBCOMPLETE 3

HYDROGEN PEROXIDE ESKATA 3selenium sulfide (2.25 %) (shampoo) 1selenium sulfide (2.3 %) (shampoo) 1selenium sulfide (2.5 %) (lotion) 1SELENIUM SULFIDE TERSI FOAM 3

SULFACETAMIDE SODIUM OVACE PLUS (10 %)(CREAM (G)) 3

SULFACETAMIDE SODIUM OVACE PLUS (10 %)(SHAMPOO) 2

SULFACETAMIDE SODIUM OVACE PLUS (9.8 %)(FOAM) 3

SULFACETAMIDE SODIUM OVACE PLUS (9.8 %)(LOTION) 3 ST

sulfacetamide sodium (10 %) (cleanser) 1sulfacetamide sodium (10 %) (clnsr gel) 1sulfacetamide sodium (10 %) (shampoo) 3


Drug Name Tier Requirements/LimitsANTISEPTICS,MISCELLANEOUS

GUAIACOL 3EMOLLIENTS

ammonium lactate (12 %) (cream (g)) 1ammonium lactate (12 %) (lotion) 1DICAPRYLYL CARBONATE/DIMETH LOYON 3emol53/namgfs/ha/nahypochlorit 1emol53/sod mag fl.sil/cyclomet AURSTAT 1emollient combination no.10 BIAFINE 1EMOLLIENT COMBINATION NO.10 LUXAMEND 3EMOLLIENT COMBINATION NO.101 CERAMAX 3EMOLLIENT COMBINATION NO.103 CERACADE 3EMOLLIENT COMBINATION NO.104 DEXERYL 3EMOLLIENT COMBINATION NO.107 NUTRASEB 3EMOLLIENT COMBINATION NO.109 NEOCERA 3emollient combination no.32 1EMOLLIENT COMBINATION NO.32 EPICERAM 3emollient combination no.35 1EMOLLIENT COMBINATION NO.38 NEOSALUS 3EMOLLIENT COMBINATION NO.44 HPR 3EMOLLIENT COMBINATION NO.44 HYLATOPIC 3EMOLLIENT COMBINATION NO.47 NEOSALUS 3EMOLLIENT COMBINATION NO.47 NEOSALUS CP 3EMOLLIENT COMBINATION NO.53 ATOPADERM 3EMOLLIENT COMBINATION NO.53 HPR PLUS 3EMOLLIENT COMBINATION NO.53 HYLATOPICPLUS 3EMOLLIENT COMBINATION NO.53 NIVATOPIC PLUS 3

EMOLLIENT COMBINATION NO.60 ATRAPROHYDROGEL 3

EMOLLIENT COMBINATION NO.60 CELACYN 3

EMOLLIENT COMBINATION NO.60 LEVICYNANTIPRURITIC SG 3

EMOLLIENT COMBINATION NO.60 RESTIZAN 3EMOLLIENT COMBINATION NO.60 SEBUDERM 3

EMOLLIENT COMBINATION NO.60 SP SCARMANAGEMENT 3

EMOLLIENT COMBINATION NO.80 PRESERA 3EMOLLIENT COMBOS NO.47, NO.60 ATRAPRO CP 3HYALURONT/E/EMOL 12/ALLAN/SHEA XCLAIR 3PALM OIL SYNERDERM 3PALM OIL/EUCALYPTUS OIL PHLAG SPRAY 3PALM OIL/HYALURONATE SODIUM ENTTY 3vite ac/grape/hyaluronic acid ATOPICLAIR 1

IODINE ANTISEPTICSpovidone-iodine (5 %) (solution) 1

IRRIGANTSacetic acid 1mannitol/sorbitol solution 1neomycin sulf/polymyxin b sulf 1

ORGAN PRESERVATION SOLN-BELZER VIASPAN BELZER-UW 3

PHYSIOLOGICAL IRRIG SOLN NO.1 PHYSIOLYTE 3PHYSIOLOGICAL IRRIG SOLN NO.1 PHYSIOSOL 3ringer's solution 1

RINGER'S SOLUTION,LACTATED LACTATEDRINGERS 3

SOD,POT CHLOR/MAG/SOD,POT PHOS TIS-U-SOLPENTALYTE 3


Drug Name Tier Requirements/LimitsSODIUM CHLOR/HYPOCHLOROUS ACID VASHE WOUND 3

SODIUM CHLOR/HYPOCHLOROUS ACID VASHE WOUNDTHERAPY 3

sodium chloride irrig solution (0.9 %) (irrig soln) 1sorbitol solution 1water for irrigation,sterile 1

IRRITANTS/COUNTER-IRRITANTSCAPSAICIN/SKIN CLEANSER QUTENZA 3 PA

KERATOLYTICSbenzoyl peroxide (4 %) (gel (gram)) 1benzoyl peroxide (5.3%) (foam) 1benzoyl peroxide (6 %) (towelette) 1benzoyl peroxide (7 %) (cleanser) 1benzoyl peroxide (8 %) (gel (gram)) 1benzoyl peroxide (9.8 %) (foam) 1BENZOYL PEROXIDE PACNEX HP 3BENZOYL PEROXIDE PACNEX LP 3benzoyl peroxide microspheres 1BENZOYL PEROXIDE/SULFUR NUOX 3BENZOYL PEROXIDE/VIT E MIX INOVA 3

PODOFILOX CONDYLOX (0.5 %)(GEL (GRAM)) 3 ST

podofilox CONDYLOX (0.5 %)(SOLUTION) 1

podophyllum resin 1SALICYLIC AC/BENZOYL PER/VIT E INOVA 4-1 3SALICYLIC AC/BENZOYL PER/VIT E INOVA 8-2 3SALICYLIC ACID BENSAL HP 3SALICYLIC ACID KERALYT SCALP 3salicylic acid (26 %) (liquid) 1salicylic acid (27.5 %) (liq-film) 1salicylic acid (28.5 %) (sol-filmer) 3salicylic acid (6 %) (cream (g)) 1salicylic acid (6 %) (crm er (g)) 1salicylic acid (6 %) (foam) 1salicylic acid (6 %) (gel (gram)) 1salicylic acid (6 %) (lotion er) 1salicylic acid (6 %) (lotion) 1salicylic acid (6 %) (shampoo) 1SALICYLIC ACID SALIMEZ FORTE 3SALICYLIC ACID ULTRASAL-ER 3salicylic acid/ammon lact/aloe SALKERA 1

SALICYLIC ACID/CERAMIDE COMB 1 SALEX (6 %)(COMBO. PKG) 3

salicylic acid/ceramide comb 1 SALEX (6 %) (KITCLCMER) 1

SALICYLIC ACID/UREA SALVAX DUO PLUS 3silver nitrate 1silver nitrate applicator 1UREA HYDRO 35 3UREA KERAFOAM 3UREA RYNODERM 3UREA URAMAXIN 3urea 1UREA UREVAZ 3UREA/EMOLLIENT COMBINATION 65 URAMAXIN GT 3

OXIDIZING AGENTSHYP AC/SOD CHL/SOD SUL/SOD PHO LEVICYN 3



HYPOC ACID/SOD HYPO/NACL/WATER ATRAPRO DERMALSPRAY 3

HYPOC ACID/SOD HYPO/NACL/WATER HYCLODEX 3HYPOC ACID/SOD HYPO/NACL/WATER MICROCYN 3

PROTECTIVESBIO/CARB/EQUIS/ETHAN/CHIT/MSM GENADUR 3CARBIT/EQUIS XT/ETHAN/CHIT/MSM GENADUR 3DI-ME SILOX/DIMETHIC/HEXAMETHY BEAU RX 3 ST, QL: 30gm IN 30 DAYSDIME/DIME CR/TRIMETH/SILIC PAD SILIPAC 3DIMET/DIMET CROSSPOL/T.M.SILIC KELARX 3GEL PAD/DMC/DIME/DEC/OCT/VIT E SCARCARE 3

HOCL/NA HY/NAMGF/NA PH/NACL/WA MICROCYNHYDROGEL 3

HYALURONATE SODIUM BIONECT 3hyaluronate sodium/he-cell/peg 1HYALURONATE/ALLANTOIN/ALOE EXT RADIAPLEXRX 3petrolatum,white 3POLYDIMETHYLSILOXANES/SILICON RECEDO 3POLY-UREAURETHANE NUVAIL 3PROTECTIVES COMBINATION NO.2 TETRIX 3protectives2/ceramide 1,3,6-11 TETRIX 1

TOPICAL ANTI-INFLAMMATORY STEROID-LOCAL ANESTHETICHYDROCORTISONE/PRAMOXINE ANALPRAM HC 2HYDROCORTISONE/PRAMOXINE EPIFOAM 3HYDROCORTISONE/PRAMOXINE NOVACORT 3

HYDROCORTISONE/PRAMOXINE PRAMOSONE (1 %-1%) (CREAM (G)) 2

HYDROCORTISONE/PRAMOXINE PRAMOSONE (1 %-1%) (LOTION) 2

HYDROCORTISONE/PRAMOXINE PRAMOSONE (1 %-1%) (OINT. (G)) 2

hydrocortisone/pramoxine PRAMOSONE (2.5%-1 %) (CREAM (G)) 1

HYDROCORTISONE/PRAMOXINE PRAMOSONE (2.5%-1 %) (LOTION) 2

HYDROCORTISONE/PRAMOXINE PRAMOSONE (2.5%-1 %) (OINT. (G)) 2

HYDROCORTISONE/PRAMOXINE/EMOLL PRAMOSONE E 3lidocaine/hydrocortisone ac LIDAMANTLE HC 1

TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTSALITRETINOIN PANRETIN 4BEXAROTENE TARGRETIN 4 PAdiclofenac sodium SOLARAZE 1 QL: 100gm PER FILLfluorouracil CARAC 1 PAfluorouracil EFUDEX 1FLUOROURACIL FLUOROPLEX 3FLUOROURACIL TOLAK 3

INGENOL MEBUTATE PICATO (0.015 %)(GEL (EA)) 2 QL: 3 IN 28 DAYS

INGENOL MEBUTATE PICATO (0.05 %)(GEL (EA)) 2 QL: 2 IN 28 DAYS

MECHLORETHAMINE HCL VALCHLOR 4 PATOPICAL LOCAL ANESTHETICS

BENZOCAINE ANACAINE 3cocaine hcl 1ethyl chloride 1lidocaine (5 %) (adh. patch) 1lidocaine (5 %) (oint. (g)) 1 ST, QL: 240gm IN 30 DAYS


Drug Name Tier Requirements/LimitsLIDOCAINE LIDOPAC 3LIDOCAINE LIDOVEX 3LIDOCAINE TRANZAREL 3LIDOCAINE ZTLIDO 3LIDOCAINE HCL ANASTIA 3LIDOCAINE HCL ASTERO 3LIDOCAINE HCL LDO PLUS 3lidocaine hcl (3 %) (cream (g)) 1lidocaine hcl (3 %) (lotion) 1lidocaine hcl (3.88 %) (cream (g)) 1lidocaine hcl (4 %) (solution) 1LIDOCAINE HCL LIDOPIN 3LIDOCAINE HCL LIDORX 3LIDOCAINE HCL NUMBONEX 3LIDOCAINE HCL/ALOE/COLLAGEN LIDOTREX 3LIDOCAINE HCL/ALOE/COLLAGEN VEXASYN 3LIDOCAINE HCL/COLLAGEN REGENECARE 3LIDOCAINE HCL/ME-SALICYL/MENTH WPR PLUS 3LIDOCAINE HCL/PALM OIL KAMDOY 3LIDOCAINE/BENZOCAIN/ME-SAL/CAP ADAZIN 3

LIDOCAINE/DIMETHICONE DERMACINRX ZRMPAK 3

LIDOCAINE/DIMETHICONE DERMAZYL 3

LIDOCAINE/EMOLLIENT CMB NO.102 DERMACINRX PHNPAK 3

LIDOCAINE/EMOLLIENT CMB NO.102 NEURCAINE 3

LIDOCAINE/GAUZE/ALGINATEWOUNDDEBRIDEMENT-LIDOCAINE

3

LIDOCAINE/KINESIOLOGY TAPE XRYLIDERM 3LIDOCAINE/MENTHOL MENTHO-CAINE 3LIDOCAINE/METHYL SAL/MENTHOL SOLUPAK 3LIDOCAINE/PRILO/M.SALICY/MENTH PAINGO KFT 3lidocaine/prilocaine AGONEAZE 3

lidocaine/prilocaine DERMACINRXEMPRICAINE 3

lidocaine/prilocaine DERMACINRXPRIZOPAK 3

LIDOCAINE/PRILOCAINE DOLOTRANZ 3lidocaine/prilocaine EMLA 1lidocaine/prilocaine LEVA SET 3lidocaine/prilocaine LIDOPRIL 3lidocaine/prilocaine LIDOPRIL XR 3

lidocaine/prilocaine LIDO-PRILO CAINEPACK 3

lidocaine/prilocaine LIPROZONEPAK 3lidocaine/prilocaine LIVIXIL PAK 3lidocaine/prilocaine MEDOLOR PAK 3lidocaine/prilocaine PRILOLID 3lidocaine/prilocaine PRILOVIX 3lidocaine/prilocaine RELADOR PAK 3

lidocaine/prilocaine RELADOR PAKPLUS 3

lidocaine/racepinep/tetracaine 3LIDOCAINE/SKIN CLEANSER NO.37 LIDORXKIT 3lidocaine/tetracaine PLIAGLIS 1LIDOCAINE/TETRACAINE SYNERA 3LIDOCAINE/TRANSPARENT DRESSING LIDOTRANS 5 PAK 3NORFLURANE/PENTAFLUOROPROPANE PAIN EASE 3



NORFLURANE/PENTAFLUOROPROPANE SPRAY ANDSTRETCH 3

TETRACAINE HCL PONTOCAINE 3TETRACAINE/BENZOCAINE/BUTAMBEN CETACAINE 3

TETRACAINE/BENZOCAINE/BUTAMBEN CETACAINEANESTHETIC 3

VIT E/LIDOCAINE/ALOE/COLLAGEN LIDOTREX 3VIT E/LIDOCAINE/ALOE/COLLAGEN REGENECARE 3

TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMESCOLLAGENASE CLOSTRIDIUM HIST. SANTYL 3

HYALURONIDASE, HUMAN RECOMB. HYQVIA HYCOMPONENT 3

DERMATOLOGY - PIGMENTATION DISORDERSHYPOPIGMENTATION AGENTS

FLUOCINOLONE/TRETINOIN/H-QUIN TRI-LUMA 3hydroquinone BLANCHE 1hydroquinone ELDOQUIN FORTE 1hydroquinone LUSTRA 1hydroquinone microspheres 1

HYDROQUINONE/ASCORBIC ACID C-CLARIFYINGSERUM 3

HYDROQUINONE/OXYBEN/OCTINOXATE NU-DERMSUNFADER 3

HYDROQUINONE/VIT C/VIT E ACET C-THERAPY NIGHTCREAM 3

DERMATOLOGY - PSORIASIS/ECZEMAANTIPSORIATIC AGENTS,SYSTEMIC

acitretin SORIATANE 4BRODALUMAB SILIQ 4 PAGUSELKUMAB TREMFYA 4 PA

IXEKIZUMAB TALTZAUTOINJECTOR 4 PA

IXEKIZUMABTALTZAUTOINJECTOR (2PACK)

4 PA

IXEKIZUMABTALTZAUTOINJECTOR (3PACK)

4 PA

IXEKIZUMAB TALTZ SYRINGE 4 PAmethoxsalen (10 mg) (cap lq rap) 1

SECUKINUMAB COSENTYX (2SYRINGES) 2 PA

SECUKINUMAB COSENTYX PEN 2 PA

SECUKINUMAB COSENTYX PEN (2PENS) 2 PA

SECUKINUMAB COSENTYXSYRINGE 2 PA

ANTIPSORIATICS AGENTSANTHRALIN DRITHOCREME HP 2 STANTHRALIN MICRONIZED ZITHRANOL 3 STcalcipotriene DOVONEX 1 STCALCIPOTRIENE SORILUX 3 STcalcitriol VECTICAL 1 ST

TAZAROTENE TAZORAC (0.05 %)(CREAM (G)) 2

TAZAROTENE TAZORAC (0.05 %)(GEL (GRAM)) 2



tazarotene TAZORAC (0.1 %)(CREAM (G)) 1

TAZAROTENE TAZORAC (0.1 %)(GEL (GRAM)) 2

ECZEMA AGENTS,SYSTEMIC,INTERLEUKIN-4 REC.ANTAG MABDUPILUMAB DUPIXENT 4 PA

TOPICAL AGENTS,MISCELLANEOUSGABAPENTIN NEURAPTINE 3UREA GORDON'S UREA 3

TOPICAL IMMUNOSUPPRESSIVE AGENTSPIMECROLIMUS ELIDEL 2 STtacrolimus PROTOPIC 1

TOPICAL VIT D ANALOG/ANTIINFLAMMATORY, STEROIDALCALCIPOTRIENE/BETAMETHASONE ENSTILAR 3 ST

calcipotriene/betamethasone TACLONEX (0.005-.064) (OINT. (G)) 1 ST

CALCIPOTRIENE/BETAMETHASONE TACLONEX (0.005-.064) (SUSPENSION) 3 ST

DIABETESANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB.

alogliptin benz/metformin hcl KAZANO 3 STLINAGLIPTIN/METFORMIN HCL JENTADUETO 2LINAGLIPTIN/METFORMIN HCL JENTADUETO XR 2SAXAGLIPTIN HCL/METFORMIN HCL KOMBIGLYZE XR 3 STSITAGLIPTIN PHOS/METFORMIN HCL JANUMET 2SITAGLIPTIN PHOS/METFORMIN HCL JANUMET XR 2

ANTIHYPERGLY,DPP-4 ENZYME INHIB &THIAZOLIDINEDIONEalogliptin benz/pioglitazone OSENI 3 ST

ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST)ALBIGLUTIDE TANZEUM 3 STDULAGLUTIDE TRULICITY 2 STEXENATIDE BYETTA 2 STEXENATIDE MICROSPHERES BYDUREON 2 STEXENATIDE MICROSPHERES BYDUREON BCISE 2 STEXENATIDE MICROSPHERES BYDUREON PEN 2 STLIRAGLUTIDE VICTOZA 2-PAK 3 STLIRAGLUTIDE VICTOZA 3-PAK 3 STLIXISENATIDE ADLYXIN 3 STSEMAGLUTIDE OZEMPIC 3 ST

ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIBCANAGLIFLOZIN INVOKANA 3 STDAPAGLIFLOZIN PROPANEDIOL FARXIGA 2 STEMPAGLIFLOZIN JARDIANCE 2 STERTUGLIFLOZIN PIDOLATE STEGLATRO 3 ST

ANTIHYPERGLYCEMIC - DOPAMINE RECEPTOR AGONISTSBROMOCRIPTINE MESYLATE CYCLOSET 3 ST

ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S)acarbose PRECOSE 1miglitol GLYSET 1

ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPEPRAMLINTIDE ACETATE SYMLINPEN 120 2PRAMLINTIDE ACETATE SYMLINPEN 60 2

ANTIHYPERGLYCEMIC, DPP-4 INHIBITORSalogliptin benzoate NESINA 3 STLINAGLIPTIN TRADJENTA 2SAXAGLIPTIN HCL ONGLYZA 3 ST


Drug Name Tier Requirements/LimitsSITAGLIPTIN PHOSPHATE JANUVIA 2

ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPEchlorpropamide DIABINESE 1glimepiride AMARYL 1glipizide GLUCOTROL 1glipizide GLUCOTROL XL 1glyburide 1glyburide,micronized GLYNASE 1nateglinide STARLIX 1repaglinide PRANDIN 1tolazamide TOLINASE 1tolbutamide ORINASE 1

ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S)pioglitazone hcl ACTOS 1ROSIGLITAZONE MALEATE AVANDIA 3 ST

ANTIHYPERGLYCEMIC, SGLT-2 & DPP-4 INHIBITOR COMB.DAPAGLIFLOZIN/SAXAGLIPTIN HCL QTERN 3 STEMPAGLIFLOZIN/LINAGLIPTIN GLYXAMBI 2 STERTUGLIFLOZIN/SITAGLIPTIN STEGLUJAN 3 ST

ANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA)metformin hcl FORTAMET 1 STmetformin hcl GLUCOPHAGE 1metformin hcl GLUCOPHAGE XR 1metformin hcl GLUMETZA 1 STmetformin hcl RIOMET 1METFORMIN/BLOOD SUGAR DIAGNOST DM2 3

ANTIHYPERGLYCEMIC,INSULIN & GLP-1 RECEPTOR AGONISTINSULIN DEGLUDEC/LIRAGLUTIDE XULTOPHY 100-3.6 2 STINSULIN GLARGINE/LIXISENATIDE SOLIQUA 100-33 2 ST

ANTIHYPERGLYCEMIC,INSULIN-REL STIM.& BIGUANIDE CMBglipizide/metformin hcl METAGLIP 1glyburide/metformin hcl 1repaglinide/metformin hcl PRANDIMET 1

ANTIHYPERGLYCEMIC,INSULIN-RESPONSE & RELEASE COMB.pioglitazone hcl/glimepiride DUETACT 1 ST

ANTIHYPERGLYCEMIC-GLUCOCORTICOID RECEPTOR BLOCKERMIFEPRISTONE KORLYM 4 PA

ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR & BIGUANIDE COMBCANAGLIFLOZIN/METFORMIN HCL INVOKAMET 3 STCANAGLIFLOZIN/METFORMIN HCL INVOKAMET XR 3 STDAPAGLIFLOZIN/METFORMIN HCL XIGDUO XR 2 STEMPAGLIFLOZIN/METFORMIN HCL SYNJARDY 2 STEMPAGLIFLOZIN/METFORMIN HCL SYNJARDY XR 2 STERTUGLIFLOZIN/METFORMIN SEGLUROMET 3 ST

ANTIHYPERGLYCM,INSUL-RESP.ENHANCER & BIGUANIDE CMBpioglitazone hcl/metformin hcl ACTOPLUS MET 1 STPIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET XR 2 ST

BLOOD SUGAR DIAGNOSTICS

BLOOD SUGAR DIAGNOSTIC ACCU-CHEK AVIVAPLUS 6

BLOOD SUGAR DIAGNOSTIC ACCU-CHEK GUIDETEST STRIP 6

BLOOD SUGAR DIAGNOSTIC ACCU-CHEKSMARTVIEW 6

BLOOD SUGAR DIAGNOSTIC ACCUTRENDGLUCOSE 6



BLOOD SUGAR DIAGNOSTICADVANCEDGLUCOSE TESTSTRIP

6

BLOOD SUGAR DIAGNOSTICADVANCEDGLUCOSE TESTSTRIPS

6

BLOOD SUGAR DIAGNOSTIC ADVOCATE REDI-CODE 6

BLOOD SUGAR DIAGNOSTIC ADVOCATE REDI-CODE+ 6

BLOOD SUGAR DIAGNOSTIC ADVOCATE TESTSTRIP 6

BLOOD SUGAR DIAGNOSTIC AGAMATRIX AMP 6BLOOD SUGAR DIAGNOSTIC ASSURE 4 6BLOOD SUGAR DIAGNOSTIC ASSURE PLATINUM 6

BLOOD SUGAR DIAGNOSTIC ASSURE PRISMMULTI 6

BLOOD SUGAR DIAGNOSTIC BLOOD GLUCOSETEST STRIP 6

BLOOD SUGAR DIAGNOSTIC CARESENS N 6

BLOOD SUGAR DIAGNOSTIC CARETOUCH TESTSTRIP 6

BLOOD SUGAR DIAGNOSTICCHOICEDMCLARUS TESTSTRIPS

6

BLOOD SUGAR DIAGNOSTIC CLEVER CHOICEMICRO TEST STRIP 6

BLOOD SUGAR DIAGNOSTIC CLEVER CHOICEPRO 6

BLOOD SUGAR DIAGNOSTIC CLEVER CHOICETALK 6

BLOOD SUGAR DIAGNOSTIC CLEVER CHOICETEST STRIPS 6

BLOOD SUGAR DIAGNOSTIC CLEVER CHOICEVOICE+ TST STRIP 6

BLOOD SUGAR DIAGNOSTIC CONTOUR NEXTTEST STRIP 6

BLOOD SUGAR DIAGNOSTIC CONTOUR TESTSTRIP 6

BLOOD SUGAR DIAGNOSTIC COOL GLUCOSETEST STRIP 6

BLOOD SUGAR DIAGNOSTICDARIO BLOODGLUCOSE TESTSTRIP

6

BLOOD SUGAR DIAGNOSTIC DIATRUE PLUS 6BLOOD SUGAR DIAGNOSTIC EASY GLUCO G2 6BLOOD SUGAR DIAGNOSTIC EASY PLUS II 6BLOOD SUGAR DIAGNOSTIC EASY STEP 6BLOOD SUGAR DIAGNOSTIC EASY TALK 6

BLOOD SUGAR DIAGNOSTIC EASY TOUCH TESTSTRIP 6

BLOOD SUGAR DIAGNOSTIC EASY TRAK 6BLOOD SUGAR DIAGNOSTIC EASYGLUCO PLUS 6

BLOOD SUGAR DIAGNOSTIC EASYGLUCO TESTSTRIPS 6

BLOOD SUGAR DIAGNOSTIC EASYMAX 6BLOOD SUGAR DIAGNOSTIC EASYMAX 15 6

BLOOD SUGAR DIAGNOSTIC ELEMENTCOMPACT 6



BLOOD SUGAR DIAGNOSTIC ELEMENT TESTSTRIPS 6

BLOOD SUGAR DIAGNOSTIC EMBRACE 6BLOOD SUGAR DIAGNOSTIC EMBRACE EVO 6BLOOD SUGAR DIAGNOSTIC EMBRACE PRO 6BLOOD SUGAR DIAGNOSTIC EVENCARE 6BLOOD SUGAR DIAGNOSTIC EVENCARE G2 6BLOOD SUGAR DIAGNOSTIC EVENCARE G3 6

BLOOD SUGAR DIAGNOSTICEVENCARE MINIGLUCOSE TESTSTR

6

BLOOD SUGAR DIAGNOSTICEVENCAREPROVIEW TESTSTRIP

6

BLOOD SUGAR DIAGNOSTIC EVOLUTION TESTSTRIPS 6

BLOOD SUGAR DIAGNOSTIC EZ SMART 6BLOOD SUGAR DIAGNOSTIC EZ SMART PLUS 6

BLOOD SUGAR DIAGNOSTIC FIFTY50 TESTSTRIP 6

BLOOD SUGAR DIAGNOSTIC FORA 6 CONNECTGLUCOSE STRIP 6

BLOOD SUGAR DIAGNOSTIC FORA D15G 6BLOOD SUGAR DIAGNOSTIC FORA D20 6

BLOOD SUGAR DIAGNOSTIC FORA D40-G31TEST STRIPS 6

BLOOD SUGAR DIAGNOSTIC FORA G20 6

BLOOD SUGAR DIAGNOSTICFORA G30-PREMIUM V10 TESTSTRP

6

BLOOD SUGAR DIAGNOSTIC FORA GD50 TESTSTRIPS 6

BLOOD SUGAR DIAGNOSTIC FORA TEST STRIP 6

BLOOD SUGAR DIAGNOSTIC FORA TN'G VOICETEST STRIPS 6

BLOOD SUGAR DIAGNOSTIC FORA V10 6

BLOOD SUGAR DIAGNOSTIC FORA V10-V12-D10-D20 6

BLOOD SUGAR DIAGNOSTIC FORA V12 6BLOOD SUGAR DIAGNOSTIC FORA V20 6BLOOD SUGAR DIAGNOSTIC FORA V30A 6BLOOD SUGAR DIAGNOSTIC FORACARE GD20 6BLOOD SUGAR DIAGNOSTIC FORACARE GD40 6

BLOOD SUGAR DIAGNOSTICFORTISCAREGLUCOSE TESTSTRIPS

6

BLOOD SUGAR DIAGNOSTIC FREESTYLEINSULINX 6

BLOOD SUGAR DIAGNOSTICFREESTYLEINSULINX TESTSTRIPS

6

BLOOD SUGAR DIAGNOSTIC FREESTYLE LITESTRIPS 6

BLOOD SUGAR DIAGNOSTIC FREESTYLEPRECISION NEO 6

BLOOD SUGAR DIAGNOSTIC FREESTYLE TESTSTRIPS 6

BLOOD SUGAR DIAGNOSTICGE100 BLOODGLUCOSE TESTSTRIP

6


Drug Name Tier Requirements/LimitsBLOOD SUGAR DIAGNOSTIC GENSTRIP 6

BLOOD SUGAR DIAGNOSTIC GENULTIMATETEST STRIP 6

BLOOD SUGAR DIAGNOSTIC GLUCO NAVII 6

BLOOD SUGAR DIAGNOSTIC GLUCOCARD 01SENSOR PLUS 6

BLOOD SUGAR DIAGNOSTIC GLUCOCARDEXPRESSION 6

BLOOD SUGAR DIAGNOSTIC GLUCOCARDSHINE 6

BLOOD SUGAR DIAGNOSTIC GLUCOCARDVITAL 6

BLOOD SUGAR DIAGNOSTIC GLUCOCARDVITAL SENSOR 6

BLOOD SUGAR DIAGNOSTIC GLUCOCOMGLUCOSE 6

BLOOD SUGAR DIAGNOSTIC GLUCOSE TESTSTRIP 6

BLOOD SUGAR DIAGNOSTIC GOODLIFE AC-302TEST STRIP 6

BLOOD SUGAR DIAGNOSTICHARMONYGLUCOSE TESTSTRIP

6

BLOOD SUGAR DIAGNOSTIC HEALTHPRO TESTSTRIPS 6

BLOOD SUGAR DIAGNOSTIC IGLUCOSE TESTSTRIP 6

BLOOD SUGAR DIAGNOSTIC INFINITY TESTSTRIPS 6

BLOOD SUGAR DIAGNOSTIC INFINITY VOICETEST STRIP 6

BLOOD SUGAR DIAGNOSTIC MICRO 6BLOOD SUGAR DIAGNOSTIC MICRODOT 6BLOOD SUGAR DIAGNOSTIC MICRODOT XTRA 6BLOOD SUGAR DIAGNOSTIC MYGLUCOHEALTH 6

BLOOD SUGAR DIAGNOSTIC NEUTEK 2TEKTEST STRIPS 6

BLOOD SUGAR DIAGNOSTICNOVA MAXGLUCOSE TESTSTRIPS

6

BLOOD SUGAR DIAGNOSTIC ON CALL EXPRESSTEST STRIP 6

BLOOD SUGAR DIAGNOSTIC ON CALL PLUSTEST STRIP 6

BLOOD SUGAR DIAGNOSTIC ON CALL VIVIDTEST STRIP 6

BLOOD SUGAR DIAGNOSTIC ONETOUCH ULTRABLUE TEST STRP 6

BLOOD SUGAR DIAGNOSTIC ONETOUCH VERIO 6BLOOD SUGAR DIAGNOSTIC OPTIUM 6BLOOD SUGAR DIAGNOSTIC OPTIUM EZ 6BLOOD SUGAR DIAGNOSTIC OPTUMRX 6

BLOOD SUGAR DIAGNOSTIC PHARMACISTCHOICE 6

BLOOD SUGAR DIAGNOSTIC PRECISION PCX 6

BLOOD SUGAR DIAGNOSTIC PRECISION PCXPLUS 6

BLOOD SUGAR DIAGNOSTIC PRECISION POINTOF CARE 6

BLOOD SUGAR DIAGNOSTIC PRECISION Q-I-D 6


Drug Name Tier Requirements/LimitsBLOOD SUGAR DIAGNOSTIC PRECISION XTRA 6

BLOOD SUGAR DIAGNOSTIC PREMIER TESTSTRIP 6

BLOOD SUGAR DIAGNOSTIC PREMIUM BLOODGLUCOSE TEST 6

BLOOD SUGAR DIAGNOSTIC PREMIUM V10 6

BLOOD SUGAR DIAGNOSTIC PRO VOICE V8-V9TEST STRIP 6

BLOOD SUGAR DIAGNOSTIC PRODIGY NOCODING 6

BLOOD SUGAR DIAGNOSTIC QUINTET 6BLOOD SUGAR DIAGNOSTIC QUINTET AC 6BLOOD SUGAR DIAGNOSTIC REFUAH PLUS 6

BLOOD SUGAR DIAGNOSTIC RELION CONFIRM-MICRO 6

BLOOD SUGAR DIAGNOSTIC RELION PRIMETEST STRIPS 6

BLOOD SUGAR DIAGNOSTIC REVEAL TESTSTRIP 6

BLOOD SUGAR DIAGNOSTIC RIGHTEST GS100TEST STRIPS 6

BLOOD SUGAR DIAGNOSTIC RIGHTEST GS250STEST STRIPS 6




BLOOD SUGAR DIAGNOSTIC SMART SENSETEST STRIPS 6

BLOOD SUGAR DIAGNOSTIC SMARTEST TEST 6

BLOOD SUGAR DIAGNOSTIC SOLUS V2 TESTSTRIPS 6

BLOOD SUGAR DIAGNOSTIC SURE-TESTEASYPLUS MINI 6

BLOOD SUGAR DIAGNOSTIC TD GOLD TESTSTRIP 6

BLOOD SUGAR DIAGNOSTIC TELCARE 6BLOOD SUGAR DIAGNOSTIC TEST N'GO 6BLOOD SUGAR DIAGNOSTIC TEST STRIPS 6

BLOOD SUGAR DIAGNOSTICTRUE METRIXGLUCOSE TESTSTRIP

6

BLOOD SUGAR DIAGNOSTIC TRUE METRIX PROTEST STRIP 6

BLOOD SUGAR DIAGNOSTIC TRUETEST TESTSTRIPS 6

BLOOD SUGAR DIAGNOSTIC TRUETRACK TESTSTRIP 6

BLOOD SUGAR DIAGNOSTIC ULTIMA 6BLOOD SUGAR DIAGNOSTIC ULTRATRAK 6

BLOOD SUGAR DIAGNOSTIC ULTRATRAKULTIMATE 6

BLOOD SUGAR DIAGNOSTIC UNISTRIP1 6

BLOOD SUGAR DIAGNOSTIC VERASENS TESTSTRIP 6

BLOOD SUGAR DIAGNOSTIC WAVESENSE JAZZ 6

BLOOD SUGAR DIAGNOSTIC WAVESENSEPRESTO 6


Drug Name Tier Requirements/LimitsBLOOD SUGAR DIAGNOSTIC, DISC BREEZE 2 6

BLOOD SUGAR DIAGNOSTIC, DRUMACCU-CHEKCOMPACT PLUSSTRIPS

6

DIABETIC SUPPLIESBLOOD GLUCOSE CNTL HIGH,NORMAL 2TEK 6

BLOOD GLUCOSE CNTL HIGH,NORMAL AGAMATRIXCONTROL 6

BLOOD GLUCOSE CNTL HIGH,NORMAL ASSURE DOSE 6BLOOD GLUCOSE CNTL HIGH,NORMAL ASSURE PRISM 6

BLOOD GLUCOSE CNTL HIGH,NORMAL BLOOD GLUCOSECONTROL 6

BLOOD GLUCOSE CNTL HIGH,NORMAL CARESENS 6BLOOD GLUCOSE CNTL HIGH,NORMAL EMBRACE PRO 6

BLOOD GLUCOSE CNTL HIGH,NORMAL GLUCOCARD 01CONTROL 6

BLOOD GLUCOSE CNTL HIGH,NORMAL ON CALL PLUSCONTROL 6

BLOOD GLUCOSE CNTL HIGH,NORMAL ON CALL VIVIDCONTROL 6

BLOOD GLUCOSE CNTL HIGH,NORMAL OPTUMRX 6BLOOD GLUCOSE CONTROL HIGH,LOW ACCU-CHEK 6

BLOOD GLUCOSE CONTROL HIGH,LOWACCU-CHEKCOMPACT PLUSCONTROL

6

BLOOD GLUCOSE CONTROL HIGH,LOW ACCU-CHEK GUIDECONTROL SOLN 6

BLOOD GLUCOSE CONTROL HIGH,LOW ACCUTRENDGLUCOSE 6

BLOOD GLUCOSE CONTROL HIGH,LOWEASY TOUCHCONTROLSOLUTION

6

BLOOD GLUCOSE CONTROL HIGH,LOW EVENCARE 6BLOOD GLUCOSE CONTROL HIGH,LOW EVENCARE G2 6BLOOD GLUCOSE CONTROL HIGH,LOW EVENCARE G3 6

BLOOD GLUCOSE CONTROL HIGH,LOWEVENCAREPROVIEWCONTROL SOLN

6

BLOOD GLUCOSE CONTROL HIGH,LOWFREESTYLECONTROLSOLUTION

6

BLOOD GLUCOSE CONTROL HIGH,LOWHARMONYCONTROLSOLUTION

6

BLOOD GLUCOSE CONTROL HIGH,LOWHEALTHPROGLUCOSECONTROL SOLN

6

BLOOD GLUCOSE CONTROL HIGH,LOW MICRODOT 6

BLOOD GLUCOSE CONTROL HIGH,LOWTELCARECONTROLSOLUTION

6

BLOOD GLUCOSE CONTROL HIGH,LOW ULTRATRAK 6

BLOOD GLUCOSE CONTROL HIGH,LOW ULTRATRAKULTIMATE 6

BLOOD GLUCOSE CTL HIGH,NML,LOWGLUCOSECONTROLSOLUTION

6

BLOOD GLUCOSE CTL HIGH,NML,LOWMYGLUCOHEALTHCONTROLSOLUTION

6



BLOOD GLUCOSE CTL HIGH,NML,LOW ON CALL EXPRESSCONTROL SOLN 6

BLOOD GLUCOSE STRIPS-DISPMETER SIDEKICK 6

BLOOD GLUCOSE,KETONE CNTRL NML NOVAMAX PLUSGLU-KET 6

BLOOD-GLU METER,CONT/TRANSMIT GUARDIAN REAL-TIME 6

BLOOD-GLUC TRANSMITTER/SENSOR ENLITE 3

BLOOD-GLUC TRANSMITTER/SENSOR PARADIGM REAL-TIME 3

BLOOD-GLUC,BP METER,ADULT CUFF FORA D15 6BLOOD-GLUC,BP METER,ADULT CUFF FORA D40 6BLOOD-GLUC.METER, WRIST BP MON 2TEK 6BLOOD-GLUC.METER, WRIST BP MON ADVOCATE DUO 6BLOOD-GLUC.METER, WRIST BP MON FORA D10 6BLOOD-GLUCOSE CALIB. CONTROL ASSURE 4 6BLOOD-GLUCOSE CALIB. CONTROL MEDISENSE 6

BLOOD-GLUCOSE CALIB. CONTROL MEDISENSECONTROL 6

BLOOD-GLUCOSE CALIB. CONTROL MEDISENSEGLUCOSE KETONE 6

BLOOD-GLUCOSE CALIB. CONTROL PRECISION 6

BLOOD-GLUCOSE CALIB. CONTROLPRECISIONGLUCOSECONTROL

6

BLOOD-GLUCOSE CONTROL, HIGHADVOCATECONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, HIGH ADVOCATE REDI-CODE+ CTRL SOLN 6

BLOOD-GLUCOSE CONTROL, HIGH AGAMATRIXCONTROL 6

BLOOD-GLUCOSE CONTROL, HIGH BREEZE 2 6

BLOOD-GLUCOSE CONTROL, HIGHCLEVER CHOICECONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, HIGH CONTOUR 6

BLOOD-GLUCOSE CONTROL, HIGH CONTROLSOLUTION 6

BLOOD-GLUCOSE CONTROL, HIGH COOL CONTROLSOLUTION 6

BLOOD-GLUCOSE CONTROL, HIGH DIATRUE 6BLOOD-GLUCOSE CONTROL, HIGH EASY PLUS II 6BLOOD-GLUCOSE CONTROL, HIGH EASY TALK 6BLOOD-GLUCOSE CONTROL, HIGH EASY TRAK 6

BLOOD-GLUCOSE CONTROL, HIGHELEMENTCOMPACTCONTROL SOLN

6

BLOOD-GLUCOSE CONTROL, HIGHELEMENTCONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, HIGH EMBRACE 6BLOOD-GLUCOSE CONTROL, HIGH EZ SMART 6BLOOD-GLUCOSE CONTROL, HIGH FORACARE GDH 6BLOOD-GLUCOSE CONTROL, HIGH FORTISCARE 6

BLOOD-GLUCOSE CONTROL, HIGHGLUCOCOMCONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, HIGH INFINITY CONTROLSOLUTION 6


Drug Name Tier Requirements/LimitsBLOOD-GLUCOSE CONTROL, HIGH ONETOUCH VERIO 6

BLOOD-GLUCOSE CONTROL, HIGHREFUAH PLUSGLUCOSECONTROL

6

BLOOD-GLUCOSE CONTROL, HIGHRIGHTESTCONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, HIGHSOLUS V2CONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, HIGH TD GOLD LEVEL 3CONTROL SOL 6

BLOOD-GLUCOSE CONTROL, HIGH TRUE METRIX 6BLOOD-GLUCOSE CONTROL, HIGH TRUECONTROL 6BLOOD-GLUCOSE CONTROL, HIGH UNISTRIP 6

BLOOD-GLUCOSE CONTROL, LOWADVOCATECONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, LOW ADVOCATE REDI-CODE+ CTRL SOLN 6

BLOOD-GLUCOSE CONTROL, LOW BREEZE 2 6

BLOOD-GLUCOSE CONTROL, LOWCLEVER CHOICECONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, LOW CONTOUR 6

BLOOD-GLUCOSE CONTROL, LOWCONTOUR NEXTCONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, LOW CONTROLSOLUTION 6

BLOOD-GLUCOSE CONTROL, LOW DIATRUE 6BLOOD-GLUCOSE CONTROL, LOW EASY PLUS II 6BLOOD-GLUCOSE CONTROL, LOW EASY TALK 6BLOOD-GLUCOSE CONTROL, LOW EASY TRAK 6BLOOD-GLUCOSE CONTROL, LOW EASYMAX 6BLOOD-GLUCOSE CONTROL, LOW EASYMAX 15 6

BLOOD-GLUCOSE CONTROL, LOWELEMENTCONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, LOW EMBRACE EVO 6

BLOOD-GLUCOSE CONTROL, LOWEMBRACEGLUCOSECONTROL SOLN

6

BLOOD-GLUCOSE CONTROL, LOW EZ SMART 6BLOOD-GLUCOSE CONTROL, LOW FORACARE GDH 6BLOOD-GLUCOSE CONTROL, LOW FORTISCARE 6

BLOOD-GLUCOSE CONTROL, LOW INFINITY CONTROLSOLUTION 6

BLOOD-GLUCOSE CONTROL, LOWPRODIGYCONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, LOWSOLUS V2CONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, LOW TD GOLD LEVEL 1CONTROL SOL 6

BLOOD-GLUCOSE CONTROL, LOW TRUE METRIX 6BLOOD-GLUCOSE CONTROL, LOW TRUECONTROL 6BLOOD-GLUCOSE CONTROL, LOW UNISTRIP 6



BLOOD-GLUCOSE CONTROL, NORMAL ACCU-CHEKSMARTVIEW 6

BLOOD-GLUCOSE CONTROL, NORMAL ASSURE DOSE 6

BLOOD-GLUCOSE CONTROL, NORMAL BLOOD-GLUCOSECONTROL 6

BLOOD-GLUCOSE CONTROL, NORMAL BREEZE 2 6BLOOD-GLUCOSE CONTROL, NORMAL CARESENS 6

BLOOD-GLUCOSE CONTROL, NORMALCHOICEDMCLARUS CONTROLSOLN

6

BLOOD-GLUCOSE CONTROL, NORMALCLEVER CHOICECONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, NORMAL CONTOUR 6

BLOOD-GLUCOSE CONTROL, NORMALCONTOUR NEXTCONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, NORMAL CONTROLSOLUTION 6

BLOOD-GLUCOSE CONTROL, NORMAL COOL CONTROLSOLUTION 6

BLOOD-GLUCOSE CONTROL, NORMAL DIATRUE 6

BLOOD-GLUCOSE CONTROL, NORMAL EASYGLUCO PLUSCONTROL NORMAL 6

BLOOD-GLUCOSE CONTROL, NORMAL EASYMAX 6BLOOD-GLUCOSE CONTROL, NORMAL EASYMAX 15 6

BLOOD-GLUCOSE CONTROL, NORMALELEMENTCOMPACTCONTROL SOLN

6

BLOOD-GLUCOSE CONTROL, NORMALELEMENTCONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, NORMALEVENCARE MINIGLUCOSECONTROL

6

BLOOD-GLUCOSE CONTROL, NORMALEVOLUTIONCONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, NORMAL EZ SMART 6

BLOOD-GLUCOSE CONTROL, NORMAL FORA CONTROLSOLUTION 6

BLOOD-GLUCOSE CONTROL, NORMAL FORACARE GDH 6BLOOD-GLUCOSE CONTROL, NORMAL FORTISCARE 6

BLOOD-GLUCOSE CONTROL, NORMALFREESTYLECONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, NORMALGE100 CONTROLSOLUTIONNORMAL

6

BLOOD-GLUCOSE CONTROL, NORMAL GLUCOCARD 01CONTROL 6

BLOOD-GLUCOSE CONTROL, NORMAL GLUCOCARDEXPRESSION 6

BLOOD-GLUCOSE CONTROL, NORMAL GLUCOCARDSHINE 6

BLOOD-GLUCOSE CONTROL, NORMALGLUCOCOMCONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, NORMAL GLUCOSECONTROL 6



BLOOD-GLUCOSE CONTROL, NORMALGLUCOSECONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, NORMAL INFINITY CONTROLSOLUTION 6

BLOOD-GLUCOSE CONTROL, NORMAL INFINITY VOICECONTROL SOLN 6

BLOOD-GLUCOSE CONTROL, NORMAL MEDISENSE 6

BLOOD-GLUCOSE CONTROL, NORMALMEDISENSEGLUCOSE KETONECONTR

6

BLOOD-GLUCOSE CONTROL, NORMAL METER-CHECK 6BLOOD-GLUCOSE CONTROL, NORMAL MICRODOT 6

BLOOD-GLUCOSE CONTROL, NORMALNOVA MAXGLUCOSECONTROL SOLN

6

BLOOD-GLUCOSE CONTROL, NORMAL ONETOUCH ULTRACONTROL SOLN 6

BLOOD-GLUCOSE CONTROL, NORMAL ONETOUCH VERIO 6

BLOOD-GLUCOSE CONTROL, NORMALRIGHTESTCONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, NORMAL RIGHTEST GC250SCONTROL SOLN 6

BLOOD-GLUCOSE CONTROL, NORMAL SMARTEST 6

BLOOD-GLUCOSE CONTROL, NORMAL SURE-TESTEASYPLUS MINI 6

BLOOD-GLUCOSE CONTROL, NORMAL TD GOLD LEVEL 2CONTROL SOL 6

BLOOD-GLUCOSE CONTROL, NORMAL TRUE METRIX 6BLOOD-GLUCOSE CONTROL, NORMAL ULTRATRAK 6

BLOOD-GLUCOSE CONTROL, NORMALVERASENSCONTROLSOLUTION

6

BLOOD-GLUCOSE CONTROL, NORMALWAVESENSECONTROLSOLUTION

6

BLOOD-GLUCOSE METER ACCU-CHEK AVIVAPLUS 6

BLOOD-GLUCOSE METER ACCU-CHEK GUIDEMONITOR SYSTEM 6

BLOOD-GLUCOSE METER ACCU-CHEK NANOSMARTVIEW 6

BLOOD-GLUCOSE METER ADVANCEDGLUCOSE METER 6

BLOOD-GLUCOSE METERADVOCATE BLOODGLUCOSEMONITOR

6

BLOOD-GLUCOSE METER ADVOCATE REDI-CODE 6

BLOOD-GLUCOSE METER ADVOCATE REDI-CODE PLUS 6

BLOOD-GLUCOSE METER AGAMATRIX AMP 6BLOOD-GLUCOSE METER ASSURE PLATINUM 6

BLOOD-GLUCOSE METER ASSURE PRISMMULTI 6

BLOOD-GLUCOSE METER BLOOD GLUCOSEMETER 6

BLOOD-GLUCOSE METER BLOOD GLUCOSEMONITORING 6


Drug Name Tier Requirements/LimitsBLOOD-GLUCOSE METER 6BLOOD-GLUCOSE METER CARESENS N 6

BLOOD-GLUCOSE METER CARESENS NVOICE 6

BLOOD-GLUCOSE METERCARETOUCHGLUCOSEMONITORING

6

BLOOD-GLUCOSE METER CHOICEDMCLARUS 6

BLOOD-GLUCOSE METERCLEVER CHEKBLOOD GLUCOSESYST

6

BLOOD-GLUCOSE METER CLEVER CHOICE 6

BLOOD-GLUCOSE METER CLEVER CHOICEBLOOD GLUC SYS 6

BLOOD-GLUCOSE METER CLEVER CHOICEHD GLUCOSE SYST 6

BLOOD-GLUCOSE METER CLEVER CHOICEMICRO 6

BLOOD-GLUCOSE METER CLEVER CHOICEPRO 6

BLOOD-GLUCOSE METER CLEVER CHOICETALK 6

BLOOD-GLUCOSE METER CONTOUR 6BLOOD-GLUCOSE METER CONTOUR LINK 6BLOOD-GLUCOSE METER CONTOUR NEXT 6BLOOD-GLUCOSE METER CONTOUR NEXT EZ 6

BLOOD-GLUCOSE METER CONTOUR NEXTONE 6

BLOOD-GLUCOSE METER CONTROL AST 6

BLOOD-GLUCOSE METER COOL BLOODGLUCOSE 6

BLOOD-GLUCOSE METER COOL BLOODGLUCOSE METER 6

BLOOD-GLUCOSE METER DIATRUE PLUS 6BLOOD-GLUCOSE METER EASY CHECK 6BLOOD-GLUCOSE METER EASY PLUS II 6BLOOD-GLUCOSE METER EASY STEP 6BLOOD-GLUCOSE METER EASY TALK 6

BLOOD-GLUCOSE METEREASY TOUCHGLUCOSEMONITOR

6

BLOOD-GLUCOSE METER EASY TRAK 6BLOOD-GLUCOSE METER EASYGLUCO 6

BLOOD-GLUCOSE METER EASYGLUCOMETER 6

BLOOD-GLUCOSE METEREASYGLUCOMETER STARTERKIT

6

BLOOD-GLUCOSE METER EASYMAX L 6BLOOD-GLUCOSE METER EASYMAX NG 6

BLOOD-GLUCOSE METER EASYMAX VSPEAKING 6

BLOOD-GLUCOSE METER EASYMAX V2 6BLOOD-GLUCOSE METER EASY-TOUCH 6

BLOOD-GLUCOSE METER ELEMENTCOMPACT 6

BLOOD-GLUCOSE METER ELEMENTCOMPACT V 6

BLOOD-GLUCOSE METER ELEMENT PLUS 6


Drug Name Tier Requirements/LimitsBLOOD-GLUCOSE METER EMBRACE 6BLOOD-GLUCOSE METER EMBRACE EVO 6BLOOD-GLUCOSE METER EMBRACE PRO 6BLOOD-GLUCOSE METER EVENCARE 6BLOOD-GLUCOSE METER EVENCARE G2 6BLOOD-GLUCOSE METER EVENCARE G3 6

BLOOD-GLUCOSE METER EVENCARE MINIMONITOR SYSTEM 6

BLOOD-GLUCOSE METEREVOLUTIONBLOOD GLUCOSEMETER

6

BLOOD-GLUCOSE METER EZ SMART 6BLOOD-GLUCOSE METER EZ SMART PLUS 6BLOOD-GLUCOSE METER FORA D20 6BLOOD-GLUCOSE METER FORA G20 6BLOOD-GLUCOSE METER FORA G30A 6BLOOD-GLUCOSE METER FORA GD50 6

BLOOD-GLUCOSE METER FORA PREMIUMV10 6

BLOOD-GLUCOSE METER FORA TEST N'GOVOICE 6

BLOOD-GLUCOSE METER FORA TN'G VOICE 6BLOOD-GLUCOSE METER FORA V10 6BLOOD-GLUCOSE METER FORA V12 6BLOOD-GLUCOSE METER FORA V20 6BLOOD-GLUCOSE METER FORA V30A 6BLOOD-GLUCOSE METER FORACARE GD20 6BLOOD-GLUCOSE METER FORACARE GD40A 6BLOOD-GLUCOSE METER FORACARE GD40B 6

BLOOD-GLUCOSE METERFORTISCAREBLOOD GLUCOSESYST

6

BLOOD-GLUCOSE METER FREESTYLE FLASHSYSTEM 6

BLOOD-GLUCOSE METER FREESTYLEFREEDOM 6

BLOOD-GLUCOSE METER FREESTYLEFREEDOM LITE 6

BLOOD-GLUCOSE METER FREESTYLEINSULINX 6

BLOOD-GLUCOSE METER FREESTYLE LITEMETER 6

BLOOD-GLUCOSE METERFREESTYLEPRECISION NEOMETER

6

BLOOD-GLUCOSE METER FREESTYLESIDEKICK II 6

BLOOD-GLUCOSE METER FREESTYLESYSTEM 6

BLOOD-GLUCOSE METER GDRIVE 6

BLOOD-GLUCOSE METER GE100 BLOODGLUCOSE SYSTEM 6

BLOOD-GLUCOSE METER GLUCO NAVII 6BLOOD-GLUCOSE METER GLUCOCARD 01 6

BLOOD-GLUCOSE METER GLUCOCARDEXPRESSION 6

BLOOD-GLUCOSE METER GLUCOCARDSHINE 6

BLOOD-GLUCOSE METER GLUCOCARDSHINE XL 6



BLOOD-GLUCOSE METER GLUCOCARDVITAL 6

BLOOD-GLUCOSE METER GLUCOCOMBLOOD GLUCOSE 6

BLOOD-GLUCOSE METER GOODLIFE AC-302GLUCOSE METER 6

BLOOD-GLUCOSE METERHEALTHPROGLUCOSEMONITOR

6

BLOOD-GLUCOSE METERIGLUCOSE BLOODGLUCOSEMONITOR

6

BLOOD-GLUCOSE METER INFINITY 6

BLOOD-GLUCOSE METERINFINITY VOICEGLUCOSEMONITOR

6

BLOOD-GLUCOSE METER JAZZ WIRELESS 2 6BLOOD-GLUCOSE METER MICRODOT 6BLOOD-GLUCOSE METER MYGLUCOHEALTH 6

BLOOD-GLUCOSE METER NOVA MAX BLOODGLUCOSE METER 6

BLOOD-GLUCOSE METER ON CALL EXPRESSMETER 6

BLOOD-GLUCOSE METER ON CALL PLUSMETER 6

BLOOD-GLUCOSE METER ON CALL VIVIDMETER 6

BLOOD-GLUCOSE METER ON CALL VIVIDPAL 6

BLOOD-GLUCOSE METER ONETOUCHULTRA2 6

BLOOD-GLUCOSE METER ONETOUCHULTRAMINI 6

BLOOD-GLUCOSE METER ONETOUCH VERIO 6

BLOOD-GLUCOSE METER ONETOUCH VERIOFLEX 6

BLOOD-GLUCOSE METER ONETOUCH VERIOIQ 6

BLOOD-GLUCOSE METER OPTUMRX 6

BLOOD-GLUCOSE METER PHARMACISTCHOICE 6

BLOOD-GLUCOSE METER PRECISION 6BLOOD-GLUCOSE METER PRECISION XTRA 6BLOOD-GLUCOSE METER PREMIER BLU 6BLOOD-GLUCOSE METER PREMIER VOICE 6

BLOOD-GLUCOSE METER PREMIUM BLOODGLUCOSE 6

BLOOD-GLUCOSE METER PREMIUM V10 6BLOOD-GLUCOSE METER PRESTO PRO 6

BLOOD-GLUCOSE METERPRO VOICE V8GLUCOSEMONITOR

6

BLOOD-GLUCOSE METERPRO VOICE V9GLUCOSEMONITOR

6

BLOOD-GLUCOSE METER PRODIGY 6

BLOOD-GLUCOSE METER PRODIGYAUTOCODE 6

BLOOD-GLUCOSE METER PRODIGY POCKET 6BLOOD-GLUCOSE METER PRODIGY VOICE 6


Drug Name Tier Requirements/LimitsBLOOD-GLUCOSE METER QUINTET 6BLOOD-GLUCOSE METER QUINTET AC 6BLOOD-GLUCOSE METER REFUAH PLUS 6

BLOOD-GLUCOSE METER RELION ALL-IN-ONE 6

BLOOD-GLUCOSE METER RELION CONFIRM 6BLOOD-GLUCOSE METER RELION MICRO 6BLOOD-GLUCOSE METER RELION PRIME 6

BLOOD-GLUCOSE METER REVEAL BLOODGLUCOSE METER 6

BLOOD-GLUCOSE METER RIGHTEST GM100SYSTEM 6

BLOOD-GLUCOSE METER RIGHTEST GM250SMETER 6

BLOOD-GLUCOSE METER RIGHTEST GM260METER 6



BLOOD-GLUCOSE METER SMART CARESENSN 6

BLOOD-GLUCOSE METERSMART SENSEMONITORINGSYSTEM

6

BLOOD-GLUCOSE METER SMARTEST EJECT 6

BLOOD-GLUCOSE METER SMARTESTPERSONA 6

BLOOD-GLUCOSE METER SMARTESTPRONTO 6

BLOOD-GLUCOSE METER SMARTESTPROTEGE 6

BLOOD-GLUCOSE METER SMARTEST SMARTCODE 6

BLOOD-GLUCOSE METER SMARTESTTALKING 6

BLOOD-GLUCOSE METER SOLUS V2 6

BLOOD-GLUCOSE METER SURE-TESTEASYPLUS MINI 6

BLOOD-GLUCOSE METERTD GOLD BLOODGLUCOSEMONITOR

6

BLOOD-GLUCOSE METERTD GOLD VOICEGLUCOSEMONITOR

6

BLOOD-GLUCOSE METER TELCARE 6BLOOD-GLUCOSE METER TELCARE BGM 6BLOOD-GLUCOSE METER TEST N'GO 6

BLOOD-GLUCOSE METER TRUE METRIX AIRGLUCOSE METER 6

BLOOD-GLUCOSE METERTRUE METRIXBLOOD GLUCOSEMTR

6

BLOOD-GLUCOSE METER TRUE METRIX GO 6

BLOOD-GLUCOSE METER TRUE2GO BLOODGLUCOSE SYSTEM 6

BLOOD-GLUCOSE METERTRUERESULTBLOOD GLUCOSESYSTM

6



BLOOD-GLUCOSE METERTRUETRACKBLOOD GLUCOSESYSTEM

6

BLOOD-GLUCOSE METER TRUETRACKSMART SYSTEM 6

BLOOD-GLUCOSE METER ULTIMA 6BLOOD-GLUCOSE METER ULTRATRAK 6BLOOD-GLUCOSE METER ULTRATRAK PRO 6

BLOOD-GLUCOSE METER ULTRATRAKULTIMATE 6

BLOOD-GLUCOSE METER VERASENS BLOODGLUCOSE METER 6

BLOOD-GLUCOSE METER VERASENS METERSTARTER KIT 6

BLOOD-GLUCOSE METER WAVESENSE AMP 6

BLOOD-GLUCOSE METER WAVESENSEPRESTO 6

BLOOD-GLUCOSE METER, DRUM-TYPE ACCU-CHEK 6

BLOOD-GLUCOSE METER, WIRELESS CONTOUR NEXTLINK 6

BLOOD-GLUCOSE METER, WIRELESS CONTOUR NEXTLINK 2.4 6

BLOOD-GLUCOSE METER,CONTINUOUS DEXCOM 6 PABLOOD-GLUCOSE METER,CONTINUOUS DEXCOM G4 6 PABLOOD-GLUCOSE METER,CONTINUOUS DEXCOM G5 3 PABLOOD-GLUCOSE METER,CONTINUOUS DEXCOM G6 6 PA

BLOOD-GLUCOSE METER,MOBILE DEVDARIO BLOODGLUCOSEMONITOR

6

BLOOD-GLUCOSE SENSOR DEXCOM G5-G4SENSOR 3 PA

BLOOD-GLUCOSE SENSOR DEXCOM G6 3 PA

BLOOD-GLUCOSE SENSOR ENLITE GLUCOSESENSOR 3

BLOOD-GLUCOSE SENSOR FREESTYLENAVIGATOR 3

BLOOD-GLUCOSE SENSOR GUARDIANSENSOR 3 3

BLOOD-GLUCOSE SENSOR SOF-SENSOR 3BLOOD-GLUCOSE TRANSMITTER DEXCOM G4 3 PABLOOD-GLUCOSE TRANSMITTER DEXCOM G5 3 PABLOOD-GLUCOSE TRANSMITTER DEXCOM G6 3 PABLOOD-GLUCOSE TRANSMITTER GUARDIAN LINK 3 3

BLOOD-GLUCOSE TRANSMITTERMINILINK REAL-TIMETRANSMITTER

3

BLOOD-GLUCOSE TRANSMITTERMINIMED 630GGUARDIAN STARTKT

3

DIABETIC SUPPLIES,MISCELL ALKALINEBATTERIES 6

DIABETIC SUPPLIES,MISCELL CHEMSTRIP BGDIARY 6

DIABETIC SUPPLIES,MISCELL ENLITE SERTER 6DIABETIC SUPPLIES,MISCELL EZ-VAC 6

DIABETIC SUPPLIES,MISCELL GLUCOCOMAUTOLINK 6

DIABETIC SUPPLIES,MISCELL GUARDIAN RTCHARGER 6



DIABETIC SUPPLIES,MISCELL GUARDIAN RTSTARTER KIT 6

DIABETIC SUPPLIES,MISCELL GUARDIAN RTSYSTEM 6

DIABETIC SUPPLIES,MISCELL GUARDIAN TESTPLUG 6

DIABETIC SUPPLIES,MISCELLGUARDIANTRANSMITTERTAPE

6

DIABETIC SUPPLIES,MISCELL INSUL-CAP 6DIABETIC SUPPLIES,MISCELL INSUL-EZE 6

DIABETIC SUPPLIES,MISCELL MAGNI-GUIDEMAGNIFIER 6

DIABETIC SUPPLIES,MISCELL MEDTRONICREMOTE CONTROL 6

DIABETIC SUPPLIES,MISCELLMINIMED QUICK-SERTER (MISCELL)(OTC)

6

DIABETIC SUPPLIES,MISCELL OVAL TAPE 6

DIABETIC SUPPLIES,MISCELL PARADIGMREMOTE CONTROL 6

DIABETIC SUPPLIES,MISCELLREPLACEMENTPEDIATRICMONITOR

6

DIABETIC SUPPLIES,MISCELL SEN-SERTER 6DIABETIC SUPPLIES,MISCELL SOF-SERTER 6

FLASH GLUCOSE SCANNING READER FREESTYLE LIBRE10 DAY READER 2 PA

FLASH GLUCOSE SCANNING READER FREESTYLE LIBRE14 DAY READER 2 PA

FLASH GLUCOSE SENSOR FREESTYLE LIBRE10 DAY SENSOR 2 PA

FLASH GLUCOSE SENSOR FREESTYLE LIBRE14 DAY SENSOR 2 PA

INFUSION SET FOR INSULIN PUMP AUTOSOFT 30 3INFUSION SET FOR INSULIN PUMP AUTOSOFT 90 3INFUSION SET FOR INSULIN PUMP AUTOSOFT XC 3

INFUSION SET FOR INSULIN PUMP CLEO 90 INFUSIONSET 3

INFUSION SET FOR INSULIN PUMP COMFORT 3INFUSION SET FOR INSULIN PUMP COMFORT SHORT 3

INFUSION SET FOR INSULIN PUMP CONTACT DETACHINFUSION SET 3

INFUSION SET FOR INSULIN PUMP INSET 30 INFUSIONSET 3

INFUSION SET FOR INSULIN PUMP INSET INFUSIONSET 3

INFUSION SET FOR INSULIN PUMP MINIMED 3INFUSION SET FOR INSULIN PUMP MINIMED PRO-SET 3INFUSION SET FOR INSULIN PUMP MIO INFUSION SET 3

INFUSION SET FOR INSULIN PUMP QUICK-SETPARADIGM 3

INFUSION SET FOR INSULIN PUMP SURE-T PARADIGM 3INFUSION SET FOR INSULIN PUMP T:30 INFUSION SET 3INFUSION SET FOR INSULIN PUMP T:90 3

INFUSION SET FOR INSULIN PUMP TRUSTEELINFUSION SET 3

INFUSION SET FOR INSULIN PUMP VARISOFTINFUSION SET 3

INSULIN ADMIN. SUPPLIES AUTOJECT 2 6


Drug Name Tier Requirements/LimitsINSULIN ADMIN. SUPPLIES AUTOPEN 6

INSULIN ADMIN. SUPPLIES HUMAPENLUXURA HD 6

INSULIN ADMIN. SUPPLIES INPEN (FORHUMALOG) 6

INSULIN ADMIN. SUPPLIES INPEN (FORNOVOLOG) 6

INSULIN ADMIN. SUPPLIES NOVOPEN ECHO 6INSULIN PUMP CARTRIDGE OMNIPOD 3INSULIN PUMP CARTRIDGE OMNIPOD DASH 3INSULIN PUMP CARTRIDGE T:FLEX 3INSULIN PUMP CARTRIDGE T:SLIM 3INSULIN PUMP CARTRIDGE T:SLIM G4 3

INSULIN PUMP CONTROLLER OMNIPOD DASHPDM KIT 3

INSULIN PUMP/INFUS. SET/METER ACCU-CHEK 3

LANCETS ONETOUCHSURESOFT 6

LANCING DEVICE ADJUSTABLELANCING DEVICE 6

LANCING DEVICE ADVOCATELANCING DEVICE 6

LANCING DEVICE ADVOCATE RAPID-SAFE 6

LANCING DEVICE ALTERNATE SITELANCING DEVICE 6

LANCING DEVICE AQUA LANCELANCING DEVICE 6

LANCING DEVICE AUTO-LANCETMINI 6

LANCING DEVICE AUTOLET LANCINGDEVICE 6

LANCING DEVICE AUTOLET PLUS 6

LANCING DEVICE CARELANCE ULTLANCING DEVICE 6

LANCING DEVICE CAREONE 6

LANCING DEVICE CARESENS PREMLANCING DEVICE 6

LANCING DEVICE CARETOUCHLANCING DEVICE 6

LANCING DEVICE DROPLET LANCINGDEVICE 6

LANCING DEVICE EASY CLICK 6

LANCING DEVICE EASY MINI EJECTLANCING DEVICE 6

LANCING DEVICE EASY TOUCHLANCING DEVICE 6

LANCING DEVICE FORA LANCINGDEVICE 6

LANCING DEVICEHEALTHYACCENTSAUTOLET

6

LANCING DEVICE INCONTROLLANCING DEVICE 6

LANCING DEVICE 6LANCING DEVICE LANCING SYSTEM 6LANCING DEVICE LITE TOUCH 6

LANCING DEVICE MINI LANCINGDEVICE 6



LANCING DEVICE ON CALL LANCINGDEVICE 6

LANCING DEVICE ON CALL PLUSLANCING DEVICE 6

LANCING DEVICE PRODIGY LANCINGDEVICE 6

LANCING DEVICE RELIAMED MINILANCING DEVICE 6

LANCING DEVICE RIGHTEST GD500 6

LANCING DEVICE SMARTDIABETESVANTAGE 6

LANCING DEVICE SURE COMFORTLANCING PEN 6

LANCING DEVICE SUREFLEX 6LANCING DEVICE SURE-PEN 6LANCING DEVICE TRUEDRAW 6LANCING DEVICE ULTI-LANCE 6LANCING DEVICE/LANCETS ACCU-CHEK 6

LANCING DEVICE/LANCETSACCU-CHEKFASTCLIXLANCING DEV

6

LANCING DEVICE/LANCETS ACCU-CHEKSOFTCLIX 6

LANCING DEVICE/LANCETS ADVANCEDLANCING DEVICE 6

LANCING DEVICE/LANCETS AUTOLETIMPRESSION 6

LANCING DEVICE/LANCETS HYPOLANCE 6LANCING DEVICE/LANCETS LANCING DEVICE 6LANCING DEVICE/LANCETS LANZO 6LANCING DEVICE/LANCETS MICROLET 2 6

LANCING DEVICE/LANCETS MICROLET NEXTLANCING DEVICE 6

LANCING DEVICE/LANCETS MULTI-LANCET 6

LANCING DEVICE/LANCETS ONETOUCHDELICA 6

LANCING DEVICE/LANCETS SOLUS V2LANCING DEVICE 6

LANCING DEVICE/LANCETS SUREFLEX 6LANCING DEVICE/LANCETS ULTI-LANCE 6LANCING DEVICE/LANCETS UNISTIK 2 6LANCING DEVICE/LANCETS UNISTIK 2 EXTRA 6

LANCING DEVICE/LANCETS UNISTIK 2NORMAL 6

LANCING DEVICE/LANCETS UNISTIK 3 6

LANCING DEVICE/LANCETS UNISTIK 3COMFORT 6

LANCING DEVICE/LANCETS UNISTIK 3NEONATAL 6

NEEDLE CLIP AND STORAGE DEVICE SAFE-CLIP (EACH)(OTC) 6

SUBCUTANEOUS INSULIN PUMP MINIMED 530G 3SUBCUTANEOUS INSULIN PUMP MINIMED 630G 3SUBCUTANEOUS INSULIN PUMP MINIMED 670G 3SUBCUTANEOUS INSULIN PUMP OMNIPOD 3SUBCUTANEOUS INSULIN PUMP ONETOUCH PING 3

SUBCUTANEOUS INSULIN PUMPREVELPROGRAMMABLEPUMP

3

SUBCUTANEOUS INSULIN PUMP T:FLEX 3


Drug Name Tier Requirements/LimitsSUBCUTANEOUS INSULIN PUMP T:SLIM 3SUBCUTANEOUS INSULIN PUMP T:SLIM G4 3SUBCUTANEOUS INSULIN PUMP T:SLIM X2 3

SUBCUTANEOUS INSULIN PUMP T:SLIM X2 WITHBASAL-IQ 3

SUB-Q INSULIN DEVICE, 20 UNIT VGO 20 3SUB-Q INSULIN DEVICE, 30 UNIT VGO 30 3SUB-Q INSULIN DEVICE, 40 UNIT VGO 40 3SUBQ INSULIN PUMP,GLUC.MON.SYS ANIMAS VIBE 3

DIABETIC ULCER PREPARATIONS,TOPICALBECAPLERMIN REGRANEX 2

HYPERGLYCEMICSDIAZOXIDE PROGLYCEM 3GLUCAGON,HUMAN RECOMBINANT GLUCAGEN 3

GLUCAGON,HUMAN RECOMBINANT GLUCAGONEMERGENCY KIT 2

INSULINSINSULIN ASPART NOVOLOG 3 ST

INSULIN ASPART NOVOLOGFLEXPEN 3 ST

INSULIN ASPART (NIACINAMIDE) FIASP 3 STINSULIN ASPART (NIACINAMIDE) FIASP FLEXTOUCH 3 ST

INSULIN ASPART PROT/INSULN ASP NOVOLOG MIX 70-30 3 ST

INSULIN ASPART PROT/INSULN ASP NOVOLOG MIX 70-30 FLEXPEN 3 ST

INSULIN DEGLUDEC TRESIBAFLEXTOUCH U-100 2

INSULIN DEGLUDEC TRESIBAFLEXTOUCH U-200 2

INSULIN DETEMIR LEVEMIR 2

INSULIN DETEMIR LEVEMIRFLEXTOUCH 2

INSULIN GLARGINE,HUM.REC.ANLOG BASAGLARKWIKPEN U-100 3 ST

INSULIN GLARGINE,HUM.REC.ANLOG LANTUS 2INSULIN GLARGINE,HUM.REC.ANLOG LANTUS SOLOSTAR 2

INSULIN GLARGINE,HUM.REC.ANLOG TOUJEO MAXSOLOSTAR 2

INSULIN GLARGINE,HUM.REC.ANLOG TOUJEO SOLOSTAR 2INSULIN GLULISINE APIDRA 3 STINSULIN GLULISINE APIDRA SOLOSTAR 3 STINSULIN LISPRO ADMELOG 3 ST

INSULIN LISPRO ADMELOGSOLOSTAR 3 ST

INSULIN LISPRO HUMALOG 2

INSULIN LISPRO HUMALOG JUNIORKWIKPEN 2

INSULIN LISPRO HUMALOGKWIKPEN U-100 2

INSULIN LISPRO HUMALOGKWIKPEN U-200 2

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 50-50 2

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 50-50 KWIKPEN 2

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 75-25 2



INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 75-25 KWIKPEN 2

INSULIN NPH HUM/REG INSULIN HM HUMULIN 70/30KWIKPEN 2

INSULIN NPH HUM/REG INSULIN HM HUMULIN 70-30 2INSULIN NPH HUM/REG INSULIN HM NOVOLIN 70-30 3 STINSULIN NPH HUMAN ISOPHANE HUMULIN N 2

INSULIN NPH HUMAN ISOPHANE HUMULIN NKWIKPEN 3

INSULIN NPH HUMAN ISOPHANE NOVOLIN N 3 STINSULIN REGULAR, HUMAN AFREZZA 3 PAINSULIN REGULAR, HUMAN HUMULIN R 2INSULIN REGULAR, HUMAN HUMULIN R U-500 2

INSULIN REGULAR, HUMAN HUMULIN R U-500KWIKPEN 2

INSULIN REGULAR, HUMAN NOVOLIN R 3 STSELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)

metformin hcl 1

EAR - GENERAL DISORDERSEAR PREPARATIONS ANTI-INFLAMMATORY

fluocinolone acetonide oil DERMOTIC 1EAR PREPARATIONS, MISC. ANTI-INFECTIVES

acetic acid VOSOL 1hydrocortisone/acetic acid VOSOL HC 1HYDROCORTISONE/PRAMOXINE/C-XYL CORTANE-B 3

EAR PREPARATIONS,ANTIBIOTICSCIPROFLOXACIN OTIPRIO 3ciprofloxacin hcl CETRAXAL 1NEOMYC/COLIST/HYDROCORT/THONZN COLY-MYCIN S 3neomycin/polymyxin b/hydrocort 1ofloxacin 1

OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICSCIPROFLOXACIN HCL/DEXAMETH CIPRODEX 2CIPROFLOXACIN HCL/FLUOCINOLONE OTOVEL 3CIPROFLOXACIN/HYDROCORTISONE CIPRO HC 3

ELECTROLYTE REGULATIONARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS

TOLVAPTAN JYNARQUE 4 PA

TOLVAPTAN SAMSCA (15 MG)(TABLET) 4 QL: 30 IN 365 DAYS

TOLVAPTAN SAMSCA (30 MG)(TABLET) 4 QL: 60 IN 365 DAYS

BICARBONATE PRODUCING/CONTAINING AGENTS

CHOLERA VAC BUFFER COMP 1 OF 2VAXCHORABUFFERCOMPONENT

3

ELECTROLYTE DEPLETERScalcium acetate ELIPHOS 1calcium acetate PHOSLO 1CALCIUM ACETATE PHOSLYRA 3FERRIC CITRATE AURYXIA 3 QL: 12 IN 1 DAY

LANTHANUM CARBONATE FOSRENOL (1000MG) (POWD PACK) 3

lanthanum carbonate FOSRENOL (1000MG) (TAB CHEW) 1




LANTHANUM CARBONATE FOSRENOL (750MG) (POWD PACK) 3


PATIROMER CALCIUM SORBITEX VELTASSA 3 PA, QL: 1 IN 1 DAYsevelamer carbonate RENVELA 1SEVELAMER HCL RENAGEL 3sodium polystyrene sulfon/sorb 1SODIUM POLYSTYRENE SULFON/SORB SPS 3sodium polystyrene sulfonate 1SODIUM ZIRCONIUM CYCLOSILICATE LOKELMA 3 PASUCROFERRIC OXYHYDROXIDE VELPHORO 2

POTASSIUM REPLACEMENTpot chloride/pot bicarb/cit ac 1POTASSIUM BICARBONATE/CIT AC EFFER-K 3potassium bicarbonate/cit ac KLOR-CON-EF 1potassium chloride 1

SODIUM/SALINE PREPARATIONS0.9 % sodium chloride (0.9 %) (iv soln) 10.9 % sodium chloride (0.9 %) (syringe) 10.9 % sodium chloride (0.9 %) (vial) 10.9 % sodium chloride (pggybk prt) 10.9 % sodium chloride (pgy vl prt) 1bacteriostatic sodium chloride 1sodium chloride 0.45 % 1

ENDOCRINE DISORDER - FERTILITYDRUGS TO TREAT IMPOTENCY

TADALAFIL CIALIS 3 PAFERTILITY STIMULATING PREPARATIONS,NON-FSH

clomiphene citrate SEROPHENE 1FOLLICLE STIM./LUTEINIZING HORMONES

MENOTROPINS MENOPUR 4FOLLICLE-STIMULATING HORMONE (FSH)

FOLLITROPIN ALFA, RECOMBINANT GONAL-F 4FOLLITROPIN ALFA, RECOMBINANT GONAL-F RFF 4

FOLLITROPIN ALFA, RECOMBINANT GONAL-F RFFREDI-JECT 4

FOLLITROPIN BETA,RECOMB FOLLISTIM AQ 4 STUROFOLLITROPIN BRAVELLE 4 ST

HUMAN CHORIONIC GONADOTROPIN (HCG)CHORIOGONADOTROPIN ALFA OVIDREL 2

CHORIONIC GONADOTROPIN, HUMAN CHORIONICGONADOTROPIN 2

CHORIONIC GONADOTROPIN, HUMAN NOVAREL 2CHORIONIC GONADOTROPIN, HUMAN PREGNYL 2

PREGNANCY FACILITATING/MAINTAINING AGENT,HORMONALPROGESTERONE, MICRONIZED CRINONE 2PROGESTERONE, MICRONIZED ENDOMETRIN 2

ENDOCRINE DISORDER - OTHERANTIDIURETIC AND VASOPRESSOR HORMONES

desmopressin (nonrefrigerated) DDAVP 1DESMOPRESSIN ACETATE DDAVP 2desmopressin acetate 1DESMOPRESSIN ACETATE NOCTIVA 3 QL: 3.8gm IN 30 DAYSDESMOPRESSIN ACETATE STIMATE 3


Drug Name Tier Requirements/LimitsANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR.

HISTRELIN ACETATE VANTAS 4LEUPROLIDE ACETATE ELIGARD 4 PAleuprolide acetate 4 PA

BONE FORMATION STIM. AGENTS - PARATHYROID HORMONETERIPARATIDE FORTEO 4 PA, QL: 2.4mL IN 28 DAYS

BONE FORMATION STIMULATING AGTS - PTH REL PEPTIDESABALOPARATIDE TYMLOS 4 PA

BONE RESORPTION INHIBITOR & VITAMIN D COMBINATIONSALENDRONATE SODIUM/VITAMIN D3 FOSAMAX PLUS D 2

BONE RESORPTION INHIBITORSALENDRONATE SODIUM BINOSTO 3 ST, QL: 4 IN 28 DAYS

alendronate sodium FOSAMAX (10 MG)(TABLET) 1





alendronate sodiumFOSAMAX (70MG/75ML)(SOLUTION)


CALCITONIN,SALMON,SYNTHETIC MIACALCIN(200/ML) (VIAL) 3

calcitonin,salmon,syntheticMIACALCIN(200/SPRAY)(SPRAY/PUMP)

1

etidronate disodium DIDRONEL 1ibandronate sodium BONIVA 1raloxifene hcl EVISTA 1 PA, QL: 1 IN 1 DAYrisedronate sodium (150 mg) (tablet) 1 ST, QL: 1 IN 30 DAYSrisedronate sodium (30 mg) (tablet) 1 ST, QL: 1 IN 1 DAYrisedronate sodium (35 mg) (tablet dr) 1 ST, QL: 1 IN 7 DAYSrisedronate sodium (35 mg) (tablet) 1 ST, QL: 1 IN 7 DAYSrisedronate sodium (5 mg) (tablet) 1 ST, QL: 1 IN 1 DAY

CALCIMIMETIC,PARATHYROID CALCIUM ENHANCER

CINACALCET HCL SENSIPAR (30 MG)(TABLET) 4 QL: 2 IN 1 DAY



GROWTH HORMONE RECEPTOR ANTAGONISTSPEGVISOMANT SOMAVERT 4

GROWTH HORMONE RELEASING HORMONE (GHRH) & ANALOGSTESAMORELIN ACETATE EGRIFTA 4 PA

GROWTH HORMONESSOMATROPIN GENOTROPIN 4 PASOMATROPIN HUMATROPE 4 PA

SOMATROPIN NORDITROPINFLEXPRO 4 PA

SOMATROPIN NUTROPIN AQNUSPIN 4 PA

SOMATROPIN OMNITROPE 4 PASOMATROPIN SAIZEN 4 PA



SOMATROPIN SAIZEN-SAIZENPREP 4 PA

SOMATROPIN SEROSTIM 4 PASOMATROPIN ZOMACTON 4 PASOMATROPIN ZORBTIVE 4 PA

HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPECALCIFEDIOL RAYALDEE 2 QL: 2 IN 1 DAYdoxercalciferol 1paricalcitol 1

INSULIN-LIKE GROWTH FACTOR-1 (IGF-1) HORMONESMECASERMIN INCRELEX 4 PA

LEPTIN HORMONE ANALOGSMETRELEPTIN MYALEPT 4 QL: 1 IN 1 DAY

LHRH(GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTSNAFARELIN ACETATE SYNAREL 4 PA

LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTSCETRORELIX ACETATE CETROTIDE 4ELAGOLIX SODIUM ORILISSA 3GANIRELIX ACETATE 4

LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTYHISTRELIN ACETATE SUPPRELIN LA 4

PARATHYROID HORMONESPARATHYROID HORMONE NATPARA 4 PA

PITUITARY SUPPRESSIVE AGENTScabergoline DOSTINEX 1danazol DANOCRINE 1

ENDOCRINE DISORDER - THYROIDANTITHYROID PREPARATIONS

methimazole TAPAZOLE 1propylthiouracil 1

IODINE CONTAINING AGENTSpotassium iodide (1 g/ml) (solution) 1potassium iodide/iodine 1

THYROID HORMONESlevothyroxine sodium LEVO-T 1levothyroxine sodium LEVOXYL 1levothyroxine sodium SYNTHROID 1LEVOTHYROXINE SODIUM TIROSINT 3levothyroxine sodium UNITHROID 1liothyronine sodium CYTOMEL 1LIOTRIX THYROLAR-1 3LIOTRIX THYROLAR-1/2 3LIOTRIX THYROLAR-1/4 3LIOTRIX THYROLAR-2 3LIOTRIX THYROLAR-3 3THYROID,PORK ARMOUR THYROID 2thyroid,pork (113.75 mg) (tablet) 1thyroid,pork (120 mg) (tablet) 3thyroid,pork (130 mg) (tablet) 1thyroid,pork (146.25 mg) (tablet) 1thyroid,pork (15 mg) (tablet) 1thyroid,pork (16.25 mg) (tablet) 1thyroid,pork (162.5 mg) (tablet) 1thyroid,pork (195 mg) (tablet) 1thyroid,pork (260 mg) (tablet) 1thyroid,pork (30 mg) (tablet) 1


Drug Name Tier Requirements/Limitsthyroid,pork (32.5 mg) (tablet) 1thyroid,pork (325 mg) (tablet) 1thyroid,pork (48.75 mg) (tablet) 1thyroid,pork (60 mg) (tablet) 1thyroid,pork (65 mg) (tablet) 1thyroid,pork (81.25 mg) (tablet) 1thyroid,pork (90 mg) (tablet) 1thyroid,pork (97.5 mg) (tablet) 1

EYE - GENERAL DISORDERSEYE ANTIBIOTIC, GLUCOCORTICOID AND NSAID COMB.

prednisolon/gatiflox/bromfenac 1EYE ANTIBIOTIC-CORTICOID COMBINATIONS

gatifloxacin/dexamethasone 1GENTAMICIN SULF/PREDNISOLONE PRED-G 3neomycin/bacit/p-myx/hydrocort 1neomycin/polymyxin b/dexametha 1neomycin/polymyxin b/hydrocort 1prednisolone acet/gatifloxacin 1

tobramycin/dexamethasone TOBRADEX (0.3 %-0.1%) (DROPS SUSP) 1

TOBRAMYCIN/DEXAMETHASONE TOBRADEX (0.3 %-0.1%) (OINT. (G)) 2

TOBRAMYCIN/DEXAMETHASONE TOBRADEX ST 3TOBRAMYCIN/LOTEPRED ETAB ZYLET 2

EYE ANTIHISTAMINESALCAFTADINE LASTACAFT 3 ST, QL: 3mL IN 30 DAYSazelastine hcl OPTIVAR 1BEPOTASTINE BESILATE BEPREVE 3 ST, QL: 10mL IN 30 DAYSEMEDASTINE DIFUMARATE EMADINE 3 ST, QL: 10mL IN 30 DAYSepinastine hcl ELESTAT 1olopatadine hcl PATADAY 1 QL: 3mL IN 30 DAYSolopatadine hcl PATANOL 1OLOPATADINE HCL PAZEO 3 ST, QL: 2.5mL IN 30 DAYS

EYE ANTIINFLAMMATORY AGENTSbromfenac sodium 1BROMFENAC SODIUM BROMSITE 3BROMFENAC SODIUM PROLENSA 2DEXAMETHASONE MAXIDEX 3dexamethasone sodium phosphate 1diclofenac sodium VOLTAREN 1DIFLUPREDNATE DUREZOL 2fluorometholone FML 1FLUOROMETHOLONE FML FORTE 2FLUOROMETHOLONE FML S.O.P. 2FLUOROMETHOLONE ACETATE FLAREX 2flurbiprofen sodium OCUFEN 1ketorolac tromethamine ACULAR 1ketorolac tromethamine ACULAR LS 1KETOROLAC TROMETHAMINE/PF ACUVAIL 3LOTEPREDNOL ETABONATE ALREX 2LOTEPREDNOL ETABONATE LOTEMAX 2NEPAFENAC ILEVRO 2NEPAFENAC NEVANAC 3prednisolone acetate OMNIPRED 1prednisolone acetate PRED FORTE 1PREDNISOLONE ACETATE PRED MILD 2prednisolone acetate/bromfenac 1


Drug Name Tier Requirements/Limitsprednisolone acetate/pf 1prednisolone sod phosphate 1

EYE ANTIVIRALSGANCICLOVIR ZIRGAN 2trifluridine VIROPTIC 1

EYE LOCAL ANESTHETICS

benoxinate hcl/fluorescein sod FLUORESCEIN-BENOXINATE 1

benoxinate hcl/fluorescein sod FLURESS 1benoxinate hcl/fluorescein sod FLUROX 1LIDOCAINE HCL/PF AKTEN 3proparacaine hcl 1proparacaine/fluorescein sod 1tetracaine hcl TETCAINE 1TETRACAINE HCL TETRAVISC 3TETRACAINE HCL TETRAVISC FORTE 3

tetracaine hcl/pf TETRACAINEHYDROCHLORIDE 1

EYE SULFONAMIDESsulfacetamide sodium SODIUM SULAMYD 1SULFACETAMIDE/PREDNISOLONE BLEPHAMIDE 2SULFACETAMIDE/PREDNISOLONE BLEPHAMIDE S.O.P. 2sulfacetamide/prednisolone sp 1

EYE VASOCONSTRICTORS (RX ONLY)phenylephrine hcl 1

OPHTHALMIC ANTIBIOTICSAZITHROMYCIN AZASITE 3bacitracin 1bacitracin/polymyxin b sulfate 1BESIFLOXACIN HCL BESIVANCE 2

ciprofloxacin hcl CILOXAN (0.3 %)(DROPS) 1

CIPROFLOXACIN HCL CILOXAN (0.3 %)(OINT. (G)) 2

erythromycin base ILOTYCIN 1gatifloxacin ZYMAXID 1gentamicin sulfate GARAMYCIN 1gentamicin sulfate GENTAK 1levofloxacin 1MOXIFLOXACIN HCL MOXEZA 2moxifloxacin hcl VIGAMOX 1NATAMYCIN NATACYN 3neomycin sulf/bacitracin/poly NEO-POLYCIN 1neomycin/polymyxn b/gramicidin NEOSPORIN 1ofloxacin OCUFLOX 1polymyxin b sulf/trimethoprim POLYTRIM 1

tobramycin TOBREX (0.3 %)(DROPS) 1

TOBRAMYCIN TOBREX (0.3 %)(OINT. (G)) 2

OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPECYCLOSPORINE RESTASIS 2 QL: 60 IN 30 DAYS

CYCLOSPORINE RESTASISMULTIDOSE 2 QL: 5.5mL IN 30 DAYS

cyclosporine/chondroit sulf a 1LIFITEGRAST XIIDRA 2 QL: 60 IN 30 DAYS


Drug Name Tier Requirements/LimitsOPHTHALMIC MAST CELL STABILIZERS

cromolyn sodium OPTICROM 1LODOXAMIDE TROMETHAMINE ALOMIDE 2NEDOCROMIL SODIUM ALOCRIL 2

OPHTHALMIC PREPARATIONS, MISCELLANEOUSHYPOCHLOROUS ACID/SODIUM CHLOR ACUICYN 3HYPOCHLOROUS ACID/SODIUM CHLOR AVENOVA 3HYPOCHLOROUS ACID/SODIUM CHLOR HYPOCYN 3

EYE - GLAUCOMACARBONIC ANHYDRASE INHIBITORS

acetazolamide 1methazolamide NEPTAZANE 1

MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS

apraclonidine hcl IOPIDINE (0.5 %)(DROPS) 1

APRACLONIDINE HCL IOPIDINE (1 %)(DROPERETTE) 3

betaxolol hcl BETOPTIC 1BETAXOLOL HCL BETOPTIC S 3

BIMATOPROST LUMIGAN (0.01 %)(DROPS) 2 QL: 1mL IN 12 DAYS

bimatoprost LUMIGAN (0.03 %)(DROPS) 1 QL: 1mL IN 12 DAYS

brimonidine tartrate ALPHAGAN 1

BRIMONIDINE TARTRATE ALPHAGAN P (0.1%) (DROPS) 2

brimonidine tartrate ALPHAGAN P (0.15%) (DROPS) 1

BRIMONIDINE TARTRATE/TIMOLOL COMBIGAN 2brimonidine/dorzolamide/pf 1BRINZOLAMIDE AZOPT 2BRINZOLAMIDE/BRIMONIDINE TART SIMBRINZA 2carteolol hcl OCUPRESS 1dorzolamide hcl TRUSOPT 1dorzolamide hcl/pf 1dorzolamide hcl/timolol maleat COSOPT 1dorzolamide/timolol/pf (2 %-0.5 %) (droperette) 1 ST, QL: 2 IN 1 DAYdorzolamide/timolol/pf (2 %-0.5 %) (drops) 1

ECHOTHIOPHATE IODIDE PHOSPHOLINEIODIDE 3

latanoprost XALATAN 1latanoprost/pf 1LATANOPROSTENE BUNOD VYZULTA 3 ST, QL: 5mL IN 30 DAYSlevobunolol hcl BETAGAN 1metipranolol OPTIPRANOLOL 1NETARSUDIL MESYLATE RHOPRESSA 3 ST, QL: 2.5mL IN 30 DAYSpilocarpine hcl ISOPTO CARPINE 1TAFLUPROST/PF ZIOPTAN 3 ST, QL: 1 IN 1 DAYtimolo/brimon/dorzo/latanop/pf 1TIMOLOL BETIMOL 3timolol maleate ISTALOL 1timolol maleate TIMOPTIC 1timolol maleate TIMOPTIC-XE 1timolol maleate/latanoprost/pf 1

TIMOLOL MALEATE/PF TIMOPTICOCUDOSE 3 ST, QL: 2 IN 1 DAY

timolol/brimonidin/dorzolam/pf 1timolol/dorzolamide/latanop/pf 1


Drug Name Tier Requirements/LimitsTRAVOPROST TRAVATAN Z 2 QL: 1mL IN 12 DAYS

MYDRIATICSatropine sulfate 1atropine sulfate ISOPTO ATROPINE 1atropine sulfate/0.9 %sod chlr 1cyclopentol/lido/pe/tropicamid 3cyclopentolat/tropic/phenyleph 1cyclopentolate hcl CYCLOGYL 1CYCLOPENTOLATE/PHENYLEPHRINE CYCLOMYDRIL 3

homatropine hbr ISOPTOHOMATROPINE 1

HYDROXYAMPHETAMINE/TROPICAMIDE PAREMYD 3tropicamide MYDRIACYL 1

OPHTHALMIC ANTIFIBROTIC AGENTSMITOMYCIN MITOSOL 3

EYE - MISCELLANEOUSARTIFICIAL TEARS

acetylcysteine in water/pf 1HYDROXYPROPYL CELLULOSE LACRISERT 3

EYE PREPARATIONS, MISCELLANEOUS (OTC)GELATIN GELFILM 3

OPHTHALMIC CYSTINE DEPLETING AGENTSCYSTEAMINE HCL CYSTARAN 4 PA

FLUID REPLACEMENTNUCLEIC ACID/NUCLEOTIDE SUPPLEMENTS

URIDINE TRIACETATE XURIDEN 4 PA

GOUT AND RELATED DISEASESCOLCHICINE

colchicine COLCRYS 1 QL: 4 IN 1 DAYcolchicine MITIGARE 1 QL: 2 IN 1 DAYprobenecid/colchicine 1

HYPERURICEMIA TX - PURINE INHIBITORSallopurinol ZYLOPRIM 1FEBUXOSTAT ULORIC 2 ST, QL: 1 IN 1 DAY

URICOSURIC AGENTSLESINURAD ZURAMPIC 3 ST, QL: 1 IN 1 DAYprobenecid BENEMID 1

URICOSURIC AND XANTHINE OXIDASE INHIBITOR COMB.LESINURAD/ALLOPURINOL DUZALLO 3 ST, QL: 1 IN 1 DAY

HEMATOLOGICAL DISORDERSANTICOAGULANTS,COUMARIN TYPE

warfarin sodium COUMADIN 1ANTIFIBRINOLYTIC AGENTS

AMINOCAPROIC ACID AMICAR 3tranexamic acid LYSTEDA 1

ANTIHEMOPHILIC FACTORSANTIHEM.FVIII,SIN-CHN,B-DM TRU AFSTYLA 4ANTIHEMO.FVIII,FULL LENGTH PEG ADYNOVATE 4ANTIHEMOPH.FVIII REC,FC FUSION ELOCTATE 4ANTIHEMOPH.FVIII,B-DOM TRUNCAT NOVOEIGHT 4ANTIHEMOPH.FVIII,B-DOMAIN DEL XYNTHA 4

ANTIHEMOPH.FVIII,B-DOMAIN DEL XYNTHASOLOFUSE 4

ANTIHEMOPH.FVIII,HEK B-DELETE NUWIQ 4


Drug Name Tier Requirements/LimitsANTIHEMOPHIL.FVIII,FULL LENGTH ADVATE 4ANTIHEMOPHIL.FVIII,FULL LENGTH HELIXATE FS 4ANTIHEMOPHIL.FVIII,FULL LENGTH KOGENATE FS 4ANTIHEMOPHIL.FVIII,FULL LENGTH KOVALTRY 4ANTIHEMOPHILIC FACTOR, HUM REC RECOMBINATE 4ANTIHEMOPHILIC FACTOR, HUMAN HEMOFIL M 4ANTIHEMOPHILIC FACTOR, HUMAN KOATE 4ANTIHEMOPHILIC FACTOR, HUMAN MONOCLATE-P 4ANTIHEMOPHILIC FACTOR/VWF ALPHANATE 4ANTIHEMOPHILIC FACTOR/VWF HUMATE-P 4ANTIHEMOPHILIC FACTOR/VWF WILATE 4ANTIHEMOPHILIC FVIII,REC PORC OBIZUR 4ANTI-INHIBITOR COAGULANT COMP. FEIBA NF 4COAGULATION FACTOR VIIA,RECOMB NOVOSEVEN RT 4FVIII REC,B-DOM DELET PEG-AUCL JIVI 4

BLOOD FACTORS,MISCELLANEOUSFACTOR XIII CORIFACT 4VON WILLEBRAND FACTOR VONVENDI 4

CITRATES AS ANTICOAGULANTScitrate phosphate dextros soln 1DEXTROSE/SOD CITRATE/CITRIC AC ACD 3sodium citrate (4 % (3 ml)) (syringe) 3sodium citrate (4 % (4 ml)) (syringe) 1sodium citrate (4 g/100 ml) (solution) 1sodium citrate in 0.9 % nacl 3

DIRECT FACTOR XA INHIBITORS

APIXABAN ELIQUIS (2.5 MG)(TABLET) 2 QL: 2 IN 1 DAY

APIXABAN ELIQUIS (5 MG (74))(TAB DS PK) 2 QL: 74 IN 30 DAYS

APIXABAN ELIQUIS (5 MG)(TABLET) 2 QL: 74 IN 30 DAYS

BETRIXABAN MALEATE BEVYXXA 3 QL: 43 IN 42 DAYSEDOXABAN TOSYLATE SAVAYSA 3 ST, QL: 1 IN 1 DAY

RIVAROXABAN XARELTO (10 MG)(TABLET) 2 QL: 1 IN 1 DAY

RIVAROXABAN XARELTO (15 MG)(TABLET) 2 QL: 2 IN 1 DAY FOR 21 DAYS

THEN 1 IN 1 DAY

RIVAROXABAN XARELTO (15 MG-20MG) (TAB DS PK) 2 QL: 51 IN 30 DAYS

RIVAROXABAN XARELTO (20 MG)(TABLET) 2 QL: 1 IN 1 DAY

FACTOR IX PREPARATIONSFACTOR IX ALPHANINE SD 4FACTOR IX MONONINE 4FACTOR IX CPLX(PCC)NO4,3FACTOR PROFILNINE 4FACTOR IX CPLX(PCC)NO6,3FACTOR BEBULIN 4FACTOR IX HUMAN REC,PEGYLATED REBINYN 4FACTOR IX HUMAN RECOMB,THR 148 IXINITY 4FACTOR IX HUMAN RECOMBINANT BENEFIX 4FACTOR IX HUMAN RECOMBINANT RIXUBIS 4FACTOR IX REC, FC FUSION PROTN ALPROLIX 4FACTOR IX RECOM,ALBUMIN FUSION IDELVION 4

FACTOR X PREPARATIONSCOAGULATION FACTOR X COAGADEX 4

FACTOR XIII PREPARATIONSFACTOR XIII A-SUBUNIT,RECOMB TRETTEN 4


Drug Name Tier Requirements/LimitsHEMATINICS,OTHER

DARBEPOETIN ALFA IN POLYSORBAT ARANESP 4 PAEPOETIN ALFA EPOGEN 4 PAEPOETIN ALFA PROCRIT 4 PAEPOETIN ALFA-EPBX RETACRIT 4 PAMETHOXY PEG-EPOETIN BETA MIRCERA 4 PA

HEMOPHILIA TREATMENT AGENTS,NON-FACTOR REPLACEMENTEMICIZUMAB-KXWH HEMLIBRA 4 PA

HEMORRHEOLOGIC AGENTSpentoxifylline TRENTAL 1

HEPARIN AND RELATED PREPARATIONS

DALTEPARIN SODIUM,PORCINEFRAGMIN(10000/ML)(SYRINGE)


DALTEPARIN SODIUM,PORCINEFRAGMIN(12500/0.5)(SYRINGE)





4 QL: 7.2mL IN 30 DAYS

DALTEPARIN SODIUM,PORCINEFRAGMIN(2500/0.2ML)(SYRINGE)


DALTEPARIN SODIUM,PORCINE FRAGMIN(25000/ML) (VIAL) 4 QL: 7.6mL IN 30 DAYS





enoxaparin sodium LOVENOX (100MG/ML) (SYRINGE) 4 QL: 20mL IN 30 DAYS

enoxaparin sodiumLOVENOX(120MG/.8ML)(SYRINGE)


enoxaparin sodium LOVENOX (150MG/ML) (SYRINGE) 4 QL: 20mL IN 30 DAYS

enoxaparin sodiumLOVENOX(300MG/3ML)(VIAL)


enoxaparin sodiumLOVENOX(30MG/0.3ML)(SYRINGE)








fondaparinux sodiumARIXTRA(10MG/0.8ML)(SYRINGE)




fondaparinux sodium ARIXTRA (2.5MG/0.5) (SYRINGE) 4 QL: 5mL IN 30 DAYS

fondaparinux sodiumARIXTRA(5MG/0.4ML)(SYRINGE)


fondaparinux sodiumARIXTRA(7.5MG/0.6)(SYRINGE)


heparin sod,porcine/0.9 % nacl (100/ml) (kit) 1heparin sod,porcine/0.9 % nacl (2500/500ml) (iv soln) 3heparin sod,porcine/0.9 % nacl (5000/500ml) (iv soln) 3heparin sodium,porcine 1heparin sodium,porcine/d5w 1heparin sodium,porcine/pf (1 unit/ml) (syringe) 1heparin sodium,porcine/pf (10 unit/ml) (syringe) 1heparin sodium,porcine/pf (10 unit/ml) (vial) 1heparin sodium,porcine/pf (100/ml (1)) (syringe) 1heparin sodium,porcine/pf (100/ml (1)) (vial) 1heparin sodium,porcine/pf (1000/10 ml) (syringe) 1heparin sodium,porcine/pf (1000/ml) (vial) 1heparin sodium,porcine/pf (200/2 ml) (syringe) 1heparin sodium,porcine/pf (300/3 ml) (syringe) 1heparin sodium,porcine/pf (500/5 ml) (syringe) 1heparin sodium,porcine/pf (5000/0.5ml) (syringe) 1

LEUKOCYTE (WBC) STIMULANTSFILGRASTIM NEUPOGEN 4 PAFILGRASTIM-AAFI NIVESTYM 4 PAFILGRASTIM-SNDZ ZARXIO 4 PA

PEGFILGRASTIMNEULASTA (6MG/0.6ML) (SYR W/INJ)

4

PEGFILGRASTIMNEULASTA (6MG/0.6ML)(SYRINGE)

4 PA

PEGFILGRASTIM-JMDB FULPHILA 4 PASARGRAMOSTIM LEUKINE 4 PATBO-FILGRASTIM GRANIX 4 PA

PLATELET AGGREGATION INHIBITORSaspirin 5

aspirin BAYER CHEWABLEASPIRIN 5

ASPIRIN DURLAZA 3 PAaspirin ECOTRIN 5aspirin/dipyridamole AGGRENOX 1ASPIRIN/OMEPRAZOLE YOSPRALA 3 PAcilostazol PLETAL 1

clopidogrel bisulfate PLAVIX (300 MG)(TABLET) 1 QL: 4 IN 30 DAYS

clopidogrel bisulfate PLAVIX (75 MG)(TABLET) 1

dipyridamole PERSANTINE 1prasugrel hcl EFFIENT 1 QL: 1 IN 1 DAYTICAGRELOR BRILINTA 2 QL: 2 IN 1 DAYVORAPAXAR SULFATE ZONTIVITY 3 QL: 1 IN 1 DAY

PLATELET REDUCING AGENTSanagrelide hcl AGRYLIN 1

SICKLE CELL ANEMIA AGENTSHYDROXYUREA DROXIA 3


Drug Name Tier Requirements/LimitsHYDROXYUREA SIKLOS 3 QL: 2 IN 1 DAY

SPLEEN TYROSINE KINASE INHIBITORSFOSTAMATINIB DISODIUM TAVALISSE 4 PA

THROMBIN INHIBITORS,SEL.,DIRECT,&REV.-HIRUDIN TYPEDESIRUDIN IPRIVASK 4 PA, QL: 2 IN 1 DAY

THROMBIN INHIBITORS,SELECTIVE,DIRECT, & REVERSIBLEDABIGATRAN ETEXILATE MESYLATE PRADAXA 3 ST, QL: 2 IN 1 DAY

THROMBOPOIETIN RECEPTOR AGONISTSAVATROMBOPAG MALEATE DOPTELET 4 PAELTROMBOPAG OLAMINE PROMACTA 4 PALUSUTROMBOPAG MULPLETA 4 PA

TOPICAL HEMOSTATICSFERRIC SUBSULFATE ASTRINGYN 3ferric subsulfate 3FIBRINOGEN/THROMBIN(HUMAN DER) EVARREST 3FIBRINOGEN/THROMBIN(HUMAN DER) TACHOSIL 3GELATIN SPONGE,ABSORB/PORCINE GELFOAM 3MICROFIBRILLAR COLLAGEN AVITENE 3MICROFIBRILLAR COLLAGEN ENDO-AVITENE 3MICROFIBRILLAR COLLAGEN SYRINGE AVITENE 3MICROFIBRILLAR COLLAGEN ULTRAFOAM 3thromb-cal-cell-dressing,hemos 3thrombin (bovine) 1THROMBIN (RECOMBINANT) RECOTHROM 3THROMBIN,BOVINE/GELATIN SPONGE GELFOAM JMI 3THROMBIN,HU/FIBRINOGEN/CALCIUM EVICEL 3thrombin/cal/cmc/gel/dress,hem 3

VITAMIN K PREPARATIONSphytonadione (vit k1) (10 mg/ml) (ampul) 1phytonadione (vit k1) (1mg/0.5ml) (ampul) 1phytonadione (vit k1) (1mg/0.5ml) (syringe) 1phytonadione (vit k1) (5 mg) (tablet) 1

HORMONAL DEFICIENCYANDROGENIC AGENTS

methyltestosterone ANDROID 1 PAMETHYLTESTOSTERONE METHITEST 2 PAmethyltestosterone TESTRED 1 PAoxandrolone OXANDRIN 1 PAOXYMETHOLONE ANADROL-50 3 PATESTOSTERONE ANDRODERM 3 PA

TESTOSTERONE ANDROGEL (1.25G-1.62) (GEL PACKET) 2 PA

testosteroneANDROGEL(12.5/1.25G) (GELMD PMP)

1 PA

TESTOSTERONEANDROGEL (2.5G-1.62%) (GELPACKET)

2 PA

TESTOSTERONEANDROGEL(20.25/1.25) (GELMD PMP)

2 PA

testosteroneANDROGEL(25MG(1%)) (GELPACKET)

1 PA

testosterone ANDROGEL (50 MG(1%)) (GEL PACKET) 1 PA

testosterone AXIRON 1 PA


Drug Name Tier Requirements/Limitstestosterone FORTESTA 1 PATESTOSTERONE NATESTO 3 PATESTOSTERONE STRIANT 3 PAtestosterone TESTIM 1 PATESTOSTERONE TESTOPEL 3testosterone VOGELXO 1 PA

testosterone cypionate DEPO-TESTOSTERONE 1 PA

testosterone enanthate DELATESTRYL 1 PAESTROGEN & PROGESTIN WITH ANTIMINERALOCORTICOID CB

DROSPIRENONE/ESTRADIOL ANGELIQ 3ESTROGEN & SELECTIVE ESTROGEN RECEPT MOD(SERM)COMB

ESTROGENS,CONJ/BAZEDOXIFENE DUAVEE 2ESTROGEN/ANDROGEN COMBINATIONS

estrogen,ester/me-testosterone COVARYX 1estrogen,ester/me-testosterone COVARYX H.S. 1

ESTROGENIC AGENTSESTRADIOL ALORA 2 QL: 2 IN 7 DAYSestradiol CLIMARA 1 QL: 1 IN 7 DAYSESTRADIOL DIVIGEL 2ESTRADIOL ELESTRIN 3estradiol ESTRACE 1ESTRADIOL ESTROGEL 3ESTRADIOL EVAMIST 3ESTRADIOL MENOSTAR 3 QL: 1 IN 7 DAYSESTRADIOL MINIVELLE 2 QL: 2 IN 7 DAYSestradiol VIVELLE-DOT 1 QL: 2 IN 7 DAYSESTRADIOL CYPIONATE DEPO-ESTRADIOL 3ESTRADIOL VALERATE DELESTROGEN 3estradiol valerate 3ESTRADIOL/LEVONORGESTREL CLIMARA PRO 3 QL: 1 IN 7 DAYSestradiol/norethindrone acet ACTIVELLA 1ESTRADIOL/NORETHINDRONE ACET COMBIPATCH 2 QL: 2 IN 7 DAYSESTRADIOL/NORGESTIMATE PREFEST 3ESTROGEN,CON/M-PROGEST ACET PREMPHASE 2ESTROGEN,CON/M-PROGEST ACET PREMPRO 2ESTROGENS, CONJUGATED PREMARIN 2ESTROGENS,ESTERIFIED MENEST 2estropipate ORTHO-EST 1norethindrone ac-eth estradiol FEMHRT 1norethindrone ac-eth estradiol JEVANTIQUE 1norethindrone ac-eth estradiol JEVANTIQUE LO 1

LHRH (GNRH) AGONIST ANALOG AND PROGESTIN COMBLEUPROLIDE/NORETHINDRONE ACET LUPANETA PACK 4

PROGESTATIONAL AGENTSmedroxyprogesterone acetate PROVERA 1norethindrone acetate AYGESTIN 1progesterone 1PROGESTERONE, MICRONIZED CRINONE 3progesterone, micronized PROMETRIUM 1

IMMUNIZATIONANTISERA

IGG/HYALURONIDASE,RECOMBINANT HYQVIA 4 PAIMMUN GLOB G(IGG)/GLY/IGA OV50 CUVITRU 4 PA

IMMUN GLOB G(IGG)/GLY/IGA OV50 GAMMAGARDLIQUID 4 PA



IMMUN GLOB G(IGG)/GLY/IGA OV50 HYQVIA IGCOMPONENT 4 PA

IMMUN GLOB G(IGG)/PRO/IGA 0-50 HIZENTRA 4 PAIMMUNE GLOBUL G/GLY/IGA AVG 46 GAMMAKED 4 PAIMMUNE GLOBUL G/GLY/IGA AVG 46 GAMUNEX-C 4 PA

ENTERIC VIRUS VACCINESROTAVIRUS VAC,LIVE ATT, 89-12 ROTARIX 3ROTAVIRUS VACCINE,LIVE ORAL PV ROTATEQ 3

GRAM (-) BACILLI (NON-ENTERIC) VACCINESTYPHOID VACC,LIVE,ATTENUATED VIVOTIF 3

GRAM NEGATIVE COCCI VACCINESMENINGOCOCCAL B VACCINE,4-COMP BEXSERO 3N.MENINGITIDIS B,LIPID FHBP RC TRUMENBA 3

INFLUENZA VIRUS VACCINES

FLU VAC QS 18-19 (4YR UP) CELL FLUCELVAX QUAD2018-2019 5 QL: 0.5mL IN 180 DAYS

FLU VAC QS 18-19(4YR UP)CEL/PF FLUCELVAX QUAD2018-2019 5 QL: 0.5mL IN 180 DAYS

FLU VAC QV 2018(18YR UP)RCM/PF FLUBLOK QUAD2018-2019 5 AGE: >= 18 YEARS, QL: 0.5mL IN

180 DAYS

FLU VACC QS 2018 (6-35MOS)/PF FLUZONE QUADPEDI 2018-2019 5 QL: 0.25mL IN 180 DAYS

FLU VACC QS2018-19 36MOS UP/PF FLUZONE QUAD2018-2019 5 QL: 0.5mL IN 180 DAYS

FLU VACC QS2018-19(6MOS UP)/PF FLUARIX QUAD2018-2019 5 QL: 0.5mL IN 180 DAYS

FLU VACC QS2018-19(6MOS UP)/PF FLULAVAL QUAD2018-2019 5 QL: 0.5mL IN 180 DAYS

FLU VACC QUAD 2018(5 YR UP)/PF AFLURIA QUAD2018-2019 5 QL: 0.5mL IN 180 DAYS

FLU VACC QUAD 2018-19(5 YR UP) AFLURIA QUAD2018-2019 5 QL: 0.5mL IN 180 DAYS

FLU VACC QUAD 2018-19(6MOS UP) FLULAVAL QUAD2018-2019 5 QL: 0.5mL IN 180 DAYS

FLU VACC QUAD 2018-19(6MOS UP) FLUZONE QUAD2018-2019 5 QL: 0.5mL IN 180 DAYS

FLU VACC QV LIVE 2018(2-49YRS) FLUMIST QUAD2018-2019 5 QL: 1 IN 180 DAYS

FLU VACC TS2018(65UP)/MF59C/PF FLUAD 2018-2019 5 AGE: >= 65 YEARS, QL: 0.5mL IN180 DAYS

FLU VACC TS2018-19(65YR UP)/PF FLUZONE HIGH-DOSE 2018-2019 5 AGE: >= 65 YEARS, QL: 0.5mL IN

180 DAYSFLU VACCIN TS2018-19 5YR UP/PF AFLURIA 2018-2019 5 QL: 0.5mL IN 180 DAYSFLU VACCINE TS2018-19(5 YR UP) AFLURIA 2018-2019 5 QL: 0.5mL IN 180 DAYS

TOXIN-PRODUCING BACILLI VACCINES/TOXOIDS

CHOLERA VACCINE, LIVEVAXCHORAACTIVECOMPONENT

3

CHOLERA VACCINE, LIVE VAXCHORAVACCINE 3

VIRAL/TUMORIGENIC VACCINES

ADENOVIRUS LIVE TYPES-4,7 VACC ADENOVIRUS TYPE4 AND TYPE 7 3

ADENOVIRUS VACCINE LIVE TYPE-4 ADENOVIRUS TYPE4 3

ADENOVIRUS VACCINE LIVE TYPE-7 ADENOVIRUS TYPE7 3



IMMUNOSUPPRESSION/MODULATIONIMMUNOMODULATORS

imiquimod ALDARA 1 QL: 24 IN 30 DAYS

IMIQUIMOD ZYCLARA (2.5 %)(CRM MD PMP) 3 ST, QL: 7.5gm IN 28 DAYS

IMIQUIMOD ZYCLARA (3.75 %)(CREAM PACK) 3 ST, QL: 1 IN 1 DAY

imiquimod ZYCLARA (3.75 %)(CRM MD PMP) 1 ST, QL: 7.5gm IN 28 DAYS

INTERFERON ALFA-2B,RECOMB. INTRON A 2 PAINTERFERON ALFA-N3 ALFERON N 4INTERFERON GAMMA-1B,RECOMB. ACTIMMUNE 4

IMMUNOSUPPRESSIVESAZATHIOPRINE AZASAN 3azathioprine IMURAN 1cyclosporine SANDIMMUNE 4CYCLOSPORINE SANDIMMUNE 4cyclosporine, modified GENGRAF 4cyclosporine, modified NEORAL 4EVEROLIMUS ZORTRESS 2mycophenolate mofetil CELLCEPT 1mycophenolate sodium MYFORTIC 1

sirolimus RAPAMUNE (0.5MG) (TABLET) 1

sirolimus RAPAMUNE (1 MG)(TABLET) 1

SIROLIMUSRAPAMUNE (1MG/ML)(SOLUTION)

2

sirolimus RAPAMUNE (2 MG)(TABLET) 1

TACROLIMUS ASTAGRAF XL 4TACROLIMUS ENVARSUS XR 4tacrolimus PROGRAF 4

INFECTIOUS DISEASE - BACTERIALABSORBABLE SULFONAMIDES

sulfamethoxazole/trimethoprim 1BETALACTAMS

AZTREONAM LYSINE CAYSTON 2 PACEPHALOSPORINS - 1ST GENERATION

cefadroxil DURICEF 1cephalexin KEFLEX 1

CEPHALOSPORINS - 2ND GENERATIONcefaclor CECLOR 1cefaclor CECLOR CD 1cefprozil CEFZIL 1cefuroxime axetil CEFTIN 1

CEPHALOSPORINS - 3RD GENERATIONcefdinir OMNICEF 1cefditoren pivoxil SPECTRACEF 1

CEFIXIME SUPRAX (100 MG)(TAB CHEW) 2

cefiximeSUPRAX (100MG/5ML) (SUSPRECON)

1

CEFIXIME SUPRAX (200 MG)(TAB CHEW) 2



cefiximeSUPRAX (200MG/5ML) (SUSPRECON)

1

CEFIXIME SUPRAX (400 MG)(CAPSULE) 2

CEFIXIMESUPRAX (500MG/5ML) (SUSPRECON)

2

cefpodoxime proxetil VANTIN 1CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC.

FOSFOMYCIN TROMETHAMINE MONUROL 3meth/meblue/sod phos/psal/hyos 1METH/MEBLUE/SOD PHOS/PSAL/HYOS PHOSPHASAL 2METH/MEBLUE/SOD PHOS/PSAL/HYOS URETRON D-S 2METH/MEBLUE/SOD PHOS/PSAL/HYOS URIN D.S. 2methen/mblue/sal/sod phos/hyos 1methenam/m.blue/salicyl/hyoscy 1methenam/sod phos/mblue/hyoscy URYL 1METHENAM/SOD PHOS/MBLUE/HYOSCY UTA 3methenamine hippurate HIPREX 1methenamine mandelate MANDELAMINE 1TRIMETHOPRIM PRIMSOL 2trimethoprim PROLOPRIM 1TRIMETHOPRIM TRIMPEX 2

MACROLIDESazithromycin ZITHROMAX 1

azithromycin ZITHROMAX TRI-PAK 1

clarithromycin BIAXIN 1clarithromycin BIAXIN XL 1ERYTHROMYCIN BASE ERY-TAB 2erythromycin base 1ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 200 2ERYTHROMYCIN ETHYLSUCCINATE ERYPED 200 2ERYTHROMYCIN ETHYLSUCCINATE ERYPED 400 2erythromycin ethylsuccinate 1

erythromycin stearate ERYTHRCINSTEARATE 1

FIDAXOMICIN DIFICID 2 ST, QL: 20 IN 30 DAYSNITROFURAN DERIVATIVES

nitrofurantoin FURADANTIN 1nitrofurantoin macrocrystal MACRODANTIN 1nitrofurantoin monohyd/m-cryst MACROBID 1

OXAZOLIDINONESlinezolid ZYVOX 1TEDIZOLID PHOSPHATE SIVEXTRO 2 ST, QL: 6 IN 6 DAYS

PENICILLINSamoxicillin AMOXIL 1AMOXICILLIN MOXATAG 3

AMOXICILLIN/POTASSIUM CLAVAUGMENTIN (125-31.25/) (SUSPRECON)

3 ST, QL: 150mL IN 30 DAYS

amoxicillin/potassium clavAUGMENTIN (200-28.5/5) (SUSPRECON)

1

amoxicillin/potassium clavAUGMENTIN (200-28.5MG) (TABCHEW)

1



amoxicillin/potassium clav AUGMENTIN (250-125 MG) (TABLET) 1

amoxicillin/potassium clavAUGMENTIN (250-62.5/5) (SUSPRECON)

1

amoxicillin/potassium clav AUGMENTIN (400-57MG) (TAB CHEW) 1

amoxicillin/potassium clavAUGMENTIN (400-57MG/5) (SUSPRECON)

1



amoxicillin/potassium clav AUGMENTIN ES-600 1amoxicillin/potassium clav AUGMENTIN XR 1ampicillin trihydrate AMPICILLIN 1dicloxacillin sodium PATHOCIL 1penicillin v potassium 1penicillin v potassium VEETIDS 1

QUINOLONESCIPROFLOXACIN CIPRO 2ciprofloxacin 1ciprofloxacin hcl CIPRO 1ciprofloxacin/ciprofloxa hcl CIPRO XR 1DELAFLOXACIN MEGLUMINE BAXDELA 3 PAGEMIFLOXACIN MESYLATE FACTIVE 3levofloxacin LEVAQUIN 1moxifloxacin hcl AVELOX 1moxifloxacin hcl AVELOX ABC PACK 1ofloxacin FLOXIN 1

TETRACYCLINESdemeclocycline hcl DECLOMYCIN 1DOXYCYCLINE CALCIUM VIBRAMYCIN 2doxycycline hyclate ACTICLATE 1 ST, QL: 2 IN 1 DAY

doxycycline hyclate DORYX (100 MG)(TABLET DR) 1 ST, QL: 2 IN 1 DAY





DOXYCYCLINE HYCLATE DORYX MPC 3 ST, QL: 2 IN 1 DAYdoxycycline hyclate MORGIDOX 1 QL: 2 IN 1 DAYdoxycycline hyclate TARGADOX 1 ST, QL: 4 IN 1 DAYdoxycycline hyclate VIBRAMYCIN 1 QL: 2 IN 1 DAYdoxycycline hyclate VIBRA-TABS 1 QL: 2 IN 1 DAYdoxycycline monohydrate ADOXA 1 QL: 2 IN 1 DAYdoxycycline monohydrate AVIDOXY 1 QL: 2 IN 1 DAY

doxycycline monohydrate MONODOX (100MG) (CAPSULE) 1 QL: 2 IN 1 DAY

doxycycline monohydrate MONODOX (50 MG)(CAPSULE) 1 QL: 2 IN 1 DAY

doxycycline monohydrate MONODOX (50 MG)(TABLET) 1 QL: 2 IN 1 DAY



doxycycline monohydrate MONODOX (75 MG)(CAPSULE) 1 ST, QL: 2 IN 1 DAY

doxycycline monohydrate MONODOX (75 MG)(TABLET) 1 QL: 2 IN 1 DAY

doxycycline monohydrate ORACEA 1 ST, AGE: >= 18 YEARS, QL: 1 IN 1DAY

doxycycline monohydrate VIBRAMYCIN 1DOXYCYCLINE/BENZOYL PEROXIDE BENZODOX 30 3 ST, QL: 1 IN 30 DAYSDOXYCYCLINE/BENZOYL PEROXIDE BENZODOX 60 3 ST, QL: 1 IN 30 DAYSDOXYCYCLINE/SALICY/OCT/ZINC OX AVIDOXY DK 3 ST, QL: 1 IN 30 DAYSDOXYCYCLINE/SKIN CLEANSER NO19 MORGIDOX 3 ST, QL: 1 IN 30 DAYSminocycline hcl (100 mg) (capsule) 1minocycline hcl (100 mg) (tablet) 1

minocycline hcl (115mg) (tab er 24h) 1 ST, AGE: >= 12 YEARS, QL: 1 IN 1DAY

minocycline hcl (135 mg) (tab er 24h) 1 AGE: >= 12 YEARS, QL: 1 IN 1 DAYminocycline hcl (45 mg) (tab er 24h) 1 AGE: >= 12 YEARS, QL: 1 IN 1 DAYminocycline hcl (50 mg) (capsule) 1minocycline hcl (50 mg) (tablet) 1

minocycline hcl (65 mg) (tab er 24h) 1 ST, AGE: >= 12 YEARS, QL: 1 IN 1DAY

minocycline hcl (75 mg) (capsule) 1minocycline hcl (75 mg) (tablet) 1minocycline hcl (90 mg) (tab er 24h) 1 AGE: >= 12 YEARS, QL: 1 IN 1 DAY

MINOCYCLINE HCL SOLODYN 3 ST, AGE: >= 12 YEARS, QL: 1 IN 1DAY

MINOCYCLINE HCL XIMINO 3 ST, AGE: >= 12 YEARS, QL: 1 IN 1DAY

tetracycline hcl PANMYCIN 1tetracycline hcl SUMYCIN 1

INFECTIOUS DISEASE - FUNGALANTIFUNGAL AGENTS

clotrimazole MYCELEX 1fluconazole DIFLUCAN 1flucytosine ANCOBON 1ISAVUCONAZONIUM SULFATE CRESEMBA 3ITRACONAZOLE ONMEL 3

itraconazoleSPORANOX (10MG/ML)(SOLUTION)

3

itraconazole SPORANOX (100MG) (CAPSULE) 1

ketoconazole NIZORAL 1MICONAZOLE ORAVIG 3POSACONAZOLE NOXAFIL 3terbinafine hcl 1voriconazole VFEND 1

ANTIFUNGAL ANTIBIOTICSgriseofulvin ultramicrosize 1griseofulvin, microsize GRIFULVIN V 1nystatin 1

INFECTIOUS DISEASE - MISCELLANEOUSAMINOGLYCOSIDES

neomycin sulfate 1TOBRAMYCIN BETHKIS 4 PATOBRAMYCIN TOBI PODHALER 2 PAtobramycin in 0.225% sod chlor TOBI 1 PA


Drug Name Tier Requirements/Limitstobramycin/nebulizer KITABIS PAK 1 PA

ANTIBACTERIAL AGENTS,MISCELLANEOUS

glycine urologic solution AMINOACETICACID 1

ANTILEPROTICSdapsone 1THALIDOMIDE THALOMID 2 PA, QL: 2 IN 1 DAY

ANTI-MYCOBACTERIUM AGENTSAMINOSALICYLIC ACID PASER 3ethambutol hcl MYAMBUTOL 1ETHIONAMIDE TRECATOR 3isoniazid 1pyrazinamide 1rifabutin MYCOBUTIN 1

ANTITUBERCULAR ANTIBIOTICSBEDAQUILINE FUMARATE SIRTURO 4 PAcycloserine SEROMYCIN 1RIFAMP/ISONIAZID/PYRAZINAMIDE RIFATER 3rifampin RIFADIN 1RIFAMPIN/ISONIAZID RIFAMATE 2RIFAPENTINE PRIFTIN 3

LINCOSAMIDESclindamycin hcl CLEOCIN HCL 1

clindamycin palmitate hcl CLEOCINPALMITATE 1

RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS

RIFAXIMIN XIFAXAN (200 MG)(TABLET) 3 QL: 9 PER FILL

RIFAXIMIN XIFAXAN (550 MG)(TABLET) 2 PA

VANCOMYCIN AND DERIVATIVES

VANCOMYCIN HCLFIRVANQ (25MG/ML) (SOLNRECON)

2 QL: 300mL PER FILL

VANCOMYCIN HCLFIRVANQ (50MG/ML) (SOLNRECON)

2 QL: 600mL PER FILL

vancomycin hcl (125 mg) (capsule) 1 QL: 56 PER FILLvancomycin hcl (125mg/2.5) (syringe) 3vancomycin hcl (250 mg) (capsule) 1 QL: 112 PER FILL

INFECTIOUS DISEASE - PARASITIC2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL

SECNIDAZOLE SOLOSEC 3 ST, QL: 1 IN 30 DAYStinidazole TINDAMAX 1

AMEBACIDESparomomycin sulfate HUMATIN 1

ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTSmetronidazole FLAGYL 1

ANTHELMINTICSALBENDAZOLE ALBENZA 2ivermectin STROMECTOL 1MEBENDAZOLE EMVERM 3 PApraziquantel BILTRICIDE 1

ANTIMALARIAL DRUGSARTEMETHER/LUMEFANTRINE COARTEM 3atovaquone/proguanil hcl MALARONE 1


Drug Name Tier Requirements/Limitschloroquine phosphate 1hydroxychloroquine sulfate PLAQUENIL 1mefloquine hcl LARIAM 1PRIMAQUINE PHOSPHATE PRIMAQUINE 2PYRIMETHAMINE DARAPRIM 4 PAquinine sulfate QUALAQUIN 1

ANTIPARASITICSNITAZOXANIDE ALINIA 3

ANTIPROTOZOAL DRUGS,MISCELLANEOUSatovaquone MEPRON 1benznidazole 1MILTEFOSINE IMPAVIDO 3 PAPENTAMIDINE ISETHIONATE NEBUPENT 2

INFECTIOUS DISEASE - VIRALANTIRETROVIRAL-INTEGRASE INHIBITOR AND NNRTI COMB.

DOLUTEGRAVIR/RILPIVIRINE JULUCA 2ANTIRETROVIRAL-NUCLEOSIDE,NUCLEOTIDE,PROTEASE INH.

DARUNAVIR/COB/EMTRI/TENOF ALAF SYMTUZA 2ANTIVIRALS, GENERAL

ACYCLOVIR SITAVIG 3 QL: 4 IN 365 DAYSacyclovir ZOVIRAX 1famciclovir FAMVIR 1LETERMOVIR PREVYMIS 4 PA

oseltamivir phosphate TAMIFLU (30 MG)(CAPSULE) 1 QL: 40 IN 183 DAYS


oseltamivir phosphateTAMIFLU (6MG/ML) (SUSPRECON)



ribavirin VIRAZOLE 1rimantadine hcl FLUMADINE 1valacyclovir hcl VALTREX 1valganciclovir hcl VALCYTE 1ZANAMIVIR RELENZA 3 QL: 40 IN 183 DAYS

ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIBDARUNAVIR ETHANOLATE PREZISTA 2DARUNAVIR/COBICISTAT PREZCOBIX 2TIPRANAVIR APTIVUS 2TIPRANAVIR/VITAMIN E TPGS APTIVUS 2

ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOGEMTRICITABINE/TENOFOV ALAFENAM DESCOVY 2EMTRICITABINE/TENOFOVIR (TDF) TRUVADA 2LAMIVUDINE/TENOFOVIR DISOP FUM CIMDUO 2

ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMBabacavir sulfate/lamivudine EPZICOM 1abacavir/lamivudine/zidovudine TRIZIVIR 1lamivudine/zidovudine COMBIVIR 1

ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG.MARAVIROC SELZENTRY 2

ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORSENFUVIRTIDE FUZEON 2

ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTIDELAVIRDINE MESYLATE RESCRIPTOR 2


Drug Name Tier Requirements/LimitsDORAVIRINE PIFELTRO 2efavirenz SUSTIVA 1ETRAVIRINE INTELENCE 2nevirapine VIRAMUNE 1nevirapine VIRAMUNE XR 1RILPIVIRINE HCL EDURANT 2

ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTIabacavir sulfate ZIAGEN 1DIDANOSINE VIDEX 2didanosine VIDEX EC 1EMTRICITABINE EMTRIVA 2lamivudine EPIVIR 1

STAVUDINE ZERIT (1 MG/ML)(SOLN RECON) 2

stavudine ZERIT (15 MG)(CAPSULE) 1




zidovudine RETROVIR 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI

TENOFOVIR DISOPROXIL FUMARATE VIREAD (150 MG)(TABLET) 2



tenofovir disoproxil fumarate VIREAD (300 MG)(TABLET) 1

TENOFOVIR DISOPROXIL FUMARATEVIREAD(40MG/SCOOP)(POWDER)

2

ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB

LOPINAVIR/RITONAVIR KALETRA (100MG-25MG) (TABLET) 2

LOPINAVIR/RITONAVIR KALETRA (200MG-50MG) (TABLET) 2

lopinavir/ritonavir KALETRA (400-100/5) (SOLUTION) 1

ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS

atazanavir sulfate REYATAZ (150 MG)(CAPSULE) 1



ATAZANAVIR SULFATE REYATAZ (50 MG)(POWD PACK) 2

ATAZANAVIR SULFATE/COBICISTAT EVOTAZ 2

FOSAMPRENAVIR CALCIUM LEXIVA (50 MG/ML)(ORAL SUSP) 2

fosamprenavir calcium LEXIVA (700 MG)(TABLET) 1

INDINAVIR SULFATE CRIXIVAN 2NELFINAVIR MESYLATE VIRACEPT 2



RITONAVIR NORVIR (100 MG)(CAPSULE) 2

RITONAVIR NORVIR (100 MG)(POWD PACK) 2

ritonavir NORVIR (100 MG)(TABLET) 1

RITONAVIRNORVIR (80MG/ML)(SOLUTION)

2

SAQUINAVIR MESYLATE INVIRASE 2ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR

DOLUTEGRAVIR SODIUM TIVICAY 2RALTEGRAVIR POTASSIUM ISENTRESS 2RALTEGRAVIR POTASSIUM ISENTRESS HD 2

ARTV CMB NUCLEOSIDE,NUCLEOTIDE,&NON-NUCLEOSIDE RTIDORAVIRINE/LAMIVU/TENOFOV DISO DELSTRIGO 2EFAVIRENZ/EMTRICIT/TENOFOVR DF ATRIPLA 2EFAVIRENZ/LAMIVU/TENOFOV DISOP SYMFI 2EFAVIRENZ/LAMIVU/TENOFOV DISOP SYMFI LO 2EMTRICITA/RILPIVIRINE/TENOF DF COMPLERA 2EMTRICITAB/RILPIVIRI/TENOF ALA ODEFSEY 2

ARV CMB-NRTI,N(T)RTI, INTEGRASE INHIBITORBICTEGRAV/EMTRICIT/TENOFOV ALA BIKTARVY 2ELVITEG/COB/EMTRI/TENOF ALAFEN GENVOYA 2ELVITEG/COB/EMTRI/TENOFO DISOP STRIBILD 2

ARV COMB-NRTIS & INTEGRASE INHIBITORABACAVIR/DOLUTEGRAVIR/LAMIVUDI TRIUMEQ 2

CYTOCHROME P450 INHIBITORSCOBICISTAT TYBOST 2

HEP C - NS5A, NS3/4A, NUCLEOTIDE NS5B INHIB COMBOSOFOSBUVIR/VELPATAS/VOXILAPREV VOSEVI 4 PA

HEP C VIRUS - NS5A & NS5B POLYMERASE INHIB. COMBO.LEDIPASVIR/SOFOSBUVIR HARVONI 4 PASOFOSBUVIR/VELPATASVIR EPCLUSA 4 PA

HEP C VIRUS,NUCLEOTIDE ANALOG NS5B POLYMERASE INHSOFOSBUVIR SOVALDI 4 PA

HEPATITIS B TREATMENT AGENTSadefovir dipivoxil HEPSERA 1 QL: 1 IN 1 DAY

ENTECAVIRBARACLUDE (0.05MG/ML)(SOLUTION)


entecavir BARACLUDE (0.5MG) (TABLET) 1 QL: 1 IN 1 DAY

entecavir BARACLUDE (1MG) (TABLET) 1 QL: 1 IN 1 DAY

lamivudine EPIVIR HBV (100MG) (TABLET) 1 QL: 1 IN 1 DAY

LAMIVUDINEEPIVIR HBV (25MG/5 ML)(SOLUTION)


TENOFOVIR ALAFENAMIDE FUMARATE VEMLIDY 2 ST, QL: 1 IN 1 DAYHEPATITIS C TREATMENT AGENTS

PEGINTERFERON ALFA-2A PEGASYS 2 PA

PEGINTERFERON ALFA-2A PEGASYSPROCLICK 2 PA

PEGINTERFERON ALFA-2B PEGINTRON 2 PARIBAVIRIN REBETOL 2


Drug Name Tier Requirements/Limitsribavirin (200 mg) (capsule) 1ribavirin (200 mg) (tablet) 1ribavirin (200-400 mg) (tab ds pk) 1 STribavirin (200-400(7)) (tab ds pk) 1 STribavirin (400 mg) (tablet) 1 STribavirin (400-400 mg) (tab ds pk) 1 STribavirin (400-400(7)) (tab ds pk) 1 STribavirin (600 mg) (tablet) 1 STribavirin (600-400 mg) (tab ds pk) 1 STribavirin (600-400(7)) (tab ds pk) 1 STribavirin (600-600 mg) (tab ds pk) 1 STribavirin (600-600(7)) (tab ds pk) 1 ST

HEPATITIS C VIRUS - NS5A REPLICATION COMPLEX INHIBDACLATASVIR DIHYDROCHLORIDE DAKLINZA 4 PA

HEPATITIS C VIRUS - NS5A, NS3/4A, NS5B INHIB CMB.OMBITA/PARITAP/RITON/DASABUVIR VIEKIRA PAK 4 PAOMBITA/PARITAP/RITON/DASABUVIR VIEKIRA XR 4 PA

HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMBELBASVIR/GRAZOPREVIR ZEPATIER 4 PAGLECAPREVIR/PIBRENTASVIR MAVYRET 4 PAOMBITASVIR/PARITAPREV/RITONAV TECHNIVIE 4 PA

INFLAMMATORY DISEASEANTI-ARTHRITIC AND CHELATING AGENTS

PENICILLAMINE CUPRIMINE 2 PAPENICILLAMINE DEPEN 2 PA

ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTSMETHOTREXATE/PF OTREXUP 4 ST, QL: 1.6mL IN 28 DAYS

METHOTREXATE/PFRASUVO(10MG/0.2ML)(AUTO INJCT)

4 ST, QL: 0.8mL IN 28 DAYS

METHOTREXATE/PF RASUVO (12.5/0.25)(AUTO INJCT) 4 ST, QL: 1mL IN 28 DAYS



METHOTREXATE/PF RASUVO (17.5/0.35)(AUTO INJCT) 4 ST, QL: 1.4mL IN 28 DAYS



METHOTREXATE/PF RASUVO (22.5/0.45)(AUTO INJCT) 4 ST, QL: 1.8mL IN 28 DAYS





METHOTREXATE/PFRASUVO(7.5MG/0.15) (AUTOINJCT)


ANTI-FLAM. INTERLEUKIN-1 RECEPTOR ANTAGONISTANAKINRA KINERET 4 PARILONACEPT ARCALYST 4

ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITORADALIMUMAB HUMIRA 4 PA



ADALIMUMABHUMIRAPEDIATRICCROHN'S

4 PA

ADALIMUMAB HUMIRA PEN 4 PA

ADALIMUMABHUMIRA PENCROHN-UC-HSSTARTER

4 PA

ADALIMUMAB HUMIRA PENPSORIASIS-UVEITIS 4 PA

CERTOLIZUMAB PEGOL CIMZIA 4 PAETANERCEPT ENBREL 4 PAETANERCEPT ENBREL MINI 4 PA

ETANERCEPT ENBRELSURECLICK 4 PA

GOLIMUMAB SIMPONI 2 PAANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR

leflunomide ARAVA 1ANTI-INFLAMMATORY,PHOSPHODIESTERASE-4(PDE4) INHIB.

APREMILAST OTEZLA 4 PAANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITOR

ABATACEPT ORENCIA 4 PA

ABATACEPT ORENCIACLICKJECT 4 PA

BRADYKININ B2 RECEPTOR ANTAGONISTSICATIBANT ACETATE FIRAZYR 4 PA

C1 ESTERASE INHIBITORSC1 ESTERASE INHIBITOR BERINERT 4 PAC1 ESTERASE INHIBITOR CINRYZE 4 PAC1 ESTERASE INHIBITOR HAEGARDA 4 PAC1 ESTERASE INHIBITOR, RECOMB RUCONEST 4 PA

GLUCOCORTICOIDSBETAMETHASON/NORFLURAN/PENTFLU BETALOAN SUIK 3BETAMETHASON/NORFLURAN/PENTFLU POD-CARE 100CG 3budesonide ENTOCORT EC 1budesonide UCERIS 1 STcortisone acetate CORTONE 1DEFLAZACORT EMFLAZA 4 PADEXAMETH/PF/NORFLUR/HFC 245FA DMT SUIK 3dexamethasone (0.5 mg) (tablet) 1dexamethasone (0.5 mg/5ml) (elixir) 1dexamethasone (0.5 mg/5ml) (solution) 1dexamethasone (0.75 mg) (tablet) 1dexamethasone (1 mg) (tablet) 1dexamethasone (1.5 mg(49)) (tab ds pk) 1 STdexamethasone (1.5 mg) (tablet) 1dexamethasone (1.5mg (21)) (tab ds pk) 1 STdexamethasone (1.5mg (35)) (tab ds pk) 1 STdexamethasone (1.5mg (51)) (tab ds pk) 1 STdexamethasone (2 mg) (tablet) 1dexamethasone (4 mg) (tablet) 1dexamethasone (6 mg) (tablet) 1DEXAMETHASONE INTENSOL 3DEXAMETHASONE SODIUM PHOSPHATE DEXONTO 3hydrocortisone CORTEF 1hydrocortisone sod succinate 3HYDROCORTISONE SOD SUCCINATE SOLU-CORTEF 3HYDROCORTISONE SODIUM SUCC/PF SOLU-CORTEF 3



ME-PREDNIS/NORFLURAN/HFC 245FA MEDROLOAN IISUIK 3

ME-PREDNIS/NORFLURAN/HFC 245FA MEDROLOAN SUIK 3ME-PREDNIS/NORFLURAN/HFC 245FA P-CARE D40G 3ME-PREDNIS/NORFLURAN/HFC 245FA P-CARE D80G 3

methylprednisolone MEDROL (16 MG)(TABLET) 1

METHYLPREDNISOLONE MEDROL (2 MG)(TABLET) 2


methylprednisolone MEDROL (4 MG)(TAB DS PK) 1



PREDNISOLONE MILLIPRED 2PREDNISOLONE MILLIPRED DP 2prednisolone ORAPRED 1prednisolone sod phosphate 1prednisone 1PREDNISONE INTENSOL 2PREDNISONE RAYOS 3 STTRIAMCIN/NORFLURANE/HFC 245FA P-CARE K40G 3TRIAMCIN/NORFLURANE/HFC 245FA P-CARE K80G 3TRIAMCIN/NORFLURANE/HFC 245FA POD-CARE 100KG 3TRIAMCIN/NORFLURANE/HFC 245FA TRILOAN II SUIK 3TRIAMCIN/NORFLURANE/HFC 245FA TRILOAN SUIK 3

GOLD SALTSAURANOFIN RIDAURA 4

IMMUNOMODULATOR,B-LYMPHOCYTE STIM(BLYS)-SPEC INHIBBELIMUMAB BENLYSTA 4 PA

INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORSSARILUMAB KEVZARA 4 PATOCILIZUMAB ACTEMRA 4 PA

JANUS KINASE (JAK) INHIBITORSBARICITINIB OLUMIANT 4 PATOFACITINIB CITRATE XELJANZ 4 PATOFACITINIB CITRATE XELJANZ XR 4 PA

MINERALOCORTICOIDSfludrocortisone acetate FLORINEF 1

MONOCLONAL ANTIBODY-HUMAN INTERLEUKIN 12/23 INHIBUSTEKINUMAB STELARA 4 PA

NASAL NSAIDS, COX NON-SELECTIVE,SYSTEMIC ANALGESICKETOROLAC TROMETHAMINE SPRIX 3 ST, QL: 5 IN 30 DAYS

NSAID & HISTAMINE H2 RECEPTOR ANTAGONIST COMB.IBUPROFEN/FAMOTIDINE DUEXIS 3 ST, QL: 3 IN 1 DAY

NSAID & TOPICAL IRRITANT COUNTER-IRRITANT COMB.DICLOFENAC SODIUM/CAPSAICIN FLEXIPAK 3DICLOFENAC SODIUM/CAPSAICIN NUDICLO 3DICLOFENAC/CAPSICUM OLEORESIN INFLAMMACIN 3DICLOFENAC/CAPSICUM OLEORESIN XENAFLAMM 3ETODOLAC/CAPSAICIN/ME-SAL/MENT NUDROXIPAK E-400 3IBUPROFEN/CAPSAI/M-SAL/MENTHOL NUDROXIPAK I-800 3

IBUPROFEN/IRR.COUNT-IRRIT.NO.2 COMFORT PAC-IBUPROFEN 3



MELOXICAM/IRRIT.CNTR-IRR CMB 2 COMFORT PAC-MELOXICAM 3

NABUMETONE/CAPSAI/M-SALICY/MEN NUDROXIPAK N-500 3

NAPROXEN/IRRITANT CNTR-IRRIT 2 COMFORT PAC-NAPROXEN 3

NSAID, COX INHIBITOR-TYPE & PROTON PUMP INHIB COMBNAPROXEN/ESOMEPRAZOLE MAG VIMOVO 3 ST

NSAIDS (COX NON-SPECIFIC INHIB)& PROSTAGLANDIN CMBdiclofenac sodium/misoprostol ARTHROTEC 50 1diclofenac sodium/misoprostol ARTHROTEC 75 1

NSAIDS, CYCLOOXYGENASE 2 INHIBITOR - TYPEcelecoxib CELEBREX 1

NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPEdiclofenac potassium CATAFLAM 1DICLOFENAC POTASSIUM ZIPSOR 3 ST, QL: 4 IN 1 DAYdiclofenac sodium VOLTAREN 1diclofenac sodium VOLTAREN-XR 1DICLOFENAC SUBMICRONIZED ZORVOLEX 3 ST, QL: 3 IN 1 DAYetodolac LODINE 1etodolac LODINE XL 1fenoprofen calcium FENORTHO 1fenoprofen calcium NALFON 1flurbiprofen ANSAID 1

ibuprofenMOTRIN (100MG/5ML) (ORALSUSP)

1

ibuprofen MOTRIN (400 MG)(TABLET) 1



indomethacin INDOCIN (25 MG)(CAPSULE) 1

INDOMETHACIN INDOCIN (25 MG/5ML) (ORAL SUSP) 2

indomethacin INDOCIN (50 MG)(CAPSULE) 1

INDOMETHACIN INDOCIN (50 MG)(SUPP.RECT) 3 PA

indomethacin INDOCIN SR 1INDOMETHACIN, SUBMICRONIZED TIVORBEX 3 ST, QL: 3 IN 1 DAYketoprofen 1

ketorolac tromethamine TORADOL (10 MG)(TABLET) 1 QL: 20 IN 5 DAYS

ketorolac tromethamineTORADOL (15MG/ML)(CARTRIDGE)

1

ketorolac tromethamine TORADOL (15MG/ML) (SYRINGE) 3

ketorolac tromethamine TORADOL (15MG/ML) (VIAL) 1

ketorolac tromethamineTORADOL (30MG/ML)(CARTRIDGE)

1

ketorolac tromethamine TORADOL (30MG/ML) (SYRINGE) 3

ketorolac tromethamine TORADOL (30MG/ML) (VIAL) 1



ketorolac tromethamineTORADOL(30MG/ML(1))(VIAL)

1

ketorolac tromethamine TORADOL (60 MG/2ML) (CARTRIDGE) 1

ketorolac tromethamine TORADOL (60 MG/2ML) (SYRINGE) 1

ketorolac tromethamine TORADOL (60 MG/2ML) (VIAL) 1

KETOROLAC/NORFLURANE/HFC 245FA TORONOVA II SUIK 3KETOROLAC/NORFLURANE/HFC 245FA TORONOVA SUIK 3meclofenamate sodium MECLOMEN 1mefenamic acid 1meloxicam MOBIC 1MELOXICAM, SUBMICRONIZED VIVLODEX 3 ST, QL: 1 IN 1 DAYnabumetone RELAFEN 1naproxen EC-NAPROSYN 1naproxen NAPROSYN 1naproxen sodium ANAPROX 1naproxen sodium ANAPROX DS 1

naproxen sodium NAPRELAN (375MG) (TBMP 24HR) 1

naproxen sodium NAPRELAN (500MG) (TBMP 24HR) 1

NAPROXEN SODIUM NAPRELAN (750MG) (TBMP 24HR) 3

oxaprozin DAYPRO 1piroxicam FELDENE 1sulindac CLINORIL 1tolmetin sodium TOLECTIN 1tolmetin sodium TOLECTIN DS 1

NSAIDS,COX-2 SEL.INHIB.(SYST)-TOP.IRRITANT CTR-IRRCELECOXIB/CAPSAICIN/MENTHOL CAPXIB 3CELECOXIB/LIDOCAINE/MENTHOL LIDOXIB 3

PLASMA KALLIKREIN INHIBITORSLANADELUMAB-FLYO TAKHZYRO 4 PA

LOCAL ANESTHESIALOCAL ANESTHETICS

B-CAINE/ZINC CL/PINE/CETYLPYRD BUCALSEP 3bupivacaine hcl/0.9 % nacl/pf 3BUPIVACAINE/PF/NORFLU/HFC245FA MARVONA SUIK 3BUPIVACAINE/PF/NORFLU/HFC245FA P-CARE MG 3lidocaine hcl 1lidocaine hcl/dextrose 7.5%/pf 3lidocaine hcl/pf 3LIDOCAINE/PF/NORFLUR/HFC 245FA ACCUCAINE 3ropivacaine in 0.9% sod chl/pf 3TETRACAINE HCL/OXYMETAZ HCL KOVANAZE 3

LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATBOWEL ANTIINFLAMATORY AGENTS

sulfadiazine 1CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TX

MESALAMINE CANASA 2mesalamine SFROWASA 1mesalamine w/cleansing wipes ROWASA 1

DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLATbalsalazide disodium COLAZAL 1


Drug Name Tier Requirements/LimitsMESALAMINE APRISO 2mesalamine ASACOL HD 1MESALAMINE DELZICOL 3 ST

MESALAMINE LIALDA (1.2 G)(TABLET DR) 1

MESALAMINE PENTASA 2OLSALAZINE SODIUM DIPENTUM 3 STsulfasalazine AZULFIDINE 1

HEMORRHOIDAL PREP, ANTI-INFAM STEROID/LOCAL ANESTHHYDROCORT/PRAMOXN/SKIN CLNSR16 ZYPRAM 3hydrocortisone/lidocaine/aloe ANA-LEX HC 1hydrocortisone/lidocaine/aloe ANAMANTLE HC 1hydrocortisone/lidocaine/aloe RECTAGEL HC 1

hydrocortisone/pramoxineANALPRAM HC (1%-1 %)(CREAM/APPL)

1

hydrocortisone/pramoxineANALPRAM HC (2.5%-1 %)(CREAM/APPL)

1

hydrocortisone/pramoxineANALPRAM HC(2.5-1%(4G))(CREAM/APPL)

3

hydrocortisone/pramoxine PRAMCORT 1HYDROCORTISONE/PRAMOXINE PROCORT 3HYDROCORTISONE/PRAMOXINE PROCTOFOAM-HC 2lidocaine/hydrocortisone ac ANAMANTLE HC 1

lidocaine/hydrocortisone ac ANAMANTLE HCFORTE 1

IBS AGENTS,MIXED OPIOID RECEP AGONISTS/ANTAGONISTSELUXADOLINE VIBERZI 3 PA

IRRITABLE BOWEL AGENTS,GUANYLATE CYLASE-C AGONISTLINACLOTIDE LINZESS 2 QL: 1 IN 1 DAYPLECANATIDE TRULANCE 3 ST, QL: 1 IN 1 DAY

LOCAL ANORECTAL NITRATE PREPARATIONSNITROGLYCERIN RECTIV 3

RECTAL PREPARATIONShydrocortisone acetate ANUSOL-HC 1hydrocortisone acetate HEMMOREX-HC 1hydrocortisone acetate PROCTOCORT 1

RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR)BUDESONIDE UCERIS 3 SThydrocortisone CORTENEMA 1HYDROCORTISONE ACETATE CORTIFOAM 3

LOWER GASTROINTESTINAL DISORDERS - OTHERAMMONIA INHIBITORS

ACETOHYDROXAMIC ACID LITHOSTAT 3CARGLUMIC ACID CARBAGLU 4GLYCEROL PHENYLBUTYRATE RAVICTI 4 PAlactulose CHRONULAC 1sodium phenylbutyrate BUPHENYL 4

ANTIDIARRHEAL - G.I. CHLORIDE CHANNEL INHIBITORSCROFELEMER MYTESI 3 ST, QL: 2 IN 1 DAY

ANTIDIARRHEAL - TRYPTOPHAN HYDROXYLASE INHIBITORTELOTRISTAT ETIPRATE XERMELO 4 PA

ANTIDIARRHEALSDEXTRANOMER/HYALURONATE/NACL SOLESTA 4DIFENOXIN HCL/ATROPINE SULFATE MOTOFEN 3 ST, QL: 8 IN 1 DAY


Drug Name Tier Requirements/Limitsdiphenoxylate hcl/atropine LOMOTIL 1loperamide hcl (2 mg) (capsule) 1opium tincture 1paregoric 1

BILE SALTSCHENODIOL CHENODAL 4 PACHOLIC ACID CHOLBAM 4 PAursodiol ACTIGALL 1ursodiol URSO 1ursodiol URSO FORTE 1

FARNESOID X RECEPTOR (FXR) AGONIST, BILE AC ANALOGOBETICHOLIC ACID OCALIVA 4 PA

IRRITABLE BOWEL SYND. AGENT,5HT-3 ANTAGONIST-TYPEalosetron hcl LOTRONEX 1

LAXATIVES AND CATHARTICS

bisac/nacl/nahco3/kcl/peg 3350 HALFLYTELY-BISACODYL 1 AGE: 50-75 YEARS

lactulose CHRONULAC 1LACTULOSE KRISTALOSE 2LUBIPROSTONE AMITIZA 3 ST, QL: 2 IN 1 DAYPEG 3350/SOD CHLOR/POTASS CIT GIALAX 3PEG3350/SOD SUL/NACL/KCL/ASB/C MOVIPREP 3 AGE: 50-75 YEARSPEG3350/SOD SUL/NACL/KCL/ASB/C PLENVU 3 AGE: 50-75 YEARS

peg3350/sod sulf,bicarb,cl/kcl COLYTE WITHFLAVOR PACKETS 1 AGE: 50-75 YEARS

PEG3350/SOD SULF,BICARB,CL/KCL GOLYTELY (227.1-21.5) (POWD PACK) 2 AGE: 50-75 YEARS

peg3350/sod sulf,bicarb,cl/kclGOLYTELY (236-22.74G) (SOLNRECON)

1 AGE: 50-75 YEARS

polyethylene glycol 3350 MIRALAX 1SOD PHOSPHATE MBAS/SOD PHOS,DI OSMOPREP 3 AGE: 50-75 YEARSSOD PICOSULF/MAG OX/CITRIC AC CLENPIQ 2 AGE: 50-75 YEARSSOD PICOSULF/MAG OX/CITRIC AC PREPOPIK 2 AGE: 50-75 YEARS

sodium chloride/nahco3/kcl/peg NULYTELY WITHFLAVOR PACKS 1 AGE: 50-75 YEARS

SODIUM, POTASSIUM,MAG SULFATES SUPREP 2 AGE: 50-75 YEARSNARCOTIC ANTAGONISTS, PERIPHERALLY-ACTING

ALVIMOPAN ENTEREG 3

METHYLNALTREXONE BROMIDERELISTOR(12MG/0.6ML)(SYRINGE)

3 PA, QL: 0.6mL IN 1 DAY

METHYLNALTREXONE BROMIDERELISTOR(12MG/0.6ML)(VIAL)


METHYLNALTREXONE BROMIDE RELISTOR (150 MG)(TABLET) 3 PA, QL: 3 IN 1 DAY

METHYLNALTREXONE BROMIDERELISTOR (8MG/0.4ML)(SYRINGE)


NALDEMEDINE TOSYLATE SYMPROIC 3 ST, QL: 1 IN 1 DAYNALOXEGOL OXALATE MOVANTIK 2 QL: 1 IN 1 DAY

SBS - GLUCAGON-LIKE PEPTIDE-2 (GLP-2) ANALOGSTEDUGLUTIDE GATTEX 4 PA

MEDICAL SUPPLIESBANDAGES AND RELATED SUPPLIES

BISMUTH TRIBROMOPH/PETROLATUM XEROFORM 3



BISMUTH TRIBROMOPH/PETROLATUMXEROFORMPETROLATUMDRESSING

3

COLLAGEN/SOD ALGIN/CARBOXYMETH BIOSTEP 3DRESS,COLLAGN/SILV/ALGINAT/CMC BIOSTEP AG 3FOAM BANDAGE ALLEVYN 3

FOAM BANDAGE ALLEVYNADHESIVE 3

FOAM BANDAGE ALLEVYN HEEL 3FOAM BANDAGE ALLEVYN LIFE 3FOAM/GAUZE/LIDOCA/CHLHX/ISOPRO VACUSTIM BLACK 3GAUZE BANDAGE CURITY AMD 3

GEL DRESSINGCARRASYNHYDROGELWOUND

3

GEL DRESSING CURAFIL 3GEL DRESSING KERAGEL 3GEL DRESSING KERAGELT 3GEL DRESSING SPECTRAGEL 3GEL-MATRIX PAD DRESS, SILICONE CICATRACE PAD 3GEL-MATRIX PAD DRESS, SILICONE SCARCINPAD 3GEL-MATRIX PAD DRESS, SILICONE SILIVEX 3GEL-MATRIX PAD DRESS, SILICONE SIL-K 3HYDROCOLLOID DRESSING REPLICARE 3HYDROCOLLOID DRESSING REPLICARE THIN 3HYDROCOLLOID DRESSING REPLICARE ULTRA 3

HYDROCOLLOID DRESSING REPLICARE ULTRASACRUM 3

IODOFORM CURITYIODOFORM 3

METH BLUE/GEN VIOLET/FOAM BAND HYDROFERA BLUEREADY 3

POLYHEXAM BIGUAN/GAUZE BANDAGE CURITY AMD 3POLYHEXAM BIGUAN/GAUZE BANDAGE KERLIX AMD 3

POLYHEXAM BIGUAN/GAUZE BANDAGE KERLIX AMDBANDAGE 3

PORCINE ACELL SUBMUCOSA,MESHED OASIS ULTRA 3PORCINE SUBMUCOSA, FENESTRATED OASIS ULTRA 3PORCINE SUBMUCOSA, FENESTRATED WOUND MATRIX 3PVA/GENTIAN VIOLET/METHYL BLUE HYDROFERA BLUE 3SILV/BANDG/LIDOCA/CHLORHEX/ALC VACUSTIM SILVER 3SILVER ACTICOAT 3SILVER ACTICOAT 7 3SILVER ACTICOAT FLEX 3 3SILVER ACTICOAT FLEX 7 3SILVER SULFADIAZ/FOAM BANDAGE ALLEVYN AG 3

SILVER SULFADIAZ/FOAM BANDAGE ALLEVYN AGADHESIVE 3

SILVER SULFADIAZ/FOAM BANDAGE ALLEVYN AGGENTLE 3

SILVER SULFATE/FOAM BANDAGE RESTORE 3

SILVER SULFATE/NON-ADH BANDAGE RESTORE CONTACTLAYER SILVER 3

SILVER/CALCIUM ALGINATE RESTORE 3

SILVER/CALCIUM ALGINATE RESTORE CALCIUMALGINATE 3

SILVER/FOAM BANDAGE ACTICOATSURGICAL 3


Drug Name Tier Requirements/LimitsCATHETERS AND RELATED DEVICES

CATHETER ADVANCE PLUSINTERMITTENT 3

CATHETER APOGEE HCINTERMITTENT 3

CATHETERAPOGEE ICINTERMITTENTCATHETR

3

CATHETER DOVER LATEXFOLEY CATHETER 3

CATHETERDOVER REDRUBBER ROBIBSONCATH

3

CATHETER FEMALE SELFCATHETER 3

CATHETER KENGUARD 3

CATHETERMAGIC3INTERMITTENTCATHETER

3

CATHETER ROBINSON CLEARVINYL CATHETER 3

CATHETER SPEEDICATH 3CATHETER TOUCH-TROL 3

CATHETERIZATION TRAY DOVERUNIVERSAL 3

CATHETERIZATION TRAY KENGUARD 3DRAINAGE BAG CURITY 3

DRAINAGE BAG DOVERADVANTAGE 3

DRAINAGE BAGDOVERADVANTAGEDRAINAGE

3

DRAINAGE BAG DOVER PREMIUM 3DRAINAGE BAG MONO-FLO 3

URINARY BAG/CATH TRAY DOVER COATEDLATEX FOLEY 3

URINARY BAG/CATHETER ADVANCE PLUSINTERMITTENT 3

URINARY BAG/CATHETERVAPRO PLUSINTERMITTCATHETER

3

DURABLE MEDICAL EQUIPMENT,MISC

MEDICAL SUPPLY, MISCELLANEOUS AMIELLE VAGINALTRAINER 3

MEDICAL SUPPLY, MISCELLANEOUS ARGYLE 3

MEDICAL SUPPLY, MISCELLANEOUS JETCO-SPRAYCANNULA 3

MEDICAL SUPPLY, MISCELLANEOUS PRO-CEPTIONFERTILITY PAK 3

MEDICAL SUPPLY, MISCELLANEOUS RECONSTITUBE 3

MEDICAL SUPPLY, MISCELLANEOUS T.E.D. SEQUNTCOMPRESS DEVICE 3

NEBULIZER ACCESSORIES AERONEB GO 3NEBULIZER ACCESSORIES AIR FILTER 3NEBULIZER ACCESSORIES ALL FLOW 1000 3NEBULIZER ACCESSORIES ALL FLOW 3000 KIT 3NEBULIZER ACCESSORIES ALL FLOW 3000 PFT 3NEBULIZER ACCESSORIES ALL FLOW 4000 3NEBULIZER ACCESSORIES ALL FLOW 5000 3


Drug Name Tier Requirements/LimitsNEBULIZER ACCESSORIES ALL FLOW 6000 3

NEBULIZER ACCESSORIES BABYCONVERSION KIT 3

NEBULIZER ACCESSORIESBABYCONVERSION PACK1

3

NEBULIZER ACCESSORIESBABYCONVERSION PACK2

3

NEBULIZER ACCESSORIESERAPIDNEBULIZERHANDSET

3

NEBULIZER ACCESSORIES FILTER PAD 3

NEBULIZER ACCESSORIES FILTER, VALVE SETFOR LL & LC 3

NEBULIZER ACCESSORIESINNOSPIREREPLACEMENTFILTER

3

NEBULIZER ACCESSORIES INSPIRATION ELITEFILTER 3

NEBULIZER ACCESSORIES MASK SET WITH Y-PIECE 3

NEBULIZER ACCESSORIES MOUTHPIECE 3NEBULIZER ACCESSORIES NOSE CLIP 3

NEBULIZER ACCESSORIES PARI LC PLUSNEBULIZER 3

NEBULIZER ACCESSORIES PILLOW MASK FORCHILDREN 3

NEBULIZER ACCESSORIES REUSABLENEBULIZER KIT 3

NEBULIZER ACCESSORIES RUBBERMOUTHPIECE 3

NEBULIZER ACCESSORIES SAMI THE SEALMASK 3

NEBULIZER ACCESSORIES SIDESTREAMMASK 3

NEBULIZER ACCESSORIES SILICONE MASK 3NEBULIZER ACCESSORIES SMARTMASK KIDS 3

NEBULIZER ACCESSORIES TREK S PORTABLEPWR KIT 3

TENS UNIT TENS 502 3TENS UNIT TENS 504 3

TENS UNIT ELECTRODES PRO COMFORTTENS ELECTRODE 3

TENS UNITS AND TENS ELECTRODES CEFALY 3

TENS UNITS AND TENS ELECTRODES PRO COMFORTTENS UNIT 3

DURABLE MEDICAL EQUIPMENT,MISC(GROUP 1)

BLADE LANCET, SAFETYASSUREHAEMOLANCEPLUS

6

BLADE LANCET, SAFETY MEDLANCE PLUSSPECIAL BLADE 6

BLADE LANCET, SAFETY MICROTAINERLANCETS 6

LANCETS 1ST TIER UNILETCOMFORTOUCH 6

LANCETS ACCU-CHEK 6



LANCETSACCU-CHEKFASTCLIX LANCETDRUM

6

LANCETS ACCU-CHEK SAFE-T-PRO 6

LANCETS ACCU-CHEK SAFE-T-PRO PLUS 6

LANCETS ACCU-CHEKSOFTCLIX 6

LANCETS ACTI-LANCE 6

LANCETS ADVANCEDTRAVEL LANCETS 6

LANCETS ADVOCATELANCET 6

LANCETS ADVOCATELANCETS 6

LANCETS ALTERNATE SITELANCETS 6

LANCETSASSUREHAEMOLANCEPLUS

6

LANCETS ASSURE LANCE 6

LANCETS ASSURE LANCEPLUS 6

LANCETS BD MICROTAINERLANCETS 6

LANCETS BD ULTRA-FINE 6LANCETS BD ULTRA-FINE II 6LANCETS BLOOD LANCETS 6

LANCETS BULLSEYE MINISAFETY LANCETS 6

LANCETS CAREONE 6LANCETS CARESENS 6

LANCETS CARETOUCHTWIST LANCET 6

LANCETS CLEVER CHEKLANCETS 6

LANCETS COAGUCHEK 6LANCETS COLOR LANCETS 6LANCETS COMFORT EZ 6

LANCETS COMFORTLANCETS 6

LANCETS DROPLET LANCETS 6LANCETS EASY COMFORT 6LANCETS EASY TOUCH 6

LANCETS EASY TOUCHLANCETS 6

LANCETS EASY TWIST & CAPLANCETS 6

LANCETS EMBRACE 6LANCETS E-Z JECT LANCETS 6

LANCETS EZ SMARTLANCETS 6

LANCETS E-ZJECT LANCETS 6

LANCETS FIFTY50 SAFETYSEAL LANCETS 6

LANCETSFINE 30UNIVERSALLANCETS

6

LANCETS FINGERSTIX 6


Drug Name Tier Requirements/LimitsLANCETS FORA LANCETS 6

LANCETS FORACARELANCETS 6

LANCETS FREESTYLELANCETS 6

LANCETS FREESTYLEUNISTIK 2 6

LANCETS GLUCOCOM 6

LANCETS GLUCOCOMLANCETS 6

LANCETSHEALTHYACCENTS UNILETLANCET

6

LANCETS INCONTROL SUPERTHIN LANCETS 6

LANCETS INCONTROL ULTRATHIN LANCETS 6

LANCETS INJECT EASELANCETS 6

LANCETS INVACARELANCETS 6

LANCETS 6LANCETS THIN 6LANCETS ULTRA THIN 6LANCETS LITE TOUCH 6

LANCETS MEDISENSE THINLANCETS 6

LANCETS MEDLANCE PLUS 6

LANCETS MICRO THINLANCETS 6

LANCETS MICROLET 6

LANCETS MONOLETLANCETS 6

LANCETS MONOLET THINLANCETS 6

LANCETS MYGLUCOHEALTHLANCETS 6

LANCETS NOVA SAFETYLANCETS 6

LANCETS NOVA SUREFLEX 6LANCETS ON CALL LANCET 6

LANCETS ON CALL PLUSLANCET 6

LANCETS ONETOUCHDELICA 6

LANCETS ONETOUCHLANCETS 6

LANCETS ONETOUCHSURESOFT 6

LANCETS ON-THE-GO 6

LANCETSPRESSUREACTIVATEDLANCETS

6

LANCETS PRO COMFORTLANCET 6

LANCETS PRO COMFORTLANCETS 6

LANCETS PRODIGY LANCETS 6

LANCETS PRODIGY TWISTTOP LANCET 6



LANCETS PUSH BUTTONSAFETY LANCETS 6

LANCETS READYLANCESAFETY LANCETS 6

LANCETS RELIAMED 6

LANCETS RELIAMED SAFETYSEAL LANCETS 6

LANCETS RELION THIN 6

LANCETS RIGHTEST GL300LANCETS 6

LANCETS SAFETY LANCETS 6

LANCETS SAFETY SEALLANCETS 6

LANCETS SAFETY-LET 6LANCETS SINGLE-LET 6LANCETS SMART SENSE 6

LANCETS SMART SENSELANCETS 6

LANCETS SMARTESTLANCET 6

LANCETS SOFT TOUCH 6LANCETS SOLUS V2 6

LANCETS SOLUS V2LANCETS 6

LANCETS STERILANCE TL 6

LANCETS SUPER THINLANCETS 6

LANCETS SURE COMFORTLANCETS 6

LANCETS SURE-LANCE 6LANCETS SURE-TOUCH 6

LANCETS TECHLITELANCETS 6

LANCETS TELCARE 6LANCETS THIN LANCETS 6

LANCETSTOPCAREUNIVERSAL1LANCET

6

LANCETSTOPCAREUNIVERSAL1 THINLANCET

6

LANCETS TRUEPLUSLANCETS 6

LANCETS TWIST LANCETS 6LANCETS ULTILET BASIC 6LANCETS ULTILET CLASSIC 6LANCETS ULTILET LANCETS 6LANCETS ULTILET SAFETY 6

LANCETS ULTRA FINELANCETS 6

LANCETS ULTRA THINLANCETS 6

LANCETS ULTRA THIN PLUS 6

LANCETS ULTRA THIN PLUSLANCETS 6

LANCETS ULTRA-CARELANCETS 6

LANCETS ULTRALANCE 6LANCETS ULTRA-THIN II 6



LANCETS ULTRATLCLANCETS 6

LANCETS UNILETCOMFORTOUCH 6

LANCETS UNILET EXCELITE 6

LANCETS UNILET EXCELITEII 6

LANCETS UNILET GPLANCET 6

LANCETS UNILET LANCET 6LANCETS UNILET LANCETS 6LANCETS UNISTIK 3 6LANCETS UNISTIK 3 EXTRA 6LANCETS UNISTIK CZT 6LANCETS UNISTIK PRO 6LANCETS UNISTIK SAFETY 6LANCETS UNISTIK TOUCH 6LANCETS UNIVERSAL 1 6

FEEDING DEVICESENTERAL PUMP ACCESS.HYDROLYSIS RELIZORB 3

FEEDER CONT, GRAVITY SET,ENFIT ENTERAL GRAVITYBAG SET-ENFIT 3

FEEDER CONTAINER ARGYLE 3

FEEDER CONTAINER W-GRAVITY SET KANGAROOGRAVITY SET 3

FEEDER CONTAINER WITH PUMP SET KANGAROO EPUMPSET 3

GASTROSTOMY TUBE, ENFIT COMPAT ENFITGASTROTUBE 3

PUMP SET KANGAROO 924SAFETY SCREW 3

INCONTINENCE SUPPLIES

FECAL COLL W-CHARCOAL/CATH/SYR FLEXI-SEALSIGNAL FMS 3

MEDICAL SUPPLIES,MISCELLANEOUS

TRANSFER SET/SYRINGE/BAND/TUBEVARITHENAADMINISTRATIONPACK

3

MEDICAL SUPPLIES,MISCELLANEOUS(GROUP 2)MIDDLE EAR INFLATION DEVICE EAR POPPER 3TOPICAL CREAM METERED-DOSE DEV PCCA ACCUPEN-15 3

MEDICAL SUPPLIES,MISCELLANEOUS(GROUP 3)INFUSION SET FOR INSULIN PUMP COMFORT 3INFUSION SET FOR INSULIN PUMP COMFORT SHORT 3INFUSION SET FOR INSULIN PUMP INFUSION SET 3

INFUSION SET FOR INSULIN PUMP QUICK RELEASESOFT TEFLON 3

INFUSION SET FOR INSULIN PUMP SILHOUETTE 3INFUSION SET FOR INSULIN PUMP SOF-SET 3INFUSION SET FOR INSULIN PUMP SOF-SET MICRO 3MYELOGRAM TRAY 3

PARENTERAL ADMINISTRATION SETS

ASSEMBLY SYS,VIAL TO TRNSF,CLSPHASEALASSEMBLYFIXTURE

3

CLAMP, IV TUBING PHASEALINFUSION 3



CONNECTOR LUER LOCK,CLOSD SYST PHASEALCONNECTOR LUER 3

INFUSION ADAPTER, CLOSED SYSTM PHASEALADAPTER 3

INJECTION PORTS I-PORT 3INJECTION PORTS I-PORT ADVANCE 3

INTRAVENOUS ADMINISTRATION SET RATE FLOWREGULATOR IV SET 3

INTRAVENOUS CATHETER INSYTEAUTOGUARD 3

INTRAVENOUS CATHETER INSYTE IVCATHETER 3

INTRAVENOUS CATHETER NEXIVA 3

INTRAVENOUS CATHETER KIT SAF-T-INTIMA IVCATHETER 3

INTRAVENOUS EQUIPMENT MONOJECT LUERADAPTER 3

INTRAVENOUS EXTEN.SET-FILTER FILTEREDEXTENSION SET 3

INTRAVENOUS EXTENSION SET MICROBOREEXTENSION SET 3

INTRAVENOUS PIGGYBACK SET PHASEALSECONDARY SET 3

NEEDLE INJECTOR,LUER,CLOSD SYS PHASEALINJECTOR LUER 3

NEEDLE INJECTR,LUER LOCK,CLOSD PHASEALINJECTOR LUER 3

SUBCUTANEOUS ADMIN. SET ACCU-CHEK RAPIDD 3

SUBCUTANEOUS ADMIN. SET INSUFLON 3SUB-Q INFUSION PUMP ACCESSORY ACCU-CHEK 3SUB-Q INFUSION PUMP ACCESSORY ACCU-CHEK SPIRIT 3SUB-Q INFUSION PUMP ACCESSORY INSET 30 TUBING 3

SUB-Q INFUSION PUMP ACCESSORY PARADIGMINFUSION 3

SUB-Q INFUSION PUMP ACCESSORY PARADIGMSILHOUETTE 3

SUB-Q INFUSION PUMP ACCESSORY POLYFIN QR 3SUB-Q INFUSION PUMP ACCESSORY SILHOUETTE 3SUB-Q INFUSION PUMP ACCESSORY SURE-T 3

TRANSFER SETSHI-VOLUMEPUMPINGCHAMBER

3

Y-SITE CONNECTOR, CLOSED SYSTM PHASEAL Y-SITE 3SYRINGES AND ACCESSORIES

ALCOHOL SWAB CAP KENDALLDISINFECTANT CAP 3

INSULIN PUMP SYRINGE, 1.8 ML MINIMEDRESERVOIR 1

INSULIN PUMP SYRINGE, 1.8 ML PARADIGM 1

INSULIN PUMP SYRINGE, 3 ML MINIMEDRESERVOIR 1

INSULIN PUMP SYRINGE, 3 ML PARADIGM 1

SYR,NDL 0.3 ML,INS,SAFE,D.UNIT SAFESNAP INSULINSYRINGE 1

SYR,NDL 1 ML,INS,SAFE,DISP UNT SAFESNAP INSULINSYRINGE 1

SYR,NDL,INS,SAFE 0.5ML,DISP UN SAFESNAP INSULINSYRINGE 1

SYRGE-NDL,INS 0.3 ML HALF MARK INSULIN SYRINGE 1



SYRGE-NDL,INS 0.3 ML HALF MARK TECHLITE INSULINSYRINGE 1

SYRGE-NDL,INS 0.3 ML HALF MARK ULTICARE INSULINSYRINGE 1

SYRGE-NDL,INS 0.3 ML HALF MARK ULTRA COMFORT 1

SYRGE-NDL,INS 0.3 ML HALF MARK VEO INSULINSYRINGE 1

SYRGE-NDL,INS 0.5 ML HALF MARK TECHLITE INSULINSYRINGE 1

SYRING W-NEEDL 0.5 ML,KIT-TRAY ALLERGIST TRAY 1

SYRING W-NEEDL 0.5 ML,KIT-TRAY ALLERGIST TRAYSYR-PERM NEEDLE 1

SYRINGE 3 ML,SAFETY,DISP UNIT

SAFESNAPSYRINGE (20GX11/2") (DISP SYRIN)(OTC)

1

SYRINGE 3 ML,SAFETY,DISP UNITSAFESNAPSYRINGE (20GX1")(DISP SYRIN) (OTC)

1


SAFESNAPSYRINGE (21 G X1") (DISP SYRIN)(OTC)

1



1



1


1



1


1


1


SAFESNAPSYRINGE(25GX5/8") (DISPSYRIN) (OTC)

1

SYRINGE ACCESSORY LEVER LOCKCANNULA 3

SYRINGE AND NEEDLE,INSULIN,1ML ADVOCATESYRINGES 1

SYRINGE AND NEEDLE,INSULIN,1ML CARETOUCHINSULIN SYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML COMFORT EZ 1

SYRINGE AND NEEDLE,INSULIN,1ML EASY COMFORTINSULIN SYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML EASY TOUCH 1

SYRINGE AND NEEDLE,INSULIN,1ML EASY TOUCHINSULIN SYRINGE 1



SYRINGE AND NEEDLE,INSULIN,1ML EASY-TOUCHINSULIN SYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML ECLIPSE SYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML FREESTYLEPRECISION 1

SYRINGE AND NEEDLE,INSULIN,1ML INSULIN SYRINGE 1SYRINGE AND NEEDLE,INSULIN,1ML LITE TOUCH 1

SYRINGE AND NEEDLE,INSULIN,1ML LITETOUCHINSULIN SYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML MAXI-COMFORT 1

SYRINGE AND NEEDLE,INSULIN,1ML MONOJECTINSULIN SYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML PRO COMFORTINSULIN SYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML PRODIGY INSULINSYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML SAFETYGLIDEINSULIN SYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML SAFETYGLIDESYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML SURE COMFORT 1

SYRINGE AND NEEDLE,INSULIN,1ML SURE COMFORTINSULIN SYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML SURE-JECTINSULIN SYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML TECHLITE INSULINSYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML TERUMO INSULINSYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML THINPRO INSULINSYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML TOPCARE ULTRACOMFORT 1

SYRINGE AND NEEDLE,INSULIN,1ML TRUEPLUS INSULINSYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML ULTICARE 1

SYRINGE AND NEEDLE,INSULIN,1ML ULTICARE INSULINSYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML ULTILET INSULINSYRINGE 1

SYRINGE AND NEEDLE,INSULIN,1ML ULTRA COMFORT 1SYRINGE AND NEEDLE,INSULIN,1ML ULTRA-THIN II 1SYRINGE AND NEEDLE,INSULIN,1ML VANISHPOINT 1

SYRINGE AND NEEDLE,INSULIN,1ML VEO INSULINSYRINGE 1

SYRINGE DISPOSABLE IRRIG,70 ML TOOMEY SYRINGE 1

SYRINGE DISPOSABLE IRRIGATION DAVOL IRRIGATIONSYRINGE 1

SYRINGE DISPOSABLE IRRIGATION IRRIGATIONSYRINGE 1

SYRINGE WITH CANNULA, 10 ML INTERLINKSYRINGE 1

SYRINGE WITH CANNULA, 10 MLINTERLINKSYRINGE W-CANNULA

1

SYRINGE WITH CANNULA, 3 ML SYRINGE 1

SYRINGE WITH CANNULA, 5 ML INTERLINKSYRINGE 1



SYRINGE WITH CANNULA, 6 MLMONOJECTSMARTIPCANNULA

1

SYRINGE WITH CANNULA,DISP.12MLMONOJECTSMARTIPCANNULA

1

SYRINGE WITH NEEDLE, 0.5 ML ALLERGIST TRAY 1

SYRINGE WITH NEEDLE, 0.5 ML MONOJECT TBSYRINGE 1

SYRINGE WITH NEEDLE, 0.5 ML TUBERCULINSYRINGE 1

SYRINGE WITH NEEDLE, 1 ML ALLERGIST TRAY 1

SYRINGE WITH NEEDLE, 1 MLALLERGY SYRINGE(27GX1/2") (DISPSYRIN) (OTC)

1

SYRINGE WITH NEEDLE, 1 MLALLERGY SYRINGE(28GX1/2") (DISPSYRIN) (OTC)

1

SYRINGE WITH NEEDLE, 1 ML EASY TOUCH 1

SYRINGE WITH NEEDLE, 1 ML EASY TOUCHFLURINGE 1

SYRINGE WITH NEEDLE, 1 ML ECLIPSE LUER-LOKSYRINGE 1

SYRINGE WITH NEEDLE, 1 ML ECLIPSE SYRINGE-NEEDLE 1

SYRINGE WITH NEEDLE, 1 ML EXEL TB WITHNEEDLE 1

SYRINGE WITH NEEDLE, 1 ML LUER-LOKSYRINGE-NEEDLE 1

SYRINGE WITH NEEDLE, 1 ML MONOJECT TB 1

SYRINGE WITH NEEDLE, 1 ML MONOJECT TBSYRINGE 1

SYRINGE WITH NEEDLE, 1 ML SAFETYGLIDEALLERGY 1

SYRINGE WITH NEEDLE, 1 ML SAFETYGLIDEALLERGY SYRINGE 1

SYRINGE WITH NEEDLE, 1 ML SAFETYGLIDESYRINGE 1

SYRINGE WITH NEEDLE, 1 ML SAFETYGLIDE TBSYRINGE 1

SYRINGE WITH NEEDLE, 1 ML SYRINGE WITHNEEDLE DISP 1

SYRINGE WITH NEEDLE, 1 MLSYRINGE-PRECISIONGLIDENEEDLE

1

SYRINGE WITH NEEDLE, 1 ML TB SYRINGE 1

SYRINGE WITH NEEDLE, 1 ML TERUMO ALLERGYSYRINGE 1

SYRINGE WITH NEEDLE, 1 ML TUBERCULINSYRINGE 1

SYRINGE WITH NEEDLE, 1 ML TUBERCULINSYRINGE-NEEDLE 1

SYRINGE WITH NEEDLE, 1 ML ULTICARE 1SYRINGE WITH NEEDLE, 1 ML VANISHPOINT 1


SYRINGE WITH NEEDLE, 10 ML SAFETYGLIDESYRINGE 1

SYRINGE WITH NEEDLE, 12 ML MONOJECTSYRINGE 1




SYRINGE WITH NEEDLE, 5 MLTERUMOHYPODERMICNEEDLE-SYRIN

1

SYRINGE WITH NEEDLE, 5 ML VANISHPOINT 1SYRINGE WITH NEEDLE, 6 ML MONOJECT 1

SYRINGE WITH NEEDLE, 6 ML MONOJECTSYRINGE 1

SYRINGE WITH NEEDLE, INSULINMONOJECTINSULIN SAFETYSYRNG

1

SYRINGE WITH NEEDLE,DISPOSABLE MONOJECT 1

SYRINGE W-NEEDLE 1 ML,KIT-TRAY ALLERGIST TRAYSYR-DETACH NDL 1

SYRINGE W-NEEDLE 1 ML,KIT-TRAYMONOJECTALLERGY TRAY-NEEDLE

1

SYRINGE W-NEEDLE,DISPOSAB,3 ML EASY TOUCH 1

SYRINGE W-NEEDLE,DISPOSAB,3 ML ECLIPSE LUER-LOKSYRINGE 1

SYRINGE W-NEEDLE,DISPOSAB,3 ML EXEL SYRINGE 1SYRINGE W-NEEDLE,DISPOSAB,3 ML INTEGRA SYRINGE 1

SYRINGE W-NEEDLE,DISPOSAB,3 ML LUER-LOKSYRINGE-NEEDLE 1

SYRINGE W-NEEDLE,DISPOSAB,3 ML

MONOJECTSYRINGE (20GX11/2") (DISP SYRIN)(OTC)

1

SYRINGE W-NEEDLE,DISPOSAB,3 MLMONOJECTSYRINGE (20GX1")(DISP SYRIN) (OTC)

1


MONOJECTSYRINGE(20GX3/4") (DISPSYRIN) (OTC)

1


MONOJECTSYRINGE (21 G X1") (DISP SYRIN)(OTC)

1



1



1


1


1


1


MONOJECTSYRINGE(25GX5/8") (DISPSYRIN) (OTC)

1




MONOJECTSYRINGE(27GX1.25") (DISPSYRIN) (OTC)

1

SYRINGE W-NEEDLE,DISPOSAB,3 ML PRECISIONGLIDE 1


SAFETYGLIDESYRINGE (22GX11/2") (DISP SYRIN)(OTC)

1


SAFETYGLIDESYRINGE(25GX5/8") (DISPSYRIN) (OTC)

1

SYRINGE W-NEEDLE,DISPOSAB,3 ML TERUMO SYRINGE 1SYRINGE W-NEEDLE,DISPOSAB,3 ML VANISHPOINT 1

SYRINGE, DISPOSABLE SYRINGE WITHOUTNEEDLE 1

SYRINGE, DISPOSABLE, 1 ML BULK SYRINGE 1

SYRINGE, DISPOSABLE, 1 ML CAREPOINT LUERSLIP SYRINGE 1

SYRINGE, DISPOSABLE, 1 ML EASY GLIDE LUERLOCK SYRINGE 1

SYRINGE, DISPOSABLE, 1 ML EASY GLIDE LUERSLIP TB SYRING 1

SYRINGE, DISPOSABLE, 1 ML EASY TOUCH LUERLOCK SYRINGE 1

SYRINGE, DISPOSABLE, 1 ML EXEL TUBERCULINSYRINGE 1

SYRINGE, DISPOSABLE, 1 ML LUERSLIP SYRINGE 1

SYRINGE, DISPOSABLE, 1 ML MONOJECT LUERLOCK TB SYRINGE 1

SYRINGE, DISPOSABLE, 1 ML MONOJECTPHARMACY TRAY 1

SYRINGE, DISPOSABLE, 1 ML MONOJECT TBSYRINGE 1

SYRINGE, DISPOSABLE, 1 MLMONOJECTTUBERCULINSYRINGE

1

SYRINGE, DISPOSABLE, 1 MLNORM-JECTTUBERKULINSYRINGE

1

SYRINGE, DISPOSABLE, 1 ML TUBERCULINSYRINGE 1


SYRINGE, DISPOSABLE, 10 MLEASY GLIDEDENTAL IRRIGSYRING

1



SYRINGE, DISPOSABLE, 10 MLEASY TOUCHSHEATHLOCKSYRINGE

1

SYRINGE, DISPOSABLE, 10 ML EASY TOUCH UNI-SLIP 1

SYRINGE, DISPOSABLE, 10 ML EXEL SYRINGE 1

SYRINGE, DISPOSABLE, 10 ML NORM-JECTSYRINGE 1



SYRINGE, DISPOSABLE, 10 ML SAFETY-LOKSAFETY SYRINGE 1

SYRINGE, DISPOSABLE, 10 ML SYRINGE 1

SYRINGE, DISPOSABLE, 12 ML MONOJECTCONTROL SYRINGE 1

SYRINGE, DISPOSABLE, 12 ML MONOJECTSAFETY SYRINGE 1

SYRINGE, DISPOSABLE, 12 ML MONOJECTSYRINGE 1

SYRINGE, DISPOSABLE, 12 ML SYRINGE WITHOUTNEEDLE 1

SYRINGE, DISPOSABLE, 140 ML MONOJECT 1SYRINGE, DISPOSABLE, 20 ML BULK SYRINGE 1SYRINGE, DISPOSABLE, 20 ML EXEL SYRINGE 1

SYRINGE, DISPOSABLE, 20 ML LUER-LOKSYRINGE 1


SYRINGE, DISPOSABLE, 20 ML NORM-JECTSYRINGE 1

SYRINGE, DISPOSABLE, 20 ML SYRINGE 1SYRINGE, DISPOSABLE, 20 ML SYRINGE BULK 1




SYRINGE, DISPOSABLE, 3 MLEASY TOUCHSHEATHLOCKSYRINGE

1



SYRINGE, DISPOSABLE, 3 ML MONOJECTSAFETY SYRINGE 1


SYRINGE, DISPOSABLE, 3 MLMONOJECTSYRINGEPHARMACY TRAY

1


SYRINGE, DISPOSABLE, 3 ML SYRINGE 1SYRINGE, DISPOSABLE, 30 ML EXEL SYRINGE 1

SYRINGE, DISPOSABLE, 30 ML LUER LOCKSYRINGE 1

SYRINGE, DISPOSABLE, 30 ML LUER-LOK TIPSYRINGE 1

SYRINGE, DISPOSABLE, 30 ML SYRINGE 1SYRINGE, DISPOSABLE, 30 ML TERUMO SYRINGE 1

SYRINGE, DISPOSABLE, 35 ML MONOJECT (DISPSYRIN) (OTC) 1

SYRINGE, DISPOSABLE, 35 ML SYRINGE 1









SYRINGE, DISPOSABLE, 5 ML SYRINGE 1SYRINGE, DISPOSABLE, 50 ML EXEL SYRINGE 1


SYRINGE, DISPOSABLE, 6 MLMONOJECTSYRINGEPHARMACY TRAY

1

SYRINGE, DISPOSABLE, 60 MLEASY GLIDECATHETER TIPSYRING

1


SYRINGE, DISPOSABLE, 60 ML MONOJECT 1


SYRINGE, DISPOSABLE, 60 ML SYRINGE (DISPSYRIN) 1

SYRINGE, DISPOSABLE, 60 ML SYRINGE BULK 1

SYRINGE, DISPOSABLE, 60 ML SYRINGECATHETER TIP 1


SYRINGE, NEEDLE, CANNULA,10 ML TWINPAK DUALCANNULA 1

SYRINGE, SAFETY 3 ML ULTICARE SAFETYSYRINGE 1

SYRINGE,INSUL U-500,NDL,0.5ML INSULIN SYRINGEU-500 1

SYRINGE,INSULIN,NEEDLESS 1 ML EASY TOUCH LUERLOCK INSULIN 1

SYRINGE,INSULIN,NEEDLESS 1 ML EASY TOUCH UNI-SLIP 1

SYRINGE,INSULIN,NEEDLESS 1 ML INSULIN SYRINGE 1

SYRINGE,INSULIN,NEEDLESS 1 ML LUER-LOKSYRINGE 1

SYRINGE,NDLE,SAFE 1.5 ML,D.UNT ULTICARESYRINGE 1

SYRINGE,NEEDLE,INSULN,SAFE,1ML ASSURE IDINSULIN SAFETY 1

SYRINGE,NEEDLE,INSULN,SAFE,1ML EASY TOUCHFLIPLOCK INSULIN 1

SYRINGE,NEEDLE,INSULN,SAFE,1ML EASY TOUCHINSULIN SAFETY 1

SYRINGE,NEEDLE,INSULN,SAFE,1MLEASY TOUCHSHEATHLOCKINSULIN

1

SYRINGE,NEEDLE,INSULN,SAFE,1MLMAGELLANINSULIN SAFETYSYRNG

1

SYRINGE,NEEDLE,INSULN,SAFE,1ML SAFETYGLIDEINSULIN SYRINGE 1

SYRINGE,NEEDLE,INSULN,SF 0.5ML ASSURE IDINSULIN SAFETY 1

SYRINGE,NEEDLE,INSULN,SF 0.5ML EASY TOUCHINSULIN SAFETY 1



SYRINGE,NEEDLE,INSULN,SF 0.5MLMAGELLANINSULIN SAFETYSYRNG

1

SYRINGE,NEEDLE,INSULN,SF 0.5ML MAGELLANINSULIN SYRINGE 1

SYRINGE,NEEDLE,INSULN,SF 0.5ML SAFETYGLIDEINSULIN SYRINGE 1

SYRINGE,NEEDLE,INSULN,SF,0.3MLMAGELLANINSULIN SAFETYSYRNG

1

SYRINGE,NEEDLE,INSULN,SF,0.3ML MAGELLANINSULIN SYRINGE 1

SYRINGE,NEEDLE,INSULN,SF,0.3ML SAFETYGLIDEINSULIN SYRINGE 1

SYRINGE,SAFE 3 ML,DISPOSL UNIT SAFESNAPSYRINGE 1

SYRINGE,SAFE 5 ML,DISPOSL UNIT SAFESNAPSYRINGE 1

SYRINGE,SAFETY 1 ML,DISP UNIT

SAFESNAPALLERGY SYRINGE(27GX1/2") (DISPSYRIN) (OTC)

1


SAFESNAPTUBERCULINSYRINGE(25GX5/8") (DISPSYRIN) (OTC)

1


SAFESNAPTUBERCULINSYRINGE(27GX1/2") (DISPSYRIN) (OTC)

1



1

SYRINGE,SAFETY 10 ML,DISP UNITSAFESNAPSYRINGE (20GX1")(DISP SYRIN) (OTC)

1



1



1



1

SYRINGE,SAFETY 10 ML,DISP UNITSAFESNAPSYRINGE (22GX1")(DISP SYRIN) (OTC)

1

SYRINGE,SAFETY 5 ML, DISP UNIT


1

SYRINGE,SAFETY 5 ML, DISP UNITSAFESNAPSYRINGE (20GX1")(DISP SYRIN) (OTC)

1





1



1



1

SYRINGE,SAFETY 5 ML, DISP UNITSAFESNAPSYRINGE (22GX1")(DISP SYRIN) (OTC)

1

SYRINGE,SAFETY NEEDLE,10 MLEASY TOUCHFLIPLOCKSYRINGE

1

SYRINGE,SAFETY NEEDLE,10 MLEASY TOUCHFLIPLOCKSYRINGES

1

SYRINGE,SAFETY NEEDLE,10 ML

EASY TOUCHSHEATHLOCKSYRG-NDL (22GX11/2") (DISP SYRIN)(OTC)

1

SYRINGE,SAFETY NEEDLE,10 ML

EASY TOUCHSHEATHLOCKSYRG-NDL(25GX1") (DISPSYRIN) (OTC)

1

SYRINGE,SAFETY NEEDLE,10 ML SAFETY-LOKSAFETY SYRINGES 1

SYRINGE,SAFETY NEEDLE,10 ML TERUMOSURGUARD2 1

SYRINGE,SAFETY NEEDLE,10 ML VANISHPOINTSYRINGE 1

SYRINGE,SAFETY NEEDLE,12 ML MONOJECTSAFETY SYRINGE 1

SYRINGE,SAFETY WITH NEEDLE,1MLEASY TOUCHFLIPLOCKSYRINGES

1

SYRINGE,SAFETY WITH NEEDLE,1MLEASY TOUCHFLURINGEFLIPLOCK

1

SYRINGE,SAFETY WITH NEEDLE,1MLEASY TOUCHFLURINGESHEATHLOCK

1

SYRINGE,SAFETY WITH NEEDLE,1MLEASY TOUCHTUBERCULINFLIPLOCK

1

SYRINGE,SAFETY WITH NEEDLE,1MLEASY TOUCHTUBERCULINSHEATHLK

1

SYRINGE,SAFETY WITH NEEDLE,1ML MAGELLANSAFETY SYRINGE 1

SYRINGE,SAFETY WITH NEEDLE,1MLMAGELLANTUBERCULINSYRINGE

1

SYRINGE,SAFETY WITH NEEDLE,1ML MONOJECTMAGELLAN 1



SYRINGE,SAFETY WITH NEEDLE,1MLMONOJECTTUBERCULINSAFETY SYR

1

SYRINGE,SAFETY WITH NEEDLE,1ML SAFETY-LOKSAFETY SYRINGES 1

SYRINGE,SAFETY WITH NEEDLE,1ML SYRINGE-NEEDLE 1

SYRINGE,SAFETY WITH NEEDLE,1ML TERUMOSURGUARD2 1

SYRINGE,SAFETY WITH NEEDLE,1ML ULTICARE TBSAFETY SYRINGE 1

SYRINGE,SAFETY WITH NEEDLE,3MLEASY TOUCHFLIPLOCKSYRINGE

1


1

SYRINGE,SAFETY WITH NEEDLE,3MLEASY TOUCHSHEATHLOCKSYRG-NDL

1

SYRINGE,SAFETY WITH NEEDLE,3ML ECLIPSE LUER-LOKSYRINGE 1

SYRINGE,SAFETY WITH NEEDLE,3ML ECLIPSE SYRINGE 1SYRINGE,SAFETY WITH NEEDLE,3ML INTEGRA SYRINGE 1SYRINGE,SAFETY WITH NEEDLE,3ML MONOJECT 1

SYRINGE,SAFETY WITH NEEDLE,3ML MONOJECTMAGELLAN 1

SYRINGE,SAFETY WITH NEEDLE,3ML SAFETY SYRINGEWITH SHIELD 1

SYRINGE,SAFETY WITH NEEDLE,3ML SAFETY SYRINGE-NEEDLE 1

SYRINGE,SAFETY WITH NEEDLE,3ML SAFETYGLIDESYRINGE 1


SYRINGE,SAFETY WITH NEEDLE,3ML SAFETY-LOKSYRINGES 1


SYRINGE,SAFETY WITH NEEDLE,3ML ULTICARE SAFETYSYRINGE 1

SYRINGE,SAFETY WITH NEEDLE,5MLEASY TOUCHFLIPLOCKSYRINGE

1


1

SYRINGE,SAFETY WITH NEEDLE,5MLEASY TOUCHSHEATHLOCKSYRG-NDL

1

SYRINGE,SAFETY WITH NEEDLE,5ML SAFETYGLIDESYRINGE 1



SYRINGE,SAFETY WITH NEEDLE,5ML VANISHPOINTSYRINGE 1

SYRINGE,SAFETY,10 ML,DISP UNIT SAFESNAPSYRINGE 1



SYRINGE-NEEDLE,INSULIN,0.5 ML ADVOCATESYRINGES 1

SYRINGE-NEEDLE,INSULIN,0.5 ML CARETOUCHINSULIN SYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML COMFORT EZ 1

SYRINGE-NEEDLE,INSULIN,0.5 ML EASY COMFORTINSULIN SYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML EASY TOUCH 1

SYRINGE-NEEDLE,INSULIN,0.5 ML EASY TOUCHINSULIN SYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML FREESTYLEPRECISION 1

SYRINGE-NEEDLE,INSULIN,0.5 ML INSULIN SYRINGE 1SYRINGE-NEEDLE,INSULIN,0.5 ML LITE TOUCH 1

SYRINGE-NEEDLE,INSULIN,0.5 ML LITETOUCHINSULIN SYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML MAXI-COMFORT 1SYRINGE-NEEDLE,INSULIN,0.5 ML MONOJECT 1

SYRINGE-NEEDLE,INSULIN,0.5 ML MONOJECTINSULIN SYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML PRO COMFORTINSULIN SYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML PRODIGY INSULINSYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML SAFETYGLIDEINSULIN SYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML SURE COMFORT 1

SYRINGE-NEEDLE,INSULIN,0.5 ML SURE COMFORTINSULIN SYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML SURE-JECTINSULIN SYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML TERUMO INSULINSYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML THINPRO INSULINSYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML TOPCARE ULTRACOMFORT 1

SYRINGE-NEEDLE,INSULIN,0.5 ML TRUEPLUS INSULINSYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML ULTICARE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML ULTICARE INSULINSYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML ULTILET INSULINSYRINGE 1

SYRINGE-NEEDLE,INSULIN,0.5 ML ULTRA COMFORT 1SYRINGE-NEEDLE,INSULIN,0.5 ML ULTRA-THIN II 1SYRINGE-NEEDLE,INSULIN,0.5 ML VANISHPOINT 1

SYRINGE-NEEDLE,INSULIN,0.5 ML VEO INSULINSYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML ADVOCATESYRINGES 1

SYRING-NEEDL,DISP,INSUL,0.3 ML CARETOUCHINSULIN SYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML COMFORT EZ 1

SYRING-NEEDL,DISP,INSUL,0.3 ML EASY COMFORTINSULIN SYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML EASY TOUCH 1

SYRING-NEEDL,DISP,INSUL,0.3 ML EASY TOUCHINSULIN SYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML INSULIN SYRINGE 1


Drug Name Tier Requirements/LimitsSYRING-NEEDL,DISP,INSUL,0.3 ML LITE TOUCH 1

SYRING-NEEDL,DISP,INSUL,0.3 ML LITETOUCHINSULIN SYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML MONOJECTINSULIN SYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML PRODIGY INSULINSYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML SAFETYGLIDEINSULIN SYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML SURE COMFORT 1

SYRING-NEEDL,DISP,INSUL,0.3 ML SURE COMFORTINSULIN SYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML SURE-JECTINSULIN SYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML TERUMO INSULINSYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML THINPRO INSULINSYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML TOPCARE ULTRACOMFORT 1

SYRING-NEEDL,DISP,INSUL,0.3 ML TRUEPLUS INSULINSYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML ULTICARE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML ULTICARE INSULINSYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML ULTILET INSULINSYRINGE 1

SYRING-NEEDL,DISP,INSUL,0.3 ML ULTRA COMFORT 1SYRING-NEEDL,DISP,INSUL,0.3 ML ULTRA-THIN II 1

SYRING-NEEDL,DISP,INSUL,0.3 ML VEO INSULINSYRINGE 1

MISCELLANEOUS AGENTSANAPHYLAXIS THERAPY AGENTS

EPINEPHRINE AUVI-Q 3 QL: 2 IN 365 DAYSepinephrine 1 QL: 4 PER FILLEPINEPHRINE EPIPEN 2 QL: 4 PER FILLEPINEPHRINE EPIPEN 2-PAK 2 QL: 4 PER FILLEPINEPHRINE EPIPEN JR 2 QL: 4 PER FILLEPINEPHRINE EPIPEN JR 2-PAK 2 QL: 4 PER FILL

GENETIC D/O TX-EXON INCLUSION ANTISENSE OLIGONUCLENUSINERSEN SODIUM/PF SPINRAZA 4

MISCELLANEOUS AGENTSLIVER EXTRACT (BEEF-PORK) NEXAVIR 3

PARASYMPATHETIC AGENTSbethanechol chloride URECHOLINE 1cevimeline hcl EVOXAC 1guanidine hcl GUANIDINE 1pilocarpine hcl SALAGEN 1

PHARMACOLOGICAL CHAPERONE-ALPHA-GALACTOSID.A STABZMIGALASTAT HCL GALAFOLD 4 PA

PKU TREATMENT AGENTS - PHENYLALANINE AMMONIA LYASEPEGVALIASE-PQPZ PALYNZIQ 4 PA

PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASESAPROPTERIN DIHYDROCHLORIDE KUVAN 4 PA

SYSTEMIC ENZYME INHIBITORSALPHA-1-PROTEINASE INHIBITOR ARALAST NP 4ALPHA-1-PROTEINASE INHIBITOR PROLASTIN C 4


Drug Name Tier Requirements/LimitsALPHA-1-PROTEINASE INHIBITOR ZEMAIRA 4

TOPICAL ANTICHOLINERGIC HYPERHIDROSIS TX AGENTSGLYCOPYRRONIUM TOSYLATE QBREXZA 3

NEOPLASTIC DISEASEALKYLATING AGENTS

ALTRETAMINE HEXALEN 4BUSULFAN MYLERAN 4CARMUSTINE IN POLIFEPROSAN 20 GLIADEL 4CHLORAMBUCIL LEUKERAN 4cyclophosphamide 4hydroxyurea HYDREA 1LOMUSTINE GLEOSTINE 4 PAmelphalan ALKERAN 1temozolomide TEMODAR 4 PA

ANTIANDROGENIC AGENTSABIRATERONE ACET,SUBMICRONIZED YONSA 4 PA, QL: 4 IN 1 DAY

ABIRATERONE ACETATE ZYTIGA (250 MG)(TABLET) 4 PA, QL: 3 IN 1 DAY

ABIRATERONE ACETATE ZYTIGA (500 MG)(TABLET) 4 PA, QL: 2 IN 1 DAY

APALUTAMIDE ERLEADA 4 PA, QL: 4 IN 1 DAYbicalutamide CASODEX 1ENZALUTAMIDE XTANDI 4 PA, QL: 4 IN 1 DAYflutamide EULEXIN 1nilutamide NILANDRON 4 QL: 2 IN 1 DAY

ANTIMETABOLITES

capecitabine XELODA (150 MG)(TABLET) 1 PA, QL: 28 IN 21 DAYS

capecitabine XELODA (500 MG)(TABLET) 1 PA, QL: 112 IN 21 DAYS

mercaptopurine PURINETHOL 1MERCAPTOPURINE PURIXAN 4 ST

METHOTREXATE XATMEP 4 ST, AGE: < 12 YEARS, QL: 120mLIN 60 DAYS

methotrexate sodium FOLEX 1

METHOTREXATE SODIUM TREXALL (10 MG)(TABLET) 2


methotrexate sodium TREXALL (2.5 MG)(TABLET) 1


METHOTREXATE SODIUM TREXALL (7.5 MG)(TABLET) 2

methotrexate sodium/pf FOLEX 1THIOGUANINE TABLOID 4TRIFLURIDINE/TIPIRACIL HCL LONSURF 4 PA

ANTINEOPLASTIC AROMATASE INHIBITORSanastrozole ARIMIDEX 1exemestane AROMASIN 1letrozole FEMARA 1

ANTINEOPLASTIC - BRAF KINASE INHIBITORSDABRAFENIB MESYLATE TAFINLAR 4 PAENCORAFENIB BRAFTOVI 4 PA, QL: 6 IN 1 DAYVEMURAFENIB ZELBORAF 4 PA, QL: 8 IN 1 DAY


Drug Name Tier Requirements/LimitsANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR

SONIDEGIB PHOSPHATE ODOMZO 4 PAVISMODEGIB ERIVEDGE 4 PA, QL: 1 IN 1 DAY

ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORSRUXOLITINIB PHOSPHATE JAKAFI 4 PA, QL: 2 IN 1 DAY

ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORSBINIMETINIB MEKTOVI 4 PA, QL: 6 IN 1 DAYCOBIMETINIB FUMARATE COTELLIC 4 PA, QL: 63 IN 28 DAYSTRAMETINIB DIMETHYL SULFOXIDE MEKINIST 4 PA

ANTINEOPLASTIC - MTOR KINASE INHIBITORSEVEROLIMUS AFINITOR 4 PAEVEROLIMUS AFINITOR DISPERZ 4 PA

ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORSTOPOTECAN HCL HYCAMTIN 4

ANTINEOPLASTIC COMB - KINASE AND AROMATASE INHIBIT

RIBOCICLIB SUCCINATE/LETROZOLE KISQALI FEMARACO-PACK 4 PA

ANTINEOPLASTIC IMMUNOMODULATOR AGENTSLENALIDOMIDE REVLIMID 4 PA, QL: 1 IN 1 DAYPEGINTERFERON ALFA-2B SYLATRON 2POMALIDOMIDE POMALYST 4 PA

ANTINEOPLASTIC LHRH(GNRH) ANTAGONIST,PITUIT.SUPPRS

DEGARELIX ACETATE FIRMAGON (120MG) (VIAL) 4 QL: 2 IN 365 DAYS

DEGARELIX ACETATE FIRMAGON (80 MG)(VIAL) 4 QL: 1 IN 30 DAYS

ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORSABEMACICLIB VERZENIO 4 PA, QL: 2 IN 1 DAYACALABRUTINIB CALQUENCE 4 PAAFATINIB DIMALEATE GILOTRIF 4 PAALECTINIB HCL ALECENSA 4 PA, QL: 8 IN 1 DAY

AXITINIB INLYTA (1 MG)(TABLET) 4 PA, QL: 6 IN 1 DAY

AXITINIB INLYTA (5 MG)(TABLET) 4 PA, QL: 4 IN 1 DAY

BOSUTINIB BOSULIF (100 MG)(TABLET) 4 PA, QL: 3 IN 1 DAY



BRIGATINIB ALUNBRIG 4 PACABOZANTINIB S-MALATE CABOMETYX 4 PACABOZANTINIB S-MALATE COMETRIQ 4 PA, QL: 112 IN 28 DAYSCERITINIB ZYKADIA 4 PACRIZOTINIB XALKORI 4 PA, QL: 2 IN 1 DAY

DASATINIB SPRYCEL (100 MG)(TABLET) 4 PA, QL: 1 IN 1 DAY








ERLOTINIB HCL TARCEVA (100 MG)(TABLET) 4 PA, QL: 3 IN 1 DAY



GEFITINIB IRESSA 4 PAIBRUTINIB IMBRUVICA 4 PAIDELALISIB ZYDELIG 4 PA

imatinib mesylate GLEEVEC (100 MG)(TABLET) 4 PA, QL: 3 IN 1 DAY

imatinib mesylate GLEEVEC (400 MG)(TABLET) 4 PA, QL: 2 IN 1 DAY

IXAZOMIB CITRATE NINLARO 4 PALAPATINIB DITOSYLATE TYKERB 4 PALENVATINIB MESYLATE LENVIMA 4 PAMIDOSTAURIN RYDAPT 4 PANERATINIB MALEATE NERLYNX 4 PANILOTINIB HCL TASIGNA 4 PA, QL: 4 IN 1 DAYNIRAPARIB TOSYLATE ZEJULA 4 PAOLAPARIB LYNPARZA 4 PA, QL: 4 IN 1 DAYOSIMERTINIB MESYLATE TAGRISSO 4 PA, QL: 1 IN 1 DAYPALBOCICLIB IBRANCE 4 PAPAZOPANIB HCL VOTRIENT 4 PA, QL: 4 IN 1 DAY

PONATINIB HCL ICLUSIG (15 MG)(TABLET) 4 PA, QL: 2 IN 1 DAY

PONATINIB HCL ICLUSIG (45 MG)(TABLET) 4 PA, QL: 1 IN 1 DAY

REGORAFENIB STIVARGA 4 PA, QL: 3 IN 1 DAYRIBOCICLIB SUCCINATE KISQALI 4 PARUCAPARIB CAMSYLATE RUBRACA 4 PA, QL: 4 IN 1 DAYSORAFENIB TOSYLATE NEXAVAR 4 PA, QL: 4 IN 1 DAYSUNITINIB MALATE SUTENT 4 PA, QL: 1 IN 1 DAY

VANDETANIB CAPRELSA (100MG) (TABLET) 4 PA, QL: 2 IN 1 DAY

VANDETANIB CAPRELSA (300MG) (TABLET) 4 PA, QL: 1 IN 1 DAY

ANTINEOPLASTIC,HISTONE DEACETYLASE INHIBITORS,HDISPANOBINOSTAT LACTATE FARYDAK 4 PAVORINOSTAT ZOLINZA 4

ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORSVENETOCLAX VENCLEXTA 4 PA

VENETOCLAX VENCLEXTASTARTING PACK 4 PA

ANTINEOPLASTIC-ISOCITRATE DEHYDROGENASE INHIBITORSENASIDENIB MESYLATE IDHIFA 4 PAIVOSIDENIB TIBSOVO 4 PA, QL: 2 IN 1 DAY

ANTINEOPLASTICS,MISCELLANEOUSetoposide VEPESID 1MITOTANE LYSODREN 4OMACETAXINE MEPESUCCINATE SYNRIBO 4 PAPROCARBAZINE HCL MATULANE 4tretinoin VESANOID 4

CHEMOTHERAPY RESCUE/ANTIDOTE AGENTSleucovorin calcium WELLCOVORIN 1MESNA MESNEX 3URIDINE TRIACETATE VISTOGARD 4 QL: 24 IN 14 DAYS


Drug Name Tier Requirements/LimitsINTRAPLEURAL SCLEROSING AGENTS, ANTINEOPLAST. ADJ.

TALC SCLEROSOL 3

TALC STERITALC (2 G)(VIAL) 3



talc STERITALC (5 G)(VIAL) 1

PHOTOACTIVATED, ANTINEOPLS. & PREMALIGNANT LESIONSAMINOLEVULINIC ACID HCL AMELUZ 3AMINOLEVULINIC ACID HCL LEVULAN 3

RADIOACTIVE THERAPEUTIC AGENTSSODIUM IODIDE-131 HICON 3

SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM)tamoxifen citrate NOLVADEX 5TAMOXIFEN CITRATE SOLTAMOX 2TOREMIFENE CITRATE FARESTON 4 PA

SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR)bexarotene TARGRETIN 4 PA

STEROID ANTINEOPLASTICSESTRAMUSTINE PHOSPHATE SODIUM EMCYT 4megestrol acetate MEGACE 1

NEUROLOGICAL DISEASE - MISCELLANEOUSAGENTS TO TREAT MULTIPLE SCLEROSIS

DIMETHYL FUMARATE TECFIDERA 2 PA

FINGOLIMOD HCL GILENYA (0.25 MG)(CAPSULE) 2 PA

FINGOLIMOD HCL GILENYA (0.5 MG)(CAPSULE) 2 PA

glatiramer acetate COPAXONE 1 PAINTERFERON BETA-1A AVONEX 2 PAINTERFERON BETA-1A AVONEX PEN 2 PAINTERFERON BETA-1A/ALBUMIN AVONEX 2 PAINTERFERON BETA-1A/ALBUMIN REBIF 2 PAINTERFERON BETA-1A/ALBUMIN REBIF REBIDOSE 2 PAINTERFERON BETA-1B BETASERON 2 PAINTERFERON BETA-1B EXTAVIA 2 PAPEGINTERFERON BETA-1A PLEGRIDY 2 PAPEGINTERFERON BETA-1A PLEGRIDY PEN 2 PATERIFLUNOMIDE AUBAGIO 2 PA

AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKRdalfampridine AMPYRA 4 PA

AMYOTROPHIC LATERAL SCLEROSIS AGENTSriluzole RILUTEK 3

FIBROMYALGIA AGENTS,SEROTONIN-NOREPINEPH RU INHIBMILNACIPRAN HCL SAVELLA 2

MOVEMENT DISORDERS(DRUG THERAPY)DEUTETRABENAZINE AUSTEDO 4 PA

GABAPENTIN ENACARBIL HORIZANT (300MG) (TABLET ER) 3 ST, QL: 1 IN 1 DAY

GABAPENTIN ENACARBIL HORIZANT (600MG) (TABLET ER) 3 ST, QL: 2 IN 1 DAY

tetrabenazine XENAZINE 4 PAVALBENAZINE TOSYLATE INGREZZA 4 PA


Drug Name Tier Requirements/LimitsNEUROPATHIC AGENTS

PREGABALIN LYRICA CR (165MG) (TAB ER 24H) 3 ST, QL: 3 IN 1 DAY

PREGABALIN LYRICA CR (330MG) (TAB ER 24H) 3 ST, QL: 2 IN 1 DAY

PREGABALIN LYRICA CR (82.5MG) (TAB ER 24H) 3 ST, QL: 3 IN 1 DAY

POSTHERPETIC NEURALGIA AGENTS

GABAPENTIN GRALISE (300 MG)(TAB ER 24H) 3 ST, QL: 3 IN 1 DAY

GABAPENTIN GRALISE (300-600MG) (TAB ER 24H) 3 ST, QL: 39 IN 15 DAYS

GABAPENTIN GRALISE (600 MG)(TAB ER 24H) 3 ST, QL: 3 IN 1 DAY

PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTSDEXTROMETHORPHAN HBR/QUINIDINE NUEDEXTA 3 PA

ORAL/PHARYNGEAL DISORDERSDENTAL AIDS AND PREPARATIONS

chlorhexidine gluconate PERIDEX 1chlorhexidine gluconate PERIOGARD 1DENTAL SUCTION/CHLRHEX/SWB1/MW Q-CARE RX 3DENTL SUCTION DEV/CHLORHX/SWB1 Q-CARE RX 3

triamcinolone acetonide KENALOG INORABASE 1

NOSE PREPARATIONS ANTIBIOTICS

MUPIROCIN CALCIUM BACTROBANNASAL 2

NOSE PREPARATIONS, MISCELLANEOUS (RX)cocaine hcl GOPRELTO 1HYPROMELLOSE ALZAIR 3ipratropium bromide ATROVENT 1

PERIODONTAL COLLAGENASE INHIBITORSdoxycycline hyclate PERIOSTAT 1

PERIODONTAL TETRACYCLINE ANTIINFECTIVE, LOCALMINOCYCLINE HCL MICROSPHERES ARESTIN 4

OTHER DRUGSABORTIFACIENT,PROGESTERONE RECEPTOR ANTAGONIST-TYP

MIFEPRISTONE MIFEPREX 3AGENTS FOR CORNEAL COLLAGEN CROSS-LINKING

RIBOFLAVIN 5-PHOS/20 % DEXTRAN PHOTREXAVISCOUS 3

RIBOFLAVIN 5-PHOSPHATE SOD(B2) PHOTREXA 3AGENTS FOR STOMATOLOGICAL USE

SUCRALFATE MALATE, POLYMERIZED ORAFATE 3SUCRALFATE MALATE, POLYMERIZED PROTHELIAL 3SULFURIC ACID/SULFONAT. PHENOL DEBACTEROL 3

ANTIDOTES,MISCELLANEOUSACETYLCYSTEINE CETYLEV 3

ANTIVENINSCENTRUROIDES(SCORPN) ANTIVENOM ANASCORP 3

APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND.megestrol acetate MEGACE 1megestrol acetate MEGACE ES 1 ST


Drug Name Tier Requirements/LimitsBLOOD COLLECTION SET WITH LOCAL ANESTHETICS

BLOOD COLLECT SET/LIDOC/PRILOCCADIRACOMPLIANTBLOOD STAT

3

BLOOD COLLECT SET/LIDOC/PRILOC LIDO BDK 3BLOOD TESTING PREPARATIONS,IN-VITRO

PROTHROMBIN TIME/INR TEST METR COAGUCHEK XS 3BULK CHEMICALS

DIMETHYL SULFOXIDE 3HYDROCHLORIC ACID 3HYDROGEN PEROXIDE 3HYDROXYETHYL METHACRYLATE 3LACTIC ACID 3TRICHLOROACETIC ACID TRI-CHLOR 3TRICHLOROACETIC ACID 3VITAMIN E ACETATE 3

CARDIOPLEGIC SOLUTIONSadenosine/lidocaine/mag/sod ch 3cardioplegic 21 (reperfus 4:1) 3cardioplegic no.14 (maint 8:1) 3cardioplegic no.15(induct 8:1) 3cardioplegic no.17(induct 4:1) 3cardioplegic no.18(induct 8:1) 3cardioplegic no.19 (maint 4:1) 3cardioplegic no.20 (maint 4:1) 3cardioplegic no.22(induct 4:1) 3cardioplegic no.23(induct 4:1) 3cardioplegic solution no.1 PLEGISOL 1cardioplegic solution no.10 3cardioplegic solution no.16 3

CHELATING AGENTSGLUTATHIONE 3GLUTATHIONE-L 3

CHOLINESTERASE REACTIVAT.&MUSCARINIC ANTG.ANTIDOTEPRALIDOXIME CHLORIDE/ATROPINE DUODOTE 3

CHOLINESTERASE REACTIVATING,ORGANOPHOS. ANTIDOTESPRALIDOXIME CHLORIDE 3

CONCEPTION ASSISTANCE SUPPLIESCONCEPTION ASSIST.SUPPLIES NO1 CONCEPTION 3

CONDOMS

CONDOMS, FEMALE FC2 FEMALECONDOM 5 QL: 30 IN 30 DAYS

CRYOPRESERVATIVE AGENTSDIMETHYL SULFOXIDE CRYOSERV 3

DILUENT SOLUTIONSCHEMO THEAPY DILUENT NO.1/PF ELLIOTTS B 3

DILUENT, INSULIN ASPART NO.1 DILUTING MEDIUMFOR NOVOLOG 3

DILUENT,LIVE ROTAVIRUS VACC,CA DILUENT FORROTARIX 3

DRUGS TO TREAT HEREDITARY TYROSINEMIANITISINONE NITYR 4 PANITISINONE ORFADIN 4 PA

DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCINGELIGLUSTAT TARTRATE CERDELGA 4 PAmiglustat ZAVESCA 4 PA


Drug Name Tier Requirements/LimitsFLAVORING AGENTS

ETHYL ACETATE 3GENERAL ANESTHETICS - BENZODIAZEPINE, INJECTABLE

midazolam hcl 3midazolam hcl/pf 3

GENERAL ANESTHETICS,INHALANTDESFLURANE SUPRANE 3isoflurane 1sevoflurane ULTANE 1

GENERAL INHALATION AGENTSSODIUM CHLORIDE FOR INHALATION HYPER-SAL 3SODIUM CHLORIDE FOR INHALATION NEBUSAL 3sodium chloride for inhalation 1

HOMEOPATHIC DRUGSHOMEOPATHIC DRUGS AURUMHEEL 3

HOMEOPATHIC DRUGS CANTHARISCOMPOSITUM 3

HOMEOPATHIC DRUGS CRALONIN 3HOMEOPATHIC DRUGS EYE 3HOMEOPATHIC DRUGS LAMIOFLUR 3

HOMEOPATHIC DRUGS PLANTAGO-HOMACCORD 3

HOMEOPATHIC DRUGS POPULUSCOMPOSITUM 3

HOMEOPATHIC DRUGS PSORINOHEEL 3HOMEOPATHIC DRUGS RENEEL 3

HOMEOPATHIC DRUGS SABAL-HOMACCORD 3

HOMEOPATHIC DRUGS SYZYGIUMCOMPOSITUM 3

HOMEOPATHIC DRUGS VERTIGOHEEL 3INTRA-UTERINE DEVICES (IUD'S)

COPPER PARAGARD T 380-A 5LEVONORGESTREL KYLEENA 5LEVONORGESTREL LILETTA 5LEVONORGESTREL MIRENA 5LEVONORGESTREL SKYLA 5

JOINT TISSUE REPLACEMENTAUTOL CHRONDROCY/COLLAGEN,PORC MACI 3

METABOLIC DEFICIENCY AGENTSBETAINE CYSTADANE 4LEVOCARNITINE CARNITOR SF 3levocarnitine 1levocarnitine (with sugar) CARNITOR 1

METABOLIC DISEASE ENZYME REPLACE, HYPOPHOSPHATASIAASFOTASE ALFA STRENSIQ 4 PA

METALLIC POISON,AGENTS TO TREATDEFERASIROX EXJADE 4 PADEFERASIROX JADENU 4 PADEFERASIROX JADENU SPRINKLE 4 PADEFERIPRONE FERRIPROX 4 PAdeferoxamine mesylate DESFERAL 1 PA

deferoxamine mesylate DESFERALMESYLATE 1 PA

PRUSSIAN BLUE (INSOLUBLE) RADIOGARDASE 3SUCCIMER CHEMET 3trientine hcl SYPRINE 4 PA


Drug Name Tier Requirements/LimitsZINC ACETATE GALZIN 3

MUSCARINIC RECEPTOR ANTAGONISTSATROPINE SULFATE ATROPEN 3

NEEDLES/NEEDLELESS DEVICESBLUNT NEEDLE, DISPOSABLE BLUNT NEEDLE 3

NEEDLES, BLOOD COLLECTION MONOJECT BLOODCOLLECTION 3

NEEDLES, DISPOSABLE

EASY TOUCHHYPODERMICNEEDLE (30GX1/2")(DIS NEEDLE) (OTC)

1

NEEDLES, DISPOSABLE

EXELHYPODERMICNEEDLE (30GX1/2")(DIS NEEDLE) (OTC)

1

NEEDLES, DISPOSABLE HYPODERMICNEEDLE 3

NEEDLES, DISPOSABLEPOLY HUB NEEDLE(30GX1/2") (DISNEEDLE) (OTC)

1

NEEDLES, DISPOSABLE

SPECIALTY USENEEDLES(30GX1/2") (DISNEEDLE) (OTC)

1

NEEDLES, FILTER FILTER NEEDLE 3

NEEDLES, SAFETY

EASY TOUCHFLIPLOCK NEEDLE(30GX1/2") (DISNEEDLE) (OTC)

1

NEEDLES, SAFETY ECLIPSE NEEDLE 3

NEEDLES, SAFETY NEEDLE (18GX11/2") (DIS NEEDLE) 3

NEEDLES, SAFETY NEEDLE (30GX1/2")(DIS NEEDLE) (OTC) 1

NEEDLES, SAFETY

TERUMOSURGUARD2(18GX1 1/2") (DISNEEDLE)

3

NEEDLES, SAFETY

TERUMOSURGUARD2(18GX1") (DISNEEDLE)

3

NEEDLES, SAFETY


3

NEEDLES, SAFETY


3

NEEDLES, SAFETY


3

NEEDLES, SAFETY


3



NEEDLES, SAFETYTERUMOSURGUARD2 (21 GX 1") (DIS NEEDLE)

3

NEEDLES, SAFETY


3

NEEDLES, SAFETY


3

NEEDLES, SAFETY


3

NEEDLES, SAFETY


3

NEEDLES, SAFETY


3

NEEDLES, SAFETY


3

NEEDLES, SAFETY


3

NEEDLES, SAFETY

TERUMOSURGUARD2(25GX5/8") (DISNEEDLE)

3

NEEDLES, SAFETY


3

NEEDLES, SAFETY


3

NEEDLES, SAFETY


1

PEN NEEDLE, DIABETIC 1ST TIER UNIFINEPENTIPS 1

PEN NEEDLE, DIABETIC 1ST TIER UNIFINEPENTIPS PLUS 1

PEN NEEDLE, DIABETIC ADVOCATE PENNEEDLE 1

PEN NEEDLE, DIABETIC ADVOCATE PENNEEDLES 1

PEN NEEDLE, DIABETIC CAREFINE PENNEEDLE 1

PEN NEEDLE, DIABETIC CARETOUCH PENNEEDLE 1

PEN NEEDLE, DIABETIC CLICKFINE 1PEN NEEDLE, DIABETIC COMFORT EZ 1



PEN NEEDLE, DIABETIC DROPLET PENNEEDLE 1

PEN NEEDLE, DIABETIC EASY COMFORTPEN NEEDLES 1

PEN NEEDLE, DIABETIC EASY GLIDE PENNEEDLE 1

PEN NEEDLE, DIABETIC EASY TOUCH PENNEEDLE 1

PEN NEEDLE, DIABETICHEALTHYACCENTS UNIFINEPENTIP

1

PEN NEEDLE, DIABETIC INCONTROL PENNEEDLE 1

PEN NEEDLE, DIABETIC INSULIN PENNEEDLE 1

PEN NEEDLE, DIABETIC INSUPEN 1PEN NEEDLE, DIABETIC LITE TOUCH 1

PEN NEEDLE, DIABETIC MINI ULTRA-THINII 1

PEN NEEDLE, DIABETIC NEEDLES 1PEN NEEDLE, DIABETIC NOVOFINE 32 1PEN NEEDLE, DIABETIC NOVOFINE PLUS 1PEN NEEDLE, DIABETIC NOVOTWIST 1PEN NEEDLE, DIABETIC PEN NEEDLE 1PEN NEEDLE, DIABETIC PEN NEEDLES 1PEN NEEDLE, DIABETIC PENTIPS 1

PEN NEEDLE, DIABETIC PRO COMFORT PENNEEDLE 1

PEN NEEDLE, DIABETIC RELION PENNEEDLES 1

PEN NEEDLE, DIABETIC SURE COMFORT 1

PEN NEEDLE, DIABETIC SURE-FINE PENNEEDLES 1

PEN NEEDLE, DIABETIC TECHLITE PENNEEDLE 1

PEN NEEDLE, DIABETIC TOPCARECLICKFINE 1

PEN NEEDLE, DIABETIC TRUEPLUS PENNEEDLE 1

PEN NEEDLE, DIABETIC ULTICARE PENNEEDLE 1

PEN NEEDLE, DIABETIC ULTILET PENNEEDLE 1

PEN NEEDLE, DIABETIC ULTRA-FINE MICROPEN NEEDLE 1

PEN NEEDLE, DIABETIC ULTRA-FINE MINIPEN NEEDLE 1

PEN NEEDLE, DIABETIC ULTRA-FINE NANOPEN NEEDLE 1

PEN NEEDLE, DIABETICULTRA-FINEORIGINAL PENNEEDLE

1

PEN NEEDLE, DIABETIC ULTRA-FINE SHORTPEN NEEDLE 1

PEN NEEDLE, DIABETIC ULTRA-THIN II 1PEN NEEDLE, DIABETIC UNIFINE PENTIPS 1

PEN NEEDLE, DIABETIC UNIFINE PENTIPSPLUS 1

PEN NEEDLE, DIABETIC, SAFETY ASSURE ID PENNEEDLE 1



PEN NEEDLE, DIABETIC, SAFETY DROPSAFE PENNEEDLE 1

PEN NEEDLE, DIABETIC, SAFETYHEALTHYACCENTS UNIFINEPENTIP

1

PEN NEEDLE, DIABETIC, SAFETY NOVOFINEAUTOCOVER 1

PEN NEEDLE,DUAL SAFETY,DIABETC AUTOSHIELD DUOPEN NEEDLE 1

TRANSFER DEVICE, CLOSED SYSTEM PHASEALPROTECTOR 3

NUTRITIONAL THERAPY, MED COND SPECIAL FORMULATIONGLUTAMINE ENDARI 4 PAGLUTAMINE NUTRESTORE 3

OINTMENT/CREAM BASESEMOLLIENT BASE RADIAGEL 3

OPHTHALMIC SURGICAL AIDSedetate disodium 3

ORAL MUCOSITIS/STOMATITIS AGENTSGLY/CARB H.POLYMR A/POT HYDROX MUGARD 3POT SOR/HE-CELLULOS/POV/HYALUR GELCLAIR 3POT SORBATE/MALTO/ALOE/MANN PS ORAMAGICRX 3POVID/TAUR/ZN/PEG40 CASTOR OIL GELX 3

ORAL MUCOSITIS/STOMATITIS ANTI-INFLAMMATORY AGENTMUCOSITIS AND STOMATITIS COMB2 EPISIL 3

PHARMACEUTICAL ADJUVANTS, TABLETING

CELLULOSE MICROCRYSTALLINE CELLULOSE 3

PRESERVATIVESFORMALDEHYDE FORMA-RAY 3

RADIOPHARMACEUTICALS ELEMENTSINDIUM-111 CHLORIDE INDICLOR 3

SALIVA STIMULANT AGENTSSORBITOL/SALIVA 1/MALIC/C.PHOS NUMOISYN 3

SALIVA SUBSTITUTE AGENTSFLAXSEED NUMOISYN 3SALIVA SUBSTITUTE COMB NO.10 NEUTRASAL 3SALIVA SUBSTITUTE COMB NO.11 SALIVAMAX 3SALIVA SUBSTITUTE COMBO NO.2 CAPHOSOL 3SALIVA SUBSTITUTE COMBO NO.3 AQUORAL 3SALIVA SUBSTITUTE COMBO NO.5 BOCASAL 3

SEXUAL DYSFUNCTION DEVICES

VACUUM ERECTION DEVICE SYSTEM RAPPORT VACUUMTHERAPY 3

SKIN TISSUE REPLACEMENTCULT SKIN SUBST,HUMAN-BOVINE APLIGRAF 3CULT SKIN SUBST,HUMAN-BOVINE DERMAGRAFT 3EXTRACELL MATRIX, OVINE, FENES ENDOFORM 3EXTRACELL MATRIX,PORCINE,FENES MATRISTEM 3EXTRACELLULAR MATRIX, OVINE ENDOFORM 3

EXTRACELLULAR MATRIX,PORCINE MATRISTEMMICROMATRIX 3

HUMAN REGENERATIVE TISSUE MTRX EPIFIX AMNIOTICMEMBRANE 3

HUMAN REGENERATIVE TISSUE MTRX GRAFIX CORE 3HUMAN REGENERATIVE TISSUE MTRX GRAFIX PRIME 3HUMAN REGENERATIVE TISSUE MTRX GRAFIX XC 3


Drug Name Tier Requirements/LimitsHUMAN REGENERATIVE TISSUE MTRX STRAVIX 3HUMAN REGENERATIVE TISSUE MTRX TRUSKIN 3TISSUE MATRIX, KERATIN-OVINE KERAMATRIX 3

SOLVENTS

MINERAL OIL MURI-LUBEMINERAL OIL 3

PROPYLENE GLYCOL 3SODIUM SUCCINATE 3

SOMATOSTATIC AGENTSoctreotide acetate 4PASIREOTIDE DIASPARTATE SIGNIFOR 4 PA

SUPPORT HOSIERY

COMP.STOCKING,KNEE,LONG,MEDIUMT.E.D. ANTI-EMBOLISMSTOCKING

3

COMP.STOCKING,THIGH,LONG,LARGET.E.D. ANTI-EMBOLISMSTOCKING

3

COMP.STOCKING,THIGH,LONG,SMALLT.E.D. ANTI-EMBOLISMSTOCKING

3

COMP.STOCKING,THIGH,LONG,X-LRGT.E.D. ANTI-EMBOLISMSTOCKING

3

COMP.STOCKING,THIGH,LONG,X-SMLT.E.D. ANTI-EMBOLISMSTOCKING

3

COMP.STOCKING,THIGH,SHORT,SMALT.E.D. ANTI-EMBOLISMSTOCKING

3

COMPR.STOCKING,KNEE,LONG,LARGET.E.D. ANTI-EMBOLISMSTOCKING

3

COMPR.STOCKING,KNEE,LONG,SMALLT.E.D. ANTI-EMBOLISMSTOCKING

3

COMPR.STOCKING,KNEE,LONG,X-LRGT.E.D. ANTI-EMBOLISMSTOCKING

3

COMPR.STOCKING,THIGH,REG,LARGET.E.D. ANTI-EMBOLISMSTOCKING

3

COMPR.STOCKING,THIGH,REG,SMALLT.E.D. ANTI-EMBOLISMSTOCKING

3

COMPR.STOCKING,THIGH,REG,X-LRGT.E.D. ANTI-EMBOLISMSTOCKING

3

COMPR.STOCKING,THIGH,REG,X-SMLT.E.D. ANTI-EMBOLISMSTOCKING

3

COMPR.STOCKING,THIGH,SHORT,LRGT.E.D. ANTI-EMBOLISMSTOCKING

3

COMPR.STOCKING,THIGH,SHORT,MEDT.E.D. ANTI-EMBOLISMSTOCKING

3

COMPRES.STOCKING,KNEE,REG,SMALT.E.D. ANTI-EMBOLISMSTOCKING

3



COMPRES.STOCKING,KNEE,REG,XLRGT.E.D. ANTI-EMBOLISMSTOCKING

3

COMPRES.STOCKING,THIGH,REG,MEDT.E.D. ANTI-EMBOLISMSTOCKING

3

COMPRESS.STOCKING,KNEE,REG,LRGT.E.D. ANTI-EMBOLISMSTOCKING

3

COMPRESS.STOCKING,KNEE,REG,MEDT.E.D. ANTI-EMBOLISMSTOCKING

3

COMPRS.STOCKING,THIGH,LONG,MEDT.E.D. ANTI-EMBOLISMSTOCKING

3

SUSPENDING AGENTSGELATIN GELFILM 3LAURETH 4 BRIJ L4 3

SWEETENERSSACCHARIN 3

TISSUE/WOUND ADHESIVESTHROMBIN/FIBRINOG/APROTIN/CALC ARTISS 3THROMBIN/FIBRINOG/APROTIN/CALC TISSEEL VHSD 3

TOPICAL ANTI-INFLAMMATORY NSAID-LOCAL ANESTHETICDICLOFENAC/LIDOCAINE/TAPE TRIXYLITRAL 3

TOPICAL ANTISEPTIC DRYING AGENTSformaldehyde 1

URINE ACETONE TEST AIDS

URINE ACETONE TEST,STRIPS KETONE CARETEST STRIP 6

URINE ACETONE TEST,STRIPS KETONE TESTSTRIP 6

URINE ACETONE TEST,STRIPS KETOSTIXREAGENT 6

URINE ACETONE TEST,STRIPS TRUEPLUS KETONETEST STRIP 6

VEHICLESCITRIC ACID 3SORBITOL SOLUTION SORBITOL 3

WOUND HEALING AGENTS, LOCALBALSAM PERU/CASTOR OIL VENELEX 3

EMOL60/H.ACID/SOD CHL,SUL,PHOS CELACYN POSTPROCEDURE 3

MUPIROCIN/CHLORHEXIDINE/DIMETH DERMACINRXCLORHEXACIN 3

MUPIROCIN/CHLORHEXIDINE/DIMETHDERMACINRXSURGICALPHARMAPAK

3

MUPIROCIN/CHLORHEXIDINE/DIMETHDERMAWERXSURGICAL PLUSPAK

3

MUPIROCIN/CHLORHEXIDINE/DIMETH NUSURGEPAK 3

MUPIROCIN/CHLORHEXIDINE/DIMETH WHYTEDERMSURGIPAK 3

OTHER RESPIRATORY DISORDERSANTIFIBROTIC THERAPY - PYRIDONE ANALOGS

PIRFENIDONE ESBRIET 4 PA


Drug Name Tier Requirements/LimitsCYSTIC FIB.TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATOR

IVACAFTOR KALYDECO 4 PACYSTIC FIBROSIS-CFTR POTENTIATOR & CORRECTOR COMB.

LUMACAFTOR/IVACAFTOR ORKAMBI 4 PATEZACAFTOR/IVACAFTOR SYMDEKO 4 PA

LUNG SURFACTANTSBERACTANT SURVANTA 3CALFACTANT INFASURF 3LUCINACTANT SURFAXIN 3PORACTANT ALFA CUROSURF 3

MUCOLYTICSacetylcysteine MUCOMYST 1DORNASE ALFA PULMOZYME 4 PA

PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORSNINTEDANIB ESYLATE OFEV 4 PA

PAIN MANAGEMENT - ANALGESICSANALGESIC, NON-SALICYLATE & BARBITURATE COMB.

BUTALBITAL/ACETAMINOPHEN ALLZITAL 3 ST, QL: 12 IN 1 DAYbutalbital/acetaminophen (50mg-300mg) (capsule) 1 QL: 6 IN 1 DAYbutalbital/acetaminophen (50mg-300mg) (tablet) 1 ST, QL: 6 IN 1 DAYbutalbital/acetaminophen (50mg-325mg) (tablet) 1

ANALGESIC, SALICYLATE, BARBITURATE,& XANTHINE CMBbutalbital/aspirin/caffeine 1

ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMBbutalb/acetaminophen/caffeine 1BUTALB/ACETAMINOPHEN/CAFFEINE VANATOL LQ 3BUTALB/ACETAMINOPHEN/CAFFEINE VANATOL S 3

ANALGESIC/ANTIPYRETICS, SALICYLATESaspirin (325 mg) (tablet dr) (otc) 5aspirin (325 mg) (tablet) (otc) 5choline salicyl/mag salicylate 1diflunisal DOLOBID 1salsalate DISALCID 1

ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATIONhydrocodone/ibuprofen IBUDONE 1hydrocodone/ibuprofen VICOPROFEN 1ibuprofen/oxycodone hcl 1

ANALGESICS, NEURONAL-TYPE CALCIUM CHANNEL BLOCKERSZICONOTIDE ACETATE PRIALT 4

ANALGESICS, NON-NARCOTICSclonidine hcl/pf 1

ANALGESICS,NARCOTICS

acetaminophen/caff/dihydrocod 1 ST, AGE: >= 12 YEARS, QL: 10 IN 1DAY

buprenorphine BUTRANS 1 QL: 4 IN 28 DAYSBUPRENORPHINE HCL BELBUCA 3 ST, QL: 2 IN 1 DAYBUPRENORPHINE HCL BUPRENEX 3buprenorphine hcl 1butorphanol tartrate STADOL 1carisoprodol/aspirin/codeine 1 AGE: >= 12 YEARScodeine sulfate CODEINE 1 AGE: >= 12 YEARSfentanyl DURAGESIC 1 PA, QL: 1 IN 3 DAYSFENTANYL SUBSYS 3 PAFENTANYL CITRATE ABSTRAL 3 PAfentanyl citrate ACTIQ 1 PA


Drug Name Tier Requirements/LimitsFENTANYL CITRATE FENTORA 3 PAFENTANYL CITRATE LAZANDA 3 PAfentanyl citrate/pf 3fentanyl citrate-0.9 % nacl/pf 3fentanyl/bupivacaine/ns/pf 3fentanyl/ropivacaine/ns/pf 3HYDROCODONE BITARTRATE HYSINGLA ER 2 QL: 1 IN 1 DAYHYDROCODONE BITARTRATE ZOHYDRO ER 3 QL: 2 IN 1 DAYHYDROMORPHONE HCL DILAUDID 3hydromorphone hcl (1 mg/ml) (liquid) 1hydromorphone hcl (110mg/55ml) (pca syring) 3hydromorphone hcl (12 mg) (tab er 24h) 1 PA, QL: 1 IN 1 DAYhydromorphone hcl (16 mg) (tab er 24h) 1 PA, QL: 1 IN 1 DAYhydromorphone hcl (2 mg) (tablet) 1hydromorphone hcl (3 mg) (supp.rect) 1hydromorphone hcl (32 mg) (tab er 24h) 1 PA, QL: 2 IN 1 DAYhydromorphone hcl (4 mg) (tablet) 1hydromorphone hcl (60 mg/30ml) (pca syring) 3hydromorphone hcl (8 mg) (tab er 24h) 1 PA, QL: 1 IN 1 DAYhydromorphone hcl (8 mg) (tablet) 1hydromorphone hcl in 0.9% nacl 3hydromorphone hcl/0.9% nacl/pf 3hydromorphone/bupiv/0.9nacl/pf 3hydromorphone/ropiv/sod chl/pf 3levorphanol tartrate LEVO-DROMORAN 1

meperidine hclDEMEROL (10MG/ML)(CARTRIDGE)

1

meperidine hcl DEMEROL (100 MG)(TABLET) 3 QL: 6 IN 1 DAY

meperidine hcl DEMEROL (50 MG)(TABLET) 3 QL: 6 IN 1 DAY

meperidine hcl DEMEROL (50 MG/5ML) (SOLUTION) 3 QL: 30mL IN 1 DAY

MEPERIDINE HCL/PF DEMEROL (100MG/ML) (SYRINGE) 3

meperidine hcl/pf DEMEROL (100MG/ML) (VIAL) 1






methadone hcl (10 mg) (tablet) 1 QL: 4 IN 1 DAYmethadone hcl (10 mg/5 ml) (solution) 1 QL: 20mL IN 1 DAYmethadone hcl (10 mg/ml) (oral conc) 1 QL: 4mL IN 1 DAYmethadone hcl (10 mg/ml) (vial) 1 QL: 4mL IN 1 DAYmethadone hcl (40 mg) (tablet sol) 1 QL: 1 IN 1 DAYmethadone hcl (5 mg) (tablet) 1 QL: 8 IN 1 DAYmethadone hcl (5 mg/5 ml) (solution) 1 QL: 40mL IN 1 DAYMORPHINE SULFATE ARYMO ER 3 QL: 3 IN 1 DAY

MORPHINE SULFATE KADIAN (200 MG)(CAP ER PEL) 3 QL: 1 IN 1 DAY



MORPHINE SULFATE KADIAN (40 MG)(CAP ER PEL) 3 QL: 2 IN 1 DAY

MORPHINE SULFATE MORPHABOND ER 3 QL: 2 IN 1 DAYmorphine sulfate (10 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (10 mg) (supp.rect) 1morphine sulfate (10 mg/5 ml) (solution) 1morphine sulfate (100 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (100 mg) (tablet er) 1 QL: 3 IN 1 DAYmorphine sulfate (100 mg/5ml) (solution) 1morphine sulfate (10mg/0.7ml) (pen injctr) 1morphine sulfate (120 mg) (cpmp 24hr) 1 QL: 2 IN 1 DAYmorphine sulfate (15 mg) (tablet er) 1 QL: 3 IN 1 DAYMORPHINE SULFATE (15 MG) (TABLET) 2morphine sulfate (20 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (20 mg) (supp.rect) 1morphine sulfate (20 mg/5 ml) (solution) 1morphine sulfate (200 mg) (tablet er) 1 QL: 3 IN 1 DAYmorphine sulfate (30 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (30 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate (30 mg) (supp.rect) 1morphine sulfate (30 mg) (tablet er) 1 QL: 3 IN 1 DAYMORPHINE SULFATE (30 MG) (TABLET) 2morphine sulfate (30 mg/30ml) (pca syring) 3morphine sulfate (45 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate (5 mg) (supp.rect) 1morphine sulfate (50 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (60 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (60 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate (60 mg) (tablet er) 1 QL: 3 IN 1 DAYmorphine sulfate (75 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate (80 mg) (cap er pel) 1 QL: 2 IN 1 DAYmorphine sulfate (90 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate in 0.9 % nacl 3morphine sulfate/d5w 3

MORPHINE SULFATE/NALTREXONE EMBEDA (100MG-4MG) (CAP ER PO) 3 QL: 4 IN 1 DAY

MORPHINE SULFATE/NALTREXONE EMBEDA (20MG-0.8MG) (CAP ER PO) 3 QL: 2 IN 1 DAY


MORPHINE SULFATE/NALTREXONE EMBEDA (50 MG-2MG) (CAP ER PO) 3 QL: 2 IN 1 DAY



morphine sulfate/pf 1nalbuphine hcl 1opium/belladonna alkaloids 1OXYCODONE HCL OXAYDO 3oxycodone hcl (10 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (10 mg) (tablet) 1oxycodone hcl (10mg/0.5ml) (syringe) 3oxycodone hcl (15 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (15 mg) (tablet) 1oxycodone hcl (20 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (20 mg) (tablet) 1oxycodone hcl (20 mg/ml) (oral conc) 1oxycodone hcl (30 mg) (tab er 12h) 1 QL: 2 IN 1 DAY


Drug Name Tier Requirements/Limitsoxycodone hcl (30 mg) (tablet) 1oxycodone hcl (40 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (5 mg) (capsule) 1oxycodone hcl (5 mg) (tablet) 1oxycodone hcl (5 mg/5 ml) (solution) 1oxycodone hcl (60 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (80 mg) (tab er 12h) 1 QL: 4 IN 1 DAYOXYCODONE HCL OXYCONTIN 2 QL: 2 IN 1 DAYOXYCODONE HCL ROXYBOND 3

OXYCODONE MYRISTATE XTAMPZA ER (13.5MG) (CAP SPR 12) 3 QL: 2 IN 1 DAY

OXYCODONE MYRISTATE XTAMPZA ER (18MG) (CAP SPR 12) 3 QL: 2 IN 1 DAY




oxymorphone hcl OPANA 1

oxymorphone hcl OPANA ER (10 MG)(TAB ER 12H) 1 QL: 2 IN 1 DAY






oxymorphone hcl OPANA ER (7.5 MG)(TAB ER 12H) 1 QL: 2 IN 1 DAY

pentazocine hcl/naloxone hcl TALWIN NX 1PENTAZOCINE LACTATE TALWIN 3TAPENTADOL HCL NUCYNTA 2 QL: 6 IN 1 DAYTAPENTADOL HCL NUCYNTA ER 2 QL: 2 IN 1 DAY

tramadol hcl CONZIP 1 ST, AGE: >= 12 YEARS, QL: 1 IN 1DAY

tramadol hcl RYZOLT 1 AGE: >= 12 YEARStramadol hcl ULTRAM 1 AGE: >= 12 YEARStramadol hcl ULTRAM ER 1 AGE: >= 12 YEARS

ANTIMIGRAINE PREPARATIONSalmotriptan malate 1 ST, QL: 8 IN 30 DAYSDICLOFENAC POTASSIUM CAMBIA 3 QL: 3 IN 10 DAYSdihydroergotamine mesylate D.H.E.45 1 QL: 15mL IN 14 DAYSdihydroergotamine mesylate MIGRANAL 1 QL: 8mL IN 28 DAYSeletriptan hydrobromide RELPAX 1 ST, QL: 6 IN 30 DAYS

ERENUMAB-AOOE AIMOVIGAUTOINJECTOR 3 PA

ERENUMAB-AOOEAIMOVIGAUTOINJECTOR (2PACK)

3 PA

ERGOTAMINE TARTRATE ERGOMAR 3 QL: 10 IN 7 DAYSergotamine tartrate/caffeine CAFERGOT 1 QL: 10 IN 7 DAYSERGOTAMINE TARTRATE/CAFFEINE MIGERGOT 3 QL: 5 IN 7 DAYSFREMANEZUMAB-VFRM AJOVY 3frovatriptan succinate FROVA 1 ST, QL: 12 IN 30 DAYS


Drug Name Tier Requirements/Limitsisomethept/dichlphn/acetaminop (65-100-325)(capsule) 1

isomethepten/caf/acetaminophen PRODRIN 3naratriptan hcl AMERGE 1 QL: 8 IN 30 DAYSrizatriptan benzoate 1 QL: 12 IN 30 DAYSsumatriptan IMITREX 1 QL: 6 IN 15 DAYSSUMATRIPTAN SU/MENTHOL/CAMPHOR MIGRANOW 3

SUMATRIPTAN SUCC/NAPROXEN SOD TREXIMET (10 MG-60MG) (TABLET) 3 ST, QL: 9 IN 60 DAYS

sumatriptan succ/naproxen sod TREXIMET (85MG-500MG) (TABLET) 1 ST, QL: 9 IN 30 DAYS

sumatriptan succinate IMITREX (100 MG)(TABLET) 1 QL: 8 IN 30 DAYS


sumatriptan succinateIMITREX (4MG/0.5ML)(CARTRIDGE)


sumatriptan succinateIMITREX (4MG/0.5ML) (PENINJCTR)



sumatriptan succinateIMITREX (6MG/0.5ML)(CARTRIDGE)


sumatriptan succinateIMITREX (6MG/0.5ML) (PENINJCTR)


sumatriptan succinate IMITREX (6MG/0.5ML) (VIAL) 1 QL: 5mL IN 28 DAYS

SUMATRIPTAN SUCCINATE ONZETRA XSAIL 3 ST, QL: 16 IN 30 DAYS

SUMATRIPTAN SUCCINATE

SUMAVELDOSEPRO (4MG/0.5ML) (NDL FRINJ)


SUMATRIPTAN SUCCINATE

SUMAVELDOSEPRO (6MG/0.5ML) (NDL FRINJ)


SUMATRIPTAN SUCCINATE ZEMBRACESYMTOUCH 3 ST, QL: 8mL IN 28 DAYS

ZOLMITRIPTAN ZOMIG (2.5 MG)(SPRAY) 2 ST, QL: 12 IN 30 DAYS

zolmitriptan ZOMIG (2.5 MG)(TABLET) 1 ST, QL: 8 IN 30 DAYS

ZOLMITRIPTAN ZOMIG (5 MG)(SPRAY) 2 ST, QL: 6 IN 15 DAYS

zolmitriptan ZOMIG (5 MG)(TABLET) 1 ST, QL: 8 IN 30 DAYS

zolmitriptan ZOMIG ZMT 1 ST, QL: 8 IN 30 DAYSNARC.& NON-SAL.ANALGESIC,BARBITURATE &XANTHINE CMB

butalbit/acetamin/caff/codeine FIORICET WITHCODEINE 1 AGE: >= 12 YEARS

NARCOTIC & SALICYLATE ANALGESICS, BARB.& XANTHINE

codeine/butalbital/asa/caffein FIORINAL WITHCODEINE #3 1 AGE: >= 12 YEARS

NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMBacetaminophen with codeine (120-12mg/5) (solution) 1 AGE: >= 12 YEARSacetaminophen with codeine (300mg/12.5) (solution) 3 AGE: >= 12 YEARS


Drug Name Tier Requirements/Limitsacetaminophen with codeine (300mg-15mg) (tablet) 1 AGE: >= 12 YEARSacetaminophen with codeine (300mg-30mg) (tablet) 1 AGE: >= 12 YEARSacetaminophen with codeine (300mg-60mg) (tablet) 1 AGE: >= 12 YEARShydrocodone/acetaminophen (10mg-300mg) (tablet) 1 QL: 13 IN 1 DAYhydrocodone/acetaminophen (10mg-325mg) (tablet) 1 QL: 12 IN 1 DAYhydrocodone/acetaminophen (2.5-325 mg) (tablet) 1hydrocodone/acetaminophen (5 mg-300mg) (tablet) 1 QL: 13 IN 1 DAYhydrocodone/acetaminophen (5 mg-325mg) (tablet) 1 QL: 12 IN 1 DAYhydrocodone/acetaminophen (7.5-300 mg) (tablet) 1 QL: 13 IN 1 DAYhydrocodone/acetaminophen (7.5-325 mg) (tablet) 1 QL: 12 IN 1 DAYhydrocodone/acetaminophen (7.5-325/15) (solution) 1 QL: 184mL IN 1 DAYHYDROCODONE/ACETAMINOPHEN LORTAB 3oxycodone hcl/acetaminophen 1 QL: 12 IN 1 DAYOXYCODONE HCL/ACETAMINOPHEN PRIMLEV 3 QL: 13 IN 1 DAYtramadol hcl/acetaminophen ULTRACET 1 AGE: >= 12 YEARS

NARCOTIC AND SALICYLATE ANALGESIC COMBINATIONoxycodone hcl/aspirin 1

NARCOTIC WITHDRAWAL THERAPY AGENTSBUPRENORPHINE HCL PROBUPHINE 4buprenorphine hcl SUBUTEX 1BUPRENORPHINE HCL/NALOXONE HCL BUNAVAIL 3

BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE (12 MG-3 MG) (FILM) 2

BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE (2 MG-0.5MG) (FILM) 2

buprenorphine hcl/naloxone hcl SUBOXONE (2 MG-0.5MG) (TAB SUBL) 1

BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE (4MG-1MG) (FILM) 2

BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE (8 MG-2MG) (FILM) 2

buprenorphine hcl/naloxone hcl SUBOXONE (8 MG-2MG) (TAB SUBL) 1

BUPRENORPHINE HCL/NALOXONE HCL ZUBSOLV 2LOFEXIDINE HCL LUCEMYRA 3 PA

PARKINSONS DISEASEANTIPARKINSONISM DRUGS,ANTICHOLINERGIC

benztropine mesylate COGENTIN 1trihexyphenidyl hcl ARTANE 1

ANTIPARKINSONISM DRUGS,OTHERAMANTADINE HCL GOCOVRI 4 PAAMANTADINE HCL OSMOLEX ER 3 PAamantadine hcl SYMMETREL 1bromocriptine mesylate PARLODEL 1CARBIDOPA/LEVODOPA DUOPA 4 PAcarbidopa/levodopa PARCOPA 1CARBIDOPA/LEVODOPA RYTARY 3 ST, QL: 10 IN 1 DAYcarbidopa/levodopa SINEMET 10-100 1carbidopa/levodopa SINEMET 25-100 1carbidopa/levodopa SINEMET 25-250 1carbidopa/levodopa SINEMET CR 1carbidopa/levodopa/entacapone STALEVO 100 1carbidopa/levodopa/entacapone STALEVO 125 1carbidopa/levodopa/entacapone STALEVO 150 1carbidopa/levodopa/entacapone STALEVO 200 1carbidopa/levodopa/entacapone STALEVO 50 1carbidopa/levodopa/entacapone STALEVO 75 1entacapone COMTAN 1


Drug Name Tier Requirements/Limitspramipexole di-hcl MIRAPEX 1pramipexole di-hcl MIRAPEX ER 1 ST, QL: 1 IN 1 DAYrasagiline mesylate AZILECT 1 QL: 1 IN 1 DAYropinirole hcl REQUIP 1ropinirole hcl REQUIP XL 1 ST, QL: 1 IN 1 DAYROTIGOTINE NEUPRO 2 ST, QL: 1 IN 1 DAYSAFINAMIDE MESYLATE XADAGO 3 ST, QL: 1 IN 1 DAYselegiline hcl 1SELEGILINE HCL ZELAPAR 3 QL: 2 IN 1 DAYtolcapone TASMAR 1 ST, QL: 3 IN 1 DAY

DECARBOXYLASE INHIBITORScarbidopa LODOSYN 1

SEIZURE DISORDERANTICONVULSANT - BENZODIAZEPINE TYPE

CLOBAZAM ONFI (10 MG)(TABLET) 3 ST, QL: 2 IN 1 DAY

CLOBAZAM ONFI (2.5 MG/ML)(ORAL SUSP) 3 ST, QL: 480mL IN 30 DAYS

CLOBAZAM ONFI (20 MG)(TABLET) 3 ST, QL: 2 IN 1 DAY

clonazepam 1diazepam DIASTAT 1 QL: 1 PER FILLdiazepam DIASTAT ACUDIAL 1 QL: 1 PER FILL

ANTICONVULSANTS

BRIVARACETAM BRIVIACT (10 MG)(TABLET) 3 ST, QL: 2 IN 1 DAY

BRIVARACETAMBRIVIACT (10MG/ML)(SOLUTION)





BRIVARACETAM BRIVIACT (50 MG/5ML) (VIAL) 3 ST


carbamazepine CARBATROL 1carbamazepine TEGRETOL 1carbamazepine TEGRETOL XR 1divalproex sodium DEPAKOTE 1divalproex sodium DEPAKOTE ER 1

divalproex sodium DEPAKOTESPRINKLE 1

ESLICARBAZEPINE ACETATE APTIOM (200 MG)(TABLET) 3 ST, QL: 1 IN 1 DAY




ethosuximide ZARONTIN 1ETHOTOIN PEGANONE 3

felbamate FELBATOL (400 MG)(TABLET) 1 ST, QL: 9 IN 1 DAY



felbamate FELBATOL (600 MG)(TABLET) 1 ST, QL: 6 IN 1 DAY

felbamateFELBATOL (600MG/5ML) (ORALSUSP)


gabapentin NEURONTIN 1

GABAPENTIN/CAPSAI/ME-SAL/MENTH SMARTRX GABA-VKIT 3

GABAPENTIN/LIDOCAINE/MENTHOL ACTIVE-PAC 3

GABAPENTIN/LIDOCAINE/MENTHOL SMARTRXGABAKIT 3

LACOSAMIDE VIMPAT (10 MG/ML)(SOLUTION) 2 ST, QL: 1200mL IN 30 DAYS

LACOSAMIDE VIMPAT (100 MG)(TABLET) 2 ST, QL: 2 IN 1 DAY



LACOSAMIDEVIMPAT(200MG/20ML)(VIAL)

3


LACOSAMIDEVIMPAT (50MG-100MG) (TAB DSPK)

3

lamotrigine LAMICTAL 1lamotrigine LAMICTAL (BLUE) 1

lamotrigine LAMICTAL(GREEN) 1

lamotrigine LAMICTAL(ORANGE) 1

lamotrigineLAMICTAL ODT(100 MG) (TABRAPDIS)


lamotrigineLAMICTAL ODT(200 MG) (TABRAPDIS)


lamotrigine LAMICTAL ODT (25MG) (TAB RAPDIS) 1 ST, QL: 6 IN 1 DAY

lamotrigine LAMICTAL ODT (50MG) (TAB RAPDIS) 1 ST, QL: 6 IN 1 DAY

lamotrigine LAMICTAL ODT(BLUE) 1 ST

lamotrigine LAMICTAL ODT(GREEN) 1 ST

lamotrigine LAMICTAL ODT(ORANGE) 1 ST

lamotrigine LAMICTAL XR (100MG) (TAB ER 24) 1 ST, QL: 3 IN 1 DAY








LAMOTRIGINE LAMICTAL XR(BLUE) 3 ST

LAMOTRIGINE LAMICTAL XR(GREEN) 3 ST

LAMOTRIGINE LAMICTAL XR(ORANGE) 3 ST

levetiracetam KEPPRA 1levetiracetam KEPPRA XR 1levetiracetam ROWEEPRA 1levetiracetam ROWEEPRA XR 1

LEVETIRACETAM SPRITAM (1000 MG)(TAB SUSP) 3 ST, QL: 2 IN 1 DAY




METHSUXIMIDE CELONTIN 3

OXCARBAZEPINE OXTELLAR XR (150MG) (TAB ER 24H) 3 ST, QL: 1 IN 1 DAY



oxcarbazepine TRILEPTAL 1

PERAMPANELFYCOMPA (0.5MG/ML) (ORALSUSP)


PERAMPANEL FYCOMPA (10 MG)(TABLET) 3 ST, QL: 1 IN 1 DAY






phenytoin DILANTIN 1phenytoin DILANTIN-125 1

phenytoin sodium extended DILANTIN (100 MG)(CAPSULE) 1

PHENYTOIN SODIUM EXTENDED DILANTIN (30 MG)(CAPSULE) 2

phenytoin sodium extended PHENYTEK 1PREGABALIN LYRICA 2primidone MYSOLINE 1

RUFINAMIDE BANZEL (200 MG)(TABLET) 3 ST, QL: 16 IN 1 DAY

RUFINAMIDEBANZEL (40MG/ML) (ORALSUSP)


RUFINAMIDE BANZEL (400 MG)(TABLET) 3 ST, QL: 8 IN 1 DAY



tiagabine hcl GABITRIL (12 MG)(TABLET) 1 ST, QL: 4 IN 1 DAY




topiramate QUDEXY XR (100MG) (CAP SPR 24) 1 ST, QL: 1 IN 1 DAY





topiramate TOPAMAX 1

TOPIRAMATE TROKENDI XR (100MG) (CAP ER 24H) 2 ST, QL: 2 IN 1 DAY




valproic acid DEPAKENE 1

valproic acid (as sodium salt)DEPAKENE (250MG/5ML)(SOLUTION)

1

valproic acid (as sodium salt)DEPAKENE(500MG/10ML)(SOLUTION)

3

vigabatrin SABRIL 4 QL: 6 IN 1 DAYVIGABATRIN SABRIL 4 QL: 6 IN 1 DAYzonisamide ZONEGRAN 1

SKELETAL MUSCLE DISORDERAGENTS TO TX PERIODIC PARALYSIS - CARBON ANHYD INH

DICHLORPHENAMIDE KEVEYIS 4 PASKELETAL MUSCLE RELAX.& TOP.IRRITANT COUNTER-IRRITANT

CYCLOBENZAPRINE/IRR CNTR-IRR 2COMFORT PAC-CYCLOBENZAPRINE

3

TIZANIDINE/IRRITANT CNTR-IRRT2 COMFORT PAC-TIZANIDINE 3

SKELETAL MUSCLE RELAXANTSbaclofen 1BACLOFEN GABLOFEN 3

BACLOFEN LIORESALINTRATHECAL 3

carisoprodol SOMA 1 QL: 4 IN 1 DAYcarisoprodol/aspirin SOMA COMPOUND 1chlorzoxazone (250 mg) (tablet) 1 ST, QL: 4 IN 1 DAYchlorzoxazone (500 mg) (tablet) 1CHLORZOXAZONE LORZONE 3 ST, QL: 4 IN 1 DAYCYCLOBENZAPRINE HCL AMRIX 3cyclobenzaprine hcl FEXMID 1cyclobenzaprine hcl FLEXERIL 1


Drug Name Tier Requirements/LimitsCYCLOBENZAPRINE/TENS ELECTRODE CYCLOTENS 3CYCLOBENZAPRINE/TENS UNIT/ELEC CYCLOTENS 3dantrolene sodium DANTRIUM 1

metaxalone SKELAXIN (400 MG)(TABLET) 3

metaxalone SKELAXIN (800 MG)(TABLET) 1

methocarbamol ROBAXIN 1methocarbamol ROBAXIN-750 1orphenadrine citrate NORFLEX 1tizanidine hcl ZANAFLEX 1

SMOKING CESSATIONSMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS)

nicotine NICODERM CQ 5 AGE: >= 18 YEARS, QL: 1 IN 1 DAYNICOTINE PATCH 5 AGE: >= 18 YEARS, QL: 1 IN 1 DAY

NICOTINE NICOTROL 5 ST, AGE: >= 18 YEARS, QL: 1008 IN90 DAYS

NICOTINE NICOTROL NS 5 ST, AGE: >= 18 YEARS, QL: 160mLIN 90 DAYS

nicotine polacrilex (2 mg) (gum) (otc) 5 AGE: >= 18 YEARS, QL: 24 IN 1DAY

nicotine polacrilex (2 mg) (lozenge) (otc) 5 AGE: >= 18 YEARS, QL: 20 IN 1DAY

nicotine polacrilex (2 mg) (lozng mini) (otc) 5 AGE: >= 18 YEARS, QL: 20 IN 1DAY

nicotine polacrilex (4 mg) (gum) (otc) 5 AGE: >= 18 YEARS, QL: 24 IN 1DAY

nicotine polacrilex (4 mg) (lozenge) (otc) 5 AGE: >= 18 YEARS, QL: 20 IN 1DAY

nicotine polacrilex (4 mg) (lozng mini) (otc) 5 AGE: >= 18 YEARS, QL: 20 IN 1DAY

SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONISTVARENICLINE TARTRATE CHANTIX 5 AGE: >= 18 YEARS, QL: 2 IN 1 DAY

SMOKING DETERRENTS, OTHERbupropion hcl ZYBAN 5 AGE: >= 18 YEARS, QL: 2 IN 1 DAY

UPPER GASTROINTESTINAL DISORDERS - DIGESTIVEGASTRIC ENZYMES

SACROSIDASE SUCRAID 4 PAPANCREATIC ENZYMES

LIPASE/PROTEASE/AMYLASE CREON 2LIPASE/PROTEASE/AMYLASE PANCREAZE 3LIPASE/PROTEASE/AMYLASE PERTZYE 3LIPASE/PROTEASE/AMYLASE VIOKACE 3LIPASE/PROTEASE/AMYLASE ZENPEP 2

UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASEANTICHOLINERGICS/ANTISPASMODICS

dicyclomine hcl 1BELLADONNA ALKALOIDS

hyoscyamine sulfate HYOSYNE 1hyoscyamine sulfate LEVBID 1hyoscyamine sulfate LEVSIN 1hyoscyamine sulfate LEVSIN-SL 1hyoscyamine sulfate NULEV 1hyoscyamine sulfate SYMAX 1HYOSCYAMINE SULFATE SYMAX DUOTAB 3hyoscyamine sulfate SYMAX-SL 1


Drug Name Tier Requirements/Limitshyoscyamine sulfate SYMAX-SR 1methscopolamine bromide PAMINE 1methscopolamine bromide PAMINE FORTE 1

PHENOBARB/HYOSCY/ATROPINE/SCOP BELLADONNA-PHENOBARBITAL 3 ST, QL: 1200mL IN 30 DAYS

PHENOBARB/HYOSCY/ATROPINE/SCOP DONNATAL (16.2MG) (TABLET) 3 ST, QL: 8 IN 1 DAY

PHENOBARB/HYOSCY/ATROPINE/SCOPDONNATAL(16.2MG/5ML)(ELIXIR)


phenobarb/hyoscy/atropine/scop 1 ST, QL: 8 IN 1 DAY

PHENOBARB/HYOSCY/ATROPINE/SCOP PHENOHYTRO (16.2MG) (TABLET) 3 ST, QL: 8 IN 1 DAY

PHENOBARB/HYOSCY/ATROPINE/SCOPPHENOHYTRO(16.2MG/5ML)(ELIXIR)


UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASEANTICHOLINERGICS,QUATERNARY AMMONIUM

chlordiazepoxide/clidinium br LIBRAX 1GLYCOPYRROLATE CUVPOSA 3GLYCOPYRROLATE GLYCATE 3 ST, QL: 3 IN 1 DAYglycopyrrolate 1propantheline bromide PRO-BANTHINE 1

ANTI-ULCER PREPARATIONSmisoprostol CYTOTEC 1

sucralfate CARAFATE (1 G)(TABLET) 1

SUCRALFATE CARAFATE (1 G/10ML) (ORAL SUSP) 2

ANTI-ULCER-H.PYLORI AGENTSBISMUTH/METRONID/TETRACYCLINE PYLERA 3lansoprazole/amoxiciln/clarith 1 QL: 112 IN 10 DAYSOMEPRAZOLE/CLARITH/AMOXICILLIN OMECLAMOX-PAK 3

HISTAMINE H2-RECEPTOR INHIBITORScimetidine TAGAMET 1cimetidine hcl TAGAMET 1famotidine PEPCID 1nizatidine AXID 1ranitidine hcl ZANTAC 1

INTESTINAL MOTILITY STIMULANTSmetoclopramide hcl METOZOLV ODT 1metoclopramide hcl REGLAN 1

PROTON-PUMP INHIBITORSDEXLANSOPRAZOLE DEXILANT 3 ST, QL: 1 IN 1 DAY

ESOMEPRAZOLE MAGNESIUM NEXIUM (10 MG)(SUSPDR PKT) 2 ST, QL: 1 IN 1 DAY

ESOMEPRAZOLE MAGNESIUM NEXIUM (2.5 MG)(SUSPDR PKT) 2 ST, QL: 1 IN 1 DAY

esomeprazole magnesium NEXIUM (20 MG)(CAPSULE DR) 1 QL: 1 IN 1 DAY


esomeprazole magnesium NEXIUM (40 MG)(CAPSULE DR) 1 QL: 2 IN 1 DAY




Drug Name Tier Requirements/Limitsesomeprazole strontium 3 ST, QL: 4 IN 1 DAYlansoprazole (15 mg) (capsule dr) 1lansoprazole (15 mg) (tab rap dr) 1 STlansoprazole (30 mg) (capsule dr) 1lansoprazole (30 mg) (tab rap dr) 1 STomeprazole (10 mg) (capsule dr) 1omeprazole (20 mg) (capsule dr) 1omeprazole (40 mg) (capsule dr) 1OMEPRAZOLE MAGNESIUM PRILOSEC 3omeprazole/sodium bicarbonate OMEPPI 1 ST, QL: 1 IN 1 DAY

omeprazole/sodium bicarbonate ZEGERID (20-1680MG) (PACKET) 1 ST, QL: 1 IN 1 DAY

omeprazole/sodium bicarbonate ZEGERID (20MG-1.1G) (CAPSULE) 1 ST, QL: 1 IN 1 DAY

omeprazole/sodium bicarbonate ZEGERID (40-1680MG) (PACKET) 1 ST, QL: 1 IN 1 DAY

omeprazole/sodium bicarbonate ZEGERID (40MG-1.1G) (CAPSULE) 1 ST, QL: 1 IN 1 DAY

pantoprazole sodium 1PANTOPRAZOLE SODIUM PROTONIX 3 STrabeprazole sodium ACIPHEX 1 QL: 1 IN 1 DAY

RABEPRAZOLE SODIUM ACIPHEXSPRINKLE 3 ST, QL: 1 IN 1 DAY

URINARY TRACT - FUNCTIONAL DISORDERSBENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS

alfuzosin hcl UROXATRAL 1dutasteride AVODART 1finasteride PROSCAR 1SILODOSIN RAPAFLO 3 STtamsulosin hcl FLOMAX 1

BPH AGENTS,5-ALPHA-RED INH & ALPHA-1-ADR ANTG CMBdutasteride/tamsulosin hcl JALYN 1 ST

KIDNEY STONE AGENTSCYSTEAMINE BITARTRATE CYSTAGON 4CYSTEAMINE BITARTRATE PROCYSBI 4 PATIOPRONIN THIOLA 4

OVERACTIVE BLADDER AGENTS, BETA-3 ADRENERGIC RECEPMIRABEGRON MYRBETRIQ 2 ST

URINARY PH MODIFIERSCITRIC AC/GLUCONOLACT/MAG CARB RENACIDIN 3CITRIC ACID/SODIUM CITRATE ORACIT 3CITRIC ACID/SODIUM CITRATE SHOHL'S MODIFIED 3METHENAMINE/SOD PHOSPHATE MBAS UROQID-ACID NO.2 3potassium citrate UROCIT-K 1potassium citrate/citric acid 1POTASSIUM PHOSPHATE,MONOBASIC K-PHOS ORIGINAL 3SOD PHOS,M-B/K PHOS,MONOB K-PHOS NO.2 3

URINARY TRACT ANALGESIC AGENTSPENTOSAN POLYSULFATE SODIUM ELMIRON 2

URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE)phenazopyridine hcl PYRIDIUM 1

URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG.darifenacin hydrobromide ENABLEX 1 STSOLIFENACIN SUCCINATE VESICARE 2 ST

URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENTFESOTERODINE FUMARATE TOVIAZ 2 STflavoxate hcl URISPAS 1


Drug Name Tier Requirements/LimitsOXYBUTYNIN OXYTROL 3 STOXYBUTYNIN CHLORIDE GELNIQUE 3 SToxybutynin chloride 1tolterodine tartrate DETROL 1 STtolterodine tartrate DETROL LA 1 STtrospium chloride SANCTURA 1 STtrospium chloride SANCTURA XR 1 ST

VAGINAL DISORDERSVAGINAL ANTIBIOTICS

CLINDAMYCIN PHOSPHATE CLEOCIN (100 MG)(SUPP.VAG) 3 ST, QL: 3 IN 30 DAYS

clindamycin phosphate CLEOCIN (2 %)(CREAM/APPL) 1

CLINDAMYCIN PHOSPHATE CLINDESSE 3

metronidazole METROGEL-VAGINAL 1

METRONIDAZOLE NUVESSA 3METRONIDAZOLE VANDAZOLE 2

VAGINAL ANTIFUNGALSBUTOCONAZOLE NITRATE GYNAZOLE 1 2miconazole nitrate (200 mg) (supp.vag) 1terconazole TERAZOL 3 1terconazole TERAZOL 7 1

VAGINAL ANTISEPTICSACETIC ACID/OXYQUINOLINE FEM PH 3ACETIC ACID/OXYQUINOLINE RELAGARD 3OXYQUINOLINE/SOD.LAURYL SULFAT TRIMO-SAN 3

VAGINAL ESTROGEN PREPARATIONSestradiol ESTRACE 1ESTRADIOL ESTRING 3 QL: 1 IN 90 DAYSestradiol VAGIFEM 1ESTRADIOL ACETATE FEMRING 3 QL: 1 IN 84 DAYSESTROGENS, CONJUGATED PREMARIN 2

VAGINAL SULFONAMIDESSULFANILAMIDE AVC 2

VITAMIN AND/OR MINERAL DEFICIENCYCALCIUM REPLACEMENT

calcium/mag/d3/b12/fa/b6/boron 1FLUORIDE PREPARATIONS

FLUORIDE (SODIUM) CLINPRO 5000 3fluoride (sodium) (0.25(0.55)) (tab chew) (otc) 5 AGE: <= 6 YEARSfluoride (sodium) (0.5 mg/ml) (drops) (otc) 5 AGE: <= 6 YEARSfluoride (sodium) (0.5(1.1)mg) (tab chew) (otc) 5 AGE: <= 6 YEARSfluoride (sodium) (1.1 %) (cream (g)) 1fluoride (sodium) (1.1 %) (gel (gram)) 1fluoride (sodium) (1mg(2.2mg)) (tab chew) (otc) 5 AGE: <= 6 YEARSFLUORIDE (SODIUM) FLUORIDEX 3FLUORIDE (SODIUM) PREVIDENT 3FLUORIDE (SODIUM) PREVIDENT 5000 3

SODIUM FLUORIDE/POTASSIUM NIT PREVIDENT 5000ENAMEL PROTECT 3

SODIUM FLUORIDE/POTASSIUM NIT PREVIDENT 5000SENSITIVE 3

FOLIC ACID PREPARATIONSfolic acid (0.4 mg) (tablet) (otc) 5folic acid (0.8 mg) (tablet) (otc) 5


Drug Name Tier Requirements/Limitsfolic acid (1 mg) (tablet) 1folic acid (5 mg/ml) (vial) 1

IRON REPLACEMENTferrous sulfate (15 mg/ml) (drops) (otc) 5 AGE: < 1 YEAR

PRENATAL VITAMIN PREPARATIONSPNV 102/IRON/FOLATE 1/DSS/DHA VITAFOL FE+ 3pnv 11/iron fum/folic acid/om3 1pnv 112/iron/folic/om3/dha/epa 3

PNV 117/IRON/FOLIC/OM3/DHA/EPA DUET DHABALANCED 3

pnv 15/iron fum,ps/folic acid CONCEPT OB 1pnv 16/iron fum,ps/folic/om-3 CONCEPT DHA 1PNV 19/IRON PS,HEME/FOLIC/DHA PREFERA-OB ONE 3pnv 21/iron ps,heme ppep/folic PREFERA OB 1PNV 22/IRON,GLUC/FOLIC/DSS/DHA PNV OB+DHA 3

PNV 30/IRON CARB,AG/FOLIC/OM3 OB COMPLETEWITH DHA 3

pnv 39/iron/folic/docusate/dha 1PNV 55/IRON FUM,B-G/FOLIC ACID NATACHEW 3pnv 66/iron/folic/docusate/dha 1PNV 67/IRON PS/FOLATE NO.1/DHA VITAFOL ULTRA 3

pnv 69/iron/folic/docusate/dha CITRANATALHARMONY 1

PNV 76/IRON,GLUC/FOLIC/DSS/DHA CITRANATAL DHA 3pnv 80/iron fum/folic/dss/dha NEXA SELECT 1PNV 85/IRON/FOLIC/DHA/FISH OIL OB COMPLETE ONE 3

PNV NO.106/IRON/FOLATE NO6/DHA OB COMPLETEGOLD 3

PNV NO.111/IRON/FOLATE/DHA NESTABS ONE 3pnv no.118/iron fumarate/fa 1pnv no.5/ferrous fum/folic ac 1pnv no.66/iron,carb/folic/dha ACTIVE OB 1PNV NO.80/IRON/MFOLATE/DSS/DHA FOLET ONE 3PNV NO.80/IRON/MFOLATE/DSS/DHA OBSTETRIX ONE 3

PNV NO.88/IRON PS,HEME/FA/DHA PREFERA-OB PLUSDHA 3

pnv, calcium 70/iron/folic/dha NATELLE ONE 1pnv,calcium 72/iron,carb/folic 1pnv,calcium 72/iron/folic acid 1pnv/ferrous fum/docusate/folic 1pnv/iron,carb/docusat/folic ac 1pnv119/iron fum/folic/docusate 1pnv19/iron bg,s.p/folic ac/om3 1PNV53/IRON FUM/FA/DOCUSATE/DHA NEXA PLUS 3

PNV59/IRON,CARB,FUM/FA/DSS/DHA CITRANATALHARMONY 3

PNV72/IRON,GLUC/FOLIC/DSS/DHA CITRANATAL 90DHA 3

PNV73/IRON,GLUC/FOLIC/DSS/DHA CITRANATALASSURE 3

pnv81/iron edta,ps/folic/omeg3 1

PNV83/IRON,CARB,ASP/FOLIC ACID OB COMPLETEPREMIER 3

prenat 115/iron fum/folic/dss 1prenat vit 17/iron/folic/om3,6 1PRENAT90/IRON FUM,PS/FOLIC/DHA PROVIDA DHA 3prenatal 105/iron/folic ac/dha VITATRUE 1PRENATAL 114/IRON A-G/FOLATE 1 PRENATE ELITE 3PRENATAL 118/IRON/FOLATE 6/DHA PRIMACARE 3


Drug Name Tier Requirements/Limitsprenatal 12/iron/folic/dss/om3 OBTREX DHA 1

PRENATAL 2/IRON/FOLIC ACID/OM3 COMPLETE NATALDHA 3

PRENATAL 2/IRON/FOLIC ACID/OM3 TRUST NATAL DHA 3

PRENATAL 25/IRON/FOLATE 6/DHA VITAMEDMD ONERX 3

PRENATAL 26/IRON PS/FOLIC/DHA VITAFOL-ONE 3

prenatal 34/iron/folic/dss/dha CITRANATALHARMONY 1

PRENATAL 38/IRON/FOLATE 6/DHA PRENATE DHA 3prenatal 47/iron/folate 1/dha 1prenatal 53/iron/folic ac/omg3 1prenatal 54/iron/folic ac/omg3 1prenatal 57/iron/folic/dss/dha 1

prenatal 59/iron/folic/dss/dha CITRANATALHARMONY 1

prenatal 68/iron/folic no1/dha 1PRENATAL 78/IRON/FOLATE 1/DHA PRENATE DHA 3PRENATAL 86/IRON/FOLIC/DHA/EPA NESTABS ABC 3PRENATAL 87/IRON BIS/FOLIC/DHA NESTABS DHA 3PRENATAL 93/IRON/FOLATE 9/DHA TRISTART DHA 3

prenatal comb no.42/folic acid VITAMEDMDREDICHEW RX 1

PRENATAL NO.123/IRON/FOLIC AC ELITE-OB 3PRENATAL NO.123/IRON/FOLIC AC OB COMPLETE 3prenatal no.52/iron/fa/dha 1prenatal no.75/iron/folate no1 1PRENATAL NO.77/IRON ASP GLY/FA PRENATE STAR 3prenatal no115/iron/folic acid 1prenatal no13/iron ps/folate 1 1

PRENATAL NO35/IRON/FOLATE6/DHA PRENATEESSENTIAL 3

prenatal no4/iron fum,ps/folic 1PRENATAL VIT 10/IRON FUM/FOLIC VITAFOL-OB 3prenatal vit 10/iron/folic/dha 1prenatal vit 14/iron fum/folic 1PRENATAL VIT 33/IRON/FOLIC/DHA SELECT-OB + DHA 3PRENATAL VIT 36/IRON/FOLATE 6 PRENATE ELITE 3PRENATAL VIT 43/IRON/FOLIC/DSS ATABEX EC 3prenatal vit 55/iron/folic/om3 1PRENATAL VIT 65/IRON FUM,PS/FA PROVIDA OB 3

PRENATAL VIT 84/IRON/FA 1/DHA PRENATEESSENTIAL 3

PRENATAL VIT 85/IRON/FA 1/DHA PRENATE PIXIE 3PRENATAL VIT 87/IRON/FOLIC/DHA PRENATE MINI 3prenatal vit no.109/iron/fa 1

PRENATAL VIT NO.112/FOLATE NO6 PRENATECHEWABLE 3

prenatal vit no.127/iron/folic 1prenatal vit,cal 73/iron/folic 1prenatal vit,cal 74/iron/folic 1prenatal vit,calc76/iron/folic 1PRENATAL VIT,CALC76/IRON/FOLIC THRIVITE RX 3prenatal vit,calc78/iron/folic 1prenatal vit/iron bisgly/folic 1prenatal vit/iron fum/folic ac (65 mg-1 mg) (capsule) 1prenatal vit/iron fum/folic ac (65 mg-1 mg) (tablet) 1prenatal vit100/iron/folic/om3 1PRENATAL VIT103/IRON FUM/FOLIC TRICARE 3


Drug Name Tier Requirements/LimitsPRENATAL VIT106/IRON/FOLIC/OM3 DUET DHA 400 3prenatal vit108/iron,crb/folic 1PRENATAL VIT114/FOLATE6/GINGER PRENATE AM 3PRENATAL VIT127/IRON/FOLIC/DSS OBSTETRIX EC 3prenatal vit128/iron/folic acd 1prenatal vit136/iron/folic acd 1

prenatal vit22/iron/folic/om3s PREFERA-OB PLUSDHA 1

prenatal vit27,calcium/iron/fa TRINATAL RX 1 1PRENATAL VIT37/IRON/FOLIC ACID PRENATA 3

PRENATAL VIT68/IRON/FA NO6/DHA PRENATEENHANCE 3

PRENATAL VIT69/IRON/FOLATE6/DH PRENATE RESTORE 3PRENATAL VIT83/IRON/FOLAT6/DHA CADEAU DHA 3prenatal vit86/iron/folic acid NESTABS 1prenatal vits15/iron/folic/dss 1prenatal vits16/iron/folic/dss 1prenatal vits18/iron/folic/dss 1prenatal,calc no.65/iron/folic 1prenatal,calc.40/iron/folate 1 1

PRENATAL56/IRON/FOLIC ACID/DHA OB COMPLETEPETITE 3

prenatal64/iron/lmfolate/algal NEEVODHA 1prenatal71/iron/folic acid/dha VITAPEARL 1

PRENATAL72/IRON FUM/FA/OM3/DHA PRENATAL PLUS-DHA 3

PRENATAL81/IRON/FOLIC/DOCUSATE CITRANATAL RX 3PRENATAL92/IRON/FOLATE8/PS-DHA ENBRACE HR 3

PRENATAL VITAMINS WITHOUT IRONpnv/folic ac/b6/calcium/ginger B-NEXA 1

VITAMIN B PREPARATIONSPOTASSIUM AMINOBENZOATE POTABA 3vitamins b1,b2,b3,b5,and b6 1

VITAMIN B1 PREPARATIONSthiamine hcl (100 mg/ml) (vial) 1

VITAMIN B12 PREPARATIONScyanocobalamin (vitamin b-12) (1000mcg/ml) (vial) 1CYANOCOBALAMIN (VITAMIN B-12) NASCOBAL 3hydroxocobalamin 1

VITAMIN B6 PREPARATIONSpyridoxine hcl (vitamin b6) (100 mg/ml) (vial) 1

VITAMIN C PREPARATIONSASCORBATE SODIUM ASCOR 3ascorbic acid (500 mg/ml) (vial) 1

VITAMIN D PREPARATIONScalcitriol ROCALTROL 1ergocalciferol (vitamin d2) (50000 unit) (capsule) 1


STEP THERAPY EDITS • ABILIFY (1 MG/ML) (SOLUTION) Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,

Citalopram Hydrobromide, Clozapine, Duloxetine HCL, Escitalopram Oxalate,Fluoxetine HCL, Olanzapine, Paroxetine HCL, Paroxetine Mesylate, Paxil, Pexeva,Quetiapine Fumarate, Risperidone, Sarafem, Seroquel XR, Sertraline HCL,Venlafaxine HCL, Versacloz, or Ziprasidone HCL in 365 days

• ABILIFY DISCMELT (10 MG) (TABRAPDIS)

Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,Citalopram Hydrobromide, Clozapine, Duloxetine HCL, Escitalopram Oxalate,Fluoxetine HCL, Olanzapine, Paroxetine HCL, Paroxetine Mesylate, Paxil, Pexeva,Quetiapine Fumarate, Risperidone, Sarafem, Seroquel XR, Sertraline HCL,Venlafaxine HCL, Versacloz, or Ziprasidone HCL in 365 days

• ABILIFY DISCMELT (15 MG) (TABRAPDIS)

Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,Citalopram Hydrobromide, Clozapine, Duloxetine HCL, Escitalopram Oxalate,Fluoxetine HCL, Olanzapine, Paroxetine HCL, Paroxetine Mesylate, Paxil, Pexeva,Quetiapine Fumarate, Risperidone, Sarafem, Seroquel XR, Sertraline HCL,Venlafaxine HCL, Versacloz, or Ziprasidone HCL in 365 days

• ABSORICA Must meet any of the following requirements: Absorica or Isotretinoin in 120 days• ACANYA Must meet the following requirement: Clindamycin Phos/benzoyl Perox in 120 days• ACETAMINOPHEN/CAFF/DIHYDROCODMust meet the following requirement: Acetaminophen With Codeine in 120 days• ACIPHEX SPRINKLE Must meet 2 of the following requirements: First-lansoprazole, First-omeprazole,

Lansoprazole, Omeprazole, Pantoprazole Sodium, or Protonix in 365 days• ACTICLATE Must meet the following requirement: Doxycycline Monohydrate in 120 days• ACTOPLUS MET Must meet any of the following requirements: Avandamet, Avandaryl, Avandia,

Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL,Glyburide, Glyburide/metformin HCL, Metformin HCL, Tolazamide, or Tolbutamidein 120 days

• ACTOPLUS MET XR Must meet any of the following requirements: Avandamet, Avandaryl, Avandia,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL,Glyburide, Glyburide/metformin HCL, Metformin HCL, Tolazamide, or Tolbutamidein 120 days

• ADLYXIN Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise,Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide,Glipizide/metformin HCL, Glyburide, Glyburide micronized, Glyburide/metforminHCL, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Tolazamide, Tolbutamide, or Trulicity in 365days

• ADMELOG Must meet any of the following requirements: Admelog Solostar, Admelog, HumalogJunior Kwikpen, Humalog Kwikpen U-100, Humalog Kwikpen U-200, or Humalogin 120 days

• ADMELOG SOLOSTAR Must meet any of the following requirements: Admelog Solostar, Admelog, HumalogJunior Kwikpen, Humalog Kwikpen U-100, Humalog Kwikpen U-200, or Humalogin 120 days

• ADZENYS ER Must meet the following requirement: Dextroamphetamine/amphetamine in 120 days• ADZENYS XR-ODT Must meet the following requirement: Dextroamphetamine/amphetamine in 120 days• AEROSPAN Must meet 2 of the following requirements: Arnuity Ellipta, Flovent Diskus, Flovent

HFA, Qvar Redihaler, or Qvar in 365 days• ALLZITAL Must meet the following requirement: Butalbital/acetaminophen in 120 days• ALMOTRIPTAN MALATE Must meet the following requirement: Rizatriptan Benzoate or Sumatriptan Succinate

in 180 days• ALTOPREV Must meet 2 of the following requirements: Altoprev, Atorvastatin Calcium,

Lovastatin, Pravastatin Sodium, or Simvastatin in 365 days• ALVESCO Must meet 2 of the following requirements: Arnuity Ellipta, Flovent Diskus, Flovent

HFA, Qvar Redihaler, or Qvar in 365 days• AMITIZA Must meet any of the following requirements: Linzess or Movantik in 120 days• ANTARA (30 MG) (CAPSULE) Must meet any of the following requirements: Antara, Fenofibrate Nanocrystallized,

Fenofibrate, Fenofibrate micronized, Gemfibrozil, or Triglide in 120 days• ANTARA (90 MG) (CAPSULE) Must meet any of the following requirements: Antara, Fenofibrate Nanocrystallized,

Fenofibrate, Fenofibrate micronized, Gemfibrozil, or Triglide in 120 days• ANZEMET (100 MG) (TABLET) Must meet any of the following requirements: Anzemet, Ondansetron, or

Ondansetron HCL in 120 days

Medication Prescribing Limitations


• ANZEMET (50 MG) (TABLET) Must meet any of the following requirements: Anzemet, Ondansetron, orOndansetron HCL in 120 days

• APIDRA Must meet any of the following requirements: Humalog, Humalog Kwikpen U-100,or Humalog Kwikpen U-200 in 120 days

• APIDRA SOLOSTAR Must meet any of the following requirements: Humalog, Humalog Kwikpen U-100,or Humalog Kwikpen U-200 in 120 days

• APLENZIN Must meet any of the following requirements: Bupropion HCL or Forfivo XL in 120days

• APTENSIO XR Must meet any of the following requirements: Aptensio XR,Dextroamphetamine/amphetamine, Methylphenidate HCL, Mydayis, Quillichew ER,Quillivant XR, or Relexxii in 120 days

• APTIOM (200 MG) (TABLET) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine,Levetiracetam, Oxcarbazepine, Neuraptine, Oxtellar XR, Spritam, Stavzor,Topiramate, Trokendi XR, Valproic Acid (as Sodium Salt), Valproic Acid, orZonisamide in 365 days




• ARCAPTA NEOHALER Must meet any of the following requirements: Striverdi Respimat or Serevent Diskusin 120 days

• ARMONAIR RESPICLICK Must meet 2 of the following requirements: Arnuity Ellipta, Flovent Diskus, FloventHFA, Qvar Redihaler, or Qvar in 365 days

• ASMANEX Must meet 2 of the following requirements: Arnuity Ellipta, Flovent Diskus, FloventHFA, Qvar Redihaler, or Qvar in 365 days

• ASMANEX HFA Must meet 2 of the following requirements: Arnuity Ellipta, Flovent Diskus, FloventHFA, Qvar Redihaler, or Qvar in 365 days

• ASTEPRO Must meet the following requirement: Azelastine HCL in 120 days• AUGMENTIN (125-31.25/) (SUSPRECON) Must meet the following requirement: Amoxicillin/potassium Clav in 120 days• AVANDIA Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,

Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburidemicronized, Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL,Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Tolazamide, orTolbutamide in 120 days

• AVIDOXY DK Must meet the following requirement: Doxycycline Monohydrate in 120 days• BANZEL (200 MG) (TABLET) Must meet any of the following requirements: Divalproex Sodium, Lamictal,

Lamictal Xr, Lamotrigine, Stavzor, Topiramate, Trokendi XR, or Valproic Acid in120 days

• BANZEL (40 MG/ML) (ORAL SUSP) Must meet any of the following requirements: Divalproex Sodium, Lamictal,Lamictal Xr, Lamotrigine, Stavzor, Topiramate, Trokendi XR, or Valproic Acid in120 days

• BANZEL (400 MG) (TABLET) Must meet any of the following requirements: Divalproex Sodium, Lamictal,Lamictal Xr, Lamotrigine, Stavzor, Topiramate, Trokendi XR, or Valproic Acid in120 days

• BASAGLAR KWIKPEN U-100 Must meet any of the following requirements: Lantus Solostar, Lantus, LevemirFlexpen, Levemir Flextouch, Levemir, Toujeo Max Solostar, Toujeo Solostar, TresibaFlextouch U-100, or Tresiba Flextouch U-200 in 120 days

• BEAU RX Must meet any of the following requirements: Kelo-cote or Recedo in 120 days• BECONASE AQ Must meet the following requirement: Flunisolide or Fluticasone Propionate in 120

days



• BELBUCA Must meet the following requirement: Buprenorphine in 120 days• BELLADONNA-PHENOBARBITAL Must meet 2 of the following requirements: Dicyclomine HCL, Hyoscyamine

Sulfate, or Symax Duotab in 365 days• BELSOMRA Must meet any of the following requirements: Eszopiclone, Zaleplon, or Zolpidem

Tartrate in 120 days• BENZODOX 30 Must meet the following requirement: Doxycycline Monohydrate in 120 days• BENZODOX 60 Must meet the following requirement: Doxycycline Monohydrate in 120 days• BEPREVE Must meet 2 of the following requirements: Azelastine HCL, Epinastine HCL,

Olopatadine HCL, or Pataday in 365 days• BEVESPI AEROSPHERE Must meet the following requirement: Anoro Ellipta and Stiolto Respimat in 365

days• BINOSTO Must meet 2 of the following requirements: Alendronate Sodium, Fosamax Plus D,

or Ibandronate Sodium in 365 days• BRAVELLE Must meet any of the following requirements: Gonal-F RFF, Gonal-F RFF Redi-ject,

or Gonal-F in 120 days• BRISDELLE Must meet any of the following requirements: Paroxetine HCL, Paxil, or Venlafaxine

HCL in 120 days• BRIVIACT (10 MG) (TABLET) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,

Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine,Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor,Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days

• BRIVIACT (10 MG/ML) (SOLUTION) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine,Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor,Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days

• BRIVIACT (100 MG) (TABLET) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine,Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor,Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days



• BRIVIACT (50 MG/5 ML) (VIAL) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine,Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor,Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days


• BUTALBITAL/ACETAMINOPHEN(50MG-300MG) (TABLET) Must meet the following requirement: Butalbital/acetaminophen in 120 days• BYDUREON Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,


• BYDUREON BCISE Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburidemicronized, Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL,Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Tolazamide, orTolbutamide in 120 days

• BYDUREON PEN Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburidemicronized, Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL,Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Tolazamide, orTolbutamide in 120 days



• BYETTA Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburidemicronized, Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL,Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Tolazamide, orTolbutamide in 120 days

• CAROSPIR Must meet the following requirement: Spironolactone in 120 days• CESAMET Must meet any of the following requirements: Ondansetron or Ondansetron HCL in

120 days• CHLORZOXAZONE (250 MG) (TABLET)Must meet the following requirement: Chlorzoxazone in 120 days• CLARINEX (2.5 MG) (TAB RAPDIS) Must meet any of the following requirements: Desloratadine or Levocetirizine

Dihydrochloride in 120 days• CLARINEX (2.5 MG/5ML) (SYRUP) Must meet any of the following requirements: Levocetirizine Dihydrochloride or

Desloratadine in 120 days• CLARINEX (5 MG) (TAB RAPDIS) Must meet any of the following requirements: Desloratadine or Levocetirizine

Dihydrochloride in 120 days• CLARINEX-D 12 HOUR Must meet any of the following requirements: Levocetirizine Dihydrochloride or

Desloratadine in 120 days• CLEOCIN (100 MG) (SUPP.VAG) Must meet 2 of the following requirements: Clindamycin HCL, Clindamycin

Palmitate HCL, Clindamycin Phosphate, Metronidazole, Tinidazole, or Vandazole in365 days

• CLINDAGEL Must meet the following requirement: Clindamycin Phosphate in 120 days• CONDYLOX (0.5 %) (GEL (GRAM)) Must meet the following requirement: Podofilox in 120 days• CONZIP Must meet the following requirement: Tramadol HCL in 120 days• CORDRAN (4MCG/SQ CM) (MED.TAPE)

Must meet the following requirement: Topical Anti-inflammatory Steroidal in 120days

• COTEMPLA XR-ODT (17.3 MG) (TABRAP BP)

Must meet any of the following requirements: Aptensio XR,Dextroamphetamine/amphetamine, Methylphenidate HCL, Mydayis, Quillichew ER,Quillivant XR, or Relexxii in 120 days





• CYCLOSET Must meet any of the following requirements: Glipizide/metformin HCL,Glyburide/metformin HCL, or Metformin HCL in 180 days

• DALIRESP Must meet any of the following requirements: Advair Diskus, Breo Ellipta, SereventDiskus, Spiriva Respimat, or Spiriva in 120 days

• DAYTRANA Must meet the following requirement: Methylphenidate HCL or Quillivant XR in 120days

• DELZICOL Must meet any of the following requirements: Apriso, Balsalazide Disodium, Lialda,or Pentasa in 120 days

• DERMACINRX SILAPAK Must meet 3 of the following requirements: Amerigel Barrier, Dimethicone, ScarTreatment, Silicone Disc, Silicone Roll, Silicone Scar, Silicone Sheet, Silicone Tape,or Triamcinolone Acetonide in 365 days

• DERMAWERX SDS Must meet 3 of the following requirements: Amerigel Barrier, Dimethicone, ScarTreatment, Silicone Disc, Silicone Roll, Silicone Scar, Silicone Sheet, Silicone Tape,or Triamcinolone Acetonide in 365 days

• DESVENLAFAXINE ER Must meet 2 of the following requirements: Bupropion HCL, CitalopramHydrobromide, Escitalopram Oxalate, Fluoxetine HCL, Forfivo XL, Mirtazapine,Paroxetine HCL, Paxil, Sarafem, Sertraline HCL, or Venlafaxine HCL in 365 days

• DESVENLAFAXINE FUMARATE ER Must meet 2 of the following requirements: Bupropion HCL, CitalopramHydrobromide, Escitalopram Oxalate, Fluoxetine HCL, Forfivo XL, Mirtazapine,Paroxetine HCL, Paxil, Sarafem, Sertraline HCL, or Venlafaxine HCL in 365 days

• DETROL Must meet the following requirement: Oxybutynin Chloride in 120 days• DETROL LA Must meet the following requirement: Oxybutynin Chloride in 120 days• DEXAMETHASONE (1.5 MG(49)) (TABDS PK) Must meet the following requirement: Dexamethasone in 120 days• DEXAMETHASONE (1.5MG (21)) (TABDS PK) Must meet the following requirement: Dexamethasone in 120 days• DEXAMETHASONE (1.5MG (35)) (TABDS PK) Must meet the following requirement: Dexamethasone in 120 days



• DEXAMETHASONE (1.5MG (51)) (TABDS PK) Must meet the following requirement: Dexamethasone in 120 days• DEXILANT Must meet any of the following requirements: Lansoprazole, Omeprazole,

Pantoprazole Sodium, Prilosec OTC, or Protonix in 120 days• DIFICID Must meet the following requirement: Vancomycin HCL in 120 days• DIPENTUM Must meet any of the following requirements: Apriso, Balsalazide Disodium, Lialda,

or Pentasa in 120 days• DONNATAL (16.2 MG) (TABLET) Must meet 2 of the following requirements: Dicyclomine HCL, Hyoscyamine

Sulfate, or Symax Duotab in 365 days• DONNATAL (16.2MG/5ML) (ELIXIR) Must meet 2 of the following requirements: Dicyclomine HCL, Hyoscyamine

Sulfate, or Symax Duotab in 365 days• DORYX (100 MG) (TABLET DR) Must meet any of the following requirements: Doxycycline Hyclate or Doxycycline

Monohydrate in 120 days• DORYX (150 MG) (TABLET DR) Must meet the following requirement: Doxycycline Monohydrate in 120 days• DORYX (200 MG) (TABLET DR) Must meet any of the following requirements: Doxycycline Hyclate or Doxycycline

Monohydrate in 120 days• DORYX (50 MG) (TABLET DR) Must meet any of the following requirements: Doxycycline Hyclate or Doxycycline

Monohydrate in 120 days• DORYX (75 MG) (TABLET DR) Must meet the following requirement: Doxycycline Monohydrate in 120 days• DORYX MPC Must meet any of the following requirements: Doxycycline Hyclate or Doxycycline

Monohydrate in 120 days• DORZOLAMIDE/TIMOLOL/PF (2 %-0.5%) (DROPERETTE) Must meet the following requirement: Dorzolamide HCL/timolol Maleat in 120 days• DOVONEX Must meet the following requirement: Topical Anti-inflammatory Steroidal in 120

days• DRITHOCREME HP Must meet the following requirement: Topical Anti-inflammatory Steroidal in 120

days• DUETACT Must meet any of the following requirements: Avandamet, Avandaryl, Avandia,

Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL,Glyburide, Glyburide/metformin HCL, Metformin HCL, Tolazamide, or Tolbutamidein 120 days

• DUEXIS Must meet the following requirement: Ibuprofen in 120 days• DULOXETINE HCL (40 MG) (CAPSULEDR) Must meet the following requirement: Duloxetine HCL in 120 days• DUZALLO Must meet the following requirement: Allopurinol in 120 days• DYANAVEL XR Must meet the following requirement: Dextroamphetamine/amphetamine in 120 days• DYMISTA Must meet the following requirement: Flunisolide or Fluticasone Propionate in 365

days• EDARBI Must meet any of the following requirements: Amlodipine Besylate/benazepril,

Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,Captopril/hydrochlorothiazide, Diovan HCT, Enalapril Maleate,Enalapril/hydrochlorothiazide, Epaned, Fosinopril Sodium,Fosinopril/hydrochlorothiazide, Irbesartan, Irbesartan/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, Trandolapril/verapamil HCL, orValsartan/hydrochlorothiazide in 120 days

• EDARBYCLOR Must meet any of the following requirements: Amlodipine Besylate/benazepril,Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,Captopril/hydrochlorothiazide, Diovan HCT, Enalapril Maleate,Enalapril/hydrochlorothiazide, Epaned, Fosinopril Sodium,Fosinopril/hydrochlorothiazide, Irbesartan, Irbesartan/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, Trandolapril/verapamil HCL, orValsartan/hydrochlorothiazide in 120 days

• EDLUAR Must meet any of the following requirements: Edluar or Zolpidem Tartrate in 180days

• ELIDEL Must meet the following requirement: Topical Anti-inflammatory Steroidal in 120days



• EMADINE Must meet 2 of the following requirements: Azelastine HCL, Epinastine HCL,Olopatadine HCL, or Pataday in 365 days

• ENABLEX Must meet the following requirement: Oxybutynin Chloride in 120 days• ENSTILAR Must meet the following requirement: Topical Anti-inflammatory Steroidal in 120

days• EPANED Must meet the following requirement: Enalapril Maleate in 120 days• EPIDUO Must meet the following requirement: Adapalene in 120 days• EPIDUO FORTE Must meet the following requirement: Adapalene in 120 days• ESOMEPRAZOLE STRONTIUM Must meet any of the following requirements: First-lansoprazole, First-omeprazole,

Lansoprazole, Omeprazole, Pantoprazole Sodium, or Protonix in 120 days• EUCRISA Must meet the following requirement: Topical Anti-inflammatory Steroidal in 120

days• FANAPT (1 MG) (TABLET) Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,

Clozapine, Olanzapine, Quetiapine Fumarate, Seroquel XR, Versacloz, orZiprasidone HCL in 365 days

• FANAPT (10 MG) (TABLET) Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,Clozapine, Olanzapine, Quetiapine Fumarate, Seroquel XR, Versacloz, orZiprasidone HCL in 365 days


• FANAPT (1-2-4-6MG) (TAB DS PK) Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,Clozapine, Olanzapine, Quetiapine Fumarate, Seroquel XR, Versacloz, orZiprasidone HCL in 365 days





• FARXIGA Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburidemicronized, Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL,Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Tolazamide, orTolbutamide in 120 days

• FAZACLO Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,Clozapine, Olanzapine, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz,or Ziprasidone HCL in 365 days

• FELBATOL (400 MG) (TABLET) Must meet any of the following requirements: Lamictal, Lamictal (blue), Lamictal(green), Lamictal (orange), Lamictal XR (blue), Lamictal XR (green), Lamictal XR(orange), Lamotrigine, Topiramate, or Trokendi XR in 120 days

• FELBATOL (600 MG) (TABLET) Must meet any of the following requirements: Lamictal, Lamictal (blue), Lamictal(green), Lamictal (orange), Lamictal XR (blue), Lamictal XR (green), Lamictal XR(orange), Lamotrigine, Topiramate, or Trokendi XR in 120 days

• FELBATOL (600 MG/5ML) (ORAL SUSP)Must meet any of the following requirements: Lamictal, Lamictal (blue), Lamictal(green), Lamictal (orange), Lamictal XR (blue), Lamictal XR (green), Lamictal XR(orange), Lamotrigine, Topiramate, or Trokendi XR in 120 days

• FETZIMA Must meet 2 of the following requirements: Bupropion HCL, CitalopramHydrobromide, Escitalopram Oxalate, Fetzima, Fluoxetine HCL, Forfivo XL,Mirtazapine, Paroxetine HCL, Paxil, Sarafem, Sertraline HCL, or Venlafaxine HCLin 365 days

• FIASP Must meet any of the following requirements: Humalog Junior Kwikpen, HumalogKwikpen U-100, Humalog Kwikpen U-200, or Humalog in 120 days

• FIASP FLEXTOUCH Must meet any of the following requirements: Humalog Junior Kwikpen, HumalogKwikpen U-100, Humalog Kwikpen U-200, or Humalog in 120 days

• FOLLISTIM AQ Must meet any of the following requirements: Gonal-F RFF, Gonal-F RFF Redi-ject,or Gonal-F in 120 days



• FORFIVO XL Must meet the following requirement: Bupropion HCL in 120 days• FORTAMET Must meet the following requirement: Metformin HCL in 120 days• FROVA Must meet any of the following requirements: Rizatriptan Benzoate or Sumatriptan

Succinate in 180 days• FYCOMPA (0.5 MG/ML) (ORAL SUSP) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,

Equetro, Fanatrex, Fycompa, Gabapentin, Gralise, Lamictal, Lamictal XR,Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam,Stavzor, Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days

• FYCOMPA (10 MG) (TABLET) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,Equetro, Fanatrex, Fycompa, Gabapentin, Gralise, Lamictal, Lamictal XR,Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam,Stavzor, Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days






• GABITRIL (12 MG) (TABLET) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine,Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor,Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days




• GELNIQUE Must meet the following requirement: Oxybutynin Chloride in 120 days• GLUMETZA Must meet the following requirement: Metformin HCL in 120 days• GLYCATE Must meet the following requirement: Glycopyrrolate in 120 days• GLYXAMBI Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,


• GONITRO Must meet the following requirements: Two generic sublingual Nitroglycerinproducts in 365 days

• GRALISE (300 MG) (TAB ER 24H) Must meet any of the following requirements: Gabapentin or Gralise in 120 days• GRALISE (300-600 MG) (TAB ER 24H) Must meet any of the following requirements: Gabapentin or Gralise in 120 days• GRALISE (600 MG) (TAB ER 24H) Must meet any of the following requirements: Gabapentin or Gralise in 120 days• HEMANGEOL Must meet the following requirement: Propranolol HCL in 120 days



• HORIZANT (300 MG) (TABLET ER) Must meet any of the following requirements: Fanatrex, Gabapentin, Gralise,Neuraptine, Pramipexole Di-HCL, or Ropinirole HCL in 120 days

• HORIZANT (600 MG) (TABLET ER) Must meet any of the following requirements: Fanatrex, Gabapentin, Gralise,Neuraptine, Pramipexole Di-HCL, or Ropinirole HCL in 120 days

• IMPOYZ Must meet the following requirement: Topical Anti-inflammatory Steroidal in 120days

• INCRUSE ELLIPTA Must meet any of the following requirements: Spiriva Respimat or Spiriva in 120days

• INDERAL XL Must meet the following requirement: Propranolol HCL in 120 days• INNOPRAN XL Must meet the following requirement: Propranolol HCL in 120 days• INTERMEZZO Must meet the following requirement: Zolpidem Tartrate in 120 days• INVEGA (1.5 MG) (TAB ER 24) Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,


• INVEGA (3 MG) (TAB ER 24) Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,Clozapine, Olanzapine, Quetiapine Fumarate, Seroquel XR, Versacloz, orZiprasidone HCL in 365 days



• INVOKAMET Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide,Glyburide micronized, Glyburide/metformin HCL, Jardiance, Metformin HCL,Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metforminHCL, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days

• INVOKAMET XR Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide,Glyburide micronized, Glyburide/metformin HCL, Jardiance, Metformin HCL,Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metforminHCL, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days

• INVOKANA Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide,Glyburide micronized, Glyburide/metformin HCL, Jardiance, Metformin HCL,Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metforminHCL, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days

• JALYN Must meet any of the following requirements: Alfuzosin HCL, Doxazosin Mesylate,Finasteride, Prazosin HCL, Rapaflo, Tamsulosin HCL, or Terazosin HCL in 120 days

• JARDIANCE Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburidemicronized, Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL,Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Tolazamide, orTolbutamide in 120 days

• KARBINAL ER Must meet the following requirement: Carbinoxamine Maleate in 120 days• KAZANO Must meet any of the following requirements: Janumet, Janumet XR, Januvia,

Jentadueto, Jentadueto XR, or Tradjenta in 120 days• KHEDEZLA Must meet 2 of the following requirements: Bupropion HCL, Citalopram

Hydrobromide, Desvenlafaxine ER, Desvenlafaxine, Escitalopram Oxalate,Fluoxetine HCL, Forfivo XL, Mirtazapine, Paroxetine HCL, Paxil, Sarafem,Sertraline HCL, or Venlafaxine HCL in 365 days

• KOMBIGLYZE XR Must meet any of the following requirements: Janumet, Janumet XR, Januvia,Jentadueto, Jentadueto XR, or Tradjenta in 120 days

• KYTRIL Must meet any of the following requirements: Ondansetron HCL or Ondansetron in120 days

• LAMICTAL ODT (100 MG) (TABRAPDIS)

Must meet any of the following requirements: Lamictal (blue), Lamictal (green),Lamictal (orange), or Lamotrigine in 120 days

• LAMICTAL ODT (200 MG) (TABRAPDIS)

Must meet any of the following requirements: Lamictal (blue), Lamictal (green),Lamictal (orange), or Lamotrigine in 120 days

• LAMICTAL ODT (25 MG) (TAB RAPDIS)Must meet any of the following requirements: Lamictal (blue), Lamictal (green),Lamictal (orange), or Lamotrigine in 120 days



• LAMICTAL ODT (50 MG) (TAB RAPDIS)Must meet any of the following requirements: Lamictal (blue), Lamictal (green),Lamictal (orange), or Lamotrigine in 120 days

• LAMICTAL ODT (BLUE) Must meet any of the following requirements: Lamictal (blue), Lamictal (green),Lamictal (orange), or Lamotrigine in 120 days

• LAMICTAL ODT (GREEN) Must meet any of the following requirements: Lamictal (blue), Lamictal (green),Lamictal (orange), or Lamotrigine in 120 days

• LAMICTAL ODT (ORANGE) Must meet any of the following requirements: Lamictal (blue), Lamictal (green),Lamictal (orange), or Lamotrigine in 120 days

• LAMICTAL XR (100 MG) (TAB ER 24) Must meet any of the following requirements: Lamictal (blue), Lamictal (green),Lamictal (orange), or Lamotrigine in 120 days






• LAMICTAL XR (BLUE) Must meet any of the following requirements: Lamictal (blue), Lamictal (green),Lamictal (orange), or Lamotrigine in 120 days

• LAMICTAL XR (GREEN) Must meet any of the following requirements: Lamictal (blue), Lamictal (green),Lamictal (orange), or Lamotrigine in 120 days

• LAMICTAL XR (ORANGE) Must meet any of the following requirements: Lamictal (blue), Lamictal (green),Lamictal (orange), or Lamotrigine in 120 days

• LANSOPRAZOLE (15 MG) (TAB RAPDR)

Must meet any of the following requirements: Lansoprazole, Omeprazole, orPantoprazole Sodium in 120 days

• LANSOPRAZOLE (30 MG) (TAB RAPDR)

Must meet any of the following requirements: Lansoprazole, Omeprazole, orPantoprazole Sodium in 120 days

• LASTACAFT Must meet 2 of the following requirements: Azelastine HCL, Epinastine HCL,Olopatadine HCL, or Pataday in 365 days

• LATUDA (120 MG) (TABLET) Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,Clozapine, Olanzapine, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz,or Ziprasidone HCL in 365 days





• LESCOL Must meet 2 of the following requirements: Altoprev, Atorvastatin Calcium,Lovastatin, Pravastatin Sodium, or Simvastatin in 365 days

• LESCOL XL Must meet 2 of the following requirements: Altoprev, Atorvastatin Calcium,Lovastatin, Pravastatin Sodium, or Simvastatin in 365 days

• LIDOCAINE (5 %) (OINT. (G)) Must meet the following requirement: Lidocaine HCL in 120 days• LORZONE Must meet the following requirement: Chlorzoxazone in 120 days• LUVOX CR Must meet any of the following requirements: Citalopram Hydrobromide,

Escitalopram Oxalate, Fluoxetine HCL, Fluvoxamine Maleate, Paroxetine HCL,Paxil, Sarafem, or Sertraline HCL in 120 days

• LUZU Must meet 2 of the following requirements: Clotrimazole AND Ketoconazole in 365days

• LYRICA CR (165 MG) (TAB ER 24H)Must meet 2 of the following requirements: Amitriptyline HCL, Desipramine HCL,Divalproex Sodium, Doxepin HCL, Duloxetine HCL, Fanatrex, Gabapentin, Gralise,Imipramine HCL, Imipramine Pamoate, Maprotiline HCL, Neuraptine, Nortriptyline



HCL, Stavzor, Valproic Acid (as Sodium Salt), Valproic Acid, or Venlafaxine HCL in365 days

• LYRICA CR (330 MG) (TAB ER 24H) Must meet 2 of the following requirements: Amitriptyline HCL, Desipramine HCL,Divalproex Sodium, Doxepin HCL, Duloxetine HCL, Fanatrex, Gabapentin, Gralise,Imipramine HCL, Imipramine Pamoate, Maprotiline HCL, Neuraptine, NortriptylineHCL, Stavzor, Valproic Acid (as Sodium Salt), Valproic Acid, or Venlafaxine HCL in365 days

• LYRICA CR (82.5 MG) (TAB ER 24H) Must meet 2 of the following requirements: Amitriptyline HCL, Desipramine HCL,Divalproex Sodium, Doxepin HCL, Duloxetine HCL, Fanatrex, Gabapentin, Gralise,Imipramine HCL, Imipramine Pamoate, Maprotiline HCL, Neuraptine, NortriptylineHCL, Stavzor, Valproic Acid (as Sodium Salt), Valproic Acid, or Venlafaxine HCL in365 days

• MARINOL Must meet any of the following requirements: Anzemet, Aprepitant, DexamethasoneIntensol, Dexamethasone, Granisetron HCL, Maxidex, Medrol, Megestrol Acetate,Methylprednisolone, Ondansetron HCL, Ondansetron, Ozurdex, Sancuso, Sustol, orZuplenz in 120 days

• MEGACE ES Must meet the following requirement: Megestrol Acetate in 120 days• MINOCYCLINE HCL (115MG) (TAB ER24H) Must meet the following requirement: Minocycline HCL in 120 days• MINOCYCLINE HCL (65 MG) (TAB ER24H) Must meet the following requirement: Minocycline HCL in 120 days• MIRAPEX ER Must meet any of the following requirements: Pramipexole Di-HCL or Ropinirole

HCL in 120 days• MONODOX (75 MG) (CAPSULE) Must meet the following requirement: Doxycycline Monohydrate in 120 days• MORGIDOX Must meet the following requirement: Doxycycline Monohydrate in 120 days• MOTOFEN Must meet the following requirement: Diphenoxylate HCL/Atropine in 120 days• MYDAYIS Must meet the following requirement: Dextroamphetamine/amphetamine in 120 days• MYRBETRIQ Must meet the following requirement: Oxybutynin Chloride in 120 days• MYTESI Must meet the following requirement: Antiretrovirals in 120 days• NAMZARIC (14MG-10MG) (CAP SPR24)

Must meet 2 of the following requirements: Donepezil HCL, Memantine HCL, orNamenda XR in 365 days

• NAMZARIC (21 MG-10MG) (CAP SPR24)


• NAMZARIC (28 MG-10MG) (CAP SPR24)


• NAMZARIC (7 MG-10 MG) (CAP SPR24)


• NAMZARIC (7-10/14-10) (CAP24 DSPK) Must meet 2 of the following requirements: Donepezil HCL, Memantine HCL, orNamenda XR in 365 days

• NEO-SYNALAR Must meet 2 of the following requirements: Bacitracin Zinc, Bacitracin, CapexShampoo, Fluocinolone Acetonide, Iluvien, or Retisert in 365 days

• NESINA Must meet any of the following requirements: Janumet, Janumet XR, Januvia,Jentadueto, Jentadueto XR, or Tradjenta in 120 days

• NEUPRO Must meet any of the following requirements: Pramipexole Di-HCL or RopiniroleHCL in 120 days

• NEXIUM (10 MG) (SUSPDR PKT) Must meet any of the following requirements: Lansoprazole, Omeprazole,Pantoprazole Sodium, Prilosec OTC, or Protonix in 120 days

• NEXIUM (2.5 MG) (SUSPDR PKT) Must meet any of the following requirements: Lansoprazole, Omeprazole,Pantoprazole Sodium, Prilosec OTC, or Protonix in 120 days




• NIASPAN Must meet any of the following requirements: Altoprev, Antara, AtorvastatinCalcium, Fenofibrate, Fenofibrate micronized, Fenofibrate Nanocrystallized,Flolipid, Gemfibrozil, Lovastatin, Pravastatin Sodium, Simvastatin, or Triglide in 365days

• NICOTROL Must meet any of the following requirements: Nicotine, Nicotine Patch, or PyrithioneZinc in 120 days



• NICOTROL NS Must meet any of the following requirements: Nicotine, Nicotine Patch, or PyrithioneZinc in 120 days

• NORITATE Must meet the following requirement: Metronidazole in 120 days• NOVOLIN 70-30 Must meet any of the following requirements: Humulin 70-30 or Humulin 70/30

Kwikpen in 120 days• NOVOLIN N Must meet the following requirement: Humulin N in 120 days• NOVOLIN R Must meet any of the following requirements: Humulin R or Humulin R U-500 in

120 days• NOVOLOG Must meet any of the following requirements: Humalog, Humalog Kwikpen U-100,

or Humalog Kwikpen U-200 in 120 days• NOVOLOG FLEXPEN Must meet any of the following requirements: Humalog, Humalog Kwikpen U-100,

or Humalog Kwikpen U-200 in 120 days• NOVOLOG MIX 70-30 Must meet any of the following requirements: Humalog Mix 75-25 or Humalog Mix

75-25 Kwikpen in 120 days• NOVOLOG MIX 70-30 FLEXPEN Must meet any of the following requirements: Humalog Mix 75-25 or Humalog Mix

75-25 Kwikpen in 120 days• NUTRIARX Must meet 3 of the following requirements: Amerigel Barrier, Dimethicone, Scar

Treatment, Silicone Disc, Silicone Roll, Silicone Scar, Silicone Sheet, Silicone Tape,or Triamcinolone Acetonide in 365 days

• OBREDON Must meet any of the following requirements: Hydrocodone Bit/homatrop Me-br in120 days

• OMEPPI Must meet any of the following requirements: Lansoprazole, Omeprazole,Pantoprazole Sodium, Prilosec OTC, or Protonix in 120 days

• OMNARIS Must meet the following requirement: Flunisolide or Fluticasone Propionate in 120days

• ONEXTON Must meet the following requirement: Clindamycin Phos/benzoyl Perox in 120 days• ONFI (10 MG) (TABLET) Must meet any of the following requirements: Lamictal, Lamictal XR, Lamotrigine,

Topiramate, or Trokendi XR in 120 days• ONFI (2.5 MG/ML) (ORAL SUSP) Must meet any of the following requirements: Lamictal, Lamictal XR, Lamotrigine,

Topiramate, or Trokendi XR in 120 days• ONFI (20 MG) (TABLET) Must meet any of the following requirements: Lamictal, Lamictal XR, Lamotrigine,

Topiramate, or Trokendi XR in 120 days• ONGLYZA Must meet any of the following requirements: Janumet, Janumet XR, Januvia,

Jentadueto, Jentadueto XR, or Tradjenta in 120 days• ONZETRA XSAIL Must meet the following requirement: Sumatriptan in 180 days• ORACEA Must meet the following requirement: Doxycycline Monohydrate in 120 days• OSENI Must meet any of the following requirements: Janumet, Janumet XR, Januvia,

Jentadueto, Jentadueto XR, or Tradjenta in 120 days• OTREXUP Must meet any of the following requirements: Methotrexate Sodium, Methotrexate

Sodium/pf, Rheumatrex, or Trexall in 120 days• OVACE PLUS (9.8 %) (LOTION) Must meet any of the following requirements: Ciclopirox or Ketoconazole in 120

days• OXTELLAR XR (150 MG) (TAB ER 24H) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,

Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine,Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor,Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days

• OXTELLAR XR (300 MG) (TAB ER 24H) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine,Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor,Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days

• OXTELLAR XR (600 MG) (TAB ER 24H) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine,Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor,Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days

• OXYTROL Must meet the following requirement: Oxybutynin Chloride in 120 days• OZEMPIC Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise,

Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide,Glipizide/metformin HCL, Glyburide, Glyburide micronized, Glyburide/metforminHCL, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Tolazamide, Tolbutamide, or Trulicity in 365days

• PATANASE Must meet the following requirement: Azelastine HCL in 120 days



• PAZEO Must meet 2 of the following requirements: Azelastine HCL, Epinastine HCL,Olopatadine HCL, or Pataday in 365 days

• PENNSAID (20MG/G(2%)) (SOL MDPMP)

Must meet any of the following requirements: Diclofenac Sodium or Pennsaid in 120days

• PEXEVA Must meet the following requirement: Paroxetine HCL or Paxil in 120 days• PHENOBARB/HYOSCY/ATROPINE/SCOP

Must meet 2 of the following requirements: Dicyclomine HCL, HyoscyamineSulfate, or Symax Duotab in 365 days

• PHENOHYTRO (16.2 MG) (TABLET) Must meet 2 of the following requirements: Dicyclomine HCL, HyoscyamineSulfate, or Symax Duotab in 365 days

• PHENOHYTRO (16.2MG/5ML) (ELIXIR) Must meet 2 of the following requirements: Dicyclomine HCL, HyoscyamineSulfate, or Symax Duotab in 365 days

• PRADAXA Must meet 2 of the following requirements: Eliquis AND Xarelto in 365 days• PRESTALIA Must meet 2 of the following requirements: Amlodipine Besylate, Amlodipine

Besylate/benazepril, Benazepril HCL, Captopril, Enalapril Maleate, Epaned,Fosinopril Sodium, Lisinopril, Moexipril HCL, Perindopril Erbumine, Qbrelis,Quinapril HCL, Ramipril, or Trandolapril in 365 days

• PROTONIX Must meet any of the following requirements: Omeprazole Magnesium, Omeprazole,Pantoprazole Sodium, Prilosec OTC, or Prilosec in 120 days

• PRUDOXIN Must meet the following requirement: Topical Anti-inflammatory Steroidal in 120days

• PULMICORT FLEXHALER Must meet 2 of the following requirements: Arnuity Ellipta, Flovent Diskus, FloventHFA, Qvar Redihaler, or Qvar in 365 days

• PURIXAN Must meet the following requirement: Mercaptopurine in 120 days• QBRELIS Must meet the following requirement: Lisinopril in 120 days• QNASL Must meet any of the following requirements: Flunisolide, Fluticasone Propionate, or

Qnasl Children in 120 days• QNASL CHILDREN Must meet any of the following requirements: Flunisolide, Fluticasone Propionate, or

Qnasl in 120 days• QTERN Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,

Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide,Glyburide micronized, Glyburide/metformin HCL, Jardiance, Metformin HCL,Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metforminHCL, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days

• QUDEXY XR (100 MG) (CAP SPR 24) Must meet the following requirement: Topiramate in 120 days• QUDEXY XR (150 MG) (CAP SPR 24) Must meet the following requirement: Topiramate in 120 days• QUDEXY XR (200 MG) (CAP SPR 24) Must meet the following requirement: Topiramate in 120 days• QUDEXY XR (25 MG) (CAP SPR 24) Must meet the following requirement: Topiramate in 120 days• QUDEXY XR (50 MG) (CAP SPR 24) Must meet the following requirement: Topiramate in 120 days• QUILLICHEW ER (20 MG) (TABCBP24H) Must meet the following requirement: Methylphenidate HCL in 120 days• QUILLICHEW ER (30 MG) (TABCBP24H) Must meet the following requirement: Methylphenidate HCL in 120 days• QUILLICHEW ER (40 MG) (TABCBP24H) Must meet the following requirement: Methylphenidate HCL in 120 days• QUILLIVANT XR (5 MG/ML) (SU ERRC24) Must meet the following requirement: Methylphenidate HCL in 120 days• QUILLIVANT XR (5 MG/ML) (SU ERRC24) Must meet the following requirement: Methylphenidate HCL in 120 days• QUILLIVANT XR (5 MG/ML) (SU ERRC24) Must meet the following requirement: Methylphenidate HCL in 120 days• QUILLIVANT XR (5 MG/ML) (SU ERRC24) Must meet the following requirement: Methylphenidate HCL in 120 days• RAPAFLO Must meet any of the following requirements: Alfuzosin HCL, Doxazosin Mesylate,

Finasteride, Prazosin HCL, Rapaflo, Tamsulosin HCL, or Terazosin HCL in 120 days• RASUVO (10MG/0.2ML) (AUTO INJCT) Must meet 2 of the following requirements: Methotrexate Sodium, Methotrexate

Sodium/pf, Otrexup, Rheumatrex, or Trexall in 365 days• RASUVO (12.5/0.25) (AUTO INJCT) Must meet 2 of the following requirements: Methotrexate Sodium, Methotrexate

Sodium/pf, Otrexup, Rheumatrex, or Trexall in 365 days• RASUVO (15MG/0.3ML) (AUTO INJCT) Must meet 2 of the following requirements: Methotrexate Sodium, Methotrexate

Sodium/pf, Otrexup, Rheumatrex, or Trexall in 365 days• RASUVO (17.5/0.35) (AUTO INJCT) Must meet 2 of the following requirements: Methotrexate Sodium, Methotrexate

Sodium/pf, Otrexup, Rheumatrex, or Trexall in 365 days



• RASUVO (20MG/0.4ML) (AUTO INJCT) Must meet 2 of the following requirements: Methotrexate Sodium, MethotrexateSodium/pf, Otrexup, Rheumatrex, or Trexall in 365 days

• RASUVO (22.5/0.45) (AUTO INJCT) Must meet 2 of the following requirements: Methotrexate Sodium, MethotrexateSodium/pf, Otrexup, Rheumatrex, or Trexall in 365 days



• RASUVO (7.5MG/0.15) (AUTO INJCT) Must meet 2 of the following requirements: Methotrexate Sodium, MethotrexateSodium/pf, Otrexup, Rheumatrex, or Trexall in 365 days

• RAYOS Must meet any of the following requirements: Prednisone or Prednisone Intensol in120 days

• RELPAX Must meet the following requirement: Rizatriptan Benzoate or Sumatriptan Succinatein 180 days

• REQUIP XL Must meet any of the following requirements: Pramipexole Di-HCL or RopiniroleHCL in 120 days

• RETIN-A MICRO PUMP (0.06 %) (GELW/PUMP)

Must meet the following requirements: Generic Tretinoin Microspheres 0.04% and0.10% in 365 days

• RETIN-A MICRO PUMP (0.08 %) (GELW/PUMP)

Must meet the following requirements: Generic Tretinoin Microspheres 0.04% and0.10% in 365 days

• REXULTI Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,Citalopram Hydrobromide, Clozapine, Duloxetine HCL, Escitalopram Oxalate,Fluoxetine HCL, Olanzapine, Paroxetine HCL, Paroxetine Mesylate, Paxil, Pexeva,Quetiapine Fumarate, Risperidone, Sarafem, Seroquel XR, Sertraline HCL,Venlafaxine HCL, Versacloz, or Ziprasidone HCL in 365 days

• RHOPRESSA Must meet 2 of the following requirements: Alphagan P, Azopt, Combigan,Latanoprost, Lumigan, Simbrinza, or Travatan Z in 365 days

• RIBAVIRIN (200-400 MG) (TAB DS PK) Must meet the following requirement: Ribavirin in 120 days• RIBAVIRIN (200-400(7)) (TAB DS PK) Must meet the following requirement: Ribavirin in 120 days• RIBAVIRIN (400 MG) (TABLET) Must meet the following requirement: Ribavirin in 120 days• RIBAVIRIN (400-400 MG) (TAB DS PK) Must meet the following requirement: Ribavirin in 120 days• RIBAVIRIN (400-400(7)) (TAB DS PK) Must meet the following requirement: Ribavirin in 120 days• RIBAVIRIN (600 MG) (TABLET) Must meet the following requirement: Ribavirin in 120 days• RIBAVIRIN (600-400 MG) (TAB DS PK) Must meet the following requirement: Ribavirin in 120 days• RIBAVIRIN (600-400(7)) (TAB DS PK) Must meet the following requirement: Ribavirin in 120 days• RIBAVIRIN (600-600 MG) (TAB DS PK) Must meet the following requirement: Ribavirin in 120 days• RIBAVIRIN (600-600(7)) (TAB DS PK) Must meet the following requirement: Ribavirin in 120 days• RISEDRONATE SODIUM (150 MG)(TABLET)

Must meet the following requirement: Alendronate Sodium and Ibandronate Sodiumin 365 days

• RISEDRONATE SODIUM (30 MG)(TABLET)


• RISEDRONATE SODIUM (35 MG)(TABLET DR)






• ROZEREM Must meet any of the following requirements: Eszopiclone, Zaleplon, or ZolpidemTartrate in 120 days

• RYTARY Must meet the following requirement: Carbidopa/levodopa in 120 days• RYVENT Must meet the following requirements: Carbinoxamine tablet (4mg) and solution

(4mg/5mL) in 365 days• SANCTURA Must meet the following requirement: Oxybutynin Chloride in 120 days• SANCTURA XR Must meet the following requirement: Oxybutynin Chloride in 120 days• SANCUSO Must meet any of the following requirements: Ondansetron or Ondansetron HCL in

120 days• SAPHRIS Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,

Clozapine, Olanzapine, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz,or Ziprasidone HCL in 365 days

• SAVAYSA Must meet 2 of the following requirements: Eliquis AND Xarelto in 365 days• SEEBRI NEOHALER Must meet any of the following requirements: Spiriva Respimat or Spiriva in 120

days



• SEGLUROMET Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide,Glyburide micronized, Glyburide/metformin HCL, Jardiance, Metformin HCL,Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metforminHCL, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days

• SERNIVO Must meet the following requirement: Triamcinolone Acetonide in 120 days• SILENOR Must meet any of the following requirements: Doxepin HCL, Eszopiclone, Silenor,

Zaleplon, or Zolpidem Tartrate in 120 days• SIVEXTRO Must meet the following requirement: Linezolid in 120 days• SOLIQUA 100-33 Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise,

Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide,Glipizide/metformin HCL, Glyburide, Glyburide micronized, Glyburide/metforminHCL, Lantus Solostar, Lantus, Levemir Flexpen, Levemir Flextouch, Levemir,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, PioglitazoneHCL/metformin HCL, Tolazamide, Tolbutamide, Toujeo Solostar, Tresiba FlextouchU-100, Tresiba Flextouch U-200, or Trulicity in 365 days

• SOLODYN Must meet the following requirement: Minocycline HCL in 120 days• SOLOSEC Must meet 2 of the following requirements: Clindamycin HCL, Clindamycin

Palmitate HCL, Clindamycin Phosphate, Metronidazole, Tinidazole, or Vandazole in365 days

• SOOLANTRA Must meet the following requirement: Finacea in 120 days• SORILUX Must meet the following requirement: Topical Anti-inflammatory Steroidal in 120

days• SOTYLIZE (5 MG/ML) (SOLUTION) Must meet the following requirement: Sotalol HCL in 120 days• SPRITAM (1000 MG) (TAB SUSP) Must meet any of the following requirements: Levetiracetam in 120 days• SPRITAM (250 MG) (TAB SUSP) Must meet the following requirement: Levetiracetam in 120 days• SPRITAM (500 MG) (TAB SUSP) Must meet the following requirement: Levetiracetam in 120 days• SPRITAM (750 MG) (TAB SUSP) Must meet the following requirement: Levetiracetam in 120 days• SPRIX Must meet the following requirement: Nsaids, Cyclooxygenase Inhibitor-type in 120

days• STEGLATRO Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,

Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide,Glyburide micronized, Glyburide/metformin HCL, Jardiance, Metformin HCL,Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metforminHCL, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days

• STEGLUJAN Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide,Glyburide micronized, Glyburide/metformin HCL, Jardiance, Metformin HCL,Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metforminHCL, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days

• SUMAVEL DOSEPRO (4 MG/0.5ML)(NDL FR INJ)

Must meet any of the following requirements: Alsuma, Sumatriptan, or SumatriptanSuccinate in 180 days

• SUMAVEL DOSEPRO (6 MG/0.5ML)(NDL FR INJ)

Must meet any of the following requirements: Alsuma, Sumatriptan, or SumatriptanSuccinate in 180 days

• SURE RESULT TAC PAK Must meet 3 of the following requirements: Amerigel Barrier, Dimethicone, ScarTreatment, Silicone Disc, Silicone Roll, Silicone Scar, Silicone Sheet, Silicone Tape,or Triamcinolone Acetonide in 365 days

• SYMPROIC Must meet the following requirement: Movantik in 120 days• SYNDROS Must meet the following requirement: Dronabinol or Megestrol Acetate in 120 days• SYNJARDY Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,


• SYNJARDY XR Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburidemicronized, Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL,Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Tolazamide, orTolbutamide in 120 days

• TACLONEX (0.005-.064) (OINT. (G)) Must meet the following requirements: Topical Anti-inflammatory Steroidal in 120days



• TACLONEX (0.005-.064) (SUSPENSION) Must meet the following requirements: Topical Anti-inflammatory Steroidal in 120days

• TANZEUM Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise,Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide,Glipizide/metformin HCL, Glyburide, Glyburide micronized, Glyburide/metforminHCL, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Tolazamide, Tolbutamide, or Trulicity in 365days

• TARGADOX Must meet any of the following requirements: Doxycycline Hyclate or DoxycyclineMonohydrate in 120 days

• TASMAR Must meet the following requirement: Entacapone in 120 days• TIMOPTIC OCUDOSE Must meet any of the following requirements: Timolol Maleate or Timoptic Ocudose

in 120 days• TIVORBEX Must meet the following requirement: Indomethacin in 120 days• TOPICORT (0.25 %) (SPRAY) Must meet any of the following requirements: Betamethasone Dipropionate,

Desoximetasone, Fluocinonide, or Mometasone Furoate in 120 days• TOVIAZ Must meet the following requirement: Oxybutynin Chloride in 120 days• TREXIMET (10 MG-60MG) (TABLET) Must meet any of the following requirements: Almotriptan Malate, Alsuma,

Eletriptan Hydrobromide, Frovatriptan Succinate, Naratriptan HCL, Onzetra Xsail,Rizatriptan Benzoate, Sumatriptan Succinate/Naproxen Sodium, SumatriptanSuccinate, Sumatriptan, Sumavel Dosepro, Treximet, Zecuity, Zembrace Symtouch,Zolmitriptan, or Zomig in 180 days

• TREXIMET (85MG-500MG) (TABLET) Must meet any of the following requirements: Almotriptan Malate, Alsuma,Eletriptan Hydrobromide, Frovatriptan Succinate, Naratriptan HCL, Onzetra Xsail,Rizatriptan Benzoate, Sumatriptan Succinate/Naproxen Sodium, SumatriptanSuccinate, Sumatriptan, Sumavel Dosepro, Treximet, Zecuity, Zembrace Symtouch,Zolmitriptan, or Zomig in 180 days

• TRIGLIDE Must meet any of the following requirements: Antara, Fenofibrate micronized,Fenofibrate Nanocrystallized, or Gemfibrozil in 120 days

• TRINTELLIX Must meet 2 of the following requirements: Bupropion HCL, CitalopramHydrobromide, Escitalopram Oxalate, Fluoxetine HCL, Forfivo XL, Mirtazapine,Paroxetine HCL, Paxil, Sarafem, Sertraline HCL, or Venlafaxine HCL in 365 days

• TROKENDI XR (100 MG) (CAP ER 24H) Must meet the following requirement: Topiramate in 120 days• TROKENDI XR (200 MG) (CAP ER 24H) Must meet the following requirement: Topiramate in 120 days• TROKENDI XR (25 MG) (CAP ER 24H) Must meet the following requirement: Topiramate in 120 days• TROKENDI XR (50 MG) (CAP ER 24H) Must meet the following requirement: Topiramate in 120 days• TRULANCE Must meet the following requirement: Linzess in 120 days• TRULICITY Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,


• TUDORZA PRESSAIR Must meet any of the following requirements: Spiriva Respimat or Spiriva in 120days

• TUZISTRA XR Must meet any of the following requirements: Promethazine HCL/codeine in 120days

• UCERIS Must meet any of the following requirements: Mesalamine or MesalamineW/cleansing Wipes in 120 days

• UCERIS Must meet the following requirement: Balsalazide Disodium in 120 days• ULORIC Must meet any of the following requirements: Allopurinol or Uloric in 120 days• UTIBRON NEOHALER Must meet the following requirement: Anoro Ellipta and Stiolto Respimat in 365

days• VECTICAL Must meet the following requirement: Topical Anti-inflammatory Steroidal in 120

days• VEMLIDY Must meet the following requirement: Tenofovir Disoproxil Fumarate in 120 days• VEREGEN Must meet 2 of the following requirements: Imiquimod AND Podofilox in 120 days• VERSACLOZ Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,

Clozapine, Olanzapine, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz,or Ziprasidone HCL in 365 days

• VESICARE Must meet the following requirement: Oxybutynin Chloride in 120 days• VICTOZA 2-PAK Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise,

Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide,



Glipizide/metformin HCL, Glyburide, Glyburide micronized, Glyburide/metforminHCL, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Tolazamide, Tolbutamide, or Trulicity in 365days

• VICTOZA 3-PAK Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise,Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide,Glipizide/metformin HCL, Glyburide, Glyburide micronized, Glyburide/metforminHCL, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride,Pioglitazone HCL/metformin HCL, Tolazamide, Tolbutamide, or Trulicity in 365days

• VIIBRYD Must meet 2 of the following requirements: Bupropion HCL, CitalopramHydrobromide, Escitalopram Oxalate, Fluoxetine HCL, Forfivo XL, Mirtazapine,Paroxetine HCL, Paxil, Sarafem, Sertraline HCL, or Venlafaxine HCL in 365 days

• VIMOVO Must meet any of the following requirements: Naprelan, Naproxen, or NaproxenSodium in 120 days

• VIMPAT (10 MG/ML) (SOLUTION) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine,Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor,Topiramate, Trokendi XR, or Valproic Acid in 365 days

• VIMPAT (100 MG) (TABLET) Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium,Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine,Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor,Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days




• VIVLODEX Must meet the following requirement: Meloxicam in 120 days• VRAYLAR (1.5 MG) (CAPSULE) Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,


• VRAYLAR (1.5 MG-3MG) (CAP DS PK) Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,Clozapine, Olanzapine, Quetiapine Fumarate, Seroquel XR, Versacloz, orZiprasidone HCL in 365 days

• VRAYLAR (3 MG) (CAPSULE) Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,Clozapine, Olanzapine, Quetiapine Fumarate, Seroquel XR, Versacloz, orZiprasidone HCL in 365 days

• VRAYLAR (4.5 MG) (CAPSULE) Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,Clozapine, Olanzapine, Quetiapine Fumarate, Seroquel XR, Versacloz, orZiprasidone HCL in 365 days

• VRAYLAR (6 MG) (CAPSULE) Must meet 2 of the following requirements: Abilify Maintena, Abilify, Aripiprazole,Clozapine, Olanzapine, Quetiapine Fumarate, Seroquel XR, Versacloz, orZiprasidone HCL in 365 days

• VYTORIN (10 MG-80MG) (TABLET) Must meet the following requirement: Simvastatin in 365 days• VYVANSE Must meet any of the following requirements: Aptensio XR, Citalopram

Hydrobromide, Dextroamphetamine/amphetamine, Escitalopram Oxalate, FluoxetineHCL, Fluvoxamine Maleate, Methylphenidate HCL, Mydayis, Paroxetine HCL,Paxil, Quillichew ER, Quillivant XR, Relexxii, Sarafem, Sertraline HCL,Topiramate, or Trokendi XR in 120 days

• VYZULTA Must meet 2 of the following requirements: Alphagan P, Azopt, Combigan,Latanoprost, Lumigan, Simbrinza, or Travatan Z in 365 days

• XADAGO Must meet any of the following requirements: Carbidopa/levodopa, Duopa, or Rytaryin 120 days

• XATMEP Must meet any of the following requirements: Methotrexate Sodium, MethotrexateSodium/pf, or Trexall in 120 days



• XERESE Must meet any of the following requirements: Acyclovir, Famciclovir, Sitavig,Valacyclovir HCL, or Zovirax in 120 days

• XHANCE Must meet 2 of the following requirements: Children's Flonase Sensimist, FlonaseSensimist, Flunisolide, Fluticasone Propionate, Mometasone Furoate, QnaslChildren, or Qnasl in 365 days

• XIGDUO XR Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide,Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburidemicronized, Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL,Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Tolazamide, orTolbutamide in 120 days

• XIMINO Must meet the following requirement: Minocycline HCL in 120 days• XULTOPHY 100-3.6 Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise,

Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide,Glipizide/metformin HCL, Glyburide, Glyburide micronized, Glyburide/metforminHCL, Lantus Solostar, Lantus, Levemir Flexpen, Levemir Flextouch, Levemir,Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, PioglitazoneHCL/metformin HCL, Tolazamide, Tolbutamide, Toujeo Solostar, Tresiba FlextouchU-100, Tresiba Flextouch U-200, or Trulicity in 365 days

• XYZAL (2.5 MG/5ML) (SOLUTION) Must meet any of the following requirements: Desloratadine or LevocetirizineDihydrochloride in 120 days

• ZEGERID (20-1680MG) (PACKET) Must meet any of the following requirements: Lansoprazole, Omeprazole,Pantoprazole Sodium, Prilosec OTC, or Protonix in 120 days

• ZEGERID (20MG-1.1G) (CAPSULE) Must meet any of the following requirements: Lansoprazole, Omeprazole,Pantoprazole Sodium, Prilosec OTC, or Protonix in 120 days

• ZEGERID (40-1680MG) (PACKET) Must meet any of the following requirements: Lansoprazole, Omeprazole,Pantoprazole Sodium, Prilosec OTC, or Protonix in 120 days

• ZEGERID (40MG-1.1G) (CAPSULE) Must meet any of the following requirements: Lansoprazole, Omeprazole,Pantoprazole Sodium, Prilosec OTC, or Protonix in 120 days

• ZEMBRACE SYMTOUCH Must meet any of the following requirements: Alsuma or Sumatriptan Succinate in120 days

• ZENZEDI (15 MG) (TABLET) Must meet the following requirement: Dextroamphetamine Sulfate in 120 days• ZENZEDI (2.5 MG) (TABLET) Must meet the following requirement: Dextroamphetamine Sulfate in 120 days• ZENZEDI (20 MG) (TABLET) Must meet the following requirement: Dextroamphetamine Sulfate in 120 days• ZENZEDI (30 MG) (TABLET) Must meet the following requirement: Dextroamphetamine Sulfate in 120 days• ZENZEDI (7.5 MG) (TABLET) Must meet the following requirement: Dextroamphetamine Sulfate in 120 days• ZETONNA Must meet the following requirement: Flunisolide or Fluticasone Propionate in 120

days• ZIOPTAN Must meet 2 of the following requirements: Latanoprost, Lumigan, or Travatan Z in

365 days• ZIPSOR Must meet any of the following requirements: Diclo Gel, Diclofenac Sodium,

Diclofenac Sodium/misoprostol, Diclofono, Diclozor, Dyloject, Pennsaid, or VopacMds in 120 days

• ZITHRANOL Must meet the following requirement: Topical Anti-inflammatory Steroidal in 120days

• ZOCOR (80 MG) (TABLET) Must meet the following requirement: Vytorin in 365 days• ZOLPIMIST Must meet the following requirement: Zolpidem Tartrate in 120 days• ZOMIG (2.5 MG) (SPRAY) Must meet any of the following requirements: Rizatriptan Benzoate or Sumatriptan

Succinate in 180 days• ZOMIG (2.5 MG) (TABLET) Must meet any of the following requirements: Rizatriptan Benzoate or Sumatriptan

Succinate in 180 days• ZOMIG (5 MG) (SPRAY) Must meet any of the following requirements: Rizatriptan Benzoate or Sumatriptan

Succinate in 180 days• ZOMIG (5 MG) (TABLET) Must meet any of the following requirements: Rizatriptan Benzoate or Sumatriptan

Succinate in 180 days• ZOMIG ZMT Must meet any of the following requirements: Rizatriptan Benzoate or Sumatriptan

Succinate in 180 days• ZONALON Must meet the following requirement: Topical Anti-inflammatory Steroidal in 120

days• ZORVOLEX Must meet any of the following requirements: Diclo Gel, Diclofenac Sodium,

Diclofono, Diclozor, Dyloject, Pennsaid, or Vopac Mds in 120 days• ZUPLENZ (4 MG) (FILM) Must meet any of the following requirements: Ondansetron or Ondansetron HCL in

120 days



• ZUPLENZ (8 MG) (FILM) Must meet any of the following requirements: Ondansetron or Ondansetron HCL in120 days

• ZURAMPIC Must meet the following requirement: Allopurinol in 120 days• ZYCLARA (2.5 %) (CRM MD PMP) Must meet any of the following requirements: Diclofenac Sodium, Fluorouracil, or

Imiquimod in 120 days• ZYCLARA (3.75 %) (CREAM PACK) Must meet any of the following requirements: Diclofenac Sodium, Fluorouracil, or

Imiquimod in 120 days• ZYCLARA (3.75 %) (CRM MD PMP) Must meet any of the following requirements: Diclofenac Sodium, Fluorouracil, or

Imiquimod in 120 days• ZYFLO Must meet 2 of the following requirements: Montelukast Sodium AND Zafirlukast in

365 days• ZYFLO CR Must meet 2 of the following requirements: Montelukast Sodium AND Zafirlukast in

365 days• ZYPITAMAG Must meet the following requirement: Livalo in 120 days



- # -0.9 % SODIUM CHLORIDE............................................ 760.9 % SODIUM CHLORIDE (0.9 %) (IV SOLN)................0.9 % SODIUM CHLORIDE (0.9 %) (SYRINGE)..............0.9 % SODIUM CHLORIDE (0.9 %) (VIAL)......................0.9 % SODIUM CHLORIDE (PGGYBK PRT)....................0.9 % SODIUM CHLORIDE (PGY VL PRT)......................1ST TIER UNIFINE PENTIPS....................................... 1321ST TIER UNIFINE PENTIPS PLUS............................ 1321ST TIER UNILET COMFORTOUCH.......................... 1062TEK............................................................................61, 62

- A -ABACAVIR SULFATE..................................................... 95ABACAVIR SULFATE/LAMIVUDINE...........................94ABACAVIR/DOLUTEGRAVIR/LAMIVUDI.................. 96ABACAVIR/LAMIVUDINE/ZIDOVUDINE...................94ABALOPARATIDE...........................................................77ABATACEPT.....................................................................98ABEMACICLIB..............................................................125ABILIFY (1 MG/ML) (SOLUTION)........................27, 154ABILIFY (10 MG) (TABLET)..........................................27ABILIFY (15 MG) (TABLET)..........................................27ABILIFY (2 MG) (TABLET)............................................27ABILIFY (20 MG) (TABLET)..........................................27ABILIFY (30 MG) (TABLET)..........................................27ABILIFY (5 MG) (TABLET)............................................27ABILIFY DISCMELT (10 MG) (TAB RAPDIS)...... 27,154ABILIFY DISCMELT (15 MG) (TAB RAPDIS)...... 28,154ABIRATERONE ACET,SUBMICRONIZED................. 124ABIRATERONE ACETATE........................................... 124ABSORICA............................................................... 43, 154ABSTRAL....................................................................... 137ACALABRUTINIB......................................................... 125ACAMPROSATE CALCIUM...........................................27ACANYA...................................................................43, 154ACARBOSE...................................................................... 55ACCOLATE.......................................................................19ACCUCAINE.................................................................. 101ACCU-CHEK.................................. 61, 70, 72, 73, 106, 111ACCU-CHEK AVIVA PLUS.......................................56, 65ACCU-CHEK COMPACT PLUS CONTROL..................61ACCU-CHEK COMPACT PLUS STRIPS....................... 61ACCU-CHEK FASTCLIX LANCET DRUM.................107ACCU-CHEK FASTCLIX LANCING DEV.................... 73ACCU-CHEK GUIDE CONTROL SOLN........................61ACCU-CHEK GUIDE MONITOR SYSTEM.................. 65ACCU-CHEK GUIDE TEST STRIP................................ 56ACCU-CHEK NANO SMARTVIEW...............................65ACCU-CHEK RAPID D................................................. 111ACCU-CHEK SAFE-T-PRO........................................... 107ACCU-CHEK SAFE-T-PRO PLUS................................ 107ACCU-CHEK SMARTVIEW..................................... 56, 64ACCU-CHEK SOFTCLIX........................................ 73, 107ACCU-CHEK SPIRIT.....................................................111ACCUPRIL........................................................................33ACCURETIC.....................................................................32ACCUTREND GLUCOSE..........................................56, 61ACD................................................................................... 83ACE AEROSOL CLOUD ENHANCER...........................20ACEBUTOLOL HCL........................................................33ACEON..............................................................................33ACETAMINOPHEN WITH CODEINE................. 141, 142ACETAMINOPHEN WITH CODEINE (120-12MG/5)(SOLUTION).........................................................................ACETAMINOPHEN WITH CODEINE (300MG/12.5)(SOLUTION).........................................................................ACETAMINOPHEN WITH CODEINE (300MG-15MG)(TABLET)..............................................................................ACETAMINOPHEN WITH CODEINE (300MG-30MG)(TABLET)..............................................................................ACETAMINOPHEN WITH CODEINE (300MG-60MG)(TABLET)..............................................................................ACETAMINOPHEN/CAFF/DIHYDROCOD........ 137, 154ACETAZOLAMIDE..........................................................81ACETIC ACID............................................................ 50, 75ACETIC ACID/OXYQUINOLINE.................................150ACETOHYDROXAMIC ACID...................................... 102ACETYLCYSTEINE.............................................. 128, 137ACETYLCYSTEINE IN WATER/PF............................... 82ACIPHEX........................................................................ 149ACIPHEX SPRINKLE............................................ 149, 154ACITRETIN...................................................................... 54ACLIDINIUM BROMIDE................................................ 18ACLOVATE....................................................................... 47ACTEMRA........................................................................99ACTICLATE..............................................................91, 154ACTICOAT......................................................................104ACTICOAT 7...................................................................104ACTICOAT FLEX 3........................................................104

ACTICOAT FLEX 7........................................................104ACTICOAT SURGICAL.................................................104ACTIGALL..................................................................... 103ACTI-LANCE................................................................. 107ACTIMMUNE...................................................................89ACTIQ............................................................................. 137ACTIVE OB.................................................................... 151ACTIVELLA..................................................................... 87ACTIVE-PAC.................................................................. 144ACTOPLUS MET..................................................... 56, 154ACTOPLUS MET XR...............................................56, 154ACTOS.............................................................................. 56ACUICYN......................................................................... 81ACULAR........................................................................... 79ACULAR LS..................................................................... 79ACUVAIL.......................................................................... 79ACYCLOVIR.............................................................. 45, 94ACYCLOVIR/HYDROCORTISONE............................... 45ACZONE (5 %) (GEL (GRAM))...................................... 43ACZONE (7.5 %) (GEL W/PUMP).................................. 43ADALAT CC..................................................................... 35ADALIMUMAB......................................................... 97, 98ADAPALENE....................................................................44ADAPALENE/BENZOYL PEROXIDE............................43ADASUVE........................................................................ 28ADAZIN............................................................................ 53ADCIRCA......................................................................... 36ADDERALL......................................................................26ADDERALL XR (10 MG) (CAP ER 24H).......................26ADDERALL XR (15 MG) (CAP ER 24H).......................26ADDERALL XR (20 MG) (CAP ER 24H).......................26ADDERALL XR (25 MG) (CAP ER 24H).......................26ADDERALL XR (30 MG) (CAP ER 24H).......................27ADDERALL XR (5 MG) (CAP ER 24H).........................27ADEFOVIR DIPIVOXIL.................................................. 96ADEMPAS.........................................................................35ADENOSINE/LIDOCAINE/MAG/SOD CH..................129ADENOVIRUS LIVE TYPES-4,7 VACC.........................88ADENOVIRUS TYPE 4....................................................88ADENOVIRUS TYPE 4 AND TYPE 7............................ 88ADENOVIRUS TYPE 7....................................................88ADENOVIRUS VACCINE LIVE TYPE-4....................... 88ADENOVIRUS VACCINE LIVE TYPE-7....................... 88ADJUSTABLE LANCING DEVICE................................72ADLYXIN................................................................. 55, 154ADMELOG............................................................... 74, 154ADMELOG SOLOSTAR.......................................... 74, 154ADOXA............................................................................. 91ADRENALIN CHLORIDE...............................................43ADVAIR DISKUS............................................................. 18ADVAIR HFA....................................................................18ADVANCE PLUS INTERMITTENT............................. 105ADVANCED GLUCOSE METER....................................65ADVANCED GLUCOSE TEST STRIP............................57ADVANCED GLUCOSE TEST STRIPS......................... 57ADVANCED LANCING DEVICE...................................73ADVANCED TRAVEL LANCETS................................ 107ADVATE............................................................................ 83ADVOCATE BLOOD GLUCOSE MONITOR................ 65ADVOCATE CONTROL SOLUTION....................... 62, 63ADVOCATE DUO............................................................ 62ADVOCATE LANCET................................................... 107ADVOCATE LANCETS................................................. 107ADVOCATE LANCING DEVICE................................... 72ADVOCATE PEN NEEDLE........................................... 132ADVOCATE PEN NEEDLES.........................................132ADVOCATE RAPID-SAFE.............................................. 72ADVOCATE REDI-CODE..........................................57, 65ADVOCATE REDI-CODE PLUS.....................................65ADVOCATE REDI-CODE+............................................. 57ADVOCATE REDI-CODE+ CTRL SOLN.................62, 63ADVOCATE SYRINGES........................................112, 122ADVOCATE TEST STRIP................................................57ADYNOVATE....................................................................82ADZENYS ER...........................................................26, 154ADZENYS XR-ODT.................................................26, 154AEROBIKA.......................................................................21AEROCHAMBER MINI...................................................20AEROCHAMBER MV..................................................... 20AEROCHAMBER PLUS FLOW-VU......................... 20, 21AEROCHAMBER WITH FLOWSIGNAL.......................20AEROCHAMBER Z-STAT PLUS.............................. 20, 21AEROECLIPSE II............................................................. 21AEROGEAR ASTHMA ACTION KIT............................ 23AERONEB GO................................................................105AERONEB GO NEBULIZER...........................................21AEROSPAN...............................................................19, 154AEROTRACH PLUS.........................................................20AEROVENT PLUS........................................................... 20AFATINIB DIMALEATE............................................... 125AFINITOR.......................................................................125AFINITOR DISPERZ..................................................... 125

AFLURIA 2018-2019........................................................88AFLURIA QUAD 2018-2019........................................... 88AFREZZA......................................................................... 75AFSTYLA......................................................................... 82AGAMATRIX AMP....................................................57, 65AGAMATRIX CONTROL..........................................61, 62AGGRENOX..................................................................... 85AGONEAZE......................................................................53AGRYLIN..........................................................................85AIMOVIG AUTOINJECTOR......................................... 140AIMOVIG AUTOINJECTOR (2 PACK)........................ 140AIR FILTER.................................................................... 105AIRDUO RESPICLICK....................................................18AIRS DISPOSABLE NEBULIZER..................................21AIRZONE PEAK FLOW METER....................................23AJOVY............................................................................ 140AKTEN..............................................................................80AKTIPAK.......................................................................... 44AKYNZEO........................................................................ 17ALA-QUIN........................................................................43ALBENDAZOLE.............................................................. 93ALBENZA.........................................................................93ALBIGLUTIDE.................................................................55ALBUTEROL SULFATE..................................................18ALCAFTADINE................................................................79ALCLOMETASONE DIPROPIONATE........................... 47ALCOHOL SWAB CAP................................................. 111ALCORTIN A (2 %-1 %-1%) (GEL (GRAM))................ 43ALCORTIN A (2 %-1 %-1%) (GEL PACKET)................43ALDACTAZIDE (25 MG-25MG) (TABLET).................. 35ALDACTAZIDE (50 MG-50MG) (TABLET).................. 35ALDACTONE................................................................... 35ALDARA...........................................................................89ALDOMET........................................................................33ALDORIL 15.....................................................................33ALDORIL 25.....................................................................33ALECENSA.................................................................... 125ALECTINIB HCL........................................................... 125ALENDRONATE SODIUM............................................. 77ALENDRONATE SODIUM/VITAMIN D3......................77ALEVICYN PLUS............................................................ 49ALFERON N..................................................................... 89ALFUZOSIN HCL.......................................................... 149ALINIA..............................................................................94ALIROCUMAB.................................................................38ALISKIREN HEMIFUMARATE..................................... 36ALISKIREN/HYDROCHLOROTHIAZIDE.................... 36ALITRETINOIN............................................................... 52ALKALINE BATTERIES................................................. 70ALKERAN...................................................................... 124ALL FLOW 1000............................................................ 105ALL FLOW 3000 KIT.....................................................105ALL FLOW 3000 PFT.................................................... 105ALL FLOW 4000............................................................ 105ALL FLOW 5000............................................................ 105ALL FLOW 6000............................................................ 106ALLEGRA-D 24 HOUR (180-240MG) (TAB ER 24H)........................................................................................... 16ALLERGIST TRAY................................................ 112, 114ALLERGIST TRAY SYR-DETACH NDL..................... 115ALLERGIST TRAY SYR-PERM NEEDLE...................112ALLERGY SYRINGE (27GX1/2") (DISP SYRIN) (OTC)......................................................................................... 114ALLERGY SYRINGE (28GX1/2") (DISP SYRIN) (OTC)......................................................................................... 114ALLEVYN...................................................................... 104ALLEVYN ADHESIVE................................................. 104ALLEVYN AG................................................................104ALLEVYN AG ADHESIVE...........................................104ALLEVYN AG GENTLE............................................... 104ALLEVYN HEEL........................................................... 104ALLEVYN LIFE............................................................. 104ALLOPURINOL............................................................... 82ALLZITAL.............................................................. 137, 154ALMOTRIPTAN MALATE.................................... 140, 154ALOCRIL.......................................................................... 81ALOGLIPTIN BENZ/METFORMIN HCL...................... 55ALOGLIPTIN BENZ/PIOGLITAZONE.......................... 55ALOGLIPTIN BENZOATE.............................................. 55ALOMIDE.........................................................................81ALORA..............................................................................87ALOSETRON HCL.........................................................103ALPHA-1-PROTEINASE INHIBITOR.................. 123, 124ALPHAGAN..................................................................... 81ALPHAGAN P (0.1 %) (DROPS).....................................81ALPHAGAN P (0.15 %) (DROPS)...................................81ALPHANATE....................................................................83ALPHANINE SD.............................................................. 83ALPRAZOLAM................................................................ 27ALPRAZOLAM INTENSOL...............................................ALPROLIX........................................................................83ALREX.............................................................................. 79


Index

ALTABAX......................................................................... 45ALTACE............................................................................ 33ALTERA NEBULIZER.....................................................21ALTERNATE SITE LANCETS...................................... 107ALTERNATE SITE LANCING DEVICE.........................72ALTOPREV...............................................................37, 154ALTRETAMINE..............................................................124ALUMINUM CHLORIDE................................................49ALUNBRIG.....................................................................125ALUPENT......................................................................... 18ALVESCO................................................................. 19, 154ALVIMOPAN.................................................................. 103ALZAIR...........................................................................128AMANTADINE HCL......................................................142AMARYL.......................................................................... 56AMBIEN............................................................................30AMBIEN CR..................................................................... 30AMBRISENTAN...............................................................36AMCINONIDE..................................................................47AMELUZ.........................................................................127AMERGE........................................................................ 141AMICAR........................................................................... 82AMIELLE VAGINAL TRAINER................................... 105AMILORIDE HCL............................................................35AMILORIDE/HYDROCHLOROTHIAZIDE...................35AMINOACETIC ACID..................................................... 93AMINOCAPROIC ACID.................................................. 82AMINOLEVULINIC ACID HCL...................................127AMINOSALICYLIC ACID.............................................. 93AMIODARONE HCL....................................................... 31AMITIZA................................................................ 103, 154AMITRIPTYLINE HCL................................................... 26AMITRIPTYLINE/CHLORDIAZEPOXIDE................... 26AMLODIPINE BES/OLMESARTAN MED.................... 33AMLODIPINE BESYLATE............................................. 34AMLODIPINE BESYLATE/BENAZEPRIL.................... 32AMLODIPINE BESYLATE/VALSARTAN..................... 33AMLODIPINE/ATORVASTATIN.....................................39AMLODIPINE/VALSARTAN/HCTHIAZID................... 32AMMONIUM LACTATE..................................................50AMMONIUM LACTATE (12 %) (CREAM (G)).................AMMONIUM LACTATE (12 %) (LOTION).......................AMOXAPINE................................................................... 26AMOXICILLIN.................................................................90AMOXICILLIN/POTASSIUM CLAV........................ 90, 91AMOXIL........................................................................... 90AMPHETAMINE.............................................................. 26AMPHETAMINE SULFATE............................................ 26AMPICILLIN.................................................................... 91AMPICILLIN TRIHYDRATE.......................................... 91AMPYRA........................................................................ 127AMRIX............................................................................ 146AMYL NITRITE............................................................... 39ANACAINE.......................................................................52ANADROL-50...................................................................86ANAFRANIL.................................................................... 26ANAGRELIDE HCL.........................................................85ANAKINRA...................................................................... 97ANA-LEX HC................................................................. 102ANALPRAM HC.............................................................. 52ANALPRAM HC (1 %-1 %) (CREAM/APPL).............. 102ANALPRAM HC (2.5 %-1 %) (CREAM/APPL)........... 102ANALPRAM HC (2.5-1%(4G)) (CREAM/APPL).........102ANAMANTLE HC..........................................................102ANAMANTLE HC FORTE............................................ 102ANAPROX...................................................................... 101ANAPROX DS................................................................ 101ANASCORP.................................................................... 128ANASTIA..........................................................................53ANASTROZOLE............................................................ 124ANCOBON........................................................................92ANDRODERM..................................................................86ANDROGEL (1.25G-1.62) (GEL PACKET).................... 86ANDROGEL (12.5/1.25G) (GEL MD PMP)....................86ANDROGEL (2.5G-1.62%) (GEL PACKET)...................86ANDROGEL (20.25/1.25) (GEL MD PMP).....................86ANDROGEL (25MG(1%)) (GEL PACKET)....................86ANDROGEL (50 MG (1%)) (GEL PACKET)..................86ANDROID......................................................................... 86ANGELIQ..........................................................................87ANIMAS VIBE................................................................. 74ANORO ELLIPTA............................................................ 18ANSAID.......................................................................... 100ANTABUSE...................................................................... 27ANTARA (130 MG) (CAPSULE).................................... 38ANTARA (30 MG) (CAPSULE).............................. 38, 154ANTARA (43 MG) (CAPSULE)...................................... 39ANTARA (90 MG) (CAPSULE).............................. 39, 154ANTHRALIN.................................................................... 54ANTHRALIN MICRONIZED.......................................... 54ANTIHEM.FVIII,SIN-CHN,B-DM TRU......................... 82ANTIHEMO.FVIII,FULL LENGTH PEG....................... 82

ANTIHEMOPH.FVIII REC,FC FUSION.........................82ANTIHEMOPH.FVIII,B-DOM TRUNCAT..................... 82ANTIHEMOPH.FVIII,B-DOMAIN DEL.........................82ANTIHEMOPH.FVIII,HEK B-DELETE......................... 82ANTIHEMOPHIL.FVIII,FULL LENGTH....................... 83ANTIHEMOPHILIC FACTOR, HUM REC.....................83ANTIHEMOPHILIC FACTOR, HUMAN........................83ANTIHEMOPHILIC FACTOR/VWF...............................83ANTIHEMOPHILIC FVIII,REC PORC...........................83ANTI-INHIBITOR COAGULANT COMP.......................83ANUSOL-HC.................................................................. 102ANZEMET (100 MG) (TABLET)............................ 17, 154ANZEMET (50 MG) (TABLET).............................. 17, 155APALUTAMIDE............................................................. 124APEXICON....................................................................... 47APEXICON E....................................................................47APIDRA.................................................................... 74, 155APIDRA SOLOSTAR............................................... 74, 155APIXABAN.......................................................................83APLENZIN................................................................25, 155APLIGRAF......................................................................134APOGEE HC INTERMITTENT.....................................105APOGEE IC INTERMITTENT CATHETR................... 105APRACLONIDINE HCL.................................................. 81APREMILAST.................................................................. 98APREPITANT................................................................... 17APRESOLINE...................................................................33APRISO........................................................................... 102APTENSIO XR......................................................... 30, 155APTIOM (200 MG) (TABLET).............................. 143, 155APTIOM (400 MG) (TABLET).............................. 143, 155APTIOM (600 MG) (TABLET).............................. 143, 155APTIOM (800 MG) (TABLET).............................. 143, 155APTIVUS.......................................................................... 94AQUA GLYCOLIC HC.....................................................48AQUA LANCE LANCING DEVICE............................... 72AQUORAL...................................................................... 134ARALAST NP.................................................................123ARANESP......................................................................... 84ARAVA.............................................................................. 98ARCALYST.......................................................................97ARCAPTA NEOHALER.......................................... 18, 155ARESTIN........................................................................ 128ARFORMOTEROL TARTRATE...................................... 18ARGYLE................................................................. 105, 110ARICEPT...........................................................................24ARICEPT ODT................................................................. 24ARIMIDEX..................................................................... 124ARIPIPRAZOLE.........................................................27, 28ARIXTRA (10MG/0.8ML) (SYRINGE).......................... 84ARIXTRA (2.5 MG/0.5) (SYRINGE).............................. 85ARIXTRA (5MG/0.4ML) (SYRINGE)............................ 85ARIXTRA (7.5MG/0.6) (SYRINGE)............................... 85ARMODAFINIL............................................................... 29ARMONAIR RESPICLICK......................................19, 155ARMOUR THYROID.......................................................78ARNUITY ELLIPTA........................................................ 19AROMASIN.................................................................... 124ARTANE..........................................................................142ARTEMETHER/LUMEFANTRINE.................................93ARTHROTEC 50.............................................................100ARTHROTEC 75.............................................................100ARTISS............................................................................136ARYMO ER.....................................................................138ASACOL HD...................................................................102ASCOR............................................................................ 153ASCORBATE SODIUM................................................. 153ASCORBIC ACID...........................................................153ASCORBIC ACID (500 MG/ML) (VIAL)...........................ASENAPINE MALEATE..................................................28ASENDIN..........................................................................26ASFOTASE ALFA.......................................................... 130ASMANEX................................................................19, 155ASMANEX HFA.......................................................19, 155ASPIRIN....................................................................85, 137ASPIRIN (325 MG) (TABLET DR) (OTC)..........................ASPIRIN (325 MG) (TABLET) (OTC).................................ASPIRIN/DIPYRIDAMOLE............................................ 85ASPIRIN/OMEPRAZOLE................................................85ASSEMBLY SYS,VIAL TO TRNSF,CLS......................110ASSURE 4................................................................... 57, 62ASSURE DOSE...........................................................61, 64ASSURE HAEMOLANCE PLUS.......................... 106, 107ASSURE ID INSULIN SAFETY....................................118ASSURE ID PEN NEEDLE............................................133ASSURE LANCE............................................................107ASSURE LANCE PLUS.................................................107ASSURE PLATINUM.................................................57, 65ASSURE PRISM............................................................... 61ASSURE PRISM MULTI............................................57, 65ASTAGRAF XL................................................................ 89ASTELIN...........................................................................16

ASTEPRO..................................................................16, 155ASTERO............................................................................53ASTHMA CHECK............................................................23ASTHMAPACK CHILDREN'S........................................ 23ASTRINGYN.................................................................... 86ATABEX EC....................................................................152ATACAND.........................................................................33ATACAND HCT................................................................32ATARAX........................................................................... 16ATAZANAVIR SULFATE.................................................95ATAZANAVIR SULFATE/COBICISTAT.........................95ATENOLOL...................................................................... 34ATENOLOL/CHLORTHALIDONE.................................34ATOMOXETINE HCL......................................................31ATOPADERM................................................................... 50ATOPICLAIR.................................................................... 50ATORVASTATIN CALCIUM..................................... 36, 37ATOVAQUONE.................................................................94ATOVAQUONE/PROGUANIL HCL................................93ATRALIN.......................................................................... 44ATRAPRO CP................................................................... 50ATRAPRO DERMAL SPRAY..........................................52ATRAPRO HYDROGEL.................................................. 50ATRIPLA...........................................................................96ATROPEN....................................................................... 131ATROPINE SULFATE.............................................. 82, 131ATROPINE SULFATE/0.9 %SOD CHLR........................ 82ATROVENT...............................................................18, 128ATROVENT HFA..............................................................18AUBAGIO....................................................................... 127AUGMENTIN (125-31.25/) (SUSP RECON).......... 90, 155AUGMENTIN (200-28.5/5) (SUSP RECON).................. 90AUGMENTIN (200-28.5MG) (TAB CHEW)...................90AUGMENTIN (250-125 MG) (TABLET)........................ 91AUGMENTIN (250-62.5/5) (SUSP RECON).................. 91AUGMENTIN (400-57MG) (TAB CHEW)......................91AUGMENTIN (400-57MG/5) (SUSP RECON)............... 91AUGMENTIN (500-125 MG) (TABLET)........................ 91AUGMENTIN (875-125 MG) (TABLET)........................ 91AUGMENTIN ES-600...................................................... 91AUGMENTIN XR.............................................................91AURANOFIN.................................................................... 99AURSTAT..........................................................................50AURUMHEEL.................................................................130AURYXIA......................................................................... 75AUSTEDO.......................................................................127AUTOJECT 2.................................................................... 71AUTOL CHRONDROCY/COLLAGEN,PORC............. 130AUTO-LANCET MINI..................................................... 72AUTOLET IMPRESSION................................................ 73AUTOLET LANCING DEVICE...................................... 72AUTOLET PLUS.............................................................. 72AUTOPEN.........................................................................72AUTOSHIELD DUO PEN NEEDLE............................. 134AUTOSOFT 30..................................................................71AUTOSOFT 90..................................................................71AUTOSOFT XC................................................................ 71AUVI-Q........................................................................... 123AVALIDE...........................................................................32AVANDIA..................................................................56, 155AVAPRO............................................................................ 33AVAR (10-5%(W/W)) (CLEANSER)............................... 46AVAR (9.5 %-5 %) (FOAM)............................................. 46AVAR (9.5 %-5 %) (MED. PAD)...................................... 46AVAR LS (10 %-2 %) (CLEANSER)............................... 46AVAR LS (10 %-2 %) (FOAM).........................................46AVAR LS (10 %-2 %) (MED. PAD)..................................46AVAR-E............................................................................. 46AVAR-E GREEN...............................................................46AVAR-E LS........................................................................46AVATROMBOPAG MALEATE........................................ 86AVC................................................................................. 150AVELOX............................................................................91AVELOX ABC PACK....................................................... 91AVENOVA.........................................................................81AVIDOXY......................................................................... 91AVIDOXY DK...........................................................92, 155AVITENE...........................................................................86AVODART.......................................................................149AVONEX......................................................................... 127AVONEX PEN.................................................................127AXID............................................................................... 148AXIRON............................................................................86AXITINIB........................................................................125AYGESTIN........................................................................87AZASAN........................................................................... 89AZASITE...........................................................................80AZATHIOPRINE.............................................................. 89AZELAIC ACID................................................................43AZELAS/FLUTICASONE/SOD CHLORID....................16AZELASTINE HCL....................................................16, 79AZELASTINE/FLUTICASONE...................................... 16


Index

AZELEX............................................................................43AZILECT.........................................................................143AZILSARTAN MED/CHLORTHALIDONE................... 32AZILSARTAN MEDOXOMIL......................................... 33AZITHROMYCIN.......................................................80, 90AZOPT.............................................................................. 81AZOR................................................................................ 33AZTREONAM LYSINE....................................................89AZULFIDINE..................................................................102

- B -BABY CONVERSION KIT............................................106BABY CONVERSION PACK 1..................................... 106BABY CONVERSION PACK 2..................................... 106BABY NEBULIZER......................................................... 21BACITRACIN................................................................... 80BACITRACIN/POLYMYXIN B SULFATE..................... 80BACLOFEN.................................................................... 146BACTERIOSTATIC SODIUM CHLORIDE.................... 76BACTROBAN................................................................... 44BACTROBAN NASAL................................................... 128BALCOLTRA....................................................................40BALSALAZIDE DISODIUM.........................................101BALSAM PERU/CASTOR OIL..................................... 136BANZEL (200 MG) (TABLET)..............................145, 155BANZEL (40 MG/ML) (ORAL SUSP).................. 145, 155BANZEL (400 MG) (TABLET)..............................145, 155BARACLUDE (0.05 MG/ML) (SOLUTION).................. 96BARACLUDE (0.5 MG) (TABLET)................................ 96BARACLUDE (1 MG) (TABLET)................................... 96BARICITINIB................................................................... 99BASAGLAR KWIKPEN U-100............................... 74, 155BAXDELA........................................................................ 91BAYER CHEWABLE ASPIRIN....................................... 85B-CAINE/ZINC CL/PINE/CETYLPYRD......................101BD MICROTAINER LANCETS.....................................107BD ULTRA-FINE............................................................107BD ULTRA-FINE II........................................................107BEAU RX.................................................................. 52, 155BEBULIN.......................................................................... 83BECAPLERMIN............................................................... 74BECLOMETHASONE DIPROPIONATE.................. 16, 19BECONASE AQ........................................................16, 155BEDAQUILINE FUMARATE.......................................... 93BELBUCA...............................................................137, 156BELIMUMAB...................................................................99BELLADONNA-PHENOBARBITAL.................... 148, 156BELSOMRA..............................................................30, 156BENAZEPRIL HCL.......................................................... 33BENAZEPRIL/HYDROCHLOROTHIAZIDE................. 32BENEFIX.......................................................................... 83BENEMID......................................................................... 82BENICAR..........................................................................33BENICAR HCT.................................................................32BENLYSTA....................................................................... 99BENOXINATE HCL/FLUORESCEIN SOD.................... 80BENSAL HP......................................................................51BENZACLIN.....................................................................43BENZAMYCIN.................................................................44BENZNIDAZOLE.............................................................94BENZOCAINE..................................................................52BENZODOX 30........................................................ 92, 156BENZODOX 60........................................................ 92, 156BENZONATATE............................................................... 41BENZOYL PEROXIDE.................................................... 51BENZOYL PEROXIDE (4 %) (GEL (GRAM))...................BENZOYL PEROXIDE (5.3%) (FOAM).............................BENZOYL PEROXIDE (6 %) (TOWELETTE)...................BENZOYL PEROXIDE (7 %) (CLEANSER)......................BENZOYL PEROXIDE (8 %) (GEL (GRAM))...................BENZOYL PEROXIDE (9.8 %) (FOAM)............................BENZOYL PEROXIDE MICROSPHERES..................... 51BENZOYL PEROXIDE/HYDROCORTISON................. 43BENZOYL PEROXIDE/SULFUR....................................51BENZOYL PEROXIDE/VIT E MIX................................ 51BENZTROPINE MESYLATE........................................ 142BENZYL ALCOHOL....................................................... 45BEPOTASTINE BESILATE..............................................79BEPREVE..................................................................79, 156BERACTANT..................................................................137BERINERT........................................................................ 98BESIFLOXACIN HCL......................................................80BESIVANCE..................................................................... 80BETAGAN.........................................................................81BETAINE.........................................................................130BETALOAN SUIK............................................................98BETAMETHASON/NORFLURAN/PENTFLU...............98BETAMETHASONE DIPROPIONATE........................... 47BETAMETHASONE VALERATE................................... 47BETAMETHASONE/PROPYLENE GLYC..................... 47BETASERON.................................................................. 127BETAXOLOL HCL.....................................................34, 81

BETHANECHOL CHLORIDE.......................................123BETHKIS.......................................................................... 92BETIMOL..........................................................................81BETOPTIC........................................................................ 81BETOPTIC S..................................................................... 81BETRIXABAN MALEATE.............................................. 83BEVESPI AEROSPHERE........................................ 18, 156BEVYXXA........................................................................83BEXAROTENE......................................................... 52, 127BEXSERO......................................................................... 88BEYAZ.............................................................................. 40BIAFINE............................................................................50BIAXIN............................................................................. 90BIAXIN XL....................................................................... 90BICALUTAMIDE........................................................... 124BICTEGRAV/EMTRICIT/TENOFOV ALA.................... 96BIDIL.................................................................................36BIKTARVY....................................................................... 96BILTRICIDE..................................................................... 93BIMATOPROST................................................................81BINIMETINIB................................................................ 125BINOSTO.................................................................. 77, 156BIO/CARB/EQUIS/ETHAN/CHIT/MSM........................ 52BIONECT.......................................................................... 52BIOSTEP......................................................................... 104BIOSTEP AG.................................................................. 104BISAC/NACL/NAHCO3/KCL/PEG 3350...................... 103BISMUTH TRIBROMOPH/PETROLATUM.........103, 104BISMUTH/METRONID/TETRACYCLINE.................. 148BISOPROLOL FUMARATE............................................ 34BISOPROLOL/HYDROCHLOROTHIAZIDE.................34BLADE LANCET, SAFETY.......................................... 106BLANCHE........................................................................ 54BLEPHAMIDE..................................................................80BLEPHAMIDE S.O.P........................................................80BLOCADREN...................................................................34BLOOD COLLECT SET/LIDOC/PRILOC....................129BLOOD GLUCOSE CNTL HIGH,NORMAL................. 61BLOOD GLUCOSE CONTROL...................................... 61BLOOD GLUCOSE CONTROL HIGH,LOW................. 61BLOOD GLUCOSE CTL HIGH,NML,LOW.............61, 62BLOOD GLUCOSE METER............................................65BLOOD GLUCOSE MONITORING............................... 65BLOOD GLUCOSE STRIPS-DISPMETER.................... 62BLOOD GLUCOSE TEST STRIP....................................57BLOOD GLUCOSE,KETONE CNTRL NML................. 62BLOOD LANCETS.........................................................107BLOOD SUGAR DIAGNOSTIC................................ 56-60BLOOD SUGAR DIAGNOSTIC, DISC...........................61BLOOD SUGAR DIAGNOSTIC, DRUM........................61BLOOD-GLU METER,CONT/TRANSMIT.................... 62BLOOD-GLUC TRANSMITTER/SENSOR....................62BLOOD-GLUC,BP METER,ADULT CUFF....................62BLOOD-GLUC.METER, WRIST BP MON.................... 62BLOOD-GLUCOSE CALIB. CONTROL........................ 62BLOOD-GLUCOSE CONTROL...................................... 64BLOOD-GLUCOSE CONTROL, HIGH.................... 62, 63BLOOD-GLUCOSE CONTROL, LOW........................... 63BLOOD-GLUCOSE CONTROL, NORMAL.............64, 65BLOOD-GLUCOSE METER......................................65-70BLOOD-GLUCOSE METER, DRUM-TYPE.................. 70BLOOD-GLUCOSE METER, WIRELESS......................70BLOOD-GLUCOSE METER,CONTINUOUS................ 70BLOOD-GLUCOSE METER,MOBILE DEV..................70BLOOD-GLUCOSE SENSOR......................................... 70BLOOD-GLUCOSE TRANSMITTER.............................70BLUNT NEEDLE........................................................... 131BLUNT NEEDLE, DISPOSABLE................................. 131B-NEXA.......................................................................... 153BOCASAL.......................................................................134BONIVA............................................................................ 77BONJESTA........................................................................17BOSENTAN...................................................................... 36BOSULIF (100 MG) (TABLET).....................................125BOSULIF (400 MG) (TABLET).....................................125BOSULIF (500 MG) (TABLET).....................................125BOSUTINIB.................................................................... 125BP 10-1.............................................................................. 46BRAFTOVI......................................................................124BRAVELLE............................................................... 76, 156BREATHERITE................................................................ 20BREATHERITE SPACER-ADULT MASK......................21BREATHERITE SPACER-INFANT MASK.....................20BREATHERITE SPACER-LG CHLD MSK.....................21BREATHERITE SPACER-NEONATE MSK....................20BREATHERITE SPACER-SM CHLD MSK.................... 20BREATHRITE...................................................................20BREEZE 2....................................................................61-64BREO ELLIPTA................................................................18BREXPIPRAZOLE........................................................... 28BRIGATINIB...................................................................125BRIJ L4............................................................................136

BRILINTA......................................................................... 85BRIMONIDINE TARTRATE......................................43, 81BRIMONIDINE TARTRATE/TIMOLOL........................ 81BRIMONIDINE/DORZOLAMIDE/PF............................ 81BRINZOLAMIDE.............................................................81BRINZOLAMIDE/BRIMONIDINE TART...................... 81BRISDELLE..............................................................25, 156BRIVARACETAM.......................................................... 143BRIVIACT (10 MG) (TABLET).............................143, 156BRIVIACT (10 MG/ML) (SOLUTION).................143, 156BRIVIACT (100 MG) (TABLET)...........................143, 156BRIVIACT (25 MG) (TABLET).............................143, 156BRIVIACT (50 MG) (TABLET).............................143, 156BRIVIACT (50 MG/5 ML) (VIAL)........................ 143, 156BRIVIACT (75 MG) (TABLET).............................143, 156BRODALUMAB............................................................... 54BROMFENAC SODIUM.................................................. 79BROMOCRIPTINE MESYLATE.............................55, 142BROMPHENIRA/PSEUDOEPHED/CODEIN.................41BROMPHENIRAMINE/P-EPH/CODEINE..................... 41BROMPHENIRAMINE/PSEUDOEPHED/DM............... 43BROMPHENIRAMINE/PSEUDOEPHED/DM (2-30-10/5)(SYRUP)................................................................................BROMSITE....................................................................... 79BROVANA.........................................................................18BUCALSEP.....................................................................101BUDESONIDE....................................................19, 98, 102BUDESONIDE/FORMOTEROL FUMARATE............... 18BULK SYRINGE.................................................... 116, 117BULLSEYE MINI SAFETY LANCETS........................107BUMETANIDE................................................................. 35BUMEX.............................................................................35BUNAVAIL......................................................................142BUPHENYL.................................................................... 102BUPIVACAINE HCL/0.9 % NACL/PF.......................... 101BUPIVACAINE/PF/NORFLU/HFC245FA.....................101BUPRENEX.................................................................... 137BUPRENORPHINE........................................................ 137BUPRENORPHINE HCL....................................... 137, 142BUPRENORPHINE HCL/NALOXONE HCL............... 142BUPROPION HBR............................................................25BUPROPION HCL....................................................25, 147BUSPAR............................................................................ 27BUSPIRONE HCL............................................................ 27BUSULFAN.....................................................................124BUTABARBITAL SODIUM.............................................29BUTALB/ACETAMINOPHEN/CAFFEINE.................. 137BUTALBIT/ACETAMIN/CAFF/CODEINE.................. 141BUTALBITAL/ACETAMINOPHEN.............................. 137BUTALBITAL/ACETAMINOPHEN (50MG-300MG)(CAPSULE)...........................................................................BUTALBITAL/ACETAMINOPHEN (50MG-300MG)(TABLET)........................................................................156BUTALBITAL/ACETAMINOPHEN (50MG-325MG)(TABLET)..............................................................................BUTALBITAL/ASPIRIN/CAFFEINE............................ 137BUTENAFINE HCL......................................................... 44BUTISOL SODIUM..........................................................29BUTOCONAZOLE NITRATE....................................... 150BUTORPHANOL TARTRATE.......................................137BUTRANS.......................................................................137BUTYLATED HYDROXYTOLUENE.............................43BUTYLATED HYDROXYTOLUENE(BHT)......................BYDUREON............................................................. 55, 156BYDUREON BCISE.................................................55, 156BYDUREON PEN.....................................................55, 156BYETTA....................................................................55, 157BYSTOLIC........................................................................34BYVALSON...................................................................... 32

- C -C1 ESTERASE INHIBITOR............................................ 98C1 ESTERASE INHIBITOR, RECOMB..........................98CABERGOLINE............................................................... 78CABOMETYX................................................................ 125CABOZANTINIB S-MALATE.......................................125CADEAU DHA............................................................... 153CADEXOMER IODINE................................................... 43CADIRA COMPLIANT BLOOD STAT.........................129CADUET........................................................................... 39CAFCIT............................................................................. 23CAFERGOT.................................................................... 140CAFFEINE CITRATE.......................................................23CALAN..............................................................................35CALAN SR........................................................................35CALCIFEDIOL................................................................. 78CALCIPOTRIENE............................................................ 54CALCIPOTRIENE/BETAMETHASONE........................ 55CALCITONIN,SALMON,SYNTHETIC..........................77CALCITRIOL............................................................54, 153CALCIUM ACETATE.......................................................75CALCIUM/MAG/D3/B12/FA/B6/BORON.................... 150


Index

CALFACTANT................................................................137CALQUENCE................................................................. 125CAMBIA......................................................................... 140CAMPRAL........................................................................ 27CANAGLIFLOZIN........................................................... 55CANAGLIFLOZIN/METFORMIN HCL......................... 56CANASA......................................................................... 101CANDESARTAN CILEXETIL.........................................33CANDESARTAN/HYDROCHLOROTHIAZID...............32CANTHARIS COMPOSITUM.......................................130CAPCOF............................................................................42CAPECITABINE.............................................................124CAPEX SHAMPOO..........................................................47CAPHOSOL.................................................................... 134CAPOTEN......................................................................... 33CAPOZIDE........................................................................32CAPRELSA (100 MG) (TABLET)................................. 126CAPRELSA (300 MG) (TABLET)................................. 126CAPSAICIN/SKIN CLEANSER...................................... 51CAPTOPRIL......................................................................33CAPTOPRIL/HYDROCHLOROTHIAZIDE....................32CAPXIB...........................................................................101CARAC..............................................................................52CARAFATE (1 G) (TABLET).........................................148CARAFATE (1 G/10 ML) (ORAL SUSP)...................... 148CARBAGLU....................................................................102CARBAMAZEPINE................................................. 27, 143CARBATROL..................................................................143CARBIDOPA...................................................................143CARBIDOPA/LEVODOPA............................................ 142CARBIDOPA/LEVODOPA/ENTACAPONE................. 142CARBINOXAMINE MALEATE......................................16CARBIT/EQUIS XT/ETHAN/CHIT/MSM......................52CARDIOPLEGIC 21 (REPERFUS 4:1)......................... 129CARDIOPLEGIC NO.14 (MAINT 8:1)......................... 129CARDIOPLEGIC NO.15(INDUCT 8:1)........................ 129CARDIOPLEGIC NO.17(INDUCT 4:1)........................ 129CARDIOPLEGIC NO.18(INDUCT 8:1)........................ 129CARDIOPLEGIC NO.19 (MAINT 4:1)......................... 129CARDIOPLEGIC NO.20 (MAINT 4:1)......................... 129CARDIOPLEGIC NO.22(INDUCT 4:1)........................ 129CARDIOPLEGIC NO.23(INDUCT 4:1)........................ 129CARDIOPLEGIC SOLUTION NO.1............................. 129CARDIOPLEGIC SOLUTION NO.10........................... 129CARDIOPLEGIC SOLUTION NO.16........................... 129CARDIZEM...................................................................... 34CARDIZEM CD................................................................34CARDIZEM LA (120 MG) (TAB ER 24H)......................34CARDIZEM LA (180 MG) (TAB ER 24H)......................34CARDIZEM LA (240 MG) (TAB ER 24H)......................34CARDIZEM LA (300 MG) (TAB ER 24H)......................34CARDIZEM LA (360 MG) (TAB ER 24H)......................34CARDIZEM LA (420 MG) (TAB ER 24H)......................35CARDIZEM SR.................................................................35CARDURA........................................................................32CARDURA XL................................................................. 32CAREFINE PEN NEEDLE.............................................132CARELANCE ULT LANCING DEVICE........................ 72CAREONE................................................................ 72, 107CAREPOINT LUER SLIP SYRINGE............................116CARESENS.........................................................61, 64, 107CARESENS N............................................................. 57, 66CARESENS N VOICE......................................................66CARESENS PREM LANCING DEVICE........................ 72CARETOUCH GLUCOSE MONITORING.....................66CARETOUCH INSULIN SYRINGE......................112, 122CARETOUCH LANCING DEVICE................................ 72CARETOUCH PEN NEEDLE........................................132CARETOUCH TEST STRIP............................................ 57CARETOUCH TWIST LANCET...................................107CARGLUMIC ACID.......................................................102CARIPRAZINE HCL........................................................27CARISOPRODOL...........................................................146CARISOPRODOL/ASPIRIN.......................................... 146CARISOPRODOL/ASPIRIN/CODEINE....................... 137CARMUSTINE IN POLIFEPROSAN 20.......................124CARNITOR.....................................................................130CARNITOR SF............................................................... 130CAROSPIR................................................................35, 157CARRASYN HYDROGEL WOUND............................ 104CARTEOLOL HCL...........................................................81CARVEDILOL.................................................................. 32CARVEDILOL PHOSPHATE.......................................... 32CASODEX...................................................................... 124CATAFLAM.................................................................... 100CATAPRES........................................................................33CATAPRES-TTS 1............................................................ 33CATAPRES-TTS 2............................................................ 33CATAPRES-TTS 3............................................................ 33CATHETER.....................................................................105CATHETERIZATION TRAY..........................................105CAYA CONTOURED....................................................... 41

CAYSTON.........................................................................89C-CLARIFYING SERUM................................................ 54CECLOR............................................................................89CECLOR CD..................................................................... 89CEFACLOR.......................................................................89CEFADROXIL...................................................................89CEFALY.......................................................................... 106CEFDINIR.........................................................................89CEFDITOREN PIVOXIL..................................................89CEFIXIME.................................................................. 89, 90CEFPODOXIME PROXETIL........................................... 90CEFPROZIL...................................................................... 89CEFTIN............................................................................. 89CEFUROXIME AXETIL.................................................. 89CEFZIL..............................................................................89CELACYN.........................................................................50CELACYN POST PROCEDURE................................... 136CELEBREX.....................................................................100CELECOXIB................................................................... 100CELECOXIB/CAPSAICIN/MENTHOL........................ 101CELECOXIB/LIDOCAINE/MENTHOL....................... 101CELEXA............................................................................25CELLCEPT........................................................................89CELLULOSE.................................................................. 134CELONTIN..................................................................... 145CENTANY.........................................................................44CENTANY AT...................................................................44CENTRUROIDES(SCORPN) ANTIVENOM................128CEPHALEXIN.................................................................. 89CERACADE......................................................................50CERAMAX....................................................................... 50CERDELGA.................................................................... 129CERITINIB......................................................................125CERTOLIZUMAB PEGOL.............................................. 98CERVICAL CAP...............................................................41CERVIDIL......................................................................... 41CESAMET.................................................................17, 157CETACAINE..................................................................... 54CETACAINE ANESTHETIC............................................54CETIRIZINE HCL............................................................ 16CETRAXAL...................................................................... 75CETRORELIX ACETATE................................................ 78CETROTIDE..................................................................... 78CETYLEV....................................................................... 128CEVIMELINE HCL........................................................123CHANTIX....................................................................... 147CHEMET.........................................................................130CHEMO THEAPY DILUENT NO.1/PF........................ 129CHEMSTRIP BG DIARY.................................................70CHENODAL................................................................... 103CHENODIOL.................................................................. 103CHLORAMBUCIL......................................................... 124CHLORDIAZEPOXIDE HCL.......................................... 27CHLORDIAZEPOXIDE/CLIDINIUM BR.................... 148CHLORHEXIDINE GLUCONATE................................128CHLOROQUINE PHOSPHATE....................................... 94CHLOROTHIAZIDE.........................................................36CHLORPHEN/PSEUDOEPHED/CODEINE................... 42CHLORPHENIRAMINE/CODEINE PHOS.................... 42CHLORPHENIRAMINE/PE/CODEINE..........................42CHLORPHENIRAMINE/PHENYLEPH/DM.................. 43CHLORPHENIRAMINE/PHENYLEPH/DM (1-2-3MG/ML) (DROPS)..............................................................CHLORPHENIRAMINE/PHENYLEPHRINE................ 41CHLORPHENIRAMINE/PHENYLEPHRINE (1MG-2MG/ML) (DROPS)..............................................................CHLORPROMAZINE HCL..............................................29CHLORPROPAMIDE....................................................... 56CHLORTHALIDONE.......................................................36CHLORZOXAZONE...................................................... 146CHLORZOXAZONE (250 MG) (TABLET).................. 157CHLORZOXAZONE (500 MG) (TABLET)........................CHOICEDM CLARUS..................................................... 66CHOICEDM CLARUS CONTROL SOLN...................... 64CHOICEDM CLARUS TEST STRIPS.............................57CHOLBAM..................................................................... 103CHOLERA VAC BUFFER COMP 1 OF 2....................... 75CHOLERA VACCINE, LIVE........................................... 88CHOLESTYRAMINE (WITH SUGAR).......................... 38CHOLESTYRAMINE/ASPARTAME.............................. 38CHOLIC ACID................................................................103CHOLINE SALICYL/MAG SALICYLATE.................. 137CHORIOGONADOTROPIN ALFA..................................76CHORIONIC GONADOTROPIN.....................................76CHORIONIC GONADOTROPIN, HUMAN....................76CHRONULAC.........................................................102, 103CIALIS.............................................................................. 76CICATRACE PAD...........................................................104CICLESONIDE........................................................... 17, 19CICLODAN.................................................................44, 45CICLOPIROX....................................................................44CICLOPIROX OLAMINE................................................ 44

CICLOPIROX/SKIN CLEANSER NO.28........................44CICLOPIROX/SKIN CLEANSER NO.40........................45CICLOPIROX/UREA/CAMPH/MEN/EUC..................... 45CILOSTAZOL................................................................... 85CILOXAN (0.3 %) (DROPS)............................................ 80CILOXAN (0.3 %) (OINT. (G))........................................ 80CIMDUO........................................................................... 94CIMETIDINE.................................................................. 148CIMETIDINE HCL......................................................... 148CIMZIA............................................................................. 98CINACALCET HCL......................................................... 77CINRYZE.......................................................................... 98CIPRO................................................................................91CIPRO HC......................................................................... 75CIPRO XR......................................................................... 91CIPRODEX....................................................................... 75CIPROFLOXACIN......................................................75, 91CIPROFLOXACIN HCL.......................................75, 80, 91CIPROFLOXACIN HCL/DEXAMETH........................... 75CIPROFLOXACIN HCL/FLUOCINOLONE...................75CIPROFLOXACIN/CIPROFLOXA HCL.........................91CIPROFLOXACIN/HYDROCORTISONE...................... 75CITALOPRAM HYDROBROMIDE................................ 25CITRANATAL 90 DHA.................................................. 151CITRANATAL ASSURE................................................ 151CITRANATAL DHA....................................................... 151CITRANATAL HARMONY................................... 151, 152CITRANATAL RX.......................................................... 153CITRATE PHOSPHATE DEXTROS SOLN.................... 83CITRIC AC/GLUCONOLACT/MAG CARB.................149CITRIC ACID..................................................................136CITRIC ACID/SODIUM CITRATE............................... 149CLAMP, IV TUBING......................................................110CLARIFOAM EF.............................................................. 46CLARINEX (2.5 MG) (TAB RAPDIS).................... 16, 157CLARINEX (2.5 MG/5ML) (SYRUP)..................... 16, 157CLARINEX (5 MG) (TAB RAPDIS)....................... 16, 157CLARINEX (5 MG) (TABLET)....................................... 16CLARINEX-D 12 HOUR..........................................16, 157CLARITHROMYCIN....................................................... 90CLEMASTINE FUMARATE........................................... 16CLENPIQ........................................................................ 103CLEO 90 INFUSION SET................................................ 71CLEOCIN (100 MG) (SUPP.VAG)......................... 150, 157CLEOCIN (2 %) (CREAM/APPL)................................. 150CLEOCIN HCL................................................................. 93CLEOCIN PALMITATE................................................... 93CLEOCIN T.......................................................................44CLEVER CHEK BLOOD GLUCOSE SYST...................66CLEVER CHEK LANCETS...........................................107CLEVER CHOICE............................................................66CLEVER CHOICE BLOOD GLUC SYS.........................66CLEVER CHOICE CONTROL SOLUTION..............62-64CLEVER CHOICE HD GLUCOSE SYST.......................66CLEVER CHOICE HOLDING CHAMBER..............20, 21CLEVER CHOICE MICRO..............................................66CLEVER CHOICE MICRO TEST STRIP....................... 57CLEVER CHOICE NEBULIZER.....................................22CLEVER CHOICE PRO............................................. 57, 66CLEVER CHOICE TALK...........................................57, 66CLEVER CHOICE TEST STRIPS................................... 57CLEVER CHOICE VOICE+ TST STRIP.........................57CLEVER CHOICE WHISPER AIRE PED...................... 22CLICKFINE.................................................................... 132CLIMARA.........................................................................87CLIMARA PRO................................................................ 87CLINDACIN ETZ............................................................. 44CLINDACIN P.................................................................. 44CLINDACIN PAC............................................................. 44CLINDAGEL.............................................................44, 157CLINDAMYCIN HCL...................................................... 93CLINDAMYCIN PALMITATE HCL................................93CLINDAMYCIN PHOS/BENZOYL PEROX.................. 43CLINDAMYCIN PHOS/SKIN CLNSR 19...................... 44CLINDAMYCIN PHOSPHATE............................... 44, 150CLINDAMYCIN/BENZOYL/EMOL CMB94................. 43CLINDAMYCIN/TRETINOIN.........................................43CLINDESSE....................................................................150CLINORIL.......................................................................101CLINPRO 5000............................................................... 150CLIOQUINOL/HYDROCORTISONE............................. 43CLISTIN............................................................................ 16CLOBAZAM................................................................... 143CLOBETASOL PROPIONATE.........................................47CLOBETASOL PROPIONATE/EMOLL..........................47CLOBETASOL/SKIN CLEANSER NO.28......................47CLOBEX........................................................................... 47CLOCORTOLONE PIVALATE........................................47CLODAN...........................................................................47CLODERM........................................................................47CLOMIPHENE CITRATE................................................ 76CLOMIPRAMINE HCL................................................... 26


Index

CLONAZEPAM.............................................................. 143CLONIDINE......................................................................33CLONIDINE HCL.......................................................30, 33CLONIDINE HCL/CHLORTHALIDONE....................... 33CLONIDINE HCL/PF..................................................... 137CLOPIDOGREL BISULFATE..........................................85CLORAZEPATE DIPOTASSIUM.................................... 27CLOTRIMAZOLE...................................................... 45, 92CLOTRIMAZOLE (1 %) (CREAM (G))..............................CLOTRIMAZOLE (1 %) (SOLUTION)...............................CLOTRIMAZOLE/BETAMETH DIP/ZINC.................... 44CLOTRIMAZOLE/BETAMETHASONE DIP................. 44CLOZAPINE..................................................................... 28CLOZARIL........................................................................28COAGADEX..................................................................... 83COAGUCHEK................................................................ 107COAGUCHEK XS.......................................................... 129COAGULATION FACTOR VIIA,RECOMB................... 83COAGULATION FACTOR X...........................................83COARTEM........................................................................ 93COBICISTAT.....................................................................96COBIMETINIB FUMARATE.........................................125COCAINE HCL.........................................................52, 128CODEINE........................................................................137CODEINE PHOSPHATE/GUAIFENESIN.......................42CODEINE PHOSPHATE/GUAIFENESIN (10-100MG/5)(LIQUID) (OTC)...................................................................CODEINE PHOSPHATE/GUAIFENESIN (10-200MG/5)(LIQUID) (OTC)...................................................................CODEINE PHOSPHATE/GUAIFENESIN (20-200/10)(LIQUID) (OTC)...................................................................CODEINE PHOSPHATE/GUAIFENESIN (7.5-225/5)(LIQUID) (OTC)...................................................................CODEINE PHOSPHATE/GUAIFENESIN (8-200 MG/5)(LIQUID) (OTC)...................................................................CODEINE POLI/CHLORPHENIR POLIS.......................42CODEINE SULFATE......................................................137CODEINE/BUTALBITAL/ASA/CAFFEIN................... 141CODITUSSIN DAC.......................................................... 42COGENTIN.....................................................................142COLAZAL.......................................................................101COLCHICINE................................................................... 82COLCRYS......................................................................... 82COLESEVELAM HCL..................................................... 38COLESTID (1 G) (TABLET)............................................38COLESTID (5 G) (GRANULES)..................................... 38COLESTID (5 G) (PACKET)............................................38COLESTID (7.5 G) (PACKET).........................................38COLESTIPOL HCL.......................................................... 38COLLAGEN/SOD ALGIN/CARBOXYMETH..............104COLLAGENASE CLOSTRIDIUM HIST.........................54COLOR LANCETS.........................................................107COLY-MYCIN S............................................................... 75COLYTE WITH FLAVOR PACKETS............................103COMBIGAN......................................................................81COMBIPATCH..................................................................87COMBIPRES (0.1MG-15MG) (TABLET)....................... 33COMBIPRES (0.2-15MG) (TABLET)..............................33COMBIPRES (0.3MG-15MG) (TABLET)....................... 33COMBIVENT RESPIMAT............................................... 18COMBIVIR....................................................................... 94COMETRIQ.................................................................... 125COMFORT................................................................ 71, 110COMFORT EZ........................................ 107, 112, 122, 132COMFORT LANCETS................................................... 107COMFORT PAC-CYCLOBENZAPRINE...................... 146COMFORT PAC-IBUPROFEN.........................................99COMFORT PAC-MELOXICAM.................................... 100COMFORT PAC-NAPROXEN....................................... 100COMFORT PAC-TIZANIDINE......................................146COMFORT SHORT.................................................. 71, 110COMP.STOCKING,KNEE,LONG,MEDIUM................135COMP.STOCKING,THIGH,LONG,LARGE................. 135COMP.STOCKING,THIGH,LONG,SMALL................. 135COMP.STOCKING,THIGH,LONG,X-LRG.................. 135COMP.STOCKING,THIGH,LONG,X-SML.................. 135COMP.STOCKING,THIGH,SHORT,SMAL.................. 135COMPACT SPACE CHAMBER.................................20, 21COMPACT SPACE CHAMBER PLUS............................ 20COMP-AIR NEBULIZER COMPRESSOR..................... 22COMPAT ENFIT GASTROTUBE.................................. 110COMPAZINE.................................................................... 17COMPLERA......................................................................96COMPLETE NATAL DHA.............................................152COMPR.STOCKING,KNEE,LONG,LARGE................ 135COMPR.STOCKING,KNEE,LONG,SMALL................135COMPR.STOCKING,KNEE,LONG,X-LRG................. 135COMPR.STOCKING,THIGH,REG,LARGE................. 135COMPR.STOCKING,THIGH,REG,SMALL................. 135COMPR.STOCKING,THIGH,REG,X-LRG.................. 135COMPR.STOCKING,THIGH,REG,X-SML.................. 135COMPR.STOCKING,THIGH,SHORT,LRG.................. 135

COMPR.STOCKING,THIGH,SHORT,MED................. 135COMPRES.STOCKING,KNEE,REG,SMAL.................135COMPRES.STOCKING,KNEE,REG,XLRG.................136COMPRES.STOCKING,THIGH,REG,MED................. 136COMPRESS.STOCKING,KNEE,REG,LRG..................136COMPRESS.STOCKING,KNEE,REG,MED.................136COMPRESSOR, FOR NEBULIZER..........................19, 20COMPRS.STOCKING,THIGH,LONG,MED................ 136COMTAN........................................................................ 142CONCEPT DHA............................................................. 151CONCEPT OB.................................................................151CONCEPTION................................................................ 129CONCEPTION ASSIST.SUPPLIES NO1...................... 129CONCEPTROL................................................................. 40CONCERTA (18 MG) (TAB ER 24).................................30CONCERTA (27 MG) (TAB ER 24).................................30CONCERTA (36 MG) (TAB ER 24).................................30CONCERTA (54 MG) (TAB ER 24).................................30CONDOMS, FEMALE................................................... 129CONDYLOX (0.5 %) (GEL (GRAM))..................... 51, 157CONDYLOX (0.5 %) (SOLUTION).................................51CONNECTOR LUER LOCK,CLOSD SYST.................111CONTACT DETACH INFUSION SET............................ 71CONTOUR.............................................................62-64, 66CONTOUR LINK............................................................. 66CONTOUR NEXT............................................................ 66CONTOUR NEXT CONTROL SOLUTION..............63, 64CONTOUR NEXT EZ...................................................... 66CONTOUR NEXT LINK..................................................70CONTOUR NEXT LINK 2.4............................................70CONTOUR NEXT ONE................................................... 66CONTOUR NEXT TEST STRIP......................................57CONTOUR TEST STRIP..................................................57CONTROL AST................................................................ 66CONTROL SOLUTION.............................................. 62-64CONZIP...................................................................140, 157COOL BLOOD GLUCOSE.............................................. 66COOL BLOOD GLUCOSE METER................................66COOL CONTROL SOLUTION..................................62, 64COOL GLUCOSE TEST STRIP.......................................57COPAXONE....................................................................127COPPER.......................................................................... 130CORDARONE...................................................................31CORDRAN (0.025 %) (CREAM (G)).............................. 47CORDRAN (0.05 %) (CREAM (G))................................ 47CORDRAN (0.05 %) (LOTION)...................................... 48CORDRAN (0.05 %) (OINT. (G)).................................... 48CORDRAN (4MCG/SQ CM) (MED. TAPE)........... 48, 157COREG..............................................................................32COREG CR....................................................................... 32CORGARD........................................................................34CORIFACT........................................................................ 83CORLANOR..................................................................... 39CORTANE-B..................................................................... 75CORTEF............................................................................ 98CORTENEMA.................................................................102CORTIFOAM.................................................................. 102CORTISONE ACETATE...................................................98CORTISPORIN........................................................... 46, 47CORTONE.........................................................................98CORZIDE.......................................................................... 34COSENTYX (2 SYRINGES)............................................54COSENTYX PEN............................................................. 54COSENTYX PEN (2 PENS)............................................. 54COSENTYX SYRINGE....................................................54COSOPT............................................................................ 81COTELLIC...................................................................... 125COTEMPLA XR-ODT (17.3 MG) (TAB RAP BP)...... 30,157COTEMPLA XR-ODT (25.9 MG) (TAB RAP BP)...... 30,157COTEMPLA XR-ODT (8.6 MG) (TAB RAP BP)...... 30,157COUMADIN..................................................................... 82COVARYX.........................................................................87COVARYX H.S................................................................. 87COZAAR...........................................................................33CRALONIN.....................................................................130CREON............................................................................147CRESEMBA......................................................................92CRESTOR (10 MG) (TABLET)........................................37CRESTOR (20 MG) (TABLET)........................................37CRESTOR (40 MG) (TABLET)........................................37CRESTOR (5 MG) (TABLET)..........................................37CRINONE....................................................................76, 87CRISABOROLE................................................................46CRIXIVAN........................................................................ 95CRIZOTINIB...................................................................125CROFELEMER............................................................... 102CROMOLYN SODIUM.............................................. 19, 81CROTAMITON................................................................. 45CROTAN............................................................................45

CRYOSERV.....................................................................129C-THERAPY NIGHT CREAM........................................ 54CULT SKIN SUBST,HUMAN-BOVINE....................... 134CUPRIMINE..................................................................... 97CURAFIL........................................................................ 104CURITY.......................................................................... 105CURITY AMD................................................................ 104CURITY IODOFORM.................................................... 104CUROSURF.................................................................... 137CUTIVATE........................................................................ 48CUVITRU..........................................................................87CUVPOSA.......................................................................148CYANOCOBALAMIN (VITAMIN B-12)......................153CYANOCOBALAMIN (VITAMIN B-12) (1000MCG/ML)(VIAL)...................................................................................CYCLESSA.......................................................................40CYCLOBENZAPRINE HCL..........................................146CYCLOBENZAPRINE/IRR CNTR-IRR 2.................... 146CYCLOBENZAPRINE/TENS ELECTRODE................147CYCLOBENZAPRINE/TENS UNIT/ELEC.................. 147CYCLOCORT................................................................... 47CYCLOGYL......................................................................82CYCLOMYDRIL.............................................................. 82CYCLOPENTOL/LIDO/PE/TROPICAMID.................... 82CYCLOPENTOLAT/TROPIC/PHENYLEPH.................. 82CYCLOPENTOLATE HCL.............................................. 82CYCLOPENTOLATE/PHENYLEPHRINE..................... 82CYCLOPHOSPHAMIDE............................................... 124CYCLOSERINE................................................................93CYCLOSET...............................................................55, 157CYCLOSPORINE....................................................... 80, 89CYCLOSPORINE, MODIFIED........................................89CYCLOSPORINE/CHONDROIT SULF A......................80CYCLOTENS..................................................................147CYPROHEPTADINE HCL............................................... 16CYSTADANE..................................................................130CYSTAGON.................................................................... 149CYSTARAN...................................................................... 82CYSTEAMINE BITARTRATE.......................................149CYSTEAMINE HCL.........................................................82CYTOMEL........................................................................ 78CYTOTEC....................................................................... 148

- D -D.H.E.45.......................................................................... 140DABIGATRAN ETEXILATE MESYLATE..................... 86DABRAFENIB MESYLATE.......................................... 124DACLATASVIR DIHYDROCHLORIDE.........................97DAKLINZA.......................................................................97DALFAMPRIDINE......................................................... 127DALIRESP................................................................ 19, 157DALTEPARIN SODIUM,PORCINE................................ 84DANAZOL........................................................................ 78DANOCRINE....................................................................78DANTRIUM....................................................................147DANTROLENE SODIUM.............................................. 147DAPAGLIFLOZIN PROPANEDIOL................................ 55DAPAGLIFLOZIN/METFORMIN HCL.......................... 56DAPAGLIFLOZIN/SAXAGLIPTIN HCL........................56DAPSONE................................................................... 43, 93DARAPRIM...................................................................... 94DARBEPOETIN ALFA IN POLYSORBAT..................... 84DARIFENACIN HYDROBROMIDE............................. 149DARIO BLOOD GLUCOSE MONITOR......................... 70DARIO BLOOD GLUCOSE TEST STRIP...................... 57DARUNAVIR ETHANOLATE......................................... 94DARUNAVIR/COB/EMTRI/TENOF ALAF.................... 94DARUNAVIR/COBICISTAT............................................ 94DASATINIB.................................................................... 125DAVOL IRRIGATION SYRINGE.................................. 113DAYPRO..........................................................................101DAYTRANA..............................................................30, 157DDAVP.............................................................................. 76DEBACTEROL............................................................... 128DECLOMYCIN.................................................................91DEFERASIROX.............................................................. 130DEFERIPRONE.............................................................. 130DEFEROXAMINE MESYLATE.................................... 130DEFLAZACORT...............................................................98DEGARELIX ACETATE................................................ 125DELAFLOXACIN MEGLUMINE................................... 91DELATESTRYL................................................................87DELAVIRDINE MESYLATE...........................................94DELESTROGEN...............................................................87DELFEN............................................................................ 40DELSTRIGO..................................................................... 96DELZICOL..............................................................102, 157DEMADEX....................................................................... 35DEMECLOCYCLINE HCL..............................................91DEMEROL (10 MG/ML) (CARTRIDGE)......................138DEMEROL (100 MG) (TABLET).................................. 138DEMEROL (100 MG/ML) (SYRINGE).........................138


Index

DEMEROL (100 MG/ML) (VIAL).................................138DEMEROL (25 MG/ML) (SYRINGE)...........................138DEMEROL (25 MG/ML) (VIAL)...................................138DEMEROL (50 MG) (TABLET).................................... 138DEMEROL (50 MG/5 ML) (SOLUTION)..................... 138DEMEROL (50 MG/ML) (SYRINGE)...........................138DEMEROL (50 MG/ML) (VIAL)...................................138DEMEROL (75 MG/ML) (SYRINGE)...........................138DEMSER........................................................................... 33DEMULEN........................................................................40DEMULEN 1-50-21.......................................................... 40DENAVIR.......................................................................... 45DENTAL SUCTION/CHLRHEX/SWB1/MW............... 128DENTL SUCTION DEV/CHLORHX/SWB1................ 128DEPAKENE.....................................................................146DEPAKENE (250 MG/5ML) (SOLUTION)...................146DEPAKENE (500MG/10ML) (SOLUTION)..................146DEPAKOTE.....................................................................143DEPAKOTE ER...............................................................143DEPAKOTE SPRINKLE.................................................143DEPEN.............................................................................. 97DEPO-ESTRADIOL......................................................... 87DEPO-PROVERA............................................................. 40DEPO-SUBQ PROVERA 104...........................................40DEPO-TESTOSTERONE................................................. 87DERMACINRX CLORHEXACIN................................. 136DERMACINRX EMPRICAINE....................................... 53DERMACINRX LEXITRAL............................................ 49DERMACINRX PHN PAK...............................................53DERMACINRX PRIZOPAK............................................ 53DERMACINRX SILAPAK....................................... 48, 157DERMACINRX SILAZONE............................................ 48DERMACINRX SURGICAL PHARMAPAK................136DERMACINRX THERAZOLE PAK............................... 44DERMACINRX ZRM PAK.............................................. 53DERMAGRAFT..............................................................134DERMA-SMOOTHE-FS...................................................47DERMASORB HC............................................................48DERMASORB TA............................................................ 48DERMATOP......................................................................48DERMAWERX SDS................................................. 48, 157DERMAWERX SURGICAL PLUS PAK....................... 136DERMAZENE...................................................................43DERMAZYL..................................................................... 53DERMOTIC.......................................................................75DESCOVY.........................................................................94DESFERAL..................................................................... 130DESFERAL MESYLATE............................................... 130DESFLURANE............................................................... 130DESIPRAMINE HCL....................................................... 26DESIRUDIN......................................................................86DESLORATADINE...........................................................16DESLORATADINE/PSEUDOEPHEDRINE....................16DESMOPRESSIN (NONREFRIGERATED)................... 76DESMOPRESSIN ACETATE........................................... 76DESOG-E.ESTRADIOL/E.ESTRADIOL........................ 40DESOGEN.........................................................................40DESOGESTREL-ETHINYL ESTRADIOL..................... 40DESONATE.......................................................................47DESONIDE....................................................................... 47DESOWEN........................................................................47DESOXIMETASONE....................................................... 47DESOXYN........................................................................ 27DESVENLAFAXINE........................................................25DESVENLAFAXINE ER................................................157DESVENLAFAXINE FUMARATE................................. 25DESVENLAFAXINE FUMARATE ER......................... 157DESVENLAFAXINE SUCCINATE................................. 25DESYREL......................................................................... 25DETROL..................................................................150, 157DETROL LA........................................................... 150, 157DEUTETRABENAZINE................................................ 127DEVILBISS COMPACT................................................... 19DEVILBISS DISPOSABLE NEBULIZER...................... 22DEVILBISS PULMO-AIDE............................................. 19DEVILBISS PULMOMATE............................................. 19DEVILBISS PULMONEB LT COMP-NEB.....................22DEVILBISS TRAVELER..................................................22DEXAMETH/PF/NORFLUR/HFC 245FA.......................98DEXAMETHASONE..................................................79, 98DEXAMETHASONE (0.5 MG) (TABLET).........................DEXAMETHASONE (0.5 MG/5ML) (ELIXIR)..................DEXAMETHASONE (0.5 MG/5ML) (SOLUTION)...........DEXAMETHASONE (0.75 MG) (TABLET).......................DEXAMETHASONE (1 MG) (TABLET)............................DEXAMETHASONE (1.5 MG(49)) (TAB DS PK)....... 157DEXAMETHASONE (1.5 MG) (TABLET).........................DEXAMETHASONE (1.5MG (21)) (TAB DS PK)....... 157DEXAMETHASONE (1.5MG (35)) (TAB DS PK)....... 157DEXAMETHASONE (1.5MG (51)) (TAB DS PK)....... 158DEXAMETHASONE (2 MG) (TABLET)............................DEXAMETHASONE (4 MG) (TABLET)............................

DEXAMETHASONE (6 MG) (TABLET)............................DEXAMETHASONE INTENSOL.......................................DEXAMETHASONE SODIUM PHOSPHATE......... 79, 98DEXCHLORPHEN/PHENYLEPH/CODEINE................ 42DEXCOM.......................................................................... 70DEXCOM G4.................................................................... 70DEXCOM G5.................................................................... 70DEXCOM G5-G4 SENSOR..............................................70DEXCOM G6.................................................................... 70DEXEDRINE (10 MG) (CAPSULE ER)..........................26DEXEDRINE (10 MG) (TABLET)...................................26DEXEDRINE (15 MG) (CAPSULE ER)..........................26DEXEDRINE (5 MG) (CAPSULE ER)............................26DEXEDRINE (5 MG) (TABLET).....................................26DEXERYL.........................................................................50DEXILANT............................................................. 148, 158DEXLANSOPRAZOLE..................................................148DEXMETHYLPHENIDATE HCL....................................30DEXONTO........................................................................ 98DEXTRANOMER/HYALURONATE/NACL.................102DEXTROAMPHETAMINE SULFATE............................ 26DEXTROAMPHETAMINE/AMPHETAMINE..........26, 27DEXTROMETHORPHAN HBR/QUINIDINE.............. 128DEXTROSE/SOD CITRATE/CITRIC AC....................... 83DIABETIC SUPPLIES,MISCELL..............................70, 71DIABINESE...................................................................... 56DIAPHRAGMS, CONTOURED...................................... 41DIAPHRAGMS, WIDE SEAL..........................................41DIASTAT......................................................................... 143DIASTAT ACUDIAL...................................................... 143DIATRUE..................................................................... 62-64DIATRUE PLUS..........................................................57, 66DIAZEPAM............................................................... 27, 143DIAZOXIDE..................................................................... 74DIBENZYLINE.................................................................32DICAPRYLYL CARBONATE/DIMETH......................... 50DICHLORPHENAMIDE................................................ 146DICLEGIS......................................................................... 17DICLO GEL...................................................................... 49DICLO GEL-XRYLIX SHEET.........................................48DICLOFEN SOD/KINESIOLOGY TAPE..................48, 49DICLOFENAC EPOLAMINE.......................................... 49DICLOFENAC POTASSIUM................................. 100, 140DICLOFENAC SODIUM............................. 49, 52, 79, 100DICLOFENAC SODIUM/CAPSAICIN..................... 49, 99DICLOFENAC SODIUM/MENTHOL.............................49DICLOFENAC SODIUM/MISOPROSTOL...................100DICLOFENAC SUBMICRONIZED...............................100DICLOFENAC/CAPSICUM OLEORESIN............... 49, 99DICLOFENAC/LIDOCAINE/TAPE...............................136DICLOFENAC/ME-SALIC/MENTH/CAMP.................. 49DICLOFENAC/MET SALICYL/MENTHOL.................. 49DICLOFONO.................................................................... 49DICLOPAK....................................................................... 49DICLOPR.......................................................................... 49DICLOTRAL.....................................................................49DICLOXACILLIN SODIUM............................................91DICLOZOR....................................................................... 49DICYCLOMINE HCL.................................................... 147DIDANOSINE...................................................................95DIDRONEL....................................................................... 77DIFENOXIN HCL/ATROPINE SULFATE.....................102DIFFERIN......................................................................... 44DIFICID.....................................................................90, 158DIFLORASONE DIACETATE......................................... 47DIFLORASONE DIACETATE/EMOLL.......................... 47DIFLUCAN....................................................................... 92DIFLUNISAL..................................................................137DIFLUPREDNATE........................................................... 79DIGOXIN.......................................................................... 32DIHYDROERGOTAMINE MESYLATE....................... 140DILACOR XR................................................................... 35DILANTIN...................................................................... 145DILANTIN (100 MG) (CAPSULE)................................145DILANTIN (30 MG) (CAPSULE)..................................145DILANTIN-125...............................................................145DILATRATE-SR................................................................39DILAUDID...................................................................... 138DILTIAZEM HCL.......................................................34, 35DILUENT FOR ROTARIX............................................. 129DILUENT, INSULIN ASPART NO.1.............................129DILUENT,LIVE ROTAVIRUS VACC,CA......................129DILUTING MEDIUM FOR NOVOLOG....................... 129DI-ME SILOX/DIMETHIC/HEXAMETHY.................... 52DIME/DIME CR/TRIMETH/SILIC PAD.........................52DIMET/DIMET CROSSPOL/T.M.SILIC......................... 52DIMETHYL FUMARATE..............................................127DIMETHYL SULFOXIDE............................................. 129DINOPROSTONE.............................................................41DIOVAN............................................................................ 33DIOVAN HCT................................................................... 32DIPENTUM.............................................................102, 158

DIPHENOXYLATE HCL/ATROPINE........................... 103DIPROLENE..................................................................... 47DIPROLENE AF............................................................... 47DIPYRIDAMOLE............................................................. 85DISALCID.......................................................................137DISOPYRAMIDE PHOSPHATE..................................... 31DISULFIRAM...................................................................27DITHOL............................................................................ 49DIURIL (250 MG) (TABLET).......................................... 36DIURIL (250 MG/5ML) (ORAL SUSP).......................... 36DIURIL (500 MG) (TABLET).......................................... 36DIVALPROEX SODIUM................................................143DIVIGEL........................................................................... 87DM2...................................................................................56DMT SUIK........................................................................ 98DOFETILIDE.................................................................... 31DOLASETRON MESYLATE...........................................17DOLOBID....................................................................... 137DOLOTRANZ................................................................... 53DOLUTEGRAVIR SODIUM............................................96DOLUTEGRAVIR/RILPIVIRINE....................................94DONEPEZIL HCL............................................................ 24DONNATAL (16.2 MG) (TABLET)....................... 148, 158DONNATAL (16.2MG/5ML) (ELIXIR)................. 148, 158DOPTELET....................................................................... 86DORAL..............................................................................30DORAVIRINE................................................................... 95DORAVIRINE/LAMIVU/TENOFOV DISO....................96DORNASE ALFA........................................................... 137DORYX (100 MG) (TABLET DR)........................... 91, 158DORYX (150 MG) (TABLET DR)........................... 91, 158DORYX (200 MG) (TABLET DR)........................... 91, 158DORYX (50 MG) (TABLET DR)............................. 91, 158DORYX (75 MG) (TABLET DR)............................. 91, 158DORYX MPC............................................................91, 158DORZOLAMIDE HCL..................................................... 81DORZOLAMIDE HCL/PF............................................... 81DORZOLAMIDE HCL/TIMOLOL MALEAT.................81DORZOLAMIDE/TIMOLOL/PF..................................... 81DORZOLAMIDE/TIMOLOL/PF (2 %-0.5 %)(DROPERETTE)............................................................. 158DORZOLAMIDE/TIMOLOL/PF (2 %-0.5 %) (DROPS)...............................................................................................DOSTINEX....................................................................... 78DOVER ADVANTAGE...................................................105DOVER ADVANTAGE DRAINAGE............................. 105DOVER COATED LATEX FOLEY................................105DOVER LATEX FOLEY CATHETER...........................105DOVER PREMIUM........................................................ 105DOVER RED RUBBER ROBIBSON CATH................. 105DOVER UNIVERSAL.................................................... 105DOVONEX................................................................54, 158DOXAZOSIN MESYLATE.............................................. 32DOXEPIN HCL.....................................................26, 30, 49DOXERCALCIFEROL..................................................... 78DOXYCYCLINE CALCIUM........................................... 91DOXYCYCLINE HYCLATE................................... 91, 128DOXYCYCLINE MONOHYDRATE.........................91, 92DOXYCYCLINE/BENZOYL PEROXIDE.......................92DOXYCYCLINE/SALICY/OCT/ZINC OX.....................92DOXYCYCLINE/SKIN CLEANSER NO19....................92DOXYLAMINE SUCCINATE/VIT B6............................ 17DRAINAGE BAG............................................................105DRESS,COLLAGN/SILV/ALGINAT/CMC................... 104DRITHOCREME HP................................................ 54, 158DRONABINOL................................................................. 17DRONEDARONE HCL.................................................... 32DROPLET LANCETS.................................................... 107DROPLET LANCING DEVICE.......................................72DROPLET PEN NEEDLE.............................................. 133DROPSAFE PEN NEEDLE............................................134DROSPIR/ETH ESTRA/LEVOMEFOL CA.................... 40DROSPIRENONE/ESTRADIOL......................................87DROXIA............................................................................ 85DROXIDOPA.................................................................... 39DRYSOL............................................................................49DUAC................................................................................ 43DUAVEE............................................................................87DUET DHA 400.............................................................. 153DUET DHA BALANCED.............................................. 151DUETACT................................................................. 56, 158DUEXIS.....................................................................99, 158DULAGLUTIDE............................................................... 55DULERA........................................................................... 19DULOXETINE HCL.........................................................25DULOXETINE HCL (20 MG) (CAPSULE DR)..................DULOXETINE HCL (30 MG) (CAPSULE DR)..................DULOXETINE HCL (40 MG) (CAPSULE DR)............158DULOXETINE HCL (60 MG) (CAPSULE DR)..................DUODOTE...................................................................... 129DUONEB...........................................................................18DUOPA............................................................................142


Index

DUPILUMAB....................................................................55DUPIXENT....................................................................... 55DURAGESIC...................................................................137DUREZOL.........................................................................79DURICEF.......................................................................... 89DURLAZA........................................................................ 85DUTASTERIDE.............................................................. 149DUTASTERIDE/TAMSULOSIN HCL...........................149DUTOPROL (100-12.5MG) (TAB ER 24H).................... 34DUTOPROL (25-12.5 MG) (TAB ER 24H)..................... 34DUTOPROL (50-12.5 MG) (TAB ER 24H)..................... 34DUZALLO................................................................ 82, 158DYANAVEL XR........................................................26, 158DYAZIDE.......................................................................... 35DYMISTA..................................................................16, 158DYNACIRC.......................................................................35DYRENIUM...................................................................... 35

- E -E.E.S. 200.......................................................................... 90E101/NAMG FL/NA PH/NACL/HA-NAH.......................49EAR POPPER..................................................................110EASIVENT..................................................................20, 21EASY CHECK.................................................................. 66EASY CLICK....................................................................72EASY COMFORT...........................................................107EASY COMFORT INSULIN SYRINGE............... 112, 122EASY COMFORT PEN NEEDLES............................... 133EASY GLIDE CATHETER TIP SYRING......................118EASY GLIDE DENTAL IRRIG SYRING..................... 116EASY GLIDE LUER LOCK SYRINGE.................116-118EASY GLIDE LUER SLIP TB SYRING....................... 116EASY GLIDE PEN NEEDLE.........................................133EASY GLUCO G2............................................................ 57EASY MINI EJECT LANCING DEVICE........................72EASY PLUS II................................................ 57, 62, 63, 66EASY STEP.................................................................57, 66EASY TALK....................................................57, 62, 63, 66EASY TOUCH................................ 107, 112, 114, 115, 122EASY TOUCH CONTROL SOLUTION......................... 61EASY TOUCH FLIPLOCK INSULIN........................... 118EASY TOUCH FLIPLOCK NEEDLE (30GX1/2") (DISNEEDLE) (OTC).............................................................131EASY TOUCH FLIPLOCK SYRINGE..................120, 121EASY TOUCH FLIPLOCK SYRINGES............... 120, 121EASY TOUCH FLURINGE........................................... 114EASY TOUCH FLURINGE FLIPLOCK....................... 120EASY TOUCH FLURINGE SHEATHLOCK................ 120EASY TOUCH GLUCOSE MONITOR........................... 66EASY TOUCH HYPODERMIC NEEDLE (30GX1/2")(DIS NEEDLE) (OTC).................................................... 131EASY TOUCH INSULIN SAFETY............................... 118EASY TOUCH INSULIN SYRINGE.....................112, 122EASY TOUCH LANCETS............................................. 107EASY TOUCH LANCING DEVICE............................... 72EASY TOUCH LUER LOCK INSULIN........................118EASY TOUCH LUER LOCK SYRINGE.............. 116, 117EASY TOUCH PEN NEEDLE....................................... 133EASY TOUCH SHEATHLOCK INSULIN....................118EASY TOUCH SHEATHLOCK SYRG-NDL................121EASY TOUCH SHEATHLOCK SYRG-NDL (22GX11/2") (DISP SYRIN) (OTC)............................................ 120EASY TOUCH SHEATHLOCK SYRG-NDL (25GX1")(DISP SYRIN) (OTC)..................................................... 120EASY TOUCH SHEATHLOCK SYRINGE...........116, 117EASY TOUCH TEST STRIP............................................57EASY TOUCH TUBERCULIN FLIPLOCK..................120EASY TOUCH TUBERCULIN SHEATHLK................ 120EASY TOUCH UNI-SLIP...................................... 116, 118EASY TRAK................................................... 57, 62, 63, 66EASY TWIST & CAP LANCETS..................................107EASYGLUCO................................................................... 66EASYGLUCO METER.....................................................66EASYGLUCO METER STARTER KIT...........................66EASYGLUCO PLUS........................................................ 57EASYGLUCO PLUS CONTROL NORMAL.................. 64EASYGLUCO TEST STRIPS.......................................... 57EASYMAX............................................................57, 63, 64EASYMAX 15.......................................................57, 63, 64EASYMAX L.................................................................... 66EASYMAX NG.................................................................66EASYMAX V SPEAKING...............................................66EASYMAX V2..................................................................66EASY-TOUCH.................................................................. 66EASY-TOUCH INSULIN SYRINGE.............................113EBASE CONTROLLER................................................... 19ECHOTHIOPHATE IODIDE............................................81ECLIPSE LUER-LOK SYRINGE.................. 114, 115, 121ECLIPSE NEEDLE......................................................... 131ECLIPSE SYRINGE............................................... 113, 121ECLIPSE SYRINGE-NEEDLE...................................... 114EC-NAPROSYN..............................................................101

ECONAZOLE NITRATE..................................................45ECOTRIN.......................................................................... 85ECOZA.............................................................................. 45EDARBI.....................................................................33, 158EDARBYCLOR........................................................ 32, 158EDECRIN.......................................................................... 35EDETATE DISODIUM................................................... 134EDLUAR................................................................... 30, 158EDOXABAN TOSYLATE................................................ 83EDURANT........................................................................ 95EFAVIRENZ......................................................................95EFAVIRENZ/EMTRICIT/TENOFOVR DF......................96EFAVIRENZ/LAMIVU/TENOFOV DISOP.....................96EFFER-K........................................................................... 76EFFEXOR..........................................................................25EFFEXOR XR................................................................... 25EFFIENT........................................................................... 85EFINACONAZOLE.......................................................... 45EFUDEX............................................................................52EGRIFTA...........................................................................77ELAGOLIX SODIUM...................................................... 78ELAVIL............................................................................. 26ELBASVIR/GRAZOPREVIR...........................................97ELDOQUIN FORTE......................................................... 54ELEMENT COMPACT...............................................57, 66ELEMENT COMPACT CONTROL SOLN................62, 64ELEMENT COMPACT V.................................................66ELEMENT CONTROL SOLUTION...........................62-64ELEMENT PLUS..............................................................66ELEMENT TEST STRIPS................................................ 58ELESTAT...........................................................................79ELESTRIN........................................................................ 87ELETRIPTAN HYDROBROMIDE................................ 140ELIDEL..................................................................... 55, 158ELIGARD..........................................................................77ELIGLUSTAT TARTRATE.............................................129ELIPHOS...........................................................................75ELIQUIS (2.5 MG) (TABLET)......................................... 83ELIQUIS (5 MG (74)) (TAB DS PK)................................83ELIQUIS (5 MG) (TABLET)............................................ 83ELITE-OB....................................................................... 152ELIXOPHYLLIN.............................................................. 23ELLA................................................................................. 41ELLIOTTS B................................................................... 129ELMIRON....................................................................... 149ELOCON........................................................................... 48ELOCTATE....................................................................... 82ELTROMBOPAG OLAMINE...........................................86ELUXADOLINE.............................................................102ELVITEG/COB/EMTRI/TENOF ALAFEN..................... 96ELVITEG/COB/EMTRI/TENOFO DISOP...................... 96EMADINE.................................................................79, 159EMBEDA (100MG-4MG) (CAP ER PO)....................... 139EMBEDA (20MG-0.8MG) (CAP ER PO)...................... 139EMBEDA (30MG-1.2MG) (CAP ER PO)...................... 139EMBEDA (50 MG-2 MG) (CAP ER PO)....................... 139EMBEDA (60MG-2.4MG) (CAP ER PO)...................... 139EMBEDA (80MG-3.2MG) (CAP ER PO)...................... 139EMBRACE.................................................... 58, 62, 67, 107EMBRACE EVO................................................... 58, 63, 67EMBRACE GLUCOSE CONTROL SOLN......................63EMBRACE PRO....................................................58, 61, 67EMCYT........................................................................... 127EMEDASTINE DIFUMARATE....................................... 79EMEND (125 MG) (CAPSULE).......................................17EMEND (125 MG) (SUSP RECON)................................ 17EMEND (125MG-80MG) (CAP DS PK)..........................17EMEND (40 MG) (CAPSULE).........................................17EMEND (80 MG) (CAPSULE).........................................17EMFLAZA........................................................................ 98EMICIZUMAB-KXWH....................................................84EMLA................................................................................ 53EMOL53/NAMGFS/HA/NAHYPOCHLORIT................ 50EMOL53/SOD MAG FL.SIL/CYCLOMET.....................50EMOL60/H.ACID/SOD CHL,SUL,PHOS..................... 136EMOLLIENT BASE....................................................... 134EMOLLIENT COMBINATION NO.10............................50EMOLLIENT COMBINATION NO.101..........................50EMOLLIENT COMBINATION NO.103..........................50EMOLLIENT COMBINATION NO.104..........................50EMOLLIENT COMBINATION NO.107..........................50EMOLLIENT COMBINATION NO.109..........................50EMOLLIENT COMBINATION NO.32............................50EMOLLIENT COMBINATION NO.35............................50EMOLLIENT COMBINATION NO.38............................50EMOLLIENT COMBINATION NO.43............................49EMOLLIENT COMBINATION NO.44............................50EMOLLIENT COMBINATION NO.47............................50EMOLLIENT COMBINATION NO.53............................50EMOLLIENT COMBINATION NO.60............................50EMOLLIENT COMBINATION NO.80............................50EMOLLIENT COMBINATION NO.85............................49

EMOLLIENT COMBOS NO.47, NO.60.......................... 50EMOLLIENT NO43/SKIN CLEANSER27......................49EMPAGLIFLOZIN............................................................55EMPAGLIFLOZIN/LINAGLIPTIN..................................56EMPAGLIFLOZIN/METFORMIN HCL..........................56EMSAM.............................................................................29EMTRICITA/RILPIVIRINE/TENOF DF......................... 96EMTRICITAB/RILPIVIRI/TENOF ALA.........................96EMTRICITABINE.............................................................95EMTRICITABINE/TENOFOV ALAFENAM..................94EMTRICITABINE/TENOFOVIR (TDF)..........................94EMTRIVA..........................................................................95EMVERM..........................................................................93ENABLEX...............................................................149, 159ENALAPRIL MALEATE..................................................33ENALAPRIL/HYDROCHLOROTHIAZIDE................... 32ENASIDENIB MESYLATE............................................126ENBRACE HR................................................................ 153ENBREL............................................................................98ENBREL MINI..................................................................98ENBREL SURECLICK.....................................................98ENCORAFENIB............................................................. 124ENDARI.......................................................................... 134ENDO-AVITENE.............................................................. 86ENDOFORM...................................................................134ENDOMETRIN.................................................................76ENFUVIRTIDE................................................................. 94ENLITE............................................................................. 62ENLITE GLUCOSE SENSOR..........................................70ENLITE SERTER..............................................................70ENOXAPARIN SODIUM................................................. 84ENSTILAR................................................................ 55, 159ENTACAPONE............................................................... 142ENTECAVIR..................................................................... 96ENTERAL GRAVITY BAG SET-ENFIT....................... 110ENTERAL PUMP ACCESS.HYDROLYSIS................. 110ENTEREG....................................................................... 103ENTOCORT EC................................................................ 98ENTRESTO.......................................................................39ENTTY.............................................................................. 50ENVARSUS XR................................................................ 89ENZALUTAMIDE.......................................................... 124EPANED....................................................................33, 159EPCLUSA..........................................................................96EPICERAM....................................................................... 50EPIDUO.....................................................................43, 159EPIDUO FORTE....................................................... 43, 159EPIFIX AMNIOTIC MEMBRANE................................134EPIFOAM..........................................................................52EPINASTINE HCL........................................................... 79EPINEPHRINE..........................................................32, 123EPINEPHRINE HCL.........................................................43EPIPEN............................................................................123EPIPEN 2-PAK................................................................123EPIPEN JR.......................................................................123EPIPEN JR 2-PAK...........................................................123EPISIL............................................................................. 134EPIVIR.............................................................................. 95EPIVIR HBV (100 MG) (TABLET)................................. 96EPIVIR HBV (25 MG/5 ML) (SOLUTION).................... 96EPLERENONE..................................................................35EPOETIN ALFA............................................................... 84EPOETIN ALFA-EPBX....................................................84EPOGEN............................................................................84EPROSARTAN MESYLATE............................................ 33EPZICOM..........................................................................94EQUETRO.........................................................................27ERAPID NEBULIZER......................................................22ERAPID NEBULIZER HANDSET................................ 106ERENUMAB-AOOE.......................................................140ERGOCALCIFEROL (VITAMIN D2)........................... 153ERGOCALCIFEROL (VITAMIN D2) (50000 UNIT)(CAPSULE)...........................................................................ERGOLOID MESYLATES...............................................40ERGOMAR..................................................................... 140ERGOTAMINE TARTRATE...........................................140ERGOTAMINE TARTRATE/CAFFEINE...................... 140ERIVEDGE..................................................................... 125ERLEADA.......................................................................124ERLOTINIB HCL........................................................... 126ERTACZO..........................................................................45ERTUGLIFLOZIN PIDOLATE........................................ 55ERTUGLIFLOZIN/METFORMIN................................... 56ERTUGLIFLOZIN/SITAGLIPTIN................................... 56ERYPED 200..................................................................... 90ERYPED 400..................................................................... 90ERY-TAB........................................................................... 90ERYTHRCIN STEARATE................................................90ERYTHROMYCIN BASE.......................................... 80, 90ERYTHROMYCIN BASE IN ETHANOL....................... 44ERYTHROMYCIN ETHYLSUCCINATE........................90ERYTHROMYCIN STEARATE.......................................90


Index

ERYTHROMYCIN/BENZOYL PEROXIDE................... 44ESBRIET......................................................................... 136ESCITALOPRAM OXALATE..........................................25ESKATA............................................................................ 49ESLICARBAZEPINE ACETATE................................... 143ESOMEPRAZOLE MAGNESIUM................................ 148ESOMEPRAZOLE STRONTIUM..........................149, 159ESTAZOLAM................................................................... 30ESTRACE..................................................................87, 150ESTRADIOL............................................................. 87, 150ESTRADIOL ACETATE.................................................150ESTRADIOL CYPIONATE.............................................. 87ESTRADIOL VALERATE................................................ 87ESTRADIOL VALERATE/DIENOGEST........................ 40ESTRADIOL/LEVONORGESTREL............................... 87ESTRADIOL/NORETHINDRONE ACET.......................87ESTRADIOL/NORGESTIMATE..................................... 87ESTRAMUSTINE PHOSPHATE SODIUM.................. 127ESTRING........................................................................ 150ESTROGEL....................................................................... 87ESTROGEN,CON/M-PROGEST ACET.......................... 87ESTROGEN,ESTER/ME-TESTOSTERONE...................87ESTROGENS, CONJUGATED................................ 87, 150ESTROGENS,CONJ/BAZEDOXIFENE.......................... 87ESTROGENS,ESTERIFIED.............................................87ESTROPIPATE.................................................................. 87ESTROSTEP FE................................................................41ESZOPICLONE................................................................ 30ETANERCEPT.................................................................. 98ETHACRYNIC ACID....................................................... 35ETHAMBUTOL HCL.......................................................93ETHINYL ESTRADIOL/DROSPIRENONE................... 40ETHIONAMIDE............................................................... 93ETHOSUXIMIDE........................................................... 143ETHOTOIN..................................................................... 143ETHYL ACETATE.......................................................... 130ETHYL CHLORIDE......................................................... 52ETHYNODIOL D-ETHINYL ESTRADIOL....................40ETIDRONATE DISODIUM..............................................77ETODOLAC.................................................................... 100ETODOLAC/CAPSAICIN/ME-SAL/MENT................... 99ETONOGESTREL............................................................ 40ETONOGESTREL/ETHINYL ESTRADIOL...................40ETOPOSIDE....................................................................126ETRAFON-A.....................................................................26ETRAVIRINE....................................................................95EUCRISA.................................................................. 46, 159EULEXIN........................................................................ 124EURAX..............................................................................45EVAMIST.......................................................................... 87EVARREST....................................................................... 86EVEKEO........................................................................... 26EVENCARE.......................................................... 58, 61, 67EVENCARE G2.................................................... 58, 61, 67EVENCARE G3.................................................... 58, 61, 67EVENCARE MINI GLUCOSE CONTROL.....................64EVENCARE MINI GLUCOSE TEST STR......................58EVENCARE MINI MONITOR SYSTEM....................... 67EVENCARE PROVIEW CONTROL SOLN....................61EVENCARE PROVIEW TEST STRIP.............................58EVEROLIMUS..........................................................89, 125EVICEL............................................................................. 86EVISTA............................................................................. 77EVOCLIN..........................................................................44EVOLOCUMAB............................................................... 38EVOLUTION BLOOD GLUCOSE METER....................67EVOLUTION CONTROL SOLUTION............................64EVOLUTION TEST STRIPS............................................58EVOTAZ............................................................................ 95EVOXAC......................................................................... 123EVZIO............................................................................... 29EXEL HYPODERMIC NEEDLE (30GX1/2") (DISNEEDLE) (OTC).............................................................131EXEL SYRINGE..................................................... 115-118EXEL TB WITH NEEDLE............................................. 114EXEL TUBERCULIN SYRINGE.................................. 116EXELDERM......................................................................45EXELON........................................................................... 24EXEMESTANE............................................................... 124EXENATIDE..................................................................... 55EXENATIDE MICROSPHERES...................................... 55EXFORGE.........................................................................33EXFORGE HCT................................................................32EXJADE.......................................................................... 130EXTAVIA........................................................................ 127EXTINA.............................................................................45EXTRACELL MATRIX, OVINE, FENES..................... 134EXTRACELL MATRIX,PORCINE,FENES.................. 134EXTRACELLULAR MATRIX, OVINE.........................134EXTRACELLULAR MATRIX,PORCINE.....................134EYE..................................................................................130E-Z JECT LANCETS...................................................... 107

EZ SMART.......................................................58, 62-64, 67EZ SMART LANCETS...................................................107EZ SMART PLUS....................................................... 58, 67E-Z SPACER..................................................................... 20EZETIMIBE...................................................................... 38EZETIMIBE/SIMVASTATIN........................................... 36E-ZJECT LANCETS....................................................... 107EZ-VAC............................................................................. 70

- F -FABIOR.............................................................................44FACTIVE...........................................................................91FACTOR IX.......................................................................83FACTOR IX CPLX(PCC)NO4,3FACTOR....................... 83FACTOR IX CPLX(PCC)NO6,3FACTOR....................... 83FACTOR IX HUMAN REC,PEGYLATED......................83FACTOR IX HUMAN RECOMB,THR 148.....................83FACTOR IX HUMAN RECOMBINANT.........................83FACTOR IX REC, FC FUSION PROTN..........................83FACTOR IX RECOM,ALBUMIN FUSION.....................83FACTOR XIII.................................................................... 83FACTOR XIII A-SUBUNIT,RECOMB............................ 83FAMCICLOVIR................................................................ 94FAMOTIDINE.................................................................148FAMVIR............................................................................ 94FANAPT (1 MG) (TABLET).................................... 28, 159FANAPT (10 MG) (TABLET).................................. 28, 159FANAPT (12 MG) (TABLET).................................. 28, 159FANAPT (1-2-4-6MG) (TAB DS PK).......................28, 159FANAPT (2 MG) (TABLET).................................... 28, 159FANAPT (4 MG) (TABLET).................................... 28, 159FANAPT (6 MG) (TABLET).................................... 28, 159FANAPT (8 MG) (TABLET).................................... 28, 159FARESTON..................................................................... 127FARXIGA..................................................................55, 159FARYDAK.......................................................................126FAZACLO................................................................. 28, 159FC2 FEMALE CONDOM...............................................129FEBUXOSTAT.................................................................. 82FECAL COLL W-CHARCOAL/CATH/SYR................. 110FEEDER CONT, GRAVITY SET,ENFIT....................... 110FEEDER CONTAINER.................................................. 110FEEDER CONTAINER W-GRAVITY SET................... 110FEEDER CONTAINER WITH PUMP SET................... 110FEIBA NF..........................................................................83FELBAMATE..........................................................143, 144FELBATOL (400 MG) (TABLET)..........................143, 159FELBATOL (600 MG) (TABLET)..........................144, 159FELBATOL (600 MG/5ML) (ORAL SUSP).......... 144, 159FELDENE........................................................................101FELODIPINE.................................................................... 35FEM PH........................................................................... 150FEMALE SELF CATHETER..........................................105FEMARA.........................................................................124FEMCAP........................................................................... 41FEMCON FE..................................................................... 41FEMHRT........................................................................... 87FEMRING....................................................................... 150FENOFIBRATE.................................................................38FENOFIBRATE NANOCRYSTALLIZED....................... 38FENOFIBRATE,MICRONIZED.................................38, 39FENOFIBRIC ACID......................................................... 39FENOFIBRIC ACID (CHOLINE).................................... 39FENOGLIDE.....................................................................38FENOPROFEN CALCIUM............................................ 100FENORTHO.................................................................... 100FENTANYL.....................................................................137FENTANYL CITRATE........................................... 137, 138FENTANYL CITRATE/PF..............................................138FENTANYL CITRATE-0.9 % NACL/PF....................... 138FENTANYL/BUPIVACAINE/NS/PF............................. 138FENTANYL/ROPIVACAINE/NS/PF............................. 138FENTORA.......................................................................138FERRIC CITRATE............................................................75FERRIC SUBSULFATE....................................................86FERRIPROX....................................................................130FERROUS SULFATE......................................................151FERROUS SULFATE (15 MG/ML) (DROPS) (OTC)..........FESOTERODINE FUMARATE..................................... 149FETZIMA.................................................................. 25, 159FEXMID.......................................................................... 146FEXOFENADINE/PSEUDOEPHEDRINE...................... 16FIASP........................................................................ 74, 159FIASP FLEXTOUCH................................................74, 159FIBRICOR.........................................................................39FIBRINOGEN/THROMBIN(HUMAN DER).................. 86FIDAXOMICIN.................................................................90FIFTY50 SAFETY SEAL LANCETS............................ 107FIFTY50 TEST STRIP......................................................58FILGRASTIM................................................................... 85FILGRASTIM-AAFI.........................................................85FILGRASTIM-SNDZ........................................................85

FILTER NEEDLE............................................................131FILTER PAD................................................................... 106FILTER, VALVE SET FOR LL & LC............................ 106FILTERED EXTENSION SET....................................... 111FINACEA.......................................................................... 43FINASTERIDE................................................................149FINE 30 UNIVERSAL LANCETS.................................107FINGERSTIX.................................................................. 107FINGOLIMOD HCL....................................................... 127FIORICET WITH CODEINE......................................... 141FIORINAL WITH CODEINE #3....................................141FIRAZYR.......................................................................... 98FIRMAGON (120 MG) (VIAL)......................................125FIRMAGON (80 MG) (VIAL)........................................125FIRVANQ (25 MG/ML) (SOLN RECON)........................93FIRVANQ (50 MG/ML) (SOLN RECON)........................93FLAGYL............................................................................93FLAREX............................................................................79FLASH GLUCOSE SCANNING READER.....................71FLASH GLUCOSE SENSOR...........................................71FLAVOXATE HCL..........................................................149FLAXSEED.....................................................................134FLECAINIDE ACETATE..................................................32FLECTOR..........................................................................49FLEXERIL...................................................................... 146FLEXICHAMBER............................................................ 20FLEXICHAMBER MASK................................................21FLEXIPAK........................................................................ 99FLEXI-SEAL SIGNAL FMS.......................................... 110FLOLIPID..........................................................................37FLOMAX........................................................................ 149FLONASE......................................................................... 17FLORINEF........................................................................ 99FLOVENT DISKUS (100 MCG) (BLST W/DEV)...........19FLOVENT DISKUS (250 MCG) (BLST W/DEV)...........19FLOVENT DISKUS (50 MCG) (BLST W/DEV).............19FLOVENT HFA (110 MCG) (AER W/ADAP).................19FLOVENT HFA (220 MCG) (AER W/ADAP).................19FLOVENT HFA (44 MCG) (AER W/ADAP)...................19FLOXIN.............................................................................91FLU VAC QS 18-19 (4YR UP) CELL.............................. 88FLU VAC QS 18-19(4YR UP)CEL/PF............................. 88FLU VAC QV 2018(18YR UP)RCM/PF.......................... 88FLU VACC QS 2018 (6-35MOS)/PF................................ 88FLU VACC QS2018-19 36MOS UP/PF............................88FLU VACC QS2018-19(6MOS UP)/PF............................88FLU VACC QUAD 2018(5 YR UP)/PF ............................ 88FLU VACC QUAD 2018-19(5 YR UP) ............................ 88FLU VACC QUAD 2018-19(6MOS UP).......................... 88FLU VACC QV LIVE 2018(2-49YRS).............................88FLU VACC TS2018(65UP)/MF59C/PF............................88FLU VACC TS2018-19(65YR UP)/PF............................. 88FLU VACCIN TS2018-19 5YR UP/PF.............................88FLU VACCINE TS2018-19(5 YR UP) ............................. 88FLUAD 2018-2019............................................................88FLUARIX QUAD 2018-2019........................................... 88FLUBLOK QUAD 2018-2019.......................................... 88FLUCELVAX QUAD 2018-2019......................................88FLUCONAZOLE.............................................................. 92FLUCYTOSINE................................................................ 92FLUDROCORTISONE ACETATE................................... 99FLULAVAL QUAD 2018-2019.........................................88FLUMADINE....................................................................94FLUMIST QUAD 2018-2019............................................88FLUNISOLIDE........................................................... 17, 19FLUOCINOLONE ACETONIDE.....................................47FLUOCINOLONE ACETONIDE OIL............................. 75FLUOCINOLONE/EMOL COMB NO.65....................... 47FLUOCINOLONE/SHOWER CAP..................................47FLUOCINOLONE/SKIN CLNSR10/TAPE..................... 47FLUOCINOLONE/SKIN CLNSR28................................ 47FLUOCINOLONE/TRETINOIN/H-QUIN.......................54FLUOCINOLONE/UREA/SILICONE,ADH................... 47FLUOCINONIDE..............................................................47FLUOCINONIDE/EMOLLIENT BASE.......................... 47FLUORESCEIN-BENOXINATE......................................80FLUORIDE (SODIUM).................................................. 150FLUORIDE (SODIUM) (0.25(0.55)) (TAB CHEW) (OTC)...............................................................................................FLUORIDE (SODIUM) (0.5 MG/ML) (DROPS) (OTC)...............................................................................................FLUORIDE (SODIUM) (0.5(1.1)MG) (TAB CHEW)(OTC).....................................................................................FLUORIDE (SODIUM) (1.1 %) (CREAM (G))...................FLUORIDE (SODIUM) (1.1 %) (GEL (GRAM))................FLUORIDE (SODIUM) (1MG(2.2MG)) (TAB CHEW)(OTC).....................................................................................FLUORIDEX...................................................................150FLUOROMETHOLONE...................................................79FLUOROMETHOLONE ACETATE................................ 79FLUOROPLEX................................................................. 52FLUOROURACIL.............................................................52


Index

FLUOXETINE HCL..........................................................25FLUPHENAZINE HCL.................................................... 29FLURANDRENOLIDE.............................................. 47, 48FLURAZEPAM HCL........................................................ 30FLURBIPROFEN............................................................100FLURBIPROFEN SODIUM............................................. 79FLURESS.......................................................................... 80FLUROX............................................................................80FLUTAMIDE...................................................................124FLUTICASONE FUROATE............................................. 19FLUTICASONE PROPIONATE...........................17, 19, 48FLUTICASONE/SALMETEROL.....................................18FLUTICASONE/SOD CHL/SOD BICARB.....................17FLUTICASONE/UMECLIDIN/VILANTER................... 19FLUTICASONE/VILANTEROL......................................18FLUVASTATIN SODIUM................................................ 37FLUVOXAMINE MALEATE...........................................25FLUZONE HIGH-DOSE 2018-2019................................ 88FLUZONE QUAD 2018-2019.......................................... 88FLUZONE QUAD PEDI 2018-2019.................................88FML................................................................................... 79FML FORTE......................................................................79FML S.O.P......................................................................... 79FOAM BANDAGE..........................................................104FOAM/GAUZE/LIDOCA/CHLHX/ISOPRO................. 104FOCALIN.......................................................................... 30FOCALIN XR................................................................... 30FOLET ONE....................................................................151FOLEX............................................................................ 124FOLIC ACID........................................................... 150, 151FOLIC ACID (0.4 MG) (TABLET) (OTC)...........................FOLIC ACID (0.8 MG) (TABLET) (OTC)...........................FOLIC ACID (1 MG) (TABLET).........................................FOLIC ACID (5 MG/ML) (VIAL)........................................FOLLISTIM AQ........................................................76, 159FOLLITROPIN ALFA, RECOMBINANT....................... 76FOLLITROPIN BETA,RECOMB.....................................76FONDAPARINUX SODIUM......................................84, 85FORA 6 CONNECT GLUCOSE STRIP.......................... 58FORA CONTROL SOLUTION........................................64FORA D10.........................................................................62FORA D15.........................................................................62FORA D15G......................................................................58FORA D20...................................................................58, 67FORA D40.........................................................................62FORA D40-G31 TEST STRIPS........................................58FORA G20...................................................................58, 67FORA G30A......................................................................67FORA G30-PREMIUM V10 TEST STRP........................58FORA GD50......................................................................67FORA GD50 TEST STRIPS............................................. 58FORA LANCETS............................................................108FORA LANCING DEVICE.............................................. 72FORA PREMIUM V10..................................................... 67FORA TEST N'GO VOICE...............................................67FORA TEST STRIP.......................................................... 58FORA TN'G VOICE..........................................................67FORA TN'G VOICE TEST STRIPS................................. 58FORA V10...................................................................58, 67FORA V10-V12-D10-D20................................................ 58FORA V12...................................................................58, 67FORA V20...................................................................58, 67FORA V30A................................................................58, 67FORACARE GD20..................................................... 58, 67FORACARE GD40........................................................... 58FORACARE GD40A........................................................ 67FORACARE GD40B.........................................................67FORACARE GDH....................................................... 62-64FORACARE LANCETS................................................. 108FORFIVO XL............................................................ 25, 160FORMALDEHYDE................................................ 134, 136FORMA-RAY..................................................................134FORMOTEROL FUMARATE.......................................... 18FORTAMET.............................................................. 56, 160FORTEO............................................................................ 77FORTESTA........................................................................87FORTISCARE..............................................................62-64FORTISCARE BLOOD GLUCOSE SYST...................... 67FORTISCARE GLUCOSE TEST STRIPS....................... 58FOSAMAX (10 MG) (TABLET)...................................... 77FOSAMAX (35 MG) (TABLET)...................................... 77FOSAMAX (40 MG) (TABLET)...................................... 77FOSAMAX (5 MG) (TABLET)........................................ 77FOSAMAX (70 MG) (TABLET)...................................... 77FOSAMAX (70 MG/75ML) (SOLUTION)......................77FOSAMAX PLUS D......................................................... 77FOSAMPRENAVIR CALCIUM.......................................95FOSFOMYCIN TROMETHAMINE................................ 90FOSINOPRIL SODIUM................................................... 33FOSINOPRIL/HYDROCHLOROTHIAZIDE.................. 32FOSRENOL (1000 MG) (POWD PACK)......................... 75FOSRENOL (1000 MG) (TAB CHEW)........................... 75

FOSRENOL (500 MG) (TAB CHEW)............................. 75FOSRENOL (750 MG) (POWD PACK)........................... 76FOSRENOL (750 MG) (TAB CHEW)............................. 76FOSTAMATINIB DISODIUM......................................... 86FRAGMIN (10000/ML) (SYRINGE)............................... 84FRAGMIN (12500/0.5) (SYRINGE)................................ 84FRAGMIN (15000/0.6) (SYRINGE)................................ 84FRAGMIN (18000/0.72) (SYRINGE).............................. 84FRAGMIN (2500/0.2ML) (SYRINGE)............................ 84FRAGMIN (25000/ML) (VIAL)....................................... 84FRAGMIN (5000/0.2ML) (SYRINGE)............................ 84FRAGMIN (7500/0.3ML) (SYRINGE)............................ 84FREESTYLE CONTROL SOLUTION...................... 61, 64FREESTYLE FLASH SYSTEM.......................................67FREESTYLE FREEDOM................................................. 67FREESTYLE FREEDOM LITE....................................... 67FREESTYLE INSULINX........................................... 58, 67FREESTYLE INSULINX TEST STRIPS.........................58FREESTYLE LANCETS................................................ 108FREESTYLE LIBRE 10 DAY READER......................... 71FREESTYLE LIBRE 10 DAY SENSOR.......................... 71FREESTYLE LIBRE 14 DAY READER......................... 71FREESTYLE LIBRE 14 DAY SENSOR.......................... 71FREESTYLE LITE METER.............................................67FREESTYLE LITE STRIPS............................................. 58FREESTYLE NAVIGATOR..............................................70FREESTYLE PRECISION..................................... 113, 122FREESTYLE PRECISION NEO...................................... 58FREESTYLE PRECISION NEO METER........................67FREESTYLE SIDEKICK II..............................................67FREESTYLE SYSTEM.................................................... 67FREESTYLE TEST STRIPS............................................ 58FREESTYLE UNISTIK 2............................................... 108FREMANEZUMAB-VFRM........................................... 140FROTEK............................................................................ 49FROVA.....................................................................140, 160FROVATRIPTAN SUCCINATE......................................140FULPHILA........................................................................ 85FURADANTIN................................................................. 90FUROSEMIDE..................................................................35FUZEON............................................................................94FVIII REC,B-DOM DELET PEG-AUCL.........................83FYCOMPA (0.5 MG/ML) (ORAL SUSP).............. 145, 160FYCOMPA (10 MG) (TABLET).............................145, 160FYCOMPA (12 MG) (TABLET).............................145, 160FYCOMPA (2 MG) (TABLET)...............................145, 160FYCOMPA (4 MG) (TABLET)...............................145, 160FYCOMPA (6 MG) (TABLET)...............................145, 160FYCOMPA (8 MG) (TABLET)...............................145, 160

- G -GABAPENTIN..................................................55, 128, 144GABAPENTIN ENACARBIL........................................ 127GABAPENTIN/CAPSAI/ME-SAL/MENTH................. 144GABAPENTIN/LIDOCAINE/MENTHOL.................... 144GABITRIL (12 MG) (TABLET).............................146, 160GABITRIL (16 MG) (TABLET).............................146, 160GABITRIL (2 MG) (TABLET)...............................146, 160GABITRIL (4 MG) (TABLET)...............................146, 160GABLOFEN.................................................................... 146GALAFOLD....................................................................123GALANTAMINE HBR.....................................................24GALZIN.......................................................................... 131GAMMAGARD LIQUID..................................................87GAMMAKED................................................................... 88GAMUNEX-C...................................................................88GANCICLOVIR................................................................80GANIRELIX ACETATE................................................... 78GARAMYCIN...................................................................80GASTROCROM................................................................19GASTROSTOMY TUBE, ENFIT...................................110GATIFLOXACIN.............................................................. 80GATIFLOXACIN/DEXAMETHASONE......................... 79GATTEX..........................................................................103GAUZE BANDAGE........................................................104GDRIVE............................................................................ 67GE100 BLOOD GLUCOSE SYSTEM............................. 67GE100 BLOOD GLUCOSE TEST STRIP....................... 58GE100 CONTROL SOLUTION NORMAL.....................64GEFITINIB......................................................................126GEL DRESSING............................................................. 104GEL PAD/DMC/DIME/DEC/OCT/VIT E........................52GELATIN.................................................................. 82, 136GELATIN SPONGE,ABSORB/PORCINE.......................86GELCLAIR......................................................................134GELFILM.................................................................. 82, 136GELFOAM........................................................................ 86GELFOAM JMI.................................................................86GEL-MATRIX PAD DRESS, SILICONE.......................104GELNIQUE............................................................. 150, 160GELX...............................................................................134GEMFIBROZIL.................................................................39

GEMIFLOXACIN MESYLATE....................................... 91GENADUR........................................................................52GENERESS FE................................................................. 41GENGRAF........................................................................ 89GENOTROPIN.................................................................. 77GENSTRIP........................................................................ 59GENTAK........................................................................... 80GENTAMICIN SULF/PREDNISOLONE........................ 79GENTAMICIN SULFATE...........................................44, 80GENTIAN VIOLET/BRGREEN/PROFLAV....................45GENULTIMATE TEST STRIP......................................... 59GENVOYA........................................................................ 96GEODON.......................................................................... 29GIALAX.......................................................................... 103GILENYA (0.25 MG) (CAPSULE)................................ 127GILENYA (0.5 MG) (CAPSULE).................................. 127GILOTRIF....................................................................... 125GLATIRAMER ACETATE............................................. 127GLECAPREVIR/PIBRENTASVIR.................................. 97GLEEVEC (100 MG) (TABLET)................................... 126GLEEVEC (400 MG) (TABLET)................................... 126GLEOSTINE................................................................... 124GLIADEL........................................................................ 124GLIMEPIRIDE..................................................................56GLIPIZIDE........................................................................ 56GLIPIZIDE/METFORMIN HCL......................................56GLUCAGEN..................................................................... 74GLUCAGON EMERGENCY KIT................................... 74GLUCAGON,HUMAN RECOMBINANT.......................74GLUCO NAVII............................................................59, 67GLUCOCARD 01............................................................. 67GLUCOCARD 01 CONTROL....................................61, 64GLUCOCARD 01 SENSOR PLUS.................................. 59GLUCOCARD EXPRESSION............................. 59, 64, 67GLUCOCARD SHINE..........................................59, 64, 67GLUCOCARD SHINE XL............................................... 67GLUCOCARD VITAL................................................59, 68GLUCOCARD VITAL SENSOR..................................... 59GLUCOCOM.................................................................. 108GLUCOCOM AUTOLINK............................................... 70GLUCOCOM BLOOD GLUCOSE.................................. 68GLUCOCOM CONTROL SOLUTION......................62, 64GLUCOCOM GLUCOSE................................................. 59GLUCOCOM LANCETS............................................... 108GLUCOPHAGE................................................................ 56GLUCOPHAGE XR..........................................................56GLUCOSE CONTROL..................................................... 64GLUCOSE CONTROL SOLUTION.......................... 61, 65GLUCOSE TEST STRIP.................................................. 59GLUCOTROL................................................................... 56GLUCOTROL XL............................................................. 56GLUMETZA............................................................. 56, 160GLUTAMINE..................................................................134GLUTATHIONE..............................................................129GLUTATHIONE-L................................................................GLY/CARB H.POLYMR A/POT HYDROX.................. 134GLYBURIDE.....................................................................56GLYBURIDE,MICRONIZED...........................................56GLYBURIDE/METFORMIN HCL...................................56GLYCATE............................................................... 148, 160GLYCEROL PHENYLBUTYRATE...............................102GLYCINE UROLOGIC SOLUTION................................93GLYCOPYRROL/NEBULIZER/ACCESSOR................. 18GLYCOPYRROLATE............................................... 18, 148GLYCOPYRROLATE/FORMOTEROL FUM................. 18GLYCOPYRROLATE/NEB.ACCESSORIES.................. 18GLYCOPYRRONIUM TOSYLATE...............................124GLYNASE......................................................................... 56GLYSET............................................................................ 55GLYXAMBI.............................................................. 56, 160GOCOVRI....................................................................... 142GOLIMUMAB.................................................................. 98GOLYTELY (227.1-21.5) (POWD PACK)..................... 103GOLYTELY (236-22.74G) (SOLN RECON)................. 103GONAL-F..........................................................................76GONAL-F RFF..................................................................76GONAL-F RFF REDI-JECT............................................. 76GONITRO................................................................. 39, 160GOODLIFE AC-302 GLUCOSE METER........................68GOODLIFE AC-302 TEST STRIP................................... 59GOPRELTO.....................................................................128GORDON'S UREA........................................................... 55GR POL-ORC/SW VER/RYE/KENT/TIM...................... 16GRAFIX CORE...............................................................134GRAFIX PRIME............................................................. 134GRAFIX XC....................................................................134GRALISE (300 MG) (TAB ER 24H)...................... 128, 160GRALISE (300-600 MG) (TAB ER 24H)...............128, 160GRALISE (600 MG) (TAB ER 24H)...................... 128, 160GRANISETRON............................................................... 17GRANISETRON HCL...................................................... 17GRANIX............................................................................85


Index

GRASS POLLEN-TIMOTHY, STANDARD....................16GRASTEK.........................................................................16GRIFULVIN V.................................................................. 92GRISEOFULVIN ULTRAMICROSIZE........................... 92GRISEOFULVIN, MICROSIZE....................................... 92GUAIACOL.......................................................................50GUAIFENESIN/HYDROCODONE................................. 42GUANFACINE HCL...................................................30, 33GUANIDINE................................................................... 123GUANIDINE HCL.......................................................... 123GUARDIAN LINK 3.........................................................70GUARDIAN REAL-TIME................................................62GUARDIAN RT CHARGER............................................ 70GUARDIAN RT STARTER KIT...................................... 71GUARDIAN RT SYSTEM............................................... 71GUARDIAN SENSOR 3...................................................70GUARDIAN TEST PLUG................................................ 71GUARDIAN TRANSMITTER TAPE...............................71GUSELKUMAB................................................................54GYNAZOLE 1.................................................................150GYNOL II..........................................................................40

- H -HAEGARDA..................................................................... 98HALCINONIDE................................................................48HALDOL...........................................................................29HALFLYTELY-BISACODYL.........................................103HALOBETASOL PROPIONATE..................................... 48HALOBETASOL/LACTIC ACID.....................................48HALOG............................................................................. 48HALOPERIDOL............................................................... 29HALOPERIDOL LACTATE............................................. 29HARMONY CONTROL SOLUTION..............................61HARMONY GLUCOSE TEST STRIP.............................59HARVONI......................................................................... 96HEALTHPRO GLUCOSE CONTROL SOLN................. 61HEALTHPRO GLUCOSE MONITOR............................. 68HEALTHPRO TEST STRIPS........................................... 59HEALTHY ACCENTS AUTOLET...................................72HEALTHY ACCENTS UNIFINE PENTIP............ 133, 134HEALTHY ACCENTS UNILET LANCET....................108HELIXATE FS...................................................................83HEMANGEOL.......................................................... 34, 160HEMLIBRA...................................................................... 84HEMMOREX-HC........................................................... 102HEMOFIL M..................................................................... 83HEPARIN SOD,PORCINE/0.9 % NACL......................... 85HEPARIN SOD,PORCINE/0.9 % NACL (100/ML) (KIT)...............................................................................................HEPARIN SOD,PORCINE/0.9 % NACL (2500/500ML)(IV SOLN).............................................................................HEPARIN SOD,PORCINE/0.9 % NACL (5000/500ML)(IV SOLN).............................................................................HEPARIN SODIUM,PORCINE....................................... 85HEPARIN SODIUM,PORCINE/D5W..............................85HEPARIN SODIUM,PORCINE/PF..................................85HEPARIN SODIUM,PORCINE/PF (1 UNIT/ML)(SYRINGE)...........................................................................HEPARIN SODIUM,PORCINE/PF (10 UNIT/ML)(SYRINGE)...........................................................................HEPARIN SODIUM,PORCINE/PF (10 UNIT/ML)(VIAL)...................................................................................HEPARIN SODIUM,PORCINE/PF (100/ML (1))(SYRINGE)...........................................................................HEPARIN SODIUM,PORCINE/PF (100/ML (1)) (VIAL)...............................................................................................HEPARIN SODIUM,PORCINE/PF (1000/10 ML)(SYRINGE)...........................................................................HEPARIN SODIUM,PORCINE/PF (1000/ML) (VIAL)...............................................................................................HEPARIN SODIUM,PORCINE/PF (200/2 ML)(SYRINGE)...........................................................................HEPARIN SODIUM,PORCINE/PF (300/3 ML)(SYRINGE)...........................................................................HEPARIN SODIUM,PORCINE/PF (500/5 ML)(SYRINGE)...........................................................................HEPARIN SODIUM,PORCINE/PF (5000/0.5ML)(SYRINGE)...........................................................................HEPSERA..........................................................................96HETLIOZ.......................................................................... 29HEXALEN...................................................................... 124HICON.............................................................................127HIPREX.............................................................................90HISTEX-AC...................................................................... 42HISTRELIN ACETATE.............................................. 77, 78HI-VOLUME PUMPING CHAMBER........................... 111HIZENTRA....................................................................... 88HOCL/NA HY/NAMGF/NA PH/NACL/WA....................52HOMATROPINE HBR......................................................82HOME NEBULIZER PLUS SIDESTREAM................... 22HOMEOPATHIC DRUGS...............................................130HORIZANT (300 MG) (TABLET ER)................... 127, 161

HORIZANT (600 MG) (TABLET ER)................... 127, 161HPR....................................................................................50HPR PLUS.........................................................................50HUMALOG.......................................................................74HUMALOG JUNIOR KWIKPEN.................................... 74HUMALOG KWIKPEN U-100........................................ 74HUMALOG KWIKPEN U-200........................................ 74HUMALOG MIX 50-50....................................................74HUMALOG MIX 50-50 KWIKPEN................................ 74HUMALOG MIX 75-25....................................................74HUMALOG MIX 75-25 KWIKPEN................................ 75HUMAN REGENERATIVE TISSUE MTRX........ 134, 135HUMAPEN LUXURA HD............................................... 72HUMATE-P....................................................................... 83HUMATIN.........................................................................93HUMATROPE................................................................... 77HUMIRA........................................................................... 97HUMIRA PEDIATRIC CROHN'S....................................98HUMIRA PEN...................................................................98HUMIRA PEN CROHN-UC-HS STARTER.................... 98HUMIRA PEN PSORIASIS-UVEITIS.............................98HUMULIN 70/30 KWIKPEN...........................................75HUMULIN 70-30.............................................................. 75HUMULIN N.....................................................................75HUMULIN N KWIKPEN................................................. 75HUMULIN R.....................................................................75HUMULIN R U-500..........................................................75HUMULIN R U-500 KWIKPEN...................................... 75HYALURONATE SODIUM..............................................52HYALURONATE SODIUM/HE-CELL/PEG................... 52HYALURONATE/ALLANTOIN/ALOE EXT..................52HYALURONIDASE, HUMAN RECOMB.......................54HYALURONT/E/EMOL 12/ALLAN/SHEA....................50HYCAMTIN....................................................................125HYCLODEX..................................................................... 52HYDERGINE.................................................................... 40HYDRALAZINE HCL......................................................33HYDREA.........................................................................124HYDRO 35........................................................................ 51HYDROCHLORIC ACID............................................... 129HYDROCHLOROTHIAZIDE.......................................... 36HYDROCODONE BIT/HOMATROP ME-BR.................42HYDROCODONE BIT/HOMATROP ME-BR (5 MG-1.5MG) (TABLET)................................................................HYDROCODONE BIT/HOMATROP ME-BR (5-1.5MG/5) (SYRUP)....................................................................HYDROCODONE BITARTRATE..................................138HYDROCODONE/ACETAMINOPHEN........................142HYDROCODONE/ACETAMINOPHEN (10MG-300MG)(TABLET)..............................................................................HYDROCODONE/ACETAMINOPHEN (10MG-325MG)(TABLET)..............................................................................HYDROCODONE/ACETAMINOPHEN (2.5-325 MG)(TABLET)..............................................................................HYDROCODONE/ACETAMINOPHEN (5 MG-300MG)(TABLET)..............................................................................HYDROCODONE/ACETAMINOPHEN (5 MG-325MG)(TABLET)..............................................................................HYDROCODONE/ACETAMINOPHEN (7.5-300 MG)(TABLET)..............................................................................HYDROCODONE/ACETAMINOPHEN (7.5-325 MG)(TABLET)..............................................................................HYDROCODONE/ACETAMINOPHEN (7.5-325/15)(SOLUTION).........................................................................HYDROCODONE/CHLORPHEN P-STIREX.................42HYDROCODONE/CHLORPHENIRAMINE.................. 42HYDROCODONE/CPM/PSEUDOEPHED..................... 42HYDROCODONE/IBUPROFEN................................... 137HYDROCOLLOID DRESSING..................................... 104HYDROCORT/MIN OIL/PETROLAT,WHT................... 48HYDROCORT/PRAMOXN/SKIN CLNSR16................102HYDROCORT/SAL ACID/SULF/SHAMP1....................48HYDROCORTISONE......................................... 48, 98, 102HYDROCORTISONE (1 %) (CREAM (G)).........................HYDROCORTISONE (1 %) (CRM/PE APP)......................HYDROCORTISONE (1 %) (OINT. (G)).............................HYDROCORTISONE (2 %) (LOTION)...............................HYDROCORTISONE (2.5 %) (CREAM (G))......................HYDROCORTISONE (2.5 %) (CRM/PE APP)...................HYDROCORTISONE (2.5 %) (KIT)....................................HYDROCORTISONE (2.5 %) (LOTION)............................HYDROCORTISONE (2.5 %) (OINT. (G))..........................HYDROCORTISONE ACET/ALOE VERA.................... 48HYDROCORTISONE ACETATE.............................48, 102HYDROCORTISONE BUTYRATE................................. 48HYDROCORTISONE BUTYRATE/EMOLL.................. 48HYDROCORTISONE PROBUTATE............................... 48HYDROCORTISONE SOD SUCCINATE....................... 98HYDROCORTISONE SODIUM SUCC/PF..................... 98HYDROCORTISONE VALERATE..................................48HYDROCORTISONE/ACETIC ACID............................. 75HYDROCORTISONE/IODOQUIN/ALOE 2................... 43

HYDROCORTISONE/IODOQUINOL.............................43HYDROCORTISONE/IODOQUINOL/ALOE.................44HYDROCORTISONE/LIDOCAINE/ALOE.................. 102HYDROCORTISONE/PRAMOXINE...................... 52, 102HYDROCORTISONE/PRAMOXINE/C-XYL................. 75HYDROCORTISONE/PRAMOXINE/EMOLL............... 52HYDROCORTISONE/SKIN CLEANSER25...................48HYDROCORTISONE/SKIN CLEANSER35...................48HYDROFERA BLUE......................................................104HYDROFERA BLUE READY....................................... 104HYDROGEN PEROXIDE.........................................49, 129HYDROMORPHONE HCL............................................138HYDROMORPHONE HCL (1 MG/ML) (LIQUID)............HYDROMORPHONE HCL (110MG/55ML) (PCASYRING)...............................................................................HYDROMORPHONE HCL (12 MG) (TAB ER 24H).........HYDROMORPHONE HCL (16 MG) (TAB ER 24H).........HYDROMORPHONE HCL (2 MG) (TABLET)..................HYDROMORPHONE HCL (3 MG) (SUPP.RECT).............HYDROMORPHONE HCL (32 MG) (TAB ER 24H).........HYDROMORPHONE HCL (4 MG) (TABLET)..................HYDROMORPHONE HCL (60 MG/30ML) (PCASYRING)...............................................................................HYDROMORPHONE HCL (8 MG) (TAB ER 24H)...........HYDROMORPHONE HCL (8 MG) (TABLET)..................HYDROMORPHONE HCL IN 0.9% NACL..................138HYDROMORPHONE HCL/0.9% NACL/PF................. 138HYDROMORPHONE/BUPIV/0.9NACL/PF................. 138HYDROMORPHONE/ROPIV/SOD CHL/PF................ 138HYDROQUINONE........................................................... 54HYDROQUINONE MICROSPHERES............................ 54HYDROQUINONE/ASCORBIC ACID........................... 54HYDROQUINONE/OXYBEN/OCTINOXATE............... 54HYDROQUINONE/VIT C/VIT E ACET......................... 54HYDROXOCOBALAMIN..............................................153HYDROXYAMPHETAMINE/TROPICAMIDE...............82HYDROXYCHLOROQUINE SULFATE......................... 94HYDROXYETHYL METHACRYLATE........................129HYDROXYPROPYL CELLULOSE.................................82HYDROXYUREA...............................................85, 86, 124HYDROXYZINE HCL......................................................16HYDROXYZINE PAMOATE........................................... 16HYGROTON..................................................................... 36HYLATOPIC..................................................................... 50HYLATOPICPLUS........................................................... 50HYOSCYAMINE SULFATE...................................147, 148HYOSYNE...................................................................... 147HYP AC/SOD CHL/SOD SUL/SOD PHO....................... 51HYPER-SAL................................................................... 130HYPOC ACID/SOD HYPO/NACL/WATER.................... 52HYPOCHLOROUS ACID/SODIUM CHLOR................. 81HYPOCYN........................................................................ 81HYPODERMIC NEEDLE.............................................. 131HYPOLANCE................................................................... 73HYPROMELLOSE......................................................... 128HYQVIA............................................................................87HYQVIA HY COMPONENT...........................................54HYQVIA IG COMPONENT............................................ 88HYSINGLA ER...............................................................138HYTRIN............................................................................ 32HYZAAR...........................................................................32

- I -IBANDRONATE SODIUM...............................................77IBRANCE........................................................................126IBRUTINIB..................................................................... 126IBUDONE....................................................................... 137IBUPROFEN................................................................... 100IBUPROFEN/CAPSAI/M-SAL/MENTHOL....................99IBUPROFEN/FAMOTIDINE............................................99IBUPROFEN/IRR.COUNT-IRRIT.NO.2..........................99IBUPROFEN/OXYCODONE HCL................................ 137ICATIBANT ACETATE.................................................... 98ICLUSIG (15 MG) (TABLET)........................................126ICLUSIG (45 MG) (TABLET)........................................126ICOSAPENT ETHYL....................................................... 39IDELALISIB................................................................... 126IDELVION.........................................................................83IDHIFA............................................................................ 126IGG/HYALURONIDASE,RECOMBINANT................... 87IGLUCOSE BLOOD GLUCOSE MONITOR..................68IGLUCOSE TEST STRIP................................................. 59ILEVRO.............................................................................79ILOPERIDONE.................................................................28ILOPROST TROMETHAMINE....................................... 36ILOTYCIN.........................................................................80IMATINIB MESYLATE................................................. 126IMBRUVICA...................................................................126IMDUR.............................................................................. 39IMIPRAMINE HCL.......................................................... 26IMIPRAMINE PAMOATE................................................26IMIQUIMOD.....................................................................89


Index

IMITREX.........................................................................141IMITREX (100 MG) (TABLET).....................................141IMITREX (25 MG) (TABLET).......................................141IMITREX (4 MG/0.5ML) (CARTRIDGE)..................... 141IMITREX (4 MG/0.5ML) (PEN INJCTR)......................141IMITREX (50 MG) (TABLET).......................................141IMITREX (6 MG/0.5ML) (CARTRIDGE)..................... 141IMITREX (6 MG/0.5ML) (PEN INJCTR)......................141IMITREX (6 MG/0.5ML) (VIAL).................................. 141IMMUN GLOB G(IGG)/GLY/IGA OV50..................87, 88IMMUN GLOB G(IGG)/PRO/IGA 0-50.......................... 88IMMUNE GLOBUL G/GLY/IGA AVG 46...................... 88IMPAVIDO........................................................................ 94IMPOYZ.................................................................... 47, 161IMURAN........................................................................... 89IN-CHECK NASAL WITH MASK.................................. 23IN-CHECK ORAL............................................................ 23INCONTROL LANCING DEVICE..................................72INCONTROL PEN NEEDLE......................................... 133INCONTROL SUPER THIN LANCETS....................... 108INCONTROL ULTRA THIN LANCETS.......................108INCRELEX........................................................................78INCRUSE ELLIPTA..................................................18, 161INDACATEROL MALEATE............................................ 18INDACATEROL/GLYCOPYRROLATE.......................... 18INDAPAMIDE...................................................................36INDERAL..........................................................................34INDERAL LA................................................................... 34INDERAL XL........................................................... 34, 161INDERIDE-40/25.............................................................. 34INDERIDE-80/25.............................................................. 34INDICLOR...................................................................... 134INDINAVIR SULFATE..................................................... 95INDIUM-111 CHLORIDE..............................................134INDOCIN (25 MG) (CAPSULE)....................................100INDOCIN (25 MG/5 ML) (ORAL SUSP)...................... 100INDOCIN (50 MG) (CAPSULE)....................................100INDOCIN (50 MG) (SUPP.RECT)................................. 100INDOCIN SR...................................................................100INDOMETHACIN.......................................................... 100INDOMETHACIN, SUBMICRONIZED........................100INFASURF...................................................................... 137INFINITY.......................................................................... 68INFINITY CONTROL SOLUTION..................... 62, 63, 65INFINITY TEST STRIPS................................................. 59INFINITY VOICE CONTROL SOLN..............................65INFINITY VOICE GLUCOSE MONITOR......................68INFINITY VOICE TEST STRIP...................................... 59INFLAMMACIN...............................................................99INFLAMMA-K................................................................. 49INFUSION ADAPTER, CLOSED SYSTM................... 111INFUSION SET...............................................................110INFUSION SET FOR INSULIN PUMP...................71, 110INGENOL MEBUTATE....................................................52INGREZZA..................................................................... 127INHALER, ASSIST DEVICES.........................................20INHALER,ASSIST DEV,SMALL MASK..................20, 21INHALER,ASSIST DEVICE,ACCESORY......................21INHALER,ASSIST DEVICE,LG MASK.........................21INHALER,ASSIST DEVICE,MED MASK..................... 21INJECT EASE LANCETS.............................................. 108INJECTION PORTS........................................................111INLYTA (1 MG) (TABLET)........................................... 125INLYTA (5 MG) (TABLET)........................................... 125INNOPRAN XL........................................................ 34, 161INNOSPIRE DELUXE..................................................... 22INNOSPIRE ELEGANCE................................................ 22INNOSPIRE ESSENCE.................................................... 22INNOSPIRE MINI............................................................ 22INNOSPIRE REPLACEMENT FILTER........................ 106INOVA............................................................................... 51INOVA 4-1.........................................................................51INOVA 8-2.........................................................................51INPEN (FOR HUMALOG)...............................................72INPEN (FOR NOVOLOG)................................................72INSET 30 INFUSION SET............................................... 71INSET 30 TUBING.........................................................111INSET INFUSION SET.................................................... 71INSPIRACHAMBER.................................................. 20, 21INSPIRATION ELITE FILTER...................................... 106INSPRA............................................................................. 35INSUFLON......................................................................111INSUL-CAP...................................................................... 71INSUL-EZE.......................................................................71INSULIN ADMIN. SUPPLIES...................................71, 72INSULIN ASPART............................................................74INSULIN ASPART (NIACINAMIDE)............................. 74INSULIN ASPART PROT/INSULN ASP.........................74INSULIN DEGLUDEC.....................................................74INSULIN DEGLUDEC/LIRAGLUTIDE......................... 56INSULIN DETEMIR.........................................................74INSULIN GLARGINE,HUM.REC.ANLOG....................74

INSULIN GLARGINE/LIXISENATIDE..........................56INSULIN GLULISINE..................................................... 74INSULIN LISPRO.............................................................74INSULIN LISPRO PROTAMIN/LISPRO...................74, 75INSULIN NPH HUM/REG INSULIN HM...................... 75INSULIN NPH HUMAN ISOPHANE............................. 75INSULIN PEN NEEDLE................................................ 133INSULIN PUMP CARTRIDGE........................................72INSULIN PUMP CONTROLLER.................................... 72INSULIN PUMP SYRINGE, 1.8 ML............................. 111INSULIN PUMP SYRINGE, 3 ML................................ 111INSULIN PUMP/INFUS. SET/METER........................... 72INSULIN REGULAR, HUMAN...................................... 75INSULIN SYRINGE............................... 111, 113, 118, 122INSULIN SYRINGE U-500............................................118INSUPEN........................................................................ 133INSYTE AUTOGUARD................................................. 111INSYTE IV CATHETER................................................ 111INTEGRA SYRINGE............................................. 115, 121INTELENCE..................................................................... 95INTERFERON ALFA-2B,RECOMB................................89INTERFERON ALFA-N3................................................. 89INTERFERON BETA-1A............................................... 127INTERFERON BETA-1A/ALBUMIN............................127INTERFERON BETA-1B................................................127INTERFERON GAMMA-1B,RECOMB..........................89INTERLINK SYRINGE..................................................113INTERLINK SYRINGE W-CANNULA........................ 113INTERMEZZO..........................................................30, 161INTRAVENOUS ADMINISTRATION SET.................. 111INTRAVENOUS CATHETER........................................ 111INTRAVENOUS CATHETER KIT................................ 111INTRAVENOUS EQUIPMENT..................................... 111INTRAVENOUS EXTEN.SET-FILTER......................... 111INTRAVENOUS EXTENSION SET..............................111INTRAVENOUS PIGGYBACK SET............................. 111INTRON A........................................................................ 89INTUNIV...........................................................................30INVACARE LANCETS.................................................. 108INVEGA (1.5 MG) (TAB ER 24)............................. 28, 161INVEGA (3 MG) (TAB ER 24)................................ 28, 161INVEGA (6 MG) (TAB ER 24)................................ 28, 161INVEGA (9 MG) (TAB ER 24)................................ 28, 161INVIRASE.........................................................................96INVOKAMET........................................................... 56, 161INVOKAMET XR.....................................................56, 161INVOKANA.............................................................. 55, 161IODINE/POTASSIUM IODIDE........................................44IODINE/POTASSIUM IODIDE (5%-10%) (SOLUTION)...............................................................................................IODOFLEX....................................................................... 43IODOFORM.................................................................... 104IODOQUINOL/ALOE P-SACCHARIDE 1..................... 44IODOSORB.......................................................................43IOPIDINE (0.5 %) (DROPS).............................................81IOPIDINE (1 %) (DROPERETTE)...................................81I-PORT.............................................................................111I-PORT ADVANCE.........................................................111IPRATROPIUM BROMIDE......................................18, 128IPRATROPIUM/ALBUTEROL SULFATE...................... 18IPRIVASK......................................................................... 86IRBESARTAN...................................................................33IRBESARTAN/HYDROCHLOROTHIAZIDE.................32IRESSA............................................................................126IRRIGATION SYRINGE................................................ 113ISAVUCONAZONIUM SULFATE...................................92ISENTRESS...................................................................... 96ISENTRESS HD................................................................96ISOCARBOXAZID...........................................................25ISOCHRON....................................................................... 39ISOFLURANE................................................................ 130ISOMETHEPT/DICHLPHN/ACETAMINOP................ 141ISOMETHEPT/DICHLPHN/ACETAMINOP (65-100-325)(CAPSULE)...........................................................................ISOMETHEPTEN/CAF/ACETAMINOPHEN............... 141ISONIAZID....................................................................... 93ISOPTO ATROPINE......................................................... 82ISOPTO CARPINE........................................................... 81ISOPTO HOMATROPINE................................................82ISORDIL (10 MG) (TABLET)..........................................39ISORDIL (20 MG) (TABLET)..........................................39ISORDIL (30 MG) (TABLET)..........................................39ISORDIL (40 MG) (TABLET)..........................................39ISORDIL TITRADOSE.................................................... 39ISOSORBIDE DINIT/HYDRALAZINE.......................... 36ISOSORBIDE DINITRATE..............................................39ISOSORBIDE MONONITRATE......................................39ISOTRETINOIN................................................................43ISOXSUPRINE HCL........................................................ 40ISRADIPINE..................................................................... 35ISTALOL........................................................................... 81ITRACONAZOLE.............................................................92

IVABRADINE HCL.......................................................... 39IVACAFTOR................................................................... 137IVERMECTIN.......................................................43, 45, 93IVOSIDENIB...................................................................126IXAZOMIB CITRATE....................................................126IXEKIZUMAB.................................................................. 54IXINITY............................................................................ 83

- J -JADENU.......................................................................... 130JADENU SPRINKLE......................................................130JAKAFI............................................................................125JALYN..................................................................... 149, 161JANUMET.........................................................................55JANUMET XR.................................................................. 55JANUVIA.......................................................................... 56JARDIANCE............................................................. 55, 161JAZZ WIRELESS 2...........................................................68JENTADUETO.................................................................. 55JENTADUETO XR........................................................... 55JETCO-SPRAY CANNULA...........................................105JEVANTIQUE................................................................... 87JEVANTIQUE LO.............................................................87JIVI.................................................................................... 83JUBLIA..............................................................................45JULUCA............................................................................ 94JUXTAPID.........................................................................38JYNARQUE...................................................................... 75

- K -KADIAN (200 MG) (CAP ER PEL)...............................138KADIAN (40 MG) (CAP ER PEL).................................139KALETRA (100MG-25MG) (TABLET).......................... 95KALETRA (200MG-50MG) (TABLET).......................... 95KALETRA (400-100/5) (SOLUTION).............................95KALYDECO....................................................................137KAMDOY..........................................................................53KANGAROO 924 SAFETY SCREW.............................110KANGAROO EPUMP SET............................................ 110KANGAROO GRAVITY SET........................................ 110KAPSPARGO SPRINKLE................................................34KAPVAY............................................................................30KARBINAL ER.........................................................16, 161KAZANO.................................................................. 55, 161KEFLEX............................................................................ 89KELARX........................................................................... 52KENALOG IN ORABASE............................................. 128KENDALL DISINFECTANT CAP.................................111KENGUARD................................................................... 105KEPPRA.......................................................................... 145KEPPRA XR................................................................... 145KERAFOAM..................................................................... 51KERAGEL.......................................................................104KERAGELT.....................................................................104KERALYT SCALP............................................................51KERAMATRIX............................................................... 135KERLIX AMD................................................................ 104KERLIX AMD BANDAGE............................................ 104KERLONE.........................................................................34KERYDIN..........................................................................45KETOCONAZOLE..................................................... 45, 92KETONE CARE TEST STRIP....................................... 136KETONE TEST STRIP...................................................136KETOPROFEN..........................................................49, 100KETOROLAC TROMETHAMINE.....................79, 99-101KETOROLAC TROMETHAMINE/PF.............................79KETOROLAC/NORFLURANE/HFC 245FA.................101KETOSTIX REAGENT.................................................. 136KEVEYIS........................................................................ 146KEVZARA........................................................................ 99KHEDEZLA.............................................................. 25, 161KINERET.......................................................................... 97KISQALI......................................................................... 126KISQALI FEMARA CO-PACK......................................125KITABIS PAK................................................................... 93KLARON...........................................................................43KLOR-CON-EF.................................................................76KOATE.............................................................................. 83KOGENATE FS.................................................................83KOMBIGLYZE XR...................................................55, 161KORLYM.......................................................................... 56KOVALTRY.......................................................................83KOVANAZE.................................................................... 101K-PHOS NO.2................................................................. 149K-PHOS ORIGINAL.......................................................149KRISTALOSE................................................................. 103KUVAN........................................................................... 123KWELL............................................................................. 45KYLEENA.......................................................................130KYNAMRO.......................................................................36KYTRIL.....................................................................17, 161


Index

- L -LABETALOL HCL........................................................... 32LACOSAMIDE............................................................... 144LACRISERT......................................................................82LACTATED RINGERS..................................................... 50LACTIC ACID................................................................ 129LACTULOSE.......................................................... 102, 103LAMICTAL..................................................................... 144LAMICTAL (BLUE).......................................................144LAMICTAL (GREEN).................................................... 144LAMICTAL (ORANGE).................................................144LAMICTAL ODT (100 MG) (TAB RAPDIS)........ 144, 161LAMICTAL ODT (200 MG) (TAB RAPDIS)........ 144, 161LAMICTAL ODT (25 MG) (TAB RAPDIS).......... 144, 161LAMICTAL ODT (50 MG) (TAB RAPDIS).......... 144, 162LAMICTAL ODT (BLUE)......................................144, 162LAMICTAL ODT (GREEN)...................................144, 162LAMICTAL ODT (ORANGE)............................... 144, 162LAMICTAL XR (100 MG) (TAB ER 24)...............144, 162LAMICTAL XR (200 MG) (TAB ER 24)...............144, 162LAMICTAL XR (25 MG) (TAB ER 24).................144, 162LAMICTAL XR (250 MG) (TAB ER 24)...............144, 162LAMICTAL XR (300 MG) (TAB ER 24)...............144, 162LAMICTAL XR (50 MG) (TAB ER 24).................145, 162LAMICTAL XR (BLUE)........................................ 145, 162LAMICTAL XR (GREEN)..................................... 145, 162LAMICTAL XR (ORANGE).................................. 145, 162LAMIOFLUR.................................................................. 130LAMIVUDINE............................................................95, 96LAMIVUDINE/TENOFOVIR DISOP FUM.................... 94LAMIVUDINE/ZIDOVUDINE........................................ 94LAMOTRIGINE......................................................144, 145LANADELUMAB-FLYO............................................... 101LANCETS.......................................................... 72, 106-110LANCETS THIN...................................................................LANCETS ULTRA THIN.....................................................LANCING DEVICE....................................................72, 73LANCING DEVICE/LANCETS.......................................73LANCING SYSTEM.........................................................72LANOXIN (125 MCG) (TABLET)...................................32LANOXIN (187.5 MCG) (TABLET)................................32LANOXIN (250 MCG) (TABLET)...................................32LANOXIN (62.5 MCG) (TABLET)..................................32LANSOPRAZOLE.......................................................... 149LANSOPRAZOLE (15 MG) (CAPSULE DR).....................LANSOPRAZOLE (15 MG) (TAB RAP DR)................ 162LANSOPRAZOLE (30 MG) (CAPSULE DR).....................LANSOPRAZOLE (30 MG) (TAB RAP DR)................ 162LANSOPRAZOLE/AMOXICILN/CLARITH................148LANTHANUM CARBONATE...................................75, 76LANTUS............................................................................74LANTUS SOLOSTAR...................................................... 74LANZO..............................................................................73LAPATINIB DITOSYLATE............................................126LARIAM............................................................................94LASIX................................................................................35LASTACAFT.............................................................79, 162LATANOPROST............................................................... 81LATANOPROST/PF..........................................................81LATANOPROSTENE BUNOD........................................ 81LATUDA (120 MG) (TABLET)................................28, 162LATUDA (20 MG) (TABLET)..................................28, 162LATUDA (40 MG) (TABLET)..................................28, 162LATUDA (60 MG) (TABLET)..................................28, 162LATUDA (80 MG) (TABLET)..................................28, 162LAURETH 4....................................................................136LAZANDA...................................................................... 138LC D NEBULIZER SET................................................... 22LC PLUS........................................................................... 22LC PLUS NEBULIZER-PED MASK...............................22LC SPRINT NEBULIZER................................................ 22LC STAR........................................................................... 22LDO PLUS........................................................................ 53LEDIPASVIR/SOFOSBUVIR.......................................... 96LEFLUNOMIDE...............................................................98LENALIDOMIDE........................................................... 125LENVATINIB MESYLATE............................................ 126LENVIMA.......................................................................126LESCOL.................................................................... 37, 162LESCOL XL..............................................................37, 162LESINURAD.....................................................................82LESINURAD/ALLOPURINOL........................................82LETAIRIS..........................................................................36LETERMOVIR..................................................................94LETROZOLE.................................................................. 124LEUCOVORIN CALCIUM............................................ 126LEUKERAN....................................................................124LEUKINE.......................................................................... 85LEUPROLIDE ACETATE.................................................77LEUPROLIDE/NORETHINDRONE ACET.................... 87LEVA SET......................................................................... 53

LEVALBUTEROL HCL................................................... 18LEVALBUTEROL TARTRATE........................................18LEVAQUIN....................................................................... 91LEVATOL..........................................................................34LEVBID...........................................................................147LEVEMIR..........................................................................74LEVEMIR FLEXTOUCH.................................................74LEVER LOCK CANNULA............................................ 112LEVETIRACETAM........................................................ 145LEVICYN....................................................................49, 51LEVICYN ANTIPRURITIC SG....................................... 50LEVOBUNOLOL HCL.....................................................81LEVOCARNITINE......................................................... 130LEVOCARNITINE (WITH SUGAR).............................130LEVOCETIRIZINE DIHYDROCHLORIDE................... 16LEVO-DROMORAN...................................................... 138LEVOFLOXACIN.......................................................80, 91LEVOMILNACIPRAN HCL............................................ 25LEVONORGEST/ETH.ESTRADIOL/IRON....................40LEVONORGESTREL...............................................40, 130LEVONORGESTREL-ETHIN ESTRADIOL.................. 40LEVONORGESTREL-ETHIN ESTRADIOL (0.1-0.02MG) (TABLET)..............................................................LEVONORGESTREL-ETHIN ESTRADIOL (0.15-0.03)(TABLET)..............................................................................LEVONORGESTREL-ETHIN ESTRADIOL (0.15-0.03)(TBDSPK 3MO)....................................................................LEVONORGESTREL-ETHIN ESTRADIOL (6-5-10)(TABLET)..............................................................................LEVONORGESTREL-ETHIN ESTRADIOL (90-20MCG) (TABLET)..................................................................LEVORPHANOL TARTRATE....................................... 138LEVO-T............................................................................. 78LEVOTHYROXINE SODIUM......................................... 78LEVOXYL.........................................................................78LEVSIN........................................................................... 147LEVSIN-SL..................................................................... 147LEVULAN...................................................................... 127LEXAPRO......................................................................... 25LEXIVA (50 MG/ML) (ORAL SUSP)..............................95LEXIVA (700 MG) (TABLET)......................................... 95LEXIXRYL........................................................................49LIALDA (1.2 G) (TABLET DR).....................................102LIBRAX.......................................................................... 148LIDAMANTLE HC...........................................................52LIDEX............................................................................... 47LIDEX-E............................................................................47LIDO BDK...................................................................... 129LIDOCAINE................................................................52, 53LIDOCAINE (5 %) (ADH. PATCH).....................................LIDOCAINE (5 %) (OINT. (G))..................................... 162LIDOCAINE HCL.....................................................53, 101LIDOCAINE HCL (3 %) (CREAM (G))..............................LIDOCAINE HCL (3 %) (LOTION)....................................LIDOCAINE HCL (3.88 %) (CREAM (G)).........................LIDOCAINE HCL (4 %) (SOLUTION)...............................LIDOCAINE HCL/ALOE/COLLAGEN.......................... 53LIDOCAINE HCL/COLLAGEN...................................... 53LIDOCAINE HCL/DEXTROSE 7.5%/PF......................101LIDOCAINE HCL/ME-SALICYL/MENTH....................53LIDOCAINE HCL/PALM OIL......................................... 53LIDOCAINE HCL/PF............................................... 80, 101LIDOCAINE/BENZOCAIN/ME-SAL/CAP.................... 53LIDOCAINE/DIMETHICONE.........................................53LIDOCAINE/EMOLLIENT CMB NO.102......................53LIDOCAINE/GAUZE/ALGINATE.................................. 53LIDOCAINE/HYDROCORTISONE AC..................52, 102LIDOCAINE/KINESIOLOGY TAPE...............................53LIDOCAINE/MENTHOL.................................................53LIDOCAINE/METHYL SAL/MENTHOL.......................53LIDOCAINE/PF/NORFLUR/HFC 245FA..................... 101LIDOCAINE/PRILO/M.SALICY/MENTH..................... 53LIDOCAINE/PRILOCAINE.............................................53LIDOCAINE/RACEPINEP/TETRACAINE.....................53LIDOCAINE/SKIN CLEANSER NO.37..........................53LIDOCAINE/TETRACAINE........................................... 53LIDOCAINE/TRANSPARENT DRESSING....................53LIDOPAC.......................................................................... 53LIDOPIN........................................................................... 53LIDOPRIL......................................................................... 53LIDOPRIL XR...................................................................53LIDO-PRILO CAINE PACK.............................................53LIDORX............................................................................ 53LIDORXKIT......................................................................53LIDOTRANS 5 PAK......................................................... 53LIDOTREX................................................................. 53, 54LIDOVEX..........................................................................53LIDOXIB......................................................................... 101LIFITEGRAST.................................................................. 80LILETTA......................................................................... 130LIMBITROL......................................................................26LIMBITROL DS................................................................26

LINACLOTIDE............................................................... 102LINAGLIPTIN.................................................................. 55LINAGLIPTIN/METFORMIN HCL................................ 55LINDANE..........................................................................45LINEZOLID...................................................................... 90LINZESS......................................................................... 102LIORESAL INTRATHECAL......................................... 146LIOTHYRONINE SODIUM.............................................78LIOTRIX........................................................................... 78LIPASE/PROTEASE/AMYLASE...................................147LIPITOR (10 MG) (TABLET).......................................... 36LIPITOR (20 MG) (TABLET).......................................... 37LIPITOR (40 MG) (TABLET).......................................... 37LIPITOR (80 MG) (TABLET).......................................... 37LIPOCHOL PLUS.............................................................39LIPOFEN...........................................................................38LIPROZONEPAK..............................................................53LIRAGLUTIDE.................................................................55LISDEXAMFETAMINE DIMESYLATE.........................27LISINOPRIL......................................................................33LISINOPRIL/HYDROCHLOROTHIAZIDE....................32LITE TOUCH............................72, 108, 113, 122, 123, 133LITEAIRE......................................................................... 20LITETOUCH.....................................................................21LITETOUCH INSULIN SYRINGE................113, 122, 123LITHIUM CARBONATE..................................................27LITHIUM CITRATE......................................................... 27LITHOSTAT.................................................................... 102LIVALO............................................................................. 37LIVER EXTRACT (BEEF-PORK).................................123LIVIXIL PAK.................................................................... 53LIXISENATIDE................................................................ 55L-NORGEST/E.ESTRADIOL-E.ESTRAD...................... 41LO LOESTRIN FE............................................................ 41LOCOID............................................................................ 48LOCOID LIPOCREAM.................................................... 48LODINE.......................................................................... 100LODINE XL.................................................................... 100LODOSYN...................................................................... 143LODOXAMIDE TROMETHAMINE............................... 81LOESTRIN........................................................................ 41LOESTRIN 24 FE............................................................. 41LOESTRIN FE.................................................................. 41LOFEXIDINE HCL.........................................................142LOFIBRA.................................................................... 38, 39LOKELMA........................................................................76LOMITAPIDE MESYLATE............................................. 38LOMOTIL....................................................................... 103LOMUSTINE.................................................................. 124LONHALA MAGNAIR REFILL......................................18LONHALA MAGNAIR STARTER.................................. 18LONITEN.......................................................................... 33LONSURF....................................................................... 124LO-OVRAL-28..................................................................41LO-OVRAL-8....................................................................41LOPERAMIDE HCL.......................................................103LOPERAMIDE HCL (2 MG) (CAPSULE)..........................LOPID................................................................................39LOPINAVIR/RITONAVIR................................................ 95LOPRESSOR HCT............................................................34LOPROX......................................................................44, 45LORAZEPAM................................................................... 27LORTAB..........................................................................142LORZONE...............................................................146, 162LOSARTAN POTASSIUM............................................... 33LOSARTAN/HYDROCHLOROTHIAZIDE.....................32LOSEASONIQUE.............................................................41LOTEMAX........................................................................79LOTENSIN........................................................................33LOTENSIN HCT...............................................................32LOTEPREDNOL ETABONATE.......................................79LOTREL............................................................................ 32LOTRISONE..................................................................... 44LOTRONEX.................................................................... 103LOVASTATIN....................................................................37LOVAZA............................................................................39LOVENOX (100 MG/ML) (SYRINGE)........................... 84LOVENOX (120MG/.8ML) (SYRINGE)......................... 84LOVENOX (150 MG/ML) (SYRINGE)........................... 84LOVENOX (300MG/3ML) (VIAL)..................................84LOVENOX (30MG/0.3ML) (SYRINGE)......................... 84LOVENOX (40MG/0.4ML) (SYRINGE)......................... 84LOVENOX (60MG/0.6ML) (SYRINGE)......................... 84LOVENOX (80MG/0.8ML) (SYRINGE)......................... 84LOXAPINE....................................................................... 28LOXAPINE SUCCINATE.................................................28LOXITANE........................................................................28LOYON..............................................................................50LOZOL.............................................................................. 36LUBIPROSTONE............................................................103LUCEMYRA...................................................................142LUCINACTANT..............................................................137


Index

LUDIOMIL........................................................................26LUER LOCK SYRINGE.................................................117LUER-LOK SYRINGE........................................... 117, 118LUER-LOK SYRINGE-NEEDLE.......................... 114, 115LUER-LOK TIP SYRINGE............................................ 117LUERSLIP SYRINGE.................................................... 116LULICONAZOLE.............................................................45LUMACAFTOR/IVACAFTOR.......................................137LUMIGAN (0.01 %) (DROPS)......................................... 81LUMIGAN (0.03 %) (DROPS)......................................... 81LUNESTA......................................................................... 30LUPANETA PACK............................................................87LURASIDONE HCL.........................................................28LUSTRA............................................................................54LUSUTROMBOPAG........................................................ 86LUVOX..............................................................................25LUVOX CR............................................................... 25, 162LUXAMEND.................................................................... 50LUXIQ...............................................................................47LUZU.........................................................................45, 162LYNPARZA.....................................................................126LYRICA...........................................................................145LYRICA CR (165 MG) (TAB ER 24H).................. 128, 162LYRICA CR (330 MG) (TAB ER 24H).................. 128, 163LYRICA CR (82.5 MG) (TAB ER 24H)................. 128, 163LYSODREN.................................................................... 126LYSTEDA..........................................................................82

- M -MACI............................................................................... 130MACITENTAN................................................................. 36MACROBID...................................................................... 90MACRODANTIN..............................................................90MAFENIDE ACETATE.................................................... 46MAGELLAN INSULIN SAFETY SYRNG........... 118, 119MAGELLAN INSULIN SYRINGE................................119MAGELLAN SAFETY SYRINGE.................................120MAGELLAN TUBERCULIN SYRINGE...................... 120MAGIC3 INTERMITTENT CATHETER...................... 105MAGNI-GUIDE MAGNIFIER......................................... 71MALARONE.....................................................................93MALATHION....................................................................45MANDELAMINE............................................................. 90MANNITOL...................................................................... 35MANNITOL/SORBITOL SOLUTION............................ 50MAPROTILINE HCL........................................................26MARAVIROC....................................................................94MARINOL.................................................................17, 163MARPLAN........................................................................25MARVONA SUIK...........................................................101MASK SET WITH Y-PIECE.......................................... 106MATRISTEM.................................................................. 134MATRISTEM MICROMATRIX.....................................134MATULANE................................................................... 126MAVIK.............................................................................. 33MAVYRET........................................................................ 97MAXI-COMFORT.................................................. 113, 122MAXIDEX........................................................................ 79MAXZIDE.........................................................................35MAXZIDE-25 MG............................................................ 35MEBENDAZOLE............................................................. 93MECAMYLAMINE HCL.................................................33MECASERMIN.................................................................78MECHLORETHAMINE HCL..........................................52MECLIZINE HCL.............................................................17MECLIZINE HCL (12.5 MG) (TABLET)............................MECLIZINE HCL (25 MG) (TABLET)...............................MECLOFENAMATE SODIUM..................................... 101MECLOMEN.................................................................. 101MEDICAL SUPPLY, MISCELLANEOUS.....................105MEDISENSE...............................................................62, 65MEDISENSE CONTROL................................................. 62MEDISENSE GLUCOSE KETONE................................ 62MEDISENSE GLUCOSE KETONE CONTR..................65MEDISENSE THIN LANCETS..................................... 108MEDLANCE PLUS........................................................ 108MEDLANCE PLUS SPECIAL BLADE.........................106MEDOLOR PAK...............................................................53MEDROL (16 MG) (TABLET).........................................99MEDROL (2 MG) (TABLET)...........................................99MEDROL (32 MG) (TABLET).........................................99MEDROL (4 MG) (TAB DS PK)...................................... 99MEDROL (4 MG) (TABLET)...........................................99MEDROL (8 MG) (TABLET)...........................................99MEDROLOAN II SUIK.................................................... 99MEDROLOAN SUIK........................................................99MEDROXYPROGESTERONE ACETATE................ 40, 87MEDTRONIC REMOTE CONTROL...............................71MEFENAMIC ACID.......................................................101MEFLOQUINE HCL........................................................ 94MEGACE.................................................................127, 128MEGACE ES...........................................................128, 163

MEGESTROL ACETATE....................................... 127, 128MEKINIST...................................................................... 125MEKTOVI....................................................................... 125MELLARIL....................................................................... 29MELOXICAM.................................................................101MELOXICAM, SUBMICRONIZED.............................. 101MELOXICAM/IRRIT.CNTR-IRR CMB 2..................... 100MELPHALAN.................................................................124MEMANTINE HCL..........................................................24MEMANTINE HCL/DONEPEZIL HCL..........................24M-END PE.........................................................................41MENEST........................................................................... 87MENINGOCOCCAL B VACCINE,4-COMP...................88MENOPUR........................................................................76MENOSTAR......................................................................87MENOTROPINS............................................................... 76MENTAX...........................................................................44MENTHO-CAINE.............................................................53MEPERIDINE HCL........................................................ 138MEPERIDINE HCL/PF...................................................138ME-PREDNIS/NORFLURAN/HFC 245FA..................... 99MEPROBAMATE............................................................. 27MEPRON...........................................................................94MERCAPTOPURINE..................................................... 124MESALAMINE.......................................................101, 102MESALAMINE W/CLEANSING WIPES..................... 101MESNA........................................................................... 126MESNEX.........................................................................126MESTINON (180 MG) (TABLET ER).............................24MESTINON (60 MG) (TABLET).....................................24MESTINON (60 MG/5 ML) (SYRUP)............................. 24METAGLIP........................................................................56METAPROTERENOL SULFATE.....................................18METAXALONE..............................................................147METER-CHECK...............................................................65METFORMIN HCL.................................................... 56, 75METFORMIN/BLOOD SUGAR DIAGNOST.................56METH BLUE/GEN VIOLET/FOAM BAND................. 104METH/MEBLUE/SOD PHOS/PSAL/HYOS................... 90METHADONE HCL....................................................... 138METHADONE HCL (10 MG) (TABLET)...........................METHADONE HCL (10 MG/5 ML) (SOLUTION)............METHADONE HCL (10 MG/ML) (ORAL CONC)............METHADONE HCL (10 MG/ML) (VIAL)..........................METHADONE HCL (40 MG) (TABLET SOL)...................METHADONE HCL (5 MG) (TABLET).............................METHADONE HCL (5 MG/5 ML) (SOLUTION)..............METHAMPHETAMINE HCL..........................................27METHAZOLAMIDE........................................................ 81METHEN/MBLUE/SAL/SOD PHOS/HYOS...................90METHENAM/M.BLUE/SALICYL/HYOSCY.................90METHENAM/SOD PHOS/MBLUE/HYOSCY............... 90METHENAMINE HIPPURATE....................................... 90METHENAMINE MANDELATE.................................... 90METHENAMINE/SOD PHOSPHATE MBAS...............149METHIMAZOLE.............................................................. 78METHIONINE/INOSI/CHOL/FOLIC AC....................... 39METHITEST..................................................................... 86METHOCARBAMOL.....................................................147METHOTREXATE......................................................... 124METHOTREXATE SODIUM.........................................124METHOTREXATE SODIUM/PF................................... 124METHOTREXATE/PF......................................................97METHOXSALEN............................................................. 54METHOXSALEN (10 MG) (CAP LQ RAP)........................METHOXY PEG-EPOETIN BETA..................................84METHSCOPOLAMINE BROMIDE.............................. 148METHSUXIMIDE.......................................................... 145METHYCLOTHIAZIDE...................................................36METHYLDOPA................................................................ 33METHYLDOPA/HYDROCHLOROTHIAZIDE.............. 33METHYLERGONOVINE MALEATE............................. 41METHYLNALTREXONE BROMIDE........................... 103METHYLPHENIDATE.....................................................30METHYLPHENIDATE HCL......................................30, 31METHYLPHENIDATE HCL (10 MG) (CPBP 30-70).........METHYLPHENIDATE HCL (10 MG) (CPBP 50-50).........METHYLPHENIDATE HCL (10 MG) (TAB CHEW).........METHYLPHENIDATE HCL (10 MG) (TABLET ER)........METHYLPHENIDATE HCL (10 MG) (TABLET)..............METHYLPHENIDATE HCL (10 MG/5 ML)(SOLUTION).........................................................................METHYLPHENIDATE HCL (18 MG) (TAB ER 24)..........METHYLPHENIDATE HCL (2.5 MG) (TAB CHEW)........METHYLPHENIDATE HCL (20 MG) (CPBP 30-70).........METHYLPHENIDATE HCL (20 MG) (CPBP 50-50).........METHYLPHENIDATE HCL (20 MG) (TABLET ER)........METHYLPHENIDATE HCL (20 MG) (TABLET)..............METHYLPHENIDATE HCL (27 MG) (TAB ER 24)..........METHYLPHENIDATE HCL (30 MG) (CPBP 30-70).........METHYLPHENIDATE HCL (30 MG) (CPBP 50-50).........METHYLPHENIDATE HCL (36 MG) (TAB ER 24)..........

METHYLPHENIDATE HCL (40 MG) (CPBP 30-70).........METHYLPHENIDATE HCL (40 MG) (CPBP 50-50).........METHYLPHENIDATE HCL (5 MG) (TAB CHEW)...........METHYLPHENIDATE HCL (5 MG) (TABLET)................METHYLPHENIDATE HCL (5 MG/5 ML) (SOLUTION)...............................................................................................METHYLPHENIDATE HCL (50 MG) (CPBP 30-70).........METHYLPHENIDATE HCL (54 MG) (TAB ER 24)..........METHYLPHENIDATE HCL (60 MG) (CPBP 30-70).........METHYLPHENIDATE HCL (60 MG) (CPBP 50-50).........METHYLPHENIDATE HCL (72 MG) (TAB ER 24)..........METHYLPREDNISOLONE............................................ 99METHYLTESTOSTERONE.............................................86METIPRANOLOL............................................................ 81METOCLOPRAMIDE HCL........................................... 148METOLAZONE................................................................ 36METOPROLOL SU/HYDROCHLOROTHIAZ............... 34METOPROLOL SUCCINATE..........................................34METOPROLOL TARTRATE............................................34METOPROLOL/HYDROCHLOROTHIAZIDE...............34METOZOLV ODT...........................................................148METRELEPTIN................................................................ 78METROCREAM............................................................... 43METROGEL......................................................................43METROGEL-VAGINAL................................................. 150METROLOTION...............................................................43METRONIDAZOLE........................................... 43, 93, 150METRONIDAZOLE/SKIN CLEANSER 23.................... 43METYROSINE..................................................................33MEVACOR........................................................................ 37MEXILETINE HCL.......................................................... 32MEXITIL...........................................................................32MIACALCIN (200/ML) (VIAL).......................................77MIACALCIN (200/SPRAY) (SPRAY/PUMP)................. 77MICARDIS........................................................................33MICARDIS HCT...............................................................32MICONAZOLE................................................................. 92MICONAZOLE NITRATE............................................. 150MICONAZOLE NITRATE (200 MG) (SUPP.VAG)............MICONAZOLE NITRATE/ZINC OX/PET...................... 45MICORT-HC..................................................................... 48MICRO.............................................................................. 59MICRO AIR...................................................................... 22MICRO THIN LANCETS...............................................108MICROBORE EXTENSION SET.................................. 111MICROCHAMBER...........................................................20MICROCRYSTALLINE CELLULOSE..........................134MICROCYN......................................................................52MICROCYN HYDROGEL............................................... 52MICRODOT.................................................... 59, 61, 65, 68MICRODOT XTRA.......................................................... 59MICROFIBRILLAR COLLAGEN................................... 86MICROLET..................................................................... 108MICROLET 2.................................................................... 73MICROLET NEXT LANCING DEVICE.........................73MICROLIFE PEAK FLOW.............................................. 23MICROSPACER................................................................20MICROTAINER LANCETS........................................... 106MIDAMOR........................................................................35MIDAZOLAM HCL..................................................30, 130MIDAZOLAM HCL/PF.................................................. 130MIDAZOLAM/KETAMINE/ONDANSETRON.............. 30MIDDLE EAR INFLATION DEVICE........................... 110MIDODRINE HCL........................................................... 39MIDOSTAURIN..............................................................126MIFEPREX......................................................................128MIFEPRISTONE.......................................................56, 128MIGALASTAT HCL....................................................... 123MIGERGOT.................................................................... 140MIGLITOL........................................................................ 55MIGLUSTAT................................................................... 129MIGRANAL....................................................................140MIGRANOW...................................................................141MILLIPRED...................................................................... 99MILLIPRED DP................................................................99MILNACIPRAN HCL.....................................................127MILTEFOSINE................................................................. 94MINASTRIN 24 FE...........................................................41MINERAL OIL............................................................... 135MINI LANCING DEVICE................................................72MINI PLUS NEBULIZER................................................ 22MINI ULTRA-THIN II....................................................133MINILINK REAL-TIME TRANSMITTER..................... 70MINIMED......................................................................... 71MINIMED 530G............................................................... 73MINIMED 630G............................................................... 73MINIMED 630G GUARDIAN START KT......................70MINIMED 670G............................................................... 73MINIMED PRO-SET........................................................ 71MINIMED QUICK-SERTER (MISCELL) (OTC)........... 71MINIMED RESERVOIR.................................................111MINIPRESS...................................................................... 32


Index

MINIVELLE......................................................................87MINI-WRIGHT PEAK FLOW METER...........................23MINOCYCLINE HCL...................................................... 92MINOCYCLINE HCL (100 MG) (CAPSULE)....................MINOCYCLINE HCL (100 MG) (TABLET).......................MINOCYCLINE HCL (115MG) (TAB ER 24H)...........163MINOCYCLINE HCL (135 MG) (TAB ER 24H)................MINOCYCLINE HCL (45 MG) (TAB ER 24H)..................MINOCYCLINE HCL (50 MG) (CAPSULE)......................MINOCYCLINE HCL (50 MG) (TABLET).........................MINOCYCLINE HCL (65 MG) (TAB ER 24H)............163MINOCYCLINE HCL (75 MG) (CAPSULE)......................MINOCYCLINE HCL (75 MG) (TABLET).........................MINOCYCLINE HCL (90 MG) (TAB ER 24H)..................MINOCYCLINE HCL MICROSPHERES..................... 128MINOXIDIL......................................................................33MIO INFUSION SET........................................................71MIPOMERSEN SODIUM................................................ 36MIRABEGRON...............................................................149MIRALAX.......................................................................103MIRAPEX....................................................................... 143MIRAPEX ER......................................................... 143, 163MIRCERA......................................................................... 84MIRCETTE....................................................................... 40MIRENA..........................................................................130MIRTAZAPINE.................................................................25MIRVASO..........................................................................43MISOPROSTOL..............................................................148MISTASSIST.....................................................................23MISTASSIST KIT............................................................. 23MITE,D.FARINAE-D.PTERONYSSINUS...................... 16MITIGARE........................................................................82MITOMYCIN....................................................................82MITOSOL..........................................................................82MITOTANE..................................................................... 126MOBIC............................................................................ 101MODAFINIL..................................................................... 29MODICON........................................................................ 41MODURETIC 5-50........................................................... 35MOEXIPRIL HCL.............................................................33MOEXIPRIL/HYDROCHLOROTHIAZIDE....................32MOMETASONE FUROATE.................................17, 19, 48MOMETASONE/FORMOTEROL....................................19MONOCLATE-P............................................................... 83MONODOX (100 MG) (CAPSULE)................................ 91MONODOX (50 MG) (CAPSULE).................................. 91MONODOX (50 MG) (TABLET).....................................91MONODOX (75 MG) (CAPSULE).......................... 92, 163MONODOX (75 MG) (TABLET).....................................92MONO-FLO.................................................................... 105MONOJECT.................................... 115, 117, 118, 121, 122MONOJECT (DISP SYRIN) (OTC)............................... 117MONOJECT ALLERGY TRAY-NEEDLE.................... 115MONOJECT BLOOD COLLECTION........................... 131MONOJECT CONTROL SYRINGE..............................117MONOJECT INSULIN SAFETY SYRNG.................... 115MONOJECT INSULIN SYRINGE.................113, 122, 123MONOJECT LUER ADAPTER..................................... 111MONOJECT LUER LOCK TB SYRINGE.................... 116MONOJECT MAGELLAN.....................................120, 121MONOJECT PHARMACY TRAY................................. 116MONOJECT SAFETY SYRINGE..........................117, 120MONOJECT SMARTIP CANNULA............................. 114MONOJECT SYRINGE..........................114, 115, 117, 118MONOJECT SYRINGE (20GX1 1/2") (DISP SYRIN)(OTC)...............................................................................115MONOJECT SYRINGE (20GX1") (DISP SYRIN) (OTC)......................................................................................... 115MONOJECT SYRINGE (20GX3/4") (DISP SYRIN)(OTC)...............................................................................115MONOJECT SYRINGE (21 G X 1") (DISP SYRIN)(OTC)...............................................................................115MONOJECT SYRINGE (21GX1 1/2") (DISP SYRIN)(OTC)...............................................................................115MONOJECT SYRINGE (22GX1 1/2") (DISP SYRIN)(OTC)...............................................................................115MONOJECT SYRINGE (22GX1") (DISP SYRIN) (OTC)......................................................................................... 115MONOJECT SYRINGE (23GX1") (DISP SYRIN) (OTC)......................................................................................... 115MONOJECT SYRINGE (25GX1") (DISP SYRIN) (OTC)......................................................................................... 115MONOJECT SYRINGE (25GX5/8") (DISP SYRIN)(OTC)...............................................................................115MONOJECT SYRINGE (27GX1.25") (DISP SYRIN)(OTC)...............................................................................116MONOJECT SYRINGE PHARMACY TRAY.......117, 118MONOJECT TB..............................................................114MONOJECT TB SYRINGE....................................114, 116MONOJECT TUBERCULIN SAFETY SYR.................121MONOJECT TUBERCULIN SYRINGE....................... 116MONOKET....................................................................... 39

MONOLET LANCETS...................................................108MONOLET THIN LANCETS........................................ 108MONONINE......................................................................83MONOPRIL...................................................................... 33MONOPRIL-HCT............................................................. 32MONTELUKAST SODIUM.............................................19MONUROL....................................................................... 90MORGIDOX....................................................... 91, 92, 163MORPHABOND ER.......................................................139MORPHINE SULFATE...........................................138, 139MORPHINE SULFATE (10 MG) (CAP ER PEL)................MORPHINE SULFATE (10 MG) (SUPP.RECT).................MORPHINE SULFATE (10 MG/5 ML) (SOLUTION)........MORPHINE SULFATE (100 MG) (CAP ER PEL)..............MORPHINE SULFATE (100 MG) (TABLET ER)...............MORPHINE SULFATE (100 MG/5ML) (SOLUTION).......MORPHINE SULFATE (10MG/0.7ML) (PEN INJCTR)...............................................................................................MORPHINE SULFATE (120 MG) (CPMP 24HR)...............MORPHINE SULFATE (15 MG) (TABLET ER).................MORPHINE SULFATE (15 MG) (TABLET).......................MORPHINE SULFATE (20 MG) (CAP ER PEL)................MORPHINE SULFATE (20 MG) (SUPP.RECT).................MORPHINE SULFATE (20 MG/5 ML) (SOLUTION)........MORPHINE SULFATE (200 MG) (TABLET ER)...............MORPHINE SULFATE (30 MG) (CAP ER PEL)................MORPHINE SULFATE (30 MG) (CPMP 24HR).................MORPHINE SULFATE (30 MG) (SUPP.RECT).................MORPHINE SULFATE (30 MG) (TABLET ER).................MORPHINE SULFATE (30 MG) (TABLET).......................MORPHINE SULFATE (30 MG/30ML) (PCA SYRING)...............................................................................................MORPHINE SULFATE (45 MG) (CPMP 24HR).................MORPHINE SULFATE (5 MG) (SUPP.RECT)...................MORPHINE SULFATE (50 MG) (CAP ER PEL)................MORPHINE SULFATE (60 MG) (CAP ER PEL)................MORPHINE SULFATE (60 MG) (CPMP 24HR).................MORPHINE SULFATE (60 MG) (TABLET ER).................MORPHINE SULFATE (75 MG) (CPMP 24HR).................MORPHINE SULFATE (80 MG) (CAP ER PEL)................MORPHINE SULFATE (90 MG) (CPMP 24HR).................MORPHINE SULFATE IN 0.9 % NACL....................... 139MORPHINE SULFATE/D5W.........................................139MORPHINE SULFATE/NALTREXONE....................... 139MORPHINE SULFATE/PF............................................. 139MOTOFEN.............................................................. 102, 163MOTRIN (100 MG/5ML) (ORAL SUSP)...................... 100MOTRIN (400 MG) (TABLET)...................................... 100MOTRIN (600 MG) (TABLET)...................................... 100MOTRIN (800 MG) (TABLET)...................................... 100MOUTHPIECE................................................................106MOVANTIK.................................................................... 103MOVIPREP..................................................................... 103MOXATAG........................................................................ 90MOXEZA.......................................................................... 80MOXIFLOXACIN HCL..............................................80, 91MUCOMYST.................................................................. 137MUCOSITIS AND STOMATITIS COMB2................... 134MUCUS CLEARING DEVICE........................................ 21MUGARD........................................................................134MULPLETA...................................................................... 86MULTAQ........................................................................... 32MULTI-LANCET..............................................................73MUPIROCIN..................................................................... 44MUPIROCIN CALCIUM..........................................44, 128MUPIROCIN/CHLORHEXIDINE/DIMETH.................136MURI-LUBE MINERAL OIL........................................ 135MY MDI PORTABLE NEBULISER................................ 22MYALEPT.........................................................................78MYAMBUTOL..................................................................93MYCELEX........................................................................ 92MYCOBUTIN................................................................... 93MYCOPHENOLATE MOFETIL......................................89MYCOPHENOLATE SODIUM....................................... 89MYCOSTATIN..................................................................45MYDAYIS................................................................. 27, 163MYDRIACYL................................................................... 82MYELOGRAM TRAY....................................................110MYFORTIC.......................................................................89MYGLUCOHEALTH................................................. 59, 68MYGLUCOHEALTH CONTROL SOLUTION...............61MYGLUCOHEALTH LANCETS.................................. 108MYLERAN......................................................................124MYRBETRIQ..........................................................149, 163MYSOLINE.....................................................................145MYTESI.................................................................. 102, 163

- N -N.MENINGITIDIS B,LIPID FHBP RC............................88NA MG FL/NA PHO/NACL/HA/NA HYP...................... 49NABILONE....................................................................... 17NABUMETONE..............................................................101

NABUMETONE/CAPSAI/M-SALICY/MEN................100NADOLOL........................................................................ 34NADOLOL/BENDROFLUMETHIAZIDE.......................34NAFARELIN ACETATE...................................................78NAFTIFINE HCL..............................................................45NAFTIN (1 %) (CREAM (G)).......................................... 45NAFTIN (1 %) (GEL (GRAM))........................................45NAFTIN (2 %) (CREAM (G)).......................................... 45NAFTIN (2 %) (GEL (GRAM))........................................45NALBUPHINE HCL.......................................................139NALDEMEDINE TOSYLATE....................................... 103NALFON......................................................................... 100NALOXEGOL OXALATE..............................................103NALOXONE HCL............................................................ 29NALTREXONE HCL........................................................29NAMENDA (10 MG) (TABLET)..................................... 24NAMENDA (2 MG/ML) (SOLUTION)........................... 24NAMENDA (5 MG) (TABLET)....................................... 24NAMENDA (5 MG-10 MG) (TAB DS PK)......................24NAMENDA XR (14 MG) (CAP SPR 24).........................24NAMENDA XR (21 MG) (CAP SPR 24).........................24NAMENDA XR (28 MG) (CAP SPR 24).........................24NAMENDA XR (7 MG) (CAP SPR 24)...........................24NAMENDA XR (7-14-21-28) (CAP24 DSPK)................ 24NAMZARIC (14MG-10MG) (CAP SPR 24)............24, 163NAMZARIC (21 MG-10MG) (CAP SPR 24)...........24, 163NAMZARIC (28 MG-10MG) (CAP SPR 24)...........24, 163NAMZARIC (7 MG-10 MG) (CAP SPR 24)............24, 163NAMZARIC (7-10/14-10) (CAP24 DSPK).............. 24, 163NAPRELAN (375 MG) (TBMP 24HR)..........................101NAPRELAN (500 MG) (TBMP 24HR)..........................101NAPRELAN (750 MG) (TBMP 24HR)..........................101NAPROSYN.................................................................... 101NAPROXEN.................................................................... 101NAPROXEN SODIUM................................................... 101NAPROXEN/ESOMEPRAZOLE MAG......................... 100NAPROXEN/IRRITANT CNTR-IRRIT 2...................... 100NARATRIPTAN HCL..................................................... 141NARCAN (0.4 MG/ML) (SYRINGE).............................. 29NARCAN (1 MG/ML) (SYRINGE)................................. 29NARCAN (4 MG) (SPRAY)............................................. 29NARDIL............................................................................ 25NASAL EXHALATION RESISTANC.DEV....................21NASALIDE....................................................................... 17NASCOBAL.................................................................... 153NASONEX........................................................................ 17NATACHEW....................................................................151NATACYN.........................................................................80NATAMYCIN....................................................................80NATAZIA.......................................................................... 40NATEGLINIDE................................................................. 56NATELLE ONE...............................................................151NATESTO..........................................................................87NATPARA......................................................................... 78NATROBA.........................................................................45NAVANE............................................................................29NEBIVOLOL HCL............................................................34NEBIVOLOL HCL/VALSARTAN................................... 32NEBULIZER............................................................... 21, 22NEBULIZER ACCESSORIES................................105, 106NEBULIZER AND COMPRESSOR.......................... 22, 23NEBUPENT...................................................................... 94NEBUSAL.......................................................................130NEDOCROMIL SODIUM................................................ 81NEEDLE (18GX1 1/2") (DIS NEEDLE)........................131NEEDLE (30GX1/2") (DIS NEEDLE) (OTC)............... 131NEEDLE CLIP AND STORAGE DEVICE......................73NEEDLE INJECTOR,LUER,CLOSD SYS.................... 111NEEDLE INJECTR,LUER LOCK,CLOSD................... 111NEEDLES........................................................................133NEEDLES, BLOOD COLLECTION..............................131NEEDLES, DISPOSABLE............................................. 131NEEDLES, FILTER........................................................ 131NEEDLES, SAFETY.............................................. 131, 132NEEVODHA................................................................... 153NEFAZODONE HCL........................................................25NELFINAVIR MESYLATE.............................................. 95NEOCERA........................................................................ 50NEOMYC/BACIT/POLYMYX/HYDROCORT............... 46NEOMYC/COLIST/HYDROCORT/THONZN................75NEOMYCIN SULF/BACITRACIN/POLY.......................80NEOMYCIN SULF/POLYMYXIN B SULF....................50NEOMYCIN SULFATE....................................................92NEOMYCIN SULFATE/FLUOCINOLONE....................47NEOMYCIN/BACIT/P-MYX/HYDROCORT................. 79NEOMYCIN/FLUOCINOLONE/EMOLL 65..................47NEOMYCIN/POLYMYXIN B/DEXAMETHA...............79NEOMYCIN/POLYMYXIN B/HYDROCORT...... 47, 75,79NEOMYCIN/POLYMYXN B/GRAMICIDIN................. 80NEO-POLYCIN.................................................................80NEORAL........................................................................... 89


Index

NEOSALUS...................................................................... 50NEOSALUS CP.................................................................50NEOSPORIN.....................................................................80NEO-SYNALAR....................................................... 47, 163NEPAFENAC.................................................................... 79NEPTAZANE.................................................................... 81NERATINIB MALEATE.................................................126NERLYNX.......................................................................126NESINA.....................................................................55, 163NESTABS........................................................................153NESTABS ABC...............................................................152NESTABS DHA.............................................................. 152NESTABS ONE...............................................................151NETARSUDIL MESYLATE.............................................81NETUPITANT/PALONOSETRON HCL......................... 17NEUAC..............................................................................43NEULASTA (6 MG/0.6ML) (SYR W/ INJ)..................... 85NEULASTA (6 MG/0.6ML) (SYRINGE)........................ 85NEUPOGEN......................................................................85NEUPRO................................................................. 143, 163NEURAPTINE.................................................................. 55NEURCAINE.................................................................... 53NEURONTIN.................................................................. 144NEUTEK 2TEK TEST STRIPS........................................59NEUTRASAL..................................................................134NEVANAC.........................................................................79NEVIRAPINE................................................................... 95NEXA PLUS................................................................... 151NEXA SELECT...............................................................151NEXAVAR.......................................................................126NEXAVIR........................................................................123NEXIUM (10 MG) (SUSPDR PKT).......................148, 163NEXIUM (2.5 MG) (SUSPDR PKT)......................148, 163NEXIUM (20 MG) (CAPSULE DR).............................. 148NEXIUM (20 MG) (SUSPDR PKT).......................148, 163NEXIUM (40 MG) (CAPSULE DR).............................. 148NEXIUM (40 MG) (SUSPDR PKT).......................148, 163NEXIUM (5 MG) (SUSPDR PKT).........................148, 163NEXIVA...........................................................................111NEXPLANON...................................................................40NIACIN............................................................................. 39NIACOR............................................................................ 39NIASPAN.................................................................. 39, 163NICARDIPINE HCL.........................................................35NICODERM CQ............................................................. 147NICOTINE.......................................................................147NICOTINE PATCH...............................................................NICOTINE POLACRILEX.............................................147NICOTINE POLACRILEX (2 MG) (GUM) (OTC).............NICOTINE POLACRILEX (2 MG) (LOZENGE) (OTC)...............................................................................................NICOTINE POLACRILEX (2 MG) (LOZNG MINI)(OTC).....................................................................................NICOTINE POLACRILEX (4 MG) (GUM) (OTC).............NICOTINE POLACRILEX (4 MG) (LOZENGE) (OTC)...............................................................................................NICOTINE POLACRILEX (4 MG) (LOZNG MINI)(OTC).....................................................................................NICOTROL............................................................. 147, 163NICOTROL NS....................................................... 147, 164NIFEDIPINE..................................................................... 35NILANDRON..................................................................124NILOTINIB HCL............................................................ 126NILUTAMIDE.................................................................124NIMODIPINE....................................................................35NIMOTOP......................................................................... 35NINLARO....................................................................... 126NINTEDANIB ESYLATE.............................................. 137NIRAPARIB TOSYLATE............................................... 126NISOLDIPINE.................................................................. 35NITAZOXANIDE..............................................................94NITISINONE...................................................................129NITRO-BID....................................................................... 39NITRO-DUR (0.1MG/HR) (PATCH TD24)..................... 39NITRO-DUR (0.2MG/HR) (PATCH TD24)..................... 39NITRO-DUR (0.3 MG/HR) (PATCH TD24).................... 40NITRO-DUR (0.4MG/HR) (PATCH TD24)..................... 40NITRO-DUR (0.6MG/HR) (PATCH TD24)..................... 40NITRO-DUR (0.8MG/HR) (PATCH TD24)..................... 40NITROFURANTOIN........................................................ 90NITROFURANTOIN MACROCRYSTAL....................... 90NITROFURANTOIN MONOHYD/M-CRYST................90NITROGLYCERIN............................................. 39, 40, 102NITROLINGUAL..............................................................40NITROMIST......................................................................40NITROSTAT...................................................................... 40NITRO-TIME.................................................................... 40NITYR............................................................................. 129NIVATOPIC PLUS............................................................ 50NIVESTYM.......................................................................85NIZATIDINE...................................................................148NIZORAL....................................................................45, 92

NOCTIVA..........................................................................76NOLIX...............................................................................48NOLVADEX.................................................................... 127NONOXYNOL 9...............................................................40NORDITROPIN FLEXPRO..............................................77NORELGESTROMIN/ETHIN.ESTRADIOL.................. 41NORETH-ETHINYL ESTRADIOL/IRON...................... 41NORETHINDRONE......................................................... 41NORETHINDRONE ACETATE....................................... 87NORETHINDRONE AC-ETH ESTRADIOL.............41, 87NORETHINDRONE-E.ESTRADIOL-IRON................... 41NORETHINDRONE-ETHINYL ESTRAD...................... 41NORFLEX.......................................................................147NORFLURANE/PENTAFLUOROPROPANE........... 53, 54NORGESTIMATE-ETHINYL ESTRADIOL...................41NORGESTREL-ETHINYL ESTRADIOL....................... 41NORITATE................................................................ 43, 164NORM-JECT SYRINGE.........................................116, 117NORM-JECT TUBERKULIN SYRINGE...................... 116NORMLGEL AG.............................................................. 44NORPACE......................................................................... 31NORPACE CR...................................................................31NORPRAMIN................................................................... 26NOR-Q-D.......................................................................... 41NORTHERA......................................................................39NORTRIPTYLINE HCL................................................... 26NORVASC......................................................................... 34NORVIR (100 MG) (CAPSULE)......................................96NORVIR (100 MG) (POWD PACK).................................96NORVIR (100 MG) (TABLET).........................................96NORVIR (80 MG/ML) (SOLUTION).............................. 96NOSE CLIP..................................................................... 106NOVA MAX BLOOD GLUCOSE METER..................... 68NOVA MAX GLUCOSE CONTROL SOLN....................65NOVA MAX GLUCOSE TEST STRIPS.......................... 59NOVA SAFETY LANCETS........................................... 108NOVA SUREFLEX......................................................... 108NOVACORT...................................................................... 52NOVAMAX PLUS GLU-KET.......................................... 62NOVAREL.........................................................................76NOVOEIGHT.................................................................... 82NOVOFINE 32................................................................ 133NOVOFINE AUTOCOVER............................................ 134NOVOFINE PLUS.......................................................... 133NOVOLIN 70-30....................................................... 75, 164NOVOLIN N..............................................................75, 164NOVOLIN R..............................................................75, 164NOVOLOG................................................................74, 164NOVOLOG FLEXPEN............................................. 74, 164NOVOLOG MIX 70-30.............................................74, 164NOVOLOG MIX 70-30 FLEXPEN.......................... 74, 164NOVOPEN ECHO.............................................................72NOVOSEVEN RT............................................................. 83NOVOTWIST.................................................................. 133NOXAFIL..........................................................................92NOXIPAK..........................................................................47NUCORT........................................................................... 48NUCYNTA...................................................................... 140NUCYNTA ER................................................................ 140NU-DERM SUNFADER...................................................54NUDICLO................................................................... 49, 99NUDROXIPAK E-400.......................................................99NUDROXIPAK I-800........................................................99NUDROXIPAK N-500.................................................... 100NUEDEXTA....................................................................128NULEV............................................................................147NULYTELY WITH FLAVOR PACKS............................103NUMBONEX.................................................................... 53NUMOISYN....................................................................134NUOX................................................................................51NUPLAZID....................................................................... 30NUSINERSEN SODIUM/PF.......................................... 123NUSURGEPAK...............................................................136NUTRASEB...................................................................... 50NUTRESTORE............................................................... 134NUTRIARX...............................................................48, 164NUTROPIN AQ NUSPIN................................................. 77NUVAIL.............................................................................52NUVARING.......................................................................40NUVESSA.......................................................................150NUVIGIL (150 MG) (TABLET).......................................29NUVIGIL (200 MG) (TABLET).......................................29NUVIGIL (250 MG) (TABLET).......................................29NUVIGIL (50 MG) (TABLET).........................................29NUWIQ..............................................................................82NYAMYC.......................................................................... 45NYMALIZE...................................................................... 35NYSTATIN.................................................................. 45, 92NYSTATIN/TRIAMCIN................................................... 45NYSTATIN/TRIAMCIN (100000-0.1) (CREAM (G)).........NYSTATIN/TRIAMCIN (100000-0.1) (OINT. (G)).............NYSTEX............................................................................45

NYSTOP............................................................................45

- O -OASIS ULTRA................................................................104OB COMPLETE..............................................................152OB COMPLETE GOLD..................................................151OB COMPLETE ONE.................................................... 151OB COMPLETE PETITE............................................... 153OB COMPLETE PREMIER........................................... 151OB COMPLETE WITH DHA.........................................151OBETICHOLIC ACID.................................................... 103OBIZUR............................................................................ 83OBREDON................................................................ 42, 164OBSTETRIX EC............................................................. 153OBSTETRIX ONE.......................................................... 151OBTREX DHA................................................................152OCALIVA........................................................................103OCTREOTIDE ACETATE.............................................. 135OCUFEN........................................................................... 79OCUFLOX.........................................................................80OCUPRESS....................................................................... 81ODACTRA........................................................................ 16ODEFSEY......................................................................... 96ODOMZO........................................................................125OFEV...............................................................................137OFLOXACIN.........................................................75, 80, 91OLANZAPINE.................................................................. 28OLANZAPINE/FLUOXETINE HCL............................... 30OLAPARIB......................................................................126OLMESARTAN MEDOXOMIL.......................................33OLMESARTAN/AMLODIPIN/HCTHIAZID.................. 32OLMESARTAN/HYDROCHLOROTHIAZIDE...............32OLODATEROL HCL........................................................ 18OLOPATADINE HCL................................................. 16, 79OLSALAZINE SODIUM................................................102OLUMIANT...................................................................... 99OLUX................................................................................ 47OLUX-E............................................................................ 47OMACETAXINE MEPESUCCINATE........................... 126OMBITA/PARITAP/RITON/DASABUVIR..................... 97OMBITASVIR/PARITAPREV/RITONAV....................... 97OMBRA COMPRESSOR SYSTEM................................ 22OMECLAMOX-PAK...................................................... 148OMEGA-3 ACID ETHYL ESTERS................................. 39OMEPPI...................................................................149, 164OMEPRAZOLE.............................................................. 149OMEPRAZOLE (10 MG) (CAPSULE DR).........................OMEPRAZOLE (20 MG) (CAPSULE DR).........................OMEPRAZOLE (40 MG) (CAPSULE DR).........................OMEPRAZOLE MAGNESIUM.....................................149OMEPRAZOLE/CLARITH/AMOXICILLIN................ 148OMEPRAZOLE/SODIUM BICARBONATE.................149OMNARIS................................................................. 17, 164OMNICEF......................................................................... 89OMNIPOD...................................................................72, 73OMNIPOD DASH.............................................................72OMNIPOD DASH PDM KIT............................................72OMNIPRED...................................................................... 79OMNITROPE.................................................................... 77ON CALL EXPRESS CONTROL SOLN.........................62ON CALL EXPRESS METER......................................... 68ON CALL EXPRESS TEST STRIP..................................59ON CALL LANCET....................................................... 108ON CALL LANCING DEVICE....................................... 73ON CALL PLUS CONTROL............................................61ON CALL PLUS LANCET.............................................108ON CALL PLUS LANCING DEVICE.............................73ON CALL PLUS METER.................................................68ON CALL PLUS TEST STRIP.........................................59ON CALL VIVID CONTROL.......................................... 61ON CALL VIVID METER............................................... 68ON CALL VIVID PAL......................................................68ON CALL VIVID TEST STRIP....................................... 59ONDANSETRON..............................................................17ONDANSETRON HCL.....................................................17ONDANSETRON HCL (24 MG) (TABLET).......................ONDANSETRON HCL (4 MG) (TABLET).........................ONDANSETRON HCL (4 MG/5 ML) (SOLUTION)..........ONDANSETRON HCL (8 MG) (TABLET).........................ONETOUCH DELICA..............................................73, 108ONETOUCH LANCETS................................................ 108ONETOUCH PING........................................................... 73ONETOUCH SURESOFT........................................ 72, 108ONETOUCH ULTRA BLUE TEST STRP.......................59ONETOUCH ULTRA CONTROL SOLN........................ 65ONETOUCH ULTRA2..................................................... 68ONETOUCH ULTRAMINI.............................................. 68ONETOUCH VERIO...................................... 59, 63, 65, 68ONETOUCH VERIO FLEX............................................. 68ONETOUCH VERIO IQ...................................................68ONEXTON................................................................ 43, 164ONFI (10 MG) (TABLET)...................................... 143, 164


Index

ONFI (2.5 MG/ML) (ORAL SUSP)........................143, 164ONFI (20 MG) (TABLET)...................................... 143, 164ONGLYZA................................................................ 55, 164ONMEL............................................................................. 92ON-THE-GO................................................................... 108ONZETRA XSAIL..................................................141, 164OPANA............................................................................ 140OPANA ER (10 MG) (TAB ER 12H)..............................140OPANA ER (15 MG) (TAB ER 12H)..............................140OPANA ER (20 MG) (TAB ER 12H)..............................140OPANA ER (30 MG) (TAB ER 12H)..............................140OPANA ER (40 MG) (TAB ER 12H)..............................140OPANA ER (5 MG) (TAB ER 12H)................................140OPANA ER (7.5 MG) (TAB ER 12H).............................140OPIUM TINCTURE........................................................103OPIUM/BELLADONNA ALKALOIDS........................ 139OPSUMIT..........................................................................36OPTICHAMBER...............................................................21OPTICHAMBER DIAMOND.................................... 20, 21OPTICROM.......................................................................81OPTIPRANOLOL............................................................. 81OPTIUM............................................................................ 59OPTIUM EZ...................................................................... 59OPTIVAR...........................................................................79OPTUMRX............................................................59, 61, 68ORACEA................................................................... 92, 164ORACIT...........................................................................149ORAFATE........................................................................128ORALAIR (100 IR) (TAB SUBL).................................... 16ORALAIR (100-300 IR) (TAB SUBL)............................. 16ORALAIR (300 IR) (TAB SUBL).................................... 16ORAMAGICRX.............................................................. 134ORAP.................................................................................27ORAPRED.........................................................................99ORAVIG............................................................................ 92ORENCIA..........................................................................98ORENCIA CLICKJECT................................................... 98ORENITRAM ER............................................................. 36ORFADIN........................................................................129ORGAN PRESERVATION SOLN-BELZER................... 50ORILISSA......................................................................... 78ORINASE.......................................................................... 56ORKAMBI...................................................................... 137ORPHENADRINE CITRATE.........................................147ORTHO EVRA..................................................................41ORTHO MICRONOR....................................................... 41ORTHO TRI-CYCLEN..................................................... 41ORTHO TRI-CYCLEN LO...............................................41ORTHO-CEPT...................................................................40ORTHO-CYCLEN............................................................ 41ORTHO-EST..................................................................... 87ORTHO-NOVUM..............................................................41OSELTAMIVIR PHOSPHATE......................................... 94OSENI........................................................................55, 164OSIMERTINIB MESYLATE..........................................126OSMOLEX ER................................................................142OSMOPREP.................................................................... 103OTEZLA............................................................................98OTIPRIO............................................................................75OTOVEL............................................................................75OTREXUP................................................................. 97, 164OVACE PLUS (10 %) (CREAM (G))............................... 49OVACE PLUS (10 %) (SHAMPOO)................................ 49OVACE PLUS (9.8 %) (FOAM)........................................49OVACE PLUS (9.8 %) (LOTION)............................ 49, 164OVAL TAPE...................................................................... 71OVCON-35........................................................................ 41OVIDE............................................................................... 45OVIDREL.......................................................................... 76OVRAL..............................................................................41OXANDRIN...................................................................... 86OXANDROLONE............................................................. 86OXAPROZIN...................................................................101OXAYDO.........................................................................139OXAZEPAM......................................................................27OXCARBAZEPINE........................................................ 145OXICONAZOLE NITRATE............................................. 45OXISTAT (1 %) (CREAM (G)).........................................45OXISTAT (1 %) (LOTION)...............................................45OXTELLAR XR (150 MG) (TAB ER 24H)........... 145, 164OXTELLAR XR (300 MG) (TAB ER 24H)........... 145, 164OXTELLAR XR (600 MG) (TAB ER 24H)........... 145, 164OXYBUTYNIN...............................................................150OXYBUTYNIN CHLORIDE..........................................150OXYCODONE HCL............................................... 139, 140OXYCODONE HCL (10 MG) (TAB ER 12H).....................OXYCODONE HCL (10 MG) (TABLET)...........................OXYCODONE HCL (10MG/0.5ML) (SYRINGE)..............OXYCODONE HCL (15 MG) (TAB ER 12H).....................OXYCODONE HCL (15 MG) (TABLET)...........................OXYCODONE HCL (20 MG) (TAB ER 12H).....................OXYCODONE HCL (20 MG) (TABLET)...........................

OXYCODONE HCL (20 MG/ML) (ORAL CONC)............OXYCODONE HCL (30 MG) (TAB ER 12H).....................OXYCODONE HCL (30 MG) (TABLET)...........................OXYCODONE HCL (40 MG) (TAB ER 12H).....................OXYCODONE HCL (5 MG) (CAPSULE)...........................OXYCODONE HCL (5 MG) (TABLET).............................OXYCODONE HCL (5 MG/5 ML) (SOLUTION)..............OXYCODONE HCL (60 MG) (TAB ER 12H).....................OXYCODONE HCL (80 MG) (TAB ER 12H).....................OXYCODONE HCL/ACETAMINOPHEN.................... 142OXYCODONE HCL/ASPIRIN...................................... 142OXYCODONE MYRISTATE......................................... 140OXYCONTIN..................................................................140OXYMETAZOLINE HCL................................................ 43OXYMETHOLONE..........................................................86OXYMORPHONE HCL................................................. 140OXYQUINOLINE/SOD.LAURYL SULFAT..................150OXYTROL...............................................................150, 164OZEMPIC..................................................................55, 164

- P -PACNEX HP......................................................................51PACNEX LP...................................................................... 51PAIN EASE....................................................................... 53PAINGO KFT.................................................................... 53PALBOCICLIB............................................................... 126PALGIC............................................................................. 16PALIPERIDONE............................................................... 28PALM OIL.........................................................................50PALM OIL/EUCALYPTUS OIL.......................................50PALM OIL/HYALURONATE SODIUM.......................... 50PALYNZIQ...................................................................... 123PAMELOR.........................................................................26PAMINE.......................................................................... 148PAMINE FORTE.............................................................148PANCREAZE.................................................................. 147PANDEL............................................................................48PANMYCIN...................................................................... 92PANOBINOSTAT LACTATE..........................................126PANRETIN........................................................................52PANTOPRAZOLE SODIUM..........................................149PAPAVERINE HCL...........................................................40PARADIGM.................................................................... 111PARADIGM INFUSION.................................................111PARADIGM REAL-TIME................................................62PARADIGM REMOTE CONTROL................................. 71PARADIGM SILHOUETTE...........................................111PARAGARD T 380-A..................................................... 130PARATHYROID HORMONE.......................................... 78PARCOPA........................................................................142PAREGORIC................................................................... 103PAREMYD........................................................................ 82PARI LC PLUS NEBULIZER........................................ 106PARI LC SPRINT SINUS................................................. 22PARI SINUS AEROSOL SYSTEM..................................22PARICALCITOL...............................................................78PARLODEL.....................................................................142PARNATE..........................................................................25PAROMOMYCIN SULFATE............................................93PAROXETINE HCL..........................................................25PAROXETINE MESYLATE............................................. 25PASER............................................................................... 93PASIREOTIDE DIASPARTATE..................................... 135PATADAY.......................................................................... 79PATANASE................................................................16, 164PATANOL..........................................................................79PATHOCIL........................................................................ 91PATIROMER CALCIUM SORBITEX............................. 76PAXIL (10 MG) (TABLET).............................................. 25PAXIL (10 MG/5 ML) (ORAL SUSP)..............................25PAXIL (20 MG) (TABLET).............................................. 25PAXIL (30 MG) (TABLET).............................................. 25PAXIL (40 MG) (TABLET).............................................. 25PAXIL CR..........................................................................25PAZEO.......................................................................79, 165PAZOPANIB HCL...........................................................126P-CARE D40G.................................................................. 99P-CARE D80G.................................................................. 99P-CARE K40G.................................................................. 99P-CARE K80G.................................................................. 99P-CARE MG....................................................................101PCCA ACCUPEN-15...................................................... 110PEAK FLOW METER...................................................... 23PEAK FLOW METER/INH ASSIT DEV.........................23PEAK-AIR.........................................................................23PEDIATRIC DINOSAUR NEBULIZER.......................... 23PEDIATRIC DOG NEBULIZER...................................... 23PEDIATRIC FROG NEBULIZER.................................... 23PEG 3350/SOD CHLOR/POTASS CIT.......................... 103PEG3350/SOD SUL/NACL/KCL/ASB/C.......................103PEG3350/SOD SULF,BICARB,CL/KCL....................... 103PEGANONE....................................................................143

PEGASYS..........................................................................96PEGASYS PROCLICK.....................................................96PEGFILGRASTIM............................................................85PEGFILGRASTIM-JMDB................................................85PEGINTERFERON ALFA-2A..........................................96PEGINTERFERON ALFA-2B..................................96, 125PEGINTERFERON BETA-1A........................................127PEGINTRON.....................................................................96PEGVALIASE-PQPZ...................................................... 123PEGVISOMANT...............................................................77PEN NEEDLE................................................................. 133PEN NEEDLE, DIABETIC.....................................132, 133PEN NEEDLE, DIABETIC, SAFETY................... 133, 134PEN NEEDLE,DUAL SAFETY,DIABETC................... 134PEN NEEDLES............................................................... 133PENBUTOLOL SULFATE............................................... 34PENCICLOVIR................................................................. 45PENICILLAMINE............................................................ 97PENICILLIN V POTASSIUM.......................................... 91PENLAC............................................................................44PENNSAID (1.5 %) (DROPS).......................................... 49PENNSAID (20MG/G(2%)) (SOL MD PMP)..........49, 165PENTAMIDINE ISETHIONATE......................................94PENTASA........................................................................102PENTAZINE VC WITH CODEINE................................. 42PENTAZOCINE HCL/NALOXONE HCL..................... 140PENTAZOCINE LACTATE............................................140PENTIPS..........................................................................133PENTOSAN POLYSULFATE SODIUM........................149PENTOXIFYLLINE..........................................................84PEPCID............................................................................148PERAMPANEL............................................................... 145PERFOROMIST................................................................18PERIACTIN.......................................................................16PERIDEX........................................................................ 128PERINDOPRIL ARG/AMLODIPINE BES......................32PERINDOPRIL ERBUMINE........................................... 33PERIOGARD.................................................................. 128PERIOSTAT.....................................................................128PERMETHRIN..................................................................45PERMETHRIN (5 %) (CREAM (G))...................................PERPHENAZINE..............................................................29PERPHENAZINE/AMITRIPTYLINE HCL.....................26PERSANTINE...................................................................85PERSONAL BEST............................................................ 23PERTZYE........................................................................ 147PETROLATUM,WHITE................................................... 52PEXEVA.................................................................... 25, 165PFLEX TRAINER.............................................................23PHARMACIST CHOICE............................................59, 68PHASEAL ADAPTER.................................................... 111PHASEAL ASSEMBLY FIXTURE............................... 110PHASEAL CONNECTOR LUER.................................. 111PHASEAL INFUSION....................................................110PHASEAL INJECTOR LUER........................................ 111PHASEAL PROTECTOR............................................... 134PHASEAL SECONDARY SET...................................... 111PHASEAL Y-SITE.......................................................... 111PHEN TUSS DM...............................................................43PHENAZOPYRIDINE HCL........................................... 149PHENELZINE SULFATE................................................. 25PHENERGAN............................................................. 16, 17PHENERGAN VC.......................................................16, 41PHENERGAN VC WITH CODEINE...............................42PHENERGAN WITH CODEINE..................................... 42PHENOBARB/HYOSCY/ATROPINE/SCOP........ 148, 165PHENOBARBITAL.......................................................... 29PHENOHYTRO (16.2 MG) (TABLET)..................148, 165PHENOHYTRO (16.2MG/5ML) (ELIXIR)........... 148, 165PHENOXYBENZAMINE HCL........................................32PHEN-TUSS AD............................................................... 41PHENYLEPHRINE HCL..................................................80PHENYLEPHRINE HCL/PROMETH HCL.....................41PHENYTEK.................................................................... 145PHENYTOIN.................................................................. 145PHENYTOIN SODIUM EXTENDED........................... 145PHLAG SPRAY.................................................................50PHOSLO............................................................................75PHOSLYRA.......................................................................75PHOSPHASAL..................................................................90PHOSPHOLINE IODIDE................................................. 81PHOTREXA.................................................................... 128PHOTREXA VISCOUS.................................................. 128PHYSIOLOGICAL IRRIG SOLN NO.1.......................... 50PHYSIOLYTE................................................................... 50PHYSIOSOL..................................................................... 50PHYTONADIONE (VIT K1)............................................86PHYTONADIONE (VIT K1) (10 MG/ML) (AMPUL)........PHYTONADIONE (VIT K1) (1MG/0.5ML) (AMPUL)...............................................................................................PHYTONADIONE (VIT K1) (1MG/0.5ML) (SYRINGE)...............................................................................................


Index

PHYTONADIONE (VIT K1) (5 MG) (TABLET)................PICATO (0.015 %) (GEL (EA))........................................52PICATO (0.05 %) (GEL (EA))..........................................52PIFELTRO......................................................................... 95PIKO 1............................................................................... 23PILLOW MASK FOR CHILDREN................................106PILOCARPINE HCL................................................ 81, 123PIMAVANSERIN TARTRATE......................................... 30PIMECROLIMUS............................................................. 55PIMOZIDE........................................................................ 27PINDOLOL....................................................................... 34PIOGLITAZONE HCL......................................................56PIOGLITAZONE HCL/GLIMEPIRIDE...........................56PIOGLITAZONE HCL/METFORMIN HCL................... 56PIRFENIDONE............................................................... 136PIROXICAM................................................................... 101PITAVASTATIN CALCIUM............................................. 37PITAVASTATIN MAGNESIUM....................................... 37PLAN B ONE-STEP......................................................... 40PLANTAGO-HOMACCORD......................................... 130PLAQUENIL..................................................................... 94PLAVIX (300 MG) (TABLET)......................................... 85PLAVIX (75 MG) (TABLET)........................................... 85PLECANATIDE.............................................................. 102PLEGISOL...................................................................... 129PLEGRIDY......................................................................127PLEGRIDY PEN............................................................. 127PLENDIL...........................................................................35PLENVU..........................................................................103PLETAL.............................................................................85PLEXION.......................................................................... 46PLEXION (10-5%(W/W)) (LOTION).............................. 46PLEXION (9.8%-4.8%) (CLEANSER)............................ 46PLEXION (9.8%-4.8%) (CREAM (G))............................ 46PLEXION (9.8%-4.8%) (LOTION).................................. 46PLEXION (9.8%-4.8%) (MED. PAD).............................. 46PLEXION TS.....................................................................46PLIAGLIS..........................................................................53PLIXDA.............................................................................44PNV 102/IRON/FOLATE 1/DSS/DHA.......................... 151PNV 11/IRON FUM/FOLIC ACID/OM3....................... 151PNV 112/IRON/FOLIC/OM3/DHA/EPA....................... 151PNV 117/IRON/FOLIC/OM3/DHA/EPA....................... 151PNV 15/IRON FUM,PS/FOLIC ACID........................... 151PNV 16/IRON FUM,PS/FOLIC/OM-3...........................151PNV 19/IRON PS,HEME/FOLIC/DHA......................... 151PNV 21/IRON PS,HEME PPEP/FOLIC......................... 151PNV 22/IRON,GLUC/FOLIC/DSS/DHA.......................151PNV 30/IRON CARB,AG/FOLIC/OM3.........................151PNV 39/IRON/FOLIC/DOCUSATE/DHA..................... 151PNV 55/IRON FUM,B-G/FOLIC ACID.........................151PNV 66/IRON/FOLIC/DOCUSATE/DHA..................... 151PNV 67/IRON PS/FOLATE NO.1/DHA.........................151PNV 69/IRON/FOLIC/DOCUSATE/DHA..................... 151PNV 76/IRON,GLUC/FOLIC/DSS/DHA.......................151PNV 80/IRON FUM/FOLIC/DSS/DHA......................... 151PNV 85/IRON/FOLIC/DHA/FISH OIL..........................151PNV NO.106/IRON/FOLATE NO6/DHA...................... 151PNV NO.111/IRON/FOLATE/DHA............................... 151PNV NO.118/IRON FUMARATE/FA............................ 151PNV NO.5/FERROUS FUM/FOLIC AC........................151PNV NO.66/IRON,CARB/FOLIC/DHA........................ 151PNV NO.80/IRON/MFOLATE/DSS/DHA..................... 151PNV NO.88/IRON PS,HEME/FA/DHA......................... 151PNV OB+DHA................................................................151PNV, CALCIUM 70/IRON/FOLIC/DHA....................... 151PNV,CALCIUM 72/IRON,CARB/FOLIC...................... 151PNV,CALCIUM 72/IRON/FOLIC ACID....................... 151PNV/FERROUS FUM/DOCUSATE/FOLIC.................. 151PNV/FOLIC AC/B6/CALCIUM/GINGER.....................153PNV/IRON,CARB/DOCUSAT/FOLIC AC.................... 151PNV119/IRON FUM/FOLIC/DOCUSATE.................... 151PNV19/IRON BG,S.P/FOLIC AC/OM3......................... 151PNV53/IRON FUM/FA/DOCUSATE/DHA................... 151PNV59/IRON,CARB,FUM/FA/DSS/DHA.....................151PNV72/IRON,GLUC/FOLIC/DSS/DHA........................151PNV73/IRON,GLUC/FOLIC/DSS/DHA........................151PNV81/IRON EDTA,PS/FOLIC/OMEG3...................... 151PNV83/IRON,CARB,ASP/FOLIC ACID....................... 151POCKET CHAMBER....................................................... 20POCKET PEAK................................................................ 23POD-CARE 100CG...........................................................98POD-CARE 100KG...........................................................99PODOFILOX.....................................................................51PODOPHYLLUM RESIN.................................................51POLY HUB NEEDLE (30GX1/2") (DIS NEEDLE) (OTC)......................................................................................... 131POLYDIMETHYLSILOXANES/SILICON..................... 52POLYETHYLENE GLYCOL 3350.................................103POLYFIN QR.................................................................. 111POLYHEXAM BIGUAN/GAUZE BANDAGE..............104POLYMYXIN B SULF/TRIMETHOPRIM......................80

POLYTRIM....................................................................... 80POLY-TUSSIN AC............................................................ 41POLY-UREAURETHANE................................................ 52POMALIDOMIDE.......................................................... 125POMALYST.................................................................... 125PONATINIB HCL........................................................... 126PONTOCAINE..................................................................54POPULUS COMPOSITUM............................................130PORACTANT ALFA.......................................................137PORCINE ACELL SUBMUCOSA,MESHED............... 104PORCINE SUBMUCOSA, FENESTRATED.................104PORTABLE NEBULIZER SYSTEM............................... 23POSACONAZOLE............................................................92POT CHLORIDE/POT BICARB/CIT AC........................ 76POT SOR/HE-CELLULOS/POV/HYALUR...................134POT SORBATE/MALTO/ALOE/MANN PS..................134POTABA.......................................................................... 153POTASSIUM AMINOBENZOATE................................ 153POTASSIUM BICARBONATE/CIT AC.......................... 76POTASSIUM CHLORIDE................................................76POTASSIUM CITRATE..................................................149POTASSIUM CITRATE/CITRIC ACID.........................149POTASSIUM IODIDE...................................................... 78POTASSIUM IODIDE (1 G/ML) (SOLUTION)..................POTASSIUM IODIDE/IODINE........................................78POTASSIUM PHOSPHATE,MONOBASIC...................149POVID/TAUR/ZN/PEG40 CASTOR OIL...................... 134POVIDONE-IODINE........................................................ 50POVIDONE-IODINE (5 %) (SOLUTION)..........................PRADAXA................................................................ 86, 165PRALIDOXIME CHLORIDE.........................................129PRALIDOXIME CHLORIDE/ATROPINE.................... 129PRALUENT PEN..............................................................38PRAMCORT....................................................................102PRAMIPEXOLE DI-HCL...............................................143PRAMLINTIDE ACETATE..............................................55PRAMOSONE (1 %-1 %) (CREAM (G)).........................52PRAMOSONE (1 %-1 %) (LOTION)...............................52PRAMOSONE (1 %-1 %) (OINT. (G)).............................52PRAMOSONE (2.5 %-1 %) (CREAM (G))......................52PRAMOSONE (2.5 %-1 %) (LOTION)............................52PRAMOSONE (2.5 %-1 %) (OINT. (G))..........................52PRAMOSONE E............................................................... 52PRANDIMET.................................................................... 56PRANDIN..........................................................................56PRASUGREL HCL........................................................... 85PRAVACHOL.................................................................... 37PRAVASTATIN SODIUM.................................................37PRAZIQUANTEL............................................................. 93PRAZOSIN HCL...............................................................32PRECISION.................................................................62, 68PRECISION GLUCOSE CONTROL............................... 62PRECISION PCX..............................................................59PRECISION PCX PLUS................................................... 59PRECISION POINT OF CARE........................................ 59PRECISION Q-I-D............................................................59PRECISION XTRA.....................................................60, 68PRECISIONGLIDE.........................................................116PRECOSE..........................................................................55PRED FORTE....................................................................79PRED MILD......................................................................79PRED-G.............................................................................79PREDNICARBATE...........................................................48PREDNISOLON/GATIFLOX/BROMFENAC................. 79PREDNISOLONE............................................................. 99PREDNISOLONE ACET/GATIFLOXACIN....................79PREDNISOLONE ACETATE...........................................79PREDNISOLONE ACETATE/BROMFENAC................. 79PREDNISOLONE ACETATE/PF..................................... 80PREDNISOLONE SOD PHOSPHATE...................... 80, 99PREDNISONE.................................................................. 99PREDNISONE INTENSOL..................................................PREFERA OB................................................................. 151PREFERA-OB ONE........................................................151PREFERA-OB PLUS DHA.................................... 151, 153PREFEST...........................................................................87PREGABALIN........................................................ 128, 145PREGNYL.........................................................................76PREMARIN...............................................................87, 150PREMIER BLU................................................................. 68PREMIER TEST STRIP....................................................60PREMIER VOICE.............................................................68PREMIUM BLOOD GLUCOSE...................................... 68PREMIUM BLOOD GLUCOSE TEST............................60PREMIUM V10...........................................................60, 68PREMPHASE....................................................................87PREMPRO.........................................................................87PRENAT 115/IRON FUM/FOLIC/DSS..........................151PRENAT VIT 17/IRON/FOLIC/OM3,6..........................151PRENAT90/IRON FUM,PS/FOLIC/DHA...................... 151PRENATA........................................................................153PRENATAL 105/IRON/FOLIC AC/DHA.......................151

PRENATAL 114/IRON A-G/FOLATE 1.........................151PRENATAL 118/IRON/FOLATE 6/DHA.......................151PRENATAL 12/IRON/FOLIC/DSS/OM3....................... 152PRENATAL 2/IRON/FOLIC ACID/OM3.......................152PRENATAL 25/IRON/FOLATE 6/DHA.........................152PRENATAL 26/IRON PS/FOLIC/DHA..........................152PRENATAL 34/IRON/FOLIC/DSS/DHA.......................152PRENATAL 38/IRON/FOLATE 6/DHA.........................152PRENATAL 47/IRON/FOLATE 1/DHA.........................152PRENATAL 53/IRON/FOLIC AC/OMG3...................... 152PRENATAL 54/IRON/FOLIC AC/OMG3...................... 152PRENATAL 57/IRON/FOLIC/DSS/DHA.......................152PRENATAL 59/IRON/FOLIC/DSS/DHA.......................152PRENATAL 68/IRON/FOLIC NO1/DHA...................... 152PRENATAL 78/IRON/FOLATE 1/DHA.........................152PRENATAL 86/IRON/FOLIC/DHA/EPA.......................152PRENATAL 87/IRON BIS/FOLIC/DHA........................ 152PRENATAL 93/IRON/FOLATE 9/DHA.........................152PRENATAL COMB NO.42/FOLIC ACID......................152PRENATAL NO.123/IRON/FOLIC AC..........................152PRENATAL NO.52/IRON/FA/DHA............................... 152PRENATAL NO.75/IRON/FOLATE NO1...................... 152PRENATAL NO.77/IRON ASP GLY/FA........................152PRENATAL NO115/IRON/FOLIC ACID.......................152PRENATAL NO13/IRON PS/FOLATE 1....................... 152PRENATAL NO35/IRON/FOLATE6/DHA.................... 152PRENATAL NO4/IRON FUM,PS/FOLIC...................... 152PRENATAL PLUS-DHA.................................................153PRENATAL VIT 10/IRON FUM/FOLIC........................152PRENATAL VIT 10/IRON/FOLIC/DHA........................152PRENATAL VIT 14/IRON FUM/FOLIC........................152PRENATAL VIT 33/IRON/FOLIC/DHA........................152PRENATAL VIT 36/IRON/FOLATE 6........................... 152PRENATAL VIT 43/IRON/FOLIC/DSS.........................152PRENATAL VIT 55/IRON/FOLIC/OM3........................152PRENATAL VIT 65/IRON FUM,PS/FA.........................152PRENATAL VIT 84/IRON/FA 1/DHA........................... 152PRENATAL VIT 85/IRON/FA 1/DHA........................... 152PRENATAL VIT 87/IRON/FOLIC/DHA........................152PRENATAL VIT NO.109/IRON/FA............................... 152PRENATAL VIT NO.112/FOLATE NO6....................... 152PRENATAL VIT NO.127/IRON/FOLIC.........................152PRENATAL VIT,CAL 73/IRON/FOLIC.........................152PRENATAL VIT,CAL 74/IRON/FOLIC.........................152PRENATAL VIT,CALC76/IRON/FOLIC.......................152PRENATAL VIT,CALC78/IRON/FOLIC.......................152PRENATAL VIT/IRON BISGLY/FOLIC....................... 152PRENATAL VIT/IRON FUM/FOLIC AC...................... 152PRENATAL VIT/IRON FUM/FOLIC AC (65 MG-1 MG)(CAPSULE)...........................................................................PRENATAL VIT/IRON FUM/FOLIC AC (65 MG-1 MG)(TABLET)..............................................................................PRENATAL VIT100/IRON/FOLIC/OM3.......................152PRENATAL VIT103/IRON FUM/FOLIC.......................152PRENATAL VIT106/IRON/FOLIC/OM3.......................153PRENATAL VIT108/IRON,CRB/FOLIC....................... 153PRENATAL VIT114/FOLATE6/GINGER..................... 153PRENATAL VIT127/IRON/FOLIC/DSS........................153PRENATAL VIT128/IRON/FOLIC ACD....................... 153PRENATAL VIT136/IRON/FOLIC ACD....................... 153PRENATAL VIT22/IRON/FOLIC/OM3S.......................153PRENATAL VIT27,CALCIUM/IRON/FA......................153PRENATAL VIT37/IRON/FOLIC ACID........................153PRENATAL VIT68/IRON/FA NO6/DHA...................... 153PRENATAL VIT69/IRON/FOLATE6/DH...................... 153PRENATAL VIT83/IRON/FOLAT6/DHA......................153PRENATAL VIT86/IRON/FOLIC ACID........................153PRENATAL VITS15/IRON/FOLIC/DSS........................153PRENATAL VITS16/IRON/FOLIC/DSS........................153PRENATAL VITS18/IRON/FOLIC/DSS........................153PRENATAL,CALC NO.65/IRON/FOLIC.......................153PRENATAL,CALC.40/IRON/FOLATE 1....................... 153PRENATAL56/IRON/FOLIC ACID/DHA......................153PRENATAL64/IRON/LMFOLATE/ALGAL.................. 153PRENATAL71/IRON/FOLIC ACID/DHA......................153PRENATAL72/IRON FUM/FA/OM3/DHA....................153PRENATAL81/IRON/FOLIC/DOCUSATE.................... 153PRENATAL92/IRON/FOLATE8/PS-DHA..................... 153PRENATE AM................................................................ 153PRENATE CHEWABLE................................................. 152PRENATE DHA.............................................................. 152PRENATE ELITE....................................................151, 152PRENATE ENHANCE....................................................153PRENATE ESSENTIAL..................................................152PRENATE MINI..............................................................152PRENATE PIXIE.............................................................152PRENATE RESTORE..................................................... 153PRENATE STAR............................................................. 152PREPIDIL..........................................................................41PREPOPIK...................................................................... 103PRESERA..........................................................................50PRESSURE ACTIVATED LANCETS............................108


Index

PRESTALIA.............................................................. 32, 165PRESTO PRO....................................................................68PREVIDENT................................................................... 150PREVIDENT 5000.......................................................... 150PREVIDENT 5000 ENAMEL PROTECT...................... 150PREVIDENT 5000 SENSITIVE.....................................150PREVYMIS....................................................................... 94PREZCOBIX..................................................................... 94PREZISTA......................................................................... 94PRIALT............................................................................137PRIFTIN............................................................................ 93PRILOLID......................................................................... 53PRILOSEC...................................................................... 149PRILOVIX.........................................................................53PRIMACARE.................................................................. 151PRIMAQUINE.................................................................. 94PRIMAQUINE PHOSPHATE...........................................94PRIMEAIRE......................................................................20PRIMIDONE................................................................... 145PRIMLEV........................................................................142PRIMSOL.......................................................................... 90PRINIVIL.......................................................................... 33PRISTIQ............................................................................ 25PRO COMFORT INSULIN SYRINGE.................. 113, 122PRO COMFORT LANCET.............................................108PRO COMFORT LANCETS...........................................108PRO COMFORT PEN NEEDLE.................................... 133PRO COMFORT TENS ELECTRODE.......................... 106PRO COMFORT TENS UNIT........................................ 106PRO VOICE V8 GLUCOSE MONITOR..........................68PRO VOICE V8-V9 TEST STRIP .................................... 60PRO VOICE V9 GLUCOSE MONITOR..........................68PROAIR HFA.................................................................... 18PROAIR RESPICLICK..................................................... 18PROAMATINE..................................................................39PRO-BANTHINE............................................................ 148PROBENECID.................................................................. 82PROBENECID/COLCHICINE......................................... 82PROBUPHINE................................................................ 142PROCARBAZINE HCL..................................................126PROCARDIA.................................................................... 35PROCARDIA XL (30 MG) (TAB ER 24).........................35PROCARDIA XL (60 MG) (TAB ER 24).........................35PROCARDIA XL (60 MG) (TABLET ER)...................... 35PROCARDIA XL (90 MG) (TAB ER 24).........................35PROCARDIA XL (90 MG) (TABLET ER)...................... 35PROCENTRA....................................................................26PRO-CEPTION FERTILITY PAK..................................105PROCHAMBER................................................................20PROCHLORPERAZINE...................................................17PROCHLORPERAZINE MALEATE............................... 17PROCORT....................................................................... 102PROCRIT...........................................................................84PROCTOCORT............................................................... 102PROCTOFOAM-HC....................................................... 102PROCYSBI......................................................................149PRODIGY..........................................................................68PRODIGY AUTOCODE................................................... 68PRODIGY CONTROL SOLUTION................................. 63PRODIGY INSULIN SYRINGE.................... 113, 122, 123PRODIGY LANCETS.....................................................108PRODIGY LANCING DEVICE....................................... 73PRODIGY MINI-MIST.....................................................22PRODIGY NO CODING.................................................. 60PRODIGY POCKET......................................................... 68PRODIGY TWIST TOP LANCET................................. 108PRODIGY VOICE.............................................................68PRODRIN........................................................................141PROFILNINE.................................................................... 83PROGESTERONE.............................................................87PROGESTERONE, MICRONIZED............................76, 87PROGLYCEM................................................................... 74PROGRAF......................................................................... 89PROLASTIN C................................................................123PROLENSA.......................................................................79PROLIXIN.........................................................................29PROLOPRIM.....................................................................90PROMACTA......................................................................86PROMETHAZINE HCL............................................. 16, 17PROMETHAZINE HCL/CODEINE.................................42PROMETHAZINE/DEXTROMETHORPHAN............... 43PROMETHAZINE/PHENYLEPH/CODEINE................. 42PROMETRIUM.................................................................87PROMISEB....................................................................... 49PROMISEB COMPLETE................................................. 49PRONEB ULTRA II.......................................................... 23PROPAFENONE HCL...................................................... 32PROPANTHELINE BROMIDE......................................148PROPARACAINE HCL.................................................... 80PROPARACAINE/FLUORESCEIN SOD........................ 80PROPRANOLOL HCL..................................................... 34PROPRANOLOL/HYDROCHLOROTHIAZID...............34

PROPYLENE GLYCOL..................................................135PROPYLTHIOURACIL.................................................... 78PRO-RED AC.................................................................... 42PROSCAR....................................................................... 149PROSTIN E2 VAGINAL SUPPOSITORY....................... 41PROTECTIVES COMBINATION NO.2.......................... 52PROTECTIVES2/CERAMIDE 1,3,6-11...........................52PROTHELIAL................................................................. 128PROTHROMBIN TIME/INR TEST METR................... 129PROTONIX............................................................. 149, 165PROTOPIC........................................................................ 55PROTRIPTYLINE HCL....................................................26PROVENT......................................................................... 21PROVENTIL HFA.............................................................18PROVERA......................................................................... 87PROVIDA DHA.............................................................. 151PROVIDA OB................................................................. 152PROVIGIL......................................................................... 29PROZAC............................................................................25PROZAC WEEKLY.......................................................... 25PRUDOXIN............................................................... 49, 165PRUSSIAN BLUE (INSOLUBLE).................................130PSEUDOEPHED/CHLOR-MAL/BELL ALK..................41PSEUDOEPHED/CODEINE/GUAIFEN..........................42PSEUDOEPHEDRINE HCL/ACRIVAS...........................16PSORCON.........................................................................47PSORINOHEEL.............................................................. 130PULMICORT (0.25MG/2ML) (AMPUL-NEB)............... 19PULMICORT (0.5 MG/2ML) (AMPUL-NEB)................ 19PULMICORT (1 MG/2 ML) (AMPUL-NEB).................. 19PULMICORT FLEXHALER.................................... 19, 165PULMO-AIDE.................................................................. 20PULMONEB LT COMPRESSOR NEBUL...................... 23PULMOZYME................................................................ 137PUMP SET...................................................................... 110PURINETHOL................................................................ 124PURIXAN................................................................124, 165PUSH BUTTON SAFETY LANCETS...........................109PVA/GENTIAN VIOLET/METHYL BLUE.................. 104PYLERA..........................................................................148PYRAZINAMIDE............................................................. 93PYRIDIUM......................................................................149PYRIDOSTIGMINE BROMIDE...................................... 24PYRIDOXINE HCL (VITAMIN B6)..............................153PYRIDOXINE HCL (VITAMIN B6) (100 MG/ML)(VIAL)...................................................................................PYRIMETHAMINE..........................................................94

- Q -QBRELIS...................................................................33, 165QBREXZA...................................................................... 124Q-CARE RX....................................................................128QNASL...................................................................... 16, 165QNASL CHILDREN.................................................16, 165QTERN...................................................................... 56, 165QUAKE..............................................................................21QUALAQUIN....................................................................94QUARTETTE.................................................................... 41QUAZEPAM......................................................................30QUDEXY XR (100 MG) (CAP SPR 24)................ 146, 165QUDEXY XR (150 MG) (CAP SPR 24)................ 146, 165QUDEXY XR (200 MG) (CAP SPR 24)................ 146, 165QUDEXY XR (25 MG) (CAP SPR 24).................. 146, 165QUDEXY XR (50 MG) (CAP SPR 24).................. 146, 165QUESTRAN...................................................................... 38QUESTRAN LIGHT......................................................... 38QUETIAPINE FUMARATE....................................... 28, 29QUICK RELEASE SOFT TEFLON............................... 110QUICK-SET PARADIGM................................................ 71QUILLICHEW ER (20 MG) (TAB CBP24H).......... 31, 165QUILLICHEW ER (30 MG) (TAB CBP24H).......... 31, 165QUILLICHEW ER (40 MG) (TAB CBP24H).......... 31, 165QUILLIVANT XR (5 MG/ML) (SU ER RC24)....... 31, 165QUINAPRIL HCL.............................................................33QUINAPRIL/HYDROCHLOROTHIAZIDE.................... 32QUINIDINE GLUCONATE..............................................32QUINIDINE SULFATE.....................................................32QUININE SULFATE.........................................................94QUINJA............................................................................. 44QUINTET.................................................................... 60, 69QUINTET AC..............................................................60, 69QUTENZA........................................................................ 51QVAR REDIHALER.........................................................19

- R -RABEPRAZOLE SODIUM............................................149RADIAGEL..................................................................... 134RADIAPLEXRX............................................................... 52RADIOGARDASE..........................................................130RAGWITEK...................................................................... 16RALOXIFENE HCL......................................................... 77RALTEGRAVIR POTASSIUM.........................................96RAMELTEON................................................................... 29

RAMIPRIL........................................................................ 33RANEXA (1000 MG) (TAB ER 12H).............................. 39RANEXA (500 MG) (TAB ER 12H)................................ 39RANITIDINE HCL......................................................... 148RANOLAZINE..................................................................39RAPAFLO............................................................... 149, 165RAPAMUNE (0.5 MG) (TABLET).................................. 89RAPAMUNE (1 MG) (TABLET)..................................... 89RAPAMUNE (1 MG/ML) (SOLUTION)......................... 89RAPAMUNE (2 MG) (TABLET)..................................... 89RAPPORT VACUUM THERAPY.................................. 134RASAGILINE MESYLATE............................................143RASUVO (10MG/0.2ML) (AUTO INJCT).............. 97, 165RASUVO (12.5/0.25) (AUTO INJCT)......................97, 165RASUVO (15MG/0.3ML) (AUTO INJCT).............. 97, 165RASUVO (17.5/0.35) (AUTO INJCT)......................97, 165RASUVO (20MG/0.4ML) (AUTO INJCT).............. 97, 166RASUVO (22.5/0.45) (AUTO INJCT)......................97, 166RASUVO (25MG/0.5ML) (AUTO INJCT).............. 97, 166RASUVO (30MG/0.6ML) (AUTO INJCT).............. 97, 166RASUVO (7.5MG/0.15) (AUTO INJCT)................. 97, 166RATE FLOW REGULATOR IV SET............................. 111RAVICTI..........................................................................102RAYALDEE.......................................................................78RAYOS...................................................................... 99, 166RAZADYNE (12 MG) (TABLET)....................................24RAZADYNE (4 MG) (TABLET)......................................24RAZADYNE (4 MG/ML) (SOLUTION)..........................24RAZADYNE (8 MG) (TABLET)......................................24RAZADYNE ER............................................................... 24READYLANCE SAFETY LANCETS........................... 109REBETOL......................................................................... 96REBIF.............................................................................. 127REBIF REBIDOSE......................................................... 127REBINYN..........................................................................83RECEDO........................................................................... 52RECOMBINATE............................................................... 83RECONSTITUBE........................................................... 105RECOTHROM...................................................................86RECTAGEL HC.............................................................. 102RECTIV...........................................................................102REFUAH PLUS...........................................................60, 69REFUAH PLUS GLUCOSE CONTROL..........................63REGENECARE...........................................................53, 54REGLAN......................................................................... 148REGORAFENIB............................................................. 126REGRANEX......................................................................74RELADOR PAK................................................................53RELADOR PAK PLUS..................................................... 53RELAFEN....................................................................... 101RELAGARD....................................................................150RELENZA......................................................................... 94RELEXXII.........................................................................31RELIAMED.....................................................................109RELIAMED MINI LANCING DEVICE..........................73RELIAMED SAFETY SEAL LANCETS.......................109RELION ALL-IN-ONE.....................................................69RELION CONFIRM......................................................... 69RELION CONFIRM-MICRO........................................... 60RELION MICRO...............................................................69RELION PEN NEEDLES............................................... 133RELION PRIME............................................................... 69RELION PRIME TEST STRIPS.......................................60RELION THIN................................................................ 109RELISTOR (12MG/0.6ML) (SYRINGE)....................... 103RELISTOR (12MG/0.6ML) (VIAL)...............................103RELISTOR (150 MG) (TABLET)...................................103RELISTOR (8 MG/0.4ML) (SYRINGE)........................ 103RELIZORB......................................................................110RELPAX.................................................................. 140, 166REMODULIN................................................................... 36RENACIDIN....................................................................149RENAGEL.........................................................................76RENEEL.......................................................................... 130RENVELA.........................................................................76REPAGLINIDE................................................................. 56REPAGLINIDE/METFORMIN HCL............................... 56REPATHA PUSHTRONEX.............................................. 38REPATHA SURECLICK.................................................. 38REPATHA SYRINGE....................................................... 38REPLACEMENT PEDIATRIC MONITOR..................... 71REPLICARE....................................................................104REPLICARE THIN......................................................... 104REPLICARE ULTRA......................................................104REPLICARE ULTRA SACRUM.................................... 104REQUIP...........................................................................143REQUIP XL.............................................................143, 166RESCRIPTOR................................................................... 94RESECTISOL....................................................................35RESTASIS......................................................................... 80RESTASIS MULTIDOSE................................................. 80RESTIZAN........................................................................ 50


Index

RESTORE........................................................................104RESTORE CALCIUM ALGINATE................................104RESTORE CONTACT LAYER SILVER........................104RESTORIL........................................................................ 30RETACRIT........................................................................ 84RETAPAMULIN............................................................... 45RETIN-A........................................................................... 44RETIN-A MICRO............................................................. 44RETIN-A MICRO PUMP (0.04 %) (GEL W/PUMP)......44RETIN-A MICRO PUMP (0.06 %) (GEL W/PUMP)......44, 166RETIN-A MICRO PUMP (0.08 %) (GEL W/PUMP)......44, 166RETIN-A MICRO PUMP (0.1 %) (GEL W/PUMP)........ 44RETROVIR........................................................................95REUSABLE NEBULIZER KIT......................................106REVATIO (10 MG/ML) (SUSP RECON).........................35REVATIO (20 MG) (TABLET)......................................... 36REVEAL BLOOD GLUCOSE METER...........................69REVEAL TEST STRIP..................................................... 60REVEL PROGRAMMABLE PUMP................................73REVIA............................................................................... 29REVLIMID......................................................................125REXULTI...................................................................28, 166REYATAZ (150 MG) (CAPSULE)................................... 95REYATAZ (200 MG) (CAPSULE)................................... 95REYATAZ (300 MG) (CAPSULE)................................... 95REYATAZ (50 MG) (POWD PACK)................................ 95RHOFADE.........................................................................43RHOPRESSA............................................................ 81, 166RIBAVIRIN........................................................... 94, 96, 97RIBAVIRIN (200 MG) (CAPSULE).....................................RIBAVIRIN (200 MG) (TABLET)........................................RIBAVIRIN (200-400 MG) (TAB DS PK)..................... 166RIBAVIRIN (200-400(7)) (TAB DS PK)........................ 166RIBAVIRIN (400 MG) (TABLET)..................................166RIBAVIRIN (400-400 MG) (TAB DS PK)..................... 166RIBAVIRIN (400-400(7)) (TAB DS PK)........................ 166RIBAVIRIN (600 MG) (TABLET)..................................166RIBAVIRIN (600-400 MG) (TAB DS PK)..................... 166RIBAVIRIN (600-400(7)) (TAB DS PK)........................ 166RIBAVIRIN (600-600 MG) (TAB DS PK)..................... 166RIBAVIRIN (600-600(7)) (TAB DS PK)........................ 166RIBOCICLIB SUCCINATE............................................126RIBOCICLIB SUCCINATE/LETROZOLE....................125RIBOFLAVIN 5-PHOS/20 % DEXTRAN......................128RIBOFLAVIN 5-PHOSPHATE SOD(B2)...................... 128RIDAURA......................................................................... 99RIFABUTIN...................................................................... 93RIFADIN........................................................................... 93RIFAMATE........................................................................93RIFAMP/ISONIAZID/PYRAZINAMIDE........................ 93RIFAMPIN........................................................................ 93RIFAMPIN/ISONIAZID................................................... 93RIFAPENTINE..................................................................93RIFATER........................................................................... 93RIFAXIMIN...................................................................... 93RIGHTEST CONTROL SOLUTION......................... 63, 65RIGHTEST GC250S CONTROL SOLN.......................... 65RIGHTEST GD500........................................................... 73RIGHTEST GL300 LANCETS.......................................109RIGHTEST GM100 SYSTEM..........................................69RIGHTEST GM250S METER..........................................69RIGHTEST GM260 METER............................................ 69RIGHTEST GM300 SYSTEM..........................................69RIGHTEST GM550 SYSTEM..........................................69RIGHTEST GS100 TEST STRIPS................................... 60RIGHTEST GS250S TEST STRIPS................................. 60RIGHTEST GS260 TEST STRIPS................................... 60RIGHTEST GS300 TEST STRIPS................................... 60RIGHTEST GS550 TEST STRIPS................................... 60RILONACEPT...................................................................97RILPIVIRINE HCL...........................................................95RILUTEK........................................................................ 127RILUZOLE......................................................................127RIMANTADINE HCL...................................................... 94RINGER'S SOLUTION.................................................... 50RINGER'S SOLUTION,LACTATED............................... 50RIOCIGUAT......................................................................35RIOMET............................................................................ 56RISEDRONATE SODIUM............................................... 77RISEDRONATE SODIUM (150 MG) (TABLET)..........166RISEDRONATE SODIUM (30 MG) (TABLET)............166RISEDRONATE SODIUM (35 MG) (TABLET DR)......166RISEDRONATE SODIUM (35 MG) (TABLET)............166RISEDRONATE SODIUM (5 MG) (TABLET)..............166RISPERIDONE................................................................. 29RISPERIDONE (0.25 MG) (TAB RAPDIS).........................RISPERIDONE (0.25 MG) (TABLET).................................RISPERIDONE (0.5 MG) (TAB RAPDIS)...........................

RISPERIDONE (0.5 MG) (TABLET)...................................RISPERIDONE (1 MG) (TAB RAPDIS)..............................RISPERIDONE (1 MG) (TABLET)......................................RISPERIDONE (1 MG/ML) (SOLUTION).........................RISPERIDONE (2 MG) (TAB RAPDIS)..............................RISPERIDONE (2 MG) (TABLET)......................................RISPERIDONE (3 MG) (TAB RAPDIS)..............................RISPERIDONE (3 MG) (TABLET)......................................RISPERIDONE (4 MG) (TAB RAPDIS)..............................RISPERIDONE (4 MG) (TABLET)......................................RITEFLO...........................................................................20RITONAVIR...................................................................... 96RIVAROXABAN...............................................................83RIVASTIGMINE............................................................... 24RIVASTIGMINE TARTRATE.......................................... 24RIXUBIS........................................................................... 83RIZATRIPTAN BENZOATE.......................................... 141ROBAXIN....................................................................... 147ROBAXIN-750................................................................ 147ROBINSON CLEAR VINYL CATHETER.................... 105ROCALTROL.................................................................. 153ROFLUMILAST............................................................... 19ROLAPITANT HCL..........................................................17ROPINIROLE HCL.........................................................143ROPIVACAINE IN 0.9% SOD CHL/PF.........................101ROSADAN........................................................................ 43ROSANIL.......................................................................... 46ROSIGLITAZONE MALEATE........................................ 56ROSULA (10 %-4.5 %) (CLEANSER)............................ 46ROSULA (10 %-5 %) (MED. PAD)..................................46ROSUVASTATIN CALCIUM...........................................37ROTARIX.......................................................................... 88ROTATEQ..........................................................................88ROTAVIRUS VAC,LIVE ATT, 89-12................................88ROTAVIRUS VACCINE,LIVE ORAL PV........................88ROTIGOTINE..................................................................143ROWASA.........................................................................101ROWEEPRA....................................................................145ROWEEPRA XR............................................................. 145ROXYBOND................................................................... 140ROZEREM................................................................ 29, 166RUBBER MOUTHPIECE...............................................106RUBRACA...................................................................... 126RUCAPARIB CAMSYLATE..........................................126RUCONEST...................................................................... 98RUFINAMIDE................................................................ 145RUXOLITINIB PHOSPHATE........................................ 125RYDAPT..........................................................................126RYNODERM.....................................................................51RYTARY..................................................................142, 166RYTHMOL........................................................................32RYTHMOL SR..................................................................32RYVENT................................................................... 16, 166RYZOLT.......................................................................... 140

- S -SABAL-HOMACCORD................................................. 130SABRIL........................................................................... 146SACCHARIN.................................................................. 136SACROSIDASE.............................................................. 147SACUBITRIL/VALSARTAN............................................39SAFE-CLIP (EACH) (OTC)..............................................73SAFESNAP ALLERGY SYRINGE (27GX1/2") (DISPSYRIN) (OTC)................................................................ 119SAFESNAP INSULIN SYRINGE.................................. 111SAFESNAP SYRINGE........................................... 119, 121SAFESNAP SYRINGE (20GX1 1/2") (DISP SYRIN)(OTC).......................................................................112, 119SAFESNAP SYRINGE (20GX1") (DISP SYRIN) (OTC)................................................................................. 112, 119SAFESNAP SYRINGE (21 G X 1") (DISP SYRIN) (OTC)......................................................................... 112, 119, 120SAFESNAP SYRINGE (21GX1 1/2") (DISP SYRIN)(OTC)...............................................................112, 119, 120SAFESNAP SYRINGE (22GX1 1/2") (DISP SYRIN)(OTC)...............................................................112, 119, 120SAFESNAP SYRINGE (22GX1") (DISP SYRIN) (OTC)......................................................................... 112, 119, 120SAFESNAP SYRINGE (23GX1 1/2") (DISP SYRIN)(OTC)...............................................................................112SAFESNAP SYRINGE (23GX1") (DISP SYRIN) (OTC)......................................................................................... 112SAFESNAP SYRINGE (25GX1") (DISP SYRIN) (OTC)......................................................................................... 112SAFESNAP SYRINGE (25GX5/8") (DISP SYRIN) (OTC)......................................................................................... 112SAFESNAP TUBERCULIN SYRINGE (25GX5/8") (DISPSYRIN) (OTC)................................................................ 119SAFESNAP TUBERCULIN SYRINGE (27GX1/2") (DISPSYRIN) (OTC)................................................................ 119SAFETY LANCETS....................................................... 109SAFETY SEAL LANCETS............................................ 109

SAFETY SYRINGE WITH SHIELD............................. 121SAFETY SYRINGE-NEEDLE....................................... 121SAFETYGLIDE ALLERGY...........................................114SAFETYGLIDE ALLERGY SYRINGE........................ 114SAFETYGLIDE INSULIN SYRINGE...... 113, 118, 119,122, 123SAFETYGLIDE SYRINGE............................113, 114, 121SAFETYGLIDE SYRINGE (22GX1 1/2") (DISP SYRIN)(OTC)...............................................................................116SAFETYGLIDE SYRINGE (25GX5/8") (DISP SYRIN)(OTC)...............................................................................116SAFETYGLIDE TB SYRINGE......................................114SAFETY-LET.................................................................. 109SAFETY-LOK SAFETY SYRINGE.......................117, 118SAFETY-LOK SAFETY SYRINGES.................... 120, 121SAFETY-LOK SYRINGES.............................................121SAFINAMIDE MESYLATE...........................................143SAF-T-INTIMA IV CATHETER.................................... 111SAFYRAL......................................................................... 40SAIZEN............................................................................. 77SAIZEN-SAIZENPREP.................................................... 78SALAGEN.......................................................................123SALEX (6 %) (COMBO. PKG)........................................ 51SALEX (6 %) (KIT CLCMER).........................................51SALICYLIC AC/BENZOYL PER/VIT E.........................51SALICYLIC ACID............................................................51SALICYLIC ACID (26 %) (LIQUID)..................................SALICYLIC ACID (27.5 %) (LIQ-FILM)............................SALICYLIC ACID (28.5 %) (SOL-FILMER)......................SALICYLIC ACID (6 %) (CREAM (G)).............................SALICYLIC ACID (6 %) (CRM ER (G)).............................SALICYLIC ACID (6 %) (FOAM).......................................SALICYLIC ACID (6 %) (GEL (GRAM))...........................SALICYLIC ACID (6 %) (LOTION ER).............................SALICYLIC ACID (6 %) (LOTION)...................................SALICYLIC ACID (6 %) (SHAMPOO)...............................SALICYLIC ACID/AMMON LACT/ALOE....................51SALICYLIC ACID/CERAMIDE COMB 1...................... 51SALICYLIC ACID/UREA................................................51SALIMEZ FORTE.............................................................51SALIVA SUBSTITUTE COMB NO.10..........................134SALIVA SUBSTITUTE COMB NO.11..........................134SALIVA SUBSTITUTE COMBO NO.2.........................134SALIVA SUBSTITUTE COMBO NO.3.........................134SALIVA SUBSTITUTE COMBO NO.5.........................134SALIVAMAX..................................................................134SALKERA.........................................................................51SALMETEROL XINAFOATE..........................................18SALSALATE...................................................................137SALVAX DUO PLUS........................................................51SAMI THE SEAL..............................................................23SAMI THE SEAL MASK............................................... 106SAMSCA (15 MG) (TABLET)......................................... 75SAMSCA (30 MG) (TABLET)......................................... 75SANCTURA............................................................150, 166SANCTURA XR..................................................... 150, 166SANCUSO.................................................................17, 166SANDIMMUNE................................................................89SANTYL............................................................................54SAPHRIS...................................................................28, 166SAPROPTERIN DIHYDROCHLORIDE....................... 123SAQUINAVIR MESYLATE............................................. 96SARAFEM........................................................................ 25SARGRAMOSTIM........................................................... 85SARILUMAB....................................................................99SAVAYSA..................................................................83, 166SAVELLA........................................................................127SAXAGLIPTIN HCL........................................................ 55SAXAGLIPTIN HCL/METFORMIN HCL......................55SCALACORT DK............................................................. 48SCARCARE...................................................................... 52SCARCINPAD................................................................ 104SCLEROSOL...................................................................127SCOPOLAMINE...............................................................17SEASONIQUE.................................................................. 41SEBUDERM......................................................................50SECNIDAZOLE................................................................93SECOBARBITAL SODIUM.............................................29SECONAL SODIUM........................................................ 29SECTRAL..........................................................................33SECUKINUMAB.............................................................. 54SEEBRI NEOHALER............................................... 18, 166SEGLUROMET.........................................................56, 167SELECT-OB + DHA....................................................... 152SELEGILINE.................................................................... 29SELEGILINE HCL......................................................... 143SELENIUM SULFIDE......................................................49SELENIUM SULFIDE (2.25 %) (SHAMPOO)...................SELENIUM SULFIDE (2.3 %) (SHAMPOO).....................SELENIUM SULFIDE (2.5 %) (LOTION)..........................SELEXIPAG...................................................................... 36SELZENTRY.....................................................................94


Index

SEMAGLUTIDE............................................................... 55SEMPREX-D.....................................................................16SEN-SERTER....................................................................71SENSIPAR (30 MG) (TABLET)....................................... 77SENSIPAR (60 MG) (TABLET)....................................... 77SENSIPAR (90 MG) (TABLET)....................................... 77SEREVENT DISKUS....................................................... 18SERNIVO.................................................................. 47, 167SEROMYCIN....................................................................93SEROPHENE.................................................................... 76SEROQUEL.......................................................................28SEROQUEL XR (150 MG) (TAB ER 24H)......................28SEROQUEL XR (200 MG) (TAB ER 24H)......................28SEROQUEL XR (300 MG) (TAB ER 24H)......................28SEROQUEL XR (400 MG) (TAB ER 24H)......................28SEROQUEL XR (50 MG) (TAB ER 24H)........................28SEROQUEL XR (50-200-300) (TAB24HDSPK)............. 29SEROSTIM........................................................................78SERTACONAZOLE NITRATE........................................ 45SERTRALINE HCL.......................................................... 25SERZONE......................................................................... 25SEVELAMER CARBONATE.......................................... 76SEVELAMER HCL.......................................................... 76SEVOFLURANE.............................................................130SFROWASA.................................................................... 101SHOHL'S MODIFIED.................................................... 149SIDEKICK.........................................................................62SIDESTREAM.................................................................. 22SIDESTREAM MASK....................................................106SIDESTREAM NEBULIZER........................................... 22SIDESTREAM PLUS....................................................... 22SIGNIFOR.......................................................................135SIKLOS............................................................................. 86SILAZONE-II....................................................................48SILDENAFIL CITRATE.............................................35, 36SILENOR.................................................................. 30, 167SILHOUETTE.........................................................110, 111SILICONE MASK.....................................................21, 106SILIPAC.............................................................................52SILIQ................................................................................. 54SILIVEX..........................................................................104SIL-K............................................................................... 104SILODOSIN.................................................................... 149SILV/BANDG/LIDOCA/CHLORHEX/ALC................. 104SILVADENE......................................................................46SILVER......................................................................44, 104SILVER CARBONATE.....................................................44SILVER NITRATE...................................................... 44, 51SILVER NITRATE APPLICATOR...................................51SILVER SULFADIAZ/FOAM BANDAGE.................... 104SILVER SULFADIAZINE................................................ 46SILVER SULFATE/FOAM BANDAGE......................... 104SILVER SULFATE/NON-ADH BANDAGE.................. 104SILVER/CALCIUM ALGINATE....................................104SILVER/FOAM BANDAGE........................................... 104SILVRSTAT....................................................................... 44SIMBRINZA..................................................................... 81SIMPONI...........................................................................98SIMVASTATIN............................................................37, 38SINECATECHINS............................................................ 45SINEMET 10-100............................................................142SINEMET 25-100............................................................142SINEMET 25-250............................................................142SINEMET CR..................................................................142SINEQUAN....................................................................... 26SINGLE-LET.................................................................. 109SINGULAIR......................................................................19SINUSTAR.................................................................. 22, 23SINUVA.............................................................................17SIROLIMUS......................................................................89SIRTURO...........................................................................93SITAGLIPTIN PHOS/METFORMIN HCL...................... 55SITAGLIPTIN PHOSPHATE............................................56SITAVIG............................................................................ 94SIVEXTRO................................................................90, 167SKELAXIN (400 MG) (TABLET)..................................147SKELAXIN (800 MG) (TABLET)..................................147SKLICE............................................................................. 45SKYLA............................................................................ 130SLO-PHYLLIN................................................................. 23SMART CARESENS N.................................................... 69SMART SENSE...............................................................109SMART SENSE LANCETS............................................109SMART SENSE MONITORING SYSTEM..................... 69SMART SENSE TEST STRIPS........................................60SMARTDIABETES VANTAGE....................................... 73SMARTEST.......................................................................65SMARTEST EJECT.......................................................... 69SMARTEST LANCET....................................................109SMARTEST PERSONA....................................................69SMARTEST PRONTO......................................................69SMARTEST PROTEGE.................................................... 69

SMARTEST SMART CODE............................................ 69SMARTEST TALKING.................................................... 69SMARTEST TEST............................................................ 60SMARTMASK KIDS......................................................106SMARTRX GABAKIT................................................... 144SMARTRX GABA-V KIT.............................................. 144SOD PHOS,M-B/K PHOS,MONOB.............................. 149SOD PHOSPHATE MBAS/SOD PHOS,DI....................103SOD PICOSULF/MAG OX/CITRIC AC........................103SOD,POT CHLOR/MAG/SOD,POT PHOS..................... 50SODIUM CHLOR/HYPOCHLOROUS ACID................. 51SODIUM CHLORIDE 0.45 %.......................................... 76SODIUM CHLORIDE FOR INHALATION.................. 130SODIUM CHLORIDE IRRIG SOLUTION..................... 51SODIUM CHLORIDE IRRIG SOLUTION (0.9 %)(IRRIG SOLN)......................................................................SODIUM CHLORIDE/NAHCO3/KCL/PEG................. 103SODIUM CITRATE.......................................................... 83SODIUM CITRATE (4 % (3 ML)) (SYRINGE)..................SODIUM CITRATE (4 % (4 ML)) (SYRINGE)..................SODIUM CITRATE (4 G/100 ML) (SOLUTION)...............SODIUM CITRATE IN 0.9 % NACL...............................83SODIUM FLUORIDE/POTASSIUM NIT......................150SODIUM IODIDE-131................................................... 127SODIUM OXYBATE........................................................ 27SODIUM PHENYLBUTYRATE....................................102SODIUM POLYSTYRENE SULFON/SORB.................. 76SODIUM POLYSTYRENE SULFONATE.......................76SODIUM SUCCINATE...................................................135SODIUM SULAMYD.......................................................80SODIUM SULFACETAMIDE-SULFUR......................... 46SODIUM THIOSULFATE/SAL ACID.............................45SODIUM ZIRCONIUM CYCLOSILICATE.................... 76SODIUM, POTASSIUM,MAG SULFATES................... 103SOFOSBUVIR.................................................................. 96SOFOSBUVIR/VELPATAS/VOXILAPREV....................96SOFOSBUVIR/VELPATASVIR....................................... 96SOF-SENSOR................................................................... 70SOF-SERTER.................................................................... 71SOF-SET..........................................................................110SOF-SET MICRO............................................................110SOFT TOUCH.................................................................109SOLARAZE...................................................................... 52SOLESTA........................................................................ 102SOLIFENACIN SUCCINATE.........................................149SOLIQUA 100-33......................................................56, 167SOLODYN................................................................ 92, 167SOLOSEC..................................................................93, 167SOLTAMOX.................................................................... 127SOLU-CORTEF................................................................ 98SOLUPAK......................................................................... 53SOLUS V2.................................................................69, 109SOLUS V2 CONTROL SOLUTION................................ 63SOLUS V2 LANCETS....................................................109SOLUS V2 LANCING DEVICE...................................... 73SOLUS V2 TEST STRIPS................................................ 60SOMA..............................................................................146SOMA COMPOUND......................................................146SOMATROPIN............................................................77, 78SOMAVERT...................................................................... 77SONATA............................................................................ 30SONIDEGIB PHOSPHATE............................................ 125SOOLANTRA........................................................... 43, 167SOOTHENEB COMPRESSOR NEBULIZER................. 23SOOTHENEB MESH NEBULIZER................................ 22SORAFENIB TOSYLATE..............................................126SORBITOL......................................................................136SORBITOL SOLUTION...........................................51, 136SORBITOL/SALIVA 1/MALIC/C.PHOS.......................134SORIATANE..................................................................... 54SORILUX.................................................................. 54, 167SOTALOL HCL.................................................................34SOTYLIZE (5 MG/ML) (SOLUTION).................... 34, 167SOVALDI.......................................................................... 96SP ANTIPRURITIC.......................................................... 49SP SCAR MANAGEMENT..............................................50SPACE CHAMBER PLUS................................................20SPECIALTY USE NEEDLES (30GX1/2") (DIS NEEDLE)(OTC)...............................................................................131SPECTAZOLE...................................................................45SPECTRACEF...................................................................89SPECTRAGEL................................................................ 104SPEEDICATH................................................................. 105SPINOSAD........................................................................45SPINRAZA......................................................................123SPIRIVA............................................................................ 18SPIRIVA RESPIMAT........................................................18SPIROMETER/DRUG DELIVERY ADAPT................... 23SPIROMETERS AND ACCESSORIES........................... 23SPIRONOLACT/HYDROCHLOROTHIAZID.................35SPIRONOLACTONE........................................................35SPORANOX (10 MG/ML) (SOLUTION)........................ 92

SPORANOX (100 MG) (CAPSULE)............................... 92SPRAY AND STRETCH.................................................. 54SPRITAM (1000 MG) (TAB SUSP)....................... 145, 167SPRITAM (250 MG) (TAB SUSP)......................... 145, 167SPRITAM (500 MG) (TAB SUSP)......................... 145, 167SPRITAM (750 MG) (TAB SUSP)......................... 145, 167SPRIX........................................................................ 99, 167SPRYCEL (100 MG) (TABLET).................................... 125SPRYCEL (140 MG) (TABLET).................................... 125SPRYCEL (20 MG) (TABLET)...................................... 125SPRYCEL (50 MG) (TABLET)...................................... 125SPRYCEL (70 MG) (TABLET)...................................... 125SPRYCEL (80 MG) (TABLET)...................................... 125SPS.....................................................................................76STADOL..........................................................................137STALEVO 100.................................................................142STALEVO 125.................................................................142STALEVO 150.................................................................142STALEVO 200.................................................................142STALEVO 50...................................................................142STALEVO 75...................................................................142STARLIX...........................................................................56STAVUDINE..................................................................... 95STEGLATRO.............................................................55, 167STEGLUJAN.............................................................56, 167STELARA......................................................................... 99STELAZINE......................................................................29STERILANCE TL........................................................... 109STERITALC (2 G) (VIAL)............................................. 127STERITALC (3 G) (VIAL)............................................. 127STERITALC (4 G) (VIAL)............................................. 127STERITALC (5 G) (VIAL)............................................. 127STIMATE.......................................................................... 76STIOLTO RESPIMAT.......................................................18STIVARGA......................................................................126STRATTERA (10 MG) (CAPSULE)................................ 31STRATTERA (100 MG) (CAPSULE).............................. 31STRATTERA (18 MG) (CAPSULE)................................ 31STRATTERA (25 MG) (CAPSULE)................................ 31STRATTERA (40 MG) (CAPSULE)................................ 31STRATTERA (60 MG) (CAPSULE)................................ 31STRATTERA (80 MG) (CAPSULE)................................ 31STRAVIX.........................................................................135STRENSIQ...................................................................... 130STRIANT.......................................................................... 87STRIBILD......................................................................... 96STRIVERDI RESPIMAT.................................................. 18STROMECTOL.................................................................93SUBCUTANEOUS ADMIN. SET.................................. 111SUBCUTANEOUS INSULIN PUMP.........................73, 74SUBOXONE (12 MG-3 MG) (FILM).............................142SUBOXONE (2 MG-0.5MG) (FILM).............................142SUBOXONE (2 MG-0.5MG) (TAB SUBL)................... 142SUBOXONE (4MG-1MG) (FILM).................................142SUBOXONE (8 MG-2 MG) (FILM)...............................142SUBOXONE (8 MG-2 MG) (TAB SUBL)..................... 142SUB-Q INFUSION PUMP ACCESSORY......................111SUB-Q INSULIN DEVICE, 20 UNIT.............................. 74SUB-Q INSULIN DEVICE, 30 UNIT.............................. 74SUB-Q INSULIN DEVICE, 40 UNIT.............................. 74SUBQ INSULIN PUMP,GLUC.MON.SYS......................74SUBSYS.......................................................................... 137SUBUTEX.......................................................................142SUCCIMER.....................................................................130SUCRAID........................................................................147SUCRALFATE................................................................ 148SUCRALFATE MALATE, POLYMERIZED................. 128SUCROFERRIC OXYHYDROXIDE............................... 76SULAR.............................................................................. 35SULCONAZOLE NITRATE.............................................45SULFACETAMIDE SOD/SULFUR/UREA..................... 46SULFACETAMIDE SODIUM.............................. 43, 49, 80SULFACETAMIDE SODIUM (10 %) (CLEANSER)..........SULFACETAMIDE SODIUM (10 %) (CLNSR GEL).........SULFACETAMIDE SODIUM (10 %) (SHAMPOO)...........SULFACETAMIDE SODIUM/SULFUR..........................46SULFACETAMIDE/PREDNISOLONE........................... 80SULFACETAMIDE/PREDNISOLONE SP...................... 80SULFACETAMIDE/SULFUR/CLEANSR23................... 46SULFACET-R....................................................................46SULFACT SOD/SULUR/AVOB/OTN/OCT.....................46SULFADIAZINE.............................................................101SULFAMETHOXAZOLE/TRIMETHOPRIM................. 89SULFAMYLON (50 G) (PACKET).................................. 46SULFAMYLON (8.5 %) (CREAM (G))...........................46SULFANILAMIDE......................................................... 150SULFASALAZINE......................................................... 102SULFURIC ACID/SULFONAT. PHENOL.................... 128SULINDAC..................................................................... 101SUMADAN....................................................................... 46SUMADAN XLT...............................................................46SUMATRIPTAN..............................................................141


Index

SUMATRIPTAN SU/MENTHOL/CAMPHOR.............. 141SUMATRIPTAN SUCC/NAPROXEN SOD...................141SUMATRIPTAN SUCCINATE.......................................141SUMAVEL DOSEPRO (4 MG/0.5ML) (NDL FR INJ)......141, 167SUMAVEL DOSEPRO (6 MG/0.5ML) (NDL FR INJ)......141, 167SUMAXIN.........................................................................46SUMAXIN CP...................................................................46SUMAXIN TS................................................................... 46SUMYCIN.........................................................................92SUNITINIB MALATE.................................................... 126SUNRISE COMPRESSOR-NEBULIZER........................20SUPER THIN LANCETS............................................... 109SUPPRELIN LA................................................................78SUPRANE....................................................................... 130SUPRAX (100 MG) (TAB CHEW).................................. 89SUPRAX (100 MG/5ML) (SUSP RECON)......................89SUPRAX (200 MG) (TAB CHEW).................................. 89SUPRAX (200 MG/5ML) (SUSP RECON)......................90SUPRAX (400 MG) (CAPSULE)..................................... 90SUPRAX (500 MG/5ML) (SUSP RECON)......................90SUPREP...........................................................................103SURE COMFORT................................... 113, 122, 123, 133SURE COMFORT INSULIN SYRINGE........113, 122, 123SURE COMFORT LANCETS........................................ 109SURE COMFORT LANCING PEN................................. 73SURE RESULT DSS PREMIUM PACK.......................... 49SURE RESULT TAC PAK........................................ 48, 167SURE-FINE PEN NEEDLES..........................................133SUREFLEX....................................................................... 73SURE-JECT INSULIN SYRINGE................. 113, 122, 123SURE-LANCE................................................................ 109SURE-PEN........................................................................ 73SURE-T........................................................................... 111SURE-T PARADIGM....................................................... 71SURE-TEST EASYPLUS MINI...........................60, 65, 69SURE-TOUCH................................................................ 109SURFAXIN......................................................................137SURMONTIL.................................................................... 26SURVANTA.....................................................................137SUSTIVA........................................................................... 95SUTENT.......................................................................... 126SUVOREXANT................................................................ 30SYLATRON.....................................................................125SYMAX...........................................................................147SYMAX DUOTAB..........................................................147SYMAX-SL.....................................................................147SYMAX-SR.....................................................................148SYMBICORT.................................................................... 18SYMBYAX........................................................................30SYMDEKO......................................................................137SYMFI............................................................................... 96SYMFI LO.........................................................................96SYMLINPEN 120............................................................. 55SYMLINPEN 60............................................................... 55SYMMETREL.................................................................142SYMPROIC............................................................. 103, 167SYMTUZA........................................................................ 94SYNALAR.........................................................................47SYNALAR TS...................................................................47SYNAREL......................................................................... 78SYNDROS.................................................................17, 167SYNERA........................................................................... 53SYNERDERM...................................................................50SYNJARDY...............................................................56, 167SYNJARDY XR........................................................ 56, 167SYNRIBO........................................................................126SYNTHROID.................................................................... 78SYPRINE.........................................................................130SYR,NDL 0.3 ML,INS,SAFE,D.UNIT...........................111SYR,NDL 1 ML,INS,SAFE,DISP UNT......................... 111SYR,NDL,INS,SAFE 0.5ML,DISP UN..........................111SYRGE-NDL,INS 0.3 ML HALF MARK..............111, 112SYRGE-NDL,INS 0.5 ML HALF MARK......................112SYRING W-NEEDL 0.5 ML,KIT-TRAY....................... 112SYRINGE........................................................ 113, 117, 118SYRINGE (DISP SYRIN)...............................................118SYRINGE 3 ML,SAFETY,DISP UNIT.......................... 112SYRINGE ACCESSORY................................................112SYRINGE AND NEEDLE,INSULIN,1ML............112, 113SYRINGE AVITENE........................................................ 86SYRINGE BULK.................................................... 117, 118SYRINGE CATHETER TIP............................................118SYRINGE DISPOSABLE IRRIG,70 ML.......................113SYRINGE DISPOSABLE IRRIGATION.......................113SYRINGE WITH CANNULA, 10 ML........................... 113SYRINGE WITH CANNULA, 3 ML............................. 113SYRINGE WITH CANNULA, 5 ML............................. 113SYRINGE WITH CANNULA, 6 ML............................. 114SYRINGE WITH CANNULA,DISP.12ML....................114SYRINGE WITH NEEDLE DISP.................................. 114

SYRINGE WITH NEEDLE, 0.5 ML.............................. 114SYRINGE WITH NEEDLE, 1 ML................................. 114SYRINGE WITH NEEDLE, 10 ML............................... 114SYRINGE WITH NEEDLE, 12 ML............................... 114SYRINGE WITH NEEDLE, 5 ML................................. 115SYRINGE WITH NEEDLE, 6 ML................................. 115SYRINGE WITH NEEDLE, INSULIN.......................... 115SYRINGE WITH NEEDLE,DISPOSABLE...................115SYRINGE WITHOUT NEEDLE............................ 116-118SYRINGE W-NEEDLE 1 ML,KIT-TRAY..................... 115SYRINGE W-NEEDLE,DISPOSAB,3 ML............ 115, 116SYRINGE, DISPOSABLE..............................................116SYRINGE, DISPOSABLE, 1 ML...................................116SYRINGE, DISPOSABLE, 10 ML.........................116, 117SYRINGE, DISPOSABLE, 12 ML.................................117SYRINGE, DISPOSABLE, 140 ML...............................117SYRINGE, DISPOSABLE, 20 ML.................................117SYRINGE, DISPOSABLE, 3 ML...................................117SYRINGE, DISPOSABLE, 30 ML.................................117SYRINGE, DISPOSABLE, 35 ML.................................117SYRINGE, DISPOSABLE, 5 ML...........................117, 118SYRINGE, DISPOSABLE, 50 ML.................................118SYRINGE, DISPOSABLE, 6 ML...................................118SYRINGE, DISPOSABLE, 60 ML.................................118SYRINGE, NEEDLE, CANNULA,10 ML.....................118SYRINGE, SAFETY 3 ML.............................................118SYRINGE,INSUL U-500,NDL,0.5ML...........................118SYRINGE,INSULIN,NEEDLESS 1 ML........................ 118SYRINGE,NDLE,SAFE 1.5 ML,D.UNT....................... 118SYRINGE,NEEDLE,INSULN,SAFE,1ML.................... 118SYRINGE,NEEDLE,INSULN,SF 0.5ML.............. 118, 119SYRINGE,NEEDLE,INSULN,SF,0.3ML.......................119SYRINGE,SAFE 3 ML,DISPOSL UNIT....................... 119SYRINGE,SAFE 5 ML,DISPOSL UNIT....................... 119SYRINGE,SAFETY 1 ML,DISP UNIT..........................119SYRINGE,SAFETY 10 ML,DISP UNIT........................119SYRINGE,SAFETY 5 ML, DISP UNIT.................119, 120SYRINGE,SAFETY NEEDLE,10 ML........................... 120SYRINGE,SAFETY NEEDLE,12 ML........................... 120SYRINGE,SAFETY WITH NEEDLE,1ML...........120, 121SYRINGE,SAFETY WITH NEEDLE,3ML...................121SYRINGE,SAFETY WITH NEEDLE,5ML...................121SYRINGE,SAFETY,10 ML,DISP UNIT........................ 121SYRINGE-NEEDLE....................................................... 121SYRINGE-NEEDLE,INSULIN,0.5 ML......................... 122SYRINGE-PRECISIONGLIDE NEEDLE..................... 114SYRING-NEEDL,DISP,INSUL,0.3 ML................. 122, 123SYZYGIUM COMPOSITUM.........................................130

- T -T.E.D. ANTI-EMBOLISM STOCKING.................135, 136T.E.D. SEQUNT COMPRESS DEVICE.........................105T:30 INFUSION SET........................................................ 71T:90....................................................................................71T:FLEX........................................................................72, 73T:SLIM........................................................................ 72, 74T:SLIM G4...................................................................72, 74T:SLIM X2.........................................................................74T:SLIM X2 WITH BASAL-IQ..........................................74TABLOID........................................................................ 124TACHOSIL........................................................................ 86TACLONEX (0.005-.064) (OINT. (G)).....................55, 167TACLONEX (0.005-.064) (SUSPENSION)............. 55, 168TACROLIMUS............................................................ 55, 89TADALAFIL............................................................... 36, 76TAFINLAR......................................................................124TAFLUPROST/PF.............................................................81TAGAMET...................................................................... 148TAGRISSO...................................................................... 126TAKE ACTION................................................................. 40TAKHZYRO....................................................................101TALC............................................................................... 127TALTZ AUTOINJECTOR.................................................54TALTZ AUTOINJECTOR (2 PACK)................................54TALTZ AUTOINJECTOR (3 PACK)................................54TALTZ SYRINGE............................................................. 54TALWIN.......................................................................... 140TALWIN NX................................................................... 140TAMBOCOR..................................................................... 32TAMIFLU (30 MG) (CAPSULE)..................................... 94TAMIFLU (45 MG) (CAPSULE)..................................... 94TAMIFLU (6 MG/ML) (SUSP RECON)..........................94TAMIFLU (75 MG) (CAPSULE)..................................... 94TAMOXIFEN CITRATE.................................................127TAMSULOSIN HCL.......................................................149TANZEUM................................................................ 55, 168TAPAZOLE....................................................................... 78TAPENTADOL HCL.......................................................140TARCEVA (100 MG) (TABLET)....................................126TARCEVA (150 MG) (TABLET)....................................126TARCEVA (25 MG) (TABLET)......................................126TARGADOX............................................................. 91, 168

TARGRETIN............................................................. 52, 127TASIGNA........................................................................ 126TASIMELTEON................................................................ 29TASMAR................................................................. 143, 168TAVABOROLE..................................................................45TAVALISSE....................................................................... 86TAVIST.............................................................................. 16TAYTULLA.......................................................................41TAZAROTENE......................................................44, 54, 55TAZORAC (0.05 %) (CREAM (G))..................................54TAZORAC (0.05 %) (GEL (GRAM))...............................54TAZORAC (0.1 %) (CREAM (G))....................................55TAZORAC (0.1 %) (GEL (GRAM)).................................55TB SYRINGE..................................................................114TBO-FILGRASTIM.......................................................... 85TD GOLD BLOOD GLUCOSE MONITOR.................... 69TD GOLD LEVEL 1 CONTROL SOL.............................63TD GOLD LEVEL 2 CONTROL SOL.............................65TD GOLD LEVEL 3 CONTROL SOL.............................63TD GOLD TEST STRIP................................................... 60TD GOLD VOICE GLUCOSE MONITOR......................69TECFIDERA................................................................... 127TECHLITE INSULIN SYRINGE...........................112, 113TECHLITE LANCETS................................................... 109TECHLITE PEN NEEDLE............................................. 133TECHNIVIE...................................................................... 97TEDIZOLID PHOSPHATE...............................................90TEDUGLUTIDE............................................................. 103TEGRETOL.....................................................................143TEGRETOL XR.............................................................. 143TEKTURNA......................................................................36TEKTURNA HCT.............................................................36TELCARE........................................................... 60, 69, 109TELCARE BGM............................................................... 69TELCARE CONTROL SOLUTION.................................61TELMISARTAN................................................................33TELMISARTAN/AMLODIPINE......................................33TELMISARTAN/HYDROCHLOROTHIAZID................ 32TELOTRISTAT ETIPRATE............................................ 102TEMAZEPAM...................................................................30TEMODAR......................................................................124TEMOVATE...................................................................... 47TEMOVATE E................................................................... 47TEMOVATE EMOLLIENT...............................................47TEMOZOLOMIDE......................................................... 124TENEX.............................................................................. 33TENOFOVIR ALAFENAMIDE FUMARATE.................96TENOFOVIR DISOPROXIL FUMARATE......................95TENORETIC 100.............................................................. 34TENORETIC 50................................................................ 34TENORMIN...................................................................... 34TENS 502........................................................................ 106TENS 504........................................................................ 106TENS UNIT.....................................................................106TENS UNIT ELECTRODES.......................................... 106TENS UNITS AND TENS ELECTRODES................... 106TERAZOL 3.................................................................... 150TERAZOL 7.................................................................... 150TERAZOSIN HCL............................................................ 32TERBINAFINE HCL........................................................ 92TERBUTALINE SULFATE.............................................. 18TERCONAZOLE............................................................ 150TERIFLUNOMIDE.........................................................127TERIPARATIDE............................................................... 77TERSI FOAM....................................................................49TERUMO ALLERGY SYRINGE...................................114TERUMO HYPODERMIC NEEDLE-SYRIN............... 115TERUMO INSULIN SYRINGE..................... 113, 122, 123TERUMO SURGUARD2........................................120, 121TERUMO SURGUARD2 (18GX1 1/2") (DIS NEEDLE)......................................................................................... 131TERUMO SURGUARD2 (18GX1") (DIS NEEDLE)......131TERUMO SURGUARD2 (19GX1 1/2") (DIS NEEDLE)......................................................................................... 131TERUMO SURGUARD2 (19GX1") (DIS NEEDLE)......131TERUMO SURGUARD2 (20GX1 1/2") (DIS NEEDLE)......................................................................................... 131TERUMO SURGUARD2 (20GX1") (DIS NEEDLE)......131TERUMO SURGUARD2 (21 G X 1") (DIS NEEDLE)......132TERUMO SURGUARD2 (21GX1 1/2") (DIS NEEDLE)......................................................................................... 132TERUMO SURGUARD2 (22GX1 1/2") (DIS NEEDLE)......................................................................................... 132TERUMO SURGUARD2 (22GX1") (DIS NEEDLE)......132TERUMO SURGUARD2 (23GX1 1/2") (DIS NEEDLE)......................................................................................... 132


Index

TERUMO SURGUARD2 (23GX1") (DIS NEEDLE)......132TERUMO SURGUARD2 (25GX1 1/2") (DIS NEEDLE)......................................................................................... 132TERUMO SURGUARD2 (25GX1") (DIS NEEDLE)......132TERUMO SURGUARD2 (25GX5/8") (DIS NEEDLE)......132TERUMO SURGUARD2 (26GX1/2") (DIS NEEDLE)......132TERUMO SURGUARD2 (27GX1/2") (DIS NEEDLE)......132TERUMO SURGUARD2 (30GX1 1/2") (DIS NEEDLE)......................................................................................... 132TERUMO SYRINGE.............................................. 116, 117TESAMORELIN ACETATE.............................................77TESSALON.......................................................................41TESSALON PERLE..........................................................41TEST N'GO................................................................. 60, 69TEST STRIPS....................................................................60TESTIM.............................................................................87TESTOPEL........................................................................87TESTOSTERONE....................................................... 86, 87TESTOSTERONE CYPIONATE...................................... 87TESTOSTERONE ENANTHATE.................................... 87TESTRED..........................................................................86TETCAINE........................................................................80TETRABENAZINE.........................................................127TETRACAINE HCL................................................... 54, 80TETRACAINE HCL/OXYMETAZ HCL....................... 101TETRACAINE HCL/PF....................................................80TETRACAINE HYDROCHLORIDE............................... 80TETRACAINE/BENZOCAINE/BUTAMBEN.................54TETRACYCLINE HCL.................................................... 92TETRAHYDROZOLINE HCL.........................................43TETRAVISC......................................................................80TETRAVISC FORTE........................................................ 80TETRIX............................................................................. 52TEVETEN......................................................................... 33TEXACORT...................................................................... 48TEZACAFTOR/IVACAFTOR........................................ 137THALIDOMIDE............................................................... 93THALOMID...................................................................... 93THEO-24........................................................................... 23THEO-DUR.......................................................................24THEOPHYLLINE ANHYDROUS............................. 23, 24THERMAZENE................................................................ 46THIAMINE HCL.............................................................153THIAMINE HCL (100 MG/ML) (VIAL).............................THIN LANCETS.............................................................109THINPRO INSULIN SYRINGE.....................113, 122, 123THIOGUANINE..............................................................124THIOLA.......................................................................... 149THIORIDAZINE HCL...................................................... 29THIOTHIXENE.................................................................29THORAZINE.................................................................... 29THRESHOLD IMT........................................................... 23THRESHOLD PEP............................................................23THRIVITE RX................................................................ 152THROMB-CAL-CELL-DRESSING,HEMOS..................86THROMBIN (BOVINE)....................................................86THROMBIN (RECOMBINANT)..................................... 86THROMBIN,BOVINE/GELATIN SPONGE....................86THROMBIN,HU/FIBRINOGEN/CALCIUM.................. 86THROMBIN/CAL/CMC/GEL/DRESS,HEM...................86THROMBIN/FIBRINOG/APROTIN/CALC.................. 136THYROID,PORK........................................................78, 79THYROID,PORK (113.75 MG) (TABLET).........................THYROID,PORK (120 MG) (TABLET)..............................THYROID,PORK (130 MG) (TABLET)..............................THYROID,PORK (146.25 MG) (TABLET).........................THYROID,PORK (15 MG) (TABLET)................................THYROID,PORK (16.25 MG) (TABLET)...........................THYROID,PORK (162.5 MG) (TABLET)...........................THYROID,PORK (195 MG) (TABLET)..............................THYROID,PORK (260 MG) (TABLET)..............................THYROID,PORK (30 MG) (TABLET)................................THYROID,PORK (32.5 MG) (TABLET).............................THYROID,PORK (325 MG) (TABLET)..............................THYROID,PORK (48.75 MG) (TABLET)...........................THYROID,PORK (60 MG) (TABLET)................................THYROID,PORK (65 MG) (TABLET)................................THYROID,PORK (81.25 MG) (TABLET)...........................THYROID,PORK (90 MG) (TABLET)................................THYROID,PORK (97.5 MG) (TABLET).............................THYROLAR-1.................................................................. 78THYROLAR-1/2............................................................... 78THYROLAR-1/4............................................................... 78THYROLAR-2.................................................................. 78THYROLAR-3.................................................................. 78TIAGABINE HCL...........................................................146TIAZAC.............................................................................35

TIBSOVO........................................................................ 126TICAGRELOR.................................................................. 85TICALAST........................................................................ 16TICANASE........................................................................17TICASPRAY..................................................................... 17TIGAN...............................................................................17TIKOSYN..........................................................................31TIMOLO/BRIMON/DORZO/LATANOP/PF................... 81TIMOLOL......................................................................... 81TIMOLOL MALEATE................................................34, 81TIMOLOL MALEATE/LATANOPROST/PF................... 81TIMOLOL MALEATE/PF................................................ 81TIMOLOL/BRIMONIDIN/DORZOLAM/PF.................. 81TIMOLOL/DORZOLAMIDE/LATANOP/PF.................. 81TIMOPTIC........................................................................ 81TIMOPTIC OCUDOSE.............................................81, 168TIMOPTIC-XE..................................................................81TINDAMAX......................................................................93TINIDAZOLE................................................................... 93TIOPRONIN....................................................................149TIOTROPIUM BR/OLODATEROL HCL........................ 18TIOTROPIUM BROMIDE................................................18TIPRANAVIR....................................................................94TIPRANAVIR/VITAMIN E TPGS................................... 94TIROSINT......................................................................... 78TISSEEL VHSD..............................................................136TISSUE MATRIX, KERATIN-OVINE...........................135TIS-U-SOL PENTALYTE.................................................50TIVICAY........................................................................... 96TIVORBEX............................................................. 100, 168TIZANIDINE HCL......................................................... 147TIZANIDINE/IRRITANT CNTR-IRRT2....................... 146TOBI.................................................................................. 92TOBI PODHALER............................................................92TOBRADEX (0.3 %-0.1%) (DROPS SUSP).................... 79TOBRADEX (0.3 %-0.1%) (OINT. (G)).......................... 79TOBRADEX ST................................................................79TOBRAMYCIN.......................................................... 80, 92TOBRAMYCIN IN 0.225% SOD CHLOR...................... 92TOBRAMYCIN/DEXAMETHASONE............................79TOBRAMYCIN/LOTEPRED ETAB................................ 79TOBRAMYCIN/NEBULIZER......................................... 93TOBREX (0.3 %) (DROPS).............................................. 80TOBREX (0.3 %) (OINT. (G))..........................................80TOCILIZUMAB................................................................99TODAY CONTRACEPTIVE SPONGE............................40TOFACITINIB CITRATE................................................. 99TOFRANIL........................................................................26TOFRANIL-PM................................................................ 26TOLAK..............................................................................52TOLAZAMIDE................................................................. 56TOLBUTAMIDE...............................................................56TOLCAPONE..................................................................143TOLECTIN......................................................................101TOLECTIN DS................................................................101TOLINASE........................................................................ 56TOLMETIN SODIUM.................................................... 101TOLTERODINE TARTRATE......................................... 150TOLVAPTAN.....................................................................75TOOMEY SYRINGE......................................................113TOPAMAX...................................................................... 146TOPCARE CLICKFINE................................................. 133TOPCARE ULTRA COMFORT..................... 113, 122, 123TOPCARE UNIVERSAL1 LANCET.............................109TOPCARE UNIVERSAL1 THIN LANCET.................. 109TOPICAL CREAM METERED-DOSE DEV................ 110TOPICORT (0.05 %) (CREAM (G)).................................47TOPICORT (0.05 %) (GEL (GRAM)).............................. 47TOPICORT (0.05 %) (OINT. (G)).....................................47TOPICORT (0.25 %) (CREAM (G)).................................47TOPICORT (0.25 %) (OINT. (G)).....................................47TOPICORT (0.25 %) (SPRAY).................................47, 168TOPIRAMATE................................................................ 146TOPOTECAN HCL.........................................................125TOPROL XL......................................................................34TORADOL (10 MG) (TABLET).....................................100TORADOL (15 MG/ML) (CARTRIDGE)......................100TORADOL (15 MG/ML) (SYRINGE)........................... 100TORADOL (15 MG/ML) (VIAL)...................................100TORADOL (30 MG/ML) (CARTRIDGE)......................100TORADOL (30 MG/ML) (SYRINGE)........................... 100TORADOL (30 MG/ML) (VIAL)...................................100TORADOL (30MG/ML(1)) (VIAL)............................... 101TORADOL (60 MG/2 ML) (CARTRIDGE)...................101TORADOL (60 MG/2 ML) (SYRINGE)........................ 101TORADOL (60 MG/2 ML) (VIAL)................................101TOREMIFENE CITRATE...............................................127TORONOVA II SUIK......................................................101TORONOVA SUIK..........................................................101TORSEMIDE.................................................................... 35TOUCH-TROL................................................................ 105TOUJEO MAX SOLOSTAR.............................................74

TOUJEO SOLOSTAR....................................................... 74TOVIAZ...................................................................149, 168TRACLEER.......................................................................36TRADJENTA.....................................................................55TRAMADOL HCL..........................................................140TRAMADOL HCL/ACETAMINOPHEN.......................142TRAMETINIB DIMETHYL SULFOXIDE....................125TRANDATE...................................................................... 32TRANDOLAPRIL.............................................................33TRANDOLAPRIL/VERAPAMIL HCL............................32TRANEXAMIC ACID...................................................... 82TRANSDERM-SCOP (1 MG/3 DAY) (PATCH TD 3)......17TRANSFER DEVICE, CLOSED SYSTEM...................134TRANSFER SET/SYRINGE/BAND/TUBE.................. 110TRANSFER SETS...........................................................111TRANYLCYPROMINE SULFATE..................................25TRANZAREL....................................................................53TRAVATAN Z....................................................................82TRAVOPROST..................................................................82TRAZODONE HCL..........................................................25TRECATOR.......................................................................93TREK S COMBO PACK...................................................23TREK S COMPACT COMPRESSOR.............................. 23TREK S PORTABLE PWR KIT..................................... 106TRELEGY ELLIPTA........................................................ 19TREMFYA.........................................................................54TRENTAL......................................................................... 84TREPROSTINIL............................................................... 36TREPROSTINIL DIOLAMINE........................................36TREPROSTINIL SODIUM...............................................36TREPROSTINIL/NEB ACCESSORIES...........................36TREPROSTINIL/NEBULIZER/ACCESOR.....................36TRESIBA FLEXTOUCH U-100.......................................74TRESIBA FLEXTOUCH U-200.......................................74TRETINOIN.............................................................. 44, 126TRETINOIN MICROSPHERES.......................................44TRETINOIN/EMOL 9/SKIN CLEANSR1.......................44TRETIN-X.........................................................................44TRETTEN..........................................................................83TREXALL (10 MG) (TABLET)..................................... 124TREXALL (15 MG) (TABLET)..................................... 124TREXALL (2.5 MG) (TABLET).................................... 124TREXALL (5 MG) (TABLET)....................................... 124TREXALL (7.5 MG) (TABLET).................................... 124TREXIMET (10 MG-60MG) (TABLET)................141, 168TREXIMET (85MG-500MG) (TABLET)...............141, 168TRIAMCIN/NORFLURANE/HFC 245FA.......................99TRIAMCINOLONE ACETON/SILICONES................... 48TRIAMCINOLONE ACETONIDE.......................... 48, 128TRIAMCINOLONE/DIMETH/SILICONE...................... 48TRIAMCINOLONE/EMOLLIENT COMB86................. 48TRIAMTERENE............................................................... 35TRIAMTERENE/HYDROCHLOROTHIAZID................35TRIAVIL 2-10....................................................................26TRIAVIL 2-25....................................................................26TRIAVIL 4-25....................................................................26TRIAVIL 4-50....................................................................26TRIAZOLAM....................................................................30TRIBENZOR.....................................................................32TRICARE........................................................................ 152TRI-CHLOR.................................................................... 129TRICHLOROACETIC ACID..........................................129TRICOR.............................................................................38TRIENTINE HCL........................................................... 130TRIFLUOPERAZINE HCL.............................................. 29TRIFLURIDINE................................................................80TRIFLURIDINE/TIPIRACIL HCL................................ 124TRIGLIDE.................................................................38, 168TRIHEXYPHENIDYL HCL........................................... 142TRILAFON........................................................................29TRILEPTAL.................................................................... 145TRILIPIX...........................................................................39TRILOAN II SUIK............................................................99TRILOAN SUIK................................................................99TRI-LUMA........................................................................54TRIMETHOBENZAMIDE HCL...................................... 17TRIMETHOPRIM.............................................................90TRIMIPRAMINE MALEATE.......................................... 26TRIMO-SAN................................................................... 150TRIMPEX..........................................................................90TRINATAL RX 1.............................................................153TRI-NORINYL..................................................................41TRINTELLIX............................................................ 25, 168TRIPROLIDINE/PHENYLEPH/CODEINE.....................42TRISTART DHA............................................................. 152TRIUMEQ......................................................................... 96TRIXYLITRAL...............................................................136TRIZIVIR.......................................................................... 94TROKENDI XR (100 MG) (CAP ER 24H)............146, 168TROKENDI XR (200 MG) (CAP ER 24H)............146, 168TROKENDI XR (25 MG) (CAP ER 24H)..............146, 168


Index

TROKENDI XR (50 MG) (CAP ER 24H)..............146, 168TROPICAMIDE................................................................ 82TROSPIUM CHLORIDE................................................ 150TRUE METRIX...........................................................63, 65TRUE METRIX AIR GLUCOSE METER.......................69TRUE METRIX BLOOD GLUCOSE MTR.....................69TRUE METRIX GLUCOSE TEST STRIP.......................60TRUE METRIX GO..........................................................69TRUE METRIX PRO TEST STRIP..................................60TRUE2GO BLOOD GLUCOSE SYSTEM...................... 69TRUECONTROL.............................................................. 63TRUEDRAW..................................................................... 73TRUEPLUS INSULIN SYRINGE..................113, 122, 123TRUEPLUS KETONE TEST STRIP..............................136TRUEPLUS LANCETS.................................................. 109TRUEPLUS PEN NEEDLE............................................ 133TRUERESULT BLOOD GLUCOSE SYSTM..................69TRUETEST TEST STRIPS...............................................60TRUETRACK BLOOD GLUCOSE SYSTEM.................70TRUETRACK SMART SYSTEM.................................... 70TRUETRACK TEST STRIP............................................. 60TRULANCE............................................................ 102, 168TRULICITY.............................................................. 55, 168TRUMENBA..................................................................... 88TRUNEB NEBULIZER.................................................... 22TRUSKIN........................................................................ 135TRUSOPT..........................................................................81TRUST NATAL DHA......................................................152TRUSTEEL INFUSION SET............................................71TRUVADA.........................................................................94TRUZONE PEAK FLOW METER...................................23TUBERCULIN SYRINGE......................................114, 116TUBERCULIN SYRINGE-NEEDLE.............................114TUDORZA PRESSAIR.............................................18, 168TUSNEL C........................................................................ 42TUSSICAPS...................................................................... 42TUSSIONEX..................................................................... 42TUZISTRA XR......................................................... 42, 168TWINPAK DUAL CANNULA.......................................118TWIST LANCETS.......................................................... 109TWYNSTA........................................................................ 33TYBOST............................................................................96TYKERB......................................................................... 126TYMLOS...........................................................................77TYPHOID VACC,LIVE,ATTENUATED..........................88TYVASO............................................................................36TYVASO INSTITUTIONAL START KIT........................36TYVASO REFILL KIT..................................................... 36TYVASO STARTER KIT..................................................36TYZINE.............................................................................43

- U -UCERIS............................................................. 98, 102, 168ULESFIA...........................................................................45ULIPRISTAL ACETATE...................................................41ULORIC.................................................................... 82, 168ULTANE.......................................................................... 130ULTICARE..............................................113, 114, 122, 123ULTICARE INSULIN SYRINGE...........112, 113, 122, 123ULTICARE PEN NEEDLE.............................................133ULTICARE SAFETY SYRINGE........................... 118, 121ULTICARE SYRINGE....................................................118ULTICARE TB SAFETY SYRINGE............................. 121ULTI-LANCE....................................................................73ULTILET BASIC.............................................................109ULTILET CLASSIC........................................................109ULTILET INSULIN SYRINGE......................113, 122, 123ULTILET LANCETS...................................................... 109ULTILET PEN NEEDLE................................................ 133ULTILET SAFETY......................................................... 109ULTIMA...................................................................... 60, 70ULTRA COMFORT................................ 112, 113, 122, 123ULTRA FINE LANCETS............................................... 109ULTRA THIN LANCETS...............................................109ULTRA THIN PLUS....................................................... 109ULTRA THIN PLUS LANCETS.................................... 109ULTRA-CARE LANCETS............................................. 109ULTRACET.....................................................................142ULTRA-FINE MICRO PEN NEEDLE........................... 133ULTRA-FINE MINI PEN NEEDLE...............................133ULTRA-FINE NANO PEN NEEDLE.............................133ULTRA-FINE ORIGINAL PEN NEEDLE.....................133ULTRA-FINE SHORT PEN NEEDLE........................... 133ULTRAFOAM...................................................................86ULTRALANCE............................................................... 109ULTRAM.........................................................................140ULTRAM ER...................................................................140ULTRASAL-ER................................................................ 51ULTRA-THIN II..............................109, 113, 122, 123, 133ULTRATLC LANCETS.................................................. 110ULTRATRAK..................................................60, 61, 65, 70ULTRATRAK PRO........................................................... 70

ULTRATRAK ULTIMATE................................... 60, 61, 70ULTRAVATE (0.05 %) (CREAM (G))..............................48ULTRAVATE (0.05 %) (LOTION)....................................48ULTRAVATE (0.05 %) (OINT. (G))..................................48ULTRAVATE X................................................................. 48UMECLIDINIUM BRM/VILANTEROL TR...................18UMECLIDINIUM BROMIDE..........................................18UNIFINE PENTIPS.........................................................133UNIFINE PENTIPS PLUS..............................................133UNILET COMFORTOUCH............................................110UNILET EXCELITE.......................................................110UNILET EXCELITE II................................................... 110UNILET GP LANCET.................................................... 110UNILET LANCET.......................................................... 110UNILET LANCETS........................................................110UNIPHYL..........................................................................24UNIRETIC.........................................................................32UNISTIK 2........................................................................ 73UNISTIK 2 EXTRA.......................................................... 73UNISTIK 2 NORMAL...................................................... 73UNISTIK 3................................................................ 73, 110UNISTIK 3 COMFORT.................................................... 73UNISTIK 3 EXTRA........................................................ 110UNISTIK 3 NEONATAL.................................................. 73UNISTIK CZT.................................................................110UNISTIK PRO.................................................................110UNISTIK SAFETY......................................................... 110UNISTIK TOUCH...........................................................110UNISTRIP......................................................................... 63UNISTRIP1....................................................................... 60UNITHROID..................................................................... 78UNIVASC.......................................................................... 33UNIVERSAL 1................................................................110UPTRAVI...........................................................................36URAMAXIN..................................................................... 51URAMAXIN GT............................................................... 51UREA.......................................................................... 51, 55UREA/EMOLLIENT COMBINATION 65.......................51URECHOLINE................................................................123URETRON D-S................................................................. 90UREVAZ............................................................................51URIDINE TRIACETATE.......................................... 82, 126URIN D.S.......................................................................... 90URINARY BAG/CATH TRAY....................................... 105URINARY BAG/CATHETER.........................................105URINE ACETONE TEST,STRIPS................................. 136URISPAS......................................................................... 149UROCIT-K.......................................................................149UROFOLLITROPIN......................................................... 76UROQID-ACID NO.2..................................................... 149UROXATRAL................................................................. 149URSO...............................................................................103URSO FORTE................................................................. 103URSODIOL..................................................................... 103URYL.................................................................................90USTEKINUMAB.............................................................. 99UTA................................................................................... 90UTIBRON NEOHALER........................................... 18, 168

- V -VACUSTIM BLACK.......................................................104VACUSTIM SILVER.......................................................104VACUUM ERECTION DEVICE SYSTEM................... 134VAGIFEM........................................................................150VALACYCLOVIR HCL....................................................94VALBENAZINE TOSYLATE.........................................127VALCHLOR...................................................................... 52VALCYTE......................................................................... 94VALGANCICLOVIR HCL............................................... 94VALISONE........................................................................47VALPROIC ACID........................................................... 146VALPROIC ACID (AS SODIUM SALT)....................... 146VALSARTAN.................................................................... 33VALSARTAN/HYDROCHLOROTHIAZIDE............ 32, 33VALTREX..........................................................................94VANATOL LQ.................................................................137VANATOL S....................................................................137VANCOMYCIN HCL....................................................... 93VANCOMYCIN HCL (125 MG) (CAPSULE).....................VANCOMYCIN HCL (125MG/2.5) (SYRINGE)................VANCOMYCIN HCL (250 MG) (CAPSULE).....................VANDAZOLE................................................................. 150VANDETANIB................................................................ 126VANISHPOINT................................................113-116, 122VANISHPOINT SYRINGE.....................................120, 121VANOS.............................................................................. 47VANOXIDE-HC................................................................ 43VANTAS............................................................................ 77VANTIN.............................................................................90VAPRO PLUS INTERMITT CATHETER......................105VARENICLINE TARTRATE.......................................... 147VARISOFT INFUSION SET.............................................71

VARITHENA ADMINISTRATION PACK.................... 110VARUBI.............................................................................17VASCEPA (0.5 GRAM) (CAPSULE)...............................39VASCEPA (1 G) (CAPSULE)........................................... 39VASERETIC......................................................................32VASHE WOUND.............................................................. 51VASHE WOUND THERAPY...........................................51VASOTEC..........................................................................33VAXCHORA ACTIVE COMPONENT............................88VAXCHORA BUFFER COMPONENT........................... 75VAXCHORA VACCINE................................................... 88VCF....................................................................................40VECAMYL........................................................................33VECTICAL................................................................54, 168VEETIDS...........................................................................91VELPHORO...................................................................... 76VELTASSA........................................................................76VELTIN (1.2-0.025%) (GEL (GRAM))............................43VEMLIDY................................................................. 96, 168VEMURAFENIB............................................................ 124VENCLEXTA..................................................................126VENCLEXTA STARTING PACK.................................. 126VENELEX.......................................................................136VENETOCLAX.............................................................. 126VENLAFAXINE HCL...................................................... 25VENLAFAXINE HCL ER....................................................VENTAVIS........................................................................ 36VENTOLIN HFA (90 MCG) (HFA AER AD)..................18VEO INSULIN SYRINGE......................112, 113, 122, 123VEPESID.........................................................................126VERAPAMIL HCL........................................................... 35VERASENS BLOOD GLUCOSE METER......................70VERASENS CONTROL SOLUTION..............................65VERASENS METER STARTER KIT.............................. 70VERASENS TEST STRIP................................................ 60VERDESO.........................................................................47VEREGEN.................................................................45, 168VERELAN.........................................................................35VERELAN PM..................................................................35VERSACLOZ............................................................28, 168VERSICLEAR...................................................................45VERTIGOHEEL..............................................................130VERZENIO..................................................................... 125VESANOID.....................................................................126VESICARE..............................................................149, 168VEXASYN........................................................................ 53VFEND.............................................................................. 92VGO 20..............................................................................74VGO 30..............................................................................74VGO 40..............................................................................74VIASPAN BELZER-UW.................................................. 50VIBERZI..........................................................................102VIBRAMYCIN............................................................91, 92VIBRA-TABS....................................................................91VICOPROFEN................................................................ 137VICTOZA 2-PAK......................................................55, 168VICTOZA 3-PAK......................................................55, 169VIDEX...............................................................................95VIDEX EC.........................................................................95VIEKIRA PAK.................................................................. 97VIEKIRA XR.................................................................... 97VIGABATRIN................................................................. 146VIGAMOX........................................................................ 80VIIBRYD...................................................................25, 169VILAZODONE HCL........................................................ 25VIMOVO................................................................. 100, 169VIMPAT (10 MG/ML) (SOLUTION).....................144, 169VIMPAT (100 MG) (TABLET)............................... 144, 169VIMPAT (150 MG) (TABLET)............................... 144, 169VIMPAT (200 MG) (TABLET)............................... 144, 169VIMPAT (200MG/20ML) (VIAL).................................. 144VIMPAT (50 MG) (TABLET)................................. 144, 169VIMPAT (50MG-100MG) (TAB DS PK)....................... 144VIOKACE....................................................................... 147VIOS AEROSOL DELIVERY SYSTEM......................... 23VIRACEPT........................................................................95VIRAMUNE......................................................................95VIRAMUNE XR............................................................... 95VIRAZOLE....................................................................... 94VIREAD (150 MG) (TABLET)........................................ 95VIREAD (200 MG) (TABLET)........................................ 95VIREAD (250 MG) (TABLET)........................................ 95VIREAD (300 MG) (TABLET)........................................ 95VIREAD (40MG/SCOOP) (POWDER)............................95VIROPTIC......................................................................... 80VISKEN.............................................................................34VISMODEGIB................................................................ 125VISTARIL......................................................................... 16VISTOGARD.................................................................. 126VIT E/LIDOCAINE/ALOE/COLLAGEN........................ 54VITAFOL FE+.................................................................151VITAFOL ULTRA...........................................................151


Index

VITAFOL-OB..................................................................152VITAFOL-ONE............................................................... 152VITAMEDMD ONE RX................................................. 152VITAMEDMD REDICHEW RX.................................... 152VITAMIN E ACETATE...................................................129VITAMINS B1,B2,B3,B5,AND B6................................ 153VITAPEARL................................................................... 153VITATRUE...................................................................... 151VITE AC/GRAPE/HYALURONIC ACID........................ 50VITUZ............................................................................... 42VIVACTIL......................................................................... 26VIVELLE-DOT................................................................. 87VIVLODEX.............................................................101, 169VIVOTIF............................................................................88VIXONE NEBULIZER.....................................................22VOGELXO........................................................................ 87VOLTAREN.........................................................49, 79, 100VOLTAREN-XR..............................................................100VON WILLEBRAND FACTOR....................................... 83VONVENDI...................................................................... 83VOPAC MDS.....................................................................49VORAPAXAR SULFATE................................................. 85VORICONAZOLE............................................................ 92VORINOSTAT.................................................................126VORTEX........................................................................... 20VORTEX HOLDING CHAMBER-CHILD......................21VORTEX HOLDING CHAMBER-TODDLER................21VORTEX VHC FROG MASK.......................................... 21VORTEX VHC LADYBUG MASK................................. 21VORTIOXETINE HYDROBROMIDE............................. 25VOSEVI.............................................................................96VOSOL.............................................................................. 75VOSOL HC........................................................................75VOTRIENT......................................................................126VRAYLAR (1.5 MG) (CAPSULE)...........................27, 169VRAYLAR (1.5 MG-3MG) (CAP DS PK)...............27, 169VRAYLAR (3 MG) (CAPSULE)..............................27, 169VRAYLAR (4.5 MG) (CAPSULE)...........................27, 169VRAYLAR (6 MG) (CAPSULE)..............................27, 169VUSION............................................................................ 45VYTONE...........................................................................44VYTORIN (10 MG-10MG) (TABLET)............................36VYTORIN (10 MG-20MG) (TABLET)............................36VYTORIN (10 MG-40MG) (TABLET)............................36VYTORIN (10 MG-80MG) (TABLET)....................36, 169VYVANSE.................................................................27, 169VYZULTA................................................................. 81, 169

- W -WARFARIN SODIUM...................................................... 82WATER FOR IRRIGATION,STERILE............................ 51WAVESENSE AMP.......................................................... 70WAVESENSE CONTROL SOLUTION........................... 65WAVESENSE JAZZ.......................................................... 60WAVESENSE PRESTO.............................................. 60, 70WEED POLLEN-SHORT RAGWEED............................ 16WELCHOL (3.75 G) (POWD PACK)...............................38WELCHOL (625 MG) (TABLET).................................... 38WELLBUTRIN................................................................. 25WELLBUTRIN SR........................................................... 25WELLBUTRIN XL........................................................... 25WELLCOVORIN............................................................ 126WHYTEDERM SURGIPAK...........................................136WHYTEDERM TDPAK................................................... 48WHYTEDERM TRILASIL PAK......................................48WIDE SEAL DIAPHRAGM.............................................41WILATE............................................................................ 83WILLIS THE WHALE COMPRESSR NEB.................... 23WOUND DEBRIDEMENT-LIDOCAINE........................53WOUND MATRIX..........................................................104WPR PLUS........................................................................53

- X -XADAGO................................................................ 143, 169XALATAN.........................................................................81XALKORI....................................................................... 125XARELTO (10 MG) (TABLET)....................................... 83XARELTO (15 MG) (TABLET)....................................... 83XARELTO (15 MG-20MG) (TAB DS PK).......................83XARELTO (20 MG) (TABLET)....................................... 83XATMEP................................................................. 124, 169XCLAIR............................................................................ 50XELITRAL........................................................................49XELJANZ.......................................................................... 99XELJANZ XR................................................................... 99XELODA (150 MG) (TABLET)..................................... 124XELODA (500 MG) (TABLET)..................................... 124XENAFLAMM..................................................................99XENAZINE..................................................................... 127XERESE.................................................................... 45, 170XERMELO...................................................................... 102XEROFORM................................................................... 103XEROFORM PETROLATUM DRESSING................... 104

XHANCE...................................................................17, 170XIFAXAN (200 MG) (TABLET)......................................93XIFAXAN (550 MG) (TABLET)......................................93XIGDUO XR............................................................. 56, 170XIIDRA............................................................................. 80XILAPAK.......................................................................... 47XIMINO.................................................................... 92, 170XOLEGEL.........................................................................45XOPENEX.........................................................................18XOPENEX CONCENTRATE...........................................18XOPENEX HFA................................................................18XRYLIDERM....................................................................53XRYLIX............................................................................ 49XTAMPZA ER (13.5 MG) (CAP SPR 12)......................140XTAMPZA ER (18 MG) (CAP SPR 12).........................140XTAMPZA ER (27 MG) (CAP SPR 12).........................140XTAMPZA ER (36 MG) (CAP SPR 12).........................140XTAMPZA ER (9 MG) (CAP SPR 12)...........................140XTANDI.......................................................................... 124XULTOPHY 100-3.6.................................................56, 170XURIDEN......................................................................... 82XYNTHA.......................................................................... 82XYNTHA SOLOFUSE..................................................... 82XYREM.............................................................................27XYZAL (2.5 MG/5ML) (SOLUTION).....................16, 170XYZAL (5 MG) (TABLET).............................................. 16

- Y -YASMIN 28....................................................................... 40YAZ....................................................................................40YONSA............................................................................124YOSPRALA...................................................................... 85Y-SITE CONNECTOR, CLOSED SYSTM....................111

- Z -ZAFIRLUKAST................................................................ 19ZALEPLON.......................................................................30ZANAFLEX.................................................................... 147ZANAMIVIR.....................................................................94ZANTAC..........................................................................148ZARONTIN..................................................................... 143ZAROXOLYN................................................................... 36ZARXIO............................................................................ 85ZAVESCA....................................................................... 129ZEBETA............................................................................ 34ZEGERID (20-1680MG) (PACKET)...................... 149, 170ZEGERID (20MG-1.1G) (CAPSULE)................... 149, 170ZEGERID (40-1680MG) (PACKET)...................... 149, 170ZEGERID (40MG-1.1G) (CAPSULE)................... 149, 170ZEJULA...........................................................................126ZELAPAR........................................................................143ZELBORAF.....................................................................124ZEMAIRA....................................................................... 124ZEMBRACE SYMTOUCH.................................... 141, 170ZENCIA.............................................................................46ZENPEP...........................................................................147ZENZEDI (15 MG) (TABLET).................................26, 170ZENZEDI (2.5 MG) (TABLET)................................26, 170ZENZEDI (20 MG) (TABLET).................................26, 170ZENZEDI (30 MG) (TABLET).................................26, 170ZENZEDI (7.5 MG) (TABLET)................................26, 170ZEPATIER......................................................................... 97ZERIT (1 MG/ML) (SOLN RECON)............................... 95ZERIT (15 MG) (CAPSULE)........................................... 95ZERIT (20 MG) (CAPSULE)........................................... 95ZERIT (30 MG) (CAPSULE)........................................... 95ZERIT (40 MG) (CAPSULE)........................................... 95ZESTORETIC................................................................... 32ZESTRIL........................................................................... 33ZETIA................................................................................38ZETONNA.................................................................17, 170ZIAC.................................................................................. 34ZIAGEN.............................................................................95ZIANA (1.2-0.025%) (GEL (GRAM))..............................43ZICONOTIDE ACETATE............................................... 137ZIDOVUDINE...................................................................95ZILEUTON..................................................................17, 18ZINC ACETATE..............................................................131ZIOPTAN...................................................................81, 170ZIPRASIDONE HCL........................................................ 29ZIPSOR....................................................................100, 170ZIRGAN............................................................................ 80ZITHRANOL............................................................ 54, 170ZITHROMAX................................................................... 90ZITHROMAX TRI-PAK................................................... 90ZOCOR (10 MG) (TABLET)............................................ 38ZOCOR (20 MG) (TABLET)............................................ 38ZOCOR (40 MG) (TABLET)............................................ 38ZOCOR (5 MG) (TABLET).............................................. 38ZOCOR (80 MG) (TABLET).................................... 38, 170ZODRYL AC 25................................................................42ZODRYL AC 30................................................................42ZODRYL AC 35................................................................42

ZODRYL AC 40................................................................42ZODRYL AC 50................................................................42ZODRYL AC 60................................................................42ZODRYL AC 80................................................................42ZODRYL DAC 25............................................................. 42ZODRYL DAC 30............................................................. 42ZODRYL DAC 35............................................................. 42ZODRYL DAC 40............................................................. 42ZODRYL DAC 50............................................................. 42ZODRYL DAC 60............................................................. 42ZODRYL DAC 80............................................................. 42ZODRYL DEC 25............................................................. 42ZODRYL DEC 30............................................................. 42ZODRYL DEC 35............................................................. 42ZODRYL DEC 40............................................................. 42ZODRYL DEC 50............................................................. 42ZODRYL DEC 60............................................................. 42ZODRYL DEC 80............................................................. 42ZOFRAN ODT.................................................................. 17ZOHYDRO ER................................................................138ZOLINZA........................................................................ 126ZOLMITRIPTAN............................................................ 141ZOLOFT............................................................................ 25ZOLPIDEM TARTRATE.................................................. 30ZOLPIMIST.............................................................. 30, 170ZOMACTON.....................................................................78ZOMIG (2.5 MG) (SPRAY).................................... 141, 170ZOMIG (2.5 MG) (TABLET)................................. 141, 170ZOMIG (5 MG) (SPRAY)....................................... 141, 170ZOMIG (5 MG) (TABLET).................................... 141, 170ZOMIG ZMT...........................................................141, 170ZONALON................................................................ 49, 170ZONATUSS....................................................................... 41ZONEGRAN................................................................... 146ZONISAMIDE................................................................ 146ZONTIVITY......................................................................85ZORBTIVE........................................................................78ZORTRESS........................................................................89ZORVOLEX............................................................ 100, 170ZOVIRAX..........................................................................94ZOVIRAX (5 %) (CREAM (G))....................................... 45ZOVIRAX (5 %) (OINT. (G))........................................... 45ZTLIDO.............................................................................53Z-TUSS AC....................................................................... 42ZUBSOLV....................................................................... 142ZUPLENZ (4 MG) (FILM)....................................... 17, 170ZUPLENZ (8 MG) (FILM)....................................... 17, 171ZURAMPIC...............................................................82, 171ZYBAN............................................................................147ZYCLARA (2.5 %) (CRM MD PMP)...................... 89, 171ZYCLARA (3.75 %) (CREAM PACK).................... 89, 171ZYCLARA (3.75 %) (CRM MD PMP).................... 89, 171ZYDELIG........................................................................ 126ZYFLO...................................................................... 17, 171ZYFLO CR................................................................ 18, 171ZYKADIA....................................................................... 125ZYLET...............................................................................79ZYLOPRIM.......................................................................82ZYMAXID........................................................................ 80ZYPITAMAG............................................................ 37, 171ZYPRAM.........................................................................102ZYPREXA.........................................................................28ZYPREXA ZYDIS............................................................ 28ZYRTEC (1 MG/ML) (SOLUTION)................................ 16ZYTIGA (250 MG) (TABLET).......................................124ZYTIGA (500 MG) (TABLET).......................................124ZYVOX..............................................................................90


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