2017 National Preferred Formulary Comprehensive - … National Preferred Formulary.pdfThe 2017 National Preferred Formulary drug list is shown below. ... clindamycin hcl . ... edrophonium

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National Preferred Formulary 2018

This document represents the efforts of the Remedy-One Pharmacy and Therapeutics (P&T) and Formulary Committees, in collaboration with Kroger Prescription Plans (KPP), to provide physicians and pharmacists with a method to evaluate the safety, efficacy and cost-effectiveness of commercially available drug products. A structured approach to the drug selection.

This is accomplished through the auspices of the P&T and Formulary Committees. These committees meet quarterly and more often as warranted to ensure clinical relevancy of the Formulary. To accommodate changes to this document, updates are made accessible as necessary.

The P&T and Formulary Committees use the following criteria in the evaluation of drug selection for the Portfolio Formulary:Drug safety profileDrug efficacyComparison of relevant therapeutic benefits to current formulary agents of similar use, and to minimize therapeuticduplication where possibleCost-effectiveness relative to comparable therapies

How to Use the FormularyThe Formulary is a list of medications available to KPP members under their pharmacy benefit. All drugs are listed by their generic names and most common proprietary (branded) name. The Formulary may be accessed by using the index, either by generic or proprietary name (in capital letters) and by therapeutic drug category. In situations where an FDA approved generic equivalent is available, brand names are listed for reference purposes only. Brand names usually cost more and are not preferred over generic alternatives. Any drugs not found in this formulary listing or any formulary updates published by KPP are considered non-formulary drugs and require prior authorization.

All drugs are listed in each category in alphabetical order by generic name. All drugs have a generic name. If the generic drug is FDA approved it will appear bolded in the formulary listing.

Some drugs on the formulary have certain process requirements or limitations for coverage. These are denoted throughout the document using the following symbols:

AGE Age Edit Drug may not be recommended for some patients based on age.

G Gender Edit Drug may not be recommended for some patients base on gender.

PA Prior Authorization

Requires your doctor to request prior authorization to support use of this drug.

QL Quantity Limit Coverage may be limited to specific quantities per prescription and/or time period

SP Specialty Requires your doctor to request prior authorization to support use of this drug. Drugs may need to be filled at a Specialty pharmacy as opposed to retail.

ST Step Therapy Coverage may depend on previous use of another drug

Benefit Coverage and LimitationsThis printed Formulary does not provide information regarding the specific coverage and limitations an individual member may have. Many members have specific benefit inclusions, exclusions, copays, or a lack of coverage, which are not reflected in the Formulary. For example, drugs for the treatment of infertility may not be covered. Refer to your benefit summary for more information regarding your specific coverage.

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National Preferred FormularyJanuary 2018

The Formulary applies only to outpatient drugs provided to members, and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact their Plan Sponsor or KPP at (800) 482-1285.

Excluded Agents As new drugs become available, they will be considered for coverage under the Natural Preferred Formulary. The plan administrator has the right to decide what drugs are covered and to what extent, as well as the right to modify coverage including the exclusion of any prescription drugs. Please note that prescribing guidelines such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to Formulary Therapeutic Alternatives.

Depending upon a member’s specific benefit, the following topics may apply:

1. Generic SubstitutionWhen available, FDA approved generic drug used in most situations, regardless of the brand name indicated. Members usually have lower copays and or co-insurance when they use generic drugs.This policy is not meant to preclude or supplant any state statues that may exist. All drugs that are or become available generically are subject to review by the P&T Committee. KPP approves such multi- source drugs for addition to the MAC list based on the following criteria:

A multi- source drug product manufactured by at least one (1) nationally marketed company.At least one (1) of the generic manufacturer’s products must have an “A” rating or the generic product has been determined to be unassociated with efficacy, safety or bioequivalency concerns by the P&T Committee.Drug product will be approved for generic substitution by the P&T Committee.

If a member requests a brand name drug instead of an approved generic, the member, based on their coverage, is typically required to pay the difference in cost between the brand and the generic. Doctors can request prior authorization if they determine that there is a medical need for the brand name drug.

2. Three Tier Benefit The Formulary may be applied to a three tier benefit design, where the member shares the cost of prescription drug therapy at three levels of copayment. In most instances, generically available drugs will be covered under the first or lowest copay tier, branded drugs listed on the Formulary will be covered under the second copay tier, and branded drugs not on the Formulary will be covered under the third or highest copay tier.

3. Medication Request ProcessDepending upon plan benefit design, a medication request process may apply as follows:

A. Formulary DrugsDrugs that are listed in the Formulary with associated Prior Authorization (PA) require evaluation, per P&T Committee Prior Authorization guidelines prior to dispensing at a network pharmacy. Each request will be reviewed on an individual patient need basis. If the request does not meet the guidelines established by the P&T Committee, the request will not be approved and alternative therapy may be recommended.

B. Non-Formulary DrugsAny drug not found in the Formulary listing, or any Formulary updates published by KPP, shall be considered a Non-Formulary drug. Coverage for non-formulary agents may be applied for in advance. When a member gives a prescription order for a non-formulary drug to a pharmacist, the pharmacist will evaluate the patient’s drug history and contact the physician to determine if there is a reasonable medical need for a non-formulary drug. Each request will be reviewed on an individual patient need basis. Approval will be given if a documented medical need exists. The following basic guidelines are used:

The use of formulary drugs is contraindicated in the patient.The patient has failed an appropriate trial of formulary or related agents.



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National Preferred FormularyJanuary 2018

The choices available in the formulary are not suited for the present patient care need, and the drug selected is required for patient safety.The use of a formulary drug may provoke an underlying condition, which would be detrimental to patient care.

If the request does not meet the guidelines established by the P&T Committees, the request will not be approved and alternative therapy may be recommended.

C. Obtaining CoverageCoverage, questions or information regarding the medication request or formulary process may be obtained by:1. Faxing a completed Medication Request Form to MedImpact at (858) 790-7100.2. Contacting KPP at (800) 482-1285 and providing all necessary information requested.

KPP will provide an authorization number, specific for the medical need, for all approved requests. Non-approved requests may be appealed. The prescriber must provide information to support the appeal on the basis of medical necessity. Prior Authorization is generally not available for drugs that are specifically excluded by benefit design.

4. General ExclusionsA. Over the Counter (OTC) medications or their equivalents, unless otherwise specified in the Formulary listing.B. Nicotine Smoking Cessation products (i.e., transdermal nicotine, nicotine gum, nicotine inhaler).C. Drugs specifically listed as not covered.D. Any drug products used for cosmetic purposes.E. Experimental drug products or any drug product used in an experimental manner.F. Replacement of lost or stolen medication.G. Non self-administered injectable drug products unless otherwise specified in the Formulary listing.H. Foreign sourced drugs or drugs not approved by the United States Food & Drug Administration.

The P&T and Formulary Committees recognize that not all medical needs can be met with this document and encourageinquiries about alternative therapies.

5. Pharmacist and Physician CommunicationThe Formulary is a tool to promote cost- effective prescription drug use. The P&T and Formulary Committees have madeevery attempt to create a document that meets all therapeutic needs; however the art of medicine makes this formidable task.



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National Preferred Formulary 2018 Exclusions

The excluded medications shown below are not covered on the formulary. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price.

Take action to avoid paying full price. If you’re currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card.

Drug Class Excluded Medications Preferred AlternativesAUTONOMIC & CENTRAL NERVOUS SYSTEM Anti-Migraine Therapy Sumavel Dosepro sumatriptan injection

Duchenne Muscular Dystrophy (DMD) AgentsEmflaza prednisone solution, prednisone tablets

Exondys 51 No alternatives recommended

Long-Acting Opioid Oral Analgesics Opana ER, Oxycodone ER hydromorphone ER, morphine sulfate ER,oxymorphone ER, Hysingla ER, Nucynta ER,Oxycontin

Narcotic Analgesics Buprenorphine Patches, Butrans fentanyl patches, hydromorphone ER, morphine sulfate ER, oxymorphone ER, Hysingla ER, Nucynta ER, Oxycontin

Narcotic Antagonists Evzio naloxone syringe, Narcan Nasal Spray

Transmucosal Fentanyl Analgesics Abstral, Fentora, Lazanda fentanyl citrate lozenges

DERMATOLOGICAL Oral Agents For Rosacea

Doxycycline 40 MG Capsules Oracea

Topical Acne/Antibiotic Combinations Aktipak, Veltinclindamycin/benzoyl peroxide, clindamycin/tretinoin, erythromycin/benzoyl peroxide, Acanya, Onexton

Topical Agents for Actinic Keratosis Fluorouracil 0.5% Cream, Zyclara diclofenac 3% gel, fluorouracil 2% solution,fluorouracil 5% cream, imiquimod 5% cream, Carac, Picato

DIABETES Blood Glucose Meters & Test Strips

Abbott (FreeStyle, Precision), Bayer (Breeze, Contour),

National Medical (Advocate), Omnis Health (Embrace, Victory), Roche (Accu-Chek), Trividia (TRUEtest, TRUEtrack), UniStrip

LifeScan (OneTouch), Kroger

Dipeptidyl Peptidase-4 Inhibitors & Combinations

Alogliptin, Nesina, Onglyza Januvia, Tradjenta

Alogliptin/Metformin, Kazano, Kombiglyze XR Janumet, Janumet XR, Jentadueto, Jentadueto XR

Glucagon-Like Peptide-1 Agonists Adlyxin, Tanzeum, Victoza Bydureon, Byetta, Trulicity

InsulinsNovolin Humulin

Apidra, NovoLog Humalog

EAR/NOSE Nasal Steroids

Beconase AQ, Zetonna budesonide, flunisolide, fluticasone, mometasone, Qnasl

Otic Fluoroquinolone Antibiotics Cetraxalciprofloxacin ear solution, ofloxacin ear solution, Ciprodex, Otovel

ENDOCRINE (OTHER) Estrogen and Estrogen Modifiers for Vaginal Symptoms

Femring estradiol patches, estradiol tablets, yuvafem,Estrace Cream, Estring, Premarin Cream, Premarin Tablets

Growth HormonesGenotropin,Humatrope,Nutropin AQ, Nutropin AQNuspin, Omnitrope, Saizen, SaizenPrep,Zomacton

Norditropin

Somatostatin Analogs Sandostatin LAR Depot, Signifor LAR Somatuline DepotTopical Estrogen Gels Estrogel Divigel

Topical Testosterone Products Fortesta, Natesto, Testim, Testosterone Gel, Vogelxo

AndroGel 1.62%



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National Preferred Formulary 2018 Exclusions

Drug Class Excluded Medications Preferred AlternativesGASTROINTESTINAL Inflammatory Bowel Agents

Asacol HD, Delzicol, Dipentum, Mesalamine 800 MG Delayed-Release

balsalazide disodium, mesalamine1.2 gmdelayed release, sulfasalazine, Apriso, Pentasa

Irritable Bowel Syndrome and Chronic Constipation Agents

Trulance Amitiza, Linzess

Pancreatic Enzymes Pancreaze, Pertzye, Ultresa Creon, Zenpep

Proton Pump InhibitorsAciphex Sprinkle, Prevacid Solutab, Prilosec Suspension, Protonix Suspension

esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, Nexium Packets

HEMATOLOGICAL Erythropoiesis-Stimulating Agents Aranesp, Epogen ProcritGranulocyte Colony Stimulating Factors Neupogen Granix, Zarxio

HEPATITIS Hepatitis C

Daklinza, Mavyret,Olysio, Technivie, Viekira Pak, Viekira XR, Zepatier

Epclusa, Harvoni, Sovaldi, Vosevi

MUSCULOSKELETAL & RHEUMATOLOGY Gout Therapy Colchicine Colcrys, Mitigare

Osteoporosis Forteo Tymlos

OBSTETICAL & GYNECOLOGICAL Gonadotropin-Releasing Hormone (GnRH) Antagonists (for Infertility)

Ganirelix Acetate Cetrotide

Ovulatory Stimulants (Follitropins) Bravelle, Gonal-f, Gonal-f RFF, Gonal-f RFF Redi-ject Follistim AQ

Vaginal Progesterones Endometrin Crinone 8%Gel

OPTHALMIC AntiglaucomaDrugs(Beta-AdrenergicBlockers)

Istalol,TimopticOcudose Betaxolol drops, levobunolol drops, timolol drops, Alphagan P 0.1%, Combigan

AntiglaucomaDrugs(OphthalmicProstaglandins) Zioptan Bimatoprost drops, latanoprost drops, Lumigan, Travatan Z

OphthalmicNon-SteroidalAnti-InflammatoryDrugs(NSAIDs) Acuvail, Nevanac bromfenac drops, diclofenac drops, ketorolac drops, Illevro, Prolensa

OSTEOARTHRITIS HyaluronicAcidDerivatives

Gel-One,Gelsyn-3,Genvisc850,Hyalgan,Hymovis, Supartz,SupartzFX,Synvisc,Synvisc-One

Euflexxa, Monovisc, Orthovisc

RENAL DISEASE Phosphate Binders

Fosrenol, Renagel Sevelamer carbonate, Phoslyra, Renvela Tablets, Velphoro

RESPIRATORY Epinephrine Auto-Injector Systems

Auvi-Q,EpinephrineAuto-Injector(byA-SMedication, Impax &Lineage)

Epinephrine Auto-Injector (by Mylan), EpiPen, EpiPen Jr

Pulmonary Anti-Inflammatory Inhalers Alvesco, ArmonAir RespiClick, Arnuity Ellipta, Flovent Diskus/HFA, Pulmicort Flexhaler

Asmanex HFA/Twisthaler, Qvar

Short-Acting Beta2-Agonist Inhalers Levalbuterol HFA, Proventil HFA,Xopenex HFA ProAir HFA/Respiclick, Ventolin HFA

UROLOGICAL ErectileDysfunctionOralAgents Levitra, Staxyn, Stendra Cialis, Viagra

WEIGHT LOSS Weight Loss Agents Qsymia Benzphetamine, diethylpropion, phentermine

Indication Based Management

Drug Class Excluded Medications Preferred Alternatives INFLAMMATORY CONDITIONS*

* Please note that product placement for this class is under consideration and changes may occur based upon changes inmarketdynamicsandnewproduct launches.

Cimzia, Entyvio, Inflectra, Kineret, Orencia, Orencia Clickjet, Rituxan, Rituxan Hycela, Siliq, Simponi, Simponi Aria, Taltz

Cosentyx, Enbrel, Humira, Otezla

Drug Name Tier Requirements/LimitsALLERGY

ANTIHISTAMINES - 1ST GENERATIONcarbinoxamine maleate CLISTIN 1 AGE: >= 2 YEARScarbinoxamine maleate PALGIC 1 AGE: >= 2 YEARSclemastine fumarate TAVIST 1cyproheptadine hcl PERIACTIN 1

diphenhydramine hcl BENADRYL (50MG/ML) (SYRINGE) 1

diphenhydramine hcl BENADRYL (50MG/ML) (VIAL) 1

hydroxyzine hcl ATARAX 1hydroxyzine hcl VISTARIL 1hydroxyzine pamoate VISTARIL 1

promethazine hcl PHENERGAN (12.5MG) (TABLET) 1

promethazine hcl PHENERGAN (25MG) (TABLET) 1

promethazine hcl PHENERGAN (25MG/ML) (SYRINGE) 1

promethazine hcl PHENERGAN (25MG/ML) (VIAL) 1

promethazine hcl PHENERGAN (50MG) (TABLET) 1

promethazine hcl PHENERGAN (50MG/ML) (VIAL) 1

promethazine hcl PHENERGAN VC 1ANTIHISTAMINES - 2ND GENERATION

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

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

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

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

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

1 QL: 10mL IN 1 DAY

levocetirizine dihydrochloride XYZAL (5 MG)(TABLET) 1

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

NASAL ANTIHISTAMINE & ANTI-INFLAM. STEROID COMB.AZELAS/FLUTICASONE/SOD CHLORID TICALAST 3AZELASTINE/FLUTICASONE DYMISTA 2 ST, QL: 23gm IN 30 DAYS

NASAL ANTI-INFLAMMATORY STEROIDSBECLOMETHASONE DIPROPIONATE QNASL 2 QL: 8.7gm IN 30 DAYSBECLOMETHASONE DIPROPIONATE QNASL CHILDREN 2 QL: 4.9gm IN 30 DAYSCICLESONIDE OMNARIS 3 STflunisolide NASALIDE 1 QL: 25mL IN 30 DAYSfluticasone propionate FLONASE 1 QL: 16gm IN 30 DAYSFLUTICASONE PROPIONATE XHANCE 3 ST, QL: 16mL IN 30 DAYSFLUTICASONE/SOD CHL/SOD BICARB TICANASE 3FLUTICASONE/SOD CHL/SOD BICARB TICASPRAY 3mometasone furoate NASONEX 1 QL: 17gm IN 30 DAYS

National Formulary

KROGER PRESCRIPTION PLANS Page 1 of 113

Drug Name Tier Requirements/LimitsANTIEMESIS/ANTIVERTIGO

ANTIEMETIC/ANTIVERTIGO AGENTSaprepitant EMEND (125 MG)

(CAPSULE) 1 QL: 1 IN 21 DAYS

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

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

aprepitant EMEND (40 MG)(CAPSULE) 1 QL: 1 IN 28 DAYS

aprepitant EMEND (80 MG)(CAPSULE) 1 QL: 2 IN 21 DAYS

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

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

dronabinol MARINOL 1 ST, QL: 2 IN 1 DAYDRONABINOL SYNDROS 3 ST, QL: 60mL IN 30 DAYSFOSAPREPITANT DIMEGLUMINE EMEND 2GRANISETRON SANCUSO 2 ST, QL: 1 IN 7 DAYS

granisetron hcl KYTRIL (1 MG)(TABLET) 1 ST, QL: 8 IN 30 DAYS

meclizine hcl ANTIVERT (12.5MG) (TABLET) 1

meclizine hcl ANTIVERT (25 MG)(TABLET) 1

NETUPITANT/PALONOSETRON HCL AKYNZEO 2 QL: 1 IN 28 DAYSondansetron ZOFRAN ODT 1

ondansetron hcl ZOFRAN (2 MG/ML)(VIAL) 1

ondansetron hcl ZOFRAN (24 MG)(TABLET) 1


ondansetron hcl ZOFRAN (4 MG/5ML) (SOLUTION) 1 QL: 50mL IN 15 DAYS


ondansetron hcl in 0.9 % nacl 1ondansetron hcl in d5w 1

ondansetron hcl/pfZOFRANPRESERVATIVEFREE

1

prochlorperazine COMPAZINE 1prochlorperazine maleate COMPAZINE 1promethazine hcl PHENERGAN 1

ROLAPITANT HCL VARUBI (90 MG)(TABLET) 2 QL: 2 IN 14 DAYS

scopolamine TRANSDERM-SCOP 1

trimethobenzamide hcl TIGAN (300 MG)(CAPSULE) 1

ASTHMA AND COPDANTICHOLINERGIC, ORALLY INHALED SHORT ACTING

ipratropium bromide ATROVENT 1IPRATROPIUM BROMIDE ATROVENT HFA 2 QL: 25.8gm IN 30 DAYS

ANTICHOLINERGICS, ORALLY INHALED LONG ACTINGACLIDINIUM BROMIDE TUDORZA

PRESSAIR 2

National Formulary


Drug Name Tier Requirements/LimitsGLYCOPYRROLATE SEEBRI NEOHALER 3TIOTROPIUM BROMIDE SPIRIVA 2 QL: 1 INHALER IN 30 DAYSTIOTROPIUM BROMIDE SPIRIVA RESPIMAT 2 QL: 4gm IN 30 DAYSUMECLIDINIUM BROMIDE INCRUSE ELLIPTA 2 ST, QL: 1 INHALER IN 30 DAYS

BETA-ADRENERGIC AGENTSalbuterol sulfate 1metaproterenol sulfate ALUPENT 1terbutaline sulfate (2.5 mg) (tablet) 1terbutaline sulfate (5 mg) (tablet) 1

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

ALBUTEROL SULFATE PROAIRRESPICLICK 2

ALBUTEROL SULFATE VENTOLIN HFA 2levalbuterol hcl XOPENEX 1

levalbuterol hcl XOPENEXCONCENTRATE 1

terbutaline sulfate BRETHINE (2.5 MG)(TABLET) 1

BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTINGINDACATEROL MALEATE ARCAPTA

NEOHALER 2 QL: 1 INHALER IN 30 DAYS

OLODATEROL HCL STRIVERDIRESPIMAT 2 QL: 4gm IN 30 DAYS

BETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTINGARFORMOTEROL TARTRATE BROVANA 3 QL: 120mL IN 30 DAYSFORMOTEROL FUMARATE PERFOROMIST 2 QL: 120mL IN 30 DAYSSALMETEROL XINAFOATE SEREVENT DISKUS 2 QL: 1 INHALER IN 30 DAYS

BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONSGLYCOPYRROLATE/FORMOTEROL FUM BEVESPI

AEROSPHERE 2

INDACATEROL/GLYCOPYRROLATE UTIBRONNEOHALER 3

IPRATROPIUM/ALBUTEROL SULFATE COMBIVENTRESPIMAT 2

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

BETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONSBUDESONIDE/FORMOTEROL FUMARATE SYMBICORT 2 QL: 10.2gm IN 30 DAYSFLUTICASONE/SALMETEROL ADVAIR DISKUS 2 QL: 1 INHALER IN 30 DAYSFLUTICASONE/SALMETEROL ADVAIR HFA 2 QL: 12gm IN 30 DAYS

fluticasone/salmeterol AIRDUORESPICLICK 1

FLUTICASONE/VILANTEROL BREO ELLIPTA 2 QL: 1 INHALER IN 30 DAYSMOMETASONE/FORMOTEROL DULERA 2 QL: 13gm IN 30 DAYS

BETA-ADRENERGIC-ANTICHOLINERGIC-GLUCOCORT, INHALEDFLUTICASONE/UMECLIDIN/VILANTER TRELEGY ELLIPTA 3 ST, QL: 1 INHALER IN 30 DAYS

GLUCOCORTICOIDS, ORALLY INHALEDBECLOMETHASONE DIPROPIONATE QVAR 2 QL: 17.4gm IN 30 DAYSBECLOMETHASONE DIPROPIONATE QVAR REDIHALER 2 QL: 21.2gm IN 30 DAYS

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

1 QL: 120mL IN 30 DAYS

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


National Formulary


Drug Name Tier Requirements/Limits

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


BUDESONIDE PULMICORTFLEXHALER 3 ST, QL: 1 INHALER IN 30 DAYS

FLUTICASONE FUROATE ARNUITY ELLIPTA 3 ST, QL: 1 INHALER IN 30 DAYS

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

3 ST, QL: 1 INHALER IN 30 DAYS


3 ST, QL: 2 INHALERS IN 30 DAYS


3 ST, QL: 1 INHALER IN 30 DAYS

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

3 ST, QL: 12gm IN 30 DAYS


3 ST, QL: 24gm IN 30 DAYS


3 ST, QL: 21.2gm IN 30 DAYS

MOMETASONE FUROATE ASMANEX 2 QL: 1 IN 30 DAYSMOMETASONE FUROATE ASMANEX HFA 2 QL: 13gm IN 30 DAYS

INTERLEUKIN-5(IL-5) RECEPTOR ALPHA ANTAGONIST, MABBENRALIZUMAB FASENRA 3 PA

LEUKOTRIENE RECEPTOR ANTAGONISTSmontelukast sodium SINGULAIR 1zafirlukast ACCOLATE 1

MAST CELL STABILIZERScromolyn sodium GASTROCROM 1

MAST CELL STABILIZERS, ORALLY INHALEDcromolyn sodium 1

MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E(IGE)OMALIZUMAB XOLAIR 2 PA, SP

MONOCLONAL ANTIBODY - INTERLEUKIN-5 ANTAGONISTSMEPOLIZUMAB NUCALA 2 PA, SP

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

RESPIRATORY AIDS,DEVICES,EQUIPMENT

PEAK FLOW METERMINI-WRIGHTPEAK FLOWMETER

3

PEAK FLOW METER TRUZONE PEAKFLOW METER 3

PEAK FLOW METER/INH ASSIT DEVAEROGEARASTHMA ACTIONKIT

3

PEAK FLOW METER/INH ASSIT DEV ASTHMAPACKCHILDREN'S 3

XANTHINEScaffeine citrate CAFCIT (60 MG/3

ML) (SOLUTION) 1

theophylline anhydrous SLO-PHYLLIN 1theophylline anhydrous THEO-DUR 1theophylline anhydrous UNIPHYL 1

National Formulary


Drug Name Tier Requirements/LimitsAUTONOMIC NERVOUS SYSTEM DISORDERS

ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTSmemantine hcl NAMENDA (10 MG)

(TABLET) 1 QL: 2 IN 1 DAY

memantine hclNAMENDA (2MG/ML)(SOLUTION)


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

MEMANTINE HCL NAMENDA XR (14MG) (CAP SPR 24) 2 QL: 1 IN 1 DAY




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

2 QL: 28 IN 28 DAYS

ALZHEIMER'S THX,NMDA RECEPT ANTAG & CHOLINES INHIBMEMANTINE HCL/DONEPEZIL HCL NAMZARIC (14MG-

10MG) (CAP SPR 24) 2 ST, QL: 1 IN 1 DAY

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

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

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

2 ST, QL: 1 IN 1 DAY

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

2 ST, QL: 28 IN 28 DAYS

CHOLINESTERASE INHIBITORSdonepezil hcl ARICEPT 1donepezil hcl ARICEPT ODT 1

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


galantamine hbrRAZADYNE (4MG/ML)(SOLUTION)



galantamine hbr RAZADYNE ER 1 QL: 1 IN 1 DAY

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

pyridostigmine bromide MESTINON (60 MG)(TABLET) 1

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

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

BEHAVIORAL HEALTH - ANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS

mirtazapine REMERON 1

National Formulary


Drug Name Tier Requirements/LimitsMAOIS - NON-SELECTIVE & IRREVERSIBLE

phenelzine sulfate NARDIL 1tranylcypromine sulfate PARNATE 1

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

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

paroxetine hcl PAXIL (10 MG)(TABLET) 1




paroxetine hcl PAXIL CR 1sertraline hcl ZOLOFT 1st. john's wort (300 mg) (capsule) (otc) 1

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

SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)desvenlafaxine succinate PRISTIQ 1 QL: 1 IN 1 DAYduloxetine hcl (20 mg) (capsule dr) 1 QL: 2 IN 1 DAYduloxetine hcl (30 mg) (capsule dr) 1 QL: 2 IN 1 DAYduloxetine hcl (60 mg) (capsule dr) 1 QL: 2 IN 1 DAYLEVOMILNACIPRAN HCL FETZIMA 2 ST, QL: 1 IN 1 DAYvenlafaxine hcl EFFEXOR 1venlafaxine hcl EFFEXOR XR 1venlafaxine hcl er 1

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

SSRI & SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANTVORTIOXETINE HYDROBROMIDE TRINTELLIX 3 QL: 1 IN 1 DAY

TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNSamitriptyline/chlordiazepoxide LIMBITROL 1amitriptyline/chlordiazepoxide LIMBITROL DS 1

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

TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIBamitriptyline hcl ELAVIL 1amoxapine ASENDIN 1clomipramine hcl ANAFRANIL 1desipramine hcl NORPRAMIN 1

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Drug Name Tier Requirements/Limitsdoxepin hcl SINEQUAN 1imipramine hcl TOFRANIL 1imipramine pamoate TOFRANIL-PM 1maprotiline hcl LUDIOMIL 1nortriptyline hcl PAMELOR 1protriptyline hcl VIVACTIL 1trimipramine maleate SURMONTIL 1

BEHAVIORAL HEALTH - OTHERADRENERGICS, AROMATIC, NON-CATECHOLAMINE

AMPHETAMINE ADZENYS ER 3AMPHETAMINE ADZENYS XR-ODT 3AMPHETAMINE SULFATE EVEKEO 2 PA

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

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

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

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

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

dextroamphetamine sulfate PROCENTRA 1 QL: 1800mL IN 30 DAYSdextroamphetamine/amphetamine ADDERALL 1 QL: 2 IN 1 DAY

dextroamphetamine/amphetamine ADDERALL XR (10MG) (CAP ER 24H) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAY






DEXTROAMPHETAMINE/AMPHETAMINE MYDAYIS 3 ST, AGE: <= 18 YEARS, QL: 1 IN 1DAY

LISDEXAMFETAMINE DIMESYLATE VYVANSE 2 ST, QL: 1 IN 1 DAYmethamphetamine hcl DESOXYN 1 QL: 5 IN 1 DAY

ANTI-ALCOHOLIC PREPARATIONSacamprosate calcium CAMPRAL 1disulfiram ANTABUSE 1NALTREXONE MICROSPHERES VIVITROL 2

ANTI-ANXIETY DRUGSALPRAZOLAM INTENSOL 2alprazolam NIRAVAM 1alprazolam XANAX 1alprazolam XANAX XR 1buspirone hcl BUSPAR 1chlordiazepoxide hcl LIBRIUM 1clorazepate dipotassium TRANXENE T-TAB 1diazepam intensol 1

diazepam VALIUM (10 MG)(TABLET) 1

diazepam VALIUM (2 MG)(TABLET) 1

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Drug Name Tier Requirements/Limitsdiazepam VALIUM (5 MG)

(TABLET) 1

diazepam VALIUM (5 MG/5ML) (SOLUTION) 1

lorazepam ATIVAN 1lorazepam intensol 1meprobamate 1oxazepam SERAX 1

ANTI-MANIA DRUGSlithium carbonate 1lithium citrate 1

ANTI-NARCOLEPSY & ANTI-CATAPLEXY,SEDATIVE-TYPE AGTSODIUM OXYBATE XYREM 2 PA

ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINESpimozide ORAP 1

ANTIPSYCHOTIC-ATYPICAL,D3/D2 PARTIAL AG-5HT MIXEDCARIPRAZINE HCL VRAYLAR (1.5 MG)

(CAPSULE) 3 QL: 1 IN 1 DAY

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

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

CARIPRAZINE HCL VRAYLAR (4.5 MG)(CAPSULE) 3 QL: 1 IN 1 DAY

CARIPRAZINE HCL VRAYLAR (6 MG)(CAPSULE) 3 QL: 1 IN 1 DAY

ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXEDaripiprazole ABILIFY (1 MG/ML)

(SOLUTION) 1 ST, QL: 30mL IN 1 DAY

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






aripiprazoleABILIFY DISCMELT(10 MG) (TABRAPDIS)


aripiprazoleABILIFY DISCMELT(15 MG) (TABRAPDIS)


ARIPIPRAZOLE ABILIFYMAINTENA 2

ARIPIPRAZOLE LAUROXILARISTADA (441MG/1.6) (SUSERSYR)

2


2


2

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Drug Name Tier Requirements/LimitsANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS

LOXAPINE ADASUVE 3loxapine succinate LOXITANE 1

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

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





olanzapine ZYPREXA (10 MG)(TABLET) 1 QL: 1 IN 1 DAY


olanzapine ZYPREXA (2.5 MG)(TABLET) 1 QL: 1 IN 1 DAY



olanzapine ZYPREXA (7.5 MG)(TABLET) 1 QL: 1 IN 1 DAY

olanzapine ZYPREXA ZYDIS 1 QL: 1 IN 1 DAY

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

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



quetiapine fumarate SEROQUEL 1 QL: 3 IN 1 DAY

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





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

3

risperidone RISPERDAL (0.25MG) (TABLET) 1 QL: 2 IN 1 DAY

risperidone RISPERDAL (0.5MG) (TABLET) 1 QL: 2 IN 1 DAY

risperidone RISPERDAL (1 MG)(TABLET) 1 QL: 2 IN 1 DAY

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risperidoneRISPERDAL (1MG/ML)(SOLUTION)

1 QL: 8mL IN 1 DAY




risperidone RISPERDAL M-TAB 1 QL: 2 IN 1 DAY

RISPERIDONE MICROSPHERES RISPERDALCONSTA 2

ziprasidone hcl GEODON 1 QL: 2 IN 1 DAYANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES

thiothixene NAVANE 1ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES

haloperidol HALDOL 1haloperidol decanoate HALDOL 1

haloperidol decanoate HALDOLDECANOATE 100 1

haloperidol decanoate HALDOLDECANOATE 50 1

haloperidol lactate HALDOL 1ANTI-PSYCHOTICS,PHENOTHIAZINES

chlorpromazine hcl THORAZINE (10MG) (TABLET) 1





fluphenazine hcl PROLIXIN (1 MG)(TABLET) 1


fluphenazine hcl PROLIXIN (2.5 MG)(TABLET) 1

fluphenazine hcl PROLIXIN (2.5MG/5ML) (ELIXIR) 1


fluphenazine hclPROLIXIN (5MG/ML) (ORALCONC)

1

perphenazine TRILAFON 1thioridazine hcl MELLARIL 1trifluoperazine hcl STELAZINE 1

BARBITURATESphenobarbital 1SECOBARBITAL SODIUM SECONAL SODIUM 2

HSDD AGENTS-MIXED SEROTONIN AGONIST/ANTAGONISTSFLIBANSERIN ADDYI 3 PA

HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTSTASIMELTEON HETLIOZ 3 PA

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Drug Name Tier Requirements/LimitsNARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS

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




modafinil PROVIGIL 1 QL: 2 IN 1 DAYNARCOTIC ANTAGONISTS

naloxone hcl NARCAN (0.4MG/ML) (SYRINGE) 1

naloxone hcl NARCAN (0.4MG/ML) (VIAL) 1

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

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

naltrexone hcl REVIA 1SEDATIVE-HYPNOTICS,NON-BARBITURATE

estazolam PROSOM 1eszopiclone LUNESTA 1 QL: 1 IN 1 DAYflurazepam hcl DALMANE 1midazolam hcl VERSED 1quazepam DORAL 1SUVOREXANT BELSOMRA 3 QL: 1 IN 1 DAYtemazepam RESTORIL 1triazolam HALCION 1zaleplon SONATA 1 QL: 1 IN 1 DAYzolpidem tartrate AMBIEN 1 QL: 1 IN 1 DAYzolpidem tartrate AMBIEN CR 1 QL: 1 IN 1 DAYZOLPIDEM TARTRATE EDLUAR 3zolpidem tartrate INTERMEZZO 1ZOLPIDEM TARTRATE ZOLPIMIST 3

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

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

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

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

3 ST, AGE: <= 18 YEARS, QL: 1 IN 1DAY





METHYLPHENIDATE DAYTRANA 2 ST, AGE: <= 18 YEARS, QL: 1 IN 1DAY

METHYLPHENIDATE HCL APTENSIO XR 3 QL: 1 IN 1 DAYmethylphenidate hcl (10 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (10 mg) (tab chew) 1 QL: 3 IN 1 DAYmethylphenidate hcl (10 mg) (tablet er) 1

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Drug Name Tier Requirements/Limitsmethylphenidate hcl (10 mg) (tablet) 1 QL: 3 IN 1 DAYmethylphenidate hcl (10 mg/5 ml) (solution) 1methylphenidate hcl (18 mg) (tab er 24) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (2.5 mg) (tab chew) 1 QL: 3 IN 1 DAYmethylphenidate hcl (20 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (20 mg) (cpbp 50-50) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (20 mg) (tablet er) 1 AGE: <= 18 YEARS, QL: 3 IN 1 DAYmethylphenidate hcl (20 mg) (tablet) 1 QL: 3 IN 1 DAYmethylphenidate hcl (27 mg) (tab er 24) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (30 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 2 IN 1 DAYmethylphenidate hcl (30 mg) (cpbp 50-50) 1 AGE: <= 18 YEARS, QL: 2 IN 1 DAYmethylphenidate hcl (36 mg) (tab er 24) 1 AGE: <= 18 YEARS, QL: 2 IN 1 DAYmethylphenidate hcl (40 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (40 mg) (cpbp 50-50) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (5 mg) (tab chew) 1 QL: 3 IN 1 DAYmethylphenidate hcl (5 mg) (tablet) 1 QL: 3 IN 1 DAYmethylphenidate hcl (5 mg/5 ml) (solution) 1methylphenidate hcl (50 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (54 mg) (tab er 24) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (60 mg) (cpbp 30-70) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (60 mg) (cpbp 50-50) 1 AGE: <= 18 YEARS, QL: 1 IN 1 DAYmethylphenidate hcl (72 mg) (tab er 24) 1

METHYLPHENIDATE HCLQUILLICHEW ER(20 MG) (TABCBP24H)






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

2 ST, QL: 12mL IN 1 DAY

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

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







CARDIOVASCULAR DISEASE - ARRHYTHMIAANTIARRHYTHMICS

amiodarone hcl CORDARONE (100MG) (TABLET) 1



disopyramide phosphate NORPACE 1

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Drug Name Tier Requirements/Limitsdofetilide TIKOSYN 1DRONEDARONE HCL MULTAQ 3flecainide acetate TAMBOCOR 1mexiletine hcl MEXITIL 1propafenone hcl RYTHMOL 1propafenone hcl RYTHMOL SR 1quinidine gluconate (324 mg) (tablet er) 1quinidine sulfate 1

CARDIOVASCULAR DISEASE - CARDIAC STIMULANTADRENERGIC AGENTS,CATECHOLAMINES

epinephrine (0.1 mg/ml) (syringe) 1DIGITALIS GLYCOSIDES

DIGOXIN 2

digoxin LANOXIN (125MCG) (TABLET) 1

digoxin LANOXIN (250MCG) (TABLET) 1

CARDIOVASCULAR DISEASE - HYPERTENSIONACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION

amlodipine besylate/benazepril LOTREL 1PERINDOPRIL ARG/AMLODIPINE BES PRESTALIA 3trandolapril/verapamil hcl TARKA 1

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

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

labetalol hcl TRANDATE (100MG) (TABLET) 1



ALPHA-ADRENERGIC BLOCKING AGENTSdoxazosin mesylate CARDURA 1

phenoxybenzamine hcl DIBENZYLINE (10MG) (CAPSULE) 1

prazosin hcl MINIPRESS 1terazosin hcl HYTRIN 1

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

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

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

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Drug Name Tier Requirements/Limitstelmisartan/hydrochlorothiazid MICARDIS HCT 1valsartan/hydrochlorothiazide DIOVAN HCT 1

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

ANTIHYPERTENSIVES, ACE INHIBITORSbenazepril hcl LOTENSIN 1captopril CAPOTEN 1enalapril maleate VASOTEC 1fosinopril sodium MONOPRIL 1lisinopril PRINIVIL 1lisinopril ZESTRIL 1moexipril hcl UNIVASC 1perindopril erbumine ACEON 1quinapril hcl ACCUPRIL 1ramipril ALTACE 1trandolapril MAVIK 1

ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONISTAZILSARTAN MEDOXOMIL EDARBI 2 STcandesartan cilexetil ATACAND 1irbesartan AVAPRO 1losartan potassium COZAAR 1olmesartan medoxomil BENICAR 1 STtelmisartan MICARDIS 1valsartan DIOVAN 1

ANTIHYPERTENSIVES, MISCELLANEOUSMETYROSINE DEMSER 2

ANTIHYPERTENSIVES, SYMPATHOLYTICclonidine CATAPRES-TTS 1 1clonidine CATAPRES-TTS 2 1clonidine CATAPRES-TTS 3 1clonidine hcl CATAPRES 1clonidine hcl/chlorthalidone COMBIPRES 1guanfacine hcl TENEX 1methyldopa ALDOMET 1methyldopa/hydrochlorothiazide ALDORIL 15 1methyldopa/hydrochlorothiazide ALDORIL 25 1

ANTIHYPERTENSIVES, VASODILATORShydralazine hcl APRESOLINE (10

MG) (TABLET) 1

hydralazine hcl APRESOLINE (100MG) (TABLET) 1



minoxidil LONITEN 1BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl SECTRAL 1atenolol TENORMIN 1betaxolol hcl KERLONE 1bisoprolol fumarate ZEBETA 1metoprolol succinate TOPROL XL 1metoprolol tartrate (100 mg) (tablet) 1metoprolol tartrate (25 mg) (tablet) 1metoprolol tartrate (37.5 mg) (tablet) 1

National Formulary


Drug Name Tier Requirements/Limitsmetoprolol tartrate (50 mg) (tablet) 1metoprolol tartrate (75 mg) (tablet) 1nadolol CORGARD 1NEBIVOLOL HCL BYSTOLIC 2pindolol VISKEN 1

propranolol hcl INDERAL (10 MG)(TABLET) 1


propranolol hcl INDERAL (20 MG/5ML) (SOLUTION) 1


propranolol hclINDERAL(40MG/5ML)(SOLUTION)

1



propranolol hcl INDERAL LA 1sotalol hcl (120 mg) (tablet) 1sotalol hcl (160 mg) (tablet) 1sotalol hcl (240 mg) (tablet) 1sotalol hcl (80 mg) (tablet) 1

SOTALOL HCLSOTYLIZE (5MG/ML)(SOLUTION)

2 ST, QL: 3840mL IN 30 DAYS

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

atenolol/chlorthalidone TENORETIC 100 1atenolol/chlorthalidone TENORETIC 50 1bisoprolol/hydrochlorothiazide ZIAC 1metoprolol/hydrochlorothiazide LOPRESSOR HCT 1nadolol/bendroflumethiazide CORZIDE 1propranolol/hydrochlorothiazid INDERIDE-40/25 1propranolol/hydrochlorothiazid INDERIDE-80/25 1

CALCIUM CHANNEL BLOCKING AGENTSamlodipine besylate NORVASC 1

diltiazem hcl CARDIZEM (120MG) (TABLET) 1

diltiazem hcl CARDIZEM (30 MG)(TABLET) 1



diltiazem hcl CARDIZEM CD 1

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





diltiazem hcl CARDIZEM SR 1

National Formulary


Drug Name Tier Requirements/Limitsdiltiazem hcl DILACOR XR 1diltiazem hcl TIAZAC 1felodipine PLENDIL 1isradipine DYNACIRC 1nicardipine hcl (20 mg) (capsule) 1nicardipine hcl (30 mg) (capsule) 1nifedipine ADALAT CC 1nifedipine PROCARDIA 1nifedipine PROCARDIA XL 1nimodipine NIMOTOP 1

NIMODIPINENYMALIZE(30MG/10ML)(SOLUTION)

3 PA, SP

nisoldipine SULAR 1

verapamil hcl CALAN (120 MG)(TABLET) 1



verapamil hcl CALAN SR 1verapamil hcl VERELAN 1verapamil hcl VERELAN PM 1

LOOP DIURETICSbumetanide BUMEX (0.5 MG)

(TABLET) 1

bumetanide BUMEX (1 MG)(TABLET) 1

bumetanide BUMEX (2 MG)(TABLET) 1

ethacrynic acid EDECRIN 1

furosemide LASIX (10 MG/ML)(SOLUTION) 1

furosemide LASIX (20 MG)(TABLET) 1


furosemide LASIX (40MG/5ML)(SOLUTION) 1


torsemide DEMADEX 1OSMOTIC DIURETICS

MANNITOL RESECTISOL 2POTASSIUM SPARING DIURETICS

amiloride hcl MIDAMOR 1eplerenone INSPRA 1spironolactone ALDACTONE 1

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

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

1

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

PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATORRIOCIGUAT ADEMPAS 2 PA

National Formulary


Drug Name Tier Requirements/LimitsPULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIB

sildenafil citrate REVATIO (10MG/12.5) (VIAL) 1 PA, SP

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

TADALAFIL ADCIRCA 2 PA, SPPULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST

AMBRISENTAN LETAIRIS 2 PABOSENTAN TRACLEER 2 PAMACITENTAN OPSUMIT 2 PA

PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPEEPOPROSTENOL SODIUM (ARGININE) VELETRI 2 PAepoprostenol sodium (glycine) FLOLAN 1 PAILOPROST TROMETHAMINE VENTAVIS 2 PASELEXIPAG UPTRAVI 2 PATREPROSTINIL TYVASO 2 PATREPROSTINIL DIOLAMINE ORENITRAM ER 3 PATREPROSTINIL SODIUM REMODULIN 2 PA

TREPROSTINIL/NEB ACCESSORIES TYVASO REFILLKIT 2 PA

TREPROSTINIL/NEBULIZER/ACCESORTYVASOINSTITUTIONALSTART KIT

2 PA

TREPROSTINIL/NEBULIZER/ACCESOR TYVASO STARTERKIT 2 PA

RENIN INHIBITOR, DIRECTALISKIREN HEMIFUMARATE TEKTURNA 2 PA

RENIN INHIBITOR, DIRECT/THIAZIDE DIURETIC COMBALISKIREN/HYDROCHLOROTHIAZIDE TEKTURNA HCT 2 PA

THIAZIDE AND RELATED DIURETICSchlorothiazide DIURIL (250 MG)

(TABLET) 1

chlorothiazide DIURIL (500 MG)(TABLET) 1

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

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

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



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

ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS

atorvastatin calcium LIPITOR (10 MG)(TABLET) 1

AGE: $0 COPAY IF AGE 40-75YEARS AND NO HISTORY OFSECONDARY CARDIOVASCULARDISEASE PREVENTIONMEDICATIONS IN 120 DAYS, QL: 1IN 1 DAY

National Formulary



atorvastatin calcium LIPITOR (20 MG)(TABLET) 1


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

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

fluvastatin sodium LESCOL 1

ST, AGE: $0 COPAY IF AGE 40-75YEARS AND NO HISTORY OFSECONDARY CARDIOVASCULARDISEASE PREVENTIONMEDICATIONS IN 120 DAYS, QL: 2IN 1 DAY

fluvastatin sodium LESCOL XL 1


LOVASTATIN ALTOPREV 3


lovastatin MEVACOR 1


PITAVASTATIN CALCIUM LIVALO 2


pravastatin sodium PRAVACHOL 1


rosuvastatin calcium CRESTOR (10 MG)(TABLET) 1


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

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

rosuvastatin calcium CRESTOR (5 MG)(TABLET) 1


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simvastatin ZOCOR (10 MG)(TABLET) 1








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

ANTIHYPERLIPIDEMIC - MTP INHIBITORLOMITAPIDE MESYLATE JUXTAPID 2 PA

ANTIHYPERLIPIDEMIC - PCSK9 INHIBITORSALIROCUMAB PRALUENT PEN 2 PA, SP

EVOLOCUMAB REPATHAPUSHTRONEX 2 PA

EVOLOCUMAB REPATHASURECLICK 2 PA, SP

EVOLOCUMAB REPATHA SYRINGE 2 PA, SPBILE SALT SEQUESTRANTS

cholestyramine (with sugar) QUESTRAN 1cholestyramine/aspartame QUESTRAN LIGHT 1COLESEVELAM HCL WELCHOL 2

colestipol hcl COLESTID (1 G)(TABLET) 1

colestipol hcl COLESTID (5 G)(GRANULES) 1

colestipol hcl COLESTID (5 G)(PACKET) 1

LIPOTROPICSezetimibe ZETIA 1 QL: 1 IN 1 DAYfenofibrate FENOGLIDE 3

FENOFIBRATE LIPOFEN (150 MG)(CAPSULE) 3 ST

FENOFIBRATE LIPOFEN (50 MG)(CAPSULE) 3 ST

fenofibrate LOFIBRA 3fenofibrate nanocrystallized TRICOR 1

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

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

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

National Formulary


Drug Name Tier Requirements/LimitsFENOFIBRATE,MICRONIZED ANTARA (90 MG)

(CAPSULE) 3

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

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

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

niacin NIASPAN 1omega-3 acid ethyl esters LOVAZA 1 QL: 4 IN 1 DAYomega-3 fatty acids/fish oil (300-1000mg) (capsule)(otc) 1

CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTSADRENERGIC VASOPRESSOR AGENTS

midodrine hcl PROAMATINE 1ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)

SACUBITRIL/VALSARTAN ENTRESTO 2 QL: 2 IN 1 DAYANTIANGINAL & ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMIC

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

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

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

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

CARDIOVASCULAR DISEASE - VASODILATIONVASODILATORS,CORONARY

amyl nitrite 1ISOSORBIDE DINITRATE DILATRATE-SR 2isosorbide dinitrate ISOCHRON 1

isosorbide dinitrate ISORDIL (10 MG)(TABLET) 1



isosorbide dinitrate ISORDILTITRADOSE 1

isosorbide mononitrate IMDUR 1isosorbide mononitrate MONOKET 1NITROGLYCERIN NITRO-BID 2

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

1


1


1


1

nitroglycerin NITROLINGUAL 1

National Formulary


Drug Name Tier Requirements/Limitsnitroglycerin NITROMIST 1nitroglycerin NITROSTAT 1nitroglycerin NITRO-TIME 1

VASODILATORS,PERIPHERALergoloid mesylates HYDERGINE 1isoxsuprine hcl 1papaverine hcl 1papaverine/phentolamine/water 3

CONTRACEPTION/OXYTOCICSCONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC

ETONOGESTREL/ETHINYL ESTRADIOL NUVARING 0 QL: 1 IN 28 DAYSCONTRACEPTIVES,IMPLANTABLE

ETONOGESTREL NEXPLANON 0 QL: 1 IN 365 DAYSCONTRACEPTIVES,INJECTABLE

medroxyprogesterone acetate DEPO-PROVERA 0 QL: 1mL IN 84 DAYSCONTRACEPTIVES,INTRAVAGINAL

nonoxynol 9 CONCEPTROL 0nonoxynol 9 DELFEN 0NONOXYNOL 9 GYNOL II 0

NONOXYNOL 9TODAYCONTRACEPTIVESPONGE

0

NONOXYNOL 9 VCF 0CONTRACEPTIVES,ORAL

desog-e.estradiol/e.estradiol MIRCETTE 0desogestrel-ethinyl estradiol CYCLESSA 0desogestrel-ethinyl estradiol DESOGEN 0desogestrel-ethinyl estradiol ORTHO-CEPT 0drospir/eth estra/levomefol ca BEYAZ 0 STDROSPIR/ETH ESTRA/LEVOMEFOL CA SAFYRAL 0 STESTRADIOL VALERATE/DIENOGEST NATAZIA 0 STethinyl estradiol/drospirenone YASMIN 28 0 STethinyl estradiol/drospirenone YAZ 0 STethynodiol d-ethinyl estradiol DEMULEN 0ethynodiol d-ethinyl estradiol DEMULEN 1-50-21 0levonorgestrel-ethin estradiol AMETHYST 0levonorgestrel-ethin estradiol AVIANE 0levonorgestrel-ethin estradiol NORDETTE-28 0levonorgestrel-ethin estradiol SEASONALE 0 QL: 91 IN 84 DAYSlevonorgestrel-ethin estradiol TRIVORA 0l-norgest/e.estradiol-e.estrad LOSEASONIQUE 0 QL: 91 IN 84 DAYSl-norgest/e.estradiol-e.estrad SEASONIQUE 0 QL: 91 IN 84 DAYSnoreth-ethinyl estradiol/iron FEMCON FE 0noreth-ethinyl estradiol/iron GENERESS FE 0norethindrone NOR-Q-D 0norethindrone ORTHO MICRONOR 0norethindrone ac-eth estradiol LOESTRIN 0norethindrone-e.estradiol-iron ESTROSTEP FE 0NORETHINDRONE-E.ESTRADIOL-IRON LO LOESTRIN FE 0 STnorethindrone-e.estradiol-iron LOESTRIN 24 FE 0norethindrone-e.estradiol-iron LOESTRIN FE 0norethindrone-e.estradiol-iron MINASTRIN 24 FE 0NORETHINDRONE-E.ESTRADIOL-IRON TAYTULLA 0norethindrone-ethinyl estrad MODICON 0norethindrone-ethinyl estrad ORTHO-NOVUM 0norethindrone-ethinyl estrad OVCON-35 0norethindrone-ethinyl estrad TRI-NORINYL 0

National Formulary


Drug Name Tier Requirements/Limitsnorgestimate-ethinyl estradiol ORTHO TRI-

CYCLEN 0

norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO 0

norgestimate-ethinyl estradiol ORTHO-CYCLEN 0norgestrel-ethinyl estradiol LO-OVRAL-28 0norgestrel-ethinyl estradiol LO-OVRAL-8 0norgestrel-ethinyl estradiol OVRAL 0

CONTRACEPTIVES,TRANSDERMALnorelgestromin/ethin.estradiol ORTHO EVRA 0 QL: 3 IN 28 DAYS

DIAPHRAGMS/CERVICAL CAPDIAPHRAGMS, CONTOURED CAYA CONTOURED 0

DIAPHRAGMS, WIDE SEAL WIDE SEALDIAPHRAGM 0

OXYTOCICSDINOPROSTONE CERVIDIL 3DINOPROSTONE PREPIDIL 3

DINOPROSTONEPROSTIN E2VAGINALSUPPOSITORY

3

METHYLERGONOVINE MALEATE METHERGINE 2COUGH AND COLD

1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONSchlorpheniramine/phenylephrine (1mg-2mg/ml)(drops) 1

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

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

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

NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESThydrocodone/cpm/pseudoephed ZUTRIPRO 1

promethazine/phenyleph/codeine PENTAZINE VCWITH CODEINE 1 AGE: >= 12 YEARS

promethazine/phenyleph/codeine PHENERGAN VCWITH CODEINE 1 AGE: >= 12 YEARS

NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINEhydrocodone/chlorphen p-stirex TUSSIONEX 1

promethazine hcl/codeine PHENERGAN WITHCODEINE 1 AGE: >= 12 YEARS

NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMB.hydrocodone bit/homatrop me-br 1

NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESTbrompheniramine/pseudoephed/dm (2-30-10/5)(syrup) 1

chlorpheniramine/phenyleph/dm (1-2-3mg/ml)(drops) 1

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

NON-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT CMBGUAIFEN/DEXTROMETHORPHAN/PE G-TUSICOF 2GUAIFEN/DEXTROMETHORPHAN/PE TUSICOF 2

National Formulary


Drug Name Tier Requirements/LimitsNON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB.

GUAIFENESIN/DEXTROMETHORPHAN SCOT-TUSSINSENIOR 2

NOSE PREPARATIONS, VASOCONSTRICTORS (RX)EPINEPHRINE HCL ADRENALIN

CHLORIDE 3

TETRAHYDROZOLINE HCL TYZINE 3DERMATOLOGY - ACNE

ACNE AGENTS,SYSTEMICISOTRETINOIN ABSORICA 2 STisotretinoin 1

ACNE AGENTS,TOPICALadapalene/benzoyl peroxide EPIDUO 1 ST, AGE: <= 25 YEARSADAPALENE/BENZOYL PEROXIDE EPIDUO FORTE 2 ST, AGE: <= 25 YEARSAZELAIC ACID AZELEX 3CLINDAMYCIN PHOS/BENZOYL PEROX ACANYA 2 ST

clindamycin phos/benzoyl perox BENZACLIN (1 %-5%) (GEL (GRAM)) 1

clindamycin phos/benzoyl perox DUAC 1CLINDAMYCIN PHOS/BENZOYL PEROX ONEXTON 2 STclindamycin/tretinoin ZIANA 1

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

sulfacetamide sodium KLARON 1ANTICORROSIVE AGENTS

BUTYLATED HYDROXYTOLUENE(BHT)(POWDER) 2

KERATOLYTIC-GLUCOCORTICOID COMBINATIONSBENZOYL PEROXIDE/HYDROCORTISON VANOXIDE-HC 3

ROSACEA AGENTS, TOPICALAZELAIC ACID FINACEA 2BRIMONIDINE TARTRATE MIRVASO 2IVERMECTIN SOOLANTRA 2 STmetronidazole METROCREAM 1metronidazole METROGEL 1metronidazole METROLOTION 1METRONIDAZOLE NORITATE 3metronidazole ROSADAN 1

TOPICAL PREPARATIONS,ANTIBACTERIALSCADEXOMER IODINE IODOFLEX 3CADEXOMER IODINE IODOSORB 3hydrocortisone/iodoquinol DERMAZENE 1hydrocortisone/iodoquinol/aloe VYTONE 1iodine/potassium iodide (5%-10%) (solution) 1SILVER CARBONATE NORMLGEL AG 3silver nitrate 1

VITAMIN A DERIVATIVESadapalene DIFFERIN 1 AGE: <= 25 YEARStretinoin ATRALIN 1 AGE: <= 25 YEARStretinoin RETIN-A 1 AGE: <= 25 YEARStretinoin microspheres RETIN-A MICRO 1 AGE: <= 25 YEARS

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

1 AGE: <= 25 YEARS

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

3 ST

National Formulary



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

1 AGE: <= 25 YEARS

DERMATOLOGY - ANTIINFECTIVETOPICAL ANTIBIOTICS

clindamycin phosphate CLEOCIN T 1clindamycin phosphate CLINDACIN ETZ 1clindamycin phosphate CLINDACIN P 1clindamycin phosphate EVOCLIN 1erythromycin base/ethanol ERY 1erythromycin base/ethanol ERYGEL 1erythromycin base/ethanol ERYMAX 1erythromycin/benzoyl peroxide BENZAMYCIN 1gentamicin sulfate 1mupirocin BACTROBAN 1mupirocin CENTANY 1mupirocin calcium BACTROBAN 1

TOPICAL ANTIFUNGAL/ANTIINFLAMMATORY,STERIOD AGENTCLOTRIMAZOLE/BETAMETH DIP/ZINC DERMACINRX

THERAZOLE PAK 3

clotrimazole/betamethasone dip LOTRISONE 1TOPICAL ANTIFUNGALS

ciclopirox CICLODAN 1ciclopirox LOPROX 1ciclopirox PENLAC 1ciclopirox olamine CICLODAN 1ciclopirox olamine LOPROX 1CICLOPIROX/SKIN CLEANSER NO.28 CICLODAN 3ciclopirox/urea/camph/men/euc CICLODAN 1clotrimazole (1 %) (cream (g)) 1clotrimazole (1 %) (solution) 1econazole nitrate SPECTAZOLE 1gentian violet/brgreen/proflav 1

ketoconazole EXTINA (2 %)(FOAM) 1

ketoconazole NIZORAL 1LULICONAZOLE LUZU 3 QL: 60gm IN 28 DAYS

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

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

nystatin MYCOSTATIN 1nystatin NYAMYC 1nystatin NYSTEX 1nystatin NYSTOP 1nystatin/triamcin 1

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

TOPICAL ANTIPARASITICSlindane KWELL 1malathion OVIDE 1permethrin (5 %) (cream (g)) 1spinosad NATROBA 1

TOPICAL ANTIVIRALSACYCLOVIR ZOVIRAX (5 %)

(CREAM (G)) 2

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

National Formulary


Drug Name Tier Requirements/LimitsTOPICAL SULFONAMIDES

mafenide acetate 1MAFENIDE ACETATE SULFAMYLON 2silver sulfadiazine SILVADENE 1silver sulfadiazine THERMAZENE 1sulfacetamide sod/sulfur/urea 1

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

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

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

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

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

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

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

sulfacetamide sodium/sulfur PLEXION TS 1

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

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

sulfacetamide sodium/sulfurSODIUMSULFACETAMIDE-SULFUR

1

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

DERMATOLOGY - ANTIINFLAMMATORYTOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDAL

NEOMYCIN SULFATE/FLUOCINOLONE NEO-SYNALAR 3 STNEOMYCIN/FLUOCINOLONE/EMOLL 65 NEO-SYNALAR 3 ST

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

National Formulary


Drug Name Tier Requirements/Limitsclobetasol propionate/emoll TEMOVATE

EMOLLIENT 1

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

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

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

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

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

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

diflorasone diacetate APEXICON 1diflorasone diacetate PSORCON 1DIFLORASONE DIACETATE/EMOLL APEXICON E 2

fluocinolone acetonide DERMA-SMOOTHE-FS 1

fluocinolone acetonide SYNALAR 1

fluocinolone/shower cap DERMA-SMOOTHE-FS 1

fluocinonide LIDEX 1fluocinonide VANOS 1fluocinonide/emollient base LIDEX-E 1

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

flurandrenolide CORDRAN (0.05 %)(LOTION) 1

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

flurandrenolide NOLIX 1fluticasone propionate CUTIVATE 1

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

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

HYDROCORT/SAL ACID/SULF/SHAMP1 SCALACORT DK 3hydrocortisone (1 %) (cream (g)) 1hydrocortisone (1 %) (crm/pe app) 1hydrocortisone (1 %) (oint. (g)) 1hydrocortisone (2.5 %) (cream (g)) 1hydrocortisone (2.5 %) (crm/pe app) 1hydrocortisone (2.5 %) (kit) 1hydrocortisone (2.5 %) (lotion) 1hydrocortisone (2.5 %) (oint. (g)) 1

HYDROCORTISONE SCALACORT (2 %)(LOTION) 2

HYDROCORTISONE ACET/ALOE VERA NUCORT 3

hydrocortisone butyrate LOCOID (0.1 %)(CREAM (G)) 1

hydrocortisone butyrate LOCOID (0.1 %)(OINT. (G)) 1

hydrocortisone butyrate LOCOID (0.1 %)(SOLUTION) 1

hydrocortisone butyrate/emoll LOCOIDLIPOCREAM 1

hydrocortisone valerate 1

National Formulary


Drug Name Tier Requirements/LimitsHYDROCORTISONE/SKIN CLEANSER25 AQUA GLYCOLIC

HC 3

mometasone furoate ELOCON 1prednicarbate DERMATOP 1triamcinolone acetonide 1

TOPICAL ANTI-INFLAMMATORY, NSAIDSDICLOFENAC EPOLAMINE FLECTOR 2diclofenac sodium VOLTAREN 1

DERMATOLOGY - ANTIPRURITIC DRUGSANTIPRURITICS,TOPICAL

E101/NAMG FL/NA PH/NACL/HA-NAH ALEVICYN PLUS 3NA MG FL/NA PHO/NACL/HA/NA HYP LEVICYN 3NA MG FL/NA PHO/NACL/HA/NA HYP SP ANTIPRURITIC 3

DERMATOLOGY - MISCELLANEOUSANTISEBORRHEIC AGENTS

selenium sulfide (2.25 %) (shampoo) 1selenium sulfide (2.5 %) (lotion) 1

SELENIUM SULFIDE/ALOE VERA DANDRUFFSHAMPOO 2

SELENIUM SULFIDE/ALOE VERA SELSUN BLUEMOISTURIZING 2

sulfacetamide sodium 1ANTISEPTICS,MISCELLANEOUS

GUAIACOL 2EMOLLIENTS

ammonium lactate (12 %) (cream (g)) 1ammonium lactate (12 %) (lotion) 1emol53/namgfs/ha/nahypochlorit 1emol53/sod mag fl.sil/cyclomet AURSTAT 1emollient combination no.10 BIAFINE 1EMOLLIENT COMBINATION NO.10 LUXAMEND 3EMOLLIENT COMBINATION NO.101 CERAMAX 3EMOLLIENT COMBINATION NO.103 CERACADE 3EMOLLIENT COMBINATION NO.104 DEXERYL 3EMOLLIENT COMBINATION NO.107 NUTRASEB 3emollient combination no.32 1emollient combination no.35 1

EMOLLIENT COMBINATION NO.60 ATRAPROHYDROGEL 3

EMOLLIENT COMBINATION NO.60 CELACYN 3

EMOLLIENT COMBINATION NO.60 LEVICYNANTIPRURITIC SG 3

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

EMOLLIENT COMBINATION NO.60 SP SCARMANAGEMENT 3

PALM OIL/EUCALYPTUS OIL PHLAG SPRAY 3vite ac/grape/hyaluronic acid ATOPICLAIR 1

IRRIGANTSacetic acid 1mannitol/sorbitol solution 1

neomycin sulf/polymyxin b sulf NEOSPORIN G.U.IRRIGANT 1

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

National Formulary


Drug Name Tier Requirements/LimitsRINGER'S SOLUTION,LACTATED LACTATED

RINGERS 3

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

SODIUM CHLOR/HYPOCHLOROUS ACID VASHE WOUND 3

SODIUM CHLOR/HYPOCHLOROUS ACID VASHE WOUNDTHERAPY 3

sorbitol solution 1water for irrigation,sterile (irrig soln) 1

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

podofilox CONDYLOX (0.5 %)(SOLUTION) 1

salicylic acid (26 %) (liquid) 1salicylic acid (27.5 %) (liq-film) 1salicylic acid (28.5 %) (sol-filmer) 1salicylic acid (6 %) (cream (g)) 1salicylic acid (6 %) (crm er (g)) 1salicylic acid (6 %) (foam) 1salicylic acid (6 %) (gel (gram)) 1salicylic acid (6 %) (lotion er) 1salicylic acid (6 %) (lotion) 1salicylic acid (6 %) (shampoo) 1SALICYLIC ACID SALIMEZ FORTE 3SALICYLIC ACID ULTRASAL-ER 3salicylic acid/ceramide comb 1 SALEX 1silver nitrate 1silver nitrate applicator 1urea 1UREA/EMOLLIENT COMBINATION 65 URAMAXIN GT 3urea/lactic acid/zinc undecyl 1

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

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

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

BIO/CARB/EQUIS/ETHAN/CHIT/MSM GENADUR 3CARBIT/EQUIS XT/ETHAN/CHIT/MSM GENADUR 3

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

HYALURONATE SODIUM/HE-CELL/PEG HYGEL 3petrolatum,white (oint pack) 1POLYDIMETHYLSILOXANES/SILICON RECEDO 3POLY-UREAURETHANE NUVAIL 3PROTECTIVES COMBINATION NO.2 TETRIX 3protectives2/ceramide 1,3,6-11 TETRIX 1

TOPICAL ANTI-INFLAMMATORY STEROID-LOCAL ANESTHETICHYDROCORTISONE/PRAMOXINE ANALPRAM HC 3

National Formulary


Drug Name Tier Requirements/Limitshydrocortisone/pramoxine PRAMOSONE (2.5

%-1 %) (CREAM (G)) 1

lidocaine/hydrocortisone ac LIDAMANTLE HC 1TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTS

ALITRETINOIN PANRETIN 3BEXAROTENE TARGRETIN 2 PAdiclofenac sodium SOLARAZE 1 PA, QL: 100gm PER FILL

FLUOROURACIL CARAC (0.5 %)(CREAM (G)) 2

fluorouracil EFUDEX 1

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

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

MECHLORETHAMINE HCL VALCHLOR 2 PATOPICAL LOCAL ANESTHETICS

BENZOCAINE ANACAINE 3cocaine hcl 1ethyl chloride 1lidocaine (5 %) (adh. patch) 1lidocaine (5 %) (oint. (g)) 1 ST, QL: 240gm IN 30 DAYSLIDOCAINE TRANZAREL 3LIDOCAINE HCL ANASTIA 3LIDOCAINE HCL ASTERO 3LIDOCAINE HCL LDO PLUS 3lidocaine hcl (3 %) (cream (g)) 1lidocaine hcl (3 %) (lotion) 1lidocaine hcl (4 %) (solution) 1LIDOCAINE HCL LIDOPIN 3LIDOCAINE HCL NUMBONEX 3lidocaine/prilocaine EMLA 1

LIDOCAINE/RACEPINEP/TETRACAINE L.E.T. (LIDO-EPINEPH-TETRA) 3

LIDOCAINE/TETRACAINE PLIAGLIS (7 %-7 %)(CREAM (G)) 3

TETRACAINE HCL PONTOCAINE 3TETRACAINE/BENZOCAINE/BUTAMBEN CETACAINE 3

TETRACAINE/BENZOCAINE/BUTAMBEN CETACAINEANESTHETIC 3

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

HYALURONIDASE, HUMAN RECOMB. HYQVIA HYCOMPONENT 3

DERMATOLOGY - PSORIASIS/ECZEMAANTIPSORIATIC AGENTS,SYSTEMIC

acitretin SORIATANE 1GUSELKUMAB TREMFYA 3 PA, SPmethoxsalen 1

SECUKINUMAB COSENTYX (2SYRINGES) 2 PA, SP

SECUKINUMAB COSENTYX PEN 2 PA, SP

SECUKINUMAB COSENTYX PEN (2PENS) 2 PA, SP

SECUKINUMAB COSENTYXSYRINGE 2 PA, SP

ANTIPSORIATICS AGENTSANTHRALIN DRITHOCREME HP 2 STANTHRALIN MICRONIZED ZITHRANOL 3

National Formulary


Drug Name Tier Requirements/Limitscalcipotriene DOVONEX 1 STcalcitriol VECTICAL 1 ST

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

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

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

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

ECZEMA AGENTS,SYSTEMIC,INTERLEUKIN-4 REC.ANTAG MABDUPILUMAB DUPIXENT 3 PA, SP

TOPICAL AGENTS,MISCELLANEOUSUREA GORDO-UREA 3

TOPICAL IMMUNOSUPPRESSIVE AGENTSPIMECROLIMUS ELIDEL 2 STtacrolimus PROTOPIC 1

TOPICAL VIT D ANALOG/ANTIINFLAMMATORY, STEROIDALCALCIPOTRIENE/BETAMETHASONE ENSTILAR 2 ST

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

CALCIPOTRIENE/BETAMETHASONE TACLONEX (0.005-.064) (SUSPENSION) 2

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

LINAGLIPTIN/METFORMIN HCL JENTADUETO 2 QL: 2 IN 1 DAY

LINAGLIPTIN/METFORMIN HCLJENTADUETO XR(2.5-1000MG) (TABBP 24H)

2 QL: 2 IN 1 DAY

LINAGLIPTIN/METFORMIN HCLJENTADUETO XR(5MG-1000MG) (TABBP 24H)

2 QL: 1 IN 1 DAY

SITAGLIPTIN PHOS/METFORMIN HCL JANUMET 2 QL: 2 IN 1 DAY

SITAGLIPTIN PHOS/METFORMIN HCLJANUMET XR (100-1000MG) (TBMP24HR)

2 QL: 1 IN 1 DAY

SITAGLIPTIN PHOS/METFORMIN HCLJANUMET XR (50-1000 MG) (TBMP24HR)

2 QL: 2 IN 1 DAY

SITAGLIPTIN PHOS/METFORMIN HCLJANUMET XR(50MG-500MG)(TBMP 24HR)

2 QL: 2 IN 1 DAY

ANTIHYPERGLY,DPP-4 ENZYME INHIB &THIAZOLIDINEDIONEalogliptin benz/pioglitazone OSENI 1

ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST)DULAGLUTIDE TRULICITY 2 ST, QL: 2mL IN 28 DAYSEXENATIDE BYETTA 2 STEXENATIDE MICROSPHERES BYDUREON 2 ST, QL: 1 IN 7 DAYSEXENATIDE MICROSPHERES BYDUREON BCISE 2 ST, QL: 1mL IN 7 DAYSEXENATIDE MICROSPHERES BYDUREON PEN 2 ST, QL: 1 IN 7 DAYS

ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIBCANAGLIFLOZIN INVOKANA 2 ST, QL: 1 IN 1 DAYDAPAGLIFLOZIN PROPANEDIOL FARXIGA 2 STEMPAGLIFLOZIN JARDIANCE 2 ST, QL: 1 IN 1 DAYERTUGLIFLOZIN PIDOLATE STEGLATRO 3

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

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Drug Name Tier Requirements/Limitsmiglitol GLYSET 1

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

ANTIHYPERGLYCEMIC, DPP-4 INHIBITORSLINAGLIPTIN TRADJENTA 2 QL: 1 IN 1 DAYSITAGLIPTIN PHOSPHATE JANUVIA 2 QL: 1 IN 1 DAY

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

ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S)pioglitazone hcl ACTOS 1

ANTIHYPERGLYCEMIC, SGLT-2 & DPP-4 INHIBITOR COMB.EMPAGLIFLOZIN/LINAGLIPTIN GLYXAMBI 2 ST, QL: 1 IN 1 DAY

ANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA)metformin hcl FORTAMET 1 STmetformin hcl GLUCOPHAGE 1metformin hcl GLUCOPHAGE XR 1

ANTIHYPERGLYCEMIC,INSULIN & GLP-1 RECEPTOR AGONISTINSULIN DEGLUDEC/LIRAGLUTIDE XULTOPHY 100-3.6 2 ST, QL: 15mL IN 28 DAYSINSULIN GLARGINE/LIXISENATIDE SOLIQUA 100-33 2 ST, QL: 30mL IN 28 DAYS

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

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

ANTIHYPERGLYCEMIC-GLUCOCORTICOID RECEPTOR BLOCKERMIFEPRISTONE KORLYM 3 PA

ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR & BIGUANIDE COMBCANAGLIFLOZIN/METFORMIN HCL INVOKAMET 2 ST, QL: 2 IN 1 DAYCANAGLIFLOZIN/METFORMIN HCL INVOKAMET XR 2 ST, QL: 2 IN 1 DAY

DAPAGLIFLOZIN/METFORMIN HCLXIGDUO XR (10-1000 MG) (TAB BP24H)

2 ST

DAPAGLIFLOZIN/METFORMIN HCLXIGDUO XR (10MG-500MG) (TAB BP24H)

2 ST

DAPAGLIFLOZIN/METFORMIN HCLXIGDUO XR (2.5-1000MG) (TAB BP24H)

3 ST

DAPAGLIFLOZIN/METFORMIN HCLXIGDUO XR (5 MG-500MG) (TAB BP24H)

2 ST

DAPAGLIFLOZIN/METFORMIN HCLXIGDUO XR (5MG-1000MG) (TAB BP24H)

2 ST

EMPAGLIFLOZIN/METFORMIN HCL SYNJARDY 2 ST, QL: 2 IN 1 DAY

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EMPAGLIFLOZIN/METFORMIN HCLSYNJARDY XR (10-1000 MG) (TAB BP24H)


EMPAGLIFLOZIN/METFORMIN HCLSYNJARDY XR(12.5-1000) (TAB BP24H)


EMPAGLIFLOZIN/METFORMIN HCLSYNJARDY XR (25-1000 MG) (TAB BP24H)


EMPAGLIFLOZIN/METFORMIN HCLSYNJARDY XR(5MG-1000MG) (TABBP 24H)


ANTIHYPERGLYCM,INSUL-RESP.ENHANCER & BIGUANIDE CMBpioglitazone hcl/metformin hcl ACTOPLUS MET 1 ST

BLOOD SUGAR DIAGNOSTICS

BLOOD SUGAR DIAGNOSTICBLOOD GLUCOSETEST STRIP (STRIP)(OTC)

1

BLOOD SUGAR DIAGNOSTIC CONTOUR 2 PABLOOD SUGAR DIAGNOSTIC CONTOUR NEXT 2 PA

BLOOD SUGAR DIAGNOSTIC ONETOUCH ULTRATEST STRIPS 2

BLOOD SUGAR DIAGNOSTIC ONETOUCH VERIO 2

BLOOD SUGAR DIAGNOSTICPREMIUM BLOODGLUCOSE TEST(STRIP) (OTC)

1

BLOOD SUGAR DIAGNOSTIC WAVESENSEPRESTO 1

DIABETIC SUPPLIESBLOOD-GLUCOSE METER ONETOUCH

ULTRA2 2

BLOOD-GLUCOSE METER ONETOUCHULTRAMINI 2

BLOOD-GLUCOSE METER ONETOUCH VERIO 2

BLOOD-GLUCOSE METER ONETOUCH VERIOFLEX 2

BLOOD-GLUCOSE METER ONETOUCH VERIOIQ 2

BLOOD-GLUCOSE METERPREMIUM BLOODGLUCOSE (EACH)(OTC)

1

BLOOD-GLUCOSE METER WAVESENSEPRESTO (KIT) (OTC) 1

BLOOD-GLUCOSE METER,CONTINUOUS DEXCOM G4(EACH) 2

DIABETIC ULCER PREPARATIONS,TOPICALBECAPLERMIN REGRANEX 2

HYPERGLYCEMICSDIAZOXIDE PROGLYCEM 2GLUCAGON,HUMAN RECOMBINANT GLUCAGEN 2

GLUCAGON,HUMAN RECOMBINANT GLUCAGONEMERGENCY KIT 2

INSULINSINSULIN DEGLUDEC TRESIBA

FLEXTOUCH U-100 2 QL: 30mL IN 28 DAYS

INSULIN DEGLUDEC TRESIBAFLEXTOUCH U-200 2 QL: 18mL IN 28 DAYS

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INSULIN DETEMIR LEVEMIRFLEXTOUCH 2 QL: 30mL IN 28 DAYS

Drug Name Tier Requirements/LimitsINSULIN DETEMIR LEVEMIR 2 QL: 40mL IN 28 DAYS

INSULIN DETEMIR LEVEMIRFLEXTOUCH 2 QL: 30mL IN 28 DAYS

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

INSULIN GLARGINE,HUM.REC.ANLOG LANTUS 2 QL: 40mL IN 28 DAYSINSULIN GLARGINE,HUM.REC.ANLOG LANTUS SOLOSTAR 2 QL: 30mL IN 28 DAYSINSULIN GLARGINE,HUM.REC.ANLOG TOUJEO SOLOSTAR 2 QL: 13.5mL IN 28 DAYS

INSULIN LISPROHUMALOG(100/ML)(CARTRIDGE)


INSULIN LISPRO HUMALOG(100/ML) (VIAL) 2 QL: 40mL IN 28 DAYS

INSULIN LISPRO HUMALOG JUNIORKWIKPEN 2 QL: 30mL IN 28 DAYS

INSULIN LISPRO HUMALOGKWIKPEN U-100 2 QL: 30mL IN 28 DAYS

INSULIN LISPRO HUMALOGKWIKPEN U-200 2 QL: 12mL IN 28 DAYS

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 50-50 2 QL: 40mL IN 28 DAYS

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 50-50 KWIKPEN 2 QL: 30mL IN 28 DAYS

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 75-25 2 QL: 40mL IN 28 DAYS

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 75-25 KWIKPEN 2 QL: 30mL IN 28 DAYS

INSULIN NPH HUM/REG INSULIN HM HUMULIN 70/30KWIKPEN 2 QL: 30mL IN 28 DAYS

INSULIN NPH HUM/REG INSULIN HM HUMULIN 70-30 2 QL: 40mL IN 28 DAYSINSULIN NPH HUMAN ISOPHANE HUMULIN N 2 QL: 40mL IN 28 DAYS

INSULIN NPH HUMAN ISOPHANE HUMULIN NKWIKPEN 2 QL: 30mL IN 28 DAYS

INSULIN REGULAR, HUMAN HUMULIN R 2 QL: 40mL IN 28 DAYSINSULIN REGULAR, HUMAN HUMULIN R U-500 2 QL: 40mL IN 28 DAYS

INSULIN REGULAR, HUMAN HUMULIN R U-500KWIKPEN 2 QL: 24mL IN 28 DAYS

EAR - GENERAL DISORDERSEAR PREPARATIONS ANTI-INFLAMMATORY

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

acetic acid VOSOL 1hydrocortisone/acetic acid VOSOL HC 1

EAR PREPARATIONS,ANTIBIOTICSCIPROFLOXACIN OTIPRIO 3ciprofloxacin hcl CETRAXAL 1neomycin/polymyxin b/hydrocort 1ofloxacin FLOXIN 1

OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICSCIPROFLOXACIN HCL/DEXAMETH CIPRODEX 2CIPROFLOXACIN HCL/FLUOCINOLONE OTOVEL 2

ELECTROLYTE REGULATIONARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS

TOLVAPTAN SAMSCA (15 MG)(TABLET) 2 QL: 30 IN 365 DAYS

TOLVAPTAN SAMSCA (30 MG)(TABLET) 2 QL: 60 IN 365 DAYS

National Formulary


Drug Name Tier Requirements/LimitsELECTROLYTE DEPLETERS

calcium acetate ELIPHOS 1calcium acetate PHOSLO 1CALCIUM ACETATE PHOSLYRA 2calcium carb/mag carb/folic ac 1

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



PATIROMER CALCIUM SORBITEX VELTASSA 2 PA, QL: 1 IN 1 DAYsevelamer carbonate RENVELA 1sodium polystyrene sulfon/sorb 1SODIUM POLYSTYRENE SULFON/SORB SPS 2sodium polystyrene sulfonate 1SUCROFERRIC OXYHYDROXIDE VELPHORO 2

POTASSIUM REPLACEMENTpot chloride/pot bicarb/cit ac 1potassium bicarbonate/cit ac KLOR-CON-EF 1potassium chloride (10 meq) (capsule er) 1potassium chloride (10 meq) (tab er prt) 1potassium chloride (10 meq) (tablet er) 1potassium chloride (15 meq) (tab er prt) 1potassium chloride (20 meq) (packet) 1potassium chloride (20 meq) (tab er prt) 1potassium chloride (20 meq) (tablet er) 1potassium chloride (20meq/15ml) (liquid) 1potassium chloride (40meq/15ml) (liquid) 1potassium chloride (8 meq) (capsule er) 1potassium chloride (8 meq) (tablet er) 1

ENDOCRINE DISORDER - FERTILITYDRUGS TO TREAT IMPOTENCY

ALPROSTADIL CAVERJECT 2 QL: 1 IN 5 DAYS

ALPROSTADIL EDEX (10 MCG)(KIT) 3 QL: 3 IN 30 DAYS

ALPROSTADIL EDEX (20 MCG)(KIT) 3 QL: 3 IN 30 DAYS

ALPROSTADIL MUSE 2 QL: 1 IN 5 DAYSpapav/phentolam/alprost/water 3papaverine hcl/alprostad/water 3phentolamine/alprostadil/water 3sildenafil citrate VIAGRA 2 QL: 1 IN 5 DAYS

TADALAFIL CIALIS (10 MG)(TABLET) 2 PA, QL: 1 IN 5 DAYS

TADALAFIL CIALIS (2.5 MG)(TABLET) 2 PA, QL: 1 IN 1 DAY

TADALAFIL CIALIS (20 MG)(TABLET) 2 PA, QL: 1 IN 5 DAYS

TADALAFIL CIALIS (5 MG)(TABLET) 2 PA, QL: 1 IN 1 DAY

FERTILITY STIMULATING PREPARATIONS,NON-FSHclomiphene citrate SEROPHENE 3

FOLLICLE STIM./LUTEINIZING HORMONESMENOTROPINS MENOPUR 2

FOLLICLE-STIMULATING HORMONE (FSH)FOLLITROPIN ALFA, RECOMBINANT GONAL-F 3 ST

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Drug Name Tier Requirements/LimitsFOLLITROPIN ALFA, RECOMBINANT GONAL-F RFF 3 ST

FOLLITROPIN ALFA, RECOMBINANT GONAL-F RFFREDI-JECT 3 ST

FOLLITROPIN BETA,RECOMB FOLLISTIM AQ 2HUMAN CHORIONIC GONADOTROPIN (HCG)

CHORIONIC GONADOTROPIN, HUMAN CHORIONICGONADOTROPIN 2

CHORIONIC GONADOTROPIN, HUMAN NOVAREL 2PREGNANCY FACILITATING/MAINTAINING AGENT,HORMONAL

HYDROXYPROGESTERONE CAPROAT/PF MAKENA 2 PA, SPHYDROXYPROGESTERONE CAPROATE MAKENA 2 PA, SPPROGESTERONE, MICRONIZED CRINONE 2

ENDOCRINE DISORDER - OTHERANTIDIURETIC AND VASOPRESSOR HORMONES

desmopressin (nonrefrigerated) DDAVP 1desmopressin acetate 1DESMOPRESSIN ACETATE STIMATE 2 SP

ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR.GOSERELIN ACETATE ZOLADEX 2 PA, SPHISTRELIN ACETATE VANTAS 2 SP

LEUPROLIDE ACETATE ELIGARD (22.5 MG)(SYRINGE) 2 PA, SP

LEUPROLIDE ACETATE ELIGARD (30 MG)(SYRINGE) 2 PA, SP

LEUPROLIDE ACETATE ELIGARD (45 MG)(SYRINGE) 2 PA, SP

LEUPROLIDE ACETATE ELIGARD (7.5 MG)(SYRINGE) 2 PA, SP

leuprolide acetate (1 mg/0.2ml) (kit) 1 SPleuprolide acetate (1 mg/0.2ml) (vial) 1 SP

BONE FORMATION STIMULATING AGTS - PTH REL PEPTIDESABALOPARATIDE TYMLOS 2 PA, SP

BONE RESORPTION INHIBITORSalendronate sodium FOSAMAX (10 MG)

(TABLET) 1

alendronate sodium FOSAMAX (35 MG)(TABLET) 1




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


CALCITONIN,SALMON,SYNTHETIC MIACALCIN(200/ML) (VIAL) 2

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

1

DENOSUMAB XGEVA 2 PA, SPetidronate disodium DIDRONEL 1

ibandronate sodium BONIVA (150 MG)(TABLET) 1

pamidronate disodium 1 SPraloxifene hcl EVISTA 1 PA, QL: 1 IN 1 DAY

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Drug Name Tier Requirements/Limitsrisedronate sodium ACTONEL (150 MG)

(TABLET) 1 ST, QL: 1 IN 30 DAYS

risedronate sodium ACTONEL (30 MG)(TABLET) 1 ST, QL: 1 IN 1 DAY

risedronate sodium ACTONEL (35 MG)(TABLET) 1 ST, QL: 1 IN 7 DAYS

risedronate sodium ACTONEL (5 MG)(TABLET) 1 ST, QL: 1 IN 1 DAY

risedronate sodium ATELVIA 1 ST, QL: 1 IN 7 DAYSzoledronic ac/mannitol/0.9nacl 1 SPzoledronic acid ZOMETA 1 SPzoledronic acid/mannitol-water 1 SPZOLEDRONIC ACID/MANNITOL-WATER ZOMETA 2 SP

CALCIMIMETIC,PARATHYROID CALCIUM ENHANCERCINACALCET HCL SENSIPAR 2ETELCALCETIDE HYDROCHLORIDE PARSABIV 3 PA, SP

GROWTH HORMONE RECEPTOR ANTAGONISTSPEGVISOMANT SOMAVERT 2

GROWTH HORMONE RELEASING HORMONE (GHRH) & ANALOGSTESAMORELIN ACETATE EGRIFTA 2 PA, SP

GROWTH HORMONESSOMATROPIN NORDITROPIN

FLEXPRO 2 PA, SP

SOMATROPIN SEROSTIM (4 MG)(VIAL) 2 PA



HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPEdoxercalciferol HECTOROL (0.5

MCG) (CAPSULE) 1

doxercalciferol HECTOROL (1 MCG)(CAPSULE) 1

doxercalciferol HECTOROL (2.5MCG) (CAPSULE) 1

paricalcitol (1 mcg) (capsule) 1paricalcitol (2 mcg) (capsule) 1paricalcitol (4mcg) (capsule) 1

INSULIN-LIKE GROWTH FACTOR-1 (IGF-1) HORMONESMECASERMIN INCRELEX 2 PA

LEPTIN HORMONE ANALOGSMETRELEPTIN MYALEPT 2 QL: 1 IN 1 DAY

LHRH(GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTSLEUPROLIDE ACETATE LUPRON DEPOT 2 SP

LEUPROLIDE ACETATE LUPRON DEPOT(LUPANETA) 2 SP

NAFARELIN ACETATE SYNAREL 2LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTS

CETRORELIX ACETATE CETROTIDE 2LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY

LEUPROLIDE ACETATE LUPRON DEPOT-PED 2 SP

TRIPTORELIN PAMOATE TRIPTODUR 3 PA, QL: 1 IN 180 DAYSPARATHYROID HORMONES

PARATHYROID HORMONE NATPARA 2 PA

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SP

Drug Name Tier Requirements/LimitsPITUITARY SUPPRESSIVE AGENTS

cabergoline DOSTINEX 1danazol DANOCRINE 1

ENDOCRINE DISORDER - THYROIDANTITHYROID PREPARATIONS

methimazole TAPAZOLE 1propylthiouracil 1

IODINE CONTAINING AGENTSpotassium iodide/iodine 1

THYROID HORMONESlevothyroxine sodium LEVO-T 1levothyroxine sodium LEVOXYL 1

levothyroxine sodium SYNTHROID (100MCG) (TABLET) 1





levothyroxine sodium SYNTHROID(175MCG) (TABLET) 1







LEVOTHYROXINE SODIUM TIROSINT 3levothyroxine sodium UNITHROID 1liothyronine sodium CYTOMEL 1THYROID,PORK ARMOUR THYROID 2thyroid,pork 1

EYE - GENERAL DISORDERSEYE ANTIBIOTIC, GLUCOCORTICOID AND NSAID COMB.

gatifloxacin/prednisol/nepafen 1EYE ANTIBIOTIC-CORTICOID COMBINATIONS

gatifloxacin/prednisolone 1neomycin/bacit/p-myx/hydrocort 1neomycin/polymyxin b/dexametha 1neomycin/polymyxin b/hydrocort 1

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

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

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

EYE ANTIHISTAMINESALCAFTADINE LASTACAFT 3

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Drug Name Tier Requirements/Limitsazelastine hcl OPTIVAR 1BEPOTASTINE BESILATE BEPREVE 2EMEDASTINE DIFUMARATE EMADINE 3epinastine hcl ELESTAT 1olopatadine hcl PATADAY 1 QL: 2.5mL IN 30 DAYSolopatadine hcl PATANOL 1OLOPATADINE HCL PAZEO 2 ST

EYE ANTI-INFECTIVES (RX ONLY)povidone-iodine BETADINE 1

EYE ANTIINFLAMMATORY AGENTSbromfenac sodium 1BROMFENAC SODIUM PROLENSA 2dexamethasone sod phosphate DEXASOL 1diclofenac sodium VOLTAREN 1fluorometholone FML 1flurbiprofen sodium OCUFEN 1ketorolac tromethamine ACULAR 1ketorolac tromethamine ACULAR LS 1LOTEPREDNOL ETABONATE ALREX 2LOTEPREDNOL ETABONATE LOTEMAX 2NEPAFENAC ILEVRO 2prednisolone acetate OMNIPRED 1prednisolone acetate PRED FORTE 1prednisolone acetate/nepafenac 1prednisolone sod phosphate 1

EYE ANTIVIRALStrifluridine VIROPTIC 1

EYE LOCAL ANESTHETICSbenoxinate hcl/fluorescein sod FLUORESCEIN-

BENOXINATE 1

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

tetracaine hcl/pf TETRACAINEHYDROCHLORIDE 1

EYE SULFONAMIDESsulfacetamide sodium SODIUM SULAMYD 1sulfacetamide/prednisolone sp 1

EYE VASOCONSTRICTORS (RX ONLY)phenylephrine hcl 1

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

ciprofloxacin hcl CILOXAN (0.3 %)(DROPS) 1

erythromycin base ILOTYCIN 1gatifloxacin ZYMAXID 1gentamicin sulfate GARAMYCIN 1gentamicin sulfate GENTAK 1levofloxacin 1MOXIFLOXACIN HCL MOXEZA 3moxifloxacin hcl VIGAMOX 1

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Drug Name Tier Requirements/LimitsNATAMYCIN NATACYN 2neomycin sulf/bacitracin/poly NEO-POLYCIN 1neomycin/polymyxn b/gramicidin NEOSPORIN 1ofloxacin OCUFLOX 1polymyxin b sulf/trimethoprim POLYTRIM 1

tobramycin TOBREX (0.3 %)(DROPS) 1

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

CYCLOSPORINE RESTASISMULTIDOSE 2 QL: 5.5mL IN 30 DAYS

LIFITEGRAST XIIDRA 2 QL: 60 IN 30 DAYSOPHTHALMIC MAST CELL STABILIZERS

cromolyn sodium OPTICROM 1OPHTHALMIC PREPARATIONS, MISCELLANEOUS

HYPOCHLOROUS ACID/SODIUM CHLOR ACUICYN 3HYPOCHLOROUS ACID/SODIUM CHLOR AVENOVA 3

EYE - GLAUCOMACARBONIC ANHYDRASE INHIBITORS

acetazolamide 1methazolamide NEPTAZANE 1

MIOTICS/OTHER INTRAOC. PRESSURE REDUCERSapraclonidine hcl IOPIDINE (0.5 %)

(DROPS) 1

betaxolol hcl BETOPTIC 1

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

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

brimonidine tartrate ALPHAGAN 1

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

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

BRIMONIDINE TARTRATE/TIMOLOL COMBIGAN 2BRINZOLAMIDE AZOPT 3BRINZOLAMIDE/BRIMONIDINE TART SIMBRINZA 3carteolol hcl OCUPRESS 1dorzolamide hcl TRUSOPT 1dorzolamide hcl/timolol maleat COSOPT 1DORZOLAMIDE/TIMOLOL/PF COSOPT PF 3 QL: 2 IN 1 DAY

ECHOTHIOPHATE IODIDE PHOSPHOLINEIODIDE 2

latanoprost XALATAN 1LATANOPROSTENE BUNOD VYZULTA 3levobunolol hcl BETAGAN 1metipranolol OPTIPRANOLOL 1pilocarpine hcl ISOPTO CARPINE 1TIMOLOL BETIMOL 3timolol maleate ISTALOL 1timolol maleate TIMOPTIC 1timolol maleate TIMOPTIC-XE 1TRAVOPROST TRAVATAN Z 2 QL: 1mL IN 12 DAYS

MYDRIATICSatropine sulfate 1atropine sulfate ISOPTO ATROPINE 1atropine sulfate/0.9 %sod chlr 1

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Drug Name Tier Requirements/Limitscyclopentol/lido/pe/tropicamid 1cyclopentolat/tropic/phenyleph 1cyclopentolate hcl CYCLOGYL 1CYCLOPENTOLATE/PHENYLEPHRINE CYCLOMYDRIL 3

homatropine hbr ISOPTOHOMATROPINE 1

HYDROXYAMPHETAMINE/TROPICAMIDE PAREMYD 3tropicamide MYDRIACYL 1

OPHTHALMIC ANTIFIBROTIC AGENTSMITOMYCIN MITOSOL 3

EYE - MISCELLANEOUSARTIFICIAL TEARS

acetylcysteine in water/pf 1EYE PREPARATIONS, MISCELLANEOUS (OTC)

GELATIN GELFILM 3OCULAR PHOTOACTIVATED VESSEL-OCCLUDING AGENTS

VERTEPORFIN VISUDYNE 2OPHTHALMIC CYSTINE DEPLETING AGENTS

CYSTEAMINE HCL CYSTARAN 2 PAFLUID REPLACEMENT

NUCLEIC ACID/NUCLEOTIDE SUPPLEMENTSURIDINE TRIACETATE XURIDEN 2 PA

GOUT AND RELATED DISEASESCOLCHICINE

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

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

HYPERURICEMIA TX - URATE-OXIDASE ENZYME-TYPEPEGLOTICASE KRYSTEXXA 2 SP

URICOSURIC AGENTSprobenecid BENEMID 1

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

HEMATOLOGICAL DISORDERSANTICOAGULANTS,COUMARIN TYPE

warfarin sodium COUMADIN 1ANTIFIBRINOLYTIC AGENTS

AMINOCAPROIC ACID AMICAR 2FIBRINOGEN RIASTAP 2 SPtranexamic acid CYKLOKAPRON 1 SPtranexamic acid LYSTEDA 1

ANTIHEMOPHILIC FACTORSANTIHEM.FVIII,SIN-CHN,B-DM TRU AFSTYLA (1000 (+/

-)) (VIAL) 2 SP

ANTIHEM.FVIII,SIN-CHN,B-DM TRU AFSTYLA (1500 (+/-)) (VIAL) 3 SP


ANTIHEM.FVIII,SIN-CHN,B-DM TRU AFSTYLA (250 (+/-))(VIAL) 2 SP

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Drug Name Tier Requirements/LimitsANTIHEM.FVIII,SIN-CHN,B-DM TRU AFSTYLA (2500 (+/

-)) (VIAL) 3 SP


ANTIHEM.FVIII,SIN-CHN,B-DM TRU AFSTYLA (500 (+/-))(VIAL) 2 SP

ANTIHEMO.FVIII,FULL LENGTH PEG ADYNOVATE (1000(+/-)) (VIAL) 2 SP







ANTIHEMOPH.FVIII,B-DOM TRUNCAT NOVOEIGHT 2 SP

ANTIHEMOPHIL.FVIII,FULL LENGTH ADVATE (1000 (+/-))(VIAL) 2 SP







ANTIHEMOPHIL.FVIII,FULL LENGTH HELIXATE FS 2 SPANTIHEMOPHIL.FVIII,FULL LENGTH KOGENATE FS 2 SPANTIHEMOPHIL.FVIII,FULL LENGTH KOVALTRY 2ANTIHEMOPHILIC FACTOR, HUMAN HEMOFIL M 2 SP

ANTIHEMOPHILIC FACTOR, HUMAN KOATE (1000 (+/-))(VIAL) 2 SP

ANTIHEMOPHILIC FACTOR, HUMAN KOATE (500 (+/-))(VIAL) 3 SP

ANTIHEMOPHILIC FACTOR, HUMAN MONOCLATE-P(1000 (+/-)) (VIAL) 2 SP

ANTIHEMOPHILIC FACTOR, HUMAN MONOCLATE-P(1500 (+/-)) (VIAL) 2 SP

ANTIHEMOPHILIC FACTOR/VWF ALPHANATE 2 SPANTIHEMOPHILIC FACTOR/VWF HUMATE-P 2 SP

ANTIHEMOPHILIC FACTOR/VWF WILATE (1K-1KUNIT) (VIAL) 2 SP

ANTIHEMOPHILIC FACTOR/VWF WILATE (450-450)(VIAL) 2

ANTIHEMOPHILIC FACTOR/VWF WILATE (500-500)(VIAL) 2 SP

ANTIHEMOPHILIC FACTOR/VWF WILATE (900-900)(VIAL) 2

ANTIHEMOPHILIC FVIII,REC PORC OBIZUR 2ANTI-INHIBITOR COAGULANT COMP. FEIBA NF 2 SPCOAGULATION FACTOR VIIA,RECOMB NOVOSEVEN RT 2 SP

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Drug Name Tier Requirements/LimitsANTIPORPHYRIA FACTORS

HEMIN PANHEMATIN 3 SPBLOOD FACTORS,MISCELLANEOUS

FACTOR XIII CORIFACT 2 SPVON WILLEBRAND FACTOR VONVENDI 2

CITRATES AS ANTICOAGULANTScitrate phosphate dextros soln 1DEXTROSE/SOD CITRATE/CITRIC AC ACD 2sodium citrate 1sodium citrate in 0.9 % nacl 1

DIRECT FACTOR XA INHIBITORSAPIXABAN ELIQUIS (2.5 MG)


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

BETRIXABAN MALEATE BEVYXXA 3 PA, QL: 43 IN 42 DAYS

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


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


FACTOR IX PREPARATIONSFACTOR IX ALPHANINE SD 2 SPFACTOR IX MONONINE 2 SPFACTOR IX CPLX(PCC)NO4,3FACTOR PROFILNINE 2 SPFACTOR IX CPLX(PCC)NO6,3FACTOR BEBULIN 2 SPFACTOR IX HUMAN REC,PEGYLATED REBINYN 3FACTOR IX HUMAN RECOMB,THR 148 IXINITY 2FACTOR IX HUMAN RECOMBINANT BENEFIX 2 SPFACTOR IX REC, FC FUSION PROTN ALPROLIX 2 SP

FACTOR X PREPARATIONSCOAGULATION FACTOR X COAGADEX 2 SP

FACTOR XIII PREPARATIONSFACTOR XIII A-SUBUNIT,RECOMB TRETTEN 2 SP

HEMATINICS,OTHEREPOETIN ALFA PROCRIT

(10000/ML) (VIAL) 2 PA, SP

EPOETIN ALFA PROCRIT (2000/ML)(VIAL) 2 PA, SP

EPOETIN ALFA PROCRIT(20000/2ML) (VIAL) 2 PA, SP

EPOETIN ALFA PROCRIT(20000/ML) (VIAL) 2 PA, SP



EPOETIN ALFA PROCRIT(40000/ML) (VIAL) 2 PA, SP

METHOXY PEG-EPOETIN BETA MIRCERA 3 PAHEMOPHILIA TREATMENT AGENTS,NON-FACTOR REPLACEMENT

EMICIZUMAB-KXWH HEMLIBRA 3 PA, SPHEMORRHEOLOGIC AGENTS

pentoxifylline TRENTAL 1

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SP

Drug Name Tier Requirements/LimitsHEPARIN AND RELATED PREPARATIONS

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


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





2 QL: 7.2mL IN 30 DAYS

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


DALTEPARIN SODIUM,PORCINE FRAGMIN(25000/ML) (VIAL) 2 QL: 7.6mL IN 30 DAYS





enoxaparin sodium LOVENOX (100MG/ML) (SYRINGE) 1 QL: 20mL IN 30 DAYS

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


enoxaparin sodium LOVENOX (150MG/ML) (SYRINGE) 1 QL: 20mL IN 30 DAYS

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


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








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


fondaparinux sodium ARIXTRA (2.5MG/0.5) (SYRINGE) 1 QL: 5mL IN 30 DAYS

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


fondaparinux sodiumARIXTRA(7.5MG/0.6)(SYRINGE)


heparin sod,porcine/0.9 % nacl 1heparin sod,pork in 0.45% nacl 1

HEPARIN SOD,PORK IN 0.45% NACL HEPARIN SODIUMIN 0.45% NACL 3

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Drug Name Tier Requirements/LimitsHEPARIN SOD,PORK IN 0.45% NACL HEPARIN SODIUM-

0.45% NACL 3

heparin sodium,porcine 1heparin sodium,porcine/d5w 1heparin sodium,porcine/ns/pf 1heparin sodium,porcine/pf 1

HUMAN MONOCLONAL ANTIBODY COMPLEMENT(C5) INHIBITORECULIZUMAB SOLIRIS 2 PA, SP

LEUKOCYTE (WBC) STIMULANTSFILGRASTIM NEUPOGEN 3 PA, SPFILGRASTIM-SNDZ ZARXIO 2 SPPEGFILGRASTIM NEULASTA 2 PA, SP

SARGRAMOSTIM LEUKINE (250 MCG)(VIAL) 2 PA, SP

TBO-FILGRASTIM GRANIX 2 PAPLASMA PROTEINS

ANTITHROMBIN III (PLASMA DER) THROMBATE III 2 SPPLATELET AGGREGATION INHIBITORS

aspirin 0

aspirin BAYER CHEWABLEASPIRIN 0

aspirin ECOTRIN 0aspirin/dipyridamole AGGRENOX 1cilostazol PLETAL 1

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

clopidogrel bisulfate PLAVIX (75 MG)(TABLET) 1

dipyridamole PERSANTINE 1prasugrel hcl EFFIENT 1 QL: 1 IN 1 DAYTICAGRELOR BRILINTA 2 QL: 2 IN 1 DAYticlopidine hcl TICLID 1VORAPAXAR SULFATE ZONTIVITY 2 QL: 1 IN 1 DAY

PLATELET REDUCING AGENTSanagrelide hcl AGRYLIN 1

PROTEIN C PREPARATIONSPROTEIN C, HUMAN CEPROTIN (1000

UNIT) (VIAL) 2 SP

PROTEIN C, HUMAN CEPROTIN (500UNIT) (VIAL) 2 SP

SICKLE CELL ANEMIA AGENTSHYDROXYUREA DROXIA 2

THROMBIN INHIBITORS,SELECTIVE,DIRECT, & REVERSIBLEARGATROBAN 3 SP

THROMBOPOIETIN RECEPTOR AGONISTSELTROMBOPAG OLAMINE PROMACTA 2 PAROMIPLOSTIM NPLATE 2 SP

TOPICAL HEMOSTATICSFERRIC SUBSULFATE ASTRINGYN 3ferric subsulfate 1FIBRINOGEN/THROMBIN(HUMAN DER) EVARREST 3FIBRINOGEN/THROMBIN(HUMAN DER) RAPLIXA 3FIBRINOGEN/THROMBIN(HUMAN DER) TACHOSIL 3GELATIN SPONGE,ABSORBABLE GELFOAM 3MICROFIBRILLAR COLLAGEN AVITENE 3MICROFIBRILLAR COLLAGEN ENDO-AVITENE 3MICROFIBRILLAR COLLAGEN SYRINGE AVITENE 3

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Drug Name Tier Requirements/LimitsMICROFIBRILLAR COLLAGEN ULTRAFOAM 3thrombin (bovine) 1THROMBIN (RECOMBINANT) RECOTHROM 3THROMBIN,BOVINE/GELATIN SPONGE GELFOAM JMI 3THROMBIN,HU/FIBRINOGEN/CALCIUM EVICEL 3THROMBIN/FIBRINOGN/APROTIN/CAL TISSEEL VHSD 3

VITAMIN K PREPARATIONSPHYTONADIONE (VIT K1) MEPHYTON 2phytonadione (vit k1) (10 mg/ml) (ampul) 1phytonadione (vit k1) (1mg/0.5ml) (ampul) 1phytonadione (vit k1) (1mg/0.5ml) (syringe) 1

HORMONAL DEFICIENCYANDROGENIC AGENTS

methyltestosterone ANDROID 1 PAMETHYLTESTOSTERONE METHITEST 2 PAmethyltestosterone TESTRED 1 PAoxandrolone OXANDRIN 1 PATESTOSTERONE ANDRODERM 2 PA

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

testosteroneANDROGEL(12.5/1.25G) (GELMD PMP)

1 PA

TESTOSTERONEANDROGEL (2.5G-1.62%) (GELPACKET)

2 PA

TESTOSTERONEANDROGEL(20.25/1.25) (GELMD PMP)

2 PA

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

1 PA

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

testosterone AXIRON 1 PAtestosterone TESTIM 1 PAtestosterone VOGELXO 1 PA

testosterone cypionate DEPO-TESTOSTERONE 1 PA

testosterone enanthate DELATESTRYL 1 PAESTROGEN & SELECTIVE ESTROGEN RECEPT MOD(SERM)COMB

ESTROGENS,CONJ/BAZEDOXIFENE DUAVEE 2ESTROGEN/ANDROGEN COMBINATIONS

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

ESTROGENIC AGENTSESTRADIOL ALORA 3 QL: 2 IN 7 DAYSestradiol CLIMARA 1 QL: 1 IN 7 DAYSESTRADIOL DIVIGEL 2estradiol ESTRACE 1ESTRADIOL MINIVELLE 3 QL: 2 IN 7 DAYSestradiol VIVELLE-DOT 1 QL: 2 IN 7 DAYSESTRADIOL CYPIONATE DEPO-ESTRADIOL 2ESTRADIOL/LEVONORGESTREL CLIMARA PRO 3 QL: 1 IN 7 DAYSestradiol/norethindrone acet ACTIVELLA 1ESTRADIOL/NORETHINDRONE ACET COMBIPATCH 2 QL: 2 IN 7 DAYSESTROGEN,CON/M-PROGEST ACET PREMPHASE 2ESTROGEN,CON/M-PROGEST ACET PREMPRO 2

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Drug Name Tier Requirements/LimitsESTROGENS, CONJUGATED PREMARIN (0.3 MG)

(TABLET) 2

ESTROGENS, CONJUGATED PREMARIN(0.45MG) (TABLET) 2

ESTROGENS, CONJUGATED PREMARIN (0.625MG) (TABLET) 2

ESTROGENS, CONJUGATED PREMARIN (0.9 MG)(TABLET) 2

ESTROGENS, CONJUGATED PREMARIN (1.25MG) (TABLET) 2

ESTROGENS,ESTERIFIED MENEST 3estropipate OGEN 2.5 1estropipate ORTHO-EST 1norethindrone ac-eth estradiol FEMHRT 1norethindrone ac-eth estradiol JEVANTIQUE 1norethindrone ac-eth estradiol JEVANTIQUE LO 1

PROGESTATIONAL AGENTSMEDROXYPROGESTERONE ACETATE DEPO-PROVERA 2medroxyprogesterone acetate PROVERA 1norethindrone acetate AYGESTIN 1progesterone 1PROGESTERONE, MICRONIZED CRINONE 2progesterone, micronized PROMETRIUM 1

IMMUNIZATIONANTISERA

CYTOMEGALOVIRUS IMMUNE GLOBULN CYTOGAM 2 SPHEPATITIS B IMMUN GLOB/MALTOSE HEPAGAM B 2 SPHEPATITIS B IMMUNE GLOBULIN HYPERHEP B S-D 2 SPIMMUN GLOB G(IGG)/GLY/IGA 0-50 GAMMAPLEX 3 PA, SP

IMMUN GLOB G(IGG)/GLY/IGA OV50GAMMAGARDLIQUID (10 %)(VIAL)

2 PA, SP

IMMUN GLOB G(IGG)/GLY/IGA OV50 HYQVIA IGCOMPONENT 3 PA

IMMUN GLOB G(IGG)/PRO/IGA 0-50 HIZENTRA (1 G/5ML) (VIAL) 2 PA, SP




IMMUN GLOB G(IGG)/PRO/IGA 0-50 PRIVIGEN (10 %)(VIAL) 2 PA, SP

IMMUN GLOB G/GLY/GLUC/IGA 0-50 GAMMAGARD S-D 2 PA, SP

IMMUNE GLOBUL G (IGG)/GLYCINE GAMASTAN S-D (15%-18 %) (VIAL) 2 PA, SP

IMMUNE GLOBUL G/GLY/IGA AVG 46 GAMMAKED 2 PA, SP

IMMUNE GLOBUL G/GLY/IGA AVG 46 GAMUNEX-C (1G/10 ML) (VIAL) 2 PA, SP

IMMUNE GLOBUL G/GLY/IGA AVG 46 GAMUNEX-C (10G/100ML) (VIAL) 2 PA, SP

IMMUNE GLOBUL G/GLY/IGA AVG 46 GAMUNEX-C(2.5G/25ML) (VIAL) 2 PA, SP

IMMUNE GLOBUL G/GLY/IGA AVG 46 GAMUNEX-C (20G/200ML) (VIAL) 2 PA, SP

IMMUNE GLOBUL G/GLY/IGA AVG 46 GAMUNEX-C (40G/400ML) (VIAL) 2 SP

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Drug Name Tier Requirements/LimitsIMMUNE GLOBUL G/GLY/IGA AVG 46 GAMUNEX-C (5

G/50 ML) (VIAL) 2 PA, SP

LYMPHOCYTE IMMUNE GLOB,RABBIT THYMOGLOBULIN 2 SPENTERIC VIRUS VACCINES

ROTAVIRUS VACCINE,LIVE ORAL PV ROTATEQ 2GRAM (-) BACILLI (NON-ENTERIC) VACCINES

TYPHOID VACC,LIVE,ATTENUATED VIVOTIF 2TYPHOID VACC,LIVE,ATTENUATED VIVOTIF BERNA 2

GRAM NEGATIVE COCCI VACCINESMENING VAC A,C,Y,W-135 DIP/PF MENACTRA 0 AGE: 11-23 YEARS, QL: 0.5mL IN

365 DAYS

MENINGOCOCCAL B VACCINE,4-COMP BEXSERO 0 AGE: 10-25 YEARS, QL: 1mL IN 365DAYS

N.MENINGITIDIS B,LIPID FHBP RC TRUMENBA 0 AGE: 10-25 YEARS, QL: 1.5mL IN365 DAYS

GRAM POSITIVE COCCI VACCINESPNEUMOC 13-VAL CONJ-DIP CRM/PF PREVNAR 13 0 AGE: >= 65 YEARS, QL: 0.5mL IN

365 DAYSPNEUMOCOCCAL 23-VAL P-SAC VAC PNEUMOVAX 23 0 QL: 0.5mL IN 365 DAYS

INFLUENZA VIRUS VACCINESFLU VAC QS 17-18 (4YR UP) CELL FLUCELVAX QUAD

2017-2018 0 QL: 0.5mL IN 180 DAYS

FLU VAC QS 17-18(4YR UP)CEL/PF FLUCELVAX QUAD2017-2018 0 QL: 0.5mL IN 180 DAYS

FLU VAC QV 2017(18YR UP)RCM/PF FLUBLOK QUAD2017-2018 0 AGE: >= 18 YEARS, QL: 0.5mL IN

180 DAYSFLU VAC TS 2017-18(4 YR UP)/PF FLUVIRIN 2017-2018 0 QL: 0.5mL IN 180 DAYS

FLU VAC TV 2017(18YR UP)RCM/PF FLUBLOK 2017-2018 0 AGE: >= 18 YEARS, QL: 0.5mL IN180 DAYS

FLU VACC QS 2017 (18-64YRS)/PFFLUZONEINTRADERM QUAD2017-18

0 AGE: >= 18 YEARS, QL: 0.1mL IN180 DAYS

FLU VACC QS 2017 (6-35MOS)/PF FLUZONE QUADPEDI 2017-2018 0 QL: 0.25mL IN 180 DAYS

FLU VACC QS2017-18 36MOS UP/PF FLUARIX QUAD2017-2018 0 QL: 0.5mL IN 180 DAYS

FLU VACC QS2017-18 36MOS UP/PF FLUZONE QUAD2017-2018 0 QL: 0.5mL IN 180 DAYS

FLU VACC QS2017-18(6MOS UP)/PF FLULAVAL QUAD2017-2018 0 QL: 0.5mL IN 180 DAYS

FLU VACC QUAD 2017(5 YR UP)/PF AFLURIA QUAD2017-2018 0 QL: 0.5mL IN 180 DAYS

FLU VACC QUAD 2017-18(5 YR UP) AFLURIA QUAD2017-2018 0 QL: 0.5mL IN 180 DAYS

FLU VACC QUAD 2017-18(6MOS UP) FLULAVAL QUAD2017-2018 0 QL: 0.5mL IN 180 DAYS

FLU VACC QUAD 2017-18(6MOS UP) FLUZONE QUAD2017-2018 0 QL: 0.5mL IN 180 DAYS

FLU VACC QV LIVE 2017(2-49YRS) FLUMIST QUAD2017-2018 3 QL: 1 IN 180 DAYS

FLU VACC TS2017(65UP)/MF59C/PF FLUAD 2017-2018 0 AGE: >= 65 YEARS, QL: 0.5mL IN180 DAYS

FLU VACC TS2017-18(65YR UP)/PF FLUZONE HIGH-DOSE 2017-2018 0 AGE: >= 65 YEARS, QL: 0.5mL IN

180 DAYSFLU VACCIN TS2017-18 5YR UP/PF AFLURIA 2017-2018 0 QL: 0.5mL IN 180 DAYSFLU VACCINE TS2017-18(4 YR UP) FLUVIRIN 2017-2018 0 QL: 0.5mL IN 180 DAYSFLU VACCINE TS2017-18(5 YR UP) AFLURIA 2017-2018 0 QL: 0.5mL IN 180 DAYS

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Drug Name Tier Requirements/LimitsTOXIN-PRODUCING BACILLI VACCINES/TOXOIDS

CHOLERA VACCINE, LIVEVAXCHORAACTIVECOMPONENT

2

CHOLERA VACCINE, LIVE VAXCHORAVACCINE 2

VACCINE/TOXOID PREPARATIONS,COMBINATIONSDIPH,PERTUSS(ACELL),TET VAC/PF ADACEL TDAP 0 AGE: >= 18 YEARS, QL: 0.5mL IN

365 DAYS

DIPHTH,PERTUSS(ACELL),TET VAC BOOSTRIX TDAP 0 AGE: >= 18 YEARS, QL: 0.5mL IN365 DAYS

MEASLES,MUMPS,RUB,VARICELLA/PF PROQUAD 0 AGE: >= 18 YEARS, QL: 2 IN 365DAYS

MEASLES,MUMPS,RUBELLA VACC/PF M-M-R II VACCINE 0 AGE: >= 18 YEARS, QL: 2 IN 365DAYS

TETANUS, DIPHTHERIA TOX,ADULTTETANUSDIPHTHERIATOXOIDS

0 AGE: >= 18 YEARS, QL: 0.5mL IN365 DAYS

VIRAL/TUMORIGENIC VACCINESADENOVIRUS LIVE TYPES-4,7 VACC ADENOVIRUS TYPE

4 AND TYPE 7 3

ADENOVIRUS VACCINE LIVE TYPE-4 ADENOVIRUS TYPE4 3

ADENOVIRUS VACCINE LIVE TYPE-7 ADENOVIRUS TYPE7 3

HEPATITIS A AND B VACCINE/PF TWINRIX 0 AGE: >= 18 YEARS, QL: 4mL IN365 DAYS

HEPATITIS A VIRUS VACCINE/PF HAVRIX (1440/ML)(SYRINGE) 0 AGE: >= 18 YEARS, QL: 2mL IN

365 DAYS

HEPATITIS A VIRUS VACCINE/PF HAVRIX (1440/ML)(VIAL) 0 AGE: >= 18 YEARS, QL: 2mL IN

365 DAYS

HEPATITIS A VIRUS VACCINE/PFVAQTA (50UNIT/ML)(SYRINGE)

0 AGE: >= 18 YEARS, QL: 2mL IN365 DAYS

HEPATITIS A VIRUS VACCINE/PF VAQTA (50UNIT/ML) (VIAL) 0 AGE: >= 18 YEARS, QL: 2mL IN

365 DAYSHEPATITIS B VACCINE/CPG1018/PF HEPLISAV-B 0

HEPATITIS B VIRUS VACCINE/PF ENGERIX-B ADULT 0 AGE: >= 18 YEARS, QL: 3mL IN365 DAYS

HEPATITIS B VIRUS VACCINE/PFRECOMBIVAX HB(10 MCG/ML)(SYRINGE)

0 AGE: >= 18 YEARS, QL: 3mL IN365 DAYS

HEPATITIS B VIRUS VACCINE/PF RECOMBIVAX HB(10 MCG/ML) (VIAL) 0 AGE: >= 18 YEARS, QL: 3mL IN

365 DAYS

HEPATITIS B VIRUS VACCINE/PF RECOMBIVAX HB(40 MCG/ML) (VIAL) 0 AGE: >= 18 YEARS, QL: 3mL IN

365 DAYS

HPV VACCINE 9-VALENT/PF GARDASIL 9 0 AGE: 9-26 YEARS, QL: 1.5mL IN365 DAYS

VARICELLA VACCINE LIVE/PF VARIVAX VACCINE 0 AGE: >= 18 YEARS, QL: 2 IN 365DAYS

VARICELLA-ZOSTER GE VAC,2 OF 2SHINGRIX GEANTIGENCOMPONENT

0 AGE: >= 50 YEARS, QL: 2 IN 365DAYS

VARICELLA-ZOSTER GE/AS01B/PF SHINGRIX 0 AGE: >= 50 YEARS, QL: 2 IN 365DAYS

ZOSTER VACCINE LIVE/PF ZOSTAVAX 0 AGE: >= 60 YEARS, QL: 1 IN 365DAYS

National Formulary


Drug Name Tier Requirements/LimitsIMMUNOSUPPRESSION/MODULATION

IMMUNOMODULATORSALDESLEUKIN PROLEUKIN 2 SPimiquimod ALDARA 1 QL: 24 IN 30 DAYSINTERFERON ALFA-2B,RECOMB. INTRON A 2 PA, SPINTERFERON ALFA-N3 ALFERON N 2 SPINTERFERON GAMMA-1B,RECOMB. ACTIMMUNE 2

IMMUNOSUPP - MONOCLONAL AB INHIBITING T LYMPH FXNBASILIXIMAB SIMULECT 2 SP

IMMUNOSUPPRESSIVESazathioprine IMURAN 1BELATACEPT NULOJIX 2 SP

cyclosporine SANDIMMUNE (100MG) (CAPSULE) 1

CYCLOSPORINESANDIMMUNE (100MG/ML)(SOLUTION)

2

cyclosporine SANDIMMUNE (25MG) (CAPSULE) 1

cyclosporine SANDIMMUNE (250MG/5ML) (AMPUL) 1 SP

cyclosporine, modified GENGRAF 1cyclosporine, modified NEORAL 1EVEROLIMUS ZORTRESS 2mycophenolate mofetil CELLCEPT 1mycophenolate mofetil hcl CELLCEPT 1mycophenolate sodium MYFORTIC 1

sirolimus RAPAMUNE (0.5MG) (TABLET) 1

sirolimus RAPAMUNE (1 MG)(TABLET) 1

SIROLIMUSRAPAMUNE (1MG/ML)(SOLUTION)

2

sirolimus RAPAMUNE (2 MG)(TABLET) 1

tacrolimus PROGRAF (0.5 MG)(CAPSULE) 1

tacrolimus PROGRAF (1 MG)(CAPSULE) 1

tacrolimus PROGRAF (5 MG)(CAPSULE) 1

INFECTIOUS DISEASE - BACTERIALBETALACTAMS

AZTREONAM LYSINE CAYSTON 2 PA, SPCEPHALOSPORINS - 1ST GENERATION

cefadroxil DURICEF 1cephalexin KEFLEX 1

CEPHALOSPORINS - 2ND GENERATIONcefaclor CECLOR 1cefaclor CECLOR CD 1cefprozil CEFZIL 1

cefuroxime axetil CEFTIN (250 MG)(TABLET) 1

cefuroxime axetil CEFTIN (500 MG)(TABLET) 1

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Drug Name Tier Requirements/LimitsCEPHALOSPORINS - 3RD GENERATION

cefdinir OMNICEF 1cefditoren pivoxil SPECTRACEF 1

cefiximeSUPRAX (100MG/5ML) (SUSPRECON)

1

cefiximeSUPRAX (200MG/5ML) (SUSPRECON)

1

cefpodoxime proxetil VANTIN 1ceftibuten CEDAX 1

CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC.meth/meblue/sod phos/psal/hyos 1METH/MEBLUE/SOD PHOS/PSAL/HYOS PHOSPHASAL 2METH/MEBLUE/SOD PHOS/PSAL/HYOS URETRON D-S 2METH/MEBLUE/SOD PHOS/PSAL/HYOS URIN D.S. 2methen/mblue/sal/sod phos/hyos 1methenam/m.blue/salicyl/hyoscy 1methenam/sod phos/mblue/hyoscy URYL 1methenam/sod phos/mblue/hyoscy UTA 1methenamine hippurate HIPREX 1methenamine mandelate MANDELAMINE 1trimethoprim PROLOPRIM 1

MACROLIDESazithromycin ZITHROMAX (1 G)

(PACKET) 1

azithromycinZITHROMAX (100MG/5ML) (SUSPRECON)

1

azithromycinZITHROMAX (200MG/5ML) (SUSPRECON)

1

azithromycin ZITHROMAX (250MG) (TABLET) 1



azithromycin ZITHROMAX TRI-PAK 1

clarithromycin BIAXIN 1clarithromycin BIAXIN XL 1ERYTHROMYCIN BASE ERY-TAB 2erythromycin base 1erythromycin ethylsuccinate 1

erythromycin stearate ERYTHRCINSTEARATE 1

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

OXAZOLIDINONES

linezolidZYVOX (100MG/5ML) (SUSPRECON)

1

linezolid ZYVOX (600 MG)(TABLET) 1

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Drug Name Tier Requirements/LimitsPENICILLINS

amoxicillin AMOXIL 1

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

2

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

1

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

1

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

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

1

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

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

1



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

QUINOLONESciprofloxacin 1ciprofloxacin hcl CIPRO 1ciprofloxacin/ciprofloxa hcl CIPRO XR 1

DELAFLOXACIN MEGLUMINE BAXDELA (450 MG)(TABLET) 3 PA

levofloxacin LEVAQUIN (250 MG)(TABLET) 1

levofloxacinLEVAQUIN(250MG/10ML)(SOLUTION)

1



moxifloxacin hcl AVELOX 1moxifloxacin hcl AVELOX ABC PACK 1ofloxacin FLOXIN 1

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

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


doxycycline hyclate DORYX (200 MG)(TABLET DR) 1 ST

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Drug Name Tier Requirements/Limitsdoxycycline hyclate DORYX (50 MG)

(TABLET DR) 1 ST, QL: 2 IN 1 DAY


doxycycline hyclate MORGIDOX 1 QL: 2 IN 1 DAY

doxycycline hyclate VIBRAMYCIN (100MG) (CAPSULE) 1 QL: 2 IN 1 DAY

doxycycline hyclate VIBRA-TABS 1 QL: 2 IN 1 DAYdoxycycline monohydrate ADOXA 1 QL: 2 IN 1 DAYdoxycycline monohydrate AVIDOXY 1 QL: 2 IN 1 DAY

doxycycline monohydrateMONDOXYNE NL(100 MG)(CAPSULE)

1 QL: 2 IN 1 DAY

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

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

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

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

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

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

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

DOXYCYCLINE MONOHYDRATE ORACEA (40 MG)(CAP IR DR) 2 ST, AGE: >= 18 YEARS, QL: 1 IN 1

DAYdoxycycline monohydrate VIBRAMYCIN 1minocycline hcl DYNACIN 1

minocycline hcl MINOCIN (100 MG)(CAPSULE) 1



MINOCYCLINE HCL SOLODYN (105 MG)(TAB ER 24H) 2 ST, AGE: >= 12 YEARS, QL: 1 IN 1

DAY

MINOCYCLINE HCL SOLODYN (115MG)(TAB ER 24H) 2 ST, AGE: >= 12 YEARS, QL: 1 IN 1

DAY

minocycline hcl SOLODYN (135 MG)(TAB ER 24H) 1 ST, AGE: >= 12 YEARS, QL: 1 IN 1

DAY


DAY


DAY


DAY


DAY


DAYtetracycline hcl PANMYCIN 1tetracycline hcl SUMYCIN 1

INFECTIOUS DISEASE - FUNGALANTIFUNGAL AGENTS

clotrimazole MYCELEX 1fluconazole DIFLUCAN 1

National Formulary


Drug Name Tier Requirements/Limitsflucytosine ANCOBON 1

ISAVUCONAZONIUM SULFATE CRESEMBA (186MG) (CAPSULE) 2

ITRACONAZOLESPORANOX (10MG/ML)(SOLUTION)

2

itraconazole SPORANOX (100MG) (CAPSULE) 1

ketoconazole NIZORAL 1

POSACONAZOLE NOXAFIL (100 MG)(TABLET DR) 2

POSACONAZOLENOXAFIL (200MG/5ML) (ORALSUSP)

2

terbinafine hcl LAMISIL 1voriconazole VFEND 1

ANTIFUNGAL ANTIBIOTICSgriseofulvin ultramicrosize GRIS-PEG 1griseofulvin, microsize GRIFULVIN V 1nystatin 1

INFECTIOUS DISEASE - MISCELLANEOUSAMINOGLYCOSIDES

neomycin sulfate 1TOBRAMYCIN BETHKIS 2 PA, SP

TOBRAMYCINTOBI PODHALER(28 MG) (CAPW/DEV)

2 PA, SP

TOBRAMYCIN TOBI PODHALER(28 MG) (CAPSULE) 2 SP

tobramycin in 0.225% sod chlor TOBI (300 MG/5ML)(AMPUL-NEB) 1 PA, SP

TOBRAMYCIN/NEBULIZERKITABIS PAK (300MG/5ML) (AMPUL-NEB)

2 PA, SP

ANTIBACTERIAL AGENTS,MISCELLANEOUSglycine urologic solution AMINOACETIC

ACID 1

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

ANTI-MYCOBACTERIUM AGENTSAMINOSALICYLIC ACID PASER 3ethambutol hcl MYAMBUTOL 1ETHIONAMIDE TRECATOR 3isoniazid (100 mg) (tablet) 1isoniazid (300 mg) (tablet) 1isoniazid (50 mg/5 ml) (solution) 1pyrazinamide 1rifabutin MYCOBUTIN 1

ANTITUBERCULAR ANTIBIOTICSBEDAQUILINE FUMARATE SIRTURO 2 PAcycloserine SEROMYCIN 1RIFAMP/ISONIAZID/PYRAZINAMIDE RIFATER 3

rifampin RIFADIN (150 MG)(CAPSULE) 1

rifampin RIFADIN (300 MG)(CAPSULE) 1

RIFAPENTINE PRIFTIN 2

National Formulary


Drug Name Tier Requirements/LimitsLINCOSAMIDES

clindamycin hcl CLEOCIN HCL 1

clindamycin palmitate hcl CLEOCINPALMITATE 1

RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICSRIFAXIMIN XIFAXAN (200 MG)

(TABLET) 2 QL: 9 PER FILL

RIFAXIMIN XIFAXAN (550 MG)(TABLET) 2 PA

VANCOMYCIN AND DERIVATIVESvancomycin hcl (125 mg) (capsule) 1 QL: 40 IN 30 DAYSvancomycin hcl (125mg/2.5) (syringe) 1vancomycin hcl (250 mg) (capsule) 1 QL: 80 IN 30 DAYS

INFECTIOUS DISEASE - PARASITIC2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL

SECNIDAZOLE SOLOSEC 3tinidazole TINDAMAX 1

AMEBACIDESparomomycin sulfate HUMATIN 1

ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTSmetronidazole FLAGYL 1

ANTHELMINTICSALBENDAZOLE ALBENZA 2ivermectin STROMECTOL 1MEBENDAZOLE EMVERM 2 PAPRAZIQUANTEL BILTRICIDE 2

ANTIMALARIAL DRUGSARTEMETHER/LUMEFANTRINE COARTEM 2atovaquone/proguanil hcl MALARONE 1chloroquine phosphate 1hydroxychloroquine sulfate PLAQUENIL 1mefloquine hcl LARIAM 1PRIMAQUINE PHOSPHATE PRIMAQUINE 2PYRIMETHAMINE DARAPRIM 2 PAquinine sulfate QUALAQUIN 1

ANTIPARASITICSNITAZOXANIDE ALINIA 2

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

INFECTIOUS DISEASE - VIRALANTIRETROVIRAL-INTEGRASE INHIBITOR AND NNRTI COMB.

DOLUTEGRAVIR/RILPIVIRINE JULUCA 3 SPANTIVIRAL MONOCLONAL ANTIBODIES

PALIVIZUMAB SYNAGIS 2 PA, SPANTIVIRALS, GENERAL

acyclovir ZOVIRAX 1famciclovir FAMVIR 1LETERMOVIR PREVYMIS 3 SP

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


National Formulary



oseltamivir phosphateTAMIFLU (6MG/ML) (SUSPRECON)



ribavirin VIRAZOLE 1rimantadine hcl FLUMADINE 1valacyclovir hcl VALTREX 1valganciclovir hcl VALCYTE 1ZANAMIVIR RELENZA 2 QL: 40 IN 183 DAYS

ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB

DARUNAVIR ETHANOLATEPREZISTA (100MG/ML) (ORALSUSP)


DARUNAVIR ETHANOLATE PREZISTA (150 MG)(TABLET) 2 QL: 8 IN 1 DAY




DARUNAVIR/COBICISTAT PREZCOBIX 3 QL: 1 IN 1 DAYTIPRANAVIR APTIVUS 2 PA, QL: 4 IN 1 DAYTIPRANAVIR/VITAMIN E TPGS APTIVUS 2 PA, QL: 380mL IN 30 DAYS

ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOGEMTRICITABINE/TENOFOV ALAFENAM DESCOVY 2 QL: 1 IN 1 DAYEMTRICITABINE/TENOFOVIR (TDF) TRUVADA 2 QL: 1 IN 1 DAY

ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMBabacavir sulfate/lamivudine EPZICOM 1 QL: 1 IN 1 DAYabacavir/lamivudine/zidovudine TRIZIVIR 1 PA, QL: 2 IN 1 DAYlamivudine/zidovudine COMBIVIR 1 QL: 2 IN 1 DAY

ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG.MARAVIROC SELZENTRY (150

MG) (TABLET) 2 PA, QL: 2 IN 1 DAY

MARAVIROCSELZENTRY (20MG/ML)(SOLUTION)

2 PA, QL: 31mL IN 1 DAY

MARAVIROC SELZENTRY (25MG) (TABLET) 2 PA, QL: 4 IN 1 DAY



ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORSENFUVIRTIDE FUZEON 2 ST, QL: 2 IN 1 DAY

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

efavirenz SUSTIVA (200 MG)(CAPSULE) 1

efavirenz SUSTIVA (50 MG)(CAPSULE) 1

EFAVIRENZ SUSTIVA (600 MG)(TABLET) 2

ETRAVIRINE INTELENCE (100MG) (TABLET) 2 PA, QL: 4 IN 1 DAY

ETRAVIRINE INTELENCE (200MG) (TABLET) 2 PA, QL: 2 IN 1 DAY

National Formulary


Drug Name Tier Requirements/LimitsETRAVIRINE INTELENCE (25 MG)

(TABLET) 2 PA, QL: 4 IN 1 DAY

nevirapine VIRAMUNE (200MG) (TABLET) 1 QL: 2 IN 1 DAY

nevirapineVIRAMUNE (50MG/5 ML) (ORALSUSP)


nevirapine VIRAMUNE XR (100MG) (TAB ER 24H) 1 QL: 3 IN 1 DAY

nevirapine VIRAMUNE XR (400MG) (TAB ER 24H) 1 QL: 1 IN 1 DAY

RILPIVIRINE HCL EDURANT 2 PA, QL: 1 IN 1 DAYANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI

DIDANOSINE VIDEX 2 QL: 600mL IN 30 DAYS

didanosine VIDEX EC (125 MG)(CAPSULE DR) 1 QL: 2 IN 1 DAY




EMTRICITABINEEMTRIVA (10MG/ML)(SOLUTION)


EMTRICITABINE EMTRIVA (200 MG)(CAPSULE) 2 QL: 1 IN 1 DAY

lamivudine EPIVIR (10 MG/ML)(SOLUTION) 1 QL: 960mL IN 30 DAYS

lamivudine EPIVIR (150 MG)(TABLET) 1 QL: 2 IN 1 DAY

lamivudine EPIVIR (300 MG)(TABLET) 1 QL: 1 IN 1 DAY

stavudine (1 mg/ml) (soln recon) 1 QL: 2400mL IN 30 DAYSstavudine (15 mg) (capsule) 1 QL: 2 IN 1 DAYstavudine (20 mg) (capsule) 1 QL: 2 IN 1 DAYstavudine (30 mg) (capsule) 1 QL: 2 IN 1 DAYstavudine (40 mg) (capsule) 1 QL: 2 IN 1 DAY

zidovudine RETROVIR (10MG/ML) (SYRUP) 1 QL: 1920mL IN 30 DAYS

zidovudine RETROVIR (100 MG)(CAPSULE) 1 QL: 6 IN 1 DAY

zidovudine RETROVIR (300 MG)(TABLET) 1 QL: 2 IN 1 DAY

ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTITENOFOVIR DISOPROXIL FUMARATE VIREAD (150 MG)


TENOFOVIR DISOPROXIL FUMARATE VIREAD (200 MG)(TABLET) 2 QL: 1 IN 1 DAY

TENOFOVIR DISOPROXIL FUMARATE VIREAD (250 MG)(TABLET) 2 QL: 1 IN 1 DAY

tenofovir disoproxil fumarate VIREAD (300 MG)(TABLET) 1 QL: 1 IN 1 DAY

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

2 QL: 240gm IN 30 DAYS

ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMBLOPINAVIR/RITONAVIR KALETRA (100MG-

25MG) (TABLET) 2 QL: 2 IN 1 DAY

National Formulary


Drug Name Tier Requirements/LimitsLOPINAVIR/RITONAVIR KALETRA (200MG-

50MG) (TABLET) 2 QL: 4 IN 1 DAY

lopinavir/ritonavir KALETRA (400-100/5) (SOLUTION) 1 QL: 480mL IN 30 DAYS

ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORSatazanavir sulfate REYATAZ (150 MG)

(CAPSULE) 1 QL: 2 IN 1 DAY

atazanavir sulfate REYATAZ (200 MG)(CAPSULE) 1 QL: 2 IN 1 DAY

atazanavir sulfate REYATAZ (300 MG)(CAPSULE) 1 QL: 1 IN 1 DAY

ATAZANAVIR SULFATE REYATAZ (50 MG)(POWD PACK) 2 QL: 5 IN 1 DAY

FOSAMPRENAVIR CALCIUM LEXIVA (50 MG/ML)(ORAL SUSP) 2 PA, QL: 1800mL IN 30 DAYS

fosamprenavir calcium LEXIVA (700 MG)(TABLET) 1 PA, QL: 4 IN 1 DAY, SP

INDINAVIR SULFATE CRIXIVAN 2NELFINAVIR MESYLATE VIRACEPT 2

RITONAVIR NORVIR (100 MG)(CAPSULE) 2 QL: 12 IN 1 DAY

RITONAVIR NORVIR (100 MG)(TABLET) 2 QL: 12 IN 1 DAY

RITONAVIRNORVIR (80MG/ML)(SOLUTION)


SAQUINAVIR MESYLATE INVIRASE (200 MG)(CAPSULE) 2 ST, QL: 10 IN 1 DAY

SAQUINAVIR MESYLATE INVIRASE (500 MG)(TABLET) 2 ST, QL: 4 IN 1 DAY

ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTRDOLUTEGRAVIR SODIUM TIVICAY 2 PA, QL: 2 IN 1 DAY

RALTEGRAVIR POTASSIUM ISENTRESS (100MG) (POWD PACK) 2 QL: 2 IN 1 DAY

RALTEGRAVIR POTASSIUM ISENTRESS (100MG) (TAB CHEW) 2 QL: 6 IN 1 DAY

RALTEGRAVIR POTASSIUM ISENTRESS (25 MG)(TAB CHEW) 2 QL: 6 IN 1 DAY

RALTEGRAVIR POTASSIUM ISENTRESS (400MG) (TABLET) 2 QL: 2 IN 1 DAY

RALTEGRAVIR POTASSIUM ISENTRESS HD 2 QL: 2 IN 1 DAYARTV CMB NUCLEOSIDE,NUCLEOTIDE,&NON-NUCLEOSIDE RTI

EFAVIRENZ/EMTRICIT/TENOFOVR DF ATRIPLA 2 QL: 1 IN 1 DAYEMTRICITA/RILPIVIRINE/TENOF DF COMPLERA 2 PA, QL: 1 IN 1 DAYEMTRICITAB/RILPIVIRI/TENOF ALA ODEFSEY 2 QL: 1 IN 1 DAY

ARV CMB-NRTI,N(T)RTI, INTEGRASE INHIBITORELVITEG/COB/EMTRI/TENOF ALAFEN GENVOYA 2 QL: 1 IN 1 DAYELVITEG/COB/EMTRI/TENOFO DISOP STRIBILD 2 QL: 1 IN 1 DAY

ARV COMB-NRTIS & INTEGRASE INHIBITORABACAVIR/DOLUTEGRAVIR/LAMIVUDI TRIUMEQ 2 QL: 1 IN 1 DAY

HEP C - NS5A, NS3/4A, NUCLEOTIDE NS5B INHIB COMBOSOFOSBUVIR/VELPATAS/VOXILAPREV VOSEVI 3 PA, SP

HEP C VIRUS - NS5A & NS5B POLYMERASE INHIB. COMBO.LEDIPASVIR/SOFOSBUVIR HARVONI 2 PA, SPSOFOSBUVIR/VELPATASVIR EPCLUSA 2 PA, SP

HEP C VIRUS,NUCLEOTIDE ANALOG NS5B POLYMERASE INHSOFOSBUVIR SOVALDI 3 PA, SP

National Formulary


Drug Name Tier Requirements/LimitsHEPATITIS B TREATMENT AGENTS

adefovir dipivoxil HEPSERA 1 QL: 1 IN 1 DAY

ENTECAVIRBARACLUDE (0.05MG/ML)(SOLUTION)

2 QL: 630mL IN 30 DAYS, SP

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

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

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

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


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

PEGINTERFERON ALFA-2A PEGASYS 2 PA, SP

PEGINTERFERON ALFA-2A PEGASYSPROCLICK 2 PA, SP

ribavirin (200 mg) (capsule) 1 SPribavirin (200 mg) (tablet) 1 SPribavirin (200-400(7)) (tab ds pk) 1 ST, SP

HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMBGLECAPREVIR/PIBRENTASVIR MAVYRET 2 PA, SP

INFLAMMATORY DISEASEANTI-ARTHRITIC AND CHELATING AGENTS

PENICILLAMINE DEPEN 2 PAANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS

METHOTREXATE/PF OTREXUP 2 ST, QL: 1.6mL IN 28 DAYS

METHOTREXATE/PFRASUVO(10MG/0.2ML)(AUTO INJCT)

2 ST, QL: 0.8mL IN 28 DAYS

METHOTREXATE/PF RASUVO (12.5/0.25)(AUTO INJCT) 2 ST, QL: 1mL IN 28 DAYS



METHOTREXATE/PF RASUVO (17.5/0.35)(AUTO INJCT) 2 ST, QL: 1.4mL IN 28 DAYS



METHOTREXATE/PF RASUVO (22.5/0.45)(AUTO INJCT) 2 QL: 1.8mL IN 28 DAYS





METHOTREXATE/PFRASUVO(7.5MG/0.15) (AUTOINJCT)


ANTI-FLAM. INTERLEUKIN-1 RECEPTOR ANTAGONISTRILONACEPT ARCALYST 2

ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITORADALIMUMAB HUMIRA 2 PA, SP

National Formulary


SP


ADALIMUMABHUMIRAPEDIATRICCROHN'S

2 PA, SP

ADALIMUMAB HUMIRA PEN 2 PA, SP

ADALIMUMABHUMIRA PENCROHN-UC-HSSTARTER

2 PA, SP

ADALIMUMAB HUMIRA PENPSORIASIS-UVEITIS 2 PA, SP

ETANERCEPT ENBREL 2 PA, SPETANERCEPT ENBREL MINI 2 PA, SP

ETANERCEPT ENBRELSURECLICK 2 PA, SP

GOLIMUMAB SIMPONI ARIA 2 PA, SPANTI-INFLAMMATORY, INTERLEUKIN-1 BETA BLOCKERS

CANAKINUMAB/PF ILARIS 2 PAANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR

leflunomide ARAVA 1ANTI-INFLAMMATORY,PHOSPHODIESTERASE-4(PDE4) INHIB.

APREMILAST OTEZLA (10-20-30MG) (TAB DS PK) 2 PA, SP

APREMILAST OTEZLA (30 MG)(TABLET) 2 PA, SP

ANTI-INFLAMMATORY/ANTIARTHRITICS AGENTS, MISC.GLUCOSAMINE HCL/CHONDROITIN SU GLUCOSAMINE-

CHONDROITIN 2

GLUCOSAMINE SULF/CHONDROITIN A GLUCOSAMINE-CHONDROITIN 2

ANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITORABATACEPT ORENCIA 3 PA, SP

BRADYKININ B2 RECEPTOR ANTAGONISTSICATIBANT ACETATE FIRAZYR 2 PA, SP

C1 ESTERASE INHIBITORSC1 ESTERASE INHIBITOR BERINERT 2 PAC1 ESTERASE INHIBITOR CINRYZE 2 PAC1 ESTERASE INHIBITOR HAEGARDA 3 PA

GLUCOCORTICOIDSBETAMETHASON/NORFLURAN/PENTFLU BETALOAN SUIK 3budesonide ENTOCORT EC 1BUDESONIDE UCERIS 2 STcortisone acetate CORTONE 1dexamethasone 1DEXAMETHASONE INTENSOL 2hydrocortisone CORTEF 1

methylprednisolone MEDROL (16 MG)(TABLET) 1


methylprednisolone MEDROL (4 MG)(TAB DS PK) 1



PREDNISOLONE MILLIPRED 2PREDNISOLONE MILLIPRED DP 2prednisolone ORAPRED 1prednisolone sod phosphate 1

National Formulary


Drug Name Tier Requirements/Limitsprednisone 1PREDNISONE INTENSOL 2

GOLD SALTSAURANOFIN RIDAURA 2 SP

IMMUNOMODULATOR,B-LYMPHOCYTE STIM(BLYS)-SPEC INHIBBELIMUMAB BENLYSTA (120

MG) (VIAL) 2 SP

BELIMUMABBENLYSTA (200MG/ML) (AUTOINJCT)

3 PA, SP

BELIMUMAB BENLYSTA (200MG/ML) (SYRINGE) 3 PA, SP

BELIMUMAB BENLYSTA (400MG) (VIAL) 2 SP

INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORSSARILUMAB KEVZARA 3 SPTOCILIZUMAB ACTEMRA 3 PA, SP

JANUS KINASE (JAK) INHIBITORSTOFACITINIB CITRATE XELJANZ 3 PA, SP

TOFACITINIB CITRATE XELJANZ XR (11MG) (TAB ER 24H) 3 PA, SP

MINERALOCORTICOIDSfludrocortisone acetate FLORINEF 1

MONOCLONAL ANTIBODY-HUMAN INTERLEUKIN 12/23 INHIBUSTEKINUMAB STELARA 3 PA, SP

NSAIDS (COX NON-SPECIFIC INHIB)& PROSTAGLANDIN CMBdiclofenac sodium/misoprostol ARTHROTEC 50 1diclofenac sodium/misoprostol ARTHROTEC 75 1

NSAIDS, CYCLOOXYGENASE 2 INHIBITOR - TYPEcelecoxib CELEBREX 1

NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPEcelecoxib CELEBREX 1diclofenac potassium CATAFLAM 1diclofenac sodium VOLTAREN 1diclofenac sodium VOLTAREN-XR 1etodolac LODINE 1etodolac LODINE XL 1fenoprofen calcium FENORTHO 1fenoprofen calcium NALFON 1flurbiprofen ANSAID 1IBUPROFEN CALDOLOR 2 SP

ibuprofen MOTRIN (400 MG)(TABLET) 1



indomethacin INDOCIN (25 MG)(CAPSULE) 1

indomethacin INDOCIN (50 MG)(CAPSULE) 1

INDOMETHACIN INDOCIN (50 MG)(SUPP.RECT) 3

indomethacin INDOCIN SR 1ketoprofen ORUDIS 1ketoprofen ORUVAIL 1

National Formulary


Drug Name Tier Requirements/LimitsKETOROLAC TROMETHAMINE READYSHARP

KETOROLAC 3

ketorolac tromethamine TORADOL 1KETOROLAC/NORFLURANE/HFC 245FA TORONOVA II SUIK 3KETOROLAC/NORFLURANE/HFC 245FA TORONOVA SUIK 3meclofenamate sodium MECLOMEN 1mefenamic acid 1meloxicam MOBIC 1nabumetone RELAFEN 1naproxen EC-NAPROSYN 1naproxen NAPROSYN 1naproxen sodium ANAPROX 1naproxen sodium ANAPROX DS 1oxaprozin DAYPRO 1piroxicam FELDENE 1sulindac CLINORIL 1tolmetin sodium TOLECTIN 1tolmetin sodium TOLECTIN DS 1

LOCAL ANESTHESIALOCAL ANESTHETICS

lidocaine hcl (2 %) (jelly(ml)) 1lidocaine hcl (2 %) (solution) 1

LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATABSORBABLE SULFONAMIDES

sulfamethoxazole/trimethoprim (200-40mg/5) (oralsusp) 1

sulfamethoxazole/trimethoprim (400mg-80mg)(tablet) 1

sulfamethoxazole/trimethoprim (800-160 mg)(tablet) 1

sulfamethoxazole/trimethoprim (800-160/20) (oralsusp) 1

sulfamethoxazole/trimethoprim (80-16mg/ml) (vial) 1 SPBOWEL ANTIINFLAMATORY AGENTS

sulfadiazine 1CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TX

MESALAMINE CANASA 2mesalamine SFROWASA 1mesalamine w/cleansing wipes ROWASA 1

DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLATbalsalazide disodium COLAZAL 1MESALAMINE APRISO 2mesalamine LIALDA 1MESALAMINE PENTASA 2sulfasalazine AZULFIDINE 1

DRUGS TO TX CHRONIC INFLAMM. DISEASE OF COLONINFLIXIMAB REMICADE 2 PA, SPINFLIXIMAB-ABDA RENFLEXIS 3 PA, SPINFLIXIMAB-DYYB INFLECTRA 2 PA, SP

HEMORRHOIDAL PREP, ANTI-INFAM STEROID/LOCAL ANESTHHYDROCORT/PRAMOXN/SKIN CLNSR16 ZYPRAM 3hydrocortisone/lidocaine/aloe ANA-LEX HC 1hydrocortisone/lidocaine/aloe ANAMANTLE HC 1hydrocortisone/lidocaine/aloe RECTAGEL HC 1hydrocortisone/pramoxine ANALPRAM HC 1hydrocortisone/pramoxine PRAMCORT 1

National Formulary


Drug Name Tier Requirements/Limitslidocaine/hydrocortisone ac ANAMANTLE HC 1

lidocaine/hydrocortisone ac ANAMANTLE HCFORTE 1

IBS AGENTS,MIXED OPIOID RECEP AGONISTS/ANTAGONISTSELUXADOLINE VIBERZI 2 PA

INTEGRIN RECEPTOR ANTAGONIST, MONOCLONAL ANTIBODYVEDOLIZUMAB ENTYVIO 2 PA, SP

IRRITABLE BOWEL AGENTS,GUANYLATE CYLASE-C AGONISTLINACLOTIDE LINZESS 2

LOCAL ANORECTAL NITRATE PREPARATIONSNITROGLYCERIN RECTIV 2

RECTAL PREPARATIONShydrocortisone acetate 1

RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR)hydrocortisone CORTENEMA 1HYDROCORTISONE ACETATE CORTIFOAM 2

TOPICAL ANTI-INFLAMMATORY STEROIDALhydrocortisone acetate ANUSOL-HC 1hydrocortisone acetate HEMMOREX-HC 1hydrocortisone acetate PROCTOCORT 1hydrocortisone acetate RECTACORT-HC 1

LOWER GASTROINTESTINAL DISORDERS - OTHERAMMONIA INHIBITORS

ACETOHYDROXAMIC ACID LITHOSTAT 3CARGLUMIC ACID CARBAGLU 2GLYCEROL PHENYLBUTYRATE RAVICTI 2 PAlactulose CHRONULAC 1

sodium phenylbutyrate BUPHENYL (0.94G/G) (POWDER) 1

sodium phenylbutyrate BUPHENYL (500MG) (TABLET) 1 SP

ANTIDIARRHEAL - TRYPTOPHAN HYDROXYLASE INHIBITORTELOTRISTAT ETIPRATE XERMELO 2 PA

ANTIDIARRHEALSdiphenoxylate hcl/atropine LOMOTIL 1loperamide hcl (2 mg) (capsule) 1opium tincture 1paregoric 1

BILE SALTSCHENODIOL CHENODAL 2CHOLIC ACID CHOLBAM 2 PAursodiol ACTIGALL 1ursodiol URSO 1ursodiol URSO FORTE 1

FARNESOID X RECEPTOR (FXR) AGONIST, BILE AC ANALOGOBETICHOLIC ACID OCALIVA 2 PA

IRRITABLE BOWEL SYND. AGENT,5HT-3 ANTAGONIST-TYPEalosetron hcl LOTRONEX 1

LAXATIVES AND CATHARTICSbisac/nacl/nahco3/kcl/peg 3350 HALFLYTELY-

BISACODYL 1 AGE: 50-75 YEARS

lactulose CHRONULAC 1LUBIPROSTONE AMITIZA 2 ST, QL: 2 IN 1 DAYPEG 3350/SOD CHLOR/POTASS CIT GIALAX 3

peg3350/sod sulf,bicarb,cl/kcl COLYTE WITHFLAVOR PACKETS 1 AGE: 50-75 YEARS

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peg3350/sod sulf,bicarb,cl/kclGOLYTELY (236-22.74G) (SOLNRECON)

1 AGE: 50-75 YEARS

polyethylene glycol 3350 MIRALAX (17G)(POWD PACK) 1

polyethylene glycol 3350MIRALAX(17G/DOSE)(POWDER)

1

PSYLLIUM HUSK KONSYL EASY MIX 2

PSYLLIUM HUSK (WITH DEXTROSE) KONSYLFORMULA-D 2

SOD PICOSULF/MAG OX/CITRIC AC CLENPIQ 3 AGE: 50-75 YEARSSOD PICOSULF/MAG OX/CITRIC AC PREPOPIK 2 AGE: 50-75 YEARS

sodium chloride/nahco3/kcl/peg NULYTELY WITHFLAVOR PACKS 1 AGE: 50-75 YEARS

SODIUM, POTASSIUM,MAG SULFATES SUPREP 2 AGE: 50-75 YEARSNARCOTIC ANTAGONISTS, PERIPHERALLY-ACTING

ALVIMOPAN ENTEREG 3

METHYLNALTREXONE BROMIDERELISTOR(12MG/0.6ML)(SYRINGE)

2 PA, QL: 0.6mL IN 1 DAY

METHYLNALTREXONE BROMIDERELISTOR(12MG/0.6ML)(VIAL)


METHYLNALTREXONE BROMIDE RELISTOR (150 MG)(TABLET) 3 PA, QL: 3 IN 1 DAY

METHYLNALTREXONE BROMIDERELISTOR (8MG/0.4ML)(SYRINGE)


NALOXEGOL OXALATE MOVANTIK 2 QL: 1 IN 1 DAYMEDICAL SUPPLIES

DURABLE MEDICAL EQUIPMENT,MISC(GROUP 1)LANCETS (EACH) (OTC) 1

LANCETSMICRO THINLANCETS (33GAUGE) (EACH)(OTC)

1

LANCETS ONE TOUCHDELICA 2

LANCETS ONETOUCHDELICA 2

LANCETS ONETOUCHLANCETS 2

LANCETS ONETOUCHSURESOFT 2

LANCETSSUPER THINLANCETS (EACH)(OTC)

1

LANCETSUNIVERSAL 1 (26GAUGE) (EACH)(OTC)

1

PARENTERAL ADMINISTRATION SETSSUB-Q INFUSION PUMP ACCESSORY PARADIGM

SILHOUETTE 3

SUB-Q INFUSION PUMP ACCESSORY POLYFIN QR 3SUB-Q INFUSION PUMP ACCESSORY SILHOUETTE 3

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Drug Name Tier Requirements/LimitsMISCELLANEOUS AGENTS

ANAPHYLAXIS THERAPY AGENTSepinephrine ADRENACLICK 1epinephrine EPIPEN 1epinephrine EPIPEN 2-PAK 1epinephrine EPIPEN JR 1epinephrine EPIPEN JR 2-PAK 1

GENETIC D/O TX-EXON SKIPPING ANTISENSE OLIGONUCLEOETEPLIRSEN EXONDYS 51 3 PA

METABOLIC DX ENZYME REPLACEMENT,LYSO.ACID LIP.DEF.SEBELIPASE ALFA KANUMA 2 PA

MISCELLANEOUS AGENTSLIVER EXTRACT (BEEF-PORK) NEXAVIR 3

PARASYMPATHETIC AGENTSbethanechol chloride URECHOLINE 1cevimeline hcl EVOXAC 1guanidine hcl GUANIDINE 1pilocarpine hcl SALAGEN 1

SYSTEMIC ENZYME INHIBITORSALPHA-1-PROTEINASE INHIBITOR ARALAST NP 2

ALPHA-1-PROTEINASE INHIBITOR PROLASTIN C (1000MG) (VIAL) 2

ALPHA-1-PROTEINASE INHIBITOR PROLASTIN C (1000MG/20) (VIAL) 3

ALPHA-1-PROTEINASE INHIBITOR ZEMAIRA 2NEOPLASTIC DISEASE

ALKYLATING AGENTSALTRETAMINE HEXALEN 2 SPBENDAMUSTINE HCL BENDEKA 2 SPBENDAMUSTINE HCL TREANDA 2 SPbusulfan BUSULFEX 1 SPBUSULFAN MYLERAN 2 SPCARMUSTINE BICNU 2 SPCHLORAMBUCIL LEUKERAN 2CYCLOPHOSPHAMIDE 2hydroxyurea HYDREA 1LOMUSTINE GLEOSTINE 2 SPmelphalan ALKERAN 1melphalan hcl ALKERAN 1 SPoxaliplatin ELOXATIN 1 SP

temozolomide TEMODAR (100 MG)(CAPSULE) 1 PA, SP

TEMOZOLOMIDE TEMODAR (100 MG)(VIAL) 2 PA, SP






THIOTEPA TEPADINA 3 SP

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Drug Name Tier Requirements/LimitsANTIANDROGENIC AGENTS

ABIRATERONE ACETATE ZYTIGA (250 MG)(TABLET) 2 PA, QL: 4 IN 1 DAY, SP

ABIRATERONE ACETATE ZYTIGA (500 MG)(TABLET) 3 PA, QL: 2 IN 1 DAY, SP

bicalutamide CASODEX 1ENZALUTAMIDE XTANDI 2 PA, QL: 4 IN 1 DAY, SPflutamide EULEXIN 1nilutamide NILANDRON 1 QL: 150 AFTER 30 DAYS

ANTIBIOTIC ANTINEOPLASTICSdoxorubicin hcl 1 SPdoxorubicin hcl peg-liposomal DOXIL 1 SPepirubicin hcl ELLENCE 1 SPSTREPTOZOCIN ZANOSAR 2 SP

ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODYOBINUTUZUMAB GAZYVA 2 PA, SPOFATUMUMAB ARZERRA 2 PA, SPRITUXIMAB RITUXAN 2 PA, SPRITUXIMAB/HYALURONIDASE,HUMAN RITUXAN HYCELA 2 PA, SP

ANTIMETABOLITESazacitidine VIDAZA 1 SP

capecitabine XELODA (150 MG)(TABLET) 1 PA, QL: 28 IN 21 DAYS, SP

capecitabine XELODA (500 MG)(TABLET) 1 PA, QL: 112 IN 21 DAYS, SP

clofarabine CLOLAR 1 SPdecitabine DACOGEN 1 SPgemcitabine hcl 1 SPmercaptopurine PURINETHOL 1MERCAPTOPURINE PURIXAN 2 ST

METHOTREXATE XATMEP 3 ST, AGE: < 12 YEARS, QL: 120mLIN 60 DAYS, SP

methotrexate sodium FOLEX 1

methotrexate sodium TREXALL (2.5 MG)(TABLET) 1

methotrexate sodium/pf FOLEX 1NELARABINE ARRANON 2 SPPEMETREXED DISODIUM ALIMTA 2 PA, SPPENTOSTATIN NIPENT 3 SPPRALATREXATE FOLOTYN 2 SPTHIOGUANINE TABLOID 2TRIFLURIDINE/TIPIRACIL HCL LONSURF 2 PA

ANTINEOPLAST EGF RECEPTOR BLOCKER RCMB MC ANTIBODYCETUXIMAB ERBITUX 2 PA, SPPANITUMUMAB VECTIBIX 2 PA, SPPERTUZUMAB PERJETA 2 PA, SP

TRASTUZUMAB HERCEPTIN (150MG) (VIAL) 3 PA, SP

TRASTUZUMAB HERCEPTIN (440MG) (VIAL) 2 PA, SP

ANTINEOPLAST HUM VEGF INHIBITOR RECOMB MC ANTIBODYBEVACIZUMAB AVASTIN 2 PA, SP

ANTINEOPLASTIC - ANTIBIOTIC AND ANTIMETABOLITEDAUNORUBICIN/CYTARABINE LIPOS VYXEOS 3 PA, SP

ANTINEOPLASTIC - ANTI-CD38 MONOCLONAL ANTIBODYDARATUMUMAB DARZALEX 2 PA, SP

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Drug Name Tier Requirements/LimitsANTINEOPLASTIC AROMATASE INHIBITORS

anastrozole ARIMIDEX 1exemestane AROMASIN 1letrozole FEMARA 1

ANTINEOPLASTIC - EPOTHILONES AND ANALOGSIXABEPILONE IXEMPRA 2 PA, SP

ANTINEOPLASTIC - HALICHONDRIN B ANALOGSERIBULIN MESYLATE HALAVEN 2 PA, SP

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORVISMODEGIB ERIVEDGE 2 PA, QL: 1 IN 1 DAY, SP

ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORSRUXOLITINIB PHOSPHATE JAKAFI 2 PA, QL: 2 IN 1 DAY

ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORSCOBIMETINIB FUMARATE COTELLIC 2 PA, QL: 63 IN 28 DAYSTRAMETINIB DIMETHYL SULFOXIDE MEKINIST 2 PA

ANTINEOPLASTIC - MTOR KINASE INHIBITORSEVEROLIMUS AFINITOR (10 MG)

(TABLET) 2 PA, QL: 2 IN 1 DAY, SP

EVEROLIMUS AFINITOR (2.5 MG)(TABLET) 2 PA, QL: 1 IN 1 DAY, SP

EVEROLIMUS AFINITOR (5 MG)(TABLET) 2 PA, QL: 1 IN 1 DAY, SP

EVEROLIMUS AFINITOR (7.5 MG)(TABLET) 2 PA, QL: 2 IN 1 DAY, SP

EVEROLIMUS AFINITOR DISPERZ 2 PA, SPTEMSIROLIMUS TORISEL 2 PA, SP

ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORSIRINOTECAN LIPOSOMAL ONIVYDE 2 PA, SP

TOPOTECAN HCL HYCAMTIN (0.25MG) (CAPSULE) 2 SP

TOPOTECAN HCL HYCAMTIN (1 MG)(CAPSULE) 2 SP

TRABECTEDIN YONDELIS 2 PA, SPANTINEOPLASTIC - VEGF-A,B & P1GF INHIBITOR

ZIV-AFLIBERCEPT ZALTRAP 2 PA, SPANTINEOPLASTIC - VEGFR ANTAGONIST

RAMUCIRUMAB CYRAMZA 2 PA, SPANTINEOPLASTIC- CD22 ANTIBODY-CYTOTOXIC ANTIBIOTIC

INOTUZUMAB OZOGAMICIN BESPONSA 3 PA, SPANTINEOPLASTIC COMB - KINASE AND AROMATASE INHIBIT

RIBOCICLIB SUCCINATE/LETROZOLE KISQALI FEMARACO-PACK 3 SP

ANTINEOPLASTIC IMMUNOMODULATOR AGENTSLENALIDOMIDE REVLIMID 2 PA, QL: 1 IN 1 DAY, SPPEGINTERFERON ALFA-2B SYLATRON 2 PA, SPPOMALIDOMIDE POMALYST 2 PA, SP

ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORSABEMACICLIB VERZENIO 3 PA, QL: 2 IN 1 DAYACALABRUTINIB CALQUENCE 3 PAAFATINIB DIMALEATE GILOTRIF 2 PAALECTINIB HCL ALECENSA 2 PA, QL: 8 IN 1 DAY

AXITINIB INLYTA (1 MG)(TABLET) 2 PA, QL: 6 IN 1 DAY, SP

AXITINIB INLYTA (5 MG)(TABLET) 2 PA, QL: 4 IN 1 DAY, SP

BORTEZOMIB 2 PA, SP

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Drug Name Tier Requirements/LimitsBORTEZOMIB VELCADE 2 PA, SP

BOSUTINIB BOSULIF (100 MG)(TABLET) 2 PA, QL: 4 IN 1 DAY, SP

BOSUTINIB BOSULIF (400 MG)(TABLET) 2 PA, QL: 1 IN 1 DAY

BOSUTINIB BOSULIF (500 MG)(TABLET) 2 PA, QL: 1 IN 1 DAY, SP

BRIGATINIB ALUNBRIG 3 PACARFILZOMIB KYPROLIS 2 PACERITINIB ZYKADIA 2 PACOPANLISIB DI-HCL ALIQOPA 3 PA, SPCRIZOTINIB XALKORI 2 PA, QL: 2 IN 1 DAY, SPDABRAFENIB MESYLATE TAFINLAR 2 PA

DASATINIB SPRYCEL (100 MG)(TABLET) 2 PA, QL: 1 IN 1 DAY, SP






ERLOTINIB HCL TARCEVA (100 MG)(TABLET) 2 PA, QL: 3 IN 1 DAY, SP



GEFITINIB IRESSA 2 PAIBRUTINIB IMBRUVICA 2 PAIDELALISIB ZYDELIG 2 PA, SP

imatinib mesylate GLEEVEC (100 MG)(TABLET) 1 PA, QL: 3 IN 1 DAY, SP

imatinib mesylate GLEEVEC (400 MG)(TABLET) 1 PA, QL: 2 IN 1 DAY, SP

IXAZOMIB CITRATE NINLARO 2 PA, SPLAPATINIB DITOSYLATE TYKERB 2 PALENVATINIB MESYLATE LENVIMA 2 PAMIDOSTAURIN RYDAPT 3 PA, SPNERATINIB MALEATE NERLYNX 3 PA, QL: 6 IN 1 DAYNILOTINIB HCL TASIGNA 2 PA, QL: 4 IN 1 DAY, SPNIRAPARIB TOSYLATE ZEJULA 3 PA

OLAPARIB LYNPARZA (100MG) (TABLET) 2 PA, QL: 4 IN 1 DAY

OLAPARIB LYNPARZA (150MG) (TABLET) 2 PA, QL: 4 IN 1 DAY

OLAPARIB LYNPARZA (50 MG)(CAPSULE) 2 PA, QL: 16 IN 1 DAY

OSIMERTINIB MESYLATE TAGRISSO 2 PA, QL: 1 IN 1 DAYPALBOCICLIB IBRANCE 2 PA, SPPAZOPANIB HCL VOTRIENT 2 PA, QL: 4 IN 1 DAY

PONATINIB HCL ICLUSIG (15 MG)(TABLET) 2 PA, QL: 2 IN 1 DAY

PONATINIB HCL ICLUSIG (45 MG)(TABLET) 2 PA, QL: 1 IN 1 DAY

REGORAFENIB STIVARGA 2 PA, QL: 3 IN 1 DAY

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Drug Name Tier Requirements/LimitsRUCAPARIB CAMSYLATE RUBRACA (200 MG)

(TABLET) 2 PA, QL: 4 IN 1 DAY

RUCAPARIB CAMSYLATE RUBRACA (250 MG)(TABLET) 3 QL: 4 IN 1 DAY

RUCAPARIB CAMSYLATE RUBRACA (300 MG)(TABLET) 2 PA, QL: 4 IN 1 DAY

SORAFENIB TOSYLATE NEXAVAR 2 PA, QL: 4 IN 1 DAYSUNITINIB MALATE SUTENT 2 PA, QL: 1 IN 1 DAY, SP

VANDETANIB CAPRELSA (100MG) (TABLET) 2 PA, QL: 2 IN 1 DAY

VANDETANIB CAPRELSA (300MG) (TABLET) 2 PA, QL: 1 IN 1 DAY

VEMURAFENIB ZELBORAF 2 PA, QL: 8 IN 1 DAY, SPANTINEOPLASTIC, PDGFR-ALPHA BLOCKER MC ANTIBODY

OLARATUMAB LARTRUVO 2 PAANTINEOPLASTIC,ANTI-PROGRAMMED DEATH-1 (PD-1) MAB

NIVOLUMAB OPDIVO 2 PA, SPPEMBROLIZUMAB KEYTRUDA 2 PA, SP

ANTINEOPLASTIC,HISTONE DEACETYLASE INHIBITORS,HDISromidepsin ISTODAX 1 PA, SPVORINOSTAT ZOLINZA 2 SP

ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORSVENETOCLAX VENCLEXTA 2

VENETOCLAX VENCLEXTASTARTING PACK 2

ANTINEOPLASTIC-CD19 DIR. CAR-T CELL IMMUNOTHERAPYAXICABTAGENE CILOLEUCEL YESCARTA 3 PATISAGENLECLEUCEL KYMRIAH 3 PA

ANTINEOPLASTIC-INTERLEUKIN-6(IL-6)INHIB,ANTIBODYSILTUXIMAB SYLVANT 2 PA, SP

ANTINEOPLASTIC-ISOCITRATE DEHYDROGENASE INHIBITORSENASIDENIB MESYLATE IDHIFA 3 PA, QL: 1 IN 1 DAY

ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXESADO-TRASTUZUMAB EMTANSINE KADCYLA 2 PA, SPALEMTUZUMAB CAMPATH 3 SP

BLINATUMOMAB BLINCYTO (35MCG) (KIT) 2 PA

BLINATUMOMAB BLINCYTO (35MCG) (VIAL) 3 PA, SP

BRENTUXIMAB VEDOTIN ADCETRIS 2 PA, SPDINUTUXIMAB UNITUXIN 2 PA, SPGEMTUZUMAB OZOGAMICIN MYLOTARG 3 PA, SP

ANTINEOPLASTICS,MISCELLANEOUSARSENIC TRIOXIDE TRISENOX 2 SPASPARAGINASE (ERWINIA CHRYSAN) ERWINAZE 3 PACABAZITAXEL JEVTANA 2 SPdocetaxel 1 SPetoposide TOPOSAR 1 SPetoposide VEPESID 1ETOPOSIDE PHOSPHATE ETOPOPHOS 2 SPMITOTANE LYSODREN 2OMACETAXINE MEPESUCCINATE SYNRIBO 2 PAPACLITAXEL PROTEIN-BOUND ABRAXANE 2 PA, SPPEGASPARGASE ONCASPAR 2 PA, SPPROCARBAZINE HCL MATULANE 2

tretinoin VESANOID (10 MG)(CAPSULE) 1

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Drug Name Tier Requirements/LimitsANTI-PROGRAMMED CELL DEATH-LIGAND 1 (PD-L1) MAB

AVELUMAB BAVENCIO 3 PADURVALUMAB IMFINZI 3 PA

CHEMOTHERAPY RESCUE/ANTIDOTE AGENTSGLUCARPIDASE VORAXAZE 2

leucovorin calcium WELLCOVORIN (10MG) (TABLET) 1




MESNA MESNEX (400 MG)(TABLET) 2

URIDINE TRIACETATE VISTOGARD 2 QL: 24 IN 14 DAYSCYTOTOXIC T-LYMPHOCYTE ANTIGEN(CTLA-4)RMC ANTIBODY

IPILIMUMAB YERVOY 2 PA, SPINTRAPLEURAL SCLEROSING AGENTS, ANTINEOPLAST. ADJ.

TALC SCLEROSOL 3talc STERITALC 1

PHOTOACTIVATED, ANTINEOPLASTIC AGENTS (SYSTEMIC)PORFIMER SODIUM PHOTOFRIN 2 PA, SP

PHOTOACTIVATED, ANTINEOPLS. & PREMALIGNANT LESIONSAMINOLEVULINIC ACID HCL AMELUZ 3AMINOLEVULINIC ACID HCL LEVULAN 3

SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM)FULVESTRANT FASLODEX 2 PA, SPtamoxifen citrate NOLVADEX 0TOREMIFENE CITRATE FARESTON 2 PA

SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR)bexarotene TARGRETIN 1 PA

STEROID ANTINEOPLASTICSESTRAMUSTINE PHOSPHATE SODIUM EMCYT 2megestrol acetate MEGACE 1

VINCA ALKALOIDSVINCRISTINE SULFATE LIPOSOMAL MARQIBO 2 PA, SP

NEUROLOGICAL DISEASE - MISCELLANEOUSAGENTS TO TREAT MULTIPLE SCLEROSIS

ALEMTUZUMAB LEMTRADA 2 PADIMETHYL FUMARATE TECFIDERA 2 PA, SP

FINGOLIMOD HCL GILENYA (0.5 MG)(CAPSULE) 2 PA, SP

glatiramer acetate COPAXONE (20MG/ML) (SYRINGE) 1 PA, SP

glatiramer acetate COPAXONE (40MG/ML) (SYRINGE) 1 PA, SP

INTERFERON BETA-1A AVONEX 2 PA, SPINTERFERON BETA-1A AVONEX PEN 2 PA, SPINTERFERON BETA-1A/ALBUMIN AVONEX 2 PA, SP

INTERFERON BETA-1A/ALBUMINREBIF(22MCG/.5ML)(SYRINGE)

2 PA, SP

INTERFERON BETA-1A/ALBUMINREBIF(44MCG/.5ML)(SYRINGE)

2 PA, SP

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Drug Name Tier Requirements/LimitsINTERFERON BETA-1A/ALBUMIN REBIF (8.8-22(6))

(SYRINGE) 2 PA, SP

INTERFERON BETA-1A/ALBUMINREBIF REBIDOSE(22MCG/.5ML) (PENINJCTR)

2 PA, SP

INTERFERON BETA-1A/ALBUMINREBIF REBIDOSE(44MCG/.5ML) (PENINJCTR)

2 PA, SP

INTERFERON BETA-1A/ALBUMINREBIF REBIDOSE(8.8-22(6)) (PENINJCTR)

2 PA, SP

INTERFERON BETA-1B BETASERON (0.3MG) (KIT) 2 PA, SP

INTERFERON BETA-1B BETASERON (0.3MG) (VIAL) 2 PA, SP

INTERFERON BETA-1B EXTAVIA 2 PA, SPOCRELIZUMAB OCREVUS 3 SP

PEGINTERFERON BETA-1APLEGRIDY(125MCG/0.5)(SYRINGE)

2 PA, SP

PEGINTERFERON BETA-1A PLEGRIDY (63-94MCG) (SYRINGE) 2 PA, SP

PEGINTERFERON BETA-1APLEGRIDY PEN(125MCG/0.5) (PENINJCTR)

2 PA, SP

PEGINTERFERON BETA-1APLEGRIDY PEN (63-94 MCG) (PENINJCTR)

2 PA, SP

AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKRDALFAMPRIDINE AMPYRA 2 PA

AMYOTROPHIC LATERAL SCLEROSIS AGENTSEDARAVONE RADICAVA 2riluzole RILUTEK 1

FIBROMYALGIA AGENTS,SEROTONIN-NOREPINEPH RU INHIBMILNACIPRAN HCL SAVELLA 2

LEUKOCYTE ADHESION INHIB,ALPHA4-MEDIAT IGG4K MC ABNATALIZUMAB TYSABRI 2 PA

METABOLIC DISEASE ENZYME REPLACEMENT, BATTEN DISEACERLIPONASE ALFA BRINEURA 3 SP

MOVEMENT DISORDERS(DRUG THERAPY)DEUTETRABENAZINE AUSTEDO 3 PA

tetrabenazine XENAZINE (12.5MG) (TABLET) 1 PA, SP

tetrabenazine XENAZINE (25 MG)(TABLET) 1 PA, SP

VALBENAZINE TOSYLATE INGREZZA (40 MG)(CAPSULE) 3 PA, QL: 1 IN 1 DAY

VALBENAZINE TOSYLATE INGREZZA (80 MG)(CAPSULE) 3 PA, QL: 1 IN 1 DAY, SP

PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTSDEXTROMETHORPHAN HBR/QUINIDINE NUEDEXTA 2 PA

ORAL/PHARYNGEAL DISORDERSDENTAL AIDS AND PREPARATIONS

chlorhexidine gluconate 1

triamcinolone acetonide KENALOG INORABASE 1

KERATINOCYTE GROWTH FACTOR (KGF)PALIFERMIN KEPIVANCE 2 SP

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Drug Name Tier Requirements/LimitsNOSE PREPARATIONS, MISCELLANEOUS (RX)

ipratropium bromide ATROVENT 1PERIODONTAL COLLAGENASE INHIBITORS

doxycycline hyclate PERIOSTAT 1OTHER DRUGS

ABORTIFACIENT,PROGESTERONE RECEPTOR ANTAGONIST-TYPMIFEPRISTONE MIFEPREX 3

ANTIDOTES,MISCELLANEOUSACETYLCYSTEINE CETYLEV 3

APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND.megestrol acetate MEGACE 1megestrol acetate MEGACE ES 1

DRUGS TO TREAT HEREDITARY TYROSINEMIANITISINONE NITYR 3 PANITISINONE ORFADIN 2 PA

DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCINGELIGLUSTAT TARTRATE CERDELGA 2 PAMIGLUSTAT ZAVESCA 2 PA

INTRA-UTERINE DEVICES (IUD'S)COPPER PARAGARD T 380-A 0LEVONORGESTREL KYLEENA 0LEVONORGESTREL MIRENA 0LEVONORGESTREL SKYLA 0

METABOLIC DEFICIENCY AGENTSBETAINE CYSTADANE 2levocarnitine (330 mg) (tablet) 1levocarnitine (with sugar) CARNITOR 1

METABOLIC DISEASE ENZYME REPLACE, HYPOPHOSPHATASIAASFOTASE ALFA STRENSIQ 2 PA

METABOLIC DISEASE ENZYME REPLACEMENT, FABRY'S DXAGALSIDASE BETA FABRAZYME 2 SP

METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DXIMIGLUCERASE CEREZYME 2 PA, SPTALIGLUCERASE ALFA ELELYSO 2 PAVELAGLUCERASE ALFA VPRIV 2 PA, SP

METABOLIC DISEASE ENZYME REPLACEMENT,POMPE DISEASEALGLUCOSIDASE ALFA LUMIZYME 2 PA, SP

METABOLIC DX ENZYME REPLACE, MUCOPOLYSACCHARIDOSISELOSULFASE ALFA VIMIZIM 2 PA, SPGALSULFASE NAGLAZYME 2 SPIDURSULFASE ELAPRASE 2 SPLARONIDASE ALDURAZYME 2 SPVESTRONIDASE ALFA-VJBK MEPSEVII 3

METABOLIC DX ENZYME REPLACEMT,SEV.COMB.IMMUNE DEF.PEGADEMASE BOVINE ADAGEN 2

METALLIC POISON,AGENTS TO TREATDEFERASIROX EXJADE 2 PADEFERASIROX JADENU 2 PA, SP

DEFERASIROXJADENU SPRINKLE(180 MG) (GRANPACK)

2 PA, SP


2 PA, SP

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3 PA, SP

DEFERIPRONE FERRIPROX 2 PAdeferoxamine mesylate DESFERAL 1 PA

deferoxamine mesylate DESFERALMESYLATE 1 PA

PRUSSIAN BLUE (INSOLUBLE) RADIOGARDASE 3SUCCIMER CHEMET 2ZINC ACETATE GALZIN 3

MUSCARINIC RECEPTOR ANTAGONISTSATROPINE SULFATE ATROPEN 3

NEEDLES/NEEDLELESS DEVICES

PEN NEEDLE, DIABETICCLICKFINE (31 GX1/4"") (DISNEEDLE) (OTC)

2

PEN NEEDLE, DIABETICCLICKFINE (31GX5/16"") (DISNEEDLE) (OTC)

2

PEN NEEDLE, DIABETICCLICKFINE (32GX5/32"") (DISNEEDLE) (OTC)

2

PEN NEEDLE, DIABETICPEN NEEDLE (30GX5/16"") (DISNEEDLE)

3

PEN NEEDLE, DIABETICPEN NEEDLE (31 GX1/4"") (DISNEEDLE) (OTC)

1


3


3

PEN NEEDLE, DIABETICPEN NEEDLE (31GX5/16"") (DISNEEDLE) (OTC)

1

PEN NEEDLE, DIABETICPEN NEEDLE (32GX5/32"") (DISNEEDLE) (OTC)

1

NEUROMUSCULAR BLOCKING AGENTSONABOTULINUMTOXINA BOTOX 2 PA, SPRIMABOTULINUMTOXINB MYOBLOC 2 PA, SP

NUTRITIONAL THERAPY, MED COND SPECIAL FORMULATIONGLUTAMINE ENDARI 3 PAGLUTAMINE NUTRESTORE 3 PA

PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASESAPROPTERIN DIHYDROCHLORIDE KUVAN (100 MG)

(POWD PACK) 2 PA, SP

SAPROPTERIN DIHYDROCHLORIDE KUVAN (100 MG)(TABLET SOL) 2 PA, SP

SAPROPTERIN DIHYDROCHLORIDE KUVAN (500 MG)(POWD PACK) 2 PA

SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)paroxetine mesylate BRISDELLE 1 ST, QL: 1 IN 1 DAY

SOMATOSTATIC AGENTSoctreotide acetate SANDOSTATIN (100

MCG/ML) (AMPUL) 1 SP

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octreotide acetateSANDOSTATIN (100MCG/ML)(SYRINGE)

1 SP

octreotide acetate SANDOSTATIN (100MCG/ML) (VIAL) 1 SP

octreotide acetateSANDOSTATIN(1000MCG/ML)(VIAL)

1 SP


octreotide acetate SANDOSTATIN (50MCG/ML) (AMPUL) 1 SP


1 SP


octreotide acetate SANDOSTATIN (500MCG/ML) (AMPUL) 1 SP


1 SP


PASIREOTIDE DIASPARTATE SIGNIFOR 2 PAOTHER RESPIRATORY DISORDERS

ANTIFIBROTIC THERAPY - PYRIDONE ANALOGSPIRFENIDONE ESBRIET (267 MG)

(CAPSULE) 2 PA

PIRFENIDONE ESBRIET (267 MG)(TABLET) 3 PA

PIRFENIDONE ESBRIET (801 MG)(TABLET) 3 PA

CYSTIC FIB.TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATORIVACAFTOR KALYDECO 2 PA, SP

CYSTIC FIBROSIS-CFTR POTENTIATOR & CORRECTOR COMB.LUMACAFTOR/IVACAFTOR ORKAMBI 2 PA, SP

LUNG SURFACTANTSBERACTANT SURVANTA 3CALFACTANT INFASURF 3LUCINACTANT SURFAXIN 3PORACTANT ALFA CUROSURF 3

MUCOLYTICSacetylcysteine MUCOMYST 1DORNASE ALFA PULMOZYME 2 PA, SP

PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORSNINTEDANIB ESYLATE OFEV 2 PA

PAIN MANAGEMENT - ANALGESICSANALGESIC, NON-SALICYLATE & BARBITURATE COMB.

BUTALBITAL/ACETAMINOPHEN ALLZITAL 3butalbital/acetaminophen BUPAP 1 ST, QL: 6 IN 1 DAYbutalbital/acetaminophen BUTAPAP 1butalbital/acetaminophen ORBIVAN CF 1 ST, QL: 6 IN 1 DAY

ANALGESIC, SALICYLATE, BARBITURATE,& XANTHINE CMBbutalbital/aspirin/caffeine 1

ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMBbutalb/acetaminophen/caffeine ESGIC 1

National Formulary


Drug Name Tier Requirements/Limitsbutalb/acetaminophen/caffeine FIORICET 1BUTALB/ACETAMINOPHEN/CAFFEINE VANATOL LQ 3BUTALB/ACETAMINOPHEN/CAFFEINE VANATOL S 3

ANALGESIC/ANTIPYRETICS, SALICYLATESaspirin (325 mg) (tablet dr) (otc) 0aspirin (325 mg) (tablet) (otc) 0diflunisal DOLOBID 1salsalate DISALCID 1

ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATIONhydrocodone/ibuprofen IBUDONE 1hydrocodone/ibuprofen REPREXAIN 1hydrocodone/ibuprofen VICOPROFEN 1ibuprofen/oxycodone hcl COMBUNOX 1

ANALGESICS,NARCOTICSbuprenorphine BUTRANS 1 QL: 1 IN 7 DAYSbuprenorphine hcl 1butorphanol tartrate STADOL 1codeine sulfate CODEINE 1 AGE: >= 12 YEARSfentanyl DURAGESIC 1 PA, QL: 1 IN 3 DAYS

fentanyl citrate ACTIQ (1200 MCG)(LOZENGE HD) 1 PA





fentanyl citrate ACTIQ (800 MCG)(LOZENGE HD) 1

HYDROCODONE BITARTRATE HYSINGLA ER 2 QL: 1 IN 1 DAY

hydrocodone/acetaminophen HYCET (7.5-325/15)(SOLUTION) 1 QL: 180mL IN 1 DAY

hydrocodone/acetaminophen LORTAB (10MG-325MG) (TABLET) 1 QL: 12 IN 1 DAY

hydrocodone/acetaminophen LORTAB (5 MG-325MG) (TABLET) 1 QL: 12 IN 1 DAY

hydrocodone/acetaminophen LORTAB (7.5-325MG) (TABLET) 1 QL: 12 IN 1 DAY

hydrocodone/acetaminophen NORCO 1 QL: 12 IN 1 DAYhydrocodone/acetaminophen VERDROCET 1hydrocodone/acetaminophen XODOL 10-300 1 QL: 13 IN 1 DAYhydrocodone/acetaminophen XODOL 5-300 1 QL: 13 IN 1 DAYhydrocodone/acetaminophen XODOL 7.5-300 1 QL: 13 IN 1 DAYHYDROMORPHONE HCL DILAUDID 3hydromorphone hcl (12 mg) (tab er 24h) 1 PA, QL: 1 IN 1 DAYhydromorphone hcl (16 mg) (tab er 24h) 1 PA, QL: 1 IN 1 DAYhydromorphone hcl (2 mg) (tablet) 1hydromorphone hcl (3 mg) (supp.rect) 1hydromorphone hcl (32 mg) (tab er 24h) 1 PA, QL: 2 IN 1 DAYhydromorphone hcl (4 mg) (tablet) 1hydromorphone hcl (8 mg) (tab er 24h) 1 PA, QL: 1 IN 1 DAYhydromorphone hcl (8 mg) (tablet) 1levorphanol tartrate LEVO-DROMORAN 1

meperidine hcl DEMEROL (100 MG)(TABLET) 1 QL: 6 IN 1 DAY

meperidine hcl DEMEROL (50 MG)(TABLET) 1 QL: 6 IN 1 DAY

National Formulary


Drug Name Tier Requirements/Limitsmethadone hcl (10 mg) (tablet) 1 QL: 4 IN 1 DAYmethadone hcl (10 mg/5 ml) (solution) 1 ST, QL: 20mL IN 1 DAYmethadone hcl (5 mg) (tablet) 1 QL: 8 IN 1 DAYmethadone hcl (5 mg/5 ml) (solution) 1 ST, QL: 40mL IN 1 DAYMORPHINE SULFATE ARYMO ER 3 QL: 3 IN 1 DAYMORPHINE SULFATE MORPHABOND ER 3 QL: 2 IN 1 DAYmorphine sulfate (10 mg) (supp.rect) 1morphine sulfate (10 mg/5 ml) (solution) 1morphine sulfate (100 mg) (tablet er) 1 QL: 3 IN 1 DAYmorphine sulfate (100 mg/5ml) (solution) 1morphine sulfate (120 mg) (cpmp 24hr) 1 QL: 2 IN 1 DAYmorphine sulfate (15 mg) (tablet er) 1 QL: 3 IN 1 DAYMORPHINE SULFATE (15 MG) (TABLET) 2morphine sulfate (20 mg) (supp.rect) 1morphine sulfate (20 mg/5 ml) (solution) 1morphine sulfate (200 mg) (tablet er) 1 QL: 3 IN 1 DAYmorphine sulfate (30 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate (30 mg) (supp.rect) 1morphine sulfate (30 mg) (tablet er) 1 QL: 3 IN 1 DAYMORPHINE SULFATE (30 MG) (TABLET) 2morphine sulfate (45 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate (5 mg) (supp.rect) 1morphine sulfate (60 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate (60 mg) (tablet er) 1 QL: 3 IN 1 DAYmorphine sulfate (75 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYmorphine sulfate (90 mg) (cpmp 24hr) 1 QL: 1 IN 1 DAYoxycodone hcl (10 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (10 mg) (tablet) 1oxycodone hcl (10mg/0.5ml) (syringe) 1oxycodone hcl (15 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (15 mg) (tablet) 1oxycodone hcl (20 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (20 mg) (tablet) 1oxycodone hcl (20 mg/ml) (oral conc) 1oxycodone hcl (30 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (30 mg) (tablet) 1oxycodone hcl (40 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (5 mg) (capsule) 1oxycodone hcl (5 mg) (tablet) 1oxycodone hcl (5 mg/5 ml) (solution) 1oxycodone hcl (60 mg) (tab er 12h) 1 QL: 2 IN 1 DAYoxycodone hcl (80 mg) (tab er 12h) 1 QL: 4 IN 1 DAYoxycodone hcl/acetaminophen PERCOCET 1 QL: 12 IN 1 DAYoxycodone hcl/acetaminophen ROXICET 1 QL: 61mL IN 1 DAYoxycodone hcl/aspirin ENDODAN 1oxycodone hcl/aspirin PERCODAN 1

oxymorphone hcl OPANA (10 MG)(TABLET) 1

oxymorphone hcl OPANA (5 MG)(TABLET) 1

oxymorphone hcl OPANA ER (10 MG)(TAB ER 12H) 1 QL: 2 IN 1 DAY




National Formulary


Drug Name Tier Requirements/Limitsoxymorphone hcl OPANA ER (40 MG)

(TAB ER 12H) 1 QL: 4 IN 1 DAY


oxymorphone hcl OPANA ER (7.5 MG)(TAB ER 12H) 1 QL: 2 IN 1 DAY

TAPENTADOL HCL NUCYNTA 2 QL: 6 IN 1 DAYTAPENTADOL HCL NUCYNTA ER 2 QL: 2 IN 1 DAYtramadol hcl RYZOLT 1 AGE: >= 12 YEARStramadol hcl ULTRAM 1 AGE: >= 12 YEARStramadol hcl ULTRAM ER 1 AGE: >= 12 YEARStramadol hcl/acetaminophen ULTRACET 1 AGE: >= 12 YEARS

ANTIMIGRAINE PREPARATIONSalmotriptan malate AXERT 1 ST, QL: 2 IN 5 DAYSdihydroergotamine mesylate D.H.E. 45 1dihydroergotamine mesylate D.H.E.45 1 QL: 15mL IN 14 DAYSdihydroergotamine mesylate MIGRANAL 1 QL: 8mL IN 28 DAYSeletriptan hbr RELPAX 1 ST, QL: 2 IN 5 DAYSERGOTAMINE TARTRATE ERGOMAR 3 QL: 10 IN 7 DAYSergotamine tartrate/caffeine CAFERGOT 1 QL: 10 IN 7 DAYSERGOTAMINE TARTRATE/CAFFEINE MIGERGOT 2 QL: 5 IN 7 DAYSfrovatriptan succinate FROVA 1 ST, QL: 3 IN 5 DAYSisomethept/dichlphn/acetaminop 1isomethepten/caf/acetaminophen PRODRIN 1naratriptan hcl AMERGE 1 QL: 3 IN 5 DAYSrizatriptan benzoate MAXALT 1 QL: 3 IN 5 DAYSrizatriptan benzoate MAXALT MLT 1 QL: 3 IN 5 DAYSsumatriptan IMITREX 1 QL: 6 IN 15 DAYSSUMATRIPTAN SUCC/NAPROXEN SOD TREXIMET 3 QL: 1 IN 3 DAYS

sumatriptan succinate IMITREX (100 MG)(TABLET) 1 QL: 3 IN 5 DAYS


sumatriptan succinateIMITREX (4MG/0.5ML)(CARTRIDGE)


sumatriptan succinateIMITREX (4MG/0.5ML) (PENINJCTR)



sumatriptan succinateIMITREX (6MG/0.5ML)(CARTRIDGE)


sumatriptan succinateIMITREX (6MG/0.5ML) (PENINJCTR)


sumatriptan succinate IMITREX (6MG/0.5ML) (VIAL) 1 QL: 1mL IN 14 DAYS

SUMATRIPTAN SUCCINATE ONZETRA XSAIL 3

SUMATRIPTAN SUCCINATE ZEMBRACESYMTOUCH 3

ZOLMITRIPTAN ZOMIG (2.5 MG)(SPRAY) 2 ST, QL: 12 IN 30 DAYS

zolmitriptan ZOMIG (2.5 MG)(TABLET) 1 ST, QL: 2 IN 5 DAYS

ZOLMITRIPTAN ZOMIG (5 MG)(SPRAY) 2 ST, QL: 6 IN 15 DAYS

National Formulary


Drug Name Tier Requirements/Limitszolmitriptan ZOMIG (5 MG)

(TABLET) 1 ST, QL: 2 IN 5 DAYS

zolmitriptan ZOMIG ZMT 1 ST, QL: 2 IN 5 DAYSNARC.& NON-SAL.ANALGESIC,BARBITURATE &XANTHINE CMB

butalbit/acetamin/caff/codeine FIORICET WITHCODEINE 1 AGE: >= 12 YEARS

NARCOTIC & SALICYLATE ANALGESICS, BARB.& XANTHINEcodeine/butalbital/asa/caffein FIORINAL WITH

CODEINE #3 1 AGE: >= 12 YEARS

NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMBacetaminophen with codeine 1 AGE: >= 12 YEARS

NARCOTIC WITHDRAWAL THERAPY AGENTSbuprenorphine hcl (2 mg) (tab subl) 1 QL: 3 IN 1 DAYbuprenorphine hcl (8 mg) (tab subl) 1 QL: 3 IN 1 DAY

BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE (12 MG-3 MG) (FILM) 2 QL: 2 IN 1 DAY

BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE (2 MG-0.5MG) (FILM) 2 QL: 1 IN 1 DAY

buprenorphine hcl/naloxone hcl SUBOXONE (2 MG-0.5MG) (TAB SUBL) 1 QL: 3 IN 1 DAY

BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE (4MG-1MG) (FILM) 2 QL: 1 IN 1 DAY

BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE (8 MG-2MG) (FILM) 2 QL: 2 IN 1 DAY

buprenorphine hcl/naloxone hcl SUBOXONE (8 MG-2MG) (TAB SUBL) 1 QL: 3 IN 1 DAY

BUPRENORPHINE HCL/NALOXONE HCLZUBSOLV (0.7-0.18MG) (TABSUBL)

2 QL: 1 IN 1 DAY


2 QL: 1 IN 1 DAY

BUPRENORPHINE HCL/NALOXONE HCL ZUBSOLV (11.4-2.9MG) (TAB SUBL) 2 QL: 1 IN 1 DAY


2 QL: 1 IN 1 DAY



PARKINSONS DISEASEANTIPARKINSONISM DRUGS,ANTICHOLINERGIC

benztropine mesylate COGENTIN (0.5 MG)(TABLET) 1

benztropine mesylate COGENTIN (1 MG)(TABLET) 1

benztropine mesylate COGENTIN (2 MG)(TABLET) 1

trihexyphenidyl hcl ARTANE 1ANTIPARKINSONISM DRUGS,OTHER

AMANTADINE HCL GOCOVRI (137 MG)(CAP ER 24H) 3 PA, QL: 2 IN 1 DAY

AMANTADINE HCL GOCOVRI (68.5 MG)(CAP ER 24H) 3 PA, QL: 1 IN 1 DAY

amantadine hcl SYMMETREL 1APOMORPHINE HCL APOKYN 2 PA, QL: 2mL IN 1 DAYbromocriptine mesylate PARLODEL 1

National Formulary


Drug Name Tier Requirements/Limitscarbidopa/levodopa PARCOPA 1CARBIDOPA/LEVODOPA RYTARY 3 QL: 10 IN 1 DAYcarbidopa/levodopa SINEMET 10-100 1carbidopa/levodopa SINEMET 25-100 1carbidopa/levodopa SINEMET 25-250 1carbidopa/levodopa SINEMET CR 1carbidopa/levodopa/entacapone STALEVO 100 1carbidopa/levodopa/entacapone STALEVO 125 1carbidopa/levodopa/entacapone STALEVO 150 1carbidopa/levodopa/entacapone STALEVO 200 1carbidopa/levodopa/entacapone STALEVO 50 1carbidopa/levodopa/entacapone STALEVO 75 1entacapone COMTAN 1pramipexole di-hcl MIRAPEX 1pramipexole di-hcl MIRAPEX ER 1 ST, QL: 1 IN 1 DAYrasagiline mesylate AZILECT 1 QL: 1 IN 1 DAYropinirole hcl REQUIP 1ropinirole hcl REQUIP XL 1 ST, QL: 1 IN 1 DAYROTIGOTINE NEUPRO 3 QL: 1 IN 1 DAYSAFINAMIDE MESYLATE XADAGO 3 QL: 1 IN 1 DAYselegiline hcl ELDEPRYL 1tolcapone TASMAR 1 ST, QL: 3 IN 1 DAY

DECARBOXYLASE INHIBITORScarbidopa LODOSYN 1

SEIZURE DISORDERANTICONVULSANTS

carbamazepine CARBATROL 1carbamazepine TEGRETOL 1carbamazepine TEGRETOL XR 1clonazepam KLONOPIN 1

clonazepamKLONOPINRAPIDLYDISINTEGRATING

1

diazepam DIASTAT 1 QL: 1 PER FILLdiazepam DIASTAT ACUDIAL 1 QL: 1 PER FILLdivalproex sodium DEPAKOTE 1divalproex sodium DEPAKOTE ER 1

divalproex sodium DEPAKOTESPRINKLE 1

ESLICARBAZEPINE ACETATE APTIOM (200 MG)(TABLET) 3 QL: 1 IN 1 DAY




ethosuximide ZARONTIN 1ETHOTOIN PEGANONE 2

felbamate FELBATOL (400 MG)(TABLET) 1 ST, QL: 9 IN 1 DAY

felbamate FELBATOL (600 MG)(TABLET) 1 ST, QL: 6 IN 1 DAY

felbamateFELBATOL (600MG/5ML) (ORALSUSP)


gabapentin NEURONTIN 1

National Formulary


Drug Name Tier Requirements/LimitsLACOSAMIDE VIMPAT (10 MG/ML)

(SOLUTION) 2 ST, QL: 1200mL IN 30 DAYS

LACOSAMIDE VIMPAT (100 MG)(TABLET) 2 ST, QL: 2 IN 1 DAY




LACOSAMIDEVIMPAT (50MG-100MG) (TAB DSPK)

3

lamotrigine LAMICTAL 1lamotrigine LAMICTAL (BLUE) 1

lamotrigine LAMICTAL(GREEN) 1

lamotrigine LAMICTAL(ORANGE) 1

lamotrigineLAMICTAL ODT(100 MG) (TABRAPDIS)


lamotrigineLAMICTAL ODT(200 MG) (TABRAPDIS)


lamotrigine LAMICTAL ODT (25MG) (TAB RAPDIS) 1 ST, QL: 6 IN 1 DAY

lamotrigine LAMICTAL ODT (50MG) (TAB RAPDIS) 1 ST, QL: 6 IN 1 DAY

lamotrigine LAMICTAL ODT(BLUE) 1 ST

lamotrigine LAMICTAL ODT(GREEN) 1 ST

lamotrigine LAMICTAL ODT(ORANGE) 1 ST

lamotrigine LAMICTAL XR (100MG) (TAB ER 24) 1 ST

lamotrigine LAMICTAL XR (200MG) (TAB ER 24) 1 ST, QL: 2 IN 1 DAY





levetiracetamKEPPRA (100MG/ML)(SOLUTION)

1

levetiracetam KEPPRA (1000 MG)(TABLET) 1



levetiracetamKEPPRA (500MG/5ML)(SOLUTION)

1

National Formulary


Drug Name Tier Requirements/Limitslevetiracetam KEPPRA (750 MG)

(TABLET) 1

levetiracetam KEPPRA XR 1levetiracetam ROWEEPRA 1METHSUXIMIDE CELONTIN 2oxcarbazepine TRILEPTAL 1

PERAMPANELFYCOMPA (0.5MG/ML) (ORALSUSP)


PERAMPANEL FYCOMPA (10 MG)(TABLET) 2 ST, QL: 1 IN 1 DAY






phenytoin DILANTIN 1phenytoin DILANTIN-125 1

phenytoin sodium extended DILANTIN (100 MG)(CAPSULE) 1

PHENYTOIN SODIUM EXTENDED DILANTIN (30 MG)(CAPSULE) 2

phenytoin sodium extended PHENYTEK 1PREGABALIN LYRICA 2primidone MYSOLINE 1

RUFINAMIDE BANZEL (200 MG)(TABLET) 2 ST, QL: 16 IN 1 DAY

RUFINAMIDEBANZEL (40MG/ML) (ORALSUSP)


RUFINAMIDE BANZEL (400 MG)(TABLET) 2 ST, QL: 8 IN 1 DAY

TIAGABINE HCL GABITRIL (12 MG)(TABLET) 2 ST, QL: 4 IN 1 DAY

TIAGABINE HCL GABITRIL (16 MG)(TABLET) 2 ST, QL: 3 IN 1 DAY

tiagabine hcl GABITRIL (2 MG)(TABLET) 1 ST, QL: 4 IN 1 DAY

tiagabine hcl GABITRIL (4 MG)(TABLET) 1 ST, QL: 4 IN 1 DAY

TOPIRAMATE QUDEXY XR (100MG) (CAP SPR 24) 2 ST, QL: 1 IN 1 DAY





topiramate TOPAMAX 1

TOPIRAMATE TROKENDI XR (100MG) (CAP ER 24H) 3 QL: 1 IN 1 DAY


National Formulary


Drug Name Tier Requirements/LimitsTOPIRAMATE TROKENDI XR (25

MG) (CAP ER 24H) 3 QL: 1 IN 1 DAY


valproic acid DEPAKENE 1valproic acid (as sodium salt) DEPAKENE 1

vigabatrin SABRIL (500 MG)(POWD PACK) 1 QL: 6 IN 1 DAY

VIGABATRIN SABRIL (500 MG)(TABLET) 2 QL: 6 IN 1 DAY

zonisamide ZONEGRAN 1BENZODIAZEPINES

CLOBAZAM ONFI (10 MG)(TABLET) 2 ST, QL: 2 IN 1 DAY

CLOBAZAM ONFI (2.5 MG/ML)(ORAL SUSP) 2 ST, QL: 480mL IN 30 DAYS

CLOBAZAM ONFI (20 MG)(TABLET) 2 ST, QL: 2 IN 1 DAY

SKELETAL MUSCLE DISORDERSKELETAL MUSCLE RELAXANTS

baclofen LIORESAL 1carisoprodol SOMA 1 ST, QL: 4 IN 1 DAYchlorzoxazone (500 mg) (tablet) 1CYCLOBENZAPRINE HCL AMRIX 3cyclobenzaprine hcl FEXMID 1cyclobenzaprine hcl FLEXERIL 1

dantrolene sodium DANTRIUM (100MG) (CAPSULE) 1

dantrolene sodium DANTRIUM (25 MG)(CAPSULE) 1

dantrolene sodium DANTRIUM (50 MG)(CAPSULE) 1

metaxalone SKELAXIN 1

methocarbamol ROBAXIN (500 MG)(TABLET) 1

methocarbamol ROBAXIN-750 1

orphenadrine citrate NORFLEX (100 MG)(TABLET ER) 1

tizanidine hcl ZANAFLEX 1SMOKING CESSATION

SMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS)nicotine NICODERM CQ 0 AGE: >= 18 YEARS, QL: 1 IN 1 DAYNICOTINE PATCH 0 AGE: >= 18 YEARS, QL: 1 IN 1 DAYnicotine polacrilex NICORETTE 0 AGE: >= 18 YEARS, QL: 9 IN 1 DAY

SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONISTVARENICLINE TARTRATE CHANTIX 0 AGE: >= 18 YEARS, QL: 2 IN 1 DAY

SMOKING DETERRENTS, OTHERbupropion hcl ZYBAN 0 AGE: >= 18 YEARS, QL: 2 IN 1 DAY

UPPER GASTROINTESTINAL DISORDERS - DIGESTIVEGASTRIC ENZYMES

SACROSIDASE SUCRAID 2 PAPANCREATIC ENZYMES

LIPASE/PROTEASE/AMYLASE CREON 2LIPASE/PROTEASE/AMYLASE VIOKACE 2

LIPASE/PROTEASE/AMYLASE ZENPEP (10-34-55K)(CAPSULE DR) 2

National Formulary


Drug Name Tier Requirements/LimitsLIPASE/PROTEASE/AMYLASE ZENPEP (15-51-82K)

(CAPSULE DR) 2

LIPASE/PROTEASE/AMYLASE ZENPEP (20-63-84K)(CAPSULE DR) 3

LIPASE/PROTEASE/AMYLASEZENPEP (25-85-136K) (CAPSULEDR)

2

LIPASE/PROTEASE/AMYLASE ZENPEP (3K-10K-16K) (CAPSULE DR) 2

LIPASE/PROTEASE/AMYLASE ZENPEP (40-126-168)(CAPSULE DR) 2

LIPASE/PROTEASE/AMYLASE ZENPEP (5K-17K-27K) (CAPSULE DR) 2

UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASEANTICHOLINERGICS/ANTISPASMODICS

dicyclomine hcl (10 mg) (capsule) 1dicyclomine hcl (10 mg/5 ml) (solution) 1dicyclomine hcl (20 mg) (tablet) 1

BELLADONNA ALKALOIDShyoscyamine sulfate HYOSYNE 1hyoscyamine sulfate LEVBID 1

hyoscyamine sulfate LEVSIN (0.125 MG)(TABLET) 1

hyoscyamine sulfate LEVSIN-SL 1hyoscyamine sulfate NULEV 1hyoscyamine sulfate SYMAX 1hyoscyamine sulfate SYMAX-SL 1hyoscyamine sulfate SYMAX-SR 1methscopolamine bromide PAMINE 1methscopolamine bromide PAMINE FORTE 1

PHENOBARB/HYOSCY/ATROPINE/SCOPDONNATAL(16.2MG/5ML)(ELIXIR)

3

UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASEANTICHOLINERGICS,QUATERNARY AMMONIUM

chlordiazepoxide/clidinium br LIBRAX 1

glycopyrrolate ROBINUL (1 MG)(TABLET) 1

glycopyrrolate ROBINUL FORTE 1ANTI-ULCER PREPARATIONS

misoprostol CYTOTEC 1

sucralfate CARAFATE (1 G)(TABLET) 1

SUCRALFATE CARAFATE (1 G/10ML) (ORAL SUSP) 2

ANTI-ULCER-H.PYLORI AGENTSBISMUTH/METRONID/TETRACYCLINE PYLERA 2lansoprazole/amoxiciln/clarith PREVPAC 1 QL: 112 IN 10 DAYS

HISTAMINE H2-RECEPTOR INHIBITORScimetidine TAGAMET 1cimetidine hcl TAGAMET 1

famotidine PEPCID (20 MG)(TABLET) 1

famotidine PEPCID (40 MG)(TABLET) 1

famotidine PEPCID (40MG/5ML)(ORAL SUSP) 1

National Formulary


Drug Name Tier Requirements/Limitsnizatidine AXID 1

ranitidine hcl ZANTAC (15MG/ML) (SYRUP) 1

ranitidine hcl ZANTAC (150 MG)(CAPSULE) 1

ranitidine hcl ZANTAC (150 MG)(TABLET) 1

ranitidine hcl ZANTAC (300 MG)(CAPSULE) 1

ranitidine hcl ZANTAC (300 MG)(TABLET) 1

INTESTINAL MOTILITY STIMULANTSmetoclopramide hcl METOZOLV ODT 1

metoclopramide hcl REGLAN (10 MG)(TABLET) 1

metoclopramide hclREGLAN (10MG/10ML)(SOLUTION)

1

metoclopramide hcl REGLAN (5 MG)(TABLET) 1

metoclopramide hcl REGLAN (5 MG/5ML) (SOLUTION) 1

PROTON-PUMP INHIBITORSDEXLANSOPRAZOLE DEXILANT (60 MG)

(CAP DR BP) 3 QL: 1 IN 1 DAY

ESOMEPRAZOLE MAGNESIUM NEXIUM (10 MG)(SUSPDR PKT) 2 ST, QL: 1 IN 1 DAY

ESOMEPRAZOLE MAGNESIUM NEXIUM (2.5 MG)(SUSPDR PKT) 2 ST, QL: 1 IN 1 DAY

esomeprazole magnesium NEXIUM (20 MG)(CAPSULE DR) 1 ST, QL: 1 IN 1 DAY


esomeprazole magnesium NEXIUM (40 MG)(CAPSULE DR) 1 ST, QL: 1 IN 1 DAY



lansoprazole PREVACID (15 MG)(CAPSULE DR) 1

lansoprazole PREVACID (30 MG)(CAPSULE DR) 1

omeprazole PRILOSEC (10 MG)(CAPSULE DR) 1



omeprazole/sodium bicarbonate OMEPPI 1 ST, QL: 1 IN 1 DAYomeprazole/sodium bicarbonate ZEGERID 1 ST, QL: 1 IN 1 DAY

pantoprazole sodium PROTONIX (20 MG)(TABLET DR) 1

pantoprazole sodium PROTONIX (40 MG)(TABLET DR) 1

rabeprazole sodium ACIPHEX 1 QL: 1 IN 1 DAYURINARY TRACT - FUNCTIONAL DISORDERS

BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTSalfuzosin hcl UROXATRAL 1

National Formulary


Drug Name Tier Requirements/Limitsdutasteride AVODART 1finasteride PROSCAR 1SILODOSIN RAPAFLO 2 STtamsulosin hcl FLOMAX 1

BPH AGENTS,5-ALPHA-RED INH & ALPHA-1-ADR ANTG CMBdutasteride/tamsulosin hcl JALYN 1 ST

KIDNEY STONE AGENTSCYSTEAMINE BITARTRATE CYSTAGON 2TIOPRONIN THIOLA 3

OVERACTIVE BLADDER AGENTS, BETA-3 ADRENERGIC RECEPMIRABEGRON MYRBETRIQ 2 ST

URINARY PH MODIFIERSCITRIC AC/GLUCONOLACT/MAG CARB RENACIDIN 2citric acid/sodium citrate CYTRA-2 1potassium citrate UROCIT-K 1potassium citrate/citric acid CYTRA-K 1POTASSIUM PHOSPHATE,MONOBASIC K-PHOS ORIGINAL 2sod phos di, mono/k phos mono (250 mg) (tablet) 1sod/pot/k cit/sod cit/cit acid CYTRA-3 1sod/pot/k cit/sod cit/cit acid TRICITRATES 1

URINARY TRACT ANALGESIC AGENTSPENTOSAN POLYSULFATE SODIUM ELMIRON 2

URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE)phenazopyridine hcl PYRIDIUM 1

URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG.darifenacin hydrobromide ENABLEX 1 STSOLIFENACIN SUCCINATE VESICARE 2 ST

URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENTFESOTERODINE FUMARATE TOVIAZ 2 STflavoxate hcl URISPAS 1oxybutynin chloride DITROPAN 1oxybutynin chloride DITROPAN XL 1

OXYBUTYNIN CHLORIDE GELNIQUE (10 %)(GEL PACKET) 2 ST

OXYBUTYNIN CHLORIDEGELNIQUE (100MG/G) (GEL MDPMP)

3 ST

tolterodine tartrate DETROL 1 STtolterodine tartrate DETROL LA 1 STtrospium chloride SANCTURA 1 STtrospium chloride SANCTURA XR 1 ST

VAGINAL DISORDERSVAGINAL ANTIBIOTICS

clindamycin phosphate CLEOCIN (2 %)(CREAM/APPL) 1

metronidazole METROGEL-VAGINAL 1

METRONIDAZOLE VANDAZOLE 2VAGINAL ANTIFUNGALS

miconazole nitrate (200 mg) (supp.vag) 1terconazole TERAZOL 3 1terconazole TERAZOL 7 1

VAGINAL ESTROGEN PREPARATIONSestradiol ESTRACE 1ESTRADIOL ESTRING 2 QL: 1 IN 90 DAYSestradiol VAGIFEM 1

National Formulary


Drug Name Tier Requirements/LimitsESTROGENS, CONJUGATED PREMARIN 2

VITAMIN AND/OR MINERAL DEFICIENCYFLUORIDE PREPARATIONS

fluoride (sodium) (0.25(0.55)) (tab chew) 0 AGE: <= 6 YEARSfluoride (sodium) (0.5 mg/ml) (drops) 0 AGE: <= 6 YEARSfluoride (sodium) (0.5(1.1)mg) (tab chew) 0 AGE: <= 6 YEARSfluoride (sodium) (1.1 %) (cream (g)) 1fluoride (sodium) (1.1 %) (gel (gram)) 1fluoride (sodium) (1mg(2.2mg)) (tab chew) 0 AGE: <= 6 YEARS

FOLIC ACID PREPARATIONSfolic acid (0.4 mg) (tablet) (otc) 0folic acid (0.8 mg) (tablet) (otc) 0folic acid (1 mg) (tablet) 1

PRENATAL VITAMIN PREPARATIONSiron,carb/vit c/vit b12/folic 1pnv 11/iron fum/folic acid/om3 1pnv 15/iron fum,ps/folic acid CONCEPT OB 1pnv 16/iron fum,ps/folic/om-3 CONCEPT DHA 1pnv 19/iron ps,heme/folic/dha PREFERA-OB ONE 1pnv 21/iron ps,heme ppep/folic PREFERA OB 1pnv 39/iron/folic/docusate/dha 1pnv 66/iron/folic/docusate/dha 1pnv 69/iron/folic/docusate/dha 1pnv 80/iron fum/folic/dss/dha NEXA SELECT 1pnv no.118/iron fumarate/fa (29 mg-1 mg) (tabchew) 1

pnv no.5/ferrous fum/folic ac 1pnv, calcium 62/iron/folic/dha 1pnv,calc 35/iron/folic/dss/om3 1pnv,calcium 72/iron,carb/folic 1pnv,calcium 72/iron/folic acid 1pnv,calcium37/iron/folic/omeg3 1pnv/ferrous fum/docusate/folic 1pnv/ferrous fum/folic acid/sel 1pnv/iron,carb/docusat/folic ac 1pnv119/iron fum/folic/docusate 1pnv19/iron bg,s.p/folic ac/om3 1pnv81/iron edta,ps/folic/omeg3 1prenat vit 17/iron/folic/om3,6 1prenatal 105/iron/folic ac/dha VITATRUE 1prenatal 12/iron/folic/dss/om3 OBTREX DHA 1

prenatal 34/iron/folic/dss/dha CITRANATALHARMONY 1

prenatal 47/iron/folate 1/dha 1prenatal 53/iron/folic ac/omg3 1prenatal 54/iron/folic ac/omg3 1

prenatal 59/iron/folic/dss/dha CITRANATALHARMONY 1

prenatal 68/iron/folic no1/dha 1prenatal 87/iron bis/folic/dha NESTABS DHA 1

prenatal comb no.42/folic acid VITAMEDMDREDICHEW RX 1

prenatal vit 14/iron fum/folic 1prenatal vit 55/iron/folic/om3 1prenatal vit 7/iron/folic/dha 1prenatal vit no.109/iron/fa 1prenatal vit,cal 73/iron/folic 1prenatal vit,cal 74/iron/folic 1

National Formulary


Drug Name Tier Requirements/Limitsprenatal vit,calc76/iron/folic 1prenatal vit,calc78/iron/folic 1prenatal vit/iron bisgly/folic 1prenatal vit/iron fum/folic ac (65 mg-1 mg)(capsule) 1

prenatal vit/iron fum/folic ac (65 mg-1 mg) (tablet) 1prenatal vit27,calcium/iron/fa TRINATAL RX 1 1prenatal vit86/iron/folic acid NESTABS 1prenatal vits15/iron/folic/dss 1prenatal vits16/iron/folic/dss 1prenatal vits18/iron/folic/dss 1prenatal,calc.40/iron/folate 1 1prenatal71/iron/folic acid/dha VITAPEARL 1

PRENATAL VITAMINS WITHOUT IRONpnv/folic ac/b6/calcium/ginger B-NEXA 1

VITAMIN D PREPARATIONScalcitriol ROCALTROL 1cholecalciferol (vitamin d3) (1000 unit) (capsule)(otc) 0 AGE: >= 65 YEARS

cholecalciferol (vitamin d3) (1000 unit) (tab chew)(otc) 0 AGE: >= 65 YEARS

cholecalciferol (vitamin d3) (1000 unit) (tablet) (otc) 0 AGE: >= 65 YEARScholecalciferol (vitamin d3) (2000 unit) (capsule)(otc) 0 AGE: >= 65 YEARS

cholecalciferol (vitamin d3) (2000 unit) (tablet) (otc) 0 AGE: >= 65 YEARScholecalciferol (vitamin d3) (400 unit) (capsule)(otc) 0 AGE: >= 65 YEARS

cholecalciferol (vitamin d3) (400 unit) (tab chew)(otc) 0 AGE: >= 65 YEARS

cholecalciferol (vitamin d3) (400 unit) (tablet) (otc) 0 AGE: >= 65 YEARS

National Formulary


STEP THERAPY EDITS • ABILIFY (1 MG/ML) (SOLUTION) At least 2 prior prescriptions for Abilify Maintena, Abilify, Aripiprazole, Citalopram

Hydrobromide, Clozapine, Duloxetine HCL, Escitalopram Oxalate, Fluoxetine HCL,Olanzapine, Paroxetine HCL, Paroxetine Mesylate, Paxil, Pexeva, QuetiapineFumarate, Risperidone, Sarafem, Seroquel XR, Sertraline HCL, Venlafaxine HCL,Versacloz, or Ziprasidone HCL in the past 365 days

• ABILIFY DISCMELT (10 MG) (TABRAPDIS)

At least 2 prior prescriptions for Abilify Maintena, Abilify, Aripiprazole, CitalopramHydrobromide, Clozapine, Duloxetine HCL, Escitalopram Oxalate, Fluoxetine HCL,Olanzapine, Paroxetine HCL, Paroxetine Mesylate, Paxil, Pexeva, QuetiapineFumarate, Risperidone, Sarafem, Seroquel XR, Sertraline HCL, Venlafaxine HCL,Versacloz, or Ziprasidone HCL in the past 365 days

• ABILIFY DISCMELT (15 MG) (TABRAPDIS)

At least 2 prior prescriptions for Abilify Maintena, Abilify, Aripiprazole, CitalopramHydrobromide, Clozapine, Duloxetine HCL, Escitalopram Oxalate, Fluoxetine HCL,Olanzapine, Paroxetine HCL, Paroxetine Mesylate, Paxil, Pexeva, QuetiapineFumarate, Risperidone, Sarafem, Seroquel XR, Sertraline HCL, Venlafaxine HCL,Versacloz, or Ziprasidone HCL in the past 365 days

• ABSORICA Prior prescription for Absorica or Isotretinoin in the past 120 days• ACANYA Prior prescription for Clindamycin Phos/benzoyl Perox in the past 120 days• ACTICLATE Prior prescription for Doxycycline Monohydrate in the past 120 days• ACTONEL (150 MG) (TABLET) At least 2 prior prescriptions for Alendronate Sodium, Fosamax Plus D, or

Ibandronate Sodium in the past 365 days• ACTONEL (30 MG) (TABLET) At least 2 prior prescriptions for Alendronate Sodium, Fosamax Plus D, or



Ibandronate Sodium in the past 365 days• ACTOPLUS MET Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,

Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, PioglitazoneHCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• AMITIZA Prior prescription for Linzess or Movantik in the past 120 days• ARNUITY ELLIPTA Prior prescription for Asmanex HFA, Asmanex, Qvar Redihaler, or Qvar in the past

365 days• ATELVIA At least 2 prior prescriptions for Alendronate Sodium, Fosamax Plus D, or

Ibandronate Sodium in the past 365 days• AXERT Prior prescription for Rizatriptan Benzoate or Sumatriptan Succinate in the past 180

days• AZOR Prior prescription for Amlodipine Besylate/benazepril, Benazepril HCL,

Benazepril/hydrochlorothiazide, Captopril, Captopril/hydrochlorothiazide, EnalaprilMaleate, Enalapril/hydrochlorothiazide, Epaned, Fosinopril Sodium,Fosinopril/hydrochlorothiazide, Irbesartan, Irbesartan/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Olmesartan/amlodipin/hcthiazid, Olmesartan/hydrochlorothiazide, PerindoprilErbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide, Ramipril,Trandolapril, Trandolapril/verapamil HCL, or Valsartan/hydrochlorothiazide in thepast 120 days

• BANZEL (200 MG) (TABLET) Prior prescription for Divalproex Sodium, Lamictal, Lamictal, Lamotrigine, Stavzor,Topiramate, Trokendi XR, or Valproic Acid in the past 120 days

• BANZEL (40 MG/ML) (ORAL SUSP) Prior prescription for Divalproex Sodium, Lamictal, Lamictal, Lamotrigine, Stavzor,Topiramate, Trokendi XR, or Valproic Acid in the past 120 days

• BANZEL (400 MG) (TABLET) Prior prescription for Divalproex Sodium, Lamictal, Lamictal, Lamotrigine, Stavzor,Topiramate, Trokendi XR, or Valproic Acid in the past 120 days

• BENICAR Prior prescription for Amlodipine Bes/olmesartan Med, AmlodipineBesylate/benazepril, Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,Captopril/hydrochlorothiazide, Enalapril Maleate, Enalapril/hydrochlorothiazide,Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazide, Irbesartan,Irbesartan/hydrochlorothiazide, Lisinopril, Lisinopril/hydrochlorothiazide, LosartanPotassium, Losartan/hydrochlorothiazide, Moexipril HCL,Moexipril/hydrochlorothiazide, Olmesartan/amlodipin/hcthiazid,

Medication Prescribing Limitations


Olmesartan/hydrochlorothiazide, Perindopril Erbumine, Qbrelis, Quinapril HCL,Quinapril/hydrochlorothiazide, Ramipril, Trandolapril, Trandolapril/verapamil HCL,or Valsartan/hydrochlorothiazide in the past 120 days

• BENICAR HCT Prior prescription for Amlodipine Bes/olmesartan Med, AmlodipineBesylate/benazepril, Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,Captopril/hydrochlorothiazide, Enalapril Maleate, Enalapril/hydrochlorothiazide,Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazide, Irbesartan,Irbesartan/hydrochlorothiazide, Lisinopril, Lisinopril/hydrochlorothiazide, LosartanPotassium, Losartan/hydrochlorothiazide, Moexipril HCL,Moexipril/hydrochlorothiazide, Olmesartan Medoxomil,Olmesartan/hydrochlorothiazide, Perindopril Erbumine, Qbrelis, Quinapril HCL,Quinapril/hydrochlorothiazide, Ramipril, Trandolapril, Trandolapril/verapamil HCL,or Valsartan/hydrochlorothiazide in the past 365 days

• BEYAZ At least 2 prior prescriptions for Desog-e.estradiol/e.estradiol, Desogestrel-ethinylEstradiol, Ethinyl Estradiol/drospirenone, Ethynodiol D-ethinyl Estradiol, L-norgest/e.estradiol-e.estrad, Levonorgestrel-ethin Estradiol, Lo Loestrin Fe, Noreth-ethinyl Estradiol/iron, Norethindrone Ac-eth Estradiol, Norethindrone,Norethindrone-e.estradiol-iron, Norethindrone-ethinyl Estrad, Norethindrone-mestranol, Norgestimate-ethinyl Estradiol, or Norgestrel-ethinyl Estradiol in the past365 days

• BRISDELLE Prior prescription for Paroxetine HCL, Paxil, or Venlafaxine HCL in the past 120days

• BUPAP Prior prescription for Butalbital/acetaminophen in the past 120 days• BYDUREON Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,


• BYDUREON BCISE Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, PioglitazoneHCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• BYDUREON PEN Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, PioglitazoneHCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• BYETTA Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, PioglitazoneHCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• COTEMPLA XR-ODT (17.3 MG) (TABRAP BP)

Prior prescription for Methylphenidate HCL, Quillivant XR, or Ritalin LA in the past120 days





• DAYTRANA Prior prescription for Methylphenidate HCL, Quillivant XR, or Ritalin LA in the past120 days

• DETROL Prior prescription for Oxybutynin Chloride in the past 120 days• DETROL LA Prior prescription for Oxybutynin Chloride in the past 120 days• DORYX (100 MG) (TABLET DR) Prior prescription for Doxycycline Hyclate or Doxycycline Monohydrate in the past

120 days• DORYX (150 MG) (TABLET DR) Prior prescription for Doxycycline Monohydrate in the past 120 days• DORYX (200 MG) (TABLET DR) Prior prescription for Doxycycline Hyclate or Doxycycline Monohydrate in the past

120 days• DORYX (50 MG) (TABLET DR) Prior prescription for Doxycycline Monohydrate in the past 120 days• DORYX (75 MG) (TABLET DR) Prior prescription for Doxycycline Monohydrate in the past 120 days• DOVONEX Prior prescription for a Topical Anti-inflammatory Steroidal in the past 120 days• DRITHOCREME HP Prior prescription for a Topical Anti-inflammatory Steroidal in the past 120 days



• DUETACT Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, PioglitazoneHCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• DUZALLO Prior prescription for Allopurinol and Uloric in the past 120 days• DYMISTA Prior prescription for Flunisolide or Fluticasone Propionate in the past 365 days• EDARBI Prior prescription for Amlodipine Besylate/benazepril, Benazepril HCL,

Benazepril/hydrochlorothiazide, Captopril, Captopril/hydrochlorothiazide, EnalaprilMaleate, Enalapril/hydrochlorothiazide, Epaned, Fosinopril Sodium,Fosinopril/hydrochlorothiazide, Irbesartan, Irbesartan/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, Trandolapril/verapamil HCL, orValsartan/hydrochlorothiazide in the past 120 days

• EDARBYCLOR Prior prescription for Amlodipine Besylate/benazepril, Benazepril HCL,Benazepril/hydrochlorothiazide, Captopril, Captopril/hydrochlorothiazide, EnalaprilMaleate, Enalapril/hydrochlorothiazide, Epaned, Fosinopril Sodium,Fosinopril/hydrochlorothiazide, Irbesartan, Irbesartan/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, Trandolapril/verapamil HCL, orValsartan/hydrochlorothiazide in the past 120 days

• ELIDEL Prior prescription for a Topical Anti-inflammatory Steroidal in the past 120 days• ENABLEX Prior prescription for Oxybutynin Chloride in the past 120 days• ENSTILAR Prior prescription for a Topical Anti-inflammatory Steroidal in the past 120 days• EPIDUO Prior prescription for Adapalene in the past 120 days• EPIDUO FORTE Prior prescription for Adapalene in the past 120 days• EXFORGE Prior prescription for Amlodipine Besylate/benazepril,

Amlodipine/valsartan/hcthiazid, Benazepril HCL, Benazepril/hydrochlorothiazide,Captopril, Captopril/hydrochlorothiazide, Enalapril Maleate,Enalapril/hydrochlorothiazide, Epaned, Fosinopril Sodium,Fosinopril/hydrochlorothiazide, Irbesartan, Irbesartan/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, Trandolapril/verapamil HCL, orValsartan/hydrochlorothiazide in the past 365 days

• EXFORGE HCT Prior prescription for Amlodipine Besylate/benazepril, AmlodipineBesylate/valsartan, Benazepril HCL, Benazepril/hydrochlorothiazide. Captopril,Captopril/hydrochlorothiazide, Enalapril Maleate, Enalapril/hydrochlorothiazide,Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazide, Irbesartan,Irbesartan/hydrochlorothiazide, Lisinopril, Lisinopril/hydrochlorothiazide, LosartanPotassium, Losartan/hydrochlorothiazide, Moexipril HCL,Moexipril/hydrochlorothiazide, Perindopril Erbumine, Qbrelis, Quinapril HCL,Quinapril/hydrochlorothiazide, Ramipril, Trandolapril. Trandolapril/verapamil HCL,or Valsartan/hydrochlorothiazide in the past 365 days

• FARXIGA Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, PioglitazoneHCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• FAZACLO At least 2 prior prescriptions for Olanzapine, Quetiapine Fumarate, Risperidone,Seroquel XR, or Ziprasidone HCL in the past 365 days

• FELBATOL (400 MG) (TABLET) Prior prescription for Lamictal, Lamictal XR, Lamotrigine, Topiramate, or TrokendiXR in the past 120 days

• FELBATOL (600 MG) (TABLET) Prior prescription for Lamictal, Lamictal XR, Lamotrigine, Topiramate, or TrokendiXR in the past 120 days

• FELBATOL (600 MG/5ML) (ORAL SUSP)Prior prescription for Lamictal, Lamictal XR, Lamotrigine, Topiramate, or TrokendiXR in the past 120 days



• FETZIMA At least 2 prior prescriptions for Bupropion HCL, Citalopram Hydrobromide,Escitalopram Oxalate, Fluoxetine HCL, Forfivo XL, Mirtazapine, Paroxetine HCL,Paxil, Sarafem, Sertraline HCL, or Venlafaxine HCL in the past 365 days

• FLOVENT DISKUS (100 MCG) (BLSTW/DEV)

Prior prescription for Asmanex HFA, Asmanex, Qvar Redihaler, or Qvar in the past365 days





• FLOVENT HFA (110 MCG) (AERW/ADAP)






• FORTAMET Prior prescription for Metformin HCL in the past 120 days• FROVA Prior prescription for Rizatriptan Benzoate or Sumatriptan Succinate in the past 180

days• FUZEON Prior prescription for Antiretrovirals in the past 120 days• FYCOMPA (0.5 MG/ML) (ORAL SUSP) At least 2 prior prescriptions for Carbamazepine, Divalproex Sodium, Equetro,

Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine, Levetiracetam,Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, ValproicAcid, or Zonisamide in the past 365 days

• FYCOMPA (10 MG) (TABLET) At least 2 prior prescriptions for Carbamazepine, Divalproex Sodium, Equetro,Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine, Levetiracetam,Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, ValproicAcid, or Zonisamide in the past 365 days






• GABITRIL (12 MG) (TABLET) At least 2 prior prescriptions for Carbamazepine, Divalproex Sodium, Equetro,Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine, Levetiracetam,Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, ValproicAcid, or Zonisamide in the past 365 days






• GELNIQUE (10 %) (GEL PACKET) Prior prescription for Oxybutynin Chloride in the past 120 days• GELNIQUE (100 MG/G) (GEL MD PMP) Prior prescription for Oxybutynin Chloride in the past 120 days• GLYXAMBI Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,


• GONAL-F Prior prescription for Follistim AQ in the past 120 days• GONAL-F RFF Prior prescription for Follistim AQ in the past 120 days• GONAL-F RFF REDI-JECT Prior prescription for Follistim AQ in the past 120 days• IMITREX (6 MG/0.5ML) (PEN INJCTR)

• INCRUSE ELLIPTA Prior prescription for Spiriva Respimat or Spiriva in the past 120 days• INVEGA (1.5 MG) (TAB ER 24) At least 2 prior prescriptions for Abilify Maintena, Abilify, Aripiprazole, Clozapine,

Olanzapine, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz, orZiprasidone HCL in the past 365 days

• INVEGA (3 MG) (TAB ER 24) At least 2 prior prescriptions for Abilify Maintena, Abilify, Aripiprazole, Clozapine,Olanzapine, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz, orZiprasidone HCL in the past 365 days



• INVIRASE (200 MG) (CAPSULE) Prior prescription for Atazanavir Sulfate, Atripla, Efavirenz, Isentress HD, Isentress,Prezista, Reyataz, or Sustiva in the past 120 days

• INVIRASE (500 MG) (TABLET) Prior prescription for Atazanavir Sulfate, Atripla, Efavirenz, Isentress HD, Isentress,Prezista, Reyataz, or Sustiva in the past 120 days

• INVOKAMET Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, PioglitazoneHCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• INVOKAMET XR Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, PioglitazoneHCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• INVOKANA Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, PioglitazoneHCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• JALYN Prior prescription for Alfuzosin HCL, Doxazosin Mesylate, Finasteride, PrazosinHCL, Rapaflo, Tamsulosin HCL, or Terazosin HCL in the past 120 days

• JARDIANCE Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, PioglitazoneHCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• KYTRIL (1 MG) (TABLET) Prior prescription for Ondansetron HCL or Ondansetron in the past 120 days• LAMICTAL ODT (100 MG) (TABRAPDIS) Prior prescription for Lamotrigine in the past 120 days• LAMICTAL ODT (200 MG) (TABRAPDIS) Prior prescription for Lamotrigine in the past 120 days• LAMICTAL ODT (25 MG) (TAB RAPDIS)Prior prescription for Lamotrigine in the past 120 days• LAMICTAL ODT (50 MG) (TAB RAPDIS)Prior prescription for Lamotrigine in the past 120 days• LAMICTAL ODT (BLUE) Prior prescription for Lamotrigine in the past 120 days



• LAMICTAL ODT (GREEN) Prior prescription for Lamotrigine in the past 120 days• LAMICTAL ODT (ORANGE) Prior prescription for Lamotrigine in the past 120 days• LAMICTAL XR (100 MG) (TAB ER 24) Prior prescription for Lamotrigine in the past 120 days• LAMICTAL XR (200 MG) (TAB ER 24) Prior prescription for Lamotrigine in the past 120 days• LAMICTAL XR (25 MG) (TAB ER 24) Prior prescription for Lamotrigine in the past 120 days• LAMICTAL XR (250 MG) (TAB ER 24) Prior prescription for Lamotrigine in the past 120 days• LAMICTAL XR (300 MG) (TAB ER 24) Prior prescription for Lamotrigine in the past 120 days• LAMICTAL XR (50 MG) (TAB ER 24) Prior prescription for Lamotrigine in the past 120 days• LATUDA (120 MG) (TABLET) At least 2 prior prescriptions for Abilify Maintena, Abilify, Aripiprazole, Clozapine,

Olanzapine, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz, orZiprasidone HCL in the past 365 days

• LATUDA (20 MG) (TABLET) At least 2 prior prescriptions for Abilify Maintena, Abilify, Aripiprazole, Clozapine,Olanzapine, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz, orZiprasidone HCL in the past 365 days




• LESCOL At least 2 pror prescriptions for Altoprev, Atorvastatin Calcium, Flolipid, Lovastatin,Pravastatin Sodium, or Simvastatin in the past 365 days

• LIDOCAINE (5 %) (OINT. (G)) Prior prescription for Lidocaine HCL in the past 120 days• LIPOFEN (150 MG) (CAPSULE) Prior prescription for Antara, Fenofibrate Nanocrystallized, Fenofibrate, Fenofibrate

micronized, Gemfibrozil, or Triglide in the past 120 days• LIPOFEN (50 MG) (CAPSULE) Prior prescription for Antara, Fenofibrate Nanocrystallized, Fenofibrate, Fenofibrate

micronized, Gemfibrozil, or Triglide in the past 120 days• LO LOESTRIN FE At least 2 prior prescriptions for Desog-e.estradiol/e.estradiol, Desogestrel-ethinyl

Estradiol, Ethinyl Estradiol/drospirenone, Ethynodiol D-ethinyl Estradiol, L-norgest/e.estradiol-e.estrad, Levonorgestrel, Levonorgestrel-ethin Estradiol,Norelgestromin/ethin.estradiol, Noreth-ethinyl Estradiol/iron, Norethindrone Ac-ethEstradiol, Norethindrone, Norethindrone-e.estradiol-iron, Norethindrone-ethinylEstrad, Norethindrone-mestranol, Norgestimate-ethinyl Estradiol, Norgestrel-ethinylEstradiol, or Nuvaring in the past 365 days

• MARINOL Prior prescription for Anzemet, Aprepitant, Dexamethasone Intensol,Dexamethasone, Dexpak, Granisetron HCL, Locort, Maxidex, Medrol,Methylprednisolone, Ondansetron HCL, Ondansetron, Ozurdex, Sancuso, Sustol,Zodex, Zonacort, or Zuplenz in the past 120 days

• METHADONE HCL (10 MG/5 ML)(SOLUTION) Prior prescription for an extended-release opioid in the past 120 days• METHADONE HCL (5 MG/5 ML)(SOLUTION) Prior prescription for an extended-release opioid in the past 120 days• MIRAPEX ER Prior prescription for Pramipexole Di-HCL or Ropinirole HCL in the past 120 days• MONDOXYNE NL (75 MG) (CAPSULE) Prior prescription for Doxycycline Monohydrate in the past 120 days• MONODOX (75 MG) (CAPSULE) Prior prescription for Doxycycline Monohydrate in the past 120 days• MYDAYIS Prior prescription for Dextroamphetamine/amphetamine or Mydayis in the past 120

days• MYRBETRIQ Prior prescription for Oxybutynin Chloride in the past 120 days• NAMZARIC (14MG-10MG) (CAP SPR24)

At least 2 prior prescriptions for Donepezil HCL, Memantine HCL, or Namenda XRin the past 365 days

• NAMZARIC (21 MG-10MG) (CAP SPR24)


• NAMZARIC (28 MG-10MG) (CAP SPR24)


• NAMZARIC (7 MG-10 MG) (CAP SPR24)


• NAMZARIC (7-10/14-10) (CAP24 DSPK) At least 2 prior prescriptions for Donepezil HCL, Memantine HCL, or Namenda XRin the past 365 days



• NATAZIA At least 2 prior prescriptions for Desog-e.estradiol/e.estradiol, Desogestrel-ethinylEstradiol, Ethinyl Estradiol/drospirenone, Ethynodiol D-ethinyl Estradiol, L-norgest/e.estradiol-e.estrad, Levonorgestrel, Levonorgestrel-ethin Estradiol,Norelgestromin/ethin.estradiol, Noreth-ethinyl Estradiol/iron, Norethindrone Ac-ethEstradiol, Norethindrone, Norethindrone-e.estradiol-iron, Norethindrone-ethinylEstrad, Norethindrone-mestranol, Norgestimate-ethinyl Estradiol, Norgestrel-ethinylEstradiol, or Nuvaring in the past 365 days

• NEO-SYNALAR At least 2 prior prescriptions for Bacitracin Zinc, Bacitracin, Capex Shampoo,Fluocinolone Acetonide, Iluvien, or Retisert in the past 365 days

• NEXIUM (10 MG) (SUSPDR PKT) Prior prescription for Lansoprazole, Omeprazole, Pantoprazole Sodium, PrilosecOTC, or Protonix in the past 120 days

• NEXIUM (2.5 MG) (SUSPDR PKT) Prior prescription for Lansoprazole, Omeprazole, Pantoprazole Sodium, PrilosecOTC, or Protonix in the past 120 days

• NEXIUM (20 MG) (CAPSULE DR) Prior prescription for Lansoprazole, Omeprazole, Pantoprazole Sodium, PrilosecOTC, or Protonix in the past 120 days


• NEXIUM (40 MG) (CAPSULE DR) Prior prescription for Lansoprazole, Omeprazole, Pantoprazole Sodium, PrilosecOTC, or Protonix in the past 120 days



• OMEPPI Prior prescription for Lansoprazole, Omeprazole, Pantoprazole Sodium, Prevacid,Prilosec OTC, or Protonix in the past 120 days

• OMNARIS At least 2 prior prescriptions for Budesonide, Flunisolide, Fluticasone Propionate,Mometasone Furoate, or Qnasl in the past 365 days

• ONEXTON Prior prescription for Clindamycin Phos/benzoyl Perox in the past 120 days• ONFI (10 MG) (TABLET) Prior prescription for Lamictal, Lamictal XR, Lamotrigine, Topiramate, or Trokendi

XR in the past 120 days• ONFI (2.5 MG/ML) (ORAL SUSP) Prior prescription for Lamictal, Lamictal XR, Lamotrigine, Topiramate, or Trokendi

XR in the past 120 days• ONFI (20 MG) (TABLET) Prior prescription for Lamictal, Lamictal XR, Lamotrigine, Topiramate, or Trokendi

XR in the past 120 days• ORACEA (40 MG) (CAP IR DR) Prior prescription for Doxycycline Monohydrate in the past 120 days• ORBIVAN CF Prior prescription for Butalbital/acetaminophen in the past 120 days• OTREXUP Prior prescription for Methotrexate Sodium, Methotrexate Sodium/pf, Rheumatrex,

or Trexall in the past 120 days• PAZEO Prior prescription for Olopatadine HCL in the past 120 days• PULMICORT FLEXHALER At least 2 prior prescriptions for Asmanex HFA, Asmanex, Qvar Redihaler, or Qvar

in the past 365 days• PURIXAN Prior prescription for Mercaptopurine in the past 120 days• QUDEXY XR (100 MG) (CAP SPR 24) Prior prescription for Topiramate in the past 120 days• QUDEXY XR (150 MG) (CAP SPR 24) Prior prescription for Topiramate in the past 120 days• QUDEXY XR (200 MG) (CAP SPR 24) Prior prescription for Topiramate in the past 120 days• QUDEXY XR (25 MG) (CAP SPR 24) Prior prescription for Topiramate in the past 120 days• QUDEXY XR (50 MG) (CAP SPR 24) Prior prescription for Topiramate in the past 120 days• QUILLICHEW ER (20 MG) (TABCBP24H) Prior prescription for Methylphenidate HCL or Ritalin LA in the past 102 days• QUILLICHEW ER (30 MG) (TABCBP24H) Prior prescription for Methylphenidate HCL or Ritalin LA in the past 102 days• QUILLICHEW ER (40 MG) (TABCBP24H) Prior prescription for Methylphenidate HCL or Ritalin LA in the past 102 days• QUILLIVANT XR (5 MG/ML) (SU ERRC24) Prior prescription for Methylphenidate HCL or Ritalin LA in the past 102 days• RAPAFLO Prior prescription for Alfuzosin HCL, Doxazosin Mesylate, Finasteride, Prazosin

HCL, Rapaflo, Tamsulosin HCL, or Terazosin HCL in the past 120 days• RASUVO (10MG/0.2ML) (AUTO INJCT) Prior prescription for Methotrexate Sodium, Methotrexate Sodium/pf, Rheumatrex,

or Trexall in the past 120 days• RASUVO (12.5/0.25) (AUTO INJCT) Prior prescription for Methotrexate Sodium, Methotrexate Sodium/pf, Rheumatrex,

or Trexall in the past 120 days



• RASUVO (15MG/0.3ML) (AUTO INJCT) Prior prescription for Methotrexate Sodium, Methotrexate Sodium/pf, Rheumatrex,or Trexall in the past 120 days

• RASUVO (17.5/0.35) (AUTO INJCT) Prior prescription for Methotrexate Sodium, Methotrexate Sodium/pf, Rheumatrex,or Trexall in the past 120 days




• RASUVO (7.5MG/0.15) (AUTO INJCT) Prior prescription for Methotrexate Sodium, Methotrexate Sodium/pf, Rheumatrex,or Trexall in the past 120 days

• RELPAX Prior prescription for Rizatriptan Benzoate or Sumatriptan Succinate in the past 180days

• REQUIP XL Prior prescription for Pramipexole Di-HCL or Ropinirole HCL in the past 120 days• RETIN-A MICRO PUMP (0.06 %) (GELW/PUMP)

Prior prescription for generic Tretinoin Microspheres 0.04% and 0.10% in the past120 days

• RIBAVIRIN (200-400(7)) (TAB DS PK) Prior prescription for Ribavirin in the past 120 days• SAFYRAL At least 2 prior prescriptions for Desog-e.estradiol/e.estradiol, Desogestrel-ethinyl

Estradiol, Ella, Ethynodiol D-ethinyl Estradiol, Kyleena, L-norgest/e.estradiol-e.estrad, Levonorgestrel, Levonorgestrel-ethin Estradiol, Liletta, Lo Loestrin Fe, LoMinastrin Fe, Mirena, Natazia, Noreth-ethinyl Estradiol/iron, Norethindrone Ac-ethEstradiol, Norethindrone, Norethindrone-e.estradiol-iron, Norethindrone-ethinylEstrad, Norethindrone-mestranol, Norgestimate-ethinyl Estradiol, Norgestrel-ethinylEstradiol, Skyla, or Taytulla in the past 365 days

• SANCTURA Prior prescription for Oxybutynin Chloride in the past 120 days• SANCTURA XR Prior prescription for Oxybutynin Chloride in the past 120 days• SANCUSO Prior prescription for Ondansetron HCL or Ondansetron in the past 120 days• SOLIQUA 100-33 At least 2 prior prescriptions for Bydureon Bcise, Bydureon Pen, Bydureon, Byetta,

Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glyburide, Glyburide micronized,Lantus Solostar, Lantus, Metformin HCL, Pioglitazone HCL, Riomet, Tolazamide,Tolbutamide, Toujeo Solostar, or Trulicity in the past 365 days

• SOLODYN (105 MG) (TAB ER 24H) Prior prescription for Minocycline HCL in the past 120 days• SOLODYN (115MG) (TAB ER 24H) Prior prescription for Minocycline HCL in the past 120 days• SOLODYN (135 MG) (TAB ER 24H) Prior prescription for Minocycline HCL in the past 120 days• SOLODYN (45 MG) (TAB ER 24H) Prior prescription for Minocycline HCL in the past 120 days• SOLODYN (55 MG) (TAB ER 24H) Prior prescription for Minocycline HCL in the past 120 days• SOLODYN (65 MG) (TAB ER 24H) Prior prescription for Minocycline HCL in the past 120 days• SOLODYN (80 MG) (TAB ER 24H) Prior prescription for Minocycline HCL in the past 120 days• SOLODYN (90 MG) (TAB ER 24H) Prior prescription for Minocycline HCL in the past 120 days• SOMA Prior prescription for Metaxalone and Tizanidine HCL in the past 120 days• SOOLANTRA Prior prescription for Finacea in the past 120 days• SOTYLIZE (5 MG/ML) (SOLUTION) Prior prescription for Sotalol HCL in the past 120 days• SYNDROS Prior prescription for Dronabinol in the past 120 days• SYNJARDY Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,


• SYNJARDY XR (10-1000 MG) (TAB BP24H)

Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, PioglitazoneHCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• SYNJARDY XR (12.5-1000) (TAB BP24H)


• SYNJARDY XR (25-1000 MG) (TAB BP24H)

Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, Pioglitazone



HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• SYNJARDY XR (5MG-1000MG) (TAB BP24H)


• TACLONEX (0.005-.064) (OINT. (G)) Prior prescription for a Topical Anti-inflammatory Steroidal in the past 120 days• TASMAR Prior prescription for Entacapone in the past 120 days• TOVIAZ Prior prescription for Oxybutynin Chloride in the past 120 days• TRELEGY ELLIPTA Prior prescription for Anoro Ellipta or Stiolto Respimat in the past 120 days• TRIBENZOR Prior prescription for Amlodipine Bes/olmesartan Med, Amlodipine

Besylate/benazepril, Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,Captopril/hydrochlorothiazide, Enalapril Maleate, Enalapril/hydrochlorothiazide,Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazide, Irbesartan,Irbesartan/hydrochlorothiazide, Lisinopril, Lisinopril/hydrochlorothiazide, LosartanPotassium, Losartan/hydrochlorothiazide, Moexipril HCL,Moexipril/hydrochlorothiazide, Olmesartan Medoxomil,Olmesartan/hydrochlorothiazide, Perindopril Erbumine, Qbrelis, Quinapril HCL,Quinapril/hydrochlorothiazide, Ramipril, Trandolapril, Trandolapril/verapamil HCL,or Valsartan/hydrochlorothiazide in the past 120 days

• TRULICITY Prior prescription for Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride,Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized,Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, PioglitazoneHCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, orTolbutamide in the past 120 days

• UCERIS Prior prescription for Balsalazide Disodium in the past 120 days• ULORIC Prior prescription for Allopurinol in the past 120 days• VECTICAL Prior prescription for a Topical Anti-inflammatory Steroidal in the past 120 days• VESICARE Prior prescription for Oxybutynin Chloride in the past 120 days• VIIBRYD At least 2 prior prescriptions for Bupropion HCL, Citalopram Hydrobromide,

Escitalopram Oxalate, Fluoxetine HCL, Forfivo XL, Mirtazapine, Paroxetine HCL,Paxil, Sarafem, Sertraline HCL, or Venlafaxine HCL in the past 365 days

• VIMPAT (10 MG/ML) (SOLUTION) At least 2 prior prescriptions for Carbamazepine, Divalproex Sodium, Equetro,Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine, Levetiracetam,Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, ValproicAcid, or Zonisamide in the past 365 days

• VIMPAT (100 MG) (TABLET) At least 2 prior prescriptions for Carbamazepine, Divalproex Sodium, Equetro,Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, Lamotrigine, Levetiracetam,Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, ValproicAcid, or Zonisamide in the past 365 days




• VYTORIN (10 MG-80MG) (TABLET) Prior prescription for Simvastatin in the past 365 days• VYVANSE Prior prescription for Aptensio XR, Citalopram Hydrobromide,

Dextroamphetamine/amphetamine, Escitalopram Oxalate, Fluoxetine HCL,Fluvoxamine Maleate, Methylphenidate HCL, Mydayis, Paroxetine HCL, Paxil,Quillichew ER, Quillivant XR, Ritalin LA, Sarafem, Sertraline HCL, Topiramate, orTrokendi XR in the past 120 days

• XATMEP Prior prescription for Methotrexate Sodium, Methotrexate Sodium/pf, or Trexall inthe past 120 days

• XHANCE Prior prescription for Mometasone Furoate in the past 365 days



• XIGDUO XR (10-1000 MG) (TAB BP24H)


• XIGDUO XR (10MG-500MG) (TAB BP24H)


• XIGDUO XR (2.5-1000MG) (TAB BP24H)


• XIGDUO XR (5 MG-500MG) (TAB BP24H)


• XIGDUO XR (5MG-1000MG) (TAB BP24H)


• XULTOPHY 100-3.6 At least 2 prior prescriptions for Bydureon Bcise, Bydureon Pen, Bydureon, Byetta,Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glyburide, Glyburide micronized,Lantus Solostar, Lantus, Metformin HCL, Pioglitazone HCL, Riomet, Tolazamide,Tolbutamide, Toujeo Solostar, or Trulicity in the past 365 days

• YASMIN 28 At least 2 prior prescriptions for Desog-e.estradiol/e.estradiol, Desogestrel-ethinylEstradiol, Ethinyl Estradiol/drospirenone, Ethynodiol D-ethinyl Estradiol, L-norgest/e.estradiol-e.estrad, Levonorgestrel-ethin Estradiol, Lo Loestrin Fe, Noreth-ethinyl Estradiol/iron, Norethindrone Ac-eth Estradiol, Norethindrone,Norethindrone-e.estradiol-iron, Norethindrone-ethinyl Estrad, Norethindrone-mestranol, Norgestimate-ethinyl Estradiol, or Norgestrel-ethinyl Estradiol in the past365 days

• YAZ At least 2 prior prescriptions for Desog-e.estradiol/e.estradiol, Desogestrel-ethinylEstradiol, Ethinyl Estradiol/drospirenone, Ethynodiol D-ethinyl Estradiol, L-norgest/e.estradiol-e.estrad, Levonorgestrel-ethin Estradiol, Lo Loestrin Fe, Noreth-ethinyl Estradiol/iron, Norethindrone Ac-eth Estradiol, Norethindrone,Norethindrone-e.estradiol-iron, Norethindrone-ethinyl Estrad, Norethindrone-mestranol, Norgestimate-ethinyl Estradiol, or Norgestrel-ethinyl Estradiol in the past365 days

• ZEGERID Prior prescription for Lansoprazole, Omeprazole, Pantoprazole Sodium, Prevacid,Prilosec OTC, or Protonix in the past 120 days

• ZOCOR (80 MG) (TABLET) Prior prescription for Ezetimibe/simvastatin in the past 365 days• ZOMIG (2.5 MG) (SPRAY) Prior prescription for Rizatriptan Benzoate or Sumatriptan Succinate in the past 180

days• ZOMIG (2.5 MG) (TABLET) Prior prescription for Rizatriptan Benzoate or Sumatriptan Succinate in the past 180

days• ZOMIG (5 MG) (SPRAY) Prior prescription for Rizatriptan Benzoate or Sumatriptan Succinate in the past 180

days• ZOMIG (5 MG) (TABLET) Prior prescription for Rizatriptan Benzoate or Sumatriptan Succinate in the past 180

days• ZOMIG ZMT Prior prescription for Rizatriptan Benzoate or Sumatriptan Succinate in the past 180

days



- A -ABACAVIR SULFATE/LAMIVUDINE...........................55ABACAVIR/DOLUTEGRAVIR/LAMIVUDI.................. 57ABACAVIR/LAMIVUDINE/ZIDOVUDINE...................55ABALOPARATIDE...........................................................35ABATACEPT.....................................................................59ABEMACICLIB................................................................66ABILIFY (1 MG/ML) (SOLUTION)............................8, 87ABILIFY (10 MG) (TABLET)............................................8ABILIFY (15 MG) (TABLET)............................................8ABILIFY (2 MG) (TABLET)..............................................8ABILIFY (20 MG) (TABLET)............................................8ABILIFY (30 MG) (TABLET)............................................8ABILIFY (5 MG) (TABLET)..............................................8ABILIFY DISCMELT (10 MG) (TAB RAPDIS)......... 8, 87ABILIFY DISCMELT (15 MG) (TAB RAPDIS)......... 8, 87ABILIFY MAINTENA....................................................... 8ABIRATERONE ACETATE............................................. 65ABRAXANE..................................................................... 68ABSORICA................................................................. 23, 87ACALABRUTINIB........................................................... 66ACAMPROSATE CALCIUM.............................................7ACANYA.....................................................................23, 87ACARBOSE...................................................................... 30ACCOLATE.........................................................................4ACCUPRIL........................................................................14ACCURETIC.....................................................................13ACD................................................................................... 42ACEBUTOLOL HCL........................................................14ACEON..............................................................................14ACETAMINOPHEN WITH CODEINE........................... 77ACETAZOLAMIDE..........................................................39ACETIC ACID............................................................ 27, 33ACETOHYDROXAMIC ACID........................................ 62ACETYLCYSTEINE.................................................. 71, 73ACETYLCYSTEINE IN WATER/PF............................... 40ACIPHEX.......................................................................... 83ACITRETIN...................................................................... 29ACLIDINIUM BROMIDE.................................................. 2ACLOVATE....................................................................... 25ACTEMRA........................................................................60ACTICLATE................................................................51, 87ACTIGALL....................................................................... 62ACTIMMUNE...................................................................49ACTIQ (1200 MCG) (LOZENGE HD).............................74ACTIQ (1600 MCG) (LOZENGE HD).............................74ACTIQ (200 MCG) (LOZENGE HD)...............................74ACTIQ (400 MCG) (LOZENGE HD)...............................74ACTIQ (600 MCG) (LOZENGE HD)...............................74ACTIQ (800 MCG) (LOZENGE HD)...............................74ACTIVELLA..................................................................... 45ACTONEL (150 MG) (TABLET)............................... 36, 87ACTONEL (30 MG) (TABLET)................................. 36, 87ACTONEL (35 MG) (TABLET)................................. 36, 87ACTONEL (5 MG) (TABLET)................................... 36, 87ACTOPLUS MET....................................................... 32, 87ACTOS.............................................................................. 31ACUICYN......................................................................... 39ACULAR........................................................................... 38ACULAR LS..................................................................... 38ACYCLOVIR.............................................................. 24, 54ACZONE (5 %) (GEL (GRAM))...................................... 23ADACEL TDAP................................................................ 48ADAGEN...........................................................................71ADALAT CC..................................................................... 16ADALIMUMAB......................................................... 58, 59ADAPALENE....................................................................23ADAPALENE/BENZOYL PEROXIDE............................23ADASUVE.......................................................................... 9ADCETRIS........................................................................68ADCIRCA......................................................................... 17ADDERALL........................................................................7ADDERALL XR (10 MG) (CAP ER 24H).........................7ADDERALL XR (15 MG) (CAP ER 24H).........................7ADDERALL XR (20 MG) (CAP ER 24H).........................7ADDERALL XR (25 MG) (CAP ER 24H).........................7ADDERALL XR (30 MG) (CAP ER 24H).........................7ADDERALL XR (5 MG) (CAP ER 24H)...........................7ADDYI...............................................................................10ADEFOVIR DIPIVOXIL.................................................. 58ADEMPAS.........................................................................16ADENOVIRUS LIVE TYPES-4,7 VACC.........................48ADENOVIRUS TYPE 4....................................................48ADENOVIRUS TYPE 4 AND TYPE 7............................ 48ADENOVIRUS TYPE 7....................................................48ADENOVIRUS VACCINE LIVE TYPE-4....................... 48ADENOVIRUS VACCINE LIVE TYPE-7....................... 48ADO-TRASTUZUMAB EMTANSINE............................68ADOXA............................................................................. 52ADRENACLICK...............................................................64ADRENALIN CHLORIDE...............................................23

ADVAIR DISKUS............................................................... 3ADVAIR HFA......................................................................3ADVATE (1000 (+/-)) (VIAL)...........................................41ADVATE (1500 (+/-)) (VIAL)...........................................41ADVATE (2000 (+/-)) (VIAL)...........................................41ADVATE (250 (+/-)) (VIAL).............................................41ADVATE (3000 (+/-)) (VIAL)...........................................41ADVATE (4000 (+/-)) (VIAL)...........................................41ADVATE (500 (+/-)) (VIAL).............................................41ADYNOVATE (1000 (+/-)) (VIAL).................................. 41ADYNOVATE (1500 (+/-)) (VIAL).................................. 41ADYNOVATE (2000 (+/-)) (VIAL).................................. 41ADYNOVATE (250 (+/-)) (VIAL).................................... 41ADYNOVATE (3000 (+/-)) (VIAL).................................. 41ADYNOVATE (500 (+/-)) (VIAL).................................... 41ADYNOVATE (750 (+/-)) (VIAL).................................... 41ADZENYS ER.....................................................................7ADZENYS XR-ODT...........................................................7AEROGEAR ASTHMA ACTION KIT.............................. 4AFATINIB DIMALEATE................................................. 66AFINITOR (10 MG) (TABLET)....................................... 66AFINITOR (2.5 MG) (TABLET)...................................... 66AFINITOR (5 MG) (TABLET)......................................... 66AFINITOR (7.5 MG) (TABLET)...................................... 66AFINITOR DISPERZ....................................................... 66AFLURIA 2017-2018........................................................47AFLURIA QUAD 2017-2018........................................... 47AFSTYLA (1000 (+/-)) (VIAL)........................................ 40AFSTYLA (1500 (+/-)) (VIAL)........................................ 40AFSTYLA (2000 (+/-)) (VIAL)........................................ 40AFSTYLA (250 (+/-)) (VIAL).......................................... 40AFSTYLA (2500 (+/-)) (VIAL)........................................ 41AFSTYLA (3000 (+/-)) (VIAL)........................................ 41AFSTYLA (500 (+/-)) (VIAL).......................................... 41AGALSIDASE BETA....................................................... 71AGGRENOX..................................................................... 44AGRYLIN..........................................................................44AIRDUO RESPICLICK......................................................3AKTEN..............................................................................38AKYNZEO.......................................................................... 2ALBENDAZOLE.............................................................. 54ALBENZA.........................................................................54ALBUTEROL SULFATE....................................................3ALCAFTADINE................................................................37ALCLOMETASONE DIPROPIONATE........................... 25ALDACTAZIDE (25 MG-25MG) (TABLET).................. 16ALDACTONE................................................................... 16ALDARA...........................................................................49ALDESLEUKIN................................................................49ALDOMET........................................................................14ALDORIL 15.....................................................................14ALDORIL 25.....................................................................14ALDURAZYME............................................................... 71ALECENSA...................................................................... 66ALECTINIB HCL............................................................. 66ALEMTUZUMAB...................................................... 68, 69ALENDRONATE SODIUM............................................. 35ALEVICYN PLUS............................................................ 27ALFERON N..................................................................... 49ALFUZOSIN HCL............................................................ 83ALGLUCOSIDASE ALFA............................................... 71ALIMTA............................................................................ 65ALINIA..............................................................................54ALIQOPA.......................................................................... 67ALIROCUMAB.................................................................19ALISKIREN HEMIFUMARATE..................................... 17ALISKIREN/HYDROCHLOROTHIAZIDE.................... 17ALITRETINOIN............................................................... 29ALKERAN........................................................................ 64ALLOPURINOL............................................................... 40ALLZITAL........................................................................ 73ALMOTRIPTAN MALATE.............................................. 76ALOGLIPTIN BENZ/PIOGLITAZONE.......................... 30ALORA..............................................................................45ALOSETRON HCL...........................................................62ALPHA-1-PROTEINASE INHIBITOR............................ 64ALPHAGAN..................................................................... 39ALPHAGAN P (0.1 %) (DROPS).....................................39ALPHAGAN P (0.15 %) (DROPS)...................................39ALPHANATE....................................................................41ALPHANINE SD.............................................................. 42ALPRAZOLAM.................................................................. 7ALPRAZOLAM INTENSOL...............................................ALPROLIX........................................................................42ALPROSTADIL.................................................................34ALREX.............................................................................. 38ALTACE............................................................................ 14ALTOPREV.......................................................................18ALTRETAMINE................................................................64ALUNBRIG.......................................................................67ALUPENT........................................................................... 3ALVIMOPAN.................................................................... 63

AMANTADINE HCL........................................................77AMARYL.......................................................................... 31AMBIEN............................................................................11AMBIEN CR..................................................................... 11AMBRISENTAN...............................................................17AMCINONIDE..................................................................25AMELUZ...........................................................................69AMERGE.......................................................................... 76AMETHYST......................................................................21AMICAR........................................................................... 40AMILORIDE HCL............................................................16AMILORIDE/HYDROCHLOROTHIAZIDE...................16AMINOACETIC ACID..................................................... 53AMINOCAPROIC ACID.................................................. 40AMINOLEVULINIC ACID HCL.....................................69AMINOSALICYLIC ACID.............................................. 53AMIODARONE HCL....................................................... 12AMITIZA.................................................................... 62, 87AMITRIPTYLINE HCL..................................................... 6AMITRIPTYLINE/CHLORDIAZEPOXIDE..................... 6AMLODIPINE BES/OLMESARTAN MED.................... 14AMLODIPINE BESYLATE............................................. 15AMLODIPINE BESYLATE/BENAZEPRIL.................... 13AMLODIPINE BESYLATE/VALSARTAN..................... 14AMLODIPINE/ATORVASTATIN.....................................20AMLODIPINE/VALSARTAN/HCTHIAZID................... 13AMMONIUM LACTATE..................................................27AMMONIUM LACTATE (12 %) (CREAM (G)).................AMMONIUM LACTATE (12 %) (LOTION).......................AMOXAPINE..................................................................... 6AMOXICILLIN.................................................................51AMOXICILLIN/POTASSIUM CLAV.............................. 51AMOXIL........................................................................... 51AMPHETAMINE................................................................ 7AMPHETAMINE SULFATE.............................................. 7AMPICILLIN.................................................................... 51AMPICILLIN TRIHYDRATE.......................................... 51AMPYRA.......................................................................... 70AMRIX.............................................................................. 81AMYL NITRITE............................................................... 20ANACAINE.......................................................................29ANAFRANIL...................................................................... 6ANAGRELIDE HCL.........................................................44ANA-LEX HC................................................................... 61ANALPRAM HC........................................................ 28, 61ANAMANTLE HC......................................................61, 62ANAMANTLE HC FORTE.............................................. 62ANAPROX........................................................................ 61ANAPROX DS.................................................................. 61ANASTIA..........................................................................29ANASTROZOLE.............................................................. 66ANCOBON........................................................................53ANDRODERM..................................................................45ANDROGEL (1.25G-1.62) (GEL PACKET).................... 45ANDROGEL (12.5/1.25G) (GEL MD PMP)....................45ANDROGEL (2.5G-1.62%) (GEL PACKET)...................45ANDROGEL (20.25/1.25) (GEL MD PMP).....................45ANDROGEL (25MG(1%)) (GEL PACKET)....................45ANDROGEL (50 MG (1%)) (GEL PACKET)..................45ANDROID......................................................................... 45ANORO ELLIPTA.............................................................. 3ANSAID............................................................................ 60ANTABUSE........................................................................ 7ANTARA (130 MG) (CAPSULE).................................... 19ANTARA (30 MG) (CAPSULE)...................................... 19ANTARA (43 MG) (CAPSULE)...................................... 19ANTARA (90 MG) (CAPSULE)...................................... 20ANTHRALIN.................................................................... 29ANTHRALIN MICRONIZED.......................................... 29ANTIHEM.FVIII,SIN-CHN,B-DM TRU................... 40, 41ANTIHEMO.FVIII,FULL LENGTH PEG....................... 41ANTIHEMOPH.FVIII,B-DOM TRUNCAT..................... 41ANTIHEMOPHIL.FVIII,FULL LENGTH....................... 41ANTIHEMOPHILIC FACTOR, HUMAN........................41ANTIHEMOPHILIC FACTOR/VWF...............................41ANTIHEMOPHILIC FVIII,REC PORC...........................41ANTI-INHIBITOR COAGULANT COMP.......................41ANTITHROMBIN III (PLASMA DER)...........................44ANTIVERT (12.5 MG) (TABLET).....................................2ANTIVERT (25 MG) (TABLET)........................................2ANUSOL-HC.................................................................... 62ANZEMET (100 MG) (TABLET)...................................... 2ANZEMET (50 MG) (TABLET)........................................ 2APEXICON....................................................................... 26APEXICON E....................................................................26APIXABAN.......................................................................42APLENZIN..........................................................................6APOKYN...........................................................................77APOMORPHINE HCL..................................................... 77APRACLONIDINE HCL.................................................. 39APREMILAST.................................................................. 59APREPITANT..................................................................... 2


Index

APRESOLINE (10 MG) (TABLET)................................. 14APRESOLINE (100 MG) (TABLET)............................... 14APRESOLINE (25 MG) (TABLET)................................. 14APRESOLINE (50 MG) (TABLET)................................. 14APRISO............................................................................. 61APTENSIO XR................................................................. 11APTIOM (200 MG) (TABLET)........................................ 78APTIOM (400 MG) (TABLET)........................................ 78APTIOM (600 MG) (TABLET)........................................ 78APTIOM (800 MG) (TABLET)........................................ 78APTIVUS.......................................................................... 55AQUA GLYCOLIC HC.....................................................27ARALAST NP...................................................................64ARAVA.............................................................................. 59ARCALYST.......................................................................58ARCAPTA NEOHALER.................................................... 3ARFORMOTEROL TARTRATE........................................ 3ARGATROBAN................................................................ 44ARICEPT.............................................................................5ARICEPT ODT................................................................... 5ARIMIDEX....................................................................... 66ARIPIPRAZOLE.................................................................8ARIPIPRAZOLE LAUROXIL............................................ 8ARISTADA (441 MG/1.6) (SUSER SYR)..........................8ARISTADA (662 MG/2.4) (SUSER SYR)..........................8ARISTADA (882 MG/3.2) (SUSER SYR)..........................8ARIXTRA (10MG/0.8ML) (SYRINGE).......................... 43ARIXTRA (2.5 MG/0.5) (SYRINGE).............................. 43ARIXTRA (5MG/0.4ML) (SYRINGE)............................ 43ARIXTRA (7.5MG/0.6) (SYRINGE)............................... 43ARMODAFINIL............................................................... 11ARMOUR THYROID.......................................................37ARNUITY ELLIPTA.................................................... 4, 87AROMASIN...................................................................... 66ARRANON........................................................................65ARSENIC TRIOXIDE...................................................... 68ARTANE............................................................................77ARTEMETHER/LUMEFANTRINE.................................54ARTHROTEC 50...............................................................60ARTHROTEC 75...............................................................60ARYMO ER.......................................................................75ARZERRA.........................................................................65ASENAPINE MALEATE....................................................9ASENDIN............................................................................6ASFOTASE ALFA............................................................ 71ASMANEX..........................................................................4ASMANEX HFA.................................................................4ASPARAGINASE (ERWINIA CHRYSAN).....................68ASPIRIN......................................................................44, 74ASPIRIN (325 MG) (TABLET DR) (OTC)..........................ASPIRIN (325 MG) (TABLET) (OTC).................................ASPIRIN/DIPYRIDAMOLE............................................ 44ASTELIN.............................................................................1ASTEPRO............................................................................1ASTERO............................................................................29ASTHMAPACK CHILDREN'S.......................................... 4ASTRINGYN.................................................................... 44ATACAND.........................................................................14ATACAND HCT................................................................13ATARAX............................................................................. 1ATAZANAVIR SULFATE.................................................57ATELVIA.....................................................................36, 87ATENOLOL...................................................................... 14ATENOLOL/CHLORTHALIDONE.................................15ATIVAN............................................................................... 8ATOMOXETINE HCL......................................................12ATOPICLAIR.................................................................... 27ATORVASTATIN CALCIUM..................................... 17, 18ATOVAQUONE.................................................................54ATOVAQUONE/PROGUANIL HCL................................54ATRALIN.......................................................................... 23ATRAPRO DERMAL SPRAY..........................................28ATRAPRO HYDROGEL.................................................. 27ATRIPLA...........................................................................57ATROPEN......................................................................... 72ATROPINE SULFATE................................................ 39, 72ATROPINE SULFATE/0.9 %SOD CHLR........................ 39ATROVENT...................................................................2, 71ATROVENT HFA................................................................2AUGMENTIN (125-31.25/) (SUSP RECON).................. 51AUGMENTIN (200-28.5/5) (SUSP RECON).................. 51AUGMENTIN (200-28.5MG) (TAB CHEW)...................51AUGMENTIN (250-125 MG) (TABLET)........................ 51AUGMENTIN (250-62.5/5) (SUSP RECON).................. 51AUGMENTIN (400-57MG) (TAB CHEW)......................51AUGMENTIN (400-57MG/5) (SUSP RECON)............... 51AUGMENTIN (500-125 MG) (TABLET)........................ 51AUGMENTIN (875-125 MG) (TABLET)........................ 51AUGMENTIN ES-600...................................................... 51AUGMENTIN XR.............................................................51AURANOFIN.................................................................... 60AURSTAT..........................................................................27

AUSTEDO.........................................................................70AVALIDE...........................................................................13AVAPRO............................................................................ 14AVAR (10-5%(W/W)) (CLEANSER)............................... 25AVAR LS (10 %-2 %) (CLEANSER)............................... 25AVAR-E............................................................................. 25AVAR-E GREEN...............................................................25AVAR-E LS........................................................................25AVASTIN...........................................................................65AVELOX............................................................................51AVELOX ABC PACK....................................................... 51AVELUMAB..................................................................... 69AVENOVA.........................................................................39AVIANE.............................................................................21AVIDOXY......................................................................... 52AVITENE...........................................................................44AVODART.........................................................................84AVONEX........................................................................... 69AVONEX PEN...................................................................69AXERT........................................................................ 76, 87AXICABTAGENE CILOLEUCEL...................................68AXID................................................................................. 83AXIRON............................................................................45AXITINIB..........................................................................66AYGESTIN........................................................................46AZACITIDINE..................................................................65AZASITE...........................................................................38AZATHIOPRINE.............................................................. 49AZELAIC ACID................................................................23AZELAS/FLUTICASONE/SOD CHLORID......................1AZELASTINE HCL......................................................1, 38AZELASTINE/FLUTICASONE........................................ 1AZELEX............................................................................23AZILECT...........................................................................78AZILSARTAN MED/CHLORTHALIDONE................... 13AZILSARTAN MEDOXOMIL......................................... 14AZITHROMYCIN.......................................................38, 50AZOPT.............................................................................. 39AZOR.......................................................................... 14, 87AZTREONAM LYSINE....................................................49AZULFIDINE....................................................................61

- B -BACITRACIN................................................................... 38BACITRACIN/POLYMYXIN B SULFATE..................... 38BACLOFEN...................................................................... 81BACTROBAN................................................................... 24BALSALAZIDE DISODIUM...........................................61BANZEL (200 MG) (TABLET)..................................80, 87BANZEL (40 MG/ML) (ORAL SUSP)...................... 80, 87BANZEL (400 MG) (TABLET)..................................80, 87BARACLUDE (0.05 MG/ML) (SOLUTION).................. 58BARACLUDE (0.5 MG) (TABLET)................................ 58BARACLUDE (1 MG) (TABLET)................................... 58BASAGLAR KWIKPEN U-100....................................... 33BASILIXIMAB................................................................. 49BAVENCIO....................................................................... 69BAXDELA (450 MG) (TABLET).....................................51BAYER CHEWABLE ASPIRIN....................................... 44BEBULIN.......................................................................... 42BECAPLERMIN............................................................... 32BECLOMETHASONE DIPROPIONATE...................... 1, 3BEDAQUILINE FUMARATE.......................................... 53BELATACEPT...................................................................49BELIMUMAB...................................................................60BELSOMRA......................................................................11BENADRYL (50 MG/ML) (SYRINGE).............................1BENADRYL (50 MG/ML) (VIAL).................................... 1BENAZEPRIL HCL.......................................................... 14BENAZEPRIL/HYDROCHLOROTHIAZIDE................. 13BENDAMUSTINE HCL...................................................64BENDEKA........................................................................ 64BENEFIX.......................................................................... 42BENEMID......................................................................... 40BENICAR....................................................................14, 87BENICAR HCT...........................................................13, 88BENLYSTA (120 MG) (VIAL).........................................60BENLYSTA (200 MG/ML) (AUTO INJCT).....................60BENLYSTA (200 MG/ML) (SYRINGE).......................... 60BENLYSTA (400 MG) (VIAL).........................................60BENOXINATE HCL/FLUORESCEIN SOD.................... 38BENRALIZUMAB..............................................................4BENZACLIN (1 %-5 %) (GEL (GRAM))........................ 23BENZAMYCIN.................................................................24BENZNIDAZOLE.............................................................54BENZOCAINE..................................................................29BENZONATATE............................................................... 22BENZOYL PEROXIDE.................................................... 28BENZOYL PEROXIDE (4 %) (GEL (GRAM))...................BENZOYL PEROXIDE (5.3%) (FOAM).............................BENZOYL PEROXIDE (6 %) (TOWELETTE)...................BENZOYL PEROXIDE (8 %) (GEL (GRAM))...................

BENZOYL PEROXIDE (9.8 %) (FOAM)............................BENZOYL PEROXIDE MICROSPHERES..................... 28BENZOYL PEROXIDE/HYDROCORTISON................. 23BENZOYL PEROXIDE/SULFUR....................................28BENZTROPINE MESYLATE.......................................... 77BEPOTASTINE BESILATE..............................................38BEPREVE..........................................................................38BERACTANT....................................................................73BERINERT........................................................................ 59BESIFLOXACIN HCL......................................................38BESIVANCE..................................................................... 38BESPONSA.......................................................................66BETADINE........................................................................38BETAGAN.........................................................................39BETAINE...........................................................................71BETALOAN SUIK............................................................59BETAMETHASON/NORFLURAN/PENTFLU...............59BETAMETHASONE DIPROPIONATE........................... 25BETAMETHASONE VALERATE................................... 25BETAMETHASONE/PROPYLENE GLYC..................... 25BETASERON (0.3 MG) (KIT)..........................................70BETASERON (0.3 MG) (VIAL)....................................... 70BETAXOLOL HCL.....................................................14, 39BETHANECHOL CHLORIDE.........................................64BETHKIS.......................................................................... 53BETIMOL..........................................................................39BETOPTIC........................................................................ 39BETRIXABAN MALEATE.............................................. 42BEVACIZUMAB...............................................................65BEVESPI AEROSPHERE.................................................. 3BEVYXXA........................................................................42BEXAROTENE........................................................... 29, 69BEXSERO......................................................................... 47BEYAZ........................................................................ 21, 88BIAFINE............................................................................27BIAXIN............................................................................. 50BIAXIN XL....................................................................... 50BICALUTAMIDE............................................................. 65BICNU...............................................................................64BILTRICIDE..................................................................... 54BIMATOPROST................................................................39BIO/CARB/EQUIS/ETHAN/CHIT/MSM........................ 28BISAC/NACL/NAHCO3/KCL/PEG 3350........................ 62BISMUTH/METRONID/TETRACYCLINE.................... 82BISOPROLOL FUMARATE............................................ 14BISOPROLOL/HYDROCHLOROTHIAZIDE.................15BLINATUMOMAB...........................................................68BLINCYTO (35 MCG) (KIT)........................................... 68BLINCYTO (35 MCG) (VIAL)........................................ 68BLOCADREN...................................................................15BLOOD GLUCOSE TEST STRIP (STRIP) (OTC)..........32BLOOD SUGAR DIAGNOSTIC......................................32BLOOD-GLUCOSE METER........................................... 32BLOOD-GLUCOSE METER,CONTINUOUS................ 32B-NEXA............................................................................ 86BONIVA (150 MG) (TABLET).........................................35BOOSTRIX TDAP............................................................ 48BORTEZOMIB............................................................66, 67BOSENTAN...................................................................... 17BOSULIF (100 MG) (TABLET).......................................67BOSULIF (400 MG) (TABLET).......................................67BOSULIF (500 MG) (TABLET).......................................67BOSUTINIB...................................................................... 67BOTOX..............................................................................72BP 10-1.............................................................................. 25BRENTUXIMAB VEDOTIN........................................... 68BREO ELLIPTA..................................................................3BRETHINE (2.5 MG) (TABLET).......................................3BRIGATINIB.....................................................................67BRILINTA......................................................................... 44BRIMONIDINE TARTRATE......................................23, 39BRIMONIDINE TARTRATE/TIMOLOL........................ 39BRINEURA.......................................................................70BRINZOLAMIDE.............................................................39BRINZOLAMIDE/BRIMONIDINE TART...................... 39BRISDELLE................................................................72, 88BROMFENAC SODIUM.................................................. 38BROMOCRIPTINE MESYLATE.....................................77BROMPHENIRAMINE/PSEUDOEPHED/DM............... 22BROMPHENIRAMINE/PSEUDOEPHED/DM (2-30-10/5)(SYRUP)................................................................................BROVANA...........................................................................3BUDESONIDE..........................................................3, 4, 59BUDESONIDE/FORMOTEROL FUMARATE................. 3BUMETANIDE................................................................. 16BUMEX (0.5 MG) (TABLET).......................................... 16BUMEX (1 MG) (TABLET)............................................. 16BUMEX (2 MG) (TABLET)............................................. 16BUPAP.........................................................................73, 88BUPHENYL (0.94 G/G) (POWDER)............................... 62BUPHENYL (500 MG) (TABLET).................................. 62BUPRENORPHINE.......................................................... 74


Index

BUPRENORPHINE HCL........................................... 74, 77BUPRENORPHINE HCL (2 MG) (TAB SUBL)..................BUPRENORPHINE HCL (8 MG) (TAB SUBL)..................BUPRENORPHINE HCL/NALOXONE HCL................. 77BUPROPION HBR..............................................................6BUPROPION HCL........................................................6, 81BUSPAR.............................................................................. 7BUSPIRONE HCL.............................................................. 7BUSULFAN.......................................................................64BUSULFEX.......................................................................64BUTALB/ACETAMINOPHEN/CAFFEINE.............. 73, 74BUTALBIT/ACETAMIN/CAFF/CODEINE.................... 77BUTALBITAL/ACETAMINOPHEN................................ 73BUTALBITAL/ASPIRIN/CAFFEINE.............................. 73BUTAPAP..........................................................................73BUTORPHANOL TARTRATE.........................................74BUTRANS.........................................................................74BUTYLATED HYDROXYTOLUENE.............................23BUTYLATED HYDROXYTOLUENE(BHT) (POWDER)...............................................................................................BYDUREON............................................................... 30, 88BYDUREON BCISE...................................................30, 88BYDUREON PEN.......................................................30, 88BYETTA......................................................................30, 88BYSTOLIC........................................................................15BYVALSON...................................................................... 13

- C -C1 ESTERASE INHIBITOR............................................ 59CABAZITAXEL................................................................68CABERGOLINE............................................................... 37CADEXOMER IODINE................................................... 23CADUET........................................................................... 20CAFCIT (60 MG/3 ML) (SOLUTION).............................. 4CAFERGOT...................................................................... 76CAFFEINE CITRATE.........................................................4CALAN (120 MG) (TABLET)..........................................16CALAN (40 MG) (TABLET)............................................16CALAN (80 MG) (TABLET)............................................16CALAN SR........................................................................16CALCIPOTRIENE............................................................ 30CALCIPOTRIENE/BETAMETHASONE........................ 30CALCITONIN,SALMON,SYNTHETIC..........................35CALCITRIOL..............................................................30, 86CALCIUM ACETATE.......................................................34CALCIUM CARB/MAG CARB/FOLIC AC....................34CALDOLOR......................................................................60CALFACTANT..................................................................73CALQUENCE................................................................... 66CAMPATH.........................................................................68CAMPRAL.......................................................................... 7CANAGLIFLOZIN........................................................... 30CANAGLIFLOZIN/METFORMIN HCL......................... 31CANAKINUMAB/PF....................................................... 59CANASA........................................................................... 61CANDESARTAN CILEXETIL.........................................14CANDESARTAN/HYDROCHLOROTHIAZID...............13CAPECITABINE...............................................................65CAPOTEN......................................................................... 14CAPOZIDE........................................................................13CAPRELSA (100 MG) (TABLET)................................... 68CAPRELSA (300 MG) (TABLET)................................... 68CAPTOPRIL......................................................................14CAPTOPRIL/HYDROCHLOROTHIAZIDE....................13CARAC (0.5 %) (CREAM (G))........................................ 29CARAFATE (1 G) (TABLET)...........................................82CARAFATE (1 G/10 ML) (ORAL SUSP)........................ 82CARBAGLU......................................................................62CARBAMAZEPINE......................................................... 78CARBATROL....................................................................78CARBIDOPA.....................................................................78CARBIDOPA/LEVODOPA.............................................. 78CARBIDOPA/LEVODOPA/ENTACAPONE................... 78CARBINOXAMINE MALEATE........................................1CARBIT/EQUIS XT/ETHAN/CHIT/MSM......................28CARDIZEM (120 MG) (TABLET)...................................15CARDIZEM (30 MG) (TABLET).....................................15CARDIZEM (60 MG) (TABLET).....................................15CARDIZEM (90 MG) (TABLET).....................................15CARDIZEM CD................................................................15CARDIZEM LA (180 MG) (TAB ER 24H)......................15CARDIZEM LA (240 MG) (TAB ER 24H)......................15CARDIZEM LA (300 MG) (TAB ER 24H)......................15CARDIZEM LA (360 MG) (TAB ER 24H)......................15CARDIZEM LA (420 MG) (TAB ER 24H)......................15CARDIZEM SR.................................................................15CARDURA........................................................................13CARFILZOMIB................................................................ 67CARGLUMIC ACID.........................................................62CARIPRAZINE HCL..........................................................8CARISOPRODOL.............................................................81CARMUSTINE................................................................. 64

CARNITOR.......................................................................71CARTEOLOL HCL...........................................................39CARVEDILOL.................................................................. 13CARVEDILOL PHOSPHATE.......................................... 13CASODEX........................................................................ 65CATAFLAM...................................................................... 60CATAPRES........................................................................14CATAPRES-TTS 1............................................................ 14CATAPRES-TTS 2............................................................ 14CATAPRES-TTS 3............................................................ 14CAVERJECT..................................................................... 34CAYA CONTOURED....................................................... 22CAYSTON.........................................................................49CECLOR............................................................................49CECLOR CD..................................................................... 49CEDAX..............................................................................50CEFACLOR.......................................................................49CEFADROXIL...................................................................49CEFDINIR.........................................................................50CEFDITOREN PIVOXIL..................................................50CEFIXIME........................................................................ 50CEFPODOXIME PROXETIL........................................... 50CEFPROZIL...................................................................... 49CEFTIBUTEN...................................................................50CEFTIN (250 MG) (TABLET)..........................................49CEFTIN (500 MG) (TABLET)..........................................49CEFUROXIME AXETIL.................................................. 49CEFZIL..............................................................................49CELACYN.........................................................................27CELEBREX.......................................................................60CELECOXIB..................................................................... 60CELEXA..............................................................................6CELLCEPT........................................................................49CELONTIN....................................................................... 80CENTANY.........................................................................24CEPHALEXIN.................................................................. 49CEPROTIN (1000 UNIT) (VIAL).....................................44CEPROTIN (500 UNIT) (VIAL).......................................44CERACADE......................................................................27CERAMAX....................................................................... 27CERDELGA...................................................................... 71CEREZYME......................................................................71CERITINIB........................................................................67CERLIPONASE ALFA..................................................... 70CERVIDIL......................................................................... 22CETACAINE..................................................................... 29CETACAINE ANESTHETIC............................................29CETIRIZINE HCL.............................................................. 1CETRAXAL...................................................................... 33CETRORELIX ACETATE................................................ 36CETROTIDE..................................................................... 36CETUXIMAB....................................................................65CETYLEV......................................................................... 71CEVIMELINE HCL..........................................................64CHANTIX......................................................................... 81CHEMET...........................................................................72CHENODAL..................................................................... 62CHENODIOL.................................................................... 62CHLORAMBUCIL........................................................... 64CHLORDIAZEPOXIDE HCL............................................ 7CHLORDIAZEPOXIDE/CLIDINIUM BR...................... 82CHLORHEXIDINE GLUCONATE..................................70CHLOROQUINE PHOSPHATE....................................... 54CHLOROTHIAZIDE.........................................................17CHLORPHENIRAMINE/PHENYLEPH/DM.................. 22CHLORPHENIRAMINE/PHENYLEPH/DM (1-2-3MG/ML) (DROPS)..............................................................CHLORPHENIRAMINE/PHENYLEPHRINE................ 22CHLORPHENIRAMINE/PHENYLEPHRINE (1MG-2MG/ML) (DROPS)..............................................................CHLORPROMAZINE HCL..............................................10CHLORTHALIDONE.......................................................17CHLORZOXAZONE........................................................ 81CHLORZOXAZONE (500 MG) (TABLET)........................CHOLBAM....................................................................... 62CHOLECALCIFEROL (VITAMIN D3)........................... 86CHOLECALCIFEROL (VITAMIN D3) (1000 UNIT)(CAPSULE) (OTC)...............................................................CHOLECALCIFEROL (VITAMIN D3) (1000 UNIT)(TAB CHEW) (OTC).............................................................CHOLECALCIFEROL (VITAMIN D3) (1000 UNIT)(TABLET) (OTC)..................................................................CHOLECALCIFEROL (VITAMIN D3) (2000 UNIT)(CAPSULE) (OTC)...............................................................CHOLECALCIFEROL (VITAMIN D3) (2000 UNIT)(TABLET) (OTC)..................................................................CHOLECALCIFEROL (VITAMIN D3) (400 UNIT)(CAPSULE) (OTC)...............................................................CHOLECALCIFEROL (VITAMIN D3) (400 UNIT) (TABCHEW) (OTC).......................................................................CHOLECALCIFEROL (VITAMIN D3) (400 UNIT)(TABLET) (OTC)..................................................................

CHOLERA VACCINE, LIVE........................................... 48CHOLESTYRAMINE (WITH SUGAR).......................... 19CHOLESTYRAMINE/ASPARTAME.............................. 19CHOLIC ACID..................................................................62CHORIONIC GONADOTROPIN.....................................35CHORIONIC GONADOTROPIN, HUMAN....................35CHRONULAC...................................................................62CIALIS (10 MG) (TABLET).............................................34CIALIS (2.5 MG) (TABLET)............................................34CIALIS (20 MG) (TABLET).............................................34CIALIS (5 MG) (TABLET)...............................................34CICLESONIDE................................................................... 1CICLODAN.......................................................................24CICLOPIROX....................................................................24CICLOPIROX OLAMINE................................................ 24CICLOPIROX/SKIN CLEANSER NO.28........................24CICLOPIROX/UREA/CAMPH/MEN/EUC..................... 24CILOSTAZOL................................................................... 44CILOXAN (0.3 %) (DROPS)............................................ 38CIMETIDINE.................................................................... 82CIMETIDINE HCL........................................................... 82CINACALCET HCL......................................................... 36CINRYZE.......................................................................... 59CIPRO................................................................................51CIPRO XR......................................................................... 51CIPRODEX....................................................................... 33CIPROFLOXACIN......................................................33, 51CIPROFLOXACIN HCL.......................................33, 38, 51CIPROFLOXACIN HCL/DEXAMETH........................... 33CIPROFLOXACIN HCL/FLUOCINOLONE...................33CIPROFLOXACIN/CIPROFLOXA HCL.........................51CITALOPRAM HYDROBROMIDE.................................. 6CITRANATAL HARMONY............................................. 85CITRATE PHOSPHATE DEXTROS SOLN.................... 42CITRIC AC/GLUCONOLACT/MAG CARB...................84CITRIC ACID/SODIUM CITRATE................................. 84CLARIFOAM EF.............................................................. 25CLARINEX (2.5 MG) (TAB RAPDIS).............................. 1CLARINEX (5 MG) (TAB RAPDIS)................................. 1CLARINEX (5 MG) (TABLET)......................................... 1CLARITHROMYCIN....................................................... 50CLEMASTINE FUMARATE............................................. 1CLENPIQ.......................................................................... 63CLEOCIN (2 %) (CREAM/APPL)................................... 84CLEOCIN HCL................................................................. 54CLEOCIN PALMITATE................................................... 54CLEOCIN T.......................................................................24CLICKFINE (31 G X1/4"") (DIS NEEDLE) (OTC)........ 72CLICKFINE (31 GX5/16"") (DIS NEEDLE) (OTC)....... 72CLICKFINE (32GX 5/32"") (DIS NEEDLE) (OTC)....... 72CLIMARA.........................................................................45CLIMARA PRO................................................................ 45CLINDACIN ETZ............................................................. 24CLINDACIN P.................................................................. 24CLINDAMYCIN HCL...................................................... 54CLINDAMYCIN PALMITATE HCL................................54CLINDAMYCIN PHOS/BENZOYL PEROX.................. 23CLINDAMYCIN PHOSPHATE................................. 24, 84CLINDAMYCIN/TRETINOIN.........................................23CLINORIL.........................................................................61CLISTIN.............................................................................. 1CLOBAZAM..................................................................... 81CLOBETASOL PROPIONATE.........................................25CLOBETASOL PROPIONATE/EMOLL....................25, 26CLOBETASOL/SKIN CLEANSER NO.28......................26CLOBEX........................................................................... 25CLOCORTOLONE PIVALATE........................................26CLODAN.....................................................................25, 26CLODERM........................................................................26CLOFARABINE................................................................65CLOLAR........................................................................... 65CLOMIPHENE CITRATE................................................ 34CLOMIPRAMINE HCL..................................................... 6CLONAZEPAM................................................................ 78CLONIDINE......................................................................14CLONIDINE HCL.......................................................11, 14CLONIDINE HCL/CHLORTHALIDONE....................... 14CLOPIDOGREL BISULFATE..........................................44CLORAZEPATE DIPOTASSIUM...................................... 7CLOTRIMAZOLE...................................................... 24, 52CLOTRIMAZOLE (1 %) (CREAM (G))..............................CLOTRIMAZOLE (1 %) (SOLUTION)...............................CLOTRIMAZOLE/BETAMETH DIP/ZINC.................... 24CLOTRIMAZOLE/BETAMETHASONE DIP................. 24CLOZAPINE....................................................................... 9CLOZARIL..........................................................................9COAGADEX..................................................................... 42COAGULATION FACTOR VIIA,RECOMB................... 41COAGULATION FACTOR X...........................................42COARTEM........................................................................ 54COBIMETINIB FUMARATE...........................................66COCAINE HCL.................................................................29


Index

CODEINE..........................................................................74CODEINE SULFATE........................................................74CODEINE/BUTALBITAL/ASA/CAFFEIN..................... 77COGENTIN (0.5 MG) (TABLET).................................... 77COGENTIN (1 MG) (TABLET)....................................... 77COGENTIN (2 MG) (TABLET)....................................... 77COLAZAL.........................................................................61COLCHICINE................................................................... 40COLCRYS......................................................................... 40COLESEVELAM HCL..................................................... 19COLESTID (1 G) (TABLET)............................................19COLESTID (5 G) (GRANULES)..................................... 19COLESTID (5 G) (PACKET)............................................19COLESTIPOL HCL.......................................................... 19COLLAGENASE CLOSTRIDIUM HIST.........................29COLYTE WITH FLAVOR PACKETS..............................62COMBIGAN......................................................................39COMBIPATCH..................................................................45COMBIPRES.....................................................................14COMBIVENT RESPIMAT................................................. 3COMBIVIR....................................................................... 55COMBUNOX.................................................................... 74COMPAZINE...................................................................... 2COMPLERA......................................................................57COMTAN.......................................................................... 78CONCEPT DHA............................................................... 85CONCEPT OB...................................................................85CONCEPTROL................................................................. 21CONDYLOX (0.5 %) (SOLUTION).................................28CONTOUR........................................................................ 32CONTOUR NEXT............................................................ 32COPANLISIB DI-HCL......................................................67COPAXONE (20 MG/ML) (SYRINGE)...........................69COPAXONE (40 MG/ML) (SYRINGE)...........................69COPPER............................................................................ 71CORDARONE (100 MG) (TABLET)............................... 12CORDARONE (200 MG) (TABLET)............................... 12CORDARONE (400 MG) (TABLET)............................... 12CORDRAN (0.05 %) (CREAM (G))................................ 26CORDRAN (0.05 %) (LOTION)...................................... 26CORDRAN (0.05 %) (OINT. (G)).................................... 26COREG..............................................................................13COREG CR....................................................................... 13CORGARD........................................................................15CORIFACT........................................................................ 42CORLANOR..................................................................... 20CORTEF............................................................................ 59CORTENEMA...................................................................62CORTIFOAM.................................................................... 62CORTISONE ACETATE...................................................59CORTONE.........................................................................59CORZIDE.......................................................................... 15COSENTYX (2 SYRINGES)............................................29COSENTYX PEN............................................................. 29COSENTYX PEN (2 PENS)............................................. 29COSENTYX SYRINGE....................................................29COSOPT............................................................................ 39COSOPT PF.......................................................................39COTELLIC........................................................................ 66COTEMPLA XR-ODT (17.3 MG) (TAB RAP BP)...... 11,88COTEMPLA XR-ODT (25.9 MG) (TAB RAP BP)...... 11,88COTEMPLA XR-ODT (8.6 MG) (TAB RAP BP)...... 11,88COUMADIN..................................................................... 40COVARYX.........................................................................45COVARYX H.S................................................................. 45COZAAR...........................................................................14CREON..............................................................................81CRESEMBA (186 MG) (CAPSULE)............................... 53CRESTOR (10 MG) (TABLET)........................................18CRESTOR (20 MG) (TABLET)........................................18CRESTOR (40 MG) (TABLET)........................................18CRESTOR (5 MG) (TABLET)..........................................18CRINONE....................................................................35, 46CRIXIVAN........................................................................ 57CRIZOTINIB.....................................................................67CROMOLYN SODIUM................................................ 4, 39CUROSURF...................................................................... 73CUTIVATE........................................................................ 26CYCLESSA.......................................................................21CYCLOBENZAPRINE HCL............................................81CYCLOCORT................................................................... 25CYCLOGYL......................................................................40CYCLOMYDRIL.............................................................. 40CYCLOPENTOL/LIDO/PE/TROPICAMID.................... 40CYCLOPENTOLAT/TROPIC/PHENYLEPH.................. 40CYCLOPENTOLATE HCL.............................................. 40CYCLOPENTOLATE/PHENYLEPHRINE..................... 40CYCLOPHOSPHAMIDE................................................. 64CYCLOSERINE................................................................53

CYCLOSPORINE....................................................... 39, 49CYCLOSPORINE, MODIFIED........................................49CYKLOKAPRON............................................................. 40CYPROHEPTADINE HCL................................................. 1CYRAMZA....................................................................... 66CYSTADANE....................................................................71CYSTAGON...................................................................... 84CYSTARAN...................................................................... 40CYSTEAMINE BITARTRATE.........................................84CYSTEAMINE HCL.........................................................40CYTOGAM....................................................................... 46CYTOMEGALOVIRUS IMMUNE GLOBULN.............. 46CYTOMEL........................................................................ 37CYTOTEC......................................................................... 82CYTRA-2.......................................................................... 84CYTRA-3.......................................................................... 84CYTRA-K..........................................................................84

- D -D.H.E. 45........................................................................... 76D.H.E.45............................................................................ 76DABRAFENIB MESYLATE............................................ 67DACOGEN........................................................................ 65DALFAMPRIDINE........................................................... 70DALIRESP.......................................................................... 4DALMANE....................................................................... 11DALTEPARIN SODIUM,PORCINE................................ 43DANAZOL........................................................................ 37DANDRUFF SHAMPOO..................................................27DANOCRINE....................................................................37DANTRIUM (100 MG) (CAPSULE)............................... 81DANTRIUM (25 MG) (CAPSULE)................................. 81DANTRIUM (50 MG) (CAPSULE)................................. 81DANTROLENE SODIUM................................................ 81DAPAGLIFLOZIN PROPANEDIOL................................ 30DAPAGLIFLOZIN/METFORMIN HCL.......................... 31DAPSONE................................................................... 23, 53DARAPRIM...................................................................... 54DARATUMUMAB............................................................65DARIFENACIN HYDROBROMIDE............................... 84DARUNAVIR ETHANOLATE......................................... 55DARUNAVIR/COBICISTAT............................................ 55DARZALEX......................................................................65DASATINIB...................................................................... 67DAUNORUBICIN/CYTARABINE LIPOS...................... 65DAYPRO............................................................................61DAYTRANA................................................................11, 88DDAVP.............................................................................. 35DECITABINE....................................................................65DECLOMYCIN.................................................................51DEFERASIROX.......................................................... 71, 72DEFERIPRONE................................................................ 72DEFEROXAMINE MESYLATE...................................... 72DELAFLOXACIN MEGLUMINE................................... 51DELATESTRYL................................................................45DELAVIRDINE MESYLATE...........................................55DELFEN............................................................................ 21DEMADEX....................................................................... 16DEMECLOCYCLINE HCL..............................................51DEMEROL (100 MG) (TABLET).................................... 74DEMEROL (50 MG) (TABLET)...................................... 74DEMSER........................................................................... 14DEMULEN........................................................................21DEMULEN 1-50-21.......................................................... 21DENOSUMAB.................................................................. 35DEPAKENE.......................................................................81DEPAKOTE.......................................................................78DEPAKOTE ER.................................................................78DEPAKOTE SPRINKLE...................................................78DEPEN.............................................................................. 58DEPO-ESTRADIOL......................................................... 45DEPO-PROVERA....................................................... 21, 46DEPO-TESTOSTERONE................................................. 45DERMACINRX THERAZOLE PAK............................... 24DERMA-SMOOTHE-FS...................................................26DERMATOP......................................................................27DERMAZENE...................................................................23DERMOTIC.......................................................................33DESCOVY.........................................................................55DESFERAL....................................................................... 72DESFERAL MESYLATE................................................. 72DESIPRAMINE HCL......................................................... 6DESLORATADINE.............................................................1DESMOPRESSIN (NONREFRIGERATED)................... 35DESMOPRESSIN ACETATE........................................... 35DESOG-E.ESTRADIOL/E.ESTRADIOL........................ 21DESOGEN.........................................................................21DESOGESTREL-ETHINYL ESTRADIOL..................... 21DESONIDE....................................................................... 26DESOWEN........................................................................26DESOXIMETASONE....................................................... 26DESOXYN.......................................................................... 7

DESVENLAFAXINE SUCCINATE................................... 6DESYREL........................................................................... 6DETROL......................................................................84, 88DETROL LA............................................................... 84, 88DEUTETRABENAZINE.................................................. 70DEXAMETHASONE........................................................59DEXAMETHASONE INTENSOL.......................................DEXAMETHASONE SOD PHOSPHATE.......................38DEXASOL.........................................................................38DEXCOM G4 (EACH)......................................................32DEXEDRINE (10 MG) (CAPSULE ER)............................7DEXEDRINE (10 MG) (TABLET).....................................7DEXEDRINE (15 MG) (CAPSULE ER)............................7DEXEDRINE (5 MG) (CAPSULE ER)..............................7DEXEDRINE (5 MG) (TABLET).......................................7DEXERYL.........................................................................27DEXILANT (60 MG) (CAP DR BP)................................ 83DEXLANSOPRAZOLE....................................................83DEXMETHYLPHENIDATE HCL....................................11DEXTROAMPHETAMINE SULFATE.............................. 7DEXTROAMPHETAMINE/AMPHETAMINE..................7DEXTROMETHORPHAN HBR/QUINIDINE................ 70DEXTROSE/SOD CITRATE/CITRIC AC....................... 42DIAPHRAGMS, CONTOURED...................................... 22DIAPHRAGMS, WIDE SEAL..........................................22DIASTAT........................................................................... 78DIASTAT ACUDIAL........................................................ 78DIAZEPAM............................................................... 7, 8, 78DIAZEPAM INTENSOL......................................................DIAZOXIDE..................................................................... 32DIBENZYLINE (10 MG) (CAPSULE)............................ 13DICLOFENAC EPOLAMINE.......................................... 27DICLOFENAC POTASSIUM........................................... 60DICLOFENAC SODIUM............................... 27, 29, 38, 60DICLOFENAC SODIUM/MISOPROSTOL.....................60DICLOXACILLIN SODIUM............................................51DICYCLOMINE HCL...................................................... 82DICYCLOMINE HCL (10 MG) (CAPSULE)......................DICYCLOMINE HCL (10 MG/5 ML) (SOLUTION).........DICYCLOMINE HCL (20 MG) (TABLET).........................DIDANOSINE...................................................................56DIDRONEL....................................................................... 35DIFFERIN......................................................................... 23DIFLORASONE DIACETATE......................................... 26DIFLORASONE DIACETATE/EMOLL.......................... 26DIFLUCAN....................................................................... 52DIFLUNISAL....................................................................74DIGOXIN.......................................................................... 13DIHYDROERGOTAMINE MESYLATE......................... 76DILACOR XR................................................................... 16DILANTIN........................................................................ 80DILANTIN (100 MG) (CAPSULE)..................................80DILANTIN (30 MG) (CAPSULE)....................................80DILANTIN-125.................................................................80DILATRATE-SR................................................................20DILAUDID........................................................................ 74DILTIAZEM HCL.......................................................15, 16DIMETHYL FUMARATE................................................69DINOPROSTONE.............................................................22DINUTUXIMAB...............................................................68DIOVAN............................................................................ 14DIOVAN HCT................................................................... 14DIPH,PERTUSS(ACELL),TET VAC/PF.......................... 48DIPHENHYDRAMINE HCL............................................. 1DIPHENOXYLATE HCL/ATROPINE............................. 62DIPHTH,PERTUSS(ACELL),TET VAC.......................... 48DIPROLENE..................................................................... 25DIPROLENE AF............................................................... 25DIPYRIDAMOLE............................................................. 44DISALCID.........................................................................74DISOPYRAMIDE PHOSPHATE..................................... 12DISULFIRAM.....................................................................7DITROPAN........................................................................84DITROPAN XL................................................................. 84DIURIL (250 MG) (TABLET).......................................... 17DIURIL (500 MG) (TABLET).......................................... 17DIVALPROEX SODIUM..................................................78DIVIGEL........................................................................... 45DOCETAXEL....................................................................68DOFETILIDE.................................................................... 13DOLASETRON MESYLATE.............................................2DOLOBID......................................................................... 74DOLUTEGRAVIR SODIUM............................................57DOLUTEGRAVIR/RILPIVIRINE....................................54DONEPEZIL HCL.............................................................. 5DONNATAL (16.2MG/5ML) (ELIXIR)........................... 82DORAL..............................................................................11DORNASE ALFA............................................................. 73DORYX (100 MG) (TABLET DR)............................. 51, 88DORYX (150 MG) (TABLET DR)............................. 51, 88DORYX (200 MG) (TABLET DR)............................. 51, 88DORYX (50 MG) (TABLET DR)............................... 52, 88


Index

DORYX (75 MG) (TABLET DR)............................... 52, 88DORZOLAMIDE HCL..................................................... 39DORZOLAMIDE HCL/TIMOLOL MALEAT.................39DORZOLAMIDE/TIMOLOL/PF..................................... 39DOSTINEX....................................................................... 37DOVONEX..................................................................30, 88DOXAZOSIN MESYLATE.............................................. 13DOXEPIN HCL...................................................................7DOXERCALCIFEROL..................................................... 36DOXIL............................................................................... 65DOXORUBICIN HCL.......................................................65DOXORUBICIN HCL PEG-LIPOSOMAL......................65DOXYCYCLINE HYCLATE............................... 51, 52, 71DOXYCYCLINE MONOHYDRATE...............................52DRITHOCREME HP.................................................. 29, 88DRONABINOL................................................................... 2DRONEDARONE HCL.................................................... 13DROSPIR/ETH ESTRA/LEVOMEFOL CA.................... 21DROXIA............................................................................ 44DUAC................................................................................ 23DUAVEE............................................................................45DUETACT................................................................... 31, 89DULAGLUTIDE............................................................... 30DULERA............................................................................. 3DULOXETINE HCL...........................................................6DULOXETINE HCL (20 MG) (CAPSULE DR)..................DULOXETINE HCL (30 MG) (CAPSULE DR)..................DULOXETINE HCL (60 MG) (CAPSULE DR)..................DUONEB.............................................................................3DUPILUMAB....................................................................30DUPIXENT....................................................................... 30DURAGESIC.....................................................................74DURICEF.......................................................................... 49DURVALUMAB............................................................... 69DUTASTERIDE................................................................ 84DUTASTERIDE/TAMSULOSIN HCL.............................84DUZALLO.................................................................. 40, 89DYAZIDE.......................................................................... 16DYMISTA......................................................................1, 89DYNACIN......................................................................... 52DYNACIRC.......................................................................16

- E -E101/NAMG FL/NA PH/NACL/HA-NAH.......................27ECHOTHIOPHATE IODIDE............................................39EC-NAPROSYN................................................................61ECONAZOLE NITRATE..................................................24ECOTRIN.......................................................................... 44ECULIZUMAB................................................................. 44EDARAVONE................................................................... 70EDARBI.......................................................................14, 89EDARBYCLOR.......................................................... 13, 89EDECRIN.......................................................................... 16EDEX (10 MCG) (KIT).....................................................34EDEX (20 MCG) (KIT).....................................................34EDLUAR........................................................................... 11EDURANT........................................................................ 56EFAVIRENZ......................................................................55EFAVIRENZ/EMTRICIT/TENOFOVR DF......................57EFFEXOR............................................................................6EFFEXOR XR..................................................................... 6EFFIENT........................................................................... 44EFUDEX............................................................................29EGRIFTA...........................................................................36ELAPRASE....................................................................... 71ELAVIL............................................................................... 6ELDEPRYL....................................................................... 78ELELYSO..........................................................................71ELESTAT...........................................................................38ELETRIPTAN HBR.......................................................... 76ELIDEL....................................................................... 30, 89ELIGARD (22.5 MG) (SYRINGE)...................................35ELIGARD (30 MG) (SYRINGE)......................................35ELIGARD (45 MG) (SYRINGE)......................................35ELIGARD (7.5 MG) (SYRINGE).....................................35ELIGLUSTAT TARTRATE...............................................71ELIPHOS...........................................................................34ELIQUIS (2.5 MG) (TABLET)......................................... 42ELIQUIS (5 MG) (TABLET)............................................ 42ELLENCE..........................................................................65ELMIRON......................................................................... 84ELOCON........................................................................... 27ELOSULFASE ALFA....................................................... 71ELOXATIN........................................................................64ELTROMBOPAG OLAMINE...........................................44ELUXADOLINE...............................................................62ELVITEG/COB/EMTRI/TENOF ALAFEN..................... 57ELVITEG/COB/EMTRI/TENOFO DISOP...................... 57EMADINE.........................................................................38EMCYT............................................................................. 69EMEDASTINE DIFUMARATE....................................... 38EMEND............................................................................... 2

EMEND (125 MG) (CAPSULE).........................................2EMEND (125 MG) (SUSP RECON).................................. 2EMEND (125MG-80MG) (CAP DS PK)............................2EMEND (40 MG) (CAPSULE)...........................................2EMEND (80 MG) (CAPSULE)...........................................2EMICIZUMAB-KXWH....................................................42EMLA................................................................................ 29EMOL53/NAMGFS/HA/NAHYPOCHLORIT................ 27EMOL53/SOD MAG FL.SIL/CYCLOMET.....................27EMOLLIENT COMBINATION NO.10............................27EMOLLIENT COMBINATION NO.101..........................27EMOLLIENT COMBINATION NO.103..........................27EMOLLIENT COMBINATION NO.104..........................27EMOLLIENT COMBINATION NO.107..........................27EMOLLIENT COMBINATION NO.32............................27EMOLLIENT COMBINATION NO.35............................27EMOLLIENT COMBINATION NO.60............................27EMPAGLIFLOZIN............................................................30EMPAGLIFLOZIN/LINAGLIPTIN..................................31EMPAGLIFLOZIN/METFORMIN HCL....................31, 32EMTRICITA/RILPIVIRINE/TENOF DF......................... 57EMTRICITAB/RILPIVIRI/TENOF ALA.........................57EMTRICITABINE.............................................................56EMTRICITABINE/TENOFOV ALAFENAM..................55EMTRICITABINE/TENOFOVIR (TDF)..........................55EMTRIVA (10 MG/ML) (SOLUTION)............................56EMTRIVA (200 MG) (CAPSULE)................................... 56EMVERM..........................................................................54ENABLEX...................................................................84, 89ENALAPRIL MALEATE..................................................14ENALAPRIL/HYDROCHLOROTHIAZIDE................... 13ENASIDENIB MESYLATE..............................................68ENBREL............................................................................59ENBREL MINI..................................................................59ENBREL SURECLICK.....................................................59ENDARI............................................................................ 72ENDO-AVITENE.............................................................. 44ENDODAN........................................................................75ENFUVIRTIDE................................................................. 55ENGERIX-B ADULT........................................................48ENOXAPARIN SODIUM................................................. 43ENSTILAR.................................................................. 30, 89ENTACAPONE................................................................. 78ENTECAVIR..................................................................... 58ENTEREG......................................................................... 63ENTOCORT EC................................................................ 59ENTRESTO.......................................................................20ENTYVIO..........................................................................62ENZALUTAMIDE............................................................ 65EPCLUSA..........................................................................57EPIDUO.......................................................................23, 89EPIDUO FORTE......................................................... 23, 89EPINASTINE HCL........................................................... 38EPINEPHRINE............................................................13, 64EPINEPHRINE (0.1 MG/ML) (SYRINGE).........................EPINEPHRINE HCL.........................................................23EPIPEN..............................................................................64EPIPEN 2-PAK..................................................................64EPIPEN JR.........................................................................64EPIPEN JR 2-PAK.............................................................64EPIRUBICIN HCL............................................................ 65EPIVIR (10 MG/ML) (SOLUTION).................................56EPIVIR (150 MG) (TABLET)...........................................56EPIVIR (300 MG) (TABLET)...........................................56EPIVIR HBV (100 MG) (TABLET)................................. 58EPIVIR HBV (25 MG/5 ML) (SOLUTION).................... 58EPLERENONE..................................................................16EPOETIN ALFA............................................................... 42EPOPROSTENOL SODIUM (ARGININE)..................... 17EPOPROSTENOL SODIUM (GLYCINE)....................... 17EPZICOM..........................................................................55ERBITUX.......................................................................... 65ERGOLOID MESYLATES...............................................21ERGOMAR....................................................................... 76ERGOTAMINE TARTRATE.............................................76ERGOTAMINE TARTRATE/CAFFEINE........................ 76ERIBULIN MESYLATE...................................................66ERIVEDGE....................................................................... 66ERLOTINIB HCL............................................................. 67ERTUGLIFLOZIN PIDOLATE........................................ 30ERWINAZE.......................................................................68ERY....................................................................................24ERYGEL............................................................................24ERYMAX.......................................................................... 24ERY-TAB........................................................................... 50ERYTHRCIN STEARATE................................................50ERYTHROMYCIN BASE.......................................... 38, 50ERYTHROMYCIN BASE/ETHANOL............................ 24ERYTHROMYCIN ETHYLSUCCINATE........................50ERYTHROMYCIN STEARATE.......................................50ERYTHROMYCIN/BENZOYL PEROXIDE................... 24ESBRIET (267 MG) (CAPSULE).....................................73

ESBRIET (267 MG) (TABLET)....................................... 73ESBRIET (801 MG) (TABLET)....................................... 73ESCITALOPRAM OXALATE............................................6ESGIC................................................................................73ESLICARBAZEPINE ACETATE..................................... 78ESOMEPRAZOLE MAGNESIUM.................................. 83ESTAZOLAM................................................................... 11ESTRACE....................................................................45, 84ESTRADIOL............................................................... 45, 84ESTRADIOL CYPIONATE.............................................. 45ESTRADIOL VALERATE/DIENOGEST........................ 21ESTRADIOL/LEVONORGESTREL............................... 45ESTRADIOL/NORETHINDRONE ACET.......................45ESTRAMUSTINE PHOSPHATE SODIUM.................... 69ESTRING.......................................................................... 84ESTROGEN,CON/M-PROGEST ACET.......................... 45ESTROGEN,ESTER/ME-TESTOSTERONE...................45ESTROGENS, CONJUGATED.................................. 46, 85ESTROGENS,CONJ/BAZEDOXIFENE.......................... 45ESTROGENS,ESTERIFIED.............................................46ESTROPIPATE.................................................................. 46ESTROSTEP FE................................................................21ESZOPICLONE................................................................ 11ETANERCEPT.................................................................. 59ETELCALCETIDE HYDROCHLORIDE........................ 36ETEPLIRSEN....................................................................64ETHACRYNIC ACID....................................................... 16ETHAMBUTOL HCL.......................................................53ETHINYL ESTRADIOL/DROSPIRENONE................... 21ETHIONAMIDE............................................................... 53ETHOSUXIMIDE............................................................. 78ETHOTOIN....................................................................... 78ETHYL CHLORIDE......................................................... 29ETHYNODIOL D-ETHINYL ESTRADIOL....................21ETIDRONATE DISODIUM..............................................35ETODOLAC...................................................................... 60ETONOGESTREL............................................................ 21ETONOGESTREL/ETHINYL ESTRADIOL...................21ETOPOPHOS.................................................................... 68ETOPOSIDE......................................................................68ETOPOSIDE PHOSPHATE..............................................68ETRAFON-A.......................................................................6ETRAVIRINE..............................................................55, 56EULEXIN.......................................................................... 65EVARREST....................................................................... 44EVEKEO............................................................................. 7EVEROLIMUS............................................................49, 66EVICEL............................................................................. 45EVISTA............................................................................. 35EVOCLIN..........................................................................24EVOLOCUMAB............................................................... 19EVOXAC........................................................................... 64EXELON............................................................................. 5EXEMESTANE................................................................. 66EXENATIDE..................................................................... 30EXENATIDE MICROSPHERES...................................... 30EXFORGE...................................................................14, 89EXFORGE HCT..........................................................13, 89EXJADE............................................................................ 71EXONDYS 51................................................................... 64EXTAVIA.......................................................................... 70EXTINA (2 %) (FOAM)................................................... 24EZETIMIBE...................................................................... 19EZETIMIBE/SIMVASTATIN........................................... 17

- F -FABRAZYME...................................................................71FACTOR IX.......................................................................42FACTOR IX CPLX(PCC)NO4,3FACTOR....................... 42FACTOR IX CPLX(PCC)NO6,3FACTOR....................... 42FACTOR IX HUMAN REC,PEGYLATED......................42FACTOR IX HUMAN RECOMB,THR 148.....................42FACTOR IX HUMAN RECOMBINANT.........................42FACTOR IX REC, FC FUSION PROTN..........................42FACTOR XIII.................................................................... 42FACTOR XIII A-SUBUNIT,RECOMB............................ 42FAMCICLOVIR................................................................ 54FAMOTIDINE...................................................................82FAMVIR............................................................................ 54FARESTON....................................................................... 69FARXIGA....................................................................30, 89FASENRA........................................................................... 4FASLODEX.......................................................................69FAZACLO..................................................................... 9, 89FEBUXOSTAT.................................................................. 40FEIBA NF..........................................................................41FELBAMATE....................................................................78FELBATOL (400 MG) (TABLET)..............................78, 89FELBATOL (600 MG) (TABLET)..............................78, 89FELBATOL (600 MG/5ML) (ORAL SUSP).............. 78, 89FELDENE..........................................................................61FELODIPINE.................................................................... 16


Index

FEMARA...........................................................................66FEMCON FE..................................................................... 21FEMHRT........................................................................... 46FENOFIBRATE.................................................................19FENOFIBRATE NANOCRYSTALLIZED....................... 19FENOFIBRATE,MICRONIZED.................................19, 20FENOFIBRIC ACID......................................................... 20FENOFIBRIC ACID (CHOLINE).................................... 20FENOGLIDE.....................................................................19FENOPROFEN CALCIUM.............................................. 60FENORTHO...................................................................... 60FENTANYL.......................................................................74FENTANYL CITRATE..................................................... 74FERRIC SUBSULFATE....................................................44FERRIPROX......................................................................72FESOTERODINE FUMARATE....................................... 84FETZIMA...................................................................... 6, 90FEXMID............................................................................ 81FIBRICOR.........................................................................20FIBRINOGEN................................................................... 40FIBRINOGEN/THROMBIN(HUMAN DER).................. 44FILGRASTIM................................................................... 44FILGRASTIM-SNDZ........................................................44FINACEA.......................................................................... 23FINASTERIDE..................................................................84FINGOLIMOD HCL......................................................... 69FIORICET......................................................................... 74FIORICET WITH CODEINE........................................... 77FIORINAL WITH CODEINE #3......................................77FIRAZYR.......................................................................... 59FLAGYL............................................................................54FLAVOXATE HCL............................................................84FLECAINIDE ACETATE..................................................13FLECTOR..........................................................................27FLEXERIL........................................................................ 81FLIBANSERIN................................................................. 10FLOLAN............................................................................17FLOMAX.......................................................................... 84FLONASE........................................................................... 1FLORINEF........................................................................ 60FLOVENT DISKUS (100 MCG) (BLST W/DEV).......4, 90FLOVENT DISKUS (250 MCG) (BLST W/DEV).......4, 90FLOVENT DISKUS (50 MCG) (BLST W/DEV).........4, 90FLOVENT HFA (110 MCG) (AER W/ADAP).............4, 90FLOVENT HFA (220 MCG) (AER W/ADAP).............4, 90FLOVENT HFA (44 MCG) (AER W/ADAP)...............4, 90FLOXIN.......................................................................33, 51FLU VAC QS 17-18 (4YR UP) CELL.............................. 47FLU VAC QS 17-18(4YR UP)CEL/PF............................. 47FLU VAC QV 2017(18YR UP)RCM/PF.......................... 47FLU VAC TS 2017-18(4 YR UP)/PF ................................ 47FLU VAC TV 2017(18YR UP)RCM/PF...........................47FLU VACC QS 2017 (18-64YRS)/PF...............................47FLU VACC QS 2017 (6-35MOS)/PF................................ 47FLU VACC QS2017-18 36MOS UP/PF............................47FLU VACC QS2017-18(6MOS UP)/PF............................47FLU VACC QUAD 2017(5 YR UP)/PF ............................ 47FLU VACC QUAD 2017-18(5 YR UP) ............................ 47FLU VACC QUAD 2017-18(6MOS UP).......................... 47FLU VACC QV LIVE 2017(2-49YRS).............................47FLU VACC TS2017(65UP)/MF59C/PF............................47FLU VACC TS2017-18(65YR UP)/PF............................. 47FLU VACCIN TS2017-18 5YR UP/PF.............................47FLU VACCINE TS2017-18(4 YR UP) ............................. 47FLU VACCINE TS2017-18(5 YR UP) ............................. 47FLUAD 2017-2018............................................................47FLUARIX QUAD 2017-2018........................................... 47FLUBLOK 2017-2018.......................................................47FLUBLOK QUAD 2017-2018.......................................... 47FLUCELVAX QUAD 2017-2018......................................47FLUCONAZOLE.............................................................. 52FLUCYTOSINE................................................................ 53FLUDROCORTISONE ACETATE................................... 60FLULAVAL QUAD 2017-2018.........................................47FLUMADINE....................................................................55FLUMIST QUAD 2017-2018............................................47FLUNISOLIDE................................................................... 1FLUOCINOLONE ACETONIDE.....................................26FLUOCINOLONE ACETONIDE OIL............................. 33FLUOCINOLONE/SHOWER CAP..................................26FLUOCINONIDE..............................................................26FLUOCINONIDE/EMOLLIENT BASE.......................... 26FLUORESCEIN-BENOXINATE......................................38FLUORIDE (SODIUM).................................................... 85FLUORIDE (SODIUM) (0.25(0.55)) (TAB CHEW)............FLUORIDE (SODIUM) (0.5 MG/ML) (DROPS)................FLUORIDE (SODIUM) (0.5(1.1)MG) (TAB CHEW).........FLUORIDE (SODIUM) (1.1 %) (CREAM (G))...................FLUORIDE (SODIUM) (1.1 %) (GEL (GRAM))................FLUORIDE (SODIUM) (1MG(2.2MG)) (TAB CHEW)...............................................................................................FLUOROMETHOLONE...................................................38

FLUOROURACIL.............................................................29FLUOXETINE HCL............................................................6FLUPHENAZINE HCL.................................................... 10FLURANDRENOLIDE.................................................... 26FLURAZEPAM HCL........................................................ 11FLURBIPROFEN..............................................................60FLURBIPROFEN SODIUM............................................. 38FLURESS.......................................................................... 38FLUROX............................................................................38FLUTAMIDE.....................................................................65FLUTICASONE FUROATE............................................... 4FLUTICASONE PROPIONATE...............................1, 4, 26FLUTICASONE/SALMETEROL.......................................3FLUTICASONE/SOD CHL/SOD BICARB.......................1FLUTICASONE/UMECLIDIN/VILANTER..................... 3FLUTICASONE/VILANTEROL........................................3FLUVASTATIN SODIUM................................................ 18FLUVIRIN 2017-2018...................................................... 47FLUVOXAMINE MALEATE.............................................6FLUZONE HIGH-DOSE 2017-2018................................ 47FLUZONE INTRADERM QUAD 2017-18......................47FLUZONE QUAD 2017-2018.......................................... 47FLUZONE QUAD PEDI 2017-2018.................................47FML................................................................................... 38FOCALIN.......................................................................... 11FOCALIN XR................................................................... 11FOLEX.............................................................................. 65FOLIC ACID..................................................................... 85FOLIC ACID (0.4 MG) (TABLET) (OTC)...........................FOLIC ACID (0.8 MG) (TABLET) (OTC)...........................FOLIC ACID (1 MG) (TABLET).........................................FOLLISTIM AQ................................................................35FOLLITROPIN ALFA, RECOMBINANT................. 34, 35FOLLITROPIN BETA,RECOMB.....................................35FOLOTYN.........................................................................65FONDAPARINUX SODIUM............................................43FORFIVO XL...................................................................... 6FORMOTEROL FUMARATE............................................ 3FORTAMET................................................................ 31, 90FOSAMAX (10 MG) (TABLET)...................................... 35FOSAMAX (35 MG) (TABLET)...................................... 35FOSAMAX (40 MG) (TABLET)...................................... 35FOSAMAX (5 MG) (TABLET)........................................ 35FOSAMAX (70 MG) (TABLET)...................................... 35FOSAMAX (70 MG/75ML) (SOLUTION)......................35FOSAMPRENAVIR CALCIUM.......................................57FOSAPREPITANT DIMEGLUMINE................................ 2FOSINOPRIL SODIUM................................................... 14FOSINOPRIL/HYDROCHLOROTHIAZIDE.................. 13FOSRENOL (1000 MG) (TAB CHEW)........................... 34FOSRENOL (500 MG) (TAB CHEW)............................. 34FOSRENOL (750 MG) (TAB CHEW)............................. 34FRAGMIN (10000/ML) (SYRINGE)............................... 43FRAGMIN (12500/0.5) (SYRINGE)................................ 43FRAGMIN (15000/0.6) (SYRINGE)................................ 43FRAGMIN (18000/0.72) (SYRINGE).............................. 43FRAGMIN (2500/0.2ML) (SYRINGE)............................ 43FRAGMIN (25000/ML) (VIAL)....................................... 43FRAGMIN (5000/0.2ML) (SYRINGE)............................ 43FRAGMIN (7500/0.3ML) (SYRINGE)............................ 43FROVA.........................................................................76, 90FROVATRIPTAN SUCCINATE........................................76FULVESTRANT............................................................... 69FURADANTIN................................................................. 50FUROSEMIDE..................................................................16FUZEON......................................................................55, 90FYCOMPA (0.5 MG/ML) (ORAL SUSP).................. 80, 90FYCOMPA (10 MG) (TABLET).................................80, 90FYCOMPA (12 MG) (TABLET).................................80, 90FYCOMPA (2 MG) (TABLET)...................................80, 90FYCOMPA (4 MG) (TABLET)...................................80, 90FYCOMPA (6 MG) (TABLET)...................................80, 90FYCOMPA (8 MG) (TABLET)...................................80, 90

- G -GABAPENTIN..................................................................78GABITRIL (12 MG) (TABLET).................................80, 90GABITRIL (16 MG) (TABLET).................................80, 90GABITRIL (2 MG) (TABLET)...................................80, 90GABITRIL (4 MG) (TABLET)...................................80, 90GALANTAMINE HBR.......................................................5GALSULFASE.................................................................. 71GALZIN............................................................................ 72GAMASTAN S-D (15 %-18 %) (VIAL)...........................46GAMMAGARD LIQUID (10 %) (VIAL)........................ 46GAMMAGARD S-D.........................................................46GAMMAKED................................................................... 46GAMMAPLEX..................................................................46GAMUNEX-C (1 G/10 ML) (VIAL)................................ 46GAMUNEX-C (10 G/100ML) (VIAL)............................. 46GAMUNEX-C (2.5G/25ML) (VIAL)............................... 46GAMUNEX-C (20 G/200ML) (VIAL)............................. 46

GAMUNEX-C (40 G/400ML) (VIAL)............................. 46GAMUNEX-C (5 G/50 ML) (VIAL)................................ 47GARAMYCIN...................................................................38GARDASIL 9.................................................................... 48GASTROCROM..................................................................4GATIFLOXACIN.............................................................. 38GATIFLOXACIN/PREDNISOL/NEPAFEN.................... 37GATIFLOXACIN/PREDNISOLONE............................... 37GAZYVA........................................................................... 65GEFITINIB........................................................................67GELATIN.......................................................................... 40GELATIN SPONGE,ABSORBABLE...............................44GELFILM.......................................................................... 40GELFOAM........................................................................ 44GELFOAM JMI.................................................................45GELNIQUE (10 %) (GEL PACKET)..........................84, 91GELNIQUE (100 MG/G) (GEL MD PMP)................ 84, 91GEMCITABINE HCL....................................................... 65GEMFIBROZIL.................................................................20GEMTUZUMAB OZOGAMICIN....................................68GENADUR........................................................................28GENERESS FE................................................................. 21GENGRAF........................................................................ 49GENTAK........................................................................... 38GENTAMICIN SULFATE...........................................24, 38GENTIAN VIOLET/BRGREEN/PROFLAV....................24GENVOYA........................................................................ 57GEODON.......................................................................... 10GIALAX............................................................................ 62GILENYA (0.5 MG) (CAPSULE).................................... 69GILOTRIF......................................................................... 66GLATIRAMER ACETATE............................................... 69GLECAPREVIR/PIBRENTASVIR.................................. 58GLEEVEC (100 MG) (TABLET)..................................... 67GLEEVEC (400 MG) (TABLET)..................................... 67GLEOSTINE..................................................................... 64GLIMEPIRIDE..................................................................31GLIPIZIDE........................................................................ 31GLIPIZIDE/METFORMIN HCL......................................31GLUCAGEN..................................................................... 32GLUCAGON EMERGENCY KIT................................... 32GLUCAGON,HUMAN RECOMBINANT.......................32GLUCARPIDASE............................................................. 69GLUCOPHAGE................................................................ 31GLUCOPHAGE XR..........................................................31GLUCOSAMINE HCL/CHONDROITIN SU.................. 59GLUCOSAMINE SULF/CHONDROITIN A...................59GLUCOSAMINE-CHONDROITIN................................. 59GLUCOTROL................................................................... 31GLUCOTROL XL............................................................. 31GLUCOVANCE................................................................ 31GLUTAMINE....................................................................72GLYBURIDE.....................................................................31GLYBURIDE,MICRONIZED...........................................31GLYBURIDE/METFORMIN HCL...................................31GLYCEROL PHENYLBUTYRATE.................................62GLYCINE UROLOGIC SOLUTION................................53GLYCOPYRROLATE................................................... 3, 82GLYCOPYRROLATE/FORMOTEROL FUM................... 3GLYNASE......................................................................... 31GLYSET............................................................................ 31GLYXAMBI................................................................ 31, 91GOCOVRI (137 MG) (CAP ER 24H)...............................77GOCOVRI (68.5 MG) (CAP ER 24H)..............................77GOLIMUMAB.................................................................. 59GOLYTELY (236-22.74G) (SOLN RECON)................... 63GONAL-F....................................................................34, 91GONAL-F RFF............................................................35, 91GONAL-F RFF REDI-JECT....................................... 35, 91GORDO-UREA.................................................................30GOSERELIN ACETATE...................................................35GRANISETRON................................................................. 2GRANISETRON HCL........................................................ 2GRANIX............................................................................44GRIFULVIN V.................................................................. 53GRISEOFULVIN ULTRAMICROSIZE........................... 53GRISEOFULVIN, MICROSIZE....................................... 53GRIS-PEG......................................................................... 53G-TUSICOF...................................................................... 22GUAIACOL.......................................................................27GUAIFEN/DEXTROMETHORPHAN/PE....................... 22GUAIFENESIN/DEXTROMETHORPHAN.................... 23GUANFACINE HCL...................................................11, 14GUANIDINE..................................................................... 64GUANIDINE HCL............................................................ 64GUSELKUMAB................................................................29GYNOL II..........................................................................21

- H -HAEGARDA..................................................................... 59HALAVEN.........................................................................66HALCION......................................................................... 11


Index

HALDOL...........................................................................10HALDOL DECANOATE 100........................................... 10HALDOL DECANOATE 50............................................. 10HALFLYTELY-BISACODYL...........................................62HALOBETASOL PROPIONATE..................................... 26HALOPERIDOL............................................................... 10HALOPERIDOL DECANOATE...................................... 10HALOPERIDOL LACTATE............................................. 10HARVONI......................................................................... 57HAVRIX (1440/ML) (SYRINGE).....................................48HAVRIX (1440/ML) (VIAL)............................................ 48HECTOROL (0.5 MCG) (CAPSULE).............................. 36HECTOROL (1 MCG) (CAPSULE)................................. 36HECTOROL (2.5 MCG) (CAPSULE).............................. 36HELIXATE FS...................................................................41HEMIN.............................................................................. 42HEMLIBRA...................................................................... 42HEMMOREX-HC............................................................. 62HEMOFIL M..................................................................... 41HEPAGAM B.................................................................... 46HEPARIN SOD,PORCINE/0.9 % NACL......................... 43HEPARIN SOD,PORK IN 0.45% NACL....................43, 44HEPARIN SODIUM IN 0.45% NACL............................. 43HEPARIN SODIUM,PORCINE....................................... 44HEPARIN SODIUM,PORCINE/D5W..............................44HEPARIN SODIUM,PORCINE/NS/PF............................44HEPARIN SODIUM,PORCINE/PF..................................44HEPARIN SODIUM-0.45% NACL.................................. 44HEPATITIS A AND B VACCINE/PF ............................... 48HEPATITIS A VIRUS VACCINE/PF ................................48HEPATITIS B IMMUN GLOB/MALTOSE......................46HEPATITIS B IMMUNE GLOBULIN............................. 46HEPATITIS B VACCINE/CPG1018/PF............................48HEPATITIS B VIRUS VACCINE/PF................................48HEPLISAV-B.....................................................................48HEPSERA..........................................................................58HERCEPTIN (150 MG) (VIAL)....................................... 65HERCEPTIN (440 MG) (VIAL)....................................... 65HETLIOZ.......................................................................... 10HEXALEN........................................................................ 64HIPREX.............................................................................50HISTRELIN ACETATE.................................................... 35HIZENTRA (1 G/5 ML) (VIAL)...................................... 46HIZENTRA (10 G/50 ML) (VIAL).................................. 46HIZENTRA (2 G/10 ML) (VIAL).................................... 46HIZENTRA (4 G/20 ML) (VIAL).................................... 46HOCL/NA HY/NAMGF/NA PH/NACL/WA....................28HOMATROPINE HBR......................................................40HPV VACCINE 9-VALENT/PF........................................48HUMALOG (100/ML) (CARTRIDGE)............................33HUMALOG (100/ML) (VIAL).........................................33HUMALOG JUNIOR KWIKPEN.................................... 33HUMALOG KWIKPEN U-100........................................ 33HUMALOG KWIKPEN U-200........................................ 33HUMALOG MIX 50-50....................................................33HUMALOG MIX 50-50 KWIKPEN................................ 33HUMALOG MIX 75-25....................................................33HUMALOG MIX 75-25 KWIKPEN................................ 33HUMATE-P....................................................................... 41HUMATIN.........................................................................54HUMIRA........................................................................... 58HUMIRA PEDIATRIC CROHN'S....................................59HUMIRA PEN...................................................................59HUMIRA PEN CROHN-UC-HS STARTER.................... 59HUMIRA PEN PSORIASIS-UVEITIS.............................59HUMULIN 70/30 KWIKPEN...........................................33HUMULIN 70-30.............................................................. 33HUMULIN N.....................................................................33HUMULIN N KWIKPEN................................................. 33HUMULIN R.....................................................................33HUMULIN R U-500..........................................................33HUMULIN R U-500 KWIKPEN...................................... 33HYALURONATE SODIUM/HE-CELL/PEG................... 28HYALURONIDASE, HUMAN RECOMB.......................29HYCAMTIN (0.25 MG) (CAPSULE).............................. 66HYCAMTIN (1 MG) (CAPSULE)................................... 66HYCET (7.5-325/15) (SOLUTION)................................. 74HYDERGINE.................................................................... 21HYDRALAZINE HCL......................................................14HYDREA...........................................................................64HYDROCHLOROTHIAZIDE.......................................... 17HYDROCODONE BIT/HOMATROP ME-BR.................22HYDROCODONE BITARTRATE....................................74HYDROCODONE/ACETAMINOPHEN..........................74HYDROCODONE/CHLORPHEN P-STIREX.................22HYDROCODONE/CPM/PSEUDOEPHED..................... 22HYDROCODONE/IBUPROFEN..................................... 74HYDROCORT/PRAMOXN/SKIN CLNSR16..................61HYDROCORT/SAL ACID/SULF/SHAMP1....................26HYDROCORTISONE........................................... 26, 59, 62HYDROCORTISONE (1 %) (CREAM (G)).........................HYDROCORTISONE (1 %) (CRM/PE APP)......................

HYDROCORTISONE (1 %) (OINT. (G)).............................HYDROCORTISONE (2.5 %) (CREAM (G))......................HYDROCORTISONE (2.5 %) (CRM/PE APP)...................HYDROCORTISONE (2.5 %) (KIT)....................................HYDROCORTISONE (2.5 %) (LOTION)............................HYDROCORTISONE (2.5 %) (OINT. (G))..........................HYDROCORTISONE ACET/ALOE VERA.................... 26HYDROCORTISONE ACETATE.....................................62HYDROCORTISONE BUTYRATE................................. 26HYDROCORTISONE BUTYRATE/EMOLL.................. 26HYDROCORTISONE VALERATE..................................26HYDROCORTISONE/ACETIC ACID............................. 33HYDROCORTISONE/IODOQUINOL.............................23HYDROCORTISONE/IODOQUINOL/ALOE.................23HYDROCORTISONE/LIDOCAINE/ALOE.................... 61HYDROCORTISONE/PRAMOXINE.................. 28, 29, 61HYDROCORTISONE/SKIN CLEANSER25...................27HYDROMORPHONE HCL..............................................74HYDROMORPHONE HCL (12 MG) (TAB ER 24H).........HYDROMORPHONE HCL (16 MG) (TAB ER 24H).........HYDROMORPHONE HCL (2 MG) (TABLET)..................HYDROMORPHONE HCL (3 MG) (SUPP.RECT).............HYDROMORPHONE HCL (32 MG) (TAB ER 24H).........HYDROMORPHONE HCL (4 MG) (TABLET)..................HYDROMORPHONE HCL (8 MG) (TAB ER 24H)...........HYDROMORPHONE HCL (8 MG) (TABLET)..................HYDROXYAMPHETAMINE/TROPICAMIDE...............40HYDROXYCHLOROQUINE SULFATE......................... 54HYDROXYPROGESTERONE CAPROAT/PF................ 35HYDROXYPROGESTERONE CAPROATE................... 35HYDROXYUREA.......................................................44, 64HYDROXYZINE HCL........................................................1HYDROXYZINE PAMOATE............................................. 1HYGEL..............................................................................28HYGROTON..................................................................... 17HYOSCYAMINE SULFATE.............................................82HYOSYNE........................................................................ 82HYP AC/SOD CHL/SOD SUL/SOD PHO....................... 28HYPERHEP B S-D............................................................46HYPOC ACID/SOD HYPO/NACL/WATER.................... 28HYPOCHLOROUS ACID/SODIUM CHLOR................. 39HYQVIA HY COMPONENT...........................................29HYQVIA IG COMPONENT............................................ 46HYSINGLA ER.................................................................74HYTRIN............................................................................ 13HYZAAR...........................................................................13

- I -IBANDRONATE SODIUM...............................................35IBRANCE..........................................................................67IBRUTINIB....................................................................... 67IBUDONE......................................................................... 74IBUPROFEN..................................................................... 60IBUPROFEN/OXYCODONE HCL.................................. 74ICATIBANT ACETATE.................................................... 59ICLUSIG (15 MG) (TABLET)..........................................67ICLUSIG (45 MG) (TABLET)..........................................67ICOSAPENT ETHYL....................................................... 20IDELALISIB..................................................................... 67IDHIFA.............................................................................. 68IDURSULFASE................................................................ 71ILARIS.............................................................................. 59ILEVRO.............................................................................38ILOPROST TROMETHAMINE....................................... 17ILOTYCIN.........................................................................38IMATINIB MESYLATE................................................... 67IMBRUVICA.....................................................................67IMDUR.............................................................................. 20IMFINZI............................................................................ 69IMIGLUCERASE..............................................................71IMIPRAMINE HCL............................................................ 7IMIPRAMINE PAMOATE..................................................7IMIQUIMOD.....................................................................49IMITREX...........................................................................76IMITREX (100 MG) (TABLET).......................................76IMITREX (25 MG) (TABLET).........................................76IMITREX (4 MG/0.5ML) (CARTRIDGE)....................... 76IMITREX (4 MG/0.5ML) (PEN INJCTR)........................76IMITREX (50 MG) (TABLET).........................................76IMITREX (6 MG/0.5ML) (CARTRIDGE)....................... 76IMITREX (6 MG/0.5ML) (PEN INJCTR)..................76, 91IMITREX (6 MG/0.5ML) (VIAL).................................... 76IMMUN GLOB G(IGG)/GLY/IGA 0-50.......................... 46IMMUN GLOB G(IGG)/GLY/IGA OV50........................46IMMUN GLOB G(IGG)/PRO/IGA 0-50.......................... 46IMMUN GLOB G/GLY/GLUC/IGA 0-50........................46IMMUNE GLOBUL G (IGG)/GLYCINE.........................46IMMUNE GLOBUL G/GLY/IGA AVG 46................ 46, 47IMPAVIDO........................................................................ 54IMPOYZ............................................................................ 25IMURAN........................................................................... 49INCRELEX........................................................................36

INCRUSE ELLIPTA......................................................3, 91INDACATEROL MALEATE.............................................. 3INDACATEROL/GLYCOPYRROLATE............................ 3INDAPAMIDE...................................................................17INDERAL (10 MG) (TABLET)........................................ 15INDERAL (20 MG) (TABLET)........................................ 15INDERAL (20 MG/5 ML) (SOLUTION).........................15INDERAL (40 MG) (TABLET)........................................ 15INDERAL (40MG/5ML) (SOLUTION)...........................15INDERAL (60 MG) (TABLET)........................................ 15INDERAL (80 MG) (TABLET)........................................ 15INDERAL LA................................................................... 15INDERIDE-40/25.............................................................. 15INDERIDE-80/25.............................................................. 15INDINAVIR SULFATE..................................................... 57INDOCIN (25 MG) (CAPSULE)......................................60INDOCIN (50 MG) (CAPSULE)......................................60INDOCIN (50 MG) (SUPP.RECT)................................... 60INDOCIN SR.....................................................................60INDOMETHACIN............................................................ 60INFASURF........................................................................ 73INFLECTRA..................................................................... 61INFLIXIMAB....................................................................61INFLIXIMAB-ABDA....................................................... 61INFLIXIMAB-DYYB....................................................... 61INGENOL MEBUTATE....................................................29INGREZZA (40 MG) (CAPSULE)...................................70INGREZZA (80 MG) (CAPSULE)...................................70INLYTA (1 MG) (TABLET)............................................. 66INLYTA (5 MG) (TABLET)............................................. 66INOTUZUMAB OZOGAMICIN......................................66INSPRA............................................................................. 16INSULIN ASPART PROT/INSULN ASP.........................32INSULIN DEGLUDEC.....................................................32INSULIN DEGLUDEC/LIRAGLUTIDE......................... 31INSULIN DETEMIR.........................................................33INSULIN GLARGINE,HUM.REC.ANLOG....................33INSULIN GLARGINE/LIXISENATIDE..........................31INSULIN LISPRO.............................................................33INSULIN LISPRO PROTAMIN/LISPRO.........................33INSULIN NPH HUM/REG INSULIN HM...................... 33INSULIN NPH HUMAN ISOPHANE............................. 33INSULIN REGULAR, HUMAN...................................... 33INTELENCE (100 MG) (TABLET)..................................55INTELENCE (200 MG) (TABLET)..................................55INTELENCE (25 MG) (TABLET)....................................56INTERFERON ALFA-2B,RECOMB................................49INTERFERON ALFA-N3................................................. 49INTERFERON BETA-1A................................................. 69INTERFERON BETA-1A/ALBUMIN........................69, 70INTERFERON BETA-1B..................................................70INTERFERON GAMMA-1B,RECOMB..........................49INTERMEZZO..................................................................11INTRON A........................................................................ 49INTUNIV...........................................................................11INVEGA (1.5 MG) (TAB ER 24)................................. 9, 91INVEGA (3 MG) (TAB ER 24).................................... 9, 91INVEGA (6 MG) (TAB ER 24).................................... 9, 91INVEGA (9 MG) (TAB ER 24).................................... 9, 91INVIRASE (200 MG) (CAPSULE)............................ 57, 91INVIRASE (500 MG) (TABLET)...............................57, 91INVOKAMET............................................................. 31, 91INVOKAMET XR.......................................................31, 91INVOKANA................................................................ 30, 91IODINE/POTASSIUM IODIDE........................................23IODINE/POTASSIUM IODIDE (5%-10%) (SOLUTION)...............................................................................................IODOFLEX....................................................................... 23IODOSORB.......................................................................23IOPIDINE (0.5 %) (DROPS).............................................39IPILIMUMAB................................................................... 69IPRATROPIUM BROMIDE..........................................2, 71IPRATROPIUM/ALBUTEROL SULFATE........................ 3IRBESARTAN...................................................................14IRBESARTAN/HYDROCHLOROTHIAZIDE.................13IRESSA..............................................................................67IRINOTECAN LIPOSOMAL........................................... 66IRON,CARB/VIT C/VIT B12/FOLIC.............................. 85ISAVUCONAZONIUM SULFATE...................................53ISENTRESS (100 MG) (POWD PACK)...........................57ISENTRESS (100 MG) (TAB CHEW)............................. 57ISENTRESS (25 MG) (TAB CHEW)............................... 57ISENTRESS (400 MG) (TABLET)...................................57ISENTRESS HD................................................................57ISOCHRON....................................................................... 20ISOMETHEPT/DICHLPHN/ACETAMINOP.................. 76ISOMETHEPTEN/CAF/ACETAMINOPHEN................. 76ISONIAZID....................................................................... 53ISONIAZID (100 MG) (TABLET).......................................ISONIAZID (300 MG) (TABLET).......................................ISONIAZID (50 MG/5 ML) (SOLUTION)..........................ISOPTO ATROPINE......................................................... 39


Index

ISOPTO CARPINE........................................................... 39ISOPTO HOMATROPINE................................................40ISORDIL (10 MG) (TABLET)..........................................20ISORDIL (20 MG) (TABLET)..........................................20ISORDIL (30 MG) (TABLET)..........................................20ISORDIL TITRADOSE.................................................... 20ISOSORBIDE DINITRATE..............................................20ISOSORBIDE MONONITRATE......................................20ISOTRETINOIN................................................................23ISOXSUPRINE HCL........................................................ 21ISRADIPINE..................................................................... 16ISTALOL........................................................................... 39ISTODAX.......................................................................... 68ITRACONAZOLE.............................................................53IVABRADINE HCL.......................................................... 20IVACAFTOR..................................................................... 73IVERMECTIN.............................................................23, 54IXABEPILONE.................................................................66IXAZOMIB CITRATE......................................................67IXEMPRA......................................................................... 66IXINITY............................................................................ 42

- J -JADENU............................................................................ 71JADENU SPRINKLE (180 MG) (GRAN PACK).............71JADENU SPRINKLE (360 MG) (GRAN PACK).............71JADENU SPRINKLE (90 MG) (GRAN PACK)...............72JAKAFI..............................................................................66JALYN......................................................................... 84, 91JANUMET.........................................................................30JANUMET XR (100-1000MG) (TBMP 24HR)................30JANUMET XR (50-1000 MG) (TBMP 24HR).................30JANUMET XR (50MG-500MG) (TBMP 24HR)............. 30JANUVIA.......................................................................... 31JARDIANCE............................................................... 30, 91JENTADUETO.................................................................. 30JENTADUETO XR (2.5-1000MG) (TAB BP 24H)..........30JENTADUETO XR (5MG-1000MG) (TAB BP 24H)...... 30JEVANTIQUE................................................................... 46JEVANTIQUE LO.............................................................46JEVTANA..........................................................................68JULUCA............................................................................ 54JUXTAPID.........................................................................19

- K -KADCYLA........................................................................68KALETRA (100MG-25MG) (TABLET).......................... 56KALETRA (200MG-50MG) (TABLET).......................... 57KALETRA (400-100/5) (SOLUTION).............................57KALYDECO......................................................................73KANUMA......................................................................... 64KAPVAY............................................................................11KEFLEX............................................................................ 49KENALOG IN ORABASE............................................... 70KEPIVANCE..................................................................... 70KEPPRA (100 MG/ML) (SOLUTION)............................ 79KEPPRA (1000 MG) (TABLET)...................................... 79KEPPRA (250 MG) (TABLET)........................................ 79KEPPRA (500 MG) (TABLET)........................................ 79KEPPRA (500 MG/5ML) (SOLUTION).......................... 79KEPPRA (750 MG) (TABLET)........................................ 80KEPPRA XR..................................................................... 80KERLONE.........................................................................14KETOCONAZOLE..................................................... 24, 53KETOPROFEN..................................................................60KETOROLAC TROMETHAMINE............................ 38, 61KETOROLAC/NORFLURANE/HFC 245FA...................61KEVZARA........................................................................ 60KEYTRUDA......................................................................68KISQALI FEMARA CO-PACK........................................66KITABIS PAK (300 MG/5ML) (AMPUL-NEB).............. 53KLARON...........................................................................23KLONOPIN.......................................................................78KLONOPIN RAPIDLY DISINTEGRATING...................78KLOR-CON-EF.................................................................34KOATE (1000 (+/-)) (VIAL)............................................. 41KOATE (500 (+/-)) (VIAL)............................................... 41KOGENATE FS.................................................................41KONSYL EASY MIX....................................................... 63KONSYL FORMULA-D.................................................. 63KORLYM.......................................................................... 31KOVALTRY.......................................................................41K-PHOS ORIGINAL.........................................................84KRYSTEXXA................................................................... 40KUVAN (100 MG) (POWD PACK)..................................72KUVAN (100 MG) (TABLET SOL)................................. 72KUVAN (500 MG) (POWD PACK)..................................72KWELL............................................................................. 24KYLEENA.........................................................................71KYMRIAH........................................................................ 68KYPROLIS........................................................................67KYTRIL (1 MG) (TABLET).........................................2, 91

- L -L.E.T. (LIDO-EPINEPH-TETRA).................................... 29LABETALOL HCL........................................................... 13LACOSAMIDE................................................................. 79LACTATED RINGERS..................................................... 28LACTULOSE.................................................................... 62LAMICTAL....................................................................... 79LAMICTAL (BLUE).........................................................79LAMICTAL (GREEN)...................................................... 79LAMICTAL (ORANGE)...................................................79LAMICTAL ODT (100 MG) (TAB RAPDIS)............ 79, 91LAMICTAL ODT (200 MG) (TAB RAPDIS)............ 79, 91LAMICTAL ODT (25 MG) (TAB RAPDIS).............. 79, 91LAMICTAL ODT (50 MG) (TAB RAPDIS).............. 79, 91LAMICTAL ODT (BLUE)..........................................79, 91LAMICTAL ODT (GREEN).......................................79, 92LAMICTAL ODT (ORANGE)................................... 79, 92LAMICTAL XR (100 MG) (TAB ER 24)...................79, 92LAMICTAL XR (200 MG) (TAB ER 24)...................79, 92LAMICTAL XR (25 MG) (TAB ER 24).....................79, 92LAMICTAL XR (250 MG) (TAB ER 24)...................79, 92LAMICTAL XR (300 MG) (TAB ER 24)...................79, 92LAMICTAL XR (50 MG) (TAB ER 24).....................79, 92LAMISIL........................................................................... 53LAMIVUDINE............................................................56, 58LAMIVUDINE/ZIDOVUDINE........................................ 55LAMOTRIGINE................................................................79LANCETS......................................................................... 63LANCETS (EACH) (OTC)...................................................LANOXIN (125 MCG) (TABLET)...................................13LANOXIN (250 MCG) (TABLET)...................................13LANSOPRAZOLE............................................................ 83LANSOPRAZOLE/AMOXICILN/CLARITH..................82LANTHANUM CARBONATE.........................................34LANTUS............................................................................33LANTUS SOLOSTAR...................................................... 33LAPATINIB DITOSYLATE..............................................67LARIAM............................................................................54LARONIDASE.................................................................. 71LARTRUVO...................................................................... 68LASIX (10 MG/ML) (SOLUTION)..................................16LASIX (20 MG) (TABLET)..............................................16LASIX (40 MG) (TABLET)..............................................16LASIX (40MG/5ML) (SOLUTION).................................16LASIX (80 MG) (TABLET)..............................................16LASTACAFT.....................................................................37LATANOPROST............................................................... 39LATANOPROSTENE BUNOD........................................ 39LATUDA (120 MG) (TABLET)....................................9, 92LATUDA (20 MG) (TABLET)......................................9, 92LATUDA (40 MG) (TABLET)......................................9, 92LATUDA (60 MG) (TABLET)......................................9, 92LATUDA (80 MG) (TABLET)......................................9, 92LDO PLUS........................................................................ 29LEDIPASVIR/SOFOSBUVIR.......................................... 57LEFLUNOMIDE...............................................................59LEMTRADA..................................................................... 69LENALIDOMIDE............................................................. 66LENVATINIB MESYLATE.............................................. 67LENVIMA.........................................................................67LESCOL...................................................................... 18, 92LESCOL XL......................................................................18LESINURAD/ALLOPURINOL........................................40LETAIRIS..........................................................................17LETERMOVIR..................................................................54LETROZOLE.................................................................... 66LEUCOVORIN CALCIUM.............................................. 69LEUKERAN......................................................................64LEUKINE (250 MCG) (VIAL)......................................... 44LEUPROLIDE ACETATE...........................................35, 36LEUPROLIDE ACETATE (1 MG/0.2ML) (KIT).................LEUPROLIDE ACETATE (1 MG/0.2ML) (VIAL)..............LEVALBUTEROL HCL..................................................... 3LEVAQUIN (250 MG) (TABLET)....................................51LEVAQUIN (250MG/10ML) (SOLUTION).....................51LEVAQUIN (500 MG) (TABLET)....................................51LEVAQUIN (750 MG) (TABLET)....................................51LEVBID.............................................................................82LEVEMIR..........................................................................33LEVEMIR FLEXTOUCH.................................................33LEVETIRACETAM.................................................... 79, 80LEVICYN....................................................................27, 28LEVICYN ANTIPRURITIC SG....................................... 27LEVOBUNOLOL HCL.....................................................39LEVOCARNITINE........................................................... 71LEVOCARNITINE (330 MG) (TABLET)............................LEVOCARNITINE (WITH SUGAR)...............................71LEVOCETIRIZINE DIHYDROCHLORIDE..................... 1LEVO-DROMORAN........................................................ 74LEVOFLOXACIN.......................................................38, 51LEVOMILNACIPRAN HCL.............................................. 6

LEVONORGESTREL.......................................................71LEVONORGESTREL-ETHIN ESTRADIOL.................. 21LEVORPHANOL TARTRATE......................................... 74LEVO-T............................................................................. 37LEVOTHYROXINE SODIUM......................................... 37LEVOXYL.........................................................................37LEVSIN (0.125 MG) (TABLET)...................................... 82LEVSIN-SL....................................................................... 82LEVULAN........................................................................ 69LEXAPRO........................................................................... 6LEXIVA (50 MG/ML) (ORAL SUSP)..............................57LEXIVA (700 MG) (TABLET)......................................... 57LIALDA.............................................................................61LIBRAX............................................................................ 82LIBRIUM............................................................................ 7LIDAMANTLE HC...........................................................29LIDEX............................................................................... 26LIDEX-E............................................................................26LIDOCAINE......................................................................29LIDOCAINE (5 %) (ADH. PATCH).....................................LIDOCAINE (5 %) (OINT. (G))....................................... 92LIDOCAINE HCL.......................................................29, 61LIDOCAINE HCL (2 %) (JELLY(ML))...............................LIDOCAINE HCL (2 %) (SOLUTION)...............................LIDOCAINE HCL (3 %) (CREAM (G))..............................LIDOCAINE HCL (3 %) (LOTION)....................................LIDOCAINE HCL (4 %) (SOLUTION)...............................LIDOCAINE HCL/PF....................................................... 38LIDOCAINE/HYDROCORTISONE AC....................29, 62LIDOCAINE/PRILOCAINE.............................................29LIDOCAINE/RACEPINEP/TETRACAINE.....................29LIDOCAINE/TETRACAINE........................................... 29LIDOPIN........................................................................... 29LIFITEGRAST.................................................................. 39LIMBITROL........................................................................6LIMBITROL DS..................................................................6LINACLOTIDE................................................................. 62LINAGLIPTIN.................................................................. 31LINAGLIPTIN/METFORMIN HCL................................ 30LINDANE..........................................................................24LINEZOLID...................................................................... 50LINZESS........................................................................... 62LIORESAL........................................................................ 81LIOTHYRONINE SODIUM.............................................37LIPASE/PROTEASE/AMYLASE...............................81, 82LIPITOR (10 MG) (TABLET).......................................... 17LIPITOR (20 MG) (TABLET).......................................... 18LIPITOR (40 MG) (TABLET).......................................... 18LIPITOR (80 MG) (TABLET).......................................... 18LIPOFEN (150 MG) (CAPSULE).............................. 19, 92LIPOFEN (50 MG) (CAPSULE)................................ 19, 92LISDEXAMFETAMINE DIMESYLATE...........................7LISINOPRIL......................................................................14LISINOPRIL/HYDROCHLOROTHIAZIDE....................13LITHIUM CARBONATE....................................................8LITHIUM CITRATE........................................................... 8LITHOSTAT...................................................................... 62LIVALO............................................................................. 18LIVER EXTRACT (BEEF-PORK)...................................64L-NORGEST/E.ESTRADIOL-E.ESTRAD...................... 21LO LOESTRIN FE...................................................... 21, 92LOCOID (0.1 %) (CREAM (G)).......................................26LOCOID (0.1 %) (OINT. (G))...........................................26LOCOID (0.1 %) (SOLUTION)........................................26LOCOID LIPOCREAM.................................................... 26LODINE............................................................................ 60LODINE XL...................................................................... 60LODOSYN........................................................................ 78LOESTRIN........................................................................ 21LOESTRIN 24 FE............................................................. 21LOESTRIN FE.................................................................. 21LOFIBRA.................................................................... 19, 20LOMITAPIDE MESYLATE............................................. 19LOMOTIL......................................................................... 62LOMUSTINE.................................................................... 64LONITEN.......................................................................... 14LONSURF......................................................................... 65LO-OVRAL-28..................................................................22LO-OVRAL-8....................................................................22LOPERAMIDE HCL.........................................................62LOPERAMIDE HCL (2 MG) (CAPSULE)..........................LOPID................................................................................20LOPINAVIR/RITONAVIR.......................................... 56, 57LOPRESSOR HCT............................................................15LOPROX............................................................................24LORAZEPAM..................................................................... 8LORAZEPAM INTENSOL...................................................LORTAB (10MG-325MG) (TABLET)............................. 74LORTAB (5 MG-325MG) (TABLET).............................. 74LORTAB (7.5-325 MG) (TABLET)..................................74LOSARTAN POTASSIUM............................................... 14LOSARTAN/HYDROCHLOROTHIAZIDE.....................13


Index

LOSEASONIQUE.............................................................21LOTEMAX........................................................................38LOTENSIN........................................................................14LOTENSIN HCT...............................................................13LOTEPREDNOL ETABONATE.......................................38LOTREL............................................................................ 13LOTRISONE..................................................................... 24LOTRONEX...................................................................... 62LOVASTATIN....................................................................18LOVAZA............................................................................20LOVENOX (100 MG/ML) (SYRINGE)........................... 43LOVENOX (120MG/.8ML) (SYRINGE)......................... 43LOVENOX (150 MG/ML) (SYRINGE)........................... 43LOVENOX (300MG/3ML) (VIAL)..................................43LOVENOX (30MG/0.3ML) (SYRINGE)......................... 43LOVENOX (40MG/0.4ML) (SYRINGE)......................... 43LOVENOX (60MG/0.6ML) (SYRINGE)......................... 43LOVENOX (80MG/0.8ML) (SYRINGE)......................... 43LOXAPINE......................................................................... 9LOXAPINE SUCCINATE...................................................9LOXITANE..........................................................................9LOZOL.............................................................................. 17LUBIPROSTONE..............................................................62LUCINACTANT................................................................73LUDIOMIL..........................................................................7LULICONAZOLE.............................................................24LUMACAFTOR/IVACAFTOR.........................................73LUMIGAN (0.01 %) (DROPS)......................................... 39LUMIGAN (0.03 %) (DROPS)......................................... 39LUMIZYME......................................................................71LUNESTA......................................................................... 11LUPRON DEPOT..............................................................36LUPRON DEPOT (LUPANETA)......................................36LUPRON DEPOT-PED..................................................... 36LURASIDONE HCL...........................................................9LUVOX................................................................................6LUVOX CR......................................................................... 6LUXAMEND.................................................................... 27LUXIQ...............................................................................25LUZU.................................................................................24LYMPHOCYTE IMMUNE GLOB,RABBIT................... 47LYNPARZA (100 MG) (TABLET)................................... 67LYNPARZA (150 MG) (TABLET)................................... 67LYNPARZA (50 MG) (CAPSULE).................................. 67LYRICA.............................................................................80LYSODREN...................................................................... 68LYSTEDA..........................................................................40

- M -MACITENTAN................................................................. 17MACROBID...................................................................... 50MACRODANTIN..............................................................50MAFENIDE ACETATE.................................................... 25MAKENA..........................................................................35MALARONE.....................................................................54MALATHION....................................................................24MANDELAMINE............................................................. 50MANNITOL...................................................................... 16MANNITOL/SORBITOL SOLUTION............................ 27MAPROTILINE HCL..........................................................7MARAVIROC....................................................................55MARINOL.....................................................................2, 92MARQIBO........................................................................ 69MATULANE..................................................................... 68MAVIK.............................................................................. 14MAVYRET........................................................................ 58MAXALT...........................................................................76MAXALT MLT................................................................. 76MAXZIDE.........................................................................16MAXZIDE-25 MG............................................................ 16MEASLES,MUMPS,RUB,VARICELLA/PF....................48MEASLES,MUMPS,RUBELLA VACC/PF..................... 48MEBENDAZOLE............................................................. 54MECASERMIN.................................................................36MECHLORETHAMINE HCL..........................................29MECLIZINE HCL...............................................................2MECLOFENAMATE SODIUM....................................... 61MECLOMEN.................................................................... 61MEDROL (16 MG) (TABLET).........................................59MEDROL (32 MG) (TABLET).........................................59MEDROL (4 MG) (TAB DS PK)...................................... 59MEDROL (4 MG) (TABLET)...........................................59MEDROL (8 MG) (TABLET)...........................................59MEDROXYPROGESTERONE ACETATE................ 21, 46MEFENAMIC ACID.........................................................61MEFLOQUINE HCL........................................................ 54MEGACE.....................................................................69, 71MEGACE ES.....................................................................71MEGESTROL ACETATE........................................... 69, 71MEKINIST........................................................................ 66MELLARIL....................................................................... 10MELOXICAM...................................................................61

MELPHALAN...................................................................64MELPHALAN HCL..........................................................64MEMANTINE HCL............................................................5MEMANTINE HCL/DONEPEZIL HCL............................5MENACTRA..................................................................... 47MENEST........................................................................... 46MENING VAC A,C,Y,W-135 DIP/PF...............................47MENINGOCOCCAL B VACCINE,4-COMP...................47MENOPUR........................................................................34MENOTROPINS............................................................... 34MEPERIDINE HCL.......................................................... 74MEPHYTON..................................................................... 45MEPOLIZUMAB................................................................ 4MEPROBAMATE............................................................... 8MEPRON...........................................................................54MEPSEVII.........................................................................71MERCAPTOPURINE....................................................... 65MESALAMINE.................................................................61MESALAMINE W/CLEANSING WIPES....................... 61MESNA............................................................................. 69MESNEX (400 MG) (TABLET)....................................... 69MESTINON (180 MG) (TABLET ER)...............................5MESTINON (60 MG) (TABLET).......................................5MESTINON (60 MG/5 ML) (SYRUP)............................... 5METAGLIP........................................................................31METAPROTERENOL SULFATE.......................................3METAXALONE................................................................81METFORMIN HCL.......................................................... 31METH/MEBLUE/SOD PHOS/PSAL/HYOS................... 50METHADONE HCL......................................................... 75METHADONE HCL (10 MG) (TABLET)...........................METHADONE HCL (10 MG/5 ML) (SOLUTION)........ 92METHADONE HCL (5 MG) (TABLET).............................METHADONE HCL (5 MG/5 ML) (SOLUTION).......... 92METHAMPHETAMINE HCL............................................7METHAZOLAMIDE........................................................ 39METHEN/MBLUE/SAL/SOD PHOS/HYOS...................50METHENAM/M.BLUE/SALICYL/HYOSCY.................50METHENAM/SOD PHOS/MBLUE/HYOSCY............... 50METHENAMINE HIPPURATE....................................... 50METHENAMINE MANDELATE.................................... 50METHERGINE................................................................. 22METHIMAZOLE.............................................................. 37METHITEST..................................................................... 45METHOCARBAMOL.......................................................81METHOTREXATE........................................................... 65METHOTREXATE SODIUM...........................................65METHOTREXATE SODIUM/PF..................................... 65METHOTREXATE/PF......................................................58METHOXSALEN............................................................. 29METHOXY PEG-EPOETIN BETA..................................42METHSCOPOLAMINE BROMIDE................................ 82METHSUXIMIDE............................................................ 80METHYCLOTHIAZIDE...................................................17METHYLDOPA................................................................ 14METHYLDOPA/HYDROCHLOROTHIAZIDE.............. 14METHYLERGONOVINE MALEATE............................. 22METHYLNALTREXONE BROMIDE............................. 63METHYLPHENIDATE.....................................................11METHYLPHENIDATE HCL......................................11, 12METHYLPHENIDATE HCL (10 MG) (CPBP 30-70).........METHYLPHENIDATE HCL (10 MG) (TAB CHEW).........METHYLPHENIDATE HCL (10 MG) (TABLET ER)........METHYLPHENIDATE HCL (10 MG) (TABLET)..............METHYLPHENIDATE HCL (10 MG/5 ML)(SOLUTION).........................................................................METHYLPHENIDATE HCL (18 MG) (TAB ER 24)..........METHYLPHENIDATE HCL (2.5 MG) (TAB CHEW)........METHYLPHENIDATE HCL (20 MG) (CPBP 30-70).........METHYLPHENIDATE HCL (20 MG) (CPBP 50-50).........METHYLPHENIDATE HCL (20 MG) (TABLET ER)........METHYLPHENIDATE HCL (20 MG) (TABLET)..............METHYLPHENIDATE HCL (27 MG) (TAB ER 24)..........METHYLPHENIDATE HCL (30 MG) (CPBP 30-70).........METHYLPHENIDATE HCL (30 MG) (CPBP 50-50).........METHYLPHENIDATE HCL (36 MG) (TAB ER 24)..........METHYLPHENIDATE HCL (40 MG) (CPBP 30-70).........METHYLPHENIDATE HCL (40 MG) (CPBP 50-50).........METHYLPHENIDATE HCL (5 MG) (TAB CHEW)...........METHYLPHENIDATE HCL (5 MG) (TABLET)................METHYLPHENIDATE HCL (5 MG/5 ML) (SOLUTION)...............................................................................................METHYLPHENIDATE HCL (50 MG) (CPBP 30-70).........METHYLPHENIDATE HCL (54 MG) (TAB ER 24)..........METHYLPHENIDATE HCL (60 MG) (CPBP 30-70).........METHYLPHENIDATE HCL (60 MG) (CPBP 50-50).........METHYLPHENIDATE HCL (72 MG) (TAB ER 24)..........METHYLPREDNISOLONE............................................ 59METHYLTESTOSTERONE.............................................45METIPRANOLOL............................................................ 39METOCLOPRAMIDE HCL............................................. 83METOLAZONE................................................................ 17

METOPROLOL SUCCINATE..........................................14METOPROLOL TARTRATE......................................14, 15METOPROLOL TARTRATE (100 MG) (TABLET)............METOPROLOL TARTRATE (25 MG) (TABLET)..............METOPROLOL TARTRATE (37.5 MG) (TABLET)...........METOPROLOL TARTRATE (50 MG) (TABLET)..............METOPROLOL TARTRATE (75 MG) (TABLET)..............METOPROLOL/HYDROCHLOROTHIAZIDE...............15METOZOLV ODT.............................................................83METRELEPTIN................................................................ 36METROCREAM............................................................... 23METROGEL......................................................................23METROGEL-VAGINAL................................................... 84METROLOTION...............................................................23METRONIDAZOLE............................................. 23, 54, 84METYROSINE..................................................................14MEVACOR........................................................................ 18MEXILETINE HCL.......................................................... 13MEXITIL...........................................................................13MIACALCIN (200/ML) (VIAL).......................................35MIACALCIN (200/SPRAY) (SPRAY/PUMP)................. 35MICARDIS........................................................................14MICARDIS HCT...............................................................14MICONAZOLE NITRATE............................................... 84MICONAZOLE NITRATE (200 MG) (SUPP.VAG)............MICRO THIN LANCETS (33 GAUGE) (EACH) (OTC)........................................................................................... 63MICROCYN......................................................................28MICROCYN HYDROGEL............................................... 28MICROFIBRILLAR COLLAGEN............................. 44, 45MIDAMOR........................................................................16MIDAZOLAM HCL..........................................................11MIDODRINE HCL........................................................... 20MIDOSTAURIN................................................................67MIFEPREX........................................................................71MIFEPRISTONE.........................................................31, 71MIGERGOT...................................................................... 76MIGLITOL........................................................................ 31MIGLUSTAT..................................................................... 71MIGRANAL......................................................................76MILLIPRED...................................................................... 59MILLIPRED DP................................................................59MILNACIPRAN HCL.......................................................70MILTEFOSINE................................................................. 54MINASTRIN 24 FE...........................................................21MINIPRESS...................................................................... 13MINIVELLE......................................................................45MINI-WRIGHT PEAK FLOW METER.............................4MINOCIN (100 MG) (CAPSULE)................................... 52MINOCIN (50 MG) (CAPSULE)..................................... 52MINOCIN (75 MG) (CAPSULE)..................................... 52MINOCYCLINE HCL...................................................... 52MINOXIDIL......................................................................14MIRABEGRON.................................................................84MIRALAX (17G) (POWD PACK)....................................63MIRALAX (17G/DOSE) (POWDER).............................. 63MIRAPEX......................................................................... 78MIRAPEX ER............................................................. 78, 92MIRCERA......................................................................... 42MIRCETTE....................................................................... 21MIRENA............................................................................71MIRTAZAPINE...................................................................5MIRVASO..........................................................................23MISOPROSTOL................................................................82MITIGARE........................................................................40MITOMYCIN....................................................................40MITOSOL..........................................................................40MITOTANE....................................................................... 68M-M-R II VACCINE......................................................... 48MOBIC.............................................................................. 61MODAFINIL..................................................................... 11MODICON........................................................................ 21MODURETIC 5-50........................................................... 16MOEXIPRIL HCL.............................................................14MOEXIPRIL/HYDROCHLOROTHIAZIDE....................13MOMETASONE FUROATE.....................................1, 4, 27MOMETASONE/FORMOTEROL......................................3MONDOXYNE NL (100 MG) (CAPSULE).................... 52MONDOXYNE NL (50 MG) (CAPSULE)...................... 52MONDOXYNE NL (75 MG) (CAPSULE)................ 52, 92MONOCLATE-P (1000 (+/-)) (VIAL)..............................41MONOCLATE-P (1500 (+/-)) (VIAL)..............................41MONODOX (100 MG) (CAPSULE)................................ 52MONODOX (50 MG) (CAPSULE).................................. 52MONODOX (50 MG) (TABLET).....................................52MONODOX (75 MG) (CAPSULE)............................ 52, 92MONODOX (75 MG) (TABLET).....................................52MONOKET....................................................................... 20MONONINE......................................................................42MONOPRIL...................................................................... 14MONOPRIL-HCT............................................................. 13MONTELUKAST SODIUM...............................................4


Index

MORGIDOX..................................................................... 52MORPHABOND ER.........................................................75MORPHINE SULFATE.....................................................75MORPHINE SULFATE (10 MG) (SUPP.RECT).................MORPHINE SULFATE (10 MG/5 ML) (SOLUTION)........MORPHINE SULFATE (100 MG) (TABLET ER)...............MORPHINE SULFATE (100 MG/5ML) (SOLUTION).......MORPHINE SULFATE (120 MG) (CPMP 24HR)...............MORPHINE SULFATE (15 MG) (TABLET ER).................MORPHINE SULFATE (15 MG) (TABLET).......................MORPHINE SULFATE (20 MG) (SUPP.RECT).................MORPHINE SULFATE (20 MG/5 ML) (SOLUTION)........MORPHINE SULFATE (200 MG) (TABLET ER)...............MORPHINE SULFATE (30 MG) (CPMP 24HR).................MORPHINE SULFATE (30 MG) (SUPP.RECT).................MORPHINE SULFATE (30 MG) (TABLET ER).................MORPHINE SULFATE (30 MG) (TABLET).......................MORPHINE SULFATE (45 MG) (CPMP 24HR).................MORPHINE SULFATE (5 MG) (SUPP.RECT)...................MORPHINE SULFATE (60 MG) (CPMP 24HR).................MORPHINE SULFATE (60 MG) (TABLET ER).................MORPHINE SULFATE (75 MG) (CPMP 24HR).................MORPHINE SULFATE (90 MG) (CPMP 24HR).................MOTRIN (400 MG) (TABLET)........................................ 60MOTRIN (600 MG) (TABLET)........................................ 60MOTRIN (800 MG) (TABLET)........................................ 60MOVANTIK...................................................................... 63MOXEZA.......................................................................... 38MOXIFLOXACIN HCL..............................................38, 51MUCOMYST.................................................................... 73MULTAQ........................................................................... 13MUPIROCIN..................................................................... 24MUPIROCIN CALCIUM..................................................24MUSE................................................................................ 34MYALEPT.........................................................................36MYAMBUTOL..................................................................53MYCELEX........................................................................ 52MYCOBUTIN................................................................... 53MYCOPHENOLATE MOFETIL......................................49MYCOPHENOLATE MOFETIL HCL.............................49MYCOPHENOLATE SODIUM....................................... 49MYCOSTATIN..................................................................24MYDAYIS..................................................................... 7, 92MYDRIACYL................................................................... 40MYFORTIC.......................................................................49MYLERAN........................................................................64MYLOTARG..................................................................... 68MYOBLOC....................................................................... 72MYRBETRIQ..............................................................84, 92MYSOLINE.......................................................................80

- N -N.MENINGITIDIS B,LIPID FHBP RC............................47NA MG FL/NA PHO/NACL/HA/NA HYP...................... 27NABUMETONE................................................................61NADOLOL........................................................................ 15NADOLOL/BENDROFLUMETHIAZIDE.......................15NAFARELIN ACETATE...................................................36NAFTIFINE HCL..............................................................24NAFTIN (1 %) (CREAM (G)).......................................... 24NAFTIN (2 %) (CREAM (G)).......................................... 24NAGLAZYME.................................................................. 71NALFON........................................................................... 60NALOXEGOL OXALATE................................................63NALOXONE HCL............................................................ 11NALTREXONE HCL........................................................11NALTREXONE MICROSPHERES....................................7NAMENDA (10 MG) (TABLET)....................................... 5NAMENDA (2 MG/ML) (SOLUTION)............................. 5NAMENDA (5 MG) (TABLET)......................................... 5NAMENDA XR (14 MG) (CAP SPR 24)...........................5NAMENDA XR (21 MG) (CAP SPR 24)...........................5NAMENDA XR (28 MG) (CAP SPR 24)...........................5NAMENDA XR (7 MG) (CAP SPR 24).............................5NAMENDA XR (7-14-21-28) (CAP24 DSPK).................. 5NAMZARIC (14MG-10MG) (CAP SPR 24)................5, 92NAMZARIC (21 MG-10MG) (CAP SPR 24)...............5, 92NAMZARIC (28 MG-10MG) (CAP SPR 24)...............5, 92NAMZARIC (7 MG-10 MG) (CAP SPR 24)................5, 92NAMZARIC (7-10/14-10) (CAP24 DSPK).................. 5, 92NAPROSYN...................................................................... 61NAPROXEN...................................................................... 61NAPROXEN SODIUM..................................................... 61NARATRIPTAN HCL....................................................... 76NARCAN (0.4 MG/ML) (SYRINGE).............................. 11NARCAN (0.4 MG/ML) (VIAL)...................................... 11NARCAN (1 MG/ML) (SYRINGE)................................. 11NARCAN (4 MG) (SPRAY)............................................. 11NARDIL.............................................................................. 6NASALIDE......................................................................... 1NASONEX.......................................................................... 1NATACYN.........................................................................39

NATALIZUMAB...............................................................70NATAMYCIN....................................................................39NATAZIA.................................................................... 21, 93NATEGLINIDE................................................................. 31NATPARA......................................................................... 36NATROBA.........................................................................24NAVANE............................................................................10NEBIVOLOL HCL............................................................15NEBIVOLOL HCL/VALSARTAN................................... 13NEBUPENT...................................................................... 54NEFAZODONE HCL..........................................................6NELARABINE..................................................................65NELFINAVIR MESYLATE.............................................. 57NEOMYCIN SULF/BACITRACIN/POLY.......................39NEOMYCIN SULF/POLYMYXIN B SULF....................27NEOMYCIN SULFATE....................................................53NEOMYCIN SULFATE/FLUOCINOLONE....................25NEOMYCIN/BACIT/P-MYX/HYDROCORT................. 37NEOMYCIN/FLUOCINOLONE/EMOLL 65..................25NEOMYCIN/POLYMYXIN B/DEXAMETHA...............37NEOMYCIN/POLYMYXIN B/HYDROCORT..........33, 37NEOMYCIN/POLYMYXN B/GRAMICIDIN................. 39NEO-POLYCIN.................................................................39NEORAL........................................................................... 49NEOSPORIN.....................................................................39NEOSPORIN G.U. IRRIGANT........................................ 27NEO-SYNALAR......................................................... 25, 93NEPAFENAC.................................................................... 38NEPTAZANE.................................................................... 39NERATINIB MALEATE...................................................67NERLYNX.........................................................................67NESTABS..........................................................................86NESTABS DHA................................................................ 85NETUPITANT/PALONOSETRON HCL........................... 2NEULASTA.......................................................................44NEUPOGEN......................................................................44NEUPRO........................................................................... 78NEURONTIN.................................................................... 78NEVIRAPINE................................................................... 56NEXA SELECT.................................................................85NEXAVAR.........................................................................68NEXAVIR..........................................................................64NEXIUM (10 MG) (SUSPDR PKT)...........................83, 93NEXIUM (2.5 MG) (SUSPDR PKT)..........................83, 93NEXIUM (20 MG) (CAPSULE DR).......................... 83, 93NEXIUM (20 MG) (SUSPDR PKT)...........................83, 93NEXIUM (40 MG) (CAPSULE DR).......................... 83, 93NEXIUM (40 MG) (SUSPDR PKT)...........................83, 93NEXIUM (5 MG) (SUSPDR PKT).............................83, 93NEXPLANON...................................................................21NIACIN............................................................................. 20NIASPAN.......................................................................... 20NICARDIPINE HCL.........................................................16NICARDIPINE HCL (20 MG) (CAPSULE)........................NICARDIPINE HCL (30 MG) (CAPSULE)........................NICODERM CQ............................................................... 81NICORETTE..................................................................... 81NICOTINE.........................................................................81NICOTINE PATCH...............................................................NICOTINE POLACRILEX...............................................81NIFEDIPINE..................................................................... 16NILANDRON....................................................................65NILOTINIB HCL.............................................................. 67NILUTAMIDE...................................................................65NIMODIPINE....................................................................16NIMOTOP......................................................................... 16NINLARO......................................................................... 67NINTEDANIB ESYLATE................................................ 73NIPENT............................................................................. 65NIRAPARIB TOSYLATE................................................. 67NIRAVAM........................................................................... 7NISOLDIPINE.................................................................. 16NITAZOXANIDE..............................................................54NITISINONE.....................................................................71NITRO-BID....................................................................... 20NITRO-DUR (0.1MG/HR) (PATCH TD24)..................... 20NITRO-DUR (0.2MG/HR) (PATCH TD24)..................... 20NITRO-DUR (0.4MG/HR) (PATCH TD24)..................... 20NITRO-DUR (0.6MG/HR) (PATCH TD24)..................... 20NITROFURANTOIN........................................................ 50NITROFURANTOIN MACROCRYSTAL....................... 50NITROFURANTOIN MONOHYD/M-CRYST................50NITROGLYCERIN............................................... 20, 21, 62NITROLINGUAL..............................................................20NITROMIST......................................................................21NITROSTAT...................................................................... 21NITRO-TIME.................................................................... 21NITYR............................................................................... 71NIVOLUMAB................................................................... 68NIZATIDINE.....................................................................83NIZORAL....................................................................24, 53NOLIX...............................................................................26

NOLVADEX...................................................................... 69NONOXYNOL 9...............................................................21NORCO............................................................................. 74NORDETTE-28.................................................................21NORDITROPIN FLEXPRO..............................................36NORELGESTROMIN/ETHIN.ESTRADIOL.................. 22NORETH-ETHINYL ESTRADIOL/IRON...................... 21NORETHINDRONE......................................................... 21NORETHINDRONE ACETATE....................................... 46NORETHINDRONE AC-ETH ESTRADIOL.............21, 46NORETHINDRONE-E.ESTRADIOL-IRON................... 21NORETHINDRONE-ETHINYL ESTRAD...................... 21NORFLEX (100 MG) (TABLET ER)............................... 81NORGESTIMATE-ETHINYL ESTRADIOL...................22NORGESTREL-ETHINYL ESTRADIOL....................... 22NORITATE........................................................................ 23NORMLGEL AG.............................................................. 23NORPACE......................................................................... 12NORPRAMIN..................................................................... 6NOR-Q-D.......................................................................... 21NORTRIPTYLINE HCL..................................................... 7NORVASC......................................................................... 15NORVIR (100 MG) (CAPSULE)......................................57NORVIR (100 MG) (TABLET).........................................57NORVIR (80 MG/ML) (SOLUTION).............................. 57NOVAREL.........................................................................35NOVOEIGHT.................................................................... 41

NOVOSEVEN RT............................................................. 41NOXAFIL (100 MG) (TABLET DR)................................53NOXAFIL (200 MG/5ML) (ORAL SUSP).......................53NPLATE............................................................................ 44NUCALA.............................................................................4NUCORT........................................................................... 26NUCYNTA........................................................................ 76NUCYNTA ER.................................................................. 76NUEDEXTA......................................................................70NULEV..............................................................................82NULOJIX.......................................................................... 49NULYTELY WITH FLAVOR PACKS..............................63NUMBONEX.................................................................... 29NUOX................................................................................28NUTRASEB...................................................................... 27NUTRESTORE................................................................. 72NUVAIL.............................................................................28NUVARING.......................................................................21NUVIGIL (150 MG) (TABLET).......................................11NUVIGIL (200 MG) (TABLET).......................................11NUVIGIL (250 MG) (TABLET).......................................11NUVIGIL (50 MG) (TABLET).........................................11NYAMYC.......................................................................... 24NYMALIZE (30MG/10ML) (SOLUTION)......................16NYSTATIN.................................................................. 24, 53NYSTATIN/TRIAMCIN................................................... 24NYSTEX............................................................................24NYSTOP............................................................................24

- O -OBETICHOLIC ACID...................................................... 62OBINUTUZUMAB...........................................................65OBIZUR............................................................................ 41OBTREX DHA..................................................................85OCALIVA..........................................................................62OCRELIZUMAB.............................................................. 70OCREVUS.........................................................................70OCTREOTIDE ACETATE.......................................... 72, 73OCUFEN........................................................................... 38OCUFLOX.........................................................................39OCUPRESS....................................................................... 39ODEFSEY......................................................................... 57OFATUMUMAB............................................................... 65OFEV.................................................................................73OFLOXACIN.........................................................33, 39, 51OGEN 2.5.......................................................................... 46OLANZAPINE.................................................................... 9OLANZAPINE/FLUOXETINE HCL............................... 11OLAPARIB........................................................................67OLARATUMAB................................................................68OLMESARTAN MEDOXOMIL.......................................14OLMESARTAN/AMLODIPIN/HCTHIAZID.................. 13OLMESARTAN/HYDROCHLOROTHIAZIDE...............13OLODATEROL HCL.......................................................... 3OLOPATADINE HCL................................................... 1, 38OLUX................................................................................ 25OLUX-E............................................................................ 25OMACETAXINE MEPESUCCINATE............................. 68OMALIZUMAB..................................................................4OMEGA-3 ACID ETHYL ESTERS................................. 20OMEGA-3 FATTY ACIDS/FISH OIL..............................20OMEGA-3 FATTY ACIDS/FISH OIL (300-1000MG)(CAPSULE) (OTC)...............................................................OMEPPI.......................................................................83, 93


Index

OMEPRAZOLE................................................................ 83OMEPRAZOLE/SODIUM BICARBONATE...................83OMNARIS..................................................................... 1, 93OMNICEF......................................................................... 50OMNIPRED...................................................................... 38ONABOTULINUMTOXINA............................................ 72ONCASPAR...................................................................... 68ONDANSETRON................................................................2ONDANSETRON HCL.......................................................2ONDANSETRON HCL IN 0.9 % NACL........................... 2ONDANSETRON HCL IN D5W........................................2ONDANSETRON HCL/PF................................................. 2ONE TOUCH DELICA.....................................................63ONETOUCH DELICA......................................................63ONETOUCH LANCETS.................................................. 63ONETOUCH SURESOFT................................................ 63ONETOUCH ULTRA TEST STRIPS...............................32ONETOUCH ULTRA2..................................................... 32ONETOUCH ULTRAMINI.............................................. 32ONETOUCH VERIO........................................................ 32ONETOUCH VERIO FLEX............................................. 32ONETOUCH VERIO IQ...................................................32ONEXTON.................................................................. 23, 93ONFI (10 MG) (TABLET).......................................... 81, 93ONFI (2.5 MG/ML) (ORAL SUSP)............................81, 93ONFI (20 MG) (TABLET).......................................... 81, 93ONIVYDE......................................................................... 66ONZETRA XSAIL............................................................76OPANA (10 MG) (TABLET)............................................ 75OPANA (5 MG) (TABLET).............................................. 75OPANA ER (10 MG) (TAB ER 12H)................................75OPANA ER (15 MG) (TAB ER 12H)................................75OPANA ER (20 MG) (TAB ER 12H)................................75OPANA ER (30 MG) (TAB ER 12H)................................75OPANA ER (40 MG) (TAB ER 12H)................................76OPANA ER (5 MG) (TAB ER 12H)..................................76OPANA ER (7.5 MG) (TAB ER 12H)...............................76OPDIVO............................................................................ 68OPIUM TINCTURE..........................................................62OPSUMIT..........................................................................17OPTICROM.......................................................................39OPTIPRANOLOL............................................................. 39OPTIVAR...........................................................................38ORACEA (40 MG) (CAP IR DR)...............................52, 93ORAP...................................................................................8ORAPRED.........................................................................59ORBIVAN CF..............................................................73, 93ORENCIA..........................................................................59ORENITRAM ER............................................................. 17ORFADIN..........................................................................71ORINASE.......................................................................... 31ORKAMBI........................................................................ 73ORPHENADRINE CITRATE...........................................81ORTHO EVRA..................................................................22ORTHO MICRONOR....................................................... 21ORTHO TRI-CYCLEN..................................................... 22ORTHO TRI-CYCLEN LO...............................................22ORTHO-CEPT...................................................................21ORTHO-CYCLEN............................................................ 22ORTHO-EST..................................................................... 46ORTHO-NOVUM..............................................................21ORUDIS.............................................................................60ORUVAIL.......................................................................... 60OSELTAMIVIR PHOSPHATE................................... 54, 55OSENI................................................................................30OSIMERTINIB MESYLATE............................................67OTEZLA (10-20-30MG) (TAB DS PK)............................59OTEZLA (30 MG) (TABLET).......................................... 59OTIPRIO............................................................................33OTOVEL............................................................................33OTREXUP................................................................... 58, 93OVCON-35........................................................................ 21OVIDE............................................................................... 24OVRAL..............................................................................22OXALIPLATIN................................................................. 64OXANDRIN...................................................................... 45OXANDROLONE............................................................. 45OXAPROZIN.....................................................................61OXAZEPAM........................................................................8OXCARBAZEPINE.......................................................... 80OXICONAZOLE NITRATE............................................. 24OXISTAT (1 %) (CREAM (G)).........................................24OXYBUTYNIN CHLORIDE............................................84OXYCODONE HCL......................................................... 75OXYCODONE HCL (10 MG) (TAB ER 12H).....................OXYCODONE HCL (10 MG) (TABLET)...........................OXYCODONE HCL (10MG/0.5ML) (SYRINGE)..............OXYCODONE HCL (15 MG) (TAB ER 12H).....................OXYCODONE HCL (15 MG) (TABLET)...........................OXYCODONE HCL (20 MG) (TAB ER 12H).....................OXYCODONE HCL (20 MG) (TABLET)...........................OXYCODONE HCL (20 MG/ML) (ORAL CONC)............

OXYCODONE HCL (30 MG) (TAB ER 12H).....................OXYCODONE HCL (30 MG) (TABLET)...........................OXYCODONE HCL (40 MG) (TAB ER 12H).....................OXYCODONE HCL (5 MG) (CAPSULE)...........................OXYCODONE HCL (5 MG) (TABLET).............................OXYCODONE HCL (5 MG/5 ML) (SOLUTION)..............OXYCODONE HCL (60 MG) (TAB ER 12H).....................OXYCODONE HCL (80 MG) (TAB ER 12H).....................OXYCODONE HCL/ACETAMINOPHEN...................... 75OXYCODONE HCL/ASPIRIN........................................ 75OXYMORPHONE HCL............................................. 75, 76

- P -PACLITAXEL PROTEIN-BOUND.................................. 68PACNEX HP......................................................................28PACNEX LP...................................................................... 28PALBOCICLIB................................................................. 67PALGIC............................................................................... 1PALIFERMIN....................................................................70PALIPERIDONE................................................................. 9PALIVIZUMAB................................................................ 54PALM OIL/EUCALYPTUS OIL.......................................27PAMELOR...........................................................................7PAMIDRONATE DISODIUM.......................................... 35PAMINE............................................................................ 82PAMINE FORTE...............................................................82PANHEMATIN..................................................................42PANITUMUMAB............................................................. 65PANMYCIN...................................................................... 52PANRETIN........................................................................29PANTOPRAZOLE SODIUM............................................83PAPAV/PHENTOLAM/ALPROST/WATER.....................34PAPAVERINE HCL...........................................................21PAPAVERINE HCL/ALPROSTAD/WATER.................... 34PAPAVERINE/PHENTOLAMINE/WATER.....................21PARADIGM SILHOUETTE.............................................63PARAGARD T 380-A....................................................... 71PARATHYROID HORMONE.......................................... 36PARCOPA..........................................................................78PAREGORIC..................................................................... 62PAREMYD........................................................................ 40PARICALCITOL...............................................................36PARICALCITOL (1 MCG) (CAPSULE)..............................PARICALCITOL (2 MCG) (CAPSULE)..............................PARICALCITOL (4MCG) (CAPSULE)...............................PARLODEL.......................................................................77PARNATE............................................................................6PAROMOMYCIN SULFATE............................................54PAROXETINE HCL............................................................6PAROXETINE MESYLATE............................................. 72PARSABIV........................................................................36PASER............................................................................... 53PASIREOTIDE DIASPARTATE....................................... 73PATADAY.......................................................................... 38PATANASE..........................................................................1PATANOL..........................................................................38PATHOCIL........................................................................ 51PATIROMER CALCIUM SORBITEX............................. 34PAXIL (10 MG) (TABLET)................................................ 6PAXIL (20 MG) (TABLET)................................................ 6PAXIL (30 MG) (TABLET)................................................ 6PAXIL (40 MG) (TABLET)................................................ 6PAXIL CR............................................................................6PAZEO.........................................................................38, 93PAZOPANIB HCL.............................................................67PEAK FLOW METER........................................................ 4PEAK FLOW METER/INH ASSIT DEV...........................4PEG 3350/SOD CHLOR/POTASS CIT............................ 62PEG3350/SOD SULF,BICARB,CL/KCL................... 62, 63PEGADEMASE BOVINE.................................................71PEGANONE......................................................................78PEGASPARGASE.............................................................68PEGASYS..........................................................................58PEGASYS PROCLICK.....................................................58PEGFILGRASTIM............................................................44PEGINTERFERON ALFA-2A..........................................58PEGINTERFERON ALFA-2B..........................................66PEGINTERFERON BETA-1A..........................................70PEGLOTICASE.................................................................40PEGVISOMANT...............................................................36PEMBROLIZUMAB.........................................................68PEMETREXED DISODIUM............................................65PEN NEEDLE (30G X5/16"") (DIS NEEDLE)................72PEN NEEDLE (31 G X1/4"") (DIS NEEDLE) (OTC)......72PEN NEEDLE (31 GX3/16"") (DIS NEEDLE)................72PEN NEEDLE (31 GX5/16"") (DIS NEEDLE)................72PEN NEEDLE (31 GX5/16"") (DIS NEEDLE) (OTC)......72PEN NEEDLE (32GX 5/32"") (DIS NEEDLE) (OTC)......72PEN NEEDLE, DIABETIC...............................................72

PENICILLAMINE............................................................ 58PENICILLIN V POTASSIUM.......................................... 51PENLAC............................................................................24PENTAMIDINE ISETHIONATE......................................54PENTASA..........................................................................61PENTAZINE VC WITH CODEINE................................. 22PENTOSAN POLYSULFATE SODIUM..........................84PENTOSTATIN................................................................. 65PENTOXIFYLLINE..........................................................42PEPCID (20 MG) (TABLET)............................................82PEPCID (40 MG) (TABLET)............................................82PEPCID (40MG/5ML) (ORAL SUSP)............................. 82PERAMPANEL................................................................. 80PERCOCET.......................................................................75PERCODAN......................................................................75PERFOROMIST..................................................................3PERIACTIN.........................................................................1PERINDOPRIL ARG/AMLODIPINE BES......................13PERINDOPRIL ERBUMINE........................................... 14PERIOSTAT.......................................................................71PERJETA........................................................................... 65PERMETHRIN..................................................................24PERMETHRIN (5 %) (CREAM (G))...................................PERPHENAZINE..............................................................10PERPHENAZINE/AMITRIPTYLINE HCL.......................6PERSANTINE...................................................................44PERTUZUMAB................................................................ 65PETROLATUM,WHITE................................................... 28PETROLATUM,WHITE (OINT PACK)...............................PHEN TUSS DM...............................................................22PHENAZOPYRIDINE HCL............................................. 84PHENELZINE SULFATE................................................... 6PHENERGAN..................................................................... 2PHENERGAN (12.5 MG) (TABLET)................................ 1PHENERGAN (25 MG) (TABLET)................................... 1PHENERGAN (25 MG/ML) (SYRINGE)..........................1PHENERGAN (25 MG/ML) (VIAL)..................................1PHENERGAN (50 MG) (TABLET)................................... 1PHENERGAN (50 MG/ML) (VIAL)..................................1PHENERGAN VC.........................................................1, 22PHENERGAN VC WITH CODEINE...............................22PHENERGAN WITH CODEINE..................................... 22PHENOBARB/HYOSCY/ATROPINE/SCOP.................. 82PHENOBARBITAL.......................................................... 10PHENOXYBENZAMINE HCL..................................13, 17PHENTOLAMINE/ALPROSTADIL/WATER..................34PHEN-TUSS AD............................................................... 22PHENYLEPHRINE HCL..................................................38PHENYLEPHRINE HCL/PROMETH HCL.....................22PHENYTEK...................................................................... 80PHENYTOIN.................................................................... 80PHENYTOIN SODIUM EXTENDED............................. 80PHLAG SPRAY.................................................................27PHOSLO............................................................................34PHOSLYRA.......................................................................34PHOSPHASAL..................................................................50PHOSPHOLINE IODIDE................................................. 39PHOTOFRIN..................................................................... 69PHYSIOLOGICAL IRRIG SOLN NO.1.......................... 27PHYSIOLYTE................................................................... 27PHYSIOSOL..................................................................... 27PHYTONADIONE (VIT K1)............................................45PHYTONADIONE (VIT K1) (10 MG/ML) (AMPUL)........PHYTONADIONE (VIT K1) (1MG/0.5ML) (AMPUL)...............................................................................................PHYTONADIONE (VIT K1) (1MG/0.5ML) (SYRINGE)...............................................................................................PICATO (0.015 %) (GEL (EA))........................................29PICATO (0.05 %) (GEL (EA))..........................................29PILOCARPINE HCL.................................................. 39, 64PIMECROLIMUS............................................................. 30PIMOZIDE.......................................................................... 8PINDOLOL....................................................................... 15PIOGLITAZONE HCL......................................................31PIOGLITAZONE HCL/GLIMEPIRIDE...........................31PIOGLITAZONE HCL/METFORMIN HCL................... 32PIRFENIDONE................................................................. 73PIROXICAM..................................................................... 61PITAVASTATIN CALCIUM............................................. 18PLAQUENIL..................................................................... 54PLAVIX (300 MG) (TABLET)......................................... 44PLAVIX (75 MG) (TABLET)........................................... 44PLEGRIDY (125MCG/0.5) (SYRINGE)..........................70PLEGRIDY (63-94 MCG) (SYRINGE)............................70PLEGRIDY PEN (125MCG/0.5) (PEN INJCTR).............70PLEGRIDY PEN (63-94 MCG) (PEN INJCTR).............. 70PLENDIL...........................................................................16PLETAL.............................................................................44PLEXION.......................................................................... 25PLEXION (10-5%(W/W)) (LOTION).............................. 25PLEXION (9.8%-4.8%) (CLEANSER)............................ 25PLEXION (9.8%-4.8%) (CREAM (G))............................ 25


Index

PLEXION (9.8%-4.8%) (LOTION).................................. 25PLEXION TS.....................................................................25PLIAGLIS (7 %-7 %) (CREAM (G))................................29PNEUMOC 13-VAL CONJ-DIP CRM/PF........................47PNEUMOCOCCAL 23-VAL P-SAC VAC....................... 47PNEUMOVAX 23............................................................. 47PNV 11/IRON FUM/FOLIC ACID/OM3......................... 85PNV 15/IRON FUM,PS/FOLIC ACID............................. 85PNV 16/IRON FUM,PS/FOLIC/OM-3.............................85PNV 19/IRON PS,HEME/FOLIC/DHA........................... 85PNV 21/IRON PS,HEME PPEP/FOLIC........................... 85PNV 39/IRON/FOLIC/DOCUSATE/DHA....................... 85PNV 66/IRON/FOLIC/DOCUSATE/DHA....................... 85PNV 69/IRON/FOLIC/DOCUSATE/DHA....................... 85PNV 80/IRON FUM/FOLIC/DSS/DHA........................... 85PNV NO.118/IRON FUMARATE/FA.............................. 85PNV NO.118/IRON FUMARATE/FA (29 MG-1 MG)(TAB CHEW)........................................................................PNV NO.5/FERROUS FUM/FOLIC AC..........................85PNV, CALCIUM 62/IRON/FOLIC/DHA......................... 85PNV,CALC 35/IRON/FOLIC/DSS/OM3..........................85PNV,CALCIUM 72/IRON,CARB/FOLIC........................ 85PNV,CALCIUM 72/IRON/FOLIC ACID......................... 85PNV,CALCIUM37/IRON/FOLIC/OMEG3...................... 85PNV/FERROUS FUM/DOCUSATE/FOLIC.................... 85PNV/FERROUS FUM/FOLIC ACID/SEL....................... 85PNV/FOLIC AC/B6/CALCIUM/GINGER.......................86PNV/IRON,CARB/DOCUSAT/FOLIC AC...................... 85PNV119/IRON FUM/FOLIC/DOCUSATE...................... 85PNV19/IRON BG,S.P/FOLIC AC/OM3........................... 85PNV81/IRON EDTA,PS/FOLIC/OMEG3........................ 85PODOFILOX.....................................................................28POLYDIMETHYLSILOXANES/SILICON..................... 28POLYETHYLENE GLYCOL 3350...................................63POLYFIN QR.................................................................... 63POLYMYXIN B SULF/TRIMETHOPRIM......................39POLYTRIM....................................................................... 39POLY-UREAURETHANE................................................ 28POMALIDOMIDE............................................................ 66POMALYST...................................................................... 66PONATINIB HCL............................................................. 67PONTOCAINE..................................................................29PORACTANT ALFA.........................................................73PORFIMER SODIUM.......................................................69POSACONAZOLE............................................................53POT CHLORIDE/POT BICARB/CIT AC........................ 34POTASSIUM BICARBONATE/CIT AC.......................... 34POTASSIUM CHLORIDE................................................34POTASSIUM CHLORIDE (10 MEQ) (CAPSULE ER).......POTASSIUM CHLORIDE (10 MEQ) (TAB ER PRT).........POTASSIUM CHLORIDE (10 MEQ) (TABLET ER)..........POTASSIUM CHLORIDE (15 MEQ) (TAB ER PRT).........POTASSIUM CHLORIDE (20 MEQ) (PACKET)................POTASSIUM CHLORIDE (20 MEQ) (TAB ER PRT).........POTASSIUM CHLORIDE (20 MEQ) (TABLET ER)..........POTASSIUM CHLORIDE (20MEQ/15ML) (LIQUID).......POTASSIUM CHLORIDE (40MEQ/15ML) (LIQUID).......POTASSIUM CHLORIDE (8 MEQ) (CAPSULE ER).........POTASSIUM CHLORIDE (8 MEQ) (TABLET ER)............POTASSIUM CITRATE....................................................84POTASSIUM CITRATE/CITRIC ACID...........................84POTASSIUM IODIDE/IODINE........................................37POTASSIUM PHOSPHATE,MONOBASIC.....................84POVIDONE-IODINE........................................................ 38PRALATREXATE.............................................................65PRALUENT PEN..............................................................19PRAMCORT......................................................................61PRAMIPEXOLE DI-HCL.................................................78PRAMLINTIDE ACETATE.............................................. 31PRAMOSONE (2.5 %-1 %) (CREAM (G))......................29PRANDIMET.................................................................... 31PRANDIN..........................................................................31PRASUGREL HCL........................................................... 44PRAVACHOL.................................................................... 18PRAVASTATIN SODIUM.................................................18PRAZIQUANTEL............................................................. 54PRAZOSIN HCL...............................................................13PRECOSE..........................................................................30PRED FORTE....................................................................38PREDNICARBATE...........................................................27PREDNISOLONE............................................................. 59PREDNISOLONE ACETATE...........................................38PREDNISOLONE ACETATE/NEPAFENAC...................38PREDNISOLONE SOD PHOSPHATE...................... 38, 59PREDNISONE.................................................................. 60PREDNISONE INTENSOL..................................................PREFERA OB................................................................... 85PREFERA-OB ONE..........................................................85PREGABALIN.................................................................. 80PREMARIN.......................................................................85PREMARIN (0.3 MG) (TABLET)....................................46PREMARIN (0.45MG) (TABLET)...................................46

PREMARIN (0.625 MG) (TABLET)................................46PREMARIN (0.9 MG) (TABLET)....................................46PREMARIN (1.25 MG) (TABLET)..................................46PREMIUM BLOOD GLUCOSE (EACH) (OTC).............32PREMIUM BLOOD GLUCOSE TEST (STRIP) (OTC)........................................................................................... 32PREMPHASE....................................................................45PREMPRO.........................................................................45PRENAT VIT 17/IRON/FOLIC/OM3,6............................85PRENATAL 105/IRON/FOLIC AC/DHA.........................85PRENATAL 12/IRON/FOLIC/DSS/OM3......................... 85PRENATAL 34/IRON/FOLIC/DSS/DHA.........................85PRENATAL 47/IRON/FOLATE 1/DHA...........................85PRENATAL 53/IRON/FOLIC AC/OMG3........................ 85PRENATAL 54/IRON/FOLIC AC/OMG3........................ 85PRENATAL 59/IRON/FOLIC/DSS/DHA.........................85PRENATAL 68/IRON/FOLIC NO1/DHA........................ 85PRENATAL 87/IRON BIS/FOLIC/DHA.......................... 85PRENATAL COMB NO.42/FOLIC ACID........................85PRENATAL VIT 14/IRON FUM/FOLIC..........................85PRENATAL VIT 55/IRON/FOLIC/OM3..........................85PRENATAL VIT 7/IRON/FOLIC/DHA............................85PRENATAL VIT NO.109/IRON/FA................................. 85PRENATAL VIT,CAL 73/IRON/FOLIC...........................85PRENATAL VIT,CAL 74/IRON/FOLIC...........................85PRENATAL VIT,CALC76/IRON/FOLIC.........................86PRENATAL VIT,CALC78/IRON/FOLIC.........................86PRENATAL VIT/IRON BISGLY/FOLIC......................... 86PRENATAL VIT/IRON FUM/FOLIC AC........................ 86PRENATAL VIT/IRON FUM/FOLIC AC (65 MG-1 MG)(CAPSULE)...........................................................................PRENATAL VIT/IRON FUM/FOLIC AC (65 MG-1 MG)(TABLET)..............................................................................PRENATAL VIT27,CALCIUM/IRON/FA........................86PRENATAL VIT86/IRON/FOLIC ACID..........................86PRENATAL VITS15/IRON/FOLIC/DSS..........................86PRENATAL VITS16/IRON/FOLIC/DSS..........................86PRENATAL VITS18/IRON/FOLIC/DSS..........................86PRENATAL,CALC.40/IRON/FOLATE 1......................... 86PRENATAL71/IRON/FOLIC ACID/DHA........................86PREPIDIL..........................................................................22PREPOPIK........................................................................ 63PRESTALIA...................................................................... 13PREVACID (15 MG) (CAPSULE DR).............................83PREVACID (30 MG) (CAPSULE DR).............................83PREVNAR 13....................................................................47PREVPAC..........................................................................82PREVYMIS....................................................................... 54PREZCOBIX..................................................................... 55PREZISTA (100 MG/ML) (ORAL SUSP)........................55PREZISTA (150 MG) (TABLET)..................................... 55PREZISTA (600 MG) (TABLET)..................................... 55PREZISTA (75 MG) (TABLET)....................................... 55PREZISTA (800 MG) (TABLET)..................................... 55PRIFTIN............................................................................ 53PRILOSEC (10 MG) (CAPSULE DR)............................. 83PRILOSEC (20 MG) (CAPSULE DR)............................. 83PRILOSEC (40 MG) (CAPSULE DR)............................. 83PRIMAQUINE.................................................................. 54PRIMAQUINE PHOSPHATE...........................................54PRIMIDONE..................................................................... 80PRINIVIL.......................................................................... 14PRISTIQ.............................................................................. 6PRIVIGEN (10 %) (VIAL)............................................... 46PROAIR HFA...................................................................... 3PROAIR RESPICLICK....................................................... 3PROAMATINE..................................................................20PROBENECID.................................................................. 40PROBENECID/COLCHICINE......................................... 40PROCARBAZINE HCL....................................................68PROCARDIA.................................................................... 16PROCARDIA XL.............................................................. 16PROCENTRA......................................................................7PROCHLORPERAZINE.....................................................2PROCHLORPERAZINE MALEATE................................. 2PROCRIT (10000/ML) (VIAL).........................................42PROCRIT (2000/ML) (VIAL)...........................................42PROCRIT (20000/2ML) (VIAL).......................................42PROCRIT (20000/ML) (VIAL).........................................42PROCRIT (3000/ML) (VIAL)...........................................42PROCRIT (4000/ML) (VIAL)...........................................42PROCRIT (40000/ML) (VIAL).........................................42PROCTOCORT................................................................. 62PRODRIN..........................................................................76PROFILNINE.................................................................... 42PROGESTERONE.............................................................46PROGESTERONE, MICRONIZED............................35, 46PROGLYCEM................................................................... 32PROGRAF (0.5 MG) (CAPSULE)................................... 49PROGRAF (1 MG) (CAPSULE)...................................... 49PROGRAF (5 MG) (CAPSULE)...................................... 49PROLASTIN C (1000 MG) (VIAL)................................. 64

PROLASTIN C (1000 MG/20) (VIAL)............................ 64PROLENSA.......................................................................38PROLEUKIN.....................................................................49PROLIXIN (1 MG) (TABLET)......................................... 10PROLIXIN (10 MG) (TABLET)....................................... 10PROLIXIN (2.5 MG) (TABLET)...................................... 10PROLIXIN (2.5 MG/5ML) (ELIXIR)...............................10PROLIXIN (5 MG) (TABLET)......................................... 10PROLIXIN (5 MG/ML) (ORAL CONC)..........................10PROLOPRIM.....................................................................50PROMACTA......................................................................44PROMETHAZINE HCL................................................. 1, 2PROMETHAZINE HCL/CODEINE.................................22PROMETHAZINE/DEXTROMETHORPHAN............... 22PROMETHAZINE/PHENYLEPH/CODEINE................. 22PROMETRIUM.................................................................46PROPAFENONE HCL...................................................... 13PROPARACAINE HCL.................................................... 38PROPARACAINE/FLUORESCEIN SOD........................ 38PROPRANOLOL HCL..................................................... 15PROPRANOLOL/HYDROCHLOROTHIAZID...............15PROPYLTHIOURACIL.................................................... 37PROQUAD........................................................................ 48PROSCAR......................................................................... 84PROSOM........................................................................... 11PROSTIN E2 VAGINAL SUPPOSITORY....................... 22PROTECTIVES COMBINATION NO.2.......................... 28PROTECTIVES2/CERAMIDE 1,3,6-11...........................28PROTEIN C, HUMAN...................................................... 44PROTONIX (20 MG) (TABLET DR)............................... 83PROTONIX (40 MG) (TABLET DR)............................... 83PROTOPIC........................................................................ 30PROTRIPTYLINE HCL......................................................7PROVERA......................................................................... 46PROVIGIL......................................................................... 11PROZAC..............................................................................6PROZAC WEEKLY............................................................ 6PRUSSIAN BLUE (INSOLUBLE)...................................72PSEUDOEPHED/CHLOR-MAL/BELL ALK..................22PSORCON.........................................................................26PSYLLIUM HUSK........................................................... 63PSYLLIUM HUSK (WITH DEXTROSE)........................63PULMICORT (0.25MG/2ML) (AMPUL-NEB)................. 3PULMICORT (0.5 MG/2ML) (AMPUL-NEB).................. 3PULMICORT (1 MG/2 ML) (AMPUL-NEB).................... 4PULMICORT FLEXHALER........................................ 4, 93PULMOZYME.................................................................. 73PURINETHOL.................................................................. 65PURIXAN....................................................................65, 93PYLERA............................................................................82PYRAZINAMIDE............................................................. 53PYRIDIUM........................................................................84PYRIDOSTIGMINE BROMIDE........................................ 5PYRIMETHAMINE..........................................................54

- Q -QNASL................................................................................ 1QNASL CHILDREN...........................................................1QUALAQUIN....................................................................54QUAZEPAM......................................................................11QUDEXY XR (100 MG) (CAP SPR 24).................... 80, 93QUDEXY XR (150 MG) (CAP SPR 24).................... 80, 93QUDEXY XR (200 MG) (CAP SPR 24).................... 80, 93QUDEXY XR (25 MG) (CAP SPR 24)...................... 80, 93QUDEXY XR (50 MG) (CAP SPR 24)...................... 80, 93QUESTRAN...................................................................... 19QUESTRAN LIGHT......................................................... 19QUETIAPINE FUMARATE............................................... 9QUILLICHEW ER (20 MG) (TAB CBP24H)............ 12, 93QUILLICHEW ER (30 MG) (TAB CBP24H)............ 12, 93QUILLICHEW ER (40 MG) (TAB CBP24H)............ 12, 93QUILLIVANT XR (5 MG/ML) (SU ER RC24)......... 12, 93QUINAPRIL HCL.............................................................14QUINAPRIL/HYDROCHLOROTHIAZIDE.................... 13QUINIDINE GLUCONATE..............................................13QUINIDINE GLUCONATE (324 MG) (TABLET ER)........QUINIDINE SULFATE.....................................................13QUININE SULFATE.........................................................54QVAR...................................................................................3QVAR REDIHALER...........................................................3

- R -RABEPRAZOLE SODIUM..............................................83RADICAVA....................................................................... 70RADIOGARDASE............................................................72RALOXIFENE HCL......................................................... 35RALTEGRAVIR POTASSIUM.........................................57RAMIPRIL........................................................................ 14RAMUCIRUMAB.............................................................66RANEXA (1000 MG) (TAB ER 12H).............................. 20RANEXA (500 MG) (TAB ER 12H)................................ 20RANITIDINE HCL........................................................... 83RANOLAZINE..................................................................20


Index

RAPAFLO................................................................... 84, 93RAPAMUNE (0.5 MG) (TABLET).................................. 49RAPAMUNE (1 MG) (TABLET)..................................... 49RAPAMUNE (1 MG/ML) (SOLUTION)......................... 49RAPAMUNE (2 MG) (TABLET)..................................... 49RAPLIXA.......................................................................... 44RASAGILINE MESYLATE..............................................78RASUVO (10MG/0.2ML) (AUTO INJCT)................ 58, 93RASUVO (12.5/0.25) (AUTO INJCT)........................58, 93RASUVO (15MG/0.3ML) (AUTO INJCT)................ 58, 94RASUVO (17.5/0.35) (AUTO INJCT)........................58, 94RASUVO (20MG/0.4ML) (AUTO INJCT)................ 58, 94RASUVO (22.5/0.45) (AUTO INJCT)..............................58RASUVO (25MG/0.5ML) (AUTO INJCT)................ 58, 94RASUVO (30MG/0.6ML) (AUTO INJCT)................ 58, 94RASUVO (7.5MG/0.15) (AUTO INJCT)................... 58, 94RAVICTI............................................................................62RAZADYNE (12 MG) (TABLET)......................................5RAZADYNE (4 MG) (TABLET)........................................5RAZADYNE (4 MG/ML) (SOLUTION)............................5RAZADYNE (8 MG) (TABLET)........................................5RAZADYNE ER................................................................. 5READYSHARP KETOROLAC........................................ 61REBIF (22MCG/.5ML) (SYRINGE)................................ 69REBIF (44MCG/.5ML) (SYRINGE)................................ 69REBIF (8.8-22(6)) (SYRINGE)........................................ 70REBIF REBIDOSE (22MCG/.5ML) (PEN INJCTR).......70REBIF REBIDOSE (44MCG/.5ML) (PEN INJCTR).......70REBIF REBIDOSE (8.8-22(6)) (PEN INJCTR)............... 70REBINYN..........................................................................42RECEDO........................................................................... 28RECOMBIVAX HB (10 MCG/ML) (SYRINGE).............48RECOMBIVAX HB (10 MCG/ML) (VIAL).................... 48RECOMBIVAX HB (40 MCG/ML) (VIAL).................... 48RECOTHROM...................................................................45RECTACORT-HC..............................................................62RECTAGEL HC................................................................ 61RECTIV.............................................................................62REGLAN (10 MG) (TABLET)......................................... 83REGLAN (10 MG/10ML) (SOLUTION)......................... 83REGLAN (5 MG) (TABLET)........................................... 83REGLAN (5 MG/5 ML) (SOLUTION)............................ 83REGORAFENIB............................................................... 67REGRANEX......................................................................32RELAFEN......................................................................... 61RELENZA......................................................................... 55RELISTOR (12MG/0.6ML) (SYRINGE)......................... 63RELISTOR (12MG/0.6ML) (VIAL).................................63RELISTOR (150 MG) (TABLET).....................................63RELISTOR (8 MG/0.4ML) (SYRINGE).......................... 63RELPAX...................................................................... 76, 94REMERON..........................................................................5REMICADE...................................................................... 61REMODULIN................................................................... 17RENACIDIN......................................................................84RENFLEXIS......................................................................61RENVELA.........................................................................34REPAGLINIDE................................................................. 31REPAGLINIDE/METFORMIN HCL............................... 31REPATHA PUSHTRONEX.............................................. 19REPATHA SURECLICK.................................................. 19REPATHA SYRINGE....................................................... 19REPREXAIN.....................................................................74REQUIP.............................................................................78REQUIP XL.................................................................78, 94RESCRIPTOR................................................................... 55RESECTISOL....................................................................16RESTASIS......................................................................... 39RESTASIS MULTIDOSE................................................. 39RESTIZAN........................................................................ 27RESTORIL........................................................................ 11RETIN-A........................................................................... 23RETIN-A MICRO............................................................. 23RETIN-A MICRO PUMP (0.04 %) (GEL W/PUMP)......23RETIN-A MICRO PUMP (0.06 %) (GEL W/PUMP)......23, 94RETIN-A MICRO PUMP (0.1 %) (GEL W/PUMP)........ 24RETROVIR (10 MG/ML) (SYRUP)................................. 56RETROVIR (100 MG) (CAPSULE)................................. 56RETROVIR (300 MG) (TABLET)....................................56REVATIO (10 MG/12.5) (VIAL)...................................... 17REVATIO (20 MG) (TABLET)......................................... 17REVIA............................................................................... 11REVLIMID........................................................................66REYATAZ (150 MG) (CAPSULE)................................... 57REYATAZ (200 MG) (CAPSULE)................................... 57REYATAZ (300 MG) (CAPSULE)................................... 57REYATAZ (50 MG) (POWD PACK)................................ 57RIASTAP........................................................................... 40RIBAVIRIN................................................................. 55, 58RIBAVIRIN (200 MG) (CAPSULE).....................................

RIBAVIRIN (200 MG) (TABLET)........................................RIBAVIRIN (200-400(7)) (TAB DS PK).......................... 94RIBOCICLIB SUCCINATE/LETROZOLE......................66RIDAURA......................................................................... 60RIFABUTIN...................................................................... 53RIFADIN (150 MG) (CAPSULE).....................................53RIFADIN (300 MG) (CAPSULE).....................................53RIFAMP/ISONIAZID/PYRAZINAMIDE........................ 53RIFAMPIN........................................................................ 53RIFAPENTINE..................................................................53RIFATER........................................................................... 53RIFAXIMIN...................................................................... 54RILONACEPT...................................................................58RILPIVIRINE HCL...........................................................56RILUTEK.......................................................................... 70RILUZOLE........................................................................70RIMABOTULINUMTOXINB.......................................... 72RIMANTADINE HCL...................................................... 55RINGER'S SOLUTION.................................................... 27RINGER'S SOLUTION,LACTATED............................... 28RIOCIGUAT......................................................................16RISEDRONATE SODIUM............................................... 36RISPERDAL (0.25 MG) (TABLET)................................... 9RISPERDAL (0.5 MG) (TABLET)..................................... 9RISPERDAL (1 MG) (TABLET)........................................ 9RISPERDAL (1 MG/ML) (SOLUTION)..........................10RISPERDAL (2 MG) (TABLET)...................................... 10RISPERDAL (3 MG) (TABLET)...................................... 10RISPERDAL (4 MG) (TABLET)...................................... 10RISPERDAL CONSTA..................................................... 10RISPERDAL M-TAB........................................................ 10RISPERIDONE............................................................. 9, 10RISPERIDONE MICROSPHERES.................................. 10RITALIN LA..................................................................... 12RITONAVIR...................................................................... 57RITUXAN......................................................................... 65RITUXAN HYCELA........................................................ 65RITUXIMAB.....................................................................65RITUXIMAB/HYALURONIDASE,HUMAN.................. 65RIVAROXABAN...............................................................42RIVASTIGMINE................................................................. 5RIVASTIGMINE TARTRATE............................................ 5RIZATRIPTAN BENZOATE............................................ 76ROBAXIN (500 MG) (TABLET)......................................81ROBAXIN-750.................................................................. 81ROBINUL (1 MG) (TABLET).......................................... 82ROBINUL FORTE............................................................ 82ROCALTROL.................................................................... 86ROFLUMILAST................................................................. 4ROLAPITANT HCL............................................................2ROMIDEPSIN................................................................... 68ROMIPLOSTIM................................................................44ROPINIROLE HCL...........................................................78ROSADAN........................................................................ 23ROSULA (10 %-4.5 %) (CLEANSER)............................ 25ROSULA (10 %-5 %) (MED. PAD)..................................25ROSUVASTATIN CALCIUM...........................................18ROTATEQ..........................................................................47ROTAVIRUS VACCINE,LIVE ORAL PV........................47ROTIGOTINE....................................................................78ROWASA...........................................................................61ROWEEPRA......................................................................80ROXICET.......................................................................... 75RUBRACA (200 MG) (TABLET).....................................68RUBRACA (250 MG) (TABLET).....................................68RUBRACA (300 MG) (TABLET).....................................68RUCAPARIB CAMSYLATE............................................68RUFINAMIDE.................................................................. 80RUXOLITINIB PHOSPHATE.......................................... 66RYDAPT............................................................................67RYTARY............................................................................78RYTHMOL........................................................................13RYTHMOL SR..................................................................13RYZOLT............................................................................ 76

- S -SABRIL (500 MG) (POWD PACK)..................................81SABRIL (500 MG) (TABLET)......................................... 81SACROSIDASE................................................................ 81SACUBITRIL/VALSARTAN............................................20SAFINAMIDE MESYLATE.............................................78SAFYRAL................................................................... 21, 94SALAGEN.........................................................................64SALEX.............................................................................. 28SALICYLIC ACID............................................................28SALICYLIC ACID (26 %) (LIQUID)..................................SALICYLIC ACID (27.5 %) (LIQ-FILM)............................SALICYLIC ACID (28.5 %) (SOL-FILMER)......................SALICYLIC ACID (6 %) (CREAM (G)).............................SALICYLIC ACID (6 %) (CRM ER (G)).............................SALICYLIC ACID (6 %) (FOAM).......................................SALICYLIC ACID (6 %) (GEL (GRAM))...........................

SALICYLIC ACID (6 %) (LOTION ER).............................SALICYLIC ACID (6 %) (LOTION)...................................SALICYLIC ACID (6 %) (SHAMPOO)...............................SALICYLIC ACID/CERAMIDE COMB 1...................... 28SALIMEZ FORTE.............................................................28SALMETEROL XINAFOATE............................................3SALSALATE.....................................................................74SAMSCA (15 MG) (TABLET)......................................... 33SAMSCA (30 MG) (TABLET)......................................... 33SANCTURA................................................................84, 94SANCTURA XR......................................................... 84, 94SANCUSO.....................................................................2, 94SANDIMMUNE (100 MG) (CAPSULE)......................... 49SANDIMMUNE (100 MG/ML) (SOLUTION)................49SANDIMMUNE (25 MG) (CAPSULE)........................... 49SANDIMMUNE (250 MG/5ML) (AMPUL)....................49SANDOSTATIN (100 MCG/ML) (AMPUL)....................72SANDOSTATIN (100 MCG/ML) (SYRINGE)................ 73SANDOSTATIN (100 MCG/ML) (VIAL)........................ 73SANDOSTATIN (1000MCG/ML) (VIAL)....................... 73SANDOSTATIN (200 MCG/ML) (VIAL)........................ 73SANDOSTATIN (50 MCG/ML) (AMPUL)......................73SANDOSTATIN (50 MCG/ML) (SYRINGE).................. 73SANDOSTATIN (50 MCG/ML) (VIAL).......................... 73SANDOSTATIN (500 MCG/ML) (AMPUL)....................73SANDOSTATIN (500 MCG/ML) (SYRINGE)................ 73SANDOSTATIN (500 MCG/ML) (VIAL)........................ 73SANTYL............................................................................29SAPHRIS.............................................................................9SAPROPTERIN DIHYDROCHLORIDE......................... 72SAQUINAVIR MESYLATE............................................. 57SARGRAMOSTIM........................................................... 44SARILUMAB....................................................................60SAVELLA..........................................................................70SCALACORT (2 %) (LOTION)........................................26SCALACORT DK............................................................. 26SCLEROSOL.....................................................................69SCOPOLAMINE.................................................................2SCOT-TUSSIN SENIOR...................................................23SEASONALE.................................................................... 21SEASONIQUE.................................................................. 21SEBELIPASE ALFA......................................................... 64SEBUDERM......................................................................27SECNIDAZOLE................................................................54SECOBARBITAL SODIUM.............................................10SECONAL SODIUM........................................................ 10SECTRAL..........................................................................14SECUKINUMAB.............................................................. 29SEEBRI NEOHALER......................................................... 3SELEGILINE HCL........................................................... 78SELENIUM SULFIDE......................................................27SELENIUM SULFIDE (2.25 %) (SHAMPOO)...................SELENIUM SULFIDE (2.5 %) (LOTION)..........................SELENIUM SULFIDE/ALOE VERA.............................. 27SELEXIPAG...................................................................... 17SELSUN BLUE MOISTURIZING...................................27SELZENTRY (150 MG) (TABLET).................................55SELZENTRY (20 MG/ML) (SOLUTION).......................55SELZENTRY (25 MG) (TABLET)...................................55SELZENTRY (300 MG) (TABLET).................................55SELZENTRY (75 MG) (TABLET)...................................55SENSIPAR.........................................................................36SERAX................................................................................ 8SEREVENT DISKUS......................................................... 3SEROMYCIN....................................................................53SEROPHENE.................................................................... 34SEROQUEL.........................................................................9SEROQUEL XR (150 MG) (TAB ER 24H)........................9SEROQUEL XR (200 MG) (TAB ER 24H)........................9SEROQUEL XR (300 MG) (TAB ER 24H)........................9SEROQUEL XR (400 MG) (TAB ER 24H)........................9SEROQUEL XR (50 MG) (TAB ER 24H)..........................9SEROQUEL XR (50-200-300) (TAB24HDSPK)............... 9SEROSTIM (4 MG) (VIAL)............................................. 36SEROSTIM (5 MG) (VIAL)............................................. 36SEROSTIM (6 MG) (VIAL)............................................. 36SERTRALINE HCL............................................................ 6SERZONE........................................................................... 6SEVELAMER CARBONATE.......................................... 34SFROWASA...................................................................... 61SHINGRIX........................................................................ 48SHINGRIX GE ANTIGEN COMPONENT..................... 48SIGNIFOR.........................................................................73SILDENAFIL CITRATE.............................................17, 34SILHOUETTE...................................................................63SILODOSIN...................................................................... 84SILTUXIMAB................................................................... 68SILVADENE......................................................................25SILVER CARBONATE.....................................................23SILVER NITRATE...................................................... 23, 28SILVER NITRATE APPLICATOR...................................28SILVER SULFADIAZINE................................................ 25


Index

SIMBRINZA..................................................................... 39SIMPONI ARIA................................................................ 59SIMULECT....................................................................... 49SIMVASTATIN..................................................................19SINEMET 10-100..............................................................78SINEMET 25-100..............................................................78SINEMET 25-250..............................................................78SINEMET CR....................................................................78SINEQUAN......................................................................... 7SINGULAIR........................................................................4SIROLIMUS......................................................................49SIRTURO...........................................................................53SITAGLIPTIN PHOS/METFORMIN HCL...................... 30SITAGLIPTIN PHOSPHATE............................................31SKELAXIN....................................................................... 81SKYLA.............................................................................. 71SLO-PHYLLIN................................................................... 4SOD PHOS DI, MONO/K PHOS MONO........................ 84SOD PHOS DI, MONO/K PHOS MONO (250 MG)(TABLET)..............................................................................SOD PICOSULF/MAG OX/CITRIC AC..........................63SOD,POT CHLOR/MAG/SOD,POT PHOS..................... 28SOD/POT/K CIT/SOD CIT/CIT ACID.............................84SODIUM CHLOR/HYPOCHLOROUS ACID................. 28SODIUM CHLORIDE/NAHCO3/KCL/PEG................... 63SODIUM CITRATE.......................................................... 42SODIUM CITRATE IN 0.9 % NACL...............................42SODIUM OXYBATE.......................................................... 8SODIUM PHENYLBUTYRATE......................................62SODIUM POLYSTYRENE SULFON/SORB.................. 34SODIUM POLYSTYRENE SULFONATE.......................34SODIUM SULAMYD.......................................................38SODIUM SULFACETAMIDE-SULFUR......................... 25SODIUM, POTASSIUM,MAG SULFATES..................... 63SOFOSBUVIR.................................................................. 57SOFOSBUVIR/VELPATAS/VOXILAPREV....................57SOFOSBUVIR/VELPATASVIR....................................... 57SOLARAZE...................................................................... 29SOLIFENACIN SUCCINATE...........................................84SOLIQUA 100-33........................................................31, 94SOLIRIS............................................................................ 44SOLODYN (105 MG) (TAB ER 24H)........................ 52, 94SOLODYN (115MG) (TAB ER 24H)......................... 52, 94SOLODYN (135 MG) (TAB ER 24H)........................ 52, 94SOLODYN (45 MG) (TAB ER 24H).......................... 52, 94SOLODYN (55 MG) (TAB ER 24H).......................... 52, 94SOLODYN (65 MG) (TAB ER 24H).......................... 52, 94SOLODYN (80 MG) (TAB ER 24H).......................... 52, 94SOLODYN (90 MG) (TAB ER 24H).......................... 52, 94SOLOSEC..........................................................................54SOMA..........................................................................81, 94SOMATROPIN..................................................................36SOMAVERT...................................................................... 36SONATA............................................................................ 11SOOLANTRA............................................................. 23, 94SORAFENIB TOSYLATE................................................68SORBITOL SOLUTION...................................................28SORIATANE..................................................................... 29SOTALOL HCL.................................................................15SOTALOL HCL (120 MG) (TABLET).................................SOTALOL HCL (160 MG) (TABLET).................................SOTALOL HCL (240 MG) (TABLET).................................SOTALOL HCL (80 MG) (TABLET)...................................SOTYLIZE (5 MG/ML) (SOLUTION)...................... 15, 94SOVALDI.......................................................................... 57SP ANTIPRURITIC.......................................................... 27SP SCAR MANAGEMENT..............................................27SPECTAZOLE...................................................................24SPECTRACEF...................................................................50SPINOSAD........................................................................24SPIRIVA.............................................................................. 3SPIRIVA RESPIMAT.......................................................... 3SPIRONOLACT/HYDROCHLOROTHIAZID.................16SPIRONOLACTONE........................................................16SPORANOX (10 MG/ML) (SOLUTION)........................ 53SPORANOX (100 MG) (CAPSULE)............................... 53SPRYCEL (100 MG) (TABLET)...................................... 67SPRYCEL (140 MG) (TABLET)...................................... 67SPRYCEL (20 MG) (TABLET)........................................ 67SPRYCEL (50 MG) (TABLET)........................................ 67SPRYCEL (70 MG) (TABLET)........................................ 67SPRYCEL (80 MG) (TABLET)........................................ 67SPS.....................................................................................34ST. JOHN'S WORT............................................................. 6ST. JOHN'S WORT (300 MG) (CAPSULE) (OTC).............STADOL............................................................................74STALEVO 100...................................................................78STALEVO 125...................................................................78STALEVO 150...................................................................78STALEVO 200...................................................................78STALEVO 50.....................................................................78STALEVO 75.....................................................................78

STARLIX...........................................................................31STAVUDINE..................................................................... 56STAVUDINE (1 MG/ML) (SOLN RECON)........................STAVUDINE (15 MG) (CAPSULE).....................................STAVUDINE (20 MG) (CAPSULE).....................................STAVUDINE (30 MG) (CAPSULE).....................................STAVUDINE (40 MG) (CAPSULE).....................................STEGLATRO.....................................................................30STELARA......................................................................... 60STELAZINE......................................................................10STERITALC...................................................................... 69STIMATE.......................................................................... 35STIOLTO RESPIMAT.........................................................3STIVARGA........................................................................67STRATTERA (10 MG) (CAPSULE)................................ 12STRATTERA (100 MG) (CAPSULE).............................. 12STRATTERA (18 MG) (CAPSULE)................................ 12STRATTERA (25 MG) (CAPSULE)................................ 12STRATTERA (40 MG) (CAPSULE)................................ 12STRATTERA (60 MG) (CAPSULE)................................ 12STRATTERA (80 MG) (CAPSULE)................................ 12STRENSIQ........................................................................ 71STREPTOZOCIN..............................................................65STRIBILD......................................................................... 57STRIVERDI RESPIMAT.................................................... 3STROMECTOL.................................................................54SUBOXONE (12 MG-3 MG) (FILM)...............................77SUBOXONE (2 MG-0.5MG) (FILM)...............................77SUBOXONE (2 MG-0.5MG) (TAB SUBL)..................... 77SUBOXONE (4MG-1MG) (FILM)...................................77SUBOXONE (8 MG-2 MG) (FILM).................................77SUBOXONE (8 MG-2 MG) (TAB SUBL)....................... 77SUB-Q INFUSION PUMP ACCESSORY........................63SUCCIMER.......................................................................72SUCRAID..........................................................................81SUCRALFATE.................................................................. 82SUCROFERRIC OXYHYDROXIDE............................... 34SULAR.............................................................................. 16SULFACETAMIDE SOD/SULFUR/UREA..................... 25SULFACETAMIDE SODIUM.............................. 23, 27, 38SULFACETAMIDE SODIUM/SULFUR..........................25SULFACETAMIDE/PREDNISOLONE SP...................... 38SULFACETAMIDE/SULFUR/CLEANSR23................... 25SULFACET-R....................................................................25SULFACT SOD/SULUR/AVOB/OTN/OCT.....................25SULFADIAZINE...............................................................61SULFAMETHOXAZOLE/TRIMETHOPRIM................. 61SULFAMETHOXAZOLE/TRIMETHOPRIM (200-40MG/5) (ORAL SUSP).......................................................SULFAMETHOXAZOLE/TRIMETHOPRIM (400MG-80MG) (TABLET).................................................................SULFAMETHOXAZOLE/TRIMETHOPRIM (800-160MG) (TABLET).....................................................................SULFAMETHOXAZOLE/TRIMETHOPRIM (800-160/20) (ORAL SUSP)..........................................................SULFAMETHOXAZOLE/TRIMETHOPRIM (80-16MG/ML) (VIAL)...............................................................SULFAMYLON................................................................ 25SULFASALAZINE........................................................... 61SULINDAC....................................................................... 61SUMADAN....................................................................... 25SUMADAN XLT...............................................................25SUMATRIPTAN................................................................76SUMATRIPTAN SUCC/NAPROXEN SOD.....................76SUMATRIPTAN SUCCINATE.........................................76SUMAXIN.........................................................................25SUMAXIN TS................................................................... 25SUMYCIN.........................................................................52SUNITINIB MALATE...................................................... 68SUPER THIN LANCETS (EACH) (OTC)....................... 63SUPRAX (100 MG/5ML) (SUSP RECON)......................50SUPRAX (200 MG/5ML) (SUSP RECON)......................50SUPREP.............................................................................63SURFAXIN........................................................................73SURMONTIL...................................................................... 7SURVANTA.......................................................................73SUSTIVA (200 MG) (CAPSULE).................................... 55SUSTIVA (50 MG) (CAPSULE)...................................... 55SUSTIVA (600 MG) (TABLET)....................................... 55SUTENT............................................................................ 68SUVOREXANT................................................................ 11SYLATRON.......................................................................66SYLVANT..........................................................................68SYMAX.............................................................................82SYMAX-SL.......................................................................82SYMAX-SR.......................................................................82SYMBICORT...................................................................... 3SYMBYAX........................................................................11SYMLINPEN 120............................................................. 31SYMLINPEN 60............................................................... 31SYMMETREL...................................................................77SYNAGIS.......................................................................... 54

SYNALAR.........................................................................26SYNAREL......................................................................... 36SYNDROS.....................................................................2, 94SYNJARDY.................................................................31, 94SYNJARDY XR (10-1000 MG) (TAB BP 24H).........32, 94SYNJARDY XR (12.5-1000) (TAB BP 24H)............. 32, 94SYNJARDY XR (25-1000 MG) (TAB BP 24H).........32, 94SYNJARDY XR (5MG-1000MG) (TAB BP 24H)...... 32,95SYNRIBO..........................................................................68SYNTHROID (100 MCG) (TABLET).............................. 37SYNTHROID (112 MCG) (TABLET).............................. 37SYNTHROID (125 MCG) (TABLET).............................. 37SYNTHROID (137 MCG) (TABLET).............................. 37SYNTHROID (150 MCG) (TABLET).............................. 37SYNTHROID (175MCG) (TABLET)............................... 37SYNTHROID (200 MCG) (TABLET).............................. 37SYNTHROID (25 MCG) (TABLET)................................ 37SYNTHROID (300 MCG) (TABLET).............................. 37SYNTHROID (50 MCG) (TABLET)................................ 37SYNTHROID (75 MCG) (TABLET)................................ 37SYNTHROID (88 MCG) (TABLET)................................ 37SYRINGE AVITENE........................................................ 44

- T -TABLOID.......................................................................... 65TACHOSIL........................................................................ 44TACLONEX (0.005-.064) (OINT. (G)).......................30, 95TACLONEX (0.005-.064) (SUSPENSION)..................... 30TACROLIMUS............................................................ 30, 49TADALAFIL............................................................... 17, 34TAFINLAR........................................................................67TAGAMET........................................................................ 82TAGRISSO........................................................................ 67TALC................................................................................. 69TALIGLUCERASE ALFA................................................71TAMBOCOR..................................................................... 13TAMIFLU (30 MG) (CAPSULE)..................................... 54TAMIFLU (45 MG) (CAPSULE)..................................... 54TAMIFLU (6 MG/ML) (SUSP RECON)..........................55TAMIFLU (75 MG) (CAPSULE)..................................... 55TAMOXIFEN CITRATE...................................................69TAMSULOSIN HCL.........................................................84TAPAZOLE....................................................................... 37TAPENTADOL HCL.........................................................76TARCEVA (100 MG) (TABLET)......................................67TARCEVA (150 MG) (TABLET)......................................67TARCEVA (25 MG) (TABLET)........................................67TARGRETIN............................................................... 29, 69TARKA..............................................................................13TASIGNA.......................................................................... 67TASIMELTEON................................................................ 10TASMAR..................................................................... 78, 95TAVIST................................................................................ 1TAYTULLA.......................................................................21TAZAROTENE..................................................................30TAZORAC (0.05 %) (CREAM (G))..................................30TAZORAC (0.05 %) (GEL (GRAM))...............................30TAZORAC (0.1 %) (CREAM (G))....................................30TAZORAC (0.1 %) (GEL (GRAM)).................................30TBO-FILGRASTIM.......................................................... 44TECFIDERA..................................................................... 69TEGRETOL.......................................................................78TEGRETOL XR................................................................ 78TEKTURNA......................................................................17TEKTURNA HCT.............................................................17TELMISARTAN................................................................14TELMISARTAN/AMLODIPINE......................................14TELMISARTAN/HYDROCHLOROTHIAZID................ 14TELOTRISTAT ETIPRATE.............................................. 62TEMAZEPAM...................................................................11TEMODAR (100 MG) (CAPSULE)................................. 64TEMODAR (100 MG) (VIAL)......................................... 64TEMODAR (140 MG) (CAPSULE)................................. 64TEMODAR (180 MG) (CAPSULE)................................. 64TEMODAR (20 MG) (CAPSULE)................................... 64TEMODAR (250 MG) (CAPSULE)................................. 64TEMODAR (5 MG) (CAPSULE)..................................... 64TEMOVATE...................................................................... 25TEMOVATE E................................................................... 25TEMOVATE EMOLLIENT...............................................26TEMOZOLOMIDE........................................................... 64TEMSIROLIMUS............................................................. 66TENEX.............................................................................. 14TENOFOVIR ALAFENAMIDE FUMARATE.................58TENOFOVIR DISOPROXIL FUMARATE......................56TENORETIC 100.............................................................. 15TENORETIC 50................................................................ 15TENORMIN...................................................................... 14TEPADINA........................................................................64TERAZOL 3...................................................................... 84TERAZOL 7...................................................................... 84


Index

TERAZOSIN HCL............................................................ 13TERBINAFINE HCL........................................................ 53TERBUTALINE SULFATE................................................ 3TERBUTALINE SULFATE (2.5 MG) (TABLET)................TERBUTALINE SULFATE (5 MG) (TABLET)...................TERCONAZOLE.............................................................. 84TESAMORELIN ACETATE.............................................36TESSALON.......................................................................22TESSALON PERLE..........................................................22TESTIM.............................................................................45TESTOSTERONE............................................................. 45TESTOSTERONE CYPIONATE...................................... 45TESTOSTERONE ENANTHATE.................................... 45TESTRED..........................................................................45TETANUS DIPHTHERIA TOXOIDS.............................. 48TETANUS, DIPHTHERIA TOX,ADULT........................ 48TETCAINE........................................................................38TETRABENAZINE...........................................................70TETRACAINE HCL................................................... 29, 38TETRACAINE HCL/PF....................................................38TETRACAINE HYDROCHLORIDE............................... 38TETRACAINE/BENZOCAINE/BUTAMBEN.................29TETRACYCLINE HCL.................................................... 52TETRAHYDROZOLINE HCL.........................................23TETRIX............................................................................. 28THALIDOMIDE............................................................... 53THALOMID...................................................................... 53THEO-DUR.........................................................................4THEOPHYLLINE ANHYDROUS..................................... 4THERMAZENE................................................................ 25THIOGUANINE................................................................65THIOLA............................................................................ 84THIORIDAZINE HCL...................................................... 10THIOTEPA........................................................................ 64THIOTHIXENE.................................................................10THORAZINE (10 MG) (TABLET)...................................10THORAZINE (100 MG) (TABLET).................................10THORAZINE (200 MG) (TABLET).................................10THORAZINE (25 MG) (TABLET)...................................10THORAZINE (50 MG) (TABLET)...................................10THROMBATE III.............................................................. 44THROMBIN (BOVINE)....................................................45THROMBIN (RECOMBINANT)..................................... 45THROMBIN,BOVINE/GELATIN SPONGE....................45THROMBIN,HU/FIBRINOGEN/CALCIUM.................. 45THROMBIN/FIBRINOGN/APROTIN/CAL.................... 45THYMOGLOBULIN........................................................ 47THYROID,PORK..............................................................37TIAGABINE HCL.............................................................80TIAZAC.............................................................................16TICAGRELOR.................................................................. 44TICALAST.......................................................................... 1TICANASE..........................................................................1TICASPRAY....................................................................... 1TICLID.............................................................................. 44TICLOPIDINE HCL......................................................... 44TIGAN (300 MG) (CAPSULE).......................................... 2TIKOSYN..........................................................................13TIMOLOL......................................................................... 39TIMOLOL MALEATE................................................15, 39TIMOPTIC........................................................................ 39TIMOPTIC-XE..................................................................39TINDAMAX......................................................................54TINIDAZOLE................................................................... 54TIOPRONIN......................................................................84TIOTROPIUM BR/OLODATEROL HCL.......................... 3TIOTROPIUM BROMIDE..................................................3TIPRANAVIR....................................................................55TIPRANAVIR/VITAMIN E TPGS................................... 55TIROSINT......................................................................... 37TISAGENLECLEUCEL................................................... 68TISSEEL VHSD................................................................45TIS-U-SOL PENTALYTE.................................................28TIVICAY........................................................................... 57TIZANIDINE HCL........................................................... 81TOBI (300 MG/5ML) (AMPUL-NEB).............................53TOBI PODHALER (28 MG) (CAP W/DEV)................... 53TOBI PODHALER (28 MG) (CAPSULE)....................... 53TOBRADEX (0.3 %-0.1%) (DROPS SUSP).................... 37TOBRADEX (0.3 %-0.1%) (OINT. (G)).......................... 37TOBRADEX ST................................................................37TOBRAMYCIN.......................................................... 39, 53TOBRAMYCIN IN 0.225% SOD CHLOR...................... 53TOBRAMYCIN/DEXAMETHASONE............................37TOBRAMYCIN/LOTEPRED ETAB................................ 37TOBRAMYCIN/NEBULIZER......................................... 53TOBREX (0.3 %) (DROPS).............................................. 39TOCILIZUMAB................................................................60TODAY CONTRACEPTIVE SPONGE............................21TOFACITINIB CITRATE................................................. 60TOFRANIL..........................................................................7TOFRANIL-PM.................................................................. 7

TOLAZAMIDE................................................................. 31TOLBUTAMIDE...............................................................31TOLCAPONE....................................................................78TOLECTIN........................................................................61TOLECTIN DS..................................................................61TOLINASE........................................................................ 31TOLMETIN SODIUM...................................................... 61TOLTERODINE TARTRATE........................................... 84TOLVAPTAN.....................................................................33TOPAMAX........................................................................ 80TOPICORT (0.05 %) (CREAM (G)).................................26TOPICORT (0.05 %) (GEL (GRAM)).............................. 26TOPICORT (0.05 %) (OINT. (G)).....................................26TOPICORT (0.25 %) (CREAM (G)).................................26TOPICORT (0.25 %) (OINT. (G)).....................................26TOPIRAMATE............................................................ 80, 81TOPOSAR......................................................................... 68TOPOTECAN HCL...........................................................66TOPROL XL......................................................................14TORADOL........................................................................ 61TOREMIFENE CITRATE.................................................69TORISEL...........................................................................66TORONOVA II SUIK........................................................61TORONOVA SUIK............................................................61TORSEMIDE.................................................................... 16TOUJEO SOLOSTAR....................................................... 33TOVIAZ.......................................................................84, 95TRABECTEDIN................................................................66TRACLEER.......................................................................17TRADJENTA.....................................................................31TRAMADOL HCL............................................................76TRAMADOL HCL/ACETAMINOPHEN.........................76TRAMETINIB DIMETHYL SULFOXIDE......................66TRANDATE (100 MG) (TABLET)...................................13TRANDATE (200 MG) (TABLET)...................................13TRANDATE (300 MG) (TABLET)...................................13TRANDOLAPRIL.............................................................14TRANDOLAPRIL/VERAPAMIL HCL............................13TRANEXAMIC ACID...................................................... 40TRANSDERM-SCOP......................................................... 2TRANXENE T-TAB............................................................7TRANYLCYPROMINE SULFATE....................................6TRANZAREL....................................................................29TRASTUZUMAB............................................................. 65TRAVATAN Z....................................................................39TRAVOPROST..................................................................39TRAZODONE HCL............................................................6TREANDA........................................................................ 64TRECATOR.......................................................................53TRELEGY ELLIPTA.................................................... 3, 95TREMFYA.........................................................................29TRENTAL......................................................................... 42TREPROSTINIL............................................................... 17TREPROSTINIL DIOLAMINE........................................17TREPROSTINIL SODIUM...............................................17TREPROSTINIL/NEB ACCESSORIES...........................17TREPROSTINIL/NEBULIZER/ACCESOR.....................17TRESIBA FLEXTOUCH U-100.......................................32TRESIBA FLEXTOUCH U-200.......................................32TRETINOIN................................................................ 23, 68TRETINOIN MICROSPHERES.................................23, 24TRETTEN..........................................................................42TREXALL (2.5 MG) (TABLET)...................................... 65TREXIMET....................................................................... 76TRIAMCINOLONE ACETONIDE............................ 27, 70TRIAMTERENE/HYDROCHLOROTHIAZID................16TRIAVIL 2-10......................................................................6TRIAVIL 2-25......................................................................6TRIAVIL 4-25......................................................................6TRIAVIL 4-50......................................................................6TRIAZOLAM....................................................................11TRIBENZOR...............................................................13, 95TRICITRATES.................................................................. 84TRICOR.............................................................................19TRIFLUOPERAZINE HCL.............................................. 10TRIFLURIDINE................................................................38TRIFLURIDINE/TIPIRACIL HCL.................................. 65TRIHEXYPHENIDYL HCL............................................. 77TRILAFON........................................................................10TRILEPTAL...................................................................... 80TRILIPIX...........................................................................20TRIMETHOBENZAMIDE HCL........................................ 2TRIMETHOPRIM.............................................................50TRIMIPRAMINE MALEATE............................................ 7TRINATAL RX 1...............................................................86TRI-NORINYL..................................................................21TRINTELLIX...................................................................... 6TRIPTODUR.....................................................................36TRIPTORELIN PAMOATE.............................................. 36TRISENOX........................................................................68TRIUMEQ......................................................................... 57TRIVORA..........................................................................21

TRIZIVIR.......................................................................... 55TROKENDI XR (100 MG) (CAP ER 24H)......................80TROKENDI XR (200 MG) (CAP ER 24H)......................80TROKENDI XR (25 MG) (CAP ER 24H)........................81TROKENDI XR (50 MG) (CAP ER 24H)........................81TROPICAMIDE................................................................ 40TROSPIUM CHLORIDE.................................................. 84TRULICITY................................................................ 30, 95TRUMENBA..................................................................... 47TRUSOPT..........................................................................39TRUVADA.........................................................................55TRUZONE PEAK FLOW METER.....................................4TUDORZA PRESSAIR.......................................................2TUSICOF...........................................................................22TUSSIONEX..................................................................... 22TWINRIX.......................................................................... 48TWYNSTA........................................................................ 14TYKERB........................................................................... 67TYMLOS...........................................................................35TYPHOID VACC,LIVE,ATTENUATED..........................47TYSABRI.......................................................................... 70TYVASO............................................................................17TYVASO INSTITUTIONAL START KIT........................17TYVASO REFILL KIT..................................................... 17TYVASO STARTER KIT..................................................17TYZINE.............................................................................23

- U -UCERIS....................................................................... 59, 95ULORIC...................................................................... 40, 95ULTRACET.......................................................................76ULTRAFOAM...................................................................45ULTRAM...........................................................................76ULTRAM ER.....................................................................76ULTRASAL-ER................................................................ 28ULTRAVATE (0.05 %) (CREAM (G))..............................26ULTRAVATE (0.05 %) (OINT. (G))..................................26UMECLIDINIUM BRM/VILANTEROL TR.....................3UMECLIDINIUM BROMIDE............................................3UNIPHYL............................................................................4UNIRETIC.........................................................................13UNITHROID..................................................................... 37UNITUXIN........................................................................68UNIVASC.......................................................................... 14UNIVERSAL 1 (26 GAUGE) (EACH) (OTC)................. 63UPTRAVI...........................................................................17URAMAXIN GT............................................................... 28UREA.......................................................................... 28, 30UREA/EMOLLIENT COMBINATION 65.......................28UREA/LACTIC ACID/ZINC UNDECYL........................28URECHOLINE..................................................................64URETRON D-S................................................................. 50URIDINE TRIACETATE............................................ 40, 69URIN D.S.......................................................................... 50URISPAS........................................................................... 84UROCIT-K.........................................................................84UROXATRAL................................................................... 83URSO.................................................................................62URSO FORTE................................................................... 62URSODIOL....................................................................... 62URYL.................................................................................50USTEKINUMAB.............................................................. 60UTA................................................................................... 50UTIBRON NEOHALER..................................................... 3

- V -VAGIFEM..........................................................................84VALACYCLOVIR HCL....................................................55VALBENAZINE TOSYLATE...........................................70VALCHLOR...................................................................... 29VALCYTE......................................................................... 55VALGANCICLOVIR HCL............................................... 55VALISONE........................................................................25VALIUM (10 MG) (TABLET)............................................ 7VALIUM (2 MG) (TABLET).............................................. 7VALIUM (5 MG) (TABLET).............................................. 8VALIUM (5 MG/5 ML) (SOLUTION)............................... 8VALPROIC ACID............................................................. 81VALPROIC ACID (AS SODIUM SALT)......................... 81VALSARTAN.................................................................... 14VALSARTAN/HYDROCHLOROTHIAZIDE.................. 14VALTREX..........................................................................55VANATOL LQ...................................................................74VANATOL S......................................................................74VANCOMYCIN HCL....................................................... 54VANCOMYCIN HCL (125 MG) (CAPSULE).....................VANCOMYCIN HCL (125MG/2.5) (SYRINGE)................VANCOMYCIN HCL (250 MG) (CAPSULE).....................VANDAZOLE................................................................... 84VANDETANIB.................................................................. 68VANOS.............................................................................. 26VANOXIDE-HC................................................................ 23VANTAS............................................................................ 35


Index

VANTIN.............................................................................50VAQTA (50 UNIT/ML) (SYRINGE)................................ 48VAQTA (50 UNIT/ML) (VIAL)........................................48VARENICLINE TARTRATE............................................ 81VARICELLA VACCINE LIVE/PF................................... 48VARICELLA-ZOSTER GE VAC,2 OF 2..........................48VARICELLA-ZOSTER GE/AS01B/PF............................ 48VARIVAX VACCINE........................................................48VARUBI (90 MG) (TABLET).............................................2VASCEPA (0.5 GRAM) (CAPSULE)...............................20VASCEPA (1 G) (CAPSULE)........................................... 20VASERETIC......................................................................13VASHE WOUND.............................................................. 28VASHE WOUND THERAPY...........................................28VASOTEC..........................................................................14VAXCHORA ACTIVE COMPONENT............................48VAXCHORA VACCINE................................................... 48VCF....................................................................................21VECTIBIX.........................................................................65VECTICAL..................................................................30, 95VEDOLIZUMAB.............................................................. 62VEETIDS...........................................................................51VELAGLUCERASE ALFA.............................................. 71VELCADE.........................................................................67VELETRI...........................................................................17VELPHORO...................................................................... 34VELTASSA........................................................................34VEMLIDY......................................................................... 58VEMURAFENIB.............................................................. 68VENCLEXTA....................................................................68VENCLEXTA STARTING PACK.................................... 68VENETOCLAX................................................................ 68VENLAFAXINE HCL........................................................ 6VENLAFAXINE HCL ER....................................................VENTAVIS........................................................................ 17VENTOLIN HFA................................................................ 3VEPESID...........................................................................68VERAPAMIL HCL........................................................... 16VERDROCET................................................................... 74VERELAN.........................................................................16VERELAN PM..................................................................16VERSED............................................................................11VERTEPORFIN................................................................ 40VERZENIO....................................................................... 66VESANOID (10 MG) (CAPSULE).................................. 68VESICARE..................................................................84, 95VESTRONIDASE ALFA-VJBK.......................................71VFEND.............................................................................. 53VIAGRA............................................................................34VIBERZI............................................................................62VIBRAMYCIN..................................................................52VIBRAMYCIN (100 MG) (CAPSULE)........................... 52VIBRA-TABS....................................................................52VICOPROFEN.................................................................. 74VIDAZA............................................................................ 65VIDEX...............................................................................56VIDEX EC (125 MG) (CAPSULE DR)............................56VIDEX EC (200 MG) (CAPSULE DR)............................56VIDEX EC (250 MG) (CAPSULE DR)............................56VIDEX EC (400 MG) (CAPSULE DR)............................56VIGABATRIN................................................................... 81VIGAMOX........................................................................ 38VIIBRYD.......................................................................6, 95VILAZODONE HCL.......................................................... 6VIMIZIM...........................................................................71VIMPAT (10 MG/ML) (SOLUTION).........................79, 95VIMPAT (100 MG) (TABLET)................................... 79, 95VIMPAT (150 MG) (TABLET)................................... 79, 95VIMPAT (200 MG) (TABLET)................................... 79, 95VIMPAT (50 MG) (TABLET)..................................... 79, 95VIMPAT (50MG-100MG) (TAB DS PK)......................... 79VINCRISTINE SULFATE LIPOSOMAL........................ 69VIOKACE......................................................................... 81VIRACEPT........................................................................57VIRAMUNE (200 MG) (TABLET).................................. 56VIRAMUNE (50 MG/5 ML) (ORAL SUSP)................... 56VIRAMUNE XR (100 MG) (TAB ER 24H).....................56VIRAMUNE XR (400 MG) (TAB ER 24H).....................56VIRAZOLE....................................................................... 55VIREAD (150 MG) (TABLET)........................................ 56VIREAD (200 MG) (TABLET)........................................ 56VIREAD (250 MG) (TABLET)........................................ 56VIREAD (300 MG) (TABLET)........................................ 56VIREAD (40MG/SCOOP) (POWDER)............................56VIROPTIC......................................................................... 38VISKEN.............................................................................15VISMODEGIB.................................................................. 66VISTARIL........................................................................... 1VISTOGARD.................................................................... 69VISUDYNE....................................................................... 40VITAMEDMD REDICHEW RX...................................... 85VITAPEARL..................................................................... 86

VITATRUE........................................................................ 85VITE AC/GRAPE/HYALURONIC ACID........................ 27VIVACTIL........................................................................... 7VIVELLE-DOT................................................................. 45VIVITROL...........................................................................7VIVOTIF............................................................................47VIVOTIF BERNA............................................................. 47VOGELXO........................................................................ 45VOLTAREN...........................................................27, 38, 60VOLTAREN-XR................................................................60VON WILLEBRAND FACTOR....................................... 42VONVENDI...................................................................... 42VORAPAXAR SULFATE................................................. 44VORAXAZE..................................................................... 69VORICONAZOLE............................................................ 53VORINOSTAT...................................................................68VORTIOXETINE HYDROBROMIDE............................... 6VOSEVI.............................................................................57VOSOL.............................................................................. 33VOSOL HC........................................................................33VOTRIENT........................................................................67VPRIV............................................................................... 71VRAYLAR (1.5 MG) (CAPSULE).....................................8VRAYLAR (1.5 MG-3MG) (CAP DS PK).........................8VRAYLAR (3 MG) (CAPSULE)........................................8VRAYLAR (4.5 MG) (CAPSULE).....................................8VRAYLAR (6 MG) (CAPSULE)........................................8VYTONE...........................................................................23VYTORIN (10 MG-10MG) (TABLET)............................17VYTORIN (10 MG-20MG) (TABLET)............................17VYTORIN (10 MG-40MG) (TABLET)............................17VYTORIN (10 MG-80MG) (TABLET)......................17, 95VYVANSE.....................................................................7, 95VYXEOS........................................................................... 65VYZULTA......................................................................... 39

- W -WARFARIN SODIUM...................................................... 40WATER FOR IRRIGATION,STERILE............................ 28WATER FOR IRRIGATION,STERILE (IRRIG SOLN)...............................................................................................WAVESENSE PRESTO.................................................... 32WAVESENSE PRESTO (KIT) (OTC).............................. 32WELCHOL........................................................................19WELLBUTRIN................................................................... 6WELLBUTRIN SR............................................................. 6WELLBUTRIN XL............................................................. 6WELLCOVORIN (10 MG) (TABLET).............................69WELLCOVORIN (15 MG) (TABLET).............................69WELLCOVORIN (25 MG) (TABLET).............................69WELLCOVORIN (5 MG) (TABLET)...............................69WIDE SEAL DIAPHRAGM.............................................22WILATE (1K-1K UNIT) (VIAL)......................................41WILATE (450-450) (VIAL).............................................. 41WILATE (500-500) (VIAL).............................................. 41WILATE (900-900) (VIAL).............................................. 41

- X -XADAGO.......................................................................... 78XALATAN.........................................................................39XALKORI......................................................................... 67XANAX............................................................................... 7XANAX XR........................................................................ 7XARELTO (10 MG) (TABLET)....................................... 42XARELTO (15 MG) (TABLET)....................................... 42XARELTO (15 MG-20MG) (TAB DS PK).......................42XARELTO (20 MG) (TABLET)....................................... 42XATMEP..................................................................... 65, 95XELJANZ.......................................................................... 60XELJANZ XR (11 MG) (TAB ER 24H)........................... 60XELODA (150 MG) (TABLET)....................................... 65XELODA (500 MG) (TABLET)....................................... 65XENAZINE (12.5 MG) (TABLET).................................. 70XENAZINE (25 MG) (TABLET)..................................... 70XERMELO........................................................................ 62XGEVA..............................................................................35XHANCE.......................................................................1, 95XIFAXAN (200 MG) (TABLET)......................................54XIFAXAN (550 MG) (TABLET)......................................54XIGDUO XR (10-1000 MG) (TAB BP 24H)............. 31, 96XIGDUO XR (10MG-500MG) (TAB BP 24H).......... 31, 96XIGDUO XR (2.5-1000MG) (TAB BP 24H)............. 31, 96XIGDUO XR (5 MG-500MG) (TAB BP 24H)........... 31, 96XIGDUO XR (5MG-1000MG) (TAB BP 24H).......... 31, 96XIIDRA............................................................................. 39XODOL 10-300................................................................. 74XODOL 5-300................................................................... 74XODOL 7.5-300................................................................ 74XOLAIR.............................................................................. 4XOPENEX...........................................................................3XOPENEX CONCENTRATE.............................................3XTANDI............................................................................ 65XULTOPHY 100-3.6...................................................31, 96

XURIDEN......................................................................... 40XYREM...............................................................................8XYZAL (2.5 MG/5ML) (SOLUTION)...............................1XYZAL (5 MG) (TABLET)................................................ 1

- Y -YASMIN 28................................................................. 21, 96YAZ..............................................................................21, 96YERVOY........................................................................... 69YESCARTA.......................................................................68YONDELIS....................................................................... 66

- Z -ZAFIRLUKAST.................................................................. 4ZALEPLON.......................................................................11ZALTRAP..........................................................................66ZANAFLEX...................................................................... 81ZANAMIVIR.....................................................................55ZANOSAR........................................................................ 65ZANTAC (15 MG/ML) (SYRUP)..................................... 83ZANTAC (150 MG) (CAPSULE)..................................... 83ZANTAC (150 MG) (TABLET)........................................83ZANTAC (300 MG) (CAPSULE)..................................... 83ZANTAC (300 MG) (TABLET)........................................83ZARONTIN....................................................................... 78ZAROXOLYN................................................................... 17ZARXIO............................................................................ 44ZAVESCA......................................................................... 71ZEBETA............................................................................ 14ZEGERID.................................................................... 83, 96ZEJULA.............................................................................67ZELBORAF.......................................................................68ZEMAIRA......................................................................... 64ZEMBRACE SYMTOUCH.............................................. 76ZENCIA.............................................................................25ZENPEP (10-34-55K) (CAPSULE DR)........................... 81ZENPEP (15-51-82K) (CAPSULE DR)........................... 82ZENPEP (20-63-84K) (CAPSULE DR)........................... 82ZENPEP (25-85-136K) (CAPSULE DR)......................... 82ZENPEP (3K-10K-16K) (CAPSULE DR)........................82ZENPEP (40-126-168) (CAPSULE DR).......................... 82ZENPEP (5K-17K-27K) (CAPSULE DR)........................82ZESTORETIC................................................................... 13ZESTRIL........................................................................... 14ZETIA................................................................................19ZIAC.................................................................................. 15ZIANA............................................................................... 23ZIDOVUDINE...................................................................56ZINC ACETATE................................................................72ZIPRASIDONE HCL........................................................ 10ZITHRANOL.................................................................... 29ZITHROMAX (1 G) (PACKET)....................................... 50ZITHROMAX (100 MG/5ML) (SUSP RECON)............. 50ZITHROMAX (200 MG/5ML) (SUSP RECON)............. 50ZITHROMAX (250 MG) (TABLET)................................50ZITHROMAX (500 MG) (TABLET)................................50ZITHROMAX (600 MG) (TABLET)................................50ZITHROMAX TRI-PAK................................................... 50ZIV-AFLIBERCEPT......................................................... 66ZOCOR (10 MG) (TABLET)............................................ 19ZOCOR (20 MG) (TABLET)............................................ 19ZOCOR (40 MG) (TABLET)............................................ 19ZOCOR (5 MG) (TABLET).............................................. 19ZOCOR (80 MG) (TABLET)...................................... 19, 96ZOFRAN (2 MG/ML) (VIAL)............................................2ZOFRAN (24 MG) (TABLET)............................................2ZOFRAN (4 MG) (TABLET)..............................................2ZOFRAN (4 MG/5 ML) (SOLUTION).............................. 2ZOFRAN (8 MG) (TABLET)..............................................2ZOFRAN ODT.................................................................... 2ZOFRAN PRESERVATIVE FREE..................................... 2ZOLADEX........................................................................ 35ZOLEDRONIC AC/MANNITOL/0.9NACL.................... 36ZOLEDRONIC ACID....................................................... 36ZOLEDRONIC ACID/MANNITOL-WATER.................. 36ZOLINZA.......................................................................... 68ZOLMITRIPTAN........................................................ 76, 77ZOLOFT.............................................................................. 6ZOLPIDEM TARTRATE.................................................. 11ZOLPIMIST...................................................................... 11ZOMETA........................................................................... 36ZOMIG (2.5 MG) (SPRAY)........................................ 76, 96ZOMIG (2.5 MG) (TABLET)..................................... 76, 96ZOMIG (5 MG) (SPRAY)........................................... 76, 96ZOMIG (5 MG) (TABLET)........................................ 77, 96ZOMIG ZMT...............................................................77, 96ZONATUSS....................................................................... 22ZONEGRAN..................................................................... 81ZONISAMIDE.................................................................. 81ZONTIVITY......................................................................44ZORTRESS........................................................................49ZOSTAVAX....................................................................... 48ZOSTER VACCINE LIVE/PF.......................................... 48


Index

ZOVIRAX..........................................................................54ZOVIRAX (5 %) (CREAM (G))....................................... 24ZOVIRAX (5 %) (OINT. (G))........................................... 24ZUBSOLV (0.7-0.18MG) (TAB SUBL)........................... 77ZUBSOLV (1.4-0.36MG) (TAB SUBL)........................... 77ZUBSOLV (11.4-2.9MG) (TAB SUBL)........................... 77ZUBSOLV (2.9-0.71MG) (TAB SUBL)........................... 77ZUBSOLV (5.7-1.4 MG) (TAB SUBL)............................ 77ZUBSOLV (8.6-2.1 MG) (TAB SUBL)............................ 77ZUTRIPRO........................................................................22ZYBAN..............................................................................81ZYDELIG.......................................................................... 67ZYKADIA......................................................................... 67ZYLET...............................................................................37ZYLOPRIM.......................................................................40ZYMAXID........................................................................ 38ZYPRAM...........................................................................61ZYPREXA (10 MG) (TABLET)......................................... 9ZYPREXA (15 MG) (TABLET)......................................... 9ZYPREXA (2.5 MG) (TABLET)........................................ 9ZYPREXA (20 MG) (TABLET)......................................... 9ZYPREXA (5 MG) (TABLET)........................................... 9ZYPREXA (7.5 MG) (TABLET)........................................ 9ZYPREXA ZYDIS.............................................................. 9ZYRTEC (1 MG/ML) (SOLUTION).................................. 1ZYTIGA (250 MG) (TABLET).........................................65ZYTIGA (500 MG) (TABLET).........................................65ZYVOX (100 MG/5ML) (SUSP RECON)........................50ZYVOX (600 MG) (TABLET)..........................................50


Index

Documents

2017 National Preferred Formulary Comprehensive - … National Preferred Formulary.pdfThe 2017 National Preferred Formulary drug list is shown below. ... clindamycin hcl . ... edrophonium