2017 California Marketplace Formulary · The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g. ALBENZA) and generic drugs are listed in lower-case

Kaiser Permanente 2017 California Marketplace Formulary bull Page 1 of 50

2017 California Marketplace Formulary

(List of Covered Drugs)

PLEASE READ THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER WHEN YOU PARTICIPATE IN A QUALIFIED HEALTH PLAN OFFERED BY KAISER PERMANENTE AND INCLUDES THE HEALTH INSURANCE MARKETPLACE (IN CALIFORNIA MARKETPLACE IS KNOWN AS COVERED CALIFORNIA) This formulary was updated on 4072017 and is effective as of April 07 2017 For more recent information or other questions please call our Member Service Contact Center 24 hours a day seven days a week (closed holidays) 1-800-464-4000 English 1-800-788-0616 Spanish 1-800-757-7585 Chinese dialects 711 TTY for the hearingspeech impaired

What is the Kaiser Permanente California Marketplace Formulary The California Marketplace Formulary is a list of covered drugs chosen by a group of Kaiser Permanente physicians and pharmacists known as the Pharmacy and Therapeutics Committee The Committee meets regularly to evaluate and select drugs that are safe and effective for our members This Formulary meets the requirements outlined under the Federal regulations for Qualified Health Plans being offered inside a health insurance marketplace (in California marketplace is known as Covered California)

What drugs are covered Kaiser Permanente will generally cover brand and generic drugs listed on the California Marketplace Formulary as long as the drug is medically necessary the prescription is filled at a Kaiser Permanente or an affiliated pharmacy and other coverage rules are followed

If you are prescribed a drug on the California Marketplace Formulary that drug will be covered under the terms of your drug benefit

Getting an exception to the formulary Drugs not listed on the formulary are called non-formulary drugs When a Kaiser Permanente physician determines that a non-formulary drug is medically appropriate and necessary that drug will be covered under the terms of your benefits (if you have a prescription drug benefit) If you do not have a prescription drug benefit you will be charged the full retail price for the drug

The most effective way to get an exception to the formulary is to send a secure email to your doctor You and your doctor are best able to determine your medication needs

You may also contact Member Services by submitting an online form Or call Member Services 24 hours a day 7 days a week

Are there any restrictions on the drugs covered on the Formulary Some covered drugs may have additional requirements or limits on coverage such as Quantity Limits For certain drugs Kaiser Permanente may limit the amount of the drug dispensed to a certain daysrsquo supply Additionally when there is a national shortage of a drug we may limit the quantity of the drug dispensed

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

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

What drugs are eligible to be mailed from the mail order pharmacy Most drugs can be mailed from our mail order pharmacy Some drugs (for example drugs that are extremely high cost or require special handling) may not be eligible for mailing Drugs cannot be mailed outside the United States

You can order refills through our mail-order service online at kporgrefill or by phone or mobile app There is no extra charge for mail order The appropriate cost share (according to your prescription drug benefit) will apply

Your prescription drug benefit may have a lower cost share if you use the mail order pharmacy

Please refer to your Evidence of Coverage or Certificate of Insurance for complete details of your prescription drug benefit

Kaiser Permanente California Marketplace Formulary Kaiser Permanente may add or remove drugs from the California Marketplace Formulary during the year These changes to the Formulary are based on new information or new drugs that become available

The most current California Marketplace Formulary list begins on page 4 it provides coverage information about some of the drugs covered by Kaiser Permanente You may also look for the drugs alphabetically by using the index that starts on page 28

The first column of the chart lists the drug name Brand-name drugs are capitalized (eg ALBENZA) and generic drugs are listed in lower-case italics (eg amoxicillin)

All dosage forms and strengths for a particular drug listed may not be on the Formulary Some drugs have multiple dosage forms In such cases some dosages may be on the Formulary and others not Note Some of these drugs may be available only in a clinic setting

The second column ldquoDrug Tierrdquo will indicate what tier number the drug is in Drugs on the California Marketplace Formulary are categorized in one of the three tiers

Tier 1 ndash Generic Tier

Tier 2 ndash Brand Tier

Tier 4 ndash Specialty Tier

Note The tier in which a generic or brand drug is classified under may change at any time during the year Additionally certain brand drugs may be covered at the cost share that applies for Tier 1 and certain generic drugs may be covered at the Tier 2 cost share Tier 4 is for specialty drugs that are covered at a higher cost share

The third column of the chart will indicate any requirements or limits for that drug

QL = Quantity Limits -For certain drugs we may limit the amount of drug that you can receive Additionally when there is a national shortage of a drug we may limit the quantity of the drug dispensed

Name of drug Drug Tier

Requirement Limits

ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA 2 BILTRICIDE 2 ivermectin 1 PREZCOBIX 2 ANTI-HIV AGENTS abacavir sulfate 1 2 abacavir sulfate-lamivudine 1

abacavir sulfate-lamivudine-zidovudine 1

APTIVUS 2 ATRIPLA 2 COMPLERA 2 CRIXIVAN 2 didanosine 1 2 EDURANT 2 EMTRIVA 2 FUZEON 2 QL INTELENCE 2 INVIRASE 2 ISENTRESS 2 KALETRA 2 lamivudine 1 lamivudine-zidovudine 1 LEXIVA 2 nevirapine 1 2 NORVIR 2 PREZISTA 2 RESCRIPTOR 2 REYATAZ 2 SELZENTRY 2 stavudine 1 STRIBILD 2 SUSTIVA 2 TIVICAY 2 TRIUMEQ 2 TRUVADA 2 VIRACEPT 2 VIREAD 2 zidovudine 1 2 ANTIBACTERIALS amikacin sulfate 1 amoxicillin 1 2 amoxicillin amp pot clavulanate 1 2

ampicillin 1 2 ampicillin amp sulbactam sodium 1 2

Requirement Limits

ampicillin sodium 1 2 AVELOX 2 AZACTAM IN DEXTROSE 2

azithromycin 1 2 aztreonam 1 bacitracin 1 BACTOCILL IN DEXTROSE 2

BICILLIN L-A 2 CAYSTON 4 LD cefaclor 1 cefadroxil 1 cefazolin sodium 1 2 CEFAZOLIN SODIUM-DEXTROSE 2

cefdinir 1 cefepime hcl 1 CEFEPIME-DEXTROSE 2

CEFOTAXIME SODIUM 1

cefotetan disodium 1 CEFOTETAN DISODIUM-DEXTROSE

cefoxitin sodium 1 CEFOXITIN SODIUM-DEXTROSE 2

cefpodoxime proxetil 1 ceftazidime 1 2 ceftriaxone sodium 1 CEFTRIAXONE SODIUM IN DEXTROSE

CEFTRIAXONE SODIUM-DEXTROSE 2

cefuroxime axetil 1 2 cefuroxime sodium 1 2 CEFUROXIME SODIUM-DEXTROSE 2

cephalexin 1 2 CHLORAMPHENICOL SOD SUCCINATE 2

ciprofloxacin 1 2 ciprofloxacin hcl 1 ciprofloxacin in d5w 1 clarithromycin 1 CLEOCIN IN D5W 2 clindamycin hcl 1

Requirement Limits

clindamycin palmitate hydrochloride 1 2 clindamycin phosphate 1 CUBICIN 4 demeclocycline hcl 1 dicloxacillin sodium 1 doxycycline (monohydrate) 1 doxycycline hyclate 1 ERYTHROCIN LACTOBIONATE 2 FLUCONAZOLE IN SODIUM CHLORIDE 1 FORTAZ IN D5W 2 gentamicin in saline 1 2 gentamicin sulfate 1 INVANZ 4 levofloxacin 1 levofloxacin in d5w 1 linezolid 1 4 meropenem 1 minocycline hcl 1 2 moxifloxacin hcl 1 nafcillin sodium 1 2 NAFCILLIN SODIUM IN DEXTROSE 2 neomycin sulfate 1 oxacillin sodium 1 PENICILLIN G POT IN DEXTROSE 2 penicillin g potassium 1 PENICILLIN G PROCAINE 2 PENICILLIN G SODIUM 2 penicillin v potassium 1 piperacillin sodium-tazobactam sodium 1 PRIMAXIN IV 2 PRIMSOL 2 STREPTOMYCIN SULFATE 2 SULFADIAZINE 2 sulfamethoxazole-trimethoprim 1 2 sulfasalazine 1 SUPRAX 2 SYNERCID 4 TETRACYCLINE HCL 2 tobramycin 1 4 tobramycin sulfate 1

Requirement Limits

vancomycin hcl 1 VANCOMYCIN HCL IN DEXTROSE 2 XIFAXAN 2 QL ZINACEF IN STERILE WATER 2 ZOSYN 2 ANTIFUNGALS ABELCET 2 AMBISOME 4 AMPHOTERICIN B 2 CANCIDAS 4 fluconazole 1 fluconazole in dextrose 1 fluconazole in nacl 1 flucytosine 1 griseofulvin microsize 1 2 griseofulvin ultramicrosize 1 itraconazole 1 2 ketoconazole 1 nystatin 1 nystatin (mouth-throat) 1 terbinafine hcl 1 voriconazole 1 2 ANTIHEPATITIS C AGENTS HARVONI 4 QL INFERGEN 4 QL PEG-INTRON REDIPEN 4 QL

PEGASYS 4 QL ribavirin (hepatitis c) 1 SOVALDI 4 QL ANTIMYCOBACTERIALS CAPASTAT SULFATE 2 CYCLOSERINE 2 dapsone 1 ethambutol hcl 1 isoniazid 1 2 PRIFTIN 2 pyrazinamide 1 rifabutin 1 RIFAMATE 2 rifampin 1 TRECATOR 2 ANTIPROTOZOALS ALINIA 2 atovaquone 1 atovaquone-proguanil 1

Requirement Limits

hcl chloroquine phosphate 1 COARTEM 2 DARAPRIM 2 hydroxychloroquine sulfate 1 mefloquine hcl 1 metronidazole 1 metronidazole in nacl 1 2 NEBUPENT 2 paromomycin sulfate 1 PRIMAQUINE PHOSPHATE 2 YODOXIN 2 ANTIVIRALS acyclovir 1 acyclovir sodium 1 adefovir dipivoxil 1 cidofovir 1 DAKLINZA 4 DESCOVY 2 entecavir 1 4 EPCLUSA 4 QL EVOTAZ 2 famciclovir 1 FOSCAVIR 2 ganciclovir sodium 1 GENVOYA 2 lamivudine (hbv) 1 2 ODEFSEY 2 oseltamivir phosphate 1 2 RELENZA DISKHALER 2 rimantadine hydrochloride 1 SELZENTRY 2 SYNAGIS 4 TIVICAY 2 TRUVADA 2 valacyclovir hcl 1 valganciclovir hcl 1 4 QL VIRAZOLE 4 voriconazole 1 URINARY ANTI-INFECTIVES methenamine hippurate 1 nitrofurantoin 1 nitrofurantoin macrocrystal 1 2 nitrofurantoin monohyd macro 1

Requirement Limits

trimethoprim 1 ANTIHISTAMINE DRUGS FIRST GENERATION ANTIHISTAMINES chlorpheniramine amp phenylephrine 1 cyproheptadine hcl 1 diphenhydramine hcl 1 promethazine hcl 1 ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ABRAXANE 4 ADCETRIS 2 AFINITOR 4 QL ALECENSA 4 QL ALIMTA 4 ALKERAN 2 anastrozole 1 ARRANON 4 AVASTIN 4 azacitidine 1 BENDEKA 2 4 bicalutamide 1 BICNU 2 bleomycin sulfate 1 BLINCYTO 4 CABOMETYX 4 QL LD CAMPTOSAR 1 2 capecitabine 1 QL CAPRELSA 4 QL LD cisplatin 1 cladribine 1 COSMEGEN 4 COTELLIC 4 QL cyclophosphamide 1 2 CYRAMZA 4 cytarabine 1 2 dacarbazine 1 2 DACOGEN 4 daunorubicin hcl 1 DAUNOXOME 2 DEPOCYT 2 DOCETAXEL 1 2 4 doxorubicin hcl 1 doxorubicin hcl liposomal 1 2 EMCYT 4 QL ERBITUX 4 ERIVEDGE 4 QL ERWINAZE 2 etoposide 1 2 exemestane 1

Requirement Limits

FASLODEX 4 QL fludarabine phosphate 1 fluorouracil 1 flutamide 1 GAZYVA 4 gemcitabine hcl 1 4 GLEOSTINE 2 HALAVEN 4 HERCEPTIN 4 HEXALEN 4 hydroxyurea 1 IBRANCE 4 QL idarubicin hcl 1 2 ifosfamide 1 IFOSFAMIDE-MESNA 2 imatinib mesylate 1 QL IMBRUVICA 4 QL INTRON A 4 QL IRESSA 2 QL ISTODAX 4 IXEMPRA KIT 4 JAKAFI 4 QL JEVTANA 4 KADCYLA 4 KEYTRUDA 4 KYPROLIS 4 QL LENVIMA 10 MG DAILY DOSE 4 QL

letrozole 1 LEUKERAN 2 leuprolide acetate 1 2 LONSURF 4 QL LUPRON DEPOT (3-MONTH) 2 LUPRON DEPOT (4-MONTH) 2 LUPRON DEPOT (6-MONTH) 2 LUPRON DEPOT-PED (1-MONTH) 2 LUPRON DEPOT-PED (3-MONTH) 2 LYNPARZA 4 QL LD LYSODREN 2 QL MARQIBO 4 MATULANE 4 QL megestrol acetate 1 MEKINIST 4 QL melphalan hcl 1 mercaptopurine 1 4 QL methotrexate sodium 1 mitomycin 1

Requirement Limits

mitoxantrone hcl 1 MUSTARGEN 2 MYLERAN 4 NEXAVAR 4 QL NINLARO 4 QL ONCASPAR 4 OPDIVO 4 oxaliplatin 1 paclitaxel 1 pentostatin 1 PERJETA 4 POMALYST 4 QL PROLEUKIN 4 REVLIMID 2 QL RITUXAN 2 SPRYCEL 4 QL STIVARGA 4 QL SUTENT 4 QL SYLVANT 4 TABLOID 2 TAFINLAR 4 QL TAGRISSO 4 QL tamoxifen citrate 1 TARCEVA 4 QL TARGRETIN 4 QL TASIGNA 4 QL TECENTRIQ 4 QL temozolomide 1 TENIPOSIDE 2 THIOTEPA 2 topotecan hcl 1 4 QL TORISEL 4 tretinoin (chemotherapy) 1 QL

TRISENOX 4 TYKERB 4 QL UNITUXIN 4 VELCADE 4 VENCLEXTA 4 QL VINBLASTINE SULFATE 2 vincristine sulfate 1 vinorelbine tartrate 1 VOTRIENT 4 QL XALKORI 4 QL XGEVA 4 QL XTANDI 4 QL YERVOY 4 YONDELIS 4 ZANOSAR 4 ZELBORAF 4 QL

Requirement Limits

ZYDELIG 4 QL ZYKADIA 4 QL ZYTIGA 4 QL AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS atropine sulfate 1 ATROVENT HFA 2 BELLADONNA ALKALOIDS-OPIUM 2 chlordiazepoxide hcl-clidinium bromide 1 dicyclomine hcl 1 2 DONNATAL 2 glycopyrrolate 1 2 hyoscyamine sulfate 1 2 ipratropium bromide 1 ipratropium bromide (nasal) 1 PROPANTHELINE BROMIDE 2 SCOPOLAMINE HBR 2 SPIRIVA RESPIMAT 2 STIOLTO RESPIMAT 2 AUTONOMIC DRUGS MISCELLANEOUS CHANTIX 2 nicotine 1 nicotine polacrilex 1 2 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride 1 donepezil hydrochloride 1 ENLON 2 galantamine hydrobromide 1 GUANIDINE HCL 2 neostigmine methylsulfate 1 2 PHYSOSTIGMINE SALICYLATE 2 pilocarpine hcl (oral) 1 PROSTIGMIN 2 pyridostigmine bromide 1 2 SKELETAL MUSCLE RELAXANTS atracurium besylate 1 baclofen 1 2 cisatracurium besylate 1 cyclobenzaprine hcl 1 dantrolene sodium 1 2 methocarbamol 1 pancuronium bromide 1

Requirement Limits

QUELICIN 2 rocuronium bromide 1 tizanidine hcl 1 vecuronium bromide 1 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS dihydroergotamine mesylate 1 2 ERGOMAR 2 guanfacine hcl 1 phenoxybenzamine hcl 1 PHENTOLAMINE MESYLATE 2 SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR DISKUS 2 albuterol sulfate 1 2 dobutamine hcl 1 dobutamine in d5w 1 dopamine hcl 1 2 dopamine in d5w 1 ephedrine sulfate (pressors) 1 EPINEPHRINE 2 epinephrine hcl 1 isoproterenol hcl 1 2 METAPROTERENOL SULFATE 2 midodrine hcl 1 norepinephrine bitartrate 1 phenylephrine hcl (pressors) 1 SEREVENT DISKUS 2 STRIVERDI RESPIMAT 2 terbutaline sulfate 1 BLOOD DERIVATIVES BLOOD DERIVATIVES albumin human 1 PLASMANATE 2 BLOOD FORMATION COAGULATION AND THROMBOSIS ANTIANEMIA DRUGS INFED 2 polysaccharide iron complex 1 PROFERRIN ES 2 PROFERRIN-FORTE 2 VENOFER 2 ANTIHEMORRHAGIC AGENTS

Requirement Limits

ADVATE 2 QL ALPHANATEVWF COMPLEXHUMAN 2 QL

ALPHANINE SD 2 QL aminocaproic acid 1 2 BENEFIX 2 GELFILM 2 GELFOAM SPONGE 2 HEMOFIL M 2 QL KCENTRA 2 KOGENATE FS 2 QL NOVOSEVEN RT 2 PHENOL 2 QL PRAXBIND 4 PROFILNINE 4 QL PROTAMINE SULFATE 1 RECOTHROM 2 THROMBIN-JMI 2 tranexamic acid 1 XYNTHA 2 QL ANTITHROMBOTIC AGENTS ACD-A NOCLOT-50 2 ACTIVASE 2 anagrelide hcl 1 ANGIOMAX 2 argatroban 1 2 aspirin-dipyridamole 1 BRILINTA 2 clopidogrel bisulfate 1 EFFIENT 2 heparin (porcine) in sodium chloride 1 2 heparin sod (porcine) in d5w 1 heparin sodium (porcine) 1 heparin sodium (porcine) lock flush 1 INTEGRILIN 4 LOVENOX 2 QL PRADAXA 2 PROFILNINE 4 REOPRO 2 THROMBATE III 2 TNKASE 2 warfarin sodium 1 2 HEMATOPOIETIC AGENTS LEUKINE 4 QL NEUMEGA 4 NEUPOGEN 4 QL PROCRIT 2 QL

Requirement Limits

PROMACTA 4 QL ZARXIO 2 QL HEMORRHEOLOGIC AGENTS pentoxifylline 1 CARDIOVASCULAR DRUGS ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate 1 prazosin hcl 1 tamsulosin hcl 1 terazosin hcl 1 ANTILIPEMIC AGENTS atorvastatin calcium 1 cholestyramine 1 cholestyramine light 1 colestipol hcl 1 fenofibrate 1 gemfibrozil 1 lovastatin 1 metoprolol succinate 1 pravastatin sodium 1 rosuvastatin calcium 1 simvastatin 1 BETA-ADRENERGIC BLOCKING AGENTS atenolol 1 atenolol amp chlorthalidone 1 bisoprolol amp hydrochlorothiazide 1 bisoprolol fumarate 1 BREVIBLOC IN NACL 2 carvedilol 1 esmolol hcl 1 labetalol hcl 1 metoprolol amp hydrochlorothiazide 1 metoprolol succinate 1 metoprolol tartrate 1 nadolol 1 propranolol hcl 1 sotalol hcl 1 sotalol hcl (afibafl) 1 CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besylate 1 CARDENE IV 2 CLEVIPREX 2 diltiazem hcl 1 diltiazem hcl coated beads 1 nicardipine hcl 1 nifedipine 1 nimodipine 1 verapamil hcl 1

Requirement Limits

CARDIAC DRUGS adenosine 1 amiodarone hcl 1 digoxin 1 2 disopyramide phosphate 1 2 flecainide acetate 1 ibutilide fumarate 1 lidocaine hcl (cardiac) 1 2 lidocaine in d5w 1 mexiletine hcl 1 milrinone in dextrose 1 milrinone lactate 1 PROCAINAMIDE HCL 2 propafenone hcl 1 quinidine gluconate 1 2 QUINIDINE SULFATE 1 2 TIKOSYN 2 HYPOTENSIVE AGENTS clonidine hcl 1 hydralazine hcl 1 methyldopa 1 METHYLDOPATE HCL 2 minoxidil 1 NITROPRESS 2 PROGLYCEM 4 RESERPINE 2 RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS benazepril hcl 1 captopril 1 enalaprilat 1 ENTRESTO 2 lisinopril 1 lisinopril amp hydrochlorothiazide 1 losartan potassium 1 losartan potassium amp hydrochlorothiazide 1 ramipril 1 spironolactone 1 spironolactone amp hydrochlorothiazide 1 valsartan 1 valsartan-hydrochlorothiazide 1 SCLEROSING AGENTS ETHAMOLIN 2 SOTRADECOL 2 VARITHENA 2 VASODILATING AGENTS

Requirement Limits

alprostadil 1 CAVERJECT 2 QL dipyridamole 1 isosorbide dinitrate 1 2 isosorbide mononitrate 1 LETAIRIS 4 LD LEVITRA 2 QL nitroglycerin 1 2 nitroglycerin in d5w 1 2 papaverine hcl 1 REMODULIN 4 LD sildenafil citrate (pulmonary hypertension)

TRACLEER 4 QL LD TYVASO 2 QL LD VENTAVIS 4 QL LD CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS acetaminophen w codeine 1 alfentanil 1 buprenorphine hcl 1 buprenorphine hcl-naloxone hcl dihydrate 1 QL

butorphanol tartrate 1 choline amp mag salicylate 1 CODEINE SULFATE 1 2 etodolac 1 fentanyl 1 QL fentanyl citrate 1 2 hydrocodone-acetaminophen 1 2 hydromorphone hcl 1 2 ibuprofen 1 indomethacin 1 2 INDOMETHACIN SODIUM 1 INFUMORPH 200 2 ketorolac tromethamine 1 MECLOFENAMATE SODIUM 2 mefenamic acid 1 meloxicam 1 meperidine hcl 1 methadone hcl 1 2 morphine sulfate 1 2 nabumetone 1 nalbuphine hcl 1

Requirement Limits

naproxen 1 naproxen sodium 1 NEOPROFEN 2 OFIRMEV 2 OPANA 2 oxycodone hcl 1 oxycodone w acetaminophen 1 pentazocine w naloxone 1 salsalate 1 sufentanil citrate 1 sulindac 1 tramadol hcl 1 tramadol-acetaminophen 1 ULTIVA 2 ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS amphetamine-dextroamphetamine 1 2 caffeine citrate 1 dexmethylphenidate hcl 1 dextroamphetamine sulfate 1 methylphenidate hcl 1 2 VYVANSE 2 ANTICONVULSANTS BANZEL 4 carbamazepine 1 2 CELONTIN 2 clonazepam 1 divalproex sodium 1 EQUETRO 2 ethosuximide 1 felbamate 1 fosphenytoin sodium 1 gabapentin 1 lamotrigine 1 2 levetiracetam 1 LEVETIRACETAM IN NACL 2 magnesium sulfate 1 2 oxcarbazepine 1 phenytoin 1 phenytoin sodium 1 phenytoin sodium extended 1 2 primidone 1 SABRIL 4 QL LD

Requirement Limits

topiramate 1 valproate sodium 1 valproic acid 1 ANTIMANIC AGENTS LITHIUM 2 lithium carbonate 1 ANTIMIGRAINE AGENTS ERGOLOID MESYLATES 1 ergotamine w caffeine 1 2 isometheptene-dichloralphenazone-acetaminophen

naratriptan hcl 1 rizatriptan benzoate 1 sumatriptan 1 sumatriptan succinate 1 ANTIPARKINSONIAN AGENTS amantadine hcl 1 APOKYN 4 QL AZILECT 2 benztropine mesylate 1 bromocriptine mesylate 1 cabergoline 1 carbidopa 1 2 carbidopa-levodopa 1 4 CARBIDOPA-LEVODOPA-ENTACAPONE

entacapone 1 pramipexole dihydrochloride 1 ropinirole hydrochloride 1 selegiline hcl 1 trihexyphenidyl hcl 1 ANXIOLYTICS SEDATIVES AND HYPNOTICS alprazolam 1 buspirone hcl 1 BUTISOL SODIUM 2 chlordiazepoxide hcl 1 clorazepate dipotassium 1 DIASTAT ACUDIAL 2 diazepam 1 2 droperidol 1 hydroxyzine hcl 1 2 hydroxyzine pamoate 1 2 lorazepam 1

Requirement Limits

midazolam hcl 1 NEMBUTAL 2 oxazepam 1 phenobarbital 1 2 PHENOBARBITAL SODIUM 2 PRECEDEX 2 temazepam 1 zolpidem tartrate 1 CENTRAL NERVOUS SYSTEM AGENTS MISCELLANEOUS acamprosate calcium 1 flumazenil 1 memantine hcl 1 2 riluzole 1 selegiline hcl 1 GENERAL ANESTHETICS BREVITAL SODIUM 2 etomidate 1 FORANE 2 ketamine hcl 1 propofol 1 MULTIPLE SCLEROSIS AGENTS AVONEX 4 QL EXTAVIA 2 QL glatiramer acetate 1 QL TYSABRI 4 OPIATE ANTAGONISTS naloxone hcl 1 2 naltrexone hcl 1 2 PSYCHOTHERAPEUTIC AGENTS amitriptyline hcl 1 AMOXAPINE 2 aripiprazole 1 bupropion hcl 1 chlorpromazine hcl 1 2 citalopram hydrobromide 1 clomipramine hcl 1 clozapine 1 desipramine hcl 1 doxepin hcl 1 2 duloxetine hcl 1 escitalopram oxalate 1 fluoxetine hcl 1 fluphenazine decanoate 1 fluphenazine hcl 1 2 fluvoxamine maleate 1 haloperidol 1 haloperidol decanoate 1 haloperidol lactate 1

Requirement Limits

imipramine hcl 1 loxapine succinate 1 MAPROTILINE HCL 2 mirtazapine 1 nefazodone hcl 1 2 nortriptyline hcl 1 2 olanzapine 1 ORAP 2 paroxetine hcl 1 perphenazine 1 PERPHENAZINE-AMITRIPTYLINE 2 phenelzine sulfate 1 prochlorperazine 1 prochlorperazine edisylate 1 prochlorperazine maleate 1 protriptyline hcl 1 quetiapine fumarate 1 risperidone 1 sertraline hcl 1 SURMONTIL 2 thioridazine hcl 1 thiothixene 1 tranylcypromine sulfate 1 trazodone hcl 1 trifluoperazine hcl 1 venlafaxine hcl 1 ziprasidone hcl 1 CONTRACEPTIVES (FOAMS DEVICES) CONTRACEPTIVES (FOAMS DEVICES) levonorgestrel amp eth estradiol 1 WIDE-SEAL DIAPHRAGM 60 2 DEVICES DEVICES AEROCHAMBER Z-STAT PLUS 2 AEROTRACH PLUS 2 BAYER BREEZE 2 CONTROL 2 BD INSULIN SYR ULTRAFINE II 2 BD INSULIN SYRINGE U-500 2 BD LANCET DEVICE 2 BD LANCET ULTRAFINE 33G 2 BD LUER-LOK 2

Requirement Limits

SYRINGE BD PEN NEEDLE MINI UF 2 BD SAFETYGLIDE SYRINGENEEDLE 2 DISPOSABLE POWER 2 ONETOUCH ULTRA MINI 2 PEDIATRIC SMALL MASK 2 PENLET II BLOOD SAMPLER 2 TRUZONE PEAK FLOW METER 2 DIAGNOSTIC AGENTS DIAGNOSTIC AGENTS ACETEST 2 adenosine (diagnostic) 1 ALBUSTIX 2 CHEMSTRIP 9 2 CHIRHOSTIM 2 CLINITEST 2 CONRAY 2 CORTROSYN 2 CREON 2 CYSTOGRAFIN 2 D-XYLOSE 2 DIASTIX 2 E-Z-CAT DRY 2 EOVIST 2 fluorescein sodium injection 1 fluorescein sodium topical 1 fluorescein w benoxinate 1 GADAVIST 2 GASTROGRAFIN 2 INDIGO CARMINE 2 KETO-DIASTIX 2 LEXISCAN 2 LUMASON 2 MAGNEVIST 2 METOPIRONE 2 MULTIHANCE 2 OMNIPAQUE 2 ONETOUCH ULTRA BLUE 2 THYROGEN 2 TUBERSOL 2

Requirement Limits

ELECTROLYTIC CALORIC AND WATER BALANCE ALKALINIZING AGENTS pot amp sod citrates wcitric ac 1 potassium citrate (alkalinizer) 1 potassium citrate-citric acid 1 sodium acetate 1 sodium bicarbonate 1 2 sodium citrate amp citric acid 1 THAM 2 AMMONIA DETOXICANTS lactulose 1 lactulose (encephalopathy) 1 LITHOSTAT 2 sodium phenylbutyrate 1 4 QL

CALORIC AGENTS amino acid electrolyte infusion 1 2 amino acid infusion 1 2 CLINIMIX EDEXTROSE (27510)

CLINIMIX EDEXTROSE (2755)

CLINIMIX EDEXTROSE (515) 2 CLINIMIX EDEXTROSE (520) 2 CLINIMIXDEXTROSE (2755) 2 CLINIMIXDEXTROSE (42510) 2 CLINIMIXDEXTROSE (42520) 2 CLINIMIXDEXTROSE (42525) 2 CLINIMIXDEXTROSE (515) 2 dextrose 1 2 fat emulsion 1 2 PHENEX-1 2 DIURETICS

Requirement Limits

amiloride amp hydrochlorothiazide 1 bumetanide 1 chlorthalidone 1 DYRENIUM 2 EDECRIN 2 furosemide 1 2 hydrochlorothiazide 1 indapamide 1 mannitol 1 metolazone 1 SODIUM EDECRIN 2 torsemide 1 triamterene amp hydrochlorothiazide 1 ION-REMOVING AGENTS RENVELA 2 sodium polystyrene sulfonate 1 IRRIGATING SOLUTIONS acetic acid 1 DIANEAL LOW CALCIUM425 DEX 2 lactated ringers (irrigation) 1 ringers irrigation 1 sodium chloride (gu irrigant) 1 water for irrigation sterile 1 REPLACEMENT PREPARATIONS calcium acetate (phosphate binder) 1 2 calcium chloride (dihydrate) 1 calcium gluconate 1 CHROMIC CHLORIDE 2 COPPER CHLORIDE 2 COPPER SULFATE 2 DEXTROSE 5ELECTROLYTE 48

dextrose in lactated ringers 1 dextrose in ringers 1 dextrose w sodium chloride 1 2 hetastarch in sodium chloride 1 HEXTEND 2 HYPERLYTE-CR 2

Requirement Limits

K-PHOS 2 KCL-LACTATED RINGERS-D5W 2 lactated ringers 1 LMD IN D5W 2 LMD IN NACL 2 MTE-5 CONCENTRATE 2 MAGNESIUM SULFATE IN D5W 2 MANGANESE CHLORIDE 2 PLASMA-LYTE A 2 potassium acetate 1 potassium bicarbonate 1 potassium chloride 1 2 potassium chloride in dextrose 1 potassium chloride in dextrose amp sodium chloride

potassium chloride in nacl 1 potassium chloride microencapsulated crystals cr

potassium phosphate dibasic 1 potassium phosphates 1 ringers 1 saline bacteriostatic 1 SELENIUM 2 sodium chloride 1 sodium chloride flush 1 sodium phosphate 1 trace minerals (cr-cu-mn-zn) 1 2 zinc sulfate 1 2 ZINC TRACE METAL 2 URICOSURIC AGENTS colchicine w probenecid 1 probenecid 1 ENZYMES ENZYMES ALDURAZYME 4 CEREZYME 4 ELAPRASE 4 ELITEK 4 FABRAZYME 4 HYLENEX 2

Requirement Limits

MYOZYME 4 NAGLAZYME 4 PROLASTIN-C 2 LD PULMOZYME 4 STRENSIQ 4 QL VIMIZIM 4 VORAXAZE 4 VPRIV 4 EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES BACITRACIN 2 bacitracin-polymyxin b (ophth) 1 chlorhexidine gluconate (mouth-throat)

ciprofloxacin hcl (ophth) 1 erythromycin (ophth) 1 gatifloxacin (ophth) 1 2 gentamicin sulfate (ophth) 1 MITOSOL 2 neomycin-bacitracin zn-polymyxin 1 neomycin-polymyxin-gramicidin 1 ofloxacin (ophth) 1 ofloxacin (otic) 1 polymyxin b-trimethoprim 1 sulfacetamide sodium (ophth) 1 tobramycin (ophth) 1 2 trifluridine 1 ANTI-INFLAMMATORY AGENTS CIPRODEX 2 COLY-MYCIN S 2 DEXAMETHASONE SODIUM PHOSPHATE

diclofenac sodium (ophth) 1 flunisolide (nasal) 1 fluorometholone (ophth) 1 2 flurbiprofen sodium 1 fluticasone propionate (nasal) 1 ketorolac tromethamine (ophth) 1

Requirement Limits

neomycin-polymy-dexameth 1 neomycin-polymyxin-hc (otic) 1 OZURDEX 4 prednisolone acetate (ophth) 1 2 PREDNISOLONE SODIUM PHOSPHATE

RESTASIS 2 RETISERT 2 sulfacetamide sod-prednisolone 1 2 TOBRADEX 2 VEXOL 2 ANTIALLERGIC AGENTS ALOCRIL 2 azelastine hcl 1 cromolyn sodium (ophth) 1 olopatadine hcl 1 ANTIGLAUCOMA AGENTS acetazolamide 1 2 acetazolamide sodium 1 betaxolol hcl (ophth) 1 brimonidine tartrate 1 dorzolamide hcl 1 dorzolamide hcl-timolol maleate 1 latanoprost 1 levobunolol hcl 1 2 LUMIGAN 2 methazolamide 1 MIOCHOL-E 2 MIOSTAT 2 PHOSPHOLINE IODIDE 2 pilocarpine hcl 1 timolol maleate (ophth) 1 EENT DRUGS MISCELLANEOUS acetic acid (otic) 1 ACETIC ACID-ALUMINUM ACETATE

apraclonidine hcl 1 2 EYLEA 2 HEALON5 2 JETREA 2 LACRISERT 2 LUCENTIS 2 LD

Requirement Limits

MACUGEN 2 ophthalmic irrigation solution - intraocular 1 2 VISUDYNE 2 LOCAL ANESTHETICS AKTEN 2 COCAINE HCL 2 lidocaine hcl (mouth-throat) 1 proparacaine hcl 1 2 tetracaine hcl (ophth) 1 MYDRIATICS atropine sulfate (ophthalmic) 1 2 CYCLOMYDRIL 2 cyclopentolate hcl 1 2 homatropine hbr 1 tropicamide 1 VASOCONSTRICTORS NAPHAZOLINE HCL 2 phenylephrine hcl (ophth) 1 GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS balsalazide disodium 1 mesalamine 1 2 ANTIDIARRHEA AGENTS diphenoxylate w atropine 1 2 PAREGORIC 2 ANTIEMETICS dronabinol 1 EMEND 2 QL meclizine hcl 1 ondansetron 1 ondansetron hcl 1 TRANSDERM-SCOP (15 MG) 2 ANTIULCER AGENTS AND ACID SUPPRESSANTS cimetidine hcl 1 famotidine 1 FAMOTIDINE PREMIXED 2 misoprostol 1 omeprazole 1 pantoprazole sodium 1 2 ranitidine hcl 1 sucralfate 1 2 CATHARTICS AND LAXATIVES AMITIZA 2 CASCARA SAGRADA 2

Requirement Limits

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

SORBITOL 2 CHOLELITHOLYTIC AGENTS ursodiol 1 2 DIGESTANTS CREON 2 PROKINETIC AGENTS metoclopramide hcl 1 GOLD COMPOUNDS GOLD COMPOUNDS RIDAURA 2 HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS BAL IN OIL 2 CHEMET 4 deferoxamine mesylate 1 DEPEN TITRATABS 4 EXJADE 4 QL PENTETATE CALCIUM TRISODIUM

PENTETATE ZINC TRISODIUM 2 sodium thiosulfate 1 2 HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS A-HYDROCORT 1 2 ARISTOSPAN INTRA-ARTICULAR 2 ASMANEX 120 METERED DOSES 2 betamethasone sod phosphate amp acetate 1 budesonide 1 budesonide (inhalation) 1 2 CORTISONE ACETATE 2 dexamethasone 1 2 dexamethasone sodium phosphate 1 FLOVENT HFA 2 fludrocortisone acetate 1 hydrocortisone 1 KENALOG 2 methylprednisolone 1 2 methylprednisolone 1

Requirement Limits

acetate methylprednisolone sod succ 1 2 prednisolone 1 2 prednisolone sodium phosphate 1 prednisone 1 2 QVAR 2 ANDROGENS ANDRODERM 1 2 ANDROID 2 ANDROXY 2 danazol 1 oxandrolone 1 testosterone cypionate 1 2 testosterone enanthate 1 ANTIDIABETIC AGENTS acarbose 1 BYDUREON 2 glimepiride 1 glipizide 1 glipizide-metformin hcl 1 glyburide 1 HUMALOG 2 HUMALOG MIX 5050 2 HUMULIN 7030 2 HUMULIN N 2 HUMULIN R 2 JARDIANCE 2 LANTUS 2 metformin hcl 1 pioglitazone hcl 1 TOLBUTAMIDE 2 TRADJENTA 2 ANTIHYPOGLYCEMIC AGENTS GLUCAGEN DIAGNOSTIC 2 GLUCAGEN HYPOKIT 2 GLUCAGON EMERGENCY 2 CONTRACEPTIVES desogestrel amp ethinyl estradiol 1 drospirenone-ethinyl estradiol 1 ELLA 2 ethynodiol diacet amp eth estrad 1 levonorgestrel amp eth 1

Requirement Limits

estradiol levonorgestrel (emergency oc) 1 levonorgestrel-eth estradiol (triphasic) 1 MIRENA (52 MG) 2 NECON 150 (28) 2 NECON 1011 (28) 2 NEXPLANON 2 norethin acet amp estrad-fe 1 norethindrone amp eth estradiol 1 norethindrone (contraceptive) 1 norethindrone acet amp eth estra 1 norethindrone-eth estradiol (triphasic) 1 norgestimate-ethinyl estradiol 1 norgestimate-ethinyl estradiol (triphasic) 1 norgestrel amp ethinyl estradiol 1 2 NUVARING 2 XULANE 2 ESTROGENS AND ESTROGEN AGONISTS-ANTAGONISTS clomiphene citrate 1 DEPO-ESTRADIOL 2 esterified estrogens amp methyltestosterone 1 ESTRACE 2 estradiol 1 2 estradiol valerate 1 2 PREMARIN 2 raloxifene hcl 1 GONADOTROPINS BRAVELLE 2 chorionic gonadotropin 1 MENOPUR 2 SYNAREL 4 PARATHYROID calcitonin (salmon) 1 2 FORTEO 4 QL PITUITARY desmopressin acetate 1 4 desmopressin acetate refrigerated 1 desmopressin acetate 1

Requirement Limits

spray desmopressin acetate spray refrigerated 1 HP ACTHAR 2 LD vasopressin 1 PROGESTINS DEPO-PROVERA 2 ENDOMETRIN 2 medroxyprogesterone acetate 1 medroxyprogesterone acetate (contraceptive)

norethindrone acetate 1 progesterone 1 progesterone micronized 1 SOMATROPIN AGONISTS-ANTAGONISTS MAKENA 2 QL NORDITROPIN FLEXPRO 2 4 QL

SEROSTIM 4 QL THYROID AND ANTITHYROID AGENTS levothyroxine sodium 1 2 liothyronine sodium 1 methimazole 1 propylthiouracil 1 SSKI 2 IMMUNOLOGICAL AGENTS ANTIRHEUMATIC AGENTS ENBREL 4 QL HUMIRA 4 QL KINERET 4 QL LD leflunomide 1 ORENCIA 4 QL OTEZLA 4 QL RASUVO 2 REMICADE 4 QL IMMUNE SUPPRESSANTS ATGAM 2 azathioprine 1 cyclosporine modified (for microemulsion) 1 2 mycophenolate mofetil 1 SANDIMMUNE 2 sirolimus 1 2 tacrolimus 1 2 LOCAL ANESTHETICS LOCAL ANESTHETICS bupivacaine hcl 1 bupivacaine in dextrose 1

Requirement Limits

bupivacaine w epinephrine 1 2 chloroprocaine hcl 1 2 lidocaine hcl (cardiac) 1 lidocaine hcl (local anesth) 1 lidocaine w epinephrine 1 2 mepivacaine hcl 1 NAROPIN 2 TETRACAINE HCL 2 MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine 1 acetylcysteine (antidote) 1 ACTIMMUNE 4 QL LD alendronate sodium 1 2 allopurinol 1 amifostine crystalline 1 BOTOX 2 BOTOX COSMETIC 2 BRIDION 2 CERDELGA 4 QL CINRYZE 4 QL COLCHICINE 2 CYSTADANE 4 QL LD CYSTAGON 2 QL LD dexrazoxane 1 disulfiram 1 2 ELMIRON 2 ETIDRONATE DISODIUM 2 finasteride 1 FIRAZYR 4 QL FLUOR-A-DAY 2 FUSILEV 2 GRASTEK 2 HUMIRA 2 QL INFLECTRA 4 KALYDECO 4 QL leucovorin calcium 1 levocarnitine (metabolic modifiers) 1 mesna 1 2 QL methylene blue (antidote) 1 MYOBLOC 2 octreotide acetate 1 4 QL pamidronate disodium 1 2 RIMSO-50 2 SENSIPAR 4

Requirement Limits

sodium fluoride 1 2 sodium fluoride (dental) 1 2 SOLIRIS 2 THALOMID 4 QL THIOLA 2 LD TRI-CHLOR 2 water for injection sterile 1 XELJANZ 4 QL zoledronic acid 1 OXYTOCICS OXYTOCICS CERVIDIL 2 HEMABATE 2 methylergonovine maleate 1 MIFEPREX 2 oxytocin 1 PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS ALOE VERA 2 ALPROSTADIL 2 ATROPINE SULFATE MONOHYDRATE 2 BACLOFEN 2 BACTERIOSTATIC WATER(BENZ ALC) 2 BIOTIN-D 2 BORIC ACID 2 CANTHARIDIN 2 CARBAMAZEPINE 2 CHLOROFORM 2 CHLORPROMAZINE HCL 2 CHOLESTEROL ACETATE 2 CLINDAMYCIN HCL 2 CLOBETASOL PROPIONATE 2 CLONIDINE HCL 2 CLOTRIMAZOLE 2 COAL TAR 2 COLLODION FLEXIBLE 2 CYSTEAMINE HCL 2 DEXAMETHASONE 2 DILTIAZEM HCL 2 DIPHENYLCYCLOPROPENONE 2 ESTRADIOL 2 GABAPENTIN 2

Requirement Limits

GLYCERIN 2 GLYCOPYRROLATE 2 HALOPERIDOL 2 HYDROCORTISONE 2 HYDROPHILIC 2 HYDROXOCOBALAMIN 2 HYDROXYPROGESTERONE CAPROATE 2 INDOMETHACIN 2 ISOSORBIDE 2 KETAMINE HCL 2 KETOPROFEN 2 L-ARGININE 2 L-CITRULLINE 2 L-ISOLEUCINE 2 L-PROLINE 2 L-VALINE 2 LACTIC ACID 2 LACTOSE 2 LACTOSE MONOHYDRATE 2 LIDOCAINE HCL 2 METHADONE HCL 2 METOCLOPRAMIDE HCL MONOHYDRATE

METRONIDAZOLE 2 MORPHINE SULFATE 2 NEOMYCIN SULFATE 2 PAPAVERINE HCL 2 PHENOBARBITAL 2 PHENTOLAMINE MESYLATE 2 PLURONIC F127 2 PODOPHYLLUM RESIN 2 POLYETHYLENE GLYCOL 400 2 POLYETHYLENE GLYCOL 8000 2 PROGESTERONE MICRONIZED 2 PROGESTERONE WETTABLE 2 PROPYLENE GLYCOL 2 QUINACRINE HCL 2 SALICYLIC ACID 2 SODIUM BENZOATE 2

Requirement Limits

SORBITOL 2 SQUARIC ACID DIBUTYLESTER 2 SULFUR PRECIPITATED 2 TESTOSTERONE PROPIONATE 2 THYMOL 2 TRANEXAMIC ACID 2 TRIAMCINOLONE ACETONIDE 2 UREA 2 VERAPAMIL HCL 2 water for injection sterile 1 ZINC SULFATE 2 RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS AEROSPAN 2 COMBIVENT RESPIMAT 2 CROMOLYN SODIUM 1 cromolyn sodium (mastocytosis) 1 DULERA 2 montelukast sodium 1 ANTITUSSIVES benzonatate 1 guaifenesin-codeine 1 hydrocodone w homatropine 1 phenylephrine-chlorphen-dm 1 PHENYLHISTINE DH 2 promethazine wcodeine 1 promethazine-dm 1 pseudoephedrine w codeine-gg 1 MUCOLYTIC AGENTS sodium chloride (inhalant) 1 PULMONARY SURFACTANTS CUROSURF 2 SURVANTA 2 RESPIRATORY AGENTS MISCELLANEOUS DALIRESP 2 ORKAMBI 4 QL XOLAIR 4 QL LD VASODILATING OPSUMIT 4 QL LD

Requirement Limits

SERUMS TOXOIDS AND VACCINES SERUMS ANTIVENIN LATRODECTUS MACTANS

CARIMUNE NF 2 CROFAB 2 CYTOGAM 2 DIGIFAB 2 GAMASTAN SD 2 GAMMAGARD 2 HIZENTRA 4 QL HYPERRAB SD 2 HYPERRHO SD 2 HYPERTET SD 2 HYQVIA 4 QL NABI-HB 2 VARIZIG 2 TOXOIDS ADACEL 2 DIPHTHERIA-TETANUS TOXOIDS DT

INFANRIX 2 TETANUS-DIPHTHERIA TOXOIDS TD

VACCINES ACTHIB 2 AFLURIA 2 AFLURIA PRESERVATIVE FREE

BEXSERO 2 ENGERIX-B 2 FLUARIX QUADRIVALENT 2 FLUBLOK 2 FLUCELVAX 2 FLUMIST QUADRIVALENT 2 FLUVIRIN 2 FLUVIRIN PRESERVATIVE FREE

FLUZONE HIGH-DOSE 2 GARDASIL 2 GARDASIL 9 2 HAVRIX 2 IMOVAX RABIES 2 IPOL 2

Requirement Limits

IXIARO 2 KINRIX 2 M-M-R II 2 MENOMUNE 2 MENVEO 2 PEDIARIX 2 PNEUMOVAX 23 2 PREVNAR 13 2 PROQUAD 2 RABAVERT 2 ROTARIX 2 ROTATEQ 2 THERACYS 2 TWINRIX 2 TYPHIM VI 2 VARIVAX 2 VIVOTIF 2 YF-VAX 2 ZOSTAVAX 2 SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES benzoyl peroxide-erythromycin 1 2 clindamycin phosphate (topical) 1 clindamycin phosphate vaginal 1 clindamycin phosphate-benzoyl peroxide

clindamycin phosphate-benzoyl peroxide (refrigerate)

clotrimazole 1 dakins solution 1 2 erythromycin (acne aid) 1 2 gentamicin sulfate (topical) 1 2 iodoquinol-hc 1 ketoconazole (topical) 1 malathion 1 metronidazole (topical) 1 metronidazole vaginal 1 mupirocin 1 neomycinpolymyxin b gu 1 nystatin (topical) 1 permethrin 1 2 selenium sulfide 1 silver sulfadiazine 1

Requirement Limits

SULFAMYLON 2 ANTI-INFLAMMATORY AGENTS alclometasone dipropionate 1 betamethasone dipropionate (topical) 1 betamethasone dipropionate augmented

betamethasone valerate 1 clobetasol propionate 1 2 CORDRAN 2 CORTISPORIN 2 DESOWEN 2 desoximetasone 1 fluocinolone acetonide 1 fluocinonide 1 fluticasone propionate 1 halobetasol propionate 1 hydrocortisone (intrarectal) 1 hydrocortisone (rectal) 1 hydrocortisone (topical) 1 hydrocortisone acetate (rectal) 1 mometasone furoate 1 nystatin-triamcinolone 1 pramoxine-hc 1 2 PROCTOFOAM HC 2 triamcinolone acetonide (mouth) 1 triamcinolone acetonide (topical) 1 ANTIPRURITICS AND LOCAL ANESTHETICS hydrocortisone acetate w pramoxine 1 2 lidocaine 1 lidocaine hcl 1 lidocaine-prilocaine 1 PHENOL 2 ASTRINGENTS DRYSOL 2 XERAC AC 2 CELL STIMULANTS AND PROLIFERANTS KEPIVANCE 4 RETIN-A MICRO 2 tretinoin 1 2 DEPIGMENTING AND PIGMENTING AGENTS 8-MOP 2

Requirement Limits

methoxsalen rapid 1 2 OXSORALEN 2 KERATOLYTIC AGENTS KERALYT 2 sulfacetamide sodium w sulfur 1 2 KERATOPLASTIC AGENTS ELTA TAR 2 SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS acitretin 1 AQUAPHOR 2 BENZOIN 2 benzoin compound 1 calcipotriene 1 COSENTYX 300 DOSE 4 QL

DESITIN 2 diclofenac sodium (topical) 1 DIFFERIN 2 DRITHO-CREME HP 2 ELIDEL 2 EPIDUO 2 fluorouracil (topical) 1 2 imiquimod 1 isotretinoin 1 QL LEVULAN KERASTICK 2 PODOCON 2 podofilox 1 2 SANTYL 2 sodium chloride 1 STELARA 4 tacrolimus (topical) 1 TARGRETIN 4 QL TAZORAC 2 VECTICAL 2 SMOOTH MUSCLE RELAXANTS GENITOURINARY SMOOTH MUSCLE RELAXANTS oxybutynin chloride 1 OXYTROL 2 trospium chloride 1 RESPIRATORY SMOOTH MUSCLE RELAXANTS aminophylline 1 theophylline 1 theophylline in 1 2

Requirement Limits

dextrose VITAMINS MULTIVITAMIN PREPARATIONS b-complex w c amp folic acid 1 INFUVITE 2 INFUVITE PEDIATRIC 2 ped multivitamins wfl amp iron 1 pediatric multiple vitamin w c 1 pediatric multiple vitamins w iron 1 pediatric multivitamins wfl 1 pediatric vitamins acd w fluoride 1 VITAMIN A AQUASOL A 2 VITAMIN B COMPLEX cyanocobalamin 1 FOLIC ACID 2 niacin 1 2 POTABA 2 pyridoxine hcl 1 thiamine hcl 1 VITAMIN C ascorbic acid 1 VITAMIN D calcitriol 1 ergocalciferol 1 VITAMIN K ACTIVITY phytonadione 1 2

Drugs listed below are not on the Planrsquos Formulary If your Kaiser Permanente physician determines through an exception process that one is medically necessary that drug will be covered under Drug Tier 4 with the applicable cost share

Name of drug

ANTI-INFECTIVE AGENTS ANTIBACTERIALS

BETHKIS NEB 3004ML DALVANCE SOL 500MG DIFICID TAB 200MG KITABIS PAK NEB 3005ML LINEZOLID SOLN 2MGML ORBACTIV SOL 400MG SIVEXTRO INJ 200MG SIVEXTRO TAB 200MG TYGACIL INJ 50MG VANCOCIN HCL CAP 125MG VANCOCIN HCL CAP 250MG ZYVOX SOL 2MGML

ANTIFUNGALS ANCOBON CAP 250MG ANCOBON CAP 500MG CRESEMBA SOLR 372 MG CRESEMBA CAPS 186 MG MYCAMINE INJ 100MG MYCAMINE INJ 50MG NOXAFIL SUS 40MGML NOXAFIL SOLN 300 MG167ML NOXAFIL TAB 100MG VFEND SUS 40MGML VFEND TAB 200MG VFEND TAB 50MG

ANTIMYCOBACTERIALS MYCOBUTIN CAP 150MG SIRTURO TAB 100MG

ANTIPROTOZOALS IMPAVIDO CAPS 50 MG MEPRON SUS

ANTIVIRALS BARACLUDE TAB 05MG BARACLUDE TAB 1MG DAKLINZA TABS 90 MG EPCLUSA TABS 400-100 MG HEPSERA TAB 10MG RAPIVAB SOLN 200 MG20ML TYZEKA 600 MG TABLET

Name of drug

VALCYTE TAB 450MG VEMLIDY TABS 25 MG VISTIDE INJ 75MGML

ANTIHEPATITIS C AGENTS OLYSIO CAP 150MG TECHNIVIE TABS 125-75-50 MG VIEKIRA PAK TAB VIEKIRA XR TB24 200-833-50- 3333 MG ZEPATIER TABS

ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS

AFINITOR DISPERZ TAB 2MG AFINITOR DISPERZ TAB 3MG AFINITOR DISPERZ TAB 5MG ALIMTA SOLR 100 MG ARZERRA CON 1005ML BELEODAQ INJ 500MG BOSULIF TAB 100MG BOSULIF TAB 500MG BUSULFEX INJ 6MGML COSMEGEN INJ 05MG DARZALEX SOLN 100 MG5ML DARZALEX SOLN 400 MG20ML DOCETAXEL (NON-ALCOHOL) SOLN ELOXATIN INJ 100MG ELOXATIN INJ 200MG ELOXATIN INJ 50MG EMPLICITI SOLR 300 MG EMPLICITI SOLR 400 MG EVOMELA SOLR 50 MG FARESTON 60 MG TABLET FARYDAK CAP 10MG FARYDAK CAP 15MG FARYDAK CAP 20MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG HYCAMTIN 4 MG VIAL HYCAMTIN CAP 025MG HYCAMTIN CAP 1MG ICLUSIG TAB 15MG

Name of drug

ICLUSIG TAB 45MG IMLYGIC SUSP 1000000 UNITML IMLYGIC SUSP 100000000 UNITML INLYTA TAB 1MG INLYTA TAB 5MG INTRON-A KIT 10MUML INTRON-A INJ 10MU PEN INTRON-A INJ 3MU PEN INTRON-A INJ 5MU PEN KYPROLIS 30 MG VIAL LARTRUVO SOLN 500 MG50ML LARTRUVO INJ 19019ML LENVIMA PACK 4 (2) MG (8 MG DAILY DOSE) LENVIMA PACK 10 amp 4 (2) MG (18 MG

DAILY DOSE) NIPENT INJ 10MG ODOMZO CAPS 200 MG ONIVYDE INJ 43 MG10ML PORTRAZZA SOLN 800 MG50ML PURINETHOL RUBRACA TABS SUPPRELIN LA KIT 50 MG SYLATRON KIT 200MCG SYLATRON KIT 300MCG SYLATRON KIT 600MCG SYNRIBO INJ 35MG TAXOTERE INJ 80MG4ML TEMODAR CAP 100MG TEMODAR CAP 140MG TEMODAR CAP 180MG TEMODAR CAP 20MG TEMODAR CAP 250MG TEMODAR CAP 5MG TEMODAR INJ 100MG TREANDA INJ 180MG TREANDA INJ 25MG TREANDA INJ 45MG TRELSTAR DEPOT MIXJECT INJ 375MG TRELSTAR LA MIXJECT INJ 1125MG TRELSTAR MIXJECT INJ 225MG VALSTAR SOL 40MGML VANTAS KIT 50MG VECTIBIX INJ 100MG VECTIBIX INJ 400MG ZALTRAP INJ 1004ML

Name of drug

ZALTRAP INJ 2008ML ZOLINZA CAP 100MG

AUTONOMIC DRUGS SYMPATHOMIMETIC (ADRENERGIC)

AGENTS AUVI-Q SOAJ 015 MG015ML AUVI-Q SOAJ 03 MG03ML NORTHERA CAP 100MG NORTHERA CAP 200MG NORTHERA CAP 300MG

BLOOD FORMATION COAGULATION AND THROMBOSIS

ANTIHEMORRHAGIC AGENTS BENEFIX SOLR

CYKLOKAPRON 100 MGML AMPUL PROFILNINE SD INJ RIXUBIS SOLR IXINITY SOLR

HEMATOPOIETIC AGENTS GRANIX INJ 30005 GRANIX INJ 48008 LEUKINE 500 MCGML VIAL MOZOBIL 20 MGML VIAL NEULASTA INJ 6MG06M

CARDIAC DRUGS ANTILIPEMIC AGENTS

JUXTAPID CAP 10MG JUXTAPID CAP 20MG JUXTAPID CAP 30MG JUXTAPID CAP 40MG JUXTAPID CAP 5MG JUXTAPID CAP 60MG KYNAMRO INJ 200MGML PRALUENT SOSY 150 MGML PRALUENT SOSY 75 MGML REPATHA SOSY 140 MGML REPATHA SURECLICK SOAJ 140 MGML REPATHA PUSH INJ 42035

HYPOTENSIVE AGENTS

VASODILATING AGENTS ADCIRCA TAB 20MG REVATIO INJ REVATIO TAB 20MG

CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS

Name of drug PROBUPHINE IMPLANT KIT IMPL 742

MG ILARIS INJ 180MG

ANTICONVULSANTS APTIOM TAB 200MG APTIOM TAB 400MG APTIOM TAB 600MG APTIOM TAB 800MG BRIVIACT SOLN 10 MGML BRIVIACT TABS BRIVIACT 50 MG5 ML VIAL FELBATOL SUS 6005ML FELBATOL TAB 400MG FELBATOL TAB 600MG SABRIL TAB 500MG SPRITAM TB3D

ANTIPARKINSONIAN AGENTS RYTARY TASMAR 100 MG TABLET

ANXIOLYTICSSEDATIVESHYPNOTICS HETLIOZ CAP 20MG

CENTRAL NERVOUS SYSTEM AGENTS MISCELLANEOUS

RILUTEK TAB 50MG XENAZINE TAB 125MG XENAZINE TAB 25MG XYREM SOL 500MGML

MULTIPLE SCLEROSIS AUBAGIO TAB 14MG AUBAGIO TAB 7MG COPAXONE INJ 40MGML GILENYA CAP 05MG PLEGRIDY INJ PLEGRIDY INJ PEN PLEGRIDY STARTER PACK INJ STARTER REBIF INJ 2205 REBIF INJ 4405 REBIF REBIDOSE INJ 2205 REBIF REBIDOSE INJ 4405 REBIF REBIDOSE TITRATION PACK SOL

TITRATN REBIF TITRATION PACK SOL PACK TECFIDERA CAP 120MG TECFIDERA CAP 240MG TECFIDERA STARTER PACK MIS

STARTER

Name of drug

OPIATE AGENTS EVZIO SOAJ 2 MG04ML VIVITROL 380MG INJ

PSYCHOTHERAPEUTIC AGENTS INVEGA TB24 15 MG INVEGA TB24 3 MG INVEGA TB24 6 MG INVEGA TB24 9 MG INVEGA SUSTENNA INJ 117075 INVEGA SUSTENNA INJ 23415 INVEGA SUSTENNA INJ 39025 INVEGA SUSTENNA INJ 7805ML NUPLAZID TABS 17 MG REXULTI TABS VRAYLAR CAPS VRAYLAR CPPK 15 amp 3 MG

ELECTROLYTIC CALORIC AND WATER BALANCE

AMMONIA DETOXICANTS BUPHENYL POW RAVICTI LIQ 11GMML

DIURETICS SAMSCA 15 MG TABLET SAMSCA 30 MG TABLET

ION-REMOVING AGENTS FOSRENOL CHW 1000MG FOSRENOL CHW 500MG FOSRENOL CHW 750MG FOSRENOL PACK 750 MG FOSRENOL PACK 1000 MG

EYE EAR NOSE AND THROAT (EENT) PREPARATIONS

ANTI-INFLAMMATORY AGENTS ILUVIEN 019MG IMPLANT

ENZYMES ENZYMES

CEREZYME INJ 200UNIT ELELYSO INJ 200UNIT KANUMA SOLN 20 MG10ML VIMIZIM INJ 5MG5ML

GASTROINTESTINAL DRUGS ANTIDIARRHEA AGENTS

XERMELO 250 MG TABLET ANTI-INFLAMMATORY AGENTS

DIPENTUM CAP 250MG LOTRONEX TAB 05MG

Name of drug

LOTRONEX TAB 1MG GI DRUGS MISCELLANEOUS

ENTYVIO INJ 300MG GATTEX KIT 5MG OCALIVA RELISTOR 12 MG06 ML KIT RELISTOR SOLN 8 MG04ML RELISTOR TABS 150 MG VIBERZI TABS 75 MG VIBERZI TABS 100 MG

HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS

CUPRIMINE CAPS 250 MG FERRIPROX TAB 500MG FERRIPROX SOLN 100 MGML

HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS

EMFLAZA TABS ENTOCORT EC CAP 3MG24HR UCERIS TAB 9MG

DIABETIC AGENTS KORLYM TAB 300MG

PARATHYROID NATPARA CART 100 MCG NATPARA CART 25 MCG NATPARA CART 50 MCG NATPARA CART 75 MCG

PROGESTINS MAKENA INJ 250MGML

SOMATOTROPIN AGONISTS AND ANTAGONISTS

BETASERON KIT 03 MG EGRIFTA INJ 1MG EGRIFTA SOL 2MG GENOTROPIN INJ 12MG GENOTROPIN INJ 5MG GENOTROPIN MINIQUICK INJ 02MG GENOTROPIN MINIQUICK INJ 04MG GENOTROPIN MINIQUICK INJ 06MG GENOTROPIN MINIQUICK INJ 08MG GENOTROPIN MINIQUICK INJ 12MG GENOTROPIN MINIQUICK INJ 14MG GENOTROPIN MINIQUICK INJ 16MG GENOTROPIN MINIQUICK INJ 18MG GENOTROPIN MINIQUICK INJ 1MG GENOTROPIN MINIQUICK INJ 2MG

Name of drug

HUMATROPE COMBO PACK INJ 5MG HUMATROPE INJ 12MG HUMATROPE INJ 24MG HUMATROPE INJ 6MG INCRELEX INJ 40MG4ML NORDITROPIN FLEXPRO INJ 1015ML NORDITROPIN FLEXPRO INJ 515ML NORDITROPIN NORDIFLEX PEN INJ

303ML NUTROPIN AQ INJ 10MG2ML NUTROPIN AQ NUSPIN 5 INJ NUSPIN 5 NUTROPIN AQ NUSPIN 10 SOLN 10

MG2ML NUTROPIN AQ NUSPIN 20 SOLN 20

MG2ML NUTROPIN AQ PEN INJ 10MG2ML NUTROPIN AQ PEN INJ 20MG2ML NUTROPIN INJ 10MG SAIZEN CLICKEASY INJ 88MG SAIZEN SOLR 5 MG SIGNIFOR INJ 03MGML SIGNIFOR INJ 06MGML SIGNIFOR INJ 09MGML SIGNIFOR LAR INJ 20MG SIGNIFOR LAR INJ 40MG SIGNIFOR LAR INJ 60MG SOMAVERT INJ 10MG SOMAVERT INJ 15MG SOMAVERT INJ 20MG SOMAVERT INJ 25MG SOMAVERT INJ 30 ZOMACTON SOLR 5 MG ZOMACTON SOLR 10 MG ZORBTIVE INJ 88MG

IMMUNOLOGICAL AGENTS ANTIRHEUMATIC AGENTS

ACTEMRA INJ ACTEMRA INJ 16209 ACTEMRA SOLN 80 MG4ML ACTEMRA SOLN 400 MG20ML ARAVA TAB CIMZIA KIT CIMZIA KIT 200MGML HUMIRA KIT 10MG02 HUMIRA KIT 20MG04 SIMPONI ARIA SOL 50MG4ML

Name of drug

SIMPONI INJ 100MGML SIMPONI INJ 50MG XELJANZ TAB 5MG XELJANZ XR TB24 11 MG

MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS

AMPYRA TAB 10MG ARCALYST INJ 220MG ASTAGRAF XL CP24 05 MG ASTAGRAF XL CAP 1MG ASTAGRAF XL CAP 5MG BERINERT INJ 500UNIT KUVAN POWDER KUVAN TAB 100MG LEMTRADA SOLN 12 MG12ML MYALEPT INJ 113MG NULOJIX INJ 250MG ORFADIN CAP 10MG ORFADIN CAP 2MG ORFADIN CAP 5MG ORFADIN CAPS 20 MG ORFADIN SUS 4MGML PROCYSBI CAP 25MG PROCYSBI CAP 75MG RUCONEST INJ 2100UNIT SAXENDA SIMULECT INJ 10MG SIMULECT INJ 20MG SOMATULINE DEPOT INJ 1205ML SOMATULINE DEPOT INJ 6002ML SOMATULINE DEPOT INJ 9003ML THYMOGLOBULIN INJ 25MG VISTOGARD PACK 10 GM XEOMIN SOLR 200 UNIT XURIDEN PACK 2 GM ZAVESCA CAP 100MG ZINBRYTA INJ 150MGML ZORTRESS TAB 025MG ZORTRESS TAB 05MG ZORTRESS TAB 075MG

SYSTEMIC LUPUS ERYTHEMATOSUS BENLYSTA INJ 120MG BENLYSTA INJ 400MG

RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS

CINQAIR SOLN 100 MG10ML

Name of drug

GASTROCROM 100 MG5 ML CONC NUCALA SOLR 100 MG ZYFLO CR TAB 600MG ZYFLO TAB 600MG

RESPIRATORY AGENTS MISCELLANEOUS

ARALAST NP SOLR 500 MG ESBRIET CAP 267MG EXONDYS 51 SOLN GLASSIA INJ OFEV CAP 100MG OFEV CAP 150MG ZEMAIRA SOLR 1000 MG

VASODILATING AGENTS ADEMPAS TAB 05MG ADEMPAS TAB 15MG ADEMPAS TAB 1MG ADEMPAS TAB 25MG ADEMPAS TAB 2MG OPSUMIT TAB 10MG ORENITRAM TAB 0125MG ORENITRAM TAB 025MG ORENITRAM TAB 1MG ORENITRAM TAB 25MG UPTRAVI TABS

SERUMS TOXOIDS AND VACCINES SERUMS

SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN AND

MUCOUS MEMBRANE) TACLONEX OIN TACLONEX SUSP 0005-0064 ULTRAVATE LOTN 005

SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS

PANRETIN GEL 01 REGRANEX GEL 001 RYNODERM CREA 375 SORIATANE CAP 10MG SORIATANE CAP 175MG SORIATANE CAP 25MG TALTZ SOSY 80 MGML TALTZ SOAJ 80 MGML VALCHLOR GEL 0016

VITAMINS VITAMIN D

RAYALDEE CPCR 30 MCG

8 8-MOP 21

A abacavir sulfate 4 abacavir sulfate-lamivudine 4 abacavir sulfate-lamivudine-zidovudine 4 ABELCET 5 ABRAXANE 6 acamprosate calcium 12 acarbose 17 ACD-A NOCLOT-50 9 acetaminophen w codeine 10 acetazolamide 15 acetazolamide sodium 15 ACETEST 13 acetic acid 14 15 acetic acid (otic) 15 ACETIC ACID-ALUMINUM ACETATE 15 acetylcysteine 18 acetylcysteine (antidote) 18 acitretin 22 ACTEMRA INJ 26 ACTEMRA INJ 16209 26 ACTEMRA SOLN 400 MG20ML 26 ACTEMRA SOLN 80 MG4ML 26 ACTHIB 20 ACTIMMUNE 18 ACTIVASE 9 acyclovir 6 acyclovir sodium 6 ADACEL 20 ADCETRIS 6 ADCIRCA TAB 20MG 24 adefovir dipivoxil 6 ADEMPAS TAB 05MG 27 ADEMPAS TAB 15MG 27 ADEMPAS TAB 1MG 27 ADEMPAS TAB 25MG 27 ADEMPAS TAB 2MG 27 adenosine 9 13 adenosine (diagnostic) 13 ADVAIR DISKUS 8 ADVATE 8 AEROCHAMBER Z-STAT PLUS 12 AEROSPAN 20 AEROTRACH PLUS 12

AFINITOR 6 23 AFINITOR DISPERZ TAB 2MG 23 AFINITOR DISPERZ TAB 3MG 23 AFINITOR DISPERZ TAB 5MG 23 AFLURIA 20 AFLURIA PRESERVATIVE FREE 20 A-HYDROCORT 16 AKTEN 16 ALBENZA 4 albumin human 8 ALBUSTIX 13 albuterol sulfate 8 alclometasone dipropionate 21 ALDURAZYME 14 ALECENSA 6 alendronate sodium 18 alfentanil 10 ALIMTA 6 23 ALIMTA SOLR 100 MG 23 ALINIA 5 ALKERAN 6 allopurinol 18 ALOCRIL 15 ALOE VERA 19 ALPHANATEVWF COMPLEXHUMAN 8 ALPHANINE SD 8 alprazolam 11 alprostadil 10 ALPROSTADIL 19 amantadine hcl 11 AMBISOME 5 amifostine crystalline 18 amikacin sulfate 4 amiloride amp hydrochlorothiazide 13 amino acid electrolyte infusion 13 amino acid infusion 13 aminocaproic acid 9 aminophylline 22 amiodarone hcl 9 AMITIZA 16 amitriptyline hcl 12 amlodipine besylate 9 AMOXAPINE 12 amoxicillin 4 amoxicillin amp pot clavulanate 4 amphetamine-dextroamphetamine 11 AMPHOTERICIN B 5 ampicillin 4 ampicillin amp sulbactam sodium 4

ampicillin sodium 4 AMPYRA TAB 10MG 27 anagrelide hcl 9 anastrozole 6 ANCOBON CAP 250MG 23 ANCOBON CAP 500MG 23 ANDRODERM 17 ANDROID 17 ANDROXY 17 ANGIOMAX 9 ANTIVENIN LATRODECTUS MACTANS 20 APOKYN 11 apraclonidine hcl 15 APTIOM TAB 200MG 25 APTIOM TAB 400MG 25 APTIOM TAB 600MG 25 APTIOM TAB 800MG 25 APTIVUS 4 AQUAPHOR 22 AQUASOL A 22 ARALAST NP SOLR 500 MG 27 ARAVA TAB 26 ARCALYST INJ 220MG 27 argatroban 9 aripiprazole 12 ARISTOSPAN INTRA-ARTICULAR 16 ARRANON 6 ARZERRA CON 1005ML 23 ascorbic acid 22 ASMANEX 120 METERED DOSES 16 aspirin-dipyridamole 9 ASTAGRAF XL CAP 1MG 27 ASTAGRAF XL CAP 5MG 27 ASTAGRAF XL CP24 05 MG 27 atenolol 9 atenolol amp chlorthalidone 9 ATGAM 18 atorvastatin calcium 9 atovaquone 5 atovaquone-proguanil hcl 5 atracurium besylate 8 ATRIPLA 4 atropine sulfate 8 16 atropine sulfate (ophthalmic) 16 ATROPINE SULFATE MONOHYDRATE 19 ATROVENT HFA 8 AUBAGIO TAB 14MG 25 AUBAGIO TAB 7MG 25 AUVI-Q SOAJ 015 MG015ML 24 AUVI-Q SOAJ 03 MG03ML 24 AVASTIN 6 AVELOX 4

AVONEX 12 azacitidine 6 AZACTAM IN DEXTROSE 4 azathioprine 18 azelastine hcl 15 AZILECT 11 azithromycin 4 aztreonam 4

B bacitracin 4 15 BACITRACIN 15 bacitracin-polymyxin b (ophth) 15 baclofen 8 BACLOFEN 19 BACTERIOSTATIC WATER(BENZ ALC) 19 BACTOCILL IN DEXTROSE 4 BAL IN OIL 16 balsalazide disodium 16 BANZEL 11 BARACLUDE TAB 05MG 23 BARACLUDE TAB 1MG 23 BAYER BREEZE 2 CONTROL 12 b-complex w c amp folic acid 22 BD INSULIN SYR ULTRAFINE II 12 BD INSULIN SYRINGE U-500 12 BD LANCET DEVICE 12 BD LANCET ULTRAFINE 33G 12 BD LUER-LOK SYRINGE 12 BD PEN NEEDLE MINI UF 12 BD SAFETYGLIDE SYRINGENEEDLE 12 BELEODAQ INJ 500MG 23 BELLADONNA ALKALOIDS-OPIUM 8 benazepril hcl 10 BENDEKA 6 BENEFIX 9 24 BENEFIX SOLR 24 BENLYSTA INJ 120MG 27 BENLYSTA INJ 400MG 27 BENZOIN 22 benzoin compound 22 benzonatate 20 benzoyl peroxide-erythromycin 21 benztropine mesylate 11 BERINERT INJ 500UNIT 27 betamethasone dipropionate (topical) 21 betamethasone dipropionate augmented 21 betamethasone sod phosphate amp acetate 16 betamethasone valerate 21 BETASERON KIT 03 MG 26 betaxolol hcl (ophth) 15

bethanechol chloride 8 BETHKIS NEB 3004ML 23 BEXSERO 20 bicalutamide 6 BICILLIN L-A 4 BICNU 6 BILTRICIDE 4 BIOTIN-D 19 bisoprolol amp hydrochlorothiazide 9 bisoprolol fumarate 9 bleomycin sulfate 6 BLINCYTO 6 BORIC ACID 19 BOSULIF TAB 100MG 23 BOSULIF TAB 500MG 23 BOTOX 18 BOTOX COSMETIC 18 BRAVELLE 17 BREVIBLOC IN NACL 9 BREVITAL SODIUM 12 BRIDION 18 BRILINTA 9 brimonidine tartrate 15 BRIVIACT 50 MG5 ML VIAL 25 BRIVIACT SOLN 10 MGML 25 BRIVIACT TABS 25 bromocriptine mesylate 11 budesonide 16 budesonide (inhalation) 16 bumetanide 13 BUPHENYL POW 25 bupivacaine hcl 18 bupivacaine in dextrose 18 bupivacaine w epinephrine 18 buprenorphine hcl 10 buprenorphine hcl-naloxone hcl dihydrate 10 bupropion hcl 12 buspirone hcl 11 BUSULFEX INJ 6MGML 23 BUTISOL SODIUM 11 butorphanol tartrate 10 BYDUREON 17

C cabergoline 11 CABOMETYX 6 caffeine citrate 11 calcipotriene 22 calcitonin (salmon) 17 calcitriol 22 calcium acetate (phosphate binder) 14

calcium chloride (dihydrate) 14 calcium gluconate 14 CAMPTOSAR 6 CANCIDAS 5 CANTHARIDIN 19 CAPASTAT SULFATE 5 capecitabine 6 CAPRELSA 6 captopril 10 carbamazepine 11 CARBAMAZEPINE 19 carbidopa 11 carbidopa-levodopa 11 CARBIDOPA-LEVODOPA-ENTACAPONE 11 CARDENE IV 9 CARIMUNE NF 20 carvedilol 9 CASCARA SAGRADA 16 CAVERJECT 10 CAYSTON 4 cefaclor 4 cefadroxil 4 cefazolin sodium 4 CEFAZOLIN SODIUM-DEXTROSE 4 cefdinir 4 cefepime hcl 4 CEFEPIME-DEXTROSE 4 CEFOTAXIME SODIUM 4 cefotetan disodium 4 CEFOTETAN DISODIUM-DEXTROSE 4 cefoxitin sodium 4 CEFOXITIN SODIUM-DEXTROSE 4 cefpodoxime proxetil 4 ceftazidime 4 ceftriaxone sodium 4 CEFTRIAXONE SODIUM IN DEXTROSE 4 CEFTRIAXONE SODIUM-DEXTROSE 4 cefuroxime axetil 4 cefuroxime sodium 4 CEFUROXIME SODIUM-DEXTROSE 4 CELONTIN 11 cephalexin 4 CERDELGA 18 CEREZYME 14 25 CEREZYME INJ 200UNIT 25 CERVIDIL 19 CHANTIX 8 CHEMET 16 CHEMSTRIP 9 13 CHIRHOSTIM 13 CHLORAMPHENICOL SOD SUCCINATE 4 chlordiazepoxide hcl 8 11

chlordiazepoxide hcl-clidinium bromide 8 chlorhexidine gluconate (mouth-throat) 15 CHLOROFORM 19 chloroprocaine hcl 18 chloroquine phosphate 5 chlorpheniramine amp phenylephrine 6 chlorpromazine hcl 12 CHLORPROMAZINE HCL 19 chlorthalidone 13 CHOLESTEROL ACETATE 19 cholestyramine 9 cholestyramine light 9 choline amp mag salicylate 10 chorionic gonadotropin 17 CHROMIC CHLORIDE 14 cidofovir 6 cimetidine hcl 16 CIMZIA KIT 26 CIMZIA KIT 200MGML 26 CINQAIR SOLN 100 MG10ML 27 CINRYZE 18 CIPRODEX 15 ciprofloxacin 4 15 ciprofloxacin hcl 4 15 ciprofloxacin hcl (ophth) 15 ciprofloxacin in d5w 4 cisatracurium besylate 8 cisplatin 6 citalopram hydrobromide 12 cladribine 6 clarithromycin 4 CLEOCIN IN D5W 4 CLEVIPREX 9 clindamycin hcl 4 CLINDAMYCIN HCL 19 clindamycin palmitate hydrochloride 4 clindamycin phosphate 4 21 clindamycin phosphate (topical) 21 clindamycin phosphate vaginal 21 clindamycin phosphate-benzoyl peroxide 21 clindamycin phosphate-benzoyl peroxide

(refrigerate) 21 CLINIMIX EDEXTROSE (27510) 13 CLINIMIX EDEXTROSE (2755) 13 CLINIMIX EDEXTROSE (42525) 13 CLINIMIX EDEXTROSE (515) 13 CLINIMIX EDEXTROSE (520) 13 CLINIMIXDEXTROSE (2755) 13 CLINIMIXDEXTROSE (42510) 13 CLINIMIXDEXTROSE (42520) 13 CLINIMIXDEXTROSE (42525) 13 CLINIMIXDEXTROSE (515) 13

CLINITEST 13 clobetasol propionate 21 CLOBETASOL PROPIONATE 19 clomiphene citrate 17 clomipramine hcl 12 clonazepam 11 clonidine hcl 10 CLONIDINE HCL 19 clopidogrel bisulfate 9 clorazepate dipotassium 11 clotrimazole 21 CLOTRIMAZOLE 19 clozapine 12 COAL TAR 19 COARTEM 5 COCAINE HCL 16 CODEINE SULFATE 10 COLCHICINE 18 colchicine w probenecid 14 colestipol hcl 9 COLLODION FLEXIBLE 19 COLY-MYCIN S 15 COMBIVENT RESPIMAT 20 COMPLERA 4 CONRAY 13 COPAXONE INJ 40MGML 25 COPPER CHLORIDE 14 COPPER SULFATE 14 CORDRAN 21 CORTISONE ACETATE 16 CORTISPORIN 21 CORTROSYN 13 COSENTYX 300 DOSE 22 COSMEGEN 6 23 COSMEGEN INJ 05MG 23 COTELLIC 6 CREON 13 16 CRESEMBA CAPS 186 MG 23 CRESEMBA SOLR 372 MG 23 CRIXIVAN 4 CROFAB 20 CROMOLYN SODIUM 20 cromolyn sodium (mastocytosis) 20 cromolyn sodium (ophth) 15 CUBICIN 5 CUPRIMINE CAPS 250 MG 26 CUROSURF 20 cyanocobalamin 22 cyclobenzaprine hcl 8 CYCLOMYDRIL 16 cyclopentolate hcl 16 cyclophosphamide 6

CYCLOSERINE 5 cyclosporine modified (for microemulsion) 18 CYKLOKAPRON 100 MGML AMPUL 24 cyproheptadine hcl 6 CYRAMZA 6 CYSTADANE 18 CYSTAGON 18 CYSTEAMINE HCL 19 CYSTOGRAFIN 13 cytarabine 6 CYTOGAM 20

D dacarbazine 6 DACOGEN 6 DAKLINZA 6 23 DAKLINZA TABS 90 MG 23 DALIRESP 20 DALVANCE SOL 500MG 23 danazol 17 dantrolene sodium 8 dapsone 5 DARAPRIM 6 DARZALEX SOLN 100 MG5ML 23 DARZALEX SOLN 400 MG20ML 23 daunorubicin hcl 6 DAUNOXOME 6 deferoxamine mesylate 16 demeclocycline hcl 5 DEPEN TITRATABS 16 DEPOCYT 6 DEPO-ESTRADIOL 17 DEPO-PROVERA 18 DESCOVY 6 desipramine hcl 12 DESITIN 22 desmopressin acetate 17 desmopressin acetate refrigerated 17 desmopressin acetate spray 17 desmopressin acetate spray refrigerated 17 desogestrel amp ethinyl estradiol 17 DESOWEN 21 desoximetasone 21 dexamethasone 16 DEXAMETHASONE 15 19 dexamethasone sodium phosphate 16 DEXAMETHASONE SODIUM PHOSPHATE 15 dexmethylphenidate hcl 11 dexrazoxane 18 dextroamphetamine sulfate 11 dextrose 13 14

DEXTROSE 5ELECTROLYTE 48 14 dextrose in lactated ringers 14 dextrose in ringers 14 dextrose w sodium chloride 14 DIANEAL LOW CALCIUM425 DEX 14 DIASTAT ACUDIAL 11 DIASTIX 13 diazepam 11 diclofenac sodium (ophth) 15 diclofenac sodium (topical) 22 dicloxacillin sodium 5 dicyclomine hcl 8 didanosine 4 DIFFERIN 22 DIFICID TAB 200MG 23 DIGIFAB 20 digoxin 9 dihydroergotamine mesylate 8 diltiazem hcl 9 DILTIAZEM HCL 19 diltiazem hcl coated beads 9 DIPENTUM CAP 250MG 25 diphenhydramine hcl 6 diphenoxylate w atropine 16 DIPHENYLCYCLOPROPENONE 19 DIPHTHERIA-TETANUS TOXOIDS DT 20 dipyridamole 10 disopyramide phosphate 10 DISPOSABLE POWER 13 disulfiram 18 divalproex sodium 11 dobutamine hcl 8 dobutamine in d5w 8 DOCETAXEL 6 23 DOCETAXEL (NON-ALCOHOL) SOLN 23 donepezil hydrochloride 8 DONNATAL 8 dopamine hcl 8 dopamine in d5w 8 dorzolamide hcl 15 dorzolamide hcl-timolol maleate 15 doxazosin mesylate 9 doxepin hcl 12 doxorubicin hcl 6 doxorubicin hcl liposomal 6 doxycycline (monohydrate) 5 doxycycline hyclate 5 DRITHO-CREME HP 22 dronabinol 16 droperidol 11 drospirenone-ethinyl estradiol 17 DRYSOL 21

DULERA 20 duloxetine hcl 12 D-XYLOSE 13 DYRENIUM 14

E EDECRIN 14 EDURANT 4 EFFIENT 9 EGRIFTA INJ 1MG 26 EGRIFTA SOL 2MG 26 ELAPRASE 14 ELELYSO INJ 200UNIT 25 ELIDEL 22 ELITEK 14 ELLA 17 ELMIRON 18 ELOXATIN INJ 100MG 23 ELOXATIN INJ 200MG 23 ELOXATIN INJ 50MG 23 ELTA TAR 22 EMCYT 6 EMEND 16 EMFLAZA TABS 26 EMPLICITI SOLR 300 MG 23 EMPLICITI SOLR 400 MG 23 EMTRIVA 4 enalaprilat 10 ENBREL 18 ENDOMETRIN 18 ENGERIX-B 20 ENLON 8 entacapone 11 entecavir 6 ENTOCORT EC CAP 3MG24HR 26 ENTRESTO 10 ENTYVIO INJ 300MG 26 EOVIST 13 EPCLUSA 6 23 EPCLUSA TABS 400-100 MG 23 ephedrine sulfate (pressors) 8 EPIDUO 22 EPINEPHRINE 8 epinephrine hcl 8 EQUETRO 11 ERBITUX 6 ergocalciferol 22 ERGOLOID MESYLATES 11 ERGOMAR 8 ergotamine w caffeine 11 ERIVEDGE 6

ERWINAZE 6 ERYTHROCIN LACTOBIONATE 5 erythromycin (acne aid) 21 erythromycin (ophth) 15 ESBRIET CAP 267MG 27 escitalopram oxalate 12 esmolol hcl 9 esterified estrogens amp methyltestosterone 17 ESTRACE 17 estradiol 17 ESTRADIOL 19 estradiol valerate 17 ethambutol hcl 5 ETHAMOLIN 10 ethosuximide 11 ethynodiol diacet amp eth estrad 17 ETIDRONATE DISODIUM 18 etodolac 10 etomidate 12 etoposide 6 EVOMELA SOLR 50 MG 23 EVOTAZ 6 EVZIO SOAJ 2 MG04ML 25 exemestane 6 EXJADE 16 EXONDYS 51 SOLN 27 EXTAVIA 12 EYLEA 15 E-Z-CAT DRY 13

F FABRAZYME 14 famciclovir 6 famotidine 16 FAMOTIDINE PREMIXED 16 FARESTON 60 MG TABLET 23 FARYDAK CAP 10MG 23 FARYDAK CAP 15MG 23 FARYDAK CAP 20MG 23 FASLODEX 6 fat emulsion 13 felbamate 11 FELBATOL SUS 6005ML 25 FELBATOL TAB 400MG 25 FELBATOL TAB 600MG 25 fenofibrate 9 fentanyl 10 fentanyl citrate 10 FERRIPROX SOLN 100 MGML 26 FERRIPROX TAB 500MG 26 finasteride 18

FIRAZYR 18 flecainide acetate 10 FLOVENT HFA 16 FLUARIX QUADRIVALENT 20 FLUBLOK 20 FLUCELVAX 20 fluconazole 5 fluconazole in dextrose 5 fluconazole in nacl 5 FLUCONAZOLE IN SODIUM CHLORIDE 5 flucytosine 5 fludarabine phosphate 6 fludrocortisone acetate 16 flumazenil 12 FLUMIST QUADRIVALENT 20 flunisolide (nasal) 15 fluocinolone acetonide 21 fluocinonide 21 FLUOR-A-DAY 18 fluorescein sodium injection 13 fluorescein sodium topical 13 fluorescein w benoxinate 13 fluorometholone (ophth) 15 fluorouracil 6 22 fluorouracil (topical) 22 fluoxetine hcl 12 fluphenazine decanoate 12 fluphenazine hcl 12 flurbiprofen sodium 15 flutamide 6 fluticasone propionate 15 21 fluticasone propionate (nasal) 15 FLUVIRIN 20 FLUVIRIN PRESERVATIVE FREE 20 fluvoxamine maleate 12 FLUZONE HIGH-DOSE 20 FOLIC ACID 22 FORANE 12 FORTAZ IN D5W 5 FORTEO 17 FOSCAVIR 6 fosphenytoin sodium 11 FOSRENOL CHW 1000MG 25 FOSRENOL CHW 500MG 25 FOSRENOL CHW 750MG 25 FOSRENOL PACK 1000 MG 25 FOSRENOL PACK 750 MG 25 furosemide 14 FUSILEV 18 FUZEON 4

G gabapentin 11 GABAPENTIN 19 GADAVIST 13 galantamine hydrobromide 8 GAMASTAN SD 20 GAMMAGARD 20 ganciclovir sodium 6 GARDASIL 20 GARDASIL 9 20 GASTROCROM 100 MG5 ML CONC 27 GASTROGRAFIN 13 gatifloxacin (ophth) 15 GATTEX KIT 5MG 26 GAZYVA 7 GELFILM 9 GELFOAM SPONGE 9 gemcitabine hcl 7 gemfibrozil 9 GENOTROPIN INJ 12MG 26 GENOTROPIN INJ 5MG 26 GENOTROPIN MINIQUICK INJ 02MG 26 GENOTROPIN MINIQUICK INJ 04MG 26 GENOTROPIN MINIQUICK INJ 06MG 26 GENOTROPIN MINIQUICK INJ 08MG 26 GENOTROPIN MINIQUICK INJ 12MG 26 GENOTROPIN MINIQUICK INJ 14MG 26 GENOTROPIN MINIQUICK INJ 16MG 26 GENOTROPIN MINIQUICK INJ 18MG 26 GENOTROPIN MINIQUICK INJ 1MG 26 GENOTROPIN MINIQUICK INJ 2MG 26 gentamicin in saline 5 gentamicin sulfate 5 15 21 gentamicin sulfate (ophth) 15 gentamicin sulfate (topical) 21 GENVOYA 6 GILENYA CAP 05MG 25 GILOTRIF TAB 20MG 23 GILOTRIF TAB 30MG 23 GILOTRIF TAB 40MG 23 GLASSIA INJ 27 glatiramer acetate 12 GLEOSTINE 7 glimepiride 17 glipizide 17 glipizide-metformin hcl 17 GLUCAGEN DIAGNOSTIC 17 GLUCAGEN HYPOKIT 17 GLUCAGON EMERGENCY 17 glyburide 17 GLYCERIN 19

glycopyrrolate 8 GLYCOPYRROLATE 19 GRANIX INJ 30005 24 GRANIX INJ 48008 24 GRASTEK 18 griseofulvin microsize 5 griseofulvin ultramicrosize 5 guaifenesin-codeine 20 guanfacine hcl 8 GUANIDINE HCL 8

H HALAVEN 7 halobetasol propionate 21 haloperidol 12 HALOPERIDOL 19 haloperidol decanoate 12 haloperidol lactate 12 HARVONI 5 HAVRIX 20 HEALON5 15 HEMABATE 19 HEMOFIL M 9 heparin (porcine) in sodium chloride 9 heparin sod (porcine) in d5w 9 heparin sodium (porcine) 9 heparin sodium (porcine) lock flush 9 HEPSERA TAB 10MG 23 HERCEPTIN 7 hetastarch in sodium chloride 14 HETLIOZ CAP 20MG 25 HEXALEN 7 HEXTEND 14 HIZENTRA 20 homatropine hbr 16 HP ACTHAR 17 HUMALOG 17 HUMALOG MIX 5050 17 HUMATROPE COMBO PACK INJ 5MG 26 HUMATROPE INJ 12MG 26 HUMATROPE INJ 24MG 26 HUMATROPE INJ 6MG 26 HUMIRA 18 26 HUMIRA KIT 10MG02 26 HUMIRA KIT 20MG04 26 HUMULIN 7030 17 HUMULIN N 17 HUMULIN R 17 HYCAMTIN 4 MG VIAL 23 HYCAMTIN CAP 025MG 23 HYCAMTIN CAP 1MG 23

hydralazine hcl 10 hydrochlorothiazide 14 hydrocodone w homatropine 20 hydrocodone-acetaminophen 10 hydrocortisone 16 21 HYDROCORTISONE 19 hydrocortisone (intrarectal) 21 hydrocortisone (rectal) 21 hydrocortisone (topical) 21 hydrocortisone acetate (rectal) 21 hydrocortisone acetate w pramoxine 21 hydromorphone hcl 10 HYDROPHILIC 19 HYDROXOCOBALAMIN 19 hydroxychloroquine sulfate 6 HYDROXYPROGESTERONE CAPROATE 19 hydroxyurea 7 hydroxyzine hcl 11 hydroxyzine pamoate 11 HYLENEX 14 hyoscyamine sulfate 8 HYPERLYTE-CR 14 HYPERRAB SD 20 HYPERRHO SD 20 HYPERTET SD 20 HYQVIA 20

I IBRANCE 7 ibuprofen 10 ibutilide fumarate 10 ICLUSIG TAB 15MG 23 ICLUSIG TAB 45MG 24 idarubicin hcl 7 ifosfamide 7 IFOSFAMIDE-MESNA 7 ILARIS INJ 180MG 25 ILUVIEN 019MG IMPLANT 25 imatinib mesylate 7 IMBRUVICA 7 imipramine hcl 12 imiquimod 22 IMLYGIC SUSP 1000000 UNITML 24 IMLYGIC SUSP 100000000 UNITML 24 IMOVAX RABIES 20 IMPAVIDO CAPS 50 MG 23 INCRELEX INJ 40MG4ML 26 indapamide 14 INDIGO CARMINE 13 indomethacin 10 INDOMETHACIN 10 19

INDOMETHACIN SODIUM 10 INFANRIX 20 INFED 8 INFERGEN 5 INFLECTRA 18 INFUMORPH 200 10 INFUVITE 22 INFUVITE PEDIATRIC 22 INLYTA TAB 1MG 24 INLYTA TAB 5MG 24 INTEGRILIN 9 INTELENCE 4 INTRON A 7 INTRON-A KIT 10MUML 24 INTRON-A INJ 10MU PEN 24 INTRON-A INJ 3MU PEN 24 INTRON-A INJ 5MU PEN 24 INVANZ 5 INVEGA SUSTENNA INJ 117075 25 INVEGA SUSTENNA INJ 23415 25 INVEGA SUSTENNA INJ 39025 25 INVEGA SUSTENNA INJ 7805ML 25 INVEGA TB24 15 MG 25 INVEGA TB24 3 MG 25 INVEGA TB24 6 MG 25 INVEGA TB24 9 MG 25 INVIRASE 4 iodoquinol-hc 21 IPOL 20 ipratropium bromide 8 ipratropium bromide (nasal) 8 IRESSA 7 ISENTRESS 4 isometheptene-dichloralphenazone-

acetaminophen 11 isoniazid 5 isoproterenol hcl 8 ISOSORBIDE 19 isosorbide dinitrate 10 isosorbide mononitrate 10 isotretinoin 22 ISTODAX 7 itraconazole 5 ivermectin 4 IXEMPRA KIT 7 IXIARO 20 IXINITY SOLR 24

J JAKAFI 7 JARDIANCE 17

JETREA 15 JEVTANA 7 JUXTAPID CAP 10MG 24 JUXTAPID CAP 20MG 24 JUXTAPID CAP 30MG 24 JUXTAPID CAP 40MG 24 JUXTAPID CAP 5MG 24 JUXTAPID CAP 60MG 24

K KADCYLA 7 KALETRA 4 KALYDECO 18 KANUMA SOLN 20 MG10ML 25 KCENTRA 9 KCL-LACTATED RINGERS-D5W 14 KENALOG 16 KEPIVANCE 21 KERALYT 21 ketamine hcl 12 KETAMINE HCL 19 ketoconazole 5 21 ketoconazole (topical) 21 KETO-DIASTIX 13 KETOPROFEN 19 ketorolac tromethamine 10 15 ketorolac tromethamine (ophth) 15 KEYTRUDA 7 KINERET 18 KINRIX 20 KITABIS PAK NEB 3005ML 23 KOGENATE FS 9 KORLYM TAB 300MG 26 K-PHOS 14 KUVAN POWDER 27 KUVAN TAB 100MG 27 KYNAMRO INJ 200MGML 24 KYPROLIS 7 24 KYPROLIS 30 MG VIAL 24

L labetalol hcl 9 LACRISERT 15 lactated ringers 14 lactated ringers (irrigation) 14 LACTIC ACID 19 LACTOSE 19 LACTOSE MONOHYDRATE 19 lactulose 13 lactulose (encephalopathy) 13 lamivudine 4 6

lamivudine (hbv) 6 lamivudine-zidovudine 4 lamotrigine 11 LANTUS 17 L-ARGININE 19 LARTRUVO INJ 19019ML 24 LARTRUVO SOLN 500 MG50ML 24 latanoprost 15 L-CITRULLINE 19 leflunomide 18 LEMTRADA SOLN 12 MG12ML 27 LENVIMA 7 24 LENVIMA 10 MG DAILY DOSE 7 LENVIMA PACK 10 amp 4 (2) MG (18 MG DAILY

DOSE) 24 LENVIMA PACK 4 (2) MG (8 MG DAILY DOSE)

24 LETAIRIS 10 letrozole 7 leucovorin calcium 18 LEUKERAN 7 LEUKINE 9 24 LEUKINE 500 MCGML VIAL 24 leuprolide acetate 7 levetiracetam 11 LEVETIRACETAM IN NACL 11 LEVITRA 10 levobunolol hcl 15 levocarnitine (metabolic modifiers) 18 levofloxacin 5 levofloxacin in d5w 5 levonorgestrel amp eth estradiol 12 17 levonorgestrel (emergency oc) 17 levonorgestrel-eth estradiol (triphasic) 17 levothyroxine sodium 18 LEVULAN KERASTICK 22 LEXISCAN 13 LEXIVA 4 lidocaine 10 16 18 21 lidocaine hcl 10 16 18 21 LIDOCAINE HCL 19 lidocaine hcl (cardiac) 10 18 lidocaine hcl (local anesth) 18 lidocaine hcl (mouth-throat) 16 lidocaine in d5w 10 lidocaine w epinephrine 18 lidocaine-prilocaine 21 linezolid 5 LINEZOLID SOLN 2MGML 23 liothyronine sodium 18 lisinopril 10 lisinopril amp hydrochlorothiazide 10

L-ISOLEUCINE 19 LITHIUM 11 lithium carbonate 11 LITHOSTAT 13 LMD IN D5W 14 LMD IN NACL 14 LONSURF 7 lorazepam 11 losartan potassium 10 losartan potassium amp hydrochlorothiazide 10 LOTRONEX TAB 05MG 25 LOTRONEX TAB 1MG 26 lovastatin 9 LOVENOX 9 loxapine succinate 12 L-PROLINE 19 LUCENTIS 15 LUMASON 13 LUMIGAN 15 LUPRON DEPOT (3-MONTH) 7 LUPRON DEPOT (4-MONTH) 7 LUPRON DEPOT (6-MONTH) 7 LUPRON DEPOT-PED (1-MONTH) 7 LUPRON DEPOT-PED (3-MONTH) 7 L-VALINE 19 LYNPARZA 7 LYSODREN 7

M MTE-5 CONCENTRATE 14 MACUGEN 15 magnesium sulfate 11 MAGNESIUM SULFATE IN D5W 14 MAGNEVIST 13 MAKENA 18 26 MAKENA INJ 250MGML 26 malathion 21 MANGANESE CHLORIDE 14 mannitol 14 MAPROTILINE HCL 12 MARQIBO 7 MATULANE 7 meclizine hcl 16 MECLOFENAMATE SODIUM 10 medroxyprogesterone acetate 18 medroxyprogesterone acetate (contraceptive) 18 mefenamic acid 10 mefloquine hcl 6 megestrol acetate 7 MEKINIST 7 meloxicam 10

melphalan hcl 7 memantine hcl 12 MENOMUNE 20 MENOPUR 17 MENVEO 21 meperidine hcl 10 mepivacaine hcl 18 MEPRON SUS 23 mercaptopurine 7 meropenem 5 mesalamine 16 mesna 18 METAPROTERENOL SULFATE 8 metformin hcl 17 methadone hcl 10 METHADONE HCL 19 methazolamide 15 methenamine hippurate 6 methimazole 18 methocarbamol 8 methotrexate sodium 7 methoxsalen rapid 21 methyldopa 10 METHYLDOPATE HCL 10 methylene blue (antidote) 18 methylergonovine maleate 19 methylphenidate hcl 11 methylprednisolone 16 methylprednisolone acetate 16 methylprednisolone sod succ 16 metoclopramide hcl 16 METOCLOPRAMIDE HCL MONOHYDRATE 19 metolazone 14 METOPIRONE 13 metoprolol amp hydrochlorothiazide 9 metoprolol succinate 9 metoprolol tartrate 9 metronidazole 6 21 METRONIDAZOLE 19 metronidazole (topical) 21 metronidazole in nacl 6 metronidazole vaginal 21 mexiletine hcl 10 midazolam hcl 11 midodrine hcl 8 MIFEPREX 19 milrinone in dextrose 10 milrinone lactate 10 minocycline hcl 5 minoxidil 10 MIOCHOL-E 15 MIOSTAT 15

MIRENA (52 MG) 17 mirtazapine 12 misoprostol 16 mitomycin 7 MITOSOL 15 mitoxantrone hcl 7 M-M-R II 20 mometasone furoate 21 montelukast sodium 20 morphine sulfate 10 MORPHINE SULFATE 19 moxifloxacin hcl 5 MOZOBIL 20 MGML VIAL 24 MULTIHANCE 13 mupirocin 21 MUSTARGEN 7 MYALEPT INJ 113MG 27 MYCAMINE INJ 100MG 23 MYCAMINE INJ 50MG 23 MYCOBUTIN CAP 150MG 23 mycophenolate mofetil 18 MYLERAN 7 MYOBLOC 18 MYOZYME 14

N NABI-HB 20 nabumetone 10 nadolol 9 nafcillin sodium 5 NAFCILLIN SODIUM IN DEXTROSE 5 NAGLAZYME 14 nalbuphine hcl 10 naloxone hcl 12 naltrexone hcl 12 NAPHAZOLINE HCL 16 naproxen 10 naproxen sodium 10 naratriptan hcl 11 NAROPIN 18 NATPARA CART 100 MCG 26 NATPARA CART 25 MCG 26 NATPARA CART 50 MCG 26 NATPARA CART 75 MCG 26 NEBUPENT 6 NECON 150 (28) 17 NECON 1011 (28) 17 nefazodone hcl 12 NEMBUTAL 11 neomycin sulfate 5 NEOMYCIN SULFATE 19

neomycinpolymyxin b gu 21 neomycin-bacitracin zn-polymyxin 15 neomycin-polymy-dexameth 15 neomycin-polymyxin-gramicidin 15 neomycin-polymyxin-hc (otic) 15 NEOPROFEN 10 neostigmine methylsulfate 8 NEULASTA INJ 6MG06M 24 NEUMEGA 9 NEUPOGEN 9 nevirapine 4 NEXAVAR 7 NEXPLANON 17 niacin 22 nicardipine hcl 9 nicotine 8 nicotine polacrilex 8 nifedipine 9 nimodipine 9 NINLARO 7 NIPENT INJ 10MG 24 nitrofurantoin 6 nitrofurantoin macrocrystal 6 nitrofurantoin monohyd macro 6 nitroglycerin 10 nitroglycerin in d5w 10 NITROPRESS 10 NORDITROPIN FLEXPRO 18 26 NORDITROPIN FLEXPRO INJ 1015ML 26 NORDITROPIN FLEXPRO INJ 515ML 26 NORDITROPIN NORDIFLEX PEN INJ 303ML

26 norepinephrine bitartrate 8 norethin acet amp estrad-fe 17 norethindrone amp eth estradiol 17 norethindrone (contraceptive) 17 norethindrone acet amp eth estra 17 norethindrone acetate 18 norethindrone-eth estradiol (triphasic) 17 norgestimate-ethinyl estradiol 17 norgestimate-ethinyl estradiol (triphasic) 17 norgestrel amp ethinyl estradiol 17 NORTHERA CAP 100MG 24 NORTHERA CAP 200MG 24 NORTHERA CAP 300MG 24 nortriptyline hcl 12 NORVIR 4 NOVOSEVEN RT 9 NOXAFIL SOLN 300 MG167ML 23 NOXAFIL SUS 40MGML 23 NOXAFIL TAB 100MG 23 NUCALA SOLR 100 MG 27

NULOJIX INJ 250MG 27 NUPLAZID TABS 17 MG 25 NUTROPIN AQ INJ 10MG2ML 26 NUTROPIN AQ NUSPIN 10 SOLN 10 MG2ML

26 NUTROPIN AQ NUSPIN 20 SOLN 20 MG2ML

26 NUTROPIN AQ NUSPIN 5 INJ NUSPIN 5 26 NUTROPIN AQ PEN INJ 10MG2ML 26 NUTROPIN AQ PEN INJ 20MG2ML 26 NUTROPIN INJ 10MG 26 NUVARING 17 nystatin 5 21 nystatin (mouth-throat) 5 nystatin (topical) 21 nystatin-triamcinolone 21

O OCALIVA 26 octreotide acetate 18 ODEFSEY 6 ODOMZO CAPS 200 MG 24 OFEV CAP 100MG 27 OFEV CAP 150MG 27 OFIRMEV 10 ofloxacin (ophth) 15 ofloxacin (otic) 15 olanzapine 12 olopatadine hcl 15 OLYSIO CAP 150MG 23 omeprazole 16 OMNIPAQUE 13 ONCASPAR 7 ondansetron 16 ondansetron hcl 16 ONETOUCH ULTRA BLUE 13 ONETOUCH ULTRA MINI 13 ONIVYDE INJ 43 MG10ML 24 OPANA 11 OPDIVO 7 ophthalmic irrigation solution - intraocular 15 OPSUMIT 20 27 OPSUMIT TAB 10MG 27 ORAP 12 ORBACTIV SOL 400MG 23 ORENCIA 18 ORENITRAM TAB 0125MG 27 ORENITRAM TAB 025MG 27 ORENITRAM TAB 1MG 27 ORENITRAM TAB 25MG 27 ORFADIN SUS 4MGML 27

ORFADIN CAP 10MG 27 ORFADIN CAP 2MG 27 ORFADIN CAP 5MG 27 ORFADIN CAPS 20 MG 27 ORKAMBI 20 oseltamivir phosphate 6 OTEZLA 18 oxacillin sodium 5 oxaliplatin 7 oxandrolone 17 oxazepam 11 oxcarbazepine 11 OXSORALEN 21 oxybutynin chloride 22 oxycodone hcl 11 oxycodone w acetaminophen 11 oxytocin 19 OXYTROL 22 OZURDEX 15

P paclitaxel 7 pamidronate disodium 18 pancuronium bromide 8 PANRETIN GEL 01 27 pantoprazole sodium 16 papaverine hcl 10 PAPAVERINE HCL 19 PAREGORIC 16 paromomycin sulfate 6 paroxetine hcl 12 ped multivitamins wfl amp iron 22 PEDIARIX 21 pediatric multiple vitamin w c 22 pediatric multiple vitamins w iron 22 pediatric multivitamins wfl 22 PEDIATRIC SMALL MASK 13 pediatric vitamins acd w fluoride 22 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

16 PEGASYS 5 PEG-INTRON REDIPEN 5 PENICILLIN G POT IN DEXTROSE 5 penicillin g potassium 5 PENICILLIN G PROCAINE 5 PENICILLIN G SODIUM 5 penicillin v potassium 5 PENLET II BLOOD SAMPLER 13 pentazocine w naloxone 11 PENTETATE CALCIUM TRISODIUM 16 PENTETATE ZINC TRISODIUM 16

pentostatin 7 pentoxifylline 9 PERJETA 7 permethrin 21 perphenazine 12 PERPHENAZINE-AMITRIPTYLINE 12 phenelzine sulfate 12 PHENEX-1 13 phenobarbital 11 PHENOBARBITAL 12 19 PHENOBARBITAL SODIUM 12 PHENOL 9 21 phenoxybenzamine hcl 8 PHENTOLAMINE MESYLATE 8 19 phenylephrine hcl (ophth) 16 phenylephrine hcl (pressors) 8 phenylephrine-chlorphen-dm 20 PHENYLHISTINE DH 20 phenytoin 11 phenytoin sodium 11 phenytoin sodium extended 11 PHOSPHOLINE IODIDE 15 PHYSOSTIGMINE SALICYLATE 8 phytonadione 22 pilocarpine hcl 8 15 pilocarpine hcl (oral) 8 pioglitazone hcl 17 piperacillin sodium-tazobactam sodium 5 PLASMA-LYTE A 14 PLASMANATE 8 PLEGRIDY INJ 25 PLEGRIDY INJ PEN 25 PLEGRIDY STARTER PACK INJ STARTER 25 PLURONIC F127 19 PNEUMOVAX 23 21 PODOCON 22 podofilox 22 PODOPHYLLUM RESIN 19 POLYETHYLENE GLYCOL 400 19 POLYETHYLENE GLYCOL 8000 19 polymyxin b-trimethoprim 15 polysaccharide iron complex 8 POMALYST 7 PORTRAZZA SOLN 800 MG50ML 24 pot amp sod citrates wcitric ac 13 POTABA 22 potassium acetate 14 potassium bicarbonate 14 potassium chloride 14 potassium chloride in dextrose 14 potassium chloride in dextrose amp sodium chloride

14 potassium citrate (alkalinizer) 13 potassium citrate-citric acid 13 potassium phosphate dibasic 14 potassium phosphates 14 PRADAXA 9 PRALUENT SOSY 150 MGML 24 PRALUENT SOSY 75 MGML 24 pramipexole dihydrochloride 11 pramoxine-hc 21 pravastatin sodium 9 PRAXBIND 9 prazosin hcl 9 PRECEDEX 12 prednisolone 15 16 17 prednisolone acetate (ophth) 15 prednisolone sodium phosphate 17 PREDNISOLONE SODIUM PHOSPHATE 15 prednisone 17 PREMARIN 17 PREVNAR 13 21 PREZCOBIX 4 PREZISTA 4 PRIFTIN 5 PRIMAQUINE PHOSPHATE 6 PRIMAXIN IV 5 primidone 11 PRIMSOL 5 probenecid 14 PROBUPHINE IMPLANT KIT IMPL 742 MG 25 PROCAINAMIDE HCL 10 prochlorperazine 12 prochlorperazine edisylate 12 prochlorperazine maleate 12 PROCRIT 9 PROCTOFOAM HC 21 PROCYSBI CAP 25MG 27 PROCYSBI CAP 75MG 27 PROFERRIN ES 8 PROFERRIN-FORTE 8 PROFILNINE 9 24 PROFILNINE SD INJ 24 progesterone 18 progesterone micronized 18 PROGESTERONE MICRONIZED 19 PROGESTERONE WETTABLE 19 PROGLYCEM 10 PROLASTIN-C 14 PROLEUKIN 7 PROMACTA 9

promethazine hcl 6 promethazine wcodeine 20 promethazine-dm 20 propafenone hcl 10 PROPANTHELINE BROMIDE 8 proparacaine hcl 16 propofol 12 propranolol hcl 9 PROPYLENE GLYCOL 19 propylthiouracil 18 PROQUAD 21 PROSTIGMIN 8 PROTAMINE SULFATE 9 protriptyline hcl 12 pseudoephedrine w codeine-gg 20 PULMOZYME 14 PURINETHOL 24 pyrazinamide 5 pyridostigmine bromide 8 pyridoxine hcl 22

Q QUELICIN 8 quetiapine fumarate 12 QUINACRINE HCL 19 quinidine gluconate 10 QUINIDINE SULFATE 10 QVAR 17

R RABAVERT 21 raloxifene hcl 17 ramipril 10 ranitidine hcl 16 RAPIVAB SOLN 200 MG20ML 23 RASUVO 18 RAVICTI LIQ 11GMML 25 RAYALDEE CPCR 30 MCG 27 REBIF INJ 2205 25 REBIF INJ 4405 25 REBIF REBIDOSE INJ 2205 25 REBIF REBIDOSE INJ 4405 25 REBIF REBIDOSE TITRATION PACK SOL

TITRATN 25 REBIF TITRATION PACK SOL PACK 25 RECOTHROM 9 REGRANEX GEL 001 27 RELENZA DISKHALER 6 RELISTOR 12 MG06 ML KIT 26 RELISTOR SOLN 8 MG04ML 26 RELISTOR TABS 150 MG 26

REMICADE 18 REMODULIN 10 RENVELA 14 REOPRO 9 REPATHA PUSH INJ 42035 24 REPATHA SOSY 140 MGML 24 REPATHA SURECLICK SOAJ 140 MGML 24 RESCRIPTOR 4 RESERPINE 10 RESTASIS 15 RETIN-A MICRO 21 RETISERT 15 REVATIO INJ 24 REVATIO TAB 20MG 24 REVLIMID 7 REXULTI TABS 25 REYATAZ 4 ribavirin (hepatitis c) 5 RIDAURA 16 rifabutin 5 RIFAMATE 5 rifampin 5 RILUTEK TAB 50MG 25 riluzole 12 rimantadine hydrochloride 6 RIMSO-50 18 risperidone 12 RITUXAN 7 RIXUBIS SOLR 24 rizatriptan benzoate 11 rocuronium bromide 8 ropinirole hydrochloride 11 rosuvastatin calcium 9 ROTARIX 21 ROTATEQ 21 RUBRACA TABS 24 RUCONEST INJ 2100UNIT 27 RYNODERM CREA 375 27 RYTARY 25

S SABRIL 11 25 SABRIL TAB 500MG 25 SAIZEN CLICKEASY INJ 88MG 26 SAIZEN SOLR 5 MG 26 SALICYLIC ACID 19 saline bacteriostatic 14 salsalate 11 SAMSCA 15 MG TABLET 25 SAMSCA 30 MG TABLET 25 SANDIMMUNE 18

SANTYL 22 SAXENDA 27 SCOPOLAMINE HBR 8 selegiline hcl 11 12 SELENIUM 14 selenium sulfide 21 SELZENTRY 4 6 SENSIPAR 18 SEREVENT DISKUS 8 SEROSTIM 18 sertraline hcl 12 SIGNIFOR INJ 03MGML 26 SIGNIFOR INJ 06MGML 26 SIGNIFOR INJ 09MGML 26 SIGNIFOR LAR INJ 20MG 26 SIGNIFOR LAR INJ 40MG 26 SIGNIFOR LAR INJ 60MG 26 sildenafil citrate (pulmonary hypertension) 10 silver sulfadiazine 21 SIMPONI ARIA SOL 50MG4ML 26 SIMPONI INJ 100MGML 27 SIMPONI INJ 50MG 27 SIMULECT INJ 10MG 27 SIMULECT INJ 20MG 27 simvastatin 9 sirolimus 18 SIRTURO TAB 100MG 23 SIVEXTRO INJ 200MG 23 SIVEXTRO TAB 200MG 23 sodium acetate 13 SODIUM BENZOATE 19 sodium bicarbonate 13 sodium chloride 14 20 22 sodium chloride (gu irrigant) 14 sodium chloride (inhalant) 20 sodium chloride flush 14 sodium citrate amp citric acid 13 SODIUM EDECRIN 14 sodium fluoride 18 sodium fluoride (dental) 18 sodium phenylbutyrate 13 sodium phosphate 14 sodium polystyrene sulfonate 14 sodium thiosulfate 16 SOLIRIS 18 SOMATULINE DEPOT INJ 1205ML 27 SOMATULINE DEPOT INJ 6002ML 27 SOMATULINE DEPOT INJ 9003ML 27 SOMAVERT INJ 10MG 26 SOMAVERT INJ 15MG 26 SOMAVERT INJ 20MG 26 SOMAVERT INJ 25MG 26

SOMAVERT INJ 30 26 SORBITOL 16 19 SORIATANE CAP 10MG 27 SORIATANE CAP 175MG 27 SORIATANE CAP 25MG 27 sotalol hcl 9 sotalol hcl (afibafl) 9 SOTRADECOL 10 SOVALDI 5 SPIRIVA RESPIMAT 8 spironolactone 10 spironolactone amp hydrochlorothiazide 10 SPRITAM TB3D 25 SPRYCEL 7 SQUARIC ACID DIBUTYLESTER 19 SSKI 18 stavudine 4 STELARA 22 STIOLTO RESPIMAT 8 STIVARGA 7 STRENSIQ 15 STREPTOMYCIN SULFATE 5 STRIBILD 4 STRIVERDI RESPIMAT 8 sucralfate 16 sufentanil citrate 11 sulfacetamide sodium (ophth) 15 sulfacetamide sodium w sulfur 22 sulfacetamide sod-prednisolone 15 SULFADIAZINE 5 sulfamethoxazole-trimethoprim 5 SULFAMYLON 21 sulfasalazine 5 SULFUR PRECIPITATED 19 sulindac 11 sumatriptan 11 sumatriptan succinate 11 SUPPRELIN LA KIT 50 MG 24 SUPRAX 5 SURMONTIL 12 SURVANTA 20 SUSTIVA 4 SUTENT 7 SYLATRON KIT 296MCG 24 SYLATRON KIT 444MCG 24 SYLATRON KIT 888MCG 24 SYLVANT 7 SYNAGIS 6 SYNAREL 17 SYNERCID 5 SYNRIBO INJ 35MG 24

T TABLOID 7 TACLONEX OIN 27 TACLONEX SUSP 0005-0064 27 tacrolimus 18 22 tacrolimus (topical) 22 TAFINLAR 7 TAGRISSO 7 TALTZ SOAJ 80 MGML 27 TALTZ SOSY 80 MGML 27 tamoxifen citrate 7 tamsulosin hcl 9 TARCEVA 7 TARGRETIN 7 22 TASIGNA 7 TASMAR 100 MG TABLET 25 TAXOTERE 24 TAXOTERE INJ 80MG4ML 24 TAZORAC 22 TECENTRIQ 7 TECFIDERA CAP 120MG 25 TECFIDERA CAP 240MG 25 TECFIDERA STARTER PACK MIS STARTER 25 TECHNIVIE TABS 125-75-50 MG 23 temazepam 12 TEMODAR CAP 100MG 24 TEMODAR CAP 140MG 24 TEMODAR CAP 180MG 24 TEMODAR CAP 20MG 24 TEMODAR CAP 250MG 24 TEMODAR CAP 5MG 24 TEMODAR INJ 100MG 24 temozolomide 7 TENIPOSIDE 7 terazosin hcl 9 terbinafine hcl 5 terbutaline sulfate 8 testosterone cypionate 17 testosterone enanthate 17 TESTOSTERONE PROPIONATE 20 TETANUS-DIPHTHERIA TOXOIDS TD 20 TETRACAINE HCL 18 tetracaine hcl (ophth) 16 TETRACYCLINE HCL 5 THALOMID 19 THAM 13 theophylline 22 theophylline in dextrose 22 THERACYS 21 thiamine hcl 22 THIOLA 19

thioridazine hcl 12 THIOTEPA 7 thiothixene 12 THROMBATE III 9 THROMBIN-JMI 9 THYMOGLOBULIN INJ 25MG 27 THYMOL 20 THYROGEN 13 TIKOSYN 10 timolol maleate (ophth) 15 TIVICAY 4 6 tizanidine hcl 8 TNKASE 9 TOBRADEX 15 tobramycin 5 15 tobramycin (ophth) 15 tobramycin sulfate 5 TOLBUTAMIDE 17 topiramate 11 topotecan hcl 7 TORISEL 7 torsemide 14 trace minerals (cr-cu-mn-zn) 14 TRACLEER 10 TRADJENTA 17 tramadol hcl 11 tramadol-acetaminophen 11 tranexamic acid 9 TRANEXAMIC ACID 20 TRANSDERM-SCOP (15 MG) 16 tranylcypromine sulfate 12 trazodone hcl 12 TREANDA 24 TREANDA INJ 180MG 24 TREANDA INJ 25MG 24 TREANDA INJ 45MG 24 TRECATOR 5 TRELSTAR DEPOT MIXJECT INJ 375MG 24 TRELSTAR LA MIXJECT INJ 1125MG 24 TRELSTAR MIXJECT INJ 225MG 24 tretinoin 7 21 tretinoin (chemotherapy) 7 TRIAMCINOLONE ACETONIDE 20 triamcinolone acetonide (mouth) 21 triamcinolone acetonide (topical) 21 triamterene amp hydrochlorothiazide 14 TRI-CHLOR 19 trifluoperazine hcl 12 trifluridine 15 trihexyphenidyl hcl 11 trimethoprim 6 TRISENOX 7

TRIUMEQ 4 tropicamide 16 trospium chloride 22 TRUVADA 4 6 TRUZONE PEAK FLOW METER 13 TUBERSOL 13 TWINRIX 21 TYGACIL INJ 50MG 23 TYKERB 7 TYPHIM VI 21 TYSABRI 12 TYVASO 10 TYZEKA 600 MG TABLET 23

U UCERIS TAB 9MG 26 ULTIVA 11 ULTRAVATE LOTN 005 27 UNITUXIN 7 UPTRAVI TABS 27 UREA 20 ursodiol 16

V valacyclovir hcl 6 VALCHLOR GEL 0016 27 VALCYTE TAB 450MG 23 valganciclovir hcl 6 valproate sodium 11 valproic acid 11 valsartan 10 valsartan-hydrochlorothiazide 10 VALSTAR SOL 40MGML 24 VANCOCIN HCL CAP 125MG 23 VANCOCIN HCL CAP 250MG 23 vancomycin hcl 5 VANCOMYCIN HCL IN DEXTROSE 5 VANTAS KIT 50MG 24 VARITHENA 10 VARIVAX 21 VARIZIG 20 vasopressin 18 VECAMYL TAB 25MG 24 VECTIBIX INJ 100MG 24 VECTIBIX INJ 400MG 24 VECTICAL 22 vecuronium bromide 8 VELCADE 7 VEMLIDY TABS 25 MG 23 VENCLEXTA 7 venlafaxine hcl 12

VENOFER 8 VENTAVIS 10 verapamil hcl 9 VERAPAMIL HCL 20 VEXOL 15 VFEND SUS 40MGML 23 VFEND TAB 200MG 23 VFEND TAB 50MG 23 VIBERZI TABS 100 MG 26 VIBERZI TABS 75 MG 26 VIEKIRA PAK TAB 23 VIEKIRA XR TB24 200-833-50- 3333 MG 23 VIMIZIM 15 25 VIMIZIM INJ 5MG5ML 25 VINBLASTINE SULFATE 7 vincristine sulfate 7 vinorelbine tartrate 7 VIRACEPT 4 VIRAZOLE 6 VIREAD 4 VISTIDE INJ 75MGML 23 VISTOGARD PACK 10 GM 27 VISUDYNE 15 VIVITROL 380MG INJ 25 VIVOTIF 21 VORAXAZE 15 voriconazole 5 6 VOTRIENT 7 VPRIV 15 VRAYLAR CAPS 25 VRAYLAR CPPK 15 amp 3 MG 25 VYVANSE 11

W warfarin sodium 9 water for injection sterile 19 20 water for irrigation sterile 14 WIDE-SEAL DIAPHRAGM 60 12

X XALKORI 7 XELJANZ 19 27 XELJANZ TAB 5MG 27 XELJANZ XR TB24 11 MG 27 XENAZINE TAB 125MG 25 XENAZINE TAB 25MG 25 XEOMIN SOLR 200 UNIT 27 XERAC AC 21 XERMELO 250 MG TABLET 25

XGEVA 7 XIFAXAN 5 XOLAIR 20 XTANDI 7 XULANE 17 XURIDEN PACK 2 GM 27 XYNTHA 9 XYREM SOL 500MGML 25

Y YERVOY 7 YF-VAX 21 YODOXIN 6 YONDELIS 7

Z ZALTRAP INJ 1004ML 24 ZALTRAP INJ 2008ML 24 ZANOSAR 7 ZARXIO 9 ZAVESCA CAP 100MG 27 ZELBORAF 7 ZEMAIRA SOLR 1000 MG 27 ZEPATIER TABS 23 zidovudine 4 ZINACEF IN STERILE WATER 5 ZINBRYTA INJ 150MGML 27 zinc sulfate 14 ZINC SULFATE 20 ZINC TRACE METAL 14 ziprasidone hcl 12 zoledronic acid 19 ZOLINZA CAP 100MG 24 zolpidem tartrate 12 ZOMACTON SOLR 10 MG 26 ZOMACTON SOLR 5 MG 26 ZORBTIVE INJ 88MG 26 ZORTRESS TAB 025MG 27 ZORTRESS TAB 05MG 27 ZORTRESS TAB 075MG 27 ZOSTAVAX 21 ZOSYN 5 ZYDELIG 7 ZYFLO CR TAB 600MG 27 ZYFLO TAB 600MG 27 ZYKADIA 7 ZYTIGA 7 ZYVOX SOL 2MGML 23

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除き年中無休）TTYユーザーは 711にお電話く

ださい

Khmer យយើងផដលយេវានៃអនកបកបរប យោយឥតអេនលៃដលអនកយ ើយ 24 យ ោងមយនលៃ 7 នលៃមយអាទតោយ កនងអ ងយ ោងយវើការទងអេ អនកអាច ៃអនកបកបរប យដើមោបជយយៃើយេណររបេអនក អពការរ ោបរងបលទេខភាព របេយយើង អនកកអាចយេនើេេភារៈបដលបាៃបកបរបជាភាសាបខែរ យោយឥតអេនលៃដលអនកបដរ រាៃបតទរេពទមកយយើង តាមយលខ 1-800-464-4000 បាៃ 24 យ ោងមយនលៃ 7 នលៃមយអាទតោយ (បទនលៃបណោយ) អនកយរបើ TTY យៅយលខ 711

Korean 업무 시간 동안에는 요일 및 시간에

관계없이 통역 서비스를 무료로 이용하실 수

있습니다 통역의도움을받아 건강 보험 혜택에

관하여 질문하고 답변을 들으실 수 있습니다 또한

귀하가 사용하는 언어로 번역된 자료를 요청해

무료로 제공받으실 수 있습니다 요일 및 시간에

관계없이 1-800-464-4000번으로 전화해

문의하십시오(공휴일 휴무) TTY 사용자 번호 711

Navajo

1-800-464-4000

Punjabi ਅਸੀ ਕਾਰਵਾਈ ਦ ਸਾਰ ਘਟਿਆ ਦ ਦਰਾਨ ਤਹਾਨ ਟਿਨਾ

ਟਕਸੀ ਲਾਗਤ ਦ ਟਦਨ ਦ 24 ਘਿ ਹਫਤ ਦ 7 ਟਦਨ ਦਭਾਸੀਆ

ਸਵਾਵਾ ਮਹਈਆ ਕਰਵਾਉਦ ਹਾ ਤਸੀ ਸਾਡੀ ਟਸਹਤ ਦਖਭਾਲ ਕਵਰਜ

ਿਾਰ ਆਪਣ ਸਵਾਲਾ ਦ ਜਵਾਿ ਲਈ ਇਕ ਦਭਾਸੀਏ ਦੀ ਮਦਦ ਲ ਸਕਦ

ਹ ਤਸੀ ਟਿਨਾ ਟਕਸੀ ਲਾਗਤ ਦ ਸਮਗਰੀਆ ਨ ਆਪਣੀ ਭਾਸਾ ਟਵਚ

ਅਨਵਾਦ ਕਰਵਾਉਣ ਦੀ ਿਨਤੀ ਕਰ ਸਕਦ ਹ ਿਸ ਟਸਰਫ਼ ਸਾਨ

1-800-464-4000 ਤ ਟਦਨ ਦ 24 ਘਿ ਹਫ਼ਤ ਦ 7 ਟਦਨ (ਛਿੀਆ

ਵਾਲ ਦਟ ਨ ਿਦ ਰਟਹਦਾ ਹ )ਫ਼ਨ ਕਰ TTY ਦਾ ਉਪਯਗ ਕਰਨ ਵਾਲ

711 lsquoਤ ਫ਼ਨ ਕਰਨ

Russian Мы всегда в часы работы обеспечиваем

Вас услугами устного переводчика 24 часа в сутки

7 дней в неделю Чтобы получить ответы на свои

вопросы о нашем страховом покрытии услуг

здравоохранения Вы можете воспользоваться

помощью устного переводчика Вы также можете

запросить бесплатный перевод материалов на Ваш

язык Просто позвоните нам по телефону

1-800-464-4000 который доступен 24 часа в сутки

7 дней в неделю (кроме праздничных дней)

Пользователи линии TTY могут звонить по

номеру 711

Spanish Ofrecemos servicios de traduccioacuten al espantildeol

sin costo alguno para usted durante todo el horario de

atencioacuten 24 horas al diacutea siete diacuteas a la semana Puede

contar con la ayuda de un inteacuterprete para responder las

preguntas que tenga sobre nuestra cobertura de atencioacuten

meacutedica Ademaacutes puede solicitar que los materiales se

traduzcan a su idioma sin costo alguno Solo llame al

1-800-788-0616 24 horas al diacutea siete diacuteas a la semana

(cerrado los diacuteas festivos) Los usuarios de TTY deben

llamar al 711

Tagalog May magagamit na mga serbisyo ng tagasalin

ng wika nang wala kang babayaran 24 na oras bawat

araw 7 araw bawat linggo sa lahat oras ng trabaho

Makakatulong ang tagasalin ng wika sa pagsagot sa

mga tanong mo tungkol sa iyong coverage sa

pangangalagang pangkalusugan Maaari kang humingi

ng mga babasahin na isinalin sa iyong wika nang wala

kang babayaran Tawagan lamang kami sa

1-800-464-4000 24 na oras bawat araw 7 araw bawat

linggo (sarado sa mga pista opisyal) Ang mga

gumagamit ng TTY ay maaaring tumawag sa 711

Thai เรามบรการลามฟรส าหรบคณตลอด 24 ชวโมง

ทกวนตลอดชวโมงท าการของเราคณสามารถขอใหลาม

ชวยตอบค าถามของคณทเกยวกบความคมครองการดแล

สขภาพของเราและคณยงสามารถขอใหมการแปล

เอกสารเปนภาษาทคณใชไดโดยไมมการคดคาบรการ

เพยงโทรหาเราทหมายเลข 1-800-464-4000 ตลอด 24

ชวโมงทกวน (ปดใหบรการในวนหยดราชการ) ผใช TTY

โปรดโทรไปท 711

Chinese 我們每週 7天每天 24小時在所有營業時

間内免費爲您提供口譯服務您可以請口譯員協助

回答有關我們健康保險的問題您也可以免費索取

翻譯成您所用語言的資料我們每週 7天每天 24

小時均歡迎您打電話 1-800-757-7585 前來聯絡（節假

日休息）聽障及語障專線 (TTY) 使用者請撥 711

Vietnamese Chuacuteng tocirci cung cấp dịch vụ thocircng dịch

miễn phiacute cho quyacute vị 24 giờ mỗi ngagravey 7 ngagravey trong tuần

trong tất cả caacutec giờ lagravem việc Quyacute vị coacute thể được thocircng

dịch viecircn giuacutep trả lời thắc mắc về quyền lợi bảo hiểm sức

khỏe của chuacuteng tocirci Quyacute vị cũng coacute thể yecircu cầu được cấp

miễn phiacute tagravei liệu phiecircn dịch ra ngocircn ngữ của quyacute vị Chỉ

cần gọi cho chuacuteng tocirci tại số 1-800-464-4000 24 giờ mỗi

ngagravey 7 ngagravey trong tuần (trừ caacutec ngagravey lễ) Người dugraveng

TTY xin gọi 711

Nondiscrimination Notice Kaiser Permanente does not discriminate on the basis of age race ethnicity color national origin cultural background ancestry religion sex gender identity gender expression sexual orientation marital status physical or mental disability source of payment genetic information citizenship primary language or immigration status

Language assistance services are available from our Member Services Contact Center 24 hours a day seven days a week (except closed holidays) Interpreter services including sign language are available at no cost to you during all hours of operation We can also provide you your family and friends with any special assistance needed to access our facilities and services In addition you may request health plan materials translated in your language and may also request these materials in large text or in other formats to accommodate your needs For more information call 1-800-464-4000 (TTY users call 711)

A grievance is any expression of dissatisfaction expressed by you or your authorized representative through the grievance process A grievance includes a complaint or an appeal For example if you believe that we have discriminated against you you can file a grievance Please refer to your Evidence of Coverage or Certificate of Insurance or speak with a Member Services representative for the dispute resolution options that apply to you This is especially important if you are a Medicare MediCal MRMIP MediCal Access FEHBP or CalPERS member because you have different dispute resolution options available

You may submit a grievance in the following ways

bull By completing a Complaint or Benefit ClaimRequest form at a Member Services office located at a Plan Facility(please refer to Your Guidebook for addresses)

bull By mailing your written grievance to a Member Services office at a Plan Facility (please refer to Your Guidebook foraddresses)

bull By calling our Member Service Contact Center toll free at 1-800-464-4000 (TTY users call 711)

bull By completing the grievance form on our website at kporg

Please call our Member Service Contact Center if you need help submitting a grievance

The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to discrimination on the basis of race color national origin sex age or disability You may also contact the Kaiser Permanente Civil Rights Coordinator directly at One Kaiser Plaza 12th Floor Suite 1223 Oakland CA 94612

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at ocrportalhhsgovocrportallobbyjsf or by mail or phone at US 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 wwwhhsgovocrofficefileindexhtml

Kaiser Permanente no discrimina a ninguna persona por su edad raza etnia color paiacutes de origen antecedentes culturales ascendencia religioacuten sexo identidad de geacutenero expresioacuten de geacutenero orientacioacuten sexual estado civil discapacidad fiacutesica o mental fuente de pago informacioacuten geneacutetica ciudadaniacutea lengua materna o estado migratorio

La Central de Llamadas de Servicio a los Miembros (Member Service Contact Center) brinda servicios de asistencia con el idioma las 24 horas del diacutea los siete diacuteas de la semana (excepto los diacuteas festivos) Se ofrecen servicios de interpretacioacuten sin costo alguno para usted durante el horario de atencioacuten incluido el lenguaje de sentildeas Tambieacuten podemos ofrecerle a usted a sus familiares y amigos cualquier ayuda especial que necesiten para acceder a nuestros centros de atencioacuten y servicios Ademaacutes puede solicitar los materiales del plan de salud traducidos a su idioma y tambieacuten los puede solicitar con letra grande o en otros formatos que se adapten a sus necesidades Para obtener maacutes informacioacuten llame al 1-800-788-0616 (los usuarios de la liacutenea TTY deben llamar al 711)

Una queja es una expresioacuten de inconformidad que manifiesta usted o su representante autorizado a traveacutes del proceso de quejas Una queja incluye una queja formal o una apelacioacuten Por ejemplo si usted cree que ha sufrido discriminacioacuten de nuestra parte puede presentar una queja Consulte su Evidencia de Cobertura (Evidence of Coverage) o Certificado de Seguro (Certificate of Insurance) o comuniacutequese con un representante de Servicio a los Miembros (Member Services) para conocer las opciones de resolucioacuten de disputas que le corresponden Esto tiene especial importancia si

es miembro de Medicare MediCal MRMIP (Major Risk Medical Insurance Program Programa de Seguro Meacutedico para Riesgos Mayores) MediCal Access FEHBP (Federal Employees Health Benefits Program Programa de Beneficios Meacutedicos para los Empleados Federales) o CalPERS ya que dispone de otras opciones para resolver disputas

Puede presentar una queja de las siguientes maneras

bull completando un formulario de queja o de reclamacioacutensolicitud de beneficios en una oficina de Servicio a losMiembros ubicada en un centro del plan (consulte las direcciones en Su Guiacutea)

bull enviando por correo su queja por escrito a una oficina de Servicio a los Miembros en un centro del plan (consulte lasdirecciones en Su Guiacutea)

bull llamando a la liacutenea telefoacutenica gratuita de la Central de Llamadas de Servicio a los Miembros al 1-800-788-0616 (losusuarios de la liacutenea TTY deben llamar al 711)

bull completando el formulario de queja en nuestro sitio web en kporg

Llame a nuestra Central de Llamadas de Servicio a los Miembros si necesita ayuda para presentar una queja

Se le informaraacute al coordinador de derechos civiles (Civil Rights Coordinator) de Kaiser Permanente de todas las quejas relacionadas con la discriminacioacuten por motivos de raza color paiacutes de origen geacutenero edad o discapacidad Tambieacuten puede comunicarse directamente con el coordinador de derechos civiles de Kaiser Permanente en One Kaiser Plaza 12th Floor Suite 1223 Oakland CA 94612

Tambieacuten puede presentar una queja formal de derechos civiles de forma electroacutenica ante la Oficina de Derechos Civiles (Office for Civil Rights) en el Departamento de Salud y Servicios Humanos de los Estados Unidos (U S Department of Health and Human Services) mediante el portal de quejas formales de la Oficina de Derechos Civiles (Office for Civil Rights) en ocrportalhhsgovocrportallobbyjsf o por correo postal o por teleacutefono a US 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(liacutenea TDD) Los formularios de queja formal estaacuten disponibles enwwwhhsgovocrofficefileindexhtml

Kaiser Permanente禁止以年齡種族族裔膚色原國籍文化背景血統宗教性別性別認同性別表達方式

性取向婚姻狀況生理或心理殘障支付來源遺傳資訊公民身份主要語言或移民身份為由而對任何人進行歧視

計劃成員服務聯絡中心提供語言協助服務每週七天24小時晝夜服務（法定節假日除外）本機構在全部辦公時間內免費

為您提供口譯服務其中包括手語我們還可為您您的親屬和朋友提供任何必要的特別補助以便您使用本機構的設施

與服務此外您還可請求以您的語言提供健康保險計劃資料之譯本並可請求採用大號字體或其他版本格式提供此類資

料的譯本藉以滿足您的需求若需詳細資訊請致電1-800-757-7585（TTY專線使用者請撥711）

冤情申訴係指您或您的授權代表透過冤情申訴程序所表達的不滿陳訴申訴冤情包括投訴或上訴例如如果您認為自己

受到本機構的歧視則可提出冤情申訴若需瞭解可供您選擇的適用爭議解決方案請參閱您的《承保範圍說明書》（

Evidence of Coverage）或《保險證明書》（Certificate of Insurance）或者與計劃成員服務代表交談對於MedicareMediCalMRMIPMediCal AccessFEHBP或CalPERS計劃成員這尤其重要原因在於為這些成員提供的爭議解決

方案選擇有所不同

您可透過以下方式提出冤情申訴

bull 於設在本計劃服務設施的某個計劃成員服務處填妥一份《投訴或保險福利索償請書》（請參閱您的《通訊地址指南冊》

以便查找相關地址）

bull 將您的冤情申訴書郵寄至設在本計劃服務設施的某個計劃成員服務處（請參閱您的《通訊地址指南冊》以便查找相關

地址）

bull 免費致電本機構的計劃成員服務聯絡中心電話號碼是1-800-757-7585（TTY專線使用者請撥711）

bull 在本機構的網站上填妥一份冤情申訴書網址是kporg

如果您在提交冤情申訴書的過程中需要協助請致電本機構的計劃成員服務聯絡中心

涉及種族膚色原國籍性別年齡或身體殘障歧視的一切冤情申訴都將通告給Kaiser Permanente的民權事務協調員（

Civil Rights Coordinator）您也可與Kaiser Permanente的民權事務協調員直接聯絡聯絡地址是One Kaiser Plaza 12th Floor Suite 1223 Oakland CA 94612

您還可以採用電子方式透過民權辦公處（Office for Civil Rights）的投訴入口網站（Civil Rights Complaint Portal）向美國

衛生與公共服務部民權辦公處（US Department of Health and Human Services Office for Civil Rights）提出民權投訴

網址是ocrportalhhsgovocrportallobbyjsf或者按照如下聯絡資訊採用郵寄或電話方式聯絡US 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專線）可從網站上下載投

訴書網址是wwwhhsgovocrofficefileindexhtml

California Member Services 24 hours a day seven days a week (closed holidays) 1-800-464-4000 English1- 800-788-0616 Spanish1-800-757-7585 Chinese dialects711 TTY for the hearingspeech impaired

Please recycle MOM 60379021 092015

Drug List

ANTI-INFECTIVE AGENTS

ANTIHISTAMINE DRUGS

ANTINEOPLASTIC AGENTS

AUTONOMIC DRUGS

BLOOD DERIVATIVES


CARDIOVASCULAR DRUGS

CENTRAL NERVOUS SYSTEM AGENTS

CONTRACEPTIVES (FOAMS DEVICES)

DEVICES

DIAGNOSTIC AGENTS


ENZYMES


GASTROINTESTINAL DRUGS

GOLD COMPOUNDS

HEAVY METAL ANTAGONISTS

HORMONES AND SYNTHETIC SUBSTITUTES

IMMUNOLOGICAL AGENTS

LOCAL ANESTHETICS

MISCELLANEOUS THERAPEUTIC AGENTS

OXYTOCICS

PHARMACEUTICAL AIDS

RESPIRATORY TRACT AGENTS

SERUMS TOXOIDS AND VACCINES

SKIN AND MUCOUS MEMBRANE AGENTS

SMOOTH MUSCLE RELAXANTS

VITAMINS

Drugs listed below are not on the Planrsquos Formulary

Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z


Nondiscrimination Notice

Are there any restrictions on the drugs covered on the Formulary Some covered drugs may have additional requirements or limits on coverage such as Quantity Limits For certain drugs Kaiser Permanente may limit the amount of the drug dispensed to a certain daysrsquo supply Additionally when there is a national shortage of a drug we may limit the quantity of the drug dispensed

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

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

What drugs are eligible to be mailed from the mail order pharmacy Most drugs can be mailed from our mail order pharmacy Some drugs (for example drugs that are extremely high cost or require special handling) may not be eligible for mailing Drugs cannot be mailed outside the United States

You can order refills through our mail-order service online at kporgrefill or by phone or mobile app There is no extra charge for mail order The appropriate cost share (according to your prescription drug benefit) will apply

Your prescription drug benefit may have a lower cost share if you use the mail order pharmacy

Please refer to your Evidence of Coverage or Certificate of Insurance for complete details of your prescription drug benefit

Requirement Limits

CEFOTAXIME SODIUM 1

Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

CEFOTAXIME SODIUM 1

Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

CEFOTAXIME SODIUM 1

Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

CEFOTAXIME SODIUM 1

Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Requirement Limits

Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Name of drug

HYPOTENSIVE AGENTS

MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



MG ILARIS INJ 180MG

STARTER

Name of drug

ENZYMES ENZYMES

Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Name of drug

VITAMINS VITAMIN D

8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



8 8-MOP 21

siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



siv TTY hu 711

ださい

관계없이 1-800-464-4000번으로 전화해

Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Navajo

1-800-464-4000

номеру 711

llamar al 711

TTY xin gọi 711

地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



地址）

Drug List


ANTIHISTAMINE DRUGS


AUTONOMIC DRUGS

BLOOD DERIVATIVES





DEVICES

DIAGNOSTIC AGENTS


ENZYMES



GOLD COMPOUNDS




LOCAL ANESTHETICS


OXYTOCICS

PHARMACEUTICAL AIDS





VITAMINS


Index

8 - A

B

C

D

E - F

G

H - I

J - L

M

N

O

P

Q - R

S

T

U - V

W - Z



Documents

2017 California Marketplace Formulary · The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g. ALBENZA) and generic drugs are listed in lower-case