2020 Comprehensive Formulary

This formulary was updated on 092019 For more recent information or other questions please contact Centers Plan for Healthy Living at 1-877-940-9330 or for TTY users 1-800-421-1220 seven days a week from 8 am ndash 8 pm or visit wwwcentersplancom

H6988_ENR1085_C

Centers Plan for Medicare Advantage Care (HMO)

Language Assistance Services Notification

H6988_MKT4036 Accepted 10182018

English ATTENTION If you speak English language assistance services free of charge are available to you Call 1-877-940-9330 (TTY 1-800-421-1220)

Albanian KUJDES Neumlse flitni shqip peumlr ju ka neuml dispozicion sheumlrbime teuml asistenceumls gjuheumlsore pa pageseuml Telefononi neuml 1-877-940-9330 (TTY 1-800-421-1220)

Arabic -940-1877ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

) 1220-421-800-1(رقم ھاتف الصم والبكم 9330

Bengali লয করনঃ যিদ আপিন বাংলা কথা বলেত পােরন তাহেল িনঃখরচায় ভাষা সহায়তা পিরেষবা উপল আেছ েফান করন ১-877-940-9330 (TTY ১-800-421-1220)

Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-877-940-9330（TTY1-800-421-1220）

French ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 1-877-940-9330 (ATS 1-800-421-1220)

Greek ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης οι οποίες παρέχονται δωρεάν Καλέστε 1-877-940-9330 (TTY 1-800-421-1220)

French Creole

ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 1-877-940-9330 (TTY 1-800-421-1220)

Italian

ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero 1-877-940-9330 (TTY 1-800-421-1220)

Korean

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-877-940-9330 (TTY 1-800-421-1220)번으로 전화해 주십시오

Polish UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer 1-877-940-9330 (TTY 1-800-421-1220)

Russian

ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-877-940-9330 (телетайп 1-800-421-1220)

Spanish ATENCIOacuteN Si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-877-940-9330 (TTY 1-800-421-1220)

Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-877-940-9330 (TTY 1-800-421-1220)

Urdu 877-1خبردار اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کریں-940-9330 (TTY 1-800-421-1220)

Yiddish

אויפמערקזאם אויב איר רעדט אידיש זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון (TTY 1-800-421-1220) 1-877-940-9330אפצאל רופט

H6988_NMKT3035 Accepted 10182016

Notice of Nondiscrimination

Discrimination is Against the Law

Centers Plan for Healthy Living LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Centers Plan for Healthy Living LLC does not exclude people or treat them differently because of race color national origin age disability or sex

Centers Plan for Healthy Living LLC provides bull Free aids and services to people with disabilities to communicate

effectively with us such as o Qualified sign language interpreters o Written information in other formats (large print audio accessible

electronic formats other formats) bull Free language services to people whose primary language is not English such as

o Qualified interpreters o Information written in other languages

If you need these services contact MemberParticipant Services at 1-844-274-5227 (TTY users please call 1-800-421-1220 or 711)

If you believe that Centers Plan for Healthy Living LLC has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Grievances and Appeals Department

By Mail Centers Plan for Healthy Living LLC Attn GampA Department 75 Vanderbilt Avenue Staten Island NY 10304- 2604

By Phone 1-844-274-5227 (TTY users call 1-800-421-1220) By Fax 1-347-505-7089 By Email GandAcentersplancom

You can file a grievance in person or by mail fax or email If you need help filing a grievance MemberParticipant Services is available to help you seven days a week from 8am to 8pm

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

US Department of Health and Human

Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201

1-800-368-1019 800-537-7697 (TDD)

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

H6988_ENR1085_C I

2020 Formulary

(List of Covered Drugs)

PLEASE READ THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN

CPHL 2020 Formulary ID 20015 Version 5

This formulary was updated on 09012019 For more recent information or other questions please contact

us Centers Plan for Healthy Living at 1-877-940-9330 or for TTY users 1-800-421-1220 seven days a

week 800 AM to 800 PM or visit wwwcentersplancom

Note to existing members This formulary has changed since last year Please review this document to

make sure that it still contains the drugs you take

When this drug list (formulary) refers to ldquowerdquo ldquousrdquo or ldquoourrdquo it means Centers Plan for Healthy Living

When it refers to ldquoplanrdquo or ldquoour planrdquo it means Centers Plan for Medicare Advantage Plan (HMO)

This document includes list of the drugs (formulary) for our plan which is current as of 09012019 For an

updated formulary please contact us Our contact information along with the date we last updated the

formulary appears on the front and back cover pages

You must generally use network pharmacies to use your prescription drug benefit Benefits formulary

pharmacy network andor copaymentscoinsurance may change on January 1 2020 and from time to time

during the year

What is the Centers Plan for Medicare Advantage Plan (HMO) Formulary

A formulary is a list of covered drugs selected by Centers Plan for Medicare Advantage Plan (HMO) in

consultation with a team of health care providers which represents the prescription therapies believed to be a

necessary part of a quality treatment program Centers Plan for Medicare Advantage Plan (HMO) will

generally cover the drugs listed in our formulary as long as the drug is medically necessary the prescription

is filled at a Centers Plan for Medicare Advantage Plan (HMO) network pharmacy and other plan rules are

followed For more information on how to fill your prescriptions please review your Evidence of Coverage

H6988_ENR1085_C II

Can the Formulary (drug list) change

Most changes in drug coverage happen on January 1 but we may add or remove drugs on the Drug List

during the year move them to different cost-sharing tiers or add new restrictions

Changes that can affect you this year In the below cases you will be affected by coverage changes

during the year

bull New generic drugs We may immediately remove a brand name drug on our Drug List if we are

replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with

the same or fewer restrictions Also when adding the new generic drug we may decide to keep the

brand name drug on our Drug List but immediately move it to a different cost-sharing tier or add

new restrictions If you are currently taking that brand name drug we may not tell you in advance

before we make that change but we will later provide you with information about the specific

change(s) we have made

o If we make such a change you or your prescriber can ask us to make an exception and

continue to cover the brand name drug for you The notice we provide you will also include

information on how to request an exception and you can also find information in the section

below entitled ldquoHow do I request an exception to the Centers Plan for Medicare Advantage

Plan (HMO) Formularyrdquo

bull Drugs removed from the market If the Food and Drug Administration deems a drug on our

formulary to be unsafe or the drugrsquos manufacturer removes the drug from the market we will

immediately remove the drug from our formulary and provide notice to members who take the drug

bull Other changes We may make other changes that affect members currently taking a drug For

instance we may add a generic drug that is not new to market to replace a brand name drug currently

on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing

tier Or we may make changes based on new clinical guidelines If we remove drugs from our

formulary or add prior authorization quantity limits andor step therapy restrictions on a drug or

move a drug to a higher cost-sharing tier we must notify affected members of the change at least 30

days before the change becomes effective or at the time the member requests a refill of the drug at

which time the member will receive a 30-day supply of the drug

o If we make these other changes you or your prescriber can ask us to make an exception and

Changes that will not affect you if you are currently taking the drug Generally if you are taking a drug

on our 2020 formulary that was covered at the beginning of the year we will not discontinue or reduce

coverage of the drug during the 2020 coverage year except as described above

This means these drugs will remain available at the same cost-sharing and with no new restrictions for those

members taking them for the remainder of the coverage year

The enclosed formulary is current as of 09012019 To get updated information about the drugs covered by

Centers Plan for Medicare Advantage Plan (HMO) please contact us Our contact information appears on the

front and back cover pages

H6988_ENR1085_C III

How do I use the Formulary

There are two ways to find your drug within the formulary

Medical Condition

The formulary begins on page 3 The drugs in this formulary are grouped into categories depending on

the type of medical conditions that they are used to treat For example drugs used to treat a heart

condition are listed under the category ldquoCardiovascular Agentsrdquo If you know what your drug is used

for look for the category name in the list that begins on page number 1 Then look under the category

name for your drug

Alphabetical Listing

If you are not sure what category to look under you should look for your drug in the Index that begins on

page I-1 The Index provides an alphabetical list of all of the drugs included in this document Both

brand name drugs and generic drugs are listed in the Index Look in the Index and find your drug Next

to your drug you will see the page number where you can find coverage information Turn to the page

listed in the Index and find the name of your drug in the first column of the list

What are generic drugs

Centers Plan for Medicare Advantage Plan (HMO) covers both brand name drugs and generic drugs A

generic drug is approved by the FDA as having the same active ingredient as the brand name

drug Generally generic drugs cost less than brand name drugs

Are there any restrictions on my coverage

Some covered drugs may have additional requirements or limits on coverage These requirements and limits

may include

bull Prior Authorization Centers Plan for Medicare Advantage Plan (HMO) requires you [or your

physician] to get prior authorization for certain drugs This means that you will need to get approval

from Centers Plan for Medicare Advantage Plan (HMO) before you fill your prescriptions If you

donrsquot get approval Centers Plan for Medicare Advantage Plan (HMO) may not cover the drug

bull Quantity Limits For certain drugs Centers Plan for Medicare Advantage Plan (HMO) limits the

amount of the drug that Centers Plan for Medicare Advantage Plan (HMO) will cover For example

Centers Plan for Medicare Advantage Plan (HMO) provides 12 tablets per prescription for

sumatriptan This may be in addition to a standard one-month or three-month supply

bull Step Therapy In some cases Centers Plan for Medicare Advantage Plan (HMO) requires you to

first try certain drugs to treat your medical condition before we will cover another drug for that

condition For example if Drug A and Drug B both treat your medical condition Centers Plan for

Medicare Advantage Plan (HMO) may not cover Drug B unless you try Drug A first If Drug A does

not work for you Centers Plan for Medicare Advantage Plan (HMO) will then cover Drug B

You can find out if your drug has any additional requirements or limits by looking in the formulary that

begins on page 3 You can also get more information about the restrictions applied to specific covered drugs

by visiting our Web site We have posted on line documents that explain our prior authorization restriction

and step therapy restriction You may also ask us to send you a copy Our contact information along with

the date we last updated the formulary appears on the front and back cover pages

H6988_ENR1085_C IV

You can ask Centers Plan for Medicare Advantage Plan (HMO) to make an exception to these restrictions or

limits or for a list of other similar drugs that may treat your health condition See the section ldquoHow do I

request an exception to the Centers Plan for Medicare Advantage Plan (HMO) formularyrdquo on page iv for

information about how to request an exception

What if my drug is not on the Formulary

If your drug is not included in this formulary (list of covered drugs) you should first contact Member

Services and ask if your drug is covered

If you learn that Centers Plan for Medicare Advantage Plan (HMO) does not cover your drug you have two

options

bull You can ask Member Services for a list of similar drugs that are covered by Centers Plan for

Medicare Advantage Plan (HMO) When you receive the list show it to your doctor and ask him or

her to prescribe a similar drug that is covered by Centers Plan for Medicare Advantage Plan (HMO)

bull You can ask Centers Plan for Medicare Advantage Plan (HMO) to make an exception and cover your

drug See below for information about how to request an exception

How do I request an exception to the Centers Plan for Medicare Advantage Plan

(HMO) Formulary

You can ask Centers Plan for Medicare Advantage Plan (HMO) to make an exception to our coverage rules

There are several types of exceptions that you can ask us to make

bull You can ask us to cover a drug even if it is not on our formulary If approved this drug will be

covered at a pre-determined cost-sharing level and you would not be able to ask us to provide the

drug at a lower cost-sharing level

bull You can ask us to cover a formulary drug at a lower cost-sharing level [if this drug is not on the

specialty tier If approved this would lower the amount you must pay for your drug

bull You can ask us to waive coverage restrictions or limits on your drug For example for certain drugs

Centers Plan for Medicare Advantage Plan (HMO) limits the amount of the drug that we will cover

If your drug has a quantity limit you can ask us to waive the limit and cover a greater amount

Generally Centers Plan for Medicare Advantage Plan (HMO) will only approve your request for an

exception if the alternative drugs included on the planrsquos formulary the lower cost-sharing drug or additional

utilization restrictions would not be as effective in treating your condition andor would cause you to have

adverse medical effects

You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction

exception When you request a formulary or utilization restriction exception you should submit a

statement from your prescriber or physician supporting your request Generally we must make our

decision within 72 hours of getting your prescriberrsquos supporting statement You can request an expedited

(fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72

hours for a decision If your request to expedite is granted we must give you a decision no later than 24

hours after we get a supporting statement from your doctor or other prescriber

H6988_ENR1085_C V

What do I do before I can talk to my doctor about changing my drugs or requesting an

exception

As a new or continuing member in our plan you may be taking drugs that are not on our formulary Or you

may be taking a drug that is on our formulary but your ability to get it is limited For example you may need

a prior authorization from us before you can fill your prescription You should talk to your doctor to decide

if you should switch to an appropriate drug that we cover or request a formulary exception so that we will

cover the drug you take While you talk to your doctor to determine the right course of action for you we

may cover your drug in certain cases during the first 90 days you are a member of our plan

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited we will

cover a temporary 30-day supply If your prescription is written for fewer days wersquoll allow refills to provide

up to a maximum 30-day supply of medication After your first 30-day supply we will not pay for these

drugs even if you have been a member of the plan less than 90 days

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your

ability to get your drugs is limited but you are past the first 90 days of membership in our plan we will

cover a 31-day emergency supply of that drug while you pursue a formulary exception

For more information

For more detailed information about your Centers Plan for Medicare Advantage Plan (HMO) prescription

drug coverage please review your Evidence of Coverage and other plan materials

If you have questions about Centers Plan for Medicare Advantage Plan (HMO) please contact us Our

contact information along with the date we last updated the formulary appears on the front and back cover

If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-

MEDICARE (1-800-633-4227) 24 hours a day7 day a week TTY users should call 1-877-486-2048 Or

visit httpwwwmedicaregov

Centers Plan for Medicare Advantage Plan (HMO) Formulary

The formulary below provides coverage information about the drugs covered by Centers Plan for Medicare

Advantage Plan (HMO) If you have trouble finding your drug in the list turn to the Index that begins on

page I-1

The first column of the chart lists the drug name Brand name drugs are capitalized (eg LIPITOR) and

generic drugs are listed in lower-case italics (eg atorvastatin)

The information in the RequirementsLimits column tells you if Centers Plan for Medicare Advantage Plan

(HMO) has any special requirements for coverage of your drug

Analgesics 3

Anesthetics 7

Anti-AddictionSubstance Abuse Treatment Agents 7

Antianxiety Agents 8

Antibacterials 9

Anticancer Agents 15

Anticholinergic Agents 25

Anticonvulsants 25

Antidementia Agents 29

Antidepressants 29

Antidiabetic Agents 32

Antifungals 35

Antigout Agents 37

Antihistamines 37

Anti-Infectives (Skin And Mucous Membrane) 37

Antimigraine Agents 38

Antimycobacterials 38

Antinausea Agents 39

Antiparasite Agents 41

Antiparkinsonian Agents 41

Antipsychotic Agents 43

Antivirals (Systemic) 47

Blood ProductsModifiersVolume Expanders 52

Caloric Agents 55

Cardiovascular Agents 58

Central Nervous System Agents 66

Contraceptives 70

Table of Contents

Dental And Oral Agents 76

Dermatological Agents 76

Devices 79

Enzyme ReplacementModifiers 80

Eye Ear Nose Throat Agents 81

Gastrointestinal Agents 85

Genitourinary Agents 88

Heavy Metal Antagonists 89

Hormonal Agents StimulantReplacementModifying 89

Immunological Agents 95

Inflammatory Bowel Disease Agents 103

Irrigating Solutions 104

Metabolic Bone Disease Agents 104

Miscellaneous Therapeutic Agents 105

Ophthalmic Agents 107

Replacement Preparations 108

Respiratory Tract Agents 109

Skeletal Muscle Relaxants 113

Sleep Disorder Agents 114

Vasodilating Agents 114

Vitamins And Minerals 115

You can find information on what the symbols and abbreviations in this table mean by going to the introduction

pages of this document

Drug Name

Drug Tier RequirementsLimits

Analgesics

Analgesics Miscellaneous

acetaminophen-codeine oral solution 120-

12 mg5 ml

1 NDS NM QL (2700 per

30 days)

acetaminophen-codeine oral tablet 300-15

30 days)

(Tylenol-Codeine 3) 2 NDS NM QL (360 per

30 days)

buprenorphine hcl injection solution 03

(Buprenex) 2

buprenorphine hcl injection syringe 03

butalbital-acetaminophen-caff oral tablet

50-325-40 mg

(Esgic) 2 PA-HRM QL (180 per

30 days) AGE (Max 64

Years)

butalbital-aspirin-caffeine oral capsule

50-325-40 mg

(Fiorinal) 2 PA-HRM QL (180 per

Years)

butalbital-aspirin-caffeine oral tablet 50-

325-40 mg

2 PA-HRM QL (180 per

Years)

codeine sulfate oral tablet 15 mg 30 mg

30 days)

endocet oral tablet 10-325 mg 2 NDS NM QL (180 per

30 days)

endocet oral tablet 25-325 mg 5-325 mg 2 NDS NM QL (360 per

30 days)

fentanyl citrate buccal lozenge on a

handle 1200 mcg 1600 mcg 200 mcg

400 mcg 600 mcg 800 mcg

(Actiq) 5 PA NDS NM QL (120

per 30 days)

fentanyl transdermal patch 72 hour 100

mcghr 12 mcghr 25 mcghr 50 mcghr

75 mcghr

(Duragesic) 2 NDS NM QL (10 per

30 days)

hydrocodone-acetaminophen oral solution

75-325 mg15 ml

30 days)

hydrocodone-acetaminophen oral tablet

10-325 mg

(Lorcet HD) 2 NDS NM QL (180 per

30 days)

25-325 mg

30 days)

Drug Name

hydrocodone-acetaminophen oral tablet 5-

325 mg

(Lorcet (hydrocodone)) 2 NDS NM QL (240 per

30 days)

75-325 mg

(Lorcet Plus) 2 NDS NM QL (180 per

30 days)

hydrocodone-ibuprofen oral tablet 75-200

30 days)

hydromorphone (pf) injection solution 10

(mgml) (5 ml) 10 mgml

hydromorphone oral liquid 1 mgml (Dilaudid) 2 NDS NM QL (1200 per

30 days)

hydromorphone oral tablet 2 mg 4 mg 8

(Dilaudid) 2 NDS NM QL (180 per

30 days)

LAZANDA NASAL SPRAYNON-

AEROSOL 100 MCGSPRAY 300

MCGSPRAY 400 MCGSPRAY

5 PA NDS NM QL (30

per 30 days)

lorcet (hydrocodone) oral tablet 5-325 mg 2 NDS NM QL (240 per

30 days)

lorcet hd oral tablet 10-325 mg 2 NDS NM QL (180 per

30 days)

lorcet plus oral tablet 75-325 mg 2 NDS NM QL (180 per

30 days)

methadone injection solution 10 mgml 2

methadone oral solution 10 mg5 ml 2 NDS NM QL (600 per

30 days)

methadone oral tablet 10 mg (Dolophine) 2 NDS NM QL (120 per

30 days)

methadose oral tabletsoluble 40 mg 2 NDS NM QL (30 per

30 days)

morphine 10 mgml isecure syrg lf pf

suv inner 10 mgml

morphine concentrate oral solution 100

mg5 ml (20 mgml)

30 days)

morphine injection syringe 10 mgml 4

morphine intravenous solution 10 mgml

4 mgml 8 mgml

morphine oral solution 10 mg5 ml 2 NDS NM QL (700 per

30 days)

morphine oral solution 20 mg5 ml (4

30 days)

Drug Name

MORPHINE ORAL TABLET 15 MG 4 NDS NM QL (180 per

30 days)

morphine oral tablet extended release 100

mg 200 mg 60 mg

(MS Contin) 2 NDS NM QL (60 per

30 days)

mg 30 mg

30 days)

NUCYNTA ER ORAL TABLET

EXTENDED RELEASE 12 HR 100 MG

150 MG 200 MG 250 MG 50 MG

3 NDS NM QL (60 per

30 days)

NUCYNTA ORAL TABLET 100 MG 50

MG 75 MG

30 days)

oxycodone oral solution 5 mg5 ml 2 NDS NM QL (1300 per

30 days)

oxycodone oral tablet 10 mg 2 NDS NM QL (180 per

30 days)

oxycodone oral tablet 15 mg 30 mg (Roxicodone) 2 NDS NM QL (120 per

30 days)

oxycodone oral tablet 5 mg (Roxicodone) 2 NDS NM QL (180 per

30 days)

oxycodone oral tabletoral onlyextrel12

hr 10 mg 15 mg 20 mg 30 mg 40 mg 60

mg 80 mg

(OxyContin) 3 NDS NM QL (60 per

30 days)

oxycodone-acetaminophen oral tablet 10-

325 mg

(Endocet) 2 NDS NM QL (180 per

30 days)

325 mg 5-325 mg

30 days)

325 mg

30 days)

oxycodone-aspirin oral tablet 48355-325

30 days)

tramadol oral tablet 50 mg (Ultram) 1 NDS NM QL (240 per

30 days)

tramadol-acetaminophen oral tablet 375-

325 mg

(Ultracet) 2 NDS NM QL (240 per

30 days)

XTAMPZA ER ORAL

CAPSPRINKLER12HR(DONT

CRUSH) 135 MG 18 MG 9 MG

3 NDS NM QL (60 per

30 days)

Drug Name

XTAMPZA ER ORAL

CRUSH) 27 MG

30 days)

XTAMPZA ER ORAL

CRUSH) 36 MG

30 days)

Nonsteroidal Anti-Inflammatory Agents

CALDOLOR INTRAVENOUS RECON

SOLN 800 MG8 ML (100 MGML)

celecoxib oral capsule 100 mg 200 mg 50

(Celebrex) 2 QL (60 per 30 days)

diclofenac epolamine transdermal patch

12 hour 13

(Flector) 2 PA

diclofenac potassium oral tablet 50 mg 2

diclofenac sodium oral tablet extended

release 24 hr 100 mg

(Voltaren-XR) 2

diclofenac sodium oral tabletdelayed

release (drec) 25 mg 50 mg 75 mg

diclofenac sodium topical drops 15 2 QL (300 per 30 days)

diclofenac sodium topical gel 1 (Voltaren) 2

diclofenac sodium topical gel 3 (Solaraze) 2 PA QL (100 per 28

etodolac oral capsule 200 mg 300 mg 2

etodolac oral tablet 400 mg (Lodine) 2

etodolac oral tablet 500 mg 2

flurbiprofen oral tablet 100 mg 50 mg 2

ibu oral tablet 400 mg 600 mg 800 mg 1

ibuprofen oral suspension 100 mg5 ml (Childrens Advil) 2

ibuprofen oral tablet 400 mg 600 mg 800

(IBU) 1

indomethacin oral capsule 25 mg 1 PA-HRM QL (240 per

Years)

ketorolac oral tablet 10 mg 2 PA-HRM QL (20 per 30

days) AGE (Max 64

Years)

mefenamic acid oral capsule 250 mg 2

meloxicam oral suspension 75 mg5 ml 4

meloxicam oral tablet 15 mg 75 mg (Mobic) 1

nabumetone oral tablet 500 mg 750 mg 2

Drug Name

naproxen oral tablet 250 mg 375 mg 1

naproxen oral tablet 500 mg (Naprosyn) 1

naproxen oral tabletdelayed release

(drec) 375 mg 500 mg

(EC-Naprosyn) 2

PENNSAID TOPICAL SOLUTION IN

METERED-DOSE PUMP 20 MGGRAM

ACTUATION(2 )

5 PA NDS QL (224 per

28 days)

sulindac oral tablet 150 mg 200 mg 2

VOLTAREN TOPICAL GEL 1 2

Anesthetics

Local Anesthetics

glydo mucous membrane jelly in

applicator 2

2 QL (30 per 30 days)

lidocaine (pf) injection solution 10 mgml

(1 ) 15 mgml (15 ) 20 mgml (2 )

5 mgml (05 )

(Xylocaine-MPF) 1

lidocaine (pf) intravenous solution 20

mgml (2 )

(Xylocaine (Cardiac)

lidocaine hcl injection solution 10 mgml

(1 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine) 1

lidocaine hcl mucous membrane jelly 2 2 QL (30 per 30 days)

lidocaine hcl mucous membrane solution 4

(40 mgml)

lidocaine topical adhesive

patchmedicated 5

(Lidoderm) 2 PA QL (90 per 30 days)

lidocaine topical ointment 5 2 PA QL (90 per 30 days)

lidocaine viscous mucous membrane

solution 2

lidocaine-prilocaine topical cream 25-25

2 PA QL (30 per 30 days)

ZTLIDO TOPICAL ADHESIVE

PATCHMEDICATED 18

Anti-AddictionSubstance Abuse

Treatment Agents

acamprosate oral tabletdelayed release

(drec) 333 mg

buprenorphine hcl sublingual tablet 2 mg

Drug Name

buprenorphine-naloxone sublingual film

12-3 mg 8-2 mg

(Suboxone) 2 QL (60 per 30 days)

2-05 mg 4-1 mg

buprenorphine-naloxone sublingual tablet

2-05 mg 8-2 mg

bupropion hcl (smoking deter) oral tablet

extended release 12 hr 150 mg

CHANTIX CONTINUING MONTH

BOX ORAL TABLET 1 MG

3 QL (336 per 365 days)

CHANTIX ORAL TABLET 05 MG 1

3 QL (336 per 365 days)

CHANTIX STARTING MONTH BOX

ORAL TABLETSDOSE PACK 05 MG

(11)- 1 MG (42)

disulfiram oral tablet 250 mg 500 mg (Antabuse) 2

LUCEMYRA ORAL TABLET 018 MG 5 NDS QL (228 per 14

naloxone injection solution 04 mgml 2

naloxone injection syringe 04 mgml 1

naltrexone oral tablet 50 mg 2

NARCAN NASAL SPRAYNON-

AEROSOL 4 MGACTUATION

NICOTROL INHALATION

CARTRIDGE 10 MG

4 QL (1008 per 90 days)

SUBLOCADE SUBCUTANEOUS

SOLUTION EXTENDED REL

SYRINGE 100 MG05 ML 300 MG15

ZUBSOLV SUBLINGUAL TABLET 07-

018 MG 14-036 MG 114-29 MG 29-

071 MG 57-14 MG

Antianxiety Agents

Benzodiazepines

alprazolam oral tablet 025 mg 05 mg 1

(Xanax) 1 NDS NM QL (120 per

30 days)

alprazolam oral tablet 2 mg (Xanax) 1 NDS NM QL (150 per

30 days)

buspirone oral tablet 10 mg 15 mg 30

mg 5 mg 75 mg

Drug Name

chlordiazepoxide hcl oral capsule 10 mg

25 mg 5 mg

30 days)

clonazepam oral tablet 05 mg 1 mg (Klonopin) 1 NDS NM QL (90 per

30 days)

clonazepam oral tablet 2 mg (Klonopin) 1 NDS NM QL (300 per

30 days)

clonazepam oral tabletdisintegrating

0125 mg 025 mg 05 mg 1 mg

2 NDS NM QL (90 per

30 days)

clonazepam oral tabletdisintegrating 2

30 days)

clorazepate dipotassium oral tablet 15 mg

375 mg

30 days)

clorazepate dipotassium oral tablet 75 mg (Tranxene T-Tab) 2 NDS NM QL (180 per

30 days)

diazepam 5 mgml oral conc 5 mgml 2 NDS NM QL (1200 per

30 days)

diazepam injection solution 5 mgml 2 QL (10 per 28 days)

diazepam injection syringe 5 mgml 2 QL (10 per 28 days)

diazepam oral concentrate 5 mgml (Diazepam Intensol) 2 NDS NM QL (1200 per

30 days)

diazepam oral solution 5 mg5 ml (1

30 days)

diazepam oral tablet 10 mg 2 mg 5 mg (Valium) 1 NDS NM QL (120 per

30 days)

lorazepam injection solution 2 mgml 4

(Ativan) 1 QL (2 per 30 days)

lorazepam injection syringe 2 mgml 4

lorazepam oral tablet 05 mg 1 mg (Ativan) 1 NDS NM QL (90 per

30 days)

lorazepam oral tablet 2 mg (Ativan) 1 NDS NM QL (150 per

30 days)

temazepam oral capsule 15 mg 30 mg (Restoril) 1 NDS NM QL (30 per

30 days)

Antibacterials

Aminoglycosides

BETHKIS INHALATION SOLUTION

FOR NEBULIZATION 300 MG4 ML

5 PA BvD NDS

gentamicin injection solution 20 mg2 ml

40 mgml

gentamicin sulfate (ped) (pf) injection

solution 20 mg2 ml

Drug Name

gentamicin sulfate (pf) intravenous

solution 100 mg10 ml 60 mg6 ml 80

mg8 ml

neomycin oral tablet 500 mg 1

streptomycin intramuscular recon soln 1

TOBI PODHALER INHALATION

CAPSULE WINHALATION DEVICE

5 NDS QL (224 per 28

tobramycin in 0225 nacl inhalation

solution for nebulization 300 mg5 ml

(Tobi) 5 PA BvD NDS

tobramycin sulfate injection solution 40

tobramycin with nebulizer inhalation

(Kitabis Pak) 5 PA BvD NDS

Antibacterials Miscellaneous

baciim intramuscular recon soln 50000

chloramphenicol sod succinate

intravenous recon soln 1 gram

clindamycin hcl oral capsule 150 mg 300

mg 75 mg

(Cleocin HCl) 1

clindamycin in 5 dextrose intravenous

piggyback 300 mg50 ml 600 mg50 ml

900 mg50 ml

clindamycin phosphate injection solution

150 (mgml) (6 ml)

150 mgml

(Cleocin) 2

clindamycin phosphate intravenous

solution 600 mg4 ml

(Cleocin) 2

colistin (colistimethate na) injection recon

soln 150 mg

(Coly-Mycin M

Parenteral)

5 PA BvD NDS

daptomycin intravenous recon soln 500

(Cubicin) 5 NDS

FIRVANQ ORAL RECON SOLN 25

MGML 50 MGML

linezolid 600 mg300 ml-09 nacl 600

mg300 ml

linezolid in dextrose 5 intravenous

piggyback 600 mg300 ml

(Zyvox) 5 NDS

linezolid oral suspension for reconstitution

100 mg5 ml

(Zyvox) 5 NDS

Drug Name

linezolid oral tablet 600 mg (Zyvox) 2

methenamine hippurate oral tablet 1 gram (Hiprex) 2

metronidazole in nacl (iso-os) intravenous

(Metro IV) 2

metronidazole oral tablet 250 mg 500 mg (Flagyl) 1

nitrofurantoin macrocrystal oral capsule

100 mg 25 mg 50 mg

(Macrodantin) 2 QL (120 per 30 days)

nitrofurantoin monohydm-cryst oral

capsule 100 mg

(Macrobid) 2 QL (60 per 30 days)

polymyxin b sulfate injection recon soln

500000 unit

SYNERCID INTRAVENOUS RECON

SOLN 500 MG

trimethoprim oral tablet 100 mg 1

vancomycin intravenous recon soln 1000

mg 125 gram 10 gram 5 gram 500 mg

750 mg

2 PA BvD

vancomycin oral capsule 125 mg 250 mg (Vancocin) 2

XIFAXAN ORAL TABLET 200 MG 5 PA NDS QL (9 per 30

XIFAXAN ORAL TABLET 550 MG 5 PA NDS

Cephalosporins

cefaclor oral capsule 250 mg 500 mg 2

cefaclor oral suspension for reconstitution

125 mg5 ml 250 mg5 ml 375 mg5 ml

cefadroxil oral capsule 500 mg 2

cefadroxil oral suspension for

reconstitution 250 mg5 ml 500 mg5 ml

cefazolin injection recon soln 1 gram 10

gram 500 mg

cefdinir oral capsule 300 mg 2

cefdinir oral suspension for reconstitution

125 mg5 ml 250 mg5 ml

cefditoren pivoxil oral tablet 200 mg 4

cefditoren pivoxil oral tablet 400 mg (Spectracef) 4

cefepime injection recon soln 1 gram 2

(Maxipime) 2

cefixime oral capsule 400 mg (Suprax) 2

cefotaxime injection recon soln 1 gram 2

cefoxitin intravenous recon soln 1 gram

10 gram 2 gram

Drug Name

cefpodoxime oral suspension for

cefpodoxime oral tablet 100 mg 200 mg 2

cefprozil oral suspension for

cefprozil oral tablet 250 mg 500 mg 2

ceftazidime injection recon soln 1 gram (Fortaz) 2

ceftazidime injection recon soln 2 gram 6

(Tazicef) 2

ceftriaxone injection recon soln 1 gram

10 gram 2 gram 250 mg 500 mg

cefuroxime axetil oral tablet 250 mg 500

cefuroxime sodium injection recon soln

750 mg

cefuroxime sodium intravenous recon soln

15 gram 75 gram

cephalexin oral capsule 250 mg 500 mg (Keflex) 1

cephalexin oral suspension for

TEFLARO INTRAVENOUS RECON

SOLN 400 MG 600 MG

Macrolides

azithromycin intravenous recon soln 500

(Zithromax) 2

azithromycin oral packet 1 gram (Zithromax) 4

azithromycin oral suspension for

(Zithromax) 2

azithromycin oral tablet 250 mg (6 pack)

500 mg (3 pack) 600 mg

azithromycin oral tablet 250 mg 500 mg (Zithromax) 1

clarithromycin oral suspension for

clarithromycin oral tablet 250 mg 500 mg 2

DIFICID ORAL TABLET 200 MG 5 ST NDS QL (20 per 10

erythromycin ethylsuccinate oral

suspension for reconstitution 200 mg5 ml

(EES Granules) 2

(EryPed 400) 2

erythromycin oral tablet 250 mg 500 mg 2

Miscellaneous B-Lactam Antibiotics

Drug Name

aztreonam injection recon soln 1 gram 2

(Azactam) 2

CAYSTON INHALATION SOLUTION

FOR NEBULIZATION 75 MGML

5 PA LA NDS

ertapenem injection recon soln 1 gram (Invanz) 2

imipenem-cilastatin intravenous recon

soln 250 mg

soln 500 mg

(Primaxin IV) 2

meropenem intravenous recon soln 1

gram 500 mg

(Merrem) 2

Penicillins

amoxicillin oral capsule 250 mg 500 mg 1

amoxicillin oral suspension for

250 mg5 ml 400 mg5 ml

amoxicillin oral tablet 500 mg 875 mg 1

amoxicillin oral tabletchewable 125 mg

250 mg

amoxicillin-pot clavulanate oral

suspension for reconstitution 200-285

mg5 ml 400-57 mg5 ml

mg5 ml

(Augmentin ES-600) 2

amoxicillin-pot clavulanate oral tablet

500-125 mg 875-125 mg

(Augmentin) 1

tabletchewable 200-285 mg 400-57 mg

ampicillin oral capsule 250 mg 500 mg 2

ampicillin sodium injection recon soln 1

gram 10 gram 125 mg 2 gram 250 mg

500 mg

ampicillin-sulbactam injection recon soln

15 gram 15 gram 3 gram

(Unasyn) 2

BICILLIN L-A INTRAMUSCULAR

SYRINGE 1200000 UNIT2 ML

2400000 UNIT4 ML 600000

UNITML

dicloxacillin oral capsule 250 mg 500 mg 2

nafcillin 1 gm 50 ml inj 1 gram50 ml 2

nafcillin injection recon soln 1 gram 2

nafcillin injection recon soln 10 gram 5 NDS

Drug Name

penicillin g potassium injection recon soln

20 million unit

(Pfizerpen-G) 2

penicillin g procaine intramuscular

syringe 12 million unit2 ml 600000

unitml

penicillin v potassium oral recon soln 125

mg5 ml 250 mg5 ml

penicillin v potassium oral tablet 250 mg

500 mg

pfizerpen-g injection recon soln 20 million

piperacillin-tazobactam intravenous recon

soln 225 gram 3375 gram 45 gram

405 gram

(Zosyn) 2 PA BvD

Quinolones

BAXDELA ORAL TABLET 450 MG 5 PA NDS QL (28 per 14

ciprofloxacin hcl oral tablet 250 mg 500

(Cipro) 1

ciprofloxacin in 5 dextrose intravenous

(Cipro in D5W) 2

ciprofloxacin oral

suspensionmicrocapsule recon 250 mg5

ml 500 mg5 ml

(Cipro) 2

levofloxacin in d5w intravenous piggyback

250 mg50 ml 500 mg100 ml 750 mg150

levofloxacin intravenous solution 25

levofloxacin oral solution 250 mg10 ml 2

levofloxacin oral tablet 250 mg 1

levofloxacin oral tablet 500 mg 750 mg (Levaquin) 1

moxifloxacin oral tablet 400 mg 2

Sulfonamides

sulfadiazine oral tablet 500 mg 2

sulfamethoxazole-trimethoprim

intravenous solution 400-80 mg5 ml

sulfamethoxazole-trimethoprim oral

suspension 200-40 mg5 ml

(Sulfatrim) 2

Drug Name

sulfamethoxazole-trimethoprim oral tablet

400-80 mg

(Bactrim) 1

800-160 mg

(Bactrim DS) 1

sulfatrim oral suspension 200-40 mg5 ml 4

Tetracyclines

doxy-100 intravenous recon soln 100 mg 2

doxycycline hyclate intravenous recon

soln 100 mg

(Doxy-100) 2

doxycycline hyclate oral capsule 100 mg

(Morgidox) 2

doxycycline hyclate oral tablet 100 mg 20

doxycycline monohydrate oral capsule 100

mg 50 mg

(Mondoxyne NL) 2

doxycycline monohydrate oral suspension

for reconstitution 25 mg5 ml

(Vibramycin) 2

doxycycline monohydrate oral tablet 100

(Avidoxy) 2

minocycline oral capsule 100 mg 75 mg 2

minocycline oral capsule 50 mg (Minocin) 2

mondoxyne nl oral capsule 100 mg 50 mg 2

tetracycline oral capsule 250 mg 500 mg 2

tigecycline intravenous recon soln 50 mg (Tygacil) 5 NDS

Anticancer Agents

ABRAXANE INTRAVENOUS

SUSPENSION FOR RECONSTITUTION

100 MG

adriamycin intravenous solution 10 mg5

ml 2 mgml 20 mg10 ml 50 mg25 ml

2 PA BvD

adrucil intravenous solution 25 gram50

ml 500 mg10 ml

2 PA BvD

AFINITOR DISPERZ ORAL TABLET

FOR SUSPENSION 2 MG 3 MG 5 MG

5 PA NSO NDS QL (112

per 28 days)

AFINITOR ORAL TABLET 10 MG 5 PA NSO NDS QL (56

per 28 days)

AFINITOR ORAL TABLET 25 MG 5

MG 75 MG

5 PA NSO NDS QL (28

per 28 days)

Drug Name

ALECENSA ORAL CAPSULE 150 MG 5 PA NSO NDS QL (240

per 30 days)

ALIMTA INTRAVENOUS RECON

SOLN 100 MG 500 MG

ALIQOPA INTRAVENOUS RECON

SOLN 60 MG

5 PA NSO NDS QL (3

per 28 days)

ALUNBRIG ORAL TABLET 180 MG

5 PA NSO NDS QL (30

per 30 days)

ALUNBRIG ORAL TABLET 30 MG 5 PA NSO NDS QL (120

per 30 days)

ALUNBRIG ORAL TABLETSDOSE

PACK 90 MG (7)- 180 MG (23)

5 PA NSO NDS

anastrozole oral tablet 1 mg (Arimidex) 1

arsenic trioxide intravenous solution 1

AVASTIN INTRAVENOUS SOLUTION

25 MGML

5 PA NSO NDS

azacitidine injection recon soln 100 mg (Vidaza) 5 NDS

BALVERSA ORAL TABLET 3 MG 5 PA NSO NDS QL (84

per 28 days)

BAVENCIO INTRAVENOUS

SOLUTION 20 MGML

5 PA NSO NDS

BELEODAQ INTRAVENOUS RECON

SOLN 500 MG

5 PA NSO NDS

BENDEKA INTRAVENOUS

SOLUTION 25 MGML

5 PA NSO NDS

BESPONSA INTRAVENOUS RECON

SOLN 09 MG (025 MGML INITIAL)

5 PA NSO NDS

bexarotene oral capsule 75 mg (Targretin) 5 PA NSO NDS QL (420

per 30 days)

bicalutamide oral tablet 50 mg (Casodex) 2

bleomycin injection recon soln 15 unit 30

BLINCYTO INTRAVENOUS KIT 35

5 PA NSO NDS

BORTEZOMIB INTRAVENOUS

RECON SOLN 35 MG

5 PA NSO NDS

BOSULIF ORAL TABLET 100 MG 5 PA NSO NDS QL (90

per 30 days)

Drug Name

BOSULIF ORAL TABLET 400 MG 500

5 PA NSO NDS QL (30

per 30 days)

BRAFTOVI ORAL CAPSULE 50 MG 5 PA NSO NDS QL (120

per 30 days)

CABOMETYX ORAL TABLET 20 MG

5 PA NSO NDS QL (30

per 30 days)

CABOMETYX ORAL TABLET 40 MG 5 PA NSO NDS QL (60

per 30 days)

CALQUENCE ORAL CAPSULE 100

5 PA NSO NDS QL (60

per 30 days)

CAPRELSA ORAL TABLET 100 MG 5 PA NSO NDS QL (60

per 30 days)

clofarabine intravenous solution 20 mg20

(Clolar) 5 NDS

COMETRIQ ORAL CAPSULE 100

MGDAY(80 MG X1-20 MG X1) 140

MGDAY(80 MG X1-20 MG X3) 60

MGDAY (20 MG X 3DAY)

per 28 days)

COPIKTRA ORAL CAPSULE 15 MG

5 PA NSO NDS QL (56

per 28 days)

COTELLIC ORAL TABLET 20 MG 5 PA NSO LA NDS QL

(63 per 28 days)

cyclophosphamide intravenous recon soln

1 gram 2 gram 500 mg

5 PA BvD NDS

CYCLOPHOSPHAMIDE ORAL

CAPSULE 25 MG 50 MG

2 PA BvD ST

CYRAMZA INTRAVENOUS

SOLUTION 10 MGML

5 PA NSO NDS

DARZALEX INTRAVENOUS

SOLUTION 20 MGML

5 PA NSO LA NDS

DAURISMO ORAL TABLET 100 MG 5 PA NSO NDS QL (30

per 30 days)

decitabine intravenous recon soln 50 mg (Dacogen) 5 NDS

doxorubicin intravenous solution 10 mg5

(Adriamycin) 2 PA BvD

doxorubicin peg-liposomal intravenous

suspension 2 mgml

(Doxil) 5 PA BvD NDS

Drug Name

DROXIA ORAL CAPSULE 200 MG 300

MG 400 MG

ELIGARD (3 MONTH)

SUBCUTANEOUS SYRINGE 225 MG

ELIGARD (4 MONTH)

ELIGARD (6 MONTH)

ELIGARD SUBCUTANEOUS SYRINGE

75 MG (1 MONTH)

EMCYT ORAL CAPSULE 140 MG 5 NDS

EMPLICITI INTRAVENOUS RECON

SOLN 300 MG 400 MG

5 PA NSO NDS

ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO NDS QL (30

per 30 days)

ERLEADA ORAL TABLET 60 MG 5 PA NSO NDS QL (120

per 30 days)

erlotinib oral tablet 100 mg 25 mg (Tarceva) 5 PA NSO NDS QL (60

per 30 days)

erlotinib oral tablet 150 mg (Tarceva) 5 PA NSO NDS QL (90

per 30 days)

ETOPOPHOS INTRAVENOUS RECON

SOLN 100 MG

etoposide intravenous solution 20 mgml (Toposar) 2

exemestane oral tablet 25 mg (Aromasin) 2

FARYDAK ORAL CAPSULE 10 MG 15

MG 20 MG

5 PA NSO NDS

floxuridine injection recon soln 05 gram 2 PA BvD

fluorouracil intravenous solution 1

gram20 ml

2 PA BvD

gram100 ml 500 mg10 ml

(Adrucil) 2 PA BvD

flutamide oral capsule 125 mg 2

fulvestrant intramuscular syringe 250

mg5 ml

(Faslodex) 5 NDS

GAZYVA INTRAVENOUS SOLUTION

1000 MG40 ML

5 PA NSO NDS

GILOTRIF ORAL TABLET 20 MG 30

MG 40 MG

5 PA NSO NDS QL (30

per 30 days)

GLEOSTINE ORAL CAPSULE 10 MG

40 MG 5 MG

GLEOSTINE ORAL CAPSULE 100 MG 5 NDS

Drug Name

HERCEPTIN HYLECTA

SUBCUTANEOUS SOLUTION 600 MG-

10000 UNIT5 ML

5 PA NSO NDS QL (5

per 21 days)

HERCEPTIN INTRAVENOUS RECON

SOLN 150 MG 440 MG

5 PA NSO NDS

hydroxyurea oral capsule 500 mg (Hydrea) 2

IBRANCE ORAL CAPSULE 100 MG

125 MG 75 MG

5 PA NSO NDS QL (21

per 28 days)

ICLUSIG ORAL TABLET 15 MG 5 PA NSO NDS QL (60

per 30 days)

IDHIFA ORAL TABLET 100 MG 50

5 PA NSO NDS QL (30

per 30 days)

ifosfamide intravenous recon soln 1 gram (Ifex) 2

ifosfamide intravenous solution 1 gram20

ml 3 gram60 ml

ifosfamide-mesna intravenous kit 1-1

gram 3000-1000 mg

5 PA BvD NDS

imatinib oral tablet 100 mg (Gleevec) 5 PA NSO NDS QL (90

per 30 days)

IMBRUVICA ORAL CAPSULE 140 MG 5 PA NSO NDS QL (120

per 30 days)

per 28 days)

IMBRUVICA ORAL TABLET 140 MG

280 MG 420 MG 560 MG

5 PA NSO NDS QL (28

per 28 days)

IMFINZI INTRAVENOUS SOLUTION

50 MGML

5 PA NSO NDS

IMLYGIC INJECTION SUSPENSION

10EXP6 (1 MILLION) PFUML

5 PA NSO NDS QL (4

per 365 days)

5 PA NSO NDS QL (8

per 28 days)

INLYTA ORAL TABLET 1 MG 5 PA NSO NDS QL (180

per 30 days)

IRESSA ORAL TABLET 250 MG 5 PA NSO NDS QL (60

per 30 days)

IXEMPRA INTRAVENOUS RECON

SOLN 15 MG 45 MG

Drug Name

JAKAFI ORAL TABLET 10 MG 15 MG

20 MG 25 MG 5 MG

5 PA NSO NDS QL (60

per 30 days)

KANJINTI INTRAVENOUS RECON

SOLN 420 MG

5 PA NSO NDS

KEYTRUDA INTRAVENOUS

SOLUTION 25 MGML

5 PA NSO NDS QL (8

per 21 days)

KISQALI FEMARA CO-PACK ORAL

TABLET 200 MGDAY(200 MG X 1)-25

5 PA NSO NDS QL (49

per 28 days)

5 PA NSO NDS QL (70

per 28 days)

5 PA NSO NDS QL (91

per 28 days)

KISQALI ORAL TABLET 200 MGDAY

(200 MG X 1)

5 PA NSO NDS QL (21

per 28 days)

(200 MG X 2)

5 PA NSO NDS QL (42

per 28 days)

(200 MG X 3)

5 PA NSO NDS QL (63

per 28 days)

KYPROLIS INTRAVENOUS RECON

SOLN 10 MG 30 MG 60 MG

5 PA NSO NDS

LENVIMA ORAL CAPSULE 10

MGDAY (10 MG X 1) 12 MGDAY (4

MG X 3) 14 MGDAY(10 MG X 1-4 MG

X 1) 18 MGDAY (10 MG X 1-4 MG

X2) 20 MGDAY (10 MG X 2) 24

MGDAY(10 MG X 2-4 MG X 1) 4 MG

8 MGDAY (4 MG X 2)

5 PA NSO NDS

letrozole oral tablet 25 mg (Femara) 2

LEUKERAN ORAL TABLET 2 MG 4

leuprolide subcutaneous kit 1 mg02 ml 2

LIBTAYO INTRAVENOUS SOLUTION

50 MGML

5 PA NSO NDS QL (7

per 21 days)

LONSURF ORAL TABLET 15-614 MG 5 PA NSO NDS QL (100

per 28 days)

LORBRENA ORAL TABLET 100 MG 5 PA NSO NDS QL (30

per 30 days)

Drug Name

LUMOXITI INTRAVENOUS RECON

SOLN 1 MG

5 PA NSO NDS

LUPRON DEPOT (3 MONTH)

INTRAMUSCULAR SYRINGE KIT 225

LUPRON DEPOT INTRAMUSCULAR

SYRINGE KIT 375 MG

LYNPARZA ORAL TABLET 100 MG

150 MG

per 30 days)

LYSODREN ORAL TABLET 500 MG 5 NDS

MATULANE ORAL CAPSULE 50 MG 5 NDS

megestrol oral tablet 20 mg 40 mg 2 PA NSO-HRM AGE

(Max 64 Years)

MEKINIST ORAL TABLET 05 MG 5 PA NSO NDS QL (90

per 30 days)

MEKTOVI ORAL TABLET 15 MG 5 PA NSO NDS QL (180

per 30 days)

mercaptopurine oral tablet 50 mg 2

methotrexate sodium (pf) injection recon

soln 1 gram

2 PA BvD

methotrexate sodium (pf) injection

solution 25 mgml

2 PA BvD

methotrexate sodium injection solution 25

2 PA BvD

methotrexate sodium oral tablet 25 mg 2 PA BvD ST

mitoxantrone intravenous concentrate 2

MYLOTARG INTRAVENOUS RECON

SOLN 45 MG (1 MGML INITIAL

5 PA NSO NDS

NERLYNX ORAL TABLET 40 MG 5 PA NSO NDS QL (180

per 30 days)

NEXAVAR ORAL TABLET 200 MG 5 PA NSO NDS QL (120

per 30 days)

nilutamide oral tablet 150 mg (Nilandron) 5 NDS

Drug Name

NINLARO ORAL CAPSULE 23 MG 3

MG 4 MG

5 PA NSO NDS QL (3

per 28 days)

ODOMZO ORAL CAPSULE 200 MG 5 PA NSO LA NDS

ONCASPAR INJECTION SOLUTION

750 UNITML

5 PA NSO NDS

ONIVYDE INTRAVENOUS

DISPERSION 43 MGML

OPDIVO INTRAVENOUS SOLUTION

100 MG10 ML 240 MG24 ML 40

MG4 ML

5 PA NSO NDS

PIQRAY ORAL TABLET 200 MGDAY

(200 MG X 1)

5 PA NSO NDS QL (28

per 28 days)

(200 MG X1-50 MG X1) 300 MGDAY

(150 MG X 2)

5 PA NSO NDS QL (56

per 28 days)

POLIVY INTRAVENOUS RECON

SOLN 140 MG

5 PA NSO NDS

POMALYST ORAL CAPSULE 1 MG 2

MG 3 MG 4 MG

5 PA NSO NDS QL (21

per 28 days)

PORTRAZZA INTRAVENOUS

SOLUTION 800 MG50 ML (16 MGML)

per 21 days)

PROLEUKIN INTRAVENOUS RECON

SOLN 22 MILLION UNIT

PURIXAN ORAL SUSPENSION 20

REVLIMID ORAL CAPSULE 10 MG 15

MG 25 MG 20 MG 25 MG 5 MG

5 PA NSO LA NDS QL

(28 per 28 days)

RITUXAN HYCELA SUBCUTANEOUS

SOLUTION 1400 MG117 ML (120

MGML) 1600 MG134 ML (120

5 PA NSO NDS

RITUXAN INTRAVENOUS

CONCENTRATE 10 MGML

5 PA NSO NDS

RUBRACA ORAL TABLET 200 MG

250 MG 300 MG

per 30 days)

RYDAPT ORAL CAPSULE 25 MG 5 PA NSO NDS QL (224

per 28 days)

SOLTAMOX ORAL SOLUTION 10

MG5 ML

SPRYCEL ORAL TABLET 100 MG 140

MG 50 MG 70 MG 80 MG

5 PA NSO NDS QL (30

per 30 days)

SPRYCEL ORAL TABLET 20 MG 5 PA NSO NDS QL (90

per 30 days)

Drug Name

STIVARGA ORAL TABLET 40 MG 5 PA NSO NDS QL (84

per 28 days)

SUTENT ORAL CAPSULE 125 MG 25

MG 375 MG 50 MG

5 PA NSO NDS QL (30

per 30 days)

SYLVANT INTRAVENOUS RECON

SOLN 100 MG 400 MG

5 PA NSO NDS

SYNRIBO SUBCUTANEOUS RECON

SOLN 35 MG

5 PA NSO NDS

TABLOID ORAL TABLET 40 MG 4

TAFINLAR ORAL CAPSULE 50 MG 75

per 30 days)

TAGRISSO ORAL TABLET 40 MG 80

5 PA NSO LA NDS QL

(30 per 30 days)

TALZENNA ORAL CAPSULE 025 MG 5 PA NSO NDS QL (90

per 30 days)

tamoxifen oral tablet 10 mg 20 mg 2

TARGRETIN TOPICAL GEL 1 5 PA NSO NDS QL (60

per 28 days)

TASIGNA ORAL CAPSULE 150 MG

200 MG

per 28 days)

TASIGNA ORAL CAPSULE 50 MG 5 PA NSO NDS QL (120

per 30 days)

TECENTRIQ INTRAVENOUS

MGML) 840 MG14 ML (60 MGML)

5 PA NSO NDS

TEMODAR INTRAVENOUS RECON

SOLN 100 MG

5 PA NSO NDS

thiotepa injection recon soln 15 mg (Tepadina) 5 NDS

TIBSOVO ORAL TABLET 250 MG 5 PA NSO NDS QL (60

per 30 days)

toposar intravenous solution 20 mgml 2

toremifene oral tablet 60 mg (Fareston) 5 NDS

TREANDA INTRAVENOUS RECON

SOLN 100 MG 25 MG

5 PA NSO NDS

TRELSTAR INTRAMUSCULAR

1125 MG

5 NDS QL (1 per 84 days)

225 MG

5 NDS QL (1 per 168

Drug Name

375 MG

tretinoin (chemotherapy) oral capsule 10

TYKERB ORAL TABLET 250 MG 5 PA NSO NDS

UNITUXIN INTRAVENOUS

SOLUTION 35 MGML

5 PA NSO NDS

valrubicin intravesical solution 40 mgml (Valstar) 5 NDS

VELCADE INJECTION RECON SOLN

5 PA NSO NDS

VENCLEXTA ORAL TABLET 10 MG 3 PA NSO LA QL (60

per 30 days)

VENCLEXTA ORAL TABLET 100 MG 5 PA NSO LA NDS QL

(180 per 30 days)

per 30 days)

VENCLEXTA STARTING PACK ORAL

TABLETSDOSE PACK 10 MG-50 MG-

100 MG

5 PA NSO LA NDS

VERZENIO ORAL TABLET 100 MG

150 MG 200 MG 50 MG

5 PA NSO NDS QL (56

per 28 days)

vinorelbine intravenous solution 10 mgml

50 mg5 ml

(Navelbine) 2

VITRAKVI ORAL CAPSULE 100 MG 5 PA NSO NDS QL (60

per 30 days)

VITRAKVI ORAL SOLUTION 20

per 30 days)

VIZIMPRO ORAL TABLET 15 MG 30

MG 45 MG

5 PA NSO NDS QL (30

per 30 days)

VOTRIENT ORAL TABLET 200 MG 5 PA NSO NDS QL (120

per 30 days)

VYXEOS INTRAVENOUS RECON

SOLN 44-100 MG

5 PA BvD NDS

XALKORI ORAL CAPSULE 200 MG

250 MG

5 PA NSO NDS QL (60

per 30 days)

XATMEP ORAL SOLUTION 25

4 PA BvD ST

XOSPATA ORAL TABLET 40 MG 5 PA NSO NDS QL (90

per 30 days)

Drug Name

XPOVIO ORAL TABLET 100

MGWEEK (20 MG X 5)

5 PA NSO NDS QL (20

per 28 days)

MGWEEK (20 MG X 8)

5 PA NSO NDS QL (32

per 28 days)

XPOVIO ORAL TABLET 60 MGWEEK

(20 MG X 3)

5 PA NSO NDS QL (12

per 28 days)

(20 MG X 4)

5 PA NSO NDS QL (16

per 28 days)

XTANDI ORAL CAPSULE 40 MG 5 PA NSO NDS QL (120

per 30 days)

YERVOY INTRAVENOUS SOLUTION

200 MG40 ML (5 MGML) 50 MG10

ML (5 MGML)

5 PA NSO NDS

YONDELIS INTRAVENOUS RECON

SOLN 1 MG

5 PA NSO NDS

YONSA ORAL TABLET 125 MG 5 PA NSO NDS QL (120

per 30 days)

ZEJULA ORAL CAPSULE 100 MG 5 PA NSO NDS QL (90

per 30 days)

ZELBORAF ORAL TABLET 240 MG 5 PA NSO NDS QL (240

per 30 days)

ZOLADEX SUBCUTANEOUS

IMPLANT 108 MG

IMPLANT 36 MG

ZOLINZA ORAL CAPSULE 100 MG 5 NDS

ZYDELIG ORAL TABLET 100 MG 150

5 PA NSO NDS QL (60

per 30 days)

ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO NDS QL (90

per 30 days)

ZYKADIA ORAL TABLET 150 MG 5 PA NSO NDS QL (84

per 28 days)

ZYTIGA ORAL TABLET 250 MG 500

per 30 days)

Anticholinergic Agents

AntimuscarinicsAntispasmodics

atropine injection syringe 005 mgml 01

Anticonvulsants

APTIOM ORAL TABLET 200 MG 400

5 ST NDS QL (30 per 30

Drug Name

BANZEL ORAL SUSPENSION 40

5 ST NDS

BANZEL ORAL TABLET 200 MG 400

5 ST NDS

BRIVIACT INTRAVENOUS

SOLUTION 50 MG5 ML

BRIVIACT ORAL SOLUTION 10

BRIVIACT ORAL TABLET 10 MG 100

5 NDS QL (60 per 30

carbamazepine oral capsule er

multiphase 12 hr 100 mg 200 mg 300 mg

(Carbatrol) 2

carbamazepine oral suspension 100 mg5

(Tegretol) 2

carbamazepine oral tablet 200 mg (Epitol) 2

carbamazepine oral tablet extended

release 12 hr 100 mg 200 mg 400 mg

(Tegretol XR) 2

carbamazepine oral tabletchewable 100

CELONTIN ORAL CAPSULE 300 MG 4

clobazam oral suspension 25 mgml (Onfi) 2 PA NSO QL (480 per 30

clobazam oral tablet 10 mg 20 mg (Onfi) 2 PA NSO QL (60 per 30

DIASTAT ACUDIAL RECTAL KIT

125-15-175-20 MG 5-75-10 MG

DIASTAT RECTAL KIT 25 MG 4

diazepam rectal kit 125-15-175-20 mg 5-

75-10 mg

(Diastat AcuDial) 4

diazepam rectal kit 25 mg (Diastat) 4

divalproex oral capsule delayed rel

sprinkle 125 mg

(Depakote Sprinkles) 2

divalproex oral tablet extended release 24

hr 250 mg 500 mg

(Depakote ER) 2

divalproex oral tabletdelayed release

(drec) 125 mg 250 mg 500 mg

(Depakote) 2

EPIDIOLEX ORAL SOLUTION 100

5 PA NSO NDS

epitol oral tablet 200 mg 2

ethosuximide oral capsule 250 mg (Zarontin) 2

ethosuximide oral solution 250 mg5 ml (Zarontin) 2

Drug Name

felbamate oral suspension 600 mg5 ml (Felbatol) 2

felbamate oral tablet 400 mg 600 mg (Felbatol) 2

fosphenytoin injection solution 100 mg

pe2 ml 500 mg pe10 ml

(Cerebyx) 2

FYCOMPA ORAL SUSPENSION 05

4 ST QL (720 per 30

FYCOMPA ORAL TABLET 10 MG 12

MG 8 MG

FYCOMPA ORAL TABLET 2 MG 4 ST QL (30 per 30 days)

gabapentin oral capsule 100 mg 300 mg (Neurontin) 1 QL (360 per 30 days)

gabapentin oral capsule 400 mg (Neurontin) 1 QL (270 per 30 days)

gabapentin oral solution 250 mg5 ml (Neurontin) 2 QL (2160 per 30 days)

gabapentin oral tablet 600 mg (Neurontin) 2 QL (180 per 30 days)

lamotrigine oral tablet 100 mg 150 mg

200 mg 25 mg

(Lamictal) 1

lamotrigine oral tablet chewable

dispersible 25 mg 5 mg

(Lamictal) 2

levetiracetam intravenous solution 500

mg5 ml

(Keppra) 2

levetiracetam oral solution 100 mgml (Keppra) 2

levetiracetam oral tablet 1000 mg 250

mg 500 mg 750 mg

(Keppra) 2

levetiracetam oral tablet extended release

24 hr 500 mg 750 mg

(Keppra XR) 2

LYRICA ORAL CAPSULE 100 MG 150

MG 200 MG 225 MG 25 MG 300 MG

50 MG 75 MG

LYRICA ORAL SOLUTION 20 MGML 3 QL (900 per 30 days)

oxcarbazepine oral suspension 300 mg5

ml (60 mgml)

(Trileptal) 2

oxcarbazepine oral tablet 150 mg 300 mg

600 mg

(Trileptal) 2

OXTELLAR XR ORAL TABLET

300 MG 600 MG

PEGANONE ORAL TABLET 250 MG 4

phenobarbital oral elixir 20 mg5 ml (4

2 PA NSO-HRM AGE

(Max 64 Years)

Drug Name

phenobarbital oral tablet 100 mg 15 mg

162 mg 30 mg 324 mg 60 mg 648 mg

972 mg

2 PA NSO-HRM AGE

(Max 64 Years)

phenytoin oral suspension 125 mg5 ml (Dilantin-125) 2

phenytoin oral tabletchewable 50 mg (Dilantin Infatabs) 2

phenytoin sodium extended oral capsule

100 mg

(Dilantin Extended) 2

200 mg 300 mg

(Phenytek) 2

phenytoin sodium intravenous solution 50

phenytoin sodium intravenous syringe 50

pregabalin oral capsule 100 mg 150 mg

200 mg 225 mg 25 mg 300 mg 50 mg

(Lyrica) 2 QL (90 per 30 days)

pregabalin oral solution 20 mgml (Lyrica) 2 QL (900 per 30 days)

primidone oral tablet 250 mg 50 mg (Mysoline) 2

SABRIL ORAL TABLET 500 MG 5 PA NSO NDS QL (180

per 30 days)

SPRITAM ORAL TABLET FOR

SUSPENSION 1000 MG

4 ST QL (60 per 30 days)

SUSPENSION 250 MG 500 MG 750

4 ST QL (120 per 30

subvenite oral tablet 100 mg 150 mg 200

mg 25 mg

SYMPAZAN ORAL FILM 10 MG 20

5 PA NSO NDS QL (60

per 30 days)

SYMPAZAN ORAL FILM 5 MG 4 PA NSO QL (60 per 30

tiagabine oral tablet 12 mg 16 mg 2 mg

(Gabitril) 2

topiramate oral capsule sprinkle 15 mg

(Topamax) 2

topiramate oral capsulesprinkleer 24hr

100 mg 150 mg 200 mg 25 mg 50 mg

(Qudexy XR) 4

topiramate oral tablet 100 mg 200 mg 25

mg 50 mg

(Topamax) 1

valproate sodium intravenous solution 500

mg5 ml (100 mgml)

(Depacon) 2

valproic acid (as sodium salt) oral

solution 250 mg5 ml

Drug Name

valproic acid oral capsule 250 mg (Depakene) 2

vigabatrin oral powder in packet 500 mg (Sabril) 5 PA NSO NDS QL (180

per 30 days)

vigabatrin oral tablet 500 mg (Sabril) 5 PA NSO NDS QL (180

per 30 days)

vigadrone oral powder in packet 500 mg 5 PA NSO NDS QL (180

per 30 days)

VIMPAT INTRAVENOUS SOLUTION

200 MG20 ML

VIMPAT ORAL SOLUTION 10 MGML 3 QL (1200 per 30 days)

VIMPAT ORAL TABLET 100 MG 150

MG 200 MG 50 MG

zonisamide oral capsule 100 mg 25 mg (Zonegran) 2

zonisamide oral capsule 50 mg 2

Antidementia Agents

donepezil oral tablet 10 mg 5 mg (Aricept) 1 QL (30 per 30 days)

donepezil oral tabletdisintegrating 10 mg

galantamine oral capsuleext rel pellets

24 hr 16 mg 24 mg 8 mg

(Razadyne ER) 2 QL (30 per 30 days)

galantamine oral solution 4 mgml 2 QL (200 per 30 days)

galantamine oral tablet 12 mg 4 mg 8 mg (Razadyne) 2 QL (60 per 30 days)

memantine oral capsulesprinkleer 24hr

14 mg 21 mg 28 mg 7 mg

(Namenda XR) 2 QL (30 per 30 days)

memantine oral solution 2 mgml 2 QL (360 per 30 days)

memantine oral tablet 10 mg 5 mg (Namenda) 2 QL (60 per 30 days)

NAMZARIC ORAL CAPSPRINKLEER

24HR DOSE PACK 7142128 MG-10

NAMZARIC ORAL

CAPSULESPRINKLEER 24HR 14-10

MG 21-10 MG 28-10 MG 7-10 MG

rivastigmine tartrate oral capsule 15 mg

3 mg 45 mg 6 mg

rivastigmine transdermal patch 24 hour

133 mg24 hour 46 mg24 hr 95 mg24

(Exelon) 2 QL (30 per 30 days)

Antidepressants

amitriptyline oral tablet 10 mg 100 mg

150 mg 25 mg 50 mg 75 mg

Drug Name

amoxapine oral tablet 100 mg 150 mg 25

mg 50 mg

bupropion hcl oral tablet 100 mg 75 mg 2

bupropion hcl oral tablet extended release

24 hr 150 mg 300 mg

(Wellbutrin XL) 2

bupropion hcl oral tablet sustained-

(Wellbutrin SR) 2

citalopram oral solution 10 mg5 ml 2 QL (600 per 30 days)

citalopram oral tablet 10 mg 20 mg 40

(Celexa) 1 QL (30 per 30 days)

clomipramine oral capsule 25 mg 50 mg

(Anafranil) 2

desipramine oral tablet 10 mg 25 mg (Norpramin) 2

desipramine oral tablet 100 mg 150 mg

50 mg 75 mg

desvenlafaxine succinate oral tablet

extended release 24 hr 100 mg 25 mg 50

(Pristiq) 2 QL (30 per 30 days)

doxepin oral capsule 10 mg 100 mg 150

mg 25 mg 50 mg 75 mg

doxepin oral concentrate 10 mgml 1

duloxetine oral capsuledelayed

release(drec) 20 mg 60 mg

(Cymbalta) 2 QL (60 per 30 days)

release(drec) 30 mg

EMSAM TRANSDERMAL PATCH 24

HOUR 12 MG24 HR 6 MG24 HR 9

MG24 HR

5 NDS QL (30 per 30

escitalopram oxalate oral solution 5 mg5

escitalopram oxalate oral tablet 10 mg 20

mg 5 mg

(Lexapro) 1

FETZIMA ORAL CAPSULEEXT REL

24HR DOSE PACK 20 MG (2)- 40 MG

FETZIMA ORAL

CAPSULEEXTENDED RELEASE 24

HR 120 MG 20 MG 40 MG 80 MG

fluoxetine oral capsule 10 mg 20 mg 40

(Prozac) 1

fluoxetine oral solution 20 mg5 ml (4

Drug Name

fluvoxamine oral tablet 100 mg 25 mg 50

imipramine hcl oral tablet 10 mg 25 mg

(Tofranil) 2

maprotiline oral tablet 25 mg 50 mg 75

MARPLAN ORAL TABLET 10 MG 4

mirtazapine oral tablet 15 mg 30 mg (Remeron) 2

mirtazapine oral tablet 45 mg 75 mg 2

mirtazapine oral tabletdisintegrating 15

mg 30 mg 45 mg

(Remeron SolTab) 2

nefazodone oral tablet 100 mg 150 mg

200 mg 250 mg 50 mg

nortriptyline oral capsule 10 mg 25 mg

50 mg 75 mg

(Pamelor) 1

nortriptyline oral solution 10 mg5 ml 2

paroxetine hcl oral tablet 10 mg 20 mg

30 mg 40 mg

(Paxil) 1 PA NSO-HRM AGE

(Max 64 Years)

PAXIL ORAL SUSPENSION 10 MG5

4 PA NSO-HRM AGE

(Max 64 Years)

perphenazine-amitriptyline oral tablet 2-

10 mg 2-25 mg 4-10 mg 4-25 mg 4-50

phenelzine oral tablet 15 mg (Nardil) 2

protriptyline oral tablet 10 mg 5 mg 2

sertraline oral concentrate 20 mgml (Zoloft) 2

sertraline oral tablet 100 mg 25 mg 50

(Zoloft) 1

SPRAVATO NASAL SPRAYNON-

AEROSOL 56 MG (28 MG X 2) 84 MG

(28 MG X 3)

5 PA NSO NDS

tranylcypromine oral tablet 10 mg (Parnate) 2

trazodone oral tablet 100 mg 150 mg 50

trazodone oral tablet 300 mg 2

trimipramine oral capsule 100 mg 25 mg

TRINTELLIX ORAL TABLET 10 MG

20 MG 5 MG

venlafaxine oral capsuleextended release

24hr 150 mg

(Effexor XR) 2 QL (30 per 30 days)

24hr 375 mg 75 mg

Drug Name

venlafaxine oral tablet 100 mg 25 mg

375 mg 50 mg 75 mg

VIIBRYD ORAL TABLET 10 MG 20

MG 40 MG

VIIBRYD ORAL TABLETSDOSE

PACK 10 MG (7)- 20 MG (23)

ZULRESSO INTRAVENOUS

SOLUTION 5 MGML

Antidiabetic Agents

Antidiabetic Agents Miscellaneous

acarbose oral tablet 100 mg 25 mg 50

(Precose) 2 QL (90 per 30 days)

GLYXAMBI ORAL TABLET 10-5 MG

25-5 MG

INVOKAMET ORAL TABLET 150-

1000 MG 150-500 MG 50-1000 MG

INVOKAMET ORAL TABLET 50-500

3 ST QL (120 per 30

INVOKAMET XR ORAL TABLET IR -

ER BIPHASIC 24HR 150-1000 MG

150-500 MG 50-1000 MG 50-500 MG

INVOKANA ORAL TABLET 100 MG 3 ST QL (60 per 30 days)

JANUMET ORAL TABLET 50-1000

MG 50-500 MG

JANUMET XR ORAL TABLET ER

MULTIPHASE 24 HR 100-1000 MG

MULTIPHASE 24 HR 50-1000 MG 50-

500 MG

JANUVIA ORAL TABLET 100 MG 25

MG 50 MG

JARDIANCE ORAL TABLET 10 MG 25

JENTADUETO ORAL TABLET 25-

1000 MG 25-500 MG 25-850 MG

JENTADUETO XR ORAL TABLET IR -

KORLYM ORAL TABLET 300 MG 5 PA NDS QL (112 per

28 days)

metformin oral tablet 1000 mg (Glucophage) 1 QL (75 per 30 days)

Drug Name

metformin oral tablet extended release 24

hr 500 mg

(Glucophage XR) 1 QL (120 per 30 days)

hr 750 mg

OZEMPIC SUBCUTANEOUS PEN

INJECTOR 025 MG OR 05 MG(2

MG15 ML) 1 MGDOSE (2 MG15

pioglitazone oral tablet 15 mg 30 mg 45

(Actos) 1 QL (30 per 30 days)

repaglinide oral tablet 05 mg 2 QL (120 per 30 days)

repaglinide oral tablet 1 mg (Prandin) 2 QL (120 per 30 days)

SYMLINPEN 120 SUBCUTANEOUS

PEN INJECTOR 2700 MCG27 ML

28 days)

SYNJARDY ORAL TABLET 125-1000

MG 125-500 MG 5-1000 MG 5-500

SYNJARDY XR ORAL TABLET IR -

ER BIPHASIC 24HR 10-1000 MG 25-

1000 MG

TRADJENTA ORAL TABLET 5 MG 4 ST QL (30 per 30 days)

TRULICITY SUBCUTANEOUS PEN

INJECTOR 075 MG05 ML 15 MG05

VICTOZA SUBCUTANEOUS PEN

INJECTOR 06 MG01 ML (18 MG3

Insulins

FIASP FLEXTOUCH U-100 INSULIN

SUBCUTANEOUS INSULIN PEN 100

UNITML (3 ML)

FIASP U-100 INSULIN

SUBCUTANEOUS SOLUTION 100

UNITML

Drug Name

HUMULIN R U-500 (CONC) INSULIN

UNITML

HUMULIN R U-500 (CONC) KWIKPEN

UNITML (3 ML)

LANTUS SOLOSTAR U-100 INSULIN

UNITML (3 ML)

LANTUS U-100 INSULIN

UNITML

NOVOLIN 7030 U-100 INSULIN

SUBCUTANEOUS SUSPENSION 100

UNITML (70-30)

NOVOLIN 70-30 FLEXPEN U-100

UNITML (70-30)

NOVOLIN N NPH U-100 INSULIN

UNITML

NOVOLIN R REGULAR U-100 INSULN

INJECTION SOLUTION 100 UNITML

NOVOLOG FLEXPEN U-100 INSULIN

UNITML (3 ML)

NOVOLOG MIX 70-30 U-100 INSULN

UNITML (70-30)

NOVOLOG MIX 70-30FLEXPEN U-100

UNITML (70-30)

NOVOLOG PENFILL U-100 INSULIN

SUBCUTANEOUS CARTRIDGE 100

UNITML

NOVOLOG U-100 INSULIN ASPART

UNITML

SOLIQUA 10033 SUBCUTANEOUS

INSULIN PEN 100 UNIT-33 MCGML

TOUJEO MAX U-300 SOLOSTAR

UNITML (3 ML)

Drug Name

TOUJEO SOLOSTAR U-300 INSULIN

UNITML (15 ML)

TRESIBA FLEXTOUCH U-100

UNITML (3 ML)

TRESIBA U-100 INSULIN

UNITML

XULTOPHY 10036 SUBCUTANEOUS

INSULIN PEN 100 UNIT-36 MG ML (3

Sulfonylureas

glimepiride oral tablet 1 mg 2 mg (Amaryl) 1 QL (30 per 30 days)

glimepiride oral tablet 4 mg (Amaryl) 1 QL (60 per 30 days)

glipizide oral tablet 10 mg (Glucotrol) 1 QL (120 per 30 days)

glipizide oral tablet extended release 24hr

(Glucotrol XL) 2 QL (60 per 30 days)

25 mg 5 mg

glipizide-metformin oral tablet 25-250 mg 2 QL (240 per 30 days)

glipizide-metformin oral tablet 25-500

mg 5-500 mg

glyburide micronized oral tablet 15 mg 3

mg 6 mg

(Glynase) 2 PA-HRM AGE (Max 64

Years)

glyburide oral tablet 125 mg 25 mg 5

2 PA-HRM AGE (Max 64

Years)

glyburide-metformin oral tablet 125-250

mg 25-500 mg 5-500 mg

Years)

tolazamide oral tablet 250 mg 2 QL (120 per 30 days)

Antifungals

ABELCET INTRAVENOUS

SUSPENSION 5 MGML

5 PA BvD NDS

AMBISOME INTRAVENOUS

5 PA BvD NDS

amphotericin b injection recon soln 50 mg 2 PA BvD

Drug Name

caspofungin intravenous recon soln 50

mg 70 mg

(Cancidas) 5 NDS

ciclopirox topical cream 077 (Ciclodan) 2

ciclopirox topical solution 8 (Ciclodan) 2

clotrimazole mucous membrane troche 10

clotrimazole topical cream 1 (Antifungal

(clotrimazole))

clotrimazole-betamethasone topical cream

(Lotrisone) 2

econazole topical cream 1 2

fluconazole in nacl (iso-osm) intravenous

400 mg200 ml

2 PA BvD

fluconazole oral suspension for

reconstitution 10 mgml 40 mgml

(Diflucan) 2

fluconazole oral tablet 100 mg 150 mg

200 mg 50 mg

(Diflucan) 2

flucytosine oral capsule 250 mg 500 mg (Ancobon) 5 NDS

griseofulvin microsize oral suspension 125

mg5 ml

griseofulvin microsize oral tablet 500 mg 2

itraconazole oral capsule 100 mg (Sporanox) 2

ketoconazole oral tablet 200 mg 2

ketoconazole topical cream 2 2

ketoconazole topical shampoo 2 (Nizoral) 2

miconazole-3 vaginal suppository 200 mg 2

NOXAFIL ORAL SUSPENSION 200

MG5 ML (40 MGML)

NOXAFIL ORAL TABLETDELAYED

RELEASE (DREC) 100 MG

nyamyc topical powder 100000 unitgram 2

nystatin oral suspension 100000 unitml 2

nystatin oral tablet 500000 unit 2

nystatin topical cream 100000 unitgram 2

nystatin topical ointment 100000

unitgram

nystatin topical powder 100000 unitgram (Nyamyc) 2

nystop topical powder 100000 unitgram 2

terbinafine hcl oral tablet 250 mg 1

voriconazole intravenous recon soln 200

(Vfend IV) 5 PA BvD NDS

Drug Name

voriconazole oral suspension for

reconstitution 200 mg5 ml (40 mgml)

(Vfend) 5 NDS

voriconazole oral tablet 200 mg 50 mg (Vfend) 5 NDS

Antigout Agents

Antigout Agents Other

allopurinol oral tablet 100 mg 300 mg (Zyloprim) 1

colchicine oral tablet 06 mg (Colcrys) 4 PA QL (120 per 30

febuxostat oral tablet 40 mg 80 mg (Uloric) 2 QL (30 per 30 days)

MITIGARE ORAL CAPSULE 06 MG 2 QL (60 per 30 days)

probenecid oral tablet 500 mg 2

probenecid-colchicine oral tablet 500-05

ULORIC ORAL TABLET 40 MG 80 MG 3 QL (30 per 30 days)

Antihistamines

cyproheptadine oral syrup 2 mg5 ml 2 PA-HRM AGE (Max 64

Years)

diphenhydramine hcl injection solution 50

diphenhydramine hcl injection syringe 50

diphenhydramine hcl oral elixir 125 mg5

Years)

hydroxyzine hcl intramuscular solution 25

mgml 50 mgml

hydroxyzine hcl oral solution 10 mg5 ml 2

hydroxyzine hcl oral tablet 10 mg 25 mg

levocetirizine oral solution 25 mg5 ml (Xyzal) 2

levocetirizine oral tablet 5 mg (24HR Allergy Relief) 1

promethazine oral syrup 625 mg5 ml 1 PA-HRM AGE (Max 64

Years)

Anti-Infectives (Skin And Mucous

Membrane)

clindamycin phosphate vaginal cream 2 (Cleocin) 2

metronidazole vaginal gel 075 (Metrogel Vaginal) 2

terconazole vaginal cream 04 08 2

terconazole vaginal suppository 80 mg 2

Drug Name

Antimigraine Agents

AIMOVIG AUTOINJECTOR (2 PACK)

SUBCUTANEOUS AUTO-INJECTOR

70 MGML

AIMOVIG AUTOINJECTOR

140 MGML 70 MGML

AJOVY SUBCUTANEOUS SYRINGE

225 MG15 ML

dihydroergotamine injection solution 1

(DHE45) 5 NDS QL (24 per 28

dihydroergotamine nasal spraynon-

aerosol 05 mgpump act (4 mgml)

(Migranal) 5 NDS QL (8 per 28 days)

EMGALITY PEN SUBCUTANEOUS

PEN INJECTOR 120 MGML

EMGALITY SYRINGE

SUBCUTANEOUS SYRINGE 120

EMGALITY SYRINGE

SUBCUTANEOUS SYRINGE 300 MG3

ML (100 MGML X 3)

ERGOMAR SUBLINGUAL TABLET 2

rizatriptan oral tablet 10 mg (Maxalt) 2 QL (12 per 30 days)

rizatriptan oral tablet 5 mg 2 QL (12 per 30 days)

rizatriptan oral tabletdisintegrating 10

mg 5 mg

(Maxalt-MLT) 2 QL (12 per 30 days)

sumatriptan nasal spraynon-aerosol 20

mgactuation

(Imitrex) 2 QL (12 per 30 days)

mgactuation

sumatriptan succinate oral tablet 100 mg

25 mg 50 mg

sumatriptan succinate subcutaneous

cartridge 6 mg05 ml

(Imitrex STATdose

Refill)

sumatriptan succinate subcutaneous pen

injector 4 mg05 ml 6 mg05 ml

(Imitrex STATdose Pen) 2 QL (4 per 28 days)

solution 6 mg05 ml

syringe 6 mg05 ml

Antimycobacterials

Drug Name

Antimycobacterials

CAPASTAT INJECTION RECON SOLN

1 GRAM

dapsone oral tablet 100 mg 25 mg 2

ethambutol oral tablet 100 mg 2

ethambutol oral tablet 400 mg (Myambutol) 2

isoniazid oral solution 50 mg5 ml 2

isoniazid oral tablet 100 mg 300 mg 1

PASER ORAL GRANULES DR FOR

SUSP IN PACKET 4 GRAM

PRIFTIN ORAL TABLET 150 MG 4

pyrazinamide oral tablet 500 mg 2

rifabutin oral capsule 150 mg (Mycobutin) 2

rifampin intravenous recon soln 600 mg (Rifadin) 2

rifampin oral capsule 150 mg 300 mg (Rifadin) 2

SIRTURO ORAL TABLET 100 MG 5 PA NDS QL (188 per

168 days)

TRECATOR ORAL TABLET 250 MG 4

Antinausea Agents

AKYNZEO (FOSNETUPITANT)

INTRAVENOUS RECON SOLN 235-

025 MG

AKYNZEO (NETUPITANT) ORAL

CAPSULE 300-05 MG

4 PA BvD

aprepitant oral capsule 125 mg (Emend) 2 PA BvD QL (2 per 28

aprepitant oral capsuledose pack 125 mg

(1)- 80 mg (2)

(Emend) 2 PA BvD QL (6 per 28

CINVANTI INTRAVENOUS

EMULSION 72 MGML

compro rectal suppository 25 mg 2

dimenhydrinate injection solution 50

dronabinol oral capsule 10 mg 25 mg 5

(Marinol) 2 PA QL (60 per 30 days)

EMEND (FOSAPREPITANT)

INTRAVENOUS RECON SOLN 150 MG

Drug Name

EMEND ORAL SUSPENSION FOR

RECONSTITUTION 125 MG (25 MG

ML FINAL CONC)

4 PA BvD QL (6 per 28

granisetron (pf) intravenous solution 100

granisetron hcl intravenous solution 1

mgml 1 mgml (1 ml)

granisetron hcl oral tablet 1 mg 2 PA BvD

meclizine oral tablet 125 mg 2

meclizine oral tablet 25 mg (Dramamine Less

Drowsy)

ondansetron hcl (pf) injection solution 4

mg2 ml

ondansetron hcl (pf) injection syringe 4

mg2 ml

ondansetron hcl intravenous solution 2

ondansetron hcl oral tablet 24 mg 2 PA BvD

ondansetron hcl oral tablet 4 mg 8 mg (Zofran) 2 PA BvD

ondansetron oral tabletdisintegrating 4

mg 8 mg

2 PA BvD

phenadoz rectal suppository 125 mg 25

Years)

prochlorperazine edisylate injection

solution 10 mg2 ml (5 mgml) 5 mgml

prochlorperazine maleate oral tablet 10

mg 5 mg

(Compazine) 1

prochlorperazine rectal suppository 25 mg (Compazine) 2

promethazine injection solution 25 mgml

50 mgml

(Phenergan) 2 PA-HRM AGE (Max 64

Years)

promethazine oral tablet 125 mg 25 mg

Years)

promethazine rectal suppository 125 mg

(Phenadoz) 2 PA-HRM AGE (Max 64

Years)

promethazine rectal suppository 50 mg (Phenergan) 2 PA-HRM AGE (Max 64

Years)

promethegan rectal suppository 125 mg

25 mg 50 mg

Years)

scopolamine base transdermal patch 3 day

1 mg over 3 days

(Transderm-Scop) 2 PA-HRM QL (10 per 30

days) AGE (Max 64

Years)

Drug Name

TRANSDERM-SCOP TRANSDERMAL

PATCH 3 DAY 1 MG OVER 3 DAYS

4 PA-HRM QL (10 per 30

days) AGE (Max 64

Years)

Antiparasite Agents

albendazole oral tablet 200 mg (Albenza) 5 NDS

ALINIA ORAL SUSPENSION FOR

RECONSTITUTION 100 MG5 ML

ALINIA ORAL TABLET 500 MG 5 NDS

atovaquone oral suspension 750 mg5 ml (Mepron) 5 NDS

atovaquone-proguanil oral tablet 250-100

(Malarone) 2

(Malarone Pediatric) 2

chloroquine phosphate oral tablet 250 mg

500 mg

COARTEM ORAL TABLET 20-120 MG 4

DARAPRIM ORAL TABLET 25 MG 5 PA NDS

hydroxychloroquine oral tablet 200 mg (Plaquenil) 2

IMPAVIDO ORAL CAPSULE 50 MG 5 PA NDS QL (84 per 28

ivermectin oral tablet 3 mg (Stromectol) 2

KRINTAFEL ORAL TABLET 150 MG 4

mefloquine oral tablet 250 mg 2

NEBUPENT INHALATION RECON

SOLN 300 MG

4 PA BvD

paromomycin oral capsule 250 mg 2

PENTAM INJECTION RECON SOLN

300 MG

pentamidine injection recon soln 300 mg (Pentam) 2

PRIMAQUINE ORAL TABLET 263 MG 2

Antiparkinsonian Agents

amantadine hcl oral capsule 100 mg 2

amantadine hcl oral solution 50 mg5 ml 2

APOKYN SUBCUTANEOUS

CARTRIDGE 10 MGML

5 PA NDS QL (60 per 30

benztropine injection solution 2 mg2 ml (Cogentin) 2

benztropine oral tablet 05 mg 1 mg 2 mg 2

bromocriptine oral capsule 5 mg (Parlodel) 2

bromocriptine oral tablet 25 mg (Parlodel) 2

cabergoline oral tablet 05 mg 2

Drug Name

carbidopa-levodopa oral tablet 10-100

mg 25-100 mg 25-250 mg

(Sinemet) 2

carbidopa-levodopa oral tablet extended

release 25-100 mg 50-200 mg

(Sinemet CR) 2

carbidopa-levodopa-entacapone oral

tablet 125-50-200 mg

(Stalevo 50) 4

tablet 1875-75-200 mg

(Stalevo 75) 4

(Stalevo 100) 4

tablet 3125-125-200 mg

(Stalevo 125) 4

tablet 375-150-200 mg

(Stalevo 150) 4

(Stalevo 200) 4

entacapone oral tablet 200 mg (Comtan) 2

GOCOVRI ORAL

CAPSULEEXTENDED RELEASE

24HR 137 MG

GOCOVRI ORAL

24HR 685 MG

INBRIJA 42 MG INHALATION CAP 42

30 days)

INBRIJA INHALATION CAPSULE

WINHALATION DEVICE 42 MG

30 days)

NEUPRO TRANSDERMAL PATCH 24

HOUR 1 MG24 HOUR 2 MG24

OSMOLEX ER ORAL TABLET IR -

ER BIPHASIC 24HR 129 MG 193 MG

258 MG

pramipexole oral tablet 0125 mg 025

mg 05 mg 075 mg 1 mg 15 mg

(Mirapex) 1

rasagiline oral tablet 05 mg 1 mg (Azilect) 2

ropinirole oral tablet 025 mg 3 mg 5 mg (Requip) 2

ropinirole oral tablet 05 mg 1 mg 2 mg

selegiline hcl oral capsule 5 mg 2

selegiline hcl oral tablet 5 mg 2

Drug Name

trihexyphenidyl oral elixir 04 mgml 2

trihexyphenidyl oral tablet 2 mg 5 mg 1

XADAGO ORAL TABLET 100 MG 50

Antipsychotic Agents

ABILIFY MAINTENA

INTRAMUSCULAR

SUSPENSIONEXTENDED REL

RECON 300 MG 400 MG

ABILIFY MAINTENA

INTRAMUSCULAR

SYRING 300 MG 400 MG

aripiprazole oral solution 1 mgml 5 NDS QL (900 per 30

aripiprazole oral tablet 10 mg 15 mg 20

mg 30 mg 5 mg

(Abilify) 2 QL (30 per 30 days)

aripiprazole oral tablet 2 mg (Abilify) 2 QL (60 per 30 days)

aripiprazole oral tabletdisintegrating 10

ARISTADA INITIO INTRAMUSCULAR

SYRING 675 MG24 ML

ARISTADA INTRAMUSCULAR

SYRING 1064 MG39 ML

5 NDS QL (39 per 56

SYRING 441 MG16 ML

5 NDS QL (16 per 28

SYRING 662 MG24 ML

5 NDS QL (24 per 28

SYRING 882 MG32 ML

5 NDS QL (32 per 28

chlorpromazine injection solution 25

chlorpromazine oral tablet 10 mg 100 mg

200 mg 25 mg 50 mg

clozapine oral tablet 100 mg (Clozaril) 2 QL (270 per 30 days)

Drug Name

clozapine oral tablet 200 mg 2 QL (135 per 30 days)

clozapine oral tabletdisintegrating 100

mg 125 mg 25 mg

(FazaClo) 2 ST QL (90 per 30 days)

(FazaClo) 2 ST QL (180 per 30

(FazaClo) 5 ST NDS QL (120 per

30 days)

FANAPT ORAL TABLET 1 MG 2 MG

FANAPT ORAL TABLET 10 MG 12

MG 6 MG 8 MG

FANAPT ORAL TABLETSDOSE

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

fluphenazine decanoate injection solution

25 mgml

fluphenazine hcl injection solution 25

fluphenazine hcl oral concentrate 5 mgml 2

fluphenazine hcl oral elixir 25 mg5 ml 2

fluphenazine hcl oral tablet 1 mg 10 mg

25 mg 5 mg

GEODON INTRAMUSCULAR RECON

SOLN 20 MGML (FINAL CONC)

haloperidol dec 50 mgml vial mdv 50

(Haldol Decanoate) 2

haloperidol decanoate intramuscular

solution 100 mgml

solution 100 mgml (1 ml)

solution 50 mgml

haloperidol lactate injection solution 5

(Haldol) 2

haloperidol lactate intramuscular syringe

5 mgml

haloperidol lactate oral concentrate 2

haloperidol oral tablet 05 mg 1 mg 10

mg 2 mg 20 mg 5 mg

Drug Name

INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE 117

MG075 ML

INVEGA SUSTENNA

MG15 ML

5 NDS QL (15 per 28

INVEGA SUSTENNA

MG025 ML

INVEGA SUSTENNA

MG05 ML

5 NDS QL (05 per 28

INVEGA TRINZA INTRAMUSCULAR

SYRINGE 273 MG0875 ML

5 NDS QL (0875 per 84

5 NDS QL (1315 per 84

5 NDS QL (2625 per 84

LATUDA ORAL TABLET 120 MG 20

MG 40 MG 60 MG

LATUDA ORAL TABLET 80 MG 3 QL (60 per 30 days)

loxapine succinate oral capsule 10 mg 25

mg 5 mg 50 mg

molindone oral tablet 10 mg 2 QL (240 per 30 days)

NUPLAZID ORAL CAPSULE 34 MG 5 PA NSO NDS QL (30

per 30 days)

NUPLAZID ORAL TABLET 10 MG 5 PA NSO NDS QL (30

per 30 days)

olanzapine intramuscular recon soln 10

(Zyprexa) 2 QL (30 per 30 days)

olanzapine oral tablet 10 mg 15 mg 25

mg 20 mg 5 mg 75 mg

olanzapine oral tabletdisintegrating 10

mg 15 mg 20 mg 5 mg

(Zyprexa Zydis) 2 QL (30 per 30 days)

paliperidone oral tablet extended release

24hr 15 mg 3 mg

(Invega) 2 QL (30 per 30 days)

Drug Name

24hr 6 mg

24hr 9 mg

(Invega) 5 NDS QL (30 per 30

perphenazine oral tablet 16 mg 2 mg 4

mg 8 mg

PERSERIS ABDOMINAL

SUBCUTANEOUS

SUSPENSIONEXTEND REL SYR KIT

120 MG 90 MG

pimozide oral tablet 1 mg 2 mg (Orap) 2

quetiapine oral tablet 100 mg 200 mg 25

mg 300 mg 400 mg 50 mg

(Seroquel) 2 QL (90 per 30 days)

REXULTI ORAL TABLET 025 MG 5 ST NDS QL (120 per

30 days)

REXULTI ORAL TABLET 05 MG 5 ST NDS QL (60 per 30

REXULTI ORAL TABLET 1 MG 2 MG

3 MG 4 MG

RISPERDAL CONSTA

MG2 ML 25 MG2 ML

RISPERDAL CONSTA

MG2 ML 50 MG2 ML

risperidone oral solution 1 mgml (Risperdal) 2 QL (480 per 30 days)

risperidone oral tablet 025 mg 05 mg 1

mg 2 mg 3 mg 4 mg

(Risperdal) 1 QL (60 per 30 days)

risperidone oral tabletdisintegrating 025

mg 05 mg 1 mg 2 mg

mg 4 mg

SAPHRIS SUBLINGUAL TABLET 10

MG 25 MG 5 MG

thioridazine oral tablet 10 mg 100 mg 25

mg 50 mg

thiothixene oral capsule 1 mg 10 mg 2

mg 5 mg

trifluoperazine oral tablet 1 mg 10 mg 2

mg 5 mg

VERSACLOZ ORAL SUSPENSION 50

5 ST NDS QL (540 per

30 days)

Drug Name

VRAYLAR ORAL CAPSULE 15 MG 3

MG 45 MG 6 MG

VRAYLAR ORAL CAPSULEDOSE

PACK 15 MG (1)- 3 MG (6)

ziprasidone hcl oral capsule 20 mg 40

mg 60 mg 80 mg

(Geodon) 2 QL (60 per 30 days)

ZYPREXA RELPREVV

INTRAMUSCULAR SUSPENSION FOR

RECONSTITUTION 210 MG

ZYPREXA RELPREVV

Antivirals (Systemic)

Antiretrovirals

abacavir oral solution 20 mgml (Ziagen) 2

abacavir oral tablet 300 mg (Ziagen) 2

abacavir-lamivudine oral tablet 600-300

(Epzicom) 2

abacavir-lamivudine-zidovudine oral

tablet 300-150-300 mg

(Trizivir) 5 NDS

APTIVUS ORAL CAPSULE 250 MG 5 NDS

APTIVUS ORAL SOLUTION 100

atazanavir oral capsule 150 mg 200 mg

300 mg

(Reyataz) 5 NDS

ATRIPLA ORAL TABLET 600-200-300

BIKTARVY ORAL TABLET 50-200-25

CIMDUO ORAL TABLET 300-300 MG 5 NDS

COMPLERA ORAL TABLET 200-25-

300 MG

CRIXIVAN ORAL CAPSULE 200 MG

400 MG

DELSTRIGO ORAL TABLET 100-300-

300 MG

DESCOVY ORAL TABLET 200-25 MG 5 NDS

didanosine oral capsuledelayed

release(drec) 125 mg 200 mg 250 mg

400 mg

(Videx EC) 2

Drug Name

DOVATO ORAL TABLET 50-300 MG 5 NDS

EDURANT ORAL TABLET 25 MG 5 NDS

efavirenz oral capsule 200 mg (Sustiva) 5 NDS

efavirenz oral capsule 50 mg (Sustiva) 2

efavirenz oral tablet 600 mg (Sustiva) 5 NDS

EMTRIVA ORAL CAPSULE 200 MG 4

EMTRIVA ORAL SOLUTION 10

EPIVIR HBV ORAL SOLUTION 25

MG5 ML (5 MGML)

EVOTAZ ORAL TABLET 300-150 MG 5 NDS

fosamprenavir oral tablet 700 mg (Lexiva) 5 NDS

FUZEON SUBCUTANEOUS RECON

SOLN 90 MG

GENVOYA ORAL TABLET 150-150-

200-10 MG

INTELENCE ORAL TABLET 100 MG

200 MG

INTELENCE ORAL TABLET 25 MG 4

INVIRASE ORAL TABLET 500 MG 5 NDS

ISENTRESS HD ORAL TABLET 600

ISENTRESS ORAL POWDER IN

PACKET 100 MG

ISENTRESS ORAL TABLET 400 MG 5 NDS

ISENTRESS ORAL

TABLETCHEWABLE 100 MG 25 MG

JULUCA ORAL TABLET 50-25 MG 5 NDS

KALETRA ORAL TABLET 100-25 MG 4

KALETRA ORAL TABLET 200-50 MG 5 NDS

lamivudine oral solution 10 mgml (Epivir) 2

lamivudine oral tablet 100 mg (Epivir HBV) 2

lamivudine oral tablet 150 mg 300 mg (Epivir) 2

lamivudine-zidovudine oral tablet 150-300

(Combivir) 2

LEXIVA ORAL SUSPENSION 50

lopinavir-ritonavir oral solution 400-100

mg5 ml

(Kaletra) 2

nevirapine oral suspension 50 mg5 ml (Viramune) 2

nevirapine oral tablet 200 mg (Viramune) 2

Drug Name

nevirapine oral tablet extended release 24

hr 100 mg 400 mg

(Viramune XR) 2

NORVIR ORAL CAPSULE 100 MG 4

NORVIR ORAL POWDER IN PACKET

100 MG

NORVIR ORAL SOLUTION 80 MGML 4

ODEFSEY ORAL TABLET 200-25-25

PIFELTRO ORAL TABLET 100 MG 5 NDS

PREZCOBIX ORAL TABLET 800-150

PREZISTA ORAL SUSPENSION 100

PREZISTA ORAL TABLET 150 MG

600 MG 800 MG

PREZISTA ORAL TABLET 75 MG 4

RESCRIPTOR ORAL TABLET 200 MG 4

RESCRIPTOR ORAL TABLET

DISPERSIBLE 100 MG

RETROVIR INTRAVENOUS

SOLUTION 10 MGML

REYATAZ ORAL POWDER IN

PACKET 50 MG

ritonavir oral tablet 100 mg (Norvir) 2

SELZENTRY ORAL SOLUTION 20

SELZENTRY ORAL TABLET 150 MG

300 MG 75 MG

SELZENTRY ORAL TABLET 25 MG 4

stavudine oral capsule 15 mg 20 mg 30

mg 40 mg

STRIBILD ORAL TABLET 150-150-

200-300 MG

SYMFI LO ORAL TABLET 400-300-300

SYMFI ORAL TABLET 600-300-300

SYMTUZA ORAL TABLET 800-150-

200-10 MG

tenofovir disoproxil fumarate oral tablet

300 mg

(Viread) 2

TIVICAY ORAL TABLET 10 MG 4

Drug Name

TRIUMEQ ORAL TABLET 600-50-300

TROGARZO INTRAVENOUS

TRUVADA ORAL TABLET 100-150

MG 133-200 MG 167-250 MG 200-300

VEMLIDY ORAL TABLET 25 MG 5 NDS QL (30 per 30

VIDEX 2 GM PEDIATRIC SOLN 10

MGML (FINAL)

VIDEX 4 GRAM PEDIATRIC ORAL

RECON SOLN 10 MGML (FINAL)

VIDEX EC ORAL

CAPSULEDELAYED

RELEASE(DREC) 125 MG

VIRACEPT ORAL TABLET 250 MG

625 MG

VIREAD ORAL POWDER 40

MGSCOOP (40 MGGRAM)

VIREAD ORAL TABLET 150 MG 200

MG 250 MG

zidovudine oral capsule 100 mg (Retrovir) 2

zidovudine oral syrup 10 mgml (Retrovir) 2

zidovudine oral tablet 300 mg 2

Antivirals Miscellaneous

foscarnet intravenous solution 24 mgml (Foscavir) 2 PA BvD

oseltamivir oral capsule 30 mg (Tamiflu) 2 QL (84 per 180 days)

oseltamivir oral suspension for

reconstitution 6 mgml

(Tamiflu) 2 QL (540 per 180 days)

PREVYMIS INTRAVENOUS

SOLUTION 240 MG12 ML

28 days)

PREVYMIS ORAL TABLET 240 MG

480 MG

Drug Name

RELENZA DISKHALER INHALATION

BLISTER WITH DEVICE 5

MGACTUATION

rimantadine oral tablet 100 mg (Flumadine) 2

SYNAGIS INTRAMUSCULAR

SOLUTION 100 MGML 50 MG05 ML

5 PA NDS

XOFLUZA ORAL TABLET 20 MG 40

Hcv Antivirals

EPCLUSA ORAL TABLET 400-100 MG 5 PA NDS QL (28 per 28

HARVONI ORAL TABLET 90-400 MG 5 PA NDS QL (28 per 28

ledipasvir-sofosbuvir oral tablet 90-400

(Harvoni) 5 PA NDS QL (28 per 28

MAVYRET ORAL TABLET 100-40 MG 5 PA NDS QL (84 per 28

sofosbuvir-velpatasvir oral tablet 400-100

(Epclusa) 5 PA NDS QL (28 per 28

SOVALDI ORAL TABLET 400 MG 5 PA NDS QL (28 per 28

TECHNIVIE ORAL TABLET 125-75-50

VIEKIRA PAK ORAL TABLETSDOSE

PACK 125 MG-75 MG -50 MG250 MG

5 PA NDS

VOSEVI ORAL TABLET 400-100-100

ZEPATIER ORAL TABLET 50-100 MG 5 PA NDS QL (30 per 30

Interferons

INTRON A INJECTION RECON SOLN

10 MILLION UNIT (1 ML) 18 MILLION

UNIT (1 ML) 50 MILLION UNIT (1

5 PA NSO NDS

INTRON A INJECTION SOLUTION 10

MILLION UNITML 6 MILLION

UNITML

5 PA NSO NDS

PEGASYS PROCLICK

SUBCUTANEOUS PEN INJECTOR 180

MCG05 ML

PEGASYS SUBCUTANEOUS

SOLUTION 180 MCGML

Drug Name

SYRINGE 180 MCG05 ML

PEGINTRON SUBCUTANEOUS KIT 50

MCG05 ML

SYLATRON SUBCUTANEOUS KIT

200 MCG 300 MCG 600 MCG

5 PA NSO NDS

Nucleosides And Nucleotides

acyclovir oral capsule 200 mg (Zovirax) 2

acyclovir oral suspension 200 mg5 ml (Zovirax) 2

acyclovir oral tablet 400 mg 800 mg (Zovirax) 2

acyclovir sodium intravenous recon soln

500 mg

2 PA BvD

acyclovir sodium intravenous solution 50

2 PA BvD

adefovir oral tablet 10 mg (Hepsera) 5 NDS

entecavir oral tablet 05 mg 1 mg (Baraclude) 2

famciclovir oral tablet 125 mg 250 mg

500 mg

ganciclovir sodium intravenous recon soln

500 mg

(Cytovene) 2 PA BvD

ganciclovir sodium intravenous solution

50 mgml

2 PA BvD

ribasphere oral capsule 200 mg 2

ribasphere oral tablet 600 mg 5 NDS

ribavirin inhalation recon soln 6 gram (Virazole) 5 PA BvD NDS

ribavirin oral capsule 200 mg (Ribasphere) 2

ribavirin oral tablet 200 mg (Moderiba) 2

valacyclovir oral tablet 1 gram 500 mg (Valtrex) 2

valganciclovir oral tablet 450 mg (Valcyte) 5 NDS

Blood ProductsModifiersVolume

Expanders

Anticoagulants

BEVYXXA ORAL CAPSULE 40 MG 80

ELIQUIS ORAL TABLET 25 MG 5 MG 3 QL (60 per 30 days)

ELIQUIS ORAL TABLETSDOSE

PACK 5 MG (74 TABS)

enoxaparin subcutaneous solution 300

mg3 ml

(Lovenox) 2

Drug Name

enoxaparin subcutaneous syringe 100

mgml 120 mg08 ml 150 mgml 30

mg03 ml 40 mg04 ml 60 mg06 ml 80

mg08 ml

(Lovenox) 2

fondaparinux subcutaneous syringe 10

mg08 ml 5 mg04 ml 75 mg06 ml

(Arixtra) 5 NDS

mg05 ml

(Arixtra) 2

heparin (porcine) injection cartridge

5000 unitml (1 ml)

heparin (porcine) injection solution 1000

unitml 10000 unitml 20000 unitml

5000 unitml

heparin (porcine) injection syringe 5000

unitml

heparin porcine (pf) injection solution

1000 unitml

heparin porcine (pf) injection syringe

5000 unit05 ml

jantoven oral tablet 1 mg 10 mg 2 mg

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

PRADAXA ORAL CAPSULE 110 MG

150 MG 75 MG

warfarin oral tablet 1 mg 10 mg 2 mg

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

(Coumadin) 1

XARELTO ORAL TABLET 10 MG 20

XARELTO ORAL TABLETSDOSE

PACK 15 MG (42)- 20 MG (9)

Blood Formation Modifiers

CINRYZE INTRAVENOUS RECON

SOLN 500 UNIT (5 ML)

DOPTELET (10 TAB PACK) ORAL

TABLET 20 MG

FULPHILA SUBCUTANEOUS

SYRINGE 6 MG06 ML

5 PA NDS

GRANIX SUBCUTANEOUS

SOLUTION 300 MCGML 480 MCG16

5 PA NDS

Drug Name

GRANIX SUBCUTANEOUS SYRINGE

300 MCG05 ML 480 MCG08 ML

5 PA NDS

HAEGARDA SUBCUTANEOUS

RECON SOLN 2000 UNIT

LEUKINE INJECTION RECON SOLN

250 MCG

MOZOBIL SUBCUTANEOUS

MULPLETA ORAL TABLET 3 MG 5 PA NDS QL (7 per 7

NEULASTA SUBCUTANEOUS

SYRINGE 6 MG06ML

5 PA NDS

NEUPOGEN INJECTION SOLUTION

300 MCGML 480 MCG16 ML

5 PA NDS

NEUPOGEN INJECTION SYRINGE 300

MCG05 ML 480 MCG08 ML

5 PA NDS

NIVESTYM INJECTION SOLUTION

NIVESTYM SUBCUTANEOUS

SYRINGE 300 MCG05 ML 480

MCG08 ML

5 PA NDS

PROCRIT INJECTION SOLUTION

10000 UNITML 2000 UNITML

20000 UNIT2 ML 3000 UNITML

4000 UNITML

20000 UNITML

40000 UNITML

PROMACTA ORAL POWDER IN

PACKET 125 MG

30 days)

PROMACTA ORAL TABLET 125 MG 5 PA NDS QL (30 per 30

PROMACTA ORAL TABLET 25 MG 5 PA NDS QL (120 per

30 days)

Drug Name

RETACRIT INJECTION SOLUTION

10000 UNITML 2000 UNITML 3000

UNITML 4000 UNITML

40000 UNITML

UDENYCA SUBCUTANEOUS

SYRINGE 6 MG06 ML

5 PA NDS

ZARXIO INJECTION SYRINGE 300

Hematologic Agents Miscellaneous

anagrelide oral capsule 05 mg (Agrylin) 2

anagrelide oral capsule 1 mg 2

protamine intravenous solution 10 mgml 2

TAVALISSE ORAL TABLET 100 MG

150 MG

tranexamic acid intravenous solution

1000 mg10 ml (100 mgml)

(Cyklokapron) 2

tranexamic acid oral tablet 650 mg (Lysteda) 2 QL (30 per 30 days)

Platelet-Aggregation Inhibitors

aspirin-dipyridamole oral capsule er

multiphase 12 hr 25-200 mg

(Aggrenox) 2 QL (60 per 30 days)

BRILINTA ORAL TABLET 60 MG 90

cilostazol oral tablet 100 mg 50 mg 2

clopidogrel oral tablet 75 mg (Plavix) 1

dipyridamole oral tablet 25 mg 50 mg 75

Years)

pentoxifylline oral tablet extended release

400 mg

prasugrel oral tablet 10 mg 5 mg (Effient) 2 QL (30 per 30 days)

Caloric Agents

AMINOSYN 10 INTRAVENOUS

PARENTERAL SOLUTION 10

4 PA BvD

AMINOSYN 7 WITH

ELECTROLYTES INTRAVENOUS

4 PA BvD

AMINOSYN 85 -ELECTROLYTES

INTRAVENOUS PARENTERAL

SOLUTION 85

4 PA BvD

Drug Name

AMINOSYN II 10 INTRAVENOUS

4 PA BvD

AMINOSYN II 85 -ELECTROLYTES

SOLUTION 85

4 PA BvD

AMINOSYN M 35 INTRAVENOUS

4 PA BvD

AMINOSYN-HBC 7 INTRAVENOUS

4 PA BvD

AMINOSYN-PF 10 INTRAVENOUS

4 PA BvD

AMINOSYN-PF 7 (SULFITE-FREE)

SOLUTION 7

4 PA BvD

AMINOSYN-RF 52 INTRAVENOUS

4 PA BvD

CLINIMIX 5D15W SULFITE FREE

SOLUTION 5

4 PA BvD

CLINIMIX 5D25W SULFITE-FREE

SOLUTION 5

4 PA BvD

CLINIMIX 425D10W SULF FREE

SOLUTION 425

4 PA BvD

CLINIMIX 425D5W SULFIT FREE

SOLUTION 425

4 PA BvD

CLINIMIX 425-D25W SULF-FREE

SOLUTION 425

4 PA BvD

CLINIMIX 5-D20W(SULFITE-FREE)

SOLUTION 5

4 PA BvD

CLINIMIX E 275D10W SUL FREE

SOLUTION 275

4 PA BvD

Drug Name

CLINIMIX E 275D5W SULF FREE

SOLUTION 275

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

CLINIMIX E 5D15W SULFIT FREE

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

dextrose 10 in water (d10w)

intravenous parenteral solution 10

4 PA BvD

intravenous syringe

4 PA BvD

intravenous parenteral solution

4 PA BvD

dextrose 5 in water (d5w) intravenous

parenteral solution

4 PA BvD

intravenous syringe

4 PA BvD

FREAMINE HBC 69

SOLUTION 69

4 PA BvD

Drug Name

FREAMINE III 10 INTRAVENOUS

4 PA BvD

HEPATAMINE 8 INTRAVENOUS

4 PA BvD

INTRALIPID INTRAVENOUS

EMULSION 20 30

4 PA BvD

KABIVEN INTRAVENOUS

EMULSION 331-98-39

4 PA BvD

NEPHRAMINE 54 INTRAVENOUS

4 PA BvD

NUTRILIPID INTRAVENOUS

EMULSION 20

4 PA BvD

PERIKABIVEN INTRAVENOUS

EMULSION 236-68-35

4 PA BvD

PROCALAMINE 3 INTRAVENOUS

4 PA BvD

PROSOL 20 INTRAVENOUS

PARENTERAL SOLUTION

4 PA BvD

smoflipid intravenous emulsion 20 4 PA BvD

TRAVASOL 10 INTRAVENOUS

4 PA BvD

TROPHAMINE 10 INTRAVENOUS

4 PA BvD

Cardiovascular Agents

Alpha-Adrenergic Agents

clonidine hcl oral tablet 01 mg 02 mg

(Catapres) 1

clonidine transdermal patch weekly 01

mg24 hr

(Catapres-TTS-1) 2 QL (4 per 28 days)

mg24 hr

doxazosin oral tablet 1 mg 2 mg 4 mg 8

(Cardura) 2

guanfacine oral tablet 1 mg 2 mg 1 PA-HRM AGE (Max 64

Years)

midodrine oral tablet 10 mg 25 mg 5 mg 2

NORTHERA ORAL CAPSULE 100 MG

200 MG 300 MG

30 days)

Drug Name

phenylephrine hcl injection solution 10

(Vazculep) 2

prazosin oral capsule 1 mg 2 mg 5 mg (Minipress) 2

Angiotensin Ii Receptor Antagonists

EDARBI ORAL TABLET 40 MG 80 MG 3

EDARBYCLOR ORAL TABLET 40-125

MG 40-25 MG

ENTRESTO ORAL TABLET 24-26 MG

49-51 MG 97-103 MG

irbesartan oral tablet 150 mg 300 mg 75

(Avapro) 1

irbesartan-hydrochlorothiazide oral tablet

150-125 mg 300-125 mg

(Avalide) 2

losartan oral tablet 100 mg 25 mg 50 mg (Cozaar) 1

losartan-hydrochlorothiazide oral tablet

100-125 mg 100-25 mg 50-125 mg

(Hyzaar) 1

olmesartan oral tablet 20 mg 40 mg 5 mg (Benicar) 2

olmesartan-hydrochlorothiazide oral

tablet 20-125 mg 40-125 mg 40-25 mg

(Benicar HCT) 2

telmisartan oral tablet 20 mg 40 mg 80

(Micardis) 2

valsartan oral tablet 160 mg 320 mg 40

mg 80 mg

(Diovan) 2

valsartan-hydrochlorothiazide oral tablet

160-125 mg 160-25 mg 320-125 mg

320-25 mg 80-125 mg

(Diovan HCT) 2

Angiotensin-Converting Enzyme

Inhibitors

benazepril oral tablet 10 mg 20 mg 40

(Lotensin) 1

benazepril oral tablet 5 mg 1

captopril oral tablet 100 mg 125 mg 25

mg 50 mg

enalapril maleate oral tablet 10 mg 25

mg 20 mg 5 mg

(Vasotec) 2

enalaprilat intravenous solution 125

enalapril-hydrochlorothiazide oral tablet

10-25 mg

(Vaseretic) 1

5-125 mg

fosinopril oral tablet 10 mg 20 mg 40 mg 1

lisinopril oral tablet 10 mg 20 mg 5 mg (Prinivil) 1

Drug Name

lisinopril oral tablet 25 mg 30 mg 40 mg (Zestril) 1

lisinopril-hydrochlorothiazide oral tablet

10-125 mg 20-125 mg 20-25 mg

(Zestoretic) 1

perindopril erbumine oral tablet 2 mg 4

mg 8 mg

quinapril oral tablet 10 mg 20 mg 40 mg

(Accupril) 1

ramipril oral capsule 125 mg 10 mg 25

mg 5 mg

(Altace) 1

trandolapril oral tablet 1 mg 2 mg 4 mg 2

Antiarrhythmic Agents

amiodarone oral tablet 200 mg (Pacerone) 1

disopyramide phosphate oral capsule 100

mg 150 mg

(Norpace) 2 PA-HRM AGE (Max 64

Years)

dofetilide oral capsule 125 mcg 250 mcg

500 mcg

(Tikosyn) 2

flecainide oral tablet 100 mg 150 mg 50

lidocaine (pf) intravenous syringe 100

mg5 ml (2 ) 50 mg5 ml (1 )

mexiletine oral capsule 150 mg 200 mg

250 mg

MULTAQ ORAL TABLET 400 MG 3

pacerone oral tablet 200 mg 1

procainamide injection solution 100

mgml 500 mgml

procainamide intravenous syringe 100

propafenone oral tablet 150 mg 225 mg

300 mg

quinidine sulfate oral tablet 200 mg 300

Beta-Adrenergic Blocking Agents

acebutolol oral capsule 200 mg 400 mg 2

atenolol oral tablet 100 mg 25 mg 50 mg (Tenormin) 1

atenolol-chlorthalidone oral tablet 100-25

(Tenoretic 100) 2

(Tenoretic 50) 2

betaxolol oral tablet 10 mg 20 mg 2

Drug Name

bisoprolol fumarate oral tablet 10 mg 5

bisoprolol-hydrochlorothiazide oral tablet

10-625 mg 25-625 mg 5-625 mg

(Ziac) 1

BYSTOLIC ORAL TABLET 10 MG 25

MG 20 MG 5 MG

BYVALSON ORAL TABLET 5-80 MG 3

carvedilol oral tablet 125 mg 25 mg

3125 mg 625 mg

(Coreg) 1

labetalol intravenous solution 5 mgml 2

labetalol intravenous syringe 20 mg4 ml

(5 mgml)

labetalol oral tablet 100 mg 200 mg 300

metoprolol succinate oral tablet extended

release 24 hr 100 mg 200 mg 25 mg 50

(Toprol XL) 2

metoprolol ta-hydrochlorothiaz oral tablet

100-25 mg 100-50 mg

50-25 mg

(Lopressor HCT) 2

metoprolol tartrate intravenous solution 5

mg5 ml

(Lopressor) 2

metoprolol tartrate intravenous syringe 5

mg5 ml

metoprolol tartrate oral tablet 100 mg 50

(Lopressor) 1

propranolol intravenous solution 1 mgml 2

propranolol oral capsuleextended release

24 hr 120 mg 160 mg 60 mg 80 mg

(Inderal LA) 2

propranolol oral solution 20 mg5 ml (4

mgml) 40 mg5 ml (8 mgml)

propranolol oral tablet 10 mg 20 mg 40

mg 60 mg 80 mg

propranolol-hydrochlorothiazid oral

tablet 40-25 mg 80-25 mg

sorine oral tablet 120 mg 160 mg 240

mg 80 mg

sotalol af oral tablet 120 mg 160 mg 80

sotalol oral tablet 120 mg 160 mg 240

mg 80 mg

(Betapace) 2

Drug Name

timolol maleate oral tablet 10 mg 20 mg

Calcium-Channel Blocking Agents

cartia xt oral capsuleextended release

24hr 120 mg 180 mg 240 mg 300 mg

diltiazem hcl intravenous solution 5 mgml 2

diltiazem hcl oral capsuleextended

(Tiazac) 2

release 24hr 120 mg 180 mg 240 mg 300

(Cardizem CD) 2

diltiazem hcl oral tablet 120 mg 30 mg

(Cardizem) 2

diltiazem hcl oral tablet 90 mg 2

dilt-xr oral capsuleextrel 24h degradable

120 mg 180 mg 240 mg

taztia xt oral capsuleextended release 24

hr 120 mg 180 mg 240 mg 300 mg 360

verapamil intravenous syringe 25 mgml 2

verapamil oral capsule 24 hr er pellet ct

100 mg 200 mg 300 mg

(Verelan PM) 2

verapamil oral capsuleext rel pellets 24

hr 120 mg 180 mg 240 mg

(Verelan) 2

hr 360 mg

(Verelan) 4

verapamil oral tablet 120 mg 80 mg (Calan) 1

verapamil oral tablet 40 mg 1

verapamil oral tablet extended release 120

mg 180 mg 240 mg

(Calan SR) 1

Cardiovascular Agents Miscellaneous

CORLANOR ORAL TABLET 5 MG 75

DEMSER ORAL CAPSULE 250 MG 5 NDS

digitek oral tablet 125 mcg 2 QL (30 per 30 days)

digitek oral tablet 250 mcg 2

digox oral tablet 125 mcg 2 QL (30 per 30 days)

digox oral tablet 250 mcg 2

digoxin injection syringe 250 mcgml 2

Drug Name

DIGOXIN ORAL SOLUTION 50

digoxin oral tablet 125 mcg (Digitek) 2 QL (30 per 30 days)

digoxin oral tablet 250 mcg (Digitek) 2

epinephrine injection auto-injector 015

mg03 ml

(EpiPen Jr) 3 QL (4 per 30 days)

mg03 ml

(Auvi-Q) 3 QL (4 per 30 days)

FIRAZYR SUBCUTANEOUS SYRINGE

30 MG3 ML

hydralazine injection solution 20 mgml 2

hydralazine oral tablet 10 mg 100 mg 25

mg 50 mg

icatibant subcutaneous syringe 30 mg3 ml (Firazyr) 5 PA NDS QL (18 per 30

ranolazine oral tablet extended release 12

hr 1000 mg 500 mg

(Ranexa) 2

SYMJEPI INJECTION SYRINGE 03

MG03 ML

VYNDAQEL ORAL CAPSULE 20 MG 5 PA NDS QL (120 per

30 days)

Dihydropyridines

afeditab cr oral tablet extended release 30

mg 60 mg

amlodipine oral tablet 10 mg 25 mg 5

(Norvasc) 1

amlodipine-benazepril oral capsule 10-20

mg 10-40 mg 5-10 mg 5-20 mg 5-40 mg

(Lotrel) 2

amlodipine-valsartan oral tablet 10-160

mg 10-320 mg 5-160 mg 5-320 mg

(Exforge) 2

nicardipine oral capsule 20 mg 30 mg 2

nifedipine oral tablet extended release

24hr 30 mg 60 mg 90 mg

(Procardia XL) 2

nifedipine oral tablet extended release 30

mg 60 mg 90 mg

(Adalat CC) 2

Diuretics

amiloride oral tablet 5 mg 2

amiloride-hydrochlorothiazide oral tablet

5-50 mg

bumetanide injection solution 025 mgml 2

bumetanide oral tablet 05 mg 1 mg 2 mg 2

Drug Name

chlorothiazide oral tablet 250 mg 500 mg 2

chlorothiazide sodium intravenous recon

soln 500 mg

(Diuril IV) 2

chlorthalidone oral tablet 25 mg 50 mg 2

furosemide injection solution 10 mgml 2

furosemide injection syringe 10 mgml 2

furosemide oral solution 10 mgml 40

mg5 ml (8 mgml)

furosemide oral tablet 20 mg 40 mg 80

(Lasix) 1

hydrochlorothiazide oral capsule 125 mg (Microzide) 1

hydrochlorothiazide oral tablet 125 mg

25 mg 50 mg

indapamide oral tablet 125 mg 25 mg 1

JYNARQUE ORAL TABLET 15 MG 30

30 days)

JYNARQUE ORAL TABLETS

SEQUENTIAL 45 MG (AM) 15 MG

(PM) 60 MG (AM) 30 MG (PM) 90 MG

(AM) 30 MG (PM)

methyclothiazide oral tablet 5 mg 2

spironolactone oral tablet 100 mg 25 mg

(Aldactone) 1

torsemide oral tablet 10 mg 100 mg 5 mg 1

torsemide oral tablet 20 mg (Demadex) 1

triamterene-hydrochlorothiazid oral

capsule 375-25 mg

(Dyazide) 1

capsule 50-25 mg

triamterene-hydrochlorothiazid oral tablet

375-25 mg

(Maxzide-25mg) 1

75-50 mg

(Maxzide) 1

Dyslipidemics

atorvastatin oral tablet 10 mg 20 mg 40

mg 80 mg

(Lipitor) 1

cholestyramine (with sugar) oral powder

in packet 4 gram

(Questran) 2

cholestyramine light oral powder 4 gram 2

cholestyramine light packet 4 gram 2

colestipol oral packet 5 gram (Colestid) 2

colestipol oral tablet 1 gram (Colestid) 2

Drug Name

ezetimibe oral tablet 10 mg (Zetia) 2 QL (30 per 30 days)

fenofibrate micronized oral capsule 134

mg 200 mg 67 mg

fenofibrate nanocrystallized oral tablet

145 mg 48 mg

(Tricor) 2

fenofibrate oral tablet 160 mg 54 mg 2

gemfibrozil oral tablet 600 mg (Lopid) 1

JUXTAPID ORAL CAPSULE 10 MG 30

MG 40 MG 60 MG

JUXTAPID ORAL CAPSULE 20 MG 5 PA NDS QL (90 per 30

LIVALO ORAL TABLET 1 MG 2 MG 4

lovastatin oral tablet 10 mg 20 mg 40 mg 1

niacin oral tablet 500 mg (Niacor) 2

niacin oral tablet extended release 24 hr

1000 mg 500 mg 750 mg

(Niaspan Extended-

Release)

niacor oral tablet 500 mg 2

omega-3 acid ethyl esters oral capsule 1

(Lovaza) 2 QL (120 per 30 days)

PRALUENT PEN SUBCUTANEOUS

PEN INJECTOR 150 MGML 75

pravastatin oral tablet 10 mg 1

pravastatin oral tablet 20 mg 40 mg 80

(Pravachol) 1

prevalite oral powder in packet 4 gram 2

REPATHA PUSHTRONEX

SUBCUTANEOUS WEARABLE

INJECTOR 420 MG35 ML

REPATHA SURECLICK

REPATHA SYRINGE

rosuvastatin oral tablet 10 mg 20 mg 40

mg 5 mg

(Crestor) 2 QL (30 per 30 days)

simvastatin oral tablet 10 mg 20 mg 40

mg 80 mg

(Zocor) 1 QL (30 per 30 days)

simvastatin oral tablet 5 mg 1 QL (30 per 30 days)

Drug Name

VASCEPA ORAL CAPSULE 05 GRAM 3 QL (240 per 30 days)

WELCHOL ORAL POWDER IN

PACKET 375 GRAM

WELCHOL ORAL TABLET 625 MG 2

Renin-Angiotensin-Aldosterone System

Inhibitors

aliskiren oral tablet 150 mg 300 mg (Tekturna) 2

eplerenone oral tablet 25 mg 50 mg (Inspra) 2

TEKTURNA HCT ORAL TABLET 150-

125 MG 150-25 MG 300-125 MG 300-

Vasodilators

BIDIL ORAL TABLET 20-375 MG 3

isosorbide dinitrate oral tablet 10 mg 20

mg 30 mg

isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) 2

isosorbide dinitrate oral tablet extended

release 40 mg

(ISOCHRON) 2

isosorbide mononitrate oral tablet 10 mg

isosorbide mononitrate oral tablet

minitran transdermal patch 24 hour 01

mghr 02 mghr 04 mghr 06 mghr

minoxidil oral tablet 10 mg 25 mg 2

nitroglycerin intravenous solution 50

mg10 ml (5 mgml)

nitroglycerin sublingual tablet 03 mg 04

mg 06 mg

(Nitrostat) 2

nitroglycerin transdermal patch 24 hour

01 mghr 02 mghr 04 mghr 06 mghr

(Minitran) 2

Central Nervous System Agents

atomoxetine oral capsule 10 mg 18 mg

25 mg 40 mg

(Strattera) 2 QL (60 per 30 days)

AUBAGIO ORAL TABLET 14 MG 7

Drug Name

AUSTEDO ORAL TABLET 12 MG 9

30 days)

AUSTEDO ORAL TABLET 6 MG 5 PA NDS QL (60 per 30

AVONEX (WITH ALBUMIN)

INTRAMUSCULAR KIT 30 MCG

AVONEX INTRAMUSCULAR PEN

INJECTOR KIT 30 MCG05 ML

AVONEX INTRAMUSCULAR

SYRINGE KIT 30 MCG05 ML

BETASERON SUBCUTANEOUS KIT

caffeine citrate intravenous solution 60

mg3 ml (20 mgml)

(Cafcit) 2 PA BvD

caffeine citrate oral solution 60 mg3 ml

(20 mgml)

dalfampridine oral tablet extended release

12 hr 10 mg

(Ampyra) 5 PA NDS QL (60 per 30

dexmethylphenidate oral tablet 10 mg 25

mg 5 mg

(Focalin) 2 QL (60 per 30 days)

dextroamphetamine oral tablet 10 mg 5

(Zenzedi) 2 QL (180 per 30 days)

dextroamphetamine-amphetamine oral

capsuleextended release 24hr 10 mg 15

mg 5 mg

(Adderall XR) 2 QL (30 per 30 days)

mg 30 mg

tablet 10 mg 125 mg 15 mg 20 mg 30

mg 5 mg 75 mg

(Adderall) 2 QL (60 per 30 days)

EXTAVIA SUBCUTANEOUS KIT 03

flumazenil intravenous solution 01 mgml 2

GILENYA ORAL CAPSULE 025 MG

glatiramer subcutaneous syringe 20 mgml (Copaxone) 5 PA NDS QL (30 per 30

glatopa subcutaneous syringe 20 mgml 5 PA NDS QL (30 per 30

Drug Name

guanfacine oral tablet extended release 24

hr 1 mg 2 mg 3 mg 4 mg

(Intuniv ER) 2

INGREZZA INITIATION PACK ORAL

CAPSULEDOSE PACK 40 MG (7)- 80

MG (21)

5 PA NDS

INGREZZA ORAL CAPSULE 40 MG

LEMTRADA INTRAVENOUS

SOLUTION 12 MG12 ML

lithium carbonate oral capsule 150 mg

300 mg 600 mg

lithium carbonate oral tablet 300 mg 1

lithium carbonate oral tablet extended

release 300 mg

(Lithobid) 2

release 450 mg

lithium citrate oral solution 8 meq5 ml 4

MAVENCLAD (10 TABLET PACK)

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

MAYZENT ORAL TABLET 025 MG 5 PA NDS QL (112 per

28 days)

MAYZENT ORAL TABLET 2 MG 5 PA NDS QL (30 per 30

methylphenidate hcl oral capsule er

biphasic 30-70 10 mg 20 mg 40 mg 50

mg 60 mg

biphasic 30-70 30 mg

Drug Name

methylphenidate hcl oral capsuleer

biphasic 50-50 10 mg 20 mg 40 mg

(Ritalin LA) 2 QL (30 per 30 days)

methylphenidate hcl oral solution 10 mg5

ml 5 mg5 ml

(Methylin) 2 QL (900 per 30 days)

methylphenidate hcl oral tablet 10 mg 20

mg 5 mg

(Ritalin) 2 QL (90 per 30 days)

NUEDEXTA ORAL CAPSULE 20-10

OCREVUS INTRAVENOUS

SOLUTION 30 MGML

5 PA NDS QL (20 per

180 days)

PLEGRIDY SUBCUTANEOUS PEN

INJECTOR 125 MCG05 ML

INJECTOR 63 MCG05 ML- 94

MCG05 ML

5 PA NDS

PLEGRIDY SUBCUTANEOUS

SYRINGE 63 MCG05 ML- 94 MCG05

5 PA NDS

RADICAVA INTRAVENOUS

PIGGYBACK 30 MG100 ML

28 days)

REBIF (WITH ALBUMIN)

REBIF REBIDOSE SUBCUTANEOUS

PEN INJECTOR 22 MCG05 ML 44

MCG05 ML

PEN INJECTOR 88MCG02ML-22

MCG05ML (6)

5 PA NDS

REBIF TITRATION PACK

SUBCUTANEOUS SYRINGE

88MCG02ML-22 MCG05ML (6)

5 PA NDS

riluzole oral tablet 50 mg (Rilutek) 2

SAVELLA ORAL TABLET 100 MG

125 MG 25 MG 50 MG

SAVELLA ORAL TABLETSDOSE

PACK 125 MG (5)-25 MG(8)-50 MG(42)

Drug Name

TECFIDERA ORAL

CAPSULEDELAYED

TECFIDERA ORAL

CAPSULEDELAYED

RELEASE(DREC) 120 MG (14)- 240

MG (46)

5 PA NDS

TECFIDERA ORAL

CAPSULEDELAYED

tetrabenazine oral tablet 125 mg 25 mg (Xenazine) 5 PA NDS QL (112 per

28 days)

Contraceptives

afirmelle oral tablet 01-20 mg-mcg 2

altavera (28) oral tablet 015-003 mg 2

alyacen 135 (28) oral tablet 1-35 mg-mcg 2

alyacen 777 (28) oral tablet 050751

mg- 35 mcg

amethia lo oral tabletsdose pack3 month

010 mg-20 mcg (84)10 mcg (7)

amethia oral tabletsdose pack3 month

015 mg-30 mcg (84)10 mcg (7)

apri oral tablet 015-003 mg 2

aranelle (28) oral tablet 05105-35 mg-

ashlyna oral tabletsdose pack3 month

015 mg-30 mcg (84)10 mcg (7)

aubra oral tablet 01-20 mg-mcg 2

aurovela 1530 (21) oral tablet 15-30

mg-mcg

aurovela 120 (21) oral tablet 1-20 mg-

aurovela 24 fe oral tablet 1 mg-20 mcg

(24)75 mg (4)

aurovela fe 1530 (28) oral tablet 15 mg-

30 mcg (21)75 mg (7)

aurovela fe 1-20 (28) oral tablet 1 mg-20

mcg (21)75 mg (7)

aviane oral tablet 01-20 mg-mcg 2

ayuna oral tablet 015-003 mg 2

azurette (28) oral tablet 015-002 mgx21

001 mg x 5

Drug Name

balziva (28) oral tablet 04-35 mg-mcg 2

bekyree (28) oral tablet 015-002 mgx21

001 mg x 5

blisovi 24 fe oral tablet 1 mg-20 mcg

(24)75 mg (4)

blisovi fe 1530 (28) oral tablet 15 mg-30

mcg (21)75 mg (7)

briellyn oral tablet 04-35 mg-mcg 2

camila oral tablet 035 mg 2

caziant (28) oral tablet 0112515-25

mg-mcg

cryselle (28) oral tablet 03-30 mg-mcg 2

cyclafem 135 (28) oral tablet 1-35 mg-

cyclafem 777 (28) oral tablet 050751

mg- 35 mcg

cyred oral tablet 015-003 mg 2

dasetta 135 (28) oral tablet 1-35 mg-mcg 2

dasetta 777 (28) oral tablet 050751

mg- 35 mcg

daysee oral tabletsdose pack3 month

015 mg-30 mcg (84)10 mcg (7)

deblitane oral tablet 035 mg 2

delyla (28) oral tablet 01-20 mg-mcg 2

desog-eestradioleestradiol oral tablet

015-002 mgx21 001 mg x 5

(Azurette (28)) 2

desogestrel-ethinyl estradiol oral tablet

015-003 mg

(Apri) 2

drospirenone-ethinyl estradiol oral tablet

3-002 mg

(Gianvi (28)) 2

3-003 mg

(Ocella) 2

elinest oral tablet 03-30 mg-mcg 2

ELLA ORAL TABLET 30 MG 4 QL (6 per 365 days)

emoquette oral tablet 015-003 mg 2

enpresse oral tablet 50-30 (6)75-40

(5)125-30(10)

enskyce oral tablet 015-003 mg 2

errin oral tablet 035 mg 2

estarylla oral tablet 025-35 mg-mcg 2

Drug Name

ethynodiol diac-eth estradiol oral tablet 1-

35 mg-mcg

(Kelnor 135 (28)) 2

50 mg-mcg

(Kelnor 1-50) 2

falmina (28) oral tablet 01-20 mg-mcg 2

femynor oral tablet 025-35 mg-mcg 2

hailey 24 fe oral tablet 1 mg-20 mcg

(24)75 mg (4)

heather oral tablet 035 mg 2

incassia oral tablet 035 mg 2

introvale oral tabletsdose pack3 month

015 mg-30 mcg (91)

isibloom oral tablet 015-003 mg 2

jasmiel (28) oral tablet 3-002 mg 2

jencycla oral tablet 035 mg 1

jolivette oral tablet 035 mg 4

juleber oral tablet 015-003 mg 2

junel 1530 (21) oral tablet 15-30 mg-

junel 120 (21) oral tablet 1-20 mg-mcg 2

junel fe 1530 (28) oral tablet 15 mg-30

mcg (21)75 mg (7)

junel fe 120 (28) oral tablet 1 mg-20 mcg

(21)75 mg (7)

junel fe 24 oral tablet 1 mg-20 mcg

(24)75 mg (4)

kalliga oral tablet 015-003 mg 2

kariva (28) oral tablet 015-002 mgx21

001 mg x 5

kelnor 135 (28) oral tablet 1-35 mg-mcg 2

kelnor 1-50 oral tablet 1-50 mg-mcg 2

kurvelo (28) oral tablet 015-003 mg 2

l norgesteestradiol-eestrad oral

tabletsdose pack3 month 010 mg-20 mcg

(84)10 mcg (7)

(Amethia Lo) 2 QL (91 per 84 days)

tabletsdose pack3 month 015 mg-20

mcg 015 mg-25 mcg

(Fayosim) 2 QL (91 per 84 days)

(84)10 mcg (7)

(Amethia) 2 QL (91 per 84 days)

Drug Name

larin 1530 (21) oral tablet 15-30 mg-

larin 120 (21) oral tablet 1-20 mg-mcg 2

larin 24 fe oral tablet 1 mg-20 mcg

(24)75 mg (4)

larin fe 1530 (28) oral tablet 15 mg-30

mcg (21)75 mg (7)

larin fe 120 (28) oral tablet 1 mg-20 mcg

(21)75 mg (7)

larissia oral tablet 01-20 mg-mcg 2

leena 28 oral tablet 05105-35 mg-mcg 4

lessina oral tablet 01-20 mg-mcg 2

levonest (28) oral tablet 50-30 (6)75-40

(5)125-30(10)

levonorgestrel-ethinyl estrad oral tablet

01-20 mg-mcg

(Afirmelle) 2

015-003 mg

(Altavera (28)) 2

levonorgestrel-ethinyl estrad oral

(Introvale) 2 QL (91 per 84 days)

levonorg-eth estrad triphasic oral tablet

50-30 (6)75-40 (5)125-30(10)

(Enpresse) 2

levora-28 oral tablet 015-003 mg 2

lillow (28) oral tablet 015-003 mg 2

loryna (28) oral tablet 3-002 mg 2

low-ogestrel (28) oral tablet 03-30 mg-

lo-zumandimine (28) oral tablet 3-002 mg 2

lutera (28) oral tablet 01-20 mg-mcg 2

lyza oral tablet 035 mg 2

marlissa (28) oral tablet 015-003 mg 2

microgestin fe 120 (28) oral tablet 1 mg-

20 mcg (21)75 mg (7)

mili oral tablet 025-35 mg-mcg 2

mono-linyah oral tablet 025-35 mg-mcg 2

mononessa (28) oral tablet 025-35 mg-

myzilra oral tablet 50-30 (6)75-40

(5)125-30(10)

necon 0535 (28) oral tablet 05-35 mg-

Drug Name

nikki (28) oral tablet 3-002 mg 2

nora-be oral tablet 035 mg 4

norethindrone (contraceptive) oral tablet

035 mg

(Camila) 2

norethindrone ac-eth estradiol oral tablet

1-20 mg-mcg

(Aurovela 120 (21)) 2

norethindrone-eestradiol-iron oral tablet

1 mg-20 mcg (21)75 mg (7)

(Aurovela Fe 1-20 (28)) 2

1 mg-20 mcg (24)75 mg (4)

(Aurovela 24 Fe) 2

norgestimate-ethinyl estradiol oral tablet

0180215025 mg-25 mcg

(Tri-Lo-Estarylla) 2

0180215025 mg-35 mcg (28)

(Ortho Tri-Cyclen (28)) 2

025-35 mg-mcg

(Estarylla) 2

norlyda oral tablet 035 mg 2

norlyroc oral tablet 035 mg 2

nortrel 0535 (28) oral tablet 05-35 mg-

nortrel 135 (21) oral tablet 1-35 mg-mcg

nortrel 135 (28) oral tablet 1-35 mg-mcg 2

nortrel 777 (28) oral tablet 050751

mg- 35 mcg

ogestrel (28) oral tablet 05-50 mg-mcg 2

orsythia oral tablet 01-20 mg-mcg 2

philith oral tablet 04-35 mg-mcg 2

pimtrea (28) oral tablet 015-002 mgx21

001 mg x 5

pirmella oral tablet 050751 mg- 35

mcg 1-35 mg-mcg

portia 28 oral tablet 015-003 mg 2

previfem oral tablet 025-35 mg-mcg 2

reclipsen (28) oral tablet 015-003 mg 2

setlakin oral tabletsdose pack3 month

015 mg-30 mcg (91)

sharobel oral tablet 035 mg 2

simliya (28) oral tablet 015-002 mgx21

001 mg x 5

simpesse oral tabletsdose pack3 month

015 mg-30 mcg (84)10 mcg (7)

Drug Name

sprintec (28) oral tablet 025-35 mg-mcg 2

sronyx oral tablet 01-20 mg-mcg 2

syeda oral tablet 3-003 mg 2

tarina 24 fe oral tablet 1 mg-20 mcg

(24)75 mg (4)

tarina fe 120 (28) oral tablet 1 mg-20

mcg (21)75 mg (7)

tilia fe oral tablet 1-20(5)1-30(7) 1mg-

35mcg (9)

tri femynor oral tablet 0180215025

mg-35 mcg (28)

tri-estarylla oral tablet 0180215025

mg-35 mcg (28)

tri-legest fe oral tablet 1-20(5)1-30(7)

1mg-35mcg (9)

tri-linyah oral tablet 0180215025 mg-

35 mcg (28)

tri-lo-estarylla oral tablet 0180215025

mg-25 mcg

tri-lo-marzia oral tablet 0180215025

mg-25 mcg

tri-lo-mili oral tablet 0180215025 mg-

25 mcg

tri-lo-sprintec oral tablet 0180215025

mg-25 mcg

tri-mili oral tablet 0180215025 mg-35

mcg (28)

tri-previfem (28) oral tablet

0180215025 mg-35 mcg (28)

tri-sprintec (28) oral tablet

0180215025 mg-35 mcg (28)

trivora (28) oral tablet 50-30 (6)75-40

(5)125-30(10)

tri-vylibra lo oral tablet 0180215025

mg-25 mcg

tri-vylibra oral tablet 0180215025 mg-

35 mcg (28)

tulana oral tablet 035 mg 2

velivet triphasic regimen (28) oral tablet

0112515-25 mg-mcg

vienva oral tablet 01-20 mg-mcg 2

viorele (28) oral tablet 015-002 mgx21

001 mg x 5

Drug Name

vyfemla (28) oral tablet 04-35 mg-mcg 2

vylibra oral tablet 025-35 mg-mcg 2

wera (28) oral tablet 05-35 mg-mcg 2

xulane transdermal patch weekly 150-35

mcg24 hr

zarah oral tablet 3-003 mg 2

zenchent (28) oral tablet 04-35 mg-mcg 2

zovia 135e (28) oral tablet 1-35 mg-mcg 2

zumandimine (28) oral tablet 3-003 mg 2

Dental And Oral Agents

chlorhexidine gluconate mucous

membrane mouthwash 012

(Paroex Oral Rinse) 1

oralone dental paste 01 2

paroex oral rinse mucous membrane

mouthwash 012

periogard mucous membrane mouthwash

pilocarpine hcl oral tablet 5 mg 75 mg (Salagen (pilocarpine)) 2

triamcinolone acetonide dental paste 01

(Oralone) 2

Dermatological Agents

Dermatological Agents Other

acitretin oral capsule 10 mg 175 mg 25

(Soriatane) 2

acyclovir topical ointment 5 (Zovirax) 2 QL (30 per 30 days)

ALCOHOL PADS TOPICAL PADS

MEDICATED

ammonium lactate topical cream 12 (Geri-Hydrolac) 2

ammonium lactate topical lotion 12 (AmLactin) 2

calcipotriene scalp solution 0005 2

calcipotriene topical cream 0005 (Dovonex) 2

fluorouracil topical cream 05 (Carac) 5 NDS

fluorouracil topical cream 5 (Efudex) 2

fluorouracil topical solution 2 5 2

imiquimod topical cream in packet 5 (Aldara) 2 PA NSO QL (24 per 30

methoxsalen oral capsuleliqd-filledrapid

rel 10 mg

(Oxsoralen Ultra) 5 NDS

PANRETIN TOPICAL GEL 01 5 NDS

PICATO TOPICAL GEL 0015 3 QL (3 per 56 days)

Drug Name

podofilox topical solution 05 2

SANTYL TOPICAL OINTMENT 250

UNITGRAM

TOLAK TOPICAL CREAM 4 4

VALCHLOR TOPICAL GEL 0016 5 NDS

zenatane oral capsule 10 mg 20 mg 30

mg 40 mg

Dermatological Antibacterials

clindamycin phosphate topical solution 1

(Cleocin T) 2

clindamycin phosphate topical swab 1 (Clindacin ETZ) 2

ery pads topical swab 2 2

erythromycin with ethanol topical gel 2 (Erygel) 2

erythromycin with ethanol topical solution

erythromycin with ethanol topical swab 2

(Ery Pads) 2

gentamicin topical cream 01 2

gentamicin topical ointment 01 2

metronidazole topical cream 075 (MetroCream) 2

metronidazole topical gel 075 (Rosadan) 2

metronidazole topical gel 1 (Metrogel) 2

metronidazole topical lotion 075 (MetroLotion) 2

mupirocin topical ointment 2 (Centany) 1

neomycin-polymyxin b gu irrigation

solution 40 mg-200000 unitml

rosadan topical cream 075 2

selenium sulfide topical lotion 25 2

silver sulfadiazine topical cream 1 (Silvadene) 2

ssd topical cream 1 4

sulfacetamide sodium (acne) topical

suspension 10

(Klaron) 2

Dermatological Anti-Inflammatory

Agents

ala-cort topical cream 1 1

alclometasone topical cream 005 2

alclometasone topical ointment 005 2

betamethasone dipropionate topical cream

betamethasone dipropionate topical lotion

Drug Name

betamethasone dipropionate topical

ointment 005

betamethasone valerate topical cream 01

betamethasone valerate topical lotion 01

betamethasone valerate topical ointment

betamethasone augmented topical cream

betamethasone augmented topical gel

betamethasone augmented topical lotion

betamethasone augmented topical

ointment 005

(Diprolene) 2

clobetasol scalp solution 005 (Cormax) 2

clobetasol topical cream 005 (Temovate) 2

clobetasol-emollient topical cream 005 2

clocortolone pivalate topical cream 01 (Cloderm) 4

cormax scalp solution 005 2

desoximetasone topical cream 025 (Topicort) 2

EUCRISA TOPICAL OINTMENT 2 3

fluocinolone topical cream 001 2

fluocinolone topical cream 0025 (Synalar) 2

fluocinolone topical ointment 0025 (Synalar) 2

fluocinonide topical cream 005 2

fluocinonide topical solution 005 2

fluocinonide-e topical cream 005 2

fluticasone propionate topical cream 005

(Cutivate) 2

fluticasone propionate topical ointment

halobetasol propionate topical cream 005

halobetasol propionate topical ointment

hydrocortisone topical cream 1 (Ala-Cort) 1

hydrocortisone topical cream 25 1

hydrocortisone topical lotion 25 2

hydrocortisone topical ointment 1 (Anti-Itch (HC)) 1

hydrocortisone topical ointment 25 1

Drug Name

mometasone topical cream 01 (Elocon) 2

mometasone topical ointment 01 2

mometasone topical solution 01 2

pimecrolimus topical cream 1 (Elidel) 2

prednicarbate topical cream 01 4

prednicarbate topical ointment 01 (Dermatop) 2

procto-med hc topical cream with perineal

applicator 25

proctosol hc topical cream with perineal

applicator 25

proctozone-hc topical cream with perineal

applicator 25

tacrolimus topical ointment 003 01 (Protopic) 2 QL (100 per 30 days)

triamcinolone acetonide topical cream

triamcinolone acetonide topical cream 01

(Triderm) 1

triamcinolone acetonide topical lotion

0025 01

triamcinolone acetonide topical ointment

0025 01 05

Dermatological Retinoids

adapalene topical cream 01 (Differin) 2

adapalene topical gel 01 (Differin) 2

ALTRENO TOPICAL LOTION 005 4 PA

tazarotene topical cream 01 (Avage) 2

TAZORAC TOPICAL CREAM 005 4

tretinoin topical cream 0025 (Avita) 2 PA

tretinoin topical cream 005 01 (Retin-A) 2 PA

tretinoin topical gel 001 (Retin-A) 2 PA

tretinoin topical gel 0025 (Avita) 2 PA

tretinoin topical gel 005 (Atralin) 2 PA

Scabicides And Pediculicides

malathion topical lotion 05 (Ovide) 2

permethrin topical cream 5 (Elimite) 2

Devices

ASSURE ID INSULIN SAFETY

SYRINGE 1 ML 29 GAUGE X 12

BD UF NANO PEN NEEDLE

4MMX32G 32 GAUGE X 532

Drug Name

BD VEO INS 03 ML 6MMX31G (12)

03 ML 31 GAUGE X 1564

BD VEO INS SYRING 1 ML 6MMX31G

1 ML 31 GAUGE X 1564

BD VEO INS SYRN 05 ML 6MMX31G

12 ML 31 GAUGE X 1564

GAUZE PAD TOPICAL BANDAGE 2 X

INSULIN SYRINGE-NEEDLE U-100

SYRINGE 03 ML 29 GAUGE

(Ultilet Insulin Syringe) 2

(Advocate Syringes) 2

(Lite Touch Insulin

Syringe)

PEN NEEDLE DIABETIC NEEDLE 29

GAUGE X 12

(1st Tier Unifine

Pentips)

V-GO 40 DISPOSABLE DEVICE 2

Enzyme ReplacementModifiers

ADAGEN INTRAMUSCULAR

SOLUTION 250 UNITML

ALDURAZYME INTRAVENOUS

SOLUTION 29 MG5 ML

CERDELGA ORAL CAPSULE 84 MG 5 PA NDS

CEREZYME INTRAVENOUS RECON

SOLN 400 UNIT

CREON ORAL CAPSULEDELAYED

RELEASE(DREC) 12000-38000 -

60000 UNIT 24000-76000 -120000

UNIT 3000-9500- 15000 UNIT

36000-114000- 180000 UNIT 6000-

19000 -30000 UNIT

ELAPRASE INTRAVENOUS

SOLUTION 6 MG3 ML

ELITEK INTRAVENOUS RECON

SOLN 15 MG 75 MG

FABRAZYME INTRAVENOUS RECON

SOLN 35 MG 5 MG

5 PA NDS

GALAFOLD ORAL CAPSULE 123 MG 5 PA NDS QL (14 per 28

KANUMA INTRAVENOUS SOLUTION

2 MGML

5 PA NDS

Drug Name

KRYSTEXXA INTRAVENOUS

SOLUTION 8 MGML

5 PA BvD NDS

KUVAN ORAL TABLETSOLUBLE 100

MEPSEVII INTRAVENOUS SOLUTION

2 MGML

5 PA NDS

miglustat oral capsule 100 mg (Zavesca) 5 PA NDS QL (90 per 30

NAGLAZYME INTRAVENOUS

SOLUTION 5 MG5 ML

NITYR ORAL TABLET 10 MG 2 MG 5

5 PA NDS

ORFADIN ORAL CAPSULE 10 MG 2

MG 20 MG 5 MG

5 PA NDS

ORFADIN ORAL SUSPENSION 4

5 PA NDS

PALYNZIQ SUBCUTANEOUS

ML 20 MGML

5 PA NDS

PULMOZYME INHALATION

SOLUTION 1 MGML

5 PA BvD NDS

REVCOVI INTRAMUSCULAR

5 PA NDS

STRENSIQ SUBCUTANEOUS

SOLUTION 100 MGML 40 MGML

5 PA LA NDS

VIMIZIM INTRAVENOUS SOLUTION

5 MG5 ML (1 MGML)

5 PA NDS

VPRIV INTRAVENOUS RECON SOLN

400 UNIT

ZENPEP ORAL CAPSULEDELAYED

42000 UNIT 15000-47000 -63000

UNIT 20000-63000- 84000 UNIT

25000-79000- 105000 UNIT 3000-

10000 -14000-UNIT 40000-126000-

168000 UNIT 5000-17000- 24000

Eye Ear Nose Throat Agents

Miscellaneous

apraclonidine ophthalmic (eye) drops 05

Drug Name

atropine ophthalmic (eye) drops 1 (Isopto Atropine) 4

azelastine nasal aerosolspray 137 mcg

azelastine ophthalmic (eye) drops 005 2

cromolyn ophthalmic (eye) drops 4 2

cyclopentolate ophthalmic (eye) drops 05

(Cyclogyl) 2

CYSTARAN OPHTHALMIC (EYE)

DROPS 044

epinastine ophthalmic (eye) drops 005 2

ipratropium bromide nasal spraynon-

aerosol 003

aerosol 42 mcg (006 )

olopatadine ophthalmic (eye) drops 01 (Patanol) 2

olopatadine ophthalmic (eye) drops 02 (Pataday) 2

phenylephrine hcl ophthalmic (eye) drops

proparacaine ophthalmic (eye) drops 05

(Alcaine) 2

Eye Ear Nose Throat Anti-Infectives

Agents

acetic acid otic (ear) solution 2 2

bacitracin ophthalmic (eye) ointment 500

unitgram

bacitracin-polymyxin b ophthalmic (eye)

ointment 500-10000 unitgram

(AK-Poly-Bac) 2

bleph-10 ophthalmic (eye) drops 10 2

CIPRODEX OTIC (EAR)

DROPSSUSPENSION 03-01

ciprofloxacin hcl ophthalmic (eye) drops

(Ciloxan) 1

ciprofloxacin hcl otic (ear) dropperette 02

(Cetraxal) 4

erythromycin ophthalmic (eye) ointment 5

mggram (05 )

gentak ophthalmic (eye) ointment 03 (3

mggram)

gentamicin ophthalmic (eye) drops 03 1

levofloxacin ophthalmic (eye) drops 05 2

MOXEZA OPHTHALMIC (EYE)

DROPS VISCOUS 05

Drug Name

moxifloxacin ophthalmic (eye) drops 05

(Vigamox) 2

NATACYN OPHTHALMIC (EYE)

DROPSSUSPENSION 5

neomycin-bacitracin-poly-hc ophthalmic

(eye) ointment 35-400-10000 mg-unitg-

(Neo-Polycin HC) 2

neomycin-bacitracin-polymyxin

ophthalmic (eye) ointment 35-400-10000

mg-unit-unitg

(Neo-Polycin) 2

neomycin-polymyxin b-dexameth

ophthalmic (eye) dropssuspension

35mgml-10000 unitml-01

(Maxitrol) 2

ophthalmic (eye) ointment 35 mgg-

10000 unitg-01

(Maxitrol) 2

neomycin-polymyxin-gramicidin

ophthalmic (eye) drops 175 mg-10000

unit-0025mgml

neomycin-polymyxin-hc ophthalmic (eye)

dropssuspension 35-10000-10 mg-unit-

neomycin-polymyxin-hc otic (ear)

dropssuspension 35-10000-1 mgml-

unitml-

neomycin-polymyxin-hc otic (ear) solution

35-10000-1 mgml-unitml-

neo-polycin hc ophthalmic (eye) ointment

35-400-10000 mg-unitg-1

neo-polycin ophthalmic (eye) ointment

35-400-10000 mg-unit-unitg

ofloxacin ophthalmic (eye) drops 03 (Ocuflox) 2

ofloxacin otic (ear) drops 03 2

polycin ophthalmic (eye) ointment 500-

10000 unitgram

polymyxin b sulf-trimethoprim ophthalmic

(eye) drops 10000 unit- 1 mgml

(Polytrim) 1

sulfacetamide sodium ophthalmic (eye)

drops 10

(Bleph-10) 2

ointment 10

sulfacetamide-prednisolone ophthalmic

(eye) drops 10 -023 (025 )

Drug Name

tobramycin ophthalmic (eye) drops 03 (Tobrex) 1

tobramycin-dexamethasone ophthalmic

(eye) dropssuspension 03-01

(TobraDex) 2

trifluridine ophthalmic (eye) drops 1 2

ZIRGAN OPHTHALMIC (EYE) GEL

ZYLET OPHTHALMIC (EYE)

Eye Ear Nose Throat Anti-

Inflammatory Agents

ALREX OPHTHALMIC (EYE)

DROPSSUSPENSION 02

BROMSITE OPHTHALMIC (EYE)

DROPS 0075

dexamethasone sodium phosphate

ophthalmic (eye) drops 01

diclofenac sodium ophthalmic (eye) drops

DUREZOL OPHTHALMIC (EYE)

DROPS 005

flunisolide nasal spraynon-aerosol 25

mcg (0025 )

fluorometholone ophthalmic (eye)

dropssuspension 01

(FML Liquifilm) 4

flurbiprofen sodium ophthalmic (eye)

drops 003

fluticasone propionate nasal

spraysuspension 50 mcgactuation

(24 Hour Allergy Relief) 1 QL (16 per 30 days)

ILEVRO OPHTHALMIC (EYE)

DROPSSUSPENSION 03

INVELTYS OPHTHALMIC (EYE)

DROPSSUSPENSION 1

ketorolac ophthalmic (eye) drops 05 (Acular) 2

LOTEMAX OPHTHALMIC (EYE)

DROPSGEL 05

OINTMENT 05

LOTEMAX SM OPHTHALMIC (EYE)

DROPSGEL 038

prednisolone acetate ophthalmic (eye)

dropssuspension 1

(Pred Forte) 4

prednisolone sodium phosphate

Drug Name

PROLENSA OPHTHALMIC (EYE)

DROPS 007

RESTASIS OPHTHALMIC (EYE)

DROPPERETTE 005

XIIDRA OPHTHALMIC (EYE)

DROPPERETTE 5

Gastrointestinal Agents

Antiulcer Agents And Acid Suppressants

cimetidine hcl oral solution 300 mg5 ml 2

esomeprazole sodium intravenous recon

soln 20 mg

soln 40 mg

(Nexium IV) 2

famotidine (pf) intravenous solution 20

mg2 ml

famotidine (pf)-nacl (iso-os) intravenous

famotidine intravenous solution 10 mgml 2

famotidine oral tablet 20 mg (Acid Controller) 1

famotidine oral tablet 40 mg (Pepcid) 1

lansoprazole oral capsuledelayed

release(drec) 15 mg

(Heartburn Treatment 24

release(drec) 30 mg

(Prevacid) 2 QL (60 per 30 days)

misoprostol oral tablet 100 mcg 200 mcg (Cytotec) 2

nizatidine oral capsule 150 mg 300 mg 2

omeprazole oral capsuledelayed

omeprazole-sodium bicarbonate oral

capsule 20-11 mg-gram 40-11 mg-gram

(OmePPi) 2 ST QL (30 per 30 days)

pantoprazole intravenous recon soln 40

(Protonix) 2

pantoprazole oral tabletdelayed release

(drec) 20 mg

(Protonix) 1 QL (30 per 30 days)

(drec) 40 mg

ranitidine hcl injection solution 25 mgml

50 mg2 ml (25 mgml)

(Zantac) 2

ranitidine hcl oral syrup 15 mgml 2

ranitidine hcl oral tablet 150 mg (Acid Control

(ranitidine))

ranitidine hcl oral tablet 300 mg (Zantac) 1

Drug Name

sucralfate oral tablet 1 gram (Carafate) 2

Gastrointestinal Agents Other

AMITIZA ORAL CAPSULE 24 MCG 8

CARBAGLU ORAL TABLET

DISPERSIBLE 200 MG

constulose oral solution 10 gram15 ml 2

cromolyn oral concentrate 100 mg5 ml (Gastrocrom) 2

dicyclomine oral capsule 10 mg 2

dicyclomine oral solution 10 mg5 ml 2

dicyclomine oral tablet 20 mg 2

diphenoxylate-atropine oral liquid 25-

0025 mg5 ml

Years)

diphenoxylate-atropine oral tablet 25-

0025 mg

(Lomotil) 2 PA-HRM AGE (Max 64

Years)

enulose oral solution 10 gram15 ml 2

GATTEX 30-VIAL SUBCUTANEOUS

KIT 5 MG

5 PA NDS

generlac oral solution 10 gram15 ml 2

glycopyrrolate injection solution 02

glycopyrrolate oral tablet 1 mg 2 mg 2

kionex (with sorbitol) oral suspension 15-

193 gram60 ml

lactulose oral solution 10 gram15 ml (Constulose) 2

LINZESS ORAL CAPSULE 145 MCG

290 MCG 72 MCG

LOKELMA ORAL POWDER IN

PACKET 10 GRAM 5 GRAM

loperamide oral capsule 2 mg (Anti-Diarrheal

(loperamide))

methscopolamine oral tablet 25 mg 5 mg 2

metoclopramide hcl injection solution 5

metoclopramide hcl injection syringe 5

metoclopramide hcl oral solution 5 mg5

metoclopramide hcl oral tablet 10 mg 5

(Reglan) 1

MOVANTIK ORAL TABLET 125 MG

Drug Name

OCALIVA ORAL TABLET 10 MG 5

RAVICTI ORAL LIQUID 11 GRAMML 5 PA NDS

RELISTOR ORAL TABLET 150 MG 5 PA NDS QL (90 per 30

RELISTOR SUBCUTANEOUS

SOLUTION 12 MG06 ML

28 days)

SYRINGE 12 MG06 ML

28 days)

SYRINGE 8 MG04 ML

28 days)

sodium phenylbutyrate oral tablet 500 mg (Buphenyl) 5 NDS

sodium polystyrene sulfonate oral powder 2

sodium polystyrene sulfonate oral

suspension 15 gram60 ml

sps (with sorbitol) oral suspension 15-20

gram60 ml

ursodiol oral capsule 300 mg (Actigall) 2

ursodiol oral tablet 250 mg (URSO 250) 2

ursodiol oral tablet 500 mg (URSO Forte) 2

VELTASSA ORAL POWDER IN

PACKET 168 GRAM 252 GRAM 84

VIBERZI ORAL TABLET 100 MG 75

XERMELO ORAL TABLET 250 MG 5 PA NDS QL (90 per 30

Laxatives

CLENPIQ ORAL SOLUTION 10 MG-35

GRAM -12 GRAM160 ML

gavilyte-c oral recon soln 240-2272-672

-584 gram

gavilyte-g oral recon soln 236-2274-674

-586 gram

gavilyte-n oral recon soln 420 gram 2

peg 3350-electrolytes oral recon soln 240-

2272-672 -584 gram

(Colyte with Flavor

Packs)

SUPREP BOWEL PREP KIT ORAL

RECON SOLN 175-313-16 GRAM

trilyte with flavor packets oral recon soln

420 gram

Phosphate Binders

calcium acetate oral capsule 667 mg 2

Drug Name

calcium acetate oral tablet 667 mg (Calphron) 2

PHOSLYRA ORAL SOLUTION 667 MG

(169 MG CALCIUM)5 ML

sevelamer carbonate oral powder in

packet 08 gram 24 gram

(Renvela) 5 NDS

sevelamer carbonate oral tablet 800 mg (Renvela) 2

sevelamer hcl oral tablet 400 mg 2

sevelamer hcl oral tablet 800 mg (Renagel) 2

VELPHORO ORAL

TABLETCHEWABLE 500 MG

Genitourinary Agents

Antispasmodics Urinary

bethanechol chloride oral tablet 10 mg 25

mg 5 mg 50 mg

(Urecholine) 2

MYRBETRIQ ORAL TABLET

oxybutynin chloride oral syrup 5 mg5 ml 2

oxybutynin chloride oral tablet 5 mg 2

oxybutynin chloride oral tablet extended

release 24hr 10 mg 5 mg

(Ditropan XL) 2

release 24hr 15 mg

tolterodine oral capsuleextended release

24hr 2 mg 4 mg

(Detrol LA) 2

tolterodine oral tablet 1 mg 2 mg (Detrol) 2

TOVIAZ ORAL TABLET EXTENDED

RELEASE 24 HR 4 MG 8 MG

Genitourinary Agents Miscellaneous

alfuzosin oral tablet extended release 24

hr 10 mg

(Uroxatral) 1

dutasteride oral capsule 05 mg (Avodart) 2

finasteride oral tablet 5 mg (Proscar) 1

PROCYSBI ORAL CAPSULE

DELAYED REL SPRINKLE 25 MG 75

tamsulosin oral capsule 04 mg (Flomax) 1

terazosin oral capsule 1 mg 10 mg 2 mg

THIOLA EC ORAL

TABLETDELAYED RELEASE

(DREC) 100 MG 300 MG

5 PA NDS

Drug Name

THIOLA ORAL TABLET 100 MG 5 NDS

Heavy Metal Antagonists

deferasirox oral tablet dispersible 125

mg 250 mg 500 mg

(Exjade) 5 PA NDS

deferoxamine injection recon soln 2 gram

500 mg

(Desferal) 2 PA

DEPEN TITRATABS ORAL TABLET

250 MG

5 PA NDS

FERRIPROX ORAL SOLUTION 100

5 PA NDS

FERRIPROX ORAL TABLET 500 MG 5 PA NDS

JADENU ORAL TABLET 180 MG 360

MG 90 MG

5 PA NDS

JADENU SPRINKLE ORAL

GRANULES IN PACKET 180 MG 360

MG 90 MG

5 PA NDS

penicillamine oral capsule 250 mg (Cuprimine) 5 PA NDS

trientine oral capsule 250 mg (Syprine) 5 PA NDS QL (240 per

30 days)

Hormonal Agents

StimulantReplacementModifying

Androgens

ANADROL-50 ORAL TABLET 50 MG 5 PA NDS

danazol oral capsule 100 mg 200 mg 50

testosterone cypionate intramuscular oil

100 mgml 200 mgml

(Depo-Testosterone) 2 PA

200 mgml (1 ml)

testosterone enanthate intramuscular oil

200 mgml

testosterone transdermal gel in packet 1

(25 mg25gram) 1 (50 mg5 gram)

(AndroGel) 2 PA QL (300 per 30

XYOSTED SUBCUTANEOUS AUTO-

ML 75 MG05 ML

Estrogens And Antiestrogens

amabelz oral tablet 05-01 mg 1-05 mg 2 PA-HRM AGE (Max 64

Years)

Drug Name

dotti transdermal patch semiweekly 0025

mg24 hr 00375 mg24 hr 005 mg24 hr

0075 mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

DUAVEE ORAL TABLET 045-20 MG 3 PA-HRM AGE (Max 64

Years)

estradiol oral tablet 05 mg 1 mg 2 mg (Estrace) 1 PA-HRM AGE (Max 64

Years)

estradiol transdermal patch semiweekly

0025 mg24 hr 005 mg24 hr 0075

mg24 hr 01 mg24 hr

(Alora) 2 PA-HRM QL (8 per 28

days) AGE (Max 64

Years)

00375 mg24 hr

(Dotti) 2 PA-HRM QL (8 per 28

days) AGE (Max 64

Years)

estradiol transdermal patch weekly 0025

mg24 hr 00375 mg24 hr 005 mg24 hr

006 mg24 hr 0075 mg24 hr 01 mg24

(Climara) 2 PA-HRM QL (4 per 28

days) AGE (Max 64

Years)

estradiol vaginal tablet 10 mcg (Vagifem) 2 QL (18 per 28 days)

estradiol valerate intramuscular oil 20

mgml 40 mgml

(Delestrogen) 2

estradiol-norethindrone acet oral tablet

05-01 mg

(Activella) 2 PA-HRM AGE (Max 64

Years)

FEMRING VAGINAL RING 005 MG24

HR 01 MG24 HR

fyavolv oral tablet 05-25 mg-mcg 1-5

mg-mcg

Years)

jinteli oral tablet 1-5 mg-mcg 2 PA-HRM AGE (Max 64

Years)

mimvey lo oral tablet 05-01 mg 2 PA-HRM AGE (Max 64

Years)

mimvey oral tablet 1-05 mg 2 PA-HRM AGE (Max 64

Years)

05-25 mg-mcg

(Femhrt Low Dose) 2 PA-HRM AGE (Max 64

Years)

1-5 mg-mcg

(Fyavolv) 2 PA-HRM AGE (Max 64

Years)

PREMARIN INJECTION RECON SOLN

PREMARIN ORAL TABLET 03 MG

045 MG 0625 MG 09 MG 125 MG

Years)

PREMARIN VAGINAL CREAM 0625

MGGRAM

Drug Name

PREMPHASE ORAL TABLET 0625

MG (14) 0625MG-5MG(14)

Years)

PREMPRO ORAL TABLET 03-15 MG

045-15 MG 0625-25 MG 0625-5 MG

Years)

raloxifene oral tablet 60 mg (Evista) 2

GlucocorticoidsMineralocorticoids

a-hydrocort injection recon soln 100 mg 2

betamethasone acetsod phos injection

suspension 6 mgml

(Celestone Soluspan) 2

cortisone oral tablet 25 mg 2

decadron oral elixir 05 mg5 ml 2 PA BvD

dexamethasone oral elixir 05 mg5 ml (Decadron) 2 PA BvD

dexamethasone oral tablet 05 mg 075

mg 4 mg 6 mg

(Decadron) 1 PA BvD

dexamethasone oral tablet 1 mg 15 mg 2

1 PA BvD

dexamethasone sodium phos (pf) injection

solution 10 mgml

injection solution 10 mgml 4 mgml

injection syringe 4 mgml

EMFLAZA ORAL SUSPENSION 2275

EMFLAZA ORAL TABLET 18 MG 5 PA NDS QL (30 per 30

EMFLAZA ORAL TABLET 30 MG 36

MG 6 MG

fludrocortisone oral tablet 01 mg 2

hydrocortisone oral tablet 10 mg 20 mg 5

(Cortef) 2

methylprednisolone acetate injection

suspension 40 mgml 80 mgml

(Depo-Medrol) 2

methylprednisolone oral tablet 16 mg 32

mg 4 mg 8 mg

(Medrol) 2

methylprednisolone oral tabletsdose pack

(Medrol (Pak)) 2

methylprednisolone sodium succ injection

recon soln 125 mg 40 mg

methylprednisolone sodium succ

intravenous recon soln 1000 mg

(Solu-Medrol) 2

prednisolone 15 mg5 ml soln af df 15

mg5 ml (3 mgml)

2 PA BvD

Drug Name

prednisolone oral solution 15 mg5 ml 2 PA BvD

prednisolone sodium phosphate oral

solution 25 mg5 ml (5 mgml) 5 mg

base5 ml (67 mg5 ml)

2 PA BvD

prednisone oral solution 5 mg5 ml 2 PA BvD

prednisone oral tablet 1 mg 25 mg 5 mg

1 PA BvD

prednisone oral tablet 10 mg 1 PA BvD

prednisone oral tablet 20 mg (Deltasone) 1 PA BvD

prednisone oral tabletsdose pack 10 mg

10 mg (48 pack) 5 mg 5 mg (48 pack)

SOLU-CORTEF (PF) INJECTION

RECON SOLN 100 MG2 ML

triamcinolone acetonide injection

suspension 40 mgml

(Kenalog) 2

Pituitary

desmopressin 10 mcg01 ml spr 10

mcgspray (01 ml)

(DDAVP) 2

desmopressin injection solution 4 mcgml (DDAVP) 2

desmopressin nasal spraynon-aerosol 10

mcgspray (01 ml)

desmopressin oral tablet 01 mg 02 mg (DDAVP) 2

EGRIFTA SUBCUTANEOUS RECON

SOLN 1 MG

GENOTROPIN MINIQUICK

MG025 ML

MG025 ML 06 MG025 ML 08

MG025 ML 1 MG025 ML 12

MG025 ML 14 MG025 ML 16

MG025 ML 18 MG025 ML 2

MG025 ML

5 PA NDS

GENOTROPIN SUBCUTANEOUS

CARTRIDGE 12 MGML (36 UNITML)

5 MGML (15 UNITML)

5 PA NDS

HUMATROPE INJECTION

CARTRIDGE 12 MG (36 UNIT) 24 MG

(72 UNIT) 6 MG (18 UNIT)

5 PA NDS

HUMATROPE INJECTION RECON

SOLN 5 (15 UNIT) MG

5 PA NDS

Drug Name

INCRELEX SUBCUTANEOUS

SOLUTION 10 MGML

INTRAMUSCULAR SYRINGE KIT

1125 MG

SYRINGE KIT 75 MG

LUPRON DEPOT-PED (3 MONTH)

LUPRON DEPOT-PED

INTRAMUSCULAR KIT 1125 MG 15

NOCDURNA (MEN) SUBLINGUAL

TABLETDISINTEGRATING 553 MCG

NOCDURNA (WOMEN) SUBLINGUAL

NORDITROPIN FLEXPRO

MG15 ML (67 MGML) 15 MG15

ML (10 MGML) 30 MG3 ML (10

5 PA NDS

NORDITROPIN FLEXPRO

MG15 ML (33 MGML)

NUTROPIN AQ NUSPIN

MG2 ML (5 MGML) 20 MG2 ML (10

5 PA NDS

octreotide acetate injection solution 1000

mcgml 200 mcgml

mcgml 50 mcgml 500 mcgml

(Sandostatin) 2

octreotide acetate injection syringe 100

mcgml (1 ml) 50 mcgml (1 ml) 500

mcgml (1 ml)

OMNITROPE SUBCUTANEOUS

CARTRIDGE 10 MG15 ML (67

5 PA NDS

RECON SOLN 58 MG

5 PA NDS

ORILISSA ORAL TABLET 150 MG 5 PA NDS QL (28 per 28

Drug Name

SAIZEN SAIZENPREP

MG151 ML (FINAL CONC)

5 PA NDS

SAIZEN SUBCUTANEOUS RECON

SOLN 5 MG 88 MG

5 PA NDS

SANDOSTATIN LAR DEPOT

INTRAMUSCULAR

RECON 10 MG 20 MG 30 MG

SEROSTIM SUBCUTANEOUS RECON

SOLN 4 MG 5 MG 6 MG

5 PA NDS

SIGNIFOR SUBCUTANEOUS

SOLUTION 03 MGML (1 ML) 06

MGML (1 ML) 09 MGML (1 ML)

SOMATULINE DEPOT

MG05 ML

5 PA NSO NDS QL (1

per 28 days)

SOMATULINE DEPOT

ML 90 MG03 ML

SOMAVERT SUBCUTANEOUS

RECON SOLN 10 MG 15 MG 20 MG

25 MG 30 MG

5 PA NDS

SUPPRELIN LA IMPLANT KIT 50 MG

(65 MCGDAY)

5 NDS QL (1 per 360

SYNAREL NASAL SPRAYNON-

AEROSOL 2 MGML

TRIPTODUR INTRAMUSCULAR

225 MG

5 NDS QL (1 per 168

ZOMACTON SUBCUTANEOUS

RECON SOLN 10 MG

5 PA NDS

RECON SOLN 5 MG

ZORBTIVE SUBCUTANEOUS RECON

SOLN 88 MG

5 PA NDS

Progestins

DEPO-PROVERA INTRAMUSCULAR

SUSPENSION 400 MGML

hydroxyprogesterone caproate

intramuscular oil 250 mgml

5 PA NSO NDS

Drug Name

medroxyprogesterone intramuscular

suspension 150 mgml

(Depo-Provera) 2 QL (1 per 84 days)

syringe 150 mgml

medroxyprogesterone oral tablet 10 mg

25 mg 5 mg

(Provera) 1

megestrol oral suspension 400 mg10 ml

(40 mgml)

Years)

norethindrone acetate oral tablet 5 mg (Aygestin) 2

progesterone intramuscular oil 50 mgml 2

progesterone micronized oral capsule 100

mg 200 mg

(Prometrium) 2

Thyroid And Antithyroid Agents

levothyroxine oral tablet 100 mcg 112

mcg 125 mcg 137 mcg 150 mcg 175

mcg 200 mcg 25 mcg 50 mcg 75 mcg

88 mcg

(Euthyrox) 1

levothyroxine oral tablet 300 mcg (Levo-T) 1

liothyronine oral tablet 25 mcg 5 mcg 50

(Cytomel) 2

methimazole oral tablet 10 mg 5 mg (Tapazole) 1

propylthiouracil oral tablet 50 mg 2

Immunological Agents

ACTEMRA ACTPEN

MG09 ML

5 PA NDS

ACTEMRA INTRAVENOUS

80 MG4 ML (20 MGML)

5 PA NDS

ACTEMRA SUBCUTANEOUS

SYRINGE 162 MG09 ML

5 PA NDS

ARCALYST SUBCUTANEOUS RECON

SOLN 220 MG

azathioprine oral tablet 50 mg (Imuran) 2 PA BvD

azathioprine sodium injection recon soln

100 mg

2 PA BvD

CIMZIA POWDER FOR RECONST

SUBCUTANEOUS KIT 400 MG (200

MG X 2 VIALS)

5 PA NDS

CIMZIA SUBCUTANEOUS SYRINGE

KIT 400 MG2 ML (200 MGML X 2)

5 PA NDS

Drug Name

COSENTYX (2 SYRINGES)

5 PA NDS

COSENTYX PEN (2 PENS)

5 PA NDS

cyclosporine intravenous solution 250

mg5 ml

(Sandimmune) 2 PA BvD

cyclosporine modified oral capsule 100

mg 25 mg

(Gengraf) 2 PA BvD

cyclosporine modified oral capsule 50 mg 2 PA BvD

cyclosporine modified oral solution 100

(Gengraf) 2 PA BvD

cyclosporine oral capsule 100 mg 25 mg (Sandimmune) 2 PA BvD

DUPIXENT SUBCUTANEOUS

5 PA NDS

ENBREL SUBCUTANEOUS RECON

SOLN 25 MG (1 ML)

5 PA NDS

ENBREL SUBCUTANEOUS SYRINGE

25 MG05 ML (05) 50 MGML (1 ML)

5 PA NDS

ENBREL SURECLICK

MGML (1 ML)

5 PA NDS

FLEBOGAMMA DIF INTRAVENOUS

SOLUTION 10 5

5 PA BvD NDS

GAMASTAN INTRAMUSCULAR

SOLUTION 15-18 RANGE

4 PA BvD

GAMMAGARD LIQUID INJECTION

SOLUTION 10

5 PA BvD NDS

GAMMAGARD S-D (IGA lt 1 MCGML)

INTRAVENOUS RECON SOLN 10

GRAM 5 GRAM

5 PA BvD NDS

GAMMAPLEX (WITH SORBITOL)

INTRAVENOUS SOLUTION 5

5 PA BvD NDS

GAMMAPLEX INTRAVENOUS

SOLUTION 10 10 (100 ML) 10

(200 ML)

5 PA BvD NDS

gengraf oral capsule 100 mg 25 mg 2 PA BvD

gengraf oral solution 100 mgml 2 PA BvD

Drug Name

HUMIRA PEDIATRIC CROHNS

START SUBCUTANEOUS SYRINGE

KIT 40 MG08 ML 40 MG08 ML (6

5 PA NDS

HUMIRA PEN CROHNS-UC-HS

START SUBCUTANEOUS PEN

INJECTOR KIT 40 MG08 ML

5 PA NDS

HUMIRA PEN PSOR-UVEITS-ADOL

HS SUBCUTANEOUS PEN INJECTOR

KIT 40 MG08 ML

5 PA NDS

HUMIRA PEN SUBCUTANEOUS PEN

5 PA NDS

HUMIRA SUBCUTANEOUS SYRINGE

KIT 10 MG02 ML 20 MG04 ML 40

MG08 ML

5 PA NDS

HUMIRA(CF) PEDI CROHNS

STARTER SUBCUTANEOUS

SYRINGE KIT 80 MG08 ML 80

MG08 ML-40 MG04 ML

5 PA NDS

HUMIRA(CF) PEN CROHNS-UC-HS

SUBCUTANEOUS PEN INJECTOR KIT

80 MG08 ML

5 PA NDS

HUMIRA(CF) PEN PSOR-UV-ADOL

KIT 80 MG08 ML-40 MG04 ML

5 PA NDS

HUMIRA(CF) PEN SUBCUTANEOUS

PEN INJECTOR KIT 40 MG04 ML

5 PA NDS

HUMIRA(CF) SUBCUTANEOUS

MG02 ML 40 MG04 ML

5 PA NDS

HYPERRAB (PF) INTRAMUSCULAR

SOLUTION 300 UNITML

HYPERRAB SD (PF)

INTRAMUSCULAR SOLUTION 150

UNITML

HYQVIA SUBCUTANEOUS

SOLUTION 10 GRAM 100 ML (10 )

25 GRAM 25 ML (10 ) 20 GRAM

200 ML (10 ) 30 GRAM 300 ML (10

) 5 GRAM 50 ML (10 )

5 PA BvD NDS

ILARIS (PF) SUBCUTANEOUS RECON

SOLN 150 MGML

5 PA NDS

ILARIS (PF) SUBCUTANEOUS

SOLUTION 150 MGML

5 PA NDS

Drug Name

ILUMYA SUBCUTANEOUS SYRINGE

100 MGML

5 PA NDS

IMOGAM RABIES-HT (PF)

UNITML

INFLECTRA INTRAVENOUS RECON

SOLN 100 MG

5 PA NDS

KEDRAB (PF) INTRAMUSCULAR

SOLUTION 150 UNITML

KEVZARA SUBCUTANEOUS PEN

INJECTOR 150 MG114 ML 200

MG114 ML

5 PA NDS

KEVZARA SUBCUTANEOUS

SYRINGE 150 MG114 ML 200

MG114 ML

5 PA NDS

KINERET SUBCUTANEOUS SYRINGE

100 MG067 ML

5 PA NDS

leflunomide oral tablet 10 mg 20 mg (Arava) 2

mycophenolate mofetil hcl intravenous

recon soln 500 mg

(CellCept Intravenous) 2 PA BvD

mycophenolate mofetil oral capsule 250

(CellCept) 2 PA BvD

mycophenolate mofetil oral suspension for

(CellCept) 5 PA BvD NDS

mycophenolate mofetil oral tablet 500 mg (CellCept) 2 PA BvD

NULOJIX INTRAVENOUS RECON

SOLN 250 MG

5 PA BvD NDS

OCTAGAM INTRAVENOUS

SOLUTION 10 5

5 PA BvD NDS

OLUMIANT ORAL TABLET 2 MG 5 PA NDS

ORENCIA (WITH MALTOSE)

5 PA NDS

ORENCIA CLICKJECT

125 MGML

5 PA NDS

ORENCIA SUBCUTANEOUS

SYRINGE 125 MGML 50 MG04 ML

875 MG07 ML

5 PA NDS

OTEZLA ORAL TABLET 30 MG 5 PA NDS

OTEZLA STARTER ORAL

TABLETSDOSE PACK 10 MG (4)-20

MG (4)-30 MG (47) 10 MG (4)-20 MG

(4)-30 MG(19)

5 PA NDS

Drug Name

PRIVIGEN INTRAVENOUS

SOLUTION 10

5 PA BvD NDS

PROGRAF INTRAVENOUS SOLUTION

5 MGML

4 PA BvD

PROGRAF ORAL GRANULES IN

PACKET 02 MG 1 MG

4 PA BvD ST

RASUVO (PF) SUBCUTANEOUS

AUTO-INJECTOR 10 MG02 ML 125

MG025 ML 15 MG03 ML 175

MG035 ML 20 MG04 ML 225

MG045 ML 25 MG05 ML 30 MG06

ML 75 MG015 ML

REMICADE INTRAVENOUS RECON

SOLN 100 MG

5 PA NDS

RENFLEXIS INTRAVENOUS RECON

SOLN 100 MG

5 PA NDS

RIDAURA ORAL CAPSULE 3 MG 5 NDS

SILIQ SUBCUTANEOUS SYRINGE 210

MG15 ML

5 PA NDS

SIMPONI ARIA INTRAVENOUS

SOLUTION 125 MGML

5 PA NDS

SIMPONI SUBCUTANEOUS PEN

INJECTOR 100 MGML 50 MG05 ML

5 PA NDS

SIMPONI SUBCUTANEOUS SYRINGE

100 MGML 50 MG05 ML

5 PA NDS

sirolimus oral solution 1 mgml (Rapamune) 5 PA BvD NDS

sirolimus oral tablet 05 mg 1 mg (Rapamune) 2 PA BvD

sirolimus oral tablet 2 mg (Rapamune) 5 PA BvD NDS

SKYRIZI SUBCUTANEOUS SYRINGE

KIT 150MG166ML(75 MG083 ML

5 PA NDS

STELARA INTRAVENOUS SOLUTION

130 MG26 ML

5 PA NDS

STELARA SUBCUTANEOUS

SOLUTION 45 MG05 ML

5 PA NDS

SYRINGE 45 MG05 ML 90 MGML

5 PA NDS

tacrolimus oral capsule 05 mg 1 mg 5

(Prograf) 2 PA BvD

TALTZ AUTOINJECTOR

80 MGML

5 PA NDS

Drug Name

TALTZ SYRINGE SUBCUTANEOUS

SYRINGE 80 MGML

5 PA NDS

TICE BCG INTRAVESICAL

TREMFYA SUBCUTANEOUS AUTO-

INJECTOR 100 MGML

5 PA NDS

TREMFYA SUBCUTANEOUS

SYRINGE 100 MGML

5 PA NDS

TYSABRI INTRAVENOUS SOLUTION

300 MG15 ML

5 PA LA NDS

XELJANZ ORAL TABLET 10 MG 5

5 PA NDS

XELJANZ XR ORAL TABLET

5 PA NDS

ZORTRESS ORAL TABLET 025 MG

05 MG 075 MG 1 MG

5 PA BvD NDS

Vaccines

ACTHIB (PF) INTRAMUSCULAR

RECON SOLN 10 MCG05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

INTRAMUSCULAR SUSPENSION 2

LF-(25-5-3-5 MCG)-5LF05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

INTRAMUSCULAR SYRINGE 2 LF-

(25-5-3-5 MCG)-5LF05 ML

BCG VACCINE LIVE (PF)

PERCUTANEOUS SUSPENSION FOR

3 PA BvD

BEXSERO INTRAMUSCULAR

SYRINGE 50-50-50-25 MCG05 ML

BOOSTRIX TDAP INTRAMUSCULAR

SUSPENSION 25-8-5 LF-MCG-

LF05ML

SYRINGE 25-8-5 LF-MCG-LF05ML

DAPTACEL (DTAP PEDIATRIC) (PF)

INTRAMUSCULAR SUSPENSION 15-

10-5 LF-MCG-LF05ML

ENGERIX-B (PF) INTRAMUSCULAR

SUSPENSION 20 MCGML

3 PA BvD

Drug Name

SYRINGE 20 MCGML

3 PA BvD

ENGERIX-B PEDIATRIC (PF)

MCG05 ML

3 PA BvD

GARDASIL 9 (PF) INTRAMUSCULAR

SUSPENSION 05 ML

SYRINGE 05 ML

HAVRIX (PF) INTRAMUSCULAR

SUSPENSION 1440 ELISA UNITML

720 ELISA UNIT05 ML

SYRINGE 1440 ELISA UNITML 720

ELISA UNIT05 ML

HIBERIX (PF) INTRAMUSCULAR

IMOVAX RABIES VACCINE (PF)

INTRAMUSCULAR RECON SOLN 25

3 PA BvD

INFANRIX (DTAP) (PF)

58-10 LF-MCG-LF05ML

INTRAMUSCULAR SYRINGE 25-58-10

LF-MCG-LF05ML

IPOL INJECTION SUSPENSION 40-8-

32 UNIT05 ML

IPOL INJECTION SYRINGE 40-8-32

UNIT05 ML

IXIARO (PF) INTRAMUSCULAR

SYRINGE 6 MCG05 ML

KINRIX (PF) INTRAMUSCULAR

SUSPENSION 25 LF-58 MCG-10 LF05

SYRINGE 25 LF-58 MCG-10 LF05 ML

MENACTRA (PF) INTRAMUSCULAR

SOLUTION 4 MCG05 ML

MENVEO A-C-Y-W-135-DIP (PF)

INTRAMUSCULAR KIT 10-5 MCG05

Drug Name

M-M-R II (PF) SUBCUTANEOUS

RECON SOLN 1000-12500 TCID5005

PEDIARIX (PF) INTRAMUSCULAR

SYRINGE 10 MCG-25LF-25 MCG-

10LF05 ML

PEDVAX HIB (PF) INTRAMUSCULAR

SOLUTION 75 MCG05 ML

PENTACEL (PF) INTRAMUSCULAR

KIT 15 LF UNIT-20 MCG-5 LF05 ML

PROQUAD (PF) SUBCUTANEOUS

10EXP3-43-3- 399 TCID5005

QUADRACEL (PF) INTRAMUSCULAR

SUSPENSION 15 LF-48 MCG- 5 LF

UNIT05ML

RABAVERT (PF) INTRAMUSCULAR

25 UNIT

3 PA BvD

RECOMBIVAX HB (PF)

MCGML 40 MCGML 5 MCG05 ML

3 PA BvD

RECOMBIVAX HB (PF)

MCGML 5 MCG05 ML

3 PA BvD

ROTARIX ORAL SUSPENSION FOR

RECONSTITUTION 10EXP6

CCID50ML

ROTATEQ VACCINE ORAL

SOLUTION 2 ML

SHINGRIX (PF) INTRAMUSCULAR

50 MCG05 ML

TDVAX INTRAMUSCULAR

SUSPENSION 2-2 LF UNIT05 ML

TENIVAC (PF) INTRAMUSCULAR

SUSPENSION 5 LF UNIT- 2 LF

UNIT05ML

SYRINGE 5-2 LF UNIT05 ML

TETANUSDIPHTHERIA TOX PED(PF)

INTRAMUSCULAR SUSPENSION 5-25

LF UNIT05 ML

Drug Name

TRUMENBA INTRAMUSCULAR

TWINRIX (PF) INTRAMUSCULAR

SYRINGE 720 ELISA UNIT- 20

TYPHIM VI INTRAMUSCULAR

SYRINGE 25 MCG05 ML

VAQTA (PF) INTRAMUSCULAR

SUSPENSION 25 UNIT05 ML 50

UNITML

SYRINGE 25 UNIT05 ML 50

UNITML

VARIVAX (PF) SUBCUTANEOUS

1350 UNIT05 ML

YF-VAX (PF) SUBCUTANEOUS

10 EXP474 UNIT05 ML

ZOSTAVAX (PF) SUBCUTANEOUS

19400 UNIT065 ML

Inflammatory Bowel Disease

Agents

Inflammatory Bowel Disease Agents

alosetron oral tablet 05 mg 1 mg (Lotronex) 5 NDS

APRISO ORAL CAPSULEEXTENDED

RELEASE 24HR 0375 GRAM

balsalazide oral capsule 750 mg (Colazal) 2

budesonide oral

capsuledelayedextendrelease 3 mg

(Entocort EC) 2

colocort rectal enema 100 mg60 ml 2

DIPENTUM ORAL CAPSULE 250 MG 5 ST NDS

hydrocortisone rectal enema 100 mg60 ml (Cortenema) 4

LIALDA ORAL TABLETDELAYED

RELEASE (DREC) 12 GRAM

mesalamine oral capsule (with del rel

tablets) 400 mg

(Delzicol) 2

mesalamine oral tabletdelayed release

(drec) 800 mg

(Asacol HD) 2

mesalamine rectal suppository 1000 mg (Canasa) 5 NDS

Drug Name

sulfasalazine oral tablet 500 mg (Azulfidine) 2

sulfasalazine oral tabletdelayed release

(drec) 500 mg

(Azulfidine EN-tabs) 2

UCERIS RECTAL FOAM 2

MGACTUATION

Irrigating Solutions

acetic acid irrigation solution 025 4

LACTATED RINGERS IRRIGATION

SOLUTION

sodium chloride irrigation solution 09 (Aqua Care Sodium

Chloride)

water for irrigation sterile irrigation

solution

(Aqua Care Sterile

Water)

Metabolic Bone Disease Agents

alendronate oral tablet 10 mg 5 mg 1

alendronate oral tablet 35 mg 1 QL (4 per 28 days)

alendronate oral tablet 70 mg (Fosamax) 1 QL (4 per 28 days)

calcitonin (salmon) nasal spraynon-

aerosol 200 unitactuation

calcitriol intravenous solution 1 mcgml 2

calcitriol oral capsule 025 mcg 05 mcg (Rocaltrol) 2

calcitriol oral solution 1 mcgml (Rocaltrol) 2

cinacalcet oral tablet 30 mg 60 mg (Sensipar) 5 NDS QL (60 per 30

cinacalcet oral tablet 90 mg (Sensipar) 5 NDS QL (120 per 30

doxercalciferol intravenous solution 4

mcg2 ml

(Hectorol) 2

EVENITY 105 MG117 ML SYRINGE

105 MG117 ML

30 days)

EVENITY SUBCUTANEOUS SYRINGE

210MG234ML ( 105MG117MLX2)

30 days)

FORTEO SUBCUTANEOUS PEN

INJECTOR 20 MCGDOSE - 600

MCG24 ML

ibandronate intravenous solution 3 mg3

ibandronate intravenous syringe 3 mg3

(Boniva) 2 QL (3 per 84 days)

ibandronate oral tablet 150 mg (Boniva) 2 QL (1 per 28 days)

Drug Name

MIACALCIN INJECTION SOLUTION

200 UNITML

NATPARA SUBCUTANEOUS

CARTRIDGE 100 MCGDOSE 25

MCGDOSE 50 MCGDOSE 75

MCGDOSE

paricalcitol hemodialysis port injection

solution 2 mcgml

PARICALCITOL HEMODIALYSIS

PORT INJECTION SOLUTION 5

paricalcitol oral capsule 1 mcg 2 mcg (Zemplar) 2

paricalcitol oral capsule 4 mcg 2

PROLIA SUBCUTANEOUS SYRINGE

60 MGML

RAYALDEE ORAL

HR 30 MCG

TYMLOS SUBCUTANEOUS PEN

INJECTOR 80 MCG (3120 MCG156

3 PA QL (156 per 30

zoledronic acid intravenous recon soln 4

zoledronic acid intravenous solution 4

mg5 ml

zoledronic acid-mannitol-water

intravenous piggyback 5 mg100 ml

(Reclast) 2 QL (100 per 300 days)

Miscellaneous Therapeutic Agents

ACTIMMUNE SUBCUTANEOUS

amifostine crystalline intravenous recon

soln 500 mg

(Ethyol) 2

BENLYSTA INTRAVENOUS RECON

SOLN 120 MG 400 MG

5 PA NDS

BENLYSTA SUBCUTANEOUS AUTO-

INJECTOR 200 MGML

BENLYSTA SUBCUTANEOUS

SYRINGE 200 MGML

CABLIVI INJECTION KIT 11 MG 5 PA NDS QL (30 per 30

CETYLEV ORAL TABLET

EFFERVESCENT 25 GRAM 500 MG

Drug Name

CYSTADANE ORAL POWDER 1

GRAM17 ML

droperidol injection solution 25 mgml 2

ELMIRON ORAL CAPSULE 100 MG 4 QL (90 per 30 days)

ENDARI ORAL POWDER IN PACKET

5 GRAM

30 days)

ergoloid oral tablet 1 mg 2

EXONDYS 51 INTRAVENOUS

SOLUTION 50 MGML

5 PA LA NDS

fomepizole intravenous solution 1 gramml 5 NDS

GLUCAGEN HYPOKIT INJECTION

RECON SOLN 1 MG

guanidine oral tablet 125 mg 4

hydroxyzine pamoate oral capsule 100 mg 1

hydroxyzine pamoate oral capsule 25 mg

(Vistaril) 1

KEVEYIS ORAL TABLET 50 MG 5 PA NDS QL (120 per

30 days)

leucovorin calcium injection recon soln

100 mg 200 mg 350 mg 50 mg 500 mg

leucovorin calcium injection solution 10

leucovorin calcium oral tablet 10 mg 15

mg 25 mg 5 mg

levocarnitine (with sugar) oral solution

100 mgml

(Carnitor) 2

levocarnitine oral tablet 330 mg (Carnitor) 2

LEVOLEUCOVORIN CALCIUM

levoleucovorin calcium intravenous recon

soln 50 mg

(Fusilev) 5 NDS

mesna intravenous solution 100 mgml (Mesnex) 2

MESNEX ORAL TABLET 400 MG 5 NDS

MESTINON ORAL SYRUP 60 MG5

PROGLYCEM ORAL SUSPENSION 50

pyridostigmine bromide oral syrup 60

mg5 ml

(Mestinon) 2

pyridostigmine bromide oral tablet 30 mg 2

pyridostigmine bromide oral tablet 60 mg (Mestinon) 2

Drug Name

RECTIV RECTAL OINTMENT 04

TAKHZYRO SUBCUTANEOUS

THALOMID ORAL CAPSULE 100 MG

150 MG 200 MG 50 MG

5 PA NSO NDS QL (60

per 30 days)

TOTECT INTRAVENOUS RECON

SOLN 500 MG

TYBOST ORAL TABLET 150 MG 4 QL (30 per 30 days)

VISTOGARD ORAL GRANULES IN

PACKET 10 GRAM

5 NDS QL (24 per 14

XURIDEN ORAL GRANULES IN

PACKET 2 GRAM

30 days)

Ophthalmic Agents

Antiglaucoma Agents

acetazolamide oral capsule extended

release 500 mg

acetazolamide oral tablet 125 mg 250 mg 2

acetazolamide sodium injection recon soln

500 mg

ALPHAGAN P OPHTHALMIC (EYE)

DROPS 01

AZOPT OPHTHALMIC (EYE)

DROPSSUSPENSION 1

brimonidine ophthalmic (eye) drops 02 1

carteolol ophthalmic (eye) drops 1 1

COMBIGAN OPHTHALMIC (EYE)

DROPS 02-05

dorzolamide ophthalmic (eye) drops 2 (Trusopt) 2

dorzolamide-timolol ophthalmic (eye)

drops 223-68 mgml

(Cosopt) 2

latanoprost ophthalmic (eye) drops 0005

(Xalatan) 1 QL (25 per 25 days)

levobunolol ophthalmic (eye) drops 05 1

LUMIGAN OPHTHALMIC (EYE)

DROPS 001

metipranolol ophthalmic (eye) drops 03

pilocarpine hcl ophthalmic (eye) drops 1

(Isopto Carpine) 2

RHOPRESSA OPHTHALMIC (EYE)

DROPS 002

Drug Name

SIMBRINZA OPHTHALMIC (EYE)

timolol maleate ophthalmic (eye) drops

025 05

(Timoptic) 1

timolol maleate ophthalmic (eye) gel

forming solution 025 05

(Timoptic-XE) 4

TRAVATAN Z OPHTHALMIC (EYE)

DROPS 0004

Replacement Preparations

calcium chloride intravenous syringe 100

mgml (10 )

IONOSOL-B IN D5W INTRAVENOUS

IONOSOL-MB IN D5W

SOLUTION 5

ISOLYTE-P IN 5 DEXTROSE

SOLUTION 5

ISOLYTE-S INTRAVENOUS

PARENTERAL SOLUTION

klor-con m10 oral tableter

particlescrystals 10 meq

klor-con sprinkle oral capsule extended

release 8 meq

magnesium sulfate in d5w intravenous

piggyback 1 gram100 ml

magnesium sulfate in water intravenous

parenteral solution 20 gram500 ml (4 )

40 gram1000 ml (4 )

2 PA BvD

piggyback 2 gram50 ml (4 ) 4

gram100 ml (4 ) 4 gram50 ml (8 )

2 PA BvD

magnesium sulfate injection solution 4

meqml (50 )

2 PA BvD

magnesium sulfate injection syringe 4

2 PA BvD

Drug Name

NORMOSOL-M IN 5 DEXTROSE

SOLUTION

NORMOSOL-R IV SOLUTION LF

SINGLE-USE

NORMOSOL-R PH 74 INTRAVENOUS

PARENTERAL SOLUTION

PLASMA-LYTE 148 INTRAVENOUS

PARENTERAL SOLUTION

PLASMA-LYTE A INTRAVENOUS

PARENTERAL SOLUTION

potassium chloride intravenous solution 2

2 PA BvD

meqml (20 ml)

2 PA BvD

potassium chloride oral capsule extended

release 10 meq

release 8 meq

(Klor-Con Sprinkle) 2

potassium chloride oral liquid 20 meq15

ml 40 meq15 ml

potassium chloride oral tablet extended

release 10 meq 8 meq

(K-Tab) 2

release 20 meq

(K-Tab) 4

potassium chloride oral tableter

(Klor-Con M10) 2

(Klor-Con M20) 2

potassium chloride-045 nacl

intravenous parenteral solution 20 meql

potassium citrate oral tablet extended

release 10 meq (1080 mg)

(Urocit-K 10) 2

release 15 meq

(Urocit-K 15) 2

(Urocit-K 5) 2

sodium chloride 09 intravenous

parenteral solution

Respiratory Tract Agents

Anti-Inflammatories Inhaled

Corticosteroids

Drug Name

ADVAIR DISKUS INHALATION

BLISTER WITH DEVICE 100-50

MCGDOSE 250-50 MCGDOSE 500-

50 MCGDOSE

ADVAIR HFA INHALATION HFA

AEROSOL INHALER 115-21

MCGACTUATION 230-21

MCGACTUATION 45-21

MCGACTUATION

ARNUITY ELLIPTA INHALATION

MCGACTUATION 200

MCGACTUATION 50

MCGACTUATION

BREO ELLIPTA INHALATION

MCGDOSE 200-25 MCGDOSE

budesonide inhalation suspension for

nebulization 025 mg2 ml 05 mg2 ml 1

mg2 ml

(Pulmicort) 2 PA BvD

FLOVENT 100 MCG DISKUS 100

MCGACTUATION

FLOVENT DISKUS INHALATION

MCGACTUATION 50

MCGACTUATION

FLOVENT HFA INHALATION HFA

AEROSOL INHALER 110

MCGACTUATION

AEROSOL INHALER 220

MCGACTUATION

AEROSOL INHALER 44

MCGACTUATION

SYMBICORT 160-45 MCG INHALER

60 INHALATIONS 160-45

MCGACTUATION

Drug Name

SYMBICORT 80-45 MCG INHALER 60

INHALATIONS 80-45

MCGACTUATION

SYMBICORT INHALATION HFA

MCGACTUATION 80-45

MCGACTUATION

Antileukotrienes

montelukast oral tablet 10 mg (Singulair) 1

montelukast oral tabletchewable 4 mg 5

(Singulair) 1

zafirlukast oral tablet 10 mg 20 mg (Accolate) 2

Bronchodilators

albuterol 5 mgml solution 5 mgml 2 PA BvD

albuterol sulfate inhalation hfa aerosol

inhaler 90 mcgactuation

(ProAir HFA) 2 QL (17 per 30 days)

inhaler 90 mcgactuation (nda020503)

albuterol sulfate inhalation solution for

nebulization 063 mg3 ml 125 mg3 ml

25 mg 3 ml (0083 ) 25 mg05 ml

2 PA BvD

albuterol sulfate oral syrup 2 mg5 ml 2

albuterol sulfate oral tablet extended

release 12 hr 4 mg 8 mg

ANORO ELLIPTA INHALATION

MCGACTUATION

ATROVENT HFA INHALATION HFA

AEROSOL INHALER 17

MCGACTUATION

COMBIVENT RESPIMAT

INHALATION MIST 20-100

MCGACTUATION

INCRUSE ELLIPTA INHALATION

MCGACTUATION

ipratropium bromide inhalation solution

2 PA BvD

LONHALA MAGNAIR 25 MCG

STARTER 25 MCGML

Drug Name

LONHALA MAGNAIR REFILL

INHALATION SOLUTION FOR

NEBULIZATION 25 MCGML

metaproterenol oral syrup 10 mg5 ml 1

metaproterenol oral tablet 10 mg 20 mg 2

PROAIR RESPICLICK INHALATION

AEROSOL POWDR BREATH

ACTIVATED 90 MCGACTUATION

SEREVENT DISKUS INHALATION

MCGDOSE

SPIRIVA RESPIMAT INHALATION

MIST 125 MCGACTUATION

STRIVERDI RESPIMAT INHALATION

terbutaline oral tablet 25 mg 5 mg 2

terbutaline subcutaneous solution 1 mgml 5 NDS

theophylline oral solution 80 mg15 ml 2

theophylline oral tablet extended release

12 hr 100 mg 200 mg 300 mg

(Theochron) 2

12 hr 450 mg

24 hr 400 mg 600 mg

TRELEGY ELLIPTA INHALATION

BLISTER WITH DEVICE 100-625-25

TUDORZA PRESSAIR INHALATION

(30 ACTUAT)

Respiratory Tract Agents Other

acetylcysteine intravenous solution 200

mgml (20 )

(Acetadote) 2 PA

acetylcysteine solution 100 mgml (10 )

200 mgml (20 )

2 PA BvD

CINQAIR INTRAVENOUS SOLUTION

10 MGML

5 PA NDS

cromolyn inhalation solution for

nebulization 20 mg2 ml

2 PA BvD

Drug Name

DALIRESP ORAL TABLET 250 MCG 3 QL (28 per 28 days)

ESBRIET ORAL CAPSULE 267 MG 5 PA NDS QL (270 per

30 days)

ESBRIET ORAL TABLET 267 MG 5 PA NDS QL (270 per

30 days)

ESBRIET ORAL TABLET 801 MG 5 PA NDS QL (90 per 30

FASENRA SUBCUTANEOUS

SYRINGE 30 MGML

KALYDECO ORAL GRANULES IN

PACKET 25 MG 50 MG 75 MG

KALYDECO ORAL TABLET 150 MG 5 PA NDS QL (56 per 28

NUCALA SUBCUTANEOUS AUTO-

INJECTOR 100 MGML

5 PA LA NDS QL (3 per

28 days)

NUCALA SUBCUTANEOUS RECON

SOLN 100 MG

28 days)

NUCALA SUBCUTANEOUS SYRINGE

100 MGML

28 days)

OFEV ORAL CAPSULE 100 MG 150

ORKAMBI ORAL GRANULES IN

PACKET 100-125 MG 150-188 MG

ORKAMBI ORAL TABLET 100-125

MG 200-125 MG

30 days)

PROLASTIN-C INTRAVENOUS

RECON SOLN 1000 MG

5 PA BvD NDS

SYMDEKO ORAL TABLETS

SEQUENTIAL 100-150 MG (D) 150 MG

(N) 50-75 MG (D) 75 MG (N)

XOLAIR SUBCUTANEOUS RECON

SOLN 150 MG

5 PA NDS

XOLAIR SUBCUTANEOUS SYRINGE

150 MGML 75 MG05 ML

5 PA NDS

Skeletal Muscle Relaxants

baclofen oral tablet 10 mg 20 mg 2

chlorzoxazone oral tablet 500 mg 2 PA-HRM AGE (Max 64

Years)

cyclobenzaprine oral tablet 10 mg 5 mg 1 PA-HRM AGE (Max 64

Years)

dantrolene oral capsule 100 mg 2

Drug Name

dantrolene oral capsule 25 mg 50 mg (Dantrium) 2

methocarbamol oral tablet 500 mg 2 PA-HRM AGE (Max 64

Years)

methocarbamol oral tablet 750 mg (Robaxin-750) 2 PA-HRM AGE (Max 64

Years)

revonto intravenous recon soln 20 mg 2

tizanidine oral tablet 2 mg 2

tizanidine oral tablet 4 mg (Zanaflex) 2

Sleep Disorder Agents

armodafinil oral tablet 150 mg 200 mg

250 mg 50 mg

(Nuvigil) 2 PA QL (30 per 30 days)

BELSOMRA ORAL TABLET 10 MG 15

MG 20 MG 5 MG

eszopiclone oral tablet 1 mg 2 mg 3 mg (Lunesta) 2 QL (30 per 30 days)

HETLIOZ ORAL CAPSULE 20 MG 5 PA NDS QL (30 per 30

SILENOR ORAL TABLET 3 MG 6 MG 3 QL (30 per 30 days)

XYREM ORAL SOLUTION 500 MGML 5 PA LA NDS QL (540

per 30 days)

zaleplon oral capsule 10 mg 5 mg 2 QL (30 per 30 days)

zolpidem oral tablet 10 mg 5 mg (Ambien) 1 QL (30 per 30 days)

Vasodilating Agents

ADEMPAS ORAL TABLET 05 MG 1

MG 15 MG 2 MG 25 MG

alyq oral tablet 20 mg 5 PA NDS QL (60 per 30

ambrisentan oral tablet 10 mg 5 mg (Letairis) 5 PA NDS QL (30 per 30

epoprostenol (glycine) intravenous recon

soln 05 mg

(Flolan) 2 PA

soln 15 mg

(Flolan) 5 PA NDS

OPSUMIT ORAL TABLET 10 MG 5 PA NDS QL (30 per 30

ORENITRAM ORAL TABLET

EXTENDED RELEASE 0125 MG

EXTENDED RELEASE 025 MG 1 MG

25 MG 5 MG

5 PA NDS

Drug Name

sildenafil (antihypertensive) intravenous

solution 10 mg125 ml

(Revatio) 5 PA NDS QL (375 per

1 day)

sildenafil (antihypertensive) oral tablet 20

(Revatio) 2 PA QL (90 per 30 days)

tadalafil (antihypertensive) oral tablet 20

(Adcirca) 5 PA NDS QL (60 per 30

TRACLEER ORAL TABLET FOR

SUSPENSION 32 MG

28 days)

treprostinil sodium injection solution 1

mgml 10 mgml 25 mgml 5 mgml

(Remodulin) 5 PA NDS

TYVASO INHALATION SOLUTION

(06 MGML)

5 PA NDS

UPTRAVI ORAL TABLET 1000 MCG

1200 MCG 1400 MCG 1600 MCG

400 MCG 600 MCG 800 MCG

UPTRAVI ORAL TABLET 200 MCG 5 PA NDS QL (240 per

30 days)

UPTRAVI ORAL TABLETSDOSE

PACK 200 MCG (140)- 800 MCG (60)

5 PA NDS

Vitamins And Minerals

pnv prenatal plus multivit tab sf gluten-

free 27 mg iron- 1 mg

prenatal vitamin plus low iron oral tablet

27 mg iron- 1 mg

A abacavir 47

abacavir-lamivudine 47

abacavir-lamivudine-zidovudine

ABELCET 35

ABILIFY MAINTENA 43

ABRAXANE 15

acamprosate 7

acarbose 32

acebutolol 60

acetaminophen-codeine 3

acetazolamide 107

acetazolamide sodium 107

acetic acid 82 104

acetylcysteine 112

acitretin 76

ACTEMRA 95

ACTEMRA ACTPEN 95

ACTHIB (PF) 100

ACTIMMUNE 105

acyclovir 52 76

acyclovir sodium 52

ADACEL(TDAP

ADOLESNADULT)(PF) 100

ADAGEN 80

adapalene 79

adefovir 52

ADEMPAS 114

adriamycin 15

adrucil 15

ADVAIR DISKUS 110

ADVAIR HFA 110

afeditab cr 63

AFINITOR 15

AFINITOR DISPERZ 15

afirmelle 70

a-hydrocort 91

(2 PACK) 38

AJOVY 38

AKYNZEO

(FOSNETUPITANT) 39

AKYNZEO (NETUPITANT) 39

ala-cort 77

albendazole 41

albuterol sulfate 111

alclometasone 77

ALCOHOL PADS 76

ALDURAZYME 80

ALECENSA 16

alendronate 104

alfuzosin 88

ALIMTA 16

ALINIA 41

ALIQOPA 16

aliskiren 66

allopurinol 37

alosetron 103

ALPHAGAN P 107

alprazolam 8

ALREX 84

altavera (28) 70

ALTRENO 79

ALUNBRIG 16

alyacen 135 (28) 70

alyacen 777 (28) 70

alyq 114

amabelz 89

amantadine hcl 41

AMBISOME 35

ambrisentan 114

amethia 70

amethia lo 70

amifostine crystalline 105

amiloride 63

amiloride-hydrochlorothiazide

AMINOSYN 10 55

AMINOSYN 7 WITH

ELECTROLYTES 55

AMINOSYN 85 55

AMINOSYN 85 -

ELECTROLYTES 55

AMINOSYN II 10 56

AMINOSYN II 15 56

AMINOSYN II 7 56

AMINOSYN II 85 56

AMINOSYN II 85 -

ELECTROLYTES 56

AMINOSYN M 35 56

AMINOSYN-HBC 7 56

AMINOSYN-PF 10 56

AMINOSYN-PF 7

(SULFITE-FREE) 56

AMINOSYN-RF 52 56

amiodarone 60

AMITIZA 86

amitriptyline 29

amlodipine 63

amlodipine-benazepril 63

amlodipine-valsartan 63

ammonium lactate 76

amoxapine 30

amoxicillin 13

amoxicillin-pot clavulanate 13

amphotericin b 35

ampicillin 13

ampicillin sodium 13

ampicillin-sulbactam 13

ANADROL-50 89

anagrelide 55

anastrozole 16

ANORO ELLIPTA 111

APOKYN 41

apraclonidine 81

aprepitant 39

apri 70

APRISO 103

APTIOM 25 26

APTIVUS 47

aranelle (28) 70

ARCALYST 95

aripiprazole 43

ARISTADA 43

ARISTADA INITIO 43

armodafinil 114

ARNUITY ELLIPTA 110

arsenic trioxide 16

ashlyna 70

aspirin-dipyridamole 55

ASSURE ID INSULIN

SAFETY 79

atazanavir 47

atenolol 60

atenolol-chlorthalidone 60

atomoxetine 66

atorvastatin 64

atovaquone 41

atovaquone-proguanil 41

ATRIPLA 47

atropine 25 82

ATROVENT HFA 111

AUBAGIO 66

aubra 70

aurovela 1530 (21) 70

aurovela 120 (21) 70

aurovela 24 fe 70

aurovela fe 1530 (28) 70

aurovela fe 1-20 (28) 70

AUSTEDO 67

AVASTIN 16

aviane 70

AVONEX 67

ayuna 70

azacitidine 16

azathioprine 95

azathioprine sodium 95

azelastine 82

azithromycin 12

AZOPT 107

aztreonam 13

azurette (28) 70

B baciim 10

bacitracin 82

bacitracin-polymyxin b 82

baclofen 113

balsalazide 103

BALVERSA 16

balziva (28) 71

BANZEL 26

BAVENCIO 16

BAXDELA 14

BCG VACCINE LIVE (PF) 100

BD ULTRA-FINE NANO PEN

NEEDLE 79

BD VEO INSULIN SYR HALF

UNIT 80

BD VEO INSULIN SYRINGE

bekyree (28) 71

BELEODAQ 16

BELSOMRA 114

benazepril 59

BENDEKA 16

BENLYSTA 105

benztropine 41

BESPONSA 16

betamethasone acetsod phos 91

betamethasone dipropionate 77

betamethasone valerate 78

betamethasone augmented 78

BETASERON 67

betaxolol 60

bethanechol chloride 88

BETHKIS 9

BEVYXXA 52

bexarotene 16

BEXSERO 100

bicalutamide 16

BICILLIN L-A 13

BIDIL 66

BIKTARVY 47

bisoprolol fumarate 61

bisoprolol-hydrochlorothiazide

bleomycin 16

bleph-10 82

BLINCYTO 16

blisovi 24 fe 71

blisovi fe 1530 (28) 71

blisovi fe 120 (28) 71

BOOSTRIX TDAP 100

BORTEZOMIB 16

BOSULIF 16 17

BRAFTOVI 17

BREO ELLIPTA 110

briellyn 71

BRILINTA 55

brimonidine 107

BRIVIACT 26

bromocriptine 41

BROMSITE 84

budesonide 103 110

bumetanide 63

buprenorphine hcl 3 7

buprenorphine-naloxone 8

bupropion hcl 30

bupropion hcl (smoking deter) 8

buspirone 8

butalbital-acetaminophen-caff 3

butalbital-aspirin-caffeine 3

BYSTOLIC 61

BYVALSON 61

C cabergoline 41

CABLIVI 105

CABOMETYX 17

caffeine citrate 67

calcipotriene 76

calcitonin (salmon) 104

calcitriol 104

calcium acetate 87 88

calcium chloride 108

CALDOLOR 6

CALQUENCE 17

camila 71

CAPASTAT 39

CAPRELSA 17

captopril 59

CARBAGLU 86

carbamazepine 26

carbidopa-levodopa 42

carbidopa-levodopa-entacapone

carteolol 107

cartia xt 62

carvedilol 61

caspofungin 36

CAYSTON 13

caziant (28) 71

cefaclor 11

cefadroxil 11

cefazolin 11

cefdinir 11

cefditoren pivoxil 11

cefepime 11

cefixime 11

cefotaxime 11

cefoxitin 11

cefpodoxime 12

cefprozil 12

ceftazidime 12

ceftriaxone 12

cefuroxime axetil 12

cefuroxime sodium 12

celecoxib 6

CELONTIN 26

cephalexin 12

CERDELGA 80

CEREZYME 80

CETYLEV 105

CHANTIX 8

CHANTIX CONTINUING

MONTH BOX 8

CHANTIX STARTING

MONTH BOX 8

chlordiazepoxide hcl 9

chlorhexidine gluconate 76

chloroquine phosphate 41

chlorothiazide 64

chlorothiazide sodium 64

chlorpromazine 43

chlorthalidone 64

chlorzoxazone 113

cholestyramine (with sugar) 64

cholestyramine light 64

ciclopirox 36

cilostazol 55

CIMDUO 47

cimetidine hcl 85

CIMZIA 95

CIMZIA POWDER FOR

RECONST 95

cinacalcet 104

CINQAIR 112

CINRYZE 53

CINVANTI 39

CIPRODEX 82

ciprofloxacin 14

ciprofloxacin hcl 14 82

ciprofloxacin in 5 dextrose 14

citalopram 30

clarithromycin 12

CLENPIQ 87

clindamycin hcl 10

clindamycin in 5 dextrose 10

clindamycin phosphate 10 37

CLINIMIX 5D15W

SULFITE FREE 56

CLINIMIX 5D25W

SULFITE-FREE 56

CLINIMIX 425D10W SULF

FREE 56

CLINIMIX 425D5W

SULFIT FREE 56

CLINIMIX 425-D25W

SULF-FREE 56

CLINIMIX 5-

D20W(SULFITE-FREE) 56

CLINIMIX E 275D10W

SUL FREE 56

CLINIMIX E 275D5W

SULF FREE 57

CLINIMIX E 425D10W

SUL FREE 57

CLINIMIX E 425D25W

SUL FREE 57

CLINIMIX E 425D5W

SULF FREE 57

CLINIMIX E 5D15W

SULFIT FREE 57

CLINIMIX E 5D20W

SULFIT FREE 57

CLINIMIX E 5D25W

SULFIT FREE 57

clobazam 26

clobetasol 78

clobetasol-emollient 78

clocortolone pivalate 78

clofarabine 17

clomipramine 30

clonazepam 9

clonidine 58

clonidine hcl 58

clopidogrel 55

clorazepate dipotassium 9

clotrimazole 36

clotrimazole-betamethasone 36

clozapine 43 44

COARTEM 41

codeine sulfate 3

colchicine 37

colestipol 64

colistin (colistimethate na) 10

colocort 103

COMBIGAN 107

COMBIVENT RESPIMAT 111

COMETRIQ 17

COMPLERA 47

compro 39

constulose 86

COPIKTRA 17

CORLANOR 62

cormax 78

cortisone 91

COSENTYX (2 SYRINGES) 96

COSENTYX PEN (2 PENS) 96

COTELLIC 17

CREON 80

CRIXIVAN 47

cromolyn 82 86 112

cryselle (28) 71

cyclafem 135 (28) 71

cyclobenzaprine 113

cyclopentolate 82

cyclophosphamide 17

CYCLOPHOSPHAMIDE 17

cyclosporine 96

cyclosporine modified 96

cyproheptadine 37

CYRAMZA 17

cyred 71

CYSTADANE 106

CYSTARAN 82

D dalfampridine 67

DALIRESP 113

danazol 89

dantrolene 113 114

dapsone 39

DAPTACEL (DTAP

PEDIATRIC) (PF) 100

daptomycin 10

DARAPRIM 41

DARZALEX 17

dasetta 135 (28) 71

dasetta 777 (28) 71

DAURISMO 17

daysee 71

deblitane 71

decadron 91

decitabine 17

deferasirox 89

deferoxamine 89

DELSTRIGO 47

delyla (28) 71

DEMSER 62

DEPEN TITRATABS 89

DEPO-PROVERA 94

DESCOVY 47

desipramine 30

desmopressin 92

desog-eestradioleestradiol 71

desogestrel-ethinyl estradiol 71

desoximetasone 78

desvenlafaxine succinate 30

dexamethasone 91

dexamethasone sodium phos

(pf) 91

dexamethasone sodium

phosphate 84 91

dexmethylphenidate 67

dextroamphetamine 67

dextroamphetamine-

amphetamine 67

dextrose 5 in water (d5w) 57

DIASTAT 26

DIASTAT ACUDIAL 26

diazepam 9 26

diazepam intensol 9

diclofenac epolamine 6

diclofenac potassium 6

diclofenac sodium 6 84

dicloxacillin 13

dicyclomine 86

didanosine 47

DIFICID 12

digitek 62

digox 62

digoxin 62 63

DIGOXIN 63

dihydroergotamine 38

diltiazem hcl 62

dilt-xr 62

dimenhydrinate 39

DIPENTUM 103

diphenhydramine hcl 37

diphenoxylate-atropine 86

dipyridamole 55

disopyramide phosphate 60

disulfiram 8

divalproex 26

dofetilide 60

donepezil 29

DOPTELET (10 TAB PACK)53

dorzolamide 107

dorzolamide-timolol 107

dotti 90

DOVATO 48

doxazosin 58

doxepin 30

doxercalciferol 104

doxorubicin 17

doxorubicin peg-liposomal 17

doxy-100 15

doxycycline hyclate 15

doxycycline monohydrate 15

dronabinol 39

droperidol 106

drospirenone-ethinyl estradiol 71

DROXIA 18

DUAVEE 90

duloxetine 30

DUPIXENT 96

DUREZOL 84

dutasteride 88

E econazole 36

EDARBI 59

EDARBYCLOR 59

EDURANT 48

efavirenz 48

EGRIFTA 92

ELAPRASE 80

ELIGARD 18

ELIGARD (3 MONTH) 18

elinest 71

ELIQUIS 52

ELITEK 80

ELLA 71

ELMIRON 106

EMCYT 18

EMEND 40

EMFLAZA 91

EMGALITY PEN 38

EMGALITY SYRINGE 38

emoquette 71

EMPLICITI 18

EMSAM 30

EMTRIVA 48

enalapril maleate 59

enalaprilat 59

enalapril-hydrochlorothiazide 59

ENBREL 96

ENBREL SURECLICK 96

ENDARI 106

endocet 3

ENGERIX-B (PF) 100 101

enoxaparin 52 53

enpresse 71

enskyce 71

entacapone 42

entecavir 52

ENTRESTO 59

enulose 86

EPCLUSA 51

EPIDIOLEX 26

epinastine 82

epinephrine 63

epitol 26

EPIVIR HBV 48

eplerenone 66

epoprostenol (glycine) 114

ergoloid 106

ERGOMAR 38

ERIVEDGE 18

ERLEADA 18

erlotinib 18

errin 71

ertapenem 13

ery pads 77

erythromycin 12 82

erythromycin ethylsuccinate 12

erythromycin with ethanol 77

ESBRIET 113

escitalopram oxalate 30

esomeprazole sodium 85

estarylla 71

estradiol 90

estradiol valerate 90

estradiol-norethindrone acet 90

eszopiclone 114

ethambutol 39

ethosuximide 26

ethynodiol diac-eth estradiol 72

etodolac 6

ETOPOPHOS 18

etoposide 18

EUCRISA 78

EVENITY 104

EVOTAZ 48

exemestane 18

EXONDYS 51 106

EXTAVIA 67

ezetimibe 65

F FABRAZYME 80

falmina (28) 72

famciclovir 52

famotidine 85

famotidine (pf) 85

famotidine (pf)-nacl (iso-os) 85

FANAPT 44

FARYDAK 18

FASENRA 113

febuxostat 37

felbamate 27

FEMRING 90

femynor 72

fenofibrate 65

fenofibrate micronized 65

fenofibrate nanocrystallized 65

fentanyl 3

fentanyl citrate 3

FERRIPROX 89

FETZIMA 30

FIASP FLEXTOUCH U-100

INSULIN 33

FIASP U-100 INSULIN 33

finasteride 88

FIRAZYR 63

FIRVANQ 10

FLEBOGAMMA DIF 96

flecainide 60

FLOVENT DISKUS 110

FLOVENT HFA 110

floxuridine 18

fluconazole 36

fluconazole in nacl (iso-osm) 36

flucytosine 36

fludrocortisone 91

flumazenil 67

flunisolide 84

fluocinolone 78

fluocinonide 78

fluocinonide-e 78

fluorometholone 84

fluorouracil 18 76

fluoxetine 30

fluphenazine decanoate 44

fluphenazine hcl 44

flurbiprofen 6

flurbiprofen sodium 84

flutamide 18

fluticasone propionate 78 84

fluvoxamine 31

fomepizole 106

fondaparinux 53

FORTEO 104

fosamprenavir 48

foscarnet 50

fosinopril 59

fosphenytoin 27

FREAMINE HBC 69 57

FREAMINE III 10 58

FULPHILA 53

fulvestrant 18

furosemide 64

FUZEON 48

fyavolv 90

FYCOMPA 27

G gabapentin 27

GALAFOLD 80

galantamine 29

GAMASTAN 96

GAMMAGARD LIQUID 96

GAMMAGARD S-D (IGA lt 1

MCGML) 96

GAMMAPLEX 96

GAMMAPLEX (WITH

SORBITOL) 96

ganciclovir sodium 52

GARDASIL 9 (PF) 101

GATTEX 30-VIAL 86

GAUZE PAD 80

gavilyte-c 87

gavilyte-g 87

gavilyte-n 87

GAZYVA 18

gemfibrozil 65

generlac 86

gengraf 96

GENOTROPIN 92

GENOTROPIN MINIQUICK 92

gentak 82

gentamicin 9 77 82

gentamicin sulfate (ped) (pf) 9

gentamicin sulfate (pf) 10

GENVOYA 48

GEODON 44

GILENYA 67

GILOTRIF 18

glatiramer 67

glatopa 67 68

GLEOSTINE 18

glimepiride 35

glipizide 35

glipizide-metformin 35

GLUCAGEN HYPOKIT 106

glyburide 35

glyburide micronized 35

glyburide-metformin 35

glycopyrrolate 86

glydo 7

GLYXAMBI 32

GOCOVRI 42

granisetron (pf) 40

granisetron hcl 40

GRANIX 53 54

griseofulvin microsize 36

guanfacine 58 68

guanidine 106

H HAEGARDA 54

hailey 24 fe 72

halobetasol propionate 78

haloperidol 44

haloperidol decanoate 44

haloperidol lactate 44

HARVONI 51

HAVRIX (PF) 101

heather 72

heparin (porcine) 53

heparin porcine (pf) 53

HEPATAMINE 8 58

HERCEPTIN 19

HERCEPTIN HYLECTA 19

HETLIOZ 114

HIBERIX (PF) 101

HUMATROPE 92

HUMIRA 97

HUMIRA PEDIATRIC

CROHNS START 97

HUMIRA PEN 97

HUMIRA PEN CROHNS-UC-

HS START 97

HUMIRA PEN PSOR-

UVEITS-ADOL HS 97

HUMIRA(CF) 97

STARTER 97

HUMIRA(CF) PEN 97

HUMIRA(CF) PEN CROHNS-

UC-HS 97

HUMIRA(CF) PEN PSOR-UV-

ADOL HS 97

HUMULIN R U-500 (CONC)

INSULIN 34

KWIKPEN 34

hydralazine 63

hydrochlorothiazide 64

hydrocodone-acetaminophen 3 4

hydrocodone-ibuprofen 4

hydrocortisone 78 91 103

hydromorphone 4

hydromorphone (pf) 4

hydroxychloroquine 41

hydroxyprogesterone caproate94

hydroxyurea 19

hydroxyzine hcl 37

hydroxyzine pamoate 106

HYPERRAB (PF) 97

HYPERRAB SD (PF) 97

HYQVIA 97

I ibandronate 104

IBRANCE 19

ibuprofen 6

icatibant 63

ICLUSIG 19

IDHIFA 19

ifosfamide 19

ifosfamide-mesna 19

ILARIS (PF) 97

ILEVRO 84

ILUMYA 98

imatinib 19

IMBRUVICA 19

IMFINZI 19

imipenem-cilastatin 13

imipramine hcl 31

imiquimod 76

IMLYGIC 19

IMOGAM RABIES-HT (PF) 98

IMOVAX RABIES VACCINE

(PF) 101

IMPAVIDO 41

INBRIJA 42

incassia 72

INCRELEX 93

INCRUSE ELLIPTA 111

indapamide 64

indomethacin 6

INFANRIX (DTAP) (PF) 101

INFLECTRA 98

INGREZZA 68

INGREZZA INITIATION

PACK 68

INLYTA 19

INSULIN SYRINGE-NEEDLE

U-100 80

INTELENCE 48

INTRALIPID 58

INTRON A 51

introvale 72

INVEGA SUSTENNA 45

INVEGA TRINZA 45

INVELTYS 84

INVIRASE 48

INVOKAMET 32

INVOKAMET XR 32

INVOKANA 32

IONOSOL-B IN D5W 108

IONOSOL-MB IN D5W 108

IPOL 101

ipratropium bromide 82 111

irbesartan 59

irbesartan-hydrochlorothiazide

IRESSA 19

ISENTRESS 48

ISENTRESS HD 48

isibloom 72

ISOLYTE-P IN 5

DEXTROSE 108

ISOLYTE-S 108

isoniazid 39

isosorbide dinitrate 66

isosorbide mononitrate 66

itraconazole 36

ivermectin 41

IXEMPRA 19

IXIARO (PF) 101

J JADENU 89

JADENU SPRINKLE 89

JAKAFI 20

jantoven 53

JANUMET 32

JANUMET XR 32

JANUVIA 32

JARDIANCE 32

jasmiel (28) 72

jencycla 72

JENTADUETO 32

JENTADUETO XR 32

jinteli 90

jolivette 72

juleber 72

JULUCA 48

junel 1530 (21) 72

junel 120 (21) 72

junel fe 1530 (28) 72

junel fe 120 (28) 72

junel fe 24 72

JUXTAPID 65

JYNARQUE 64

K KABIVEN 58

KALETRA 48

kalliga 72

KALYDECO 113

KANJINTI 20

KANUMA 80

kariva (28) 72

KEDRAB (PF) 98

kelnor 135 (28) 72

kelnor 1-50 72

ketoconazole 36

ketorolac 6 84

KEVEYIS 106

KEVZARA 98

KEYTRUDA 20

KINERET 98

KINRIX (PF) 101

kionex (with sorbitol) 86

KISQALI 20

KISQALI FEMARA CO-PACK

klor-con m10 108

klor-con m15 108

klor-con m20 108

klor-con sprinkle 108

KORLYM 32

KRINTAFEL 41

KRYSTEXXA 81

kurvelo (28) 72

KUVAN 81

KYPROLIS 20

L l norgesteestradiol-eestrad 72

labetalol 61

LACTATED RINGERS 104

lactulose 86

lamivudine 48

lamivudine-zidovudine 48

lamotrigine 27

lansoprazole 85

LANTUS SOLOSTAR U-100

INSULIN 34

LANTUS U-100 INSULIN 34

larin 1530 (21) 73

larin 120 (21) 73

larin 24 fe 73

larin fe 1530 (28) 73

larin fe 120 (28) 73

larissia 73

latanoprost 107

LATUDA 45

LAZANDA 4

ledipasvir-sofosbuvir 51

leena 28 73

leflunomide 98

LEMTRADA 68

LENVIMA 20

lessina 73

letrozole 20

leucovorin calcium 106

LEUKERAN 20

LEUKINE 54

leuprolide 20

levetiracetam 27

levobunolol 107

levocarnitine 106

levocarnitine (with sugar) 106

levocetirizine 37

levofloxacin 14 82

levofloxacin in d5w 14

levoleucovorin calcium 106

LEVOLEUCOVORIN

CALCIUM 106

levonest (28) 73

levonorgestrel-ethinyl estrad 73

levonorg-eth estrad triphasic 73

levora-28 73

levothyroxine 95

LEXIVA 48

LIALDA 103

LIBTAYO 20

lidocaine 7

lidocaine (pf) 7 60

lidocaine hcl 7

lidocaine viscous 7

lidocaine-prilocaine 7

lillow (28) 73

linezolid 10 11

linezolid in dextrose 5 10

linezolid-09 sodium chloride

LINZESS 86

liothyronine 95

lisinopril 59 60

lisinopril-hydrochlorothiazide 60

lithium carbonate 68

lithium citrate 68

LIVALO 65

LOKELMA 86

LONHALA MAGNAIR

REFILL 112

LONHALA MAGNAIR

STARTER 111

LONSURF 20

loperamide 86

lopinavir-ritonavir 48

lorazepam 9

LORBRENA 20

lorcet (hydrocodone) 4

lorcet hd 4

lorcet plus 4

loryna (28) 73

losartan 59

losartan-hydrochlorothiazide 59

LOTEMAX 84

LOTEMAX SM 84

lovastatin 65

low-ogestrel (28) 73

loxapine succinate 45

lo-zumandimine (28) 73

LUCEMYRA 8

LUMIGAN 107

LUMOXITI 21

LUPRON DEPOT 21 93

LUPRON DEPOT-PED 93

LUPRON DEPOT-PED (3

MONTH) 93

lutera (28) 73

LYNPARZA 21

LYRICA 27

LYSODREN 21

lyza 73

M magnesium sulfate 108

magnesium sulfate in d5w 108

magnesium sulfate in water 108

malathion 79

maprotiline 31

marlissa (28) 73

MARPLAN 31

MATULANE 21

MAVENCLAD (10 TABLET

PACK) 68

MAVENCLAD (4 TABLET

PACK) 68

MAVENCLAD (5 TABLET

PACK) 68

MAVENCLAD (6 TABLET

PACK) 68

MAVENCLAD (7 TABLET

PACK) 68

MAVENCLAD (8 TABLET

PACK) 68

MAVENCLAD (9 TABLET

PACK) 68

MAVYRET 51

MAYZENT 68

meclizine 40

medroxyprogesterone 95

mefenamic acid 6

mefloquine 41

megestrol 21 95

MEKINIST 21

MEKTOVI 21

meloxicam 6

memantine 29

MENACTRA (PF) 101

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

(PF) 101

MEPSEVII 81

mercaptopurine 21

meropenem 13

mesalamine 103

mesna 106

MESNEX 106

MESTINON 106

metaproterenol 112

metformin 32 33

methadone 4

methadose 4

methenamine hippurate 11

methimazole 95

methocarbamol 114

methotrexate sodium 21

methotrexate sodium (pf) 21

methoxsalen 76

methscopolamine 86

methyclothiazide 64

methylphenidate hcl 68 69

methylprednisolone 91

methylprednisolone acetate 91

metipranolol 107

metoclopramide hcl 86

metoprolol succinate 61

metoprolol ta-hydrochlorothiaz

metoprolol tartrate 61

metronidazole 11 37 77

metronidazole in nacl (iso-os) 11

mexiletine 60

MIACALCIN 105

miconazole-3 36

microgestin fe 120 (28) 73

midodrine 58

miglustat 81

mili 73

mimvey 90

mimvey lo 90

minitran 66

minocycline 15

minoxidil 66

mirtazapine 31

misoprostol 85

MITIGARE 37

mitoxantrone 21

M-M-R II (PF) 102

molindone 45

mometasone 79

mondoxyne nl 15

mono-linyah 73

mononessa (28) 73

montelukast 111

morphine 4 5

MORPHINE 5

morphine concentrate 4

MOVANTIK 86

MOXEZA 82

moxifloxacin 14 83

MOZOBIL 54

MULPLETA 54

MULTAQ 60

mupirocin 77

mycophenolate mofetil 98

mycophenolate mofetil hcl 98

MYLOTARG 21

MYRBETRIQ 88

myzilra 73

N nabumetone 6

nafcillin 13 14

nafcillin in dextrose iso-osm 13

NAGLAZYME 81

naloxone 8

naltrexone 8

NAMZARIC 29

naproxen 7

NARCAN 8

NATACYN 83

NATPARA 105

NEBUPENT 41

necon 0535 (28) 73

nefazodone 31

neomycin 10

neomycin-bacitracin-poly-hc 83

neomycin-polymyxin b gu 77

neomycin-polymyxin b-

dexameth 83

neomycin-polymyxin-

gramicidin 83

neomycin-polymyxin-hc 83

neo-polycin 83

neo-polycin hc 83

NEPHRAMINE 54 58

NERLYNX 21

NEULASTA 54

NEUPOGEN 54

NEUPRO 42

nevirapine 48 49

NEXAVAR 21

niacin 65

niacor 65

nicardipine 63

NICOTROL 8

nifedipine 63

nikki (28) 74

nilutamide 21

NINLARO 22

nitrofurantoin macrocrystal 11

nitrofurantoin monohydm-cryst

nitroglycerin 66

NITYR 81

NIVESTYM 54

nizatidine 85

NOCDURNA (MEN) 93

NOCDURNA (WOMEN) 93

nora-be 74

NORDITROPIN FLEXPRO 93

norethindrone (contraceptive) 74

norethindrone acetate 95

norethindrone ac-eth estradiol

norethindrone-eestradiol-iron 74

norgestimate-ethinyl estradiol 74

norlyda 74

norlyroc 74

NORMOSOL-M IN 5

DEXTROSE 109

NORMOSOL-R 109

NORMOSOL-R PH 74 109

NORTHERA 58

nortrel 0535 (28) 74

nortrel 135 (21) 74

nortrel 135 (28) 74

nortrel 777 (28) 74

nortriptyline 31

NORVIR 49

NOVOLIN 7030 U-100

INSULIN 34

NOVOLIN 70-30 FLEXPEN U-

100 34

NOVOLIN N NPH U-100

INSULIN 34

NOVOLIN R REGULAR U-

100 INSULN 34

NOVOLOG FLEXPEN U-100

INSULIN 34

NOVOLOG MIX 70-30 U-100

INSULN 34

NOVOLOG MIX 70-

30FLEXPEN U-100 34

NOVOLOG PENFILL U-100

INSULIN 34

NOVOLOG U-100 INSULIN

ASPART 34

NOXAFIL 36

NUCALA 113

NUCYNTA 5

NUCYNTA ER 5

NUEDEXTA 69

NULOJIX 98

NUPLAZID 45

NUTRILIPID 58

NUTROPIN AQ NUSPIN 93

nyamyc 36

nystatin 36

nystop 36

O OCALIVA 87

OCREVUS 69

OCTAGAM 98

octreotide acetate 93

ODEFSEY 49

ODOMZO 22

OFEV 113

ofloxacin 83

ogestrel (28) 74

olanzapine 45

olmesartan 59

olmesartan-hydrochlorothiazide

olopatadine 82

OLUMIANT 98

omega-3 acid ethyl esters 65

omeprazole 85

omeprazole-sodium bicarbonate

OMNITROPE 93

ONCASPAR 22

ondansetron 40

ondansetron hcl 40

ondansetron hcl (pf) 40

ONIVYDE 22

OPDIVO 22

OPSUMIT 114

oralone 76

ORENCIA 98

ORENCIA CLICKJECT 98

ORENITRAM 114

ORFADIN 81

ORILISSA 93 94

ORKAMBI 113

orsythia 74

oseltamivir 50

OSMOLEX ER 42

OTEZLA 98

OTEZLA STARTER 98

oxcarbazepine 27

OXTELLAR XR 27

oxybutynin chloride 88

oxycodone 5

oxycodone-acetaminophen 5

oxycodone-aspirin 5

OZEMPIC 33

P pacerone 60

paliperidone 45 46

PALYNZIQ 81

PANRETIN 76

pantoprazole 85

paricalcitol 105

PARICALCITOL 105

paroex oral rinse 76

paromomycin 41

paroxetine hcl 31

PASER 39

PAXIL 31

PEDIARIX (PF) 102

PEDVAX HIB (PF) 102

peg 3350-electrolytes 87

PEGANONE 27

PEGASYS 51 52

PEGASYS PROCLICK 51

PEGINTRON 52

PEN NEEDLE DIABETIC 80

penicillamine 89

penicillin g potassium 14

penicillin g procaine 14

penicillin v potassium 14

PENNSAID 7

PENTACEL (PF) 102

PENTAM 41

pentamidine 41

pentoxifylline 55

PERIKABIVEN 58

perindopril erbumine 60

periogard 76

permethrin 79

perphenazine 46

perphenazine-amitriptyline 31

PERSERIS 46

pfizerpen-g 14

phenadoz 40

phenelzine 31

phenobarbital 27 28

phenylephrine hcl 59 82

phenytoin 28

phenytoin sodium 28

phenytoin sodium extended 28

philith 74

PHOSLYRA 88

PICATO 76 77

PIFELTRO 49

pilocarpine hcl 76 107

pimecrolimus 79

pimozide 46

pimtrea (28) 74

pioglitazone 33

piperacillin-tazobactam 14

PIQRAY 22

pirmella 74

PLASMA-LYTE 148 109

PLASMA-LYTE A 109

PLEGRIDY 69

podofilox 77

POLIVY 22

polycin 83

polymyxin b sulfate 11

polymyxin b sulf-trimethoprim

POMALYST 22

portia 28 74

PORTRAZZA 22

potassium chloride 109

potassium citrate 109

PRADAXA 53

PRALUENT PEN 65

pramipexole 42

prasugrel 55

pravastatin 65

prazosin 59

prednicarbate 79

prednisolone 92

prednisolone acetate 84

84 91 92

prednisone 92

pregabalin 28

PREMARIN 90

PREMPHASE 91

PREMPRO 91

prenatal plus (calcium carb) 115

prenatal vitamin plus low iron

prevalite 65

previfem 74

PREVYMIS 50

PREZCOBIX 49

PREZISTA 49

PRIFTIN 39

PRIMAQUINE 41

primidone 28

PRIVIGEN 99

PROAIR RESPICLICK 112

probenecid 37

probenecid-colchicine 37

procainamide 60

PROCALAMINE 3 58

prochlorperazine 40

prochlorperazine edisylate 40

prochlorperazine maleate 40

PROCRIT 54

procto-med hc 79

proctosol hc 79

proctozone-hc 79

PROCYSBI 88

progesterone 95

progesterone micronized 95

PROGLYCEM 106

PROGRAF 99

PROLASTIN-C 113

PROLENSA 85

PROLEUKIN 22

PROLIA 105

PROMACTA 54

promethazine 37 40

promethegan 40

propafenone 60

proparacaine 82

propranolol 61

propranolol-hydrochlorothiazid

propylthiouracil 95

PROQUAD (PF) 102

PROSOL 20 58

protamine 55

protriptyline 31

PULMOZYME 81

PURIXAN 22

pyrazinamide 39

pyridostigmine bromide 106

Q QUADRACEL (PF) 102

quetiapine 46

quinapril 60

quinidine sulfate 60

R RABAVERT (PF) 102

RADICAVA 69

raloxifene 91

ramipril 60

ranitidine hcl 85

ranolazine 63

rasagiline 42

RASUVO (PF) 99

RAVICTI 87

RAYALDEE 105

REBIF (WITH ALBUMIN) 69

REBIF REBIDOSE 69

REBIF TITRATION PACK 69

reclipsen (28) 74

RECOMBIVAX HB (PF) 102

RECTIV 107

RELENZA DISKHALER 51

RELISTOR 87

REMICADE 99

RENFLEXIS 99

repaglinide 33

REPATHA PUSHTRONEX 65

REPATHA SURECLICK 65

REPATHA SYRINGE 65

RESCRIPTOR 49

RESTASIS 85

RETACRIT 55

RETROVIR 49

REVCOVI 81

REVLIMID 22

revonto 114

REXULTI 46

REYATAZ 49

RHOPRESSA 107

ribasphere 52

ribavirin 52

RIDAURA 99

rifabutin 39

rifampin 39

riluzole 69

rimantadine 51

RISPERDAL CONSTA 46

risperidone 46

ritonavir 49

RITUXAN 22

RITUXAN HYCELA 22

rivastigmine 29

rivastigmine tartrate 29

rizatriptan 38

ropinirole 42

rosadan 77

rosuvastatin 65

ROTARIX 102

ROTATEQ VACCINE 102

RUBRACA 22

RYDAPT 22

S SABRIL 28

SAIZEN 94

SAIZEN SAIZENPREP 94

SANTYL 77

SAPHRIS 46

SAVELLA 69

scopolamine base 40

selegiline hcl 42

selenium sulfide 77

SELZENTRY 49

SEREVENT DISKUS 112

SEROSTIM 94

sertraline 31

setlakin 74

sevelamer carbonate 88

sevelamer hcl 88

sharobel 74

SHINGRIX (PF) 102

SIGNIFOR 94

sildenafil (antihypertensive) 115

SILENOR 114

SILIQ 99

silver sulfadiazine 77

SIMBRINZA 108

simliya (28) 74

simpesse 74

SIMPONI 99

SIMPONI ARIA 99

simvastatin 65

sirolimus 99

SIRTURO 39

SKYRIZI 99

smoflipid 58

sodium chloride 104

sodium chloride 09 109

sodium phenylbutyrate 87

sodium polystyrene sulfonate 87

sofosbuvir-velpatasvir 51

SOLIQUA 10033 34

SOLTAMOX 22

SOLU-CORTEF (PF) 92

SOMATULINE DEPOT 94

SOMAVERT 94

sorine 61

sotalol 61

sotalol af 61

SOVALDI 51

SPIRIVA RESPIMAT 112

spironolactone 64

SPRAVATO 31

sprintec (28) 75

SPRITAM 28

SPRYCEL 22

sps (with sorbitol) 87

sronyx 75

ssd 77

stavudine 49

STELARA 99

STIVARGA 23

STRENSIQ 81

streptomycin 10

STRIBILD 49

STRIVERDI RESPIMAT 112

SUBLOCADE 8

subvenite 28

sucralfate 86

sulfacetamide sodium 83

sulfacetamide sodium (acne) 77

sulfacetamide-prednisolone 83

sulfadiazine 14

sulfasalazine 104

sulfatrim 15

sulindac 7

sumatriptan 38

sumatriptan succinate 38

SUPPRELIN LA 94

SUPREP BOWEL PREP KIT 87

SUTENT 23

syeda 75

SYLATRON 52

SYLVANT 23

SYMBICORT 110 111

SYMDEKO 113

SYMFI 49

SYMFI LO 49

SYMJEPI 63

SYMLINPEN 120 33

SYMLINPEN 60 33

SYMPAZAN 28

SYMTUZA 49

SYNAGIS 51

SYNAREL 94

SYNERCID 11

SYNJARDY 33

SYNJARDY XR 33

SYNRIBO 23

T TABLOID 23

tacrolimus 79 99

tadalafil (antihypertensive) 115

TAFINLAR 23

TAGRISSO 23

TAKHZYRO 107

TALTZ AUTOINJECTOR 99

TALTZ SYRINGE 100

TALZENNA 23

tamoxifen 23

tamsulosin 88

TARGRETIN 23

tarina 24 fe 75

tarina fe 120 (28) 75

TASIGNA 23

TAVALISSE 55

tazarotene 79

TAZORAC 79

taztia xt 62

TDVAX 102

TECENTRIQ 23

TECFIDERA 70

TECHNIVIE 51

TEFLARO 12

TEKTURNA HCT 66

telmisartan 59

temazepam 9

TEMODAR 23

TENIVAC (PF) 102

tenofovir disoproxil fumarate 49

terazosin 88

terbinafine hcl 36

terbutaline 112

terconazole 37

testosterone 89

testosterone cypionate 89

testosterone enanthate 89

TETANUSDIPHTHERIA TOX

PED(PF) 102

tetrabenazine 70

tetracycline 15

THALOMID 107

theophylline 112

THIOLA 89

THIOLA EC 88

thioridazine 46

thiotepa 23

thiothixene 46

tiagabine 28

TIBSOVO 23

TICE BCG 100

tigecycline 15

tilia fe 75

timolol maleate 62 108

TIVICAY 49 50

tizanidine 114

TOBI PODHALER 10

tobramycin 84

tobramycin in 0225 nacl 10

tobramycin sulfate 10

tobramycin with nebulizer 10

tobramycin-dexamethasone 84

TOLAK 77

tolazamide 35

tolterodine 88

topiramate 28

toposar 23

toremifene 23

torsemide 64

TOTECT 107

TOUJEO MAX U-300

SOLOSTAR 34

TOUJEO SOLOSTAR U-300

INSULIN 35

TOVIAZ 88

TRACLEER 115

TRADJENTA 33

tramadol 5

tramadol-acetaminophen 5

trandolapril 60

tranexamic acid 55

TRANSDERM-SCOP 41

tranylcypromine 31

TRAVASOL 10 58

TRAVATAN Z 108

trazodone 31

TREANDA 23

TRECATOR 39

TRELEGY ELLIPTA 112

TRELSTAR 23 24

TREMFYA 100

treprostinil sodium 115

TRESIBA U-100 INSULIN 35

tretinoin 79

tretinoin (chemotherapy) 24

tri femynor 75

triamcinolone acetonide 76 79

triamterene-hydrochlorothiazid

trientine 89

tri-estarylla 75

trifluoperazine 46

trifluridine 84

trihexyphenidyl 43

tri-legest fe 75

tri-linyah 75

tri-lo-estarylla 75

tri-lo-marzia 75

tri-lo-mili 75

tri-lo-sprintec 75

trilyte with flavor packets 87

trimethoprim 11

tri-mili 75

trimipramine 31

TRINTELLIX 31

tri-previfem (28) 75

TRIPTODUR 94

tri-sprintec (28) 75

TRIUMEQ 50

trivora (28) 75

tri-vylibra 75

tri-vylibra lo 75

TROGARZO 50

TROPHAMINE 10 58

TROPHAMINE 6 58

TRULICITY 33

TRUMENBA 103

TRUVADA 50

TUDORZA PRESSAIR 112

tulana 75

TWINRIX (PF) 103

TYBOST 107

TYKERB 24

TYMLOS 105

TYPHIM VI 103

TYSABRI 100

TYVASO 115

U UCERIS 104

UDENYCA 55

ULORIC 37

UNITUXIN 24

UPTRAVI 115

ursodiol 87

V valacyclovir 52

VALCHLOR 77

valganciclovir 52

valproate sodium 28

valproic acid 29

valproic acid (as sodium salt) 28

valrubicin 24

valsartan 59

valsartan-hydrochlorothiazide 59

vancomycin 11

VAQTA (PF) 103

VARIVAX (PF) 103

VASCEPA 66

VELCADE 24

velivet triphasic regimen (28) 75

VELPHORO 88

VELTASSA 87

VEMLIDY 50

VENCLEXTA 24

VENCLEXTA STARTING

PACK 24

venlafaxine 31 32

verapamil 62

VERSACLOZ 46

VERZENIO 24

V-GO 40 80

VIBERZI 87

VICTOZA 33

VIDEX 2 GRAM PEDIATRIC

VIDEX EC 50

VIEKIRA PAK 51

vienva 75

vigabatrin 29

vigadrone 29

VIIBRYD 32

VIMIZIM 81

VIMPAT 29

vinorelbine 24

viorele (28) 75

VIRACEPT 50

VIREAD 50

VISTOGARD 107

VITRAKVI 24

VIZIMPRO 24

VOLTAREN 7

voriconazole 36 37

VOSEVI 51

VOTRIENT 24

VPRIV 81

VRAYLAR 47

vyfemla (28) 76

vylibra 76

VYNDAQEL 63

VYXEOS 24

W warfarin 53

water for irrigation sterile 104

WELCHOL 66

wera (28) 76

X XADAGO 43

XALKORI 24

XARELTO 53

XATMEP 24

XELJANZ 100

XELJANZ XR 100

XERMELO 87

XIFAXAN 11

XIIDRA 85

XOFLUZA 51

XOLAIR 113

XOSPATA 24

XPOVIO 25

XTAMPZA ER 5 6

XTANDI 25

xulane 76

XULTOPHY 10036 35

XURIDEN 107

XYOSTED 89

XYREM 114

Y YERVOY 25

YF-VAX (PF) 103

YONDELIS 25

YONSA 25

Z zafirlukast 111

zaleplon 114

zarah 76

ZARXIO 55

ZEJULA 25

ZELBORAF 25

zenatane 77

zenchent (28) 76

ZENPEP 81

ZEPATIER 51

zidovudine 50

ziprasidone hcl 47

ZIRGAN 84

ZOLADEX 25

zoledronic acid 105

ZOLINZA 25

zolpidem 114

ZOMACTON 94

zonisamide 29

ZORBTIVE 94

ZORTRESS 100

ZOSTAVAX (PF) 103

zovia 135e (28) 76

ZTLIDO 7

ZUBSOLV 8

ZULRESSO 32

zumandimine (28) 76

ZYDELIG 25

ZYKADIA 25

ZYLET 84

ZYPREXA RELPREVV 47

ZYTIGA 25

For More Information or to Enroll Call 1-877-940-9330 (toll free)TTY Users 1-800-421-1220Seven days a week 8am-8pmMemberServicescentersplancomwwwcentersplancommapd

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Table of Contents

INDEX

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

H6988_MKT4036 Accepted 10182018

English ATTENTION If you speak English language assistance services free of charge are available to you Call 1-877-940-9330 (TTY 1-800-421-1220)

Albanian KUJDES Neumlse flitni shqip peumlr ju ka neuml dispozicion sheumlrbime teuml asistenceumls gjuheumlsore pa pageseuml Telefononi neuml 1-877-940-9330 (TTY 1-800-421-1220)

Arabic -940-1877ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

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Bengali লয করনঃ যিদ আপিন বাংলা কথা বলেত পােরন তাহেল িনঃখরচায় ভাষা সহায়তা পিরেষবা উপল আেছ েফান করন ১-877-940-9330 (TTY ১-800-421-1220)

Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-877-940-9330（TTY1-800-421-1220）

French ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 1-877-940-9330 (ATS 1-800-421-1220)

Greek ΠΡΟΣΟΧΗ Αν μιλάτε ελληνικά στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης οι οποίες παρέχονται δωρεάν Καλέστε 1-877-940-9330 (TTY 1-800-421-1220)

French Creole

ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele 1-877-940-9330 (TTY 1-800-421-1220)

Italian

ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero 1-877-940-9330 (TTY 1-800-421-1220)

Korean

주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다 1-877-940-9330 (TTY 1-800-421-1220)번으로 전화해 주십시오

Polish UWAGA Jeżeli moacutewisz po polsku możesz skorzystać z bezpłatnej pomocy językowej Zadzwoń pod numer 1-877-940-9330 (TTY 1-800-421-1220)

Russian

ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-877-940-9330 (телетайп 1-800-421-1220)

Spanish ATENCIOacuteN Si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-877-940-9330 (TTY 1-800-421-1220)

Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-877-940-9330 (TTY 1-800-421-1220)

Urdu 877-1خبردار اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کریں-940-9330 (TTY 1-800-421-1220)

Yiddish

אויפמערקזאם אויב איר רעדט אידיש זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון (TTY 1-800-421-1220) 1-877-940-9330אפצאל רופט

1-800-368-1019 800-537-7697 (TDD)

H6988_ENR1085_C I

2020 Formulary

during the year

H6988_ENR1085_C II

during the year

H6988_ENR1085_C III

Medical Condition

name for your drug

may include

H6988_ENR1085_C IV

options

(HMO) Formulary

H6988_ENR1085_C V

exception

page I-1

Analgesics 3

Anesthetics 7

Antibacterials 9

Anticonvulsants 25

Antidepressants 29

Antifungals 35

Antigout Agents 37

Antihistamines 37

Caloric Agents 55

Contraceptives 70

Table of Contents

Devices 79

Drug Name

Analgesics

12 mg5 ml

30 days)

(Buprenex) 2

50-325-40 mg

Years)

50-325-40 mg

Years)

325-40 mg

Years)

30 days)

400 mcg 600 mcg 800 mcg

per 30 days)

75 mcghr

30 days)

75-325 mg15 ml

30 days)

10-325 mg

30 days)

25-325 mg

30 days)

Drug Name

325 mg

30 days)

75-325 mg

30 days)

5 PA NDS NM QL (30

per 30 days)

30 days)

suv inner 10 mgml

mg5 ml (20 mgml)

30 days)

4 mgml 8 mgml

30 days)

Drug Name

30 days)

mg 200 mg 60 mg

30 days)

mg 30 mg

30 days)

150 MG 200 MG 250 MG 50 MG

3 NDS NM QL (60 per

30 days)

MG 75 MG

30 days)

hr 10 mg 15 mg 20 mg 30 mg 40 mg 60

mg 80 mg

30 days)

325 mg

30 days)

325 mg 5-325 mg

30 days)

325 mg

30 days)

325 mg

30 days)

XTAMPZA ER ORAL

3 NDS NM QL (60 per

30 days)

Drug Name

XTAMPZA ER ORAL

CRUSH) 27 MG

30 days)

XTAMPZA ER ORAL

CRUSH) 36 MG

30 days)

12 hour 13

(Flector) 2 PA

(Voltaren-XR) 2

(IBU) 1

Years)

days) AGE (Max 64

Years)

Drug Name

(EC-Naprosyn) 2

ACTUATION(2 )

28 days)

Anesthetics

Local Anesthetics

applicator 2

(1 ) 15 mgml (15 ) 20 mgml (2 )

5 mgml (05 )

(Xylocaine-MPF) 1

mgml (2 )

(1 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine) 1

(40 mgml)

patchmedicated 5

solution 2

PATCHMEDICATED 18

Treatment Agents

(drec) 333 mg

Drug Name

12-3 mg 8-2 mg

2-05 mg 4-1 mg

2-05 mg 8-2 mg

3 QL (336 per 365 days)

(11)- 1 MG (42)

NICOTROL INHALATION

CARTRIDGE 10 MG

4 QL (1008 per 90 days)

018 MG 14-036 MG 114-29 MG 29-

071 MG 57-14 MG

Antianxiety Agents

Benzodiazepines

30 days)

mg 5 mg 75 mg

Drug Name

25 mg 5 mg

30 days)

0125 mg 025 mg 05 mg 1 mg

2 NDS NM QL (90 per

30 days)

375 mg

30 days)

Antibacterials

Aminoglycosides

5 PA BvD NDS

40 mgml

solution 20 mg2 ml

Drug Name

mg8 ml

(Tobi) 5 PA BvD NDS

mg 75 mg

(Cleocin HCl) 1

900 mg50 ml

150 (mgml) (6 ml)

150 mgml

(Cleocin) 2

solution 600 mg4 ml

(Cleocin) 2

soln 150 mg

(Coly-Mycin M

Parenteral)

5 PA BvD NDS

(Cubicin) 5 NDS

MGML 50 MGML

mg300 ml

(Zyvox) 5 NDS

100 mg5 ml

(Zyvox) 5 NDS

Drug Name

(Metro IV) 2

100 mg 25 mg 50 mg

capsule 100 mg

500000 unit

SOLN 500 MG

750 mg

2 PA BvD

Cephalosporins

125 mg5 ml 250 mg5 ml 375 mg5 ml

gram 500 mg

125 mg5 ml 250 mg5 ml

(Maxipime) 2

10 gram 2 gram

Drug Name

(Tazicef) 2

750 mg

15 gram 75 gram

SOLN 400 MG 600 MG

Macrolides

(Zithromax) 2

500 mg (3 pack) 600 mg

(EES Granules) 2

(EryPed 400) 2

Drug Name

(Azactam) 2

5 PA LA NDS

soln 250 mg

soln 500 mg

(Primaxin IV) 2

gram 500 mg

(Merrem) 2

Penicillins

250 mg5 ml 400 mg5 ml

250 mg

mg5 ml

500-125 mg 875-125 mg

(Augmentin) 1

500 mg

(Unasyn) 2

2400000 UNIT4 ML 600000

UNITML

Drug Name

20 million unit

(Pfizerpen-G) 2

unitml

mg5 ml 250 mg5 ml

500 mg

405 gram

(Zosyn) 2 PA BvD

Quinolones

(Cipro) 1

(Cipro in D5W) 2

ciprofloxacin oral

ml 500 mg5 ml

(Cipro) 2

250 mg50 ml 500 mg100 ml 750 mg150

Sulfonamides

(Sulfatrim) 2

Drug Name

400-80 mg

(Bactrim) 1

800-160 mg

(Bactrim DS) 1

Tetracyclines

soln 100 mg

(Doxy-100) 2

(Morgidox) 2

mg 50 mg

(Mondoxyne NL) 2

(Vibramycin) 2

(Avidoxy) 2

Anticancer Agents

100 MG

2 PA BvD

ml 500 mg10 ml

2 PA BvD

per 28 days)

MG 75 MG

5 PA NSO NDS QL (28

per 28 days)

Drug Name

per 30 days)

SOLN 100 MG 500 MG

SOLN 60 MG

5 PA NSO NDS QL (3

per 28 days)

5 PA NSO NDS QL (30

per 30 days)

PACK 90 MG (7)- 180 MG (23)

5 PA NSO NDS

25 MGML

5 PA NSO NDS

per 28 days)

SOLUTION 20 MGML

5 PA NSO NDS

SOLN 500 MG

5 PA NSO NDS

BENDEKA INTRAVENOUS

SOLUTION 25 MGML

5 PA NSO NDS

per 30 days)

5 PA NSO NDS

RECON SOLN 35 MG

5 PA NSO NDS

per 30 days)

Drug Name

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (60

per 30 days)

(Clolar) 5 NDS

MGDAY(80 MG X1-20 MG X1) 140

per 28 days)

5 PA NSO NDS QL (56

per 28 days)

(63 per 28 days)

5 PA BvD NDS

CAPSULE 25 MG 50 MG

2 PA BvD ST

CYRAMZA INTRAVENOUS

SOLUTION 10 MGML

5 PA NSO NDS

SOLUTION 20 MGML

5 PA NSO LA NDS

per 30 days)

suspension 2 mgml

Drug Name

MG 400 MG

ELIGARD (3 MONTH)

ELIGARD (4 MONTH)

ELIGARD (6 MONTH)

75 MG (1 MONTH)

SOLN 300 MG 400 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG

MG 20 MG

5 PA NSO NDS

gram20 ml

2 PA BvD

(Adrucil) 2 PA BvD

mg5 ml

(Faslodex) 5 NDS

1000 MG40 ML

5 PA NSO NDS

MG 40 MG

5 PA NSO NDS QL (30

per 30 days)

40 MG 5 MG

Drug Name

HERCEPTIN HYLECTA

10000 UNIT5 ML

5 PA NSO NDS QL (5

per 21 days)

SOLN 150 MG 440 MG

5 PA NSO NDS

125 MG 75 MG

5 PA NSO NDS QL (21

per 28 days)

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

ml 3 gram60 ml

gram 3000-1000 mg

5 PA BvD NDS

per 30 days)

per 28 days)

280 MG 420 MG 560 MG

5 PA NSO NDS QL (28

per 28 days)

50 MGML

5 PA NSO NDS

5 PA NSO NDS QL (4

per 365 days)

5 PA NSO NDS QL (8

per 28 days)

per 30 days)

SOLN 15 MG 45 MG

Drug Name

20 MG 25 MG 5 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 420 MG

5 PA NSO NDS

SOLUTION 25 MGML

5 PA NSO NDS QL (8

per 21 days)

5 PA NSO NDS QL (49

per 28 days)

5 PA NSO NDS QL (70

per 28 days)

5 PA NSO NDS QL (91

per 28 days)

(200 MG X 1)

5 PA NSO NDS QL (21

per 28 days)

(200 MG X 2)

5 PA NSO NDS QL (42

per 28 days)

(200 MG X 3)

5 PA NSO NDS QL (63

per 28 days)

5 PA NSO NDS

X 1) 18 MGDAY (10 MG X 1-4 MG

X2) 20 MGDAY (10 MG X 2) 24

8 MGDAY (4 MG X 2)

5 PA NSO NDS

50 MGML

5 PA NSO NDS QL (7

per 21 days)

per 28 days)

per 30 days)

Drug Name

SOLN 1 MG

5 PA NSO NDS

SYRINGE KIT 375 MG

150 MG

per 30 days)

(Max 64 Years)

per 30 days)

soln 1 gram

2 PA BvD

solution 25 mgml

2 PA BvD

5 PA NSO NDS

per 30 days)

Drug Name

MG 4 MG

5 PA NSO NDS QL (3

per 28 days)

750 UNITML

5 PA NSO NDS

ONIVYDE INTRAVENOUS

DISPERSION 43 MGML

100 MG10 ML 240 MG24 ML 40

MG4 ML

5 PA NSO NDS

(200 MG X 1)

5 PA NSO NDS QL (28

per 28 days)

(200 MG X1-50 MG X1) 300 MGDAY

(150 MG X 2)

5 PA NSO NDS QL (56

per 28 days)

SOLN 140 MG

5 PA NSO NDS

MG 3 MG 4 MG

5 PA NSO NDS QL (21

per 28 days)

per 21 days)

5 PA NSO LA NDS QL

(28 per 28 days)

MGML) 1600 MG134 ML (120

5 PA NSO NDS

RITUXAN INTRAVENOUS

CONCENTRATE 10 MGML

5 PA NSO NDS

250 MG 300 MG

per 30 days)

per 28 days)

MG5 ML

5 PA NSO NDS QL (30

per 30 days)

Drug Name

per 28 days)

MG 375 MG 50 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 100 MG 400 MG

5 PA NSO NDS

SOLN 35 MG

5 PA NSO NDS

per 30 days)

5 PA NSO LA NDS QL

(30 per 30 days)

per 30 days)

per 28 days)

200 MG

per 28 days)

per 30 days)

5 PA NSO NDS

SOLN 100 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG 25 MG

5 PA NSO NDS

1125 MG

225 MG

5 NDS QL (1 per 168

Drug Name

375 MG

SOLUTION 35 MGML

5 PA NSO NDS

per 30 days)

(180 per 30 days)

per 30 days)

100 MG

5 PA NSO LA NDS

150 MG 200 MG 50 MG

5 PA NSO NDS QL (56

per 28 days)

50 mg5 ml

(Navelbine) 2

per 30 days)

MG 45 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 44-100 MG

5 PA BvD NDS

250 MG

5 PA NSO NDS QL (60

per 30 days)

4 PA BvD ST

per 30 days)

Drug Name

MGWEEK (20 MG X 5)

5 PA NSO NDS QL (20

per 28 days)

MGWEEK (20 MG X 8)

5 PA NSO NDS QL (32

per 28 days)

(20 MG X 3)

5 PA NSO NDS QL (12

per 28 days)

(20 MG X 4)

5 PA NSO NDS QL (16

per 28 days)

per 30 days)

200 MG40 ML (5 MGML) 50 MG10

ML (5 MGML)

5 PA NSO NDS

SOLN 1 MG

5 PA NSO NDS

per 30 days)

IMPLANT 108 MG

IMPLANT 36 MG

5 PA NSO NDS QL (60

per 30 days)

per 28 days)

per 30 days)

Anticonvulsants

Drug Name

5 ST NDS

SOLUTION 50 MG5 ML

5 NDS QL (60 per 30

(Carbatrol) 2

(Tegretol) 2

(Tegretol XR) 2

125-15-175-20 MG 5-75-10 MG

75-10 mg

(Diastat AcuDial) 4

sprinkle 125 mg

hr 250 mg 500 mg

(Depakote ER) 2

(drec) 125 mg 250 mg 500 mg

(Depakote) 2

5 PA NSO NDS

Drug Name

(Cerebyx) 2

4 ST QL (720 per 30

MG 8 MG

200 mg 25 mg

(Lamictal) 1

(Lamictal) 2

mg5 ml

(Keppra) 2

mg 500 mg 750 mg

(Keppra) 2

24 hr 500 mg 750 mg

(Keppra XR) 2

MG 200 MG 225 MG 25 MG 300 MG

50 MG 75 MG

ml (60 mgml)

(Trileptal) 2

600 mg

(Trileptal) 2

300 MG 600 MG

2 PA NSO-HRM AGE

(Max 64 Years)

Drug Name

162 mg 30 mg 324 mg 60 mg 648 mg

972 mg

2 PA NSO-HRM AGE

(Max 64 Years)

100 mg

200 mg 300 mg

(Phenytek) 2

200 mg 225 mg 25 mg 300 mg 50 mg

per 30 days)

SUSPENSION 1000 MG

4 ST QL (120 per 30

mg 25 mg

5 PA NSO NDS QL (60

per 30 days)

(Gabitril) 2

(Topamax) 2

100 mg 150 mg 200 mg 25 mg 50 mg

(Qudexy XR) 4

mg 50 mg

(Topamax) 1

mg5 ml (100 mgml)

(Depacon) 2

solution 250 mg5 ml

Drug Name

per 30 days)

200 MG20 ML

MG 200 MG 50 MG

Antidementia Agents

24 hr 16 mg 24 mg 8 mg

14 mg 21 mg 28 mg 7 mg

NAMZARIC ORAL

MG 21-10 MG 28-10 MG 7-10 MG

3 mg 45 mg 6 mg

133 mg24 hour 46 mg24 hr 95 mg24

Antidepressants

150 mg 25 mg 50 mg 75 mg

Drug Name

mg 50 mg

24 hr 150 mg 300 mg

(Wellbutrin XL) 2

(Wellbutrin SR) 2

(Anafranil) 2

50 mg 75 mg

release(drec) 30 mg

MG24 HR

5 NDS QL (30 per 30

mg 5 mg

(Lexapro) 1

FETZIMA ORAL

HR 120 MG 20 MG 40 MG 80 MG

(Prozac) 1

Drug Name

(Tofranil) 2

mg 30 mg 45 mg

(Remeron SolTab) 2

200 mg 250 mg 50 mg

50 mg 75 mg

(Pamelor) 1

30 mg 40 mg

(Max 64 Years)

4 PA NSO-HRM AGE

(Max 64 Years)

10 mg 2-25 mg 4-10 mg 4-25 mg 4-50

(Zoloft) 1

(28 MG X 3)

5 PA NSO NDS

20 MG 5 MG

24hr 150 mg

24hr 375 mg 75 mg

Drug Name

375 mg 50 mg 75 mg

MG 40 MG

PACK 10 MG (7)- 20 MG (23)

SOLUTION 5 MGML

Antidiabetic Agents

25-5 MG

1000 MG 150-500 MG 50-1000 MG

3 ST QL (120 per 30

150-500 MG 50-1000 MG 50-500 MG

MG 50-500 MG

500 MG

MG 50 MG

1000 MG 25-500 MG 25-850 MG

28 days)

Drug Name

hr 500 mg

hr 750 mg

28 days)

MG 125-500 MG 5-1000 MG 5-500

1000 MG

Insulins

UNITML (3 ML)

FIASP U-100 INSULIN

UNITML

Drug Name

UNITML

UNITML (3 ML)

UNITML

UNITML (70-30)

UNITML

UNITML (3 ML)

UNITML (70-30)

UNITML

UNITML (3 ML)

Drug Name

UNITML (15 ML)

UNITML (3 ML)

UNITML

Sulfonylureas

25 mg 5 mg

mg 5-500 mg

mg 6 mg

Years)

mg 25-500 mg 5-500 mg

Years)

Antifungals

ABELCET INTRAVENOUS

SUSPENSION 5 MGML

5 PA BvD NDS

Drug Name

mg 70 mg

(Cancidas) 5 NDS

(clotrimazole))

(Lotrisone) 2

400 mg200 ml

2 PA BvD

(Diflucan) 2

200 mg 50 mg

(Diflucan) 2

mg5 ml

MG5 ML (40 MGML)

unitgram

Drug Name

(Vfend) 5 NDS

Antigout Agents

Antihistamines

Years)

mgml 50 mgml

Years)

Membrane)

Drug Name

Antimigraine Agents

70 MGML

140 MGML 70 MGML

225 MG15 ML

EMGALITY SYRINGE

ML (100 MGML X 3)

mg 5 mg

mgactuation

25 mg 50 mg

cartridge 6 mg05 ml

(Imitrex STATdose

Refill)

solution 6 mg05 ml

syringe 6 mg05 ml

Antimycobacterials

Drug Name

Antimycobacterials

1 GRAM

168 days)

Antinausea Agents

025 MG

CAPSULE 300-05 MG

4 PA BvD

(1)- 80 mg (2)

EMULSION 72 MGML

Drug Name

ML FINAL CONC)

mgml 1 mgml (1 ml)

Drowsy)

mg2 ml

mg 8 mg

2 PA BvD

Years)

mg 5 mg

(Compazine) 1

50 mgml

Years)

25 mg 50 mg

Years)

1 mg over 3 days

days) AGE (Max 64

Years)

Drug Name

days) AGE (Max 64

Years)

Antiparasite Agents

(Malarone) 2

500 mg

SOLN 300 MG

4 PA BvD

300 MG

APOKYN SUBCUTANEOUS

CARTRIDGE 10 MGML

Drug Name

mg 25-100 mg 25-250 mg

(Sinemet) 2

(Sinemet CR) 2

(Stalevo 50) 4

tablet 1875-75-200 mg

(Stalevo 75) 4

(Stalevo 100) 4

tablet 3125-125-200 mg

(Stalevo 125) 4

tablet 375-150-200 mg

(Stalevo 150) 4

(Stalevo 200) 4

GOCOVRI ORAL

24HR 137 MG

GOCOVRI ORAL

24HR 685 MG

30 days)

258 MG

mg 05 mg 075 mg 1 mg 15 mg

(Mirapex) 1

Drug Name

ABILIFY MAINTENA

INTRAMUSCULAR

RECON 300 MG 400 MG

ABILIFY MAINTENA

INTRAMUSCULAR

mg 30 mg 5 mg

SYRING 675 MG24 ML

SYRING 1064 MG39 ML

5 NDS QL (39 per 56

SYRING 441 MG16 ML

5 NDS QL (16 per 28

SYRING 662 MG24 ML

5 NDS QL (24 per 28

SYRING 882 MG32 ML

5 NDS QL (32 per 28

200 mg 25 mg 50 mg

Drug Name

mg 125 mg 25 mg

30 days)

MG 6 MG 8 MG

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

25 mgml

25 mg 5 mg

solution 100 mgml

solution 50 mgml

(Haldol) 2

5 mgml

mg 2 mg 20 mg 5 mg

Drug Name

INVEGA SUSTENNA

MG075 ML

INVEGA SUSTENNA

MG15 ML

5 NDS QL (15 per 28

INVEGA SUSTENNA

MG025 ML

INVEGA SUSTENNA

MG05 ML

5 NDS QL (05 per 28

5 NDS QL (0875 per 84

5 NDS QL (1315 per 84

5 NDS QL (2625 per 84

MG 40 MG 60 MG

mg 5 mg 50 mg

per 30 days)

mg 20 mg 5 mg 75 mg

mg 15 mg 20 mg 5 mg

24hr 15 mg 3 mg

Drug Name

24hr 6 mg

24hr 9 mg

mg 8 mg

PERSERIS ABDOMINAL

SUBCUTANEOUS

120 MG 90 MG

mg 300 mg 400 mg 50 mg

30 days)

3 MG 4 MG

RISPERDAL CONSTA

MG2 ML 25 MG2 ML

RISPERDAL CONSTA

MG2 ML 50 MG2 ML

mg 2 mg 3 mg 4 mg

mg 05 mg 1 mg 2 mg

mg 4 mg

MG 25 MG 5 MG

mg 50 mg

mg 5 mg

30 days)

Drug Name

MG 45 MG 6 MG

PACK 15 MG (1)- 3 MG (6)

mg 60 mg 80 mg

ZYPREXA RELPREVV

Antiretrovirals

(Epzicom) 2

tablet 300-150-300 mg

(Trizivir) 5 NDS

300 mg

(Reyataz) 5 NDS

300 MG

400 MG

300 MG

400 mg

(Videx EC) 2

Drug Name

MG5 ML (5 MGML)

SOLN 90 MG

200-10 MG

200 MG

PACKET 100 MG

ISENTRESS ORAL

(Combivir) 2

mg5 ml

(Kaletra) 2

Drug Name

hr 100 mg 400 mg

(Viramune XR) 2

100 MG

600 MG 800 MG

DISPERSIBLE 100 MG

SOLUTION 10 MGML

PACKET 50 MG

300 MG 75 MG

mg 40 mg

200-300 MG

200-10 MG

300 mg

(Viread) 2

Drug Name

MG 133-200 MG 167-250 MG 200-300

MGML (FINAL)

VIDEX EC ORAL

CAPSULEDELAYED

625 MG

MGSCOOP (40 MGGRAM)

MG 250 MG

28 days)

480 MG

Drug Name

MGACTUATION

5 PA NDS

Hcv Antivirals

5 PA NDS

Interferons

5 PA NSO NDS

UNITML

5 PA NSO NDS

PEGASYS PROCLICK

MCG05 ML

SOLUTION 180 MCGML

Drug Name

MCG05 ML

200 MCG 300 MCG 600 MCG

5 PA NSO NDS

500 mg

2 PA BvD

500 mg

(Cytovene) 2 PA BvD

50 mgml

2 PA BvD

Expanders

Anticoagulants

PACK 5 MG (74 TABS)

mg3 ml

(Lovenox) 2

Drug Name

mg03 ml 40 mg04 ml 60 mg06 ml 80

mg08 ml

(Lovenox) 2

(Arixtra) 5 NDS

mg05 ml

(Arixtra) 2

5000 unitml (1 ml)

5000 unitml

unitml

1000 unitml

5000 unit05 ml

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

150 MG 75 MG

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

(Coumadin) 1

PACK 15 MG (42)- 20 MG (9)

TABLET 20 MG

SYRINGE 6 MG06 ML

5 PA NDS

GRANIX SUBCUTANEOUS

5 PA NDS

Drug Name

5 PA NDS

250 MCG

SYRINGE 6 MG06ML

5 PA NDS

MCG08 ML

5 PA NDS

4000 UNITML

20000 UNITML

40000 UNITML

PACKET 125 MG

30 days)

Drug Name

UNITML 4000 UNITML

40000 UNITML

SYRINGE 6 MG06 ML

5 PA NDS

150 MG

1000 mg10 ml (100 mgml)

(Cyklokapron) 2

Years)

400 mg

Caloric Agents

4 PA BvD

AMINOSYN 7 WITH

4 PA BvD

SOLUTION 85

4 PA BvD

Drug Name

4 PA BvD

SOLUTION 85

4 PA BvD

SOLUTION 7

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 275

4 PA BvD

Drug Name

SOLUTION 275

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

intravenous syringe

4 PA BvD

parenteral solution

4 PA BvD

intravenous syringe

4 PA BvD

FREAMINE HBC 69

SOLUTION 69

4 PA BvD

Drug Name

4 PA BvD

EMULSION 20 30

4 PA BvD

KABIVEN INTRAVENOUS

EMULSION 331-98-39

4 PA BvD

EMULSION 20

4 PA BvD

EMULSION 236-68-35

4 PA BvD

PARENTERAL SOLUTION

4 PA BvD

(Catapres) 1

mg24 hr

(Cardura) 2

Years)

200 MG 300 MG

30 days)

Drug Name

(Vazculep) 2

MG 40-25 MG

49-51 MG 97-103 MG

(Avapro) 1

150-125 mg 300-125 mg

(Avalide) 2

100-125 mg 100-25 mg 50-125 mg

(Hyzaar) 1

tablet 20-125 mg 40-125 mg 40-25 mg

(Benicar HCT) 2

(Micardis) 2

mg 80 mg

(Diovan) 2

160-125 mg 160-25 mg 320-125 mg

320-25 mg 80-125 mg

(Diovan HCT) 2

Inhibitors

(Lotensin) 1

mg 50 mg

mg 20 mg 5 mg

(Vasotec) 2

10-25 mg

(Vaseretic) 1

5-125 mg

Drug Name

10-125 mg 20-125 mg 20-25 mg

(Zestoretic) 1

mg 8 mg

(Accupril) 1

mg 5 mg

(Altace) 1

mg 150 mg

Years)

500 mcg

(Tikosyn) 2

mg5 ml (2 ) 50 mg5 ml (1 )

250 mg

mgml 500 mgml

300 mg

(Tenoretic 100) 2

(Tenoretic 50) 2

Drug Name

10-625 mg 25-625 mg 5-625 mg

(Ziac) 1

MG 20 MG 5 MG

3125 mg 625 mg

(Coreg) 1

(5 mgml)

(Toprol XL) 2

100-25 mg 100-50 mg

50-25 mg

(Lopressor HCT) 2

mg5 ml

(Lopressor) 2

mg5 ml

(Lopressor) 1

24 hr 120 mg 160 mg 60 mg 80 mg

(Inderal LA) 2

mg 60 mg 80 mg

mg 80 mg

(Betapace) 2

Drug Name

24hr 120 mg 180 mg 240 mg 300 mg

(Tiazac) 2

(Cardizem CD) 2

(Cardizem) 2

120 mg 180 mg 240 mg

hr 120 mg 180 mg 240 mg 300 mg 360

100 mg 200 mg 300 mg

(Verelan PM) 2

hr 120 mg 180 mg 240 mg

(Verelan) 2

hr 360 mg

(Verelan) 4

mg 180 mg 240 mg

(Calan SR) 1

Drug Name

mg03 ml

30 MG3 ML

mg 50 mg

hr 1000 mg 500 mg

(Ranexa) 2

MG03 ML

30 days)

Dihydropyridines

mg 60 mg

(Norvasc) 1

mg 10-40 mg 5-10 mg 5-20 mg 5-40 mg

(Lotrel) 2

mg 10-320 mg 5-160 mg 5-320 mg

(Exforge) 2

24hr 30 mg 60 mg 90 mg

(Procardia XL) 2

mg 60 mg 90 mg

(Adalat CC) 2

Diuretics

5-50 mg

Drug Name

soln 500 mg

(Diuril IV) 2

mg5 ml (8 mgml)

(Lasix) 1

25 mg 50 mg

30 days)

(PM) 60 MG (AM) 30 MG (PM) 90 MG

(AM) 30 MG (PM)

(Aldactone) 1

capsule 375-25 mg

(Dyazide) 1

capsule 50-25 mg

375-25 mg

(Maxzide-25mg) 1

75-50 mg

(Maxzide) 1

Dyslipidemics

mg 80 mg

(Lipitor) 1

in packet 4 gram

(Questran) 2

Drug Name

mg 200 mg 67 mg

145 mg 48 mg

(Tricor) 2

MG 40 MG 60 MG

1000 mg 500 mg 750 mg

(Niaspan Extended-

Release)

(Pravachol) 1

REPATHA PUSHTRONEX

REPATHA SURECLICK

REPATHA SYRINGE

mg 5 mg

mg 80 mg

Drug Name

PACKET 375 GRAM

Inhibitors

125 MG 150-25 MG 300-125 MG 300-

Vasodilators

mg 30 mg

release 40 mg

(ISOCHRON) 2

mg10 ml (5 mgml)

mg 06 mg

(Nitrostat) 2

(Minitran) 2

25 mg 40 mg

Drug Name

30 days)

mg3 ml (20 mgml)

(Cafcit) 2 PA BvD

(20 mgml)

12 hr 10 mg

mg 5 mg

mg 30 mg

mg 5 mg 75 mg

Drug Name

(Intuniv ER) 2

MG (21)

5 PA NDS

SOLUTION 12 MG12 ML

300 mg 600 mg

release 300 mg

(Lithobid) 2

release 450 mg

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

28 days)

mg 60 mg

Drug Name

ml 5 mg5 ml

mg 5 mg

OCREVUS INTRAVENOUS

SOLUTION 30 MGML

5 PA NDS QL (20 per

180 days)

MCG05 ML

5 PA NDS

28 days)

MCG05 ML

MCG05ML (6)

5 PA NDS

125 MG 25 MG 50 MG

PACK 125 MG (5)-25 MG(8)-50 MG(42)

Drug Name

TECFIDERA ORAL

CAPSULEDELAYED

TECFIDERA ORAL

CAPSULEDELAYED

MG (46)

5 PA NDS

TECFIDERA ORAL

CAPSULEDELAYED

28 days)

Contraceptives

mg- 35 mcg

010 mg-20 mcg (84)10 mcg (7)

015 mg-30 mcg (84)10 mcg (7)

mg-mcg

(24)75 mg (4)

30 mcg (21)75 mg (7)

mcg (21)75 mg (7)

001 mg x 5

Drug Name

001 mg x 5

(24)75 mg (4)

mcg (21)75 mg (7)

mg-mcg

mg- 35 mcg

015 mg-30 mcg (84)10 mcg (7)

015-002 mgx21 001 mg x 5

(Azurette (28)) 2

015-003 mg

(Apri) 2

3-002 mg

(Gianvi (28)) 2

3-003 mg

(Ocella) 2

(5)125-30(10)

Drug Name

35 mg-mcg

(Kelnor 135 (28)) 2

50 mg-mcg

(Kelnor 1-50) 2

(24)75 mg (4)

015 mg-30 mcg (91)

mcg (21)75 mg (7)

(21)75 mg (7)

(24)75 mg (4)

001 mg x 5

(84)10 mcg (7)

mcg 015 mg-25 mcg

(84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

(21)75 mg (7)

(5)125-30(10)

01-20 mg-mcg

(Afirmelle) 2

015-003 mg

(Altavera (28)) 2

50-30 (6)75-40 (5)125-30(10)

(Enpresse) 2

20 mcg (21)75 mg (7)

(5)125-30(10)

Drug Name

035 mg

(Camila) 2

1-20 mg-mcg

(Aurovela 120 (21)) 2

1 mg-20 mcg (21)75 mg (7)

1 mg-20 mcg (24)75 mg (4)

(Aurovela 24 Fe) 2

0180215025 mg-25 mcg

0180215025 mg-35 mcg (28)

025-35 mg-mcg

(Estarylla) 2

mg- 35 mcg

001 mg x 5

mcg 1-35 mg-mcg

015 mg-30 mcg (91)

001 mg x 5

015 mg-30 mcg (84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

35mcg (9)

mg-35 mcg (28)

1mg-35mcg (9)

35 mcg (28)

mg-25 mcg

25 mcg

mg-25 mcg

mcg (28)

0180215025 mg-35 mcg (28)

(5)125-30(10)

mg-25 mcg

35 mcg (28)

0112515-25 mg-mcg

001 mg x 5

Drug Name

mcg24 hr

mouthwash 012

(Oralone) 2

(Soriatane) 2

MEDICATED

rel 10 mg

Drug Name

UNITGRAM

mg 40 mg

(Cleocin T) 2

(Ery Pads) 2

suspension 10

(Klaron) 2

Agents

Drug Name

ointment 005

(Diprolene) 2

(Cutivate) 2

Drug Name

applicator 25

(Triderm) 1

0025 01

0025 01 05

Devices

Drug Name

03 ML 31 GAUGE X 1564

12 ML 31 GAUGE X 1564

(Lite Touch Insulin

Syringe)

GAUGE X 12

(1st Tier Unifine

Pentips)

SOLUTION 250 UNITML

SOLUTION 29 MG5 ML

SOLN 400 UNIT

60000 UNIT 24000-76000 -120000

UNIT 3000-9500- 15000 UNIT

36000-114000- 180000 UNIT 6000-

19000 -30000 UNIT

SOLUTION 6 MG3 ML

SOLN 15 MG 75 MG

SOLN 35 MG 5 MG

5 PA NDS

2 MGML

5 PA NDS

Drug Name

SOLUTION 8 MGML

5 PA BvD NDS

2 MGML

5 PA NDS

SOLUTION 5 MG5 ML

5 PA NDS

MG 20 MG 5 MG

5 PA NDS

ML 20 MGML

5 PA NDS

SOLUTION 1 MGML

5 PA BvD NDS

5 PA NDS

5 PA LA NDS

5 MG5 ML (1 MGML)

5 PA NDS

400 UNIT

42000 UNIT 15000-47000 -63000

UNIT 20000-63000- 84000 UNIT

25000-79000- 105000 UNIT 3000-

10000 -14000-UNIT 40000-126000-

168000 UNIT 5000-17000- 24000

Miscellaneous

Drug Name

(Cyclogyl) 2

DROPS 044

aerosol 003

(Alcaine) 2

Agents

unitgram

(AK-Poly-Bac) 2

CIPRODEX OTIC (EAR)

(Ciloxan) 1

(Cetraxal) 4

mggram (05 )

mggram)

DROPS VISCOUS 05

Drug Name

(Vigamox) 2

DROPSSUSPENSION 5

(Neo-Polycin HC) 2

mg-unit-unitg

(Neo-Polycin) 2

(Maxitrol) 2

10000 unitg-01

(Maxitrol) 2

unit-0025mgml

unitml-

35-400-10000 mg-unitg-1

10000 unitgram

(Polytrim) 1

drops 10

(Bleph-10) 2

ointment 10

(eye) drops 10 -023 (025 )

Drug Name

(TobraDex) 2

Inflammatory Agents

DROPSSUSPENSION 02

DROPS 0075

DROPS 005

mcg (0025 )

dropssuspension 01

(FML Liquifilm) 4

drops 003

DROPSSUSPENSION 03

DROPSSUSPENSION 1

DROPSGEL 05

OINTMENT 05

DROPSGEL 038

dropssuspension 1

(Pred Forte) 4

Drug Name

DROPS 007

DROPPERETTE 005

DROPPERETTE 5

soln 20 mg

soln 40 mg

(Nexium IV) 2

mg2 ml

release(drec) 15 mg

release(drec) 30 mg

(Protonix) 2

(drec) 20 mg

(drec) 40 mg

50 mg2 ml (25 mgml)

(Zantac) 2

(ranitidine))

Drug Name

DISPERSIBLE 200 MG

0025 mg5 ml

Years)

0025 mg

Years)

KIT 5 MG

5 PA NDS

193 gram60 ml

290 MCG 72 MCG

(loperamide))

(Reglan) 1

Drug Name

SOLUTION 12 MG06 ML

28 days)

SYRINGE 12 MG06 ML

28 days)

SYRINGE 8 MG04 ML

28 days)

gram60 ml

Laxatives

GRAM -12 GRAM160 ML

-584 gram

-586 gram

2272-672 -584 gram

(Colyte with Flavor

Packs)

420 gram

Phosphate Binders

Drug Name

(Renvela) 5 NDS

VELPHORO ORAL

mg 5 mg 50 mg

(Urecholine) 2

(Ditropan XL) 2

release 24hr 15 mg

24hr 2 mg 4 mg

(Detrol LA) 2

hr 10 mg

(Uroxatral) 1

THIOLA EC ORAL

5 PA NDS

Drug Name

mg 250 mg 500 mg

(Exjade) 5 PA NDS

500 mg

(Desferal) 2 PA

250 MG

5 PA NDS

MG 90 MG

5 PA NDS

MG 90 MG

5 PA NDS

30 days)

Hormonal Agents

Androgens

100 mgml 200 mgml

200 mgml (1 ml)

200 mgml

ML 75 MG05 ML

Years)

Drug Name

mg24 hr 00375 mg24 hr 005 mg24 hr

0075 mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

0025 mg24 hr 005 mg24 hr 0075

mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

00375 mg24 hr

days) AGE (Max 64

Years)

mg24 hr 00375 mg24 hr 005 mg24 hr

006 mg24 hr 0075 mg24 hr 01 mg24

days) AGE (Max 64

Years)

mgml 40 mgml

(Delestrogen) 2

05-01 mg

Years)

HR 01 MG24 HR

mg-mcg

Years)

05-25 mg-mcg

Years)

1-5 mg-mcg

Years)

045 MG 0625 MG 09 MG 125 MG

Years)

MGGRAM

Drug Name

MG (14) 0625MG-5MG(14)

Years)

045-15 MG 0625-25 MG 0625-5 MG

Years)

suspension 6 mgml

mg 4 mg 6 mg

(Decadron) 1 PA BvD

1 PA BvD

solution 10 mgml

MG 6 MG

(Cortef) 2

(Depo-Medrol) 2

mg 4 mg 8 mg

(Medrol) 2

(Medrol (Pak)) 2

(Solu-Medrol) 2

mg5 ml (3 mgml)

2 PA BvD

Drug Name

2 PA BvD

1 PA BvD

suspension 40 mgml

(Kenalog) 2

Pituitary

mcgspray (01 ml)

(DDAVP) 2

mcgspray (01 ml)

SOLN 1 MG

MG025 ML

MG025 ML 06 MG025 ML 08

MG025 ML 1 MG025 ML 12

MG025 ML 14 MG025 ML 16

MG025 ML 18 MG025 ML 2

MG025 ML

5 PA NDS

5 MGML (15 UNITML)

5 PA NDS

HUMATROPE INJECTION

5 PA NDS

SOLN 5 (15 UNIT) MG

5 PA NDS

Drug Name

SOLUTION 10 MGML

1125 MG

SYRINGE KIT 75 MG

LUPRON DEPOT-PED

NORDITROPIN FLEXPRO

ML (10 MGML) 30 MG3 ML (10

5 PA NDS

NORDITROPIN FLEXPRO

MG15 ML (33 MGML)

NUTROPIN AQ NUSPIN

5 PA NDS

mcgml 200 mcgml

(Sandostatin) 2

mcgml (1 ml)

5 PA NDS

RECON SOLN 58 MG

5 PA NDS

Drug Name

SAIZEN SAIZENPREP

5 PA NDS

SOLN 5 MG 88 MG

5 PA NDS

INTRAMUSCULAR

SOLN 4 MG 5 MG 6 MG

5 PA NDS

SOMATULINE DEPOT

MG05 ML

5 PA NSO NDS QL (1

per 28 days)

SOMATULINE DEPOT

ML 90 MG03 ML

25 MG 30 MG

5 PA NDS

(65 MCGDAY)

5 NDS QL (1 per 360

AEROSOL 2 MGML

225 MG

5 NDS QL (1 per 168

RECON SOLN 10 MG

5 PA NDS

RECON SOLN 5 MG

SOLN 88 MG

5 PA NDS

Progestins

SUSPENSION 400 MGML

5 PA NSO NDS

Drug Name

suspension 150 mgml

syringe 150 mgml

25 mg 5 mg

(Provera) 1

(40 mgml)

Years)

mg 200 mg

(Prometrium) 2

mcg 125 mcg 137 mcg 150 mcg 175

88 mcg

(Euthyrox) 1

(Cytomel) 2

ACTEMRA ACTPEN

MG09 ML

5 PA NDS

ACTEMRA INTRAVENOUS

80 MG4 ML (20 MGML)

5 PA NDS

SYRINGE 162 MG09 ML

5 PA NDS

SOLN 220 MG

100 mg

2 PA BvD

MG X 2 VIALS)

5 PA NDS

Drug Name

5 PA NDS

mg5 ml

mg 25 mg

(Gengraf) 2 PA BvD

5 PA NDS

SOLN 25 MG (1 ML)

5 PA NDS

25 MG05 ML (05) 50 MGML (1 ML)

5 PA NDS

ENBREL SURECLICK

MGML (1 ML)

5 PA NDS

SOLUTION 10 5

5 PA BvD NDS

4 PA BvD

SOLUTION 10

5 PA BvD NDS

GRAM 5 GRAM

5 PA BvD NDS

SOLUTION 10 10 (100 ML) 10

(200 ML)

5 PA BvD NDS

Drug Name

KIT 40 MG08 ML 40 MG08 ML (6

5 PA NDS

KIT 40 MG08 ML

5 PA NDS

KIT 10 MG02 ML 20 MG04 ML 40

MG08 ML

5 PA NDS

MG08 ML-40 MG04 ML

5 PA NDS

80 MG08 ML

5 PA NDS

MG02 ML 40 MG04 ML

5 PA NDS

SOLUTION 300 UNITML

HYPERRAB SD (PF)

UNITML

HYQVIA SUBCUTANEOUS

25 GRAM 25 ML (10 ) 20 GRAM

200 ML (10 ) 30 GRAM 300 ML (10

) 5 GRAM 50 ML (10 )

5 PA BvD NDS

SOLN 150 MGML

5 PA NDS

SOLUTION 150 MGML

5 PA NDS

Drug Name

100 MGML

5 PA NDS

UNITML

SOLN 100 MG

5 PA NDS

SOLUTION 150 UNITML

MG114 ML

5 PA NDS

MG114 ML

5 PA NDS

100 MG067 ML

5 PA NDS

recon soln 500 mg

(CellCept) 2 PA BvD

SOLN 250 MG

5 PA BvD NDS

OCTAGAM INTRAVENOUS

SOLUTION 10 5

5 PA BvD NDS

5 PA NDS

ORENCIA CLICKJECT

125 MGML

5 PA NDS

875 MG07 ML

5 PA NDS

OTEZLA STARTER ORAL

MG (4)-30 MG (47) 10 MG (4)-20 MG

(4)-30 MG(19)

5 PA NDS

Drug Name

SOLUTION 10

5 PA BvD NDS

5 MGML

4 PA BvD

PACKET 02 MG 1 MG

4 PA BvD ST

MG025 ML 15 MG03 ML 175

MG035 ML 20 MG04 ML 225

MG045 ML 25 MG05 ML 30 MG06

ML 75 MG015 ML

SOLN 100 MG

5 PA NDS

SOLN 100 MG

5 PA NDS

MG15 ML

5 PA NDS

SOLUTION 125 MGML

5 PA NDS

100 MGML 50 MG05 ML

5 PA NDS

130 MG26 ML

5 PA NDS

SOLUTION 45 MG05 ML

5 PA NDS

(Prograf) 2 PA BvD

TALTZ AUTOINJECTOR

80 MGML

5 PA NDS

Drug Name

SYRINGE 80 MGML

5 PA NDS

INJECTOR 100 MGML

5 PA NDS

SYRINGE 100 MGML

5 PA NDS

300 MG15 ML

5 PA LA NDS

5 PA NDS

05 MG 075 MG 1 MG

5 PA BvD NDS

Vaccines

ADACEL(TDAP

ADOLESNADULT)(PF)

LF-(25-5-3-5 MCG)-5LF05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

(25-5-3-5 MCG)-5LF05 ML

3 PA BvD

LF05ML

10-5 LF-MCG-LF05ML

SUSPENSION 20 MCGML

3 PA BvD

Drug Name

SYRINGE 20 MCGML

3 PA BvD

MCG05 ML

3 PA BvD

SUSPENSION 05 ML

SYRINGE 05 ML

720 ELISA UNIT05 ML

ELISA UNIT05 ML

3 PA BvD

58-10 LF-MCG-LF05ML

LF-MCG-LF05ML

32 UNIT05 ML

UNIT05 ML

SYRINGE 6 MCG05 ML

SOLUTION 4 MCG05 ML

Drug Name

10LF05 ML

10EXP3-43-3- 399 TCID5005

UNIT05ML

25 UNIT

3 PA BvD

RECOMBIVAX HB (PF)

3 PA BvD

RECOMBIVAX HB (PF)

MCGML 5 MCG05 ML

3 PA BvD

CCID50ML

SOLUTION 2 ML

50 MCG05 ML

TDVAX INTRAMUSCULAR

UNIT05ML

LF UNIT05 ML

Drug Name

SYRINGE 25 MCG05 ML

UNITML

1350 UNIT05 ML

10 EXP474 UNIT05 ML

19400 UNIT065 ML

Agents

budesonide oral

(Entocort EC) 2

tablets) 400 mg

(Delzicol) 2

(drec) 800 mg

(Asacol HD) 2

Drug Name

(drec) 500 mg

MGACTUATION

SOLUTION

Chloride)

solution

(Aqua Care Sterile

Water)

mcg2 ml

(Hectorol) 2

105 MG117 ML

30 days)

210MG234ML ( 105MG117MLX2)

30 days)

MCG24 ML

Drug Name

200 UNITML

MCGDOSE

solution 2 mcgml

60 MGML

RAYALDEE ORAL

HR 30 MCG

3 PA QL (156 per 30

mg5 ml

soln 500 mg

(Ethyol) 2

SOLN 120 MG 400 MG

5 PA NDS

INJECTOR 200 MGML

SYRINGE 200 MGML

CETYLEV ORAL TABLET

Drug Name

GRAM17 ML

5 GRAM

30 days)

SOLUTION 50 MGML

5 PA LA NDS

RECON SOLN 1 MG

(Vistaril) 1

30 days)

100 mg 200 mg 350 mg 50 mg 500 mg

mg 25 mg 5 mg

100 mgml

(Carnitor) 2

soln 50 mg

(Fusilev) 5 NDS

mg5 ml

(Mestinon) 2

Drug Name

150 MG 200 MG 50 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 500 MG

PACKET 10 GRAM

5 NDS QL (24 per 14

PACKET 2 GRAM

30 days)

Ophthalmic Agents

Antiglaucoma Agents

release 500 mg

500 mg

DROPS 01

DROPSSUSPENSION 1

DROPS 02-05

drops 223-68 mgml

(Cosopt) 2

DROPS 001

(Isopto Carpine) 2

DROPS 002

Drug Name

025 05

(Timoptic) 1

(Timoptic-XE) 4

DROPS 0004

mgml (10 )

IONOSOL-MB IN D5W

SOLUTION 5

PARENTERAL SOLUTION

release 8 meq

40 gram1000 ml (4 )

2 PA BvD

gram100 ml (4 ) 4 gram50 ml (8 )

2 PA BvD

meqml (50 )

2 PA BvD

Drug Name

SOLUTION

SINGLE-USE

PARENTERAL SOLUTION

2 PA BvD

meqml (20 ml)

2 PA BvD

release 10 meq

release 8 meq

ml 40 meq15 ml

(K-Tab) 2

release 20 meq

(K-Tab) 4

(Klor-Con M10) 2

(Klor-Con M20) 2

(Urocit-K 10) 2

release 15 meq

(Urocit-K 15) 2

(Urocit-K 5) 2

parenteral solution

Corticosteroids

Drug Name

50 MCGDOSE

MCGACTUATION 230-21

MCGACTUATION 45-21

MCGACTUATION

MCGACTUATION 200

MCGACTUATION 50

MCGACTUATION

mg2 ml

MCGACTUATION

MCGACTUATION 50

MCGACTUATION

AEROSOL INHALER 110

MCGACTUATION

AEROSOL INHALER 220

MCGACTUATION

AEROSOL INHALER 44

MCGACTUATION

Drug Name

INHALATIONS 80-45

MCGACTUATION

MCGACTUATION 80-45

MCGACTUATION

Antileukotrienes

(Singulair) 1

Bronchodilators

25 mg 3 ml (0083 ) 25 mg05 ml

2 PA BvD

MCGACTUATION

AEROSOL INHALER 17

MCGACTUATION

COMBIVENT RESPIMAT

MCGACTUATION

2 PA BvD

STARTER 25 MCGML

Drug Name

MCGDOSE

12 hr 100 mg 200 mg 300 mg

(Theochron) 2

12 hr 450 mg

24 hr 400 mg 600 mg

(30 ACTUAT)

mgml (20 )

(Acetadote) 2 PA

200 mgml (20 )

2 PA BvD

10 MGML

5 PA NDS

2 PA BvD

Drug Name

30 days)

SYRINGE 30 MGML

INJECTOR 100 MGML

28 days)

SOLN 100 MG

28 days)

100 MGML

28 days)

PACKET 100-125 MG 150-188 MG

MG 200-125 MG

30 days)

RECON SOLN 1000 MG

5 PA BvD NDS

(N) 50-75 MG (D) 75 MG (N)

SOLN 150 MG

5 PA NDS

150 MGML 75 MG05 ML

5 PA NDS

Years)

Drug Name

Years)

250 mg 50 mg

MG 20 MG 5 MG

per 30 days)

Vasodilating Agents

MG 15 MG 2 MG 25 MG

soln 05 mg

(Flolan) 2 PA

soln 15 mg

(Flolan) 5 PA NDS

25 MG 5 MG

5 PA NDS

Drug Name

1 day)

SUSPENSION 32 MG

28 days)

(06 MGML)

5 PA NDS

1200 MCG 1400 MCG 1600 MCG

400 MCG 600 MCG 800 MCG

30 days)

PACK 200 MCG (140)- 800 MCG (60)

5 PA NDS

27 mg iron- 1 mg

A abacavir 47

ABELCET 35

ABILIFY MAINTENA 43

ABRAXANE 15

acamprosate 7

acarbose 32

acebutolol 60

acetazolamide 107

acetic acid 82 104

acetylcysteine 112

acitretin 76

ACTEMRA 95

ACTEMRA ACTPEN 95

ACTHIB (PF) 100

ACTIMMUNE 105

acyclovir 52 76

acyclovir sodium 52

ADACEL(TDAP

ADAGEN 80

adapalene 79

adefovir 52

ADEMPAS 114

adriamycin 15

adrucil 15

ADVAIR DISKUS 110

ADVAIR HFA 110

afeditab cr 63

AFINITOR 15

AFINITOR DISPERZ 15

afirmelle 70

a-hydrocort 91

(2 PACK) 38

AJOVY 38

AKYNZEO

(FOSNETUPITANT) 39

ala-cort 77

albendazole 41

alclometasone 77

ALCOHOL PADS 76

ALDURAZYME 80

ALECENSA 16

alendronate 104

alfuzosin 88

ALIMTA 16

ALINIA 41

ALIQOPA 16

aliskiren 66

allopurinol 37

alosetron 103

ALPHAGAN P 107

alprazolam 8

ALREX 84

altavera (28) 70

ALTRENO 79

ALUNBRIG 16

alyacen 135 (28) 70

alyacen 777 (28) 70

alyq 114

amabelz 89

amantadine hcl 41

AMBISOME 35

ambrisentan 114

amethia 70

amethia lo 70

amiloride 63

AMINOSYN 10 55

AMINOSYN 7 WITH

ELECTROLYTES 55

AMINOSYN 85 55

AMINOSYN 85 -

ELECTROLYTES 55

AMINOSYN II 10 56

AMINOSYN II 15 56

AMINOSYN II 7 56

AMINOSYN II 85 56

AMINOSYN II 85 -

ELECTROLYTES 56

AMINOSYN M 35 56

AMINOSYN-HBC 7 56

AMINOSYN-PF 10 56

AMINOSYN-PF 7

(SULFITE-FREE) 56

AMINOSYN-RF 52 56

amiodarone 60

AMITIZA 86

amitriptyline 29

amlodipine 63

ammonium lactate 76

amoxapine 30

amoxicillin 13

amphotericin b 35

ampicillin 13

ANADROL-50 89

anagrelide 55

anastrozole 16

ANORO ELLIPTA 111

APOKYN 41

apraclonidine 81

aprepitant 39

apri 70

APRISO 103

APTIOM 25 26

APTIVUS 47

aranelle (28) 70

ARCALYST 95

aripiprazole 43

ARISTADA 43

ARISTADA INITIO 43

armodafinil 114

ARNUITY ELLIPTA 110

arsenic trioxide 16

ashlyna 70

ASSURE ID INSULIN

SAFETY 79

atazanavir 47

atenolol 60

atomoxetine 66

atorvastatin 64

atovaquone 41

ATRIPLA 47

atropine 25 82

ATROVENT HFA 111

AUBAGIO 66

aubra 70

aurovela 1530 (21) 70

aurovela 24 fe 70

AUSTEDO 67

AVASTIN 16

aviane 70

AVONEX 67

ayuna 70

azacitidine 16

azathioprine 95

azelastine 82

azithromycin 12

AZOPT 107

aztreonam 13

azurette (28) 70

B baciim 10

bacitracin 82

baclofen 113

balsalazide 103

BALVERSA 16

balziva (28) 71

BANZEL 26

BAVENCIO 16

BAXDELA 14

NEEDLE 79

UNIT 80

bekyree (28) 71

BELEODAQ 16

BELSOMRA 114

benazepril 59

BENDEKA 16

BENLYSTA 105

benztropine 41

BESPONSA 16

BETASERON 67

betaxolol 60

BETHKIS 9

BEVYXXA 52

bexarotene 16

BEXSERO 100

bicalutamide 16

BICILLIN L-A 13

BIDIL 66

BIKTARVY 47

bleomycin 16

bleph-10 82

BLINCYTO 16

blisovi 24 fe 71

blisovi fe 1530 (28) 71

BOOSTRIX TDAP 100

BORTEZOMIB 16

BOSULIF 16 17

BRAFTOVI 17

BREO ELLIPTA 110

briellyn 71

BRILINTA 55

brimonidine 107

BRIVIACT 26

bromocriptine 41

BROMSITE 84

budesonide 103 110

bumetanide 63

bupropion hcl 30

buspirone 8

BYSTOLIC 61

BYVALSON 61

C cabergoline 41

CABLIVI 105

CABOMETYX 17

caffeine citrate 67

calcipotriene 76

calcitriol 104

CALDOLOR 6

CALQUENCE 17

camila 71

CAPASTAT 39

CAPRELSA 17

captopril 59

CARBAGLU 86

carbamazepine 26

carteolol 107

cartia xt 62

carvedilol 61

caspofungin 36

CAYSTON 13

caziant (28) 71

cefaclor 11

cefadroxil 11

cefazolin 11

cefdinir 11

cefepime 11

cefixime 11

cefotaxime 11

cefoxitin 11

cefpodoxime 12

cefprozil 12

ceftazidime 12

ceftriaxone 12

celecoxib 6

CELONTIN 26

cephalexin 12

CERDELGA 80

CEREZYME 80

CETYLEV 105

CHANTIX 8

CHANTIX CONTINUING

MONTH BOX 8

CHANTIX STARTING

MONTH BOX 8

chlorothiazide 64

chlorpromazine 43

chlorthalidone 64

chlorzoxazone 113

ciclopirox 36

cilostazol 55

CIMDUO 47

cimetidine hcl 85

CIMZIA 95

CIMZIA POWDER FOR

RECONST 95

cinacalcet 104

CINQAIR 112

CINRYZE 53

CINVANTI 39

CIPRODEX 82

ciprofloxacin 14

citalopram 30

clarithromycin 12

CLENPIQ 87

clindamycin hcl 10

CLINIMIX 5D15W

SULFITE FREE 56

CLINIMIX 5D25W

SULFITE-FREE 56

FREE 56

CLINIMIX 425D5W

SULFIT FREE 56

CLINIMIX 425-D25W

SULF-FREE 56

CLINIMIX 5-

CLINIMIX E 275D10W

SUL FREE 56

CLINIMIX E 275D5W

SULF FREE 57

CLINIMIX E 425D10W

SUL FREE 57

CLINIMIX E 425D25W

SUL FREE 57

CLINIMIX E 425D5W

SULF FREE 57

CLINIMIX E 5D15W

SULFIT FREE 57

CLINIMIX E 5D20W

SULFIT FREE 57

CLINIMIX E 5D25W

SULFIT FREE 57

clobazam 26

clobetasol 78

clofarabine 17

clomipramine 30

clonazepam 9

clonidine 58

clonidine hcl 58

clopidogrel 55

clotrimazole 36

clozapine 43 44

COARTEM 41

codeine sulfate 3

colchicine 37

colestipol 64

colocort 103

COMBIGAN 107

COMETRIQ 17

COMPLERA 47

compro 39

constulose 86

COPIKTRA 17

CORLANOR 62

cormax 78

cortisone 91

COTELLIC 17

CREON 80

CRIXIVAN 47

cromolyn 82 86 112

cryselle (28) 71

cyclobenzaprine 113

cyclopentolate 82

cyclophosphamide 17

CYCLOPHOSPHAMIDE 17

cyclosporine 96

cyproheptadine 37

CYRAMZA 17

cyred 71

CYSTADANE 106

CYSTARAN 82

D dalfampridine 67

DALIRESP 113

danazol 89

dantrolene 113 114

dapsone 39

DAPTACEL (DTAP

PEDIATRIC) (PF) 100

daptomycin 10

DARAPRIM 41

DARZALEX 17

dasetta 135 (28) 71

dasetta 777 (28) 71

DAURISMO 17

daysee 71

deblitane 71

decadron 91

decitabine 17

deferasirox 89

deferoxamine 89

DELSTRIGO 47

delyla (28) 71

DEMSER 62

DEPEN TITRATABS 89

DEPO-PROVERA 94

DESCOVY 47

desipramine 30

desmopressin 92

desoximetasone 78

dexamethasone 91

(pf) 91

phosphate 84 91

dextroamphetamine-

amphetamine 67

DIASTAT 26

DIASTAT ACUDIAL 26

diazepam 9 26

diazepam intensol 9

dicloxacillin 13

dicyclomine 86

didanosine 47

DIFICID 12

digitek 62

digox 62

digoxin 62 63

DIGOXIN 63

diltiazem hcl 62

dilt-xr 62

dimenhydrinate 39

DIPENTUM 103

dipyridamole 55

disulfiram 8

divalproex 26

dofetilide 60

donepezil 29

dorzolamide 107

dotti 90

DOVATO 48

doxazosin 58

doxepin 30

doxercalciferol 104

doxorubicin 17

doxy-100 15

dronabinol 39

droperidol 106

DROXIA 18

DUAVEE 90

duloxetine 30

DUPIXENT 96

DUREZOL 84

dutasteride 88

E econazole 36

EDARBI 59

EDARBYCLOR 59

EDURANT 48

efavirenz 48

EGRIFTA 92

ELAPRASE 80

ELIGARD 18

elinest 71

ELIQUIS 52

ELITEK 80

ELLA 71

ELMIRON 106

EMCYT 18

EMEND 40

EMFLAZA 91

EMGALITY PEN 38

EMGALITY SYRINGE 38

emoquette 71

EMPLICITI 18

EMSAM 30

EMTRIVA 48

enalaprilat 59

ENBREL 96

ENBREL SURECLICK 96

ENDARI 106

endocet 3

enoxaparin 52 53

enpresse 71

enskyce 71

entacapone 42

entecavir 52

ENTRESTO 59

enulose 86

EPCLUSA 51

EPIDIOLEX 26

epinastine 82

epinephrine 63

epitol 26

EPIVIR HBV 48

eplerenone 66

ergoloid 106

ERGOMAR 38

ERIVEDGE 18

ERLEADA 18

erlotinib 18

errin 71

ertapenem 13

ery pads 77

erythromycin 12 82

ESBRIET 113

estarylla 71

estradiol 90

eszopiclone 114

ethambutol 39

ethosuximide 26

etodolac 6

ETOPOPHOS 18

etoposide 18

EUCRISA 78

EVENITY 104

EVOTAZ 48

exemestane 18

EXONDYS 51 106

EXTAVIA 67

ezetimibe 65

F FABRAZYME 80

falmina (28) 72

famciclovir 52

famotidine 85

famotidine (pf) 85

FANAPT 44

FARYDAK 18

FASENRA 113

febuxostat 37

felbamate 27

FEMRING 90

femynor 72

fenofibrate 65

fentanyl 3

fentanyl citrate 3

FERRIPROX 89

FETZIMA 30

INSULIN 33

finasteride 88

FIRAZYR 63

FIRVANQ 10

FLEBOGAMMA DIF 96

flecainide 60

FLOVENT DISKUS 110

FLOVENT HFA 110

floxuridine 18

fluconazole 36

flucytosine 36

fludrocortisone 91

flumazenil 67

flunisolide 84

fluocinolone 78

fluocinonide 78

fluocinonide-e 78

fluorometholone 84

fluorouracil 18 76

fluoxetine 30

fluphenazine hcl 44

flurbiprofen 6

flutamide 18

fluvoxamine 31

fomepizole 106

fondaparinux 53

FORTEO 104

fosamprenavir 48

foscarnet 50

fosinopril 59

fosphenytoin 27

FREAMINE HBC 69 57

FREAMINE III 10 58

FULPHILA 53

fulvestrant 18

furosemide 64

FUZEON 48

fyavolv 90

FYCOMPA 27

G gabapentin 27

GALAFOLD 80

galantamine 29

GAMASTAN 96

GAMMAGARD LIQUID 96

MCGML) 96

GAMMAPLEX 96

GAMMAPLEX (WITH

SORBITOL) 96

GARDASIL 9 (PF) 101

GATTEX 30-VIAL 86

GAUZE PAD 80

gavilyte-c 87

gavilyte-g 87

gavilyte-n 87

GAZYVA 18

gemfibrozil 65

generlac 86

gengraf 96

GENOTROPIN 92

gentak 82

gentamicin 9 77 82

GENVOYA 48

GEODON 44

GILENYA 67

GILOTRIF 18

glatiramer 67

glatopa 67 68

GLEOSTINE 18

glimepiride 35

glipizide 35

glyburide 35

glycopyrrolate 86

glydo 7

GLYXAMBI 32

GOCOVRI 42

granisetron (pf) 40

granisetron hcl 40

GRANIX 53 54

guanfacine 58 68

guanidine 106

H HAEGARDA 54

hailey 24 fe 72

haloperidol 44

HARVONI 51

HAVRIX (PF) 101

heather 72

HEPATAMINE 8 58

HERCEPTIN 19

HETLIOZ 114

HIBERIX (PF) 101

HUMATROPE 92

HUMIRA 97

HUMIRA PEDIATRIC

CROHNS START 97

HUMIRA PEN 97

HS START 97

HUMIRA PEN PSOR-

UVEITS-ADOL HS 97

HUMIRA(CF) 97

STARTER 97

HUMIRA(CF) PEN 97

UC-HS 97

ADOL HS 97

INSULIN 34

KWIKPEN 34

hydralazine 63

hydromorphone 4

hydroxyurea 19

hydroxyzine hcl 37

HYPERRAB (PF) 97

HYPERRAB SD (PF) 97

HYQVIA 97

I ibandronate 104

IBRANCE 19

ibuprofen 6

icatibant 63

ICLUSIG 19

IDHIFA 19

ifosfamide 19

ifosfamide-mesna 19

ILARIS (PF) 97

ILEVRO 84

ILUMYA 98

imatinib 19

IMBRUVICA 19

IMFINZI 19

imipramine hcl 31

imiquimod 76

IMLYGIC 19

(PF) 101

IMPAVIDO 41

INBRIJA 42

incassia 72

INCRELEX 93

INCRUSE ELLIPTA 111

indapamide 64

indomethacin 6

INFLECTRA 98

INGREZZA 68

INGREZZA INITIATION

PACK 68

INLYTA 19

U-100 80

INTELENCE 48

INTRALIPID 58

INTRON A 51

introvale 72

INVEGA SUSTENNA 45

INVEGA TRINZA 45

INVELTYS 84

INVIRASE 48

INVOKAMET 32

INVOKAMET XR 32

INVOKANA 32

IPOL 101

irbesartan 59

IRESSA 19

ISENTRESS 48

ISENTRESS HD 48

isibloom 72

ISOLYTE-P IN 5

DEXTROSE 108

ISOLYTE-S 108

isoniazid 39

itraconazole 36

ivermectin 41

IXEMPRA 19

IXIARO (PF) 101

J JADENU 89

JADENU SPRINKLE 89

JAKAFI 20

jantoven 53

JANUMET 32

JANUMET XR 32

JANUVIA 32

JARDIANCE 32

jasmiel (28) 72

jencycla 72

JENTADUETO 32

JENTADUETO XR 32

jinteli 90

jolivette 72

juleber 72

JULUCA 48

junel 1530 (21) 72

junel 120 (21) 72

junel fe 1530 (28) 72

junel fe 120 (28) 72

junel fe 24 72

JUXTAPID 65

JYNARQUE 64

K KABIVEN 58

KALETRA 48

kalliga 72

KALYDECO 113

KANJINTI 20

KANUMA 80

kariva (28) 72

KEDRAB (PF) 98

kelnor 135 (28) 72

kelnor 1-50 72

ketoconazole 36

ketorolac 6 84

KEVEYIS 106

KEVZARA 98

KEYTRUDA 20

KINERET 98

KINRIX (PF) 101

KISQALI 20

klor-con m10 108

klor-con m15 108

klor-con m20 108

KORLYM 32

KRINTAFEL 41

KRYSTEXXA 81

kurvelo (28) 72

KUVAN 81

KYPROLIS 20

labetalol 61

lactulose 86

lamivudine 48

lamotrigine 27

lansoprazole 85

INSULIN 34

larin 1530 (21) 73

larin 120 (21) 73

larin 24 fe 73

larin fe 1530 (28) 73

larin fe 120 (28) 73

larissia 73

latanoprost 107

LATUDA 45

LAZANDA 4

leena 28 73

leflunomide 98

LEMTRADA 68

LENVIMA 20

lessina 73

letrozole 20

LEUKERAN 20

LEUKINE 54

leuprolide 20

levetiracetam 27

levobunolol 107

levocarnitine 106

levocetirizine 37

levofloxacin 14 82

LEVOLEUCOVORIN

CALCIUM 106

levonest (28) 73

levora-28 73

levothyroxine 95

LEXIVA 48

LIALDA 103

LIBTAYO 20

lidocaine 7

lidocaine (pf) 7 60

lidocaine hcl 7

lidocaine viscous 7

lillow (28) 73

linezolid 10 11

LINZESS 86

liothyronine 95

lisinopril 59 60

lithium citrate 68

LIVALO 65

LOKELMA 86

LONHALA MAGNAIR

REFILL 112

LONHALA MAGNAIR

STARTER 111

LONSURF 20

loperamide 86

lorazepam 9

LORBRENA 20

lorcet hd 4

lorcet plus 4

loryna (28) 73

losartan 59

LOTEMAX 84

LOTEMAX SM 84

lovastatin 65

LUCEMYRA 8

LUMIGAN 107

LUMOXITI 21

LUPRON DEPOT 21 93

LUPRON DEPOT-PED 93

LUPRON DEPOT-PED (3

MONTH) 93

lutera (28) 73

LYNPARZA 21

LYRICA 27

LYSODREN 21

lyza 73

malathion 79

maprotiline 31

marlissa (28) 73

MARPLAN 31

MATULANE 21

PACK) 68

MAVENCLAD (4 TABLET

PACK) 68

MAVENCLAD (5 TABLET

PACK) 68

MAVENCLAD (6 TABLET

PACK) 68

MAVENCLAD (7 TABLET

PACK) 68

MAVENCLAD (8 TABLET

PACK) 68

MAVENCLAD (9 TABLET

PACK) 68

MAVYRET 51

MAYZENT 68

meclizine 40

mefenamic acid 6

mefloquine 41

megestrol 21 95

MEKINIST 21

MEKTOVI 21

meloxicam 6

memantine 29

MENACTRA (PF) 101

(PF) 101

MEPSEVII 81

mercaptopurine 21

meropenem 13

mesalamine 103

mesna 106

MESNEX 106

MESTINON 106

metaproterenol 112

metformin 32 33

methadone 4

methadose 4

methimazole 95

methocarbamol 114

methoxsalen 76

methscopolamine 86

methyclothiazide 64

metipranolol 107

mexiletine 60

MIACALCIN 105

miconazole-3 36

midodrine 58

miglustat 81

mili 73

mimvey 90

mimvey lo 90

minitran 66

minocycline 15

minoxidil 66

mirtazapine 31

misoprostol 85

MITIGARE 37

mitoxantrone 21

M-M-R II (PF) 102

molindone 45

mometasone 79

mondoxyne nl 15

mono-linyah 73

mononessa (28) 73

montelukast 111

morphine 4 5

MORPHINE 5

MOVANTIK 86

MOXEZA 82

moxifloxacin 14 83

MOZOBIL 54

MULPLETA 54

MULTAQ 60

mupirocin 77

MYLOTARG 21

MYRBETRIQ 88

myzilra 73

N nabumetone 6

nafcillin 13 14

NAGLAZYME 81

naloxone 8

naltrexone 8

NAMZARIC 29

naproxen 7

NARCAN 8

NATACYN 83

NATPARA 105

NEBUPENT 41

necon 0535 (28) 73

nefazodone 31

neomycin 10

dexameth 83

neomycin-polymyxin-

gramicidin 83

neo-polycin 83

neo-polycin hc 83

NEPHRAMINE 54 58

NERLYNX 21

NEULASTA 54

NEUPOGEN 54

NEUPRO 42

nevirapine 48 49

NEXAVAR 21

niacin 65

niacor 65

nicardipine 63

NICOTROL 8

nifedipine 63

nikki (28) 74

nilutamide 21

NINLARO 22

nitroglycerin 66

NITYR 81

NIVESTYM 54

nizatidine 85

NOCDURNA (MEN) 93

NOCDURNA (WOMEN) 93

nora-be 74

norlyda 74

norlyroc 74

NORMOSOL-M IN 5

DEXTROSE 109

NORMOSOL-R 109

NORTHERA 58

nortrel 0535 (28) 74

nortrel 135 (21) 74

nortrel 135 (28) 74

nortrel 777 (28) 74

nortriptyline 31

NORVIR 49

NOVOLIN 7030 U-100

INSULIN 34

100 34

NOVOLIN N NPH U-100

INSULIN 34

100 INSULN 34

INSULIN 34

INSULN 34

NOVOLOG MIX 70-

30FLEXPEN U-100 34

INSULIN 34

ASPART 34

NOXAFIL 36

NUCALA 113

NUCYNTA 5

NUCYNTA ER 5

NUEDEXTA 69

NULOJIX 98

NUPLAZID 45

NUTRILIPID 58

nyamyc 36

nystatin 36

nystop 36

O OCALIVA 87

OCREVUS 69

OCTAGAM 98

ODEFSEY 49

ODOMZO 22

OFEV 113

ofloxacin 83

ogestrel (28) 74

olanzapine 45

olmesartan 59

olopatadine 82

OLUMIANT 98

omeprazole 85

OMNITROPE 93

ONCASPAR 22

ondansetron 40

ondansetron hcl 40

ONIVYDE 22

OPDIVO 22

OPSUMIT 114

oralone 76

ORENCIA 98

ORENITRAM 114

ORFADIN 81

ORILISSA 93 94

ORKAMBI 113

orsythia 74

oseltamivir 50

OSMOLEX ER 42

OTEZLA 98

OTEZLA STARTER 98

oxcarbazepine 27

OXTELLAR XR 27

oxycodone 5

oxycodone-aspirin 5

OZEMPIC 33

P pacerone 60

paliperidone 45 46

PALYNZIQ 81

PANRETIN 76

pantoprazole 85

paricalcitol 105

PARICALCITOL 105

paromomycin 41

paroxetine hcl 31

PASER 39

PAXIL 31

PEDIARIX (PF) 102

PEDVAX HIB (PF) 102

PEGANONE 27

PEGASYS 51 52

PEGASYS PROCLICK 51

PEGINTRON 52

penicillamine 89

PENNSAID 7

PENTACEL (PF) 102

PENTAM 41

pentamidine 41

pentoxifylline 55

PERIKABIVEN 58

periogard 76

permethrin 79

perphenazine 46

PERSERIS 46

pfizerpen-g 14

phenadoz 40

phenelzine 31

phenobarbital 27 28

phenytoin 28

phenytoin sodium 28

philith 74

PHOSLYRA 88

PICATO 76 77

PIFELTRO 49

pimecrolimus 79

pimozide 46

pimtrea (28) 74

pioglitazone 33

PIQRAY 22

pirmella 74

PLASMA-LYTE 148 109

PLASMA-LYTE A 109

PLEGRIDY 69

podofilox 77

POLIVY 22

polycin 83

POMALYST 22

portia 28 74

PORTRAZZA 22

PRADAXA 53

PRALUENT PEN 65

pramipexole 42

prasugrel 55

pravastatin 65

prazosin 59

prednicarbate 79

prednisolone 92

84 91 92

prednisone 92

pregabalin 28

PREMARIN 90

PREMPHASE 91

PREMPRO 91

prevalite 65

previfem 74

PREVYMIS 50

PREZCOBIX 49

PREZISTA 49

PRIFTIN 39

PRIMAQUINE 41

primidone 28

PRIVIGEN 99

probenecid 37

procainamide 60

PROCALAMINE 3 58

prochlorperazine 40

PROCRIT 54

procto-med hc 79

proctosol hc 79

proctozone-hc 79

PROCYSBI 88

progesterone 95

PROGLYCEM 106

PROGRAF 99

PROLASTIN-C 113

PROLENSA 85

PROLEUKIN 22

PROLIA 105

PROMACTA 54

promethazine 37 40

promethegan 40

propafenone 60

proparacaine 82

propranolol 61

propylthiouracil 95

PROQUAD (PF) 102

PROSOL 20 58

protamine 55

protriptyline 31

PULMOZYME 81

PURIXAN 22

pyrazinamide 39

quetiapine 46

quinapril 60

R RABAVERT (PF) 102

RADICAVA 69

raloxifene 91

ramipril 60

ranitidine hcl 85

ranolazine 63

rasagiline 42

RASUVO (PF) 99

RAVICTI 87

RAYALDEE 105

REBIF REBIDOSE 69

reclipsen (28) 74

RECTIV 107

RELISTOR 87

REMICADE 99

RENFLEXIS 99

repaglinide 33

REPATHA SYRINGE 65

RESCRIPTOR 49

RESTASIS 85

RETACRIT 55

RETROVIR 49

REVCOVI 81

REVLIMID 22

revonto 114

REXULTI 46

REYATAZ 49

RHOPRESSA 107

ribasphere 52

ribavirin 52

RIDAURA 99

rifabutin 39

rifampin 39

riluzole 69

rimantadine 51

RISPERDAL CONSTA 46

risperidone 46

ritonavir 49

RITUXAN 22

RITUXAN HYCELA 22

rivastigmine 29

rizatriptan 38

ropinirole 42

rosadan 77

rosuvastatin 65

ROTARIX 102

ROTATEQ VACCINE 102

RUBRACA 22

RYDAPT 22

S SABRIL 28

SAIZEN 94

SANTYL 77

SAPHRIS 46

SAVELLA 69

scopolamine base 40

selegiline hcl 42

selenium sulfide 77

SELZENTRY 49

SEREVENT DISKUS 112

SEROSTIM 94

sertraline 31

setlakin 74

sevelamer hcl 88

sharobel 74

SHINGRIX (PF) 102

SIGNIFOR 94

SILENOR 114

SILIQ 99

SIMBRINZA 108

simliya (28) 74

simpesse 74

SIMPONI 99

SIMPONI ARIA 99

simvastatin 65

sirolimus 99

SIRTURO 39

SKYRIZI 99

smoflipid 58

sodium chloride 104

SOLIQUA 10033 34

SOLTAMOX 22

SOLU-CORTEF (PF) 92

SOMATULINE DEPOT 94

SOMAVERT 94

sorine 61

sotalol 61

sotalol af 61

SOVALDI 51

spironolactone 64

SPRAVATO 31

sprintec (28) 75

SPRITAM 28

SPRYCEL 22

sronyx 75

ssd 77

stavudine 49

STELARA 99

STIVARGA 23

STRENSIQ 81

streptomycin 10

STRIBILD 49

SUBLOCADE 8

subvenite 28

sucralfate 86

sulfadiazine 14

sulfasalazine 104

sulfatrim 15

sulindac 7

sumatriptan 38

SUPPRELIN LA 94

SUTENT 23

syeda 75

SYLATRON 52

SYLVANT 23

SYMBICORT 110 111

SYMDEKO 113

SYMFI 49

SYMFI LO 49

SYMJEPI 63

SYMLINPEN 120 33

SYMLINPEN 60 33

SYMPAZAN 28

SYMTUZA 49

SYNAGIS 51

SYNAREL 94

SYNERCID 11

SYNJARDY 33

SYNJARDY XR 33

SYNRIBO 23

T TABLOID 23

tacrolimus 79 99

TAFINLAR 23

TAGRISSO 23

TAKHZYRO 107

TALTZ SYRINGE 100

TALZENNA 23

tamoxifen 23

tamsulosin 88

TARGRETIN 23

tarina 24 fe 75

tarina fe 120 (28) 75

TASIGNA 23

TAVALISSE 55

tazarotene 79

TAZORAC 79

taztia xt 62

TDVAX 102

TECENTRIQ 23

TECFIDERA 70

TECHNIVIE 51

TEFLARO 12

TEKTURNA HCT 66

telmisartan 59

temazepam 9

TEMODAR 23

TENIVAC (PF) 102

terazosin 88

terbinafine hcl 36

terbutaline 112

terconazole 37

testosterone 89

PED(PF) 102

tetrabenazine 70

tetracycline 15

THALOMID 107

theophylline 112

THIOLA 89

THIOLA EC 88

thioridazine 46

thiotepa 23

thiothixene 46

tiagabine 28

TIBSOVO 23

TICE BCG 100

tigecycline 15

tilia fe 75

TIVICAY 49 50

tizanidine 114

TOBI PODHALER 10

tobramycin 84

TOLAK 77

tolazamide 35

tolterodine 88

topiramate 28

toposar 23

toremifene 23

torsemide 64

TOTECT 107

TOUJEO MAX U-300

SOLOSTAR 34

INSULIN 35

TOVIAZ 88

TRACLEER 115

TRADJENTA 33

tramadol 5

trandolapril 60

tranexamic acid 55

TRANSDERM-SCOP 41

tranylcypromine 31

TRAVASOL 10 58

TRAVATAN Z 108

trazodone 31

TREANDA 23

TRECATOR 39

TRELEGY ELLIPTA 112

TRELSTAR 23 24

TREMFYA 100

tretinoin 79

tri femynor 75

trientine 89

tri-estarylla 75

trifluoperazine 46

trifluridine 84

trihexyphenidyl 43

tri-legest fe 75

tri-linyah 75

tri-lo-estarylla 75

tri-lo-marzia 75

tri-lo-mili 75

tri-lo-sprintec 75

trimethoprim 11

tri-mili 75

trimipramine 31

TRINTELLIX 31

TRIPTODUR 94

TRIUMEQ 50

trivora (28) 75

tri-vylibra 75

tri-vylibra lo 75

TROGARZO 50

TROPHAMINE 10 58

TROPHAMINE 6 58

TRULICITY 33

TRUMENBA 103

TRUVADA 50

tulana 75

TWINRIX (PF) 103

TYBOST 107

TYKERB 24

TYMLOS 105

TYPHIM VI 103

TYSABRI 100

TYVASO 115

U UCERIS 104

UDENYCA 55

ULORIC 37

UNITUXIN 24

UPTRAVI 115

ursodiol 87

V valacyclovir 52

VALCHLOR 77

valganciclovir 52

valproate sodium 28

valproic acid 29

valrubicin 24

valsartan 59

vancomycin 11

VAQTA (PF) 103

VARIVAX (PF) 103

VASCEPA 66

VELCADE 24

VELPHORO 88

VELTASSA 87

VEMLIDY 50

VENCLEXTA 24

VENCLEXTA STARTING

PACK 24

venlafaxine 31 32

verapamil 62

VERSACLOZ 46

VERZENIO 24

V-GO 40 80

VIBERZI 87

VICTOZA 33

VIDEX EC 50

VIEKIRA PAK 51

vienva 75

vigabatrin 29

vigadrone 29

VIIBRYD 32

VIMIZIM 81

VIMPAT 29

vinorelbine 24

viorele (28) 75

VIRACEPT 50

VIREAD 50

VISTOGARD 107

VITRAKVI 24

VIZIMPRO 24

VOLTAREN 7

voriconazole 36 37

VOSEVI 51

VOTRIENT 24

VPRIV 81

VRAYLAR 47

vyfemla (28) 76

vylibra 76

VYNDAQEL 63

VYXEOS 24

W warfarin 53

WELCHOL 66

wera (28) 76

X XADAGO 43

XALKORI 24

XARELTO 53

XATMEP 24

XELJANZ 100

XELJANZ XR 100

XERMELO 87

XIFAXAN 11

XIIDRA 85

XOFLUZA 51

XOLAIR 113

XOSPATA 24

XPOVIO 25

XTAMPZA ER 5 6

XTANDI 25

xulane 76

XULTOPHY 10036 35

XURIDEN 107

XYOSTED 89

XYREM 114

Y YERVOY 25

YF-VAX (PF) 103

YONDELIS 25

YONSA 25

Z zafirlukast 111

zaleplon 114

zarah 76

ZARXIO 55

ZEJULA 25

ZELBORAF 25

zenatane 77

zenchent (28) 76

ZENPEP 81

ZEPATIER 51

zidovudine 50

ziprasidone hcl 47

ZIRGAN 84

ZOLADEX 25

zoledronic acid 105

ZOLINZA 25

zolpidem 114

ZOMACTON 94

zonisamide 29

ZORBTIVE 94

ZORTRESS 100

ZOSTAVAX (PF) 103

zovia 135e (28) 76

ZTLIDO 7

ZUBSOLV 8

ZULRESSO 32

zumandimine (28) 76

ZYDELIG 25

ZYKADIA 25

ZYLET 84

ZYPREXA RELPREVV 47

ZYTIGA 25







Medical Condition









Table of Contents

INDEX

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

1-800-368-1019 800-537-7697 (TDD)

H6988_ENR1085_C I

2020 Formulary

during the year

H6988_ENR1085_C II

during the year

H6988_ENR1085_C III

Medical Condition

name for your drug

may include

H6988_ENR1085_C IV

options

(HMO) Formulary

H6988_ENR1085_C V

exception

page I-1

Analgesics 3

Anesthetics 7

Antibacterials 9

Anticonvulsants 25

Antidepressants 29

Antifungals 35

Antigout Agents 37

Antihistamines 37

Caloric Agents 55

Contraceptives 70

Table of Contents

Devices 79

Drug Name

Analgesics

12 mg5 ml

30 days)

(Buprenex) 2

50-325-40 mg

Years)

50-325-40 mg

Years)

325-40 mg

Years)

30 days)

400 mcg 600 mcg 800 mcg

per 30 days)

75 mcghr

30 days)

75-325 mg15 ml

30 days)

10-325 mg

30 days)

25-325 mg

30 days)

Drug Name

325 mg

30 days)

75-325 mg

30 days)

5 PA NDS NM QL (30

per 30 days)

30 days)

suv inner 10 mgml

mg5 ml (20 mgml)

30 days)

4 mgml 8 mgml

30 days)

Drug Name

30 days)

mg 200 mg 60 mg

30 days)

mg 30 mg

30 days)

150 MG 200 MG 250 MG 50 MG

3 NDS NM QL (60 per

30 days)

MG 75 MG

30 days)

hr 10 mg 15 mg 20 mg 30 mg 40 mg 60

mg 80 mg

30 days)

325 mg

30 days)

325 mg 5-325 mg

30 days)

325 mg

30 days)

325 mg

30 days)

XTAMPZA ER ORAL

3 NDS NM QL (60 per

30 days)

Drug Name

XTAMPZA ER ORAL

CRUSH) 27 MG

30 days)

XTAMPZA ER ORAL

CRUSH) 36 MG

30 days)

12 hour 13

(Flector) 2 PA

(Voltaren-XR) 2

(IBU) 1

Years)

days) AGE (Max 64

Years)

Drug Name

(EC-Naprosyn) 2

ACTUATION(2 )

28 days)

Anesthetics

Local Anesthetics

applicator 2

(1 ) 15 mgml (15 ) 20 mgml (2 )

5 mgml (05 )

(Xylocaine-MPF) 1

mgml (2 )

(1 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine) 1

(40 mgml)

patchmedicated 5

solution 2

PATCHMEDICATED 18

Treatment Agents

(drec) 333 mg

Drug Name

12-3 mg 8-2 mg

2-05 mg 4-1 mg

2-05 mg 8-2 mg

3 QL (336 per 365 days)

(11)- 1 MG (42)

NICOTROL INHALATION

CARTRIDGE 10 MG

4 QL (1008 per 90 days)

018 MG 14-036 MG 114-29 MG 29-

071 MG 57-14 MG

Antianxiety Agents

Benzodiazepines

30 days)

mg 5 mg 75 mg

Drug Name

25 mg 5 mg

30 days)

0125 mg 025 mg 05 mg 1 mg

2 NDS NM QL (90 per

30 days)

375 mg

30 days)

Antibacterials

Aminoglycosides

5 PA BvD NDS

40 mgml

solution 20 mg2 ml

Drug Name

mg8 ml

(Tobi) 5 PA BvD NDS

mg 75 mg

(Cleocin HCl) 1

900 mg50 ml

150 (mgml) (6 ml)

150 mgml

(Cleocin) 2

solution 600 mg4 ml

(Cleocin) 2

soln 150 mg

(Coly-Mycin M

Parenteral)

5 PA BvD NDS

(Cubicin) 5 NDS

MGML 50 MGML

mg300 ml

(Zyvox) 5 NDS

100 mg5 ml

(Zyvox) 5 NDS

Drug Name

(Metro IV) 2

100 mg 25 mg 50 mg

capsule 100 mg

500000 unit

SOLN 500 MG

750 mg

2 PA BvD

Cephalosporins

125 mg5 ml 250 mg5 ml 375 mg5 ml

gram 500 mg

125 mg5 ml 250 mg5 ml

(Maxipime) 2

10 gram 2 gram

Drug Name

(Tazicef) 2

750 mg

15 gram 75 gram

SOLN 400 MG 600 MG

Macrolides

(Zithromax) 2

500 mg (3 pack) 600 mg

(EES Granules) 2

(EryPed 400) 2

Drug Name

(Azactam) 2

5 PA LA NDS

soln 250 mg

soln 500 mg

(Primaxin IV) 2

gram 500 mg

(Merrem) 2

Penicillins

250 mg5 ml 400 mg5 ml

250 mg

mg5 ml

500-125 mg 875-125 mg

(Augmentin) 1

500 mg

(Unasyn) 2

2400000 UNIT4 ML 600000

UNITML

Drug Name

20 million unit

(Pfizerpen-G) 2

unitml

mg5 ml 250 mg5 ml

500 mg

405 gram

(Zosyn) 2 PA BvD

Quinolones

(Cipro) 1

(Cipro in D5W) 2

ciprofloxacin oral

ml 500 mg5 ml

(Cipro) 2

250 mg50 ml 500 mg100 ml 750 mg150

Sulfonamides

(Sulfatrim) 2

Drug Name

400-80 mg

(Bactrim) 1

800-160 mg

(Bactrim DS) 1

Tetracyclines

soln 100 mg

(Doxy-100) 2

(Morgidox) 2

mg 50 mg

(Mondoxyne NL) 2

(Vibramycin) 2

(Avidoxy) 2

Anticancer Agents

100 MG

2 PA BvD

ml 500 mg10 ml

2 PA BvD

per 28 days)

MG 75 MG

5 PA NSO NDS QL (28

per 28 days)

Drug Name

per 30 days)

SOLN 100 MG 500 MG

SOLN 60 MG

5 PA NSO NDS QL (3

per 28 days)

5 PA NSO NDS QL (30

per 30 days)

PACK 90 MG (7)- 180 MG (23)

5 PA NSO NDS

25 MGML

5 PA NSO NDS

per 28 days)

SOLUTION 20 MGML

5 PA NSO NDS

SOLN 500 MG

5 PA NSO NDS

BENDEKA INTRAVENOUS

SOLUTION 25 MGML

5 PA NSO NDS

per 30 days)

5 PA NSO NDS

RECON SOLN 35 MG

5 PA NSO NDS

per 30 days)

Drug Name

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (60

per 30 days)

(Clolar) 5 NDS

MGDAY(80 MG X1-20 MG X1) 140

per 28 days)

5 PA NSO NDS QL (56

per 28 days)

(63 per 28 days)

5 PA BvD NDS

CAPSULE 25 MG 50 MG

2 PA BvD ST

CYRAMZA INTRAVENOUS

SOLUTION 10 MGML

5 PA NSO NDS

SOLUTION 20 MGML

5 PA NSO LA NDS

per 30 days)

suspension 2 mgml

Drug Name

MG 400 MG

ELIGARD (3 MONTH)

ELIGARD (4 MONTH)

ELIGARD (6 MONTH)

75 MG (1 MONTH)

SOLN 300 MG 400 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG

MG 20 MG

5 PA NSO NDS

gram20 ml

2 PA BvD

(Adrucil) 2 PA BvD

mg5 ml

(Faslodex) 5 NDS

1000 MG40 ML

5 PA NSO NDS

MG 40 MG

5 PA NSO NDS QL (30

per 30 days)

40 MG 5 MG

Drug Name

HERCEPTIN HYLECTA

10000 UNIT5 ML

5 PA NSO NDS QL (5

per 21 days)

SOLN 150 MG 440 MG

5 PA NSO NDS

125 MG 75 MG

5 PA NSO NDS QL (21

per 28 days)

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

ml 3 gram60 ml

gram 3000-1000 mg

5 PA BvD NDS

per 30 days)

per 28 days)

280 MG 420 MG 560 MG

5 PA NSO NDS QL (28

per 28 days)

50 MGML

5 PA NSO NDS

5 PA NSO NDS QL (4

per 365 days)

5 PA NSO NDS QL (8

per 28 days)

per 30 days)

SOLN 15 MG 45 MG

Drug Name

20 MG 25 MG 5 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 420 MG

5 PA NSO NDS

SOLUTION 25 MGML

5 PA NSO NDS QL (8

per 21 days)

5 PA NSO NDS QL (49

per 28 days)

5 PA NSO NDS QL (70

per 28 days)

5 PA NSO NDS QL (91

per 28 days)

(200 MG X 1)

5 PA NSO NDS QL (21

per 28 days)

(200 MG X 2)

5 PA NSO NDS QL (42

per 28 days)

(200 MG X 3)

5 PA NSO NDS QL (63

per 28 days)

5 PA NSO NDS

X 1) 18 MGDAY (10 MG X 1-4 MG

X2) 20 MGDAY (10 MG X 2) 24

8 MGDAY (4 MG X 2)

5 PA NSO NDS

50 MGML

5 PA NSO NDS QL (7

per 21 days)

per 28 days)

per 30 days)

Drug Name

SOLN 1 MG

5 PA NSO NDS

SYRINGE KIT 375 MG

150 MG

per 30 days)

(Max 64 Years)

per 30 days)

soln 1 gram

2 PA BvD

solution 25 mgml

2 PA BvD

5 PA NSO NDS

per 30 days)

Drug Name

MG 4 MG

5 PA NSO NDS QL (3

per 28 days)

750 UNITML

5 PA NSO NDS

ONIVYDE INTRAVENOUS

DISPERSION 43 MGML

100 MG10 ML 240 MG24 ML 40

MG4 ML

5 PA NSO NDS

(200 MG X 1)

5 PA NSO NDS QL (28

per 28 days)

(200 MG X1-50 MG X1) 300 MGDAY

(150 MG X 2)

5 PA NSO NDS QL (56

per 28 days)

SOLN 140 MG

5 PA NSO NDS

MG 3 MG 4 MG

5 PA NSO NDS QL (21

per 28 days)

per 21 days)

5 PA NSO LA NDS QL

(28 per 28 days)

MGML) 1600 MG134 ML (120

5 PA NSO NDS

RITUXAN INTRAVENOUS

CONCENTRATE 10 MGML

5 PA NSO NDS

250 MG 300 MG

per 30 days)

per 28 days)

MG5 ML

5 PA NSO NDS QL (30

per 30 days)

Drug Name

per 28 days)

MG 375 MG 50 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 100 MG 400 MG

5 PA NSO NDS

SOLN 35 MG

5 PA NSO NDS

per 30 days)

5 PA NSO LA NDS QL

(30 per 30 days)

per 30 days)

per 28 days)

200 MG

per 28 days)

per 30 days)

5 PA NSO NDS

SOLN 100 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG 25 MG

5 PA NSO NDS

1125 MG

225 MG

5 NDS QL (1 per 168

Drug Name

375 MG

SOLUTION 35 MGML

5 PA NSO NDS

per 30 days)

(180 per 30 days)

per 30 days)

100 MG

5 PA NSO LA NDS

150 MG 200 MG 50 MG

5 PA NSO NDS QL (56

per 28 days)

50 mg5 ml

(Navelbine) 2

per 30 days)

MG 45 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 44-100 MG

5 PA BvD NDS

250 MG

5 PA NSO NDS QL (60

per 30 days)

4 PA BvD ST

per 30 days)

Drug Name

MGWEEK (20 MG X 5)

5 PA NSO NDS QL (20

per 28 days)

MGWEEK (20 MG X 8)

5 PA NSO NDS QL (32

per 28 days)

(20 MG X 3)

5 PA NSO NDS QL (12

per 28 days)

(20 MG X 4)

5 PA NSO NDS QL (16

per 28 days)

per 30 days)

200 MG40 ML (5 MGML) 50 MG10

ML (5 MGML)

5 PA NSO NDS

SOLN 1 MG

5 PA NSO NDS

per 30 days)

IMPLANT 108 MG

IMPLANT 36 MG

5 PA NSO NDS QL (60

per 30 days)

per 28 days)

per 30 days)

Anticonvulsants

Drug Name

5 ST NDS

SOLUTION 50 MG5 ML

5 NDS QL (60 per 30

(Carbatrol) 2

(Tegretol) 2

(Tegretol XR) 2

125-15-175-20 MG 5-75-10 MG

75-10 mg

(Diastat AcuDial) 4

sprinkle 125 mg

hr 250 mg 500 mg

(Depakote ER) 2

(drec) 125 mg 250 mg 500 mg

(Depakote) 2

5 PA NSO NDS

Drug Name

(Cerebyx) 2

4 ST QL (720 per 30

MG 8 MG

200 mg 25 mg

(Lamictal) 1

(Lamictal) 2

mg5 ml

(Keppra) 2

mg 500 mg 750 mg

(Keppra) 2

24 hr 500 mg 750 mg

(Keppra XR) 2

MG 200 MG 225 MG 25 MG 300 MG

50 MG 75 MG

ml (60 mgml)

(Trileptal) 2

600 mg

(Trileptal) 2

300 MG 600 MG

2 PA NSO-HRM AGE

(Max 64 Years)

Drug Name

162 mg 30 mg 324 mg 60 mg 648 mg

972 mg

2 PA NSO-HRM AGE

(Max 64 Years)

100 mg

200 mg 300 mg

(Phenytek) 2

200 mg 225 mg 25 mg 300 mg 50 mg

per 30 days)

SUSPENSION 1000 MG

4 ST QL (120 per 30

mg 25 mg

5 PA NSO NDS QL (60

per 30 days)

(Gabitril) 2

(Topamax) 2

100 mg 150 mg 200 mg 25 mg 50 mg

(Qudexy XR) 4

mg 50 mg

(Topamax) 1

mg5 ml (100 mgml)

(Depacon) 2

solution 250 mg5 ml

Drug Name

per 30 days)

200 MG20 ML

MG 200 MG 50 MG

Antidementia Agents

24 hr 16 mg 24 mg 8 mg

14 mg 21 mg 28 mg 7 mg

NAMZARIC ORAL

MG 21-10 MG 28-10 MG 7-10 MG

3 mg 45 mg 6 mg

133 mg24 hour 46 mg24 hr 95 mg24

Antidepressants

150 mg 25 mg 50 mg 75 mg

Drug Name

mg 50 mg

24 hr 150 mg 300 mg

(Wellbutrin XL) 2

(Wellbutrin SR) 2

(Anafranil) 2

50 mg 75 mg

release(drec) 30 mg

MG24 HR

5 NDS QL (30 per 30

mg 5 mg

(Lexapro) 1

FETZIMA ORAL

HR 120 MG 20 MG 40 MG 80 MG

(Prozac) 1

Drug Name

(Tofranil) 2

mg 30 mg 45 mg

(Remeron SolTab) 2

200 mg 250 mg 50 mg

50 mg 75 mg

(Pamelor) 1

30 mg 40 mg

(Max 64 Years)

4 PA NSO-HRM AGE

(Max 64 Years)

10 mg 2-25 mg 4-10 mg 4-25 mg 4-50

(Zoloft) 1

(28 MG X 3)

5 PA NSO NDS

20 MG 5 MG

24hr 150 mg

24hr 375 mg 75 mg

Drug Name

375 mg 50 mg 75 mg

MG 40 MG

PACK 10 MG (7)- 20 MG (23)

SOLUTION 5 MGML

Antidiabetic Agents

25-5 MG

1000 MG 150-500 MG 50-1000 MG

3 ST QL (120 per 30

150-500 MG 50-1000 MG 50-500 MG

MG 50-500 MG

500 MG

MG 50 MG

1000 MG 25-500 MG 25-850 MG

28 days)

Drug Name

hr 500 mg

hr 750 mg

28 days)

MG 125-500 MG 5-1000 MG 5-500

1000 MG

Insulins

UNITML (3 ML)

FIASP U-100 INSULIN

UNITML

Drug Name

UNITML

UNITML (3 ML)

UNITML

UNITML (70-30)

UNITML

UNITML (3 ML)

UNITML (70-30)

UNITML

UNITML (3 ML)

Drug Name

UNITML (15 ML)

UNITML (3 ML)

UNITML

Sulfonylureas

25 mg 5 mg

mg 5-500 mg

mg 6 mg

Years)

mg 25-500 mg 5-500 mg

Years)

Antifungals

ABELCET INTRAVENOUS

SUSPENSION 5 MGML

5 PA BvD NDS

Drug Name

mg 70 mg

(Cancidas) 5 NDS

(clotrimazole))

(Lotrisone) 2

400 mg200 ml

2 PA BvD

(Diflucan) 2

200 mg 50 mg

(Diflucan) 2

mg5 ml

MG5 ML (40 MGML)

unitgram

Drug Name

(Vfend) 5 NDS

Antigout Agents

Antihistamines

Years)

mgml 50 mgml

Years)

Membrane)

Drug Name

Antimigraine Agents

70 MGML

140 MGML 70 MGML

225 MG15 ML

EMGALITY SYRINGE

ML (100 MGML X 3)

mg 5 mg

mgactuation

25 mg 50 mg

cartridge 6 mg05 ml

(Imitrex STATdose

Refill)

solution 6 mg05 ml

syringe 6 mg05 ml

Antimycobacterials

Drug Name

Antimycobacterials

1 GRAM

168 days)

Antinausea Agents

025 MG

CAPSULE 300-05 MG

4 PA BvD

(1)- 80 mg (2)

EMULSION 72 MGML

Drug Name

ML FINAL CONC)

mgml 1 mgml (1 ml)

Drowsy)

mg2 ml

mg 8 mg

2 PA BvD

Years)

mg 5 mg

(Compazine) 1

50 mgml

Years)

25 mg 50 mg

Years)

1 mg over 3 days

days) AGE (Max 64

Years)

Drug Name

days) AGE (Max 64

Years)

Antiparasite Agents

(Malarone) 2

500 mg

SOLN 300 MG

4 PA BvD

300 MG

APOKYN SUBCUTANEOUS

CARTRIDGE 10 MGML

Drug Name

mg 25-100 mg 25-250 mg

(Sinemet) 2

(Sinemet CR) 2

(Stalevo 50) 4

tablet 1875-75-200 mg

(Stalevo 75) 4

(Stalevo 100) 4

tablet 3125-125-200 mg

(Stalevo 125) 4

tablet 375-150-200 mg

(Stalevo 150) 4

(Stalevo 200) 4

GOCOVRI ORAL

24HR 137 MG

GOCOVRI ORAL

24HR 685 MG

30 days)

258 MG

mg 05 mg 075 mg 1 mg 15 mg

(Mirapex) 1

Drug Name

ABILIFY MAINTENA

INTRAMUSCULAR

RECON 300 MG 400 MG

ABILIFY MAINTENA

INTRAMUSCULAR

mg 30 mg 5 mg

SYRING 675 MG24 ML

SYRING 1064 MG39 ML

5 NDS QL (39 per 56

SYRING 441 MG16 ML

5 NDS QL (16 per 28

SYRING 662 MG24 ML

5 NDS QL (24 per 28

SYRING 882 MG32 ML

5 NDS QL (32 per 28

200 mg 25 mg 50 mg

Drug Name

mg 125 mg 25 mg

30 days)

MG 6 MG 8 MG

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

25 mgml

25 mg 5 mg

solution 100 mgml

solution 50 mgml

(Haldol) 2

5 mgml

mg 2 mg 20 mg 5 mg

Drug Name

INVEGA SUSTENNA

MG075 ML

INVEGA SUSTENNA

MG15 ML

5 NDS QL (15 per 28

INVEGA SUSTENNA

MG025 ML

INVEGA SUSTENNA

MG05 ML

5 NDS QL (05 per 28

5 NDS QL (0875 per 84

5 NDS QL (1315 per 84

5 NDS QL (2625 per 84

MG 40 MG 60 MG

mg 5 mg 50 mg

per 30 days)

mg 20 mg 5 mg 75 mg

mg 15 mg 20 mg 5 mg

24hr 15 mg 3 mg

Drug Name

24hr 6 mg

24hr 9 mg

mg 8 mg

PERSERIS ABDOMINAL

SUBCUTANEOUS

120 MG 90 MG

mg 300 mg 400 mg 50 mg

30 days)

3 MG 4 MG

RISPERDAL CONSTA

MG2 ML 25 MG2 ML

RISPERDAL CONSTA

MG2 ML 50 MG2 ML

mg 2 mg 3 mg 4 mg

mg 05 mg 1 mg 2 mg

mg 4 mg

MG 25 MG 5 MG

mg 50 mg

mg 5 mg

30 days)

Drug Name

MG 45 MG 6 MG

PACK 15 MG (1)- 3 MG (6)

mg 60 mg 80 mg

ZYPREXA RELPREVV

Antiretrovirals

(Epzicom) 2

tablet 300-150-300 mg

(Trizivir) 5 NDS

300 mg

(Reyataz) 5 NDS

300 MG

400 MG

300 MG

400 mg

(Videx EC) 2

Drug Name

MG5 ML (5 MGML)

SOLN 90 MG

200-10 MG

200 MG

PACKET 100 MG

ISENTRESS ORAL

(Combivir) 2

mg5 ml

(Kaletra) 2

Drug Name

hr 100 mg 400 mg

(Viramune XR) 2

100 MG

600 MG 800 MG

DISPERSIBLE 100 MG

SOLUTION 10 MGML

PACKET 50 MG

300 MG 75 MG

mg 40 mg

200-300 MG

200-10 MG

300 mg

(Viread) 2

Drug Name

MG 133-200 MG 167-250 MG 200-300

MGML (FINAL)

VIDEX EC ORAL

CAPSULEDELAYED

625 MG

MGSCOOP (40 MGGRAM)

MG 250 MG

28 days)

480 MG

Drug Name

MGACTUATION

5 PA NDS

Hcv Antivirals

5 PA NDS

Interferons

5 PA NSO NDS

UNITML

5 PA NSO NDS

PEGASYS PROCLICK

MCG05 ML

SOLUTION 180 MCGML

Drug Name

MCG05 ML

200 MCG 300 MCG 600 MCG

5 PA NSO NDS

500 mg

2 PA BvD

500 mg

(Cytovene) 2 PA BvD

50 mgml

2 PA BvD

Expanders

Anticoagulants

PACK 5 MG (74 TABS)

mg3 ml

(Lovenox) 2

Drug Name

mg03 ml 40 mg04 ml 60 mg06 ml 80

mg08 ml

(Lovenox) 2

(Arixtra) 5 NDS

mg05 ml

(Arixtra) 2

5000 unitml (1 ml)

5000 unitml

unitml

1000 unitml

5000 unit05 ml

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

150 MG 75 MG

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

(Coumadin) 1

PACK 15 MG (42)- 20 MG (9)

TABLET 20 MG

SYRINGE 6 MG06 ML

5 PA NDS

GRANIX SUBCUTANEOUS

5 PA NDS

Drug Name

5 PA NDS

250 MCG

SYRINGE 6 MG06ML

5 PA NDS

MCG08 ML

5 PA NDS

4000 UNITML

20000 UNITML

40000 UNITML

PACKET 125 MG

30 days)

Drug Name

UNITML 4000 UNITML

40000 UNITML

SYRINGE 6 MG06 ML

5 PA NDS

150 MG

1000 mg10 ml (100 mgml)

(Cyklokapron) 2

Years)

400 mg

Caloric Agents

4 PA BvD

AMINOSYN 7 WITH

4 PA BvD

SOLUTION 85

4 PA BvD

Drug Name

4 PA BvD

SOLUTION 85

4 PA BvD

SOLUTION 7

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 275

4 PA BvD

Drug Name

SOLUTION 275

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

intravenous syringe

4 PA BvD

parenteral solution

4 PA BvD

intravenous syringe

4 PA BvD

FREAMINE HBC 69

SOLUTION 69

4 PA BvD

Drug Name

4 PA BvD

EMULSION 20 30

4 PA BvD

KABIVEN INTRAVENOUS

EMULSION 331-98-39

4 PA BvD

EMULSION 20

4 PA BvD

EMULSION 236-68-35

4 PA BvD

PARENTERAL SOLUTION

4 PA BvD

(Catapres) 1

mg24 hr

(Cardura) 2

Years)

200 MG 300 MG

30 days)

Drug Name

(Vazculep) 2

MG 40-25 MG

49-51 MG 97-103 MG

(Avapro) 1

150-125 mg 300-125 mg

(Avalide) 2

100-125 mg 100-25 mg 50-125 mg

(Hyzaar) 1

tablet 20-125 mg 40-125 mg 40-25 mg

(Benicar HCT) 2

(Micardis) 2

mg 80 mg

(Diovan) 2

160-125 mg 160-25 mg 320-125 mg

320-25 mg 80-125 mg

(Diovan HCT) 2

Inhibitors

(Lotensin) 1

mg 50 mg

mg 20 mg 5 mg

(Vasotec) 2

10-25 mg

(Vaseretic) 1

5-125 mg

Drug Name

10-125 mg 20-125 mg 20-25 mg

(Zestoretic) 1

mg 8 mg

(Accupril) 1

mg 5 mg

(Altace) 1

mg 150 mg

Years)

500 mcg

(Tikosyn) 2

mg5 ml (2 ) 50 mg5 ml (1 )

250 mg

mgml 500 mgml

300 mg

(Tenoretic 100) 2

(Tenoretic 50) 2

Drug Name

10-625 mg 25-625 mg 5-625 mg

(Ziac) 1

MG 20 MG 5 MG

3125 mg 625 mg

(Coreg) 1

(5 mgml)

(Toprol XL) 2

100-25 mg 100-50 mg

50-25 mg

(Lopressor HCT) 2

mg5 ml

(Lopressor) 2

mg5 ml

(Lopressor) 1

24 hr 120 mg 160 mg 60 mg 80 mg

(Inderal LA) 2

mg 60 mg 80 mg

mg 80 mg

(Betapace) 2

Drug Name

24hr 120 mg 180 mg 240 mg 300 mg

(Tiazac) 2

(Cardizem CD) 2

(Cardizem) 2

120 mg 180 mg 240 mg

hr 120 mg 180 mg 240 mg 300 mg 360

100 mg 200 mg 300 mg

(Verelan PM) 2

hr 120 mg 180 mg 240 mg

(Verelan) 2

hr 360 mg

(Verelan) 4

mg 180 mg 240 mg

(Calan SR) 1

Drug Name

mg03 ml

30 MG3 ML

mg 50 mg

hr 1000 mg 500 mg

(Ranexa) 2

MG03 ML

30 days)

Dihydropyridines

mg 60 mg

(Norvasc) 1

mg 10-40 mg 5-10 mg 5-20 mg 5-40 mg

(Lotrel) 2

mg 10-320 mg 5-160 mg 5-320 mg

(Exforge) 2

24hr 30 mg 60 mg 90 mg

(Procardia XL) 2

mg 60 mg 90 mg

(Adalat CC) 2

Diuretics

5-50 mg

Drug Name

soln 500 mg

(Diuril IV) 2

mg5 ml (8 mgml)

(Lasix) 1

25 mg 50 mg

30 days)

(PM) 60 MG (AM) 30 MG (PM) 90 MG

(AM) 30 MG (PM)

(Aldactone) 1

capsule 375-25 mg

(Dyazide) 1

capsule 50-25 mg

375-25 mg

(Maxzide-25mg) 1

75-50 mg

(Maxzide) 1

Dyslipidemics

mg 80 mg

(Lipitor) 1

in packet 4 gram

(Questran) 2

Drug Name

mg 200 mg 67 mg

145 mg 48 mg

(Tricor) 2

MG 40 MG 60 MG

1000 mg 500 mg 750 mg

(Niaspan Extended-

Release)

(Pravachol) 1

REPATHA PUSHTRONEX

REPATHA SURECLICK

REPATHA SYRINGE

mg 5 mg

mg 80 mg

Drug Name

PACKET 375 GRAM

Inhibitors

125 MG 150-25 MG 300-125 MG 300-

Vasodilators

mg 30 mg

release 40 mg

(ISOCHRON) 2

mg10 ml (5 mgml)

mg 06 mg

(Nitrostat) 2

(Minitran) 2

25 mg 40 mg

Drug Name

30 days)

mg3 ml (20 mgml)

(Cafcit) 2 PA BvD

(20 mgml)

12 hr 10 mg

mg 5 mg

mg 30 mg

mg 5 mg 75 mg

Drug Name

(Intuniv ER) 2

MG (21)

5 PA NDS

SOLUTION 12 MG12 ML

300 mg 600 mg

release 300 mg

(Lithobid) 2

release 450 mg

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

28 days)

mg 60 mg

Drug Name

ml 5 mg5 ml

mg 5 mg

OCREVUS INTRAVENOUS

SOLUTION 30 MGML

5 PA NDS QL (20 per

180 days)

MCG05 ML

5 PA NDS

28 days)

MCG05 ML

MCG05ML (6)

5 PA NDS

125 MG 25 MG 50 MG

PACK 125 MG (5)-25 MG(8)-50 MG(42)

Drug Name

TECFIDERA ORAL

CAPSULEDELAYED

TECFIDERA ORAL

CAPSULEDELAYED

MG (46)

5 PA NDS

TECFIDERA ORAL

CAPSULEDELAYED

28 days)

Contraceptives

mg- 35 mcg

010 mg-20 mcg (84)10 mcg (7)

015 mg-30 mcg (84)10 mcg (7)

mg-mcg

(24)75 mg (4)

30 mcg (21)75 mg (7)

mcg (21)75 mg (7)

001 mg x 5

Drug Name

001 mg x 5

(24)75 mg (4)

mcg (21)75 mg (7)

mg-mcg

mg- 35 mcg

015 mg-30 mcg (84)10 mcg (7)

015-002 mgx21 001 mg x 5

(Azurette (28)) 2

015-003 mg

(Apri) 2

3-002 mg

(Gianvi (28)) 2

3-003 mg

(Ocella) 2

(5)125-30(10)

Drug Name

35 mg-mcg

(Kelnor 135 (28)) 2

50 mg-mcg

(Kelnor 1-50) 2

(24)75 mg (4)

015 mg-30 mcg (91)

mcg (21)75 mg (7)

(21)75 mg (7)

(24)75 mg (4)

001 mg x 5

(84)10 mcg (7)

mcg 015 mg-25 mcg

(84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

(21)75 mg (7)

(5)125-30(10)

01-20 mg-mcg

(Afirmelle) 2

015-003 mg

(Altavera (28)) 2

50-30 (6)75-40 (5)125-30(10)

(Enpresse) 2

20 mcg (21)75 mg (7)

(5)125-30(10)

Drug Name

035 mg

(Camila) 2

1-20 mg-mcg

(Aurovela 120 (21)) 2

1 mg-20 mcg (21)75 mg (7)

1 mg-20 mcg (24)75 mg (4)

(Aurovela 24 Fe) 2

0180215025 mg-25 mcg

0180215025 mg-35 mcg (28)

025-35 mg-mcg

(Estarylla) 2

mg- 35 mcg

001 mg x 5

mcg 1-35 mg-mcg

015 mg-30 mcg (91)

001 mg x 5

015 mg-30 mcg (84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

35mcg (9)

mg-35 mcg (28)

1mg-35mcg (9)

35 mcg (28)

mg-25 mcg

25 mcg

mg-25 mcg

mcg (28)

0180215025 mg-35 mcg (28)

(5)125-30(10)

mg-25 mcg

35 mcg (28)

0112515-25 mg-mcg

001 mg x 5

Drug Name

mcg24 hr

mouthwash 012

(Oralone) 2

(Soriatane) 2

MEDICATED

rel 10 mg

Drug Name

UNITGRAM

mg 40 mg

(Cleocin T) 2

(Ery Pads) 2

suspension 10

(Klaron) 2

Agents

Drug Name

ointment 005

(Diprolene) 2

(Cutivate) 2

Drug Name

applicator 25

(Triderm) 1

0025 01

0025 01 05

Devices

Drug Name

03 ML 31 GAUGE X 1564

12 ML 31 GAUGE X 1564

(Lite Touch Insulin

Syringe)

GAUGE X 12

(1st Tier Unifine

Pentips)

SOLUTION 250 UNITML

SOLUTION 29 MG5 ML

SOLN 400 UNIT

60000 UNIT 24000-76000 -120000

UNIT 3000-9500- 15000 UNIT

36000-114000- 180000 UNIT 6000-

19000 -30000 UNIT

SOLUTION 6 MG3 ML

SOLN 15 MG 75 MG

SOLN 35 MG 5 MG

5 PA NDS

2 MGML

5 PA NDS

Drug Name

SOLUTION 8 MGML

5 PA BvD NDS

2 MGML

5 PA NDS

SOLUTION 5 MG5 ML

5 PA NDS

MG 20 MG 5 MG

5 PA NDS

ML 20 MGML

5 PA NDS

SOLUTION 1 MGML

5 PA BvD NDS

5 PA NDS

5 PA LA NDS

5 MG5 ML (1 MGML)

5 PA NDS

400 UNIT

42000 UNIT 15000-47000 -63000

UNIT 20000-63000- 84000 UNIT

25000-79000- 105000 UNIT 3000-

10000 -14000-UNIT 40000-126000-

168000 UNIT 5000-17000- 24000

Miscellaneous

Drug Name

(Cyclogyl) 2

DROPS 044

aerosol 003

(Alcaine) 2

Agents

unitgram

(AK-Poly-Bac) 2

CIPRODEX OTIC (EAR)

(Ciloxan) 1

(Cetraxal) 4

mggram (05 )

mggram)

DROPS VISCOUS 05

Drug Name

(Vigamox) 2

DROPSSUSPENSION 5

(Neo-Polycin HC) 2

mg-unit-unitg

(Neo-Polycin) 2

(Maxitrol) 2

10000 unitg-01

(Maxitrol) 2

unit-0025mgml

unitml-

35-400-10000 mg-unitg-1

10000 unitgram

(Polytrim) 1

drops 10

(Bleph-10) 2

ointment 10

(eye) drops 10 -023 (025 )

Drug Name

(TobraDex) 2

Inflammatory Agents

DROPSSUSPENSION 02

DROPS 0075

DROPS 005

mcg (0025 )

dropssuspension 01

(FML Liquifilm) 4

drops 003

DROPSSUSPENSION 03

DROPSSUSPENSION 1

DROPSGEL 05

OINTMENT 05

DROPSGEL 038

dropssuspension 1

(Pred Forte) 4

Drug Name

DROPS 007

DROPPERETTE 005

DROPPERETTE 5

soln 20 mg

soln 40 mg

(Nexium IV) 2

mg2 ml

release(drec) 15 mg

release(drec) 30 mg

(Protonix) 2

(drec) 20 mg

(drec) 40 mg

50 mg2 ml (25 mgml)

(Zantac) 2

(ranitidine))

Drug Name

DISPERSIBLE 200 MG

0025 mg5 ml

Years)

0025 mg

Years)

KIT 5 MG

5 PA NDS

193 gram60 ml

290 MCG 72 MCG

(loperamide))

(Reglan) 1

Drug Name

SOLUTION 12 MG06 ML

28 days)

SYRINGE 12 MG06 ML

28 days)

SYRINGE 8 MG04 ML

28 days)

gram60 ml

Laxatives

GRAM -12 GRAM160 ML

-584 gram

-586 gram

2272-672 -584 gram

(Colyte with Flavor

Packs)

420 gram

Phosphate Binders

Drug Name

(Renvela) 5 NDS

VELPHORO ORAL

mg 5 mg 50 mg

(Urecholine) 2

(Ditropan XL) 2

release 24hr 15 mg

24hr 2 mg 4 mg

(Detrol LA) 2

hr 10 mg

(Uroxatral) 1

THIOLA EC ORAL

5 PA NDS

Drug Name

mg 250 mg 500 mg

(Exjade) 5 PA NDS

500 mg

(Desferal) 2 PA

250 MG

5 PA NDS

MG 90 MG

5 PA NDS

MG 90 MG

5 PA NDS

30 days)

Hormonal Agents

Androgens

100 mgml 200 mgml

200 mgml (1 ml)

200 mgml

ML 75 MG05 ML

Years)

Drug Name

mg24 hr 00375 mg24 hr 005 mg24 hr

0075 mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

0025 mg24 hr 005 mg24 hr 0075

mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

00375 mg24 hr

days) AGE (Max 64

Years)

mg24 hr 00375 mg24 hr 005 mg24 hr

006 mg24 hr 0075 mg24 hr 01 mg24

days) AGE (Max 64

Years)

mgml 40 mgml

(Delestrogen) 2

05-01 mg

Years)

HR 01 MG24 HR

mg-mcg

Years)

05-25 mg-mcg

Years)

1-5 mg-mcg

Years)

045 MG 0625 MG 09 MG 125 MG

Years)

MGGRAM

Drug Name

MG (14) 0625MG-5MG(14)

Years)

045-15 MG 0625-25 MG 0625-5 MG

Years)

suspension 6 mgml

mg 4 mg 6 mg

(Decadron) 1 PA BvD

1 PA BvD

solution 10 mgml

MG 6 MG

(Cortef) 2

(Depo-Medrol) 2

mg 4 mg 8 mg

(Medrol) 2

(Medrol (Pak)) 2

(Solu-Medrol) 2

mg5 ml (3 mgml)

2 PA BvD

Drug Name

2 PA BvD

1 PA BvD

suspension 40 mgml

(Kenalog) 2

Pituitary

mcgspray (01 ml)

(DDAVP) 2

mcgspray (01 ml)

SOLN 1 MG

MG025 ML

MG025 ML 06 MG025 ML 08

MG025 ML 1 MG025 ML 12

MG025 ML 14 MG025 ML 16

MG025 ML 18 MG025 ML 2

MG025 ML

5 PA NDS

5 MGML (15 UNITML)

5 PA NDS

HUMATROPE INJECTION

5 PA NDS

SOLN 5 (15 UNIT) MG

5 PA NDS

Drug Name

SOLUTION 10 MGML

1125 MG

SYRINGE KIT 75 MG

LUPRON DEPOT-PED

NORDITROPIN FLEXPRO

ML (10 MGML) 30 MG3 ML (10

5 PA NDS

NORDITROPIN FLEXPRO

MG15 ML (33 MGML)

NUTROPIN AQ NUSPIN

5 PA NDS

mcgml 200 mcgml

(Sandostatin) 2

mcgml (1 ml)

5 PA NDS

RECON SOLN 58 MG

5 PA NDS

Drug Name

SAIZEN SAIZENPREP

5 PA NDS

SOLN 5 MG 88 MG

5 PA NDS

INTRAMUSCULAR

SOLN 4 MG 5 MG 6 MG

5 PA NDS

SOMATULINE DEPOT

MG05 ML

5 PA NSO NDS QL (1

per 28 days)

SOMATULINE DEPOT

ML 90 MG03 ML

25 MG 30 MG

5 PA NDS

(65 MCGDAY)

5 NDS QL (1 per 360

AEROSOL 2 MGML

225 MG

5 NDS QL (1 per 168

RECON SOLN 10 MG

5 PA NDS

RECON SOLN 5 MG

SOLN 88 MG

5 PA NDS

Progestins

SUSPENSION 400 MGML

5 PA NSO NDS

Drug Name

suspension 150 mgml

syringe 150 mgml

25 mg 5 mg

(Provera) 1

(40 mgml)

Years)

mg 200 mg

(Prometrium) 2

mcg 125 mcg 137 mcg 150 mcg 175

88 mcg

(Euthyrox) 1

(Cytomel) 2

ACTEMRA ACTPEN

MG09 ML

5 PA NDS

ACTEMRA INTRAVENOUS

80 MG4 ML (20 MGML)

5 PA NDS

SYRINGE 162 MG09 ML

5 PA NDS

SOLN 220 MG

100 mg

2 PA BvD

MG X 2 VIALS)

5 PA NDS

Drug Name

5 PA NDS

mg5 ml

mg 25 mg

(Gengraf) 2 PA BvD

5 PA NDS

SOLN 25 MG (1 ML)

5 PA NDS

25 MG05 ML (05) 50 MGML (1 ML)

5 PA NDS

ENBREL SURECLICK

MGML (1 ML)

5 PA NDS

SOLUTION 10 5

5 PA BvD NDS

4 PA BvD

SOLUTION 10

5 PA BvD NDS

GRAM 5 GRAM

5 PA BvD NDS

SOLUTION 10 10 (100 ML) 10

(200 ML)

5 PA BvD NDS

Drug Name

KIT 40 MG08 ML 40 MG08 ML (6

5 PA NDS

KIT 40 MG08 ML

5 PA NDS

KIT 10 MG02 ML 20 MG04 ML 40

MG08 ML

5 PA NDS

MG08 ML-40 MG04 ML

5 PA NDS

80 MG08 ML

5 PA NDS

MG02 ML 40 MG04 ML

5 PA NDS

SOLUTION 300 UNITML

HYPERRAB SD (PF)

UNITML

HYQVIA SUBCUTANEOUS

25 GRAM 25 ML (10 ) 20 GRAM

200 ML (10 ) 30 GRAM 300 ML (10

) 5 GRAM 50 ML (10 )

5 PA BvD NDS

SOLN 150 MGML

5 PA NDS

SOLUTION 150 MGML

5 PA NDS

Drug Name

100 MGML

5 PA NDS

UNITML

SOLN 100 MG

5 PA NDS

SOLUTION 150 UNITML

MG114 ML

5 PA NDS

MG114 ML

5 PA NDS

100 MG067 ML

5 PA NDS

recon soln 500 mg

(CellCept) 2 PA BvD

SOLN 250 MG

5 PA BvD NDS

OCTAGAM INTRAVENOUS

SOLUTION 10 5

5 PA BvD NDS

5 PA NDS

ORENCIA CLICKJECT

125 MGML

5 PA NDS

875 MG07 ML

5 PA NDS

OTEZLA STARTER ORAL

MG (4)-30 MG (47) 10 MG (4)-20 MG

(4)-30 MG(19)

5 PA NDS

Drug Name

SOLUTION 10

5 PA BvD NDS

5 MGML

4 PA BvD

PACKET 02 MG 1 MG

4 PA BvD ST

MG025 ML 15 MG03 ML 175

MG035 ML 20 MG04 ML 225

MG045 ML 25 MG05 ML 30 MG06

ML 75 MG015 ML

SOLN 100 MG

5 PA NDS

SOLN 100 MG

5 PA NDS

MG15 ML

5 PA NDS

SOLUTION 125 MGML

5 PA NDS

100 MGML 50 MG05 ML

5 PA NDS

130 MG26 ML

5 PA NDS

SOLUTION 45 MG05 ML

5 PA NDS

(Prograf) 2 PA BvD

TALTZ AUTOINJECTOR

80 MGML

5 PA NDS

Drug Name

SYRINGE 80 MGML

5 PA NDS

INJECTOR 100 MGML

5 PA NDS

SYRINGE 100 MGML

5 PA NDS

300 MG15 ML

5 PA LA NDS

5 PA NDS

05 MG 075 MG 1 MG

5 PA BvD NDS

Vaccines

ADACEL(TDAP

ADOLESNADULT)(PF)

LF-(25-5-3-5 MCG)-5LF05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

(25-5-3-5 MCG)-5LF05 ML

3 PA BvD

LF05ML

10-5 LF-MCG-LF05ML

SUSPENSION 20 MCGML

3 PA BvD

Drug Name

SYRINGE 20 MCGML

3 PA BvD

MCG05 ML

3 PA BvD

SUSPENSION 05 ML

SYRINGE 05 ML

720 ELISA UNIT05 ML

ELISA UNIT05 ML

3 PA BvD

58-10 LF-MCG-LF05ML

LF-MCG-LF05ML

32 UNIT05 ML

UNIT05 ML

SYRINGE 6 MCG05 ML

SOLUTION 4 MCG05 ML

Drug Name

10LF05 ML

10EXP3-43-3- 399 TCID5005

UNIT05ML

25 UNIT

3 PA BvD

RECOMBIVAX HB (PF)

3 PA BvD

RECOMBIVAX HB (PF)

MCGML 5 MCG05 ML

3 PA BvD

CCID50ML

SOLUTION 2 ML

50 MCG05 ML

TDVAX INTRAMUSCULAR

UNIT05ML

LF UNIT05 ML

Drug Name

SYRINGE 25 MCG05 ML

UNITML

1350 UNIT05 ML

10 EXP474 UNIT05 ML

19400 UNIT065 ML

Agents

budesonide oral

(Entocort EC) 2

tablets) 400 mg

(Delzicol) 2

(drec) 800 mg

(Asacol HD) 2

Drug Name

(drec) 500 mg

MGACTUATION

SOLUTION

Chloride)

solution

(Aqua Care Sterile

Water)

mcg2 ml

(Hectorol) 2

105 MG117 ML

30 days)

210MG234ML ( 105MG117MLX2)

30 days)

MCG24 ML

Drug Name

200 UNITML

MCGDOSE

solution 2 mcgml

60 MGML

RAYALDEE ORAL

HR 30 MCG

3 PA QL (156 per 30

mg5 ml

soln 500 mg

(Ethyol) 2

SOLN 120 MG 400 MG

5 PA NDS

INJECTOR 200 MGML

SYRINGE 200 MGML

CETYLEV ORAL TABLET

Drug Name

GRAM17 ML

5 GRAM

30 days)

SOLUTION 50 MGML

5 PA LA NDS

RECON SOLN 1 MG

(Vistaril) 1

30 days)

100 mg 200 mg 350 mg 50 mg 500 mg

mg 25 mg 5 mg

100 mgml

(Carnitor) 2

soln 50 mg

(Fusilev) 5 NDS

mg5 ml

(Mestinon) 2

Drug Name

150 MG 200 MG 50 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 500 MG

PACKET 10 GRAM

5 NDS QL (24 per 14

PACKET 2 GRAM

30 days)

Ophthalmic Agents

Antiglaucoma Agents

release 500 mg

500 mg

DROPS 01

DROPSSUSPENSION 1

DROPS 02-05

drops 223-68 mgml

(Cosopt) 2

DROPS 001

(Isopto Carpine) 2

DROPS 002

Drug Name

025 05

(Timoptic) 1

(Timoptic-XE) 4

DROPS 0004

mgml (10 )

IONOSOL-MB IN D5W

SOLUTION 5

PARENTERAL SOLUTION

release 8 meq

40 gram1000 ml (4 )

2 PA BvD

gram100 ml (4 ) 4 gram50 ml (8 )

2 PA BvD

meqml (50 )

2 PA BvD

Drug Name

SOLUTION

SINGLE-USE

PARENTERAL SOLUTION

2 PA BvD

meqml (20 ml)

2 PA BvD

release 10 meq

release 8 meq

ml 40 meq15 ml

(K-Tab) 2

release 20 meq

(K-Tab) 4

(Klor-Con M10) 2

(Klor-Con M20) 2

(Urocit-K 10) 2

release 15 meq

(Urocit-K 15) 2

(Urocit-K 5) 2

parenteral solution

Corticosteroids

Drug Name

50 MCGDOSE

MCGACTUATION 230-21

MCGACTUATION 45-21

MCGACTUATION

MCGACTUATION 200

MCGACTUATION 50

MCGACTUATION

mg2 ml

MCGACTUATION

MCGACTUATION 50

MCGACTUATION

AEROSOL INHALER 110

MCGACTUATION

AEROSOL INHALER 220

MCGACTUATION

AEROSOL INHALER 44

MCGACTUATION

Drug Name

INHALATIONS 80-45

MCGACTUATION

MCGACTUATION 80-45

MCGACTUATION

Antileukotrienes

(Singulair) 1

Bronchodilators

25 mg 3 ml (0083 ) 25 mg05 ml

2 PA BvD

MCGACTUATION

AEROSOL INHALER 17

MCGACTUATION

COMBIVENT RESPIMAT

MCGACTUATION

2 PA BvD

STARTER 25 MCGML

Drug Name

MCGDOSE

12 hr 100 mg 200 mg 300 mg

(Theochron) 2

12 hr 450 mg

24 hr 400 mg 600 mg

(30 ACTUAT)

mgml (20 )

(Acetadote) 2 PA

200 mgml (20 )

2 PA BvD

10 MGML

5 PA NDS

2 PA BvD

Drug Name

30 days)

SYRINGE 30 MGML

INJECTOR 100 MGML

28 days)

SOLN 100 MG

28 days)

100 MGML

28 days)

PACKET 100-125 MG 150-188 MG

MG 200-125 MG

30 days)

RECON SOLN 1000 MG

5 PA BvD NDS

(N) 50-75 MG (D) 75 MG (N)

SOLN 150 MG

5 PA NDS

150 MGML 75 MG05 ML

5 PA NDS

Years)

Drug Name

Years)

250 mg 50 mg

MG 20 MG 5 MG

per 30 days)

Vasodilating Agents

MG 15 MG 2 MG 25 MG

soln 05 mg

(Flolan) 2 PA

soln 15 mg

(Flolan) 5 PA NDS

25 MG 5 MG

5 PA NDS

Drug Name

1 day)

SUSPENSION 32 MG

28 days)

(06 MGML)

5 PA NDS

1200 MCG 1400 MCG 1600 MCG

400 MCG 600 MCG 800 MCG

30 days)

PACK 200 MCG (140)- 800 MCG (60)

5 PA NDS

27 mg iron- 1 mg

A abacavir 47

ABELCET 35

ABILIFY MAINTENA 43

ABRAXANE 15

acamprosate 7

acarbose 32

acebutolol 60

acetazolamide 107

acetic acid 82 104

acetylcysteine 112

acitretin 76

ACTEMRA 95

ACTEMRA ACTPEN 95

ACTHIB (PF) 100

ACTIMMUNE 105

acyclovir 52 76

acyclovir sodium 52

ADACEL(TDAP

ADAGEN 80

adapalene 79

adefovir 52

ADEMPAS 114

adriamycin 15

adrucil 15

ADVAIR DISKUS 110

ADVAIR HFA 110

afeditab cr 63

AFINITOR 15

AFINITOR DISPERZ 15

afirmelle 70

a-hydrocort 91

(2 PACK) 38

AJOVY 38

AKYNZEO

(FOSNETUPITANT) 39

ala-cort 77

albendazole 41

alclometasone 77

ALCOHOL PADS 76

ALDURAZYME 80

ALECENSA 16

alendronate 104

alfuzosin 88

ALIMTA 16

ALINIA 41

ALIQOPA 16

aliskiren 66

allopurinol 37

alosetron 103

ALPHAGAN P 107

alprazolam 8

ALREX 84

altavera (28) 70

ALTRENO 79

ALUNBRIG 16

alyacen 135 (28) 70

alyacen 777 (28) 70

alyq 114

amabelz 89

amantadine hcl 41

AMBISOME 35

ambrisentan 114

amethia 70

amethia lo 70

amiloride 63

AMINOSYN 10 55

AMINOSYN 7 WITH

ELECTROLYTES 55

AMINOSYN 85 55

AMINOSYN 85 -

ELECTROLYTES 55

AMINOSYN II 10 56

AMINOSYN II 15 56

AMINOSYN II 7 56

AMINOSYN II 85 56

AMINOSYN II 85 -

ELECTROLYTES 56

AMINOSYN M 35 56

AMINOSYN-HBC 7 56

AMINOSYN-PF 10 56

AMINOSYN-PF 7

(SULFITE-FREE) 56

AMINOSYN-RF 52 56

amiodarone 60

AMITIZA 86

amitriptyline 29

amlodipine 63

ammonium lactate 76

amoxapine 30

amoxicillin 13

amphotericin b 35

ampicillin 13

ANADROL-50 89

anagrelide 55

anastrozole 16

ANORO ELLIPTA 111

APOKYN 41

apraclonidine 81

aprepitant 39

apri 70

APRISO 103

APTIOM 25 26

APTIVUS 47

aranelle (28) 70

ARCALYST 95

aripiprazole 43

ARISTADA 43

ARISTADA INITIO 43

armodafinil 114

ARNUITY ELLIPTA 110

arsenic trioxide 16

ashlyna 70

ASSURE ID INSULIN

SAFETY 79

atazanavir 47

atenolol 60

atomoxetine 66

atorvastatin 64

atovaquone 41

ATRIPLA 47

atropine 25 82

ATROVENT HFA 111

AUBAGIO 66

aubra 70

aurovela 1530 (21) 70

aurovela 24 fe 70

AUSTEDO 67

AVASTIN 16

aviane 70

AVONEX 67

ayuna 70

azacitidine 16

azathioprine 95

azelastine 82

azithromycin 12

AZOPT 107

aztreonam 13

azurette (28) 70

B baciim 10

bacitracin 82

baclofen 113

balsalazide 103

BALVERSA 16

balziva (28) 71

BANZEL 26

BAVENCIO 16

BAXDELA 14

NEEDLE 79

UNIT 80

bekyree (28) 71

BELEODAQ 16

BELSOMRA 114

benazepril 59

BENDEKA 16

BENLYSTA 105

benztropine 41

BESPONSA 16

BETASERON 67

betaxolol 60

BETHKIS 9

BEVYXXA 52

bexarotene 16

BEXSERO 100

bicalutamide 16

BICILLIN L-A 13

BIDIL 66

BIKTARVY 47

bleomycin 16

bleph-10 82

BLINCYTO 16

blisovi 24 fe 71

blisovi fe 1530 (28) 71

BOOSTRIX TDAP 100

BORTEZOMIB 16

BOSULIF 16 17

BRAFTOVI 17

BREO ELLIPTA 110

briellyn 71

BRILINTA 55

brimonidine 107

BRIVIACT 26

bromocriptine 41

BROMSITE 84

budesonide 103 110

bumetanide 63

bupropion hcl 30

buspirone 8

BYSTOLIC 61

BYVALSON 61

C cabergoline 41

CABLIVI 105

CABOMETYX 17

caffeine citrate 67

calcipotriene 76

calcitriol 104

CALDOLOR 6

CALQUENCE 17

camila 71

CAPASTAT 39

CAPRELSA 17

captopril 59

CARBAGLU 86

carbamazepine 26

carteolol 107

cartia xt 62

carvedilol 61

caspofungin 36

CAYSTON 13

caziant (28) 71

cefaclor 11

cefadroxil 11

cefazolin 11

cefdinir 11

cefepime 11

cefixime 11

cefotaxime 11

cefoxitin 11

cefpodoxime 12

cefprozil 12

ceftazidime 12

ceftriaxone 12

celecoxib 6

CELONTIN 26

cephalexin 12

CERDELGA 80

CEREZYME 80

CETYLEV 105

CHANTIX 8

CHANTIX CONTINUING

MONTH BOX 8

CHANTIX STARTING

MONTH BOX 8

chlorothiazide 64

chlorpromazine 43

chlorthalidone 64

chlorzoxazone 113

ciclopirox 36

cilostazol 55

CIMDUO 47

cimetidine hcl 85

CIMZIA 95

CIMZIA POWDER FOR

RECONST 95

cinacalcet 104

CINQAIR 112

CINRYZE 53

CINVANTI 39

CIPRODEX 82

ciprofloxacin 14

citalopram 30

clarithromycin 12

CLENPIQ 87

clindamycin hcl 10

CLINIMIX 5D15W

SULFITE FREE 56

CLINIMIX 5D25W

SULFITE-FREE 56

FREE 56

CLINIMIX 425D5W

SULFIT FREE 56

CLINIMIX 425-D25W

SULF-FREE 56

CLINIMIX 5-

CLINIMIX E 275D10W

SUL FREE 56

CLINIMIX E 275D5W

SULF FREE 57

CLINIMIX E 425D10W

SUL FREE 57

CLINIMIX E 425D25W

SUL FREE 57

CLINIMIX E 425D5W

SULF FREE 57

CLINIMIX E 5D15W

SULFIT FREE 57

CLINIMIX E 5D20W

SULFIT FREE 57

CLINIMIX E 5D25W

SULFIT FREE 57

clobazam 26

clobetasol 78

clofarabine 17

clomipramine 30

clonazepam 9

clonidine 58

clonidine hcl 58

clopidogrel 55

clotrimazole 36

clozapine 43 44

COARTEM 41

codeine sulfate 3

colchicine 37

colestipol 64

colocort 103

COMBIGAN 107

COMETRIQ 17

COMPLERA 47

compro 39

constulose 86

COPIKTRA 17

CORLANOR 62

cormax 78

cortisone 91

COTELLIC 17

CREON 80

CRIXIVAN 47

cromolyn 82 86 112

cryselle (28) 71

cyclobenzaprine 113

cyclopentolate 82

cyclophosphamide 17

CYCLOPHOSPHAMIDE 17

cyclosporine 96

cyproheptadine 37

CYRAMZA 17

cyred 71

CYSTADANE 106

CYSTARAN 82

D dalfampridine 67

DALIRESP 113

danazol 89

dantrolene 113 114

dapsone 39

DAPTACEL (DTAP

PEDIATRIC) (PF) 100

daptomycin 10

DARAPRIM 41

DARZALEX 17

dasetta 135 (28) 71

dasetta 777 (28) 71

DAURISMO 17

daysee 71

deblitane 71

decadron 91

decitabine 17

deferasirox 89

deferoxamine 89

DELSTRIGO 47

delyla (28) 71

DEMSER 62

DEPEN TITRATABS 89

DEPO-PROVERA 94

DESCOVY 47

desipramine 30

desmopressin 92

desoximetasone 78

dexamethasone 91

(pf) 91

phosphate 84 91

dextroamphetamine-

amphetamine 67

DIASTAT 26

DIASTAT ACUDIAL 26

diazepam 9 26

diazepam intensol 9

dicloxacillin 13

dicyclomine 86

didanosine 47

DIFICID 12

digitek 62

digox 62

digoxin 62 63

DIGOXIN 63

diltiazem hcl 62

dilt-xr 62

dimenhydrinate 39

DIPENTUM 103

dipyridamole 55

disulfiram 8

divalproex 26

dofetilide 60

donepezil 29

dorzolamide 107

dotti 90

DOVATO 48

doxazosin 58

doxepin 30

doxercalciferol 104

doxorubicin 17

doxy-100 15

dronabinol 39

droperidol 106

DROXIA 18

DUAVEE 90

duloxetine 30

DUPIXENT 96

DUREZOL 84

dutasteride 88

E econazole 36

EDARBI 59

EDARBYCLOR 59

EDURANT 48

efavirenz 48

EGRIFTA 92

ELAPRASE 80

ELIGARD 18

elinest 71

ELIQUIS 52

ELITEK 80

ELLA 71

ELMIRON 106

EMCYT 18

EMEND 40

EMFLAZA 91

EMGALITY PEN 38

EMGALITY SYRINGE 38

emoquette 71

EMPLICITI 18

EMSAM 30

EMTRIVA 48

enalaprilat 59

ENBREL 96

ENBREL SURECLICK 96

ENDARI 106

endocet 3

enoxaparin 52 53

enpresse 71

enskyce 71

entacapone 42

entecavir 52

ENTRESTO 59

enulose 86

EPCLUSA 51

EPIDIOLEX 26

epinastine 82

epinephrine 63

epitol 26

EPIVIR HBV 48

eplerenone 66

ergoloid 106

ERGOMAR 38

ERIVEDGE 18

ERLEADA 18

erlotinib 18

errin 71

ertapenem 13

ery pads 77

erythromycin 12 82

ESBRIET 113

estarylla 71

estradiol 90

eszopiclone 114

ethambutol 39

ethosuximide 26

etodolac 6

ETOPOPHOS 18

etoposide 18

EUCRISA 78

EVENITY 104

EVOTAZ 48

exemestane 18

EXONDYS 51 106

EXTAVIA 67

ezetimibe 65

F FABRAZYME 80

falmina (28) 72

famciclovir 52

famotidine 85

famotidine (pf) 85

FANAPT 44

FARYDAK 18

FASENRA 113

febuxostat 37

felbamate 27

FEMRING 90

femynor 72

fenofibrate 65

fentanyl 3

fentanyl citrate 3

FERRIPROX 89

FETZIMA 30

INSULIN 33

finasteride 88

FIRAZYR 63

FIRVANQ 10

FLEBOGAMMA DIF 96

flecainide 60

FLOVENT DISKUS 110

FLOVENT HFA 110

floxuridine 18

fluconazole 36

flucytosine 36

fludrocortisone 91

flumazenil 67

flunisolide 84

fluocinolone 78

fluocinonide 78

fluocinonide-e 78

fluorometholone 84

fluorouracil 18 76

fluoxetine 30

fluphenazine hcl 44

flurbiprofen 6

flutamide 18

fluvoxamine 31

fomepizole 106

fondaparinux 53

FORTEO 104

fosamprenavir 48

foscarnet 50

fosinopril 59

fosphenytoin 27

FREAMINE HBC 69 57

FREAMINE III 10 58

FULPHILA 53

fulvestrant 18

furosemide 64

FUZEON 48

fyavolv 90

FYCOMPA 27

G gabapentin 27

GALAFOLD 80

galantamine 29

GAMASTAN 96

GAMMAGARD LIQUID 96

MCGML) 96

GAMMAPLEX 96

GAMMAPLEX (WITH

SORBITOL) 96

GARDASIL 9 (PF) 101

GATTEX 30-VIAL 86

GAUZE PAD 80

gavilyte-c 87

gavilyte-g 87

gavilyte-n 87

GAZYVA 18

gemfibrozil 65

generlac 86

gengraf 96

GENOTROPIN 92

gentak 82

gentamicin 9 77 82

GENVOYA 48

GEODON 44

GILENYA 67

GILOTRIF 18

glatiramer 67

glatopa 67 68

GLEOSTINE 18

glimepiride 35

glipizide 35

glyburide 35

glycopyrrolate 86

glydo 7

GLYXAMBI 32

GOCOVRI 42

granisetron (pf) 40

granisetron hcl 40

GRANIX 53 54

guanfacine 58 68

guanidine 106

H HAEGARDA 54

hailey 24 fe 72

haloperidol 44

HARVONI 51

HAVRIX (PF) 101

heather 72

HEPATAMINE 8 58

HERCEPTIN 19

HETLIOZ 114

HIBERIX (PF) 101

HUMATROPE 92

HUMIRA 97

HUMIRA PEDIATRIC

CROHNS START 97

HUMIRA PEN 97

HS START 97

HUMIRA PEN PSOR-

UVEITS-ADOL HS 97

HUMIRA(CF) 97

STARTER 97

HUMIRA(CF) PEN 97

UC-HS 97

ADOL HS 97

INSULIN 34

KWIKPEN 34

hydralazine 63

hydromorphone 4

hydroxyurea 19

hydroxyzine hcl 37

HYPERRAB (PF) 97

HYPERRAB SD (PF) 97

HYQVIA 97

I ibandronate 104

IBRANCE 19

ibuprofen 6

icatibant 63

ICLUSIG 19

IDHIFA 19

ifosfamide 19

ifosfamide-mesna 19

ILARIS (PF) 97

ILEVRO 84

ILUMYA 98

imatinib 19

IMBRUVICA 19

IMFINZI 19

imipramine hcl 31

imiquimod 76

IMLYGIC 19

(PF) 101

IMPAVIDO 41

INBRIJA 42

incassia 72

INCRELEX 93

INCRUSE ELLIPTA 111

indapamide 64

indomethacin 6

INFLECTRA 98

INGREZZA 68

INGREZZA INITIATION

PACK 68

INLYTA 19

U-100 80

INTELENCE 48

INTRALIPID 58

INTRON A 51

introvale 72

INVEGA SUSTENNA 45

INVEGA TRINZA 45

INVELTYS 84

INVIRASE 48

INVOKAMET 32

INVOKAMET XR 32

INVOKANA 32

IPOL 101

irbesartan 59

IRESSA 19

ISENTRESS 48

ISENTRESS HD 48

isibloom 72

ISOLYTE-P IN 5

DEXTROSE 108

ISOLYTE-S 108

isoniazid 39

itraconazole 36

ivermectin 41

IXEMPRA 19

IXIARO (PF) 101

J JADENU 89

JADENU SPRINKLE 89

JAKAFI 20

jantoven 53

JANUMET 32

JANUMET XR 32

JANUVIA 32

JARDIANCE 32

jasmiel (28) 72

jencycla 72

JENTADUETO 32

JENTADUETO XR 32

jinteli 90

jolivette 72

juleber 72

JULUCA 48

junel 1530 (21) 72

junel 120 (21) 72

junel fe 1530 (28) 72

junel fe 120 (28) 72

junel fe 24 72

JUXTAPID 65

JYNARQUE 64

K KABIVEN 58

KALETRA 48

kalliga 72

KALYDECO 113

KANJINTI 20

KANUMA 80

kariva (28) 72

KEDRAB (PF) 98

kelnor 135 (28) 72

kelnor 1-50 72

ketoconazole 36

ketorolac 6 84

KEVEYIS 106

KEVZARA 98

KEYTRUDA 20

KINERET 98

KINRIX (PF) 101

KISQALI 20

klor-con m10 108

klor-con m15 108

klor-con m20 108

KORLYM 32

KRINTAFEL 41

KRYSTEXXA 81

kurvelo (28) 72

KUVAN 81

KYPROLIS 20

labetalol 61

lactulose 86

lamivudine 48

lamotrigine 27

lansoprazole 85

INSULIN 34

larin 1530 (21) 73

larin 120 (21) 73

larin 24 fe 73

larin fe 1530 (28) 73

larin fe 120 (28) 73

larissia 73

latanoprost 107

LATUDA 45

LAZANDA 4

leena 28 73

leflunomide 98

LEMTRADA 68

LENVIMA 20

lessina 73

letrozole 20

LEUKERAN 20

LEUKINE 54

leuprolide 20

levetiracetam 27

levobunolol 107

levocarnitine 106

levocetirizine 37

levofloxacin 14 82

LEVOLEUCOVORIN

CALCIUM 106

levonest (28) 73

levora-28 73

levothyroxine 95

LEXIVA 48

LIALDA 103

LIBTAYO 20

lidocaine 7

lidocaine (pf) 7 60

lidocaine hcl 7

lidocaine viscous 7

lillow (28) 73

linezolid 10 11

LINZESS 86

liothyronine 95

lisinopril 59 60

lithium citrate 68

LIVALO 65

LOKELMA 86

LONHALA MAGNAIR

REFILL 112

LONHALA MAGNAIR

STARTER 111

LONSURF 20

loperamide 86

lorazepam 9

LORBRENA 20

lorcet hd 4

lorcet plus 4

loryna (28) 73

losartan 59

LOTEMAX 84

LOTEMAX SM 84

lovastatin 65

LUCEMYRA 8

LUMIGAN 107

LUMOXITI 21

LUPRON DEPOT 21 93

LUPRON DEPOT-PED 93

LUPRON DEPOT-PED (3

MONTH) 93

lutera (28) 73

LYNPARZA 21

LYRICA 27

LYSODREN 21

lyza 73

malathion 79

maprotiline 31

marlissa (28) 73

MARPLAN 31

MATULANE 21

PACK) 68

MAVENCLAD (4 TABLET

PACK) 68

MAVENCLAD (5 TABLET

PACK) 68

MAVENCLAD (6 TABLET

PACK) 68

MAVENCLAD (7 TABLET

PACK) 68

MAVENCLAD (8 TABLET

PACK) 68

MAVENCLAD (9 TABLET

PACK) 68

MAVYRET 51

MAYZENT 68

meclizine 40

mefenamic acid 6

mefloquine 41

megestrol 21 95

MEKINIST 21

MEKTOVI 21

meloxicam 6

memantine 29

MENACTRA (PF) 101

(PF) 101

MEPSEVII 81

mercaptopurine 21

meropenem 13

mesalamine 103

mesna 106

MESNEX 106

MESTINON 106

metaproterenol 112

metformin 32 33

methadone 4

methadose 4

methimazole 95

methocarbamol 114

methoxsalen 76

methscopolamine 86

methyclothiazide 64

metipranolol 107

mexiletine 60

MIACALCIN 105

miconazole-3 36

midodrine 58

miglustat 81

mili 73

mimvey 90

mimvey lo 90

minitran 66

minocycline 15

minoxidil 66

mirtazapine 31

misoprostol 85

MITIGARE 37

mitoxantrone 21

M-M-R II (PF) 102

molindone 45

mometasone 79

mondoxyne nl 15

mono-linyah 73

mononessa (28) 73

montelukast 111

morphine 4 5

MORPHINE 5

MOVANTIK 86

MOXEZA 82

moxifloxacin 14 83

MOZOBIL 54

MULPLETA 54

MULTAQ 60

mupirocin 77

MYLOTARG 21

MYRBETRIQ 88

myzilra 73

N nabumetone 6

nafcillin 13 14

NAGLAZYME 81

naloxone 8

naltrexone 8

NAMZARIC 29

naproxen 7

NARCAN 8

NATACYN 83

NATPARA 105

NEBUPENT 41

necon 0535 (28) 73

nefazodone 31

neomycin 10

dexameth 83

neomycin-polymyxin-

gramicidin 83

neo-polycin 83

neo-polycin hc 83

NEPHRAMINE 54 58

NERLYNX 21

NEULASTA 54

NEUPOGEN 54

NEUPRO 42

nevirapine 48 49

NEXAVAR 21

niacin 65

niacor 65

nicardipine 63

NICOTROL 8

nifedipine 63

nikki (28) 74

nilutamide 21

NINLARO 22

nitroglycerin 66

NITYR 81

NIVESTYM 54

nizatidine 85

NOCDURNA (MEN) 93

NOCDURNA (WOMEN) 93

nora-be 74

norlyda 74

norlyroc 74

NORMOSOL-M IN 5

DEXTROSE 109

NORMOSOL-R 109

NORTHERA 58

nortrel 0535 (28) 74

nortrel 135 (21) 74

nortrel 135 (28) 74

nortrel 777 (28) 74

nortriptyline 31

NORVIR 49

NOVOLIN 7030 U-100

INSULIN 34

100 34

NOVOLIN N NPH U-100

INSULIN 34

100 INSULN 34

INSULIN 34

INSULN 34

NOVOLOG MIX 70-

30FLEXPEN U-100 34

INSULIN 34

ASPART 34

NOXAFIL 36

NUCALA 113

NUCYNTA 5

NUCYNTA ER 5

NUEDEXTA 69

NULOJIX 98

NUPLAZID 45

NUTRILIPID 58

nyamyc 36

nystatin 36

nystop 36

O OCALIVA 87

OCREVUS 69

OCTAGAM 98

ODEFSEY 49

ODOMZO 22

OFEV 113

ofloxacin 83

ogestrel (28) 74

olanzapine 45

olmesartan 59

olopatadine 82

OLUMIANT 98

omeprazole 85

OMNITROPE 93

ONCASPAR 22

ondansetron 40

ondansetron hcl 40

ONIVYDE 22

OPDIVO 22

OPSUMIT 114

oralone 76

ORENCIA 98

ORENITRAM 114

ORFADIN 81

ORILISSA 93 94

ORKAMBI 113

orsythia 74

oseltamivir 50

OSMOLEX ER 42

OTEZLA 98

OTEZLA STARTER 98

oxcarbazepine 27

OXTELLAR XR 27

oxycodone 5

oxycodone-aspirin 5

OZEMPIC 33

P pacerone 60

paliperidone 45 46

PALYNZIQ 81

PANRETIN 76

pantoprazole 85

paricalcitol 105

PARICALCITOL 105

paromomycin 41

paroxetine hcl 31

PASER 39

PAXIL 31

PEDIARIX (PF) 102

PEDVAX HIB (PF) 102

PEGANONE 27

PEGASYS 51 52

PEGASYS PROCLICK 51

PEGINTRON 52

penicillamine 89

PENNSAID 7

PENTACEL (PF) 102

PENTAM 41

pentamidine 41

pentoxifylline 55

PERIKABIVEN 58

periogard 76

permethrin 79

perphenazine 46

PERSERIS 46

pfizerpen-g 14

phenadoz 40

phenelzine 31

phenobarbital 27 28

phenytoin 28

phenytoin sodium 28

philith 74

PHOSLYRA 88

PICATO 76 77

PIFELTRO 49

pimecrolimus 79

pimozide 46

pimtrea (28) 74

pioglitazone 33

PIQRAY 22

pirmella 74

PLASMA-LYTE 148 109

PLASMA-LYTE A 109

PLEGRIDY 69

podofilox 77

POLIVY 22

polycin 83

POMALYST 22

portia 28 74

PORTRAZZA 22

PRADAXA 53

PRALUENT PEN 65

pramipexole 42

prasugrel 55

pravastatin 65

prazosin 59

prednicarbate 79

prednisolone 92

84 91 92

prednisone 92

pregabalin 28

PREMARIN 90

PREMPHASE 91

PREMPRO 91

prevalite 65

previfem 74

PREVYMIS 50

PREZCOBIX 49

PREZISTA 49

PRIFTIN 39

PRIMAQUINE 41

primidone 28

PRIVIGEN 99

probenecid 37

procainamide 60

PROCALAMINE 3 58

prochlorperazine 40

PROCRIT 54

procto-med hc 79

proctosol hc 79

proctozone-hc 79

PROCYSBI 88

progesterone 95

PROGLYCEM 106

PROGRAF 99

PROLASTIN-C 113

PROLENSA 85

PROLEUKIN 22

PROLIA 105

PROMACTA 54

promethazine 37 40

promethegan 40

propafenone 60

proparacaine 82

propranolol 61

propylthiouracil 95

PROQUAD (PF) 102

PROSOL 20 58

protamine 55

protriptyline 31

PULMOZYME 81

PURIXAN 22

pyrazinamide 39

quetiapine 46

quinapril 60

R RABAVERT (PF) 102

RADICAVA 69

raloxifene 91

ramipril 60

ranitidine hcl 85

ranolazine 63

rasagiline 42

RASUVO (PF) 99

RAVICTI 87

RAYALDEE 105

REBIF REBIDOSE 69

reclipsen (28) 74

RECTIV 107

RELISTOR 87

REMICADE 99

RENFLEXIS 99

repaglinide 33

REPATHA SYRINGE 65

RESCRIPTOR 49

RESTASIS 85

RETACRIT 55

RETROVIR 49

REVCOVI 81

REVLIMID 22

revonto 114

REXULTI 46

REYATAZ 49

RHOPRESSA 107

ribasphere 52

ribavirin 52

RIDAURA 99

rifabutin 39

rifampin 39

riluzole 69

rimantadine 51

RISPERDAL CONSTA 46

risperidone 46

ritonavir 49

RITUXAN 22

RITUXAN HYCELA 22

rivastigmine 29

rizatriptan 38

ropinirole 42

rosadan 77

rosuvastatin 65

ROTARIX 102

ROTATEQ VACCINE 102

RUBRACA 22

RYDAPT 22

S SABRIL 28

SAIZEN 94

SANTYL 77

SAPHRIS 46

SAVELLA 69

scopolamine base 40

selegiline hcl 42

selenium sulfide 77

SELZENTRY 49

SEREVENT DISKUS 112

SEROSTIM 94

sertraline 31

setlakin 74

sevelamer hcl 88

sharobel 74

SHINGRIX (PF) 102

SIGNIFOR 94

SILENOR 114

SILIQ 99

SIMBRINZA 108

simliya (28) 74

simpesse 74

SIMPONI 99

SIMPONI ARIA 99

simvastatin 65

sirolimus 99

SIRTURO 39

SKYRIZI 99

smoflipid 58

sodium chloride 104

SOLIQUA 10033 34

SOLTAMOX 22

SOLU-CORTEF (PF) 92

SOMATULINE DEPOT 94

SOMAVERT 94

sorine 61

sotalol 61

sotalol af 61

SOVALDI 51

spironolactone 64

SPRAVATO 31

sprintec (28) 75

SPRITAM 28

SPRYCEL 22

sronyx 75

ssd 77

stavudine 49

STELARA 99

STIVARGA 23

STRENSIQ 81

streptomycin 10

STRIBILD 49

SUBLOCADE 8

subvenite 28

sucralfate 86

sulfadiazine 14

sulfasalazine 104

sulfatrim 15

sulindac 7

sumatriptan 38

SUPPRELIN LA 94

SUTENT 23

syeda 75

SYLATRON 52

SYLVANT 23

SYMBICORT 110 111

SYMDEKO 113

SYMFI 49

SYMFI LO 49

SYMJEPI 63

SYMLINPEN 120 33

SYMLINPEN 60 33

SYMPAZAN 28

SYMTUZA 49

SYNAGIS 51

SYNAREL 94

SYNERCID 11

SYNJARDY 33

SYNJARDY XR 33

SYNRIBO 23

T TABLOID 23

tacrolimus 79 99

TAFINLAR 23

TAGRISSO 23

TAKHZYRO 107

TALTZ SYRINGE 100

TALZENNA 23

tamoxifen 23

tamsulosin 88

TARGRETIN 23

tarina 24 fe 75

tarina fe 120 (28) 75

TASIGNA 23

TAVALISSE 55

tazarotene 79

TAZORAC 79

taztia xt 62

TDVAX 102

TECENTRIQ 23

TECFIDERA 70

TECHNIVIE 51

TEFLARO 12

TEKTURNA HCT 66

telmisartan 59

temazepam 9

TEMODAR 23

TENIVAC (PF) 102

terazosin 88

terbinafine hcl 36

terbutaline 112

terconazole 37

testosterone 89

PED(PF) 102

tetrabenazine 70

tetracycline 15

THALOMID 107

theophylline 112

THIOLA 89

THIOLA EC 88

thioridazine 46

thiotepa 23

thiothixene 46

tiagabine 28

TIBSOVO 23

TICE BCG 100

tigecycline 15

tilia fe 75

TIVICAY 49 50

tizanidine 114

TOBI PODHALER 10

tobramycin 84

TOLAK 77

tolazamide 35

tolterodine 88

topiramate 28

toposar 23

toremifene 23

torsemide 64

TOTECT 107

TOUJEO MAX U-300

SOLOSTAR 34

INSULIN 35

TOVIAZ 88

TRACLEER 115

TRADJENTA 33

tramadol 5

trandolapril 60

tranexamic acid 55

TRANSDERM-SCOP 41

tranylcypromine 31

TRAVASOL 10 58

TRAVATAN Z 108

trazodone 31

TREANDA 23

TRECATOR 39

TRELEGY ELLIPTA 112

TRELSTAR 23 24

TREMFYA 100

tretinoin 79

tri femynor 75

trientine 89

tri-estarylla 75

trifluoperazine 46

trifluridine 84

trihexyphenidyl 43

tri-legest fe 75

tri-linyah 75

tri-lo-estarylla 75

tri-lo-marzia 75

tri-lo-mili 75

tri-lo-sprintec 75

trimethoprim 11

tri-mili 75

trimipramine 31

TRINTELLIX 31

TRIPTODUR 94

TRIUMEQ 50

trivora (28) 75

tri-vylibra 75

tri-vylibra lo 75

TROGARZO 50

TROPHAMINE 10 58

TROPHAMINE 6 58

TRULICITY 33

TRUMENBA 103

TRUVADA 50

tulana 75

TWINRIX (PF) 103

TYBOST 107

TYKERB 24

TYMLOS 105

TYPHIM VI 103

TYSABRI 100

TYVASO 115

U UCERIS 104

UDENYCA 55

ULORIC 37

UNITUXIN 24

UPTRAVI 115

ursodiol 87

V valacyclovir 52

VALCHLOR 77

valganciclovir 52

valproate sodium 28

valproic acid 29

valrubicin 24

valsartan 59

vancomycin 11

VAQTA (PF) 103

VARIVAX (PF) 103

VASCEPA 66

VELCADE 24

VELPHORO 88

VELTASSA 87

VEMLIDY 50

VENCLEXTA 24

VENCLEXTA STARTING

PACK 24

venlafaxine 31 32

verapamil 62

VERSACLOZ 46

VERZENIO 24

V-GO 40 80

VIBERZI 87

VICTOZA 33

VIDEX EC 50

VIEKIRA PAK 51

vienva 75

vigabatrin 29

vigadrone 29

VIIBRYD 32

VIMIZIM 81

VIMPAT 29

vinorelbine 24

viorele (28) 75

VIRACEPT 50

VIREAD 50

VISTOGARD 107

VITRAKVI 24

VIZIMPRO 24

VOLTAREN 7

voriconazole 36 37

VOSEVI 51

VOTRIENT 24

VPRIV 81

VRAYLAR 47

vyfemla (28) 76

vylibra 76

VYNDAQEL 63

VYXEOS 24

W warfarin 53

WELCHOL 66

wera (28) 76

X XADAGO 43

XALKORI 24

XARELTO 53

XATMEP 24

XELJANZ 100

XELJANZ XR 100

XERMELO 87

XIFAXAN 11

XIIDRA 85

XOFLUZA 51

XOLAIR 113

XOSPATA 24

XPOVIO 25

XTAMPZA ER 5 6

XTANDI 25

xulane 76

XULTOPHY 10036 35

XURIDEN 107

XYOSTED 89

XYREM 114

Y YERVOY 25

YF-VAX (PF) 103

YONDELIS 25

YONSA 25

Z zafirlukast 111

zaleplon 114

zarah 76

ZARXIO 55

ZEJULA 25

ZELBORAF 25

zenatane 77

zenchent (28) 76

ZENPEP 81

ZEPATIER 51

zidovudine 50

ziprasidone hcl 47

ZIRGAN 84

ZOLADEX 25

zoledronic acid 105

ZOLINZA 25

zolpidem 114

ZOMACTON 94

zonisamide 29

ZORBTIVE 94

ZORTRESS 100

ZOSTAVAX (PF) 103

zovia 135e (28) 76

ZTLIDO 7

ZUBSOLV 8

ZULRESSO 32

zumandimine (28) 76

ZYDELIG 25

ZYKADIA 25

ZYLET 84

ZYPREXA RELPREVV 47

ZYTIGA 25







Medical Condition









Table of Contents

INDEX

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

H6988_ENR1085_C I

2020 Formulary

during the year

H6988_ENR1085_C II

during the year

H6988_ENR1085_C III

Medical Condition

name for your drug

may include

H6988_ENR1085_C IV

options

(HMO) Formulary

H6988_ENR1085_C V

exception

page I-1

Analgesics 3

Anesthetics 7

Antibacterials 9

Anticonvulsants 25

Antidepressants 29

Antifungals 35

Antigout Agents 37

Antihistamines 37

Caloric Agents 55

Contraceptives 70

Table of Contents

Devices 79

Drug Name

Analgesics

12 mg5 ml

30 days)

(Buprenex) 2

50-325-40 mg

Years)

50-325-40 mg

Years)

325-40 mg

Years)

30 days)

400 mcg 600 mcg 800 mcg

per 30 days)

75 mcghr

30 days)

75-325 mg15 ml

30 days)

10-325 mg

30 days)

25-325 mg

30 days)

Drug Name

325 mg

30 days)

75-325 mg

30 days)

5 PA NDS NM QL (30

per 30 days)

30 days)

suv inner 10 mgml

mg5 ml (20 mgml)

30 days)

4 mgml 8 mgml

30 days)

Drug Name

30 days)

mg 200 mg 60 mg

30 days)

mg 30 mg

30 days)

150 MG 200 MG 250 MG 50 MG

3 NDS NM QL (60 per

30 days)

MG 75 MG

30 days)

hr 10 mg 15 mg 20 mg 30 mg 40 mg 60

mg 80 mg

30 days)

325 mg

30 days)

325 mg 5-325 mg

30 days)

325 mg

30 days)

325 mg

30 days)

XTAMPZA ER ORAL

3 NDS NM QL (60 per

30 days)

Drug Name

XTAMPZA ER ORAL

CRUSH) 27 MG

30 days)

XTAMPZA ER ORAL

CRUSH) 36 MG

30 days)

12 hour 13

(Flector) 2 PA

(Voltaren-XR) 2

(IBU) 1

Years)

days) AGE (Max 64

Years)

Drug Name

(EC-Naprosyn) 2

ACTUATION(2 )

28 days)

Anesthetics

Local Anesthetics

applicator 2

(1 ) 15 mgml (15 ) 20 mgml (2 )

5 mgml (05 )

(Xylocaine-MPF) 1

mgml (2 )

(1 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine) 1

(40 mgml)

patchmedicated 5

solution 2

PATCHMEDICATED 18

Treatment Agents

(drec) 333 mg

Drug Name

12-3 mg 8-2 mg

2-05 mg 4-1 mg

2-05 mg 8-2 mg

3 QL (336 per 365 days)

(11)- 1 MG (42)

NICOTROL INHALATION

CARTRIDGE 10 MG

4 QL (1008 per 90 days)

018 MG 14-036 MG 114-29 MG 29-

071 MG 57-14 MG

Antianxiety Agents

Benzodiazepines

30 days)

mg 5 mg 75 mg

Drug Name

25 mg 5 mg

30 days)

0125 mg 025 mg 05 mg 1 mg

2 NDS NM QL (90 per

30 days)

375 mg

30 days)

Antibacterials

Aminoglycosides

5 PA BvD NDS

40 mgml

solution 20 mg2 ml

Drug Name

mg8 ml

(Tobi) 5 PA BvD NDS

mg 75 mg

(Cleocin HCl) 1

900 mg50 ml

150 (mgml) (6 ml)

150 mgml

(Cleocin) 2

solution 600 mg4 ml

(Cleocin) 2

soln 150 mg

(Coly-Mycin M

Parenteral)

5 PA BvD NDS

(Cubicin) 5 NDS

MGML 50 MGML

mg300 ml

(Zyvox) 5 NDS

100 mg5 ml

(Zyvox) 5 NDS

Drug Name

(Metro IV) 2

100 mg 25 mg 50 mg

capsule 100 mg

500000 unit

SOLN 500 MG

750 mg

2 PA BvD

Cephalosporins

125 mg5 ml 250 mg5 ml 375 mg5 ml

gram 500 mg

125 mg5 ml 250 mg5 ml

(Maxipime) 2

10 gram 2 gram

Drug Name

(Tazicef) 2

750 mg

15 gram 75 gram

SOLN 400 MG 600 MG

Macrolides

(Zithromax) 2

500 mg (3 pack) 600 mg

(EES Granules) 2

(EryPed 400) 2

Drug Name

(Azactam) 2

5 PA LA NDS

soln 250 mg

soln 500 mg

(Primaxin IV) 2

gram 500 mg

(Merrem) 2

Penicillins

250 mg5 ml 400 mg5 ml

250 mg

mg5 ml

500-125 mg 875-125 mg

(Augmentin) 1

500 mg

(Unasyn) 2

2400000 UNIT4 ML 600000

UNITML

Drug Name

20 million unit

(Pfizerpen-G) 2

unitml

mg5 ml 250 mg5 ml

500 mg

405 gram

(Zosyn) 2 PA BvD

Quinolones

(Cipro) 1

(Cipro in D5W) 2

ciprofloxacin oral

ml 500 mg5 ml

(Cipro) 2

250 mg50 ml 500 mg100 ml 750 mg150

Sulfonamides

(Sulfatrim) 2

Drug Name

400-80 mg

(Bactrim) 1

800-160 mg

(Bactrim DS) 1

Tetracyclines

soln 100 mg

(Doxy-100) 2

(Morgidox) 2

mg 50 mg

(Mondoxyne NL) 2

(Vibramycin) 2

(Avidoxy) 2

Anticancer Agents

100 MG

2 PA BvD

ml 500 mg10 ml

2 PA BvD

per 28 days)

MG 75 MG

5 PA NSO NDS QL (28

per 28 days)

Drug Name

per 30 days)

SOLN 100 MG 500 MG

SOLN 60 MG

5 PA NSO NDS QL (3

per 28 days)

5 PA NSO NDS QL (30

per 30 days)

PACK 90 MG (7)- 180 MG (23)

5 PA NSO NDS

25 MGML

5 PA NSO NDS

per 28 days)

SOLUTION 20 MGML

5 PA NSO NDS

SOLN 500 MG

5 PA NSO NDS

BENDEKA INTRAVENOUS

SOLUTION 25 MGML

5 PA NSO NDS

per 30 days)

5 PA NSO NDS

RECON SOLN 35 MG

5 PA NSO NDS

per 30 days)

Drug Name

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (60

per 30 days)

(Clolar) 5 NDS

MGDAY(80 MG X1-20 MG X1) 140

per 28 days)

5 PA NSO NDS QL (56

per 28 days)

(63 per 28 days)

5 PA BvD NDS

CAPSULE 25 MG 50 MG

2 PA BvD ST

CYRAMZA INTRAVENOUS

SOLUTION 10 MGML

5 PA NSO NDS

SOLUTION 20 MGML

5 PA NSO LA NDS

per 30 days)

suspension 2 mgml

Drug Name

MG 400 MG

ELIGARD (3 MONTH)

ELIGARD (4 MONTH)

ELIGARD (6 MONTH)

75 MG (1 MONTH)

SOLN 300 MG 400 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG

MG 20 MG

5 PA NSO NDS

gram20 ml

2 PA BvD

(Adrucil) 2 PA BvD

mg5 ml

(Faslodex) 5 NDS

1000 MG40 ML

5 PA NSO NDS

MG 40 MG

5 PA NSO NDS QL (30

per 30 days)

40 MG 5 MG

Drug Name

HERCEPTIN HYLECTA

10000 UNIT5 ML

5 PA NSO NDS QL (5

per 21 days)

SOLN 150 MG 440 MG

5 PA NSO NDS

125 MG 75 MG

5 PA NSO NDS QL (21

per 28 days)

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

ml 3 gram60 ml

gram 3000-1000 mg

5 PA BvD NDS

per 30 days)

per 28 days)

280 MG 420 MG 560 MG

5 PA NSO NDS QL (28

per 28 days)

50 MGML

5 PA NSO NDS

5 PA NSO NDS QL (4

per 365 days)

5 PA NSO NDS QL (8

per 28 days)

per 30 days)

SOLN 15 MG 45 MG

Drug Name

20 MG 25 MG 5 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 420 MG

5 PA NSO NDS

SOLUTION 25 MGML

5 PA NSO NDS QL (8

per 21 days)

5 PA NSO NDS QL (49

per 28 days)

5 PA NSO NDS QL (70

per 28 days)

5 PA NSO NDS QL (91

per 28 days)

(200 MG X 1)

5 PA NSO NDS QL (21

per 28 days)

(200 MG X 2)

5 PA NSO NDS QL (42

per 28 days)

(200 MG X 3)

5 PA NSO NDS QL (63

per 28 days)

5 PA NSO NDS

X 1) 18 MGDAY (10 MG X 1-4 MG

X2) 20 MGDAY (10 MG X 2) 24

8 MGDAY (4 MG X 2)

5 PA NSO NDS

50 MGML

5 PA NSO NDS QL (7

per 21 days)

per 28 days)

per 30 days)

Drug Name

SOLN 1 MG

5 PA NSO NDS

SYRINGE KIT 375 MG

150 MG

per 30 days)

(Max 64 Years)

per 30 days)

soln 1 gram

2 PA BvD

solution 25 mgml

2 PA BvD

5 PA NSO NDS

per 30 days)

Drug Name

MG 4 MG

5 PA NSO NDS QL (3

per 28 days)

750 UNITML

5 PA NSO NDS

ONIVYDE INTRAVENOUS

DISPERSION 43 MGML

100 MG10 ML 240 MG24 ML 40

MG4 ML

5 PA NSO NDS

(200 MG X 1)

5 PA NSO NDS QL (28

per 28 days)

(200 MG X1-50 MG X1) 300 MGDAY

(150 MG X 2)

5 PA NSO NDS QL (56

per 28 days)

SOLN 140 MG

5 PA NSO NDS

MG 3 MG 4 MG

5 PA NSO NDS QL (21

per 28 days)

per 21 days)

5 PA NSO LA NDS QL

(28 per 28 days)

MGML) 1600 MG134 ML (120

5 PA NSO NDS

RITUXAN INTRAVENOUS

CONCENTRATE 10 MGML

5 PA NSO NDS

250 MG 300 MG

per 30 days)

per 28 days)

MG5 ML

5 PA NSO NDS QL (30

per 30 days)

Drug Name

per 28 days)

MG 375 MG 50 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 100 MG 400 MG

5 PA NSO NDS

SOLN 35 MG

5 PA NSO NDS

per 30 days)

5 PA NSO LA NDS QL

(30 per 30 days)

per 30 days)

per 28 days)

200 MG

per 28 days)

per 30 days)

5 PA NSO NDS

SOLN 100 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG 25 MG

5 PA NSO NDS

1125 MG

225 MG

5 NDS QL (1 per 168

Drug Name

375 MG

SOLUTION 35 MGML

5 PA NSO NDS

per 30 days)

(180 per 30 days)

per 30 days)

100 MG

5 PA NSO LA NDS

150 MG 200 MG 50 MG

5 PA NSO NDS QL (56

per 28 days)

50 mg5 ml

(Navelbine) 2

per 30 days)

MG 45 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 44-100 MG

5 PA BvD NDS

250 MG

5 PA NSO NDS QL (60

per 30 days)

4 PA BvD ST

per 30 days)

Drug Name

MGWEEK (20 MG X 5)

5 PA NSO NDS QL (20

per 28 days)

MGWEEK (20 MG X 8)

5 PA NSO NDS QL (32

per 28 days)

(20 MG X 3)

5 PA NSO NDS QL (12

per 28 days)

(20 MG X 4)

5 PA NSO NDS QL (16

per 28 days)

per 30 days)

200 MG40 ML (5 MGML) 50 MG10

ML (5 MGML)

5 PA NSO NDS

SOLN 1 MG

5 PA NSO NDS

per 30 days)

IMPLANT 108 MG

IMPLANT 36 MG

5 PA NSO NDS QL (60

per 30 days)

per 28 days)

per 30 days)

Anticonvulsants

Drug Name

5 ST NDS

SOLUTION 50 MG5 ML

5 NDS QL (60 per 30

(Carbatrol) 2

(Tegretol) 2

(Tegretol XR) 2

125-15-175-20 MG 5-75-10 MG

75-10 mg

(Diastat AcuDial) 4

sprinkle 125 mg

hr 250 mg 500 mg

(Depakote ER) 2

(drec) 125 mg 250 mg 500 mg

(Depakote) 2

5 PA NSO NDS

Drug Name

(Cerebyx) 2

4 ST QL (720 per 30

MG 8 MG

200 mg 25 mg

(Lamictal) 1

(Lamictal) 2

mg5 ml

(Keppra) 2

mg 500 mg 750 mg

(Keppra) 2

24 hr 500 mg 750 mg

(Keppra XR) 2

MG 200 MG 225 MG 25 MG 300 MG

50 MG 75 MG

ml (60 mgml)

(Trileptal) 2

600 mg

(Trileptal) 2

300 MG 600 MG

2 PA NSO-HRM AGE

(Max 64 Years)

Drug Name

162 mg 30 mg 324 mg 60 mg 648 mg

972 mg

2 PA NSO-HRM AGE

(Max 64 Years)

100 mg

200 mg 300 mg

(Phenytek) 2

200 mg 225 mg 25 mg 300 mg 50 mg

per 30 days)

SUSPENSION 1000 MG

4 ST QL (120 per 30

mg 25 mg

5 PA NSO NDS QL (60

per 30 days)

(Gabitril) 2

(Topamax) 2

100 mg 150 mg 200 mg 25 mg 50 mg

(Qudexy XR) 4

mg 50 mg

(Topamax) 1

mg5 ml (100 mgml)

(Depacon) 2

solution 250 mg5 ml

Drug Name

per 30 days)

200 MG20 ML

MG 200 MG 50 MG

Antidementia Agents

24 hr 16 mg 24 mg 8 mg

14 mg 21 mg 28 mg 7 mg

NAMZARIC ORAL

MG 21-10 MG 28-10 MG 7-10 MG

3 mg 45 mg 6 mg

133 mg24 hour 46 mg24 hr 95 mg24

Antidepressants

150 mg 25 mg 50 mg 75 mg

Drug Name

mg 50 mg

24 hr 150 mg 300 mg

(Wellbutrin XL) 2

(Wellbutrin SR) 2

(Anafranil) 2

50 mg 75 mg

release(drec) 30 mg

MG24 HR

5 NDS QL (30 per 30

mg 5 mg

(Lexapro) 1

FETZIMA ORAL

HR 120 MG 20 MG 40 MG 80 MG

(Prozac) 1

Drug Name

(Tofranil) 2

mg 30 mg 45 mg

(Remeron SolTab) 2

200 mg 250 mg 50 mg

50 mg 75 mg

(Pamelor) 1

30 mg 40 mg

(Max 64 Years)

4 PA NSO-HRM AGE

(Max 64 Years)

10 mg 2-25 mg 4-10 mg 4-25 mg 4-50

(Zoloft) 1

(28 MG X 3)

5 PA NSO NDS

20 MG 5 MG

24hr 150 mg

24hr 375 mg 75 mg

Drug Name

375 mg 50 mg 75 mg

MG 40 MG

PACK 10 MG (7)- 20 MG (23)

SOLUTION 5 MGML

Antidiabetic Agents

25-5 MG

1000 MG 150-500 MG 50-1000 MG

3 ST QL (120 per 30

150-500 MG 50-1000 MG 50-500 MG

MG 50-500 MG

500 MG

MG 50 MG

1000 MG 25-500 MG 25-850 MG

28 days)

Drug Name

hr 500 mg

hr 750 mg

28 days)

MG 125-500 MG 5-1000 MG 5-500

1000 MG

Insulins

UNITML (3 ML)

FIASP U-100 INSULIN

UNITML

Drug Name

UNITML

UNITML (3 ML)

UNITML

UNITML (70-30)

UNITML

UNITML (3 ML)

UNITML (70-30)

UNITML

UNITML (3 ML)

Drug Name

UNITML (15 ML)

UNITML (3 ML)

UNITML

Sulfonylureas

25 mg 5 mg

mg 5-500 mg

mg 6 mg

Years)

mg 25-500 mg 5-500 mg

Years)

Antifungals

ABELCET INTRAVENOUS

SUSPENSION 5 MGML

5 PA BvD NDS

Drug Name

mg 70 mg

(Cancidas) 5 NDS

(clotrimazole))

(Lotrisone) 2

400 mg200 ml

2 PA BvD

(Diflucan) 2

200 mg 50 mg

(Diflucan) 2

mg5 ml

MG5 ML (40 MGML)

unitgram

Drug Name

(Vfend) 5 NDS

Antigout Agents

Antihistamines

Years)

mgml 50 mgml

Years)

Membrane)

Drug Name

Antimigraine Agents

70 MGML

140 MGML 70 MGML

225 MG15 ML

EMGALITY SYRINGE

ML (100 MGML X 3)

mg 5 mg

mgactuation

25 mg 50 mg

cartridge 6 mg05 ml

(Imitrex STATdose

Refill)

solution 6 mg05 ml

syringe 6 mg05 ml

Antimycobacterials

Drug Name

Antimycobacterials

1 GRAM

168 days)

Antinausea Agents

025 MG

CAPSULE 300-05 MG

4 PA BvD

(1)- 80 mg (2)

EMULSION 72 MGML

Drug Name

ML FINAL CONC)

mgml 1 mgml (1 ml)

Drowsy)

mg2 ml

mg 8 mg

2 PA BvD

Years)

mg 5 mg

(Compazine) 1

50 mgml

Years)

25 mg 50 mg

Years)

1 mg over 3 days

days) AGE (Max 64

Years)

Drug Name

days) AGE (Max 64

Years)

Antiparasite Agents

(Malarone) 2

500 mg

SOLN 300 MG

4 PA BvD

300 MG

APOKYN SUBCUTANEOUS

CARTRIDGE 10 MGML

Drug Name

mg 25-100 mg 25-250 mg

(Sinemet) 2

(Sinemet CR) 2

(Stalevo 50) 4

tablet 1875-75-200 mg

(Stalevo 75) 4

(Stalevo 100) 4

tablet 3125-125-200 mg

(Stalevo 125) 4

tablet 375-150-200 mg

(Stalevo 150) 4

(Stalevo 200) 4

GOCOVRI ORAL

24HR 137 MG

GOCOVRI ORAL

24HR 685 MG

30 days)

258 MG

mg 05 mg 075 mg 1 mg 15 mg

(Mirapex) 1

Drug Name

ABILIFY MAINTENA

INTRAMUSCULAR

RECON 300 MG 400 MG

ABILIFY MAINTENA

INTRAMUSCULAR

mg 30 mg 5 mg

SYRING 675 MG24 ML

SYRING 1064 MG39 ML

5 NDS QL (39 per 56

SYRING 441 MG16 ML

5 NDS QL (16 per 28

SYRING 662 MG24 ML

5 NDS QL (24 per 28

SYRING 882 MG32 ML

5 NDS QL (32 per 28

200 mg 25 mg 50 mg

Drug Name

mg 125 mg 25 mg

30 days)

MG 6 MG 8 MG

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

25 mgml

25 mg 5 mg

solution 100 mgml

solution 50 mgml

(Haldol) 2

5 mgml

mg 2 mg 20 mg 5 mg

Drug Name

INVEGA SUSTENNA

MG075 ML

INVEGA SUSTENNA

MG15 ML

5 NDS QL (15 per 28

INVEGA SUSTENNA

MG025 ML

INVEGA SUSTENNA

MG05 ML

5 NDS QL (05 per 28

5 NDS QL (0875 per 84

5 NDS QL (1315 per 84

5 NDS QL (2625 per 84

MG 40 MG 60 MG

mg 5 mg 50 mg

per 30 days)

mg 20 mg 5 mg 75 mg

mg 15 mg 20 mg 5 mg

24hr 15 mg 3 mg

Drug Name

24hr 6 mg

24hr 9 mg

mg 8 mg

PERSERIS ABDOMINAL

SUBCUTANEOUS

120 MG 90 MG

mg 300 mg 400 mg 50 mg

30 days)

3 MG 4 MG

RISPERDAL CONSTA

MG2 ML 25 MG2 ML

RISPERDAL CONSTA

MG2 ML 50 MG2 ML

mg 2 mg 3 mg 4 mg

mg 05 mg 1 mg 2 mg

mg 4 mg

MG 25 MG 5 MG

mg 50 mg

mg 5 mg

30 days)

Drug Name

MG 45 MG 6 MG

PACK 15 MG (1)- 3 MG (6)

mg 60 mg 80 mg

ZYPREXA RELPREVV

Antiretrovirals

(Epzicom) 2

tablet 300-150-300 mg

(Trizivir) 5 NDS

300 mg

(Reyataz) 5 NDS

300 MG

400 MG

300 MG

400 mg

(Videx EC) 2

Drug Name

MG5 ML (5 MGML)

SOLN 90 MG

200-10 MG

200 MG

PACKET 100 MG

ISENTRESS ORAL

(Combivir) 2

mg5 ml

(Kaletra) 2

Drug Name

hr 100 mg 400 mg

(Viramune XR) 2

100 MG

600 MG 800 MG

DISPERSIBLE 100 MG

SOLUTION 10 MGML

PACKET 50 MG

300 MG 75 MG

mg 40 mg

200-300 MG

200-10 MG

300 mg

(Viread) 2

Drug Name

MG 133-200 MG 167-250 MG 200-300

MGML (FINAL)

VIDEX EC ORAL

CAPSULEDELAYED

625 MG

MGSCOOP (40 MGGRAM)

MG 250 MG

28 days)

480 MG

Drug Name

MGACTUATION

5 PA NDS

Hcv Antivirals

5 PA NDS

Interferons

5 PA NSO NDS

UNITML

5 PA NSO NDS

PEGASYS PROCLICK

MCG05 ML

SOLUTION 180 MCGML

Drug Name

MCG05 ML

200 MCG 300 MCG 600 MCG

5 PA NSO NDS

500 mg

2 PA BvD

500 mg

(Cytovene) 2 PA BvD

50 mgml

2 PA BvD

Expanders

Anticoagulants

PACK 5 MG (74 TABS)

mg3 ml

(Lovenox) 2

Drug Name

mg03 ml 40 mg04 ml 60 mg06 ml 80

mg08 ml

(Lovenox) 2

(Arixtra) 5 NDS

mg05 ml

(Arixtra) 2

5000 unitml (1 ml)

5000 unitml

unitml

1000 unitml

5000 unit05 ml

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

150 MG 75 MG

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

(Coumadin) 1

PACK 15 MG (42)- 20 MG (9)

TABLET 20 MG

SYRINGE 6 MG06 ML

5 PA NDS

GRANIX SUBCUTANEOUS

5 PA NDS

Drug Name

5 PA NDS

250 MCG

SYRINGE 6 MG06ML

5 PA NDS

MCG08 ML

5 PA NDS

4000 UNITML

20000 UNITML

40000 UNITML

PACKET 125 MG

30 days)

Drug Name

UNITML 4000 UNITML

40000 UNITML

SYRINGE 6 MG06 ML

5 PA NDS

150 MG

1000 mg10 ml (100 mgml)

(Cyklokapron) 2

Years)

400 mg

Caloric Agents

4 PA BvD

AMINOSYN 7 WITH

4 PA BvD

SOLUTION 85

4 PA BvD

Drug Name

4 PA BvD

SOLUTION 85

4 PA BvD

SOLUTION 7

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 275

4 PA BvD

Drug Name

SOLUTION 275

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

intravenous syringe

4 PA BvD

parenteral solution

4 PA BvD

intravenous syringe

4 PA BvD

FREAMINE HBC 69

SOLUTION 69

4 PA BvD

Drug Name

4 PA BvD

EMULSION 20 30

4 PA BvD

KABIVEN INTRAVENOUS

EMULSION 331-98-39

4 PA BvD

EMULSION 20

4 PA BvD

EMULSION 236-68-35

4 PA BvD

PARENTERAL SOLUTION

4 PA BvD

(Catapres) 1

mg24 hr

(Cardura) 2

Years)

200 MG 300 MG

30 days)

Drug Name

(Vazculep) 2

MG 40-25 MG

49-51 MG 97-103 MG

(Avapro) 1

150-125 mg 300-125 mg

(Avalide) 2

100-125 mg 100-25 mg 50-125 mg

(Hyzaar) 1

tablet 20-125 mg 40-125 mg 40-25 mg

(Benicar HCT) 2

(Micardis) 2

mg 80 mg

(Diovan) 2

160-125 mg 160-25 mg 320-125 mg

320-25 mg 80-125 mg

(Diovan HCT) 2

Inhibitors

(Lotensin) 1

mg 50 mg

mg 20 mg 5 mg

(Vasotec) 2

10-25 mg

(Vaseretic) 1

5-125 mg

Drug Name

10-125 mg 20-125 mg 20-25 mg

(Zestoretic) 1

mg 8 mg

(Accupril) 1

mg 5 mg

(Altace) 1

mg 150 mg

Years)

500 mcg

(Tikosyn) 2

mg5 ml (2 ) 50 mg5 ml (1 )

250 mg

mgml 500 mgml

300 mg

(Tenoretic 100) 2

(Tenoretic 50) 2

Drug Name

10-625 mg 25-625 mg 5-625 mg

(Ziac) 1

MG 20 MG 5 MG

3125 mg 625 mg

(Coreg) 1

(5 mgml)

(Toprol XL) 2

100-25 mg 100-50 mg

50-25 mg

(Lopressor HCT) 2

mg5 ml

(Lopressor) 2

mg5 ml

(Lopressor) 1

24 hr 120 mg 160 mg 60 mg 80 mg

(Inderal LA) 2

mg 60 mg 80 mg

mg 80 mg

(Betapace) 2

Drug Name

24hr 120 mg 180 mg 240 mg 300 mg

(Tiazac) 2

(Cardizem CD) 2

(Cardizem) 2

120 mg 180 mg 240 mg

hr 120 mg 180 mg 240 mg 300 mg 360

100 mg 200 mg 300 mg

(Verelan PM) 2

hr 120 mg 180 mg 240 mg

(Verelan) 2

hr 360 mg

(Verelan) 4

mg 180 mg 240 mg

(Calan SR) 1

Drug Name

mg03 ml

30 MG3 ML

mg 50 mg

hr 1000 mg 500 mg

(Ranexa) 2

MG03 ML

30 days)

Dihydropyridines

mg 60 mg

(Norvasc) 1

mg 10-40 mg 5-10 mg 5-20 mg 5-40 mg

(Lotrel) 2

mg 10-320 mg 5-160 mg 5-320 mg

(Exforge) 2

24hr 30 mg 60 mg 90 mg

(Procardia XL) 2

mg 60 mg 90 mg

(Adalat CC) 2

Diuretics

5-50 mg

Drug Name

soln 500 mg

(Diuril IV) 2

mg5 ml (8 mgml)

(Lasix) 1

25 mg 50 mg

30 days)

(PM) 60 MG (AM) 30 MG (PM) 90 MG

(AM) 30 MG (PM)

(Aldactone) 1

capsule 375-25 mg

(Dyazide) 1

capsule 50-25 mg

375-25 mg

(Maxzide-25mg) 1

75-50 mg

(Maxzide) 1

Dyslipidemics

mg 80 mg

(Lipitor) 1

in packet 4 gram

(Questran) 2

Drug Name

mg 200 mg 67 mg

145 mg 48 mg

(Tricor) 2

MG 40 MG 60 MG

1000 mg 500 mg 750 mg

(Niaspan Extended-

Release)

(Pravachol) 1

REPATHA PUSHTRONEX

REPATHA SURECLICK

REPATHA SYRINGE

mg 5 mg

mg 80 mg

Drug Name

PACKET 375 GRAM

Inhibitors

125 MG 150-25 MG 300-125 MG 300-

Vasodilators

mg 30 mg

release 40 mg

(ISOCHRON) 2

mg10 ml (5 mgml)

mg 06 mg

(Nitrostat) 2

(Minitran) 2

25 mg 40 mg

Drug Name

30 days)

mg3 ml (20 mgml)

(Cafcit) 2 PA BvD

(20 mgml)

12 hr 10 mg

mg 5 mg

mg 30 mg

mg 5 mg 75 mg

Drug Name

(Intuniv ER) 2

MG (21)

5 PA NDS

SOLUTION 12 MG12 ML

300 mg 600 mg

release 300 mg

(Lithobid) 2

release 450 mg

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

28 days)

mg 60 mg

Drug Name

ml 5 mg5 ml

mg 5 mg

OCREVUS INTRAVENOUS

SOLUTION 30 MGML

5 PA NDS QL (20 per

180 days)

MCG05 ML

5 PA NDS

28 days)

MCG05 ML

MCG05ML (6)

5 PA NDS

125 MG 25 MG 50 MG

PACK 125 MG (5)-25 MG(8)-50 MG(42)

Drug Name

TECFIDERA ORAL

CAPSULEDELAYED

TECFIDERA ORAL

CAPSULEDELAYED

MG (46)

5 PA NDS

TECFIDERA ORAL

CAPSULEDELAYED

28 days)

Contraceptives

mg- 35 mcg

010 mg-20 mcg (84)10 mcg (7)

015 mg-30 mcg (84)10 mcg (7)

mg-mcg

(24)75 mg (4)

30 mcg (21)75 mg (7)

mcg (21)75 mg (7)

001 mg x 5

Drug Name

001 mg x 5

(24)75 mg (4)

mcg (21)75 mg (7)

mg-mcg

mg- 35 mcg

015 mg-30 mcg (84)10 mcg (7)

015-002 mgx21 001 mg x 5

(Azurette (28)) 2

015-003 mg

(Apri) 2

3-002 mg

(Gianvi (28)) 2

3-003 mg

(Ocella) 2

(5)125-30(10)

Drug Name

35 mg-mcg

(Kelnor 135 (28)) 2

50 mg-mcg

(Kelnor 1-50) 2

(24)75 mg (4)

015 mg-30 mcg (91)

mcg (21)75 mg (7)

(21)75 mg (7)

(24)75 mg (4)

001 mg x 5

(84)10 mcg (7)

mcg 015 mg-25 mcg

(84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

(21)75 mg (7)

(5)125-30(10)

01-20 mg-mcg

(Afirmelle) 2

015-003 mg

(Altavera (28)) 2

50-30 (6)75-40 (5)125-30(10)

(Enpresse) 2

20 mcg (21)75 mg (7)

(5)125-30(10)

Drug Name

035 mg

(Camila) 2

1-20 mg-mcg

(Aurovela 120 (21)) 2

1 mg-20 mcg (21)75 mg (7)

1 mg-20 mcg (24)75 mg (4)

(Aurovela 24 Fe) 2

0180215025 mg-25 mcg

0180215025 mg-35 mcg (28)

025-35 mg-mcg

(Estarylla) 2

mg- 35 mcg

001 mg x 5

mcg 1-35 mg-mcg

015 mg-30 mcg (91)

001 mg x 5

015 mg-30 mcg (84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

35mcg (9)

mg-35 mcg (28)

1mg-35mcg (9)

35 mcg (28)

mg-25 mcg

25 mcg

mg-25 mcg

mcg (28)

0180215025 mg-35 mcg (28)

(5)125-30(10)

mg-25 mcg

35 mcg (28)

0112515-25 mg-mcg

001 mg x 5

Drug Name

mcg24 hr

mouthwash 012

(Oralone) 2

(Soriatane) 2

MEDICATED

rel 10 mg

Drug Name

UNITGRAM

mg 40 mg

(Cleocin T) 2

(Ery Pads) 2

suspension 10

(Klaron) 2

Agents

Drug Name

ointment 005

(Diprolene) 2

(Cutivate) 2

Drug Name

applicator 25

(Triderm) 1

0025 01

0025 01 05

Devices

Drug Name

03 ML 31 GAUGE X 1564

12 ML 31 GAUGE X 1564

(Lite Touch Insulin

Syringe)

GAUGE X 12

(1st Tier Unifine

Pentips)

SOLUTION 250 UNITML

SOLUTION 29 MG5 ML

SOLN 400 UNIT

60000 UNIT 24000-76000 -120000

UNIT 3000-9500- 15000 UNIT

36000-114000- 180000 UNIT 6000-

19000 -30000 UNIT

SOLUTION 6 MG3 ML

SOLN 15 MG 75 MG

SOLN 35 MG 5 MG

5 PA NDS

2 MGML

5 PA NDS

Drug Name

SOLUTION 8 MGML

5 PA BvD NDS

2 MGML

5 PA NDS

SOLUTION 5 MG5 ML

5 PA NDS

MG 20 MG 5 MG

5 PA NDS

ML 20 MGML

5 PA NDS

SOLUTION 1 MGML

5 PA BvD NDS

5 PA NDS

5 PA LA NDS

5 MG5 ML (1 MGML)

5 PA NDS

400 UNIT

42000 UNIT 15000-47000 -63000

UNIT 20000-63000- 84000 UNIT

25000-79000- 105000 UNIT 3000-

10000 -14000-UNIT 40000-126000-

168000 UNIT 5000-17000- 24000

Miscellaneous

Drug Name

(Cyclogyl) 2

DROPS 044

aerosol 003

(Alcaine) 2

Agents

unitgram

(AK-Poly-Bac) 2

CIPRODEX OTIC (EAR)

(Ciloxan) 1

(Cetraxal) 4

mggram (05 )

mggram)

DROPS VISCOUS 05

Drug Name

(Vigamox) 2

DROPSSUSPENSION 5

(Neo-Polycin HC) 2

mg-unit-unitg

(Neo-Polycin) 2

(Maxitrol) 2

10000 unitg-01

(Maxitrol) 2

unit-0025mgml

unitml-

35-400-10000 mg-unitg-1

10000 unitgram

(Polytrim) 1

drops 10

(Bleph-10) 2

ointment 10

(eye) drops 10 -023 (025 )

Drug Name

(TobraDex) 2

Inflammatory Agents

DROPSSUSPENSION 02

DROPS 0075

DROPS 005

mcg (0025 )

dropssuspension 01

(FML Liquifilm) 4

drops 003

DROPSSUSPENSION 03

DROPSSUSPENSION 1

DROPSGEL 05

OINTMENT 05

DROPSGEL 038

dropssuspension 1

(Pred Forte) 4

Drug Name

DROPS 007

DROPPERETTE 005

DROPPERETTE 5

soln 20 mg

soln 40 mg

(Nexium IV) 2

mg2 ml

release(drec) 15 mg

release(drec) 30 mg

(Protonix) 2

(drec) 20 mg

(drec) 40 mg

50 mg2 ml (25 mgml)

(Zantac) 2

(ranitidine))

Drug Name

DISPERSIBLE 200 MG

0025 mg5 ml

Years)

0025 mg

Years)

KIT 5 MG

5 PA NDS

193 gram60 ml

290 MCG 72 MCG

(loperamide))

(Reglan) 1

Drug Name

SOLUTION 12 MG06 ML

28 days)

SYRINGE 12 MG06 ML

28 days)

SYRINGE 8 MG04 ML

28 days)

gram60 ml

Laxatives

GRAM -12 GRAM160 ML

-584 gram

-586 gram

2272-672 -584 gram

(Colyte with Flavor

Packs)

420 gram

Phosphate Binders

Drug Name

(Renvela) 5 NDS

VELPHORO ORAL

mg 5 mg 50 mg

(Urecholine) 2

(Ditropan XL) 2

release 24hr 15 mg

24hr 2 mg 4 mg

(Detrol LA) 2

hr 10 mg

(Uroxatral) 1

THIOLA EC ORAL

5 PA NDS

Drug Name

mg 250 mg 500 mg

(Exjade) 5 PA NDS

500 mg

(Desferal) 2 PA

250 MG

5 PA NDS

MG 90 MG

5 PA NDS

MG 90 MG

5 PA NDS

30 days)

Hormonal Agents

Androgens

100 mgml 200 mgml

200 mgml (1 ml)

200 mgml

ML 75 MG05 ML

Years)

Drug Name

mg24 hr 00375 mg24 hr 005 mg24 hr

0075 mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

0025 mg24 hr 005 mg24 hr 0075

mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

00375 mg24 hr

days) AGE (Max 64

Years)

mg24 hr 00375 mg24 hr 005 mg24 hr

006 mg24 hr 0075 mg24 hr 01 mg24

days) AGE (Max 64

Years)

mgml 40 mgml

(Delestrogen) 2

05-01 mg

Years)

HR 01 MG24 HR

mg-mcg

Years)

05-25 mg-mcg

Years)

1-5 mg-mcg

Years)

045 MG 0625 MG 09 MG 125 MG

Years)

MGGRAM

Drug Name

MG (14) 0625MG-5MG(14)

Years)

045-15 MG 0625-25 MG 0625-5 MG

Years)

suspension 6 mgml

mg 4 mg 6 mg

(Decadron) 1 PA BvD

1 PA BvD

solution 10 mgml

MG 6 MG

(Cortef) 2

(Depo-Medrol) 2

mg 4 mg 8 mg

(Medrol) 2

(Medrol (Pak)) 2

(Solu-Medrol) 2

mg5 ml (3 mgml)

2 PA BvD

Drug Name

2 PA BvD

1 PA BvD

suspension 40 mgml

(Kenalog) 2

Pituitary

mcgspray (01 ml)

(DDAVP) 2

mcgspray (01 ml)

SOLN 1 MG

MG025 ML

MG025 ML 06 MG025 ML 08

MG025 ML 1 MG025 ML 12

MG025 ML 14 MG025 ML 16

MG025 ML 18 MG025 ML 2

MG025 ML

5 PA NDS

5 MGML (15 UNITML)

5 PA NDS

HUMATROPE INJECTION

5 PA NDS

SOLN 5 (15 UNIT) MG

5 PA NDS

Drug Name

SOLUTION 10 MGML

1125 MG

SYRINGE KIT 75 MG

LUPRON DEPOT-PED

NORDITROPIN FLEXPRO

ML (10 MGML) 30 MG3 ML (10

5 PA NDS

NORDITROPIN FLEXPRO

MG15 ML (33 MGML)

NUTROPIN AQ NUSPIN

5 PA NDS

mcgml 200 mcgml

(Sandostatin) 2

mcgml (1 ml)

5 PA NDS

RECON SOLN 58 MG

5 PA NDS

Drug Name

SAIZEN SAIZENPREP

5 PA NDS

SOLN 5 MG 88 MG

5 PA NDS

INTRAMUSCULAR

SOLN 4 MG 5 MG 6 MG

5 PA NDS

SOMATULINE DEPOT

MG05 ML

5 PA NSO NDS QL (1

per 28 days)

SOMATULINE DEPOT

ML 90 MG03 ML

25 MG 30 MG

5 PA NDS

(65 MCGDAY)

5 NDS QL (1 per 360

AEROSOL 2 MGML

225 MG

5 NDS QL (1 per 168

RECON SOLN 10 MG

5 PA NDS

RECON SOLN 5 MG

SOLN 88 MG

5 PA NDS

Progestins

SUSPENSION 400 MGML

5 PA NSO NDS

Drug Name

suspension 150 mgml

syringe 150 mgml

25 mg 5 mg

(Provera) 1

(40 mgml)

Years)

mg 200 mg

(Prometrium) 2

mcg 125 mcg 137 mcg 150 mcg 175

88 mcg

(Euthyrox) 1

(Cytomel) 2

ACTEMRA ACTPEN

MG09 ML

5 PA NDS

ACTEMRA INTRAVENOUS

80 MG4 ML (20 MGML)

5 PA NDS

SYRINGE 162 MG09 ML

5 PA NDS

SOLN 220 MG

100 mg

2 PA BvD

MG X 2 VIALS)

5 PA NDS

Drug Name

5 PA NDS

mg5 ml

mg 25 mg

(Gengraf) 2 PA BvD

5 PA NDS

SOLN 25 MG (1 ML)

5 PA NDS

25 MG05 ML (05) 50 MGML (1 ML)

5 PA NDS

ENBREL SURECLICK

MGML (1 ML)

5 PA NDS

SOLUTION 10 5

5 PA BvD NDS

4 PA BvD

SOLUTION 10

5 PA BvD NDS

GRAM 5 GRAM

5 PA BvD NDS

SOLUTION 10 10 (100 ML) 10

(200 ML)

5 PA BvD NDS

Drug Name

KIT 40 MG08 ML 40 MG08 ML (6

5 PA NDS

KIT 40 MG08 ML

5 PA NDS

KIT 10 MG02 ML 20 MG04 ML 40

MG08 ML

5 PA NDS

MG08 ML-40 MG04 ML

5 PA NDS

80 MG08 ML

5 PA NDS

MG02 ML 40 MG04 ML

5 PA NDS

SOLUTION 300 UNITML

HYPERRAB SD (PF)

UNITML

HYQVIA SUBCUTANEOUS

25 GRAM 25 ML (10 ) 20 GRAM

200 ML (10 ) 30 GRAM 300 ML (10

) 5 GRAM 50 ML (10 )

5 PA BvD NDS

SOLN 150 MGML

5 PA NDS

SOLUTION 150 MGML

5 PA NDS

Drug Name

100 MGML

5 PA NDS

UNITML

SOLN 100 MG

5 PA NDS

SOLUTION 150 UNITML

MG114 ML

5 PA NDS

MG114 ML

5 PA NDS

100 MG067 ML

5 PA NDS

recon soln 500 mg

(CellCept) 2 PA BvD

SOLN 250 MG

5 PA BvD NDS

OCTAGAM INTRAVENOUS

SOLUTION 10 5

5 PA BvD NDS

5 PA NDS

ORENCIA CLICKJECT

125 MGML

5 PA NDS

875 MG07 ML

5 PA NDS

OTEZLA STARTER ORAL

MG (4)-30 MG (47) 10 MG (4)-20 MG

(4)-30 MG(19)

5 PA NDS

Drug Name

SOLUTION 10

5 PA BvD NDS

5 MGML

4 PA BvD

PACKET 02 MG 1 MG

4 PA BvD ST

MG025 ML 15 MG03 ML 175

MG035 ML 20 MG04 ML 225

MG045 ML 25 MG05 ML 30 MG06

ML 75 MG015 ML

SOLN 100 MG

5 PA NDS

SOLN 100 MG

5 PA NDS

MG15 ML

5 PA NDS

SOLUTION 125 MGML

5 PA NDS

100 MGML 50 MG05 ML

5 PA NDS

130 MG26 ML

5 PA NDS

SOLUTION 45 MG05 ML

5 PA NDS

(Prograf) 2 PA BvD

TALTZ AUTOINJECTOR

80 MGML

5 PA NDS

Drug Name

SYRINGE 80 MGML

5 PA NDS

INJECTOR 100 MGML

5 PA NDS

SYRINGE 100 MGML

5 PA NDS

300 MG15 ML

5 PA LA NDS

5 PA NDS

05 MG 075 MG 1 MG

5 PA BvD NDS

Vaccines

ADACEL(TDAP

ADOLESNADULT)(PF)

LF-(25-5-3-5 MCG)-5LF05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

(25-5-3-5 MCG)-5LF05 ML

3 PA BvD

LF05ML

10-5 LF-MCG-LF05ML

SUSPENSION 20 MCGML

3 PA BvD

Drug Name

SYRINGE 20 MCGML

3 PA BvD

MCG05 ML

3 PA BvD

SUSPENSION 05 ML

SYRINGE 05 ML

720 ELISA UNIT05 ML

ELISA UNIT05 ML

3 PA BvD

58-10 LF-MCG-LF05ML

LF-MCG-LF05ML

32 UNIT05 ML

UNIT05 ML

SYRINGE 6 MCG05 ML

SOLUTION 4 MCG05 ML

Drug Name

10LF05 ML

10EXP3-43-3- 399 TCID5005

UNIT05ML

25 UNIT

3 PA BvD

RECOMBIVAX HB (PF)

3 PA BvD

RECOMBIVAX HB (PF)

MCGML 5 MCG05 ML

3 PA BvD

CCID50ML

SOLUTION 2 ML

50 MCG05 ML

TDVAX INTRAMUSCULAR

UNIT05ML

LF UNIT05 ML

Drug Name

SYRINGE 25 MCG05 ML

UNITML

1350 UNIT05 ML

10 EXP474 UNIT05 ML

19400 UNIT065 ML

Agents

budesonide oral

(Entocort EC) 2

tablets) 400 mg

(Delzicol) 2

(drec) 800 mg

(Asacol HD) 2

Drug Name

(drec) 500 mg

MGACTUATION

SOLUTION

Chloride)

solution

(Aqua Care Sterile

Water)

mcg2 ml

(Hectorol) 2

105 MG117 ML

30 days)

210MG234ML ( 105MG117MLX2)

30 days)

MCG24 ML

Drug Name

200 UNITML

MCGDOSE

solution 2 mcgml

60 MGML

RAYALDEE ORAL

HR 30 MCG

3 PA QL (156 per 30

mg5 ml

soln 500 mg

(Ethyol) 2

SOLN 120 MG 400 MG

5 PA NDS

INJECTOR 200 MGML

SYRINGE 200 MGML

CETYLEV ORAL TABLET

Drug Name

GRAM17 ML

5 GRAM

30 days)

SOLUTION 50 MGML

5 PA LA NDS

RECON SOLN 1 MG

(Vistaril) 1

30 days)

100 mg 200 mg 350 mg 50 mg 500 mg

mg 25 mg 5 mg

100 mgml

(Carnitor) 2

soln 50 mg

(Fusilev) 5 NDS

mg5 ml

(Mestinon) 2

Drug Name

150 MG 200 MG 50 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 500 MG

PACKET 10 GRAM

5 NDS QL (24 per 14

PACKET 2 GRAM

30 days)

Ophthalmic Agents

Antiglaucoma Agents

release 500 mg

500 mg

DROPS 01

DROPSSUSPENSION 1

DROPS 02-05

drops 223-68 mgml

(Cosopt) 2

DROPS 001

(Isopto Carpine) 2

DROPS 002

Drug Name

025 05

(Timoptic) 1

(Timoptic-XE) 4

DROPS 0004

mgml (10 )

IONOSOL-MB IN D5W

SOLUTION 5

PARENTERAL SOLUTION

release 8 meq

40 gram1000 ml (4 )

2 PA BvD

gram100 ml (4 ) 4 gram50 ml (8 )

2 PA BvD

meqml (50 )

2 PA BvD

Drug Name

SOLUTION

SINGLE-USE

PARENTERAL SOLUTION

2 PA BvD

meqml (20 ml)

2 PA BvD

release 10 meq

release 8 meq

ml 40 meq15 ml

(K-Tab) 2

release 20 meq

(K-Tab) 4

(Klor-Con M10) 2

(Klor-Con M20) 2

(Urocit-K 10) 2

release 15 meq

(Urocit-K 15) 2

(Urocit-K 5) 2

parenteral solution

Corticosteroids

Drug Name

50 MCGDOSE

MCGACTUATION 230-21

MCGACTUATION 45-21

MCGACTUATION

MCGACTUATION 200

MCGACTUATION 50

MCGACTUATION

mg2 ml

MCGACTUATION

MCGACTUATION 50

MCGACTUATION

AEROSOL INHALER 110

MCGACTUATION

AEROSOL INHALER 220

MCGACTUATION

AEROSOL INHALER 44

MCGACTUATION

Drug Name

INHALATIONS 80-45

MCGACTUATION

MCGACTUATION 80-45

MCGACTUATION

Antileukotrienes

(Singulair) 1

Bronchodilators

25 mg 3 ml (0083 ) 25 mg05 ml

2 PA BvD

MCGACTUATION

AEROSOL INHALER 17

MCGACTUATION

COMBIVENT RESPIMAT

MCGACTUATION

2 PA BvD

STARTER 25 MCGML

Drug Name

MCGDOSE

12 hr 100 mg 200 mg 300 mg

(Theochron) 2

12 hr 450 mg

24 hr 400 mg 600 mg

(30 ACTUAT)

mgml (20 )

(Acetadote) 2 PA

200 mgml (20 )

2 PA BvD

10 MGML

5 PA NDS

2 PA BvD

Drug Name

30 days)

SYRINGE 30 MGML

INJECTOR 100 MGML

28 days)

SOLN 100 MG

28 days)

100 MGML

28 days)

PACKET 100-125 MG 150-188 MG

MG 200-125 MG

30 days)

RECON SOLN 1000 MG

5 PA BvD NDS

(N) 50-75 MG (D) 75 MG (N)

SOLN 150 MG

5 PA NDS

150 MGML 75 MG05 ML

5 PA NDS

Years)

Drug Name

Years)

250 mg 50 mg

MG 20 MG 5 MG

per 30 days)

Vasodilating Agents

MG 15 MG 2 MG 25 MG

soln 05 mg

(Flolan) 2 PA

soln 15 mg

(Flolan) 5 PA NDS

25 MG 5 MG

5 PA NDS

Drug Name

1 day)

SUSPENSION 32 MG

28 days)

(06 MGML)

5 PA NDS

1200 MCG 1400 MCG 1600 MCG

400 MCG 600 MCG 800 MCG

30 days)

PACK 200 MCG (140)- 800 MCG (60)

5 PA NDS

27 mg iron- 1 mg

A abacavir 47

ABELCET 35

ABILIFY MAINTENA 43

ABRAXANE 15

acamprosate 7

acarbose 32

acebutolol 60

acetazolamide 107

acetic acid 82 104

acetylcysteine 112

acitretin 76

ACTEMRA 95

ACTEMRA ACTPEN 95

ACTHIB (PF) 100

ACTIMMUNE 105

acyclovir 52 76

acyclovir sodium 52

ADACEL(TDAP

ADAGEN 80

adapalene 79

adefovir 52

ADEMPAS 114

adriamycin 15

adrucil 15

ADVAIR DISKUS 110

ADVAIR HFA 110

afeditab cr 63

AFINITOR 15

AFINITOR DISPERZ 15

afirmelle 70

a-hydrocort 91

(2 PACK) 38

AJOVY 38

AKYNZEO

(FOSNETUPITANT) 39

ala-cort 77

albendazole 41

alclometasone 77

ALCOHOL PADS 76

ALDURAZYME 80

ALECENSA 16

alendronate 104

alfuzosin 88

ALIMTA 16

ALINIA 41

ALIQOPA 16

aliskiren 66

allopurinol 37

alosetron 103

ALPHAGAN P 107

alprazolam 8

ALREX 84

altavera (28) 70

ALTRENO 79

ALUNBRIG 16

alyacen 135 (28) 70

alyacen 777 (28) 70

alyq 114

amabelz 89

amantadine hcl 41

AMBISOME 35

ambrisentan 114

amethia 70

amethia lo 70

amiloride 63

AMINOSYN 10 55

AMINOSYN 7 WITH

ELECTROLYTES 55

AMINOSYN 85 55

AMINOSYN 85 -

ELECTROLYTES 55

AMINOSYN II 10 56

AMINOSYN II 15 56

AMINOSYN II 7 56

AMINOSYN II 85 56

AMINOSYN II 85 -

ELECTROLYTES 56

AMINOSYN M 35 56

AMINOSYN-HBC 7 56

AMINOSYN-PF 10 56

AMINOSYN-PF 7

(SULFITE-FREE) 56

AMINOSYN-RF 52 56

amiodarone 60

AMITIZA 86

amitriptyline 29

amlodipine 63

ammonium lactate 76

amoxapine 30

amoxicillin 13

amphotericin b 35

ampicillin 13

ANADROL-50 89

anagrelide 55

anastrozole 16

ANORO ELLIPTA 111

APOKYN 41

apraclonidine 81

aprepitant 39

apri 70

APRISO 103

APTIOM 25 26

APTIVUS 47

aranelle (28) 70

ARCALYST 95

aripiprazole 43

ARISTADA 43

ARISTADA INITIO 43

armodafinil 114

ARNUITY ELLIPTA 110

arsenic trioxide 16

ashlyna 70

ASSURE ID INSULIN

SAFETY 79

atazanavir 47

atenolol 60

atomoxetine 66

atorvastatin 64

atovaquone 41

ATRIPLA 47

atropine 25 82

ATROVENT HFA 111

AUBAGIO 66

aubra 70

aurovela 1530 (21) 70

aurovela 24 fe 70

AUSTEDO 67

AVASTIN 16

aviane 70

AVONEX 67

ayuna 70

azacitidine 16

azathioprine 95

azelastine 82

azithromycin 12

AZOPT 107

aztreonam 13

azurette (28) 70

B baciim 10

bacitracin 82

baclofen 113

balsalazide 103

BALVERSA 16

balziva (28) 71

BANZEL 26

BAVENCIO 16

BAXDELA 14

NEEDLE 79

UNIT 80

bekyree (28) 71

BELEODAQ 16

BELSOMRA 114

benazepril 59

BENDEKA 16

BENLYSTA 105

benztropine 41

BESPONSA 16

BETASERON 67

betaxolol 60

BETHKIS 9

BEVYXXA 52

bexarotene 16

BEXSERO 100

bicalutamide 16

BICILLIN L-A 13

BIDIL 66

BIKTARVY 47

bleomycin 16

bleph-10 82

BLINCYTO 16

blisovi 24 fe 71

blisovi fe 1530 (28) 71

BOOSTRIX TDAP 100

BORTEZOMIB 16

BOSULIF 16 17

BRAFTOVI 17

BREO ELLIPTA 110

briellyn 71

BRILINTA 55

brimonidine 107

BRIVIACT 26

bromocriptine 41

BROMSITE 84

budesonide 103 110

bumetanide 63

bupropion hcl 30

buspirone 8

BYSTOLIC 61

BYVALSON 61

C cabergoline 41

CABLIVI 105

CABOMETYX 17

caffeine citrate 67

calcipotriene 76

calcitriol 104

CALDOLOR 6

CALQUENCE 17

camila 71

CAPASTAT 39

CAPRELSA 17

captopril 59

CARBAGLU 86

carbamazepine 26

carteolol 107

cartia xt 62

carvedilol 61

caspofungin 36

CAYSTON 13

caziant (28) 71

cefaclor 11

cefadroxil 11

cefazolin 11

cefdinir 11

cefepime 11

cefixime 11

cefotaxime 11

cefoxitin 11

cefpodoxime 12

cefprozil 12

ceftazidime 12

ceftriaxone 12

celecoxib 6

CELONTIN 26

cephalexin 12

CERDELGA 80

CEREZYME 80

CETYLEV 105

CHANTIX 8

CHANTIX CONTINUING

MONTH BOX 8

CHANTIX STARTING

MONTH BOX 8

chlorothiazide 64

chlorpromazine 43

chlorthalidone 64

chlorzoxazone 113

ciclopirox 36

cilostazol 55

CIMDUO 47

cimetidine hcl 85

CIMZIA 95

CIMZIA POWDER FOR

RECONST 95

cinacalcet 104

CINQAIR 112

CINRYZE 53

CINVANTI 39

CIPRODEX 82

ciprofloxacin 14

citalopram 30

clarithromycin 12

CLENPIQ 87

clindamycin hcl 10

CLINIMIX 5D15W

SULFITE FREE 56

CLINIMIX 5D25W

SULFITE-FREE 56

FREE 56

CLINIMIX 425D5W

SULFIT FREE 56

CLINIMIX 425-D25W

SULF-FREE 56

CLINIMIX 5-

CLINIMIX E 275D10W

SUL FREE 56

CLINIMIX E 275D5W

SULF FREE 57

CLINIMIX E 425D10W

SUL FREE 57

CLINIMIX E 425D25W

SUL FREE 57

CLINIMIX E 425D5W

SULF FREE 57

CLINIMIX E 5D15W

SULFIT FREE 57

CLINIMIX E 5D20W

SULFIT FREE 57

CLINIMIX E 5D25W

SULFIT FREE 57

clobazam 26

clobetasol 78

clofarabine 17

clomipramine 30

clonazepam 9

clonidine 58

clonidine hcl 58

clopidogrel 55

clotrimazole 36

clozapine 43 44

COARTEM 41

codeine sulfate 3

colchicine 37

colestipol 64

colocort 103

COMBIGAN 107

COMETRIQ 17

COMPLERA 47

compro 39

constulose 86

COPIKTRA 17

CORLANOR 62

cormax 78

cortisone 91

COTELLIC 17

CREON 80

CRIXIVAN 47

cromolyn 82 86 112

cryselle (28) 71

cyclobenzaprine 113

cyclopentolate 82

cyclophosphamide 17

CYCLOPHOSPHAMIDE 17

cyclosporine 96

cyproheptadine 37

CYRAMZA 17

cyred 71

CYSTADANE 106

CYSTARAN 82

D dalfampridine 67

DALIRESP 113

danazol 89

dantrolene 113 114

dapsone 39

DAPTACEL (DTAP

PEDIATRIC) (PF) 100

daptomycin 10

DARAPRIM 41

DARZALEX 17

dasetta 135 (28) 71

dasetta 777 (28) 71

DAURISMO 17

daysee 71

deblitane 71

decadron 91

decitabine 17

deferasirox 89

deferoxamine 89

DELSTRIGO 47

delyla (28) 71

DEMSER 62

DEPEN TITRATABS 89

DEPO-PROVERA 94

DESCOVY 47

desipramine 30

desmopressin 92

desoximetasone 78

dexamethasone 91

(pf) 91

phosphate 84 91

dextroamphetamine-

amphetamine 67

DIASTAT 26

DIASTAT ACUDIAL 26

diazepam 9 26

diazepam intensol 9

dicloxacillin 13

dicyclomine 86

didanosine 47

DIFICID 12

digitek 62

digox 62

digoxin 62 63

DIGOXIN 63

diltiazem hcl 62

dilt-xr 62

dimenhydrinate 39

DIPENTUM 103

dipyridamole 55

disulfiram 8

divalproex 26

dofetilide 60

donepezil 29

dorzolamide 107

dotti 90

DOVATO 48

doxazosin 58

doxepin 30

doxercalciferol 104

doxorubicin 17

doxy-100 15

dronabinol 39

droperidol 106

DROXIA 18

DUAVEE 90

duloxetine 30

DUPIXENT 96

DUREZOL 84

dutasteride 88

E econazole 36

EDARBI 59

EDARBYCLOR 59

EDURANT 48

efavirenz 48

EGRIFTA 92

ELAPRASE 80

ELIGARD 18

elinest 71

ELIQUIS 52

ELITEK 80

ELLA 71

ELMIRON 106

EMCYT 18

EMEND 40

EMFLAZA 91

EMGALITY PEN 38

EMGALITY SYRINGE 38

emoquette 71

EMPLICITI 18

EMSAM 30

EMTRIVA 48

enalaprilat 59

ENBREL 96

ENBREL SURECLICK 96

ENDARI 106

endocet 3

enoxaparin 52 53

enpresse 71

enskyce 71

entacapone 42

entecavir 52

ENTRESTO 59

enulose 86

EPCLUSA 51

EPIDIOLEX 26

epinastine 82

epinephrine 63

epitol 26

EPIVIR HBV 48

eplerenone 66

ergoloid 106

ERGOMAR 38

ERIVEDGE 18

ERLEADA 18

erlotinib 18

errin 71

ertapenem 13

ery pads 77

erythromycin 12 82

ESBRIET 113

estarylla 71

estradiol 90

eszopiclone 114

ethambutol 39

ethosuximide 26

etodolac 6

ETOPOPHOS 18

etoposide 18

EUCRISA 78

EVENITY 104

EVOTAZ 48

exemestane 18

EXONDYS 51 106

EXTAVIA 67

ezetimibe 65

F FABRAZYME 80

falmina (28) 72

famciclovir 52

famotidine 85

famotidine (pf) 85

FANAPT 44

FARYDAK 18

FASENRA 113

febuxostat 37

felbamate 27

FEMRING 90

femynor 72

fenofibrate 65

fentanyl 3

fentanyl citrate 3

FERRIPROX 89

FETZIMA 30

INSULIN 33

finasteride 88

FIRAZYR 63

FIRVANQ 10

FLEBOGAMMA DIF 96

flecainide 60

FLOVENT DISKUS 110

FLOVENT HFA 110

floxuridine 18

fluconazole 36

flucytosine 36

fludrocortisone 91

flumazenil 67

flunisolide 84

fluocinolone 78

fluocinonide 78

fluocinonide-e 78

fluorometholone 84

fluorouracil 18 76

fluoxetine 30

fluphenazine hcl 44

flurbiprofen 6

flutamide 18

fluvoxamine 31

fomepizole 106

fondaparinux 53

FORTEO 104

fosamprenavir 48

foscarnet 50

fosinopril 59

fosphenytoin 27

FREAMINE HBC 69 57

FREAMINE III 10 58

FULPHILA 53

fulvestrant 18

furosemide 64

FUZEON 48

fyavolv 90

FYCOMPA 27

G gabapentin 27

GALAFOLD 80

galantamine 29

GAMASTAN 96

GAMMAGARD LIQUID 96

MCGML) 96

GAMMAPLEX 96

GAMMAPLEX (WITH

SORBITOL) 96

GARDASIL 9 (PF) 101

GATTEX 30-VIAL 86

GAUZE PAD 80

gavilyte-c 87

gavilyte-g 87

gavilyte-n 87

GAZYVA 18

gemfibrozil 65

generlac 86

gengraf 96

GENOTROPIN 92

gentak 82

gentamicin 9 77 82

GENVOYA 48

GEODON 44

GILENYA 67

GILOTRIF 18

glatiramer 67

glatopa 67 68

GLEOSTINE 18

glimepiride 35

glipizide 35

glyburide 35

glycopyrrolate 86

glydo 7

GLYXAMBI 32

GOCOVRI 42

granisetron (pf) 40

granisetron hcl 40

GRANIX 53 54

guanfacine 58 68

guanidine 106

H HAEGARDA 54

hailey 24 fe 72

haloperidol 44

HARVONI 51

HAVRIX (PF) 101

heather 72

HEPATAMINE 8 58

HERCEPTIN 19

HETLIOZ 114

HIBERIX (PF) 101

HUMATROPE 92

HUMIRA 97

HUMIRA PEDIATRIC

CROHNS START 97

HUMIRA PEN 97

HS START 97

HUMIRA PEN PSOR-

UVEITS-ADOL HS 97

HUMIRA(CF) 97

STARTER 97

HUMIRA(CF) PEN 97

UC-HS 97

ADOL HS 97

INSULIN 34

KWIKPEN 34

hydralazine 63

hydromorphone 4

hydroxyurea 19

hydroxyzine hcl 37

HYPERRAB (PF) 97

HYPERRAB SD (PF) 97

HYQVIA 97

I ibandronate 104

IBRANCE 19

ibuprofen 6

icatibant 63

ICLUSIG 19

IDHIFA 19

ifosfamide 19

ifosfamide-mesna 19

ILARIS (PF) 97

ILEVRO 84

ILUMYA 98

imatinib 19

IMBRUVICA 19

IMFINZI 19

imipramine hcl 31

imiquimod 76

IMLYGIC 19

(PF) 101

IMPAVIDO 41

INBRIJA 42

incassia 72

INCRELEX 93

INCRUSE ELLIPTA 111

indapamide 64

indomethacin 6

INFLECTRA 98

INGREZZA 68

INGREZZA INITIATION

PACK 68

INLYTA 19

U-100 80

INTELENCE 48

INTRALIPID 58

INTRON A 51

introvale 72

INVEGA SUSTENNA 45

INVEGA TRINZA 45

INVELTYS 84

INVIRASE 48

INVOKAMET 32

INVOKAMET XR 32

INVOKANA 32

IPOL 101

irbesartan 59

IRESSA 19

ISENTRESS 48

ISENTRESS HD 48

isibloom 72

ISOLYTE-P IN 5

DEXTROSE 108

ISOLYTE-S 108

isoniazid 39

itraconazole 36

ivermectin 41

IXEMPRA 19

IXIARO (PF) 101

J JADENU 89

JADENU SPRINKLE 89

JAKAFI 20

jantoven 53

JANUMET 32

JANUMET XR 32

JANUVIA 32

JARDIANCE 32

jasmiel (28) 72

jencycla 72

JENTADUETO 32

JENTADUETO XR 32

jinteli 90

jolivette 72

juleber 72

JULUCA 48

junel 1530 (21) 72

junel 120 (21) 72

junel fe 1530 (28) 72

junel fe 120 (28) 72

junel fe 24 72

JUXTAPID 65

JYNARQUE 64

K KABIVEN 58

KALETRA 48

kalliga 72

KALYDECO 113

KANJINTI 20

KANUMA 80

kariva (28) 72

KEDRAB (PF) 98

kelnor 135 (28) 72

kelnor 1-50 72

ketoconazole 36

ketorolac 6 84

KEVEYIS 106

KEVZARA 98

KEYTRUDA 20

KINERET 98

KINRIX (PF) 101

KISQALI 20

klor-con m10 108

klor-con m15 108

klor-con m20 108

KORLYM 32

KRINTAFEL 41

KRYSTEXXA 81

kurvelo (28) 72

KUVAN 81

KYPROLIS 20

labetalol 61

lactulose 86

lamivudine 48

lamotrigine 27

lansoprazole 85

INSULIN 34

larin 1530 (21) 73

larin 120 (21) 73

larin 24 fe 73

larin fe 1530 (28) 73

larin fe 120 (28) 73

larissia 73

latanoprost 107

LATUDA 45

LAZANDA 4

leena 28 73

leflunomide 98

LEMTRADA 68

LENVIMA 20

lessina 73

letrozole 20

LEUKERAN 20

LEUKINE 54

leuprolide 20

levetiracetam 27

levobunolol 107

levocarnitine 106

levocetirizine 37

levofloxacin 14 82

LEVOLEUCOVORIN

CALCIUM 106

levonest (28) 73

levora-28 73

levothyroxine 95

LEXIVA 48

LIALDA 103

LIBTAYO 20

lidocaine 7

lidocaine (pf) 7 60

lidocaine hcl 7

lidocaine viscous 7

lillow (28) 73

linezolid 10 11

LINZESS 86

liothyronine 95

lisinopril 59 60

lithium citrate 68

LIVALO 65

LOKELMA 86

LONHALA MAGNAIR

REFILL 112

LONHALA MAGNAIR

STARTER 111

LONSURF 20

loperamide 86

lorazepam 9

LORBRENA 20

lorcet hd 4

lorcet plus 4

loryna (28) 73

losartan 59

LOTEMAX 84

LOTEMAX SM 84

lovastatin 65

LUCEMYRA 8

LUMIGAN 107

LUMOXITI 21

LUPRON DEPOT 21 93

LUPRON DEPOT-PED 93

LUPRON DEPOT-PED (3

MONTH) 93

lutera (28) 73

LYNPARZA 21

LYRICA 27

LYSODREN 21

lyza 73

malathion 79

maprotiline 31

marlissa (28) 73

MARPLAN 31

MATULANE 21

PACK) 68

MAVENCLAD (4 TABLET

PACK) 68

MAVENCLAD (5 TABLET

PACK) 68

MAVENCLAD (6 TABLET

PACK) 68

MAVENCLAD (7 TABLET

PACK) 68

MAVENCLAD (8 TABLET

PACK) 68

MAVENCLAD (9 TABLET

PACK) 68

MAVYRET 51

MAYZENT 68

meclizine 40

mefenamic acid 6

mefloquine 41

megestrol 21 95

MEKINIST 21

MEKTOVI 21

meloxicam 6

memantine 29

MENACTRA (PF) 101

(PF) 101

MEPSEVII 81

mercaptopurine 21

meropenem 13

mesalamine 103

mesna 106

MESNEX 106

MESTINON 106

metaproterenol 112

metformin 32 33

methadone 4

methadose 4

methimazole 95

methocarbamol 114

methoxsalen 76

methscopolamine 86

methyclothiazide 64

metipranolol 107

mexiletine 60

MIACALCIN 105

miconazole-3 36

midodrine 58

miglustat 81

mili 73

mimvey 90

mimvey lo 90

minitran 66

minocycline 15

minoxidil 66

mirtazapine 31

misoprostol 85

MITIGARE 37

mitoxantrone 21

M-M-R II (PF) 102

molindone 45

mometasone 79

mondoxyne nl 15

mono-linyah 73

mononessa (28) 73

montelukast 111

morphine 4 5

MORPHINE 5

MOVANTIK 86

MOXEZA 82

moxifloxacin 14 83

MOZOBIL 54

MULPLETA 54

MULTAQ 60

mupirocin 77

MYLOTARG 21

MYRBETRIQ 88

myzilra 73

N nabumetone 6

nafcillin 13 14

NAGLAZYME 81

naloxone 8

naltrexone 8

NAMZARIC 29

naproxen 7

NARCAN 8

NATACYN 83

NATPARA 105

NEBUPENT 41

necon 0535 (28) 73

nefazodone 31

neomycin 10

dexameth 83

neomycin-polymyxin-

gramicidin 83

neo-polycin 83

neo-polycin hc 83

NEPHRAMINE 54 58

NERLYNX 21

NEULASTA 54

NEUPOGEN 54

NEUPRO 42

nevirapine 48 49

NEXAVAR 21

niacin 65

niacor 65

nicardipine 63

NICOTROL 8

nifedipine 63

nikki (28) 74

nilutamide 21

NINLARO 22

nitroglycerin 66

NITYR 81

NIVESTYM 54

nizatidine 85

NOCDURNA (MEN) 93

NOCDURNA (WOMEN) 93

nora-be 74

norlyda 74

norlyroc 74

NORMOSOL-M IN 5

DEXTROSE 109

NORMOSOL-R 109

NORTHERA 58

nortrel 0535 (28) 74

nortrel 135 (21) 74

nortrel 135 (28) 74

nortrel 777 (28) 74

nortriptyline 31

NORVIR 49

NOVOLIN 7030 U-100

INSULIN 34

100 34

NOVOLIN N NPH U-100

INSULIN 34

100 INSULN 34

INSULIN 34

INSULN 34

NOVOLOG MIX 70-

30FLEXPEN U-100 34

INSULIN 34

ASPART 34

NOXAFIL 36

NUCALA 113

NUCYNTA 5

NUCYNTA ER 5

NUEDEXTA 69

NULOJIX 98

NUPLAZID 45

NUTRILIPID 58

nyamyc 36

nystatin 36

nystop 36

O OCALIVA 87

OCREVUS 69

OCTAGAM 98

ODEFSEY 49

ODOMZO 22

OFEV 113

ofloxacin 83

ogestrel (28) 74

olanzapine 45

olmesartan 59

olopatadine 82

OLUMIANT 98

omeprazole 85

OMNITROPE 93

ONCASPAR 22

ondansetron 40

ondansetron hcl 40

ONIVYDE 22

OPDIVO 22

OPSUMIT 114

oralone 76

ORENCIA 98

ORENITRAM 114

ORFADIN 81

ORILISSA 93 94

ORKAMBI 113

orsythia 74

oseltamivir 50

OSMOLEX ER 42

OTEZLA 98

OTEZLA STARTER 98

oxcarbazepine 27

OXTELLAR XR 27

oxycodone 5

oxycodone-aspirin 5

OZEMPIC 33

P pacerone 60

paliperidone 45 46

PALYNZIQ 81

PANRETIN 76

pantoprazole 85

paricalcitol 105

PARICALCITOL 105

paromomycin 41

paroxetine hcl 31

PASER 39

PAXIL 31

PEDIARIX (PF) 102

PEDVAX HIB (PF) 102

PEGANONE 27

PEGASYS 51 52

PEGASYS PROCLICK 51

PEGINTRON 52

penicillamine 89

PENNSAID 7

PENTACEL (PF) 102

PENTAM 41

pentamidine 41

pentoxifylline 55

PERIKABIVEN 58

periogard 76

permethrin 79

perphenazine 46

PERSERIS 46

pfizerpen-g 14

phenadoz 40

phenelzine 31

phenobarbital 27 28

phenytoin 28

phenytoin sodium 28

philith 74

PHOSLYRA 88

PICATO 76 77

PIFELTRO 49

pimecrolimus 79

pimozide 46

pimtrea (28) 74

pioglitazone 33

PIQRAY 22

pirmella 74

PLASMA-LYTE 148 109

PLASMA-LYTE A 109

PLEGRIDY 69

podofilox 77

POLIVY 22

polycin 83

POMALYST 22

portia 28 74

PORTRAZZA 22

PRADAXA 53

PRALUENT PEN 65

pramipexole 42

prasugrel 55

pravastatin 65

prazosin 59

prednicarbate 79

prednisolone 92

84 91 92

prednisone 92

pregabalin 28

PREMARIN 90

PREMPHASE 91

PREMPRO 91

prevalite 65

previfem 74

PREVYMIS 50

PREZCOBIX 49

PREZISTA 49

PRIFTIN 39

PRIMAQUINE 41

primidone 28

PRIVIGEN 99

probenecid 37

procainamide 60

PROCALAMINE 3 58

prochlorperazine 40

PROCRIT 54

procto-med hc 79

proctosol hc 79

proctozone-hc 79

PROCYSBI 88

progesterone 95

PROGLYCEM 106

PROGRAF 99

PROLASTIN-C 113

PROLENSA 85

PROLEUKIN 22

PROLIA 105

PROMACTA 54

promethazine 37 40

promethegan 40

propafenone 60

proparacaine 82

propranolol 61

propylthiouracil 95

PROQUAD (PF) 102

PROSOL 20 58

protamine 55

protriptyline 31

PULMOZYME 81

PURIXAN 22

pyrazinamide 39

quetiapine 46

quinapril 60

R RABAVERT (PF) 102

RADICAVA 69

raloxifene 91

ramipril 60

ranitidine hcl 85

ranolazine 63

rasagiline 42

RASUVO (PF) 99

RAVICTI 87

RAYALDEE 105

REBIF REBIDOSE 69

reclipsen (28) 74

RECTIV 107

RELISTOR 87

REMICADE 99

RENFLEXIS 99

repaglinide 33

REPATHA SYRINGE 65

RESCRIPTOR 49

RESTASIS 85

RETACRIT 55

RETROVIR 49

REVCOVI 81

REVLIMID 22

revonto 114

REXULTI 46

REYATAZ 49

RHOPRESSA 107

ribasphere 52

ribavirin 52

RIDAURA 99

rifabutin 39

rifampin 39

riluzole 69

rimantadine 51

RISPERDAL CONSTA 46

risperidone 46

ritonavir 49

RITUXAN 22

RITUXAN HYCELA 22

rivastigmine 29

rizatriptan 38

ropinirole 42

rosadan 77

rosuvastatin 65

ROTARIX 102

ROTATEQ VACCINE 102

RUBRACA 22

RYDAPT 22

S SABRIL 28

SAIZEN 94

SANTYL 77

SAPHRIS 46

SAVELLA 69

scopolamine base 40

selegiline hcl 42

selenium sulfide 77

SELZENTRY 49

SEREVENT DISKUS 112

SEROSTIM 94

sertraline 31

setlakin 74

sevelamer hcl 88

sharobel 74

SHINGRIX (PF) 102

SIGNIFOR 94

SILENOR 114

SILIQ 99

SIMBRINZA 108

simliya (28) 74

simpesse 74

SIMPONI 99

SIMPONI ARIA 99

simvastatin 65

sirolimus 99

SIRTURO 39

SKYRIZI 99

smoflipid 58

sodium chloride 104

SOLIQUA 10033 34

SOLTAMOX 22

SOLU-CORTEF (PF) 92

SOMATULINE DEPOT 94

SOMAVERT 94

sorine 61

sotalol 61

sotalol af 61

SOVALDI 51

spironolactone 64

SPRAVATO 31

sprintec (28) 75

SPRITAM 28

SPRYCEL 22

sronyx 75

ssd 77

stavudine 49

STELARA 99

STIVARGA 23

STRENSIQ 81

streptomycin 10

STRIBILD 49

SUBLOCADE 8

subvenite 28

sucralfate 86

sulfadiazine 14

sulfasalazine 104

sulfatrim 15

sulindac 7

sumatriptan 38

SUPPRELIN LA 94

SUTENT 23

syeda 75

SYLATRON 52

SYLVANT 23

SYMBICORT 110 111

SYMDEKO 113

SYMFI 49

SYMFI LO 49

SYMJEPI 63

SYMLINPEN 120 33

SYMLINPEN 60 33

SYMPAZAN 28

SYMTUZA 49

SYNAGIS 51

SYNAREL 94

SYNERCID 11

SYNJARDY 33

SYNJARDY XR 33

SYNRIBO 23

T TABLOID 23

tacrolimus 79 99

TAFINLAR 23

TAGRISSO 23

TAKHZYRO 107

TALTZ SYRINGE 100

TALZENNA 23

tamoxifen 23

tamsulosin 88

TARGRETIN 23

tarina 24 fe 75

tarina fe 120 (28) 75

TASIGNA 23

TAVALISSE 55

tazarotene 79

TAZORAC 79

taztia xt 62

TDVAX 102

TECENTRIQ 23

TECFIDERA 70

TECHNIVIE 51

TEFLARO 12

TEKTURNA HCT 66

telmisartan 59

temazepam 9

TEMODAR 23

TENIVAC (PF) 102

terazosin 88

terbinafine hcl 36

terbutaline 112

terconazole 37

testosterone 89

PED(PF) 102

tetrabenazine 70

tetracycline 15

THALOMID 107

theophylline 112

THIOLA 89

THIOLA EC 88

thioridazine 46

thiotepa 23

thiothixene 46

tiagabine 28

TIBSOVO 23

TICE BCG 100

tigecycline 15

tilia fe 75

TIVICAY 49 50

tizanidine 114

TOBI PODHALER 10

tobramycin 84

TOLAK 77

tolazamide 35

tolterodine 88

topiramate 28

toposar 23

toremifene 23

torsemide 64

TOTECT 107

TOUJEO MAX U-300

SOLOSTAR 34

INSULIN 35

TOVIAZ 88

TRACLEER 115

TRADJENTA 33

tramadol 5

trandolapril 60

tranexamic acid 55

TRANSDERM-SCOP 41

tranylcypromine 31

TRAVASOL 10 58

TRAVATAN Z 108

trazodone 31

TREANDA 23

TRECATOR 39

TRELEGY ELLIPTA 112

TRELSTAR 23 24

TREMFYA 100

tretinoin 79

tri femynor 75

trientine 89

tri-estarylla 75

trifluoperazine 46

trifluridine 84

trihexyphenidyl 43

tri-legest fe 75

tri-linyah 75

tri-lo-estarylla 75

tri-lo-marzia 75

tri-lo-mili 75

tri-lo-sprintec 75

trimethoprim 11

tri-mili 75

trimipramine 31

TRINTELLIX 31

TRIPTODUR 94

TRIUMEQ 50

trivora (28) 75

tri-vylibra 75

tri-vylibra lo 75

TROGARZO 50

TROPHAMINE 10 58

TROPHAMINE 6 58

TRULICITY 33

TRUMENBA 103

TRUVADA 50

tulana 75

TWINRIX (PF) 103

TYBOST 107

TYKERB 24

TYMLOS 105

TYPHIM VI 103

TYSABRI 100

TYVASO 115

U UCERIS 104

UDENYCA 55

ULORIC 37

UNITUXIN 24

UPTRAVI 115

ursodiol 87

V valacyclovir 52

VALCHLOR 77

valganciclovir 52

valproate sodium 28

valproic acid 29

valrubicin 24

valsartan 59

vancomycin 11

VAQTA (PF) 103

VARIVAX (PF) 103

VASCEPA 66

VELCADE 24

VELPHORO 88

VELTASSA 87

VEMLIDY 50

VENCLEXTA 24

VENCLEXTA STARTING

PACK 24

venlafaxine 31 32

verapamil 62

VERSACLOZ 46

VERZENIO 24

V-GO 40 80

VIBERZI 87

VICTOZA 33

VIDEX EC 50

VIEKIRA PAK 51

vienva 75

vigabatrin 29

vigadrone 29

VIIBRYD 32

VIMIZIM 81

VIMPAT 29

vinorelbine 24

viorele (28) 75

VIRACEPT 50

VIREAD 50

VISTOGARD 107

VITRAKVI 24

VIZIMPRO 24

VOLTAREN 7

voriconazole 36 37

VOSEVI 51

VOTRIENT 24

VPRIV 81

VRAYLAR 47

vyfemla (28) 76

vylibra 76

VYNDAQEL 63

VYXEOS 24

W warfarin 53

WELCHOL 66

wera (28) 76

X XADAGO 43

XALKORI 24

XARELTO 53

XATMEP 24

XELJANZ 100

XELJANZ XR 100

XERMELO 87

XIFAXAN 11

XIIDRA 85

XOFLUZA 51

XOLAIR 113

XOSPATA 24

XPOVIO 25

XTAMPZA ER 5 6

XTANDI 25

xulane 76

XULTOPHY 10036 35

XURIDEN 107

XYOSTED 89

XYREM 114

Y YERVOY 25

YF-VAX (PF) 103

YONDELIS 25

YONSA 25

Z zafirlukast 111

zaleplon 114

zarah 76

ZARXIO 55

ZEJULA 25

ZELBORAF 25

zenatane 77

zenchent (28) 76

ZENPEP 81

ZEPATIER 51

zidovudine 50

ziprasidone hcl 47

ZIRGAN 84

ZOLADEX 25

zoledronic acid 105

ZOLINZA 25

zolpidem 114

ZOMACTON 94

zonisamide 29

ZORBTIVE 94

ZORTRESS 100

ZOSTAVAX (PF) 103

zovia 135e (28) 76

ZTLIDO 7

ZUBSOLV 8

ZULRESSO 32

zumandimine (28) 76

ZYDELIG 25

ZYKADIA 25

ZYLET 84

ZYPREXA RELPREVV 47

ZYTIGA 25







Medical Condition









Table of Contents

INDEX

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

H6988_ENR1085_C II

during the year

H6988_ENR1085_C III

Medical Condition

name for your drug

may include

H6988_ENR1085_C IV

options

(HMO) Formulary

H6988_ENR1085_C V

exception

page I-1

Analgesics 3

Anesthetics 7

Antibacterials 9

Anticonvulsants 25

Antidepressants 29

Antifungals 35

Antigout Agents 37

Antihistamines 37

Caloric Agents 55

Contraceptives 70

Table of Contents

Devices 79

Drug Name

Analgesics

12 mg5 ml

30 days)

(Buprenex) 2

50-325-40 mg

Years)

50-325-40 mg

Years)

325-40 mg

Years)

30 days)

400 mcg 600 mcg 800 mcg

per 30 days)

75 mcghr

30 days)

75-325 mg15 ml

30 days)

10-325 mg

30 days)

25-325 mg

30 days)

Drug Name

325 mg

30 days)

75-325 mg

30 days)

5 PA NDS NM QL (30

per 30 days)

30 days)

suv inner 10 mgml

mg5 ml (20 mgml)

30 days)

4 mgml 8 mgml

30 days)

Drug Name

30 days)

mg 200 mg 60 mg

30 days)

mg 30 mg

30 days)

150 MG 200 MG 250 MG 50 MG

3 NDS NM QL (60 per

30 days)

MG 75 MG

30 days)

hr 10 mg 15 mg 20 mg 30 mg 40 mg 60

mg 80 mg

30 days)

325 mg

30 days)

325 mg 5-325 mg

30 days)

325 mg

30 days)

325 mg

30 days)

XTAMPZA ER ORAL

3 NDS NM QL (60 per

30 days)

Drug Name

XTAMPZA ER ORAL

CRUSH) 27 MG

30 days)

XTAMPZA ER ORAL

CRUSH) 36 MG

30 days)

12 hour 13

(Flector) 2 PA

(Voltaren-XR) 2

(IBU) 1

Years)

days) AGE (Max 64

Years)

Drug Name

(EC-Naprosyn) 2

ACTUATION(2 )

28 days)

Anesthetics

Local Anesthetics

applicator 2

(1 ) 15 mgml (15 ) 20 mgml (2 )

5 mgml (05 )

(Xylocaine-MPF) 1

mgml (2 )

(1 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine) 1

(40 mgml)

patchmedicated 5

solution 2

PATCHMEDICATED 18

Treatment Agents

(drec) 333 mg

Drug Name

12-3 mg 8-2 mg

2-05 mg 4-1 mg

2-05 mg 8-2 mg

3 QL (336 per 365 days)

(11)- 1 MG (42)

NICOTROL INHALATION

CARTRIDGE 10 MG

4 QL (1008 per 90 days)

018 MG 14-036 MG 114-29 MG 29-

071 MG 57-14 MG

Antianxiety Agents

Benzodiazepines

30 days)

mg 5 mg 75 mg

Drug Name

25 mg 5 mg

30 days)

0125 mg 025 mg 05 mg 1 mg

2 NDS NM QL (90 per

30 days)

375 mg

30 days)

Antibacterials

Aminoglycosides

5 PA BvD NDS

40 mgml

solution 20 mg2 ml

Drug Name

mg8 ml

(Tobi) 5 PA BvD NDS

mg 75 mg

(Cleocin HCl) 1

900 mg50 ml

150 (mgml) (6 ml)

150 mgml

(Cleocin) 2

solution 600 mg4 ml

(Cleocin) 2

soln 150 mg

(Coly-Mycin M

Parenteral)

5 PA BvD NDS

(Cubicin) 5 NDS

MGML 50 MGML

mg300 ml

(Zyvox) 5 NDS

100 mg5 ml

(Zyvox) 5 NDS

Drug Name

(Metro IV) 2

100 mg 25 mg 50 mg

capsule 100 mg

500000 unit

SOLN 500 MG

750 mg

2 PA BvD

Cephalosporins

125 mg5 ml 250 mg5 ml 375 mg5 ml

gram 500 mg

125 mg5 ml 250 mg5 ml

(Maxipime) 2

10 gram 2 gram

Drug Name

(Tazicef) 2

750 mg

15 gram 75 gram

SOLN 400 MG 600 MG

Macrolides

(Zithromax) 2

500 mg (3 pack) 600 mg

(EES Granules) 2

(EryPed 400) 2

Drug Name

(Azactam) 2

5 PA LA NDS

soln 250 mg

soln 500 mg

(Primaxin IV) 2

gram 500 mg

(Merrem) 2

Penicillins

250 mg5 ml 400 mg5 ml

250 mg

mg5 ml

500-125 mg 875-125 mg

(Augmentin) 1

500 mg

(Unasyn) 2

2400000 UNIT4 ML 600000

UNITML

Drug Name

20 million unit

(Pfizerpen-G) 2

unitml

mg5 ml 250 mg5 ml

500 mg

405 gram

(Zosyn) 2 PA BvD

Quinolones

(Cipro) 1

(Cipro in D5W) 2

ciprofloxacin oral

ml 500 mg5 ml

(Cipro) 2

250 mg50 ml 500 mg100 ml 750 mg150

Sulfonamides

(Sulfatrim) 2

Drug Name

400-80 mg

(Bactrim) 1

800-160 mg

(Bactrim DS) 1

Tetracyclines

soln 100 mg

(Doxy-100) 2

(Morgidox) 2

mg 50 mg

(Mondoxyne NL) 2

(Vibramycin) 2

(Avidoxy) 2

Anticancer Agents

100 MG

2 PA BvD

ml 500 mg10 ml

2 PA BvD

per 28 days)

MG 75 MG

5 PA NSO NDS QL (28

per 28 days)

Drug Name

per 30 days)

SOLN 100 MG 500 MG

SOLN 60 MG

5 PA NSO NDS QL (3

per 28 days)

5 PA NSO NDS QL (30

per 30 days)

PACK 90 MG (7)- 180 MG (23)

5 PA NSO NDS

25 MGML

5 PA NSO NDS

per 28 days)

SOLUTION 20 MGML

5 PA NSO NDS

SOLN 500 MG

5 PA NSO NDS

BENDEKA INTRAVENOUS

SOLUTION 25 MGML

5 PA NSO NDS

per 30 days)

5 PA NSO NDS

RECON SOLN 35 MG

5 PA NSO NDS

per 30 days)

Drug Name

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (60

per 30 days)

(Clolar) 5 NDS

MGDAY(80 MG X1-20 MG X1) 140

per 28 days)

5 PA NSO NDS QL (56

per 28 days)

(63 per 28 days)

5 PA BvD NDS

CAPSULE 25 MG 50 MG

2 PA BvD ST

CYRAMZA INTRAVENOUS

SOLUTION 10 MGML

5 PA NSO NDS

SOLUTION 20 MGML

5 PA NSO LA NDS

per 30 days)

suspension 2 mgml

Drug Name

MG 400 MG

ELIGARD (3 MONTH)

ELIGARD (4 MONTH)

ELIGARD (6 MONTH)

75 MG (1 MONTH)

SOLN 300 MG 400 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG

MG 20 MG

5 PA NSO NDS

gram20 ml

2 PA BvD

(Adrucil) 2 PA BvD

mg5 ml

(Faslodex) 5 NDS

1000 MG40 ML

5 PA NSO NDS

MG 40 MG

5 PA NSO NDS QL (30

per 30 days)

40 MG 5 MG

Drug Name

HERCEPTIN HYLECTA

10000 UNIT5 ML

5 PA NSO NDS QL (5

per 21 days)

SOLN 150 MG 440 MG

5 PA NSO NDS

125 MG 75 MG

5 PA NSO NDS QL (21

per 28 days)

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

ml 3 gram60 ml

gram 3000-1000 mg

5 PA BvD NDS

per 30 days)

per 28 days)

280 MG 420 MG 560 MG

5 PA NSO NDS QL (28

per 28 days)

50 MGML

5 PA NSO NDS

5 PA NSO NDS QL (4

per 365 days)

5 PA NSO NDS QL (8

per 28 days)

per 30 days)

SOLN 15 MG 45 MG

Drug Name

20 MG 25 MG 5 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 420 MG

5 PA NSO NDS

SOLUTION 25 MGML

5 PA NSO NDS QL (8

per 21 days)

5 PA NSO NDS QL (49

per 28 days)

5 PA NSO NDS QL (70

per 28 days)

5 PA NSO NDS QL (91

per 28 days)

(200 MG X 1)

5 PA NSO NDS QL (21

per 28 days)

(200 MG X 2)

5 PA NSO NDS QL (42

per 28 days)

(200 MG X 3)

5 PA NSO NDS QL (63

per 28 days)

5 PA NSO NDS

X 1) 18 MGDAY (10 MG X 1-4 MG

X2) 20 MGDAY (10 MG X 2) 24

8 MGDAY (4 MG X 2)

5 PA NSO NDS

50 MGML

5 PA NSO NDS QL (7

per 21 days)

per 28 days)

per 30 days)

Drug Name

SOLN 1 MG

5 PA NSO NDS

SYRINGE KIT 375 MG

150 MG

per 30 days)

(Max 64 Years)

per 30 days)

soln 1 gram

2 PA BvD

solution 25 mgml

2 PA BvD

5 PA NSO NDS

per 30 days)

Drug Name

MG 4 MG

5 PA NSO NDS QL (3

per 28 days)

750 UNITML

5 PA NSO NDS

ONIVYDE INTRAVENOUS

DISPERSION 43 MGML

100 MG10 ML 240 MG24 ML 40

MG4 ML

5 PA NSO NDS

(200 MG X 1)

5 PA NSO NDS QL (28

per 28 days)

(200 MG X1-50 MG X1) 300 MGDAY

(150 MG X 2)

5 PA NSO NDS QL (56

per 28 days)

SOLN 140 MG

5 PA NSO NDS

MG 3 MG 4 MG

5 PA NSO NDS QL (21

per 28 days)

per 21 days)

5 PA NSO LA NDS QL

(28 per 28 days)

MGML) 1600 MG134 ML (120

5 PA NSO NDS

RITUXAN INTRAVENOUS

CONCENTRATE 10 MGML

5 PA NSO NDS

250 MG 300 MG

per 30 days)

per 28 days)

MG5 ML

5 PA NSO NDS QL (30

per 30 days)

Drug Name

per 28 days)

MG 375 MG 50 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 100 MG 400 MG

5 PA NSO NDS

SOLN 35 MG

5 PA NSO NDS

per 30 days)

5 PA NSO LA NDS QL

(30 per 30 days)

per 30 days)

per 28 days)

200 MG

per 28 days)

per 30 days)

5 PA NSO NDS

SOLN 100 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG 25 MG

5 PA NSO NDS

1125 MG

225 MG

5 NDS QL (1 per 168

Drug Name

375 MG

SOLUTION 35 MGML

5 PA NSO NDS

per 30 days)

(180 per 30 days)

per 30 days)

100 MG

5 PA NSO LA NDS

150 MG 200 MG 50 MG

5 PA NSO NDS QL (56

per 28 days)

50 mg5 ml

(Navelbine) 2

per 30 days)

MG 45 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 44-100 MG

5 PA BvD NDS

250 MG

5 PA NSO NDS QL (60

per 30 days)

4 PA BvD ST

per 30 days)

Drug Name

MGWEEK (20 MG X 5)

5 PA NSO NDS QL (20

per 28 days)

MGWEEK (20 MG X 8)

5 PA NSO NDS QL (32

per 28 days)

(20 MG X 3)

5 PA NSO NDS QL (12

per 28 days)

(20 MG X 4)

5 PA NSO NDS QL (16

per 28 days)

per 30 days)

200 MG40 ML (5 MGML) 50 MG10

ML (5 MGML)

5 PA NSO NDS

SOLN 1 MG

5 PA NSO NDS

per 30 days)

IMPLANT 108 MG

IMPLANT 36 MG

5 PA NSO NDS QL (60

per 30 days)

per 28 days)

per 30 days)

Anticonvulsants

Drug Name

5 ST NDS

SOLUTION 50 MG5 ML

5 NDS QL (60 per 30

(Carbatrol) 2

(Tegretol) 2

(Tegretol XR) 2

125-15-175-20 MG 5-75-10 MG

75-10 mg

(Diastat AcuDial) 4

sprinkle 125 mg

hr 250 mg 500 mg

(Depakote ER) 2

(drec) 125 mg 250 mg 500 mg

(Depakote) 2

5 PA NSO NDS

Drug Name

(Cerebyx) 2

4 ST QL (720 per 30

MG 8 MG

200 mg 25 mg

(Lamictal) 1

(Lamictal) 2

mg5 ml

(Keppra) 2

mg 500 mg 750 mg

(Keppra) 2

24 hr 500 mg 750 mg

(Keppra XR) 2

MG 200 MG 225 MG 25 MG 300 MG

50 MG 75 MG

ml (60 mgml)

(Trileptal) 2

600 mg

(Trileptal) 2

300 MG 600 MG

2 PA NSO-HRM AGE

(Max 64 Years)

Drug Name

162 mg 30 mg 324 mg 60 mg 648 mg

972 mg

2 PA NSO-HRM AGE

(Max 64 Years)

100 mg

200 mg 300 mg

(Phenytek) 2

200 mg 225 mg 25 mg 300 mg 50 mg

per 30 days)

SUSPENSION 1000 MG

4 ST QL (120 per 30

mg 25 mg

5 PA NSO NDS QL (60

per 30 days)

(Gabitril) 2

(Topamax) 2

100 mg 150 mg 200 mg 25 mg 50 mg

(Qudexy XR) 4

mg 50 mg

(Topamax) 1

mg5 ml (100 mgml)

(Depacon) 2

solution 250 mg5 ml

Drug Name

per 30 days)

200 MG20 ML

MG 200 MG 50 MG

Antidementia Agents

24 hr 16 mg 24 mg 8 mg

14 mg 21 mg 28 mg 7 mg

NAMZARIC ORAL

MG 21-10 MG 28-10 MG 7-10 MG

3 mg 45 mg 6 mg

133 mg24 hour 46 mg24 hr 95 mg24

Antidepressants

150 mg 25 mg 50 mg 75 mg

Drug Name

mg 50 mg

24 hr 150 mg 300 mg

(Wellbutrin XL) 2

(Wellbutrin SR) 2

(Anafranil) 2

50 mg 75 mg

release(drec) 30 mg

MG24 HR

5 NDS QL (30 per 30

mg 5 mg

(Lexapro) 1

FETZIMA ORAL

HR 120 MG 20 MG 40 MG 80 MG

(Prozac) 1

Drug Name

(Tofranil) 2

mg 30 mg 45 mg

(Remeron SolTab) 2

200 mg 250 mg 50 mg

50 mg 75 mg

(Pamelor) 1

30 mg 40 mg

(Max 64 Years)

4 PA NSO-HRM AGE

(Max 64 Years)

10 mg 2-25 mg 4-10 mg 4-25 mg 4-50

(Zoloft) 1

(28 MG X 3)

5 PA NSO NDS

20 MG 5 MG

24hr 150 mg

24hr 375 mg 75 mg

Drug Name

375 mg 50 mg 75 mg

MG 40 MG

PACK 10 MG (7)- 20 MG (23)

SOLUTION 5 MGML

Antidiabetic Agents

25-5 MG

1000 MG 150-500 MG 50-1000 MG

3 ST QL (120 per 30

150-500 MG 50-1000 MG 50-500 MG

MG 50-500 MG

500 MG

MG 50 MG

1000 MG 25-500 MG 25-850 MG

28 days)

Drug Name

hr 500 mg

hr 750 mg

28 days)

MG 125-500 MG 5-1000 MG 5-500

1000 MG

Insulins

UNITML (3 ML)

FIASP U-100 INSULIN

UNITML

Drug Name

UNITML

UNITML (3 ML)

UNITML

UNITML (70-30)

UNITML

UNITML (3 ML)

UNITML (70-30)

UNITML

UNITML (3 ML)

Drug Name

UNITML (15 ML)

UNITML (3 ML)

UNITML

Sulfonylureas

25 mg 5 mg

mg 5-500 mg

mg 6 mg

Years)

mg 25-500 mg 5-500 mg

Years)

Antifungals

ABELCET INTRAVENOUS

SUSPENSION 5 MGML

5 PA BvD NDS

Drug Name

mg 70 mg

(Cancidas) 5 NDS

(clotrimazole))

(Lotrisone) 2

400 mg200 ml

2 PA BvD

(Diflucan) 2

200 mg 50 mg

(Diflucan) 2

mg5 ml

MG5 ML (40 MGML)

unitgram

Drug Name

(Vfend) 5 NDS

Antigout Agents

Antihistamines

Years)

mgml 50 mgml

Years)

Membrane)

Drug Name

Antimigraine Agents

70 MGML

140 MGML 70 MGML

225 MG15 ML

EMGALITY SYRINGE

ML (100 MGML X 3)

mg 5 mg

mgactuation

25 mg 50 mg

cartridge 6 mg05 ml

(Imitrex STATdose

Refill)

solution 6 mg05 ml

syringe 6 mg05 ml

Antimycobacterials

Drug Name

Antimycobacterials

1 GRAM

168 days)

Antinausea Agents

025 MG

CAPSULE 300-05 MG

4 PA BvD

(1)- 80 mg (2)

EMULSION 72 MGML

Drug Name

ML FINAL CONC)

mgml 1 mgml (1 ml)

Drowsy)

mg2 ml

mg 8 mg

2 PA BvD

Years)

mg 5 mg

(Compazine) 1

50 mgml

Years)

25 mg 50 mg

Years)

1 mg over 3 days

days) AGE (Max 64

Years)

Drug Name

days) AGE (Max 64

Years)

Antiparasite Agents

(Malarone) 2

500 mg

SOLN 300 MG

4 PA BvD

300 MG

APOKYN SUBCUTANEOUS

CARTRIDGE 10 MGML

Drug Name

mg 25-100 mg 25-250 mg

(Sinemet) 2

(Sinemet CR) 2

(Stalevo 50) 4

tablet 1875-75-200 mg

(Stalevo 75) 4

(Stalevo 100) 4

tablet 3125-125-200 mg

(Stalevo 125) 4

tablet 375-150-200 mg

(Stalevo 150) 4

(Stalevo 200) 4

GOCOVRI ORAL

24HR 137 MG

GOCOVRI ORAL

24HR 685 MG

30 days)

258 MG

mg 05 mg 075 mg 1 mg 15 mg

(Mirapex) 1

Drug Name

ABILIFY MAINTENA

INTRAMUSCULAR

RECON 300 MG 400 MG

ABILIFY MAINTENA

INTRAMUSCULAR

mg 30 mg 5 mg

SYRING 675 MG24 ML

SYRING 1064 MG39 ML

5 NDS QL (39 per 56

SYRING 441 MG16 ML

5 NDS QL (16 per 28

SYRING 662 MG24 ML

5 NDS QL (24 per 28

SYRING 882 MG32 ML

5 NDS QL (32 per 28

200 mg 25 mg 50 mg

Drug Name

mg 125 mg 25 mg

30 days)

MG 6 MG 8 MG

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

25 mgml

25 mg 5 mg

solution 100 mgml

solution 50 mgml

(Haldol) 2

5 mgml

mg 2 mg 20 mg 5 mg

Drug Name

INVEGA SUSTENNA

MG075 ML

INVEGA SUSTENNA

MG15 ML

5 NDS QL (15 per 28

INVEGA SUSTENNA

MG025 ML

INVEGA SUSTENNA

MG05 ML

5 NDS QL (05 per 28

5 NDS QL (0875 per 84

5 NDS QL (1315 per 84

5 NDS QL (2625 per 84

MG 40 MG 60 MG

mg 5 mg 50 mg

per 30 days)

mg 20 mg 5 mg 75 mg

mg 15 mg 20 mg 5 mg

24hr 15 mg 3 mg

Drug Name

24hr 6 mg

24hr 9 mg

mg 8 mg

PERSERIS ABDOMINAL

SUBCUTANEOUS

120 MG 90 MG

mg 300 mg 400 mg 50 mg

30 days)

3 MG 4 MG

RISPERDAL CONSTA

MG2 ML 25 MG2 ML

RISPERDAL CONSTA

MG2 ML 50 MG2 ML

mg 2 mg 3 mg 4 mg

mg 05 mg 1 mg 2 mg

mg 4 mg

MG 25 MG 5 MG

mg 50 mg

mg 5 mg

30 days)

Drug Name

MG 45 MG 6 MG

PACK 15 MG (1)- 3 MG (6)

mg 60 mg 80 mg

ZYPREXA RELPREVV

Antiretrovirals

(Epzicom) 2

tablet 300-150-300 mg

(Trizivir) 5 NDS

300 mg

(Reyataz) 5 NDS

300 MG

400 MG

300 MG

400 mg

(Videx EC) 2

Drug Name

MG5 ML (5 MGML)

SOLN 90 MG

200-10 MG

200 MG

PACKET 100 MG

ISENTRESS ORAL

(Combivir) 2

mg5 ml

(Kaletra) 2

Drug Name

hr 100 mg 400 mg

(Viramune XR) 2

100 MG

600 MG 800 MG

DISPERSIBLE 100 MG

SOLUTION 10 MGML

PACKET 50 MG

300 MG 75 MG

mg 40 mg

200-300 MG

200-10 MG

300 mg

(Viread) 2

Drug Name

MG 133-200 MG 167-250 MG 200-300

MGML (FINAL)

VIDEX EC ORAL

CAPSULEDELAYED

625 MG

MGSCOOP (40 MGGRAM)

MG 250 MG

28 days)

480 MG

Drug Name

MGACTUATION

5 PA NDS

Hcv Antivirals

5 PA NDS

Interferons

5 PA NSO NDS

UNITML

5 PA NSO NDS

PEGASYS PROCLICK

MCG05 ML

SOLUTION 180 MCGML

Drug Name

MCG05 ML

200 MCG 300 MCG 600 MCG

5 PA NSO NDS

500 mg

2 PA BvD

500 mg

(Cytovene) 2 PA BvD

50 mgml

2 PA BvD

Expanders

Anticoagulants

PACK 5 MG (74 TABS)

mg3 ml

(Lovenox) 2

Drug Name

mg03 ml 40 mg04 ml 60 mg06 ml 80

mg08 ml

(Lovenox) 2

(Arixtra) 5 NDS

mg05 ml

(Arixtra) 2

5000 unitml (1 ml)

5000 unitml

unitml

1000 unitml

5000 unit05 ml

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

150 MG 75 MG

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

(Coumadin) 1

PACK 15 MG (42)- 20 MG (9)

TABLET 20 MG

SYRINGE 6 MG06 ML

5 PA NDS

GRANIX SUBCUTANEOUS

5 PA NDS

Drug Name

5 PA NDS

250 MCG

SYRINGE 6 MG06ML

5 PA NDS

MCG08 ML

5 PA NDS

4000 UNITML

20000 UNITML

40000 UNITML

PACKET 125 MG

30 days)

Drug Name

UNITML 4000 UNITML

40000 UNITML

SYRINGE 6 MG06 ML

5 PA NDS

150 MG

1000 mg10 ml (100 mgml)

(Cyklokapron) 2

Years)

400 mg

Caloric Agents

4 PA BvD

AMINOSYN 7 WITH

4 PA BvD

SOLUTION 85

4 PA BvD

Drug Name

4 PA BvD

SOLUTION 85

4 PA BvD

SOLUTION 7

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 275

4 PA BvD

Drug Name

SOLUTION 275

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

intravenous syringe

4 PA BvD

parenteral solution

4 PA BvD

intravenous syringe

4 PA BvD

FREAMINE HBC 69

SOLUTION 69

4 PA BvD

Drug Name

4 PA BvD

EMULSION 20 30

4 PA BvD

KABIVEN INTRAVENOUS

EMULSION 331-98-39

4 PA BvD

EMULSION 20

4 PA BvD

EMULSION 236-68-35

4 PA BvD

PARENTERAL SOLUTION

4 PA BvD

(Catapres) 1

mg24 hr

(Cardura) 2

Years)

200 MG 300 MG

30 days)

Drug Name

(Vazculep) 2

MG 40-25 MG

49-51 MG 97-103 MG

(Avapro) 1

150-125 mg 300-125 mg

(Avalide) 2

100-125 mg 100-25 mg 50-125 mg

(Hyzaar) 1

tablet 20-125 mg 40-125 mg 40-25 mg

(Benicar HCT) 2

(Micardis) 2

mg 80 mg

(Diovan) 2

160-125 mg 160-25 mg 320-125 mg

320-25 mg 80-125 mg

(Diovan HCT) 2

Inhibitors

(Lotensin) 1

mg 50 mg

mg 20 mg 5 mg

(Vasotec) 2

10-25 mg

(Vaseretic) 1

5-125 mg

Drug Name

10-125 mg 20-125 mg 20-25 mg

(Zestoretic) 1

mg 8 mg

(Accupril) 1

mg 5 mg

(Altace) 1

mg 150 mg

Years)

500 mcg

(Tikosyn) 2

mg5 ml (2 ) 50 mg5 ml (1 )

250 mg

mgml 500 mgml

300 mg

(Tenoretic 100) 2

(Tenoretic 50) 2

Drug Name

10-625 mg 25-625 mg 5-625 mg

(Ziac) 1

MG 20 MG 5 MG

3125 mg 625 mg

(Coreg) 1

(5 mgml)

(Toprol XL) 2

100-25 mg 100-50 mg

50-25 mg

(Lopressor HCT) 2

mg5 ml

(Lopressor) 2

mg5 ml

(Lopressor) 1

24 hr 120 mg 160 mg 60 mg 80 mg

(Inderal LA) 2

mg 60 mg 80 mg

mg 80 mg

(Betapace) 2

Drug Name

24hr 120 mg 180 mg 240 mg 300 mg

(Tiazac) 2

(Cardizem CD) 2

(Cardizem) 2

120 mg 180 mg 240 mg

hr 120 mg 180 mg 240 mg 300 mg 360

100 mg 200 mg 300 mg

(Verelan PM) 2

hr 120 mg 180 mg 240 mg

(Verelan) 2

hr 360 mg

(Verelan) 4

mg 180 mg 240 mg

(Calan SR) 1

Drug Name

mg03 ml

30 MG3 ML

mg 50 mg

hr 1000 mg 500 mg

(Ranexa) 2

MG03 ML

30 days)

Dihydropyridines

mg 60 mg

(Norvasc) 1

mg 10-40 mg 5-10 mg 5-20 mg 5-40 mg

(Lotrel) 2

mg 10-320 mg 5-160 mg 5-320 mg

(Exforge) 2

24hr 30 mg 60 mg 90 mg

(Procardia XL) 2

mg 60 mg 90 mg

(Adalat CC) 2

Diuretics

5-50 mg

Drug Name

soln 500 mg

(Diuril IV) 2

mg5 ml (8 mgml)

(Lasix) 1

25 mg 50 mg

30 days)

(PM) 60 MG (AM) 30 MG (PM) 90 MG

(AM) 30 MG (PM)

(Aldactone) 1

capsule 375-25 mg

(Dyazide) 1

capsule 50-25 mg

375-25 mg

(Maxzide-25mg) 1

75-50 mg

(Maxzide) 1

Dyslipidemics

mg 80 mg

(Lipitor) 1

in packet 4 gram

(Questran) 2

Drug Name

mg 200 mg 67 mg

145 mg 48 mg

(Tricor) 2

MG 40 MG 60 MG

1000 mg 500 mg 750 mg

(Niaspan Extended-

Release)

(Pravachol) 1

REPATHA PUSHTRONEX

REPATHA SURECLICK

REPATHA SYRINGE

mg 5 mg

mg 80 mg

Drug Name

PACKET 375 GRAM

Inhibitors

125 MG 150-25 MG 300-125 MG 300-

Vasodilators

mg 30 mg

release 40 mg

(ISOCHRON) 2

mg10 ml (5 mgml)

mg 06 mg

(Nitrostat) 2

(Minitran) 2

25 mg 40 mg

Drug Name

30 days)

mg3 ml (20 mgml)

(Cafcit) 2 PA BvD

(20 mgml)

12 hr 10 mg

mg 5 mg

mg 30 mg

mg 5 mg 75 mg

Drug Name

(Intuniv ER) 2

MG (21)

5 PA NDS

SOLUTION 12 MG12 ML

300 mg 600 mg

release 300 mg

(Lithobid) 2

release 450 mg

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

28 days)

mg 60 mg

Drug Name

ml 5 mg5 ml

mg 5 mg

OCREVUS INTRAVENOUS

SOLUTION 30 MGML

5 PA NDS QL (20 per

180 days)

MCG05 ML

5 PA NDS

28 days)

MCG05 ML

MCG05ML (6)

5 PA NDS

125 MG 25 MG 50 MG

PACK 125 MG (5)-25 MG(8)-50 MG(42)

Drug Name

TECFIDERA ORAL

CAPSULEDELAYED

TECFIDERA ORAL

CAPSULEDELAYED

MG (46)

5 PA NDS

TECFIDERA ORAL

CAPSULEDELAYED

28 days)

Contraceptives

mg- 35 mcg

010 mg-20 mcg (84)10 mcg (7)

015 mg-30 mcg (84)10 mcg (7)

mg-mcg

(24)75 mg (4)

30 mcg (21)75 mg (7)

mcg (21)75 mg (7)

001 mg x 5

Drug Name

001 mg x 5

(24)75 mg (4)

mcg (21)75 mg (7)

mg-mcg

mg- 35 mcg

015 mg-30 mcg (84)10 mcg (7)

015-002 mgx21 001 mg x 5

(Azurette (28)) 2

015-003 mg

(Apri) 2

3-002 mg

(Gianvi (28)) 2

3-003 mg

(Ocella) 2

(5)125-30(10)

Drug Name

35 mg-mcg

(Kelnor 135 (28)) 2

50 mg-mcg

(Kelnor 1-50) 2

(24)75 mg (4)

015 mg-30 mcg (91)

mcg (21)75 mg (7)

(21)75 mg (7)

(24)75 mg (4)

001 mg x 5

(84)10 mcg (7)

mcg 015 mg-25 mcg

(84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

(21)75 mg (7)

(5)125-30(10)

01-20 mg-mcg

(Afirmelle) 2

015-003 mg

(Altavera (28)) 2

50-30 (6)75-40 (5)125-30(10)

(Enpresse) 2

20 mcg (21)75 mg (7)

(5)125-30(10)

Drug Name

035 mg

(Camila) 2

1-20 mg-mcg

(Aurovela 120 (21)) 2

1 mg-20 mcg (21)75 mg (7)

1 mg-20 mcg (24)75 mg (4)

(Aurovela 24 Fe) 2

0180215025 mg-25 mcg

0180215025 mg-35 mcg (28)

025-35 mg-mcg

(Estarylla) 2

mg- 35 mcg

001 mg x 5

mcg 1-35 mg-mcg

015 mg-30 mcg (91)

001 mg x 5

015 mg-30 mcg (84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

35mcg (9)

mg-35 mcg (28)

1mg-35mcg (9)

35 mcg (28)

mg-25 mcg

25 mcg

mg-25 mcg

mcg (28)

0180215025 mg-35 mcg (28)

(5)125-30(10)

mg-25 mcg

35 mcg (28)

0112515-25 mg-mcg

001 mg x 5

Drug Name

mcg24 hr

mouthwash 012

(Oralone) 2

(Soriatane) 2

MEDICATED

rel 10 mg

Drug Name

UNITGRAM

mg 40 mg

(Cleocin T) 2

(Ery Pads) 2

suspension 10

(Klaron) 2

Agents

Drug Name

ointment 005

(Diprolene) 2

(Cutivate) 2

Drug Name

applicator 25

(Triderm) 1

0025 01

0025 01 05

Devices

Drug Name

03 ML 31 GAUGE X 1564

12 ML 31 GAUGE X 1564

(Lite Touch Insulin

Syringe)

GAUGE X 12

(1st Tier Unifine

Pentips)

SOLUTION 250 UNITML

SOLUTION 29 MG5 ML

SOLN 400 UNIT

60000 UNIT 24000-76000 -120000

UNIT 3000-9500- 15000 UNIT

36000-114000- 180000 UNIT 6000-

19000 -30000 UNIT

SOLUTION 6 MG3 ML

SOLN 15 MG 75 MG

SOLN 35 MG 5 MG

5 PA NDS

2 MGML

5 PA NDS

Drug Name

SOLUTION 8 MGML

5 PA BvD NDS

2 MGML

5 PA NDS

SOLUTION 5 MG5 ML

5 PA NDS

MG 20 MG 5 MG

5 PA NDS

ML 20 MGML

5 PA NDS

SOLUTION 1 MGML

5 PA BvD NDS

5 PA NDS

5 PA LA NDS

5 MG5 ML (1 MGML)

5 PA NDS

400 UNIT

42000 UNIT 15000-47000 -63000

UNIT 20000-63000- 84000 UNIT

25000-79000- 105000 UNIT 3000-

10000 -14000-UNIT 40000-126000-

168000 UNIT 5000-17000- 24000

Miscellaneous

Drug Name

(Cyclogyl) 2

DROPS 044

aerosol 003

(Alcaine) 2

Agents

unitgram

(AK-Poly-Bac) 2

CIPRODEX OTIC (EAR)

(Ciloxan) 1

(Cetraxal) 4

mggram (05 )

mggram)

DROPS VISCOUS 05

Drug Name

(Vigamox) 2

DROPSSUSPENSION 5

(Neo-Polycin HC) 2

mg-unit-unitg

(Neo-Polycin) 2

(Maxitrol) 2

10000 unitg-01

(Maxitrol) 2

unit-0025mgml

unitml-

35-400-10000 mg-unitg-1

10000 unitgram

(Polytrim) 1

drops 10

(Bleph-10) 2

ointment 10

(eye) drops 10 -023 (025 )

Drug Name

(TobraDex) 2

Inflammatory Agents

DROPSSUSPENSION 02

DROPS 0075

DROPS 005

mcg (0025 )

dropssuspension 01

(FML Liquifilm) 4

drops 003

DROPSSUSPENSION 03

DROPSSUSPENSION 1

DROPSGEL 05

OINTMENT 05

DROPSGEL 038

dropssuspension 1

(Pred Forte) 4

Drug Name

DROPS 007

DROPPERETTE 005

DROPPERETTE 5

soln 20 mg

soln 40 mg

(Nexium IV) 2

mg2 ml

release(drec) 15 mg

release(drec) 30 mg

(Protonix) 2

(drec) 20 mg

(drec) 40 mg

50 mg2 ml (25 mgml)

(Zantac) 2

(ranitidine))

Drug Name

DISPERSIBLE 200 MG

0025 mg5 ml

Years)

0025 mg

Years)

KIT 5 MG

5 PA NDS

193 gram60 ml

290 MCG 72 MCG

(loperamide))

(Reglan) 1

Drug Name

SOLUTION 12 MG06 ML

28 days)

SYRINGE 12 MG06 ML

28 days)

SYRINGE 8 MG04 ML

28 days)

gram60 ml

Laxatives

GRAM -12 GRAM160 ML

-584 gram

-586 gram

2272-672 -584 gram

(Colyte with Flavor

Packs)

420 gram

Phosphate Binders

Drug Name

(Renvela) 5 NDS

VELPHORO ORAL

mg 5 mg 50 mg

(Urecholine) 2

(Ditropan XL) 2

release 24hr 15 mg

24hr 2 mg 4 mg

(Detrol LA) 2

hr 10 mg

(Uroxatral) 1

THIOLA EC ORAL

5 PA NDS

Drug Name

mg 250 mg 500 mg

(Exjade) 5 PA NDS

500 mg

(Desferal) 2 PA

250 MG

5 PA NDS

MG 90 MG

5 PA NDS

MG 90 MG

5 PA NDS

30 days)

Hormonal Agents

Androgens

100 mgml 200 mgml

200 mgml (1 ml)

200 mgml

ML 75 MG05 ML

Years)

Drug Name

mg24 hr 00375 mg24 hr 005 mg24 hr

0075 mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

0025 mg24 hr 005 mg24 hr 0075

mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

00375 mg24 hr

days) AGE (Max 64

Years)

mg24 hr 00375 mg24 hr 005 mg24 hr

006 mg24 hr 0075 mg24 hr 01 mg24

days) AGE (Max 64

Years)

mgml 40 mgml

(Delestrogen) 2

05-01 mg

Years)

HR 01 MG24 HR

mg-mcg

Years)

05-25 mg-mcg

Years)

1-5 mg-mcg

Years)

045 MG 0625 MG 09 MG 125 MG

Years)

MGGRAM

Drug Name

MG (14) 0625MG-5MG(14)

Years)

045-15 MG 0625-25 MG 0625-5 MG

Years)

suspension 6 mgml

mg 4 mg 6 mg

(Decadron) 1 PA BvD

1 PA BvD

solution 10 mgml

MG 6 MG

(Cortef) 2

(Depo-Medrol) 2

mg 4 mg 8 mg

(Medrol) 2

(Medrol (Pak)) 2

(Solu-Medrol) 2

mg5 ml (3 mgml)

2 PA BvD

Drug Name

2 PA BvD

1 PA BvD

suspension 40 mgml

(Kenalog) 2

Pituitary

mcgspray (01 ml)

(DDAVP) 2

mcgspray (01 ml)

SOLN 1 MG

MG025 ML

MG025 ML 06 MG025 ML 08

MG025 ML 1 MG025 ML 12

MG025 ML 14 MG025 ML 16

MG025 ML 18 MG025 ML 2

MG025 ML

5 PA NDS

5 MGML (15 UNITML)

5 PA NDS

HUMATROPE INJECTION

5 PA NDS

SOLN 5 (15 UNIT) MG

5 PA NDS

Drug Name

SOLUTION 10 MGML

1125 MG

SYRINGE KIT 75 MG

LUPRON DEPOT-PED

NORDITROPIN FLEXPRO

ML (10 MGML) 30 MG3 ML (10

5 PA NDS

NORDITROPIN FLEXPRO

MG15 ML (33 MGML)

NUTROPIN AQ NUSPIN

5 PA NDS

mcgml 200 mcgml

(Sandostatin) 2

mcgml (1 ml)

5 PA NDS

RECON SOLN 58 MG

5 PA NDS

Drug Name

SAIZEN SAIZENPREP

5 PA NDS

SOLN 5 MG 88 MG

5 PA NDS

INTRAMUSCULAR

SOLN 4 MG 5 MG 6 MG

5 PA NDS

SOMATULINE DEPOT

MG05 ML

5 PA NSO NDS QL (1

per 28 days)

SOMATULINE DEPOT

ML 90 MG03 ML

25 MG 30 MG

5 PA NDS

(65 MCGDAY)

5 NDS QL (1 per 360

AEROSOL 2 MGML

225 MG

5 NDS QL (1 per 168

RECON SOLN 10 MG

5 PA NDS

RECON SOLN 5 MG

SOLN 88 MG

5 PA NDS

Progestins

SUSPENSION 400 MGML

5 PA NSO NDS

Drug Name

suspension 150 mgml

syringe 150 mgml

25 mg 5 mg

(Provera) 1

(40 mgml)

Years)

mg 200 mg

(Prometrium) 2

mcg 125 mcg 137 mcg 150 mcg 175

88 mcg

(Euthyrox) 1

(Cytomel) 2

ACTEMRA ACTPEN

MG09 ML

5 PA NDS

ACTEMRA INTRAVENOUS

80 MG4 ML (20 MGML)

5 PA NDS

SYRINGE 162 MG09 ML

5 PA NDS

SOLN 220 MG

100 mg

2 PA BvD

MG X 2 VIALS)

5 PA NDS

Drug Name

5 PA NDS

mg5 ml

mg 25 mg

(Gengraf) 2 PA BvD

5 PA NDS

SOLN 25 MG (1 ML)

5 PA NDS

25 MG05 ML (05) 50 MGML (1 ML)

5 PA NDS

ENBREL SURECLICK

MGML (1 ML)

5 PA NDS

SOLUTION 10 5

5 PA BvD NDS

4 PA BvD

SOLUTION 10

5 PA BvD NDS

GRAM 5 GRAM

5 PA BvD NDS

SOLUTION 10 10 (100 ML) 10

(200 ML)

5 PA BvD NDS

Drug Name

KIT 40 MG08 ML 40 MG08 ML (6

5 PA NDS

KIT 40 MG08 ML

5 PA NDS

KIT 10 MG02 ML 20 MG04 ML 40

MG08 ML

5 PA NDS

MG08 ML-40 MG04 ML

5 PA NDS

80 MG08 ML

5 PA NDS

MG02 ML 40 MG04 ML

5 PA NDS

SOLUTION 300 UNITML

HYPERRAB SD (PF)

UNITML

HYQVIA SUBCUTANEOUS

25 GRAM 25 ML (10 ) 20 GRAM

200 ML (10 ) 30 GRAM 300 ML (10

) 5 GRAM 50 ML (10 )

5 PA BvD NDS

SOLN 150 MGML

5 PA NDS

SOLUTION 150 MGML

5 PA NDS

Drug Name

100 MGML

5 PA NDS

UNITML

SOLN 100 MG

5 PA NDS

SOLUTION 150 UNITML

MG114 ML

5 PA NDS

MG114 ML

5 PA NDS

100 MG067 ML

5 PA NDS

recon soln 500 mg

(CellCept) 2 PA BvD

SOLN 250 MG

5 PA BvD NDS

OCTAGAM INTRAVENOUS

SOLUTION 10 5

5 PA BvD NDS

5 PA NDS

ORENCIA CLICKJECT

125 MGML

5 PA NDS

875 MG07 ML

5 PA NDS

OTEZLA STARTER ORAL

MG (4)-30 MG (47) 10 MG (4)-20 MG

(4)-30 MG(19)

5 PA NDS

Drug Name

SOLUTION 10

5 PA BvD NDS

5 MGML

4 PA BvD

PACKET 02 MG 1 MG

4 PA BvD ST

MG025 ML 15 MG03 ML 175

MG035 ML 20 MG04 ML 225

MG045 ML 25 MG05 ML 30 MG06

ML 75 MG015 ML

SOLN 100 MG

5 PA NDS

SOLN 100 MG

5 PA NDS

MG15 ML

5 PA NDS

SOLUTION 125 MGML

5 PA NDS

100 MGML 50 MG05 ML

5 PA NDS

130 MG26 ML

5 PA NDS

SOLUTION 45 MG05 ML

5 PA NDS

(Prograf) 2 PA BvD

TALTZ AUTOINJECTOR

80 MGML

5 PA NDS

Drug Name

SYRINGE 80 MGML

5 PA NDS

INJECTOR 100 MGML

5 PA NDS

SYRINGE 100 MGML

5 PA NDS

300 MG15 ML

5 PA LA NDS

5 PA NDS

05 MG 075 MG 1 MG

5 PA BvD NDS

Vaccines

ADACEL(TDAP

ADOLESNADULT)(PF)

LF-(25-5-3-5 MCG)-5LF05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

(25-5-3-5 MCG)-5LF05 ML

3 PA BvD

LF05ML

10-5 LF-MCG-LF05ML

SUSPENSION 20 MCGML

3 PA BvD

Drug Name

SYRINGE 20 MCGML

3 PA BvD

MCG05 ML

3 PA BvD

SUSPENSION 05 ML

SYRINGE 05 ML

720 ELISA UNIT05 ML

ELISA UNIT05 ML

3 PA BvD

58-10 LF-MCG-LF05ML

LF-MCG-LF05ML

32 UNIT05 ML

UNIT05 ML

SYRINGE 6 MCG05 ML

SOLUTION 4 MCG05 ML

Drug Name

10LF05 ML

10EXP3-43-3- 399 TCID5005

UNIT05ML

25 UNIT

3 PA BvD

RECOMBIVAX HB (PF)

3 PA BvD

RECOMBIVAX HB (PF)

MCGML 5 MCG05 ML

3 PA BvD

CCID50ML

SOLUTION 2 ML

50 MCG05 ML

TDVAX INTRAMUSCULAR

UNIT05ML

LF UNIT05 ML

Drug Name

SYRINGE 25 MCG05 ML

UNITML

1350 UNIT05 ML

10 EXP474 UNIT05 ML

19400 UNIT065 ML

Agents

budesonide oral

(Entocort EC) 2

tablets) 400 mg

(Delzicol) 2

(drec) 800 mg

(Asacol HD) 2

Drug Name

(drec) 500 mg

MGACTUATION

SOLUTION

Chloride)

solution

(Aqua Care Sterile

Water)

mcg2 ml

(Hectorol) 2

105 MG117 ML

30 days)

210MG234ML ( 105MG117MLX2)

30 days)

MCG24 ML

Drug Name

200 UNITML

MCGDOSE

solution 2 mcgml

60 MGML

RAYALDEE ORAL

HR 30 MCG

3 PA QL (156 per 30

mg5 ml

soln 500 mg

(Ethyol) 2

SOLN 120 MG 400 MG

5 PA NDS

INJECTOR 200 MGML

SYRINGE 200 MGML

CETYLEV ORAL TABLET

Drug Name

GRAM17 ML

5 GRAM

30 days)

SOLUTION 50 MGML

5 PA LA NDS

RECON SOLN 1 MG

(Vistaril) 1

30 days)

100 mg 200 mg 350 mg 50 mg 500 mg

mg 25 mg 5 mg

100 mgml

(Carnitor) 2

soln 50 mg

(Fusilev) 5 NDS

mg5 ml

(Mestinon) 2

Drug Name

150 MG 200 MG 50 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 500 MG

PACKET 10 GRAM

5 NDS QL (24 per 14

PACKET 2 GRAM

30 days)

Ophthalmic Agents

Antiglaucoma Agents

release 500 mg

500 mg

DROPS 01

DROPSSUSPENSION 1

DROPS 02-05

drops 223-68 mgml

(Cosopt) 2

DROPS 001

(Isopto Carpine) 2

DROPS 002

Drug Name

025 05

(Timoptic) 1

(Timoptic-XE) 4

DROPS 0004

mgml (10 )

IONOSOL-MB IN D5W

SOLUTION 5

PARENTERAL SOLUTION

release 8 meq

40 gram1000 ml (4 )

2 PA BvD

gram100 ml (4 ) 4 gram50 ml (8 )

2 PA BvD

meqml (50 )

2 PA BvD

Drug Name

SOLUTION

SINGLE-USE

PARENTERAL SOLUTION

2 PA BvD

meqml (20 ml)

2 PA BvD

release 10 meq

release 8 meq

ml 40 meq15 ml

(K-Tab) 2

release 20 meq

(K-Tab) 4

(Klor-Con M10) 2

(Klor-Con M20) 2

(Urocit-K 10) 2

release 15 meq

(Urocit-K 15) 2

(Urocit-K 5) 2

parenteral solution

Corticosteroids

Drug Name

50 MCGDOSE

MCGACTUATION 230-21

MCGACTUATION 45-21

MCGACTUATION

MCGACTUATION 200

MCGACTUATION 50

MCGACTUATION

mg2 ml

MCGACTUATION

MCGACTUATION 50

MCGACTUATION

AEROSOL INHALER 110

MCGACTUATION

AEROSOL INHALER 220

MCGACTUATION

AEROSOL INHALER 44

MCGACTUATION

Drug Name

INHALATIONS 80-45

MCGACTUATION

MCGACTUATION 80-45

MCGACTUATION

Antileukotrienes

(Singulair) 1

Bronchodilators

25 mg 3 ml (0083 ) 25 mg05 ml

2 PA BvD

MCGACTUATION

AEROSOL INHALER 17

MCGACTUATION

COMBIVENT RESPIMAT

MCGACTUATION

2 PA BvD

STARTER 25 MCGML

Drug Name

MCGDOSE

12 hr 100 mg 200 mg 300 mg

(Theochron) 2

12 hr 450 mg

24 hr 400 mg 600 mg

(30 ACTUAT)

mgml (20 )

(Acetadote) 2 PA

200 mgml (20 )

2 PA BvD

10 MGML

5 PA NDS

2 PA BvD

Drug Name

30 days)

SYRINGE 30 MGML

INJECTOR 100 MGML

28 days)

SOLN 100 MG

28 days)

100 MGML

28 days)

PACKET 100-125 MG 150-188 MG

MG 200-125 MG

30 days)

RECON SOLN 1000 MG

5 PA BvD NDS

(N) 50-75 MG (D) 75 MG (N)

SOLN 150 MG

5 PA NDS

150 MGML 75 MG05 ML

5 PA NDS

Years)

Drug Name

Years)

250 mg 50 mg

MG 20 MG 5 MG

per 30 days)

Vasodilating Agents

MG 15 MG 2 MG 25 MG

soln 05 mg

(Flolan) 2 PA

soln 15 mg

(Flolan) 5 PA NDS

25 MG 5 MG

5 PA NDS

Drug Name

1 day)

SUSPENSION 32 MG

28 days)

(06 MGML)

5 PA NDS

1200 MCG 1400 MCG 1600 MCG

400 MCG 600 MCG 800 MCG

30 days)

PACK 200 MCG (140)- 800 MCG (60)

5 PA NDS

27 mg iron- 1 mg

A abacavir 47

ABELCET 35

ABILIFY MAINTENA 43

ABRAXANE 15

acamprosate 7

acarbose 32

acebutolol 60

acetazolamide 107

acetic acid 82 104

acetylcysteine 112

acitretin 76

ACTEMRA 95

ACTEMRA ACTPEN 95

ACTHIB (PF) 100

ACTIMMUNE 105

acyclovir 52 76

acyclovir sodium 52

ADACEL(TDAP

ADAGEN 80

adapalene 79

adefovir 52

ADEMPAS 114

adriamycin 15

adrucil 15

ADVAIR DISKUS 110

ADVAIR HFA 110

afeditab cr 63

AFINITOR 15

AFINITOR DISPERZ 15

afirmelle 70

a-hydrocort 91

(2 PACK) 38

AJOVY 38

AKYNZEO

(FOSNETUPITANT) 39

ala-cort 77

albendazole 41

alclometasone 77

ALCOHOL PADS 76

ALDURAZYME 80

ALECENSA 16

alendronate 104

alfuzosin 88

ALIMTA 16

ALINIA 41

ALIQOPA 16

aliskiren 66

allopurinol 37

alosetron 103

ALPHAGAN P 107

alprazolam 8

ALREX 84

altavera (28) 70

ALTRENO 79

ALUNBRIG 16

alyacen 135 (28) 70

alyacen 777 (28) 70

alyq 114

amabelz 89

amantadine hcl 41

AMBISOME 35

ambrisentan 114

amethia 70

amethia lo 70

amiloride 63

AMINOSYN 10 55

AMINOSYN 7 WITH

ELECTROLYTES 55

AMINOSYN 85 55

AMINOSYN 85 -

ELECTROLYTES 55

AMINOSYN II 10 56

AMINOSYN II 15 56

AMINOSYN II 7 56

AMINOSYN II 85 56

AMINOSYN II 85 -

ELECTROLYTES 56

AMINOSYN M 35 56

AMINOSYN-HBC 7 56

AMINOSYN-PF 10 56

AMINOSYN-PF 7

(SULFITE-FREE) 56

AMINOSYN-RF 52 56

amiodarone 60

AMITIZA 86

amitriptyline 29

amlodipine 63

ammonium lactate 76

amoxapine 30

amoxicillin 13

amphotericin b 35

ampicillin 13

ANADROL-50 89

anagrelide 55

anastrozole 16

ANORO ELLIPTA 111

APOKYN 41

apraclonidine 81

aprepitant 39

apri 70

APRISO 103

APTIOM 25 26

APTIVUS 47

aranelle (28) 70

ARCALYST 95

aripiprazole 43

ARISTADA 43

ARISTADA INITIO 43

armodafinil 114

ARNUITY ELLIPTA 110

arsenic trioxide 16

ashlyna 70

ASSURE ID INSULIN

SAFETY 79

atazanavir 47

atenolol 60

atomoxetine 66

atorvastatin 64

atovaquone 41

ATRIPLA 47

atropine 25 82

ATROVENT HFA 111

AUBAGIO 66

aubra 70

aurovela 1530 (21) 70

aurovela 24 fe 70

AUSTEDO 67

AVASTIN 16

aviane 70

AVONEX 67

ayuna 70

azacitidine 16

azathioprine 95

azelastine 82

azithromycin 12

AZOPT 107

aztreonam 13

azurette (28) 70

B baciim 10

bacitracin 82

baclofen 113

balsalazide 103

BALVERSA 16

balziva (28) 71

BANZEL 26

BAVENCIO 16

BAXDELA 14

NEEDLE 79

UNIT 80

bekyree (28) 71

BELEODAQ 16

BELSOMRA 114

benazepril 59

BENDEKA 16

BENLYSTA 105

benztropine 41

BESPONSA 16

BETASERON 67

betaxolol 60

BETHKIS 9

BEVYXXA 52

bexarotene 16

BEXSERO 100

bicalutamide 16

BICILLIN L-A 13

BIDIL 66

BIKTARVY 47

bleomycin 16

bleph-10 82

BLINCYTO 16

blisovi 24 fe 71

blisovi fe 1530 (28) 71

BOOSTRIX TDAP 100

BORTEZOMIB 16

BOSULIF 16 17

BRAFTOVI 17

BREO ELLIPTA 110

briellyn 71

BRILINTA 55

brimonidine 107

BRIVIACT 26

bromocriptine 41

BROMSITE 84

budesonide 103 110

bumetanide 63

bupropion hcl 30

buspirone 8

BYSTOLIC 61

BYVALSON 61

C cabergoline 41

CABLIVI 105

CABOMETYX 17

caffeine citrate 67

calcipotriene 76

calcitriol 104

CALDOLOR 6

CALQUENCE 17

camila 71

CAPASTAT 39

CAPRELSA 17

captopril 59

CARBAGLU 86

carbamazepine 26

carteolol 107

cartia xt 62

carvedilol 61

caspofungin 36

CAYSTON 13

caziant (28) 71

cefaclor 11

cefadroxil 11

cefazolin 11

cefdinir 11

cefepime 11

cefixime 11

cefotaxime 11

cefoxitin 11

cefpodoxime 12

cefprozil 12

ceftazidime 12

ceftriaxone 12

celecoxib 6

CELONTIN 26

cephalexin 12

CERDELGA 80

CEREZYME 80

CETYLEV 105

CHANTIX 8

CHANTIX CONTINUING

MONTH BOX 8

CHANTIX STARTING

MONTH BOX 8

chlorothiazide 64

chlorpromazine 43

chlorthalidone 64

chlorzoxazone 113

ciclopirox 36

cilostazol 55

CIMDUO 47

cimetidine hcl 85

CIMZIA 95

CIMZIA POWDER FOR

RECONST 95

cinacalcet 104

CINQAIR 112

CINRYZE 53

CINVANTI 39

CIPRODEX 82

ciprofloxacin 14

citalopram 30

clarithromycin 12

CLENPIQ 87

clindamycin hcl 10

CLINIMIX 5D15W

SULFITE FREE 56

CLINIMIX 5D25W

SULFITE-FREE 56

FREE 56

CLINIMIX 425D5W

SULFIT FREE 56

CLINIMIX 425-D25W

SULF-FREE 56

CLINIMIX 5-

CLINIMIX E 275D10W

SUL FREE 56

CLINIMIX E 275D5W

SULF FREE 57

CLINIMIX E 425D10W

SUL FREE 57

CLINIMIX E 425D25W

SUL FREE 57

CLINIMIX E 425D5W

SULF FREE 57

CLINIMIX E 5D15W

SULFIT FREE 57

CLINIMIX E 5D20W

SULFIT FREE 57

CLINIMIX E 5D25W

SULFIT FREE 57

clobazam 26

clobetasol 78

clofarabine 17

clomipramine 30

clonazepam 9

clonidine 58

clonidine hcl 58

clopidogrel 55

clotrimazole 36

clozapine 43 44

COARTEM 41

codeine sulfate 3

colchicine 37

colestipol 64

colocort 103

COMBIGAN 107

COMETRIQ 17

COMPLERA 47

compro 39

constulose 86

COPIKTRA 17

CORLANOR 62

cormax 78

cortisone 91

COTELLIC 17

CREON 80

CRIXIVAN 47

cromolyn 82 86 112

cryselle (28) 71

cyclobenzaprine 113

cyclopentolate 82

cyclophosphamide 17

CYCLOPHOSPHAMIDE 17

cyclosporine 96

cyproheptadine 37

CYRAMZA 17

cyred 71

CYSTADANE 106

CYSTARAN 82

D dalfampridine 67

DALIRESP 113

danazol 89

dantrolene 113 114

dapsone 39

DAPTACEL (DTAP

PEDIATRIC) (PF) 100

daptomycin 10

DARAPRIM 41

DARZALEX 17

dasetta 135 (28) 71

dasetta 777 (28) 71

DAURISMO 17

daysee 71

deblitane 71

decadron 91

decitabine 17

deferasirox 89

deferoxamine 89

DELSTRIGO 47

delyla (28) 71

DEMSER 62

DEPEN TITRATABS 89

DEPO-PROVERA 94

DESCOVY 47

desipramine 30

desmopressin 92

desoximetasone 78

dexamethasone 91

(pf) 91

phosphate 84 91

dextroamphetamine-

amphetamine 67

DIASTAT 26

DIASTAT ACUDIAL 26

diazepam 9 26

diazepam intensol 9

dicloxacillin 13

dicyclomine 86

didanosine 47

DIFICID 12

digitek 62

digox 62

digoxin 62 63

DIGOXIN 63

diltiazem hcl 62

dilt-xr 62

dimenhydrinate 39

DIPENTUM 103

dipyridamole 55

disulfiram 8

divalproex 26

dofetilide 60

donepezil 29

dorzolamide 107

dotti 90

DOVATO 48

doxazosin 58

doxepin 30

doxercalciferol 104

doxorubicin 17

doxy-100 15

dronabinol 39

droperidol 106

DROXIA 18

DUAVEE 90

duloxetine 30

DUPIXENT 96

DUREZOL 84

dutasteride 88

E econazole 36

EDARBI 59

EDARBYCLOR 59

EDURANT 48

efavirenz 48

EGRIFTA 92

ELAPRASE 80

ELIGARD 18

elinest 71

ELIQUIS 52

ELITEK 80

ELLA 71

ELMIRON 106

EMCYT 18

EMEND 40

EMFLAZA 91

EMGALITY PEN 38

EMGALITY SYRINGE 38

emoquette 71

EMPLICITI 18

EMSAM 30

EMTRIVA 48

enalaprilat 59

ENBREL 96

ENBREL SURECLICK 96

ENDARI 106

endocet 3

enoxaparin 52 53

enpresse 71

enskyce 71

entacapone 42

entecavir 52

ENTRESTO 59

enulose 86

EPCLUSA 51

EPIDIOLEX 26

epinastine 82

epinephrine 63

epitol 26

EPIVIR HBV 48

eplerenone 66

ergoloid 106

ERGOMAR 38

ERIVEDGE 18

ERLEADA 18

erlotinib 18

errin 71

ertapenem 13

ery pads 77

erythromycin 12 82

ESBRIET 113

estarylla 71

estradiol 90

eszopiclone 114

ethambutol 39

ethosuximide 26

etodolac 6

ETOPOPHOS 18

etoposide 18

EUCRISA 78

EVENITY 104

EVOTAZ 48

exemestane 18

EXONDYS 51 106

EXTAVIA 67

ezetimibe 65

F FABRAZYME 80

falmina (28) 72

famciclovir 52

famotidine 85

famotidine (pf) 85

FANAPT 44

FARYDAK 18

FASENRA 113

febuxostat 37

felbamate 27

FEMRING 90

femynor 72

fenofibrate 65

fentanyl 3

fentanyl citrate 3

FERRIPROX 89

FETZIMA 30

INSULIN 33

finasteride 88

FIRAZYR 63

FIRVANQ 10

FLEBOGAMMA DIF 96

flecainide 60

FLOVENT DISKUS 110

FLOVENT HFA 110

floxuridine 18

fluconazole 36

flucytosine 36

fludrocortisone 91

flumazenil 67

flunisolide 84

fluocinolone 78

fluocinonide 78

fluocinonide-e 78

fluorometholone 84

fluorouracil 18 76

fluoxetine 30

fluphenazine hcl 44

flurbiprofen 6

flutamide 18

fluvoxamine 31

fomepizole 106

fondaparinux 53

FORTEO 104

fosamprenavir 48

foscarnet 50

fosinopril 59

fosphenytoin 27

FREAMINE HBC 69 57

FREAMINE III 10 58

FULPHILA 53

fulvestrant 18

furosemide 64

FUZEON 48

fyavolv 90

FYCOMPA 27

G gabapentin 27

GALAFOLD 80

galantamine 29

GAMASTAN 96

GAMMAGARD LIQUID 96

MCGML) 96

GAMMAPLEX 96

GAMMAPLEX (WITH

SORBITOL) 96

GARDASIL 9 (PF) 101

GATTEX 30-VIAL 86

GAUZE PAD 80

gavilyte-c 87

gavilyte-g 87

gavilyte-n 87

GAZYVA 18

gemfibrozil 65

generlac 86

gengraf 96

GENOTROPIN 92

gentak 82

gentamicin 9 77 82

GENVOYA 48

GEODON 44

GILENYA 67

GILOTRIF 18

glatiramer 67

glatopa 67 68

GLEOSTINE 18

glimepiride 35

glipizide 35

glyburide 35

glycopyrrolate 86

glydo 7

GLYXAMBI 32

GOCOVRI 42

granisetron (pf) 40

granisetron hcl 40

GRANIX 53 54

guanfacine 58 68

guanidine 106

H HAEGARDA 54

hailey 24 fe 72

haloperidol 44

HARVONI 51

HAVRIX (PF) 101

heather 72

HEPATAMINE 8 58

HERCEPTIN 19

HETLIOZ 114

HIBERIX (PF) 101

HUMATROPE 92

HUMIRA 97

HUMIRA PEDIATRIC

CROHNS START 97

HUMIRA PEN 97

HS START 97

HUMIRA PEN PSOR-

UVEITS-ADOL HS 97

HUMIRA(CF) 97

STARTER 97

HUMIRA(CF) PEN 97

UC-HS 97

ADOL HS 97

INSULIN 34

KWIKPEN 34

hydralazine 63

hydromorphone 4

hydroxyurea 19

hydroxyzine hcl 37

HYPERRAB (PF) 97

HYPERRAB SD (PF) 97

HYQVIA 97

I ibandronate 104

IBRANCE 19

ibuprofen 6

icatibant 63

ICLUSIG 19

IDHIFA 19

ifosfamide 19

ifosfamide-mesna 19

ILARIS (PF) 97

ILEVRO 84

ILUMYA 98

imatinib 19

IMBRUVICA 19

IMFINZI 19

imipramine hcl 31

imiquimod 76

IMLYGIC 19

(PF) 101

IMPAVIDO 41

INBRIJA 42

incassia 72

INCRELEX 93

INCRUSE ELLIPTA 111

indapamide 64

indomethacin 6

INFLECTRA 98

INGREZZA 68

INGREZZA INITIATION

PACK 68

INLYTA 19

U-100 80

INTELENCE 48

INTRALIPID 58

INTRON A 51

introvale 72

INVEGA SUSTENNA 45

INVEGA TRINZA 45

INVELTYS 84

INVIRASE 48

INVOKAMET 32

INVOKAMET XR 32

INVOKANA 32

IPOL 101

irbesartan 59

IRESSA 19

ISENTRESS 48

ISENTRESS HD 48

isibloom 72

ISOLYTE-P IN 5

DEXTROSE 108

ISOLYTE-S 108

isoniazid 39

itraconazole 36

ivermectin 41

IXEMPRA 19

IXIARO (PF) 101

J JADENU 89

JADENU SPRINKLE 89

JAKAFI 20

jantoven 53

JANUMET 32

JANUMET XR 32

JANUVIA 32

JARDIANCE 32

jasmiel (28) 72

jencycla 72

JENTADUETO 32

JENTADUETO XR 32

jinteli 90

jolivette 72

juleber 72

JULUCA 48

junel 1530 (21) 72

junel 120 (21) 72

junel fe 1530 (28) 72

junel fe 120 (28) 72

junel fe 24 72

JUXTAPID 65

JYNARQUE 64

K KABIVEN 58

KALETRA 48

kalliga 72

KALYDECO 113

KANJINTI 20

KANUMA 80

kariva (28) 72

KEDRAB (PF) 98

kelnor 135 (28) 72

kelnor 1-50 72

ketoconazole 36

ketorolac 6 84

KEVEYIS 106

KEVZARA 98

KEYTRUDA 20

KINERET 98

KINRIX (PF) 101

KISQALI 20

klor-con m10 108

klor-con m15 108

klor-con m20 108

KORLYM 32

KRINTAFEL 41

KRYSTEXXA 81

kurvelo (28) 72

KUVAN 81

KYPROLIS 20

labetalol 61

lactulose 86

lamivudine 48

lamotrigine 27

lansoprazole 85

INSULIN 34

larin 1530 (21) 73

larin 120 (21) 73

larin 24 fe 73

larin fe 1530 (28) 73

larin fe 120 (28) 73

larissia 73

latanoprost 107

LATUDA 45

LAZANDA 4

leena 28 73

leflunomide 98

LEMTRADA 68

LENVIMA 20

lessina 73

letrozole 20

LEUKERAN 20

LEUKINE 54

leuprolide 20

levetiracetam 27

levobunolol 107

levocarnitine 106

levocetirizine 37

levofloxacin 14 82

LEVOLEUCOVORIN

CALCIUM 106

levonest (28) 73

levora-28 73

levothyroxine 95

LEXIVA 48

LIALDA 103

LIBTAYO 20

lidocaine 7

lidocaine (pf) 7 60

lidocaine hcl 7

lidocaine viscous 7

lillow (28) 73

linezolid 10 11

LINZESS 86

liothyronine 95

lisinopril 59 60

lithium citrate 68

LIVALO 65

LOKELMA 86

LONHALA MAGNAIR

REFILL 112

LONHALA MAGNAIR

STARTER 111

LONSURF 20

loperamide 86

lorazepam 9

LORBRENA 20

lorcet hd 4

lorcet plus 4

loryna (28) 73

losartan 59

LOTEMAX 84

LOTEMAX SM 84

lovastatin 65

LUCEMYRA 8

LUMIGAN 107

LUMOXITI 21

LUPRON DEPOT 21 93

LUPRON DEPOT-PED 93

LUPRON DEPOT-PED (3

MONTH) 93

lutera (28) 73

LYNPARZA 21

LYRICA 27

LYSODREN 21

lyza 73

malathion 79

maprotiline 31

marlissa (28) 73

MARPLAN 31

MATULANE 21

PACK) 68

MAVENCLAD (4 TABLET

PACK) 68

MAVENCLAD (5 TABLET

PACK) 68

MAVENCLAD (6 TABLET

PACK) 68

MAVENCLAD (7 TABLET

PACK) 68

MAVENCLAD (8 TABLET

PACK) 68

MAVENCLAD (9 TABLET

PACK) 68

MAVYRET 51

MAYZENT 68

meclizine 40

mefenamic acid 6

mefloquine 41

megestrol 21 95

MEKINIST 21

MEKTOVI 21

meloxicam 6

memantine 29

MENACTRA (PF) 101

(PF) 101

MEPSEVII 81

mercaptopurine 21

meropenem 13

mesalamine 103

mesna 106

MESNEX 106

MESTINON 106

metaproterenol 112

metformin 32 33

methadone 4

methadose 4

methimazole 95

methocarbamol 114

methoxsalen 76

methscopolamine 86

methyclothiazide 64

metipranolol 107

mexiletine 60

MIACALCIN 105

miconazole-3 36

midodrine 58

miglustat 81

mili 73

mimvey 90

mimvey lo 90

minitran 66

minocycline 15

minoxidil 66

mirtazapine 31

misoprostol 85

MITIGARE 37

mitoxantrone 21

M-M-R II (PF) 102

molindone 45

mometasone 79

mondoxyne nl 15

mono-linyah 73

mononessa (28) 73

montelukast 111

morphine 4 5

MORPHINE 5

MOVANTIK 86

MOXEZA 82

moxifloxacin 14 83

MOZOBIL 54

MULPLETA 54

MULTAQ 60

mupirocin 77

MYLOTARG 21

MYRBETRIQ 88

myzilra 73

N nabumetone 6

nafcillin 13 14

NAGLAZYME 81

naloxone 8

naltrexone 8

NAMZARIC 29

naproxen 7

NARCAN 8

NATACYN 83

NATPARA 105

NEBUPENT 41

necon 0535 (28) 73

nefazodone 31

neomycin 10

dexameth 83

neomycin-polymyxin-

gramicidin 83

neo-polycin 83

neo-polycin hc 83

NEPHRAMINE 54 58

NERLYNX 21

NEULASTA 54

NEUPOGEN 54

NEUPRO 42

nevirapine 48 49

NEXAVAR 21

niacin 65

niacor 65

nicardipine 63

NICOTROL 8

nifedipine 63

nikki (28) 74

nilutamide 21

NINLARO 22

nitroglycerin 66

NITYR 81

NIVESTYM 54

nizatidine 85

NOCDURNA (MEN) 93

NOCDURNA (WOMEN) 93

nora-be 74

norlyda 74

norlyroc 74

NORMOSOL-M IN 5

DEXTROSE 109

NORMOSOL-R 109

NORTHERA 58

nortrel 0535 (28) 74

nortrel 135 (21) 74

nortrel 135 (28) 74

nortrel 777 (28) 74

nortriptyline 31

NORVIR 49

NOVOLIN 7030 U-100

INSULIN 34

100 34

NOVOLIN N NPH U-100

INSULIN 34

100 INSULN 34

INSULIN 34

INSULN 34

NOVOLOG MIX 70-

30FLEXPEN U-100 34

INSULIN 34

ASPART 34

NOXAFIL 36

NUCALA 113

NUCYNTA 5

NUCYNTA ER 5

NUEDEXTA 69

NULOJIX 98

NUPLAZID 45

NUTRILIPID 58

nyamyc 36

nystatin 36

nystop 36

O OCALIVA 87

OCREVUS 69

OCTAGAM 98

ODEFSEY 49

ODOMZO 22

OFEV 113

ofloxacin 83

ogestrel (28) 74

olanzapine 45

olmesartan 59

olopatadine 82

OLUMIANT 98

omeprazole 85

OMNITROPE 93

ONCASPAR 22

ondansetron 40

ondansetron hcl 40

ONIVYDE 22

OPDIVO 22

OPSUMIT 114

oralone 76

ORENCIA 98

ORENITRAM 114

ORFADIN 81

ORILISSA 93 94

ORKAMBI 113

orsythia 74

oseltamivir 50

OSMOLEX ER 42

OTEZLA 98

OTEZLA STARTER 98

oxcarbazepine 27

OXTELLAR XR 27

oxycodone 5

oxycodone-aspirin 5

OZEMPIC 33

P pacerone 60

paliperidone 45 46

PALYNZIQ 81

PANRETIN 76

pantoprazole 85

paricalcitol 105

PARICALCITOL 105

paromomycin 41

paroxetine hcl 31

PASER 39

PAXIL 31

PEDIARIX (PF) 102

PEDVAX HIB (PF) 102

PEGANONE 27

PEGASYS 51 52

PEGASYS PROCLICK 51

PEGINTRON 52

penicillamine 89

PENNSAID 7

PENTACEL (PF) 102

PENTAM 41

pentamidine 41

pentoxifylline 55

PERIKABIVEN 58

periogard 76

permethrin 79

perphenazine 46

PERSERIS 46

pfizerpen-g 14

phenadoz 40

phenelzine 31

phenobarbital 27 28

phenytoin 28

phenytoin sodium 28

philith 74

PHOSLYRA 88

PICATO 76 77

PIFELTRO 49

pimecrolimus 79

pimozide 46

pimtrea (28) 74

pioglitazone 33

PIQRAY 22

pirmella 74

PLASMA-LYTE 148 109

PLASMA-LYTE A 109

PLEGRIDY 69

podofilox 77

POLIVY 22

polycin 83

POMALYST 22

portia 28 74

PORTRAZZA 22

PRADAXA 53

PRALUENT PEN 65

pramipexole 42

prasugrel 55

pravastatin 65

prazosin 59

prednicarbate 79

prednisolone 92

84 91 92

prednisone 92

pregabalin 28

PREMARIN 90

PREMPHASE 91

PREMPRO 91

prevalite 65

previfem 74

PREVYMIS 50

PREZCOBIX 49

PREZISTA 49

PRIFTIN 39

PRIMAQUINE 41

primidone 28

PRIVIGEN 99

probenecid 37

procainamide 60

PROCALAMINE 3 58

prochlorperazine 40

PROCRIT 54

procto-med hc 79

proctosol hc 79

proctozone-hc 79

PROCYSBI 88

progesterone 95

PROGLYCEM 106

PROGRAF 99

PROLASTIN-C 113

PROLENSA 85

PROLEUKIN 22

PROLIA 105

PROMACTA 54

promethazine 37 40

promethegan 40

propafenone 60

proparacaine 82

propranolol 61

propylthiouracil 95

PROQUAD (PF) 102

PROSOL 20 58

protamine 55

protriptyline 31

PULMOZYME 81

PURIXAN 22

pyrazinamide 39

quetiapine 46

quinapril 60

R RABAVERT (PF) 102

RADICAVA 69

raloxifene 91

ramipril 60

ranitidine hcl 85

ranolazine 63

rasagiline 42

RASUVO (PF) 99

RAVICTI 87

RAYALDEE 105

REBIF REBIDOSE 69

reclipsen (28) 74

RECTIV 107

RELISTOR 87

REMICADE 99

RENFLEXIS 99

repaglinide 33

REPATHA SYRINGE 65

RESCRIPTOR 49

RESTASIS 85

RETACRIT 55

RETROVIR 49

REVCOVI 81

REVLIMID 22

revonto 114

REXULTI 46

REYATAZ 49

RHOPRESSA 107

ribasphere 52

ribavirin 52

RIDAURA 99

rifabutin 39

rifampin 39

riluzole 69

rimantadine 51

RISPERDAL CONSTA 46

risperidone 46

ritonavir 49

RITUXAN 22

RITUXAN HYCELA 22

rivastigmine 29

rizatriptan 38

ropinirole 42

rosadan 77

rosuvastatin 65

ROTARIX 102

ROTATEQ VACCINE 102

RUBRACA 22

RYDAPT 22

S SABRIL 28

SAIZEN 94

SANTYL 77

SAPHRIS 46

SAVELLA 69

scopolamine base 40

selegiline hcl 42

selenium sulfide 77

SELZENTRY 49

SEREVENT DISKUS 112

SEROSTIM 94

sertraline 31

setlakin 74

sevelamer hcl 88

sharobel 74

SHINGRIX (PF) 102

SIGNIFOR 94

SILENOR 114

SILIQ 99

SIMBRINZA 108

simliya (28) 74

simpesse 74

SIMPONI 99

SIMPONI ARIA 99

simvastatin 65

sirolimus 99

SIRTURO 39

SKYRIZI 99

smoflipid 58

sodium chloride 104

SOLIQUA 10033 34

SOLTAMOX 22

SOLU-CORTEF (PF) 92

SOMATULINE DEPOT 94

SOMAVERT 94

sorine 61

sotalol 61

sotalol af 61

SOVALDI 51

spironolactone 64

SPRAVATO 31

sprintec (28) 75

SPRITAM 28

SPRYCEL 22

sronyx 75

ssd 77

stavudine 49

STELARA 99

STIVARGA 23

STRENSIQ 81

streptomycin 10

STRIBILD 49

SUBLOCADE 8

subvenite 28

sucralfate 86

sulfadiazine 14

sulfasalazine 104

sulfatrim 15

sulindac 7

sumatriptan 38

SUPPRELIN LA 94

SUTENT 23

syeda 75

SYLATRON 52

SYLVANT 23

SYMBICORT 110 111

SYMDEKO 113

SYMFI 49

SYMFI LO 49

SYMJEPI 63

SYMLINPEN 120 33

SYMLINPEN 60 33

SYMPAZAN 28

SYMTUZA 49

SYNAGIS 51

SYNAREL 94

SYNERCID 11

SYNJARDY 33

SYNJARDY XR 33

SYNRIBO 23

T TABLOID 23

tacrolimus 79 99

TAFINLAR 23

TAGRISSO 23

TAKHZYRO 107

TALTZ SYRINGE 100

TALZENNA 23

tamoxifen 23

tamsulosin 88

TARGRETIN 23

tarina 24 fe 75

tarina fe 120 (28) 75

TASIGNA 23

TAVALISSE 55

tazarotene 79

TAZORAC 79

taztia xt 62

TDVAX 102

TECENTRIQ 23

TECFIDERA 70

TECHNIVIE 51

TEFLARO 12

TEKTURNA HCT 66

telmisartan 59

temazepam 9

TEMODAR 23

TENIVAC (PF) 102

terazosin 88

terbinafine hcl 36

terbutaline 112

terconazole 37

testosterone 89

PED(PF) 102

tetrabenazine 70

tetracycline 15

THALOMID 107

theophylline 112

THIOLA 89

THIOLA EC 88

thioridazine 46

thiotepa 23

thiothixene 46

tiagabine 28

TIBSOVO 23

TICE BCG 100

tigecycline 15

tilia fe 75

TIVICAY 49 50

tizanidine 114

TOBI PODHALER 10

tobramycin 84

TOLAK 77

tolazamide 35

tolterodine 88

topiramate 28

toposar 23

toremifene 23

torsemide 64

TOTECT 107

TOUJEO MAX U-300

SOLOSTAR 34

INSULIN 35

TOVIAZ 88

TRACLEER 115

TRADJENTA 33

tramadol 5

trandolapril 60

tranexamic acid 55

TRANSDERM-SCOP 41

tranylcypromine 31

TRAVASOL 10 58

TRAVATAN Z 108

trazodone 31

TREANDA 23

TRECATOR 39

TRELEGY ELLIPTA 112

TRELSTAR 23 24

TREMFYA 100

tretinoin 79

tri femynor 75

trientine 89

tri-estarylla 75

trifluoperazine 46

trifluridine 84

trihexyphenidyl 43

tri-legest fe 75

tri-linyah 75

tri-lo-estarylla 75

tri-lo-marzia 75

tri-lo-mili 75

tri-lo-sprintec 75

trimethoprim 11

tri-mili 75

trimipramine 31

TRINTELLIX 31

TRIPTODUR 94

TRIUMEQ 50

trivora (28) 75

tri-vylibra 75

tri-vylibra lo 75

TROGARZO 50

TROPHAMINE 10 58

TROPHAMINE 6 58

TRULICITY 33

TRUMENBA 103

TRUVADA 50

tulana 75

TWINRIX (PF) 103

TYBOST 107

TYKERB 24

TYMLOS 105

TYPHIM VI 103

TYSABRI 100

TYVASO 115

U UCERIS 104

UDENYCA 55

ULORIC 37

UNITUXIN 24

UPTRAVI 115

ursodiol 87

V valacyclovir 52

VALCHLOR 77

valganciclovir 52

valproate sodium 28

valproic acid 29

valrubicin 24

valsartan 59

vancomycin 11

VAQTA (PF) 103

VARIVAX (PF) 103

VASCEPA 66

VELCADE 24

VELPHORO 88

VELTASSA 87

VEMLIDY 50

VENCLEXTA 24

VENCLEXTA STARTING

PACK 24

venlafaxine 31 32

verapamil 62

VERSACLOZ 46

VERZENIO 24

V-GO 40 80

VIBERZI 87

VICTOZA 33

VIDEX EC 50

VIEKIRA PAK 51

vienva 75

vigabatrin 29

vigadrone 29

VIIBRYD 32

VIMIZIM 81

VIMPAT 29

vinorelbine 24

viorele (28) 75

VIRACEPT 50

VIREAD 50

VISTOGARD 107

VITRAKVI 24

VIZIMPRO 24

VOLTAREN 7

voriconazole 36 37

VOSEVI 51

VOTRIENT 24

VPRIV 81

VRAYLAR 47

vyfemla (28) 76

vylibra 76

VYNDAQEL 63

VYXEOS 24

W warfarin 53

WELCHOL 66

wera (28) 76

X XADAGO 43

XALKORI 24

XARELTO 53

XATMEP 24

XELJANZ 100

XELJANZ XR 100

XERMELO 87

XIFAXAN 11

XIIDRA 85

XOFLUZA 51

XOLAIR 113

XOSPATA 24

XPOVIO 25

XTAMPZA ER 5 6

XTANDI 25

xulane 76

XULTOPHY 10036 35

XURIDEN 107

XYOSTED 89

XYREM 114

Y YERVOY 25

YF-VAX (PF) 103

YONDELIS 25

YONSA 25

Z zafirlukast 111

zaleplon 114

zarah 76

ZARXIO 55

ZEJULA 25

ZELBORAF 25

zenatane 77

zenchent (28) 76

ZENPEP 81

ZEPATIER 51

zidovudine 50

ziprasidone hcl 47

ZIRGAN 84

ZOLADEX 25

zoledronic acid 105

ZOLINZA 25

zolpidem 114

ZOMACTON 94

zonisamide 29

ZORBTIVE 94

ZORTRESS 100

ZOSTAVAX (PF) 103

zovia 135e (28) 76

ZTLIDO 7

ZUBSOLV 8

ZULRESSO 32

zumandimine (28) 76

ZYDELIG 25

ZYKADIA 25

ZYLET 84

ZYPREXA RELPREVV 47

ZYTIGA 25







Medical Condition









Table of Contents

INDEX

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

H6988_ENR1085_C III

Medical Condition

name for your drug

may include

H6988_ENR1085_C IV

options

(HMO) Formulary

H6988_ENR1085_C V

exception

page I-1

Analgesics 3

Anesthetics 7

Antibacterials 9

Anticonvulsants 25

Antidepressants 29

Antifungals 35

Antigout Agents 37

Antihistamines 37

Caloric Agents 55

Contraceptives 70

Table of Contents

Devices 79

Drug Name

Analgesics

12 mg5 ml

30 days)

(Buprenex) 2

50-325-40 mg

Years)

50-325-40 mg

Years)

325-40 mg

Years)

30 days)

400 mcg 600 mcg 800 mcg

per 30 days)

75 mcghr

30 days)

75-325 mg15 ml

30 days)

10-325 mg

30 days)

25-325 mg

30 days)

Drug Name

325 mg

30 days)

75-325 mg

30 days)

5 PA NDS NM QL (30

per 30 days)

30 days)

suv inner 10 mgml

mg5 ml (20 mgml)

30 days)

4 mgml 8 mgml

30 days)

Drug Name

30 days)

mg 200 mg 60 mg

30 days)

mg 30 mg

30 days)

150 MG 200 MG 250 MG 50 MG

3 NDS NM QL (60 per

30 days)

MG 75 MG

30 days)

hr 10 mg 15 mg 20 mg 30 mg 40 mg 60

mg 80 mg

30 days)

325 mg

30 days)

325 mg 5-325 mg

30 days)

325 mg

30 days)

325 mg

30 days)

XTAMPZA ER ORAL

3 NDS NM QL (60 per

30 days)

Drug Name

XTAMPZA ER ORAL

CRUSH) 27 MG

30 days)

XTAMPZA ER ORAL

CRUSH) 36 MG

30 days)

12 hour 13

(Flector) 2 PA

(Voltaren-XR) 2

(IBU) 1

Years)

days) AGE (Max 64

Years)

Drug Name

(EC-Naprosyn) 2

ACTUATION(2 )

28 days)

Anesthetics

Local Anesthetics

applicator 2

(1 ) 15 mgml (15 ) 20 mgml (2 )

5 mgml (05 )

(Xylocaine-MPF) 1

mgml (2 )

(1 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine) 1

(40 mgml)

patchmedicated 5

solution 2

PATCHMEDICATED 18

Treatment Agents

(drec) 333 mg

Drug Name

12-3 mg 8-2 mg

2-05 mg 4-1 mg

2-05 mg 8-2 mg

3 QL (336 per 365 days)

(11)- 1 MG (42)

NICOTROL INHALATION

CARTRIDGE 10 MG

4 QL (1008 per 90 days)

018 MG 14-036 MG 114-29 MG 29-

071 MG 57-14 MG

Antianxiety Agents

Benzodiazepines

30 days)

mg 5 mg 75 mg

Drug Name

25 mg 5 mg

30 days)

0125 mg 025 mg 05 mg 1 mg

2 NDS NM QL (90 per

30 days)

375 mg

30 days)

Antibacterials

Aminoglycosides

5 PA BvD NDS

40 mgml

solution 20 mg2 ml

Drug Name

mg8 ml

(Tobi) 5 PA BvD NDS

mg 75 mg

(Cleocin HCl) 1

900 mg50 ml

150 (mgml) (6 ml)

150 mgml

(Cleocin) 2

solution 600 mg4 ml

(Cleocin) 2

soln 150 mg

(Coly-Mycin M

Parenteral)

5 PA BvD NDS

(Cubicin) 5 NDS

MGML 50 MGML

mg300 ml

(Zyvox) 5 NDS

100 mg5 ml

(Zyvox) 5 NDS

Drug Name

(Metro IV) 2

100 mg 25 mg 50 mg

capsule 100 mg

500000 unit

SOLN 500 MG

750 mg

2 PA BvD

Cephalosporins

125 mg5 ml 250 mg5 ml 375 mg5 ml

gram 500 mg

125 mg5 ml 250 mg5 ml

(Maxipime) 2

10 gram 2 gram

Drug Name

(Tazicef) 2

750 mg

15 gram 75 gram

SOLN 400 MG 600 MG

Macrolides

(Zithromax) 2

500 mg (3 pack) 600 mg

(EES Granules) 2

(EryPed 400) 2

Drug Name

(Azactam) 2

5 PA LA NDS

soln 250 mg

soln 500 mg

(Primaxin IV) 2

gram 500 mg

(Merrem) 2

Penicillins

250 mg5 ml 400 mg5 ml

250 mg

mg5 ml

500-125 mg 875-125 mg

(Augmentin) 1

500 mg

(Unasyn) 2

2400000 UNIT4 ML 600000

UNITML

Drug Name

20 million unit

(Pfizerpen-G) 2

unitml

mg5 ml 250 mg5 ml

500 mg

405 gram

(Zosyn) 2 PA BvD

Quinolones

(Cipro) 1

(Cipro in D5W) 2

ciprofloxacin oral

ml 500 mg5 ml

(Cipro) 2

250 mg50 ml 500 mg100 ml 750 mg150

Sulfonamides

(Sulfatrim) 2

Drug Name

400-80 mg

(Bactrim) 1

800-160 mg

(Bactrim DS) 1

Tetracyclines

soln 100 mg

(Doxy-100) 2

(Morgidox) 2

mg 50 mg

(Mondoxyne NL) 2

(Vibramycin) 2

(Avidoxy) 2

Anticancer Agents

100 MG

2 PA BvD

ml 500 mg10 ml

2 PA BvD

per 28 days)

MG 75 MG

5 PA NSO NDS QL (28

per 28 days)

Drug Name

per 30 days)

SOLN 100 MG 500 MG

SOLN 60 MG

5 PA NSO NDS QL (3

per 28 days)

5 PA NSO NDS QL (30

per 30 days)

PACK 90 MG (7)- 180 MG (23)

5 PA NSO NDS

25 MGML

5 PA NSO NDS

per 28 days)

SOLUTION 20 MGML

5 PA NSO NDS

SOLN 500 MG

5 PA NSO NDS

BENDEKA INTRAVENOUS

SOLUTION 25 MGML

5 PA NSO NDS

per 30 days)

5 PA NSO NDS

RECON SOLN 35 MG

5 PA NSO NDS

per 30 days)

Drug Name

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (60

per 30 days)

(Clolar) 5 NDS

MGDAY(80 MG X1-20 MG X1) 140

per 28 days)

5 PA NSO NDS QL (56

per 28 days)

(63 per 28 days)

5 PA BvD NDS

CAPSULE 25 MG 50 MG

2 PA BvD ST

CYRAMZA INTRAVENOUS

SOLUTION 10 MGML

5 PA NSO NDS

SOLUTION 20 MGML

5 PA NSO LA NDS

per 30 days)

suspension 2 mgml

Drug Name

MG 400 MG

ELIGARD (3 MONTH)

ELIGARD (4 MONTH)

ELIGARD (6 MONTH)

75 MG (1 MONTH)

SOLN 300 MG 400 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG

MG 20 MG

5 PA NSO NDS

gram20 ml

2 PA BvD

(Adrucil) 2 PA BvD

mg5 ml

(Faslodex) 5 NDS

1000 MG40 ML

5 PA NSO NDS

MG 40 MG

5 PA NSO NDS QL (30

per 30 days)

40 MG 5 MG

Drug Name

HERCEPTIN HYLECTA

10000 UNIT5 ML

5 PA NSO NDS QL (5

per 21 days)

SOLN 150 MG 440 MG

5 PA NSO NDS

125 MG 75 MG

5 PA NSO NDS QL (21

per 28 days)

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

ml 3 gram60 ml

gram 3000-1000 mg

5 PA BvD NDS

per 30 days)

per 28 days)

280 MG 420 MG 560 MG

5 PA NSO NDS QL (28

per 28 days)

50 MGML

5 PA NSO NDS

5 PA NSO NDS QL (4

per 365 days)

5 PA NSO NDS QL (8

per 28 days)

per 30 days)

SOLN 15 MG 45 MG

Drug Name

20 MG 25 MG 5 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 420 MG

5 PA NSO NDS

SOLUTION 25 MGML

5 PA NSO NDS QL (8

per 21 days)

5 PA NSO NDS QL (49

per 28 days)

5 PA NSO NDS QL (70

per 28 days)

5 PA NSO NDS QL (91

per 28 days)

(200 MG X 1)

5 PA NSO NDS QL (21

per 28 days)

(200 MG X 2)

5 PA NSO NDS QL (42

per 28 days)

(200 MG X 3)

5 PA NSO NDS QL (63

per 28 days)

5 PA NSO NDS

X 1) 18 MGDAY (10 MG X 1-4 MG

X2) 20 MGDAY (10 MG X 2) 24

8 MGDAY (4 MG X 2)

5 PA NSO NDS

50 MGML

5 PA NSO NDS QL (7

per 21 days)

per 28 days)

per 30 days)

Drug Name

SOLN 1 MG

5 PA NSO NDS

SYRINGE KIT 375 MG

150 MG

per 30 days)

(Max 64 Years)

per 30 days)

soln 1 gram

2 PA BvD

solution 25 mgml

2 PA BvD

5 PA NSO NDS

per 30 days)

Drug Name

MG 4 MG

5 PA NSO NDS QL (3

per 28 days)

750 UNITML

5 PA NSO NDS

ONIVYDE INTRAVENOUS

DISPERSION 43 MGML

100 MG10 ML 240 MG24 ML 40

MG4 ML

5 PA NSO NDS

(200 MG X 1)

5 PA NSO NDS QL (28

per 28 days)

(200 MG X1-50 MG X1) 300 MGDAY

(150 MG X 2)

5 PA NSO NDS QL (56

per 28 days)

SOLN 140 MG

5 PA NSO NDS

MG 3 MG 4 MG

5 PA NSO NDS QL (21

per 28 days)

per 21 days)

5 PA NSO LA NDS QL

(28 per 28 days)

MGML) 1600 MG134 ML (120

5 PA NSO NDS

RITUXAN INTRAVENOUS

CONCENTRATE 10 MGML

5 PA NSO NDS

250 MG 300 MG

per 30 days)

per 28 days)

MG5 ML

5 PA NSO NDS QL (30

per 30 days)

Drug Name

per 28 days)

MG 375 MG 50 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 100 MG 400 MG

5 PA NSO NDS

SOLN 35 MG

5 PA NSO NDS

per 30 days)

5 PA NSO LA NDS QL

(30 per 30 days)

per 30 days)

per 28 days)

200 MG

per 28 days)

per 30 days)

5 PA NSO NDS

SOLN 100 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG 25 MG

5 PA NSO NDS

1125 MG

225 MG

5 NDS QL (1 per 168

Drug Name

375 MG

SOLUTION 35 MGML

5 PA NSO NDS

per 30 days)

(180 per 30 days)

per 30 days)

100 MG

5 PA NSO LA NDS

150 MG 200 MG 50 MG

5 PA NSO NDS QL (56

per 28 days)

50 mg5 ml

(Navelbine) 2

per 30 days)

MG 45 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 44-100 MG

5 PA BvD NDS

250 MG

5 PA NSO NDS QL (60

per 30 days)

4 PA BvD ST

per 30 days)

Drug Name

MGWEEK (20 MG X 5)

5 PA NSO NDS QL (20

per 28 days)

MGWEEK (20 MG X 8)

5 PA NSO NDS QL (32

per 28 days)

(20 MG X 3)

5 PA NSO NDS QL (12

per 28 days)

(20 MG X 4)

5 PA NSO NDS QL (16

per 28 days)

per 30 days)

200 MG40 ML (5 MGML) 50 MG10

ML (5 MGML)

5 PA NSO NDS

SOLN 1 MG

5 PA NSO NDS

per 30 days)

IMPLANT 108 MG

IMPLANT 36 MG

5 PA NSO NDS QL (60

per 30 days)

per 28 days)

per 30 days)

Anticonvulsants

Drug Name

5 ST NDS

SOLUTION 50 MG5 ML

5 NDS QL (60 per 30

(Carbatrol) 2

(Tegretol) 2

(Tegretol XR) 2

125-15-175-20 MG 5-75-10 MG

75-10 mg

(Diastat AcuDial) 4

sprinkle 125 mg

hr 250 mg 500 mg

(Depakote ER) 2

(drec) 125 mg 250 mg 500 mg

(Depakote) 2

5 PA NSO NDS

Drug Name

(Cerebyx) 2

4 ST QL (720 per 30

MG 8 MG

200 mg 25 mg

(Lamictal) 1

(Lamictal) 2

mg5 ml

(Keppra) 2

mg 500 mg 750 mg

(Keppra) 2

24 hr 500 mg 750 mg

(Keppra XR) 2

MG 200 MG 225 MG 25 MG 300 MG

50 MG 75 MG

ml (60 mgml)

(Trileptal) 2

600 mg

(Trileptal) 2

300 MG 600 MG

2 PA NSO-HRM AGE

(Max 64 Years)

Drug Name

162 mg 30 mg 324 mg 60 mg 648 mg

972 mg

2 PA NSO-HRM AGE

(Max 64 Years)

100 mg

200 mg 300 mg

(Phenytek) 2

200 mg 225 mg 25 mg 300 mg 50 mg

per 30 days)

SUSPENSION 1000 MG

4 ST QL (120 per 30

mg 25 mg

5 PA NSO NDS QL (60

per 30 days)

(Gabitril) 2

(Topamax) 2

100 mg 150 mg 200 mg 25 mg 50 mg

(Qudexy XR) 4

mg 50 mg

(Topamax) 1

mg5 ml (100 mgml)

(Depacon) 2

solution 250 mg5 ml

Drug Name

per 30 days)

200 MG20 ML

MG 200 MG 50 MG

Antidementia Agents

24 hr 16 mg 24 mg 8 mg

14 mg 21 mg 28 mg 7 mg

NAMZARIC ORAL

MG 21-10 MG 28-10 MG 7-10 MG

3 mg 45 mg 6 mg

133 mg24 hour 46 mg24 hr 95 mg24

Antidepressants

150 mg 25 mg 50 mg 75 mg

Drug Name

mg 50 mg

24 hr 150 mg 300 mg

(Wellbutrin XL) 2

(Wellbutrin SR) 2

(Anafranil) 2

50 mg 75 mg

release(drec) 30 mg

MG24 HR

5 NDS QL (30 per 30

mg 5 mg

(Lexapro) 1

FETZIMA ORAL

HR 120 MG 20 MG 40 MG 80 MG

(Prozac) 1

Drug Name

(Tofranil) 2

mg 30 mg 45 mg

(Remeron SolTab) 2

200 mg 250 mg 50 mg

50 mg 75 mg

(Pamelor) 1

30 mg 40 mg

(Max 64 Years)

4 PA NSO-HRM AGE

(Max 64 Years)

10 mg 2-25 mg 4-10 mg 4-25 mg 4-50

(Zoloft) 1

(28 MG X 3)

5 PA NSO NDS

20 MG 5 MG

24hr 150 mg

24hr 375 mg 75 mg

Drug Name

375 mg 50 mg 75 mg

MG 40 MG

PACK 10 MG (7)- 20 MG (23)

SOLUTION 5 MGML

Antidiabetic Agents

25-5 MG

1000 MG 150-500 MG 50-1000 MG

3 ST QL (120 per 30

150-500 MG 50-1000 MG 50-500 MG

MG 50-500 MG

500 MG

MG 50 MG

1000 MG 25-500 MG 25-850 MG

28 days)

Drug Name

hr 500 mg

hr 750 mg

28 days)

MG 125-500 MG 5-1000 MG 5-500

1000 MG

Insulins

UNITML (3 ML)

FIASP U-100 INSULIN

UNITML

Drug Name

UNITML

UNITML (3 ML)

UNITML

UNITML (70-30)

UNITML

UNITML (3 ML)

UNITML (70-30)

UNITML

UNITML (3 ML)

Drug Name

UNITML (15 ML)

UNITML (3 ML)

UNITML

Sulfonylureas

25 mg 5 mg

mg 5-500 mg

mg 6 mg

Years)

mg 25-500 mg 5-500 mg

Years)

Antifungals

ABELCET INTRAVENOUS

SUSPENSION 5 MGML

5 PA BvD NDS

Drug Name

mg 70 mg

(Cancidas) 5 NDS

(clotrimazole))

(Lotrisone) 2

400 mg200 ml

2 PA BvD

(Diflucan) 2

200 mg 50 mg

(Diflucan) 2

mg5 ml

MG5 ML (40 MGML)

unitgram

Drug Name

(Vfend) 5 NDS

Antigout Agents

Antihistamines

Years)

mgml 50 mgml

Years)

Membrane)

Drug Name

Antimigraine Agents

70 MGML

140 MGML 70 MGML

225 MG15 ML

EMGALITY SYRINGE

ML (100 MGML X 3)

mg 5 mg

mgactuation

25 mg 50 mg

cartridge 6 mg05 ml

(Imitrex STATdose

Refill)

solution 6 mg05 ml

syringe 6 mg05 ml

Antimycobacterials

Drug Name

Antimycobacterials

1 GRAM

168 days)

Antinausea Agents

025 MG

CAPSULE 300-05 MG

4 PA BvD

(1)- 80 mg (2)

EMULSION 72 MGML

Drug Name

ML FINAL CONC)

mgml 1 mgml (1 ml)

Drowsy)

mg2 ml

mg 8 mg

2 PA BvD

Years)

mg 5 mg

(Compazine) 1

50 mgml

Years)

25 mg 50 mg

Years)

1 mg over 3 days

days) AGE (Max 64

Years)

Drug Name

days) AGE (Max 64

Years)

Antiparasite Agents

(Malarone) 2

500 mg

SOLN 300 MG

4 PA BvD

300 MG

APOKYN SUBCUTANEOUS

CARTRIDGE 10 MGML

Drug Name

mg 25-100 mg 25-250 mg

(Sinemet) 2

(Sinemet CR) 2

(Stalevo 50) 4

tablet 1875-75-200 mg

(Stalevo 75) 4

(Stalevo 100) 4

tablet 3125-125-200 mg

(Stalevo 125) 4

tablet 375-150-200 mg

(Stalevo 150) 4

(Stalevo 200) 4

GOCOVRI ORAL

24HR 137 MG

GOCOVRI ORAL

24HR 685 MG

30 days)

258 MG

mg 05 mg 075 mg 1 mg 15 mg

(Mirapex) 1

Drug Name

ABILIFY MAINTENA

INTRAMUSCULAR

RECON 300 MG 400 MG

ABILIFY MAINTENA

INTRAMUSCULAR

mg 30 mg 5 mg

SYRING 675 MG24 ML

SYRING 1064 MG39 ML

5 NDS QL (39 per 56

SYRING 441 MG16 ML

5 NDS QL (16 per 28

SYRING 662 MG24 ML

5 NDS QL (24 per 28

SYRING 882 MG32 ML

5 NDS QL (32 per 28

200 mg 25 mg 50 mg

Drug Name

mg 125 mg 25 mg

30 days)

MG 6 MG 8 MG

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

25 mgml

25 mg 5 mg

solution 100 mgml

solution 50 mgml

(Haldol) 2

5 mgml

mg 2 mg 20 mg 5 mg

Drug Name

INVEGA SUSTENNA

MG075 ML

INVEGA SUSTENNA

MG15 ML

5 NDS QL (15 per 28

INVEGA SUSTENNA

MG025 ML

INVEGA SUSTENNA

MG05 ML

5 NDS QL (05 per 28

5 NDS QL (0875 per 84

5 NDS QL (1315 per 84

5 NDS QL (2625 per 84

MG 40 MG 60 MG

mg 5 mg 50 mg

per 30 days)

mg 20 mg 5 mg 75 mg

mg 15 mg 20 mg 5 mg

24hr 15 mg 3 mg

Drug Name

24hr 6 mg

24hr 9 mg

mg 8 mg

PERSERIS ABDOMINAL

SUBCUTANEOUS

120 MG 90 MG

mg 300 mg 400 mg 50 mg

30 days)

3 MG 4 MG

RISPERDAL CONSTA

MG2 ML 25 MG2 ML

RISPERDAL CONSTA

MG2 ML 50 MG2 ML

mg 2 mg 3 mg 4 mg

mg 05 mg 1 mg 2 mg

mg 4 mg

MG 25 MG 5 MG

mg 50 mg

mg 5 mg

30 days)

Drug Name

MG 45 MG 6 MG

PACK 15 MG (1)- 3 MG (6)

mg 60 mg 80 mg

ZYPREXA RELPREVV

Antiretrovirals

(Epzicom) 2

tablet 300-150-300 mg

(Trizivir) 5 NDS

300 mg

(Reyataz) 5 NDS

300 MG

400 MG

300 MG

400 mg

(Videx EC) 2

Drug Name

MG5 ML (5 MGML)

SOLN 90 MG

200-10 MG

200 MG

PACKET 100 MG

ISENTRESS ORAL

(Combivir) 2

mg5 ml

(Kaletra) 2

Drug Name

hr 100 mg 400 mg

(Viramune XR) 2

100 MG

600 MG 800 MG

DISPERSIBLE 100 MG

SOLUTION 10 MGML

PACKET 50 MG

300 MG 75 MG

mg 40 mg

200-300 MG

200-10 MG

300 mg

(Viread) 2

Drug Name

MG 133-200 MG 167-250 MG 200-300

MGML (FINAL)

VIDEX EC ORAL

CAPSULEDELAYED

625 MG

MGSCOOP (40 MGGRAM)

MG 250 MG

28 days)

480 MG

Drug Name

MGACTUATION

5 PA NDS

Hcv Antivirals

5 PA NDS

Interferons

5 PA NSO NDS

UNITML

5 PA NSO NDS

PEGASYS PROCLICK

MCG05 ML

SOLUTION 180 MCGML

Drug Name

MCG05 ML

200 MCG 300 MCG 600 MCG

5 PA NSO NDS

500 mg

2 PA BvD

500 mg

(Cytovene) 2 PA BvD

50 mgml

2 PA BvD

Expanders

Anticoagulants

PACK 5 MG (74 TABS)

mg3 ml

(Lovenox) 2

Drug Name

mg03 ml 40 mg04 ml 60 mg06 ml 80

mg08 ml

(Lovenox) 2

(Arixtra) 5 NDS

mg05 ml

(Arixtra) 2

5000 unitml (1 ml)

5000 unitml

unitml

1000 unitml

5000 unit05 ml

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

150 MG 75 MG

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

(Coumadin) 1

PACK 15 MG (42)- 20 MG (9)

TABLET 20 MG

SYRINGE 6 MG06 ML

5 PA NDS

GRANIX SUBCUTANEOUS

5 PA NDS

Drug Name

5 PA NDS

250 MCG

SYRINGE 6 MG06ML

5 PA NDS

MCG08 ML

5 PA NDS

4000 UNITML

20000 UNITML

40000 UNITML

PACKET 125 MG

30 days)

Drug Name

UNITML 4000 UNITML

40000 UNITML

SYRINGE 6 MG06 ML

5 PA NDS

150 MG

1000 mg10 ml (100 mgml)

(Cyklokapron) 2

Years)

400 mg

Caloric Agents

4 PA BvD

AMINOSYN 7 WITH

4 PA BvD

SOLUTION 85

4 PA BvD

Drug Name

4 PA BvD

SOLUTION 85

4 PA BvD

SOLUTION 7

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 275

4 PA BvD

Drug Name

SOLUTION 275

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

intravenous syringe

4 PA BvD

parenteral solution

4 PA BvD

intravenous syringe

4 PA BvD

FREAMINE HBC 69

SOLUTION 69

4 PA BvD

Drug Name

4 PA BvD

EMULSION 20 30

4 PA BvD

KABIVEN INTRAVENOUS

EMULSION 331-98-39

4 PA BvD

EMULSION 20

4 PA BvD

EMULSION 236-68-35

4 PA BvD

PARENTERAL SOLUTION

4 PA BvD

(Catapres) 1

mg24 hr

(Cardura) 2

Years)

200 MG 300 MG

30 days)

Drug Name

(Vazculep) 2

MG 40-25 MG

49-51 MG 97-103 MG

(Avapro) 1

150-125 mg 300-125 mg

(Avalide) 2

100-125 mg 100-25 mg 50-125 mg

(Hyzaar) 1

tablet 20-125 mg 40-125 mg 40-25 mg

(Benicar HCT) 2

(Micardis) 2

mg 80 mg

(Diovan) 2

160-125 mg 160-25 mg 320-125 mg

320-25 mg 80-125 mg

(Diovan HCT) 2

Inhibitors

(Lotensin) 1

mg 50 mg

mg 20 mg 5 mg

(Vasotec) 2

10-25 mg

(Vaseretic) 1

5-125 mg

Drug Name

10-125 mg 20-125 mg 20-25 mg

(Zestoretic) 1

mg 8 mg

(Accupril) 1

mg 5 mg

(Altace) 1

mg 150 mg

Years)

500 mcg

(Tikosyn) 2

mg5 ml (2 ) 50 mg5 ml (1 )

250 mg

mgml 500 mgml

300 mg

(Tenoretic 100) 2

(Tenoretic 50) 2

Drug Name

10-625 mg 25-625 mg 5-625 mg

(Ziac) 1

MG 20 MG 5 MG

3125 mg 625 mg

(Coreg) 1

(5 mgml)

(Toprol XL) 2

100-25 mg 100-50 mg

50-25 mg

(Lopressor HCT) 2

mg5 ml

(Lopressor) 2

mg5 ml

(Lopressor) 1

24 hr 120 mg 160 mg 60 mg 80 mg

(Inderal LA) 2

mg 60 mg 80 mg

mg 80 mg

(Betapace) 2

Drug Name

24hr 120 mg 180 mg 240 mg 300 mg

(Tiazac) 2

(Cardizem CD) 2

(Cardizem) 2

120 mg 180 mg 240 mg

hr 120 mg 180 mg 240 mg 300 mg 360

100 mg 200 mg 300 mg

(Verelan PM) 2

hr 120 mg 180 mg 240 mg

(Verelan) 2

hr 360 mg

(Verelan) 4

mg 180 mg 240 mg

(Calan SR) 1

Drug Name

mg03 ml

30 MG3 ML

mg 50 mg

hr 1000 mg 500 mg

(Ranexa) 2

MG03 ML

30 days)

Dihydropyridines

mg 60 mg

(Norvasc) 1

mg 10-40 mg 5-10 mg 5-20 mg 5-40 mg

(Lotrel) 2

mg 10-320 mg 5-160 mg 5-320 mg

(Exforge) 2

24hr 30 mg 60 mg 90 mg

(Procardia XL) 2

mg 60 mg 90 mg

(Adalat CC) 2

Diuretics

5-50 mg

Drug Name

soln 500 mg

(Diuril IV) 2

mg5 ml (8 mgml)

(Lasix) 1

25 mg 50 mg

30 days)

(PM) 60 MG (AM) 30 MG (PM) 90 MG

(AM) 30 MG (PM)

(Aldactone) 1

capsule 375-25 mg

(Dyazide) 1

capsule 50-25 mg

375-25 mg

(Maxzide-25mg) 1

75-50 mg

(Maxzide) 1

Dyslipidemics

mg 80 mg

(Lipitor) 1

in packet 4 gram

(Questran) 2

Drug Name

mg 200 mg 67 mg

145 mg 48 mg

(Tricor) 2

MG 40 MG 60 MG

1000 mg 500 mg 750 mg

(Niaspan Extended-

Release)

(Pravachol) 1

REPATHA PUSHTRONEX

REPATHA SURECLICK

REPATHA SYRINGE

mg 5 mg

mg 80 mg

Drug Name

PACKET 375 GRAM

Inhibitors

125 MG 150-25 MG 300-125 MG 300-

Vasodilators

mg 30 mg

release 40 mg

(ISOCHRON) 2

mg10 ml (5 mgml)

mg 06 mg

(Nitrostat) 2

(Minitran) 2

25 mg 40 mg

Drug Name

30 days)

mg3 ml (20 mgml)

(Cafcit) 2 PA BvD

(20 mgml)

12 hr 10 mg

mg 5 mg

mg 30 mg

mg 5 mg 75 mg

Drug Name

(Intuniv ER) 2

MG (21)

5 PA NDS

SOLUTION 12 MG12 ML

300 mg 600 mg

release 300 mg

(Lithobid) 2

release 450 mg

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

28 days)

mg 60 mg

Drug Name

ml 5 mg5 ml

mg 5 mg

OCREVUS INTRAVENOUS

SOLUTION 30 MGML

5 PA NDS QL (20 per

180 days)

MCG05 ML

5 PA NDS

28 days)

MCG05 ML

MCG05ML (6)

5 PA NDS

125 MG 25 MG 50 MG

PACK 125 MG (5)-25 MG(8)-50 MG(42)

Drug Name

TECFIDERA ORAL

CAPSULEDELAYED

TECFIDERA ORAL

CAPSULEDELAYED

MG (46)

5 PA NDS

TECFIDERA ORAL

CAPSULEDELAYED

28 days)

Contraceptives

mg- 35 mcg

010 mg-20 mcg (84)10 mcg (7)

015 mg-30 mcg (84)10 mcg (7)

mg-mcg

(24)75 mg (4)

30 mcg (21)75 mg (7)

mcg (21)75 mg (7)

001 mg x 5

Drug Name

001 mg x 5

(24)75 mg (4)

mcg (21)75 mg (7)

mg-mcg

mg- 35 mcg

015 mg-30 mcg (84)10 mcg (7)

015-002 mgx21 001 mg x 5

(Azurette (28)) 2

015-003 mg

(Apri) 2

3-002 mg

(Gianvi (28)) 2

3-003 mg

(Ocella) 2

(5)125-30(10)

Drug Name

35 mg-mcg

(Kelnor 135 (28)) 2

50 mg-mcg

(Kelnor 1-50) 2

(24)75 mg (4)

015 mg-30 mcg (91)

mcg (21)75 mg (7)

(21)75 mg (7)

(24)75 mg (4)

001 mg x 5

(84)10 mcg (7)

mcg 015 mg-25 mcg

(84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

(21)75 mg (7)

(5)125-30(10)

01-20 mg-mcg

(Afirmelle) 2

015-003 mg

(Altavera (28)) 2

50-30 (6)75-40 (5)125-30(10)

(Enpresse) 2

20 mcg (21)75 mg (7)

(5)125-30(10)

Drug Name

035 mg

(Camila) 2

1-20 mg-mcg

(Aurovela 120 (21)) 2

1 mg-20 mcg (21)75 mg (7)

1 mg-20 mcg (24)75 mg (4)

(Aurovela 24 Fe) 2

0180215025 mg-25 mcg

0180215025 mg-35 mcg (28)

025-35 mg-mcg

(Estarylla) 2

mg- 35 mcg

001 mg x 5

mcg 1-35 mg-mcg

015 mg-30 mcg (91)

001 mg x 5

015 mg-30 mcg (84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

35mcg (9)

mg-35 mcg (28)

1mg-35mcg (9)

35 mcg (28)

mg-25 mcg

25 mcg

mg-25 mcg

mcg (28)

0180215025 mg-35 mcg (28)

(5)125-30(10)

mg-25 mcg

35 mcg (28)

0112515-25 mg-mcg

001 mg x 5

Drug Name

mcg24 hr

mouthwash 012

(Oralone) 2

(Soriatane) 2

MEDICATED

rel 10 mg

Drug Name

UNITGRAM

mg 40 mg

(Cleocin T) 2

(Ery Pads) 2

suspension 10

(Klaron) 2

Agents

Drug Name

ointment 005

(Diprolene) 2

(Cutivate) 2

Drug Name

applicator 25

(Triderm) 1

0025 01

0025 01 05

Devices

Drug Name

03 ML 31 GAUGE X 1564

12 ML 31 GAUGE X 1564

(Lite Touch Insulin

Syringe)

GAUGE X 12

(1st Tier Unifine

Pentips)

SOLUTION 250 UNITML

SOLUTION 29 MG5 ML

SOLN 400 UNIT

60000 UNIT 24000-76000 -120000

UNIT 3000-9500- 15000 UNIT

36000-114000- 180000 UNIT 6000-

19000 -30000 UNIT

SOLUTION 6 MG3 ML

SOLN 15 MG 75 MG

SOLN 35 MG 5 MG

5 PA NDS

2 MGML

5 PA NDS

Drug Name

SOLUTION 8 MGML

5 PA BvD NDS

2 MGML

5 PA NDS

SOLUTION 5 MG5 ML

5 PA NDS

MG 20 MG 5 MG

5 PA NDS

ML 20 MGML

5 PA NDS

SOLUTION 1 MGML

5 PA BvD NDS

5 PA NDS

5 PA LA NDS

5 MG5 ML (1 MGML)

5 PA NDS

400 UNIT

42000 UNIT 15000-47000 -63000

UNIT 20000-63000- 84000 UNIT

25000-79000- 105000 UNIT 3000-

10000 -14000-UNIT 40000-126000-

168000 UNIT 5000-17000- 24000

Miscellaneous

Drug Name

(Cyclogyl) 2

DROPS 044

aerosol 003

(Alcaine) 2

Agents

unitgram

(AK-Poly-Bac) 2

CIPRODEX OTIC (EAR)

(Ciloxan) 1

(Cetraxal) 4

mggram (05 )

mggram)

DROPS VISCOUS 05

Drug Name

(Vigamox) 2

DROPSSUSPENSION 5

(Neo-Polycin HC) 2

mg-unit-unitg

(Neo-Polycin) 2

(Maxitrol) 2

10000 unitg-01

(Maxitrol) 2

unit-0025mgml

unitml-

35-400-10000 mg-unitg-1

10000 unitgram

(Polytrim) 1

drops 10

(Bleph-10) 2

ointment 10

(eye) drops 10 -023 (025 )

Drug Name

(TobraDex) 2

Inflammatory Agents

DROPSSUSPENSION 02

DROPS 0075

DROPS 005

mcg (0025 )

dropssuspension 01

(FML Liquifilm) 4

drops 003

DROPSSUSPENSION 03

DROPSSUSPENSION 1

DROPSGEL 05

OINTMENT 05

DROPSGEL 038

dropssuspension 1

(Pred Forte) 4

Drug Name

DROPS 007

DROPPERETTE 005

DROPPERETTE 5

soln 20 mg

soln 40 mg

(Nexium IV) 2

mg2 ml

release(drec) 15 mg

release(drec) 30 mg

(Protonix) 2

(drec) 20 mg

(drec) 40 mg

50 mg2 ml (25 mgml)

(Zantac) 2

(ranitidine))

Drug Name

DISPERSIBLE 200 MG

0025 mg5 ml

Years)

0025 mg

Years)

KIT 5 MG

5 PA NDS

193 gram60 ml

290 MCG 72 MCG

(loperamide))

(Reglan) 1

Drug Name

SOLUTION 12 MG06 ML

28 days)

SYRINGE 12 MG06 ML

28 days)

SYRINGE 8 MG04 ML

28 days)

gram60 ml

Laxatives

GRAM -12 GRAM160 ML

-584 gram

-586 gram

2272-672 -584 gram

(Colyte with Flavor

Packs)

420 gram

Phosphate Binders

Drug Name

(Renvela) 5 NDS

VELPHORO ORAL

mg 5 mg 50 mg

(Urecholine) 2

(Ditropan XL) 2

release 24hr 15 mg

24hr 2 mg 4 mg

(Detrol LA) 2

hr 10 mg

(Uroxatral) 1

THIOLA EC ORAL

5 PA NDS

Drug Name

mg 250 mg 500 mg

(Exjade) 5 PA NDS

500 mg

(Desferal) 2 PA

250 MG

5 PA NDS

MG 90 MG

5 PA NDS

MG 90 MG

5 PA NDS

30 days)

Hormonal Agents

Androgens

100 mgml 200 mgml

200 mgml (1 ml)

200 mgml

ML 75 MG05 ML

Years)

Drug Name

mg24 hr 00375 mg24 hr 005 mg24 hr

0075 mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

0025 mg24 hr 005 mg24 hr 0075

mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

00375 mg24 hr

days) AGE (Max 64

Years)

mg24 hr 00375 mg24 hr 005 mg24 hr

006 mg24 hr 0075 mg24 hr 01 mg24

days) AGE (Max 64

Years)

mgml 40 mgml

(Delestrogen) 2

05-01 mg

Years)

HR 01 MG24 HR

mg-mcg

Years)

05-25 mg-mcg

Years)

1-5 mg-mcg

Years)

045 MG 0625 MG 09 MG 125 MG

Years)

MGGRAM

Drug Name

MG (14) 0625MG-5MG(14)

Years)

045-15 MG 0625-25 MG 0625-5 MG

Years)

suspension 6 mgml

mg 4 mg 6 mg

(Decadron) 1 PA BvD

1 PA BvD

solution 10 mgml

MG 6 MG

(Cortef) 2

(Depo-Medrol) 2

mg 4 mg 8 mg

(Medrol) 2

(Medrol (Pak)) 2

(Solu-Medrol) 2

mg5 ml (3 mgml)

2 PA BvD

Drug Name

2 PA BvD

1 PA BvD

suspension 40 mgml

(Kenalog) 2

Pituitary

mcgspray (01 ml)

(DDAVP) 2

mcgspray (01 ml)

SOLN 1 MG

MG025 ML

MG025 ML 06 MG025 ML 08

MG025 ML 1 MG025 ML 12

MG025 ML 14 MG025 ML 16

MG025 ML 18 MG025 ML 2

MG025 ML

5 PA NDS

5 MGML (15 UNITML)

5 PA NDS

HUMATROPE INJECTION

5 PA NDS

SOLN 5 (15 UNIT) MG

5 PA NDS

Drug Name

SOLUTION 10 MGML

1125 MG

SYRINGE KIT 75 MG

LUPRON DEPOT-PED

NORDITROPIN FLEXPRO

ML (10 MGML) 30 MG3 ML (10

5 PA NDS

NORDITROPIN FLEXPRO

MG15 ML (33 MGML)

NUTROPIN AQ NUSPIN

5 PA NDS

mcgml 200 mcgml

(Sandostatin) 2

mcgml (1 ml)

5 PA NDS

RECON SOLN 58 MG

5 PA NDS

Drug Name

SAIZEN SAIZENPREP

5 PA NDS

SOLN 5 MG 88 MG

5 PA NDS

INTRAMUSCULAR

SOLN 4 MG 5 MG 6 MG

5 PA NDS

SOMATULINE DEPOT

MG05 ML

5 PA NSO NDS QL (1

per 28 days)

SOMATULINE DEPOT

ML 90 MG03 ML

25 MG 30 MG

5 PA NDS

(65 MCGDAY)

5 NDS QL (1 per 360

AEROSOL 2 MGML

225 MG

5 NDS QL (1 per 168

RECON SOLN 10 MG

5 PA NDS

RECON SOLN 5 MG

SOLN 88 MG

5 PA NDS

Progestins

SUSPENSION 400 MGML

5 PA NSO NDS

Drug Name

suspension 150 mgml

syringe 150 mgml

25 mg 5 mg

(Provera) 1

(40 mgml)

Years)

mg 200 mg

(Prometrium) 2

mcg 125 mcg 137 mcg 150 mcg 175

88 mcg

(Euthyrox) 1

(Cytomel) 2

ACTEMRA ACTPEN

MG09 ML

5 PA NDS

ACTEMRA INTRAVENOUS

80 MG4 ML (20 MGML)

5 PA NDS

SYRINGE 162 MG09 ML

5 PA NDS

SOLN 220 MG

100 mg

2 PA BvD

MG X 2 VIALS)

5 PA NDS

Drug Name

5 PA NDS

mg5 ml

mg 25 mg

(Gengraf) 2 PA BvD

5 PA NDS

SOLN 25 MG (1 ML)

5 PA NDS

25 MG05 ML (05) 50 MGML (1 ML)

5 PA NDS

ENBREL SURECLICK

MGML (1 ML)

5 PA NDS

SOLUTION 10 5

5 PA BvD NDS

4 PA BvD

SOLUTION 10

5 PA BvD NDS

GRAM 5 GRAM

5 PA BvD NDS

SOLUTION 10 10 (100 ML) 10

(200 ML)

5 PA BvD NDS

Drug Name

KIT 40 MG08 ML 40 MG08 ML (6

5 PA NDS

KIT 40 MG08 ML

5 PA NDS

KIT 10 MG02 ML 20 MG04 ML 40

MG08 ML

5 PA NDS

MG08 ML-40 MG04 ML

5 PA NDS

80 MG08 ML

5 PA NDS

MG02 ML 40 MG04 ML

5 PA NDS

SOLUTION 300 UNITML

HYPERRAB SD (PF)

UNITML

HYQVIA SUBCUTANEOUS

25 GRAM 25 ML (10 ) 20 GRAM

200 ML (10 ) 30 GRAM 300 ML (10

) 5 GRAM 50 ML (10 )

5 PA BvD NDS

SOLN 150 MGML

5 PA NDS

SOLUTION 150 MGML

5 PA NDS

Drug Name

100 MGML

5 PA NDS

UNITML

SOLN 100 MG

5 PA NDS

SOLUTION 150 UNITML

MG114 ML

5 PA NDS

MG114 ML

5 PA NDS

100 MG067 ML

5 PA NDS

recon soln 500 mg

(CellCept) 2 PA BvD

SOLN 250 MG

5 PA BvD NDS

OCTAGAM INTRAVENOUS

SOLUTION 10 5

5 PA BvD NDS

5 PA NDS

ORENCIA CLICKJECT

125 MGML

5 PA NDS

875 MG07 ML

5 PA NDS

OTEZLA STARTER ORAL

MG (4)-30 MG (47) 10 MG (4)-20 MG

(4)-30 MG(19)

5 PA NDS

Drug Name

SOLUTION 10

5 PA BvD NDS

5 MGML

4 PA BvD

PACKET 02 MG 1 MG

4 PA BvD ST

MG025 ML 15 MG03 ML 175

MG035 ML 20 MG04 ML 225

MG045 ML 25 MG05 ML 30 MG06

ML 75 MG015 ML

SOLN 100 MG

5 PA NDS

SOLN 100 MG

5 PA NDS

MG15 ML

5 PA NDS

SOLUTION 125 MGML

5 PA NDS

100 MGML 50 MG05 ML

5 PA NDS

130 MG26 ML

5 PA NDS

SOLUTION 45 MG05 ML

5 PA NDS

(Prograf) 2 PA BvD

TALTZ AUTOINJECTOR

80 MGML

5 PA NDS

Drug Name

SYRINGE 80 MGML

5 PA NDS

INJECTOR 100 MGML

5 PA NDS

SYRINGE 100 MGML

5 PA NDS

300 MG15 ML

5 PA LA NDS

5 PA NDS

05 MG 075 MG 1 MG

5 PA BvD NDS

Vaccines

ADACEL(TDAP

ADOLESNADULT)(PF)

LF-(25-5-3-5 MCG)-5LF05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

(25-5-3-5 MCG)-5LF05 ML

3 PA BvD

LF05ML

10-5 LF-MCG-LF05ML

SUSPENSION 20 MCGML

3 PA BvD

Drug Name

SYRINGE 20 MCGML

3 PA BvD

MCG05 ML

3 PA BvD

SUSPENSION 05 ML

SYRINGE 05 ML

720 ELISA UNIT05 ML

ELISA UNIT05 ML

3 PA BvD

58-10 LF-MCG-LF05ML

LF-MCG-LF05ML

32 UNIT05 ML

UNIT05 ML

SYRINGE 6 MCG05 ML

SOLUTION 4 MCG05 ML

Drug Name

10LF05 ML

10EXP3-43-3- 399 TCID5005

UNIT05ML

25 UNIT

3 PA BvD

RECOMBIVAX HB (PF)

3 PA BvD

RECOMBIVAX HB (PF)

MCGML 5 MCG05 ML

3 PA BvD

CCID50ML

SOLUTION 2 ML

50 MCG05 ML

TDVAX INTRAMUSCULAR

UNIT05ML

LF UNIT05 ML

Drug Name

SYRINGE 25 MCG05 ML

UNITML

1350 UNIT05 ML

10 EXP474 UNIT05 ML

19400 UNIT065 ML

Agents

budesonide oral

(Entocort EC) 2

tablets) 400 mg

(Delzicol) 2

(drec) 800 mg

(Asacol HD) 2

Drug Name

(drec) 500 mg

MGACTUATION

SOLUTION

Chloride)

solution

(Aqua Care Sterile

Water)

mcg2 ml

(Hectorol) 2

105 MG117 ML

30 days)

210MG234ML ( 105MG117MLX2)

30 days)

MCG24 ML

Drug Name

200 UNITML

MCGDOSE

solution 2 mcgml

60 MGML

RAYALDEE ORAL

HR 30 MCG

3 PA QL (156 per 30

mg5 ml

soln 500 mg

(Ethyol) 2

SOLN 120 MG 400 MG

5 PA NDS

INJECTOR 200 MGML

SYRINGE 200 MGML

CETYLEV ORAL TABLET

Drug Name

GRAM17 ML

5 GRAM

30 days)

SOLUTION 50 MGML

5 PA LA NDS

RECON SOLN 1 MG

(Vistaril) 1

30 days)

100 mg 200 mg 350 mg 50 mg 500 mg

mg 25 mg 5 mg

100 mgml

(Carnitor) 2

soln 50 mg

(Fusilev) 5 NDS

mg5 ml

(Mestinon) 2

Drug Name

150 MG 200 MG 50 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 500 MG

PACKET 10 GRAM

5 NDS QL (24 per 14

PACKET 2 GRAM

30 days)

Ophthalmic Agents

Antiglaucoma Agents

release 500 mg

500 mg

DROPS 01

DROPSSUSPENSION 1

DROPS 02-05

drops 223-68 mgml

(Cosopt) 2

DROPS 001

(Isopto Carpine) 2

DROPS 002

Drug Name

025 05

(Timoptic) 1

(Timoptic-XE) 4

DROPS 0004

mgml (10 )

IONOSOL-MB IN D5W

SOLUTION 5

PARENTERAL SOLUTION

release 8 meq

40 gram1000 ml (4 )

2 PA BvD

gram100 ml (4 ) 4 gram50 ml (8 )

2 PA BvD

meqml (50 )

2 PA BvD

Drug Name

SOLUTION

SINGLE-USE

PARENTERAL SOLUTION

2 PA BvD

meqml (20 ml)

2 PA BvD

release 10 meq

release 8 meq

ml 40 meq15 ml

(K-Tab) 2

release 20 meq

(K-Tab) 4

(Klor-Con M10) 2

(Klor-Con M20) 2

(Urocit-K 10) 2

release 15 meq

(Urocit-K 15) 2

(Urocit-K 5) 2

parenteral solution

Corticosteroids

Drug Name

50 MCGDOSE

MCGACTUATION 230-21

MCGACTUATION 45-21

MCGACTUATION

MCGACTUATION 200

MCGACTUATION 50

MCGACTUATION

mg2 ml

MCGACTUATION

MCGACTUATION 50

MCGACTUATION

AEROSOL INHALER 110

MCGACTUATION

AEROSOL INHALER 220

MCGACTUATION

AEROSOL INHALER 44

MCGACTUATION

Drug Name

INHALATIONS 80-45

MCGACTUATION

MCGACTUATION 80-45

MCGACTUATION

Antileukotrienes

(Singulair) 1

Bronchodilators

25 mg 3 ml (0083 ) 25 mg05 ml

2 PA BvD

MCGACTUATION

AEROSOL INHALER 17

MCGACTUATION

COMBIVENT RESPIMAT

MCGACTUATION

2 PA BvD

STARTER 25 MCGML

Drug Name

MCGDOSE

12 hr 100 mg 200 mg 300 mg

(Theochron) 2

12 hr 450 mg

24 hr 400 mg 600 mg

(30 ACTUAT)

mgml (20 )

(Acetadote) 2 PA

200 mgml (20 )

2 PA BvD

10 MGML

5 PA NDS

2 PA BvD

Drug Name

30 days)

SYRINGE 30 MGML

INJECTOR 100 MGML

28 days)

SOLN 100 MG

28 days)

100 MGML

28 days)

PACKET 100-125 MG 150-188 MG

MG 200-125 MG

30 days)

RECON SOLN 1000 MG

5 PA BvD NDS

(N) 50-75 MG (D) 75 MG (N)

SOLN 150 MG

5 PA NDS

150 MGML 75 MG05 ML

5 PA NDS

Years)

Drug Name

Years)

250 mg 50 mg

MG 20 MG 5 MG

per 30 days)

Vasodilating Agents

MG 15 MG 2 MG 25 MG

soln 05 mg

(Flolan) 2 PA

soln 15 mg

(Flolan) 5 PA NDS

25 MG 5 MG

5 PA NDS

Drug Name

1 day)

SUSPENSION 32 MG

28 days)

(06 MGML)

5 PA NDS

1200 MCG 1400 MCG 1600 MCG

400 MCG 600 MCG 800 MCG

30 days)

PACK 200 MCG (140)- 800 MCG (60)

5 PA NDS

27 mg iron- 1 mg

A abacavir 47

ABELCET 35

ABILIFY MAINTENA 43

ABRAXANE 15

acamprosate 7

acarbose 32

acebutolol 60

acetazolamide 107

acetic acid 82 104

acetylcysteine 112

acitretin 76

ACTEMRA 95

ACTEMRA ACTPEN 95

ACTHIB (PF) 100

ACTIMMUNE 105

acyclovir 52 76

acyclovir sodium 52

ADACEL(TDAP

ADAGEN 80

adapalene 79

adefovir 52

ADEMPAS 114

adriamycin 15

adrucil 15

ADVAIR DISKUS 110

ADVAIR HFA 110

afeditab cr 63

AFINITOR 15

AFINITOR DISPERZ 15

afirmelle 70

a-hydrocort 91

(2 PACK) 38

AJOVY 38

AKYNZEO

(FOSNETUPITANT) 39

ala-cort 77

albendazole 41

alclometasone 77

ALCOHOL PADS 76

ALDURAZYME 80

ALECENSA 16

alendronate 104

alfuzosin 88

ALIMTA 16

ALINIA 41

ALIQOPA 16

aliskiren 66

allopurinol 37

alosetron 103

ALPHAGAN P 107

alprazolam 8

ALREX 84

altavera (28) 70

ALTRENO 79

ALUNBRIG 16

alyacen 135 (28) 70

alyacen 777 (28) 70

alyq 114

amabelz 89

amantadine hcl 41

AMBISOME 35

ambrisentan 114

amethia 70

amethia lo 70

amiloride 63

AMINOSYN 10 55

AMINOSYN 7 WITH

ELECTROLYTES 55

AMINOSYN 85 55

AMINOSYN 85 -

ELECTROLYTES 55

AMINOSYN II 10 56

AMINOSYN II 15 56

AMINOSYN II 7 56

AMINOSYN II 85 56

AMINOSYN II 85 -

ELECTROLYTES 56

AMINOSYN M 35 56

AMINOSYN-HBC 7 56

AMINOSYN-PF 10 56

AMINOSYN-PF 7

(SULFITE-FREE) 56

AMINOSYN-RF 52 56

amiodarone 60

AMITIZA 86

amitriptyline 29

amlodipine 63

ammonium lactate 76

amoxapine 30

amoxicillin 13

amphotericin b 35

ampicillin 13

ANADROL-50 89

anagrelide 55

anastrozole 16

ANORO ELLIPTA 111

APOKYN 41

apraclonidine 81

aprepitant 39

apri 70

APRISO 103

APTIOM 25 26

APTIVUS 47

aranelle (28) 70

ARCALYST 95

aripiprazole 43

ARISTADA 43

ARISTADA INITIO 43

armodafinil 114

ARNUITY ELLIPTA 110

arsenic trioxide 16

ashlyna 70

ASSURE ID INSULIN

SAFETY 79

atazanavir 47

atenolol 60

atomoxetine 66

atorvastatin 64

atovaquone 41

ATRIPLA 47

atropine 25 82

ATROVENT HFA 111

AUBAGIO 66

aubra 70

aurovela 1530 (21) 70

aurovela 24 fe 70

AUSTEDO 67

AVASTIN 16

aviane 70

AVONEX 67

ayuna 70

azacitidine 16

azathioprine 95

azelastine 82

azithromycin 12

AZOPT 107

aztreonam 13

azurette (28) 70

B baciim 10

bacitracin 82

baclofen 113

balsalazide 103

BALVERSA 16

balziva (28) 71

BANZEL 26

BAVENCIO 16

BAXDELA 14

NEEDLE 79

UNIT 80

bekyree (28) 71

BELEODAQ 16

BELSOMRA 114

benazepril 59

BENDEKA 16

BENLYSTA 105

benztropine 41

BESPONSA 16

BETASERON 67

betaxolol 60

BETHKIS 9

BEVYXXA 52

bexarotene 16

BEXSERO 100

bicalutamide 16

BICILLIN L-A 13

BIDIL 66

BIKTARVY 47

bleomycin 16

bleph-10 82

BLINCYTO 16

blisovi 24 fe 71

blisovi fe 1530 (28) 71

BOOSTRIX TDAP 100

BORTEZOMIB 16

BOSULIF 16 17

BRAFTOVI 17

BREO ELLIPTA 110

briellyn 71

BRILINTA 55

brimonidine 107

BRIVIACT 26

bromocriptine 41

BROMSITE 84

budesonide 103 110

bumetanide 63

bupropion hcl 30

buspirone 8

BYSTOLIC 61

BYVALSON 61

C cabergoline 41

CABLIVI 105

CABOMETYX 17

caffeine citrate 67

calcipotriene 76

calcitriol 104

CALDOLOR 6

CALQUENCE 17

camila 71

CAPASTAT 39

CAPRELSA 17

captopril 59

CARBAGLU 86

carbamazepine 26

carteolol 107

cartia xt 62

carvedilol 61

caspofungin 36

CAYSTON 13

caziant (28) 71

cefaclor 11

cefadroxil 11

cefazolin 11

cefdinir 11

cefepime 11

cefixime 11

cefotaxime 11

cefoxitin 11

cefpodoxime 12

cefprozil 12

ceftazidime 12

ceftriaxone 12

celecoxib 6

CELONTIN 26

cephalexin 12

CERDELGA 80

CEREZYME 80

CETYLEV 105

CHANTIX 8

CHANTIX CONTINUING

MONTH BOX 8

CHANTIX STARTING

MONTH BOX 8

chlorothiazide 64

chlorpromazine 43

chlorthalidone 64

chlorzoxazone 113

ciclopirox 36

cilostazol 55

CIMDUO 47

cimetidine hcl 85

CIMZIA 95

CIMZIA POWDER FOR

RECONST 95

cinacalcet 104

CINQAIR 112

CINRYZE 53

CINVANTI 39

CIPRODEX 82

ciprofloxacin 14

citalopram 30

clarithromycin 12

CLENPIQ 87

clindamycin hcl 10

CLINIMIX 5D15W

SULFITE FREE 56

CLINIMIX 5D25W

SULFITE-FREE 56

FREE 56

CLINIMIX 425D5W

SULFIT FREE 56

CLINIMIX 425-D25W

SULF-FREE 56

CLINIMIX 5-

CLINIMIX E 275D10W

SUL FREE 56

CLINIMIX E 275D5W

SULF FREE 57

CLINIMIX E 425D10W

SUL FREE 57

CLINIMIX E 425D25W

SUL FREE 57

CLINIMIX E 425D5W

SULF FREE 57

CLINIMIX E 5D15W

SULFIT FREE 57

CLINIMIX E 5D20W

SULFIT FREE 57

CLINIMIX E 5D25W

SULFIT FREE 57

clobazam 26

clobetasol 78

clofarabine 17

clomipramine 30

clonazepam 9

clonidine 58

clonidine hcl 58

clopidogrel 55

clotrimazole 36

clozapine 43 44

COARTEM 41

codeine sulfate 3

colchicine 37

colestipol 64

colocort 103

COMBIGAN 107

COMETRIQ 17

COMPLERA 47

compro 39

constulose 86

COPIKTRA 17

CORLANOR 62

cormax 78

cortisone 91

COTELLIC 17

CREON 80

CRIXIVAN 47

cromolyn 82 86 112

cryselle (28) 71

cyclobenzaprine 113

cyclopentolate 82

cyclophosphamide 17

CYCLOPHOSPHAMIDE 17

cyclosporine 96

cyproheptadine 37

CYRAMZA 17

cyred 71

CYSTADANE 106

CYSTARAN 82

D dalfampridine 67

DALIRESP 113

danazol 89

dantrolene 113 114

dapsone 39

DAPTACEL (DTAP

PEDIATRIC) (PF) 100

daptomycin 10

DARAPRIM 41

DARZALEX 17

dasetta 135 (28) 71

dasetta 777 (28) 71

DAURISMO 17

daysee 71

deblitane 71

decadron 91

decitabine 17

deferasirox 89

deferoxamine 89

DELSTRIGO 47

delyla (28) 71

DEMSER 62

DEPEN TITRATABS 89

DEPO-PROVERA 94

DESCOVY 47

desipramine 30

desmopressin 92

desoximetasone 78

dexamethasone 91

(pf) 91

phosphate 84 91

dextroamphetamine-

amphetamine 67

DIASTAT 26

DIASTAT ACUDIAL 26

diazepam 9 26

diazepam intensol 9

dicloxacillin 13

dicyclomine 86

didanosine 47

DIFICID 12

digitek 62

digox 62

digoxin 62 63

DIGOXIN 63

diltiazem hcl 62

dilt-xr 62

dimenhydrinate 39

DIPENTUM 103

dipyridamole 55

disulfiram 8

divalproex 26

dofetilide 60

donepezil 29

dorzolamide 107

dotti 90

DOVATO 48

doxazosin 58

doxepin 30

doxercalciferol 104

doxorubicin 17

doxy-100 15

dronabinol 39

droperidol 106

DROXIA 18

DUAVEE 90

duloxetine 30

DUPIXENT 96

DUREZOL 84

dutasteride 88

E econazole 36

EDARBI 59

EDARBYCLOR 59

EDURANT 48

efavirenz 48

EGRIFTA 92

ELAPRASE 80

ELIGARD 18

elinest 71

ELIQUIS 52

ELITEK 80

ELLA 71

ELMIRON 106

EMCYT 18

EMEND 40

EMFLAZA 91

EMGALITY PEN 38

EMGALITY SYRINGE 38

emoquette 71

EMPLICITI 18

EMSAM 30

EMTRIVA 48

enalaprilat 59

ENBREL 96

ENBREL SURECLICK 96

ENDARI 106

endocet 3

enoxaparin 52 53

enpresse 71

enskyce 71

entacapone 42

entecavir 52

ENTRESTO 59

enulose 86

EPCLUSA 51

EPIDIOLEX 26

epinastine 82

epinephrine 63

epitol 26

EPIVIR HBV 48

eplerenone 66

ergoloid 106

ERGOMAR 38

ERIVEDGE 18

ERLEADA 18

erlotinib 18

errin 71

ertapenem 13

ery pads 77

erythromycin 12 82

ESBRIET 113

estarylla 71

estradiol 90

eszopiclone 114

ethambutol 39

ethosuximide 26

etodolac 6

ETOPOPHOS 18

etoposide 18

EUCRISA 78

EVENITY 104

EVOTAZ 48

exemestane 18

EXONDYS 51 106

EXTAVIA 67

ezetimibe 65

F FABRAZYME 80

falmina (28) 72

famciclovir 52

famotidine 85

famotidine (pf) 85

FANAPT 44

FARYDAK 18

FASENRA 113

febuxostat 37

felbamate 27

FEMRING 90

femynor 72

fenofibrate 65

fentanyl 3

fentanyl citrate 3

FERRIPROX 89

FETZIMA 30

INSULIN 33

finasteride 88

FIRAZYR 63

FIRVANQ 10

FLEBOGAMMA DIF 96

flecainide 60

FLOVENT DISKUS 110

FLOVENT HFA 110

floxuridine 18

fluconazole 36

flucytosine 36

fludrocortisone 91

flumazenil 67

flunisolide 84

fluocinolone 78

fluocinonide 78

fluocinonide-e 78

fluorometholone 84

fluorouracil 18 76

fluoxetine 30

fluphenazine hcl 44

flurbiprofen 6

flutamide 18

fluvoxamine 31

fomepizole 106

fondaparinux 53

FORTEO 104

fosamprenavir 48

foscarnet 50

fosinopril 59

fosphenytoin 27

FREAMINE HBC 69 57

FREAMINE III 10 58

FULPHILA 53

fulvestrant 18

furosemide 64

FUZEON 48

fyavolv 90

FYCOMPA 27

G gabapentin 27

GALAFOLD 80

galantamine 29

GAMASTAN 96

GAMMAGARD LIQUID 96

MCGML) 96

GAMMAPLEX 96

GAMMAPLEX (WITH

SORBITOL) 96

GARDASIL 9 (PF) 101

GATTEX 30-VIAL 86

GAUZE PAD 80

gavilyte-c 87

gavilyte-g 87

gavilyte-n 87

GAZYVA 18

gemfibrozil 65

generlac 86

gengraf 96

GENOTROPIN 92

gentak 82

gentamicin 9 77 82

GENVOYA 48

GEODON 44

GILENYA 67

GILOTRIF 18

glatiramer 67

glatopa 67 68

GLEOSTINE 18

glimepiride 35

glipizide 35

glyburide 35

glycopyrrolate 86

glydo 7

GLYXAMBI 32

GOCOVRI 42

granisetron (pf) 40

granisetron hcl 40

GRANIX 53 54

guanfacine 58 68

guanidine 106

H HAEGARDA 54

hailey 24 fe 72

haloperidol 44

HARVONI 51

HAVRIX (PF) 101

heather 72

HEPATAMINE 8 58

HERCEPTIN 19

HETLIOZ 114

HIBERIX (PF) 101

HUMATROPE 92

HUMIRA 97

HUMIRA PEDIATRIC

CROHNS START 97

HUMIRA PEN 97

HS START 97

HUMIRA PEN PSOR-

UVEITS-ADOL HS 97

HUMIRA(CF) 97

STARTER 97

HUMIRA(CF) PEN 97

UC-HS 97

ADOL HS 97

INSULIN 34

KWIKPEN 34

hydralazine 63

hydromorphone 4

hydroxyurea 19

hydroxyzine hcl 37

HYPERRAB (PF) 97

HYPERRAB SD (PF) 97

HYQVIA 97

I ibandronate 104

IBRANCE 19

ibuprofen 6

icatibant 63

ICLUSIG 19

IDHIFA 19

ifosfamide 19

ifosfamide-mesna 19

ILARIS (PF) 97

ILEVRO 84

ILUMYA 98

imatinib 19

IMBRUVICA 19

IMFINZI 19

imipramine hcl 31

imiquimod 76

IMLYGIC 19

(PF) 101

IMPAVIDO 41

INBRIJA 42

incassia 72

INCRELEX 93

INCRUSE ELLIPTA 111

indapamide 64

indomethacin 6

INFLECTRA 98

INGREZZA 68

INGREZZA INITIATION

PACK 68

INLYTA 19

U-100 80

INTELENCE 48

INTRALIPID 58

INTRON A 51

introvale 72

INVEGA SUSTENNA 45

INVEGA TRINZA 45

INVELTYS 84

INVIRASE 48

INVOKAMET 32

INVOKAMET XR 32

INVOKANA 32

IPOL 101

irbesartan 59

IRESSA 19

ISENTRESS 48

ISENTRESS HD 48

isibloom 72

ISOLYTE-P IN 5

DEXTROSE 108

ISOLYTE-S 108

isoniazid 39

itraconazole 36

ivermectin 41

IXEMPRA 19

IXIARO (PF) 101

J JADENU 89

JADENU SPRINKLE 89

JAKAFI 20

jantoven 53

JANUMET 32

JANUMET XR 32

JANUVIA 32

JARDIANCE 32

jasmiel (28) 72

jencycla 72

JENTADUETO 32

JENTADUETO XR 32

jinteli 90

jolivette 72

juleber 72

JULUCA 48

junel 1530 (21) 72

junel 120 (21) 72

junel fe 1530 (28) 72

junel fe 120 (28) 72

junel fe 24 72

JUXTAPID 65

JYNARQUE 64

K KABIVEN 58

KALETRA 48

kalliga 72

KALYDECO 113

KANJINTI 20

KANUMA 80

kariva (28) 72

KEDRAB (PF) 98

kelnor 135 (28) 72

kelnor 1-50 72

ketoconazole 36

ketorolac 6 84

KEVEYIS 106

KEVZARA 98

KEYTRUDA 20

KINERET 98

KINRIX (PF) 101

KISQALI 20

klor-con m10 108

klor-con m15 108

klor-con m20 108

KORLYM 32

KRINTAFEL 41

KRYSTEXXA 81

kurvelo (28) 72

KUVAN 81

KYPROLIS 20

labetalol 61

lactulose 86

lamivudine 48

lamotrigine 27

lansoprazole 85

INSULIN 34

larin 1530 (21) 73

larin 120 (21) 73

larin 24 fe 73

larin fe 1530 (28) 73

larin fe 120 (28) 73

larissia 73

latanoprost 107

LATUDA 45

LAZANDA 4

leena 28 73

leflunomide 98

LEMTRADA 68

LENVIMA 20

lessina 73

letrozole 20

LEUKERAN 20

LEUKINE 54

leuprolide 20

levetiracetam 27

levobunolol 107

levocarnitine 106

levocetirizine 37

levofloxacin 14 82

LEVOLEUCOVORIN

CALCIUM 106

levonest (28) 73

levora-28 73

levothyroxine 95

LEXIVA 48

LIALDA 103

LIBTAYO 20

lidocaine 7

lidocaine (pf) 7 60

lidocaine hcl 7

lidocaine viscous 7

lillow (28) 73

linezolid 10 11

LINZESS 86

liothyronine 95

lisinopril 59 60

lithium citrate 68

LIVALO 65

LOKELMA 86

LONHALA MAGNAIR

REFILL 112

LONHALA MAGNAIR

STARTER 111

LONSURF 20

loperamide 86

lorazepam 9

LORBRENA 20

lorcet hd 4

lorcet plus 4

loryna (28) 73

losartan 59

LOTEMAX 84

LOTEMAX SM 84

lovastatin 65

LUCEMYRA 8

LUMIGAN 107

LUMOXITI 21

LUPRON DEPOT 21 93

LUPRON DEPOT-PED 93

LUPRON DEPOT-PED (3

MONTH) 93

lutera (28) 73

LYNPARZA 21

LYRICA 27

LYSODREN 21

lyza 73

malathion 79

maprotiline 31

marlissa (28) 73

MARPLAN 31

MATULANE 21

PACK) 68

MAVENCLAD (4 TABLET

PACK) 68

MAVENCLAD (5 TABLET

PACK) 68

MAVENCLAD (6 TABLET

PACK) 68

MAVENCLAD (7 TABLET

PACK) 68

MAVENCLAD (8 TABLET

PACK) 68

MAVENCLAD (9 TABLET

PACK) 68

MAVYRET 51

MAYZENT 68

meclizine 40

mefenamic acid 6

mefloquine 41

megestrol 21 95

MEKINIST 21

MEKTOVI 21

meloxicam 6

memantine 29

MENACTRA (PF) 101

(PF) 101

MEPSEVII 81

mercaptopurine 21

meropenem 13

mesalamine 103

mesna 106

MESNEX 106

MESTINON 106

metaproterenol 112

metformin 32 33

methadone 4

methadose 4

methimazole 95

methocarbamol 114

methoxsalen 76

methscopolamine 86

methyclothiazide 64

metipranolol 107

mexiletine 60

MIACALCIN 105

miconazole-3 36

midodrine 58

miglustat 81

mili 73

mimvey 90

mimvey lo 90

minitran 66

minocycline 15

minoxidil 66

mirtazapine 31

misoprostol 85

MITIGARE 37

mitoxantrone 21

M-M-R II (PF) 102

molindone 45

mometasone 79

mondoxyne nl 15

mono-linyah 73

mononessa (28) 73

montelukast 111

morphine 4 5

MORPHINE 5

MOVANTIK 86

MOXEZA 82

moxifloxacin 14 83

MOZOBIL 54

MULPLETA 54

MULTAQ 60

mupirocin 77

MYLOTARG 21

MYRBETRIQ 88

myzilra 73

N nabumetone 6

nafcillin 13 14

NAGLAZYME 81

naloxone 8

naltrexone 8

NAMZARIC 29

naproxen 7

NARCAN 8

NATACYN 83

NATPARA 105

NEBUPENT 41

necon 0535 (28) 73

nefazodone 31

neomycin 10

dexameth 83

neomycin-polymyxin-

gramicidin 83

neo-polycin 83

neo-polycin hc 83

NEPHRAMINE 54 58

NERLYNX 21

NEULASTA 54

NEUPOGEN 54

NEUPRO 42

nevirapine 48 49

NEXAVAR 21

niacin 65

niacor 65

nicardipine 63

NICOTROL 8

nifedipine 63

nikki (28) 74

nilutamide 21

NINLARO 22

nitroglycerin 66

NITYR 81

NIVESTYM 54

nizatidine 85

NOCDURNA (MEN) 93

NOCDURNA (WOMEN) 93

nora-be 74

norlyda 74

norlyroc 74

NORMOSOL-M IN 5

DEXTROSE 109

NORMOSOL-R 109

NORTHERA 58

nortrel 0535 (28) 74

nortrel 135 (21) 74

nortrel 135 (28) 74

nortrel 777 (28) 74

nortriptyline 31

NORVIR 49

NOVOLIN 7030 U-100

INSULIN 34

100 34

NOVOLIN N NPH U-100

INSULIN 34

100 INSULN 34

INSULIN 34

INSULN 34

NOVOLOG MIX 70-

30FLEXPEN U-100 34

INSULIN 34

ASPART 34

NOXAFIL 36

NUCALA 113

NUCYNTA 5

NUCYNTA ER 5

NUEDEXTA 69

NULOJIX 98

NUPLAZID 45

NUTRILIPID 58

nyamyc 36

nystatin 36

nystop 36

O OCALIVA 87

OCREVUS 69

OCTAGAM 98

ODEFSEY 49

ODOMZO 22

OFEV 113

ofloxacin 83

ogestrel (28) 74

olanzapine 45

olmesartan 59

olopatadine 82

OLUMIANT 98

omeprazole 85

OMNITROPE 93

ONCASPAR 22

ondansetron 40

ondansetron hcl 40

ONIVYDE 22

OPDIVO 22

OPSUMIT 114

oralone 76

ORENCIA 98

ORENITRAM 114

ORFADIN 81

ORILISSA 93 94

ORKAMBI 113

orsythia 74

oseltamivir 50

OSMOLEX ER 42

OTEZLA 98

OTEZLA STARTER 98

oxcarbazepine 27

OXTELLAR XR 27

oxycodone 5

oxycodone-aspirin 5

OZEMPIC 33

P pacerone 60

paliperidone 45 46

PALYNZIQ 81

PANRETIN 76

pantoprazole 85

paricalcitol 105

PARICALCITOL 105

paromomycin 41

paroxetine hcl 31

PASER 39

PAXIL 31

PEDIARIX (PF) 102

PEDVAX HIB (PF) 102

PEGANONE 27

PEGASYS 51 52

PEGASYS PROCLICK 51

PEGINTRON 52

penicillamine 89

PENNSAID 7

PENTACEL (PF) 102

PENTAM 41

pentamidine 41

pentoxifylline 55

PERIKABIVEN 58

periogard 76

permethrin 79

perphenazine 46

PERSERIS 46

pfizerpen-g 14

phenadoz 40

phenelzine 31

phenobarbital 27 28

phenytoin 28

phenytoin sodium 28

philith 74

PHOSLYRA 88

PICATO 76 77

PIFELTRO 49

pimecrolimus 79

pimozide 46

pimtrea (28) 74

pioglitazone 33

PIQRAY 22

pirmella 74

PLASMA-LYTE 148 109

PLASMA-LYTE A 109

PLEGRIDY 69

podofilox 77

POLIVY 22

polycin 83

POMALYST 22

portia 28 74

PORTRAZZA 22

PRADAXA 53

PRALUENT PEN 65

pramipexole 42

prasugrel 55

pravastatin 65

prazosin 59

prednicarbate 79

prednisolone 92

84 91 92

prednisone 92

pregabalin 28

PREMARIN 90

PREMPHASE 91

PREMPRO 91

prevalite 65

previfem 74

PREVYMIS 50

PREZCOBIX 49

PREZISTA 49

PRIFTIN 39

PRIMAQUINE 41

primidone 28

PRIVIGEN 99

probenecid 37

procainamide 60

PROCALAMINE 3 58

prochlorperazine 40

PROCRIT 54

procto-med hc 79

proctosol hc 79

proctozone-hc 79

PROCYSBI 88

progesterone 95

PROGLYCEM 106

PROGRAF 99

PROLASTIN-C 113

PROLENSA 85

PROLEUKIN 22

PROLIA 105

PROMACTA 54

promethazine 37 40

promethegan 40

propafenone 60

proparacaine 82

propranolol 61

propylthiouracil 95

PROQUAD (PF) 102

PROSOL 20 58

protamine 55

protriptyline 31

PULMOZYME 81

PURIXAN 22

pyrazinamide 39

quetiapine 46

quinapril 60

R RABAVERT (PF) 102

RADICAVA 69

raloxifene 91

ramipril 60

ranitidine hcl 85

ranolazine 63

rasagiline 42

RASUVO (PF) 99

RAVICTI 87

RAYALDEE 105

REBIF REBIDOSE 69

reclipsen (28) 74

RECTIV 107

RELISTOR 87

REMICADE 99

RENFLEXIS 99

repaglinide 33

REPATHA SYRINGE 65

RESCRIPTOR 49

RESTASIS 85

RETACRIT 55

RETROVIR 49

REVCOVI 81

REVLIMID 22

revonto 114

REXULTI 46

REYATAZ 49

RHOPRESSA 107

ribasphere 52

ribavirin 52

RIDAURA 99

rifabutin 39

rifampin 39

riluzole 69

rimantadine 51

RISPERDAL CONSTA 46

risperidone 46

ritonavir 49

RITUXAN 22

RITUXAN HYCELA 22

rivastigmine 29

rizatriptan 38

ropinirole 42

rosadan 77

rosuvastatin 65

ROTARIX 102

ROTATEQ VACCINE 102

RUBRACA 22

RYDAPT 22

S SABRIL 28

SAIZEN 94

SANTYL 77

SAPHRIS 46

SAVELLA 69

scopolamine base 40

selegiline hcl 42

selenium sulfide 77

SELZENTRY 49

SEREVENT DISKUS 112

SEROSTIM 94

sertraline 31

setlakin 74

sevelamer hcl 88

sharobel 74

SHINGRIX (PF) 102

SIGNIFOR 94

SILENOR 114

SILIQ 99

SIMBRINZA 108

simliya (28) 74

simpesse 74

SIMPONI 99

SIMPONI ARIA 99

simvastatin 65

sirolimus 99

SIRTURO 39

SKYRIZI 99

smoflipid 58

sodium chloride 104

SOLIQUA 10033 34

SOLTAMOX 22

SOLU-CORTEF (PF) 92

SOMATULINE DEPOT 94

SOMAVERT 94

sorine 61

sotalol 61

sotalol af 61

SOVALDI 51

spironolactone 64

SPRAVATO 31

sprintec (28) 75

SPRITAM 28

SPRYCEL 22

sronyx 75

ssd 77

stavudine 49

STELARA 99

STIVARGA 23

STRENSIQ 81

streptomycin 10

STRIBILD 49

SUBLOCADE 8

subvenite 28

sucralfate 86

sulfadiazine 14

sulfasalazine 104

sulfatrim 15

sulindac 7

sumatriptan 38

SUPPRELIN LA 94

SUTENT 23

syeda 75

SYLATRON 52

SYLVANT 23

SYMBICORT 110 111

SYMDEKO 113

SYMFI 49

SYMFI LO 49

SYMJEPI 63

SYMLINPEN 120 33

SYMLINPEN 60 33

SYMPAZAN 28

SYMTUZA 49

SYNAGIS 51

SYNAREL 94

SYNERCID 11

SYNJARDY 33

SYNJARDY XR 33

SYNRIBO 23

T TABLOID 23

tacrolimus 79 99

TAFINLAR 23

TAGRISSO 23

TAKHZYRO 107

TALTZ SYRINGE 100

TALZENNA 23

tamoxifen 23

tamsulosin 88

TARGRETIN 23

tarina 24 fe 75

tarina fe 120 (28) 75

TASIGNA 23

TAVALISSE 55

tazarotene 79

TAZORAC 79

taztia xt 62

TDVAX 102

TECENTRIQ 23

TECFIDERA 70

TECHNIVIE 51

TEFLARO 12

TEKTURNA HCT 66

telmisartan 59

temazepam 9

TEMODAR 23

TENIVAC (PF) 102

terazosin 88

terbinafine hcl 36

terbutaline 112

terconazole 37

testosterone 89

PED(PF) 102

tetrabenazine 70

tetracycline 15

THALOMID 107

theophylline 112

THIOLA 89

THIOLA EC 88

thioridazine 46

thiotepa 23

thiothixene 46

tiagabine 28

TIBSOVO 23

TICE BCG 100

tigecycline 15

tilia fe 75

TIVICAY 49 50

tizanidine 114

TOBI PODHALER 10

tobramycin 84

TOLAK 77

tolazamide 35

tolterodine 88

topiramate 28

toposar 23

toremifene 23

torsemide 64

TOTECT 107

TOUJEO MAX U-300

SOLOSTAR 34

INSULIN 35

TOVIAZ 88

TRACLEER 115

TRADJENTA 33

tramadol 5

trandolapril 60

tranexamic acid 55

TRANSDERM-SCOP 41

tranylcypromine 31

TRAVASOL 10 58

TRAVATAN Z 108

trazodone 31

TREANDA 23

TRECATOR 39

TRELEGY ELLIPTA 112

TRELSTAR 23 24

TREMFYA 100

tretinoin 79

tri femynor 75

trientine 89

tri-estarylla 75

trifluoperazine 46

trifluridine 84

trihexyphenidyl 43

tri-legest fe 75

tri-linyah 75

tri-lo-estarylla 75

tri-lo-marzia 75

tri-lo-mili 75

tri-lo-sprintec 75

trimethoprim 11

tri-mili 75

trimipramine 31

TRINTELLIX 31

TRIPTODUR 94

TRIUMEQ 50

trivora (28) 75

tri-vylibra 75

tri-vylibra lo 75

TROGARZO 50

TROPHAMINE 10 58

TROPHAMINE 6 58

TRULICITY 33

TRUMENBA 103

TRUVADA 50

tulana 75

TWINRIX (PF) 103

TYBOST 107

TYKERB 24

TYMLOS 105

TYPHIM VI 103

TYSABRI 100

TYVASO 115

U UCERIS 104

UDENYCA 55

ULORIC 37

UNITUXIN 24

UPTRAVI 115

ursodiol 87

V valacyclovir 52

VALCHLOR 77

valganciclovir 52

valproate sodium 28

valproic acid 29

valrubicin 24

valsartan 59

vancomycin 11

VAQTA (PF) 103

VARIVAX (PF) 103

VASCEPA 66

VELCADE 24

VELPHORO 88

VELTASSA 87

VEMLIDY 50

VENCLEXTA 24

VENCLEXTA STARTING

PACK 24

venlafaxine 31 32

verapamil 62

VERSACLOZ 46

VERZENIO 24

V-GO 40 80

VIBERZI 87

VICTOZA 33

VIDEX EC 50

VIEKIRA PAK 51

vienva 75

vigabatrin 29

vigadrone 29

VIIBRYD 32

VIMIZIM 81

VIMPAT 29

vinorelbine 24

viorele (28) 75

VIRACEPT 50

VIREAD 50

VISTOGARD 107

VITRAKVI 24

VIZIMPRO 24

VOLTAREN 7

voriconazole 36 37

VOSEVI 51

VOTRIENT 24

VPRIV 81

VRAYLAR 47

vyfemla (28) 76

vylibra 76

VYNDAQEL 63

VYXEOS 24

W warfarin 53

WELCHOL 66

wera (28) 76

X XADAGO 43

XALKORI 24

XARELTO 53

XATMEP 24

XELJANZ 100

XELJANZ XR 100

XERMELO 87

XIFAXAN 11

XIIDRA 85

XOFLUZA 51

XOLAIR 113

XOSPATA 24

XPOVIO 25

XTAMPZA ER 5 6

XTANDI 25

xulane 76

XULTOPHY 10036 35

XURIDEN 107

XYOSTED 89

XYREM 114

Y YERVOY 25

YF-VAX (PF) 103

YONDELIS 25

YONSA 25

Z zafirlukast 111

zaleplon 114

zarah 76

ZARXIO 55

ZEJULA 25

ZELBORAF 25

zenatane 77

zenchent (28) 76

ZENPEP 81

ZEPATIER 51

zidovudine 50

ziprasidone hcl 47

ZIRGAN 84

ZOLADEX 25

zoledronic acid 105

ZOLINZA 25

zolpidem 114

ZOMACTON 94

zonisamide 29

ZORBTIVE 94

ZORTRESS 100

ZOSTAVAX (PF) 103

zovia 135e (28) 76

ZTLIDO 7

ZUBSOLV 8

ZULRESSO 32

zumandimine (28) 76

ZYDELIG 25

ZYKADIA 25

ZYLET 84

ZYPREXA RELPREVV 47

ZYTIGA 25







Medical Condition









Table of Contents

INDEX

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

H6988_ENR1085_C IV

options

(HMO) Formulary

H6988_ENR1085_C V

exception

page I-1

Analgesics 3

Anesthetics 7

Antibacterials 9

Anticonvulsants 25

Antidepressants 29

Antifungals 35

Antigout Agents 37

Antihistamines 37

Caloric Agents 55

Contraceptives 70

Table of Contents

Devices 79

Drug Name

Analgesics

12 mg5 ml

30 days)

(Buprenex) 2

50-325-40 mg

Years)

50-325-40 mg

Years)

325-40 mg

Years)

30 days)

400 mcg 600 mcg 800 mcg

per 30 days)

75 mcghr

30 days)

75-325 mg15 ml

30 days)

10-325 mg

30 days)

25-325 mg

30 days)

Drug Name

325 mg

30 days)

75-325 mg

30 days)

5 PA NDS NM QL (30

per 30 days)

30 days)

suv inner 10 mgml

mg5 ml (20 mgml)

30 days)

4 mgml 8 mgml

30 days)

Drug Name

30 days)

mg 200 mg 60 mg

30 days)

mg 30 mg

30 days)

150 MG 200 MG 250 MG 50 MG

3 NDS NM QL (60 per

30 days)

MG 75 MG

30 days)

hr 10 mg 15 mg 20 mg 30 mg 40 mg 60

mg 80 mg

30 days)

325 mg

30 days)

325 mg 5-325 mg

30 days)

325 mg

30 days)

325 mg

30 days)

XTAMPZA ER ORAL

3 NDS NM QL (60 per

30 days)

Drug Name

XTAMPZA ER ORAL

CRUSH) 27 MG

30 days)

XTAMPZA ER ORAL

CRUSH) 36 MG

30 days)

12 hour 13

(Flector) 2 PA

(Voltaren-XR) 2

(IBU) 1

Years)

days) AGE (Max 64

Years)

Drug Name

(EC-Naprosyn) 2

ACTUATION(2 )

28 days)

Anesthetics

Local Anesthetics

applicator 2

(1 ) 15 mgml (15 ) 20 mgml (2 )

5 mgml (05 )

(Xylocaine-MPF) 1

mgml (2 )

(1 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine) 1

(40 mgml)

patchmedicated 5

solution 2

PATCHMEDICATED 18

Treatment Agents

(drec) 333 mg

Drug Name

12-3 mg 8-2 mg

2-05 mg 4-1 mg

2-05 mg 8-2 mg

3 QL (336 per 365 days)

(11)- 1 MG (42)

NICOTROL INHALATION

CARTRIDGE 10 MG

4 QL (1008 per 90 days)

018 MG 14-036 MG 114-29 MG 29-

071 MG 57-14 MG

Antianxiety Agents

Benzodiazepines

30 days)

mg 5 mg 75 mg

Drug Name

25 mg 5 mg

30 days)

0125 mg 025 mg 05 mg 1 mg

2 NDS NM QL (90 per

30 days)

375 mg

30 days)

Antibacterials

Aminoglycosides

5 PA BvD NDS

40 mgml

solution 20 mg2 ml

Drug Name

mg8 ml

(Tobi) 5 PA BvD NDS

mg 75 mg

(Cleocin HCl) 1

900 mg50 ml

150 (mgml) (6 ml)

150 mgml

(Cleocin) 2

solution 600 mg4 ml

(Cleocin) 2

soln 150 mg

(Coly-Mycin M

Parenteral)

5 PA BvD NDS

(Cubicin) 5 NDS

MGML 50 MGML

mg300 ml

(Zyvox) 5 NDS

100 mg5 ml

(Zyvox) 5 NDS

Drug Name

(Metro IV) 2

100 mg 25 mg 50 mg

capsule 100 mg

500000 unit

SOLN 500 MG

750 mg

2 PA BvD

Cephalosporins

125 mg5 ml 250 mg5 ml 375 mg5 ml

gram 500 mg

125 mg5 ml 250 mg5 ml

(Maxipime) 2

10 gram 2 gram

Drug Name

(Tazicef) 2

750 mg

15 gram 75 gram

SOLN 400 MG 600 MG

Macrolides

(Zithromax) 2

500 mg (3 pack) 600 mg

(EES Granules) 2

(EryPed 400) 2

Drug Name

(Azactam) 2

5 PA LA NDS

soln 250 mg

soln 500 mg

(Primaxin IV) 2

gram 500 mg

(Merrem) 2

Penicillins

250 mg5 ml 400 mg5 ml

250 mg

mg5 ml

500-125 mg 875-125 mg

(Augmentin) 1

500 mg

(Unasyn) 2

2400000 UNIT4 ML 600000

UNITML

Drug Name

20 million unit

(Pfizerpen-G) 2

unitml

mg5 ml 250 mg5 ml

500 mg

405 gram

(Zosyn) 2 PA BvD

Quinolones

(Cipro) 1

(Cipro in D5W) 2

ciprofloxacin oral

ml 500 mg5 ml

(Cipro) 2

250 mg50 ml 500 mg100 ml 750 mg150

Sulfonamides

(Sulfatrim) 2

Drug Name

400-80 mg

(Bactrim) 1

800-160 mg

(Bactrim DS) 1

Tetracyclines

soln 100 mg

(Doxy-100) 2

(Morgidox) 2

mg 50 mg

(Mondoxyne NL) 2

(Vibramycin) 2

(Avidoxy) 2

Anticancer Agents

100 MG

2 PA BvD

ml 500 mg10 ml

2 PA BvD

per 28 days)

MG 75 MG

5 PA NSO NDS QL (28

per 28 days)

Drug Name

per 30 days)

SOLN 100 MG 500 MG

SOLN 60 MG

5 PA NSO NDS QL (3

per 28 days)

5 PA NSO NDS QL (30

per 30 days)

PACK 90 MG (7)- 180 MG (23)

5 PA NSO NDS

25 MGML

5 PA NSO NDS

per 28 days)

SOLUTION 20 MGML

5 PA NSO NDS

SOLN 500 MG

5 PA NSO NDS

BENDEKA INTRAVENOUS

SOLUTION 25 MGML

5 PA NSO NDS

per 30 days)

5 PA NSO NDS

RECON SOLN 35 MG

5 PA NSO NDS

per 30 days)

Drug Name

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (60

per 30 days)

(Clolar) 5 NDS

MGDAY(80 MG X1-20 MG X1) 140

per 28 days)

5 PA NSO NDS QL (56

per 28 days)

(63 per 28 days)

5 PA BvD NDS

CAPSULE 25 MG 50 MG

2 PA BvD ST

CYRAMZA INTRAVENOUS

SOLUTION 10 MGML

5 PA NSO NDS

SOLUTION 20 MGML

5 PA NSO LA NDS

per 30 days)

suspension 2 mgml

Drug Name

MG 400 MG

ELIGARD (3 MONTH)

ELIGARD (4 MONTH)

ELIGARD (6 MONTH)

75 MG (1 MONTH)

SOLN 300 MG 400 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG

MG 20 MG

5 PA NSO NDS

gram20 ml

2 PA BvD

(Adrucil) 2 PA BvD

mg5 ml

(Faslodex) 5 NDS

1000 MG40 ML

5 PA NSO NDS

MG 40 MG

5 PA NSO NDS QL (30

per 30 days)

40 MG 5 MG

Drug Name

HERCEPTIN HYLECTA

10000 UNIT5 ML

5 PA NSO NDS QL (5

per 21 days)

SOLN 150 MG 440 MG

5 PA NSO NDS

125 MG 75 MG

5 PA NSO NDS QL (21

per 28 days)

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

ml 3 gram60 ml

gram 3000-1000 mg

5 PA BvD NDS

per 30 days)

per 28 days)

280 MG 420 MG 560 MG

5 PA NSO NDS QL (28

per 28 days)

50 MGML

5 PA NSO NDS

5 PA NSO NDS QL (4

per 365 days)

5 PA NSO NDS QL (8

per 28 days)

per 30 days)

SOLN 15 MG 45 MG

Drug Name

20 MG 25 MG 5 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 420 MG

5 PA NSO NDS

SOLUTION 25 MGML

5 PA NSO NDS QL (8

per 21 days)

5 PA NSO NDS QL (49

per 28 days)

5 PA NSO NDS QL (70

per 28 days)

5 PA NSO NDS QL (91

per 28 days)

(200 MG X 1)

5 PA NSO NDS QL (21

per 28 days)

(200 MG X 2)

5 PA NSO NDS QL (42

per 28 days)

(200 MG X 3)

5 PA NSO NDS QL (63

per 28 days)

5 PA NSO NDS

X 1) 18 MGDAY (10 MG X 1-4 MG

X2) 20 MGDAY (10 MG X 2) 24

8 MGDAY (4 MG X 2)

5 PA NSO NDS

50 MGML

5 PA NSO NDS QL (7

per 21 days)

per 28 days)

per 30 days)

Drug Name

SOLN 1 MG

5 PA NSO NDS

SYRINGE KIT 375 MG

150 MG

per 30 days)

(Max 64 Years)

per 30 days)

soln 1 gram

2 PA BvD

solution 25 mgml

2 PA BvD

5 PA NSO NDS

per 30 days)

Drug Name

MG 4 MG

5 PA NSO NDS QL (3

per 28 days)

750 UNITML

5 PA NSO NDS

ONIVYDE INTRAVENOUS

DISPERSION 43 MGML

100 MG10 ML 240 MG24 ML 40

MG4 ML

5 PA NSO NDS

(200 MG X 1)

5 PA NSO NDS QL (28

per 28 days)

(200 MG X1-50 MG X1) 300 MGDAY

(150 MG X 2)

5 PA NSO NDS QL (56

per 28 days)

SOLN 140 MG

5 PA NSO NDS

MG 3 MG 4 MG

5 PA NSO NDS QL (21

per 28 days)

per 21 days)

5 PA NSO LA NDS QL

(28 per 28 days)

MGML) 1600 MG134 ML (120

5 PA NSO NDS

RITUXAN INTRAVENOUS

CONCENTRATE 10 MGML

5 PA NSO NDS

250 MG 300 MG

per 30 days)

per 28 days)

MG5 ML

5 PA NSO NDS QL (30

per 30 days)

Drug Name

per 28 days)

MG 375 MG 50 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 100 MG 400 MG

5 PA NSO NDS

SOLN 35 MG

5 PA NSO NDS

per 30 days)

5 PA NSO LA NDS QL

(30 per 30 days)

per 30 days)

per 28 days)

200 MG

per 28 days)

per 30 days)

5 PA NSO NDS

SOLN 100 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG 25 MG

5 PA NSO NDS

1125 MG

225 MG

5 NDS QL (1 per 168

Drug Name

375 MG

SOLUTION 35 MGML

5 PA NSO NDS

per 30 days)

(180 per 30 days)

per 30 days)

100 MG

5 PA NSO LA NDS

150 MG 200 MG 50 MG

5 PA NSO NDS QL (56

per 28 days)

50 mg5 ml

(Navelbine) 2

per 30 days)

MG 45 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 44-100 MG

5 PA BvD NDS

250 MG

5 PA NSO NDS QL (60

per 30 days)

4 PA BvD ST

per 30 days)

Drug Name

MGWEEK (20 MG X 5)

5 PA NSO NDS QL (20

per 28 days)

MGWEEK (20 MG X 8)

5 PA NSO NDS QL (32

per 28 days)

(20 MG X 3)

5 PA NSO NDS QL (12

per 28 days)

(20 MG X 4)

5 PA NSO NDS QL (16

per 28 days)

per 30 days)

200 MG40 ML (5 MGML) 50 MG10

ML (5 MGML)

5 PA NSO NDS

SOLN 1 MG

5 PA NSO NDS

per 30 days)

IMPLANT 108 MG

IMPLANT 36 MG

5 PA NSO NDS QL (60

per 30 days)

per 28 days)

per 30 days)

Anticonvulsants

Drug Name

5 ST NDS

SOLUTION 50 MG5 ML

5 NDS QL (60 per 30

(Carbatrol) 2

(Tegretol) 2

(Tegretol XR) 2

125-15-175-20 MG 5-75-10 MG

75-10 mg

(Diastat AcuDial) 4

sprinkle 125 mg

hr 250 mg 500 mg

(Depakote ER) 2

(drec) 125 mg 250 mg 500 mg

(Depakote) 2

5 PA NSO NDS

Drug Name

(Cerebyx) 2

4 ST QL (720 per 30

MG 8 MG

200 mg 25 mg

(Lamictal) 1

(Lamictal) 2

mg5 ml

(Keppra) 2

mg 500 mg 750 mg

(Keppra) 2

24 hr 500 mg 750 mg

(Keppra XR) 2

MG 200 MG 225 MG 25 MG 300 MG

50 MG 75 MG

ml (60 mgml)

(Trileptal) 2

600 mg

(Trileptal) 2

300 MG 600 MG

2 PA NSO-HRM AGE

(Max 64 Years)

Drug Name

162 mg 30 mg 324 mg 60 mg 648 mg

972 mg

2 PA NSO-HRM AGE

(Max 64 Years)

100 mg

200 mg 300 mg

(Phenytek) 2

200 mg 225 mg 25 mg 300 mg 50 mg

per 30 days)

SUSPENSION 1000 MG

4 ST QL (120 per 30

mg 25 mg

5 PA NSO NDS QL (60

per 30 days)

(Gabitril) 2

(Topamax) 2

100 mg 150 mg 200 mg 25 mg 50 mg

(Qudexy XR) 4

mg 50 mg

(Topamax) 1

mg5 ml (100 mgml)

(Depacon) 2

solution 250 mg5 ml

Drug Name

per 30 days)

200 MG20 ML

MG 200 MG 50 MG

Antidementia Agents

24 hr 16 mg 24 mg 8 mg

14 mg 21 mg 28 mg 7 mg

NAMZARIC ORAL

MG 21-10 MG 28-10 MG 7-10 MG

3 mg 45 mg 6 mg

133 mg24 hour 46 mg24 hr 95 mg24

Antidepressants

150 mg 25 mg 50 mg 75 mg

Drug Name

mg 50 mg

24 hr 150 mg 300 mg

(Wellbutrin XL) 2

(Wellbutrin SR) 2

(Anafranil) 2

50 mg 75 mg

release(drec) 30 mg

MG24 HR

5 NDS QL (30 per 30

mg 5 mg

(Lexapro) 1

FETZIMA ORAL

HR 120 MG 20 MG 40 MG 80 MG

(Prozac) 1

Drug Name

(Tofranil) 2

mg 30 mg 45 mg

(Remeron SolTab) 2

200 mg 250 mg 50 mg

50 mg 75 mg

(Pamelor) 1

30 mg 40 mg

(Max 64 Years)

4 PA NSO-HRM AGE

(Max 64 Years)

10 mg 2-25 mg 4-10 mg 4-25 mg 4-50

(Zoloft) 1

(28 MG X 3)

5 PA NSO NDS

20 MG 5 MG

24hr 150 mg

24hr 375 mg 75 mg

Drug Name

375 mg 50 mg 75 mg

MG 40 MG

PACK 10 MG (7)- 20 MG (23)

SOLUTION 5 MGML

Antidiabetic Agents

25-5 MG

1000 MG 150-500 MG 50-1000 MG

3 ST QL (120 per 30

150-500 MG 50-1000 MG 50-500 MG

MG 50-500 MG

500 MG

MG 50 MG

1000 MG 25-500 MG 25-850 MG

28 days)

Drug Name

hr 500 mg

hr 750 mg

28 days)

MG 125-500 MG 5-1000 MG 5-500

1000 MG

Insulins

UNITML (3 ML)

FIASP U-100 INSULIN

UNITML

Drug Name

UNITML

UNITML (3 ML)

UNITML

UNITML (70-30)

UNITML

UNITML (3 ML)

UNITML (70-30)

UNITML

UNITML (3 ML)

Drug Name

UNITML (15 ML)

UNITML (3 ML)

UNITML

Sulfonylureas

25 mg 5 mg

mg 5-500 mg

mg 6 mg

Years)

mg 25-500 mg 5-500 mg

Years)

Antifungals

ABELCET INTRAVENOUS

SUSPENSION 5 MGML

5 PA BvD NDS

Drug Name

mg 70 mg

(Cancidas) 5 NDS

(clotrimazole))

(Lotrisone) 2

400 mg200 ml

2 PA BvD

(Diflucan) 2

200 mg 50 mg

(Diflucan) 2

mg5 ml

MG5 ML (40 MGML)

unitgram

Drug Name

(Vfend) 5 NDS

Antigout Agents

Antihistamines

Years)

mgml 50 mgml

Years)

Membrane)

Drug Name

Antimigraine Agents

70 MGML

140 MGML 70 MGML

225 MG15 ML

EMGALITY SYRINGE

ML (100 MGML X 3)

mg 5 mg

mgactuation

25 mg 50 mg

cartridge 6 mg05 ml

(Imitrex STATdose

Refill)

solution 6 mg05 ml

syringe 6 mg05 ml

Antimycobacterials

Drug Name

Antimycobacterials

1 GRAM

168 days)

Antinausea Agents

025 MG

CAPSULE 300-05 MG

4 PA BvD

(1)- 80 mg (2)

EMULSION 72 MGML

Drug Name

ML FINAL CONC)

mgml 1 mgml (1 ml)

Drowsy)

mg2 ml

mg 8 mg

2 PA BvD

Years)

mg 5 mg

(Compazine) 1

50 mgml

Years)

25 mg 50 mg

Years)

1 mg over 3 days

days) AGE (Max 64

Years)

Drug Name

days) AGE (Max 64

Years)

Antiparasite Agents

(Malarone) 2

500 mg

SOLN 300 MG

4 PA BvD

300 MG

APOKYN SUBCUTANEOUS

CARTRIDGE 10 MGML

Drug Name

mg 25-100 mg 25-250 mg

(Sinemet) 2

(Sinemet CR) 2

(Stalevo 50) 4

tablet 1875-75-200 mg

(Stalevo 75) 4

(Stalevo 100) 4

tablet 3125-125-200 mg

(Stalevo 125) 4

tablet 375-150-200 mg

(Stalevo 150) 4

(Stalevo 200) 4

GOCOVRI ORAL

24HR 137 MG

GOCOVRI ORAL

24HR 685 MG

30 days)

258 MG

mg 05 mg 075 mg 1 mg 15 mg

(Mirapex) 1

Drug Name

ABILIFY MAINTENA

INTRAMUSCULAR

RECON 300 MG 400 MG

ABILIFY MAINTENA

INTRAMUSCULAR

mg 30 mg 5 mg

SYRING 675 MG24 ML

SYRING 1064 MG39 ML

5 NDS QL (39 per 56

SYRING 441 MG16 ML

5 NDS QL (16 per 28

SYRING 662 MG24 ML

5 NDS QL (24 per 28

SYRING 882 MG32 ML

5 NDS QL (32 per 28

200 mg 25 mg 50 mg

Drug Name

mg 125 mg 25 mg

30 days)

MG 6 MG 8 MG

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

25 mgml

25 mg 5 mg

solution 100 mgml

solution 50 mgml

(Haldol) 2

5 mgml

mg 2 mg 20 mg 5 mg

Drug Name

INVEGA SUSTENNA

MG075 ML

INVEGA SUSTENNA

MG15 ML

5 NDS QL (15 per 28

INVEGA SUSTENNA

MG025 ML

INVEGA SUSTENNA

MG05 ML

5 NDS QL (05 per 28

5 NDS QL (0875 per 84

5 NDS QL (1315 per 84

5 NDS QL (2625 per 84

MG 40 MG 60 MG

mg 5 mg 50 mg

per 30 days)

mg 20 mg 5 mg 75 mg

mg 15 mg 20 mg 5 mg

24hr 15 mg 3 mg

Drug Name

24hr 6 mg

24hr 9 mg

mg 8 mg

PERSERIS ABDOMINAL

SUBCUTANEOUS

120 MG 90 MG

mg 300 mg 400 mg 50 mg

30 days)

3 MG 4 MG

RISPERDAL CONSTA

MG2 ML 25 MG2 ML

RISPERDAL CONSTA

MG2 ML 50 MG2 ML

mg 2 mg 3 mg 4 mg

mg 05 mg 1 mg 2 mg

mg 4 mg

MG 25 MG 5 MG

mg 50 mg

mg 5 mg

30 days)

Drug Name

MG 45 MG 6 MG

PACK 15 MG (1)- 3 MG (6)

mg 60 mg 80 mg

ZYPREXA RELPREVV

Antiretrovirals

(Epzicom) 2

tablet 300-150-300 mg

(Trizivir) 5 NDS

300 mg

(Reyataz) 5 NDS

300 MG

400 MG

300 MG

400 mg

(Videx EC) 2

Drug Name

MG5 ML (5 MGML)

SOLN 90 MG

200-10 MG

200 MG

PACKET 100 MG

ISENTRESS ORAL

(Combivir) 2

mg5 ml

(Kaletra) 2

Drug Name

hr 100 mg 400 mg

(Viramune XR) 2

100 MG

600 MG 800 MG

DISPERSIBLE 100 MG

SOLUTION 10 MGML

PACKET 50 MG

300 MG 75 MG

mg 40 mg

200-300 MG

200-10 MG

300 mg

(Viread) 2

Drug Name

MG 133-200 MG 167-250 MG 200-300

MGML (FINAL)

VIDEX EC ORAL

CAPSULEDELAYED

625 MG

MGSCOOP (40 MGGRAM)

MG 250 MG

28 days)

480 MG

Drug Name

MGACTUATION

5 PA NDS

Hcv Antivirals

5 PA NDS

Interferons

5 PA NSO NDS

UNITML

5 PA NSO NDS

PEGASYS PROCLICK

MCG05 ML

SOLUTION 180 MCGML

Drug Name

MCG05 ML

200 MCG 300 MCG 600 MCG

5 PA NSO NDS

500 mg

2 PA BvD

500 mg

(Cytovene) 2 PA BvD

50 mgml

2 PA BvD

Expanders

Anticoagulants

PACK 5 MG (74 TABS)

mg3 ml

(Lovenox) 2

Drug Name

mg03 ml 40 mg04 ml 60 mg06 ml 80

mg08 ml

(Lovenox) 2

(Arixtra) 5 NDS

mg05 ml

(Arixtra) 2

5000 unitml (1 ml)

5000 unitml

unitml

1000 unitml

5000 unit05 ml

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

150 MG 75 MG

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

(Coumadin) 1

PACK 15 MG (42)- 20 MG (9)

TABLET 20 MG

SYRINGE 6 MG06 ML

5 PA NDS

GRANIX SUBCUTANEOUS

5 PA NDS

Drug Name

5 PA NDS

250 MCG

SYRINGE 6 MG06ML

5 PA NDS

MCG08 ML

5 PA NDS

4000 UNITML

20000 UNITML

40000 UNITML

PACKET 125 MG

30 days)

Drug Name

UNITML 4000 UNITML

40000 UNITML

SYRINGE 6 MG06 ML

5 PA NDS

150 MG

1000 mg10 ml (100 mgml)

(Cyklokapron) 2

Years)

400 mg

Caloric Agents

4 PA BvD

AMINOSYN 7 WITH

4 PA BvD

SOLUTION 85

4 PA BvD

Drug Name

4 PA BvD

SOLUTION 85

4 PA BvD

SOLUTION 7

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 275

4 PA BvD

Drug Name

SOLUTION 275

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

intravenous syringe

4 PA BvD

parenteral solution

4 PA BvD

intravenous syringe

4 PA BvD

FREAMINE HBC 69

SOLUTION 69

4 PA BvD

Drug Name

4 PA BvD

EMULSION 20 30

4 PA BvD

KABIVEN INTRAVENOUS

EMULSION 331-98-39

4 PA BvD

EMULSION 20

4 PA BvD

EMULSION 236-68-35

4 PA BvD

PARENTERAL SOLUTION

4 PA BvD

(Catapres) 1

mg24 hr

(Cardura) 2

Years)

200 MG 300 MG

30 days)

Drug Name

(Vazculep) 2

MG 40-25 MG

49-51 MG 97-103 MG

(Avapro) 1

150-125 mg 300-125 mg

(Avalide) 2

100-125 mg 100-25 mg 50-125 mg

(Hyzaar) 1

tablet 20-125 mg 40-125 mg 40-25 mg

(Benicar HCT) 2

(Micardis) 2

mg 80 mg

(Diovan) 2

160-125 mg 160-25 mg 320-125 mg

320-25 mg 80-125 mg

(Diovan HCT) 2

Inhibitors

(Lotensin) 1

mg 50 mg

mg 20 mg 5 mg

(Vasotec) 2

10-25 mg

(Vaseretic) 1

5-125 mg

Drug Name

10-125 mg 20-125 mg 20-25 mg

(Zestoretic) 1

mg 8 mg

(Accupril) 1

mg 5 mg

(Altace) 1

mg 150 mg

Years)

500 mcg

(Tikosyn) 2

mg5 ml (2 ) 50 mg5 ml (1 )

250 mg

mgml 500 mgml

300 mg

(Tenoretic 100) 2

(Tenoretic 50) 2

Drug Name

10-625 mg 25-625 mg 5-625 mg

(Ziac) 1

MG 20 MG 5 MG

3125 mg 625 mg

(Coreg) 1

(5 mgml)

(Toprol XL) 2

100-25 mg 100-50 mg

50-25 mg

(Lopressor HCT) 2

mg5 ml

(Lopressor) 2

mg5 ml

(Lopressor) 1

24 hr 120 mg 160 mg 60 mg 80 mg

(Inderal LA) 2

mg 60 mg 80 mg

mg 80 mg

(Betapace) 2

Drug Name

24hr 120 mg 180 mg 240 mg 300 mg

(Tiazac) 2

(Cardizem CD) 2

(Cardizem) 2

120 mg 180 mg 240 mg

hr 120 mg 180 mg 240 mg 300 mg 360

100 mg 200 mg 300 mg

(Verelan PM) 2

hr 120 mg 180 mg 240 mg

(Verelan) 2

hr 360 mg

(Verelan) 4

mg 180 mg 240 mg

(Calan SR) 1

Drug Name

mg03 ml

30 MG3 ML

mg 50 mg

hr 1000 mg 500 mg

(Ranexa) 2

MG03 ML

30 days)

Dihydropyridines

mg 60 mg

(Norvasc) 1

mg 10-40 mg 5-10 mg 5-20 mg 5-40 mg

(Lotrel) 2

mg 10-320 mg 5-160 mg 5-320 mg

(Exforge) 2

24hr 30 mg 60 mg 90 mg

(Procardia XL) 2

mg 60 mg 90 mg

(Adalat CC) 2

Diuretics

5-50 mg

Drug Name

soln 500 mg

(Diuril IV) 2

mg5 ml (8 mgml)

(Lasix) 1

25 mg 50 mg

30 days)

(PM) 60 MG (AM) 30 MG (PM) 90 MG

(AM) 30 MG (PM)

(Aldactone) 1

capsule 375-25 mg

(Dyazide) 1

capsule 50-25 mg

375-25 mg

(Maxzide-25mg) 1

75-50 mg

(Maxzide) 1

Dyslipidemics

mg 80 mg

(Lipitor) 1

in packet 4 gram

(Questran) 2

Drug Name

mg 200 mg 67 mg

145 mg 48 mg

(Tricor) 2

MG 40 MG 60 MG

1000 mg 500 mg 750 mg

(Niaspan Extended-

Release)

(Pravachol) 1

REPATHA PUSHTRONEX

REPATHA SURECLICK

REPATHA SYRINGE

mg 5 mg

mg 80 mg

Drug Name

PACKET 375 GRAM

Inhibitors

125 MG 150-25 MG 300-125 MG 300-

Vasodilators

mg 30 mg

release 40 mg

(ISOCHRON) 2

mg10 ml (5 mgml)

mg 06 mg

(Nitrostat) 2

(Minitran) 2

25 mg 40 mg

Drug Name

30 days)

mg3 ml (20 mgml)

(Cafcit) 2 PA BvD

(20 mgml)

12 hr 10 mg

mg 5 mg

mg 30 mg

mg 5 mg 75 mg

Drug Name

(Intuniv ER) 2

MG (21)

5 PA NDS

SOLUTION 12 MG12 ML

300 mg 600 mg

release 300 mg

(Lithobid) 2

release 450 mg

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

28 days)

mg 60 mg

Drug Name

ml 5 mg5 ml

mg 5 mg

OCREVUS INTRAVENOUS

SOLUTION 30 MGML

5 PA NDS QL (20 per

180 days)

MCG05 ML

5 PA NDS

28 days)

MCG05 ML

MCG05ML (6)

5 PA NDS

125 MG 25 MG 50 MG

PACK 125 MG (5)-25 MG(8)-50 MG(42)

Drug Name

TECFIDERA ORAL

CAPSULEDELAYED

TECFIDERA ORAL

CAPSULEDELAYED

MG (46)

5 PA NDS

TECFIDERA ORAL

CAPSULEDELAYED

28 days)

Contraceptives

mg- 35 mcg

010 mg-20 mcg (84)10 mcg (7)

015 mg-30 mcg (84)10 mcg (7)

mg-mcg

(24)75 mg (4)

30 mcg (21)75 mg (7)

mcg (21)75 mg (7)

001 mg x 5

Drug Name

001 mg x 5

(24)75 mg (4)

mcg (21)75 mg (7)

mg-mcg

mg- 35 mcg

015 mg-30 mcg (84)10 mcg (7)

015-002 mgx21 001 mg x 5

(Azurette (28)) 2

015-003 mg

(Apri) 2

3-002 mg

(Gianvi (28)) 2

3-003 mg

(Ocella) 2

(5)125-30(10)

Drug Name

35 mg-mcg

(Kelnor 135 (28)) 2

50 mg-mcg

(Kelnor 1-50) 2

(24)75 mg (4)

015 mg-30 mcg (91)

mcg (21)75 mg (7)

(21)75 mg (7)

(24)75 mg (4)

001 mg x 5

(84)10 mcg (7)

mcg 015 mg-25 mcg

(84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

(21)75 mg (7)

(5)125-30(10)

01-20 mg-mcg

(Afirmelle) 2

015-003 mg

(Altavera (28)) 2

50-30 (6)75-40 (5)125-30(10)

(Enpresse) 2

20 mcg (21)75 mg (7)

(5)125-30(10)

Drug Name

035 mg

(Camila) 2

1-20 mg-mcg

(Aurovela 120 (21)) 2

1 mg-20 mcg (21)75 mg (7)

1 mg-20 mcg (24)75 mg (4)

(Aurovela 24 Fe) 2

0180215025 mg-25 mcg

0180215025 mg-35 mcg (28)

025-35 mg-mcg

(Estarylla) 2

mg- 35 mcg

001 mg x 5

mcg 1-35 mg-mcg

015 mg-30 mcg (91)

001 mg x 5

015 mg-30 mcg (84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

35mcg (9)

mg-35 mcg (28)

1mg-35mcg (9)

35 mcg (28)

mg-25 mcg

25 mcg

mg-25 mcg

mcg (28)

0180215025 mg-35 mcg (28)

(5)125-30(10)

mg-25 mcg

35 mcg (28)

0112515-25 mg-mcg

001 mg x 5

Drug Name

mcg24 hr

mouthwash 012

(Oralone) 2

(Soriatane) 2

MEDICATED

rel 10 mg

Drug Name

UNITGRAM

mg 40 mg

(Cleocin T) 2

(Ery Pads) 2

suspension 10

(Klaron) 2

Agents

Drug Name

ointment 005

(Diprolene) 2

(Cutivate) 2

Drug Name

applicator 25

(Triderm) 1

0025 01

0025 01 05

Devices

Drug Name

03 ML 31 GAUGE X 1564

12 ML 31 GAUGE X 1564

(Lite Touch Insulin

Syringe)

GAUGE X 12

(1st Tier Unifine

Pentips)

SOLUTION 250 UNITML

SOLUTION 29 MG5 ML

SOLN 400 UNIT

60000 UNIT 24000-76000 -120000

UNIT 3000-9500- 15000 UNIT

36000-114000- 180000 UNIT 6000-

19000 -30000 UNIT

SOLUTION 6 MG3 ML

SOLN 15 MG 75 MG

SOLN 35 MG 5 MG

5 PA NDS

2 MGML

5 PA NDS

Drug Name

SOLUTION 8 MGML

5 PA BvD NDS

2 MGML

5 PA NDS

SOLUTION 5 MG5 ML

5 PA NDS

MG 20 MG 5 MG

5 PA NDS

ML 20 MGML

5 PA NDS

SOLUTION 1 MGML

5 PA BvD NDS

5 PA NDS

5 PA LA NDS

5 MG5 ML (1 MGML)

5 PA NDS

400 UNIT

42000 UNIT 15000-47000 -63000

UNIT 20000-63000- 84000 UNIT

25000-79000- 105000 UNIT 3000-

10000 -14000-UNIT 40000-126000-

168000 UNIT 5000-17000- 24000

Miscellaneous

Drug Name

(Cyclogyl) 2

DROPS 044

aerosol 003

(Alcaine) 2

Agents

unitgram

(AK-Poly-Bac) 2

CIPRODEX OTIC (EAR)

(Ciloxan) 1

(Cetraxal) 4

mggram (05 )

mggram)

DROPS VISCOUS 05

Drug Name

(Vigamox) 2

DROPSSUSPENSION 5

(Neo-Polycin HC) 2

mg-unit-unitg

(Neo-Polycin) 2

(Maxitrol) 2

10000 unitg-01

(Maxitrol) 2

unit-0025mgml

unitml-

35-400-10000 mg-unitg-1

10000 unitgram

(Polytrim) 1

drops 10

(Bleph-10) 2

ointment 10

(eye) drops 10 -023 (025 )

Drug Name

(TobraDex) 2

Inflammatory Agents

DROPSSUSPENSION 02

DROPS 0075

DROPS 005

mcg (0025 )

dropssuspension 01

(FML Liquifilm) 4

drops 003

DROPSSUSPENSION 03

DROPSSUSPENSION 1

DROPSGEL 05

OINTMENT 05

DROPSGEL 038

dropssuspension 1

(Pred Forte) 4

Drug Name

DROPS 007

DROPPERETTE 005

DROPPERETTE 5

soln 20 mg

soln 40 mg

(Nexium IV) 2

mg2 ml

release(drec) 15 mg

release(drec) 30 mg

(Protonix) 2

(drec) 20 mg

(drec) 40 mg

50 mg2 ml (25 mgml)

(Zantac) 2

(ranitidine))

Drug Name

DISPERSIBLE 200 MG

0025 mg5 ml

Years)

0025 mg

Years)

KIT 5 MG

5 PA NDS

193 gram60 ml

290 MCG 72 MCG

(loperamide))

(Reglan) 1

Drug Name

SOLUTION 12 MG06 ML

28 days)

SYRINGE 12 MG06 ML

28 days)

SYRINGE 8 MG04 ML

28 days)

gram60 ml

Laxatives

GRAM -12 GRAM160 ML

-584 gram

-586 gram

2272-672 -584 gram

(Colyte with Flavor

Packs)

420 gram

Phosphate Binders

Drug Name

(Renvela) 5 NDS

VELPHORO ORAL

mg 5 mg 50 mg

(Urecholine) 2

(Ditropan XL) 2

release 24hr 15 mg

24hr 2 mg 4 mg

(Detrol LA) 2

hr 10 mg

(Uroxatral) 1

THIOLA EC ORAL

5 PA NDS

Drug Name

mg 250 mg 500 mg

(Exjade) 5 PA NDS

500 mg

(Desferal) 2 PA

250 MG

5 PA NDS

MG 90 MG

5 PA NDS

MG 90 MG

5 PA NDS

30 days)

Hormonal Agents

Androgens

100 mgml 200 mgml

200 mgml (1 ml)

200 mgml

ML 75 MG05 ML

Years)

Drug Name

mg24 hr 00375 mg24 hr 005 mg24 hr

0075 mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

0025 mg24 hr 005 mg24 hr 0075

mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

00375 mg24 hr

days) AGE (Max 64

Years)

mg24 hr 00375 mg24 hr 005 mg24 hr

006 mg24 hr 0075 mg24 hr 01 mg24

days) AGE (Max 64

Years)

mgml 40 mgml

(Delestrogen) 2

05-01 mg

Years)

HR 01 MG24 HR

mg-mcg

Years)

05-25 mg-mcg

Years)

1-5 mg-mcg

Years)

045 MG 0625 MG 09 MG 125 MG

Years)

MGGRAM

Drug Name

MG (14) 0625MG-5MG(14)

Years)

045-15 MG 0625-25 MG 0625-5 MG

Years)

suspension 6 mgml

mg 4 mg 6 mg

(Decadron) 1 PA BvD

1 PA BvD

solution 10 mgml

MG 6 MG

(Cortef) 2

(Depo-Medrol) 2

mg 4 mg 8 mg

(Medrol) 2

(Medrol (Pak)) 2

(Solu-Medrol) 2

mg5 ml (3 mgml)

2 PA BvD

Drug Name

2 PA BvD

1 PA BvD

suspension 40 mgml

(Kenalog) 2

Pituitary

mcgspray (01 ml)

(DDAVP) 2

mcgspray (01 ml)

SOLN 1 MG

MG025 ML

MG025 ML 06 MG025 ML 08

MG025 ML 1 MG025 ML 12

MG025 ML 14 MG025 ML 16

MG025 ML 18 MG025 ML 2

MG025 ML

5 PA NDS

5 MGML (15 UNITML)

5 PA NDS

HUMATROPE INJECTION

5 PA NDS

SOLN 5 (15 UNIT) MG

5 PA NDS

Drug Name

SOLUTION 10 MGML

1125 MG

SYRINGE KIT 75 MG

LUPRON DEPOT-PED

NORDITROPIN FLEXPRO

ML (10 MGML) 30 MG3 ML (10

5 PA NDS

NORDITROPIN FLEXPRO

MG15 ML (33 MGML)

NUTROPIN AQ NUSPIN

5 PA NDS

mcgml 200 mcgml

(Sandostatin) 2

mcgml (1 ml)

5 PA NDS

RECON SOLN 58 MG

5 PA NDS

Drug Name

SAIZEN SAIZENPREP

5 PA NDS

SOLN 5 MG 88 MG

5 PA NDS

INTRAMUSCULAR

SOLN 4 MG 5 MG 6 MG

5 PA NDS

SOMATULINE DEPOT

MG05 ML

5 PA NSO NDS QL (1

per 28 days)

SOMATULINE DEPOT

ML 90 MG03 ML

25 MG 30 MG

5 PA NDS

(65 MCGDAY)

5 NDS QL (1 per 360

AEROSOL 2 MGML

225 MG

5 NDS QL (1 per 168

RECON SOLN 10 MG

5 PA NDS

RECON SOLN 5 MG

SOLN 88 MG

5 PA NDS

Progestins

SUSPENSION 400 MGML

5 PA NSO NDS

Drug Name

suspension 150 mgml

syringe 150 mgml

25 mg 5 mg

(Provera) 1

(40 mgml)

Years)

mg 200 mg

(Prometrium) 2

mcg 125 mcg 137 mcg 150 mcg 175

88 mcg

(Euthyrox) 1

(Cytomel) 2

ACTEMRA ACTPEN

MG09 ML

5 PA NDS

ACTEMRA INTRAVENOUS

80 MG4 ML (20 MGML)

5 PA NDS

SYRINGE 162 MG09 ML

5 PA NDS

SOLN 220 MG

100 mg

2 PA BvD

MG X 2 VIALS)

5 PA NDS

Drug Name

5 PA NDS

mg5 ml

mg 25 mg

(Gengraf) 2 PA BvD

5 PA NDS

SOLN 25 MG (1 ML)

5 PA NDS

25 MG05 ML (05) 50 MGML (1 ML)

5 PA NDS

ENBREL SURECLICK

MGML (1 ML)

5 PA NDS

SOLUTION 10 5

5 PA BvD NDS

4 PA BvD

SOLUTION 10

5 PA BvD NDS

GRAM 5 GRAM

5 PA BvD NDS

SOLUTION 10 10 (100 ML) 10

(200 ML)

5 PA BvD NDS

Drug Name

KIT 40 MG08 ML 40 MG08 ML (6

5 PA NDS

KIT 40 MG08 ML

5 PA NDS

KIT 10 MG02 ML 20 MG04 ML 40

MG08 ML

5 PA NDS

MG08 ML-40 MG04 ML

5 PA NDS

80 MG08 ML

5 PA NDS

MG02 ML 40 MG04 ML

5 PA NDS

SOLUTION 300 UNITML

HYPERRAB SD (PF)

UNITML

HYQVIA SUBCUTANEOUS

25 GRAM 25 ML (10 ) 20 GRAM

200 ML (10 ) 30 GRAM 300 ML (10

) 5 GRAM 50 ML (10 )

5 PA BvD NDS

SOLN 150 MGML

5 PA NDS

SOLUTION 150 MGML

5 PA NDS

Drug Name

100 MGML

5 PA NDS

UNITML

SOLN 100 MG

5 PA NDS

SOLUTION 150 UNITML

MG114 ML

5 PA NDS

MG114 ML

5 PA NDS

100 MG067 ML

5 PA NDS

recon soln 500 mg

(CellCept) 2 PA BvD

SOLN 250 MG

5 PA BvD NDS

OCTAGAM INTRAVENOUS

SOLUTION 10 5

5 PA BvD NDS

5 PA NDS

ORENCIA CLICKJECT

125 MGML

5 PA NDS

875 MG07 ML

5 PA NDS

OTEZLA STARTER ORAL

MG (4)-30 MG (47) 10 MG (4)-20 MG

(4)-30 MG(19)

5 PA NDS

Drug Name

SOLUTION 10

5 PA BvD NDS

5 MGML

4 PA BvD

PACKET 02 MG 1 MG

4 PA BvD ST

MG025 ML 15 MG03 ML 175

MG035 ML 20 MG04 ML 225

MG045 ML 25 MG05 ML 30 MG06

ML 75 MG015 ML

SOLN 100 MG

5 PA NDS

SOLN 100 MG

5 PA NDS

MG15 ML

5 PA NDS

SOLUTION 125 MGML

5 PA NDS

100 MGML 50 MG05 ML

5 PA NDS

130 MG26 ML

5 PA NDS

SOLUTION 45 MG05 ML

5 PA NDS

(Prograf) 2 PA BvD

TALTZ AUTOINJECTOR

80 MGML

5 PA NDS

Drug Name

SYRINGE 80 MGML

5 PA NDS

INJECTOR 100 MGML

5 PA NDS

SYRINGE 100 MGML

5 PA NDS

300 MG15 ML

5 PA LA NDS

5 PA NDS

05 MG 075 MG 1 MG

5 PA BvD NDS

Vaccines

ADACEL(TDAP

ADOLESNADULT)(PF)

LF-(25-5-3-5 MCG)-5LF05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

(25-5-3-5 MCG)-5LF05 ML

3 PA BvD

LF05ML

10-5 LF-MCG-LF05ML

SUSPENSION 20 MCGML

3 PA BvD

Drug Name

SYRINGE 20 MCGML

3 PA BvD

MCG05 ML

3 PA BvD

SUSPENSION 05 ML

SYRINGE 05 ML

720 ELISA UNIT05 ML

ELISA UNIT05 ML

3 PA BvD

58-10 LF-MCG-LF05ML

LF-MCG-LF05ML

32 UNIT05 ML

UNIT05 ML

SYRINGE 6 MCG05 ML

SOLUTION 4 MCG05 ML

Drug Name

10LF05 ML

10EXP3-43-3- 399 TCID5005

UNIT05ML

25 UNIT

3 PA BvD

RECOMBIVAX HB (PF)

3 PA BvD

RECOMBIVAX HB (PF)

MCGML 5 MCG05 ML

3 PA BvD

CCID50ML

SOLUTION 2 ML

50 MCG05 ML

TDVAX INTRAMUSCULAR

UNIT05ML

LF UNIT05 ML

Drug Name

SYRINGE 25 MCG05 ML

UNITML

1350 UNIT05 ML

10 EXP474 UNIT05 ML

19400 UNIT065 ML

Agents

budesonide oral

(Entocort EC) 2

tablets) 400 mg

(Delzicol) 2

(drec) 800 mg

(Asacol HD) 2

Drug Name

(drec) 500 mg

MGACTUATION

SOLUTION

Chloride)

solution

(Aqua Care Sterile

Water)

mcg2 ml

(Hectorol) 2

105 MG117 ML

30 days)

210MG234ML ( 105MG117MLX2)

30 days)

MCG24 ML

Drug Name

200 UNITML

MCGDOSE

solution 2 mcgml

60 MGML

RAYALDEE ORAL

HR 30 MCG

3 PA QL (156 per 30

mg5 ml

soln 500 mg

(Ethyol) 2

SOLN 120 MG 400 MG

5 PA NDS

INJECTOR 200 MGML

SYRINGE 200 MGML

CETYLEV ORAL TABLET

Drug Name

GRAM17 ML

5 GRAM

30 days)

SOLUTION 50 MGML

5 PA LA NDS

RECON SOLN 1 MG

(Vistaril) 1

30 days)

100 mg 200 mg 350 mg 50 mg 500 mg

mg 25 mg 5 mg

100 mgml

(Carnitor) 2

soln 50 mg

(Fusilev) 5 NDS

mg5 ml

(Mestinon) 2

Drug Name

150 MG 200 MG 50 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 500 MG

PACKET 10 GRAM

5 NDS QL (24 per 14

PACKET 2 GRAM

30 days)

Ophthalmic Agents

Antiglaucoma Agents

release 500 mg

500 mg

DROPS 01

DROPSSUSPENSION 1

DROPS 02-05

drops 223-68 mgml

(Cosopt) 2

DROPS 001

(Isopto Carpine) 2

DROPS 002

Drug Name

025 05

(Timoptic) 1

(Timoptic-XE) 4

DROPS 0004

mgml (10 )

IONOSOL-MB IN D5W

SOLUTION 5

PARENTERAL SOLUTION

release 8 meq

40 gram1000 ml (4 )

2 PA BvD

gram100 ml (4 ) 4 gram50 ml (8 )

2 PA BvD

meqml (50 )

2 PA BvD

Drug Name

SOLUTION

SINGLE-USE

PARENTERAL SOLUTION

2 PA BvD

meqml (20 ml)

2 PA BvD

release 10 meq

release 8 meq

ml 40 meq15 ml

(K-Tab) 2

release 20 meq

(K-Tab) 4

(Klor-Con M10) 2

(Klor-Con M20) 2

(Urocit-K 10) 2

release 15 meq

(Urocit-K 15) 2

(Urocit-K 5) 2

parenteral solution

Corticosteroids

Drug Name

50 MCGDOSE

MCGACTUATION 230-21

MCGACTUATION 45-21

MCGACTUATION

MCGACTUATION 200

MCGACTUATION 50

MCGACTUATION

mg2 ml

MCGACTUATION

MCGACTUATION 50

MCGACTUATION

AEROSOL INHALER 110

MCGACTUATION

AEROSOL INHALER 220

MCGACTUATION

AEROSOL INHALER 44

MCGACTUATION

Drug Name

INHALATIONS 80-45

MCGACTUATION

MCGACTUATION 80-45

MCGACTUATION

Antileukotrienes

(Singulair) 1

Bronchodilators

25 mg 3 ml (0083 ) 25 mg05 ml

2 PA BvD

MCGACTUATION

AEROSOL INHALER 17

MCGACTUATION

COMBIVENT RESPIMAT

MCGACTUATION

2 PA BvD

STARTER 25 MCGML

Drug Name

MCGDOSE

12 hr 100 mg 200 mg 300 mg

(Theochron) 2

12 hr 450 mg

24 hr 400 mg 600 mg

(30 ACTUAT)

mgml (20 )

(Acetadote) 2 PA

200 mgml (20 )

2 PA BvD

10 MGML

5 PA NDS

2 PA BvD

Drug Name

30 days)

SYRINGE 30 MGML

INJECTOR 100 MGML

28 days)

SOLN 100 MG

28 days)

100 MGML

28 days)

PACKET 100-125 MG 150-188 MG

MG 200-125 MG

30 days)

RECON SOLN 1000 MG

5 PA BvD NDS

(N) 50-75 MG (D) 75 MG (N)

SOLN 150 MG

5 PA NDS

150 MGML 75 MG05 ML

5 PA NDS

Years)

Drug Name

Years)

250 mg 50 mg

MG 20 MG 5 MG

per 30 days)

Vasodilating Agents

MG 15 MG 2 MG 25 MG

soln 05 mg

(Flolan) 2 PA

soln 15 mg

(Flolan) 5 PA NDS

25 MG 5 MG

5 PA NDS

Drug Name

1 day)

SUSPENSION 32 MG

28 days)

(06 MGML)

5 PA NDS

1200 MCG 1400 MCG 1600 MCG

400 MCG 600 MCG 800 MCG

30 days)

PACK 200 MCG (140)- 800 MCG (60)

5 PA NDS

27 mg iron- 1 mg

A abacavir 47

ABELCET 35

ABILIFY MAINTENA 43

ABRAXANE 15

acamprosate 7

acarbose 32

acebutolol 60

acetazolamide 107

acetic acid 82 104

acetylcysteine 112

acitretin 76

ACTEMRA 95

ACTEMRA ACTPEN 95

ACTHIB (PF) 100

ACTIMMUNE 105

acyclovir 52 76

acyclovir sodium 52

ADACEL(TDAP

ADAGEN 80

adapalene 79

adefovir 52

ADEMPAS 114

adriamycin 15

adrucil 15

ADVAIR DISKUS 110

ADVAIR HFA 110

afeditab cr 63

AFINITOR 15

AFINITOR DISPERZ 15

afirmelle 70

a-hydrocort 91

(2 PACK) 38

AJOVY 38

AKYNZEO

(FOSNETUPITANT) 39

ala-cort 77

albendazole 41

alclometasone 77

ALCOHOL PADS 76

ALDURAZYME 80

ALECENSA 16

alendronate 104

alfuzosin 88

ALIMTA 16

ALINIA 41

ALIQOPA 16

aliskiren 66

allopurinol 37

alosetron 103

ALPHAGAN P 107

alprazolam 8

ALREX 84

altavera (28) 70

ALTRENO 79

ALUNBRIG 16

alyacen 135 (28) 70

alyacen 777 (28) 70

alyq 114

amabelz 89

amantadine hcl 41

AMBISOME 35

ambrisentan 114

amethia 70

amethia lo 70

amiloride 63

AMINOSYN 10 55

AMINOSYN 7 WITH

ELECTROLYTES 55

AMINOSYN 85 55

AMINOSYN 85 -

ELECTROLYTES 55

AMINOSYN II 10 56

AMINOSYN II 15 56

AMINOSYN II 7 56

AMINOSYN II 85 56

AMINOSYN II 85 -

ELECTROLYTES 56

AMINOSYN M 35 56

AMINOSYN-HBC 7 56

AMINOSYN-PF 10 56

AMINOSYN-PF 7

(SULFITE-FREE) 56

AMINOSYN-RF 52 56

amiodarone 60

AMITIZA 86

amitriptyline 29

amlodipine 63

ammonium lactate 76

amoxapine 30

amoxicillin 13

amphotericin b 35

ampicillin 13

ANADROL-50 89

anagrelide 55

anastrozole 16

ANORO ELLIPTA 111

APOKYN 41

apraclonidine 81

aprepitant 39

apri 70

APRISO 103

APTIOM 25 26

APTIVUS 47

aranelle (28) 70

ARCALYST 95

aripiprazole 43

ARISTADA 43

ARISTADA INITIO 43

armodafinil 114

ARNUITY ELLIPTA 110

arsenic trioxide 16

ashlyna 70

ASSURE ID INSULIN

SAFETY 79

atazanavir 47

atenolol 60

atomoxetine 66

atorvastatin 64

atovaquone 41

ATRIPLA 47

atropine 25 82

ATROVENT HFA 111

AUBAGIO 66

aubra 70

aurovela 1530 (21) 70

aurovela 24 fe 70

AUSTEDO 67

AVASTIN 16

aviane 70

AVONEX 67

ayuna 70

azacitidine 16

azathioprine 95

azelastine 82

azithromycin 12

AZOPT 107

aztreonam 13

azurette (28) 70

B baciim 10

bacitracin 82

baclofen 113

balsalazide 103

BALVERSA 16

balziva (28) 71

BANZEL 26

BAVENCIO 16

BAXDELA 14

NEEDLE 79

UNIT 80

bekyree (28) 71

BELEODAQ 16

BELSOMRA 114

benazepril 59

BENDEKA 16

BENLYSTA 105

benztropine 41

BESPONSA 16

BETASERON 67

betaxolol 60

BETHKIS 9

BEVYXXA 52

bexarotene 16

BEXSERO 100

bicalutamide 16

BICILLIN L-A 13

BIDIL 66

BIKTARVY 47

bleomycin 16

bleph-10 82

BLINCYTO 16

blisovi 24 fe 71

blisovi fe 1530 (28) 71

BOOSTRIX TDAP 100

BORTEZOMIB 16

BOSULIF 16 17

BRAFTOVI 17

BREO ELLIPTA 110

briellyn 71

BRILINTA 55

brimonidine 107

BRIVIACT 26

bromocriptine 41

BROMSITE 84

budesonide 103 110

bumetanide 63

bupropion hcl 30

buspirone 8

BYSTOLIC 61

BYVALSON 61

C cabergoline 41

CABLIVI 105

CABOMETYX 17

caffeine citrate 67

calcipotriene 76

calcitriol 104

CALDOLOR 6

CALQUENCE 17

camila 71

CAPASTAT 39

CAPRELSA 17

captopril 59

CARBAGLU 86

carbamazepine 26

carteolol 107

cartia xt 62

carvedilol 61

caspofungin 36

CAYSTON 13

caziant (28) 71

cefaclor 11

cefadroxil 11

cefazolin 11

cefdinir 11

cefepime 11

cefixime 11

cefotaxime 11

cefoxitin 11

cefpodoxime 12

cefprozil 12

ceftazidime 12

ceftriaxone 12

celecoxib 6

CELONTIN 26

cephalexin 12

CERDELGA 80

CEREZYME 80

CETYLEV 105

CHANTIX 8

CHANTIX CONTINUING

MONTH BOX 8

CHANTIX STARTING

MONTH BOX 8

chlorothiazide 64

chlorpromazine 43

chlorthalidone 64

chlorzoxazone 113

ciclopirox 36

cilostazol 55

CIMDUO 47

cimetidine hcl 85

CIMZIA 95

CIMZIA POWDER FOR

RECONST 95

cinacalcet 104

CINQAIR 112

CINRYZE 53

CINVANTI 39

CIPRODEX 82

ciprofloxacin 14

citalopram 30

clarithromycin 12

CLENPIQ 87

clindamycin hcl 10

CLINIMIX 5D15W

SULFITE FREE 56

CLINIMIX 5D25W

SULFITE-FREE 56

FREE 56

CLINIMIX 425D5W

SULFIT FREE 56

CLINIMIX 425-D25W

SULF-FREE 56

CLINIMIX 5-

CLINIMIX E 275D10W

SUL FREE 56

CLINIMIX E 275D5W

SULF FREE 57

CLINIMIX E 425D10W

SUL FREE 57

CLINIMIX E 425D25W

SUL FREE 57

CLINIMIX E 425D5W

SULF FREE 57

CLINIMIX E 5D15W

SULFIT FREE 57

CLINIMIX E 5D20W

SULFIT FREE 57

CLINIMIX E 5D25W

SULFIT FREE 57

clobazam 26

clobetasol 78

clofarabine 17

clomipramine 30

clonazepam 9

clonidine 58

clonidine hcl 58

clopidogrel 55

clotrimazole 36

clozapine 43 44

COARTEM 41

codeine sulfate 3

colchicine 37

colestipol 64

colocort 103

COMBIGAN 107

COMETRIQ 17

COMPLERA 47

compro 39

constulose 86

COPIKTRA 17

CORLANOR 62

cormax 78

cortisone 91

COTELLIC 17

CREON 80

CRIXIVAN 47

cromolyn 82 86 112

cryselle (28) 71

cyclobenzaprine 113

cyclopentolate 82

cyclophosphamide 17

CYCLOPHOSPHAMIDE 17

cyclosporine 96

cyproheptadine 37

CYRAMZA 17

cyred 71

CYSTADANE 106

CYSTARAN 82

D dalfampridine 67

DALIRESP 113

danazol 89

dantrolene 113 114

dapsone 39

DAPTACEL (DTAP

PEDIATRIC) (PF) 100

daptomycin 10

DARAPRIM 41

DARZALEX 17

dasetta 135 (28) 71

dasetta 777 (28) 71

DAURISMO 17

daysee 71

deblitane 71

decadron 91

decitabine 17

deferasirox 89

deferoxamine 89

DELSTRIGO 47

delyla (28) 71

DEMSER 62

DEPEN TITRATABS 89

DEPO-PROVERA 94

DESCOVY 47

desipramine 30

desmopressin 92

desoximetasone 78

dexamethasone 91

(pf) 91

phosphate 84 91

dextroamphetamine-

amphetamine 67

DIASTAT 26

DIASTAT ACUDIAL 26

diazepam 9 26

diazepam intensol 9

dicloxacillin 13

dicyclomine 86

didanosine 47

DIFICID 12

digitek 62

digox 62

digoxin 62 63

DIGOXIN 63

diltiazem hcl 62

dilt-xr 62

dimenhydrinate 39

DIPENTUM 103

dipyridamole 55

disulfiram 8

divalproex 26

dofetilide 60

donepezil 29

dorzolamide 107

dotti 90

DOVATO 48

doxazosin 58

doxepin 30

doxercalciferol 104

doxorubicin 17

doxy-100 15

dronabinol 39

droperidol 106

DROXIA 18

DUAVEE 90

duloxetine 30

DUPIXENT 96

DUREZOL 84

dutasteride 88

E econazole 36

EDARBI 59

EDARBYCLOR 59

EDURANT 48

efavirenz 48

EGRIFTA 92

ELAPRASE 80

ELIGARD 18

elinest 71

ELIQUIS 52

ELITEK 80

ELLA 71

ELMIRON 106

EMCYT 18

EMEND 40

EMFLAZA 91

EMGALITY PEN 38

EMGALITY SYRINGE 38

emoquette 71

EMPLICITI 18

EMSAM 30

EMTRIVA 48

enalaprilat 59

ENBREL 96

ENBREL SURECLICK 96

ENDARI 106

endocet 3

enoxaparin 52 53

enpresse 71

enskyce 71

entacapone 42

entecavir 52

ENTRESTO 59

enulose 86

EPCLUSA 51

EPIDIOLEX 26

epinastine 82

epinephrine 63

epitol 26

EPIVIR HBV 48

eplerenone 66

ergoloid 106

ERGOMAR 38

ERIVEDGE 18

ERLEADA 18

erlotinib 18

errin 71

ertapenem 13

ery pads 77

erythromycin 12 82

ESBRIET 113

estarylla 71

estradiol 90

eszopiclone 114

ethambutol 39

ethosuximide 26

etodolac 6

ETOPOPHOS 18

etoposide 18

EUCRISA 78

EVENITY 104

EVOTAZ 48

exemestane 18

EXONDYS 51 106

EXTAVIA 67

ezetimibe 65

F FABRAZYME 80

falmina (28) 72

famciclovir 52

famotidine 85

famotidine (pf) 85

FANAPT 44

FARYDAK 18

FASENRA 113

febuxostat 37

felbamate 27

FEMRING 90

femynor 72

fenofibrate 65

fentanyl 3

fentanyl citrate 3

FERRIPROX 89

FETZIMA 30

INSULIN 33

finasteride 88

FIRAZYR 63

FIRVANQ 10

FLEBOGAMMA DIF 96

flecainide 60

FLOVENT DISKUS 110

FLOVENT HFA 110

floxuridine 18

fluconazole 36

flucytosine 36

fludrocortisone 91

flumazenil 67

flunisolide 84

fluocinolone 78

fluocinonide 78

fluocinonide-e 78

fluorometholone 84

fluorouracil 18 76

fluoxetine 30

fluphenazine hcl 44

flurbiprofen 6

flutamide 18

fluvoxamine 31

fomepizole 106

fondaparinux 53

FORTEO 104

fosamprenavir 48

foscarnet 50

fosinopril 59

fosphenytoin 27

FREAMINE HBC 69 57

FREAMINE III 10 58

FULPHILA 53

fulvestrant 18

furosemide 64

FUZEON 48

fyavolv 90

FYCOMPA 27

G gabapentin 27

GALAFOLD 80

galantamine 29

GAMASTAN 96

GAMMAGARD LIQUID 96

MCGML) 96

GAMMAPLEX 96

GAMMAPLEX (WITH

SORBITOL) 96

GARDASIL 9 (PF) 101

GATTEX 30-VIAL 86

GAUZE PAD 80

gavilyte-c 87

gavilyte-g 87

gavilyte-n 87

GAZYVA 18

gemfibrozil 65

generlac 86

gengraf 96

GENOTROPIN 92

gentak 82

gentamicin 9 77 82

GENVOYA 48

GEODON 44

GILENYA 67

GILOTRIF 18

glatiramer 67

glatopa 67 68

GLEOSTINE 18

glimepiride 35

glipizide 35

glyburide 35

glycopyrrolate 86

glydo 7

GLYXAMBI 32

GOCOVRI 42

granisetron (pf) 40

granisetron hcl 40

GRANIX 53 54

guanfacine 58 68

guanidine 106

H HAEGARDA 54

hailey 24 fe 72

haloperidol 44

HARVONI 51

HAVRIX (PF) 101

heather 72

HEPATAMINE 8 58

HERCEPTIN 19

HETLIOZ 114

HIBERIX (PF) 101

HUMATROPE 92

HUMIRA 97

HUMIRA PEDIATRIC

CROHNS START 97

HUMIRA PEN 97

HS START 97

HUMIRA PEN PSOR-

UVEITS-ADOL HS 97

HUMIRA(CF) 97

STARTER 97

HUMIRA(CF) PEN 97

UC-HS 97

ADOL HS 97

INSULIN 34

KWIKPEN 34

hydralazine 63

hydromorphone 4

hydroxyurea 19

hydroxyzine hcl 37

HYPERRAB (PF) 97

HYPERRAB SD (PF) 97

HYQVIA 97

I ibandronate 104

IBRANCE 19

ibuprofen 6

icatibant 63

ICLUSIG 19

IDHIFA 19

ifosfamide 19

ifosfamide-mesna 19

ILARIS (PF) 97

ILEVRO 84

ILUMYA 98

imatinib 19

IMBRUVICA 19

IMFINZI 19

imipramine hcl 31

imiquimod 76

IMLYGIC 19

(PF) 101

IMPAVIDO 41

INBRIJA 42

incassia 72

INCRELEX 93

INCRUSE ELLIPTA 111

indapamide 64

indomethacin 6

INFLECTRA 98

INGREZZA 68

INGREZZA INITIATION

PACK 68

INLYTA 19

U-100 80

INTELENCE 48

INTRALIPID 58

INTRON A 51

introvale 72

INVEGA SUSTENNA 45

INVEGA TRINZA 45

INVELTYS 84

INVIRASE 48

INVOKAMET 32

INVOKAMET XR 32

INVOKANA 32

IPOL 101

irbesartan 59

IRESSA 19

ISENTRESS 48

ISENTRESS HD 48

isibloom 72

ISOLYTE-P IN 5

DEXTROSE 108

ISOLYTE-S 108

isoniazid 39

itraconazole 36

ivermectin 41

IXEMPRA 19

IXIARO (PF) 101

J JADENU 89

JADENU SPRINKLE 89

JAKAFI 20

jantoven 53

JANUMET 32

JANUMET XR 32

JANUVIA 32

JARDIANCE 32

jasmiel (28) 72

jencycla 72

JENTADUETO 32

JENTADUETO XR 32

jinteli 90

jolivette 72

juleber 72

JULUCA 48

junel 1530 (21) 72

junel 120 (21) 72

junel fe 1530 (28) 72

junel fe 120 (28) 72

junel fe 24 72

JUXTAPID 65

JYNARQUE 64

K KABIVEN 58

KALETRA 48

kalliga 72

KALYDECO 113

KANJINTI 20

KANUMA 80

kariva (28) 72

KEDRAB (PF) 98

kelnor 135 (28) 72

kelnor 1-50 72

ketoconazole 36

ketorolac 6 84

KEVEYIS 106

KEVZARA 98

KEYTRUDA 20

KINERET 98

KINRIX (PF) 101

KISQALI 20

klor-con m10 108

klor-con m15 108

klor-con m20 108

KORLYM 32

KRINTAFEL 41

KRYSTEXXA 81

kurvelo (28) 72

KUVAN 81

KYPROLIS 20

labetalol 61

lactulose 86

lamivudine 48

lamotrigine 27

lansoprazole 85

INSULIN 34

larin 1530 (21) 73

larin 120 (21) 73

larin 24 fe 73

larin fe 1530 (28) 73

larin fe 120 (28) 73

larissia 73

latanoprost 107

LATUDA 45

LAZANDA 4

leena 28 73

leflunomide 98

LEMTRADA 68

LENVIMA 20

lessina 73

letrozole 20

LEUKERAN 20

LEUKINE 54

leuprolide 20

levetiracetam 27

levobunolol 107

levocarnitine 106

levocetirizine 37

levofloxacin 14 82

LEVOLEUCOVORIN

CALCIUM 106

levonest (28) 73

levora-28 73

levothyroxine 95

LEXIVA 48

LIALDA 103

LIBTAYO 20

lidocaine 7

lidocaine (pf) 7 60

lidocaine hcl 7

lidocaine viscous 7

lillow (28) 73

linezolid 10 11

LINZESS 86

liothyronine 95

lisinopril 59 60

lithium citrate 68

LIVALO 65

LOKELMA 86

LONHALA MAGNAIR

REFILL 112

LONHALA MAGNAIR

STARTER 111

LONSURF 20

loperamide 86

lorazepam 9

LORBRENA 20

lorcet hd 4

lorcet plus 4

loryna (28) 73

losartan 59

LOTEMAX 84

LOTEMAX SM 84

lovastatin 65

LUCEMYRA 8

LUMIGAN 107

LUMOXITI 21

LUPRON DEPOT 21 93

LUPRON DEPOT-PED 93

LUPRON DEPOT-PED (3

MONTH) 93

lutera (28) 73

LYNPARZA 21

LYRICA 27

LYSODREN 21

lyza 73

malathion 79

maprotiline 31

marlissa (28) 73

MARPLAN 31

MATULANE 21

PACK) 68

MAVENCLAD (4 TABLET

PACK) 68

MAVENCLAD (5 TABLET

PACK) 68

MAVENCLAD (6 TABLET

PACK) 68

MAVENCLAD (7 TABLET

PACK) 68

MAVENCLAD (8 TABLET

PACK) 68

MAVENCLAD (9 TABLET

PACK) 68

MAVYRET 51

MAYZENT 68

meclizine 40

mefenamic acid 6

mefloquine 41

megestrol 21 95

MEKINIST 21

MEKTOVI 21

meloxicam 6

memantine 29

MENACTRA (PF) 101

(PF) 101

MEPSEVII 81

mercaptopurine 21

meropenem 13

mesalamine 103

mesna 106

MESNEX 106

MESTINON 106

metaproterenol 112

metformin 32 33

methadone 4

methadose 4

methimazole 95

methocarbamol 114

methoxsalen 76

methscopolamine 86

methyclothiazide 64

metipranolol 107

mexiletine 60

MIACALCIN 105

miconazole-3 36

midodrine 58

miglustat 81

mili 73

mimvey 90

mimvey lo 90

minitran 66

minocycline 15

minoxidil 66

mirtazapine 31

misoprostol 85

MITIGARE 37

mitoxantrone 21

M-M-R II (PF) 102

molindone 45

mometasone 79

mondoxyne nl 15

mono-linyah 73

mononessa (28) 73

montelukast 111

morphine 4 5

MORPHINE 5

MOVANTIK 86

MOXEZA 82

moxifloxacin 14 83

MOZOBIL 54

MULPLETA 54

MULTAQ 60

mupirocin 77

MYLOTARG 21

MYRBETRIQ 88

myzilra 73

N nabumetone 6

nafcillin 13 14

NAGLAZYME 81

naloxone 8

naltrexone 8

NAMZARIC 29

naproxen 7

NARCAN 8

NATACYN 83

NATPARA 105

NEBUPENT 41

necon 0535 (28) 73

nefazodone 31

neomycin 10

dexameth 83

neomycin-polymyxin-

gramicidin 83

neo-polycin 83

neo-polycin hc 83

NEPHRAMINE 54 58

NERLYNX 21

NEULASTA 54

NEUPOGEN 54

NEUPRO 42

nevirapine 48 49

NEXAVAR 21

niacin 65

niacor 65

nicardipine 63

NICOTROL 8

nifedipine 63

nikki (28) 74

nilutamide 21

NINLARO 22

nitroglycerin 66

NITYR 81

NIVESTYM 54

nizatidine 85

NOCDURNA (MEN) 93

NOCDURNA (WOMEN) 93

nora-be 74

norlyda 74

norlyroc 74

NORMOSOL-M IN 5

DEXTROSE 109

NORMOSOL-R 109

NORTHERA 58

nortrel 0535 (28) 74

nortrel 135 (21) 74

nortrel 135 (28) 74

nortrel 777 (28) 74

nortriptyline 31

NORVIR 49

NOVOLIN 7030 U-100

INSULIN 34

100 34

NOVOLIN N NPH U-100

INSULIN 34

100 INSULN 34

INSULIN 34

INSULN 34

NOVOLOG MIX 70-

30FLEXPEN U-100 34

INSULIN 34

ASPART 34

NOXAFIL 36

NUCALA 113

NUCYNTA 5

NUCYNTA ER 5

NUEDEXTA 69

NULOJIX 98

NUPLAZID 45

NUTRILIPID 58

nyamyc 36

nystatin 36

nystop 36

O OCALIVA 87

OCREVUS 69

OCTAGAM 98

ODEFSEY 49

ODOMZO 22

OFEV 113

ofloxacin 83

ogestrel (28) 74

olanzapine 45

olmesartan 59

olopatadine 82

OLUMIANT 98

omeprazole 85

OMNITROPE 93

ONCASPAR 22

ondansetron 40

ondansetron hcl 40

ONIVYDE 22

OPDIVO 22

OPSUMIT 114

oralone 76

ORENCIA 98

ORENITRAM 114

ORFADIN 81

ORILISSA 93 94

ORKAMBI 113

orsythia 74

oseltamivir 50

OSMOLEX ER 42

OTEZLA 98

OTEZLA STARTER 98

oxcarbazepine 27

OXTELLAR XR 27

oxycodone 5

oxycodone-aspirin 5

OZEMPIC 33

P pacerone 60

paliperidone 45 46

PALYNZIQ 81

PANRETIN 76

pantoprazole 85

paricalcitol 105

PARICALCITOL 105

paromomycin 41

paroxetine hcl 31

PASER 39

PAXIL 31

PEDIARIX (PF) 102

PEDVAX HIB (PF) 102

PEGANONE 27

PEGASYS 51 52

PEGASYS PROCLICK 51

PEGINTRON 52

penicillamine 89

PENNSAID 7

PENTACEL (PF) 102

PENTAM 41

pentamidine 41

pentoxifylline 55

PERIKABIVEN 58

periogard 76

permethrin 79

perphenazine 46

PERSERIS 46

pfizerpen-g 14

phenadoz 40

phenelzine 31

phenobarbital 27 28

phenytoin 28

phenytoin sodium 28

philith 74

PHOSLYRA 88

PICATO 76 77

PIFELTRO 49

pimecrolimus 79

pimozide 46

pimtrea (28) 74

pioglitazone 33

PIQRAY 22

pirmella 74

PLASMA-LYTE 148 109

PLASMA-LYTE A 109

PLEGRIDY 69

podofilox 77

POLIVY 22

polycin 83

POMALYST 22

portia 28 74

PORTRAZZA 22

PRADAXA 53

PRALUENT PEN 65

pramipexole 42

prasugrel 55

pravastatin 65

prazosin 59

prednicarbate 79

prednisolone 92

84 91 92

prednisone 92

pregabalin 28

PREMARIN 90

PREMPHASE 91

PREMPRO 91

prevalite 65

previfem 74

PREVYMIS 50

PREZCOBIX 49

PREZISTA 49

PRIFTIN 39

PRIMAQUINE 41

primidone 28

PRIVIGEN 99

probenecid 37

procainamide 60

PROCALAMINE 3 58

prochlorperazine 40

PROCRIT 54

procto-med hc 79

proctosol hc 79

proctozone-hc 79

PROCYSBI 88

progesterone 95

PROGLYCEM 106

PROGRAF 99

PROLASTIN-C 113

PROLENSA 85

PROLEUKIN 22

PROLIA 105

PROMACTA 54

promethazine 37 40

promethegan 40

propafenone 60

proparacaine 82

propranolol 61

propylthiouracil 95

PROQUAD (PF) 102

PROSOL 20 58

protamine 55

protriptyline 31

PULMOZYME 81

PURIXAN 22

pyrazinamide 39

quetiapine 46

quinapril 60

R RABAVERT (PF) 102

RADICAVA 69

raloxifene 91

ramipril 60

ranitidine hcl 85

ranolazine 63

rasagiline 42

RASUVO (PF) 99

RAVICTI 87

RAYALDEE 105

REBIF REBIDOSE 69

reclipsen (28) 74

RECTIV 107

RELISTOR 87

REMICADE 99

RENFLEXIS 99

repaglinide 33

REPATHA SYRINGE 65

RESCRIPTOR 49

RESTASIS 85

RETACRIT 55

RETROVIR 49

REVCOVI 81

REVLIMID 22

revonto 114

REXULTI 46

REYATAZ 49

RHOPRESSA 107

ribasphere 52

ribavirin 52

RIDAURA 99

rifabutin 39

rifampin 39

riluzole 69

rimantadine 51

RISPERDAL CONSTA 46

risperidone 46

ritonavir 49

RITUXAN 22

RITUXAN HYCELA 22

rivastigmine 29

rizatriptan 38

ropinirole 42

rosadan 77

rosuvastatin 65

ROTARIX 102

ROTATEQ VACCINE 102

RUBRACA 22

RYDAPT 22

S SABRIL 28

SAIZEN 94

SANTYL 77

SAPHRIS 46

SAVELLA 69

scopolamine base 40

selegiline hcl 42

selenium sulfide 77

SELZENTRY 49

SEREVENT DISKUS 112

SEROSTIM 94

sertraline 31

setlakin 74

sevelamer hcl 88

sharobel 74

SHINGRIX (PF) 102

SIGNIFOR 94

SILENOR 114

SILIQ 99

SIMBRINZA 108

simliya (28) 74

simpesse 74

SIMPONI 99

SIMPONI ARIA 99

simvastatin 65

sirolimus 99

SIRTURO 39

SKYRIZI 99

smoflipid 58

sodium chloride 104

SOLIQUA 10033 34

SOLTAMOX 22

SOLU-CORTEF (PF) 92

SOMATULINE DEPOT 94

SOMAVERT 94

sorine 61

sotalol 61

sotalol af 61

SOVALDI 51

spironolactone 64

SPRAVATO 31

sprintec (28) 75

SPRITAM 28

SPRYCEL 22

sronyx 75

ssd 77

stavudine 49

STELARA 99

STIVARGA 23

STRENSIQ 81

streptomycin 10

STRIBILD 49

SUBLOCADE 8

subvenite 28

sucralfate 86

sulfadiazine 14

sulfasalazine 104

sulfatrim 15

sulindac 7

sumatriptan 38

SUPPRELIN LA 94

SUTENT 23

syeda 75

SYLATRON 52

SYLVANT 23

SYMBICORT 110 111

SYMDEKO 113

SYMFI 49

SYMFI LO 49

SYMJEPI 63

SYMLINPEN 120 33

SYMLINPEN 60 33

SYMPAZAN 28

SYMTUZA 49

SYNAGIS 51

SYNAREL 94

SYNERCID 11

SYNJARDY 33

SYNJARDY XR 33

SYNRIBO 23

T TABLOID 23

tacrolimus 79 99

TAFINLAR 23

TAGRISSO 23

TAKHZYRO 107

TALTZ SYRINGE 100

TALZENNA 23

tamoxifen 23

tamsulosin 88

TARGRETIN 23

tarina 24 fe 75

tarina fe 120 (28) 75

TASIGNA 23

TAVALISSE 55

tazarotene 79

TAZORAC 79

taztia xt 62

TDVAX 102

TECENTRIQ 23

TECFIDERA 70

TECHNIVIE 51

TEFLARO 12

TEKTURNA HCT 66

telmisartan 59

temazepam 9

TEMODAR 23

TENIVAC (PF) 102

terazosin 88

terbinafine hcl 36

terbutaline 112

terconazole 37

testosterone 89

PED(PF) 102

tetrabenazine 70

tetracycline 15

THALOMID 107

theophylline 112

THIOLA 89

THIOLA EC 88

thioridazine 46

thiotepa 23

thiothixene 46

tiagabine 28

TIBSOVO 23

TICE BCG 100

tigecycline 15

tilia fe 75

TIVICAY 49 50

tizanidine 114

TOBI PODHALER 10

tobramycin 84

TOLAK 77

tolazamide 35

tolterodine 88

topiramate 28

toposar 23

toremifene 23

torsemide 64

TOTECT 107

TOUJEO MAX U-300

SOLOSTAR 34

INSULIN 35

TOVIAZ 88

TRACLEER 115

TRADJENTA 33

tramadol 5

trandolapril 60

tranexamic acid 55

TRANSDERM-SCOP 41

tranylcypromine 31

TRAVASOL 10 58

TRAVATAN Z 108

trazodone 31

TREANDA 23

TRECATOR 39

TRELEGY ELLIPTA 112

TRELSTAR 23 24

TREMFYA 100

tretinoin 79

tri femynor 75

trientine 89

tri-estarylla 75

trifluoperazine 46

trifluridine 84

trihexyphenidyl 43

tri-legest fe 75

tri-linyah 75

tri-lo-estarylla 75

tri-lo-marzia 75

tri-lo-mili 75

tri-lo-sprintec 75

trimethoprim 11

tri-mili 75

trimipramine 31

TRINTELLIX 31

TRIPTODUR 94

TRIUMEQ 50

trivora (28) 75

tri-vylibra 75

tri-vylibra lo 75

TROGARZO 50

TROPHAMINE 10 58

TROPHAMINE 6 58

TRULICITY 33

TRUMENBA 103

TRUVADA 50

tulana 75

TWINRIX (PF) 103

TYBOST 107

TYKERB 24

TYMLOS 105

TYPHIM VI 103

TYSABRI 100

TYVASO 115

U UCERIS 104

UDENYCA 55

ULORIC 37

UNITUXIN 24

UPTRAVI 115

ursodiol 87

V valacyclovir 52

VALCHLOR 77

valganciclovir 52

valproate sodium 28

valproic acid 29

valrubicin 24

valsartan 59

vancomycin 11

VAQTA (PF) 103

VARIVAX (PF) 103

VASCEPA 66

VELCADE 24

VELPHORO 88

VELTASSA 87

VEMLIDY 50

VENCLEXTA 24

VENCLEXTA STARTING

PACK 24

venlafaxine 31 32

verapamil 62

VERSACLOZ 46

VERZENIO 24

V-GO 40 80

VIBERZI 87

VICTOZA 33

VIDEX EC 50

VIEKIRA PAK 51

vienva 75

vigabatrin 29

vigadrone 29

VIIBRYD 32

VIMIZIM 81

VIMPAT 29

vinorelbine 24

viorele (28) 75

VIRACEPT 50

VIREAD 50

VISTOGARD 107

VITRAKVI 24

VIZIMPRO 24

VOLTAREN 7

voriconazole 36 37

VOSEVI 51

VOTRIENT 24

VPRIV 81

VRAYLAR 47

vyfemla (28) 76

vylibra 76

VYNDAQEL 63

VYXEOS 24

W warfarin 53

WELCHOL 66

wera (28) 76

X XADAGO 43

XALKORI 24

XARELTO 53

XATMEP 24

XELJANZ 100

XELJANZ XR 100

XERMELO 87

XIFAXAN 11

XIIDRA 85

XOFLUZA 51

XOLAIR 113

XOSPATA 24

XPOVIO 25

XTAMPZA ER 5 6

XTANDI 25

xulane 76

XULTOPHY 10036 35

XURIDEN 107

XYOSTED 89

XYREM 114

Y YERVOY 25

YF-VAX (PF) 103

YONDELIS 25

YONSA 25

Z zafirlukast 111

zaleplon 114

zarah 76

ZARXIO 55

ZEJULA 25

ZELBORAF 25

zenatane 77

zenchent (28) 76

ZENPEP 81

ZEPATIER 51

zidovudine 50

ziprasidone hcl 47

ZIRGAN 84

ZOLADEX 25

zoledronic acid 105

ZOLINZA 25

zolpidem 114

ZOMACTON 94

zonisamide 29

ZORBTIVE 94

ZORTRESS 100

ZOSTAVAX (PF) 103

zovia 135e (28) 76

ZTLIDO 7

ZUBSOLV 8

ZULRESSO 32

zumandimine (28) 76

ZYDELIG 25

ZYKADIA 25

ZYLET 84

ZYPREXA RELPREVV 47

ZYTIGA 25







Medical Condition









Table of Contents

INDEX

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

H6988_ENR1085_C V

exception

page I-1

Analgesics 3

Anesthetics 7

Antibacterials 9

Anticonvulsants 25

Antidepressants 29

Antifungals 35

Antigout Agents 37

Antihistamines 37

Caloric Agents 55

Contraceptives 70

Table of Contents

Devices 79

Drug Name

Analgesics

12 mg5 ml

30 days)

(Buprenex) 2

50-325-40 mg

Years)

50-325-40 mg

Years)

325-40 mg

Years)

30 days)

400 mcg 600 mcg 800 mcg

per 30 days)

75 mcghr

30 days)

75-325 mg15 ml

30 days)

10-325 mg

30 days)

25-325 mg

30 days)

Drug Name

325 mg

30 days)

75-325 mg

30 days)

5 PA NDS NM QL (30

per 30 days)

30 days)

suv inner 10 mgml

mg5 ml (20 mgml)

30 days)

4 mgml 8 mgml

30 days)

Drug Name

30 days)

mg 200 mg 60 mg

30 days)

mg 30 mg

30 days)

150 MG 200 MG 250 MG 50 MG

3 NDS NM QL (60 per

30 days)

MG 75 MG

30 days)

hr 10 mg 15 mg 20 mg 30 mg 40 mg 60

mg 80 mg

30 days)

325 mg

30 days)

325 mg 5-325 mg

30 days)

325 mg

30 days)

325 mg

30 days)

XTAMPZA ER ORAL

3 NDS NM QL (60 per

30 days)

Drug Name

XTAMPZA ER ORAL

CRUSH) 27 MG

30 days)

XTAMPZA ER ORAL

CRUSH) 36 MG

30 days)

12 hour 13

(Flector) 2 PA

(Voltaren-XR) 2

(IBU) 1

Years)

days) AGE (Max 64

Years)

Drug Name

(EC-Naprosyn) 2

ACTUATION(2 )

28 days)

Anesthetics

Local Anesthetics

applicator 2

(1 ) 15 mgml (15 ) 20 mgml (2 )

5 mgml (05 )

(Xylocaine-MPF) 1

mgml (2 )

(1 ) 20 mgml (2 ) 5 mgml (05 )

(Xylocaine) 1

(40 mgml)

patchmedicated 5

solution 2

PATCHMEDICATED 18

Treatment Agents

(drec) 333 mg

Drug Name

12-3 mg 8-2 mg

2-05 mg 4-1 mg

2-05 mg 8-2 mg

3 QL (336 per 365 days)

(11)- 1 MG (42)

NICOTROL INHALATION

CARTRIDGE 10 MG

4 QL (1008 per 90 days)

018 MG 14-036 MG 114-29 MG 29-

071 MG 57-14 MG

Antianxiety Agents

Benzodiazepines

30 days)

mg 5 mg 75 mg

Drug Name

25 mg 5 mg

30 days)

0125 mg 025 mg 05 mg 1 mg

2 NDS NM QL (90 per

30 days)

375 mg

30 days)

Antibacterials

Aminoglycosides

5 PA BvD NDS

40 mgml

solution 20 mg2 ml

Drug Name

mg8 ml

(Tobi) 5 PA BvD NDS

mg 75 mg

(Cleocin HCl) 1

900 mg50 ml

150 (mgml) (6 ml)

150 mgml

(Cleocin) 2

solution 600 mg4 ml

(Cleocin) 2

soln 150 mg

(Coly-Mycin M

Parenteral)

5 PA BvD NDS

(Cubicin) 5 NDS

MGML 50 MGML

mg300 ml

(Zyvox) 5 NDS

100 mg5 ml

(Zyvox) 5 NDS

Drug Name

(Metro IV) 2

100 mg 25 mg 50 mg

capsule 100 mg

500000 unit

SOLN 500 MG

750 mg

2 PA BvD

Cephalosporins

125 mg5 ml 250 mg5 ml 375 mg5 ml

gram 500 mg

125 mg5 ml 250 mg5 ml

(Maxipime) 2

10 gram 2 gram

Drug Name

(Tazicef) 2

750 mg

15 gram 75 gram

SOLN 400 MG 600 MG

Macrolides

(Zithromax) 2

500 mg (3 pack) 600 mg

(EES Granules) 2

(EryPed 400) 2

Drug Name

(Azactam) 2

5 PA LA NDS

soln 250 mg

soln 500 mg

(Primaxin IV) 2

gram 500 mg

(Merrem) 2

Penicillins

250 mg5 ml 400 mg5 ml

250 mg

mg5 ml

500-125 mg 875-125 mg

(Augmentin) 1

500 mg

(Unasyn) 2

2400000 UNIT4 ML 600000

UNITML

Drug Name

20 million unit

(Pfizerpen-G) 2

unitml

mg5 ml 250 mg5 ml

500 mg

405 gram

(Zosyn) 2 PA BvD

Quinolones

(Cipro) 1

(Cipro in D5W) 2

ciprofloxacin oral

ml 500 mg5 ml

(Cipro) 2

250 mg50 ml 500 mg100 ml 750 mg150

Sulfonamides

(Sulfatrim) 2

Drug Name

400-80 mg

(Bactrim) 1

800-160 mg

(Bactrim DS) 1

Tetracyclines

soln 100 mg

(Doxy-100) 2

(Morgidox) 2

mg 50 mg

(Mondoxyne NL) 2

(Vibramycin) 2

(Avidoxy) 2

Anticancer Agents

100 MG

2 PA BvD

ml 500 mg10 ml

2 PA BvD

per 28 days)

MG 75 MG

5 PA NSO NDS QL (28

per 28 days)

Drug Name

per 30 days)

SOLN 100 MG 500 MG

SOLN 60 MG

5 PA NSO NDS QL (3

per 28 days)

5 PA NSO NDS QL (30

per 30 days)

PACK 90 MG (7)- 180 MG (23)

5 PA NSO NDS

25 MGML

5 PA NSO NDS

per 28 days)

SOLUTION 20 MGML

5 PA NSO NDS

SOLN 500 MG

5 PA NSO NDS

BENDEKA INTRAVENOUS

SOLUTION 25 MGML

5 PA NSO NDS

per 30 days)

5 PA NSO NDS

RECON SOLN 35 MG

5 PA NSO NDS

per 30 days)

Drug Name

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

5 PA NSO NDS QL (60

per 30 days)

(Clolar) 5 NDS

MGDAY(80 MG X1-20 MG X1) 140

per 28 days)

5 PA NSO NDS QL (56

per 28 days)

(63 per 28 days)

5 PA BvD NDS

CAPSULE 25 MG 50 MG

2 PA BvD ST

CYRAMZA INTRAVENOUS

SOLUTION 10 MGML

5 PA NSO NDS

SOLUTION 20 MGML

5 PA NSO LA NDS

per 30 days)

suspension 2 mgml

Drug Name

MG 400 MG

ELIGARD (3 MONTH)

ELIGARD (4 MONTH)

ELIGARD (6 MONTH)

75 MG (1 MONTH)

SOLN 300 MG 400 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG

MG 20 MG

5 PA NSO NDS

gram20 ml

2 PA BvD

(Adrucil) 2 PA BvD

mg5 ml

(Faslodex) 5 NDS

1000 MG40 ML

5 PA NSO NDS

MG 40 MG

5 PA NSO NDS QL (30

per 30 days)

40 MG 5 MG

Drug Name

HERCEPTIN HYLECTA

10000 UNIT5 ML

5 PA NSO NDS QL (5

per 21 days)

SOLN 150 MG 440 MG

5 PA NSO NDS

125 MG 75 MG

5 PA NSO NDS QL (21

per 28 days)

per 30 days)

5 PA NSO NDS QL (30

per 30 days)

ml 3 gram60 ml

gram 3000-1000 mg

5 PA BvD NDS

per 30 days)

per 28 days)

280 MG 420 MG 560 MG

5 PA NSO NDS QL (28

per 28 days)

50 MGML

5 PA NSO NDS

5 PA NSO NDS QL (4

per 365 days)

5 PA NSO NDS QL (8

per 28 days)

per 30 days)

SOLN 15 MG 45 MG

Drug Name

20 MG 25 MG 5 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 420 MG

5 PA NSO NDS

SOLUTION 25 MGML

5 PA NSO NDS QL (8

per 21 days)

5 PA NSO NDS QL (49

per 28 days)

5 PA NSO NDS QL (70

per 28 days)

5 PA NSO NDS QL (91

per 28 days)

(200 MG X 1)

5 PA NSO NDS QL (21

per 28 days)

(200 MG X 2)

5 PA NSO NDS QL (42

per 28 days)

(200 MG X 3)

5 PA NSO NDS QL (63

per 28 days)

5 PA NSO NDS

X 1) 18 MGDAY (10 MG X 1-4 MG

X2) 20 MGDAY (10 MG X 2) 24

8 MGDAY (4 MG X 2)

5 PA NSO NDS

50 MGML

5 PA NSO NDS QL (7

per 21 days)

per 28 days)

per 30 days)

Drug Name

SOLN 1 MG

5 PA NSO NDS

SYRINGE KIT 375 MG

150 MG

per 30 days)

(Max 64 Years)

per 30 days)

soln 1 gram

2 PA BvD

solution 25 mgml

2 PA BvD

5 PA NSO NDS

per 30 days)

Drug Name

MG 4 MG

5 PA NSO NDS QL (3

per 28 days)

750 UNITML

5 PA NSO NDS

ONIVYDE INTRAVENOUS

DISPERSION 43 MGML

100 MG10 ML 240 MG24 ML 40

MG4 ML

5 PA NSO NDS

(200 MG X 1)

5 PA NSO NDS QL (28

per 28 days)

(200 MG X1-50 MG X1) 300 MGDAY

(150 MG X 2)

5 PA NSO NDS QL (56

per 28 days)

SOLN 140 MG

5 PA NSO NDS

MG 3 MG 4 MG

5 PA NSO NDS QL (21

per 28 days)

per 21 days)

5 PA NSO LA NDS QL

(28 per 28 days)

MGML) 1600 MG134 ML (120

5 PA NSO NDS

RITUXAN INTRAVENOUS

CONCENTRATE 10 MGML

5 PA NSO NDS

250 MG 300 MG

per 30 days)

per 28 days)

MG5 ML

5 PA NSO NDS QL (30

per 30 days)

Drug Name

per 28 days)

MG 375 MG 50 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 100 MG 400 MG

5 PA NSO NDS

SOLN 35 MG

5 PA NSO NDS

per 30 days)

5 PA NSO LA NDS QL

(30 per 30 days)

per 30 days)

per 28 days)

200 MG

per 28 days)

per 30 days)

5 PA NSO NDS

SOLN 100 MG

5 PA NSO NDS

per 30 days)

SOLN 100 MG 25 MG

5 PA NSO NDS

1125 MG

225 MG

5 NDS QL (1 per 168

Drug Name

375 MG

SOLUTION 35 MGML

5 PA NSO NDS

per 30 days)

(180 per 30 days)

per 30 days)

100 MG

5 PA NSO LA NDS

150 MG 200 MG 50 MG

5 PA NSO NDS QL (56

per 28 days)

50 mg5 ml

(Navelbine) 2

per 30 days)

MG 45 MG

5 PA NSO NDS QL (30

per 30 days)

SOLN 44-100 MG

5 PA BvD NDS

250 MG

5 PA NSO NDS QL (60

per 30 days)

4 PA BvD ST

per 30 days)

Drug Name

MGWEEK (20 MG X 5)

5 PA NSO NDS QL (20

per 28 days)

MGWEEK (20 MG X 8)

5 PA NSO NDS QL (32

per 28 days)

(20 MG X 3)

5 PA NSO NDS QL (12

per 28 days)

(20 MG X 4)

5 PA NSO NDS QL (16

per 28 days)

per 30 days)

200 MG40 ML (5 MGML) 50 MG10

ML (5 MGML)

5 PA NSO NDS

SOLN 1 MG

5 PA NSO NDS

per 30 days)

IMPLANT 108 MG

IMPLANT 36 MG

5 PA NSO NDS QL (60

per 30 days)

per 28 days)

per 30 days)

Anticonvulsants

Drug Name

5 ST NDS

SOLUTION 50 MG5 ML

5 NDS QL (60 per 30

(Carbatrol) 2

(Tegretol) 2

(Tegretol XR) 2

125-15-175-20 MG 5-75-10 MG

75-10 mg

(Diastat AcuDial) 4

sprinkle 125 mg

hr 250 mg 500 mg

(Depakote ER) 2

(drec) 125 mg 250 mg 500 mg

(Depakote) 2

5 PA NSO NDS

Drug Name

(Cerebyx) 2

4 ST QL (720 per 30

MG 8 MG

200 mg 25 mg

(Lamictal) 1

(Lamictal) 2

mg5 ml

(Keppra) 2

mg 500 mg 750 mg

(Keppra) 2

24 hr 500 mg 750 mg

(Keppra XR) 2

MG 200 MG 225 MG 25 MG 300 MG

50 MG 75 MG

ml (60 mgml)

(Trileptal) 2

600 mg

(Trileptal) 2

300 MG 600 MG

2 PA NSO-HRM AGE

(Max 64 Years)

Drug Name

162 mg 30 mg 324 mg 60 mg 648 mg

972 mg

2 PA NSO-HRM AGE

(Max 64 Years)

100 mg

200 mg 300 mg

(Phenytek) 2

200 mg 225 mg 25 mg 300 mg 50 mg

per 30 days)

SUSPENSION 1000 MG

4 ST QL (120 per 30

mg 25 mg

5 PA NSO NDS QL (60

per 30 days)

(Gabitril) 2

(Topamax) 2

100 mg 150 mg 200 mg 25 mg 50 mg

(Qudexy XR) 4

mg 50 mg

(Topamax) 1

mg5 ml (100 mgml)

(Depacon) 2

solution 250 mg5 ml

Drug Name

per 30 days)

200 MG20 ML

MG 200 MG 50 MG

Antidementia Agents

24 hr 16 mg 24 mg 8 mg

14 mg 21 mg 28 mg 7 mg

NAMZARIC ORAL

MG 21-10 MG 28-10 MG 7-10 MG

3 mg 45 mg 6 mg

133 mg24 hour 46 mg24 hr 95 mg24

Antidepressants

150 mg 25 mg 50 mg 75 mg

Drug Name

mg 50 mg

24 hr 150 mg 300 mg

(Wellbutrin XL) 2

(Wellbutrin SR) 2

(Anafranil) 2

50 mg 75 mg

release(drec) 30 mg

MG24 HR

5 NDS QL (30 per 30

mg 5 mg

(Lexapro) 1

FETZIMA ORAL

HR 120 MG 20 MG 40 MG 80 MG

(Prozac) 1

Drug Name

(Tofranil) 2

mg 30 mg 45 mg

(Remeron SolTab) 2

200 mg 250 mg 50 mg

50 mg 75 mg

(Pamelor) 1

30 mg 40 mg

(Max 64 Years)

4 PA NSO-HRM AGE

(Max 64 Years)

10 mg 2-25 mg 4-10 mg 4-25 mg 4-50

(Zoloft) 1

(28 MG X 3)

5 PA NSO NDS

20 MG 5 MG

24hr 150 mg

24hr 375 mg 75 mg

Drug Name

375 mg 50 mg 75 mg

MG 40 MG

PACK 10 MG (7)- 20 MG (23)

SOLUTION 5 MGML

Antidiabetic Agents

25-5 MG

1000 MG 150-500 MG 50-1000 MG

3 ST QL (120 per 30

150-500 MG 50-1000 MG 50-500 MG

MG 50-500 MG

500 MG

MG 50 MG

1000 MG 25-500 MG 25-850 MG

28 days)

Drug Name

hr 500 mg

hr 750 mg

28 days)

MG 125-500 MG 5-1000 MG 5-500

1000 MG

Insulins

UNITML (3 ML)

FIASP U-100 INSULIN

UNITML

Drug Name

UNITML

UNITML (3 ML)

UNITML

UNITML (70-30)

UNITML

UNITML (3 ML)

UNITML (70-30)

UNITML

UNITML (3 ML)

Drug Name

UNITML (15 ML)

UNITML (3 ML)

UNITML

Sulfonylureas

25 mg 5 mg

mg 5-500 mg

mg 6 mg

Years)

mg 25-500 mg 5-500 mg

Years)

Antifungals

ABELCET INTRAVENOUS

SUSPENSION 5 MGML

5 PA BvD NDS

Drug Name

mg 70 mg

(Cancidas) 5 NDS

(clotrimazole))

(Lotrisone) 2

400 mg200 ml

2 PA BvD

(Diflucan) 2

200 mg 50 mg

(Diflucan) 2

mg5 ml

MG5 ML (40 MGML)

unitgram

Drug Name

(Vfend) 5 NDS

Antigout Agents

Antihistamines

Years)

mgml 50 mgml

Years)

Membrane)

Drug Name

Antimigraine Agents

70 MGML

140 MGML 70 MGML

225 MG15 ML

EMGALITY SYRINGE

ML (100 MGML X 3)

mg 5 mg

mgactuation

25 mg 50 mg

cartridge 6 mg05 ml

(Imitrex STATdose

Refill)

solution 6 mg05 ml

syringe 6 mg05 ml

Antimycobacterials

Drug Name

Antimycobacterials

1 GRAM

168 days)

Antinausea Agents

025 MG

CAPSULE 300-05 MG

4 PA BvD

(1)- 80 mg (2)

EMULSION 72 MGML

Drug Name

ML FINAL CONC)

mgml 1 mgml (1 ml)

Drowsy)

mg2 ml

mg 8 mg

2 PA BvD

Years)

mg 5 mg

(Compazine) 1

50 mgml

Years)

25 mg 50 mg

Years)

1 mg over 3 days

days) AGE (Max 64

Years)

Drug Name

days) AGE (Max 64

Years)

Antiparasite Agents

(Malarone) 2

500 mg

SOLN 300 MG

4 PA BvD

300 MG

APOKYN SUBCUTANEOUS

CARTRIDGE 10 MGML

Drug Name

mg 25-100 mg 25-250 mg

(Sinemet) 2

(Sinemet CR) 2

(Stalevo 50) 4

tablet 1875-75-200 mg

(Stalevo 75) 4

(Stalevo 100) 4

tablet 3125-125-200 mg

(Stalevo 125) 4

tablet 375-150-200 mg

(Stalevo 150) 4

(Stalevo 200) 4

GOCOVRI ORAL

24HR 137 MG

GOCOVRI ORAL

24HR 685 MG

30 days)

258 MG

mg 05 mg 075 mg 1 mg 15 mg

(Mirapex) 1

Drug Name

ABILIFY MAINTENA

INTRAMUSCULAR

RECON 300 MG 400 MG

ABILIFY MAINTENA

INTRAMUSCULAR

mg 30 mg 5 mg

SYRING 675 MG24 ML

SYRING 1064 MG39 ML

5 NDS QL (39 per 56

SYRING 441 MG16 ML

5 NDS QL (16 per 28

SYRING 662 MG24 ML

5 NDS QL (24 per 28

SYRING 882 MG32 ML

5 NDS QL (32 per 28

200 mg 25 mg 50 mg

Drug Name

mg 125 mg 25 mg

30 days)

MG 6 MG 8 MG

PACK 1MG(2)-2MG(2)- 4MG(2)-

6MG(2)

25 mgml

25 mg 5 mg

solution 100 mgml

solution 50 mgml

(Haldol) 2

5 mgml

mg 2 mg 20 mg 5 mg

Drug Name

INVEGA SUSTENNA

MG075 ML

INVEGA SUSTENNA

MG15 ML

5 NDS QL (15 per 28

INVEGA SUSTENNA

MG025 ML

INVEGA SUSTENNA

MG05 ML

5 NDS QL (05 per 28

5 NDS QL (0875 per 84

5 NDS QL (1315 per 84

5 NDS QL (2625 per 84

MG 40 MG 60 MG

mg 5 mg 50 mg

per 30 days)

mg 20 mg 5 mg 75 mg

mg 15 mg 20 mg 5 mg

24hr 15 mg 3 mg

Drug Name

24hr 6 mg

24hr 9 mg

mg 8 mg

PERSERIS ABDOMINAL

SUBCUTANEOUS

120 MG 90 MG

mg 300 mg 400 mg 50 mg

30 days)

3 MG 4 MG

RISPERDAL CONSTA

MG2 ML 25 MG2 ML

RISPERDAL CONSTA

MG2 ML 50 MG2 ML

mg 2 mg 3 mg 4 mg

mg 05 mg 1 mg 2 mg

mg 4 mg

MG 25 MG 5 MG

mg 50 mg

mg 5 mg

30 days)

Drug Name

MG 45 MG 6 MG

PACK 15 MG (1)- 3 MG (6)

mg 60 mg 80 mg

ZYPREXA RELPREVV

Antiretrovirals

(Epzicom) 2

tablet 300-150-300 mg

(Trizivir) 5 NDS

300 mg

(Reyataz) 5 NDS

300 MG

400 MG

300 MG

400 mg

(Videx EC) 2

Drug Name

MG5 ML (5 MGML)

SOLN 90 MG

200-10 MG

200 MG

PACKET 100 MG

ISENTRESS ORAL

(Combivir) 2

mg5 ml

(Kaletra) 2

Drug Name

hr 100 mg 400 mg

(Viramune XR) 2

100 MG

600 MG 800 MG

DISPERSIBLE 100 MG

SOLUTION 10 MGML

PACKET 50 MG

300 MG 75 MG

mg 40 mg

200-300 MG

200-10 MG

300 mg

(Viread) 2

Drug Name

MG 133-200 MG 167-250 MG 200-300

MGML (FINAL)

VIDEX EC ORAL

CAPSULEDELAYED

625 MG

MGSCOOP (40 MGGRAM)

MG 250 MG

28 days)

480 MG

Drug Name

MGACTUATION

5 PA NDS

Hcv Antivirals

5 PA NDS

Interferons

5 PA NSO NDS

UNITML

5 PA NSO NDS

PEGASYS PROCLICK

MCG05 ML

SOLUTION 180 MCGML

Drug Name

MCG05 ML

200 MCG 300 MCG 600 MCG

5 PA NSO NDS

500 mg

2 PA BvD

500 mg

(Cytovene) 2 PA BvD

50 mgml

2 PA BvD

Expanders

Anticoagulants

PACK 5 MG (74 TABS)

mg3 ml

(Lovenox) 2

Drug Name

mg03 ml 40 mg04 ml 60 mg06 ml 80

mg08 ml

(Lovenox) 2

(Arixtra) 5 NDS

mg05 ml

(Arixtra) 2

5000 unitml (1 ml)

5000 unitml

unitml

1000 unitml

5000 unit05 ml

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

150 MG 75 MG

25 mg 3 mg 4 mg 5 mg 6 mg 75 mg

(Coumadin) 1

PACK 15 MG (42)- 20 MG (9)

TABLET 20 MG

SYRINGE 6 MG06 ML

5 PA NDS

GRANIX SUBCUTANEOUS

5 PA NDS

Drug Name

5 PA NDS

250 MCG

SYRINGE 6 MG06ML

5 PA NDS

MCG08 ML

5 PA NDS

4000 UNITML

20000 UNITML

40000 UNITML

PACKET 125 MG

30 days)

Drug Name

UNITML 4000 UNITML

40000 UNITML

SYRINGE 6 MG06 ML

5 PA NDS

150 MG

1000 mg10 ml (100 mgml)

(Cyklokapron) 2

Years)

400 mg

Caloric Agents

4 PA BvD

AMINOSYN 7 WITH

4 PA BvD

SOLUTION 85

4 PA BvD

Drug Name

4 PA BvD

SOLUTION 85

4 PA BvD

SOLUTION 7

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 275

4 PA BvD

Drug Name

SOLUTION 275

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 425

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

SOLUTION 5

4 PA BvD

intravenous syringe

4 PA BvD

parenteral solution

4 PA BvD

intravenous syringe

4 PA BvD

FREAMINE HBC 69

SOLUTION 69

4 PA BvD

Drug Name

4 PA BvD

EMULSION 20 30

4 PA BvD

KABIVEN INTRAVENOUS

EMULSION 331-98-39

4 PA BvD

EMULSION 20

4 PA BvD

EMULSION 236-68-35

4 PA BvD

PARENTERAL SOLUTION

4 PA BvD

(Catapres) 1

mg24 hr

(Cardura) 2

Years)

200 MG 300 MG

30 days)

Drug Name

(Vazculep) 2

MG 40-25 MG

49-51 MG 97-103 MG

(Avapro) 1

150-125 mg 300-125 mg

(Avalide) 2

100-125 mg 100-25 mg 50-125 mg

(Hyzaar) 1

tablet 20-125 mg 40-125 mg 40-25 mg

(Benicar HCT) 2

(Micardis) 2

mg 80 mg

(Diovan) 2

160-125 mg 160-25 mg 320-125 mg

320-25 mg 80-125 mg

(Diovan HCT) 2

Inhibitors

(Lotensin) 1

mg 50 mg

mg 20 mg 5 mg

(Vasotec) 2

10-25 mg

(Vaseretic) 1

5-125 mg

Drug Name

10-125 mg 20-125 mg 20-25 mg

(Zestoretic) 1

mg 8 mg

(Accupril) 1

mg 5 mg

(Altace) 1

mg 150 mg

Years)

500 mcg

(Tikosyn) 2

mg5 ml (2 ) 50 mg5 ml (1 )

250 mg

mgml 500 mgml

300 mg

(Tenoretic 100) 2

(Tenoretic 50) 2

Drug Name

10-625 mg 25-625 mg 5-625 mg

(Ziac) 1

MG 20 MG 5 MG

3125 mg 625 mg

(Coreg) 1

(5 mgml)

(Toprol XL) 2

100-25 mg 100-50 mg

50-25 mg

(Lopressor HCT) 2

mg5 ml

(Lopressor) 2

mg5 ml

(Lopressor) 1

24 hr 120 mg 160 mg 60 mg 80 mg

(Inderal LA) 2

mg 60 mg 80 mg

mg 80 mg

(Betapace) 2

Drug Name

24hr 120 mg 180 mg 240 mg 300 mg

(Tiazac) 2

(Cardizem CD) 2

(Cardizem) 2

120 mg 180 mg 240 mg

hr 120 mg 180 mg 240 mg 300 mg 360

100 mg 200 mg 300 mg

(Verelan PM) 2

hr 120 mg 180 mg 240 mg

(Verelan) 2

hr 360 mg

(Verelan) 4

mg 180 mg 240 mg

(Calan SR) 1

Drug Name

mg03 ml

30 MG3 ML

mg 50 mg

hr 1000 mg 500 mg

(Ranexa) 2

MG03 ML

30 days)

Dihydropyridines

mg 60 mg

(Norvasc) 1

mg 10-40 mg 5-10 mg 5-20 mg 5-40 mg

(Lotrel) 2

mg 10-320 mg 5-160 mg 5-320 mg

(Exforge) 2

24hr 30 mg 60 mg 90 mg

(Procardia XL) 2

mg 60 mg 90 mg

(Adalat CC) 2

Diuretics

5-50 mg

Drug Name

soln 500 mg

(Diuril IV) 2

mg5 ml (8 mgml)

(Lasix) 1

25 mg 50 mg

30 days)

(PM) 60 MG (AM) 30 MG (PM) 90 MG

(AM) 30 MG (PM)

(Aldactone) 1

capsule 375-25 mg

(Dyazide) 1

capsule 50-25 mg

375-25 mg

(Maxzide-25mg) 1

75-50 mg

(Maxzide) 1

Dyslipidemics

mg 80 mg

(Lipitor) 1

in packet 4 gram

(Questran) 2

Drug Name

mg 200 mg 67 mg

145 mg 48 mg

(Tricor) 2

MG 40 MG 60 MG

1000 mg 500 mg 750 mg

(Niaspan Extended-

Release)

(Pravachol) 1

REPATHA PUSHTRONEX

REPATHA SURECLICK

REPATHA SYRINGE

mg 5 mg

mg 80 mg

Drug Name

PACKET 375 GRAM

Inhibitors

125 MG 150-25 MG 300-125 MG 300-

Vasodilators

mg 30 mg

release 40 mg

(ISOCHRON) 2

mg10 ml (5 mgml)

mg 06 mg

(Nitrostat) 2

(Minitran) 2

25 mg 40 mg

Drug Name

30 days)

mg3 ml (20 mgml)

(Cafcit) 2 PA BvD

(20 mgml)

12 hr 10 mg

mg 5 mg

mg 30 mg

mg 5 mg 75 mg

Drug Name

(Intuniv ER) 2

MG (21)

5 PA NDS

SOLUTION 12 MG12 ML

300 mg 600 mg

release 300 mg

(Lithobid) 2

release 450 mg

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

ORAL TABLET 10 MG

5 PA NDS QL (20 per

336 days)

28 days)

mg 60 mg

Drug Name

ml 5 mg5 ml

mg 5 mg

OCREVUS INTRAVENOUS

SOLUTION 30 MGML

5 PA NDS QL (20 per

180 days)

MCG05 ML

5 PA NDS

28 days)

MCG05 ML

MCG05ML (6)

5 PA NDS

125 MG 25 MG 50 MG

PACK 125 MG (5)-25 MG(8)-50 MG(42)

Drug Name

TECFIDERA ORAL

CAPSULEDELAYED

TECFIDERA ORAL

CAPSULEDELAYED

MG (46)

5 PA NDS

TECFIDERA ORAL

CAPSULEDELAYED

28 days)

Contraceptives

mg- 35 mcg

010 mg-20 mcg (84)10 mcg (7)

015 mg-30 mcg (84)10 mcg (7)

mg-mcg

(24)75 mg (4)

30 mcg (21)75 mg (7)

mcg (21)75 mg (7)

001 mg x 5

Drug Name

001 mg x 5

(24)75 mg (4)

mcg (21)75 mg (7)

mg-mcg

mg- 35 mcg

015 mg-30 mcg (84)10 mcg (7)

015-002 mgx21 001 mg x 5

(Azurette (28)) 2

015-003 mg

(Apri) 2

3-002 mg

(Gianvi (28)) 2

3-003 mg

(Ocella) 2

(5)125-30(10)

Drug Name

35 mg-mcg

(Kelnor 135 (28)) 2

50 mg-mcg

(Kelnor 1-50) 2

(24)75 mg (4)

015 mg-30 mcg (91)

mcg (21)75 mg (7)

(21)75 mg (7)

(24)75 mg (4)

001 mg x 5

(84)10 mcg (7)

mcg 015 mg-25 mcg

(84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

(21)75 mg (7)

(5)125-30(10)

01-20 mg-mcg

(Afirmelle) 2

015-003 mg

(Altavera (28)) 2

50-30 (6)75-40 (5)125-30(10)

(Enpresse) 2

20 mcg (21)75 mg (7)

(5)125-30(10)

Drug Name

035 mg

(Camila) 2

1-20 mg-mcg

(Aurovela 120 (21)) 2

1 mg-20 mcg (21)75 mg (7)

1 mg-20 mcg (24)75 mg (4)

(Aurovela 24 Fe) 2

0180215025 mg-25 mcg

0180215025 mg-35 mcg (28)

025-35 mg-mcg

(Estarylla) 2

mg- 35 mcg

001 mg x 5

mcg 1-35 mg-mcg

015 mg-30 mcg (91)

001 mg x 5

015 mg-30 mcg (84)10 mcg (7)

Drug Name

(24)75 mg (4)

mcg (21)75 mg (7)

35mcg (9)

mg-35 mcg (28)

1mg-35mcg (9)

35 mcg (28)

mg-25 mcg

25 mcg

mg-25 mcg

mcg (28)

0180215025 mg-35 mcg (28)

(5)125-30(10)

mg-25 mcg

35 mcg (28)

0112515-25 mg-mcg

001 mg x 5

Drug Name

mcg24 hr

mouthwash 012

(Oralone) 2

(Soriatane) 2

MEDICATED

rel 10 mg

Drug Name

UNITGRAM

mg 40 mg

(Cleocin T) 2

(Ery Pads) 2

suspension 10

(Klaron) 2

Agents

Drug Name

ointment 005

(Diprolene) 2

(Cutivate) 2

Drug Name

applicator 25

(Triderm) 1

0025 01

0025 01 05

Devices

Drug Name

03 ML 31 GAUGE X 1564

12 ML 31 GAUGE X 1564

(Lite Touch Insulin

Syringe)

GAUGE X 12

(1st Tier Unifine

Pentips)

SOLUTION 250 UNITML

SOLUTION 29 MG5 ML

SOLN 400 UNIT

60000 UNIT 24000-76000 -120000

UNIT 3000-9500- 15000 UNIT

36000-114000- 180000 UNIT 6000-

19000 -30000 UNIT

SOLUTION 6 MG3 ML

SOLN 15 MG 75 MG

SOLN 35 MG 5 MG

5 PA NDS

2 MGML

5 PA NDS

Drug Name

SOLUTION 8 MGML

5 PA BvD NDS

2 MGML

5 PA NDS

SOLUTION 5 MG5 ML

5 PA NDS

MG 20 MG 5 MG

5 PA NDS

ML 20 MGML

5 PA NDS

SOLUTION 1 MGML

5 PA BvD NDS

5 PA NDS

5 PA LA NDS

5 MG5 ML (1 MGML)

5 PA NDS

400 UNIT

42000 UNIT 15000-47000 -63000

UNIT 20000-63000- 84000 UNIT

25000-79000- 105000 UNIT 3000-

10000 -14000-UNIT 40000-126000-

168000 UNIT 5000-17000- 24000

Miscellaneous

Drug Name

(Cyclogyl) 2

DROPS 044

aerosol 003

(Alcaine) 2

Agents

unitgram

(AK-Poly-Bac) 2

CIPRODEX OTIC (EAR)

(Ciloxan) 1

(Cetraxal) 4

mggram (05 )

mggram)

DROPS VISCOUS 05

Drug Name

(Vigamox) 2

DROPSSUSPENSION 5

(Neo-Polycin HC) 2

mg-unit-unitg

(Neo-Polycin) 2

(Maxitrol) 2

10000 unitg-01

(Maxitrol) 2

unit-0025mgml

unitml-

35-400-10000 mg-unitg-1

10000 unitgram

(Polytrim) 1

drops 10

(Bleph-10) 2

ointment 10

(eye) drops 10 -023 (025 )

Drug Name

(TobraDex) 2

Inflammatory Agents

DROPSSUSPENSION 02

DROPS 0075

DROPS 005

mcg (0025 )

dropssuspension 01

(FML Liquifilm) 4

drops 003

DROPSSUSPENSION 03

DROPSSUSPENSION 1

DROPSGEL 05

OINTMENT 05

DROPSGEL 038

dropssuspension 1

(Pred Forte) 4

Drug Name

DROPS 007

DROPPERETTE 005

DROPPERETTE 5

soln 20 mg

soln 40 mg

(Nexium IV) 2

mg2 ml

release(drec) 15 mg

release(drec) 30 mg

(Protonix) 2

(drec) 20 mg

(drec) 40 mg

50 mg2 ml (25 mgml)

(Zantac) 2

(ranitidine))

Drug Name

DISPERSIBLE 200 MG

0025 mg5 ml

Years)

0025 mg

Years)

KIT 5 MG

5 PA NDS

193 gram60 ml

290 MCG 72 MCG

(loperamide))

(Reglan) 1

Drug Name

SOLUTION 12 MG06 ML

28 days)

SYRINGE 12 MG06 ML

28 days)

SYRINGE 8 MG04 ML

28 days)

gram60 ml

Laxatives

GRAM -12 GRAM160 ML

-584 gram

-586 gram

2272-672 -584 gram

(Colyte with Flavor

Packs)

420 gram

Phosphate Binders

Drug Name

(Renvela) 5 NDS

VELPHORO ORAL

mg 5 mg 50 mg

(Urecholine) 2

(Ditropan XL) 2

release 24hr 15 mg

24hr 2 mg 4 mg

(Detrol LA) 2

hr 10 mg

(Uroxatral) 1

THIOLA EC ORAL

5 PA NDS

Drug Name

mg 250 mg 500 mg

(Exjade) 5 PA NDS

500 mg

(Desferal) 2 PA

250 MG

5 PA NDS

MG 90 MG

5 PA NDS

MG 90 MG

5 PA NDS

30 days)

Hormonal Agents

Androgens

100 mgml 200 mgml

200 mgml (1 ml)

200 mgml

ML 75 MG05 ML

Years)

Drug Name

mg24 hr 00375 mg24 hr 005 mg24 hr

0075 mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

0025 mg24 hr 005 mg24 hr 0075

mg24 hr 01 mg24 hr

days) AGE (Max 64

Years)

00375 mg24 hr

days) AGE (Max 64

Years)

mg24 hr 00375 mg24 hr 005 mg24 hr

006 mg24 hr 0075 mg24 hr 01 mg24

days) AGE (Max 64

Years)

mgml 40 mgml

(Delestrogen) 2

05-01 mg

Years)

HR 01 MG24 HR

mg-mcg

Years)

05-25 mg-mcg

Years)

1-5 mg-mcg

Years)

045 MG 0625 MG 09 MG 125 MG

Years)

MGGRAM

Drug Name

MG (14) 0625MG-5MG(14)

Years)

045-15 MG 0625-25 MG 0625-5 MG

Years)

suspension 6 mgml

mg 4 mg 6 mg

(Decadron) 1 PA BvD

1 PA BvD

solution 10 mgml

MG 6 MG

(Cortef) 2

(Depo-Medrol) 2

mg 4 mg 8 mg

(Medrol) 2

(Medrol (Pak)) 2

(Solu-Medrol) 2

mg5 ml (3 mgml)

2 PA BvD

Drug Name

2 PA BvD

1 PA BvD

suspension 40 mgml

(Kenalog) 2

Pituitary

mcgspray (01 ml)

(DDAVP) 2

mcgspray (01 ml)

SOLN 1 MG

MG025 ML

MG025 ML 06 MG025 ML 08

MG025 ML 1 MG025 ML 12

MG025 ML 14 MG025 ML 16

MG025 ML 18 MG025 ML 2

MG025 ML

5 PA NDS

5 MGML (15 UNITML)

5 PA NDS

HUMATROPE INJECTION

5 PA NDS

SOLN 5 (15 UNIT) MG

5 PA NDS

Drug Name

SOLUTION 10 MGML

1125 MG

SYRINGE KIT 75 MG

LUPRON DEPOT-PED

NORDITROPIN FLEXPRO

ML (10 MGML) 30 MG3 ML (10

5 PA NDS

NORDITROPIN FLEXPRO

MG15 ML (33 MGML)

NUTROPIN AQ NUSPIN

5 PA NDS

mcgml 200 mcgml

(Sandostatin) 2

mcgml (1 ml)

5 PA NDS

RECON SOLN 58 MG

5 PA NDS

Drug Name

SAIZEN SAIZENPREP

5 PA NDS

SOLN 5 MG 88 MG

5 PA NDS

INTRAMUSCULAR

SOLN 4 MG 5 MG 6 MG

5 PA NDS

SOMATULINE DEPOT

MG05 ML

5 PA NSO NDS QL (1

per 28 days)

SOMATULINE DEPOT

ML 90 MG03 ML

25 MG 30 MG

5 PA NDS

(65 MCGDAY)

5 NDS QL (1 per 360

AEROSOL 2 MGML

225 MG

5 NDS QL (1 per 168

RECON SOLN 10 MG

5 PA NDS

RECON SOLN 5 MG

SOLN 88 MG

5 PA NDS

Progestins

SUSPENSION 400 MGML

5 PA NSO NDS

Drug Name

suspension 150 mgml

syringe 150 mgml

25 mg 5 mg

(Provera) 1

(40 mgml)

Years)

mg 200 mg

(Prometrium) 2

mcg 125 mcg 137 mcg 150 mcg 175

88 mcg

(Euthyrox) 1

(Cytomel) 2

ACTEMRA ACTPEN

MG09 ML

5 PA NDS

ACTEMRA INTRAVENOUS

80 MG4 ML (20 MGML)

5 PA NDS

SYRINGE 162 MG09 ML

5 PA NDS

SOLN 220 MG

100 mg

2 PA BvD

MG X 2 VIALS)

5 PA NDS

Drug Name

5 PA NDS

mg5 ml

mg 25 mg

(Gengraf) 2 PA BvD

5 PA NDS

SOLN 25 MG (1 ML)

5 PA NDS

25 MG05 ML (05) 50 MGML (1 ML)

5 PA NDS

ENBREL SURECLICK

MGML (1 ML)

5 PA NDS

SOLUTION 10 5

5 PA BvD NDS

4 PA BvD

SOLUTION 10

5 PA BvD NDS

GRAM 5 GRAM

5 PA BvD NDS

SOLUTION 10 10 (100 ML) 10

(200 ML)

5 PA BvD NDS

Drug Name

KIT 40 MG08 ML 40 MG08 ML (6

5 PA NDS

KIT 40 MG08 ML

5 PA NDS

KIT 10 MG02 ML 20 MG04 ML 40

MG08 ML

5 PA NDS

MG08 ML-40 MG04 ML

5 PA NDS

80 MG08 ML

5 PA NDS

MG02 ML 40 MG04 ML

5 PA NDS

SOLUTION 300 UNITML

HYPERRAB SD (PF)

UNITML

HYQVIA SUBCUTANEOUS

25 GRAM 25 ML (10 ) 20 GRAM

200 ML (10 ) 30 GRAM 300 ML (10

) 5 GRAM 50 ML (10 )

5 PA BvD NDS

SOLN 150 MGML

5 PA NDS

SOLUTION 150 MGML

5 PA NDS

Drug Name

100 MGML

5 PA NDS

UNITML

SOLN 100 MG

5 PA NDS

SOLUTION 150 UNITML

MG114 ML

5 PA NDS

MG114 ML

5 PA NDS

100 MG067 ML

5 PA NDS

recon soln 500 mg

(CellCept) 2 PA BvD

SOLN 250 MG

5 PA BvD NDS

OCTAGAM INTRAVENOUS

SOLUTION 10 5

5 PA BvD NDS

5 PA NDS

ORENCIA CLICKJECT

125 MGML

5 PA NDS

875 MG07 ML

5 PA NDS

OTEZLA STARTER ORAL

MG (4)-30 MG (47) 10 MG (4)-20 MG

(4)-30 MG(19)

5 PA NDS

Drug Name

SOLUTION 10

5 PA BvD NDS

5 MGML

4 PA BvD

PACKET 02 MG 1 MG

4 PA BvD ST

MG025 ML 15 MG03 ML 175

MG035 ML 20 MG04 ML 225

MG045 ML 25 MG05 ML 30 MG06

ML 75 MG015 ML

SOLN 100 MG

5 PA NDS

SOLN 100 MG

5 PA NDS

MG15 ML

5 PA NDS

SOLUTION 125 MGML

5 PA NDS

100 MGML 50 MG05 ML

5 PA NDS

130 MG26 ML

5 PA NDS

SOLUTION 45 MG05 ML

5 PA NDS

(Prograf) 2 PA BvD

TALTZ AUTOINJECTOR

80 MGML

5 PA NDS

Drug Name

SYRINGE 80 MGML

5 PA NDS

INJECTOR 100 MGML

5 PA NDS

SYRINGE 100 MGML

5 PA NDS

300 MG15 ML

5 PA LA NDS

5 PA NDS

05 MG 075 MG 1 MG

5 PA BvD NDS

Vaccines

ADACEL(TDAP

ADOLESNADULT)(PF)

LF-(25-5-3-5 MCG)-5LF05 ML

ADACEL(TDAP

ADOLESNADULT)(PF)

(25-5-3-5 MCG)-5LF05 ML

3 PA BvD

LF05ML

10-5 LF-MCG-LF05ML

SUSPENSION 20 MCGML

3 PA BvD

Drug Name

SYRINGE 20 MCGML

3 PA BvD

MCG05 ML

3 PA BvD

SUSPENSION 05 ML

SYRINGE 05 ML

720 ELISA UNIT05 ML

ELISA UNIT05 ML

3 PA BvD

58-10 LF-MCG-LF05ML

LF-MCG-LF05ML

32 UNIT05 ML

UNIT05 ML

SYRINGE 6 MCG05 ML

SOLUTION 4 MCG05 ML

Drug Name

10LF05 ML

10EXP3-43-3- 399 TCID5005

UNIT05ML

25 UNIT

3 PA BvD

RECOMBIVAX HB (PF)

3 PA BvD

RECOMBIVAX HB (PF)

MCGML 5 MCG05 ML

3 PA BvD

CCID50ML

SOLUTION 2 ML

50 MCG05 ML

TDVAX INTRAMUSCULAR

UNIT05ML

LF UNIT05 ML

Drug Name

SYRINGE 25 MCG05 ML

UNITML

1350 UNIT05 ML

10 EXP474 UNIT05 ML

19400 UNIT065 ML

Agents

budesonide oral

(Entocort EC) 2

tablets) 400 mg

(Delzicol) 2

(drec) 800 mg

(Asacol HD) 2

Drug Name

(drec) 500 mg

MGACTUATION

SOLUTION

Chloride)

solution

(Aqua Care Sterile

Water)

mcg2 ml

(Hectorol) 2

105 MG117 ML

30 days)

210MG234ML ( 105MG117MLX2)

30 days)

MCG24 ML

Drug Name

200 UNITML

MCGDOSE

solution 2 mcgml

60 MGML

RAYALDEE ORAL

HR 30 MCG

3 PA QL (156 per 30

mg5 ml

soln 500 mg

(Ethyol) 2

SOLN 120 MG 400 MG

5 PA NDS

INJECTOR 200 MGML

SYRINGE 200 MGML

CETYLEV ORAL TABLET

Drug Name

GRAM17 ML

5 GRAM

30 days)

SOLUTION 50 MGML

5 PA LA NDS

RECON SOLN 1 MG

(Vistaril) 1

30 days)

100 mg 200 mg 350 mg 50 mg 500 mg

mg 25 mg 5 mg

100 mgml

(Carnitor) 2

soln 50 mg

(Fusilev) 5 NDS

mg5 ml

(Mestinon) 2

Drug Name

150 MG 200 MG 50 MG

5 PA NSO NDS QL (60

per 30 days)

SOLN 500 MG

PACKET 10 GRAM

5 NDS QL (24 per 14

PACKET 2 GRAM

30 days)

Ophthalmic Agents

Antiglaucoma Agents

release 500 mg

500 mg

DROPS 01

DROPSSUSPENSION 1

DROPS 02-05

drops 223-68 mgml

(Cosopt) 2

DROPS 001

(Isopto Carpine) 2

DROPS 002

Drug Name

025 05

(Timoptic) 1

(Timoptic-XE) 4

DROPS 0004

mgml (10 )

IONOSOL-MB IN D5W

SOLUTION 5

PARENTERAL SOLUTION

release 8 meq

40 gram1000 ml (4 )

2 PA BvD

gram100 ml (4 ) 4 gram50 ml (8 )

2 PA BvD

meqml (50 )

2 PA BvD

Drug Name

SOLUTION

SINGLE-USE

PARENTERAL SOLUTION

2 PA BvD

meqml (20 ml)

2 PA BvD

release 10 meq

release 8 meq

ml 40 meq15 ml

(K-Tab) 2

release 20 meq

(K-Tab) 4

(Klor-Con M10) 2

(Klor-Con M20) 2

(Urocit-K 10) 2

release 15 meq

(Urocit-K 15) 2

(Urocit-K 5) 2

parenteral solution

Corticosteroids

Drug Name

50 MCGDOSE

MCGACTUATION 230-21

MCGACTUATION 45-21

MCGACTUATION

MCGACTUATION 200

MCGACTUATION 50

MCGACTUATION

mg2 ml

MCGACTUATION

MCGACTUATION 50

MCGACTUATION

AEROSOL INHALER 110

MCGACTUATION

AEROSOL INHALER 220

MCGACTUATION

AEROSOL INHALER 44

MCGACTUATION

Drug Name

INHALATIONS 80-45

MCGACTUATION

MCGACTUATION 80-45

MCGACTUATION

Antileukotrienes

(Singulair) 1

Bronchodilators

25 mg 3 ml (0083 ) 25 mg05 ml

2 PA BvD

MCGACTUATION

AEROSOL INHALER 17

MCGACTUATION

COMBIVENT RESPIMAT

MCGACTUATION

2 PA BvD

STARTER 25 MCGML

Drug Name

MCGDOSE

12 hr 100 mg 200 mg 300 mg

(Theochron) 2

12 hr 450 mg

24 hr 400 mg 600 mg

(30 ACTUAT)

mgml (20 )

(Acetadote) 2 PA

200 mgml (20 )

2 PA BvD

10 MGML

5 PA NDS

2 PA BvD

Drug Name

30 days)

SYRINGE 30 MGML

INJECTOR 100 MGML

28 days)

SOLN 100 MG

28 days)

100 MGML

28 days)

PACKET 100-125 MG 150-188 MG

MG 200-125 MG

30 days)

RECON SOLN 1000 MG

5 PA BvD NDS

(N) 50-75 MG (D) 75 MG (N)

SOLN 150 MG

5 PA NDS

150 MGML 75 MG05 ML

5 PA NDS

Years)

Drug Name

Years)

250 mg 50 mg

MG 20 MG 5 MG

per 30 days)

Vasodilating Agents

MG 15 MG 2 MG 25 MG

soln 05 mg

(Flolan) 2 PA

soln 15 mg

(Flolan) 5 PA NDS

25 MG 5 MG

5 PA NDS

Drug Name

1 day)

SUSPENSION 32 MG

28 days)

(06 MGML)

5 PA NDS

1200 MCG 1400 MCG 1600 MCG

400 MCG 600 MCG 800 MCG

30 days)

PACK 200 MCG (140)- 800 MCG (60)

5 PA NDS

27 mg iron- 1 mg

A abacavir 47

ABELCET 35

ABILIFY MAINTENA 43

ABRAXANE 15

acamprosate 7

acarbose 32

acebutolol 60

acetazolamide 107

acetic acid 82 104

acetylcysteine 112

acitretin 76

ACTEMRA 95

ACTEMRA ACTPEN 95

ACTHIB (PF) 100

ACTIMMUNE 105

acyclovir 52 76

acyclovir sodium 52

ADACEL(TDAP

ADAGEN 80

adapalene 79

adefovir 52

ADEMPAS 114

adriamycin 15

adrucil 15

ADVAIR DISKUS 110

ADVAIR HFA 110

afeditab cr 63

AFINITOR 15

AFINITOR DISPERZ 15

afirmelle 70

a-hydrocort 91

(2 PACK) 38

AJOVY 38

AKYNZEO

(FOSNETUPITANT) 39

ala-cort 77

albendazole 41

alclometasone 77

ALCOHOL PADS 76

ALDURAZYME 80

ALECENSA 16

alendronate 104

alfuzosin 88

ALIMTA 16

ALINIA 41

ALIQOPA 16

aliskiren 66

allopurinol 37

alosetron 103

ALPHAGAN P 107

alprazolam 8

ALREX 84

altavera (28) 70

ALTRENO 79

ALUNBRIG 16

alyacen 135 (28) 70

alyacen 777 (28) 70

alyq 114

amabelz 89

amantadine hcl 41

AMBISOME 35

ambrisentan 114

amethia 70

amethia lo 70

amiloride 63

AMINOSYN 10 55

AMINOSYN 7 WITH

ELECTROLYTES 55

AMINOSYN 85 55

AMINOSYN 85 -

ELECTROLYTES 55

AMINOSYN II 10 56

AMINOSYN II 15 56

AMINOSYN II 7 56

AMINOSYN II 85 56

AMINOSYN II 85 -

ELECTROLYTES 56

AMINOSYN M 35 56

AMINOSYN-HBC 7 56

AMINOSYN-PF 10 56

AMINOSYN-PF 7

(SULFITE-FREE) 56

AMINOSYN-RF 52 56

amiodarone 60

AMITIZA 86

amitriptyline 29

amlodipine 63

ammonium lactate 76

amoxapine 30

amoxicillin 13

amphotericin b 35

ampicillin 13

ANADROL-50 89

anagrelide 55

anastrozole 16

ANORO ELLIPTA 111

APOKYN 41

apraclonidine 81

aprepitant 39

apri 70

APRISO 103

APTIOM 25 26

APTIVUS 47

aranelle (28) 70

ARCALYST 95

aripiprazole 43

ARISTADA 43

ARISTADA INITIO 43

armodafinil 114

ARNUITY ELLIPTA 110

arsenic trioxide 16

ashlyna 70

ASSURE ID INSULIN

SAFETY 79

atazanavir 47

atenolol 60

atomoxetine 66

atorvastatin 64

atovaquone 41

ATRIPLA 47

atropine 25 82

ATROVENT HFA 111

AUBAGIO 66

aubra 70

aurovela 1530 (21) 70

aurovela 24 fe 70

AUSTEDO 67

AVASTIN 16

aviane 70

AVONEX 67

ayuna 70

azacitidine 16

azathioprine 95

azelastine 82

azithromycin 12

AZOPT 107

aztreonam 13

azurette (28) 70

B baciim 10

bacitracin 82

baclofen 113

balsalazide 103

BALVERSA 16

balziva (28) 71

BANZEL 26

BAVENCIO 16

BAXDELA 14

NEEDLE 79

UNIT 80

bekyree (28) 71

BELEODAQ 16

BELSOMRA 114

benazepril 59

BENDEKA 16

BENLYSTA 105

benztropine 41

BESPONSA 16

BETASERON 67

betaxolol 60

BETHKIS 9

BEVYXXA 52

bexarotene 16

BEXSERO 100

bicalutamide 16

BICILLIN L-A 13

BIDIL 66

BIKTARVY 47

bleomycin 16

bleph-10 82

BLINCYTO 16

blisovi 24 fe 71

blisovi fe 1530 (28) 71

BOOSTRIX TDAP 100

BORTEZOMIB 16

BOSULIF 16 17

BRAFTOVI 17

BREO ELLIPTA 110

briellyn 71

BRILINTA 55

brimonidine 107

BRIVIACT 26

bromocriptine 41

BROMSITE 84

budesonide 103 110

bumetanide 63

bupropion hcl 30

buspirone 8

BYSTOLIC 61

BYVALSON 61

C cabergoline 41

CABLIVI 105

CABOMETYX 17

caffeine citrate 67

calcipotriene 76

calcitriol 104

CALDOLOR 6

CALQUENCE 17

camila 71

CAPASTAT 39

CAPRELSA 17

captopril 59

CARBAGLU 86

carbamazepine 26

carteolol 107

cartia xt 62

carvedilol 61

caspofungin 36

CAYSTON 13

caziant (28) 71

cefaclor 11

cefadroxil 11

cefazolin 11

cefdinir 11

cefepime 11

cefixime 11

cefotaxime 11

cefoxitin 11

cefpodoxime 12

cefprozil 12

ceftazidime 12

ceftriaxone 12

celecoxib 6

CELONTIN 26

cephalexin 12

CERDELGA 80

CEREZYME 80

CETYLEV 105

CHANTIX 8

CHANTIX CONTINUING

MONTH BOX 8

CHANTIX STARTING

MONTH BOX 8

chlorothiazide 64

chlorpromazine 43

chlorthalidone 64

chlorzoxazone 113

ciclopirox 36

cilostazol 55

CIMDUO 47

cimetidine hcl 85

CIMZIA 95

CIMZIA POWDER FOR

RECONST 95

cinacalcet 104

CINQAIR 112

CINRYZE 53

CINVANTI 39

CIPRODEX 82

ciprofloxacin 14

citalopram 30

clarithromycin 12

CLENPIQ 87

clindamycin hcl 10

CLINIMIX 5D15W

SULFITE FREE 56

CLINIMIX 5D25W

SULFITE-FREE 56

FREE 56

CLINIMIX 425D5W

SULFIT FREE 56

CLINIMIX 425-D25W

SULF-FREE 56

CLINIMIX 5-

CLINIMIX E 275D10W

SUL FREE 56

CLINIMIX E 275D5W

SULF FREE 57

CLINIMIX E 425D10W

SUL FREE 57

CLINIMIX E 425D25W

SUL FREE 57

CLINIMIX E 425D5W

SULF FREE 57

CLINIMIX E 5D15W

SULFIT FREE 57

CLINIMIX E 5D20W

SULFIT FREE 57

CLINIMIX E 5D25W

SULFIT FREE 57

clobazam 26

clobetasol 78

clofarabine 17

clomipramine 30

clonazepam 9

clonidine 58

clonidine hcl 58

clopidogrel 55

clotrimazole 36

clozapine 43 44

COARTEM 41

codeine sulfate 3

colchicine 37

colestipol 64

colocort 103

COMBIGAN 107

COMETRIQ 17

COMPLERA 47

compro 39

constulose 86

COPIKTRA 17

CORLANOR 62

cormax 78

cortisone 91

COTELLIC 17

CREON 80

CRIXIVAN 47

cromolyn 82 86 112

cryselle (28) 71

cyclobenzaprine 113

cyclopentolate 82

cyclophosphamide 17

CYCLOPHOSPHAMIDE 17

cyclosporine 96

cyproheptadine 37

CYRAMZA 17

cyred 71

CYSTADANE 106

CYSTARAN 82

D dalfampridine 67

DALIRESP 113

danazol 89

dantrolene 113 114

dapsone 39

DAPTACEL (DTAP

PEDIATRIC) (PF) 100

daptomycin 10

DARAPRIM 41

DARZALEX 17

dasetta 135 (28) 71

dasetta 777 (28) 71

DAURISMO 17

daysee 71

deblitane 71

decadron 91

decitabine 17

deferasirox 89

deferoxamine 89

DELSTRIGO 47

delyla (28) 71

DEMSER 62

DEPEN TITRATABS 89

DEPO-PROVERA 94

DESCOVY 47

desipramine 30

desmopressin 92

desoximetasone 78

dexamethasone 91

(pf) 91

phosphate 84 91

dextroamphetamine-

amphetamine 67

DIASTAT 26

DIASTAT ACUDIAL 26

diazepam 9 26

diazepam intensol 9

dicloxacillin 13

dicyclomine 86

didanosine 47

DIFICID 12

digitek 62

digox 62

digoxin 62 63

DIGOXIN 63

diltiazem hcl 62

dilt-xr 62

dimenhydrinate 39

DIPENTUM 103

dipyridamole 55

disulfiram 8

divalproex 26

dofetilide 60

donepezil 29

dorzolamide 107

dotti 90

DOVATO 48

doxazosin 58

doxepin 30

doxercalciferol 104

doxorubicin 17

doxy-100 15

dronabinol 39

droperidol 106

DROXIA 18

DUAVEE 90

duloxetine 30

DUPIXENT 96

DUREZOL 84

dutasteride 88

E econazole 36

EDARBI 59

EDARBYCLOR 59

EDURANT 48

efavirenz 48

EGRIFTA 92

ELAPRASE 80

ELIGARD 18

elinest 71

ELIQUIS 52

ELITEK 80

ELLA 71

ELMIRON 106

EMCYT 18

EMEND 40

EMFLAZA 91

EMGALITY PEN 38

EMGALITY SYRINGE 38

emoquette 71

EMPLICITI 18

EMSAM 30

EMTRIVA 48

enalaprilat 59

ENBREL 96

ENBREL SURECLICK 96

ENDARI 106

endocet 3

enoxaparin 52 53

enpresse 71

enskyce 71

entacapone 42

entecavir 52

ENTRESTO 59

enulose 86

EPCLUSA 51

EPIDIOLEX 26

epinastine 82

epinephrine 63

epitol 26

EPIVIR HBV 48

eplerenone 66

ergoloid 106

ERGOMAR 38

ERIVEDGE 18

ERLEADA 18

erlotinib 18

errin 71

ertapenem 13

ery pads 77

erythromycin 12 82

ESBRIET 113

estarylla 71

estradiol 90

eszopiclone 114

ethambutol 39

ethosuximide 26

etodolac 6

ETOPOPHOS 18

etoposide 18

EUCRISA 78

EVENITY 104

EVOTAZ 48

exemestane 18

EXONDYS 51 106

EXTAVIA 67

ezetimibe 65

F FABRAZYME 80

falmina (28) 72

famciclovir 52

famotidine 85

famotidine (pf) 85

FANAPT 44

FARYDAK 18

FASENRA 113

febuxostat 37

felbamate 27

FEMRING 90

femynor 72

fenofibrate 65

fentanyl 3

fentanyl citrate 3

FERRIPROX 89

FETZIMA 30

INSULIN 33

finasteride 88

FIRAZYR 63

FIRVANQ 10

FLEBOGAMMA DIF 96

flecainide 60

FLOVENT DISKUS 110

FLOVENT HFA 110

floxuridine 18

fluconazole 36

flucytosine 36

fludrocortisone 91

flumazenil 67

flunisolide 84

fluocinolone 78

fluocinonide 78

fluocinonide-e 78

fluorometholone 84

fluorouracil 18 76

fluoxetine 30

fluphenazine hcl 44

flurbiprofen 6

flutamide 18

fluvoxamine 31

fomepizole 106

fondaparinux 53

FORTEO 104

fosamprenavir 48

foscarnet 50

fosinopril 59

fosphenytoin 27

FREAMINE HBC 69 57

FREAMINE III 10 58

FULPHILA 53

fulvestrant 18

furosemide 64

FUZEON 48

fyavolv 90

FYCOMPA 27

G gabapentin 27

GALAFOLD 80

galantamine 29

GAMASTAN 96

GAMMAGARD LIQUID 96

MCGML) 96

GAMMAPLEX 96

GAMMAPLEX (WITH

SORBITOL) 96

GARDASIL 9 (PF) 101

GATTEX 30-VIAL 86

GAUZE PAD 80

gavilyte-c 87

gavilyte-g 87

gavilyte-n 87

GAZYVA 18

gemfibrozil 65

generlac 86

gengraf 96

GENOTROPIN 92

gentak 82

gentamicin 9 77 82

GENVOYA 48

GEODON 44

GILENYA 67

GILOTRIF 18

glatiramer 67

glatopa 67 68

GLEOSTINE 18

glimepiride 35

glipizide 35

glyburide 35

glycopyrrolate 86

glydo 7

GLYXAMBI 32

GOCOVRI 42

granisetron (pf) 40

granisetron hcl 40

GRANIX 53 54

guanfacine 58 68

guanidine 106

H HAEGARDA 54

hailey 24 fe 72

haloperidol 44

HARVONI 51

HAVRIX (PF) 101

heather 72

HEPATAMINE 8 58

HERCEPTIN 19

HETLIOZ 114

HIBERIX (PF) 101

HUMATROPE 92

HUMIRA 97

HUMIRA PEDIATRIC

CROHNS START 97

HUMIRA PEN 97

HS START 97

HUMIRA PEN PSOR-

UVEITS-ADOL HS 97

HUMIRA(CF) 97

STARTER 97

HUMIRA(CF) PEN 97

UC-HS 97

ADOL HS 97

INSULIN 34

KWIKPEN 34

hydralazine 63

hydromorphone 4

hydroxyurea 19

hydroxyzine hcl 37

HYPERRAB (PF) 97

HYPERRAB SD (PF) 97

HYQVIA 97

I ibandronate 104

IBRANCE 19

ibuprofen 6

icatibant 63

ICLUSIG 19

IDHIFA 19

ifosfamide 19

ifosfamide-mesna 19

ILARIS (PF) 97

ILEVRO 84

ILUMYA 98

imatinib 19

IMBRUVICA 19

IMFINZI 19

imipramine hcl 31

imiquimod 76

IMLYGIC 19

(PF) 101

IMPAVIDO 41

INBRIJA 42

incassia 72

INCRELEX 93

INCRUSE ELLIPTA 111

indapamide 64

indomethacin 6

INFLECTRA 98

INGREZZA 68

INGREZZA INITIATION

PACK 68

INLYTA 19

U-100 80

INTELENCE 48

INTRALIPID 58

INTRON A 51

introvale 72

INVEGA SUSTENNA 45

INVEGA TRINZA 45

INVELTYS 84

INVIRASE 48

INVOKAMET 32

INVOKAMET XR 32

INVOKANA 32

IPOL 101

irbesartan 59

IRESSA 19

ISENTRESS 48

ISENTRESS HD 48

isibloom 72

ISOLYTE-P IN 5

DEXTROSE 108

ISOLYTE-S 108

isoniazid 39

itraconazole 36

ivermectin 41

IXEMPRA 19

IXIARO (PF) 101

J JADENU 89

JADENU SPRINKLE 89

JAKAFI 20

jantoven 53

JANUMET 32

JANUMET XR 32

JANUVIA 32

JARDIANCE 32

jasmiel (28) 72

jencycla 72

JENTADUETO 32

JENTADUETO XR 32

jinteli 90

jolivette 72

juleber 72

JULUCA 48

junel 1530 (21) 72

junel 120 (21) 72

junel fe 1530 (28) 72

junel fe 120 (28) 72

junel fe 24 72

JUXTAPID 65

JYNARQUE 64

K KABIVEN 58

KALETRA 48

kalliga 72

KALYDECO 113

KANJINTI 20

KANUMA 80

kariva (28) 72

KEDRAB (PF) 98

kelnor 135 (28) 72

kelnor 1-50 72

ketoconazole 36

ketorolac 6 84

KEVEYIS 106

KEVZARA 98

KEYTRUDA 20

KINERET 98

KINRIX (PF) 101

KISQALI 20

klor-con m10 108

klor-con m15 108

klor-con m20 108

KORLYM 32

KRINTAFEL 41

KRYSTEXXA 81

kurvelo (28) 72

KUVAN 81

KYPROLIS 20

labetalol 61

lactulose 86

lamivudine 48

lamotrigine 27

lansoprazole 85

INSULIN 34

larin 1530 (21) 73

larin 120 (21) 73

larin 24 fe 73

larin fe 1530 (28) 73

larin fe 120 (28) 73

larissia 73

latanoprost 107

LATUDA 45

LAZANDA 4

leena 28 73

leflunomide 98

LEMTRADA 68

LENVIMA 20

lessina 73

letrozole 20

LEUKERAN 20

LEUKINE 54

leuprolide 20

levetiracetam 27

levobunolol 107

levocarnitine 106

levocetirizine 37

levofloxacin 14 82

LEVOLEUCOVORIN

CALCIUM 106

levonest (28) 73

levora-28 73

levothyroxine 95

LEXIVA 48

LIALDA 103

LIBTAYO 20

lidocaine 7

lidocaine (pf) 7 60

lidocaine hcl 7

lidocaine viscous 7

lillow (28) 73

linezolid 10 11

LINZESS 86

liothyronine 95

lisinopril 59 60

lithium citrate 68

LIVALO 65

LOKELMA 86

LONHALA MAGNAIR

REFILL 112

LONHALA MAGNAIR

STARTER 111

LONSURF 20

loperamide 86

lorazepam 9

LORBRENA 20

lorcet hd 4

lorcet plus 4

loryna (28) 73

losartan 59

LOTEMAX 84

LOTEMAX SM 84

lovastatin 65

LUCEMYRA 8

LUMIGAN 107

LUMOXITI 21

LUPRON DEPOT 21 93

LUPRON DEPOT-PED 93

LUPRON DEPOT-PED (3

MONTH) 93

lutera (28) 73

LYNPARZA 21

LYRICA 27

LYSODREN 21

lyza 73

malathion 79

maprotiline 31

marlissa (28) 73

MARPLAN 31

MATULANE 21

PACK) 68

MAVENCLAD (4 TABLET

PACK) 68

MAVENCLAD (5 TABLET

PACK) 68

MAVENCLAD (6 TABLET

PACK) 68

MAVENCLAD (7 TABLET

PACK) 68

MAVENCLAD (8 TABLET

PACK) 68

MAVENCLAD (9 TABLET

PACK) 68

MAVYRET 51

MAYZENT 68

meclizine 40

mefenamic acid 6

mefloquine 41

megestrol 21 95

MEKINIST 21

MEKTOVI 21

meloxicam 6

memantine 29

MENACTRA (PF) 101

(PF) 101

MEPSEVII 81

mercaptopurine 21

meropenem 13

mesalamine 103

mesna 106

MESNEX 106

MESTINON 106

metaproterenol 112

metformin 32 33

methadone 4

methadose 4

methimazole 95

methocarbamol 114

methoxsalen 76

methscopolamine 86

methyclothiazide 64

metipranolol 107

mexiletine 60

MIACALCIN 105

miconazole-3 36

midodrine 58

miglustat 81

mili 73

mimvey 90

mimvey lo 90

minitran 66

minocycline 15

minoxidil 66

mirtazapine 31

misoprostol 85

MITIGARE 37

mitoxantrone 21

M-M-R II (PF) 102

molindone 45

mometasone 79

mondoxyne nl 15

mono-linyah 73

mononessa (28) 73

montelukast 111

morphine 4 5

MORPHINE 5

MOVANTIK 86

MOXEZA 82

moxifloxacin 14 83

MOZOBIL 54

MULPLETA 54

MULTAQ 60

mupirocin 77

MYLOTARG 21

MYRBETRIQ 88

myzilra 73

N nabumetone 6

nafcillin 13 14

NAGLAZYME 81

naloxone 8

naltrexone 8

NAMZARIC 29

naproxen 7

NARCAN 8

NATACYN 83

NATPARA 105

NEBUPENT 41

necon 0535 (28) 73

nefazodone 31

neomycin 10

dexameth 83

neomycin-polymyxin-

gramicidin 83

neo-polycin 83

neo-polycin hc 83

NEPHRAMINE 54 58

NERLYNX 21

NEULASTA 54

NEUPOGEN 54

NEUPRO 42

nevirapine 48 49

NEXAVAR 21

niacin 65

niacor 65

nicardipine 63

NICOTROL 8

nifedipine 63

nikki (28) 74

nilutamide 21

NINLARO 22

nitroglycerin 66

NITYR 81

NIVESTYM 54

nizatidine 85

NOCDURNA (MEN) 93

NOCDURNA (WOMEN) 93

nora-be 74

norlyda 74

norlyroc 74

NORMOSOL-M IN 5

DEXTROSE 109

NORMOSOL-R 109

NORTHERA 58

nortrel 0535 (28) 74

nortrel 135 (21) 74

nortrel 135 (28) 74

nortrel 777 (28) 74

nortriptyline 31

NORVIR 49

NOVOLIN 7030 U-100

INSULIN 34

100 34

NOVOLIN N NPH U-100

INSULIN 34

100 INSULN 34

INSULIN 34

INSULN 34

NOVOLOG MIX 70-

30FLEXPEN U-100 34

INSULIN 34

ASPART 34

NOXAFIL 36

NUCALA 113

NUCYNTA 5

NUCYNTA ER 5

NUEDEXTA 69

NULOJIX 98

NUPLAZID 45

NUTRILIPID 58

nyamyc 36

nystatin 36

nystop 36

O OCALIVA 87

OCREVUS 69

OCTAGAM 98

ODEFSEY 49

ODOMZO 22

OFEV 113

ofloxacin 83

ogestrel (28) 74

olanzapine 45

olmesartan 59

olopatadine 82

OLUMIANT 98

omeprazole 85

OMNITROPE 93

ONCASPAR 22

ondansetron 40

ondansetron hcl 40

ONIVYDE 22

OPDIVO 22

OPSUMIT 114

oralone 76

ORENCIA 98

ORENITRAM 114

ORFADIN 81

ORILISSA 93 94

ORKAMBI 113

orsythia 74

oseltamivir 50

OSMOLEX ER 42

OTEZLA 98

OTEZLA STARTER 98

oxcarbazepine 27

OXTELLAR XR 27

oxycodone 5

oxycodone-aspirin 5

OZEMPIC 33

P pacerone 60

paliperidone 45 46

PALYNZIQ 81

PANRETIN 76

pantoprazole 85

paricalcitol 105

PARICALCITOL 105

paromomycin 41

paroxetine hcl 31

PASER 39

PAXIL 31

PEDIARIX (PF) 102

PEDVAX HIB (PF) 102

PEGANONE 27

PEGASYS 51 52

PEGASYS PROCLICK 51

PEGINTRON 52

penicillamine 89

PENNSAID 7

PENTACEL (PF) 102

PENTAM 41

pentamidine 41

pentoxifylline 55

PERIKABIVEN 58

periogard 76

permethrin 79

perphenazine 46

PERSERIS 46

pfizerpen-g 14

phenadoz 40

phenelzine 31

phenobarbital 27 28

phenytoin 28

phenytoin sodium 28

philith 74

PHOSLYRA 88

PICATO 76 77

PIFELTRO 49

pimecrolimus 79

pimozide 46

pimtrea (28) 74

pioglitazone 33

PIQRAY 22

pirmella 74

PLASMA-LYTE 148 109

PLASMA-LYTE A 109

PLEGRIDY 69

podofilox 77

POLIVY 22

polycin 83

POMALYST 22

portia 28 74

PORTRAZZA 22

PRADAXA 53

PRALUENT PEN 65

pramipexole 42

prasugrel 55

pravastatin 65

prazosin 59

prednicarbate 79

prednisolone 92

84 91 92

prednisone 92

pregabalin 28

PREMARIN 90

PREMPHASE 91

PREMPRO 91

prevalite 65

previfem 74

PREVYMIS 50

PREZCOBIX 49

PREZISTA 49

PRIFTIN 39

PRIMAQUINE 41

primidone 28

PRIVIGEN 99

probenecid 37

procainamide 60

PROCALAMINE 3 58

prochlorperazine 40

PROCRIT 54

procto-med hc 79

proctosol hc 79

proctozone-hc 79

PROCYSBI 88

progesterone 95

PROGLYCEM 106

PROGRAF 99

PROLASTIN-C 113

PROLENSA 85

PROLEUKIN 22

PROLIA 105

PROMACTA 54

promethazine 37 40

promethegan 40

propafenone 60

proparacaine 82

propranolol 61

propylthiouracil 95

PROQUAD (PF) 102

PROSOL 20 58

protamine 55

protriptyline 31

PULMOZYME 81

PURIXAN 22

pyrazinamide 39

quetiapine 46

quinapril 60

R RABAVERT (PF) 102

RADICAVA 69

raloxifene 91

ramipril 60

ranitidine hcl 85

ranolazine 63

rasagiline 42

RASUVO (PF) 99

RAVICTI 87

RAYALDEE 105

REBIF REBIDOSE 69

reclipsen (28) 74

RECTIV 107

RELISTOR 87

REMICADE 99

RENFLEXIS 99

repaglinide 33

REPATHA SYRINGE 65

RESCRIPTOR 49

RESTASIS 85

RETACRIT 55

RETROVIR 49

REVCOVI 81

REVLIMID 22

revonto 114

REXULTI 46

REYATAZ 49

RHOPRESSA 107

ribasphere 52

ribavirin 52

RIDAURA 99

rifabutin 39

rifampin 39

riluzole 69

rimantadine 51

RISPERDAL CONSTA 46

risperidone 46

ritonavir 49

RITUXAN 22

RITUXAN HYCELA 22

rivastigmine 29

rizatriptan 38

ropinirole 42

rosadan 77

rosuvastatin 65

ROTARIX 102

ROTATEQ VACCINE 102

RUBRACA 22

RYDAPT 22

S SABRIL 28

SAIZEN 94

SANTYL 77

SAPHRIS 46

SAVELLA 69

scopolamine base 40

selegiline hcl 42

selenium sulfide 77

SELZENTRY 49

SEREVENT DISKUS 112

SEROSTIM 94

sertraline 31

setlakin 74

sevelamer hcl 88

sharobel 74

SHINGRIX (PF) 102

SIGNIFOR 94

SILENOR 114

SILIQ 99

SIMBRINZA 108

simliya (28) 74

simpesse 74

SIMPONI 99

SIMPONI ARIA 99

simvastatin 65

sirolimus 99

SIRTURO 39

SKYRIZI 99

smoflipid 58

sodium chloride 104

SOLIQUA 10033 34

SOLTAMOX 22

SOLU-CORTEF (PF) 92

SOMATULINE DEPOT 94

SOMAVERT 94

sorine 61

sotalol 61

sotalol af 61

SOVALDI 51

spironolactone 64

SPRAVATO 31

sprintec (28) 75

SPRITAM 28

SPRYCEL 22

sronyx 75

ssd 77

stavudine 49

STELARA 99

STIVARGA 23

STRENSIQ 81

streptomycin 10

STRIBILD 49

SUBLOCADE 8

subvenite 28

sucralfate 86

sulfadiazine 14

sulfasalazine 104

sulfatrim 15

sulindac 7

sumatriptan 38

SUPPRELIN LA 94

SUTENT 23

syeda 75

SYLATRON 52

SYLVANT 23

SYMBICORT 110 111

SYMDEKO 113

SYMFI 49

SYMFI LO 49

SYMJEPI 63

SYMLINPEN 120 33

SYMLINPEN 60 33

SYMPAZAN 28

SYMTUZA 49

SYNAGIS 51

SYNAREL 94

SYNERCID 11

SYNJARDY 33

SYNJARDY XR 33

SYNRIBO 23

T TABLOID 23

tacrolimus 79 99

TAFINLAR 23

TAGRISSO 23

TAKHZYRO 107

TALTZ SYRINGE 100

TALZENNA 23

tamoxifen 23

tamsulosin 88

TARGRETIN 23

tarina 24 fe 75

tarina fe 120 (28) 75

TASIGNA 23

TAVALISSE 55

tazarotene 79

TAZORAC 79

taztia xt 62

TDVAX 102

TECENTRIQ 23

TECFIDERA 70

TECHNIVIE 51

TEFLARO 12

TEKTURNA HCT 66

telmisartan 59

temazepam 9

TEMODAR 23

TENIVAC (PF) 102

terazosin 88

terbinafine hcl 36

terbutaline 112

terconazole 37

testosterone 89

PED(PF) 102

tetrabenazine 70

tetracycline 15

THALOMID 107

theophylline 112

THIOLA 89

THIOLA EC 88

thioridazine 46

thiotepa 23

thiothixene 46

tiagabine 28

TIBSOVO 23

TICE BCG 100

tigecycline 15

tilia fe 75

TIVICAY 49 50

tizanidine 114

TOBI PODHALER 10

tobramycin 84

TOLAK 77

tolazamide 35

tolterodine 88

topiramate 28

toposar 23

toremifene 23

torsemide 64

TOTECT 107

TOUJEO MAX U-300

SOLOSTAR 34

INSULIN 35

TOVIAZ 88

TRACLEER 115

TRADJENTA 33

tramadol 5

trandolapril 60

tranexamic acid 55

TRANSDERM-SCOP 41

tranylcypromine 31

TRAVASOL 10 58

TRAVATAN Z 108

trazodone 31

TREANDA 23

TRECATOR 39

TRELEGY ELLIPTA 112

TRELSTAR 23 24

TREMFYA 100

tretinoin 79

tri femynor 75

trientine 89

tri-estarylla 75

trifluoperazine 46

trifluridine 84

trihexyphenidyl 43

tri-legest fe 75

tri-linyah 75

tri-lo-estarylla 75

tri-lo-marzia 75

tri-lo-mili 75

tri-lo-sprintec 75

trimethoprim 11

tri-mili 75

trimipramine 31

TRINTELLIX 31

TRIPTODUR 94

TRIUMEQ 50

trivora (28) 75

tri-vylibra 75

tri-vylibra lo 75

TROGARZO 50

TROPHAMINE 10 58

TROPHAMINE 6 58

TRULICITY 33

TRUMENBA 103

TRUVADA 50

tulana 75

TWINRIX (PF) 103

TYBOST 107

TYKERB 24

TYMLOS 105

TYPHIM VI 103

TYSABRI 100

TYVASO 115

U UCERIS 104

UDENYCA 55

ULORIC 37

UNITUXIN 24

UPTRAVI 115

ursodiol 87

V valacyclovir 52

VALCHLOR 77

valganciclovir 52

valproate sodium 28

valproic acid 29

valrubicin 24

valsartan 59

vancomycin 11

VAQTA (PF) 103

VARIVAX (PF) 103

VASCEPA 66

VELCADE 24

VELPHORO 88

VELTASSA 87

VEMLIDY 50

VENCLEXTA 24

VENCLEXTA STARTING

PACK 24

venlafaxine 31 32

verapamil 62

VERSACLOZ 46

VERZENIO 24

V-GO 40 80

VIBERZI 87

VICTOZA 33

VIDEX EC 50

VIEKIRA PAK 51

vienva 75

vigabatrin 29

vigadrone 29

VIIBRYD 32

VIMIZIM 81

VIMPAT 29

vinorelbine 24

viorele (28) 75

VIRACEPT 50

VIREAD 50

VISTOGARD 107

VITRAKVI 24

VIZIMPRO 24

VOLTAREN 7

voriconazole 36 37

VOSEVI 51

VOTRIENT 24

VPRIV 81

VRAYLAR 47

vyfemla (28) 76

vylibra 76

VYNDAQEL 63

VYXEOS 24

W warfarin 53

WELCHOL 66

wera (28) 76

X XADAGO 43

XALKORI 24

XARELTO 53

XATMEP 24

XELJANZ 100

XELJANZ XR 100

XERMELO 87

XIFAXAN 11

XIIDRA 85

XOFLUZA 51

XOLAIR 113

XOSPATA 24

XPOVIO 25

XTAMPZA ER 5 6

XTANDI 25

xulane 76

XULTOPHY 10036 35

XURIDEN 107

XYOSTED 89

XYREM 114

Y YERVOY 25

YF-VAX (PF) 103

YONDELIS 25

YONSA 25

Z zafirlukast 111

zaleplon 114

zarah 76

ZARXIO 55

ZEJULA 25

ZELBORAF 25

zenatane 77

zenchent (28) 76

ZENPEP 81

ZEPATIER 51

zidovudine 50

ziprasidone hcl 47

ZIRGAN 84

ZOLADEX 25

zoledronic acid 105

ZOLINZA 25

zolpidem 114

ZOMACTON 94

zonisamide 29

ZORBTIVE 94

ZORTRESS 100

ZOSTAVAX (PF) 103

zovia 135e (28) 76

ZTLIDO 7

ZUBSOLV 8

ZULRESSO 32

zumandimine (28) 76

ZYDELIG 25

ZYKADIA 25

ZYLET 84

ZYPREXA RELPREVV 47

ZYTIGA 25







Medical Condition









Table of Contents

INDEX

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

Documents

2020 Comprehensive Formulary