2020 Drug Formulary - Imperial Health...2019/07/17 · on the front and back cover pages. In the event of non-maintenance changes to the formulary throughout the plan year, Imperial

2020 Drug Formulary

Alameda, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Mateo, Santa Clara

Imperial Traditional (HMO) PBP 007

Imperial Traditional Plus (HMO) PBP 009

Imperial Senior Value (HMO C-SNP) PBP 005

2020 Formulary (List of Covered Drugs)

Imperial Traditional (HMO)

Imperial Traditional Plus (HMO)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File Submission ID 00020550, Version Number 4.

This formulary was updated on 7/17/2019. For more recent information or other questions, please

contact Imperial Health Plan of California, Member Services Department at 1-800-838-8271,

October 1 – March 31: Monday – Sunday, from 8:00 a.m. – 8:00 p.m. April 1 – September 30: Monday

– Friday, from 8:00 a.m. – 8:00 p.m., or visit www.Imperialhealthplan.com. This document is

available for free in Spanish.

IR_062.1 CA Drug Formulary 2020_C ENG 08/29/19

Contents What is the Imperial Health Plan of California Formulary? ..................................... 3

Can the Formulary (drug list) change? .................................................................... 3

How do I use the Formulary? ................................................................................... 4

What are generic drugs? .......................................................................................... 5

Are there any restrictions on my coverage? ............................................................ 5

How do I request an exception to the Imperial Health Plan of

California Formulary? .......................................................................................... 6

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

requesting an exception? .................................................................................... 7

For more information .............................................................................................. 8

Imperial Health Plan of California (HMO) Formulary .............................................. 8

Imperial Senior Value (HMO C-SNP) Formulary .................................................. 109

Index of Drugs ...................................................................................................... 211

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 “we,” “us,” or “our,” it means Imperial Health Plan of

California. When it refers to “plan” or “our plan,” it means Imperial Health Plan of California.

This document includes a list of the drugs (formulary) for our plan, which is current as of 7/17/2019.

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, and/or copayments/coinsurance may change on January 1, 2020,

and from time to time during the year.

What is the Imperial Health Plan of California Formulary?

A formulary is a list of covered drugs selected by Imperial Health Plan of California 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. Imperial Health Plan of California will generally

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

filled at an Imperial Health Plan of California network pharmacy, and other plan rules are followed.

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

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:

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 “How do I request an exception to the

Imperial Health Plan of California Formulary?”

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

formulary to be unsafe or the drug’s 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.

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 and/or 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 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 “How do I request an exception to the

Imperial Health Plan of California’s Formulary?”

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 7/17/2019. To get updated information about the drugs

covered by Imperial Health Plan of California, please contact us. Our contact information appears

on the front and back cover pages.

In the event of non-maintenance changes to the formulary throughout the plan year, Imperial

Health Plan of California may make changes via errata sheets mailed to you. Additionally, you may visit our website for a link to the errata sheet.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 13. 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, “CARDIOVASCULAR”. If you know what your

drug is used for, look for the category name in the list that begins on page 10. 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 210. 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?

Imperial Health Plan of California 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:

Prior Authorization: Imperial Health Plan of California requires you or your physician to get

prior authorization for certain drugs. This means that you will need to get approval from

Imperial Health Plan of California before you fill your prescriptions. If you don’t get approval,

Imperial Health Plan of California may not cover the drug.

Quantity Limits: For certain drugs, Imperial Health Plan of California limits the amount of the

drug that Imperial Health Plan of California will cover. For example, Imperial Health Plan of

California provides 60 capsules per prescription for celecoxib. This may be in addition to a

standard one-month or three-month supply.

Step Therapy: In some cases, Imperial Health Plan of California 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, Imperial

Health Plan of California may not cover Drug B unless you try Drug A first. If Drug A does not

work for you, Imperial Health Plan of California 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 13. You can also get more information about the restrictions applied to specific

covered drugs by visiting our Web site. We have posted online documents that explain our prior

authorization and step therapy restrictions. 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.

You can ask Imperial Health Plan of California 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, “How do I

request an exception to Imperial Health Plan of California Formulary?” on page 6 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 Imperial Health Plan of California does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by Imperial Health

Plan of California. When you receive the list, show it to your doctor and ask him or her to

prescribe a similar drug that is covered by Imperial Health Plan of California.

You can ask Imperial Health Plan of California 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 Imperial Health Plan of

California Formulary?

You can ask Imperial Health Plan of California to make an exception to our coverage rules. There

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

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.

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.

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

drugs, Imperial Health Plan of California 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, Imperial Health Plan of California will only approve your request for an exception if the

alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional

utilization restrictions would not be as effective in treating your condition and/or 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 prescriber’s 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.

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, we’ll 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.

Exceptions are available for beneficiaries who have experienced a change in the level of care they

are receiving which requires them to transition from one facility or treatment center to another.

Examples of situations in which beneficiaries would be eligible for the one-time temporary fill

exception when they are outside of the three-month effective date into the Part D program are as

follows:

1. Beneficiary was discharged from the hospital and was provided a discharge list of

medications based upon the formulary of the hospital.

2. Beneficiaries who end their skilled nursing facility Medicare Part A stay (where payments

include all pharmacy charges) and who need to revert back to their Part D plan formulary

3. Beneficiaries who give up Hospice Status to revert back to standard Medicare Part A and B

benefits

4. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized.

For more information

For more detailed information about your Imperial Health Plan of California prescription drug

coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Imperial Health Plan of California, please contact us. Our contact

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

cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at

1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call

1-877-486-2048. Or, visit http://www.medicare.gov.

Imperial Health Plan of California (HMO) Formulary

The formulary that begins on the next page provides coverage information about the drugs covered

by Imperial Health Plan of California. If you have trouble finding your drug in the list, turn to the

Index that begins on page 210.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., HUMIRA)

and generic drugs are listed in lower-case italics (e.g., celecoxib).

The information in the Requirements/Limits column tells you if Imperial Health Plan of California

has any special requirements for coverage of your drug.

The following table describes the abbreviations used in the Drug List Table.

ABBREVIATION MEANING

LA

This prescription may be available only at certain pharmacies. For more

information please call 1-800-546-5677-24hours a day-seven days a week.

TTY/TDD users should call 1-866-706-4757.

QL Quantity limitation. Followed by the limitation amount per days specified.

PA

This medication requires prior authorization. To obtain an exception please

call 1-800-546-5677 - 24hours a day-seven days a week. TTY/TDD users should

call 1-866-706-4757.

NEW PA

This medication requires prior authorization for new starts only. To obtain an

exception please call 1-800-546-5677 - 24hours a day- seven days a week.


B/D PA

This drug may be covered under Medicare Part B or D depending upon the

circumstances. Information may need to be submitted describing the use and

setting of drug to make the determination.

ST Step therapy protocols apply.

Note: Tier 6 – Select Care Drugs only applies to Imperial Senior Value (HMO C-SNP). Imperial

Traditional (HMO) and Imperial Traditional Plus (HMO) plan have a five (5) Tier formulary.

Imperial MAPD 2020 5-Tier (List of Covered Drugs)

List of Drugs by Medical Condition

ANALGESICS ....................................................................................................................................... 13

ANESTHETICS ..................................................................................................................................... 15

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ............................................................. 15

ANTIBACTERIALS ................................................................................................................................ 16

ANTICONVULSANTS ............................................................................................................................ 23

ANTIDEMENTIA AGENTS ..................................................................................................................... 27

ANTIDEPRESSANTS ............................................................................................................................ 28

ANTIEMETICS ...................................................................................................................................... 31

ANTIFUNGALS ..................................................................................................................................... 31

ANTIGOUT AGENTS ............................................................................................................................. 33

ANTI-INFLAMMATORY AGENTS ........................................................................................................... 34

ANTIMIGRAINE AGENTS ...................................................................................................................... 35

ANTIMYASTHENIC AGENTS ................................................................................................................. 36

ANTIMYCOBACTERIALS ....................................................................................................................... 36

ANTINEOPLASTICS ............................................................................................................................. 37

ANTIPARASITICS ................................................................................................................................. 43

ANTIPARKINSON AGENTS ................................................................................................................... 44

ANTIPSYCHOTICS ............................................................................................................................... 45

ANTIVIRALS ......................................................................................................................................... 49

ANXIOLYTICS ...................................................................................................................................... 54

BIPOLAR AGENTS ............................................................................................................................... 55

BLOOD GLUCOSE REGULATORS ......................................................................................................... 55

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS ...................................................................... 59

CARDIOVASCULAR AGENTS ................................................................................................................ 60

CENTRAL NERVOUS SYSTEM AGENTS ................................................................................................ 70

DENTAL AND ORAL AGENTS ............................................................................................................... 72

DERMATOLOGICAL AGENTS ............................................................................................................... 72

ELECTROLYTES/MINERALS/METALS/VITAMINS ................................................................................. 76

GASTROINTESTINAL AGENTS ............................................................................................................. 80

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT .................................... 82

GENITOURINARY AGENTS ................................................................................................................... 83

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) .................................... 84

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/

MODIFYING (SEX HORMONES/ MODIFIERS) .................................................................................... 85

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) .................................... 91

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)....................................... 92

HORMONAL AGENTS, SUPPRESSANT (PITUITARY) ............................................................................ 92

HORMONAL AGENTS, SUPPRESSANT (THYROID) ............................................................................... 93

IMMUNOLOGICAL AGENTS.................................................................................................................. 93

INFLAMMATORY BOWEL DISEASE AGENTS ......................................................................................... 98

METABOLIC BONE DISEASE AGENTS .................................................................................................. 98

MISCELLANEOUS ................................................................................................................................ 99

OPHTHALMIC AGENTS ........................................................................................................................ 99

OTIC AGENTS .................................................................................................................................... 103

RESPIRATORY TRACT AGENTS .......................................................................................................... 103

SKELETAL MUSCLE RELAXANTS ....................................................................................................... 107

SLEEP DISORDER AGENTS ................................................................................................................ 108

Legend

1: Preferred Generics

2: Generics

3: Preferred Brands

4: Non-Preferred Drugs

5: Specialty

BvD: Part B vs. Part D- This prescription drug may be covered under Medicare Part B or D depending

upon the circumstances. Information may need to be submitted describing the use and setting of

the drug to make the determination.

GC: Gap Coverage- We provide additional coverage of this prescription drug in the coverage gap.

Please refer to our Evidence of Coverage for more information about this coverage.

LA: Limited Access- This prescription may be available only at certain pharmacies.

MO: Mail Order Eligible- This prescription may also be available via mail.

PA: Prior Authorization- You (or your physician) are required to get prior authorization before you

fill your prescription for this drug. Without prior approval, we may not cover this drug.

PA2: Prior Authorization (New Starts Only)- You (or your physician) are required to get prior

authorization before you fill your prescription for this drug unless you are a previous user of the

drug. If you have a history of using this medication, you will not need prior authorization.

QL: Quantity Limit- There is a limit on the amount of this drug that is covered per prescription, or

within a specific time frame.

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

condition before we will cover another drug for that condition.

ST2: Step Therapy (New Starts Only)- In some cases, you may be required to first try certain drugs

to treat your medical condition before we will cover another drug for that condition unless you are

a previous user of the drug. If you have a history of using this medication, you will not need to try

other medications first.


Drug Name Drug Tier Requirements/Limits

ANALGESICS

Opioid Analgesics, Long-Acting

fentanyl transdermal patch 72hour 100mcg/hr, 37.5mcg/hr, 62.5mcg/hr, 87.5mcg/hr

4 MO; QL (10 EA per 30 days)

fentanyl transdermal patch 72hour 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr

2 GC; MO; QL (10 EA per 30 days)

methadone hcl oral tablet 10mg, 5mg 2 GC; MO

morphine sulfate er oral tablet extended release

100mg, 60mg



15mg, 200mg, 30mg


oxycodone hcl er oral tablet er 12hour abuse-deterrent 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg

4 MO

oxycodone hcl oral concentrate 100mg/5ml 4 MO; QL (180ML per 30 days)

XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-

DETERRENT 13.5MG, 18MG, 27MG, 36MG, 9MG

3 MO

ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 10MG, 15MG, 20MG, 30MG,

40MG, 50MG

3 MO

Opioid Analgesics, Short-Acting

acetaminophen-codeine #3 oral tablet 300-30mg 1 GC; MO; QL (400 EA per 30 days)

acetaminophen-codeine oral solution 120-12mg/5ml

1 GC; MO; QL (5000ML per 30 days)

acetaminophen-codeine oral tablet 300-15mg, 300-60mg


butalbital-acetaminophen oral tablet 50-325mg 2 GC; MO; QL (180 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-325-40mg


butalbital-apap-caffeine oral tablet 50-325-40mg 4 MO; QL (180 EA per 30 days)

butalbital-asa-caff-codeine oral capsule 50-325-40-30mg



butalbital-aspirin-caffeine oral capsule 50-325-40mg


codeine sulfate oral tablet 30mg 2 GC; MO; QL (360 EA per 30 days)

codeine sulfate oral tablet 60mg 4 MO; QL (360 EA per 30 days)

ENDOCET ORAL TABLET 10-325MG, 7.5-325MG 4 MO; QL (370 EA per 30 days)

ENDOCET ORAL TABLET 5-325MG 3 MO; QL (370 EA per 30 days)

fentanyl citrate buccal lozenge on a handle

1200mcg, 1600mcg, 600mcg, 800mcg

5 PA; QL (180 EA per 30 days)


200mcg, 400mcg

4 PA; MO; QL (180 EA per 30 days)

hydrocodone-acetaminophen oral solution 7.5-325mg/15ml


hydrocodone-acetaminophen oral tablet 10-325mg, 5-325mg, 7.5-325mg


hydrocodone-ibuprofen oral tablet 10-200mg, 5-200mg


hydrocodone-ibuprofen oral tablet 7.5-200mg 2 GC; MO; QL (180 EA per 30 days)

hydromorphone hcl oral liquid 1mg/ml 4 MO; QL (1920ML per 30 days)

hydromorphone hcl oral tablet 2mg, 4mg 2 GC; MO; QL (360 EA per 30 days)

hydromorphone hcl oral tablet 8mg 2 GC; MO; QL (240 EA per 30 days)

hydromorphone hcl pf injection solution

10mg/ml, 50mg/5ml 4 BvD; MO; QL (240ML per 30 days)

LORCET ORAL TABLET 5-325MG 3 MO; QL (370 EA per 30 days)

morphine sulfate (concentrate) oral solution 100mg/5ml


morphine sulfate oral solution 10mg/5ml 2 GC; MO; QL (3600ML per 30 days)

morphine sulfate oral solution 20mg/5ml 2 GC; MO; QL (2700ML per 30 days)

morphine sulfate oral tablet 15mg, 30mg 2 GC; MO; QL (180 EA per 30 days)

oxycodone hcl oral capsule 5mg 2 GC; MO; QL (180 EA per 30 days)

oxycodone hcl oral solution 5mg/5ml 4 MO; QL (1080ML per 30 days)

oxycodone hcl oral tablet 10mg, 15mg, 20mg, 30mg, 5mg



oxycodone-acetaminophen oral tablet 10-325mg, 2.5-325mg, 5-325mg, 7.5-325mg


oxycodone-aspirin oral tablet 4.8355-325mg 2 GC; MO; QL (360 EA per 30 days)

oxycodone-ibuprofen oral tablet 5-400mg 2 GC; MO; QL (360 EA per 30 days)

tramadol hcl oral tablet 50mg 1 GC; MO; QL (240 EA per 30 days)

tramadol-acetaminophen oral tablet 37.5-325mg 2 GC; MO; QL (370 EA per 30 days)

ANESTHETICS

Local Anesthetics

lidocaine external patch 5% 4 PA; MO; QL (90 EA per 30 days)

lidocaine hcl external solution 4% 4 MO; QL (50ML per 30 days)

lidocaine hcl urethral/mucosal external gel 2% 2 GC; MO; QL (30ML per 30 days)

lidocaine-prilocaine external cream 2.5-2.5% 4 MO; QL (30 GM per 30 days)

proparacaine hcl ophthalmic solution 0.5% 1 GC; MO

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

Alcohol Deterrents/Anti-Craving

acamprosate calcium oral tablet delayed release 333mg

2 GC; MO

disulfiram oral tablet 250mg, 500mg 2 GC; MO

Opioid Antagonists

naloxone hcl injection solution 0.4mg/ml 2 GC; MO

naloxone hcl injection solution cartridge

0.4mg/ml 2 GC; MO

naloxone hcl injection solution prefilled syringe

2mg/2ml 2 GC; MO

naltrexone hcl oral tablet 50mg 2 GC; MO

NARCAN NASAL LIQUID 4MG/0.1ML 3 MO

VIVITROL INTRAMUSCULAR SUSPENSION

RECONSTITUTED 380MG

5

Opioid Dependence Treatments

buprenorphine hcl sublingual tablet sublingual 2mg, 8mg

2 GC; MO


buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5mg, 8-2mg

1 GC; MO

SUBOXONE SUBLINGUAL FILM 12-3MG, 2-0.5MG,

4-1MG, 8-2MG

3 MO

Smoking Cessation Agents

bupropion hcl er (smoking det) oral tablet extended release 12hour 150mg

2 GC; MO

CHANTIX CONTINUING MONTH PAK ORAL

TABLET 1MG

3 MO

CHANTIX ORAL TABLET 0.5MG, 1MG 3 MO

CHANTIX STARTING MONTH PAK ORAL TABLET

0.5MG X 11 & 1MG X 42

3 MO

NICOTROL INHALATION INHALER 10MG 3 MO

ANTIBACTERIALS

Aminoglycosides

amikacin sulfate injection solution 500mg/2ml 4 BvD; MO

ARIKAYCE INHALATION SUSPENSION

590MG/8.4ML

4 PA; MO

gentamicin in saline intravenous solution 0.8-0.9mg/ml-%, 1-0.9mg/ml-%, 1.2-0.9mg/ml-%, 1.6-0.9mg/ml-%

2 GC; MO

gentamicin sulfate injection solution 40mg/ml 2 BvD; GC; MO

neomycin sulfate oral tablet 500mg 1 GC; MO

paromomycin sulfate oral capsule 250mg 4 MO

tobramycin inhalation nebulization solution

300mg/5ml 5 BvD

tobramycin sulfate injection solution 10mg/ml 4 BvD; MO

tobramycin sulfate injection solution 80mg/2ml 2 BvD; GC; MO

Antibacterials, Other

clindamycin hcl oral capsule 150mg, 75mg 1 GC; MO

clindamycin hcl oral capsule 300mg 2 GC; MO


clindamycin palmitate hcl oral solution reconstituted 75mg/5ml

4 MO

clindamycin phosphate in d5w intravenous solution 300mg/50ml, 600mg/50ml, 900mg/50ml

4 MO

clindamycin phosphate injection solution

300mg/2ml, 600mg/4ml, 900mg/6ml 4 BvD; MO

colistimethate sodium (cba) injection solution reconstituted 150mg

4 BvD; MO

dapsone oral tablet 100mg, 25mg 2 GC; MO

daptomycin intravenous solution reconstituted

350mg, 500mg

4 BvD; MO

FIRVANQ ORAL SOLUTION RECONSTITUTED

25MG/ML, 50MG/ML

4 MO

linezolid intravenous solution 600mg/300ml 5 PA

linezolid oral suspension reconstituted

100mg/5ml 5 PA

linezolid oral tablet 600mg 4 PA; MO

methenamine hippurate oral tablet 1gm 1 GC; MO

metronidazole in nacl intravenous solution 500-0.79mg/100ml-%

2 BvD; GC; MO

metronidazole oral tablet 250mg, 500mg 1 GC; MO

nitrofurantoin macrocrystal oral capsule 100mg, 25mg, 50mg

2 GC; MO

nitrofurantoin monohyd macro oral capsule 100mg

2 GC; MO

nitrofurantoin oral suspension 25mg/5ml 4 MO

SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200MG

5

SIVEXTRO ORAL TABLET 200MG 5

tigecycline intravenous solution reconstituted 50mg

4 BvD; MO

tinidazole oral tablet 250mg, 500mg 2 GC; MO

trimethoprim oral tablet 100mg 1 GC; MO


vancomycin hcl intravenous solution reconstituted 1gm, 10gm, 250mg, 500mg, 750mg

4 BvD; MO

vancomycin hcl oral capsule 125mg 4 MO

vancomycin hcl oral capsule 250mg 5

XIFAXAN ORAL TABLET 200MG, 550MG 4 MO

Beta-Lactam, Cephalosporins

cefaclor er oral tablet extended release 12hour

500mg

4 MO

cefaclor oral capsule 250mg, 500mg 2 GC; MO

cefaclor oral suspension reconstituted

125mg/5ml, 250mg/5ml, 375mg/5ml 4 MO

cefadroxil oral capsule 500mg 2 GC; MO

cefadroxil oral suspension reconstituted

250mg/5ml, 500mg/5ml 2 GC; MO

cefadroxil oral tablet 1gm 2 GC; MO

cefazolin sodium injection solution reconstituted

1gm, 500mg

4 MO


10gm

4 BvD; MO

cefdinir oral capsule 300mg 2 GC; MO

cefdinir oral suspension reconstituted


cefepime hcl injection solution reconstituted

1gm, 2gm

4 BvD; MO

cefixime oral suspension reconstituted

100mg/5ml, 200mg/5ml 4 MO

cefotetan disodium injection solution reconstituted 1gm, 2gm

4 MO

cefoxitin sodium injection solution reconstituted

10gm

4 BvD; MO

cefoxitin sodium intravenous solution reconstituted 1gm, 2gm

4 BvD; MO


cefpodoxime proxetil oral suspension reconstituted 100mg/5ml, 50mg/5ml

4 MO

cefpodoxime proxetil oral tablet 100mg, 200mg 4 MO

cefprozil oral suspension reconstituted 125mg/5ml, 250mg/5ml

2 GC; MO

cefprozil oral tablet 250mg, 500mg 2 GC; MO

ceftazidime injection solution reconstituted 1gm, 2gm, 6gm

4 MO

ceftriaxone sodium injection solution reconstituted 1gm, 2gm, 250mg, 500mg

4 BvD; MO

ceftriaxone sodium intravenous solution reconstituted 10gm

4 MO

cefuroxime axetil oral tablet 250mg, 500mg 2 GC; MO

cefuroxime sodium injection solution reconstituted 7.5gm, 750mg

4 BvD; MO

cefuroxime sodium intravenous solution reconstituted 1.5gm

4 BvD; MO

cephalexin oral capsule 250mg, 500mg 1 GC; MO

cephalexin oral capsule 750mg 4 MO

cephalexin oral suspension reconstituted 125mg/5ml, 250mg/5ml

2 GC; MO

cephalexin oral tablet 250mg 4 MO

cephalexin oral tablet 500mg 2 GC; MO

SUPRAX ORAL CAPSULE 400MG 4 MO

TEFLARO INTRAVENOUS SOLUTION

RECONSTITUTED 400MG, 600MG

5 BvD

Beta-Lactam, Other

AZACTAM INJECTION SOLUTION

RECONSTITUTED 2 GM

4 BvD; MO

aztreonam injection solution reconstituted 1gm 2 GC; MO

CAYSTON INHALATION SOLUTION

RECONSTITUTED 75MG

5 PA; LA


ertapenem sodium injection solution reconstituted 1gm

4 BvD; MO

imipenem-cilastatin intravenous solution reconstituted 250mg, 500mg

4 BvD; MO

meropenem intravenous solution reconstituted

1gm, 500mg

4 BvD; MO

Beta-Lactam, Penicillins

amoxicillin oral capsule 250mg, 500mg 1 GC; MO

amoxicillin oral suspension reconstituted 125mg/5ml, 200mg/5ml, 250mg/5ml, 400mg/5ml

1 GC; MO

amoxicillin oral tablet 500mg, 875mg 1 GC; MO

amoxicillin oral tablet chewable 125mg, 250mg 1 GC; MO

amoxicillin-pot clavulanate er oral tablet extended release 12hour 1000-62.5mg

4 MO

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5mg/5ml, 250-62.5mg/5ml, 400-57mg/5ml, 600-42.9mg/5ml

2 GC; MO

amoxicillin-pot clavulanate oral tablet 250-125mg, 500-125mg, 875-125mg

2 GC; MO

amoxicillin-pot clavulanate oral tablet chewable

200-28.5mg, 400-57mg

2 GC; MO

ampicillin oral capsule 500mg 1 GC; MO

ampicillin sodium injection solution reconstituted 1gm, 125mg

4 BvD; MO

ampicillin sodium intravenous solution reconstituted 10gm

4 BvD; MO

ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5)gm, 15 (10-5)gm, 3 (2-1)gm

4 BvD; MO

BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML

4 MO

BICILLIN L-A INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000

UNIT/ML

4 MO


dicloxacillin sodium oral capsule 250mg, 500mg 2 GC; MO

nafcillin sodium injection solution reconstituted 1gm, 2gm

4 BvD; MO

nafcillin sodium intravenous solution reconstituted 10gm

4 BvD; MO

oxacillin sodium injection solution reconstituted

1gm, 10gm, 2gm

4 MO

penicillin g pot in dextrose intravenous solution

40000 unit/ml, 60000 unit/ml 4 MO

penicillin g potassium injection solution reconstituted 20000000 unit

4 BvD; MO

penicillin g procaine intramuscular suspension

600000 unit/ml 4 MO

penicillin g sodium injection solution reconstituted 5000000 unit

4 BvD; MO

penicillin v potassium oral solution reconstituted


penicillin v potassium oral tablet 250mg, 500mg 1 GC; MO

piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25)gm, 3.375 (3-0.375)gm, 4.5 (4-0.5)gm, 40.5 (36-4.5)gm

4 BvD; MO

Macrolides

azithromycin intravenous solution reconstituted

500mg

2 BvD; GC; MO

azithromycin oral packet 1gm 4 MO

azithromycin oral suspension reconstituted


azithromycin oral tablet 250mg, 250mg (6 pack) 1 GC; MO

azithromycin oral tablet 500mg, 500mg (3 pack), 600mg

2 GC; MO

clarithromycin er oral tablet extended release 24hour 500mg

2 GC; MO

clarithromycin oral suspension reconstituted 125mg/5ml, 250mg/5ml

2 GC; MO


clarithromycin oral tablet 250mg, 500mg 2 GC; MO

ERY-TAB ORAL TABLET DELAYED RELEASE 250MG, 333MG, 500MG

4 MO

ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500MG

4 BvD; MO

ERYTHROCIN STEARATE ORAL TABLET 250MG 4 MO

erythromycin base oral capsule delayed release particles 250mg

2 GC; MO

erythromycin base oral tablet 250mg 2 GC; MO

erythromycin base oral tablet 500mg 4 MO

erythromycin ethylsuccinate oral suspension reconstituted 200mg/5ml, 400mg/5ml

2 GC; MO

erythromycin ethylsuccinate oral tablet 400mg 4 MO

Quinolones

ciprofloxacin hcl oral tablet 100mg 4 MO

ciprofloxacin hcl oral tablet 250mg, 500mg 1 GC; MO

ciprofloxacin hcl oral tablet 750mg 2 GC; MO

ciprofloxacin in d5w intravenous solution

200mg/100ml 4 BvD; MO

ciprofloxacin oral suspension reconstituted 500mg/5ml (10%)

4 MO

levofloxacin in d5w intravenous solution 500mg/100ml, 750mg/150ml

4 BvD; MO

levofloxacin intravenous solution 25mg/ml 4 BvD; MO

levofloxacin oral solution 25mg/ml 4 MO

levofloxacin oral tablet 250mg 2 GC; MO

levofloxacin oral tablet 500mg, 750mg 4 MO

moxifloxacin hcl in nacl intravenous solution


moxifloxacin hcl oral tablet 400mg 4 MO

ofloxacin oral tablet 300mg, 400mg 2 GC; MO

Sulfonamides


sulfacetamide sodium (acne) external lotion 10% 2 GC; MO

sulfadiazine oral tablet 500mg 4 MO

sulfamethoxazole-trimethoprim oral suspension

200-40mg/5ml 2 GC; MO

sulfamethoxazole-trimethoprim oral tablet 400-80mg, 800-160mg

1 GC; MO

Tetracyclines

DOXY 100 INTRAVENOUS SOLUTION

RECONSTITUTED 100MG

4 BvD; MO

doxycycline hyclate oral capsule 100mg, 50mg 1 GC; MO

doxycycline hyclate oral tablet 100mg, 20mg 1 GC; MO

doxycycline monohydrate oral capsule 100mg 2 GC; MO

doxycycline monohydrate oral capsule 50mg 1 GC; MO

doxycycline monohydrate oral tablet 100mg, 50mg

2 GC; MO

minocycline hcl oral capsule 100mg, 75mg 2 GC; MO

minocycline hcl oral capsule 50mg 1 GC; MO

minocycline hcl oral tablet 100mg, 50mg, 75mg 2 GC; MO

tetracycline hcl oral capsule 250mg, 500mg 2 GC; MO

ANTICONVULSANTS

Anticonvulsants, Other

BRIVIACT ORAL SOLUTION 10MG/ML 4 ST2; MO; QL (600ML per 30 days)

BRIVIACT ORAL TABLET 10MG, 100MG, 25MG, 50MG, 75MG

4 ST2; MO; QL (60 EA per 30 days)

carbamazepine er oral capsule extended release 12hour 100mg, 200mg, 300mg

2 GC; MO

carbamazepine er oral tablet extended release 12hour 100mg, 200mg, 400mg

2 GC; MO

carbamazepine oral suspension 100mg/5ml 2 GC; MO

carbamazepine oral tablet 200mg 2 GC; MO

carbamazepine oral tablet chewable 100mg 1 GC; MO


EPIDIOLEX ORAL SOLUTION 100MG/ML 4 ST2; MO

EPITOL ORAL TABLET 200MG 2 GC; MO

felbamate oral suspension 600mg/5ml 5

felbamate oral tablet 400mg, 600mg 4 MO

FYCOMPA ORAL SUSPENSION 0.5MG/ML 4 ST2; MO

levetiracetam er oral tablet extended release 24hour 500mg

2 GC; MO


3 MO

levetiracetam oral solution 100mg/ml 2 GC; MO

levetiracetam oral tablet 1000mg, 250mg, 500mg, 750mg

1 GC; MO

ROWEEPRA ORAL TABLET 1000MG, 500MG,

750MG

4 MO

ROWEEPRA XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 500MG, 750MG

4 MO

SPRITAM ORAL TABLET DISINTEGRATING

SOLUBLE 1000MG



SOLUBLE 250MG, 500MG, 750MG


Barbiturates

phenobarbital oral elixir 20mg/5ml 1 GC; MO; QL (1500ML per 30 days)

phenobarbital oral tablet 100mg, 16.2mg, 32.4mg, 64.8mg, 97.2mg


phenobarbital oral tablet 15mg, 60mg 1 GC; MO; QL (120 EA per 30 days)

phenobarbital oral tablet 30mg 1 GC; MO; QL (300 EA per 30 days)

primidone oral tablet 250mg, 50mg 1 GC; MO

Benzodiazepines

clobazam oral suspension 2.5mg/ml 5 QL (480ML per 30 days)

clobazam oral tablet 10mg 4 MO; QL (60 EA per 30 days)

clobazam oral tablet 20mg 5 QL (60 EA per 30 days)

DIASTAT ACUDIAL RECTAL GEL 10MG, 20MG 4 MO


DIASTAT PEDIATRIC RECTAL GEL 2.5MG 4 MO

diazepam rectal gel 10mg, 2.5mg, 20mg 4 MO

SYMPAZAN ORAL FILM 10MG, 20MG 5 ST2; QL (60 EA per 30 days)

SYMPAZAN ORAL FILM 5MG 4 ST2; MO; QL (60 EA per 30 days)

Calcium Channel Modifying Agents

CELONTIN ORAL CAPSULE 300MG 4 ST2; MO

ethosuximide oral capsule 250mg 2 GC; MO

ethosuximide oral solution 250mg/5ml 2 GC; MO

zonisamide oral capsule 100mg, 25mg, 50mg 2 GC; MO

Gamma-Aminobutyric Acid (Gaba) Augmenting Agents

divalproex sodium er oral tablet extended release 24hour 250mg, 500mg

2 GC; MO

divalproex sodium oral capsule delayed release sprinkle 125mg

2 GC; MO

divalproex sodium oral tablet delayed release

125mg

1 GC; MO


250mg, 500mg

2 GC; MO

FYCOMPA ORAL TABLET 10MG, 12MG, 4MG, 6MG 5 ST2; QL (30 EA per 30 days)

FYCOMPA ORAL TABLET 2MG, 8MG 4 ST2; MO; QL (30 EA per 30 days)

gabapentin oral capsule 100mg 1 GC; MO; QL (270 EA per 30 days)

gabapentin oral capsule 300mg, 400mg 2 GC; MO; QL (270 EA per 30 days)

gabapentin oral solution 250mg/5ml 2 GC; MO

gabapentin oral tablet 600mg, 800mg 2 GC; MO; QL (180 EA per 30 days)

LYRICA ORAL CAPSULE 100MG, 25MG, 50MG 3 MO; QL (90 EA per 30 days)


LYRICA ORAL SOLUTION 20MG/ML 3 MO; QL (900ML per 30 days)

tiagabine hcl oral tablet 12mg, 16mg, 2mg, 4mg 4 MO

valproate sodium oral solution 250mg/5ml 2

valproic acid oral capsule 250mg 2 GC; MO

valproic acid oral solution 250mg/5ml 2 GC; MO


vigabatrin oral packet 500mg 5 PA2; LA; QL (180 EA per 30 days)

vigabatrin oral tablet 500mg 5 PA2; LA; QL (180 EA per 30 days)

VIGADRONE ORAL PACKET 500MG 5 PA2; LA; QL (180 EA per 30 days)

Glutamate Reducing Agents

lamotrigine er oral tablet extended release 24hour 100mg, 200mg, 25mg, 250mg, 300mg, 50mg

4 MO

lamotrigine oral tablet 100mg, 150mg, 200mg, 25mg

1 GC; MO

lamotrigine oral tablet chewable 25mg, 5mg 1 GC; MO

lamotrigine oral tablet dispersible 100mg, 200mg, 25mg, 50mg

4 MO

lamotrigine starter kit-blue oral kit 35 x 25mg 2 GC; MO

lamotrigine starter kit-green oral kit 84 x 25mg & 14x100mg

2 GC; MO

lamotrigine starter kit-orange oral kit 42 x 25mg & 7 x 100mg

2 GC; MO

topiramate er oral capsule er 24hour sprinkle

100mg, 150mg, 200mg, 25mg, 50mg

4 MO

topiramate oral capsule sprinkle 15mg, 25mg 2 GC; MO

topiramate oral tablet 100mg, 200mg, 25mg, 50mg

2 GC; MO

Sodium Channel Agents

APTIOM ORAL TABLET 200MG, 400MG, 800MG 5 ST2; QL (30 EA per 30 days)

APTIOM ORAL TABLET 600MG 5 ST2; QL (60 EA per 30 days)

BANZEL ORAL SUSPENSION 40MG/ML 5 ST2; QL (2760ML per 30 days)

BANZEL ORAL TABLET 200MG 5 ST2; QL (480 EA per 30 days)


DILANTIN ORAL CAPSULE 30MG 4 MO

oxcarbazepine oral suspension 300mg/5ml 4 MO

oxcarbazepine oral tablet 150mg, 600mg 2 GC; MO

oxcarbazepine oral tablet 300mg 1 GC; MO


PEGANONE ORAL TABLET 250MG 4 ST2; MO

phenytoin oral suspension 125mg/5ml 1 GC; MO

phenytoin oral tablet chewable 50mg 1 GC; MO

phenytoin sodium extended oral capsule 100mg, 200mg, 300mg

1 GC; MO

VIMPAT ORAL SOLUTION 10MG/ML 4 ST2; MO; QL (1395ML per 30 days)

VIMPAT ORAL TABLET 100MG, 150MG, 200MG,

50MG


ANTIDEMENTIA AGENTS

Cholinesterase Inhibitors

donepezil hcl oral tablet 10mg 1 GC; MO; QL (60 EA per 30 days)



donepezil hcl oral tablet dispersible 10mg 2 GC; MO; QL (60 EA per 30 days)

donepezil hcl oral tablet dispersible 5mg 2 GC; MO; QL (30 EA per 30 days)

galantamine hydrobromide er oral capsule extended release 24hour 16mg, 24mg, 8mg


galantamine hydrobromide oral solution 4mg/ml 2 GC; MO; QL (180ML per 30 days)

galantamine hydrobromide oral tablet 12mg, 4mg, 8mg


rivastigmine tartrate oral capsule 1.5mg, 3mg, 4.5mg, 6mg


rivastigmine transdermal patch 24hour

13.3mg/24hr, 4.6mg/24hr, 9.5mg/24hr


N-Methyl-D-Aspartate (Nmda) Receptor Antagonist

memantine hcl er oral capsule extended release 24hour 14mg, 21mg, 28mg, 7mg

2 GC; MO

memantine hcl oral solution 2mg/ml 2 GC; MO; QL (360ML per 30 days)

memantine hcl oral tablet 10mg, 5mg 2 GC; MO; QL (60 EA per 30 days)

memantine hcl oral tablet 28 x 5mg & 21 x 10mg 2 GC; MO

NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 14 & 21 &28 -10MG

3 MO


NAMZARIC ORAL CAPSULE EXTENDED RELEASE

24 HOUR 14-10MG, 21-10MG, 28-10MG, 7-10MG

3 MO

ANTIDEPRESSANTS

Antidepressants, Other

bupropion hcl er (sr) oral tablet extended release 12hour 100mg






bupropion hcl er (xl) oral tablet extended release 24hour 150mg, 300mg


bupropion hcl er (xl) oral tablet extended release 24hour 450mg


bupropion hcl oral tablet 100mg 1 GC; MO; QL (180 EA per 30 days)

bupropion hcl oral tablet 75mg 1 GC; MO; QL (120 EA per 30 days)

maprotiline hcl oral tablet 25mg, 50mg, 75mg 2 GC; MO

mirtazapine oral tablet 15mg, 30mg, 45mg 1 GC; MO; QL (30 EA per 30 days)

mirtazapine oral tablet 7.5mg 1 GC; MO; QL (45 EA per 30 days)

mirtazapine oral tablet dispersible 15mg, 30mg, 45mg


nefazodone hcl oral tablet 100mg, 150mg, 200mg, 250mg, 50mg

2 GC; MO

trazodone hcl oral tablet 100mg, 150mg, 50mg 1 GC; MO

trazodone hcl oral tablet 300mg 2 GC; MO

TRINTELLIX ORAL TABLET 10MG, 20MG, 5MG 4 ST2; MO; QL (30 EA per 30 days)

VIIBRYD ORAL TABLET 10MG, 20MG, 40MG 3 ST2; MO; QL (30 EA per 30 days)

VIIBRYD STARTER PACK ORAL KIT 10 & 20MG 3 ST2; MO; QL (30 EA per 30 days)

Monoamine Oxidase Inhibitors

EMSAM TRANSDERMAL PATCH 24 HOUR

12MG/24HR, 6MG/24HR, 9MG/24HR

5 ST2; QL (30 EA per 30 days)

MARPLAN ORAL TABLET 10MG 4 ST2; MO; QL (180 EA per 30 days)


phenelzine sulfate oral tablet 15mg 1 GC; MO

tranylcypromine sulfate oral tablet 10mg 4 MO

Serotonin/Norepinephrine Reuptake Inhibitors

citalopram hydrobromide oral solution

10mg/5ml 2 GC; MO; QL (600ML per 30 days)

citalopram hydrobromide oral tablet 10mg, 40mg


citalopram hydrobromide oral tablet 20mg 1 GC; MO; QL (60 EA per 30 days)

desvenlafaxine er oral tablet extended release 24hour 100mg, 50mg


desvenlafaxine succinate er oral tablet extended release 24hour 100mg, 25mg, 50mg


duloxetine hcl oral capsule delayed release particles 20mg, 30mg, 40mg, 60mg


escitalopram oxalate oral solution 5mg/5ml 2 GC; MO; QL (600ML per 30 days)

escitalopram oxalate oral tablet 10mg 2 GC; MO; QL (45 EA per 30 days)



FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120MG, 20MG, 40MG, 80MG


FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR

THERAPY PACK 20 & 40MG


fluoxetine hcl oral capsule 10mg 1 GC; MO; QL (60 EA per 30 days)



fluoxetine hcl oral solution 20mg/5ml 2 GC; MO; QL (600ML per 30 days)

fluoxetine hcl oral tablet 10mg 2 GC; MO; QL (60 EA per 30 days)

fluoxetine hcl oral tablet 20mg 2 GC; MO; QL (120 EA per 30 days)

fluvoxamine maleate oral tablet 100mg, 25mg, 50mg


paroxetine hcl oral tablet 10mg, 20mg 1 GC; MO; QL (30 EA per 30 days)

paroxetine hcl oral tablet 30mg, 40mg 1 GC; MO; QL (60 EA per 30 days)


PAXIL ORAL SUSPENSION 10MG/5ML 4 MO; QL (900ML per 30 days)

sertraline hcl oral concentrate 20mg/ml 1 GC; MO; QL (300ML per 30 days)

sertraline hcl oral tablet 100mg 1 GC; MO; QL (60 EA per 30 days)

sertraline hcl oral tablet 25mg, 50mg 1 GC; MO; QL (90 EA per 30 days)

venlafaxine hcl er oral capsule extended release 24hour 150mg, 37.5mg, 75mg


venlafaxine hcl er oral tablet extended release 24hour 150mg, 37.5mg, 75mg


venlafaxine hcl er oral tablet extended release 24hour 225mg


venlafaxine hcl oral tablet 100mg, 25mg, 37.5mg, 50mg, 75mg


Tricyclics

amitriptyline hcl oral tablet 10mg, 25mg, 50mg 2 GC; MO

amitriptyline hcl oral tablet 100mg, 150mg, 75mg 1 GC; MO

amoxapine oral tablet 100mg, 150mg 2 GC; MO

amoxapine oral tablet 25mg, 50mg 1 GC; MO

clomipramine hcl oral capsule 25mg, 50mg, 75mg

4 MO

desipramine hcl oral tablet 10mg, 25mg 1 GC; MO

desipramine hcl oral tablet 100mg, 150mg, 50mg, 75mg

2 GC; MO

doxepin hcl oral capsule 10mg, 100mg, 150mg, 25mg, 50mg, 75mg

2 GC; MO

doxepin hcl oral concentrate 10mg/ml 2 GC; MO

imipramine hcl oral tablet 10mg, 25mg, 50mg 2 GC; MO

nortriptyline hcl oral capsule 10mg, 25mg, 50mg, 75mg

1 GC; MO

nortriptyline hcl oral solution 10mg/5ml 2 GC; MO

protriptyline hcl oral tablet 10mg, 5mg 4 MO


trimipramine maleate oral capsule 100mg, 25mg, 50mg

2 GC; MO

ANTIEMETICS

Antiemetics, Other

COMPRO RECTAL SUPPOSITORY 25MG 4 MO

meclizine hcl oral tablet 12.5mg, 25mg 1 GC; MO

prochlorperazine maleate oral tablet 5mg 1 BvD; GC; MO

prochlorperazine rectal suppository 25mg 4 MO

promethazine hcl oral tablet 12.5mg, 25mg, 50mg

1 GC; MO

scopolamine transdermal patch 72hour

1mg/3days


TRANSDERM-SCOP (1.5MG) TRANSDERMAL

PATCH 72 HOUR 1MG/3DAYS


Emetogenic Therapy Adjuncts

aprepitant oral capsule 125mg, 40mg, 80mg 4 BvD; MO; QL (30 EA per 30 days)

aprepitant oral capsule 80 & 125mg 4 BvD; MO; QL (12 EA per 30 days)

dronabinol oral capsule 10mg, 5mg 4 BvD; MO; QL (60 EA per 30 days)

dronabinol oral capsule 2.5mg 2 BvD; GC; MO; QL (60 EA per 30 days)

EMEND ORAL SUSPENSION RECONSTITUTED

125MG

4 BvD; MO

granisetron hcl oral tablet 1mg 4 BvD; MO; QL (60 EA per 30 days)

ondansetron hcl oral solution 4mg/5ml 2 BvD; GC; MO

ondansetron hcl oral tablet 24mg, 4mg, 8mg 2 BvD; GC; MO

ondansetron oral tablet dispersible 4mg, 8mg 2 BvD; GC; MO

SYNDROS ORAL SOLUTION 5MG/ML 4 BvD; MO; QL (120ML per 30 days)

VARUBI ORAL TABLET 90MG 3 BvD; MO

ANTIFUNGALS

Antifungals


ABELCET INTRAVENOUS SUSPENSION 5MG/ML 5 BvD

AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50MG

5 BvD

amphotericin b intravenous solution reconstituted 50mg

4 BvD; MO

caspofungin acetate intravenous solution reconstituted 50mg, 70mg

5 BvD

ciclopirox external gel 0.77% 2 GC; MO

ciclopirox external shampoo 1% 2 GC; MO

ciclopirox external solution 8% 1 GC; MO

ciclopirox olamine external cream 0.77% 2 GC; MO

ciclopirox olamine external suspension 0.77% 2 GC; MO

clotrimazole external cream 1% 1 GC; MO

clotrimazole external solution 1% 1 GC; MO

clotrimazole mouth/throat lozenge 10mg 1 GC; MO

econazole nitrate external cream 1% 2 GC; MO

ERAXIS INTRAVENOUS SOLUTION

RECONSTITUTED 100MG

5 BvD


RECONSTITUTED 50MG

4 BvD; MO

fluconazole in sodium chloride intravenous solution 200-0.9mg/100ml-%, 400-0.9mg/200ml-%

2 BvD; GC; MO

fluconazole oral suspension reconstituted 10mg/ml, 40mg/ml

2 GC; MO

fluconazole oral tablet 100mg, 150mg, 200mg, 50mg

2 GC; MO

flucytosine oral capsule 250mg, 500mg 5

griseofulvin microsize oral suspension 125mg/5ml

4 MO

griseofulvin microsize oral tablet 500mg 4 MO

griseofulvin ultramicrosize oral tablet 125mg, 250mg

4 MO


itraconazole oral capsule 100mg 4 PA; MO

JUBLIA EXTERNAL SOLUTION 10% 4 MO

ketoconazole external cream 2% 2 GC; MO

ketoconazole external shampoo 2% 1 GC; MO

ketoconazole oral tablet 200mg 2 GC; MO

NATACYN OPHTHALMIC SUSPENSION 5% 4 MO

NOXAFIL ORAL SUSPENSION 40MG/ML 4 PA; MO

NOXAFIL ORAL TABLET DELAYED RELEASE 100MG 5 PA

NYAMYC EXTERNAL POWDER 100000 UNIT/GM 2 GC; MO

nystatin external cream 100000 unit/gm 1 GC; MO

nystatin external ointment 100000 unit/gm 1 GC; MO

nystatin external powder 100000 unit/gm 2 GC; MO

nystatin mouth/throat suspension 100000 unit/ml

2 GC; MO

nystatin oral tablet 500000 unit 1 GC; MO

NYSTOP EXTERNAL POWDER 100000 UNIT/GM 2 GC; MO

terbinafine hcl oral tablet 250mg 4 MO

voriconazole intravenous solution reconstituted

200mg

5 BvD

voriconazole oral suspension reconstituted

40mg/ml 4 PA; MO

voriconazole oral tablet 200mg, 50mg 5 PA; QL (120 EA per 30 days)

ANTIGOUT AGENTS

Antigout Agents

allopurinol oral tablet 100mg, 300mg 1 GC; MO

colchicine oral capsule 0.6mg 2 GC; MO

colchicine oral tablet 0.6mg 2 GC; MO

colchicine-probenecid oral tablet 0.5-500mg 1 GC; MO

MITIGARE ORAL CAPSULE 0.6MG 3 MO

probenecid oral tablet 500mg 1 GC; MO


ULORIC ORAL TABLET 40MG, 80MG 3 PA; MO

ANTI-INFLAMMATORY AGENTS

Nonsteroidal Anti-Inflammatory Drugs

celecoxib oral capsule 100mg, 200mg, 400mg, 50mg

2 GC; MO

diclofenac potassium oral tablet 50mg 2 GC; MO

diclofenac sodium er oral tablet extended release 24hour 100mg

1 GC; MO

diclofenac sodium oral tablet delayed release

25mg

2 GC; MO


50mg, 75mg

1 GC; MO

diclofenac sodium transdermal gel 1% 2 GC; MO

diclofenac sodium transdermal gel 3% 4 PA; MO

diclofenac sodium transdermal solution 1.5% 4 MO

diflunisal oral tablet 500mg 2 GC; MO

etodolac oral capsule 200mg, 300mg 2 GC; MO

etodolac oral tablet 400mg, 500mg 2 GC; MO

flurbiprofen oral tablet 100mg 1 GC; MO

flurbiprofen oral tablet 50mg 2 GC; MO

IBU ORAL TABLET 600MG, 800MG 1 GC; MO

ibuprofen oral suspension 100mg/5ml 1 GC; MO

ibuprofen oral tablet 400mg, 600mg, 800mg 1 GC; MO

indomethacin oral capsule 25mg 1 GC; MO

ketoprofen oral capsule 25mg 2 GC; MO

meloxicam oral tablet 15mg, 7.5mg 1 GC; MO

nabumetone oral tablet 500mg, 750mg 1 GC; MO

naproxen dr oral tablet delayed release 375mg, 500mg

2 GC; MO

naproxen oral suspension 125mg/5ml 1 GC; MO

naproxen oral tablet 250mg, 375mg, 500mg 1 GC; MO


naproxen sodium er oral tablet extended release 24hour 500mg

4 MO

naproxen sodium oral tablet 275mg, 550mg 2 GC; MO

oxaprozin oral tablet 600mg 2 GC; MO

piroxicam oral capsule 10mg, 20mg 2 GC; MO

sulindac oral tablet 150mg, 200mg 1 GC; MO

tolmetin sodium oral capsule 400mg 2 GC; MO

tolmetin sodium oral tablet 600mg 2 GC; MO

ANTIMIGRAINE AGENTS

Antimigraine Agents, Other

dihydroergotamine mesylate nasal solution

4mg/ml 5

EMGALITY (300MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100MG/ML

3 PA; MO

EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 120MG/ML

3 PA; MO

EMGALITY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 120MG/ML

3 PA; MO

ergotamine-caffeine oral tablet 1-100mg 4 MO; QL (40 EA per 28 days)

MIGERGOT RECTAL SUPPOSITORY 2-100MG 4 MO

Serotonin (5-Ht) 1B/1D Receptor Agonists

naratriptan hcl oral tablet 1mg, 2.5mg 2 GC; MO; QL (9 EA per 30 days)

rizatriptan benzoate oral tablet 10mg 2 GC; MO; QL (12 EA per 30 days)

rizatriptan benzoate oral tablet 5mg 2 GC; MO; QL (24 EA per 30 days)

rizatriptan benzoate oral tablet dispersible 10mg 2 GC; MO; QL (12 EA per 30 days)

rizatriptan benzoate oral tablet dispersible 5mg 2 GC; MO; QL (24 EA per 30 days)

sumatriptan nasal solution 20mg/act, 5mg/act 4 MO; QL (18 EA per 30 days)

sumatriptan succinate oral tablet 100mg, 25mg, 50mg


sumatriptan succinate refill subcutaneous solution cartridge 4mg/0.5ml, 6mg/0.5ml



sumatriptan succinate subcutaneous solution

6mg/0.5ml 2 GC; MO; QL (8ML per 30 days)

sumatriptan succinate subcutaneous solution auto-injector 4mg/0.5ml

2 GC; MO; QL (4.5ML per 30 days)



sumatriptan succinate subcutaneous solution prefilled syringe 6mg/0.5ml


zolmitriptan oral tablet 2.5mg 2 GC; MO; QL (12 EA per 30 days)

zolmitriptan oral tablet 5mg 2 GC; MO; QL (6 EA per 30 days)

zolmitriptan oral tablet dispersible 2.5mg 2 GC; MO; QL (12 EA per 30 days)

zolmitriptan oral tablet dispersible 5mg 2 GC; MO; QL (6 EA per 30 days)

ANTIMYASTHENIC AGENTS

Parasympathomimetics

guanidine hcl oral tablet 125mg 2 GC; MO

pyridostigmine bromide oral solution 60mg/5ml 2 GC; MO

pyridostigmine bromide oral tablet 30mg, 60mg 1 GC; MO

ANTIMYCOBACTERIALS

Antimycobacterials, Other

pyrazinamide oral tablet 500mg 2 GC; MO

rifabutin oral capsule 150mg 4 MO

Antituberculars

ethambutol hcl oral tablet 100mg 2 GC; MO

ethambutol hcl oral tablet 400mg 1 GC; MO

isoniazid oral syrup 50mg/5ml 1 GC; MO

isoniazid oral tablet 100mg, 300mg 1 GC; MO

PASER ORAL PACKET 4 GM 4 MO

PRIFTIN ORAL TABLET 150MG 4 MO

rifampin intravenous solution reconstituted 600mg

4 BvD; MO


rifampin oral capsule 150mg, 300mg 2 GC; MO

RIFATER ORAL TABLET 50-120-300MG 4 MO

SIRTURO ORAL TABLET 100MG 5 PA

TRECATOR ORAL TABLET 250MG 4 MO

ANTINEOPLASTICS

Alkylating Agents

cyclophosphamide oral capsule 25mg, 50mg 2 BvD; GC; MO

GLEOSTINE ORAL CAPSULE 10MG, 100MG, 40MG 4 MO

LEUKERAN ORAL TABLET 2MG 4 MO

Antiangiogenic Agents

DEPEN TITRATABS ORAL TABLET 250MG 5

REVLIMID ORAL CAPSULE 10MG, 15MG, 2.5MG, 20MG, 25MG, 5MG

5 PA2; LA; QL (28 EA per 28 days)

THALOMID ORAL CAPSULE 100MG, 200MG, 50MG 5 PA2; QL (30 EA per 30 days)

THALOMID ORAL CAPSULE 150MG 5 PA2; QL (60 EA per 30 days)

Antimetabolites

DROXIA ORAL CAPSULE 200MG, 300MG, 400MG 4 MO

mercaptopurine oral tablet 50mg 2 GC; MO

methotrexate sodium (pf) injection solution

50mg/2ml 1 BvD; GC; MO

PURIXAN ORAL SUSPENSION 2000MG/100ML 4 LA; MO

TABLOID ORAL TABLET 40MG 4 PA2; MO

Antineoplastics

abiraterone acetate oral tablet 250mg 5 PA2; QL (120 EA per 30 days)

AFINITOR DISPERZ ORAL TABLET SOLUBLE 2MG,

3MG

5 PA2; QL (30 EA per 30 days)

AFINITOR DISPERZ ORAL TABLET SOLUBLE 5MG 5 PA2; QL (60 EA per 30 days)

AFINITOR ORAL TABLET 10MG, 2.5MG, 5MG,

7.5MG



ALECENSA ORAL CAPSULE 150MG 5 PA2

ALUNBRIG ORAL TABLET 180MG 5 PA2; LA; QL (30 EA per 30 days)



ALUNBRIG ORAL TABLET THERAPY PACK 90 &

180MG


BALVERSA ORAL TABLET 3MG 5 PA2; LA; QL (90 EA per 30 days)



bexarotene oral capsule 75mg 5 PA2; QL (300 EA per 30 days)

bicalutamide oral tablet 50mg 2 GC; MO

BOSULIF ORAL TABLET 100MG 5 PA2; QL (120 EA per 30 days)

BOSULIF ORAL TABLET 400MG, 500MG 5 PA2; QL (30 EA per 30 days)

BRAFTOVI ORAL CAPSULE 75MG 5 PA2; LA; QL (180 EA per 30 days)

CABOMETYX ORAL TABLET 20MG, 40MG, 60MG 5 PA2; LA

CALQUENCE ORAL CAPSULE 100MG 5 PA2; LA; QL (60 EA per 30 days)

CAPRELSA ORAL TABLET 100MG 5 PA2; LA; QL (60 EA per 30 days)


COMETRIQ (100MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20MG


COMETRIQ (140MG DAILY DOSE) ORAL KIT 1 X 80

& 3 X 20MG


COMETRIQ (60MG DAILY DOSE) ORAL KIT 20MG 5 PA2; LA; QL (84 EA per 28 days)

COPIKTRA ORAL CAPSULE 15MG, 25MG 5 PA2; LA; QL (60 EA per 30 days)

COTELLIC ORAL TABLET 20MG 5 PA2; LA; QL (63 EA per 28 days)

DAURISMO ORAL TABLET 100MG, 25MG 5 PA2

ELIGARD SUBCUTANEOUS KIT 22.5MG, 30MG,

45MG, 7.5MG

4 PA2; MO

EMCYT ORAL CAPSULE 140MG 3 MO

ERIVEDGE ORAL CAPSULE 150MG 5 PA2

ERLEADA ORAL TABLET 60MG 5 PA2; LA; QL (120 EA per 30 days)


erlotinib hcl oral tablet 100mg, 150mg 5 PA2; QL (30 EA per 30 days)

erlotinib hcl oral tablet 25mg 5 PA2; QL (90 EA per 30 days)

FARYDAK ORAL CAPSULE 10MG 5 PA2; QL (60 EA per 30 days)

FARYDAK ORAL CAPSULE 15MG, 20MG 5 PA2; QL (30 EA per 30 days)

fluorouracil external cream 5% 2 GC; MO

fluorouracil external solution 2%, 5% 2 GC; MO

flutamide oral capsule 125mg 2 GC; MO

GILOTRIF ORAL TABLET 20MG, 30MG, 40MG 5 PA2; LA; QL (30 EA per 30 days)

hydroxyurea oral capsule 500mg 1 GC; MO

IBRANCE ORAL CAPSULE 100MG, 125MG, 75MG 5 PA2

ICLUSIG ORAL TABLET 15MG 5 PA2; LA; QL (60 EA per 30 days)


IDHIFA ORAL TABLET 100MG 5 PA2; LA; QL (30 EA per 30 days)


imatinib mesylate oral tablet 100mg 5 PA2; QL (180 EA per 30 days)


IMBRUVICA ORAL CAPSULE 140MG, 70MG 5 PA2; LA; QL (120 EA per 30 days)

IMBRUVICA ORAL TABLET 140MG 5 PA2; LA; QL (120 EA per 30 days)


IMBRUVICA ORAL TABLET 420MG, 560MG 5 PA2; LA; QL (30 EA per 30 days)

INLYTA ORAL TABLET 1MG 5 PA2; QL (180 EA per 30 days)


IRESSA ORAL TABLET 250MG 5 PA2; LA

JAKAFI ORAL TABLET 10MG, 15MG, 20MG, 25MG,

5MG


KISQALI (200MG DOSE) ORAL TABLET THERAPY

PACK 200MG

5 PA2


PACK 200MG

5 PA2

KISQALI (600MG DOSE) ORAL TABLET THERAPY PACK 200MG

5 PA2


KISQALI FEMARA (400MG DOSE) ORAL TABLET

THERAPY PACK 200 & 2.5MG

5 PA2



5 PA2

KISQALI FEMARA(200MG DOSE) ORAL TABLET


5 PA2

LENVIMA (10MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 10MG

5 PA2


THERAPY PACK 3 X 4MG

5 PA2



5 PA2


THERAPY PACK 10MG & 2 X 4MG

5 PA2

LENVIMA (20MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 X 10MG

5 PA2

LENVIMA (24MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 X 10MG & 4MG

5 PA2

LENVIMA (4MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 4MG

5 PA2



5 PA2

leucovorin calcium oral tablet 10mg, 5mg 1 GC; MO

leucovorin calcium oral tablet 15mg 2 GC; MO

leucovorin calcium oral tablet 25mg 4 MO

leuprolide acetate injection kit 1mg/0.2ml 2 PA2; GC; MO

LONSURF ORAL TABLET 15-6.14MG, 20-8.19MG 5 PA2; LA

LORBRENA ORAL TABLET 100MG 5 PA2; QL (30 EA per 30 days)


LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75MG, 7.5MG

5 PA2


5 PA2


LUPRON DEPOT (4-MONTH) INTRAMUSCULAR

KIT 30MG

5 PA2


KIT 45MG

5 PA2

LYNPARZA ORAL TABLET 100MG 5 PA2; LA; QL (180 EA per 30 days)


LYSODREN ORAL TABLET 500MG 3 MO

MATULANE ORAL CAPSULE 50MG 5 PA2; LA

MEKINIST ORAL TABLET 0.5MG 5 PA2; LA; QL (120 EA per 30 days)

MEKINIST ORAL TABLET 2MG 5 PA2; LA; QL (30 EA per 30 days)

MEKTOVI ORAL TABLET 15MG 5 PA2; LA; QL (180 EA per 30 days)

MESNEX ORAL TABLET 400MG 5

NERLYNX ORAL TABLET 40MG 5 PA2; LA; QL (180 EA per 30 days)

NEXAVAR ORAL TABLET 200MG 5 PA2; LA; QL (120 EA per 30 days)

nilutamide oral tablet 150mg 5 QL (60 EA per 30 days)

NINLARO ORAL CAPSULE 2.3MG, 3MG, 4MG 5 PA2

ODOMZO ORAL CAPSULE 200MG 5 PA2; LA

PANRETIN EXTERNAL GEL 0.1% 5

PIQRAY (200MG DAILY DOSE) ORAL TABLET

THERAPY PACK 200MG

5 PA2



5 PA2



5 PA2

POMALYST ORAL CAPSULE 1MG, 2MG, 3MG, 4MG 5 PA2; LA; QL (21 EA per 28 days)

RUBRACA ORAL TABLET 200MG, 250MG, 300MG 5 PA2; LA

RYDAPT ORAL CAPSULE 25MG 5 PA2; QL (240 EA per 30 days)

SPRYCEL ORAL TABLET 100MG, 50MG, 70MG,

80MG


SPRYCEL ORAL TABLET 140MG 5 PA2; QL (30 EA per 30 days)



STIVARGA ORAL TABLET 40MG 5 PA2; LA; QL (84 EA per 28 days)

SUTENT ORAL CAPSULE 12.5MG, 25MG, 37.5MG, 50MG


SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5MG

5 PA2

TAFINLAR ORAL CAPSULE 50MG 5 PA2; LA; QL (180 EA per 30 days)


TAGRISSO ORAL TABLET 40MG, 80MG 5 PA2; LA

TALZENNA ORAL CAPSULE 0.25MG 5 PA2; LA; QL (90 EA per 30 days)

TALZENNA ORAL CAPSULE 1MG 5 PA2; LA; QL (30 EA per 30 days)

tamoxifen citrate oral tablet 10mg 1 GC; MO

tamoxifen citrate oral tablet 20mg 2 GC; MO

TARGRETIN EXTERNAL GEL 1% 5 PA2

TASIGNA ORAL CAPSULE 150MG, 200MG, 50MG 5 PA2; QL (120 EA per 30 days)

TIBSOVO ORAL TABLET 250MG 5 PA2; LA; QL (60 EA per 30 days)

TOLAK EXTERNAL CREAM 4% 4 MO

toremifene citrate oral tablet 60mg 5 PA2; QL (30 EA per 30 days)

tretinoin oral capsule 10mg 5

TYKERB ORAL TABLET 250MG 5 PA2; QL (180 EA per 30 days)

VALCHLOR EXTERNAL GEL 0.016% 5 PA2; QL (60 GM per 14 days)

VENCLEXTA ORAL TABLET 10MG, 50MG 4 PA2; LA; MO

VENCLEXTA ORAL TABLET 100MG 5 PA2; LA

VENCLEXTA STARTING PACK ORAL TABLET

THERAPY PACK 10 & 50 & 100MG

3 PA2; LA; MO

VERZENIO ORAL TABLET 100MG, 150MG, 200MG, 50MG

5 PA2; LA

VITRAKVI ORAL CAPSULE 100MG 5 PA2; QL (60 EA per 30 days)


VITRAKVI ORAL SOLUTION 20MG/ML 5 PA2

VIZIMPRO ORAL TABLET 15MG, 30MG, 45MG 5 PA2; QL (30 EA per 30 days)

VOTRIENT ORAL TABLET 200MG 5 PA2; QL (120 EA per 30 days)


XALKORI ORAL CAPSULE 200MG, 250MG 5 PA2; QL (60 EA per 30 days)

XOSPATA ORAL TABLET 40MG 5 PA2; LA

XTANDI ORAL CAPSULE 40MG 5 PA2; LA; QL (120 EA per 30 days)

YONSA ORAL TABLET 125MG 5 PA2; QL (120 EA per 30 days)

ZEJULA ORAL CAPSULE 100MG 5 PA2; LA; QL (90 EA per 30 days)

ZELBORAF ORAL TABLET 240MG 5 PA2; QL (240 EA per 30 days)

ZOLINZA ORAL CAPSULE 100MG 5 PA2; QL (120 EA per 30 days)

ZYDELIG ORAL TABLET 100MG, 150MG 5 PA2; LA; QL (60 EA per 30 days)

ZYKADIA ORAL CAPSULE 150MG 5 PA2; QL (150 EA per 30 days)

ZYKADIA ORAL TABLET 150MG 5 PA2; QL (150 EA per 30 days)

ZYTIGA ORAL TABLET 500MG 5 PA2; QL (120 EA per 30 days)

Aromatase Inhibitors, 3Rd Generation

anastrozole oral tablet 1mg 2 GC; MO

exemestane oral tablet 25mg 4 MO

letrozole oral tablet 2.5mg 2 GC; MO

ANTIPARASITICS

Anthelmintics

albendazole oral tablet 200mg 4 MO

EMVERM ORAL TABLET CHEWABLE 100MG 3 MO

ivermectin oral tablet 3mg 2 GC; MO

Antiprotozoals

ALINIA ORAL SUSPENSION RECONSTITUTED

100MG/5ML

4 MO; QL (150ML per 30 days)

ALINIA ORAL TABLET 500MG 4 MO; QL (40 EA per 30 days)

atovaquone oral suspension 750mg/5ml 5

atovaquone-proguanil hcl oral tablet 250-100mg, 62.5-25mg

2 GC; MO

benznidazole oral tablet 100mg, 12.5mg 2 GC; MO

chloroquine phosphate oral tablet 250mg, 500mg

2 GC; MO


COARTEM ORAL TABLET 20-120MG 4 MO

DARAPRIM ORAL TABLET 25MG 5

mefloquine hcl oral tablet 250mg 2 GC; MO

NEBUPENT INHALATION SOLUTION

RECONSTITUTED 300MG

4 BvD; MO

PENTAM INJECTION SOLUTION RECONSTITUTED

300MG

4 BvD; MO

primaquine phosphate oral tablet 26.3mg 4 MO

quinine sulfate oral capsule 324mg 2 PA; GC; MO

Pediculicides/Scabicides

malathion external lotion 0.5% 4 MO

permethrin external cream 5% 2 GC; MO

ANTIPARKINSON AGENTS

Anticholinergics

benztropine mesylate oral tablet 0.5mg, 1mg, 2mg

1 GC; MO

trihexyphenidyl hcl oral elixir 0.4mg/ml 1 GC; MO

trihexyphenidyl hcl oral tablet 2mg, 5mg 1 GC; MO

Antiparkinson Agents, Other

amantadine hcl oral capsule 100mg 2 GC; MO

amantadine hcl oral syrup 50mg/5ml 2 GC; MO

amantadine hcl oral tablet 100mg 2 GC; MO

carbidopa-levodopa er oral tablet extended release 25-100mg, 50-200mg

2 GC; MO

carbidopa-levodopa oral tablet 10-100mg 1 GC; MO

carbidopa-levodopa oral tablet 25-100mg, 25-250mg

2 GC; MO

carbidopa-levodopa oral tablet dispersible 10-100mg, 25-100mg

1 GC; MO

carbidopa-levodopa oral tablet dispersible 25-250mg

2 GC; MO


carbidopa-levodopa-entacapone oral tablet

12.5-50-200mg, 18.75-75-200mg, 31.25-125-200mg

2 GC; MO

carbidopa-levodopa-entacapone oral tablet 25-100-200mg, 37.5-150-200mg, 50-200-200mg

4 MO

entacapone oral tablet 200mg 2 GC; MO

GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24

HOUR 137MG, 68.5MG

5 PA; LA

RYTARY ORAL CAPSULE EXTENDED RELEASE

23.75-95MG, 36.25-145MG, 48.75-195MG, 61.25-245MG

4 ST; MO

Dopamine Agonists

APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE

30MG/3ML

5 PA; LA; QL (60ML per 28 days)

bromocriptine mesylate oral capsule 5mg 2 GC; MO

bromocriptine mesylate oral tablet 2.5mg 2 GC; MO

NEUPRO TRANSDERMAL PATCH 24 HOUR

1MG/24HR, 2MG/24HR, 3MG/24HR, 4MG/24HR,

6MG/24HR, 8MG/24HR

4 MO

pramipexole dihydrochloride er oral tablet extended release 24hour 3.75mg

2 GC; MO

pramipexole dihydrochloride oral tablet 0.125mg, 0.25mg, 0.5mg, 0.75mg, 1mg, 1.5mg

2 GC; MO

ropinirole hcl oral tablet 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg, 5mg

2 GC; MO

Monoamine Oxidase B (Mao-B) Inhibitors

rasagiline mesylate oral tablet 0.5mg, 1mg 4 MO

selegiline hcl oral capsule 5mg 2 GC; MO

selegiline hcl oral tablet 5mg 2 GC; MO

ANTIPSYCHOTICS

1St Generation/Typical

chlorpromazine hcl oral tablet 10mg, 100mg, 25mg

2 BvD; GC; MO


chlorpromazine hcl oral tablet 200mg, 50mg 4 BvD; MO

clozapine oral tablet 100mg, 200mg 2 ST2; GC; MO; QL (120 EA per 30 days)

clozapine oral tablet 25mg, 50mg 2 GC; MO; QL (120 EA per 30 days)

clozapine oral tablet dispersible 100mg, 12.5mg, 150mg, 25mg


clozapine oral tablet dispersible 200mg 5 ST2; QL (120 EA per 30 days)

fluphenazine decanoate injection solution

25mg/ml 4 MO

fluphenazine hcl injection solution 2.5mg/ml 4 MO

fluphenazine hcl oral concentrate 5mg/ml 2 GC; MO

fluphenazine hcl oral elixir 2.5mg/5ml 2 GC; MO

fluphenazine hcl oral tablet 1mg, 2.5mg 1 GC; MO

fluphenazine hcl oral tablet 10mg, 5mg 2 GC; MO

haloperidol decanoate intramuscular solution

100mg/ml, 100mg/ml 1 ml, 50mg/ml 2 GC; MO

haloperidol lactate injection solution 5mg/ml 4 MO

haloperidol lactate oral concentrate 2mg/ml 1 GC; MO

haloperidol oral tablet 0.5mg, 1mg, 10mg, 2mg, 20mg, 5mg

1 GC; MO

loxapine succinate oral capsule 10mg, 25mg, 5mg, 50mg

1 GC; MO

molindone hcl oral tablet 10mg, 25mg, 5mg 2 GC; MO

perphenazine oral tablet 16mg, 2mg 2 GC; MO

perphenazine oral tablet 4mg, 8mg 2 BvD; GC; MO

pimozide oral tablet 1mg, 2mg 2 GC; MO

prochlorperazine maleate oral tablet 10mg 1 BvD; GC; MO

thioridazine hcl oral tablet 10mg, 100mg, 25mg, 50mg

1 GC; MO

thiothixene oral capsule 1mg, 10mg, 2mg, 5mg 1 GC; MO

trifluoperazine hcl oral tablet 1mg, 10mg, 2mg, 5mg

1 GC; MO

VERSACLOZ ORAL SUSPENSION 50MG/ML 5 ST2; QL (540ML per 30 days)


2Nd Generation/Atypical

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300MG, 400MG

5 ST2

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300MG,

400MG

5 ST2

aripiprazole oral solution 1mg/ml 4 MO; QL (750ML per 30 days)

aripiprazole oral tablet 10mg, 15mg, 2mg, 20mg, 30mg, 5mg


aripiprazole oral tablet dispersible 10mg 5 QL (90 EA per 30 days)


FANAPT ORAL TABLET 1MG, 2MG, 4MG 4 ST2; MO; QL (60 EA per 30 days)

FANAPT ORAL TABLET 10MG, 12MG, 6MG, 8MG 5 ST2; QL (60 EA per 30 days)

FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4

& 6MG


INVEGA SUSTENNA INTRAMUSCULAR

SUSPENSION 117MG/0.75ML, 156MG/ML, 234MG/1.5ML, 78MG/0.5ML

5 ST2

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39MG/0.25ML

4 ST2


SUSPENSION PREFILLED SYRINGE

117MG/0.75ML, 156MG/ML, 234MG/1.5ML,

78MG/0.5ML

5 ST2

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 39MG/0.25ML

4 ST2; MO

INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273MG/0.875ML, 410MG/1.315ML,

546MG/1.75ML, 819MG/2.625ML

5 ST2

INVEGA TRINZA INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 273MG/0.875ML,

410MG/1.315ML, 546MG/1.75ML, 819MG/2.625ML

5 ST2

LATUDA ORAL TABLET 120MG 3 ST2; MO; QL (30 EA per 30 days)

LATUDA ORAL TABLET 20MG, 40MG, 60MG, 80MG 3 ST2; MO; QL (60 EA per 30 days)


NUPLAZID ORAL CAPSULE 34MG 5 PA2; LA

NUPLAZID ORAL TABLET 10MG 5 PA2; LA

olanzapine intramuscular solution reconstituted

10mg


olanzapine oral tablet 10mg, 15mg, 5mg, 7.5mg 4 MO; QL (30 EA per 30 days)

olanzapine oral tablet 2.5mg 1 GC; MO; QL (30 EA per 30 days)

olanzapine oral tablet 20mg 4 MO; QL (60 EA per 30 days)

olanzapine oral tablet dispersible 10mg, 5mg 4 MO; QL (60 EA per 30 days)


paliperidone er oral tablet extended release 24hour 1.5mg, 3mg


paliperidone er oral tablet extended release 24hour 6mg



5 QL (30 EA per 30 days)

PERSERIS SUBCUTANEOUS PREFILLED SYRINGE

120MG, 90MG


quetiapine fumarate er oral tablet extended release 24hour 150mg, 200mg, 300mg, 400mg, 50mg

4 MO

quetiapine fumarate oral tablet 100mg, 25mg, 300mg, 400mg, 50mg


quetiapine fumarate oral tablet 200mg 1 GC; MO; QL (30 EA per 30 days)

REXULTI ORAL TABLET 0.25MG, 0.5MG, 1MG,

2MG, 3MG, 4MG


RISPERDAL CONSTA INTRAMUSCULAR

SUSPENSION RECONSTITUTED 12.5MG

4 ST2; MO


SUSPENSION RECONSTITUTED 25MG, 37.5MG, 50MG

5 ST2

risperidone oral solution 1mg/ml 2 GC; MO; QL (480ML per 30 days)

risperidone oral tablet 0.25mg, 1mg, 2mg, 3mg, 4mg



risperidone oral tablet 0.5mg 2 GC; MO; QL (120 EA per 30 days)

risperidone oral tablet dispersible 0.25mg, 1mg, 2mg


risperidone oral tablet dispersible 0.5mg 2 GC; MO; QL (120 EA per 30 days)

risperidone oral tablet dispersible 3mg, 4mg 4 MO; QL (60 EA per 30 days)

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL

10MG, 2.5MG, 5MG


VRAYLAR ORAL CAPSULE 1.5MG 5 ST2; QL (60 EA per 30 days)

VRAYLAR ORAL CAPSULE 3MG, 4.5MG, 6MG 5 ST2; QL (30 EA per 30 days)

VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 &

3MG


ziprasidone hcl oral capsule 20mg, 40mg 2 GC; MO; QL (60 EA per 30 days)

ziprasidone hcl oral capsule 60mg, 80mg 4 MO; QL (60 EA per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210MG

4 ST2; MO

ANTIVIRALS

Anti-Cytomegalovirus (Cmv) Agents

valganciclovir hcl oral solution reconstituted 50mg/ml

4 MO

valganciclovir hcl oral tablet 450mg 5

ZIRGAN OPHTHALMIC GEL 0.15% 3 MO

Antihepatitis Agents

entecavir oral tablet 0.5mg, 1mg 4 PA; MO; QL (30 EA per 30 days)

EPIVIR HBV ORAL SOLUTION 5MG/ML 3 MO

lamivudine oral tablet 100mg 2 GC; MO; QL (90 EA per 30 days)

REBETOL ORAL SOLUTION 40MG/ML 5

VEMLIDY ORAL TABLET 25MG 5 PA; QL (30 EA per 30 days)

Anti-Hepatitis B (Hbv) Agents

adefovir dipivoxil oral tablet 10mg 4 PA; MO; QL (30 EA per 30 days)

BARACLUDE ORAL SOLUTION 0.05MG/ML 5 PA; QL (600ML per 30 days)


INTRON A INJECTION SOLUTION 10000000

UNIT/ML, 6000000 UNIT/ML

5 PA2

INTRON A INJECTION SOLUTION

RECONSTITUTED 10000000 UNIT, 18000000

UNIT, 50000000 UNIT

5 PA2

Anti-Hepatitis C (Hcv) Agents, Direct Acting

sofosbuvir-velpatasvir oral tablet 400-100mg 5 PA

VOSEVI ORAL TABLET 400-100-100MG 5 PA

Anti-Hepatitis C (Hcv) Agents, Other

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/0.5ML

5 PA

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML

5 PA

RIBASPHERE ORAL CAPSULE 200MG 3 MO

RIBASPHERE ORAL TABLET 600MG 5

ribavirin oral capsule 200mg 4 MO

ribavirin oral tablet 200mg 3 MO

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300

MCG, 600 MCG


Antiherpetic Agents

acyclovir oral capsule 200mg 1 GC; MO

acyclovir oral suspension 200mg/5ml 2 GC; MO

acyclovir oral tablet 400mg, 800mg 1 GC; MO

acyclovir sodium intravenous solution 50mg/ml 2 BvD; GC; MO

famciclovir oral tablet 125mg, 250mg, 500mg 2 GC; MO

valacyclovir hcl oral tablet 1gm, 500mg 2 GC; MO

Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors

ATRIPLA ORAL TABLET 600-200-300MG 5 QL (30 EA per 30 days)

COMPLERA ORAL TABLET 200-25-300MG 5 QL (30 EA per 30 days)

DELSTRIGO ORAL TABLET 100-300-300MG 5 QL (30 EA per 30 days)

EDURANT ORAL TABLET 25MG 5 QL (30 EA per 30 days)


efavirenz oral capsule 200mg 4 MO; QL (120 EA per 30 days)


efavirenz oral tablet 600mg 5 QL (30 EA per 30 days)

GENVOYA ORAL TABLET 150-150-200-10MG 5 QL (30 EA per 30 days)

INTELENCE ORAL TABLET 100MG 5 QL (120 EA per 30 days)


INTELENCE ORAL TABLET 25MG 4 MO; QL (120 EA per 30 days)

nevirapine er oral tablet extended release 24hour 100mg




nevirapine oral suspension 50mg/5ml 4 MO; QL (1200ML per 30 days)

nevirapine oral tablet 200mg 2 GC; MO; QL (60 EA per 30 days)

PIFELTRO ORAL TABLET 100MG 5 QL (30 EA per 30 days)

RESCRIPTOR ORAL TABLET 200MG 4 MO; QL (180 EA per 30 days)

SYMFI LO ORAL TABLET 400-300-300MG 5 QL (30 EA per 30 days)

SYMFI ORAL TABLET 600-300-300MG 5 QL (30 EA per 30 days)

SYMTUZA ORAL TABLET 800-150-200-10MG 5 QL (30 EA per 30 days)

VIRAMUNE ORAL SUSPENSION 50MG/5ML 4 MO; QL (1200ML per 30 days)

Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors

abacavir sulfate oral solution 20mg/ml 4 MO; QL (960ML per 30 days)

abacavir sulfate oral tablet 300mg 4 MO; QL (60 EA per 30 days)

abacavir sulfate-lamivudine oral tablet 600-300mg


abacavir-lamivudine-zidovudine oral tablet 300-150-300mg


CIMDUO ORAL TABLET 300-300MG 5 QL (30 EA per 30 days)

DESCOVY ORAL TABLET 200-25MG 5 QL (30 EA per 30 days)

didanosine oral capsule delayed release 200mg 2 GC; MO; QL (60 EA per 30 days)

didanosine oral capsule delayed release 250mg, 400mg



EMTRIVA ORAL CAPSULE 200MG 4 MO; QL (30 EA per 30 days)

EMTRIVA ORAL SOLUTION 10MG/ML 4 MO; QL (680ML per 28 days)

JULUCA ORAL TABLET 50-25MG 5 QL (30 EA per 30 days)

lamivudine oral solution 10mg/ml 4 MO; QL (900ML per 30 days)



lamivudine-zidovudine oral tablet 150-300mg 4 MO; QL (60 EA per 30 days)

stavudine oral capsule 15mg, 20mg 2 GC; MO; QL (120 EA per 30 days)

stavudine oral capsule 30mg, 40mg 2 GC; MO; QL (60 EA per 30 days)

STRIBILD ORAL TABLET 150-150-200-300MG 5 QL (30 EA per 30 days)

tenofovir disoproxil fumarate oral tablet 300mg 4 MO; QL (30 EA per 30 days)

TRIUMEQ ORAL TABLET 600-50-300MG 5 QL (30 EA per 30 days)

TRUVADA ORAL TABLET 100-150MG, 133-200MG,

167-250MG, 200-300MG


VIDEX EC ORAL CAPSULE DELAYED RELEASE 125MG


VIDEX ORAL SOLUTION RECONSTITUTED 4 GM 4 MO; QL (1200ML per 30 days)

VIREAD ORAL POWDER 40MG/GM 5 QL (240 GM per 30 days)

VIREAD ORAL TABLET 150MG, 200MG, 250MG 5 QL (30 EA per 30 days)

zidovudine oral capsule 100mg 2 GC; MO; QL (180 EA per 30 days)

zidovudine oral syrup 50mg/5ml 2 GC; MO; QL (1680ML per 28 days)

zidovudine oral tablet 300mg 2 GC; MO; QL (60 EA per 30 days)

Anti-Hiv Agents, Other

BIKTARVY ORAL TABLET 50-200-25MG 5 QL (30 EA per 30 days)

DOVATO ORAL TABLET 50-300MG 5 QL (30 EA per 30 days)

FUZEON SUBCUTANEOUS SOLUTION

RECONSTITUTED 90MG


ISENTRESS HD ORAL TABLET 600MG 5 QL (60 EA per 30 days)

ISENTRESS ORAL PACKET 100MG 4 MO; QL (60 EA per 30 days)

ISENTRESS ORAL TABLET 400MG 5 QL (120 EA per 30 days)


ISENTRESS ORAL TABLET CHEWABLE 100MG 4 MO; QL (180 EA per 30 days)


ODEFSEY ORAL TABLET 200-25-25MG 5 QL (30 EA per 30 days)

PREZISTA ORAL SUSPENSION 100MG/ML 5 QL (360ML per 30 days)

SELZENTRY ORAL SOLUTION 20MG/ML 3 MO; QL (1800ML per 30 days)

SELZENTRY ORAL TABLET 150MG 3 MO; QL (240 EA per 30 days)

SELZENTRY ORAL TABLET 25MG, 300MG 3 MO; QL (120 EA per 30 days)


TIVICAY ORAL TABLET 10MG 4 MO; QL (60 EA per 30 days)

TIVICAY ORAL TABLET 25MG 5 QL (45 EA per 30 days)


TYBOST ORAL TABLET 150MG 3 MO; QL (30 EA per 30 days)

Anti-Hiv Agents, Protease Inhibitors

APTIVUS ORAL CAPSULE 250MG 4 MO; QL (120 EA per 30 days)

APTIVUS ORAL SOLUTION 100MG/ML 4 MO; QL (285ML per 28 days)

atazanavir sulfate oral capsule 150mg, 200mg 4 MO; QL (60 EA per 30 days)

atazanavir sulfate oral capsule 300mg 5 QL (60 EA per 30 days)

CRIXIVAN ORAL CAPSULE 200MG 3 MO; QL (450 EA per 30 days)


EVOTAZ ORAL TABLET 300-150MG 5 QL (30 EA per 30 days)

fosamprenavir calcium oral tablet 700mg 5 QL (120 EA per 30 days)

INVIRASE ORAL TABLET 500MG 5 QL (120 EA per 30 days)

KALETRA ORAL TABLET 100-25MG 4 MO; QL (300 EA per 30 days)

KALETRA ORAL TABLET 200-50MG 5 QL (150 EA per 30 days)

LEXIVA ORAL SUSPENSION 50MG/ML 4 MO; QL (1575ML per 28 days)

lopinavir-ritonavir oral solution 400-100mg/5ml 4 MO; QL (400ML per 30 days)

NORVIR ORAL PACKET 100MG 4 MO; QL (360 EA per 30 days)

NORVIR ORAL SOLUTION 80MG/ML 4 MO; QL (480ML per 30 days)

PREZCOBIX ORAL TABLET 800-150MG 5 QL (30 EA per 30 days)


PREZISTA ORAL TABLET 150MG 4 MO; QL (240 EA per 30 days)

PREZISTA ORAL TABLET 600MG 5 QL (60 EA per 30 days)



REYATAZ ORAL PACKET 50MG 4 MO; QL (180 EA per 30 days)

ritonavir oral tablet 100mg 3 MO; QL (360 EA per 30 days)

VIRACEPT ORAL TABLET 250MG 4 MO; QL (300 EA per 30 days)

VIRACEPT ORAL TABLET 625MG 5 QL (120 EA per 30 days)

Anti-Influenza Agents

oseltamivir phosphate oral capsule 30mg, 45mg, 75mg

2 GC; MO

oseltamivir phosphate oral suspension reconstituted 6mg/ml

2 GC; MO

RELENZA DISKHALER INHALATION AEROSOL

POWDER BREATH ACTIVATED 5MG/BLISTER

4 MO

rimantadine hcl oral tablet 100mg 2 GC; MO

XOFLUZA ORAL TABLET THERAPY PACK 2 X

20MG, 2 X 40MG

3 MO

ANXIOLYTICS

Anxiolytics, Other

buspirone hcl oral tablet 10mg, 15mg, 30mg, 5mg, 7.5mg

1 GC; MO

hydroxyzine hcl oral syrup 10mg/5ml 4 MO

hydroxyzine hcl oral tablet 10mg, 25mg, 50mg 1 GC; MO

hydroxyzine pamoate oral capsule 100mg, 25mg, 50mg

2 GC; MO

Benzodiazepines

ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1MG/ML


alprazolam oral tablet 0.25mg, 0.5mg 2 GC; MO; QL (120 EA per 30 days)

alprazolam oral tablet 1mg 2 GC; MO; QL (240 EA per 30 days)


alprazolam oral tablet 2mg 2 GC; MO; QL (150 EA per 30 days)

chlordiazepoxide hcl oral capsule 10mg, 25mg, 5mg


clonazepam oral tablet 0.5mg, 1mg 2 GC; MO; QL (90 EA per 30 days)

clonazepam oral tablet 2mg 2 GC; MO; QL (300 EA per 30 days)

clonazepam oral tablet dispersible 0.125mg, 0.25mg, 0.5mg, 1mg


clonazepam oral tablet dispersible 2mg 2 GC; MO; QL (300 EA per 30 days)

clorazepate dipotassium oral tablet 15mg, 3.75mg, 7.5mg


diazepam oral concentrate 5mg/ml 2 GC; MO; QL (240ML per 30 days)

diazepam oral solution 5mg/5ml 4 MO; QL (1200ML per 30 days)

diazepam oral tablet 10mg 1 GC; MO; QL (120 EA per 30 days)



lorazepam oral concentrate 2mg/ml 2 GC; MO; QL (240ML per 30 days)

lorazepam oral tablet 0.5mg, 1mg, 2mg 2 GC; MO; QL (150 EA per 30 days)

BIPOLAR AGENTS

Mood Stabilizers

GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20MG

4 ST2; MO

lithium carbonate er oral tablet extended release 300mg, 450mg

1 GC; MO

lithium carbonate oral capsule 150mg, 300mg, 600mg

1 GC; MO

lithium carbonate oral tablet 300mg 1 GC; MO

lithium oral solution 8 meq/5ml 1 GC; MO

olanzapine-fluoxetine hcl oral capsule 12-25mg, 12-50mg, 6-50mg


olanzapine-fluoxetine hcl oral capsule 3-25mg, 6-25mg


BLOOD GLUCOSE REGULATORS


Antidiabetic Agents, Supply

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1ML 3 MO

COMFORT ASSIST INSULIN SYRINGE 29G X 1/2"

1ML

3 MO

EXEL COMFORT POINT PEN NEEDLE 29G X 12MM 3 MO

global alcohol prep ease pad 70% 3 MO

preferred plus insulin syringe 28g x 1/2" 0.5 ml 3 MO

RELI-ON INSULIN SYRINGE 29G 0.3ML 3 MO

Antidiabetic Agents

acarbose oral tablet 100mg, 25mg, 50mg 2 GC; MO

glimepiride oral tablet 1mg, 2mg, 4mg 1 GC; MO

glipizide er oral tablet extended release 24hour

10mg, 2.5mg, 5mg

1 GC; MO

glipizide oral tablet 10mg, 5mg 1 GC; MO

glipizide-metformin hcl oral tablet 2.5-250mg, 2.5-500mg, 5-500mg

1 GC; MO

glyburide-metformin oral tablet 1.25-250mg, 2.5-500mg, 5-500mg

2 GC; MO

INVOKAMET ORAL TABLET 150-1000MG, 150-

500MG, 50-1000MG, 50-500MG

3 MO

INVOKAMET XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 150-1000MG, 150-500MG, 50-1000MG, 50-500MG

3 MO

INVOKANA ORAL TABLET 100MG, 300MG 3 MO

JANUMET ORAL TABLET 50-1000MG, 50-500MG 3 MO

JANUMET XR ORAL TABLET EXTENDED RELEASE

24 HOUR 100-1000MG, 50-1000MG, 50-500MG

3 MO

JANUVIA ORAL TABLET 100MG, 25MG, 50MG 3 MO

JARDIANCE ORAL TABLET 10MG, 25MG 3 MO

metformin hcl er oral tablet extended release 24hour 500mg, 750mg

1 GC; MO


metformin hcl oral tablet 1000mg, 500mg, 850mg

1 GC; MO

miglitol oral tablet 100mg, 25mg, 50mg 2 GC; MO

nateglinide oral tablet 120mg, 60mg 2 GC; MO

OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.25 OR 0.5MG/DOSE, 1MG/DOSE

3 MO

pioglitazone hcl oral tablet 15mg, 30mg, 45mg 1 GC; MO

pioglitazone hcl-glimepiride oral tablet 30-2mg, 30-4mg

2 GC; MO

pioglitazone hcl-metformin hcl oral tablet 15-500mg, 15-850mg

2 GC; MO

repaglinide oral tablet 0.5mg, 1mg, 2mg 2 GC; MO

repaglinide-metformin hcl oral tablet 1-500mg, 2-500mg

2 GC; MO

SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-33 UNT-MCG/ML

3 MO

SYNJARDY ORAL TABLET 12.5-1000MG, 12.5-500MG, 5-1000MG, 5-500MG

3 MO

SYNJARDY XR ORAL TABLET EXTENDED RELEASE

24 HOUR 10-1000MG, 12.5-1000MG, 25-1000MG,

5-1000MG

3 MO

TRULICITY SUBCUTANEOUS SOLUTION PEN-

INJECTOR 0.75MG/0.5ML, 1.5MG/0.5ML

3 MO

VICTOZA SUBCUTANEOUS SOLUTION PEN-

INJECTOR 18MG/3ML

3 MO

XULTOPHY SUBCUTANEOUS SOLUTION PEN-

INJECTOR 100-3.6 UNIT-MG/ML

3 MO

Glycemic Agents

GLUCAGEN HYPOKIT INJECTION SOLUTION

RECONSTITUTED 1MG

3 MO

GLUCAGON EMERGENCY INJECTION KIT 1MG 3 MO

PROGLYCEM ORAL SUSPENSION 50MG/ML 5

Insulins


FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML

3 MO

FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML 3 MO

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3 MO

LANTUS SUBCUTANEOUS SOLUTION 100

UNIT/ML

3 MO

LEVEMIR FLEXTOUCH SUBCUTANEOUS

SOLUTION PEN-INJECTOR 100 UNIT/ML

3 MO

LEVEMIR SUBCUTANEOUS SOLUTION 100

UNIT/ML

3 MO

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

(70-30) 100 UNIT/ML

3 MO

NOVOLIN N SUBCUTANEOUS SUSPENSION 100

UNIT/ML

3 MO

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML 3 MO

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION


3 MO

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

3 MO

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML

3 MO

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML

3 MO

NOVOLOG SUBCUTANEOUS SOLUTION 100

UNIT/ML

3 MO

TOUJEO MAX SOLOSTAR SUBCUTANEOUS

SOLUTION PEN-INJECTOR 300 UNIT/ML

3 MO

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION


3 MO

TRESIBA FLEXTOUCH SUBCUTANEOUS

SOLUTION PEN-INJECTOR 100 UNIT/ML, 200

UNIT/ML

3 MO


TRESIBA SUBCUTANEOUS SOLUTION 100

UNIT/ML

3 MO

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

Anticoagulants

ELIQUIS ORAL TABLET 2.5MG, 5MG 3 MO

ELIQUIS STARTER PACK ORAL TABLET 5MG 3 MO

enoxaparin sodium subcutaneous solution

100mg/ml, 150mg/ml 4 MO; QL (30ML per 30 days)


120mg/0.8ml, 80mg/0.8ml 4 MO; QL (24ML per 30 days)


30mg/0.3ml 4 MO; QL (9ML per 30 days)

enoxaparin sodium subcutaneous solution 40mg/0.4ml


enoxaparin sodium subcutaneous solution 60mg/0.6ml


fondaparinux sodium subcutaneous solution

10mg/0.8ml 5 QL (11.2ML per 30 days)


2.5mg/0.5ml 4 MO; QL (7ML per 30 days)




7.5mg/0.6ml 5 QL (8.4ML per 30 days)

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml

2 BvD; GC; MO

heparin sodium (porcine) injection solution 5000 unit/ml

1 BvD; GC; MO

JANTOVEN ORAL TABLET 1MG, 10MG, 2MG,

2.5MG, 3MG, 4MG, 5MG, 6MG, 7.5MG

1 GC; MO

warfarin sodium oral tablet 1mg, 10mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg

1 GC; MO


XARELTO ORAL TABLET 10MG, 15MG, 2.5MG,

20MG

3 MO

XARELTO STARTER PACK ORAL TABLET THERAPY

PACK 15 & 20MG

3 MO

Blood Formation Modifiers

LEUKINE INJECTION SOLUTION RECONSTITUTED

250 MCG

5 PA

pentoxifylline er oral tablet extended release

400mg

1 GC; MO

PROMACTA ORAL PACKET 12.5MG 5 PA; QL (360 EA per 30 days)

PROMACTA ORAL TABLET 12.5MG, 25MG 5 PA; QL (60 EA per 30 days)

PROMACTA ORAL TABLET 50MG, 75MG 5 PA; QL (30 EA per 30 days)

RETACRIT INJECTION SOLUTION 10000 UNIT/ML,

4000 UNIT/ML, 40000 UNIT/ML

4 PA; MO; QL (12ML per 28 days)

RETACRIT INJECTION SOLUTION 2000 UNIT/ML 4 PA; MO; QL (23ML per 30 days)


tranexamic acid oral tablet 650mg 2 GC; MO

ZARXIO INJECTION SOLUTION PREFILLED

SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

5 PA

Platelet Modifying Agents

anagrelide hcl oral capsule 0.5mg, 1mg 2 GC; MO

aspirin-dipyridamole er oral capsule extended release 12hour 25-200mg

2 GC; MO

BRILINTA ORAL TABLET 60MG, 90MG 3 MO

CABLIVI INJECTION KIT 11MG 5 PA; LA

cilostazol oral tablet 100mg, 50mg 2 GC; MO

clopidogrel bisulfate oral tablet 75mg 2 GC; MO

prasugrel hcl oral tablet 10mg, 5mg 4 MO

YOSPRALA ORAL TABLET DELAYED RELEASE 325-

40MG, 81-40MG

3 MO

CARDIOVASCULAR AGENTS


Alpha-Adrenergic Agonists

clonidine hcl oral tablet 0.1mg, 0.2mg, 0.3mg 1 GC; MO

clonidine transdermal patch weekly 0.1mg/24hr, 0.2mg/24hr, 0.3mg/24hr

2 GC; MO

guanfacine hcl oral tablet 1mg, 2mg 1 GC; MO

methyldopa oral tablet 250mg, 500mg 1 GC; MO

midodrine hcl oral tablet 10mg, 2.5mg, 5mg 2 GC; MO

Alpha-Adrenergic Blocking Agents

doxazosin mesylate oral tablet 1mg, 2mg, 4mg 1 GC; MO; QL (45 EA per 30 days)

doxazosin mesylate oral tablet 8mg 1 GC; MO; QL (60 EA per 30 days)

prazosin hcl oral capsule 1mg, 2mg 1 GC; MO

prazosin hcl oral capsule 5mg 2 GC; MO

terazosin hcl oral capsule 1mg, 10mg, 2mg, 5mg 1 GC; MO

Angiotensin Ii Receptor Antagonists

candesartan cilexetil oral tablet 16mg, 4mg, 8mg 1 GC; MO; QL (60 EA per 30 days)

candesartan cilexetil oral tablet 32mg 1 GC; MO; QL (30 EA per 30 days)

eprosartan mesylate oral tablet 600mg 2 GC; MO; QL (30 EA per 30 days)

irbesartan oral tablet 150mg, 300mg, 75mg 1 GC; MO; QL (30 EA per 30 days)

losartan potassium oral tablet 100mg, 25mg 1 GC; MO; QL (30 EA per 30 days)

losartan potassium oral tablet 50mg 1 GC; MO; QL (60 EA per 30 days)

olmesartan medoxomil oral tablet 20mg, 40mg, 5mg

1 GC; MO

telmisartan oral tablet 20mg, 40mg, 80mg 1 GC; MO; QL (30 EA per 30 days)

valsartan oral tablet 160mg, 320mg 1 GC; MO; QL (30 EA per 30 days)

valsartan oral tablet 40mg, 80mg 1 GC; MO; QL (90 EA per 30 days)

Angiotensin-Converting Enzyme (Ace) Inhibitors

benazepril hcl oral tablet 10mg, 20mg, 40mg, 5mg

1 GC; MO

captopril oral tablet 100mg, 12.5mg, 25mg, 50mg 1 GC; MO


enalapril maleate oral tablet 10mg, 2.5mg, 20mg, 5mg

1 GC; MO

fosinopril sodium oral tablet 10mg, 20mg, 40mg 1 GC; MO

lisinopril oral tablet 10mg, 2.5mg, 20mg, 30mg, 40mg, 5mg

1 GC; MO

moexipril hcl oral tablet 15mg, 7.5mg 1 GC; MO

perindopril erbumine oral tablet 2mg, 4mg, 8mg 1 GC; MO

quinapril hcl oral tablet 10mg, 20mg, 40mg, 5mg 1 GC; MO

ramipril oral capsule 1.25mg, 10mg, 2.5mg, 5mg 1 GC; MO

trandolapril oral tablet 1mg, 2mg, 4mg 1 GC; MO

Antiarrhythmics

amiodarone hcl oral tablet 100mg, 200mg, 400mg

2 GC; MO

disopyramide phosphate oral capsule 100mg, 150mg

2 GC; MO

dofetilide oral capsule 125mcg, 250mcg, 500mcg 4 MO

flecainide acetate oral tablet 100mg, 150mg, 50mg

2 GC; MO

mexiletine hcl oral capsule 150mg, 200mg, 250mg

2 GC; MO

MULTAQ ORAL TABLET 400MG 4 MO

PACERONE ORAL TABLET 100MG, 200MG, 400MG 4 MO

propafenone hcl er oral capsule extended release 12hour 225mg, 325mg, 425mg

4 MO

propafenone hcl oral tablet 150mg, 225mg, 300mg

2 GC; MO

quinidine sulfate oral tablet 200mg, 300mg 1 GC; MO

Antihypertensive Combinations

amiloride-hydrochlorothiazide oral tablet 5-50mg

1 GC; MO

amlodipine besy-benazepril hcl oral capsule 10-20mg



amlodipine besy-benazepril hcl oral capsule 10-40mg, 5-40mg


amlodipine besy-benazepril hcl oral capsule 2.5-10mg, 5-10mg, 5-20mg


amlodipine besylate-valsartan oral tablet 10-160mg, 10-320mg, 5-160mg, 5-320mg


amlodipine-olmesartan oral tablet 10-20mg, 10-40mg, 5-20mg, 5-40mg


amlodipine-valsartan-hctz oral tablet 10-160-12.5mg, 10-160-25mg, 10-320-25mg, 5-160-12.5mg, 5-160-25mg


atenolol-chlorthalidone oral tablet 100-25mg, 50-25mg

1 GC; MO

benazepril-hydrochlorothiazide oral tablet 10-12.5mg, 20-12.5mg, 20-25mg, 5-6.25mg

2 GC; MO

bisoprolol-hydrochlorothiazide oral tablet 10-6.25mg, 2.5-6.25mg, 5-6.25mg

1 GC; MO

candesartan cilexetil-hctz oral tablet 16-12.5mg, 32-12.5mg, 32-25mg


captopril-hydrochlorothiazide oral tablet 25-15mg, 25-25mg, 50-15mg, 50-25mg

2 GC; MO

enalapril-hydrochlorothiazide oral tablet 10-25mg, 5-12.5mg

1 GC; MO

ENTRESTO ORAL TABLET 24-26MG, 49-51MG, 97-

103MG

3 PA; MO

fosinopril sodium-hctz oral tablet 10-12.5mg, 20-12.5mg

1 GC; MO

irbesartan-hydrochlorothiazide oral tablet 150-12.5mg, 300-12.5mg


lisinopril-hydrochlorothiazide oral tablet 10-12.5mg, 20-12.5mg, 20-25mg

1 GC; MO

losartan potassium-hctz oral tablet 100-12.5mg, 100-25mg, 50-12.5mg


metoprolol-hydrochlorothiazide oral tablet 100-25mg, 100-50mg, 50-25mg

1 GC; MO


olmesartan medoxomil-hctz oral tablet 20-12.5mg, 40-12.5mg, 40-25mg


olmesartan-amlodipine-hctz oral tablet 20-5-12.5mg, 40-10-12.5mg, 40-10-25mg, 40-5-12.5mg, 40-5-25mg


propranolol-hctz oral tablet 40-25mg, 80-25mg 1 GC; MO

quinapril-hydrochlorothiazide oral tablet 10-12.5mg, 20-12.5mg, 20-25mg

1 GC; MO

spironolactone-hctz oral tablet 25-25mg 1 GC; MO

TEKTURNA HCT ORAL TABLET 150-12.5MG, 150-

25MG, 300-12.5MG, 300-25MG


telmisartan-hctz oral tablet 40-12.5mg, 80-12.5mg, 80-25mg


triamterene-hctz oral capsule 37.5-25mg 1 GC; MO

triamterene-hctz oral tablet 37.5-25mg, 75-50mg 1 GC; MO

valsartan-hydrochlorothiazide oral tablet 160-12.5mg, 160-25mg, 320-12.5mg, 320-25mg, 80-12.5mg


Beta-Adrenergic Blocking Agents

acebutolol hcl oral capsule 200mg, 400mg 1 GC; MO

atenolol oral tablet 100mg, 25mg, 50mg 1 GC; MO

betaxolol hcl oral tablet 10mg, 20mg 1 GC; MO

bisoprolol fumarate oral tablet 10mg, 5mg 1 GC; MO

BYSTOLIC ORAL TABLET 10MG, 2.5MG, 20MG,

5MG

4 MO

carvedilol oral tablet 12.5mg, 25mg, 3.125mg, 6.25mg

1 GC; MO

labetalol hcl oral tablet 100mg, 200mg, 300mg 1 GC; MO

metoprolol succinate er oral tablet extended release 24hour 100mg, 25mg, 50mg

1 GC; MO

metoprolol succinate er oral tablet extended release 24hour 200mg

2 GC; MO


metoprolol tartrate oral tablet 100mg, 25mg, 50mg

1 GC; MO

nadolol oral tablet 20mg, 40mg, 80mg 2 GC; MO

pindolol oral tablet 10mg, 5mg 2 GC; MO

propranolol hcl er oral capsule extended release 24hour 120mg, 160mg, 60mg, 80mg

2 GC; MO

propranolol hcl oral solution 20mg/5ml, 40mg/5ml

2 GC; MO

propranolol hcl oral tablet 10mg, 20mg, 40mg, 60mg, 80mg

1 GC; MO

SORINE ORAL TABLET 120MG, 160MG, 240MG,

80MG

2 GC; MO

sotalol hcl (af) oral tablet 120mg, 160mg, 80mg 2 GC; MO

sotalol hcl oral tablet 120mg, 160mg, 240mg, 80mg

2 GC; MO

timolol maleate oral tablet 10mg, 5mg 1 GC; MO

timolol maleate oral tablet 20mg 2 GC; MO

Calcium Channel Blocking Agents

amlodipine besylate oral tablet 10mg, 2.5mg, 5mg

1 GC; MO

CARTIA XT ORAL CAPSULE EXTENDED RELEASE

24 HOUR 120MG, 180MG, 240MG



24 HOUR 300MG


diltiazem hcl er beads oral capsule extended release 24hour 360mg, 420mg


diltiazem hcl er coated beads oral capsule extended release 24hour 120mg, 180mg, 240mg


diltiazem hcl er coated beads oral capsule extended release 24hour 300mg


diltiazem hcl er oral capsule extended release 12hour 120mg, 60mg, 90mg

2 GC; MO

diltiazem hcl oral tablet 120mg, 90mg 2 GC; MO


diltiazem hcl oral tablet 30mg, 60mg 1 GC; MO

dilt-xr oral capsule extended release 24hour 120mg, 180mg, 240mg


felodipine er oral tablet extended release 24hour 10mg, 2.5mg, 5mg


isradipine oral capsule 2.5mg 1 GC; MO

isradipine oral capsule 5mg 2 GC; MO

nicardipine hcl oral capsule 20mg, 30mg 2 GC; MO

nifedipine er oral tablet extended release 24hour

30mg, 60mg



90mg


nifedipine er osmotic release oral tablet extended release 24hour 30mg, 60mg


nifedipine er osmotic release oral tablet extended release 24hour 90mg


TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120MG, 180MG, 240MG


TAZTIA XT ORAL CAPSULE EXTENDED RELEASE

24 HOUR 300MG, 360MG


verapamil hcl er oral capsule extended release 24hour 100mg, 300mg


verapamil hcl er oral capsule extended release 24hour 120mg, 180mg, 200mg, 240mg, 360mg


verapamil hcl er oral tablet extended release

120mg, 180mg, 240mg

1 GC; MO

verapamil hcl oral tablet 120mg, 40mg, 80mg 1 GC; MO

Cardiovascular Agents, Other

aliskiren fumarate oral tablet 150mg, 300mg 2 GC; MO; QL (30 EA per 30 days)

amlodipine-atorvastatin oral tablet 10-10mg, 10-20mg, 10-40mg, 10-80mg, 2.5-10mg, 2.5-20mg, 2.5-40mg, 5-10mg, 5-20mg, 5-40mg, 5-80mg

2 GC; MO

CINRYZE INTRAVENOUS SOLUTION

RECONSTITUTED 500 UNIT

5 PA; LA


CORLANOR ORAL TABLET 5MG, 7.5MG 4 PA; MO

DIGITEK ORAL TABLET 125 MCG, 250 MCG 2 GC; MO; QL (30 EA per 30 days)

DIGOX ORAL TABLET 125 MCG, 250 MCG 2 GC; MO; QL (30 EA per 30 days)

digoxin oral solution 0.05mg/ml 2 GC; MO; QL (255ML per 30 days)

digoxin oral tablet 125mcg, 250mcg 2 GC; MO; QL (30 EA per 30 days)

NORTHERA ORAL CAPSULE 100MG, 200MG,

300MG

5 PA; LA; QL (180 EA per 30 days)

ranolazine er oral tablet extended release 12hour 1000mg, 500mg

3 MO

RUCONEST INTRAVENOUS SOLUTION


5 PA

TAKHZYRO SUBCUTANEOUS SOLUTION

300MG/2ML


Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide er oral capsule extended release 12hour 500mg

2 GC; MO

acetazolamide oral tablet 125mg, 250mg 2 GC; MO

methazolamide oral tablet 25mg, 50mg 4 MO

Diuretics, Loop

bumetanide injection solution 0.25mg/ml 2 GC; MO

bumetanide oral tablet 0.5mg, 1mg, 2mg 2 GC; MO

furosemide injection solution 10mg/ml, 10mg/ml (4ml syringe)

2 BvD; GC; MO

furosemide oral solution 10mg/ml, 8mg/ml 1 GC; MO

furosemide oral tablet 20mg, 40mg, 80mg 1 GC; MO

torsemide oral tablet 10mg, 20mg, 5mg 1 GC; MO

torsemide oral tablet 100mg 2 GC; MO

Diuretics, Potassium-Sparing

amiloride hcl oral tablet 5mg 1 GC; MO

eplerenone oral tablet 25mg, 50mg 2 GC; MO

spironolactone oral tablet 100mg, 25mg, 50mg 1 GC; MO


Diuretics, Thiazide

chlorothiazide oral tablet 250mg 1 GC; MO

chlorothiazide oral tablet 500mg 2 GC; MO

chlorthalidone oral tablet 25mg, 50mg 1 GC; MO

hydrochlorothiazide oral capsule 12.5mg 1 GC; MO

hydrochlorothiazide oral tablet 12.5mg, 25mg, 50mg

1 GC; MO

indapamide oral tablet 1.25mg, 2.5mg 1 GC; MO

methyclothiazide oral tablet 5mg 1 GC; MO

metolazone oral tablet 10mg 2 GC; MO

metolazone oral tablet 2.5mg, 5mg 1 GC; MO

Dyslipidemics, Fibric Acid Derivatives

fenofibrate micronized oral capsule 130mg, 134mg, 200mg, 67mg


fenofibrate micronized oral capsule 43mg 2 GC; MO; QL (60 EA per 30 days)

fenofibrate oral capsule 150mg 2 GC; MO; QL (30 EA per 30 days)

fenofibrate oral capsule 50mg 2 GC; MO; QL (60 EA per 30 days)

fenofibrate oral tablet 145mg, 160mg 2 GC; MO; QL (30 EA per 30 days)

fenofibrate oral tablet 40mg, 48mg, 54mg 2 GC; MO; QL (60 EA per 30 days)

gemfibrozil oral tablet 600mg 2 GC; MO

Dyslipidemics, Hmg Coa Reductase Inhibitors

atorvastatin calcium oral tablet 10mg, 20mg, 40mg, 80mg


LIVALO ORAL TABLET 1MG, 2MG, 4MG 3 MO

lovastatin oral tablet 10mg 1 GC; MO; QL (45 EA per 30 days)



pravastatin sodium oral tablet 10mg, 20mg, 40mg, 80mg


rosuvastatin calcium oral tablet 10mg, 20mg, 40mg, 5mg

2 GC; MO


simvastatin oral tablet 10mg, 20mg, 40mg, 5mg, 80mg


Dyslipidemics, Other

cholestyramine light oral powder 4gm/dose 2 GC; MO

cholestyramine oral packet 4gm 2 GC; MO

colesevelam hcl oral packet 3.75gm 2 GC; MO

colesevelam hcl oral tablet 625mg 2 GC; MO

colestipol hcl oral packet 5gm 2 GC; MO

colestipol hcl oral tablet 1gm 2 GC; MO

ezetimibe oral tablet 10mg 2 GC; MO

JUXTAPID ORAL CAPSULE 10MG, 20MG, 30MG,

40MG, 5MG, 60MG

5 PA

niacin er (antihyperlipidemic) oral tablet extended release 1000mg, 500mg, 750mg

2 GC; MO

omega-3-acid ethyl esters oral capsule 1gm 2 GC; MO

PRALUENT SUBCUTANEOUS SOLUTION PEN-

INJECTOR 150MG/ML, 75MG/ML

4 PA; MO

PREVALITE ORAL PACKET 4 GM 4 MO

REPATHA PUSHTRONEX SYSTEM

SUBCUTANEOUS SOLUTION CARTRIDGE 420MG/3.5ML

4 PA; MO

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140MG/ML

4 PA; MO

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140MG/ML

4 PA; MO

VASCEPA ORAL CAPSULE 0.5 GM, 1 GM 4 MO

Vasodilators, Direct-Acting Arterial/Venous

isosorbide dinitrate er oral tablet extended release 40mg

2 GC; MO

isosorbide dinitrate oral tablet 10mg, 20mg, 30mg, 5mg

1 GC; MO

isosorbide mononitrate er oral tablet extended release 24hour 120mg

2 GC; MO


isosorbide mononitrate er oral tablet extended release 24hour 30mg, 60mg

1 GC; MO

isosorbide mononitrate oral tablet 10mg, 20mg 1 GC; MO

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3MG/HR, 0.8MG/HR

3 MO

nitroglycerin sublingual tablet sublingual 0.3mg, 0.4mg, 0.6mg

1 GC; MO

nitroglycerin transdermal patch 24hour

0.1mg/hr, 0.2mg/hr, 0.4mg/hr, 0.6mg/hr


nitroglycerin translingual solution 0.4mg/spray 2 GC; MO

Vasodilators, Direct-Acting Arterial

hydralazine hcl oral tablet 10mg, 100mg, 25mg, 50mg

1 GC; MO

minoxidil oral tablet 10mg, 2.5mg 1 GC; MO

CENTRAL NERVOUS SYSTEM AGENTS

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

amphetamine-dextroamphetamine oral tablet

10mg, 12.5mg, 15mg, 20mg, 5mg, 7.5mg



30mg


dextroamphetamine sulfate er oral capsule extended release 24hour 10mg






dextroamphetamine sulfate oral tablet 10mg 4 MO; QL (180 EA per 30 days)


Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines

atomoxetine hcl oral capsule 10mg, 100mg, 18mg, 25mg, 40mg, 60mg, 80mg

4 ST; MO; QL (30 EA per 30 days)

dexmethylphenidate hcl oral tablet 10mg 1 GC; MO; QL (60 EA per 30 days)


dexmethylphenidate hcl oral tablet 2.5mg 1 GC; MO; QL (240 EA per 30 days)

dexmethylphenidate hcl oral tablet 5mg 1 GC; MO; QL (120 EA per 30 days)

guanfacine hcl er oral tablet extended release 24hour 1mg, 2mg, 3mg, 4mg

4 MO

METADATE ER ORAL TABLET EXTENDED RELEASE 20MG


methylphenidate hcl er oral tablet extended release 10mg, 20mg


methylphenidate hcl oral solution 10mg/5ml 4 MO; QL (900ML per 30 days)


methylphenidate hcl oral tablet 10mg, 5mg 1 GC; MO; QL (90 EA per 30 days)

methylphenidate hcl oral tablet 20mg 2 GC; MO; QL (90 EA per 30 days)

Central Nervous System, Other

AUSTEDO ORAL TABLET 12MG, 6MG, 9MG 5 PA; LA; QL (120 EA per 30 days)

NUEDEXTA ORAL CAPSULE 20-10MG 3 PA; MO

riluzole oral tablet 50mg 4 MO

TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 284MG/1.5ML

5 PA; LA

tetrabenazine oral tablet 12.5mg 5 PA; QL (240 EA per 30 days)

tetrabenazine oral tablet 25mg 5 PA; QL (120 EA per 30 days)

TIGLUTIK ORAL SUSPENSION 50MG/10ML 5

Fibromyalgia Agents

LYRICA ORAL CAPSULE 150MG 3 MO; QL (90 EA per 30 days)


SAVELLA ORAL TABLET 100MG, 12.5MG, 25MG,

50MG


SAVELLA TITRATION PACK ORAL 12.5 & 25 &

50MG


Multiple Sclerosis Agents

AVONEX INTRAMUSCULAR KIT 30 MCG 5 PA


AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR

KIT 30 MCG/0.5ML

5 PA

AVONEX PREFILLED INTRAMUSCULAR PREFILLED

SYRINGE KIT 30 MCG/0.5ML

5 PA

BETASERON SUBCUTANEOUS KIT 0.3MG 5 PA

COPAXONE SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 20MG/ML, 40MG/ML

5 PA

dalfampridine er oral tablet extended release 12hour 10mg


GILENYA ORAL CAPSULE 0.5MG 5 PA

glatiramer acetate subcutaneous solution prefilled syringe 20mg/ml, 40mg/ml

5 PA

MAYZENT ORAL TABLET 0.25MG 5 PA; QL (210 EA per 30 days)

MAYZENT ORAL TABLET 2MG 5 PA; QL (30 EA per 30 days)

TECFIDERA ORAL 120 & 240MG 5 PA

TECFIDERA ORAL CAPSULE DELAYED RELEASE

120MG, 240MG

5 PA

DENTAL AND ORAL AGENTS

Dental And Oral Agents

chlorhexidine gluconate mouth/throat solution

0.12%

1 GC; MO

lidocaine viscous hcl mouth/throat solution 2% 4 MO

pilocarpine hcl oral tablet 5mg, 7.5mg 2 GC; MO

triamcinolone acetonide mouth/throat paste

0.1%

2 GC; MO

DERMATOLOGICAL AGENTS

Dermatological Agents

acitretin oral capsule 10mg, 25mg 4 PA; MO

acitretin oral capsule 17.5mg 5 PA

alclometasone dipropionate external cream

0.05%

2 GC; MO


alclometasone dipropionate external ointment

0.05%

2 GC; MO

amcinonide external cream 0.1% 4 MO

amcinonide external ointment 0.1% 4 MO

ammonium lactate external cream 12% 1 GC; MO

ammonium lactate external lotion 12% 1 GC; MO

AMNESTEEM ORAL CAPSULE 10MG, 20MG, 40MG 4 MO

benzoyl peroxide-erythromycin external gel 5-3%

2 GC; MO

betamethasone dipropionate aug external cream 0.05%

2 GC; MO

betamethasone dipropionate aug external lotion

0.05%

2 GC; MO

betamethasone dipropionate aug external ointment 0.05%

2 GC; MO

betamethasone dipropionate external cream

0.05%

2 GC; MO

betamethasone dipropionate external lotion

0.05%

1 GC; MO

betamethasone dipropionate external ointment 0.05%

2 GC; MO

betamethasone valerate external cream 0.1% 1 GC; MO

betamethasone valerate external lotion 0.1% 1 GC; MO

betamethasone valerate external ointment 0.1% 1 GC; MO

calcipotriene external solution 0.005% 4 MO

CLARAVIS ORAL CAPSULE 20MG, 30MG, 40MG 4 MO

clindamycin phos-benzoyl perox external gel 1-5%

2 GC; MO

clindamycin phosphate external gel 1% 2 GC; MO

clindamycin phosphate external lotion 1% 2 GC; MO

clindamycin phosphate external solution 1% 2 GC; MO

clobetasol propionate e external cream 0.05% 4 MO


clobetasol propionate external cream 0.05% 4 MO

clobetasol propionate external gel 0.05% 4 MO

clobetasol propionate external ointment 0.05% 4 MO

clobetasol propionate external solution 0.05% 2 GC; MO

clotrimazole-betamethasone external cream 1-0.05%

2 GC; MO

clotrimazole-betamethasone external lotion 1-0.05%

2 GC; MO

COLOCORT RECTAL ENEMA 100MG/60ML 2 GC; MO

desonide external cream 0.05% 4 MO

desonide external lotion 0.05% 4 MO

desonide external ointment 0.05% 2 GC; MO

desoximetasone external cream 0.05% 4 MO

desoximetasone external cream 0.25% 2 GC; MO

desoximetasone external gel 0.05% 4 MO

desoximetasone external ointment 0.25% 2 GC; MO

diflorasone diacetate external cream 0.05% 4 MO

ery external pad 2% 2 GC; MO

erythromycin external gel 2% 2 GC; MO

erythromycin external solution 2% 1 GC; MO

EUCRISA EXTERNAL OINTMENT 2% 4 MO

fluocinolone acetonide external cream 0.01%, 0.025%

2 GC; MO

fluocinolone acetonide external ointment 0.025%

2 GC; MO

fluocinolone acetonide external solution 0.01% 2 GC; MO

fluocinonide emulsified base external cream 0.05%

2 GC; MO

fluocinonide external gel 0.05% 2 GC; MO

fluocinonide external ointment 0.05% 2 GC; MO

fluocinonide external solution 0.05% 2 GC; MO


fluticasone propionate external cream 0.05% 2 GC; MO

fluticasone propionate external ointment 0.005% 2 GC; MO

gentamicin sulfate external cream 0.1% 2 GC; MO

gentamicin sulfate external ointment 0.1% 2 GC; MO

halobetasol propionate external cream 0.05% 4 MO

halobetasol propionate external ointment 0.05% 2 GC; MO

hydrocortisone ace-pramoxine rectal cream 1-1%

1 GC; MO

hydrocortisone external cream 1%, 2.5% 1 GC; MO

hydrocortisone external lotion 2.5% 1 GC; MO

hydrocortisone external ointment 1% 2 GC; MO

hydrocortisone external ointment 2.5% 1 GC; MO

hydrocortisone rectal enema 100mg/60ml 4 MO

hydrocortisone valerate external cream 0.2% 2 GC; MO

hydrocortisone valerate external ointment 0.2% 2 GC; MO

imiquimod external cream 5% 2 GC; MO

isotretinoin oral capsule 10mg, 20mg, 30mg, 40mg

4 MO

metronidazole external cream 0.75% 2 GC; MO

metronidazole external gel 0.75%, 1% 2 GC; MO

metronidazole external lotion 0.75% 2 GC; MO

mometasone furoate external cream 0.1% 1 GC; MO

mometasone furoate external ointment 0.1% 1 GC; MO

mometasone furoate external solution 0.1% 1 GC; MO

mupirocin external ointment 2% 2 GC; MO

MYORISAN ORAL CAPSULE 30MG 4 MO

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

2 GC; MO

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

2 GC; MO

PICATO EXTERNAL GEL 0.015%, 0.05% 4 MO


pimecrolimus external cream 1% 4 MO

podofilox external solution 0.5% 2 GC; MO

prednicarbate external cream 0.1% 4 MO

prednicarbate external ointment 0.1% 4 MO

PROCTO-MED HC RECTAL CREAM 2.5% 4 MO

PROCTO-PAK RECTAL CREAM 1% 4 MO

PROCTOSOL HC RECTAL CREAM 2.5% 4 MO

PROCTOZONE-HC RECTAL CREAM 2.5% 1 GC; MO

RECTIV RECTAL OINTMENT 0.4% 4 MO

REGRANEX EXTERNAL GEL 0.01% 5 PA

SANTYL EXTERNAL OINTMENT 250 UNIT/GM 4 MO

selenium sulfide external lotion 2.5% 2 GC; MO

silver sulfadiazine external cream 1% 2 GC; MO

SSD EXTERNAL CREAM 1% 2 GC; MO

tacrolimus external ointment 0.03%, 0.1% 4 MO

tazarotene external cream 0.1% 2 GC; MO

TAZORAC EXTERNAL CREAM 0.05% 4 MO

TAZORAC EXTERNAL GEL 0.05%, 0.1% 4 MO

tretinoin external cream 0.025%, 0.05%, 0.1% 2 GC; MO

tretinoin external gel 0.01%, 0.025%, 0.05% 2 GC; MO

triamcinolone acetonide external cream 0.025%, 0.1%, 0.5%

1 GC; MO

triamcinolone acetonide external lotion 0.025% 1 GC; MO

triamcinolone acetonide external lotion 0.1% 2 GC; MO

triamcinolone acetonide external ointment

0.025%, 0.1%, 0.5%

1 GC; MO

TRIDERM EXTERNAL CREAM 0.1% 2 GC; MO

UCERIS RECTAL FOAM 2MG/ACT 4 MO

ELECTROLYTES/MINERALS/METALS/VITAMINS

Electrolyte/Mineral Replacement


dextrose-nacl intravenous solution 10-0.2% 4 BvD; MO

dextrose-nacl intravenous solution 10-0.45%, 2.5-0.45%, 5-0.2%, 5-0.225%, 5-0.33%, 5-0.45%, 5-0.9%

2 BvD; GC; MO

kcl in dextrose-nacl intravenous solution 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.33 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9 meq/l-%-%

2 BvD; GC; MO

kcl-lactated ringers-d5w intravenous solution 20 meq/l

2 BvD; GC; MO

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE

10 MEQ

2 GC; MO

KLOR-CON M10 ORAL TABLET EXTENDED

RELEASE 10 MEQ

1 GC; MO


RELEASE 15 MEQ

2 GC; MO


RELEASE 20 MEQ

1 GC; MO

KLOR-CON ORAL PACKET 20 MEQ 2 GC; MO

KLOR-CON ORAL TABLET EXTENDED RELEASE 8

MEQ

2 GC; MO

KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED

RELEASE 8 MEQ

2 GC; MO

magnesium sulfate injection solution 50%, 50% (10ml syringe)

1 BvD; GC; MO

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

1 GC; MO

potassium chloride er oral capsule extended release 10 meq, 8 meq

2 GC; MO

potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq

1 GC; MO

potassium chloride in dextrose intravenous solution 20-5 meq/l-%

2 BvD; GC; MO



4 BvD; MO

potassium chloride in nacl intravenous solution

20-0.45 meq/l-%, 20-0.9 meq/l-%

2 BvD; GC; MO


40-0.9 meq/l-%

4 BvD; MO

potassium chloride intravenous solution 2 meq/ml, 2 meq/ml (20 ml), 20 meq/100ml

2 BvD; GC; MO

potassium chloride oral packet 20 meq 2 GC; MO

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

2 GC; MO

potassium citrate er oral tablet extended release

10 meq (1080mg), 15 meq (1620mg), 5 meq (540mg)

2 GC; MO

sodium chloride intravenous solution 0.45%, 0.9%, 3%, 5%

2 BvD; GC; MO

Electrolyte/Mineral/Metal Modifiers

CHEMET ORAL CAPSULE 100MG 4 MO

deferasirox oral tablet soluble 125mg, 250mg, 500mg

5 PA

FERRIPROX ORAL SOLUTION 100MG/ML 4 PA; LA; MO

FERRIPROX ORAL TABLET 500MG 5 PA; LA

IONOSOL-MB IN D5W INTRAVENOUS SOLUTION 4 MO

ISOLYTE-P IN D5W INTRAVENOUS SOLUTION 4 MO

KIONEX ORAL SUSPENSION 15 GM/60ML 2 GC; MO

LOKELMA ORAL PACKET 10 GM, 5 GM 4 MO

NORMOSOL-M IN D5W INTRAVENOUS SOLUTION 3 BvD; MO

NORMOSOL-R IN D5W INTRAVENOUS SOLUTION 3 BvD; MO

SAMSCA ORAL TABLET 15MG, 30MG 5 QL (60 EA per 30 days)

sodium chloride irrigation solution 0.9% 1 GC; MO

sodium polystyrene sulfonate oral powder 2 GC; MO

SPS ORAL SUSPENSION 15 GM/60ML 4 MO


trientine hcl oral capsule 250mg 5 PA

Nutrients

AMINOSYN II INTRAVENOUS SOLUTION 10% 4 BvD; MO

AMINOSYN-PF INTRAVENOUS SOLUTION 10%,

7%

4 BvD; MO

CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS

SOLUTION 2.75%

3 BvD; MO


SOLUTION 4.25%

3 BvD; MO

CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25%

3 BvD; MO

CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5%

3 BvD; MO

CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5%

3 BvD; MO

CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS

SOLUTION 4.25%

4 BvD; MO


SOLUTION 4.25%

4 BvD; MO

CLINIMIX/DEXTROSE (5/15) INTRAVENOUS

SOLUTION 5%

4 BvD; MO


SOLUTION 5%

4 BvD; MO

dextrose intravenous solution 10%, 5% 2 BvD; GC; MO

FREAMINE HBC INTRAVENOUS SOLUTION 6.9% 4 BvD; MO

HEPATAMINE INTRAVENOUS SOLUTION 8% 4 BvD; MO

INTRALIPID INTRAVENOUS EMULSION 20%, 30% 4 BvD; MO

ISOLYTE-S INTRAVENOUS SOLUTION 4 BvD; MO

NEPHRAMINE INTRAVENOUS SOLUTION 5.4% 4 BvD; MO

NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION 4 BvD; MO

nutrilipid intravenous emulsion 20% 4 BvD; MO

PLASMA-LYTE 148 INTRAVENOUS SOLUTION 3 BvD; MO


PLASMA-LYTE A INTRAVENOUS SOLUTION 3 BvD; MO

PREMASOL INTRAVENOUS SOLUTION 10% 4 BvD; MO

PREMASOL INTRAVENOUS SOLUTION 6% 2 BvD; GC; MO

PROCALAMINE INTRAVENOUS SOLUTION 3% 4 BvD; MO

PROSOL INTRAVENOUS SOLUTION 20% 4 BvD; MO

TPN ELECTROLYTES INTRAVENOUS SOLUTION 2 BvD; GC; MO

TRAVASOL INTRAVENOUS SOLUTION 10% 4 BvD; MO

TROPHAMINE INTRAVENOUS SOLUTION 10% 4 BvD; MO

GASTROINTESTINAL AGENTS

Antispasmodics, Gastrointestinal

dicyclomine hcl oral capsule 10mg 1 GC; MO

dicyclomine hcl oral solution 10mg/5ml 2 GC; MO

dicyclomine hcl oral tablet 20mg 1 GC; MO

glycopyrrolate oral tablet 1mg 1 GC; MO

glycopyrrolate oral tablet 2mg 2 GC; MO

Gastrointestinal Agents, Other

CREON ORAL CAPSULE DELAYED RELEASE

PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-

9500 UNIT, 36000 UNIT, 6000 UNIT

3 MO

cromolyn sodium oral concentrate 100mg/5ml 4 MO

diphenoxylate-atropine oral liquid 2.5-0.025mg/5ml

4 MO

diphenoxylate-atropine oral tablet 2.5-0.025mg 1 GC; MO

GATTEX SUBCUTANEOUS KIT 5MG 5 PA; LA

loperamide hcl oral capsule 2mg 1 GC; MO

metoclopramide hcl oral solution 5mg/5ml 1 GC; MO

metoclopramide hcl oral tablet 10mg, 5mg 1 GC; MO

MOVANTIK ORAL TABLET 12.5MG, 25MG 3 MO; QL (30 EA per 30 days)

MYTESI ORAL TABLET DELAYED RELEASE 125MG 4 PA; MO

ursodiol oral capsule 300mg 2 GC; MO


ursodiol oral tablet 250mg, 500mg 2 GC; MO

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000

UNIT, 20000-63000 UNIT, 25000-79000 UNIT,

3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT

3 MO

Histamine2 (H2) Receptor Antagonists

famotidine oral suspension reconstituted

40mg/5ml 1 GC; MO

famotidine oral tablet 20mg, 40mg 1 GC; MO

ranitidine hcl oral capsule 150mg, 300mg 1 GC; MO

ranitidine hcl oral syrup 75mg/5ml 2 GC; MO

ranitidine hcl oral tablet 150mg, 300mg 1 GC; MO

Irritable Bowel Syndrome Agents

alosetron hcl oral tablet 0.5mg 4 MO; QL (60 EA per 30 days)

alosetron hcl oral tablet 1mg 5 QL (60 EA per 30 days)

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 3 MO; QL (60 EA per 30 days)

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72

MCG


Laxatives

CLENPIQ ORAL SOLUTION 10-3.5-12MG-GM -

GM/160ML

4 MO

constulose oral solution 10gm/15ml 2 GC; MO

enulose oral solution 10gm/15ml 1 GC; MO

GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM

1 GC; MO

GAVILYTE-G ORAL SOLUTION RECONSTITUTED

236 GM

1 GC; MO

GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION

RECONSTITUTED 420 GM

1 GC; MO

generlac oral solution 10gm/15ml 1 GC; MO

lactulose oral solution 10gm/15ml 1 GC; MO


peg 3350/electrolytes oral solution reconstituted

240gm

1 GC; MO

peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420gm

1 GC; MO

peg-3350/electrolytes oral solution reconstituted

236gm

1 GC; MO

SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-

3.13-1.6 GM/177ML

4 MO

TRILYTE ORAL SOLUTION RECONSTITUTED 420

GM

1 GC; MO

Protectants

CARAFATE ORAL SUSPENSION 1 GM/10ML 4 MO

misoprostol oral tablet 100mcg, 200mcg 1 GC; MO

sucralfate oral tablet 1gm 1 GC; MO

Proton Pump Inhibitors

DEXILANT ORAL CAPSULE DELAYED RELEASE

30MG, 60MG

3 ST; MO

esomeprazole magnesium oral capsule delayed release 40mg

2 GC; MO

esomeprazole strontium oral capsule delayed release 49.3mg

2 GC; MO

omeprazole oral capsule delayed release 10mg, 20mg, 40mg

2 GC; MO

pantoprazole sodium oral tablet delayed release

20mg, 40mg

2 GC; MO

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

Enzyme Replacement/Modifiers

CARBAGLU ORAL TABLET 200MG 5 PA; LA

CYSTADANE ORAL POWDER 5

ENDARI ORAL PACKET 5 GM 4 LA; MO

GALAFOLD ORAL CAPSULE 123MG 5 PA; LA; QL (14 EA per 28 days)

KUVAN ORAL PACKET 100MG, 500MG 5 PA; LA


KUVAN ORAL TABLET SOLUBLE 100MG 5 PA; LA

levocarnitine oral solution 1gm/10ml 1 BvD; GC; MO

levocarnitine oral tablet 330mg 2 BvD; GC; MO

miglustat oral capsule 100mg 5 PA; LA

ORFADIN ORAL CAPSULE 10MG, 2MG, 20MG, 5MG 5 PA; LA

RAVICTI ORAL LIQUID 1.1 GM/ML 5 PA; LA

sodium phenylbutyrate oral powder 3gm/tsp 5 PA

sodium phenylbutyrate oral tablet 500mg 4 PA; MO

XURIDEN ORAL PACKET 2 GM 5 PA

GENITOURINARY AGENTS

Antispasmodics, Urinary

darifenacin hydrobromide er oral tablet extended release 24hour 15mg, 7.5mg

2 GC; MO

MYRBETRIQ ORAL TABLET EXTENDED RELEASE

24 HOUR 25MG, 50MG

3 MO

oxybutynin chloride er oral tablet extended release 24hour 10mg, 15mg, 5mg


oxybutynin chloride oral syrup 5mg/5ml 1 GC; MO

oxybutynin chloride oral tablet 5mg 1 GC; MO

tolterodine tartrate er oral capsule extended release 24hour 2mg, 4mg


tolterodine tartrate oral tablet 1mg, 2mg 2 GC; MO; QL (60 EA per 30 days)

Benign Prostatic Hypertrophy Agents

alfuzosin hcl er oral tablet extended release 24hour 10mg


dutasteride oral capsule 0.5mg 2 GC; MO

dutasteride-tamsulosin hcl oral capsule 0.5-0.4mg


finasteride oral tablet 5mg 1 GC; MO; QL (30 EA per 30 days)


silodosin oral capsule 4mg, 8mg 4 MO; QL (30 EA per 30 days)

tamsulosin hcl oral capsule 0.4mg 2 GC; MO; QL (60 EA per 30 days)

Genitourinary Agents, Other

bethanechol chloride oral tablet 10mg, 50mg 2 GC; MO

bethanechol chloride oral tablet 25mg, 5mg 1 GC; MO

CYSTAGON ORAL CAPSULE 150MG, 50MG 4 PA; LA; MO

ELMIRON ORAL CAPSULE 100MG 4 MO

Phosphate Binders

AURYXIA ORAL TABLET 1 GM 210MG(FE) 4 PA; MO

calcium acetate (phos binder) oral capsule

667mg

2 GC; MO

calcium acetate (phos binder) oral tablet 667mg 1 GC; MO

sevelamer carbonate oral packet 0.8gm 5 QL (540 EA per 30 days)


sevelamer carbonate oral tablet 800mg 4 MO; QL (540 EA per 30 days)

VELPHORO ORAL TABLET CHEWABLE 500MG 4 MO

Vaginal Products

clindamycin phosphate vaginal cream 2% 2 GC; MO

estradiol vaginal cream 0.1mg/gm 4 MO

estradiol vaginal tablet 10mcg 4 MO

INTRAROSA VAGINAL INSERT 6.5MG 3 PA; MO

metronidazole vaginal gel 0.75% 2 GC; MO

OSPHENA ORAL TABLET 60MG 3 PA; MO

terconazole vaginal cream 0.4%, 0.8% 2 GC; MO

terconazole vaginal suppository 80mg 2 GC; MO

VANDAZOLE VAGINAL GEL 0.75% 4 MO

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)

Glucocorticoids/Mineralocorticoids

budesonide er oral tablet extended release 24hour 9mg

4 MO


budesonide oral capsule delayed release particles 3mg

4 MO

DEXAMETHASONE INTENSOL ORAL

CONCENTRATE 1MG/ML

1 GC; MO

dexamethasone oral elixir 0.5mg/5ml 2 GC; MO

dexamethasone oral tablet 0.5mg, 0.75mg, 1mg, 1.5mg, 2mg, 4mg

1 GC; MO

dexamethasone oral tablet 6mg 2 GC; MO

hydrocortisone oral tablet 10mg, 20mg, 5mg 1 GC; MO

methylprednisolone oral tablet 16mg, 32mg, 4mg, 8mg

2 GC; MO

methylprednisolone oral tablet therapy pack 4mg

2 GC; MO

prednisolone oral solution 15mg/5ml 2 GC; MO

prednisolone sodium phosphate oral solution 10mg/5ml, 20mg/5ml

4 MO

prednisolone sodium phosphate oral solution 25mg/5ml, 6.7 (5 base)mg/5ml

2 GC; MO

prednisolone sodium phosphate oral tablet dispersible 10mg, 15mg, 30mg

2 GC; MO

PREDNISONE INTENSOL ORAL CONCENTRATE

5MG/ML

1 GC; MO

prednisone oral solution 5mg/5ml 4 MO

prednisone oral tablet 1mg, 10mg, 2.5mg, 20mg, 5mg, 50mg

1 GC; MO

prednisone oral tablet therapy pack 10mg (21), 10mg (48), 5mg (21), 5mg (48)

1 GC; MO

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

cortisone acetate oral tablet 25mg 3 MO

DEMSER ORAL CAPSULE 250MG 5

fludrocortisone acetate oral tablet 0.1mg 1 GC; MO

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS)


Anabolic Steroids

ANADROL-50 ORAL TABLET 50MG 5

oxandrolone oral tablet 10mg 5 PA

oxandrolone oral tablet 2.5mg 4 PA; MO

Androgens

ANDRODERM TRANSDERMAL PATCH 24 HOUR

2MG/24HR, 4MG/24HR

3 PA2; MO

danazol oral capsule 100mg, 50mg 2 GC; MO

danazol oral capsule 200mg 4 MO

methyltestosterone oral capsule 10mg 5

testosterone cypionate intramuscular solution

100mg/ml, 200mg/ml, 200mg/ml (1 ml) 2 PA; GC; MO

testosterone enanthate intramuscular solution 200mg/ml

2 PA; GC; MO

testosterone transdermal gel 10mg/act (2%), 12.5mg/act (1%), 20.25mg/1.25gm (1.62%), 20.25mg/act (1.62%), 25mg/2.5gm (1%), 40.5mg/2.5gm (1.62%)

2 PA; GC; MO

testosterone transdermal gel 50mg/5gm (1%) 4 PA; MO

testosterone transdermal solution 30mg/act 2 PA; GC; MO

Contraceptives

ALTAVERA ORAL TABLET 0.15-30MG-MCG 2 GC; MO

alyacen 1/35 oral tablet 1-35mg-mcg 2 GC; MO

APRI ORAL TABLET 0.15-30MG-MCG 2 GC; MO

ARANELLE ORAL TABLET 0.5/1/0.5-35MG-MCG 2 GC; MO

AUBRA ORAL TABLET 0.1-20MG-MCG 2 GC; MO

AVIANE ORAL TABLET 0.1-20MG-MCG 2 GC; MO

BALZIVA ORAL TABLET 0.4-35MG-MCG 2 GC; MO

BLISOVI FE 1.5/30 ORAL TABLET 1.5-30MG-MCG 2 GC; MO

briellyn oral tablet 0.4-35mg-mcg 2 GC; MO

CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025MG 2 GC; MO


CRYSELLE-28 ORAL TABLET 0.3-30MG-MCG 2 GC; MO

CYCLAFEM 1/35 ORAL TABLET 1-35MG-MCG 2 GC; MO

CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35MG-

MCG

2 GC; MO

CYRED ORAL TABLET 0.15-30MG-MCG 2 GC; MO

DELYLA ORAL TABLET 0.1-20MG-MCG 2 GC; MO

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01mg (21/5), 0.15-30mg-mcg

2 GC; MO

drospirenone-ethinyl estradiol oral tablet 3-0.02mg

4 MO


1 GC; MO

EMOQUETTE ORAL TABLET 0.15-30MG-MCG 2 GC; MO

ENPRESSE-28 ORAL TABLET 2 GC; MO

ENSKYCE ORAL TABLET 0.15-30MG-MCG 2 GC; MO

ESTARYLLA ORAL TABLET 0.25-35MG-MCG 2 GC; MO

ethynodiol diac-eth estradiol oral tablet 1-35mg-mcg

1 GC; MO


2 GC; MO

FALMINA ORAL TABLET 0.1-20MG-MCG 2 GC; MO

FEMYNOR ORAL TABLET 0.25-35MG-MCG 2 GC; MO

GIANVI ORAL TABLET 3-0.02MG 4 MO

INTROVALE ORAL TABLET 0.15-0.03MG 2 GC; MO

ISIBLOOM ORAL TABLET 0.15-30MG-MCG 2 GC; MO

JASMIEL ORAL TABLET 3-0.02MG 4 MO

JULEBER ORAL TABLET 0.15-30MG-MCG 2 GC; MO

JUNEL 1.5/30 ORAL TABLET 1.5-30MG-MCG 2 GC; MO

JUNEL 1/20 ORAL TABLET 1-20MG-MCG 2 GC; MO

JUNEL FE 1.5/30 ORAL TABLET 1.5-30MG-MCG 2 GC; MO

JUNEL FE 1/20 ORAL TABLET 1-20MG-MCG 2 GC; MO


KARIVA ORAL TABLET 0.15-0.02/0.01MG (21/5) 2 GC; MO

KELNOR 1/35 ORAL TABLET 1-35MG-MCG 1 GC; MO

KELNOR 1/50 ORAL TABLET 1-50MG-MCG 2 GC; MO

KURVELO ORAL TABLET 0.15-30MG-MCG 2 GC; MO

LARIN 1.5/30 ORAL TABLET 1.5-30MG-MCG 4 MO

LARIN 1/20 ORAL TABLET 1-20MG-MCG 2 GC; MO

LARIN FE 1.5/30 ORAL TABLET 1.5-30MG-MCG 4 MO

LARIN FE 1/20 ORAL TABLET 1-20MG-MCG 4 MO

LARISSIA ORAL TABLET 0.1-20MG-MCG 2 GC; MO

LEENA ORAL TABLET 0.5/1/0.5-35MG-MCG 2 GC; MO

LESSINA ORAL TABLET 0.1-20MG-MCG 2 GC; MO

LEVONEST ORAL TABLET 2 GC; MO

levonorgest-eth estrad 91-day oral tablet 0.15-0.03mg

2 GC; MO

levonorgestrel-ethinyl estrad oral tablet 0.1-20mg-mcg, 0.15-30mg-mcg

2 GC; MO

levonorg-eth estrad triphasic oral tablet 2 GC; MO

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30MG-

MCG

2 GC; MO

LORYNA ORAL TABLET 3-0.02MG 4 MO

LOW-OGESTREL ORAL TABLET 0.3-30MG-MCG 2 GC; MO

LUTERA ORAL TABLET 0.1-20MG-MCG 2 GC; MO

marlissa oral tablet 0.15-30mg-mcg 2 GC; MO

medroxyprogesterone acetate intramuscular suspension 150mg/ml

4 MO

medroxyprogesterone acetate intramuscular suspension prefilled syringe 150mg/ml

4 MO

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30MG-

MCG

2 GC; MO

MICROGESTIN 1/20 ORAL TABLET 1-20MG-MCG 2 GC; MO

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30MG-

MCG

2 GC; MO


MICROGESTIN FE 1/20 ORAL TABLET 1-20MG-

MCG

2 GC; MO

MILI ORAL TABLET 0.25-35MG-MCG 2 GC; MO

MONONESSA ORAL TABLET 0.25-35MG-MCG 2 GC; MO

NECON 0.5/35 (28) ORAL TABLET 0.5-35MG-MCG 2 GC; MO

NIKKI ORAL TABLET 3-0.02MG 4 MO

norethindrone acet-ethinyl est oral tablet 1-20mg-mcg

2 GC; MO

norgestimate-eth estradiol oral tablet 0.25-35mg-mcg

2 GC; MO

norgestim-eth estrad triphasic oral tablet

0.18/0.215/0.25mg-35mcg

1 GC; MO

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35MG-

MCG

2 GC; MO

NORTREL 1/35 (21) ORAL TABLET 1-35MG-MCG 2 GC; MO

NORTREL 1/35 (28) ORAL TABLET 1-35MG-MCG 2 GC; MO

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35MG-

MCG

2 GC; MO

NUVARING VAGINAL RING 0.12-0.015MG/24HR 4 MO

OCELLA ORAL TABLET 3-0.03MG 1 GC; MO

ORSYTHIA ORAL TABLET 0.1-20MG-MCG 2 GC; MO

PIMTREA ORAL TABLET 0.15-0.02/0.01MG (21/5) 2 GC; MO

PIRMELLA 1/35 ORAL TABLET 1-35MG-MCG 4 MO

PORTIA-28 ORAL TABLET 0.15-30MG-MCG 2 GC; MO

PREVIFEM ORAL TABLET 0.25-35MG-MCG 2 GC; MO

RECLIPSEN ORAL TABLET 0.15-30MG-MCG 2 GC; MO

SETLAKIN ORAL TABLET 0.15-0.03MG 2 GC; MO

SPRINTEC 28 ORAL TABLET 0.25-35MG-MCG 2 GC; MO

SRONYX ORAL TABLET 0.1-20MG-MCG 2 GC; MO

SYEDA ORAL TABLET 3-0.03MG 1 GC; MO

TARINA 24 FE ORAL TABLET 1-20MG-MCG(24) 4 MO


TARINA FE 1/20 ORAL TABLET 1-20MG-MCG 4 MO

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25MG-35 MCG

1 GC; MO

TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35MG-MCG

2 GC; MO

TRI-MILI ORAL TABLET 0.18/0.215/0.25MG-35

MCG

1 GC; MO

TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25MG-

35 MCG

1 GC; MO

TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25MG-

35 MCG

1 GC; MO

TRIVORA (28) ORAL TABLET 2 GC; MO

TRI-VYLIBRA ORAL TABLET 0.18/0.215/0.25MG-35

MCG

1 GC; MO

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025MG 2 GC; MO

VIENVA ORAL TABLET 0.1-20MG-MCG 2 GC; MO

VYFEMLA ORAL TABLET 0.4-35MG-MCG 2 GC; MO

VYLIBRA ORAL TABLET 0.25-35MG-MCG 2 GC; MO

ZOVIA 1/35E (28) ORAL TABLET 1-35MG-MCG 1 GC; MO

Estrogens

estradiol oral tablet 0.5mg, 1mg, 2mg 1 GC; MO

estradiol transdermal patch twice weekly 0.025mg/24hr, 0.0375mg/24hr, 0.05mg/24hr, 0.075mg/24hr, 0.1mg/24hr

2 GC; MO

estradiol transdermal patch weekly

0.025mg/24hr, 0.0375mg/24hr, 0.05mg/24hr, 0.06mg/24hr, 0.075mg/24hr, 0.1mg/24hr

2 GC; MO

MENEST ORAL TABLET 0.3MG, 0.625MG, 1.25MG 4 MO

norethindrone-eth estradiol oral tablet 1-5mg-mcg

2 GC; MO

Progestins

CAMILA ORAL TABLET 0.35MG 2 GC; MO

DEBLITANE ORAL TABLET 0.35MG 2 GC; MO


DEPO-PROVERA INTRAMUSCULAR SUSPENSION

400MG/ML

4 BvD; MO

ERRIN ORAL TABLET 0.35MG 2 GC; MO

INCASSIA ORAL TABLET 0.35MG 2 GC; MO

JOLIVETTE ORAL TABLET 0.35MG 2 GC; MO

LYZA ORAL TABLET 0.35MG 2 GC; MO

medroxyprogesterone acetate oral tablet 10mg, 2.5mg, 5mg

1 GC; MO

megestrol acetate oral suspension 40mg/ml 1 GC; MO

megestrol acetate oral suspension 625mg/5ml 4 MO

megestrol acetate oral tablet 20mg, 40mg 1 GC; MO

NORA-BE ORAL TABLET 0.35MG 2 GC; MO

norethindrone acetate oral tablet 5mg 2 GC; MO

norethindrone oral tablet 0.35mg 2 GC; MO

NORLYROC ORAL TABLET 0.35MG 2 GC; MO

PREMARIN ORAL TABLET 0.3MG, 0.45MG,

0.625MG, 0.9MG, 1.25MG

3 MO

PREMARIN VAGINAL CREAM 0.625MG/GM 3 MO

PREMPHASE ORAL TABLET 0.625-5MG 3 MO

PREMPRO ORAL TABLET 0.3-1.5MG, 0.45-1.5MG, 0.625-2.5MG, 0.625-5MG

3 MO

progesterone micronized oral capsule 100mg, 200mg

2 GC; MO

SHAROBEL ORAL TABLET 0.35MG 2 GC; MO

Selective Estrogen Receptor Modifying Agents

raloxifene hcl oral tablet 60mg 2 GC; MO; QL (30 EA per 30 days)

SOLTAMOX ORAL SOLUTION 10MG/5ML 4 PA2; MO

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

cabergoline oral tablet 0.5mg 2 GC; MO


desmopressin ace spray refrig nasal solution

0.01%

2 GC; MO

desmopressin acetate oral tablet 0.1mg, 0.2mg 2 GC; MO

INCRELEX SUBCUTANEOUS SOLUTION 40MG/4ML

5 PA; LA

NOCDURNA SUBLINGUAL TABLET SUBLINGUAL

27.7 MCG, 55.3 MCG

4 MO

OMNITROPE SUBCUTANEOUS SOLUTION

10MG/1.5ML, 5MG/1.5ML

5 PA


RECONSTITUTED 5.8MG

5 PA

ORILISSA ORAL TABLET 150MG, 200MG 5 PA

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25

MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1 GC; MO

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

1 GC; MO

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125

MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

1 GC; MO

liothyronine sodium oral tablet 25mcg, 5mcg, 50mcg

1 GC; MO

SYNTHROID ORAL TABLET 100 MCG, 112 MCG,

125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG,

25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

3 MO

UNITHROID ORAL TABLET 100 MCG, 112 MCG,

125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1 GC; MO

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

Hormonal Agents, Suppressant (Pituitary)


KORLYM ORAL TABLET 300MG 5 PA2; LA

octreotide acetate injection solution 100mcg/ml, 50mcg/ml

2 PA; GC; MO


4 PA; MO

octreotide acetate injection solution 500mcg/ml 5 PA

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3MG/ML, 0.6MG/ML, 0.9MG/ML


SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120MG/0.5ML, 60MG/0.2ML,

90MG/0.3ML

5 PA2; QL (1ML per 28 days)

SOMAVERT SUBCUTANEOUS SOLUTION

RECONSTITUTED 10MG, 15MG, 20MG, 25MG,

30MG


SYNAREL NASAL SOLUTION 2MG/ML 5 PA

TRELSTAR MIXJECT INTRAMUSCULAR

SUSPENSION RECONSTITUTED 11.25MG, 22.5MG, 3.75MG

5 PA2

HORMONAL AGENTS, SUPPRESSANT (THYROID)

Antithyroid Agents

methimazole oral tablet 10mg, 5mg 1 GC; MO

propylthiouracil oral tablet 50mg 1 GC; MO

IMMUNOLOGICAL AGENTS

Immune Suppressants

AZASAN ORAL TABLET 100MG, 75MG 3 BvD; MO

azathioprine oral tablet 50mg 2 BvD; GC; MO

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 200MG/ML

5 PA

BENLYSTA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 200MG/ML

5 PA

cyclosporine modified oral capsule 100mg, 25mg, 50mg

2 BvD; GC; MO

cyclosporine modified oral solution 100mg/ml 2 BvD; GC; MO


cyclosporine oral capsule 100mg, 25mg 2 BvD; GC; MO

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75MG, 1MG, 4MG

4 BvD; MO

GENGRAF ORAL CAPSULE 100MG 2 BvD; GC; MO

GENGRAF ORAL CAPSULE 25MG 1 BvD; GC; MO

GENGRAF ORAL SOLUTION 100MG/ML 2 BvD; GC; MO

methotrexate oral tablet 2.5mg 1 BvD; GC; MO

methotrexate sodium injection solution

50mg/2ml 1 BvD; GC; MO

mycophenolate mofetil oral capsule 250mg 4 BvD; MO

mycophenolate mofetil oral suspension reconstituted 200mg/ml

5 BvD

mycophenolate mofetil oral tablet 500mg 2 BvD; GC; MO

mycophenolate sodium oral tablet delayed release 180mg, 360mg

2 BvD; GC; MO

PROGRAF ORAL PACKET 0.2MG, 1MG 4 BvD; MO

SANDIMMUNE ORAL CAPSULE 100MG, 25MG 3 BvD; MO

SANDIMMUNE ORAL SOLUTION 100MG/ML 4 BvD; MO

sirolimus oral solution 1mg/ml 5 BvD

sirolimus oral tablet 0.5mg 2 BvD; GC; MO

sirolimus oral tablet 1mg, 2mg 4 BvD; MO

tacrolimus oral capsule 0.5mg 2 BvD; GC; MO

tacrolimus oral capsule 1mg, 5mg 4 BvD; MO

TREXALL ORAL TABLET 10MG, 15MG, 5MG, 7.5MG 4 BvD; MO

XATMEP ORAL SOLUTION 2.5MG/ML 4 BvD; MO

ZORTRESS ORAL TABLET 0.25MG 4 PA2; MO; QL (60 EA per 30 days)

ZORTRESS ORAL TABLET 0.5MG 5 PA2; QL (120 EA per 30 days)

ZORTRESS ORAL TABLET 0.75MG, 1MG 5 PA2; QL (60 EA per 30 days)

Immunomodulators

ACTIMMUNE SUBCUTANEOUS SOLUTION

2000000 UNIT/0.5ML

5 PA2; LA


ARCALYST SUBCUTANEOUS SOLUTION

RECONSTITUTED 220MG

5 PA; LA

COSENTYX (300MG DOSE) SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE 150MG/ML

5 PA

COSENTYX SENSOREADY (300MG)

SUBCUTANEOUS SOLUTION AUTO-INJECTOR

150MG/ML

5 PA

ENBREL SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 25MG/0.5ML, 50MG/ML

5 PA

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25MG

5 PA

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50MG/ML

5 PA

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT

40MG/0.8ML, 40MG/0.8ML (6 PACK), 80MG/0.8ML,

80MG/0.8ML & 40MG/0.4ML

5 PA

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR

KIT 40MG/0.4ML, 40MG/0.8ML

5 PA

HUMIRA PEN-CD/UC/HS STARTER

SUBCUTANEOUS PEN-INJECTOR KIT

40MG/0.8ML, 80MG/0.8ML

5 PA

HUMIRA PEN-PS/UV/ADOL HS START


40MG/0.8ML, 80MG/0.8ML & 40MG/0.4ML

5 PA

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE

KIT 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML, 40MG/0.4ML, 40MG/0.8ML

5 PA

leflunomide oral tablet 10mg 1 GC; MO

leflunomide oral tablet 20mg 2 GC; MO

OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML 3 BvD; MO

OCTAGAM INTRAVENOUS SOLUTION 2 GM/20ML 5 BvD

PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML,

10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30

GM/300ML, 5 GM/50ML

5 BvD


PRIVIGEN INTRAVENOUS SOLUTION 20

GM/200ML

5 BvD

STELARA SUBCUTANEOUS SOLUTION

45MG/0.5ML

5 PA

STELARA SUBCUTANEOUS SOLUTION PREFILLED


5 PA

XELJANZ ORAL TABLET 10MG, 5MG 5 PA

XELJANZ XR ORAL TABLET EXTENDED RELEASE

24 HOUR 11MG

5 PA

Vaccines

ACTHIB INTRAMUSCULAR SOLUTION

RECONSTITUTED

4 MO

ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5

(PREFILLED SYRINGE), 5-2-15.5 LF-MCG/0.5

4 MO

bcg vaccine injection injectable 4 MO

BEXSERO INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE

4 MO

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-

18.5 , 5-2.5-18.5 (0.5ML SYRINGE)

3 MO

DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-

5

4 MO

diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml

4 BvD; MO

ENGERIX-B INJECTION SUSPENSION 10

MCG/0.5ML, 20 MCG/ML

4 BvD; MO

GARDASIL 9 INTRAMUSCULAR SUSPENSION 4 MO

GARDASIL 9 INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE

4 MO

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL

U/ML, 1440 EL U/ML 1ML, 720 EL U/0.5ML, 720 EL U/0.5ML 0.5ML

4 MO

HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG

3 MO


IMOVAX RABIES INTRAMUSCULAR INJECTABLE

2.5 UNIT/ML

4 BvD; MO

INFANRIX INTRAMUSCULAR SUSPENSION 25-58-

10

4 MO

IPOL INJECTION INJECTABLE 3 MO

IXIARO INTRAMUSCULAR SUSPENSION 3 MO

KINRIX INTRAMUSCULAR SUSPENSION , INJECTION 0.5ML

4 MO

MENACTRA INTRAMUSCULAR INJECTABLE 4 MO

MENVEO INTRAMUSCULAR SOLUTION

RECONSTITUTED

4 MO

M-M-R II SUBCUTANEOUS INJECTABLE 3 MO

PEDIARIX INTRAMUSCULAR SUSPENSION 4 MO

PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5

MCG/0.5ML

4 MO

PROQUAD SUBCUTANEOUS SUSPENSION

RECONSTITUTED

4 MO

QUADRACEL INTRAMUSCULAR SUSPENSION 4 MO

RABAVERT INTRAMUSCULAR SUSPENSION

RECONSTITUTED

4 BvD; MO

RECOMBIVAX HB INJECTION SUSPENSION 10

MCG/ML, 10 MCG/ML (1ML SYRINGE), 40 MCG/ML, 5 MCG/0.5ML

4 BvD; MO

ROTARIX ORAL SUSPENSION RECONSTITUTED 4 MO

ROTATEQ ORAL SOLUTION 3 MO

SHINGRIX INTRAMUSCULAR SUSPENSION

RECONSTITUTED 50 MCG/0.5ML

3 MO

TDVAX INTRAMUSCULAR SUSPENSION 2-2

LF/0.5ML

3 BvD; MO

TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU 3 BvD; MO

TRUMENBA INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE

4 MO


TWINRIX INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 720-20 ELU-MCG/ML

4 BvD; MO

TYPHIM VI INTRAMUSCULAR SOLUTION 25

MCG/0.5ML, 25 MCG/0.5ML (0.5ML SYRINGE)

4 MO

VAQTA INTRAMUSCULAR SUSPENSION 25

UNIT/0.5ML, 25 UNIT/0.5ML 0.5ML, 50 UNIT/ML,

50 UNIT/ML 1ML

4 MO

VARIVAX SUBCUTANEOUS INJECTABLE 1350

PFU/0.5ML

4 MO

VARIZIG INTRAMUSCULAR SOLUTION 125 UNIT/1.2ML

4 MO

YF-VAX SUBCUTANEOUS INJECTABLE 4 MO

ZOSTAVAX SUBCUTANEOUS SUSPENSION

RECONSTITUTED 19400 UNT/0.65ML

4 MO

INFLAMMATORY BOWEL DISEASE AGENTS

Aminosalicylates

APRISO ORAL CAPSULE EXTENDED RELEASE 24

HOUR 0.375 GM

3 MO

balsalazide disodium oral capsule 750mg 2 GC; MO

LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM 3 MO

mesalamine rectal enema 4gm 4 MO

sulfasalazine oral tablet 500mg 1 GC; MO

sulfasalazine oral tablet delayed release 500mg 1 GC; MO

METABOLIC BONE DISEASE AGENTS

Metabolic Bone Disease Agents

alendronate sodium oral tablet 10mg, 40mg, 5mg


alendronate sodium oral tablet 35mg 1 GC; MO; QL (4 EA per 28 days)

alendronate sodium oral tablet 70mg 2 GC; MO; QL (4 EA per 28 days)

calcitonin (salmon) nasal solution 200 unit/act 2 BvD; GC; MO

calcitriol oral capsule 0.25mcg, 0.5mcg 1 BvD; GC; MO


calcitriol oral solution 1mcg/ml 2 BvD; GC; MO

cinacalcet hcl oral tablet 30mg 4 BvD; MO; QL (60 EA per 30 days)

cinacalcet hcl oral tablet 60mg 5 BvD; QL (60 EA per 30 days)


doxercalciferol oral capsule 0.5mcg, 1mcg, 2.5mcg

2 BvD; GC; MO

FORTEO SUBCUTANEOUS SOLUTION 600

MCG/2.4ML

5 PA; QL (2.4ML per 28 days)

ibandronate sodium oral tablet 150mg 1 GC; MO; QL (1 EA per 30 days)

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG,

25 MCG, 50 MCG, 75 MCG

5 LA

paricalcitol oral capsule 1mcg, 2mcg, 4mcg 4 BvD; MO

PROLIA SUBCUTANEOUS SOLUTION 60MG/ML 4 ST; QL (1ML per 180 days)

PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 60MG/ML

4 ST; MO; QL (1ML per 180 days)

risedronate sodium oral tablet 150mg 2 GC; MO; QL (1 EA per 28 days)

risedronate sodium oral tablet 30mg, 5mg 2 GC; MO; QL (30 EA per 30 days)

risedronate sodium oral tablet 35mg, 35mg (12 pack), 35mg (4 pack)


TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 MCG/1.56ML

5 PA

XGEVA SUBCUTANEOUS SOLUTION 120MG/1.7ML 5 PA; QL (2ML per 28 days)

MISCELLANEOUS

Miscellaneous

cvs gauze sterile pad 2"x2" 3 MO

hydroxychloroquine sulfate oral tablet 200mg 1 GC; MO

OPHTHALMIC AGENTS

Ophthalmic Agents, Other

atropine sulfate ophthalmic solution 1% 2 GC; MO

CYSTARAN OPHTHALMIC SOLUTION 0.44% 5 PA

RESTASIS OPHTHALMIC EMULSION 0.05% 3 MO; QL (60 EA per 30 days)


Ophthalmic Anti-Allergy Agents

azelastine hcl ophthalmic solution 0.05% 2 GC; MO

BEPREVE OPHTHALMIC SOLUTION 1.5% 4 MO

cromolyn sodium ophthalmic solution 4% 1 GC; MO

olopatadine hcl ophthalmic solution 0.1% 2 GC; MO

olopatadine hcl ophthalmic solution 0.2% 3 MO

OXERVATE OPHTHALMIC SOLUTION 0.002% 5 PA

PAZEO OPHTHALMIC SOLUTION 0.7% 4 MO

Ophthalmic Antiglaucoma Agents

ALPHAGAN P OPHTHALMIC SOLUTION 0.1% 3 MO

apraclonidine hcl ophthalmic solution 0.5% 2 GC; MO

AZOPT OPHTHALMIC SUSPENSION 1% 3 MO

betaxolol hcl ophthalmic solution 0.5% 2 GC; MO

brimonidine tartrate ophthalmic solution 0.15%, 0.2%

2 GC; MO

carteolol hcl ophthalmic solution 1% 1 GC; MO

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5% 4 MO

dorzolamide hcl ophthalmic solution 2% 1 GC; MO

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8mg/ml

4 MO

dorzolamide hcl-timolol mal pf ophthalmic solution 22.3-6.8mg/ml

4 MO

levobunolol hcl ophthalmic solution 0.5% 1 GC; MO

pilocarpine hcl ophthalmic solution 1%, 2%, 4% 2 GC; MO

RHOPRESSA OPHTHALMIC SOLUTION 0.02% 4 MO

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2% 4 MO

timolol maleate ophthalmic gel forming solution

0.25%, 0.5%

2 GC; MO

timolol maleate ophthalmic solution 0.25%, 0.5%, 0.5% (daily)

1 GC; MO

Ophthalmic Anti-Infectives


AZASITE OPHTHALMIC SOLUTION 1% 4 MO

bacitracin ophthalmic ointment 500 unit/gm 2 GC; MO

bacitracin-polymyxin b ophthalmic ointment

500-10000 unit/gm

1 GC; MO

BESIVANCE OPHTHALMIC SUSPENSION 0.6% 4 MO

ciprofloxacin hcl ophthalmic solution 0.3% 1 GC; MO

erythromycin ophthalmic ointment 5mg/gm 1 GC; MO

gatifloxacin ophthalmic solution 0.5% 2 GC; MO

GENTAK OPHTHALMIC OINTMENT 0.3% 2 GC; MO

gentamicin sulfate ophthalmic solution 0.3% 1 GC; MO

MOXEZA OPHTHALMIC SOLUTION 0.5% 3 MO

moxifloxacin hcl ophthalmic solution 0.5% 2 GC; MO

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

2 GC; MO

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

2 GC; MO

ofloxacin ophthalmic solution 0.3% 2 GC; MO

polymyxin b-trimethoprim ophthalmic solution

10000-0.1 unit/ml-%

1 GC; MO

sulfacetamide sodium ophthalmic ointment 10% 4 MO

sulfacetamide sodium ophthalmic solution 10% 1 GC; MO

tobramycin ophthalmic solution 0.3% 1 GC; MO

trifluridine ophthalmic solution 1% 2 GC; MO

Ophthalmic Anti-Inflammatories

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1%

2 GC; MO

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-

0.2%

4 MO

bromfenac sodium (once-daily) ophthalmic solution 0.09%

2 GC; MO

BROMSITE OPHTHALMIC SOLUTION 0.075% 4 MO


dexamethasone sodium phosphate ophthalmic solution 0.1%

2 GC; MO

diclofenac sodium ophthalmic solution 0.1% 2 GC; MO

DUREZOL OPHTHALMIC EMULSION 0.05% 3 MO

fluorometholone ophthalmic suspension 0.1% 2 GC; MO

flurbiprofen sodium ophthalmic solution 0.03% 1 GC; MO

ILEVRO OPHTHALMIC SUSPENSION 0.3% 3 MO

ketorolac tromethamine ophthalmic solution

0.4%, 0.5%

2 GC; MO

LOTEMAX OPHTHALMIC GEL 0.5% 4 MO

LOTEMAX OPHTHALMIC OINTMENT 0.5% 4 MO

LOTEMAX SM OPHTHALMIC GEL 0.38% 4 MO

loteprednol etabonate ophthalmic suspension

0.5%

2 GC; MO

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

2 GC; MO

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1 GC; MO

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

2 GC; MO

prednisolone acetate ophthalmic suspension 1% 2 GC; MO

prednisolone sodium phosphate ophthalmic solution 1%

2 GC; MO

PROLENSA OPHTHALMIC SOLUTION 0.07% 4 MO

sulfacetamide-prednisolone ophthalmic solution 10-0.23%

2 GC; MO

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1%

2 GC; MO

ZYLET OPHTHALMIC SUSPENSION 0.5-0.3% 4 MO

Ophthalmic Prostaglandin And Prostamide Analogs

latanoprost ophthalmic solution 0.005% 2 GC; MO

LUMIGAN OPHTHALMIC SOLUTION 0.01% 3 MO


TRAVATAN Z OPHTHALMIC SOLUTION 0.004% 3 MO

VYZULTA OPHTHALMIC SOLUTION 0.024% 4 MO

ZIOPTAN OPHTHALMIC SOLUTION 0.0015% 4 MO

OTIC AGENTS

Otic Agents

acetic acid otic solution 2% 1 GC; MO

CIPRODEX OTIC SUSPENSION 0.3-0.1% 4 MO

ciprofloxacin hcl otic solution 0.2% 4 MO

fluocinolone acetonide otic oil 0.01% 2 GC; MO

neomycin-polymyxin-hc otic solution 1% 2 GC; MO

neomycin-polymyxin-hc otic suspension 3.5-10000-1

2 GC; MO

ofloxacin otic solution 0.3% 4 MO

RESPIRATORY TRACT AGENTS

Antihistamines

cetirizine hcl oral solution 1mg/ml 1 GC; MO

clemastine fumarate oral tablet 2.68mg 1 GC; MO

desloratadine oral tablet 5mg 2 GC; MO

levocetirizine dihydrochloride oral solution

2.5mg/5ml 2 GC; MO

levocetirizine dihydrochloride oral tablet 5mg 2 GC; MO

Anti-Inflammatories, Inhaled Corticosteroids

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200

MCG/ACT, 50 MCG/ACT


ASMANEX (120 METERED DOSES) INHALATION

AEROSOL POWDER BREATH ACTIVATED 220

MCG/INH


ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110

MCG/INH, 220 MCG/INH





MCG/INH


ASMANEX HFA INHALATION AEROSOL 100

MCG/ACT, 200 MCG/ACT

3 MO; QL (26 GM per 30 days)

budesonide inhalation suspension 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml

4 BvD; MO

FLOVENT DISKUS INHALATION AEROSOL

POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST


FLOVENT HFA INHALATION AEROSOL 110



FLOVENT HFA INHALATION AEROSOL 44

MCG/ACT

3 MO; QL (21.2 GM per 30 days)

Antileukotrienes

montelukast sodium oral packet 4mg 2 GC; MO; QL (30 EA per 30 days)

montelukast sodium oral tablet 10mg 1 GC; MO; QL (30 EA per 30 days)

montelukast sodium oral tablet chewable 4mg, 5mg


zafirlukast oral tablet 10mg, 20mg 2 GC; MO; QL (60 EA per 30 days)

Bronchodilators, Anticholinergic

acetylcysteine inhalation solution 10%, 20% 2 BvD; GC; MO

ipratropium bromide inhalation solution 0.02% 1 BvD; GC; MO

SPIRIVA HANDIHALER INHALATION CAPSULE 18

MCG


SPIRIVA RESPIMAT INHALATION AEROSOL

SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT


Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)

DALIRESP ORAL TABLET 250 MCG, 500 MCG 3 MO; QL (30 EA per 30 days)

sildenafil citrate oral tablet 20mg 2 PA; GC; MO; QL (90 EA per 30 days)

theophylline er oral tablet extended release 12hour 100mg, 200mg, 300mg

1 GC; MO


theophylline er oral tablet extended release 24hour 400mg, 600mg

1 GC; MO

theophylline oral solution 80mg/15ml 4 MO

Bronchodilators, Sympathomimetic

albuterol sulfate hfa inhalation aerosol solution 108 (90 base)mcg/act (nda020983)

2 GC; MO; QL (36 GM per 30 days)

albuterol sulfate inhalation nebulization solution (2.5mg/3ml) 0.083%, (5mg/ml) 0.5%, 0.63mg/3ml, 1.25mg/3ml

2 BvD; GC; MO

albuterol sulfate oral syrup 2mg/5ml 1 GC; MO

albuterol sulfate oral tablet 2mg, 4mg 2 GC; MO

COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT


ipratropium-albuterol inhalation solution 0.5-2.5 (3)mg/3ml

2 BvD; GC; MO

SEREVENT DISKUS INHALATION AEROSOL

POWDER BREATH ACTIVATED 50 MCG/DOSE


terbutaline sulfate oral tablet 2.5mg, 5mg 2 GC; MO

VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT


Nasal Agents

azelastine hcl nasal solution 0.1%, 0.15% 2 GC; MO; QL (30ML per 25 days)

flunisolide nasal solution 25mcg/act (0.025%) 2 GC; MO; QL (50ML per 30 days)

fluticasone propionate nasal suspension

50mcg/act


ipratropium bromide nasal solution 0.03% 1 GC; MO; QL (60ML per 30 days)

ipratropium bromide nasal solution 0.06% 1 GC; MO; QL (30ML per 30 days)

mometasone furoate nasal suspension

50mcg/act


Pulmonary Antihypertensives

ADEMPAS ORAL TABLET 0.5MG, 1MG, 1.5MG,

2MG, 2.5MG



ambrisentan oral tablet 10mg, 5mg 5 PA; QL (30 EA per 30 days)

bosentan oral tablet 125mg, 62.5mg 5 PA; LA; QL (60 EA per 30 days)

OPSUMIT ORAL TABLET 10MG 5 PA; LA; QL (90 EA per 30 days)

TRACLEER ORAL TABLET SOLUBLE 32MG 5 PA; LA; QL (120 EA per 30 days)

UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG,

1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600

MCG, 800 MCG


UPTRAVI ORAL TABLET THERAPY PACK 200 & 800

MCG


Pulmonary Fibrosis Agents

ESBRIET ORAL CAPSULE 267MG 5 PA

ESBRIET ORAL TABLET 267MG, 801MG 5 PA

OFEV ORAL CAPSULE 100MG, 150MG 5 PA; LA

Respiratory Tract Agents, Other

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50

MCG/DOSE, 500-50 MCG/DOSE


ADVAIR HFA INHALATION AEROSOL 115-21

MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT


ANORO ELLIPTA INHALATION AEROSOL POWDER

BREATH ACTIVATED 62.5-25 MCG/INH


BREO ELLIPTA INHALATION AEROSOL POWDER

BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH


cromolyn sodium inhalation nebulization solution 20mg/2ml

3 BvD; MO

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200MG/1.14ML, 300MG/2ML

5 PA

epinephrine injection solution auto-injector

0.15mg/0.3ml, 0.3mg/0.3ml 2 GC; MO


fluticasone-salmeterol inhalation aerosol powder breath activated 113-14mcg/act, 232-14mcg/act, 55-14mcg/act


KALYDECO ORAL PACKET 25MG, 50MG, 75MG 5 PA; LA

KALYDECO ORAL TABLET 150MG 5 PA; LA

ORKAMBI ORAL PACKET 100-125MG, 150-188MG 5 PA; LA

ORKAMBI ORAL TABLET 100-125MG, 200-125MG 5 PA; LA

PROLASTIN-C INTRAVENOUS SOLUTION

RECONSTITUTED 1000MG

5 PA; LA

PULMOZYME INHALATION SOLUTION 1MG/ML 5 PA

STIOLTO RESPIMAT INHALATION AEROSOL

SOLUTION 2.5-2.5 MCG/ACT


SYMDEKO ORAL TABLET THERAPY PACK 100-150

& 150MG

5 PA; LA

TOBI PODHALER INHALATION CAPSULE 28MG 5 PA

TRELEGY ELLIPTA INHALATION AEROSOL

POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH


XOLAIR SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 150MG/ML, 75MG/0.5ML

5 PA; LA

XOLAIR SUBCUTANEOUS SOLUTION

RECONSTITUTED 150MG

5 PA; LA

SKELETAL MUSCLE RELAXANTS

Skeletal Muscle Relaxants

baclofen oral tablet 10mg, 20mg, 5mg 1 GC; MO

carisoprodol oral tablet 250mg 4 MO

carisoprodol oral tablet 350mg 1 GC; MO

carisoprodol-aspirin oral tablet 200-325mg 4 MO

chlorzoxazone oral tablet 375mg, 750mg 2 GC; MO

chlorzoxazone oral tablet 500mg 1 GC; MO

cyclobenzaprine hcl oral tablet 10mg, 5mg 2 GC; MO

cyclobenzaprine hcl oral tablet 7.5mg 4 MO


metaxalone oral tablet 800mg 4 MO

methocarbamol oral tablet 500mg, 750mg 1 GC; MO

orphenadrine citrate er oral tablet extended release 12hour 100mg

2 GC; MO

tizanidine hcl oral tablet 2mg, 4mg 2 GC; MO

SLEEP DISORDER AGENTS

Benzodiazepines

oxazepam oral capsule 10mg, 15mg, 30mg 2 GC; MO; QL (120 EA per 30 days)

temazepam oral capsule 15mg, 30mg 1 GC; MO; QL (30 EA per 30 days)

temazepam oral capsule 22.5mg 4 MO; QL (30 EA per 30 days)

temazepam oral capsule 7.5mg 2 GC; MO; QL (120 EA per 30 days)

Gaba Receptor Modulators

zaleplon oral capsule 10mg, 5mg 2 GC; MO; QL (30 EA per 30 days)

zolpidem tartrate oral tablet 10mg 2 GC; MO; QL (30 EA per 30 days)

zolpidem tartrate oral tablet 5mg 2 GC; MO; QL (60 EA per 30 days)

Sleep Disorders, Other

armodafinil oral tablet 150mg, 200mg, 250mg 4 PA; MO

armodafinil oral tablet 50mg 3 PA; MO

BELSOMRA ORAL TABLET 10MG, 15MG, 20MG,

5MG


HETLIOZ ORAL CAPSULE 20MG 5 PA; QL (30 EA per 30 days)

modafinil oral tablet 100mg, 200mg 3 PA; MO

SILENOR ORAL TABLET 3MG, 6MG 4 MO; QL (30 EA per 30 days)

XYREM ORAL SOLUTION 500MG/ML 5 PA; LA; QL (540ML per 30 days)

Imperial Senior Value

(HMO C-SNP)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File Submission ID 00020551, Version Number 4.


contact Imperial Health Plan of California, Member Services Department at 1-800-838-8271,

October 1 – March 31: Monday – Sunday, from 8:00 a.m. – 8:00 p.m. April 1 – September 30: Monday

– Friday, from 8:00 a.m. – 8:00 p.m., or visit www.Imperialhealthplan.com. This document is

available for free in Spanish.

To learn what the abbreviations on this table mean, see the beginning of the drug list table.

The following table describes the abbreviations used in the Drug List Table.

ABBREVIATION MEANING

LA

This prescription may be available only at certain pharmacies. For more

information please call 1-800-546-5677-24hours a day-seven days a week.


QL Quantity limitation. Followed by the limitation amount per days specified.

PA

This medication requires prior authorization. To obtain an exception please

call 1-800-546-5677 - 24hours a day-seven days a week. TTY/TDD users should

call 1-866-706-4757.

NEW PA

This medication requires prior authorization for new starts only. To obtain an

exception please call 1-800-546-5677 - 24hours a day- seven days a week.


B/D PA

This drug may be covered under Medicare Part B or D depending upon the

circumstances. Information may need to be submitted describing the use and

setting of drug to make the determination.

ST Step therapy protocols apply.


List of Drugs by Medical Condition

ANALGESICS ..................................................................................................................................... 114

ANESTHETICS ................................................................................................................................... 116

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ........................................................... 116

ANTIBACTERIALS .............................................................................................................................. 117

ANTICONVULSANTS .......................................................................................................................... 124

ANTIDEMENTIA AGENTS ................................................................................................................... 128

ANTIDEPRESSANTS .......................................................................................................................... 129

ANTIEMETICS .................................................................................................................................... 132

ANTIFUNGALS ................................................................................................................................... 132

ANTIGOUT AGENTS ........................................................................................................................... 134

ANTI-INFLAMMATORY AGENTS ......................................................................................................... 134

ANTIMIGRAINE AGENTS .................................................................................................................... 136

ANTIMYASTHENIC AGENTS ............................................................................................................... 137

ANTIMYCOBACTERIALS ..................................................................................................................... 137

ANTINEOPLASTICS ........................................................................................................................... 138

ANTIPARASITICS ............................................................................................................................... 144

ANTIPARKINSON AGENTS ................................................................................................................. 145

ANTIPSYCHOTICS ............................................................................................................................. 146

ANTIVIRALS ....................................................................................................................................... 150

ANXIOLYTICS .................................................................................................................................... 155

BIPOLAR AGENTS ............................................................................................................................. 156

BLOOD GLUCOSE REGULATORS ....................................................................................................... 156

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS .................................................................... 160

CARDIOVASCULAR AGENTS .............................................................................................................. 162

CENTRAL NERVOUS SYSTEM AGENTS .............................................................................................. 172

DENTAL AND ORAL AGENTS ............................................................................................................. 174

DERMATOLOGICAL AGENTS ............................................................................................................. 174

ELECTROLYTES/MINERALS/METALS/VITAMINS ............................................................................... 178

GASTROINTESTINAL AGENTS ........................................................................................................... 182

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT .................................. 184

GENITOURINARY AGENTS ................................................................................................................. 185

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) .................................. 186

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING

(SEX HORMONES/ MODIFIERS) ..................................................................................................... 188

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) .................................. 193

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)..................................... 194

HORMONAL AGENTS, SUPPRESSANT (PITUITARY) .......................................................................... 194

HORMONAL AGENTS, SUPPRESSANT (THYROID) ............................................................................. 195

IMMUNOLOGICAL AGENTS................................................................................................................ 195

INFLAMMATORY BOWEL DISEASE AGENTS ....................................................................................... 200

METABOLIC BONE DISEASE AGENTS ................................................................................................ 200

MISCELLANEOUS .............................................................................................................................. 201

OPHTHALMIC AGENTS ...................................................................................................................... 201

OTIC AGENTS .................................................................................................................................... 205

RESPIRATORY TRACT AGENTS .......................................................................................................... 205

SKELETAL MUSCLE RELAXANTS ....................................................................................................... 209

SLEEP DISORDER AGENTS ................................................................................................................ 210

Legend

1: Preferred Generics

2: Generics

3: Preferred Brands

4: Non-Preferred Drugs

5: Specialty

BvD: Part B vs. Part D- This prescription drug may be covered under Medicare Part B or D depending

upon the circumstances. Information may need to be submitted describing the use and setting of

the drug to make the determination.

GC: Gap Coverage- We provide additional coverage of this prescription drug in the coverage gap.

Please refer to our Evidence of Coverage for more information about this coverage.

LA: Limited Access- This prescription may be available only at certain pharmacies.

MO: Mail Order Eligible- This prescription may also be available via mail.

PA: Prior Authorization- You (or your physician) are required to get prior authorization before you

fill your prescription for this drug. Without prior approval, we may not cover this drug.

PA2: Prior Authorization (New Starts Only)- You (or your physician) are required to get prior

authorization before you fill your prescription for this drug unless you are a previous user of the

drug. If you have a history of using this medication, you will not need prior authorization.

QL: Quantity Limit- There is a limit on the amount of this drug that is covered per prescription, or

within a specific time frame.

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

condition before we will cover another drug for that condition.

ST2: Step Therapy (New Starts Only)- In some cases, you may be required to first try certain drugs

to treat your medical condition before we will cover another drug for that condition unless you are

a previous user of the drug. If you have a history of using this medication, you will not need to try

other medications first.

Imperial CSNP 2020 6-Tier (List of Covered Drugs)


ANALGESICS

Opioid Analgesics, Long-Acting

fentanyl transdermal patch 72hour 100mcg/hr, 37.5mcg/hr, 62.5mcg/hr, 87.5mcg/hr


fentanyl transdermal patch 72hour 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr

2 MO; GC; QL (10 EA per 30 days)

methadone hcl oral tablet 10mg, 5mg 2 MO; GC


100mg, 60mg



15mg, 200mg, 30mg


oxycodone hcl er oral tablet er 12hour abuse-deterrent 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg

4 MO

oxycodone hcl oral concentrate 100mg/5ml 4 MO; QL (180ML per 30 days)

XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-

DETERRENT 13.5MG, 18MG, 27MG, 36MG, 9MG

3 MO

ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 10MG, 15MG, 20MG, 30MG,

40MG, 50MG

3 MO

Opioid Analgesics, Short-Acting

acetaminophen-codeine #3 oral tablet 300-30mg 1 MO; GC; QL (400 EA per 30 days)

acetaminophen-codeine oral solution 120-12mg/5ml

1 MO; GC; QL (5000ML per 30 days)

acetaminophen-codeine oral tablet 300-15mg, 300-60mg


butalbital-acetaminophen oral tablet 50-325mg 2 MO; GC; QL (180 EA per 30 days)

butalbital-apap-caffeine oral capsule 50-325-40mg


butalbital-apap-caffeine oral tablet 50-325-40mg 4 MO; QL (180 EA per 30 days)

butalbital-asa-caff-codeine oral capsule 50-325-40-30mg



butalbital-aspirin-caffeine oral capsule 50-325-40mg


codeine sulfate oral tablet 30mg 2 MO; GC; QL (360 EA per 30 days)

codeine sulfate oral tablet 60mg 4 MO; QL (360 EA per 30 days)

ENDOCET ORAL TABLET 10-325MG, 7.5-325MG 4 MO; QL (370 EA per 30 days)

ENDOCET ORAL TABLET 5-325MG 3 MO; QL (370 EA per 30 days)


1200mcg, 1600mcg, 600mcg, 800mcg



200mcg, 400mcg

4 PA; MO; QL (180 EA per 30 days)

hydrocodone-acetaminophen oral solution 7.5-325mg/15ml


hydrocodone-acetaminophen oral tablet 10-325mg, 5-325mg, 7.5-325mg


hydrocodone-ibuprofen oral tablet 10-200mg, 5-200mg


hydrocodone-ibuprofen oral tablet 7.5-200mg 2 MO; GC; QL (180 EA per 30 days)

hydromorphone hcl oral liquid 1mg/ml 4 MO; QL (1920ML per 30 days)

hydromorphone hcl oral tablet 2mg, 4mg 2 MO; GC; QL (360 EA per 30 days)

hydromorphone hcl oral tablet 8mg 2 MO; GC; QL (240 EA per 30 days)

hydromorphone hcl pf injection solution

10mg/ml, 50mg/5ml 4 BvD; MO; QL (240ML per 30 days)

LORCET ORAL TABLET 5-325MG 3 MO; QL (370 EA per 30 days)

morphine sulfate (concentrate) oral solution 100mg/5ml


morphine sulfate oral solution 10mg/5ml 2 MO; GC; QL (3600ML per 30 days)

morphine sulfate oral solution 20mg/5ml 2 MO; GC; QL (2700ML per 30 days)

morphine sulfate oral tablet 15mg, 30mg 2 MO; GC; QL (180 EA per 30 days)

oxycodone hcl oral capsule 5mg 2 MO; GC; QL (180 EA per 30 days)

oxycodone hcl oral solution 5mg/5ml 4 MO; QL (1080ML per 30 days)

oxycodone hcl oral tablet 10mg, 15mg, 20mg, 30mg, 5mg



oxycodone-acetaminophen oral tablet 10-325mg, 2.5-325mg, 5-325mg, 7.5-325mg


oxycodone-aspirin oral tablet 4.8355-325mg 2 MO; GC; QL (360 EA per 30 days)

oxycodone-ibuprofen oral tablet 5-400mg 2 MO; GC; QL (360 EA per 30 days)

tramadol hcl oral tablet 50mg 1 MO; GC; QL (240 EA per 30 days)

tramadol-acetaminophen oral tablet 37.5-325mg 2 MO; GC; QL (370 EA per 30 days)

ANESTHETICS

Local Anesthetics

lidocaine external patch 5% 4 PA; MO; QL (90 EA per 30 days)

lidocaine hcl external solution 4% 4 MO; QL (50ML per 30 days)

lidocaine hcl urethral/mucosal external gel 2% 2 MO; GC; QL (30ML per 30 days)

lidocaine-prilocaine external cream 2.5-2.5% 4 MO; QL (30 GM per 30 days)

proparacaine hcl ophthalmic solution 0.5% 1 MO; GC

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

Alcohol Deterrents/Anti-Craving

acamprosate calcium oral tablet delayed release 333mg

2 MO; GC

disulfiram oral tablet 250mg, 500mg 2 MO; GC

Opioid Antagonists

naloxone hcl injection solution 0.4mg/ml 2 MO; GC

naloxone hcl injection solution cartridge

0.4mg/ml 2 MO; GC

naloxone hcl injection solution prefilled syringe

2mg/2ml 2 MO; GC

naltrexone hcl oral tablet 50mg 2 MO; GC

NARCAN NASAL LIQUID 4MG/0.1ML 3 MO

VIVITROL INTRAMUSCULAR SUSPENSION

RECONSTITUTED 380MG

5

Opioid Dependence Treatments

buprenorphine hcl sublingual tablet sublingual 2mg, 8mg

2 MO; GC


buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5mg, 8-2mg

1 MO; GC

SUBOXONE SUBLINGUAL FILM 12-3MG, 2-0.5MG,

4-1MG, 8-2MG

3 MO

Smoking Cessation Agents

bupropion hcl er (smoking det) oral tablet extended release 12hour 150mg

2 MO; GC

CHANTIX CONTINUING MONTH PAK ORAL

TABLET 1MG

3 MO

CHANTIX ORAL TABLET 0.5MG, 1MG 3 MO

CHANTIX STARTING MONTH PAK ORAL TABLET

0.5MG X 11 & 1MG X 42

3 MO

NICOTROL INHALATION INHALER 10MG 3 MO

ANTIBACTERIALS

Aminoglycosides

amikacin sulfate injection solution 500mg/2ml 4 BvD; MO

ARIKAYCE INHALATION SUSPENSION

590MG/8.4ML

4 PA; MO

gentamicin in saline intravenous solution 0.8-0.9mg/ml-%, 1-0.9mg/ml-%, 1.2-0.9mg/ml-%, 1.6-0.9mg/ml-%

2 MO; GC

gentamicin sulfate injection solution 40mg/ml 2 BvD; MO; GC

neomycin sulfate oral tablet 500mg 1 MO; GC

paromomycin sulfate oral capsule 250mg 4 MO

tobramycin inhalation nebulization solution

300mg/5ml 5 BvD

tobramycin sulfate injection solution 10mg/ml 4 BvD; MO

tobramycin sulfate injection solution 80mg/2ml 2 BvD; MO; GC

Antibacterials, Other

clindamycin hcl oral capsule 150mg, 75mg 1 MO; GC

clindamycin hcl oral capsule 300mg 2 MO; GC


clindamycin palmitate hcl oral solution reconstituted 75mg/5ml

4 MO

clindamycin phosphate in d5w intravenous solution 300mg/50ml, 600mg/50ml, 900mg/50ml

4 MO

clindamycin phosphate injection solution

300mg/2ml, 600mg/4ml, 900mg/6ml 4 BvD; MO

colistimethate sodium (cba) injection solution reconstituted 150mg

4 BvD; MO

dapsone oral tablet 100mg, 25mg 2 MO; GC

daptomycin intravenous solution reconstituted

350mg, 500mg

4 BvD; MO

FIRVANQ ORAL SOLUTION RECONSTITUTED

25MG/ML, 50MG/ML

4 MO

linezolid intravenous solution 600mg/300ml 5 PA

linezolid oral suspension reconstituted

100mg/5ml 5 PA

linezolid oral tablet 600mg 4 PA; MO

methenamine hippurate oral tablet 1gm 1 MO; GC

metronidazole in nacl intravenous solution 500-0.79mg/100ml-%

2 BvD; MO; GC

metronidazole oral tablet 250mg, 500mg 1 MO; GC

nitrofurantoin macrocrystal oral capsule 100mg, 25mg, 50mg

2 MO; GC

nitrofurantoin monohyd macro oral capsule 100mg

2 MO; GC

nitrofurantoin oral suspension 25mg/5ml 4 MO

SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200MG

5

SIVEXTRO ORAL TABLET 200MG 5

tigecycline intravenous solution reconstituted 50mg

4 BvD; MO

tinidazole oral tablet 250mg, 500mg 2 MO; GC

trimethoprim oral tablet 100mg 1 MO; GC


vancomycin hcl intravenous solution reconstituted 1gm, 10gm, 250mg, 500mg, 750mg

4 BvD; MO

vancomycin hcl oral capsule 125mg 4 MO

vancomycin hcl oral capsule 250mg 5

XIFAXAN ORAL TABLET 200MG, 550MG 4 MO

Beta-Lactam, Cephalosporins

cefaclor er oral tablet extended release 12hour

500mg

4 MO

cefaclor oral capsule 250mg, 500mg 2 MO; GC

cefaclor oral suspension reconstituted

125mg/5ml, 250mg/5ml, 375mg/5ml 4 MO

cefadroxil oral capsule 500mg 2 MO; GC

cefadroxil oral suspension reconstituted

250mg/5ml, 500mg/5ml 2 MO; GC

cefadroxil oral tablet 1gm 2 MO; GC


1gm, 500mg

4 MO


10gm

4 BvD; MO

cefdinir oral capsule 300mg 2 MO; GC

cefdinir oral suspension reconstituted


cefepime hcl injection solution reconstituted

1gm, 2gm

4 BvD; MO

cefixime oral suspension reconstituted


cefotetan disodium injection solution reconstituted 1gm, 2gm

4 MO

cefoxitin sodium injection solution reconstituted

10gm

4 BvD; MO

cefoxitin sodium intravenous solution reconstituted 1gm, 2gm

4 BvD; MO


cefpodoxime proxetil oral suspension reconstituted 100mg/5ml, 50mg/5ml

4 MO

cefpodoxime proxetil oral tablet 100mg, 200mg 4 MO

cefprozil oral suspension reconstituted 125mg/5ml, 250mg/5ml

2 MO; GC

cefprozil oral tablet 250mg, 500mg 2 MO; GC

ceftazidime injection solution reconstituted 1gm, 2gm, 6gm

4 MO

ceftriaxone sodium injection solution reconstituted 1gm, 2gm, 250mg, 500mg

4 BvD; MO

ceftriaxone sodium intravenous solution reconstituted 10gm

4 MO

cefuroxime axetil oral tablet 250mg, 500mg 2 MO; GC

cefuroxime sodium injection solution reconstituted 7.5gm, 750mg

4 BvD; MO

cefuroxime sodium intravenous solution reconstituted 1.5gm

4 BvD; MO

cephalexin oral capsule 250mg, 500mg 1 MO; GC

cephalexin oral capsule 750mg 4 MO

cephalexin oral suspension reconstituted 125mg/5ml, 250mg/5ml

2 MO; GC

cephalexin oral tablet 250mg 4 MO

cephalexin oral tablet 500mg 2 MO; GC

SUPRAX ORAL CAPSULE 400MG 4 MO

TEFLARO INTRAVENOUS SOLUTION

RECONSTITUTED 400MG, 600MG

5 BvD

Beta-Lactam, Other

AZACTAM INJECTION SOLUTION

RECONSTITUTED 2 GM

4 BvD; MO

aztreonam injection solution reconstituted 1gm 2 MO; GC

CAYSTON INHALATION SOLUTION

RECONSTITUTED 75MG

5 PA; LA


ertapenem sodium injection solution reconstituted 1gm

4 BvD; MO

imipenem-cilastatin intravenous solution reconstituted 250mg, 500mg

4 BvD; MO

meropenem intravenous solution reconstituted

1gm, 500mg

4 BvD; MO

Beta-Lactam, Penicillins

amoxicillin oral capsule 250mg, 500mg 1 MO; GC

amoxicillin oral suspension reconstituted 125mg/5ml, 200mg/5ml, 250mg/5ml, 400mg/5ml

1 MO; GC

amoxicillin oral tablet 500mg, 875mg 1 MO; GC

amoxicillin oral tablet chewable 125mg, 250mg 1 MO; GC

amoxicillin-pot clavulanate er oral tablet extended release 12hour 1000-62.5mg

4 MO

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5mg/5ml, 250-62.5mg/5ml, 400-57mg/5ml, 600-42.9mg/5ml

2 MO; GC

amoxicillin-pot clavulanate oral tablet 250-125mg, 500-125mg, 875-125mg

2 MO; GC

amoxicillin-pot clavulanate oral tablet chewable

200-28.5mg, 400-57mg

2 MO; GC

ampicillin oral capsule 500mg 1 MO; GC

ampicillin sodium injection solution reconstituted 1gm, 125mg

4 BvD; MO

ampicillin sodium intravenous solution reconstituted 10gm

4 BvD; MO

ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5)gm, 15 (10-5)gm, 3 (2-1)gm

4 BvD; MO

BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML

4 MO

BICILLIN L-A INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000

UNIT/ML

4 MO


dicloxacillin sodium oral capsule 250mg, 500mg 2 MO; GC

nafcillin sodium injection solution reconstituted 1gm, 2gm

4 BvD; MO

nafcillin sodium intravenous solution reconstituted 10gm

4 BvD; MO

oxacillin sodium injection solution reconstituted

1gm, 10gm, 2gm

4 MO

penicillin g pot in dextrose intravenous solution

40000 unit/ml, 60000 unit/ml 4 MO

penicillin g potassium injection solution reconstituted 20000000 unit

4 BvD; MO

penicillin g procaine intramuscular suspension

600000 unit/ml 4 MO

penicillin g sodium injection solution reconstituted 5000000 unit

4 BvD; MO

penicillin v potassium oral solution reconstituted


penicillin v potassium oral tablet 250mg, 500mg 1 MO; GC

piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25)gm, 3.375 (3-0.375)gm, 4.5 (4-0.5)gm, 40.5 (36-4.5)gm

4 BvD; MO

Macrolides

azithromycin intravenous solution reconstituted

500mg

2 BvD; MO; GC

azithromycin oral packet 1gm 4 MO

azithromycin oral suspension reconstituted


azithromycin oral tablet 250mg, 250mg (6 pack) 1 MO; GC

azithromycin oral tablet 500mg, 500mg (3 pack), 600mg

2 MO; GC

clarithromycin er oral tablet extended release 24hour 500mg

2 MO; GC

clarithromycin oral suspension reconstituted 125mg/5ml, 250mg/5ml

2 MO; GC


clarithromycin oral tablet 250mg, 500mg 2 MO; GC

ERY-TAB ORAL TABLET DELAYED RELEASE 250MG, 333MG, 500MG

4 MO

ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500MG

4 BvD; MO

ERYTHROCIN STEARATE ORAL TABLET 250MG 4 MO

erythromycin base oral capsule delayed release particles 250mg

2 MO; GC

erythromycin base oral tablet 250mg 2 MO; GC

erythromycin base oral tablet 500mg 4 MO

erythromycin ethylsuccinate oral suspension reconstituted 200mg/5ml, 400mg/5ml

2 MO; GC

erythromycin ethylsuccinate oral tablet 400mg 4 MO

Quinolones

ciprofloxacin hcl oral tablet 100mg 4 MO

ciprofloxacin hcl oral tablet 250mg, 500mg 1 MO; GC

ciprofloxacin hcl oral tablet 750mg 2 MO; GC

ciprofloxacin in d5w intravenous solution


ciprofloxacin oral suspension reconstituted 500mg/5ml (10%)

4 MO

levofloxacin in d5w intravenous solution 500mg/100ml, 750mg/150ml

4 BvD; MO

levofloxacin intravenous solution 25mg/ml 4 BvD; MO

levofloxacin oral solution 25mg/ml 4 MO

levofloxacin oral tablet 250mg 2 MO; GC

levofloxacin oral tablet 500mg, 750mg 4 MO

moxifloxacin hcl in nacl intravenous solution


moxifloxacin hcl oral tablet 400mg 4 MO

ofloxacin oral tablet 300mg, 400mg 2 MO; GC

Sulfonamides


sulfacetamide sodium (acne) external lotion 10% 2 MO; GC

sulfadiazine oral tablet 500mg 4 MO

sulfamethoxazole-trimethoprim oral suspension

200-40mg/5ml 2 MO; GC

sulfamethoxazole-trimethoprim oral tablet 400-80mg, 800-160mg

1 MO; GC

Tetracyclines

DOXY 100 INTRAVENOUS SOLUTION

RECONSTITUTED 100MG

4 BvD; MO

doxycycline hyclate oral capsule 100mg, 50mg 1 MO; GC

doxycycline hyclate oral tablet 100mg, 20mg 1 MO; GC

doxycycline monohydrate oral capsule 100mg 2 MO; GC

doxycycline monohydrate oral capsule 50mg 1 MO; GC

doxycycline monohydrate oral tablet 100mg, 50mg

2 MO; GC

minocycline hcl oral capsule 100mg, 75mg 2 MO; GC

minocycline hcl oral capsule 50mg 1 MO; GC

minocycline hcl oral tablet 100mg, 50mg, 75mg 2 MO; GC

tetracycline hcl oral capsule 250mg, 500mg 2 MO; GC

ANTICONVULSANTS

Anticonvulsants, Other

BRIVIACT ORAL SOLUTION 10MG/ML 4 ST2; MO; QL (600ML per 30 days)

BRIVIACT ORAL TABLET 10MG, 100MG, 25MG, 50MG, 75MG


carbamazepine er oral capsule extended release 12hour 100mg, 200mg, 300mg

2 MO; GC

carbamazepine er oral tablet extended release 12hour 100mg, 200mg, 400mg

2 MO; GC

carbamazepine oral suspension 100mg/5ml 2 MO; GC

carbamazepine oral tablet 200mg 2 MO; GC

carbamazepine oral tablet chewable 100mg 1 MO; GC


EPIDIOLEX ORAL SOLUTION 100MG/ML 4 ST2; MO

EPITOL ORAL TABLET 200MG 2 MO; GC

felbamate oral suspension 600mg/5ml 5

felbamate oral tablet 400mg, 600mg 4 MO

FYCOMPA ORAL SUSPENSION 0.5MG/ML 4 ST2; MO


2 MO; GC


3 MO

levetiracetam oral solution 100mg/ml 2 MO; GC

levetiracetam oral tablet 1000mg, 250mg, 500mg, 750mg

1 MO; GC

ROWEEPRA ORAL TABLET 1000MG, 500MG,

750MG

4 MO

ROWEEPRA XR ORAL TABLET EXTENDED


4 MO


SOLUBLE 1000MG



SOLUBLE 250MG, 500MG, 750MG


Barbiturates

phenobarbital oral elixir 20mg/5ml 1 MO; GC; QL (1500ML per 30 days)

phenobarbital oral tablet 100mg, 16.2mg, 32.4mg, 64.8mg, 97.2mg


phenobarbital oral tablet 15mg, 60mg 1 MO; GC; QL (120 EA per 30 days)

phenobarbital oral tablet 30mg 1 MO; GC; QL (300 EA per 30 days)

primidone oral tablet 250mg, 50mg 1 MO; GC

Benzodiazepines

clobazam oral suspension 2.5mg/ml 5 QL (480ML per 30 days)

clobazam oral tablet 10mg 4 MO; QL (60 EA per 30 days)

clobazam oral tablet 20mg 5 QL (60 EA per 30 days)

DIASTAT ACUDIAL RECTAL GEL 10MG, 20MG 4 MO


DIASTAT PEDIATRIC RECTAL GEL 2.5MG 4 MO

diazepam rectal gel 10mg, 2.5mg, 20mg 4 MO

SYMPAZAN ORAL FILM 10MG, 20MG 5 ST2; QL (60 EA per 30 days)

SYMPAZAN ORAL FILM 5MG 4 ST2; MO; QL (60 EA per 30 days)

Calcium Channel Modifying Agents

CELONTIN ORAL CAPSULE 300MG 4 ST2; MO

ethosuximide oral capsule 250mg 2 MO; GC

ethosuximide oral solution 250mg/5ml 2 MO; GC

zonisamide oral capsule 100mg, 25mg, 50mg 2 MO; GC

Gamma-Aminobutyric Acid (Gaba) Augmenting Agents

divalproex sodium er oral tablet extended release 24hour 250mg, 500mg

2 MO; GC

divalproex sodium oral capsule delayed release sprinkle 125mg

2 MO; GC


125mg

1 MO; GC


250mg, 500mg

2 MO; GC

FYCOMPA ORAL TABLET 10MG, 12MG, 4MG, 6MG 5 ST2; QL (30 EA per 30 days)

FYCOMPA ORAL TABLET 2MG, 8MG 4 ST2; MO; QL (30 EA per 30 days)

gabapentin oral capsule 100mg 1 MO; GC; QL (270 EA per 30 days)

gabapentin oral capsule 300mg, 400mg 2 MO; GC; QL (270 EA per 30 days)

gabapentin oral solution 250mg/5ml 2 MO; GC

gabapentin oral tablet 600mg, 800mg 2 MO; GC; QL (180 EA per 30 days)



LYRICA ORAL SOLUTION 20MG/ML 3 MO; QL (900ML per 30 days)

tiagabine hcl oral tablet 12mg, 16mg, 2mg, 4mg 4 MO

valproic acid oral capsule 250mg 2 MO; GC

valproic acid oral solution 250mg/5ml 2 MO; GC

vigabatrin oral packet 500mg 5 PA2; LA; QL (180 EA per 30 days)


vigabatrin oral tablet 500mg 5 PA2; LA; QL (180 EA per 30 days)

VIGADRONE ORAL PACKET 500MG 5 PA2; LA; QL (180 EA per 30 days)

Glutamate Reducing Agents

lamotrigine er oral tablet extended release 24hour 100mg, 200mg, 25mg, 250mg, 300mg, 50mg

4 MO

lamotrigine oral tablet 100mg, 150mg, 200mg, 25mg

1 MO; GC

lamotrigine oral tablet chewable 25mg, 5mg 1 MO; GC

lamotrigine oral tablet dispersible 100mg, 200mg, 25mg, 50mg

4 MO

lamotrigine starter kit-blue oral kit 35 x 25mg 2 MO; GC

lamotrigine starter kit-green oral kit 84 x 25mg & 14x100mg

2 MO; GC

lamotrigine starter kit-orange oral kit 42 x 25mg & 7 x 100mg

2 MO; GC

topiramate er oral capsule er 24hour sprinkle 100mg, 150mg, 200mg, 25mg, 50mg

4 MO

topiramate oral capsule sprinkle 15mg, 25mg 2 MO; GC

topiramate oral tablet 100mg, 200mg, 25mg, 50mg

2 MO; GC

Sodium Channel Agents

APTIOM ORAL TABLET 200MG, 400MG, 800MG 5 ST2; QL (30 EA per 30 days)

APTIOM ORAL TABLET 600MG 5 ST2; QL (60 EA per 30 days)

BANZEL ORAL SUSPENSION 40MG/ML 5 ST2; QL (2760ML per 30 days)



DILANTIN ORAL CAPSULE 30MG 4 MO

oxcarbazepine oral suspension 300mg/5ml 4 MO

oxcarbazepine oral tablet 150mg, 600mg 2 MO; GC

oxcarbazepine oral tablet 300mg 1 MO; GC

PEGANONE ORAL TABLET 250MG 4 ST2; MO


phenytoin oral suspension 125mg/5ml 1 MO; GC

phenytoin oral tablet chewable 50mg 1 MO; GC

phenytoin sodium extended oral capsule 100mg, 200mg, 300mg

1 MO; GC

VIMPAT ORAL SOLUTION 10MG/ML 4 ST2; MO; QL (1395ML per 30 days)

VIMPAT ORAL TABLET 100MG, 150MG, 200MG,

50MG


ANTIDEMENTIA AGENTS

Cholinesterase Inhibitors

donepezil hcl oral tablet 10mg 1 MO; GC; QL (60 EA per 30 days)



donepezil hcl oral tablet dispersible 10mg 2 MO; GC; QL (60 EA per 30 days)

donepezil hcl oral tablet dispersible 5mg 2 MO; GC; QL (30 EA per 30 days)

galantamine hydrobromide er oral capsule extended release 24hour 16mg, 24mg, 8mg


galantamine hydrobromide oral solution 4mg/ml 2 MO; GC; QL (180ML per 30 days)

galantamine hydrobromide oral tablet 12mg, 4mg, 8mg


rivastigmine tartrate oral capsule 1.5mg, 3mg, 4.5mg, 6mg


rivastigmine transdermal patch 24hour

13.3mg/24hr, 4.6mg/24hr, 9.5mg/24hr


N-Methyl-D-Aspartate (Nmda) Receptor Antagonist

memantine hcl er oral capsule extended release 24hour 14mg, 21mg, 28mg, 7mg

2 MO; GC

memantine hcl oral solution 2mg/ml 2 MO; GC; QL (360ML per 30 days)

memantine hcl oral tablet 10mg, 5mg 2 MO; GC; QL (60 EA per 30 days)

memantine hcl oral tablet 28 x 5mg & 21 x 10mg 2 MO; GC

NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 & 14 & 21 &28 -10MG

3 MO


NAMZARIC ORAL CAPSULE EXTENDED RELEASE

24 HOUR 14-10MG, 21-10MG, 28-10MG, 7-10MG

3 MO

ANTIDEPRESSANTS

Antidepressants, Other







bupropion hcl er (xl) oral tablet extended release 24hour 150mg, 300mg


bupropion hcl er (xl) oral tablet extended release 24hour 450mg


bupropion hcl oral tablet 100mg 1 MO; GC; QL (180 EA per 30 days)

bupropion hcl oral tablet 75mg 1 MO; GC; QL (120 EA per 30 days)

maprotiline hcl oral tablet 25mg, 50mg, 75mg 2 MO; GC

mirtazapine oral tablet 15mg, 30mg, 45mg 1 MO; GC; QL (30 EA per 30 days)

mirtazapine oral tablet 7.5mg 1 MO; GC; QL (45 EA per 30 days)

mirtazapine oral tablet dispersible 15mg, 30mg, 45mg


nefazodone hcl oral tablet 100mg, 150mg, 200mg, 250mg, 50mg

2 MO; GC

trazodone hcl oral tablet 100mg, 150mg, 50mg 1 MO; GC

trazodone hcl oral tablet 300mg 2 MO; GC

TRINTELLIX ORAL TABLET 10MG, 20MG, 5MG 4 ST2; MO; QL (30 EA per 30 days)

VIIBRYD ORAL TABLET 10MG, 20MG, 40MG 3 ST2; MO; QL (30 EA per 30 days)

VIIBRYD STARTER PACK ORAL KIT 10 & 20MG 3 ST2; MO; QL (30 EA per 30 days)

Monoamine Oxidase Inhibitors

EMSAM TRANSDERMAL PATCH 24 HOUR

12MG/24HR, 6MG/24HR, 9MG/24HR


MARPLAN ORAL TABLET 10MG 4 ST2; MO; QL (180 EA per 30 days)


phenelzine sulfate oral tablet 15mg 1 MO; GC

tranylcypromine sulfate oral tablet 10mg 4 MO

Serotonin/Norepinephrine Reuptake Inhibitors

citalopram hydrobromide oral solution

10mg/5ml 2 MO; GC; QL (600ML per 30 days)

citalopram hydrobromide oral tablet 10mg, 40mg


citalopram hydrobromide oral tablet 20mg 1 MO; GC; QL (60 EA per 30 days)

desvenlafaxine er oral tablet extended release 24hour 100mg, 50mg


desvenlafaxine succinate er oral tablet extended release 24hour 100mg, 25mg, 50mg


duloxetine hcl oral capsule delayed release particles 20mg, 30mg, 40mg, 60mg


escitalopram oxalate oral solution 5mg/5ml 2 MO; GC; QL (600ML per 30 days)

escitalopram oxalate oral tablet 10mg 2 MO; GC; QL (45 EA per 30 days)



FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120MG, 20MG, 40MG, 80MG


FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR



fluoxetine hcl oral capsule 10mg 1 MO; GC; QL (60 EA per 30 days)



fluoxetine hcl oral solution 20mg/5ml 2 MO; GC; QL (600ML per 30 days)

fluoxetine hcl oral tablet 10mg 2 MO; GC; QL (60 EA per 30 days)

fluoxetine hcl oral tablet 20mg 2 MO; GC; QL (120 EA per 30 days)

fluvoxamine maleate oral tablet 100mg, 25mg, 50mg


paroxetine hcl oral tablet 10mg, 20mg 1 MO; GC; QL (30 EA per 30 days)

paroxetine hcl oral tablet 30mg, 40mg 1 MO; GC; QL (60 EA per 30 days)


PAXIL ORAL SUSPENSION 10MG/5ML 4 MO; QL (900ML per 30 days)

sertraline hcl oral concentrate 20mg/ml 1 MO; GC; QL (300ML per 30 days)

sertraline hcl oral tablet 100mg 1 MO; GC; QL (60 EA per 30 days)

sertraline hcl oral tablet 25mg, 50mg 1 MO; GC; QL (90 EA per 30 days)

venlafaxine hcl er oral capsule extended release 24hour 150mg, 37.5mg, 75mg


venlafaxine hcl er oral tablet extended release 24hour 150mg, 37.5mg, 75mg


venlafaxine hcl er oral tablet extended release 24hour 225mg


venlafaxine hcl oral tablet 100mg, 25mg, 37.5mg, 50mg, 75mg


Tricyclics

amitriptyline hcl oral tablet 10mg, 25mg, 50mg 2 MO; GC

amitriptyline hcl oral tablet 100mg, 150mg, 75mg 1 MO; GC

amoxapine oral tablet 100mg, 150mg 2 MO; GC

amoxapine oral tablet 25mg, 50mg 1 MO; GC

clomipramine hcl oral capsule 25mg, 50mg, 75mg

4 MO

desipramine hcl oral tablet 10mg, 25mg 1 MO; GC

desipramine hcl oral tablet 100mg, 150mg, 50mg, 75mg

2 MO; GC

doxepin hcl oral capsule 10mg, 100mg, 150mg, 25mg, 50mg, 75mg

2 MO; GC

doxepin hcl oral concentrate 10mg/ml 2 MO; GC

imipramine hcl oral tablet 10mg, 25mg, 50mg 2 MO; GC

nortriptyline hcl oral capsule 10mg, 25mg, 50mg, 75mg

1 MO; GC

nortriptyline hcl oral solution 10mg/5ml 2 MO; GC

protriptyline hcl oral tablet 10mg, 5mg 4 MO

trimipramine maleate oral capsule 100mg, 25mg, 50mg

2 MO; GC


ANTIEMETICS

Antiemetics, Other

COMPRO RECTAL SUPPOSITORY 25MG 4 MO

meclizine hcl oral tablet 12.5mg, 25mg 1 MO; GC

prochlorperazine maleate oral tablet 5mg 1 BvD; MO; GC

prochlorperazine rectal suppository 25mg 4 MO

promethazine hcl oral tablet 12.5mg, 25mg, 50mg

1 MO; GC

scopolamine transdermal patch 72hour

1mg/3days


TRANSDERM-SCOP (1.5MG) TRANSDERMAL

PATCH 72 HOUR 1MG/3DAYS


Emetogenic Therapy Adjuncts

aprepitant oral capsule 125mg, 40mg, 80mg 4 BvD; MO; QL (30 EA per 30 days)

aprepitant oral capsule 80 & 125mg 4 BvD; MO; QL (12 EA per 30 days)

dronabinol oral capsule 10mg, 5mg 4 BvD; MO; QL (60 EA per 30 days)

dronabinol oral capsule 2.5mg 2 BvD; MO; GC; QL (60 EA per 30 days)

EMEND ORAL SUSPENSION RECONSTITUTED

125MG

4 BvD; MO

granisetron hcl oral tablet 1mg 4 BvD; MO; QL (60 EA per 30 days)

ondansetron hcl oral solution 4mg/5ml 2 BvD; MO; GC

ondansetron hcl oral tablet 24mg, 4mg, 8mg 2 BvD; MO; GC

ondansetron oral tablet dispersible 4mg, 8mg 2 BvD; MO; GC

SYNDROS ORAL SOLUTION 5MG/ML 4 BvD; MO; QL (120ML per 30 days)

VARUBI ORAL TABLET 90MG 3 BvD; MO

ANTIFUNGALS

Antifungals

ABELCET INTRAVENOUS SUSPENSION 5MG/ML 5 BvD

AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50MG

5 BvD


amphotericin b intravenous solution reconstituted 50mg

4 BvD; MO

caspofungin acetate intravenous solution reconstituted 50mg, 70mg

5 BvD

ciclopirox external gel 0.77% 2 MO; GC

ciclopirox external shampoo 1% 2 MO; GC

ciclopirox external solution 8% 1 MO; GC

ciclopirox olamine external cream 0.77% 2 MO; GC

ciclopirox olamine external suspension 0.77% 2 MO; GC

clotrimazole external cream 1% 1 MO; GC

clotrimazole external solution 1% 1 MO; GC

clotrimazole mouth/throat lozenge 10mg 1 MO; GC

econazole nitrate external cream 1% 2 MO; GC


RECONSTITUTED 100MG

5 BvD


RECONSTITUTED 50MG

4 BvD; MO

fluconazole in sodium chloride intravenous solution 200-0.9mg/100ml-%, 400-0.9mg/200ml-%

2 BvD; MO; GC

fluconazole oral suspension reconstituted

10mg/ml, 40mg/ml 2 MO; GC

fluconazole oral tablet 100mg, 150mg, 200mg, 50mg

2 MO; GC

flucytosine oral capsule 250mg, 500mg 5

griseofulvin microsize oral suspension

125mg/5ml 4 MO

griseofulvin microsize oral tablet 500mg 4 MO

griseofulvin ultramicrosize oral tablet 125mg, 250mg

4 MO

itraconazole oral capsule 100mg 4 PA; MO

JUBLIA EXTERNAL SOLUTION 10% 4 MO

ketoconazole external cream 2% 2 MO; GC


ketoconazole external shampoo 2% 1 MO; GC

ketoconazole oral tablet 200mg 2 MO; GC

NATACYN OPHTHALMIC SUSPENSION 5% 4 MO

NOXAFIL ORAL SUSPENSION 40MG/ML 4 PA; MO

NOXAFIL ORAL TABLET DELAYED RELEASE 100MG 5 PA

NYAMYC EXTERNAL POWDER 100000 UNIT/GM 2 MO; GC

nystatin external cream 100000 unit/gm 1 MO; GC

nystatin external ointment 100000 unit/gm 1 MO; GC

nystatin external powder 100000 unit/gm 2 MO; GC

nystatin mouth/throat suspension 100000 unit/ml

2 MO; GC

nystatin oral tablet 500000 unit 1 MO; GC

NYSTOP EXTERNAL POWDER 100000 UNIT/GM 2 MO; GC

terbinafine hcl oral tablet 250mg 4 MO

voriconazole intravenous solution reconstituted 200mg

5 BvD

voriconazole oral suspension reconstituted

40mg/ml 4 PA; MO

voriconazole oral tablet 200mg, 50mg 5 PA; QL (120 EA per 30 days)

ANTIGOUT AGENTS

Antigout Agents

allopurinol oral tablet 100mg, 300mg 1 MO; GC

colchicine oral capsule 0.6mg 2 MO; GC

colchicine oral tablet 0.6mg 2 MO; GC

colchicine-probenecid oral tablet 0.5-500mg 1 MO; GC

MITIGARE ORAL CAPSULE 0.6MG 3 MO

probenecid oral tablet 500mg 1 MO; GC

ULORIC ORAL TABLET 40MG, 80MG 3 PA; MO

ANTI-INFLAMMATORY AGENTS

Nonsteroidal Anti-Inflammatory Drugs


celecoxib oral capsule 100mg, 200mg, 400mg, 50mg

2 MO; GC

diclofenac potassium oral tablet 50mg 2 MO; GC

diclofenac sodium er oral tablet extended release 24hour 100mg

1 MO; GC


25mg

2 MO; GC


50mg, 75mg

1 MO; GC

diclofenac sodium transdermal gel 1% 2 MO; GC

diclofenac sodium transdermal gel 3% 4 PA; MO

diclofenac sodium transdermal solution 1.5% 4 MO

diflunisal oral tablet 500mg 2 MO; GC

etodolac oral capsule 200mg, 300mg 2 MO; GC

etodolac oral tablet 400mg, 500mg 2 MO; GC

flurbiprofen oral tablet 100mg 1 MO; GC

flurbiprofen oral tablet 50mg 2 MO; GC

IBU ORAL TABLET 600MG, 800MG 1 MO; GC

ibuprofen oral suspension 100mg/5ml 1 MO; GC

ibuprofen oral tablet 400mg, 600mg, 800mg 1 MO; GC

indomethacin oral capsule 25mg 1 MO; GC

ketoprofen oral capsule 25mg 2 MO; GC

meloxicam oral tablet 15mg, 7.5mg 1 MO; GC

nabumetone oral tablet 500mg, 750mg 1 MO; GC

naproxen dr oral tablet delayed release 375mg, 500mg

2 MO; GC

naproxen oral suspension 125mg/5ml 1 MO; GC

naproxen oral tablet 250mg, 375mg, 500mg 1 MO; GC

naproxen sodium er oral tablet extended release 24hour 500mg

4 MO

naproxen sodium oral tablet 275mg, 550mg 2 MO; GC


oxaprozin oral tablet 600mg 2 MO; GC

piroxicam oral capsule 10mg, 20mg 2 MO; GC

sulindac oral tablet 150mg, 200mg 1 MO; GC

tolmetin sodium oral capsule 400mg 2 MO; GC

tolmetin sodium oral tablet 600mg 2 MO; GC

ANTIMIGRAINE AGENTS

Antimigraine Agents, Other

dihydroergotamine mesylate nasal solution 4mg/ml

5

EMGALITY (300MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100MG/ML

3 PA; MO

EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 120MG/ML

3 PA; MO

EMGALITY SUBCUTANEOUS SOLUTION


3 PA; MO

ergotamine-caffeine oral tablet 1-100mg 4 MO; QL (40 EA per 28 days)

MIGERGOT RECTAL SUPPOSITORY 2-100MG 4 MO

Serotonin (5-Ht) 1B/1D Receptor Agonists

naratriptan hcl oral tablet 1mg, 2.5mg 2 MO; GC; QL (9 EA per 30 days)

rizatriptan benzoate oral tablet 10mg 2 MO; GC; QL (12 EA per 30 days)

rizatriptan benzoate oral tablet 5mg 2 MO; GC; QL (24 EA per 30 days)

rizatriptan benzoate oral tablet dispersible 10mg 2 MO; GC; QL (12 EA per 30 days)

rizatriptan benzoate oral tablet dispersible 5mg 2 MO; GC; QL (24 EA per 30 days)

sumatriptan nasal solution 20mg/act, 5mg/act 4 MO; QL (18 EA per 30 days)

sumatriptan succinate oral tablet 100mg, 25mg, 50mg


sumatriptan succinate refill subcutaneous solution cartridge 4mg/0.5ml, 6mg/0.5ml


sumatriptan succinate subcutaneous solution

6mg/0.5ml 2 MO; GC; QL (8ML per 30 days)



2 MO; GC; QL (4.5ML per 30 days)



sumatriptan succinate subcutaneous solution prefilled syringe 6mg/0.5ml


zolmitriptan oral tablet 2.5mg 2 MO; GC; QL (12 EA per 30 days)

zolmitriptan oral tablet 5mg 2 MO; GC; QL (6 EA per 30 days)

zolmitriptan oral tablet dispersible 2.5mg 2 MO; GC; QL (12 EA per 30 days)

zolmitriptan oral tablet dispersible 5mg 2 MO; GC; QL (6 EA per 30 days)

ANTIMYASTHENIC AGENTS

Parasympathomimetics

guanidine hcl oral tablet 125mg 2 MO; GC

pyridostigmine bromide oral solution 60mg/5ml 2 MO; GC

pyridostigmine bromide oral tablet 30mg, 60mg 1 MO; GC

ANTIMYCOBACTERIALS

Antimycobacterials, Other

pyrazinamide oral tablet 500mg 2 MO; GC

rifabutin oral capsule 150mg 4 MO

Antituberculars

ethambutol hcl oral tablet 100mg 2 MO; GC

ethambutol hcl oral tablet 400mg 1 MO; GC

isoniazid oral syrup 50mg/5ml 1 MO; GC

isoniazid oral tablet 100mg, 300mg 1 MO; GC

PASER ORAL PACKET 4 GM 4 MO

PRIFTIN ORAL TABLET 150MG 4 MO

rifampin intravenous solution reconstituted

600mg

4 BvD; MO

rifampin oral capsule 150mg, 300mg 2 MO; GC

RIFATER ORAL TABLET 50-120-300MG 4 MO


SIRTURO ORAL TABLET 100MG 5 PA

TRECATOR ORAL TABLET 250MG 4 MO

ANTINEOPLASTICS

Alkylating Agents

cyclophosphamide oral capsule 25mg, 50mg 2 BvD; MO; GC

GLEOSTINE ORAL CAPSULE 10MG, 100MG, 40MG 4 MO

LEUKERAN ORAL TABLET 2MG 4 MO

Antiangiogenic Agents

DEPEN TITRATABS ORAL TABLET 250MG 5

REVLIMID ORAL CAPSULE 10MG, 15MG, 2.5MG,

20MG, 25MG, 5MG


THALOMID ORAL CAPSULE 100MG, 200MG, 50MG 5 PA2; QL (30 EA per 30 days)

THALOMID ORAL CAPSULE 150MG 5 PA2; QL (60 EA per 30 days)

Antimetabolites

DROXIA ORAL CAPSULE 200MG, 300MG, 400MG 4 MO

mercaptopurine oral tablet 50mg 2 MO; GC

methotrexate sodium (pf) injection solution

50mg/2ml 1 BvD; MO; GC

PURIXAN ORAL SUSPENSION 2000MG/100ML 4 LA; MO

TABLOID ORAL TABLET 40MG 4 PA2; MO

Antineoplastics

abiraterone acetate oral tablet 250mg 5 PA2; QL (120 EA per 30 days)

AFINITOR DISPERZ ORAL TABLET SOLUBLE 2MG, 3MG


AFINITOR DISPERZ ORAL TABLET SOLUBLE 5MG 5 PA2; QL (60 EA per 30 days)

AFINITOR ORAL TABLET 10MG, 2.5MG, 5MG, 7.5MG


ALECENSA ORAL CAPSULE 150MG 5 PA2





ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180MG





bexarotene oral capsule 75mg 5 PA2; QL (300 EA per 30 days)

bicalutamide oral tablet 50mg 2 MO; GC

BOSULIF ORAL TABLET 100MG 5 PA2; QL (120 EA per 30 days)

BOSULIF ORAL TABLET 400MG, 500MG 5 PA2; QL (30 EA per 30 days)

BRAFTOVI ORAL CAPSULE 75MG 5 PA2; LA; QL (180 EA per 30 days)

CABOMETYX ORAL TABLET 20MG, 40MG, 60MG 5 PA2; LA

CALQUENCE ORAL CAPSULE 100MG 5 PA2; LA; QL (60 EA per 30 days)




& 1 X 20MG



& 3 X 20MG


COMETRIQ (60MG DAILY DOSE) ORAL KIT 20MG 5 PA2; LA; QL (84 EA per 28 days)

COPIKTRA ORAL CAPSULE 15MG, 25MG 5 PA2; LA; QL (60 EA per 30 days)

COTELLIC ORAL TABLET 20MG 5 PA2; LA; QL (63 EA per 28 days)

DAURISMO ORAL TABLET 100MG, 25MG 5 PA2

ELIGARD SUBCUTANEOUS KIT 22.5MG, 30MG, 45MG, 7.5MG

4 PA2; MO

EMCYT ORAL CAPSULE 140MG 3 MO

ERIVEDGE ORAL CAPSULE 150MG 5 PA2

ERLEADA ORAL TABLET 60MG 5 PA2; LA; QL (120 EA per 30 days)

erlotinib hcl oral tablet 100mg, 150mg 5 PA2; QL (30 EA per 30 days)

erlotinib hcl oral tablet 25mg 5 PA2; QL (90 EA per 30 days)

FARYDAK ORAL CAPSULE 10MG 5 PA2; QL (60 EA per 30 days)


FARYDAK ORAL CAPSULE 15MG, 20MG 5 PA2; QL (30 EA per 30 days)

fluorouracil external cream 5% 2 MO; GC

fluorouracil external solution 2%, 5% 2 MO; GC

flutamide oral capsule 125mg 2 MO; GC

GILOTRIF ORAL TABLET 20MG, 30MG, 40MG 5 PA2; LA; QL (30 EA per 30 days)

hydroxyurea oral capsule 500mg 1 MO; GC

IBRANCE ORAL CAPSULE 100MG, 125MG, 75MG 5 PA2







IMBRUVICA ORAL CAPSULE 140MG, 70MG 5 PA2; LA; QL (120 EA per 30 days)



IMBRUVICA ORAL TABLET 420MG, 560MG 5 PA2; LA; QL (30 EA per 30 days)



IRESSA ORAL TABLET 250MG 5 PA2; LA

JAKAFI ORAL TABLET 10MG, 15MG, 20MG, 25MG,

5MG



PACK 200MG

5 PA2


PACK 200MG

5 PA2


PACK 200MG

5 PA2



5 PA2




5 PA2

KISQALI FEMARA(200MG DOSE) ORAL TABLET


5 PA2


THERAPY PACK 10MG

5 PA2



5 PA2



5 PA2


THERAPY PACK 10MG & 2 X 4MG

5 PA2



5 PA2

LENVIMA (24MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 X 10MG & 4MG

5 PA2

LENVIMA (4MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 4MG

5 PA2

LENVIMA (8MG DAILY DOSE) ORAL CAPSULE THERAPY PACK 2 X 4MG

5 PA2

leucovorin calcium oral tablet 10mg, 5mg 1 MO; GC

leucovorin calcium oral tablet 15mg 2 MO; GC

leucovorin calcium oral tablet 25mg 4 MO

leuprolide acetate injection kit 1mg/0.2ml 2 PA2; MO; GC

LONSURF ORAL TABLET 15-6.14MG, 20-8.19MG 5 PA2; LA




KIT 3.75MG, 7.5MG

5 PA2


5 PA2

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

5 PA2



KIT 45MG

5 PA2



LYSODREN ORAL TABLET 500MG 3 MO

MATULANE ORAL CAPSULE 50MG 5 PA2; LA

MEKINIST ORAL TABLET 0.5MG 5 PA2; LA; QL (120 EA per 30 days)

MEKINIST ORAL TABLET 2MG 5 PA2; LA; QL (30 EA per 30 days)

MEKTOVI ORAL TABLET 15MG 5 PA2; LA; QL (180 EA per 30 days)

MESNEX ORAL TABLET 400MG 5

NERLYNX ORAL TABLET 40MG 5 PA2; LA; QL (180 EA per 30 days)

NEXAVAR ORAL TABLET 200MG 5 PA2; LA; QL (120 EA per 30 days)

nilutamide oral tablet 150mg 5 QL (60 EA per 30 days)

NINLARO ORAL CAPSULE 2.3MG, 3MG, 4MG 5 PA2

ODOMZO ORAL CAPSULE 200MG 5 PA2; LA

PANRETIN EXTERNAL GEL 0.1% 5


THERAPY PACK 200MG

5 PA2



5 PA2



5 PA2

POMALYST ORAL CAPSULE 1MG, 2MG, 3MG, 4MG 5 PA2; LA; QL (21 EA per 28 days)

RUBRACA ORAL TABLET 200MG, 250MG, 300MG 5 PA2; LA

RYDAPT ORAL CAPSULE 25MG 5 PA2; QL (240 EA per 30 days)

SPRYCEL ORAL TABLET 100MG, 50MG, 70MG,

80MG




STIVARGA ORAL TABLET 40MG 5 PA2; LA; QL (84 EA per 28 days)


SUTENT ORAL CAPSULE 12.5MG, 25MG, 37.5MG,

50MG


SYNRIBO SUBCUTANEOUS SOLUTION

RECONSTITUTED 3.5MG

5 PA2



TAGRISSO ORAL TABLET 40MG, 80MG 5 PA2; LA

TALZENNA ORAL CAPSULE 0.25MG 5 PA2; LA; QL (90 EA per 30 days)

TALZENNA ORAL CAPSULE 1MG 5 PA2; LA; QL (30 EA per 30 days)

tamoxifen citrate oral tablet 10mg 1 MO; GC

tamoxifen citrate oral tablet 20mg 2 MO; GC

TARGRETIN EXTERNAL GEL 1% 5 PA2

TASIGNA ORAL CAPSULE 150MG, 200MG, 50MG 5 PA2; QL (120 EA per 30 days)

TIBSOVO ORAL TABLET 250MG 5 PA2; LA; QL (60 EA per 30 days)

TOLAK EXTERNAL CREAM 4% 4 MO

toremifene citrate oral tablet 60mg 5 PA2; QL (30 EA per 30 days)

tretinoin oral capsule 10mg 5

TYKERB ORAL TABLET 250MG 5 PA2; QL (180 EA per 30 days)

VALCHLOR EXTERNAL GEL 0.016% 5 PA2; QL (60 GM per 14 days)

VENCLEXTA ORAL TABLET 10MG, 50MG 4 PA2; LA; MO

VENCLEXTA ORAL TABLET 100MG 5 PA2; LA

VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100MG

3 PA2; LA; MO

VERZENIO ORAL TABLET 100MG, 150MG, 200MG, 50MG

5 PA2; LA



VITRAKVI ORAL SOLUTION 20MG/ML 5 PA2

VIZIMPRO ORAL TABLET 15MG, 30MG, 45MG 5 PA2; QL (30 EA per 30 days)

VOTRIENT ORAL TABLET 200MG 5 PA2; QL (120 EA per 30 days)

XALKORI ORAL CAPSULE 200MG, 250MG 5 PA2; QL (60 EA per 30 days)


XOSPATA ORAL TABLET 40MG 5 PA2; LA

XTANDI ORAL CAPSULE 40MG 5 PA2; LA; QL (120 EA per 30 days)

YONSA ORAL TABLET 125MG 5 PA2; QL (120 EA per 30 days)

ZEJULA ORAL CAPSULE 100MG 5 PA2; LA; QL (90 EA per 30 days)

ZELBORAF ORAL TABLET 240MG 5 PA2; QL (240 EA per 30 days)

ZOLINZA ORAL CAPSULE 100MG 5 PA2; QL (120 EA per 30 days)

ZYDELIG ORAL TABLET 100MG, 150MG 5 PA2; LA; QL (60 EA per 30 days)

ZYKADIA ORAL CAPSULE 150MG 5 PA2; QL (150 EA per 30 days)

ZYKADIA ORAL TABLET 150MG 5 PA2; QL (150 EA per 30 days)

ZYTIGA ORAL TABLET 500MG 5 PA2; QL (120 EA per 30 days)

Aromatase Inhibitors, 3Rd Generation

anastrozole oral tablet 1mg 2 MO; GC

exemestane oral tablet 25mg 4 MO

letrozole oral tablet 2.5mg 2 MO; GC

ANTIPARASITICS

Anthelmintics

albendazole oral tablet 200mg 4 MO

EMVERM ORAL TABLET CHEWABLE 100MG 3 MO

ivermectin oral tablet 3mg 2 MO; GC

Antiprotozoals

ALINIA ORAL SUSPENSION RECONSTITUTED

100MG/5ML


ALINIA ORAL TABLET 500MG 4 MO; QL (40 EA per 30 days)

atovaquone oral suspension 750mg/5ml 5

atovaquone-proguanil hcl oral tablet 250-100mg, 62.5-25mg

2 MO; GC

benznidazole oral tablet 100mg, 12.5mg 2 MO; GC

chloroquine phosphate oral tablet 250mg, 500mg

2 MO; GC

COARTEM ORAL TABLET 20-120MG 4 MO


DARAPRIM ORAL TABLET 25MG 5

mefloquine hcl oral tablet 250mg 2 MO; GC

NEBUPENT INHALATION SOLUTION

RECONSTITUTED 300MG

4 BvD; MO

PENTAM INJECTION SOLUTION RECONSTITUTED 300MG

4 BvD; MO

primaquine phosphate oral tablet 26.3mg 4 MO

quinine sulfate oral capsule 324mg 2 PA; MO; GC

Pediculicides/Scabicides

malathion external lotion 0.5% 4 MO

permethrin external cream 5% 2 MO; GC

ANTIPARKINSON AGENTS

Anticholinergics

benztropine mesylate oral tablet 0.5mg, 1mg, 2mg

1 MO; GC

trihexyphenidyl hcl oral elixir 0.4mg/ml 1 MO; GC

trihexyphenidyl hcl oral tablet 2mg, 5mg 1 MO; GC

Antiparkinson Agents, Other

amantadine hcl oral capsule 100mg 2 MO; GC

amantadine hcl oral syrup 50mg/5ml 2 MO; GC

amantadine hcl oral tablet 100mg 2 MO; GC

carbidopa-levodopa er oral tablet extended release 25-100mg, 50-200mg

2 MO; GC

carbidopa-levodopa oral tablet 10-100mg 1 MO; GC

carbidopa-levodopa oral tablet 25-100mg, 25-250mg

2 MO; GC

carbidopa-levodopa oral tablet dispersible 10-100mg, 25-100mg

1 MO; GC

carbidopa-levodopa oral tablet dispersible 25-250mg

2 MO; GC


carbidopa-levodopa-entacapone oral tablet

12.5-50-200mg, 18.75-75-200mg, 31.25-125-200mg

2 MO; GC

carbidopa-levodopa-entacapone oral tablet 25-100-200mg, 37.5-150-200mg, 50-200-200mg

4 MO

entacapone oral tablet 200mg 2 MO; GC

GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24

HOUR 137MG, 68.5MG

5 PA; LA

RYTARY ORAL CAPSULE EXTENDED RELEASE

23.75-95MG, 36.25-145MG, 48.75-195MG, 61.25-245MG

4 ST; MO

Dopamine Agonists

APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE

30MG/3ML


bromocriptine mesylate oral capsule 5mg 2 MO; GC

bromocriptine mesylate oral tablet 2.5mg 2 MO; GC

NEUPRO TRANSDERMAL PATCH 24 HOUR

1MG/24HR, 2MG/24HR, 3MG/24HR, 4MG/24HR,

6MG/24HR, 8MG/24HR

4 MO

pramipexole dihydrochloride er oral tablet extended release 24hour 3.75mg

2 MO; GC

pramipexole dihydrochloride oral tablet 0.125mg, 0.25mg, 0.5mg, 0.75mg, 1mg, 1.5mg

2 MO; GC

ropinirole hcl oral tablet 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg, 5mg

2 MO; GC

Monoamine Oxidase B (Mao-B) Inhibitors

rasagiline mesylate oral tablet 0.5mg, 1mg 4 MO

selegiline hcl oral capsule 5mg 2 MO; GC

selegiline hcl oral tablet 5mg 2 MO; GC

ANTIPSYCHOTICS

1St Generation/Typical

chlorpromazine hcl oral tablet 10mg, 100mg, 25mg

2 BvD; MO; GC


chlorpromazine hcl oral tablet 200mg, 50mg 4 BvD; MO

clozapine oral tablet 100mg, 200mg 2 ST2; MO; GC; QL (120 EA per 30 days)

clozapine oral tablet 25mg, 50mg 2 MO; GC; QL (120 EA per 30 days)

clozapine oral tablet dispersible 100mg, 12.5mg, 150mg, 25mg


clozapine oral tablet dispersible 200mg 5 ST2; QL (120 EA per 30 days)

fluphenazine decanoate injection solution

25mg/ml 4 MO

fluphenazine hcl injection solution 2.5mg/ml 4 MO

fluphenazine hcl oral concentrate 5mg/ml 2 MO; GC

fluphenazine hcl oral elixir 2.5mg/5ml 2 MO; GC

fluphenazine hcl oral tablet 1mg, 2.5mg 1 MO; GC

fluphenazine hcl oral tablet 10mg, 5mg 2 MO; GC

haloperidol decanoate intramuscular solution

100mg/ml, 100mg/ml 1 ml, 50mg/ml 2 MO; GC

haloperidol lactate injection solution 5mg/ml 4 MO

haloperidol lactate oral concentrate 2mg/ml 1 MO; GC

haloperidol oral tablet 0.5mg, 1mg, 10mg, 2mg, 20mg, 5mg

1 MO; GC

loxapine succinate oral capsule 10mg, 25mg, 5mg, 50mg

1 MO; GC

molindone hcl oral tablet 10mg, 25mg, 5mg 2 MO; GC

perphenazine oral tablet 16mg, 2mg 2 MO; GC

perphenazine oral tablet 4mg, 8mg 2 BvD; MO; GC

pimozide oral tablet 1mg, 2mg 2 MO; GC

prochlorperazine maleate oral tablet 10mg 1 BvD; MO; GC

thioridazine hcl oral tablet 10mg, 100mg, 25mg, 50mg

1 MO; GC

thiothixene oral capsule 1mg, 10mg, 2mg, 5mg 1 MO; GC

trifluoperazine hcl oral tablet 1mg, 10mg, 2mg, 5mg

1 MO; GC

VERSACLOZ ORAL SUSPENSION 50MG/ML 5 ST2; QL (540ML per 30 days)


2Nd Generation/Atypical

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300MG, 400MG

5 ST2

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300MG,

400MG

5 ST2

aripiprazole oral solution 1mg/ml 4 MO; QL (750ML per 30 days)

aripiprazole oral tablet 10mg, 15mg, 2mg, 20mg, 30mg, 5mg




FANAPT ORAL TABLET 1MG, 2MG, 4MG 4 ST2; MO; QL (60 EA per 30 days)

FANAPT ORAL TABLET 10MG, 12MG, 6MG, 8MG 5 ST2; QL (60 EA per 30 days)

FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4

& 6MG



SUSPENSION PREFILLED SYRINGE 117MG/0.75ML, 156MG/ML, 234MG/1.5ML,

78MG/0.5ML

5 ST2


SUSPENSION PREFILLED SYRINGE 39MG/0.25ML

4 ST2; MO

INVEGA TRINZA INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 273MG/0.875ML,

410MG/1.315ML, 546MG/1.75ML, 819MG/2.625ML

5 ST2

LATUDA ORAL TABLET 120MG 3 ST2; MO; QL (30 EA per 30 days)

LATUDA ORAL TABLET 20MG, 40MG, 60MG, 80MG 3 ST2; MO; QL (60 EA per 30 days)

NUPLAZID ORAL CAPSULE 34MG 5 PA2; LA

NUPLAZID ORAL TABLET 10MG 5 PA2; LA

olanzapine intramuscular solution reconstituted

10mg


olanzapine oral tablet 10mg, 15mg, 5mg, 7.5mg 4 MO; QL (30 EA per 30 days)

olanzapine oral tablet 2.5mg 1 MO; GC; QL (30 EA per 30 days)

olanzapine oral tablet 20mg 4 MO; QL (60 EA per 30 days)




paliperidone er oral tablet extended release 24hour 1.5mg, 3mg






PERSERIS SUBCUTANEOUS PREFILLED SYRINGE 120MG, 90MG


quetiapine fumarate er oral tablet extended release 24hour 150mg, 200mg, 300mg, 400mg, 50mg

4 MO

quetiapine fumarate oral tablet 100mg, 25mg, 300mg, 400mg, 50mg


quetiapine fumarate oral tablet 200mg 1 MO; GC; QL (30 EA per 30 days)

REXULTI ORAL TABLET 0.25MG, 0.5MG, 1MG,

2MG, 3MG, 4MG



SUSPENSION RECONSTITUTED 12.5MG

4 ST2; MO


SUSPENSION RECONSTITUTED 25MG, 37.5MG, 50MG

5 ST2

risperidone oral solution 1mg/ml 2 MO; GC; QL (480ML per 30 days)

risperidone oral tablet 0.25mg, 1mg, 2mg, 3mg, 4mg


risperidone oral tablet 0.5mg 2 MO; GC; QL (120 EA per 30 days)

risperidone oral tablet dispersible 0.25mg, 1mg, 2mg


risperidone oral tablet dispersible 0.5mg 2 MO; GC; QL (120 EA per 30 days)

risperidone oral tablet dispersible 3mg, 4mg 4 MO; QL (60 EA per 30 days)

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL

10MG, 2.5MG, 5MG


VRAYLAR ORAL CAPSULE 1.5MG 5 ST2; QL (60 EA per 30 days)


VRAYLAR ORAL CAPSULE 3MG, 4.5MG, 6MG 5 ST2; QL (30 EA per 30 days)

VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3MG


ziprasidone hcl oral capsule 20mg, 40mg 2 MO; GC; QL (60 EA per 30 days)

ziprasidone hcl oral capsule 60mg, 80mg 4 MO; QL (60 EA per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION RECONSTITUTED 210MG

4 ST2; MO

ANTIVIRALS

Anti-Cytomegalovirus (Cmv) Agents

valganciclovir hcl oral solution reconstituted

50mg/ml 4 MO

valganciclovir hcl oral tablet 450mg 5

ZIRGAN OPHTHALMIC GEL 0.15% 3 MO

Antihepatitis Agents

entecavir oral tablet 0.5mg, 1mg 4 PA; MO; QL (30 EA per 30 days)

EPIVIR HBV ORAL SOLUTION 5MG/ML 3 MO

lamivudine oral tablet 100mg 2 MO; GC; QL (90 EA per 30 days)

REBETOL ORAL SOLUTION 40MG/ML 5

VEMLIDY ORAL TABLET 25MG 5 PA; QL (30 EA per 30 days)

Anti-Hepatitis B (Hbv) Agents

adefovir dipivoxil oral tablet 10mg 4 PA; MO; QL (30 EA per 30 days)

BARACLUDE ORAL SOLUTION 0.05MG/ML 5 PA; QL (600ML per 30 days)

INTRON A INJECTION SOLUTION 10000000

UNIT/ML, 6000000 UNIT/ML

5 PA2

INTRON A INJECTION SOLUTION

RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT

5 PA2

Anti-Hepatitis C (Hcv) Agents, Direct Acting

sofosbuvir-velpatasvir oral tablet 400-100mg 5 PA


VOSEVI ORAL TABLET 400-100-100MG 5 PA

Anti-Hepatitis C (Hcv) Agents, Other

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION

180 MCG/0.5ML

5 PA

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML

5 PA

RIBASPHERE ORAL CAPSULE 200MG 3 MO

RIBASPHERE ORAL TABLET 600MG 5

ribavirin oral capsule 200mg 4 MO

ribavirin oral tablet 200mg 3 MO

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300

MCG, 600 MCG


Antiherpetic Agents

acyclovir oral capsule 200mg 1 MO; GC

acyclovir oral suspension 200mg/5ml 2 MO; GC

acyclovir oral tablet 400mg, 800mg 1 MO; GC

acyclovir sodium intravenous solution 50mg/ml 2 BvD; MO; GC

famciclovir oral tablet 125mg, 250mg, 500mg 2 MO; GC

valacyclovir hcl oral tablet 1gm, 500mg 2 MO; GC

Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors

ATRIPLA ORAL TABLET 600-200-300MG 5 QL (30 EA per 30 days)

COMPLERA ORAL TABLET 200-25-300MG 5 QL (30 EA per 30 days)

DELSTRIGO ORAL TABLET 100-300-300MG 5 QL (30 EA per 30 days)

EDURANT ORAL TABLET 25MG 5 QL (30 EA per 30 days)



efavirenz oral tablet 600mg 5 QL (30 EA per 30 days)

GENVOYA ORAL TABLET 150-150-200-10MG 5 QL (30 EA per 30 days)




INTELENCE ORAL TABLET 25MG 4 MO; QL (120 EA per 30 days)





nevirapine oral suspension 50mg/5ml 4 MO; QL (1200ML per 30 days)

nevirapine oral tablet 200mg 2 MO; GC; QL (60 EA per 30 days)

PIFELTRO ORAL TABLET 100MG 5 QL (30 EA per 30 days)

RESCRIPTOR ORAL TABLET 200MG 4 MO; QL (180 EA per 30 days)

SYMFI LO ORAL TABLET 400-300-300MG 5 QL (30 EA per 30 days)

SYMFI ORAL TABLET 600-300-300MG 5 QL (30 EA per 30 days)

SYMTUZA ORAL TABLET 800-150-200-10MG 5 QL (30 EA per 30 days)

VIRAMUNE ORAL SUSPENSION 50MG/5ML 4 MO; QL (1200ML per 30 days)

Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors

abacavir sulfate oral solution 20mg/ml 4 MO; QL (960ML per 30 days)

abacavir sulfate oral tablet 300mg 4 MO; QL (60 EA per 30 days)

abacavir sulfate-lamivudine oral tablet 600-300mg


abacavir-lamivudine-zidovudine oral tablet 300-150-300mg


CIMDUO ORAL TABLET 300-300MG 5 QL (30 EA per 30 days)

DESCOVY ORAL TABLET 200-25MG 5 QL (30 EA per 30 days)

didanosine oral capsule delayed release 200mg 2 MO; GC; QL (60 EA per 30 days)

didanosine oral capsule delayed release 250mg, 400mg


EMTRIVA ORAL CAPSULE 200MG 4 MO; QL (30 EA per 30 days)

EMTRIVA ORAL SOLUTION 10MG/ML 4 MO; QL (680ML per 28 days)

JULUCA ORAL TABLET 50-25MG 5 QL (30 EA per 30 days)

lamivudine oral solution 10mg/ml 4 MO; QL (900ML per 30 days)




lamivudine-zidovudine oral tablet 150-300mg 4 MO; QL (60 EA per 30 days)

stavudine oral capsule 15mg, 20mg 2 MO; GC; QL (120 EA per 30 days)

stavudine oral capsule 30mg, 40mg 2 MO; GC; QL (60 EA per 30 days)

STRIBILD ORAL TABLET 150-150-200-300MG 5 QL (30 EA per 30 days)

tenofovir disoproxil fumarate oral tablet 300mg 4 MO; QL (30 EA per 30 days)

TRIUMEQ ORAL TABLET 600-50-300MG 5 QL (30 EA per 30 days)

TRUVADA ORAL TABLET 100-150MG, 133-200MG, 167-250MG, 200-300MG


VIDEX EC ORAL CAPSULE DELAYED RELEASE

125MG


VIDEX ORAL SOLUTION RECONSTITUTED 4 GM 4 MO; QL (1200ML per 30 days)

VIREAD ORAL POWDER 40MG/GM 5 QL (240 GM per 30 days)

VIREAD ORAL TABLET 150MG, 200MG, 250MG 5 QL (30 EA per 30 days)

zidovudine oral capsule 100mg 2 MO; GC; QL (180 EA per 30 days)

zidovudine oral syrup 50mg/5ml 2 MO; GC; QL (1680ML per 28 days)

zidovudine oral tablet 300mg 2 MO; GC; QL (60 EA per 30 days)

Anti-Hiv Agents, Other

BIKTARVY ORAL TABLET 50-200-25MG 5 QL (30 EA per 30 days)

DOVATO ORAL TABLET 50-300MG 5 QL (30 EA per 30 days)

FUZEON SUBCUTANEOUS SOLUTION

RECONSTITUTED 90MG


ISENTRESS HD ORAL TABLET 600MG 5 QL (60 EA per 30 days)

ISENTRESS ORAL PACKET 100MG 4 MO; QL (60 EA per 30 days)

ISENTRESS ORAL TABLET 400MG 5 QL (120 EA per 30 days)



ODEFSEY ORAL TABLET 200-25-25MG 5 QL (30 EA per 30 days)

PREZISTA ORAL SUSPENSION 100MG/ML 5 QL (360ML per 30 days)

SELZENTRY ORAL SOLUTION 20MG/ML 3 MO; QL (1800ML per 30 days)



SELZENTRY ORAL TABLET 25MG, 300MG 3 MO; QL (120 EA per 30 days)


TIVICAY ORAL TABLET 10MG 4 MO; QL (60 EA per 30 days)



TYBOST ORAL TABLET 150MG 3 MO; QL (30 EA per 30 days)

Anti-Hiv Agents, Protease Inhibitors

APTIVUS ORAL CAPSULE 250MG 4 MO; QL (120 EA per 30 days)

APTIVUS ORAL SOLUTION 100MG/ML 4 MO; QL (285ML per 28 days)

atazanavir sulfate oral capsule 150mg, 200mg 4 MO; QL (60 EA per 30 days)

atazanavir sulfate oral capsule 300mg 5 QL (60 EA per 30 days)



EVOTAZ ORAL TABLET 300-150MG 5 QL (30 EA per 30 days)

fosamprenavir calcium oral tablet 700mg 5 QL (120 EA per 30 days)

INVIRASE ORAL TABLET 500MG 5 QL (120 EA per 30 days)

KALETRA ORAL TABLET 100-25MG 4 MO; QL (300 EA per 30 days)

KALETRA ORAL TABLET 200-50MG 5 QL (150 EA per 30 days)

LEXIVA ORAL SUSPENSION 50MG/ML 4 MO; QL (1575ML per 28 days)

lopinavir-ritonavir oral solution 400-100mg/5ml 4 MO; QL (400ML per 30 days)

NORVIR ORAL PACKET 100MG 4 MO; QL (360 EA per 30 days)

NORVIR ORAL SOLUTION 80MG/ML 4 MO; QL (480ML per 30 days)

PREZCOBIX ORAL TABLET 800-150MG 5 QL (30 EA per 30 days)





REYATAZ ORAL PACKET 50MG 4 MO; QL (180 EA per 30 days)

ritonavir oral tablet 100mg 3 MO; QL (360 EA per 30 days)


VIRACEPT ORAL TABLET 250MG 4 MO; QL (300 EA per 30 days)

VIRACEPT ORAL TABLET 625MG 5 QL (120 EA per 30 days)

Anti-Influenza Agents

oseltamivir phosphate oral capsule 30mg, 45mg, 75mg

2 MO; GC

oseltamivir phosphate oral suspension reconstituted 6mg/ml

2 MO; GC

RELENZA DISKHALER INHALATION AEROSOL

POWDER BREATH ACTIVATED 5MG/BLISTER

4 MO

rimantadine hcl oral tablet 100mg 2 MO; GC

XOFLUZA ORAL TABLET THERAPY PACK 2 X

20MG, 2 X 40MG

3 MO

ANXIOLYTICS

Anxiolytics, Other

buspirone hcl oral tablet 10mg, 15mg, 30mg, 5mg, 7.5mg

1 MO; GC

hydroxyzine hcl oral syrup 10mg/5ml 4 MO

hydroxyzine hcl oral tablet 10mg, 25mg, 50mg 1 MO; GC

hydroxyzine pamoate oral capsule 100mg, 25mg, 50mg

2 MO; GC

Benzodiazepines

ALPRAZOLAM INTENSOL ORAL CONCENTRATE

1MG/ML


alprazolam oral tablet 0.25mg, 0.5mg 2 MO; GC; QL (120 EA per 30 days)

alprazolam oral tablet 1mg 2 MO; GC; QL (240 EA per 30 days)

alprazolam oral tablet 2mg 2 MO; GC; QL (150 EA per 30 days)

chlordiazepoxide hcl oral capsule 10mg, 25mg, 5mg


clonazepam oral tablet 0.5mg, 1mg 2 MO; GC; QL (90 EA per 30 days)

clonazepam oral tablet 2mg 2 MO; GC; QL (300 EA per 30 days)

clonazepam oral tablet dispersible 0.125mg, 0.25mg, 0.5mg, 1mg



clonazepam oral tablet dispersible 2mg 2 MO; GC; QL (300 EA per 30 days)

clorazepate dipotassium oral tablet 15mg, 3.75mg, 7.5mg


diazepam oral concentrate 5mg/ml 2 MO; GC; QL (240ML per 30 days)

diazepam oral solution 5mg/5ml 4 MO; QL (1200ML per 30 days)

diazepam oral tablet 10mg 1 MO; GC; QL (120 EA per 30 days)



lorazepam oral concentrate 2mg/ml 2 MO; GC; QL (240ML per 30 days)

lorazepam oral tablet 0.5mg, 1mg, 2mg 2 MO; GC; QL (150 EA per 30 days)

BIPOLAR AGENTS

Mood Stabilizers

GEODON INTRAMUSCULAR SOLUTION

RECONSTITUTED 20MG

4 ST2; MO

lithium carbonate er oral tablet extended release

300mg, 450mg

1 MO; GC

lithium carbonate oral capsule 150mg, 300mg, 600mg

1 MO; GC

lithium carbonate oral tablet 300mg 1 MO; GC

lithium oral solution 8 meq/5ml 1 MO; GC

olanzapine-fluoxetine hcl oral capsule 12-25mg, 12-50mg, 6-50mg


olanzapine-fluoxetine hcl oral capsule 3-25mg, 6-25mg


BLOOD GLUCOSE REGULATORS

Antidiabetic Agents, Supply

ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1ML 6 MO; GC

COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1ML

6 MO; GC

EXEL COMFORT POINT PEN NEEDLE 29G X 12MM 6 MO; GC

global alcohol prep ease pad 70% 6 MO; GC


preferred plus insulin syringe 28g x 1/2" 0.5 ml 6 MO; GC

RELI-ON INSULIN SYRINGE 29G 0.3ML 6 MO; GC

Antidiabetic Agents

acarbose oral tablet 100mg, 25mg, 50mg 1 MO; GC

glimepiride oral tablet 1mg, 2mg, 4mg 6 MO; GC

glipizide er oral tablet extended release 24hour

10mg, 2.5mg, 5mg

6 MO; GC

glipizide oral tablet 10mg, 5mg 6 MO; GC

glipizide-metformin hcl oral tablet 2.5-250mg, 2.5-500mg, 5-500mg

6 MO; GC

glyburide micronized oral tablet 1.5mg, 3mg, 6mg

1 MO; GC

glyburide oral tablet 1.25mg, 2.5mg, 5mg 1 MO; GC

glyburide-metformin oral tablet 1.25-250mg, 2.5-500mg, 5-500mg

1 MO; GC

INVOKAMET ORAL TABLET 150-1000MG, 150-

500MG, 50-1000MG, 50-500MG

3 MO

INVOKAMET XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 150-1000MG, 150-500MG, 50-

1000MG, 50-500MG

3 MO

INVOKANA ORAL TABLET 100MG, 300MG 3 MO

JANUMET ORAL TABLET 50-1000MG, 50-500MG 3 MO

JANUMET XR ORAL TABLET EXTENDED RELEASE

24 HOUR 100-1000MG, 50-1000MG, 50-500MG

3 MO

JANUVIA ORAL TABLET 100MG, 25MG, 50MG 3 MO

JARDIANCE ORAL TABLET 10MG, 25MG 3 MO

metformin hcl er oral tablet extended release 24hour 500mg, 750mg

6 MO; GC

metformin hcl oral tablet 1000mg, 500mg, 850mg

6 MO; GC

miglitol oral tablet 100mg, 25mg, 50mg 1 MO; GC

nateglinide oral tablet 120mg, 60mg 1 MO; GC


OZEMPIC SUBCUTANEOUS SOLUTION PEN-

INJECTOR 0.25 OR 0.5MG/DOSE, 1MG/DOSE

3 MO

pioglitazone hcl oral tablet 15mg, 30mg, 45mg 6 MO; GC

pioglitazone hcl-glimepiride oral tablet 30-2mg, 30-4mg

2 MO; GC

pioglitazone hcl-metformin hcl oral tablet 15-500mg, 15-850mg

1 MO; GC

repaglinide oral tablet 0.5mg, 1mg, 2mg 1 MO; GC

repaglinide-metformin hcl oral tablet 1-500mg, 2-500mg

2 MO; GC

SOLIQUA SUBCUTANEOUS SOLUTION PEN-

INJECTOR 100-33 UNT-MCG/ML

3 MO

SYMLINPEN 120 SUBCUTANEOUS SOLUTION

PEN-INJECTOR 2700 MCG/2.7ML

4 PA; MO

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-

INJECTOR 1500 MCG/1.5ML

4 PA; MO

SYNJARDY ORAL TABLET 12.5-1000MG, 12.5-

500MG, 5-1000MG, 5-500MG

3 MO

SYNJARDY XR ORAL TABLET EXTENDED RELEASE

24 HOUR 10-1000MG, 12.5-1000MG, 25-1000MG, 5-1000MG

3 MO

tolazamide oral tablet 250mg, 500mg 1 MO; GC

tolbutamide oral tablet 500mg 1 MO; GC

TRULICITY SUBCUTANEOUS SOLUTION PEN-

INJECTOR 0.75MG/0.5ML, 1.5MG/0.5ML

3 MO

VICTOZA SUBCUTANEOUS SOLUTION PEN-

INJECTOR 18MG/3ML

3 MO

XULTOPHY SUBCUTANEOUS SOLUTION PEN-

INJECTOR 100-3.6 UNIT-MG/ML

3 MO

Glycemic Agents

GLUCAGEN HYPOKIT INJECTION SOLUTION

RECONSTITUTED 1MG

3 MO

GLUCAGON EMERGENCY INJECTION KIT 1MG 2 MO; GC

PROGLYCEM ORAL SUSPENSION 50MG/ML 5


Insulins

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3 MO

FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML 3 MO

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3 MO

LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML

3 MO

LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

3 MO

LEVEMIR SUBCUTANEOUS SOLUTION 100

UNIT/ML

3 MO

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

(70-30) 100 UNIT/ML

6 MO; GC

NOVOLIN N SUBCUTANEOUS SUSPENSION 100

UNIT/ML

6 MO; GC

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML 6 MO; GC

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION


3 MO

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (70-30) 100

UNIT/ML

3 MO

NOVOLOG MIX 70/30 SUBCUTANEOUS

SUSPENSION (70-30) 100 UNIT/ML

3 MO

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML

3 MO

NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML

3 MO

TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML

3 MO

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION


3 MO


TRESIBA FLEXTOUCH SUBCUTANEOUS

SOLUTION PEN-INJECTOR 100 UNIT/ML, 200

UNIT/ML

3 MO

TRESIBA SUBCUTANEOUS SOLUTION 100

UNIT/ML

3 MO

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

Anticoagulants

COUMADIN ORAL TABLET 1MG, 10MG, 2MG,

2.5MG, 3MG, 4MG, 5MG, 6MG, 7.5MG

4 MO

ELIQUIS ORAL TABLET 2.5MG, 5MG 3 MO

ELIQUIS STARTER PACK ORAL TABLET 5MG 3 MO

enoxaparin sodium subcutaneous solution 100mg/ml, 150mg/ml



120mg/0.8ml, 80mg/0.8ml 4 MO; QL (24ML per 30 days)










2.5mg/0.5ml 4 MO; QL (7ML per 30 days)




7.5mg/0.6ml 5 QL (8.4ML per 30 days)

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml

2 BvD; MO; GC

heparin sodium (porcine) injection solution 5000 unit/ml

1 BvD; MO; GC


JANTOVEN ORAL TABLET 1MG, 10MG, 2MG,

2.5MG, 3MG, 4MG, 5MG, 6MG, 7.5MG

1 MO; GC

warfarin sodium oral tablet 1mg, 10mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg

1 MO; GC

XARELTO ORAL TABLET 10MG, 15MG, 2.5MG,

20MG

3 MO

XARELTO STARTER PACK ORAL TABLET THERAPY

PACK 15 & 20MG

3 MO

Blood Formation Modifiers

LEUKINE INJECTION SOLUTION RECONSTITUTED

250 MCG

5 PA

pentoxifylline er oral tablet extended release

400mg

1 MO; GC

PROMACTA ORAL PACKET 12.5MG 5 PA; QL (360 EA per 30 days)

PROMACTA ORAL TABLET 12.5MG, 25MG 5 PA; QL (60 EA per 30 days)

PROMACTA ORAL TABLET 50MG, 75MG 5 PA; QL (30 EA per 30 days)

RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

4 PA; MO; QL (12ML per 28 days)



tranexamic acid oral tablet 650mg 2 MO; GC

ZARXIO INJECTION SOLUTION PREFILLED

SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

5 PA

Platelet Modifying Agents

anagrelide hcl oral capsule 0.5mg, 1mg 2 MO; GC

aspirin-dipyridamole er oral capsule extended release 12hour 25-200mg

2 MO; GC

BRILINTA ORAL TABLET 60MG, 90MG 3 MO

CABLIVI INJECTION KIT 11MG 5 PA; LA

cilostazol oral tablet 100mg, 50mg 2 MO; GC

clopidogrel bisulfate oral tablet 75mg 2 MO; GC

prasugrel hcl oral tablet 10mg, 5mg 4 MO


YOSPRALA ORAL TABLET DELAYED RELEASE 325-

40MG, 81-40MG

3 MO

CARDIOVASCULAR AGENTS

Alpha-Adrenergic Agonists

clonidine hcl oral tablet 0.1mg, 0.2mg, 0.3mg 1 MO; GC

clonidine transdermal patch weekly 0.1mg/24hr, 0.2mg/24hr, 0.3mg/24hr

2 MO; GC

guanfacine hcl oral tablet 1mg, 2mg 1 MO; GC

methyldopa oral tablet 250mg, 500mg 1 MO; GC

midodrine hcl oral tablet 10mg, 2.5mg, 5mg 2 MO; GC

Alpha-Adrenergic Blocking Agents

doxazosin mesylate oral tablet 1mg, 2mg, 4mg 1 MO; GC; QL (45 EA per 30 days)

doxazosin mesylate oral tablet 8mg 1 MO; GC; QL (60 EA per 30 days)

prazosin hcl oral capsule 1mg, 2mg 1 MO; GC

prazosin hcl oral capsule 5mg 2 MO; GC

terazosin hcl oral capsule 1mg, 10mg, 2mg, 5mg 1 MO; GC

Angiotensin Ii Receptor Antagonists

candesartan cilexetil oral tablet 16mg, 4mg, 8mg 1 MO; GC; QL (60 EA per 30 days)

candesartan cilexetil oral tablet 32mg 1 MO; GC; QL (30 EA per 30 days)

EDARBI ORAL TABLET 40MG, 80MG 4 MO

EDARBYCLOR ORAL TABLET 40-12.5MG, 40-25MG 4 MO

eprosartan mesylate oral tablet 600mg 1 MO; GC; QL (30 EA per 30 days)

irbesartan oral tablet 150mg, 300mg, 75mg 6 MO; GC; QL (30 EA per 30 days)

losartan potassium oral tablet 100mg, 25mg 6 MO; GC; QL (30 EA per 30 days)

losartan potassium oral tablet 50mg 6 MO; GC; QL (60 EA per 30 days)

olmesartan medoxomil oral tablet 20mg, 40mg, 5mg

1 MO; GC

telmisartan oral tablet 20mg, 40mg, 80mg 1 MO; GC; QL (30 EA per 30 days)

valsartan oral tablet 160mg, 320mg 6 MO; GC; QL (30 EA per 30 days)

valsartan oral tablet 40mg, 80mg 6 MO; GC; QL (90 EA per 30 days)


Angiotensin-Converting Enzyme (Ace) Inhibitors

benazepril hcl oral tablet 10mg, 20mg, 40mg, 5mg

6 MO; GC

captopril oral tablet 100mg, 12.5mg, 25mg, 50mg 1 MO; GC

enalapril maleate oral tablet 10mg, 2.5mg, 20mg, 5mg

6 MO; GC

fosinopril sodium oral tablet 10mg, 20mg, 40mg 6 MO; GC

lisinopril oral tablet 10mg, 2.5mg, 20mg, 30mg, 40mg, 5mg

6 MO; GC

moexipril hcl oral tablet 15mg, 7.5mg 1 MO; GC

perindopril erbumine oral tablet 2mg, 4mg, 8mg 1 MO; GC

quinapril hcl oral tablet 10mg, 20mg, 40mg, 5mg 6 MO; GC

ramipril oral capsule 1.25mg, 10mg, 2.5mg, 5mg 6 MO; GC

trandolapril oral tablet 1mg, 2mg, 4mg 6 MO; GC

Antiarrhythmics

amiodarone hcl oral tablet 100mg, 400mg 2 MO; GC

amiodarone hcl oral tablet 200mg 1 MO; GC

disopyramide phosphate oral capsule 100mg, 150mg

2 MO; GC

dofetilide oral capsule 125mcg, 250mcg, 500mcg 4 MO

flecainide acetate oral tablet 100mg, 150mg, 50mg

2 MO; GC

mexiletine hcl oral capsule 150mg, 200mg, 250mg

2 MO; GC

MULTAQ ORAL TABLET 400MG 4 MO

NORPACE CR ORAL CAPSULE EXTENDED


4 MO

PACERONE ORAL TABLET 100MG 4 MO

PACERONE ORAL TABLET 200MG, 400MG 3 MO

propafenone hcl er oral capsule extended release 12hour 225mg, 325mg, 425mg

4 MO


propafenone hcl oral tablet 150mg, 225mg, 300mg

2 MO; GC

quinidine sulfate oral tablet 200mg, 300mg 1 MO; GC

Antihypertensive Combinations

amiloride-hydrochlorothiazide oral tablet 5-50mg

1 MO; GC

amlodipine besy-benazepril hcl oral capsule 10-20mg, 10-40mg, 5-40mg


amlodipine besy-benazepril hcl oral capsule 2.5-10mg, 5-10mg, 5-20mg


amlodipine besylate-valsartan oral tablet 10-160mg, 10-320mg, 5-160mg, 5-320mg


amlodipine-olmesartan oral tablet 10-20mg, 10-40mg, 5-20mg, 5-40mg


amlodipine-valsartan-hctz oral tablet 10-160-12.5mg, 10-160-25mg, 10-320-25mg, 5-160-12.5mg, 5-160-25mg


atenolol-chlorthalidone oral tablet 100-25mg, 50-25mg

1 MO; GC

benazepril-hydrochlorothiazide oral tablet 10-12.5mg, 20-12.5mg, 20-25mg, 5-6.25mg

6 MO; GC

bisoprolol-hydrochlorothiazide oral tablet 10-6.25mg, 2.5-6.25mg, 5-6.25mg

1 MO; GC

candesartan cilexetil-hctz oral tablet 16-12.5mg, 32-12.5mg, 32-25mg


captopril-hydrochlorothiazide oral tablet 25-15mg, 25-25mg, 50-15mg, 50-25mg

6 MO; GC

enalapril-hydrochlorothiazide oral tablet 10-25mg, 5-12.5mg

6 MO; GC

ENTRESTO ORAL TABLET 24-26MG, 49-51MG, 97-

103MG

3 PA; MO

fosinopril sodium-hctz oral tablet 10-12.5mg, 20-12.5mg

6 MO; GC


irbesartan-hydrochlorothiazide oral tablet 150-12.5mg, 300-12.5mg


lisinopril-hydrochlorothiazide oral tablet 10-12.5mg, 20-12.5mg, 20-25mg

6 MO; GC

losartan potassium-hctz oral tablet 100-12.5mg, 100-25mg, 50-12.5mg


metoprolol-hydrochlorothiazide oral tablet 100-25mg, 100-50mg, 50-25mg

1 MO; GC

olmesartan medoxomil-hctz oral tablet 20-12.5mg, 40-12.5mg, 40-25mg


olmesartan-amlodipine-hctz oral tablet 20-5-12.5mg, 40-10-12.5mg, 40-10-25mg, 40-5-12.5mg, 40-5-25mg


propranolol-hctz oral tablet 40-25mg, 80-25mg 1 MO; GC

quinapril-hydrochlorothiazide oral tablet 10-12.5mg, 20-12.5mg, 20-25mg

6 MO; GC

spironolactone-hctz oral tablet 25-25mg 1 MO; GC

TEKTURNA HCT ORAL TABLET 150-12.5MG, 150-

25MG, 300-12.5MG, 300-25MG


telmisartan-amlodipine oral tablet 40-10mg, 40-5mg, 80-10mg, 80-5mg

1 MO; GC

telmisartan-hctz oral tablet 40-12.5mg, 80-12.5mg, 80-25mg


trandolapril-verapamil hcl er oral tablet extended release 1-240mg, 2-180mg, 2-240mg, 4-240mg

1 MO; GC

triamterene-hctz oral capsule 37.5-25mg 1 MO; GC

triamterene-hctz oral tablet 37.5-25mg, 75-50mg 1 MO; GC

valsartan-hydrochlorothiazide oral tablet 160-12.5mg, 160-25mg, 320-12.5mg, 320-25mg, 80-12.5mg


Beta-Adrenergic Blocking Agents

acebutolol hcl oral capsule 200mg, 400mg 1 MO; GC

atenolol oral tablet 100mg, 25mg, 50mg 1 MO; GC


betaxolol hcl oral tablet 10mg, 20mg 1 MO; GC

bisoprolol fumarate oral tablet 10mg, 5mg 1 MO; GC

BYSTOLIC ORAL TABLET 10MG, 2.5MG, 20MG,

5MG

4 MO

carvedilol oral tablet 12.5mg, 25mg, 3.125mg, 6.25mg

1 MO; GC

carvedilol phosphate er oral capsule extended release 24hour 10mg, 20mg, 40mg, 80mg

2 MO; GC

labetalol hcl oral tablet 100mg, 200mg, 300mg 1 MO; GC

metoprolol succinate er oral tablet extended release 24hour 100mg, 25mg, 50mg

1 MO; GC

metoprolol succinate er oral tablet extended release 24hour 200mg

2 MO; GC

metoprolol tartrate oral tablet 100mg, 25mg, 50mg

1 MO; GC

nadolol oral tablet 20mg, 40mg, 80mg 2 MO; GC

pindolol oral tablet 10mg, 5mg 2 MO; GC

propranolol hcl er oral capsule extended release 24hour 120mg, 160mg, 60mg, 80mg

2 MO; GC

propranolol hcl oral solution 20mg/5ml, 40mg/5ml

2 MO; GC

propranolol hcl oral tablet 10mg, 20mg, 40mg, 60mg, 80mg

1 MO; GC

SORINE ORAL TABLET 120MG, 160MG, 240MG, 80MG

2 MO; GC

sotalol hcl (af) oral tablet 120mg, 160mg, 80mg 2 MO; GC

sotalol hcl oral tablet 120mg, 160mg, 240mg, 80mg

2 MO; GC

timolol maleate oral tablet 10mg, 5mg 1 MO; GC

timolol maleate oral tablet 20mg 2 MO; GC

Calcium Channel Blocking Agents

amlodipine besylate oral tablet 10mg, 2.5mg, 5mg

1 MO; GC



24 HOUR 120MG, 180MG, 240MG



24 HOUR 300MG


diltiazem hcl er beads oral capsule extended release 24hour 360mg, 420mg


diltiazem hcl er coated beads oral capsule extended release 24hour 120mg, 180mg, 240mg


diltiazem hcl er coated beads oral capsule extended release 24hour 300mg


diltiazem hcl er oral capsule extended release 12hour 120mg, 60mg, 90mg

2 MO; GC

diltiazem hcl oral tablet 120mg, 30mg, 60mg, 90mg

1 MO; GC

dilt-xr oral capsule extended release 24hour 120mg, 180mg, 240mg


felodipine er oral tablet extended release 24hour 10mg, 2.5mg, 5mg


isradipine oral capsule 2.5mg 1 MO; GC

isradipine oral capsule 5mg 2 MO; GC

MATZIM LA ORAL TABLET EXTENDED RELEASE 24

HOUR 180MG, 240MG, 300MG, 360MG, 420MG

2 MO; GC

nicardipine hcl oral capsule 20mg, 30mg 2 MO; GC


30mg, 60mg



90mg


nifedipine er osmotic release oral tablet extended release 24hour 30mg, 60mg


nifedipine er osmotic release oral tablet extended release 24hour 90mg


nifedipine oral capsule 10mg, 20mg 2 MO; GC


24 HOUR 120MG, 180MG, 240MG




24 HOUR 300MG, 360MG


verapamil hcl er oral capsule extended release 24hour 100mg, 300mg


verapamil hcl er oral capsule extended release 24hour 120mg, 180mg, 200mg, 240mg, 360mg


verapamil hcl er oral tablet extended release

120mg, 180mg, 240mg

1 MO; GC

verapamil hcl oral tablet 120mg, 40mg, 80mg 1 MO; GC

Cardiovascular Agents, Other

aliskiren fumarate oral tablet 150mg, 300mg 2 MO; GC; QL (30 EA per 30 days)

amlodipine-atorvastatin oral tablet 10-10mg, 10-20mg, 10-40mg, 10-80mg, 2.5-10mg, 2.5-20mg, 2.5-40mg, 5-10mg, 5-20mg, 5-40mg, 5-80mg

2 MO; GC

CINRYZE INTRAVENOUS SOLUTION


5 PA; LA

CORLANOR ORAL TABLET 5MG, 7.5MG 4 PA; MO

DIGITEK ORAL TABLET 125 MCG, 250 MCG 2 MO; GC; QL (30 EA per 30 days)

DIGOX ORAL TABLET 125 MCG, 250 MCG 2 MO; GC; QL (30 EA per 30 days)

digoxin oral solution 0.05mg/ml 2 MO; GC; QL (255ML per 30 days)

digoxin oral tablet 125mcg, 250mcg 2 MO; GC; QL (30 EA per 30 days)

LANOXIN ORAL TABLET 125 MCG 4 MO; QL (30 EA per 30 days)

LANOXIN ORAL TABLET 250 MCG 4 MO

LANOXIN ORAL TABLET 62.5 MCG 4 MO; QL (60 EA per 30 days)

NORTHERA ORAL CAPSULE 100MG, 200MG, 300MG


ranolazine er oral tablet extended release 12hour 1000mg, 500mg

3 MO

RUCONEST INTRAVENOUS SOLUTION


5 PA

TAKHZYRO SUBCUTANEOUS SOLUTION

300MG/2ML


Diuretics, Carbonic Anhydrase Inhibitors


acetazolamide er oral capsule extended release 12hour 500mg

2 MO; GC

acetazolamide oral tablet 125mg, 250mg 2 MO; GC

methazolamide oral tablet 25mg, 50mg 4 MO

Diuretics, Loop

bumetanide injection solution 0.25mg/ml 2 MO; GC

bumetanide oral tablet 0.5mg, 1mg, 2mg 1 MO; GC

furosemide injection solution 10mg/ml, 10mg/ml (4ml syringe)

2 BvD; MO; GC

furosemide oral solution 10mg/ml, 8mg/ml 1 MO; GC

furosemide oral tablet 20mg, 40mg, 80mg 1 MO; GC

torsemide oral tablet 10mg, 100mg, 20mg, 5mg 1 MO; GC

Diuretics, Potassium-Sparing

amiloride hcl oral tablet 5mg 1 MO; GC

eplerenone oral tablet 25mg, 50mg 2 MO; GC

spironolactone oral tablet 100mg, 25mg, 50mg 1 MO; GC

Diuretics, Thiazide

chlorothiazide oral tablet 250mg 1 MO; GC

chlorothiazide oral tablet 500mg 2 MO; GC

chlorthalidone oral tablet 25mg, 50mg 1 MO; GC

hydrochlorothiazide oral capsule 12.5mg 1 MO; GC

hydrochlorothiazide oral tablet 12.5mg, 25mg, 50mg

1 MO; GC

indapamide oral tablet 1.25mg, 2.5mg 1 MO; GC

methyclothiazide oral tablet 5mg 1 MO; GC

metolazone oral tablet 10mg 2 MO; GC

metolazone oral tablet 2.5mg, 5mg 1 MO; GC

Dyslipidemics, Fibric Acid Derivatives

fenofibrate micronized oral capsule 130mg, 134mg, 200mg, 67mg



fenofibrate micronized oral capsule 43mg 2 MO; GC; QL (60 EA per 30 days)

fenofibrate oral capsule 150mg 2 MO; GC; QL (30 EA per 30 days)

fenofibrate oral capsule 50mg 2 MO; GC; QL (60 EA per 30 days)

fenofibrate oral tablet 120mg 2 MO; GC

fenofibrate oral tablet 145mg, 160mg 2 MO; GC; QL (30 EA per 30 days)

fenofibrate oral tablet 40mg, 48mg 2 MO; GC; QL (60 EA per 30 days)

fenofibrate oral tablet 54mg 1 MO; GC; QL (60 EA per 30 days)

fenofibric acid oral capsule delayed release

135mg, 45mg

2 MO; GC

fenofibric acid oral tablet 105mg, 35mg 2 MO; GC

gemfibrozil oral tablet 600mg 1 MO; GC

Dyslipidemics, Hmg Coa Reductase Inhibitors

atorvastatin calcium oral tablet 10mg, 20mg, 40mg, 80mg


fluvastatin sodium er oral tablet extended release 24hour 80mg

2 MO; GC

fluvastatin sodium oral capsule 20mg, 40mg 1 MO; GC

LIVALO ORAL TABLET 1MG, 2MG, 4MG 3 MO

lovastatin oral tablet 10mg 6 MO; GC; QL (45 EA per 30 days)



pravastatin sodium oral tablet 10mg, 20mg, 40mg, 80mg


rosuvastatin calcium oral tablet 10mg, 20mg, 40mg, 5mg

6 MO; GC

simvastatin oral tablet 10mg, 20mg, 40mg, 5mg, 80mg


Dyslipidemics, Other

cholestyramine light oral powder 4gm/dose 2 MO; GC

cholestyramine oral packet 4gm 2 MO; GC

colesevelam hcl oral packet 3.75gm 2 MO; GC


colesevelam hcl oral tablet 625mg 2 MO; GC

colestipol hcl oral packet 5gm 2 MO; GC

colestipol hcl oral tablet 1gm 2 MO; GC

ezetimibe oral tablet 10mg 2 MO; GC

ezetimibe-simvastatin oral tablet 10-10mg, 10-20mg, 10-40mg, 10-80mg

2 MO; GC

JUXTAPID ORAL CAPSULE 10MG, 20MG, 30MG,

40MG, 5MG, 60MG

5 PA

niacin er (antihyperlipidemic) oral tablet extended release 1000mg, 500mg, 750mg

2 MO; GC

omega-3-acid ethyl esters oral capsule 1gm 2 MO; GC

PRALUENT SUBCUTANEOUS SOLUTION PEN-

INJECTOR 150MG/ML, 75MG/ML

4 PA; MO

PREVALITE ORAL PACKET 4 GM 4 MO

REPATHA PUSHTRONEX SYSTEM

SUBCUTANEOUS SOLUTION CARTRIDGE

420MG/3.5ML

4 PA; MO

REPATHA SUBCUTANEOUS SOLUTION


4 PA; MO

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140MG/ML

4 PA; MO

VASCEPA ORAL CAPSULE 0.5 GM, 1 GM 4 MO

Vasodilators, Direct-Acting Arterial/Venous

isosorbide dinitrate er oral tablet extended release 40mg

2 MO; GC

isosorbide dinitrate oral tablet 10mg, 20mg, 30mg, 5mg

1 MO; GC

isosorbide mononitrate er oral tablet extended release 24hour 120mg, 30mg, 60mg

1 MO; GC

isosorbide mononitrate oral tablet 10mg, 20mg 1 MO; GC

MINITRAN TRANSDERMAL PATCH 24 HOUR

0.1MG/HR, 0.2MG/HR, 0.4MG/HR, 0.6MG/HR

2 MO; GC


NITRO-DUR TRANSDERMAL PATCH 24 HOUR

0.3MG/HR, 0.8MG/HR

3 MO

nitroglycerin sublingual tablet sublingual 0.3mg, 0.4mg, 0.6mg

6 MO; GC

nitroglycerin transdermal patch 24hour

0.1mg/hr, 0.2mg/hr, 0.4mg/hr, 0.6mg/hr


nitroglycerin translingual solution 0.4mg/spray 2 MO; GC

Vasodilators, Direct-Acting Arterial

hydralazine hcl oral tablet 10mg, 100mg, 25mg, 50mg

1 MO; GC

minoxidil oral tablet 10mg, 2.5mg 1 MO; GC

CENTRAL NERVOUS SYSTEM AGENTS

Attention Deficit Hyperactivity Disorder Agents, Amphetamines


10mg, 12.5mg, 15mg, 20mg, 5mg, 7.5mg



30mg










Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines

atomoxetine hcl oral capsule 10mg, 100mg, 18mg, 25mg, 40mg, 60mg, 80mg


dexmethylphenidate hcl oral tablet 10mg 1 MO; GC; QL (60 EA per 30 days)

dexmethylphenidate hcl oral tablet 2.5mg 1 MO; GC; QL (240 EA per 30 days)

dexmethylphenidate hcl oral tablet 5mg 1 MO; GC; QL (120 EA per 30 days)


guanfacine hcl er oral tablet extended release 24hour 1mg, 2mg, 3mg, 4mg

4 MO

METADATE ER ORAL TABLET EXTENDED RELEASE

20MG


methylphenidate hcl er oral tablet extended release 10mg, 20mg




methylphenidate hcl oral tablet 10mg, 5mg 1 MO; GC; QL (90 EA per 30 days)

methylphenidate hcl oral tablet 20mg 2 MO; GC; QL (90 EA per 30 days)

Central Nervous System, Other

AUSTEDO ORAL TABLET 12MG, 6MG, 9MG 5 PA; LA; QL (120 EA per 30 days)

NUEDEXTA ORAL CAPSULE 20-10MG 3 PA; MO

riluzole oral tablet 50mg 4 MO

TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 284MG/1.5ML

5 PA; LA

tetrabenazine oral tablet 12.5mg 5 PA; QL (240 EA per 30 days)

tetrabenazine oral tablet 25mg 5 PA; QL (120 EA per 30 days)

TIGLUTIK ORAL SUSPENSION 50MG/10ML 5

Fibromyalgia Agents



SAVELLA ORAL TABLET 100MG, 12.5MG, 25MG, 50MG


SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50MG


Multiple Sclerosis Agents

AVONEX INTRAMUSCULAR KIT 30 MCG 5 PA

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR

KIT 30 MCG/0.5ML

5 PA

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML

5 PA


BETASERON SUBCUTANEOUS KIT 0.3MG 5 PA

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20MG/ML, 40MG/ML

5 PA

dalfampridine er oral tablet extended release 12hour 10mg


GILENYA ORAL CAPSULE 0.5MG 5 PA

glatiramer acetate subcutaneous solution prefilled syringe 20mg/ml, 40mg/ml

5 PA

MAYZENT ORAL TABLET 0.25MG 5 PA; QL (210 EA per 30 days)

MAYZENT ORAL TABLET 2MG 5 PA; QL (30 EA per 30 days)

TECFIDERA ORAL 120 & 240MG 5 PA

TECFIDERA ORAL CAPSULE DELAYED RELEASE

120MG, 240MG

5 PA

DENTAL AND ORAL AGENTS

Dental And Oral Agents

chlorhexidine gluconate mouth/throat solution

0.12%

1 MO; GC

lidocaine viscous hcl mouth/throat solution 2% 4 MO

pilocarpine hcl oral tablet 5mg, 7.5mg 2 MO; GC

triamcinolone acetonide mouth/throat paste 0.1%

2 MO; GC

DERMATOLOGICAL AGENTS

Dermatological Agents

acitretin oral capsule 10mg, 25mg 4 PA; MO

acitretin oral capsule 17.5mg 5 PA

alclometasone dipropionate external cream

0.05%

2 MO; GC

alclometasone dipropionate external ointment

0.05%

2 MO; GC

amcinonide external cream 0.1% 4 MO

amcinonide external ointment 0.1% 4 MO


ammonium lactate external cream 12% 1 MO; GC

ammonium lactate external lotion 12% 1 MO; GC

AMNESTEEM ORAL CAPSULE 10MG, 20MG, 40MG 4 MO

benzoyl peroxide-erythromycin external gel 5-3%

2 MO; GC

betamethasone dipropionate aug external cream 0.05%

2 MO; GC

betamethasone dipropionate aug external lotion

0.05%

2 MO; GC

betamethasone dipropionate aug external ointment 0.05%

2 MO; GC

betamethasone dipropionate external cream 0.05%

2 MO; GC

betamethasone dipropionate external lotion 0.05%

1 MO; GC

betamethasone dipropionate external ointment

0.05%

2 MO; GC

betamethasone valerate external cream 0.1% 1 MO; GC

betamethasone valerate external lotion 0.1% 1 MO; GC

betamethasone valerate external ointment 0.1% 1 MO; GC

calcipotriene external solution 0.005% 4 MO

CLARAVIS ORAL CAPSULE 20MG, 30MG, 40MG 4 MO

clindamycin phos-benzoyl perox external gel 1-5%

2 MO; GC

clindamycin phosphate external gel 1% 2 MO; GC

clindamycin phosphate external lotion 1% 2 MO; GC

clindamycin phosphate external solution 1% 2 MO; GC

clobetasol propionate e external cream 0.05% 4 MO

clobetasol propionate external cream 0.05% 4 MO

clobetasol propionate external gel 0.05% 4 MO

clobetasol propionate external ointment 0.05% 4 MO

clobetasol propionate external solution 0.05% 2 MO; GC


clotrimazole-betamethasone external cream 1-0.05%

2 MO; GC

clotrimazole-betamethasone external lotion 1-0.05%

2 MO; GC

COLOCORT RECTAL ENEMA 100MG/60ML 2 MO; GC

desonide external cream 0.05% 4 MO

desonide external lotion 0.05% 4 MO

desonide external ointment 0.05% 2 MO; GC

desoximetasone external cream 0.05% 4 MO

desoximetasone external cream 0.25% 2 MO; GC

desoximetasone external gel 0.05% 4 MO

desoximetasone external ointment 0.25% 2 MO; GC

diflorasone diacetate external cream 0.05% 4 MO

ery external pad 2% 2 MO; GC

erythromycin external gel 2% 2 MO; GC

erythromycin external solution 2% 1 MO; GC

EUCRISA EXTERNAL OINTMENT 2% 4 MO

fluocinolone acetonide external cream 0.01%, 0.025%

2 MO; GC

fluocinolone acetonide external ointment 0.025%

2 MO; GC

fluocinolone acetonide external solution 0.01% 2 MO; GC

fluocinonide emulsified base external cream

0.05%

2 MO; GC

fluocinonide external gel 0.05% 2 MO; GC

fluocinonide external ointment 0.05% 2 MO; GC

fluocinonide external solution 0.05% 2 MO; GC

fluticasone propionate external cream 0.05% 2 MO; GC

fluticasone propionate external ointment 0.005% 2 MO; GC

gentamicin sulfate external cream 0.1% 2 MO; GC

gentamicin sulfate external ointment 0.1% 2 MO; GC


halobetasol propionate external cream 0.05% 4 MO

halobetasol propionate external ointment 0.05% 2 MO; GC

hydrocortisone ace-pramoxine rectal cream 1-1%

1 MO; GC

hydrocortisone external cream 1%, 2.5% 1 MO; GC

hydrocortisone external lotion 2.5% 1 MO; GC

hydrocortisone external ointment 1% 2 MO; GC

hydrocortisone external ointment 2.5% 1 MO; GC

hydrocortisone rectal enema 100mg/60ml 4 MO

hydrocortisone valerate external cream 0.2% 2 MO; GC

hydrocortisone valerate external ointment 0.2% 2 MO; GC

imiquimod external cream 5% 2 MO; GC

isotretinoin oral capsule 10mg, 20mg, 30mg, 40mg

4 MO

metronidazole external cream 0.75% 2 MO; GC

metronidazole external gel 0.75%, 1% 2 MO; GC

metronidazole external lotion 0.75% 2 MO; GC

mometasone furoate external cream 0.1% 1 MO; GC

mometasone furoate external ointment 0.1% 1 MO; GC

mometasone furoate external solution 0.1% 1 MO; GC

mupirocin external ointment 2% 2 MO; GC

MYORISAN ORAL CAPSULE 30MG 4 MO

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

2 MO; GC

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

2 MO; GC

PICATO EXTERNAL GEL 0.015%, 0.05% 4 MO

pimecrolimus external cream 1% 4 MO

podofilox external solution 0.5% 2 MO; GC

prednicarbate external cream 0.1% 4 MO

prednicarbate external ointment 0.1% 4 MO


PROCTO-MED HC RECTAL CREAM 2.5% 4 MO

PROCTO-PAK RECTAL CREAM 1% 4 MO

PROCTOSOL HC RECTAL CREAM 2.5% 4 MO

PROCTOZONE-HC RECTAL CREAM 2.5% 1 MO; GC

RECTIV RECTAL OINTMENT 0.4% 4 MO

REGRANEX EXTERNAL GEL 0.01% 5 PA

SANTYL EXTERNAL OINTMENT 250 UNIT/GM 4 MO

selenium sulfide external lotion 2.5% 2 MO; GC

silver sulfadiazine external cream 1% 2 MO; GC

SSD EXTERNAL CREAM 1% 2 MO; GC

tacrolimus external ointment 0.03%, 0.1% 4 MO

tazarotene external cream 0.1% 2 MO; GC

TAZORAC EXTERNAL CREAM 0.05% 4 MO

TAZORAC EXTERNAL GEL 0.05%, 0.1% 4 MO

tretinoin external cream 0.025%, 0.05%, 0.1% 2 MO; GC

tretinoin external gel 0.01%, 0.025%, 0.05% 2 MO; GC

triamcinolone acetonide external cream 0.025%, 0.1%, 0.5%

1 MO; GC

triamcinolone acetonide external lotion 0.025% 1 MO; GC

triamcinolone acetonide external lotion 0.1% 2 MO; GC

triamcinolone acetonide external ointment

0.025%, 0.1%, 0.5%

1 MO; GC

TRIDERM EXTERNAL CREAM 0.1% 2 MO; GC

UCERIS RECTAL FOAM 2MG/ACT 4 MO

ELECTROLYTES/MINERALS/METALS/VITAMINS

Electrolyte/Mineral Replacement

dextrose-nacl intravenous solution 10-0.2% 4 BvD; MO

dextrose-nacl intravenous solution 10-0.45%, 2.5-0.45%, 5-0.2%, 5-0.225%, 5-0.33%, 5-0.45%, 5-0.9%

2 BvD; MO; GC


kcl in dextrose-nacl intravenous solution 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.33 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9 meq/l-%-%

2 BvD; MO; GC

kcl-lactated ringers-d5w intravenous solution 20 meq/l

2 BvD; MO; GC

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE

10 MEQ

2 MO; GC


RELEASE 10 MEQ

1 MO; GC


RELEASE 15 MEQ

2 MO; GC


RELEASE 20 MEQ

1 MO; GC

KLOR-CON ORAL PACKET 20 MEQ 2 MO; GC

KLOR-CON ORAL TABLET EXTENDED RELEASE 8

MEQ

2 MO; GC

KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED

RELEASE 8 MEQ

2 MO; GC

magnesium sulfate injection solution 50%, 50% (10ml syringe)

1 BvD; MO; GC

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

1 MO; GC

potassium chloride er oral capsule extended release 10 meq, 8 meq

2 MO; GC

potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq

1 MO; GC


2 BvD; MO; GC


4 BvD; MO


20-0.45 meq/l-%, 20-0.9 meq/l-%

2 BvD; MO; GC



40-0.9 meq/l-%

4 BvD; MO

potassium chloride intravenous solution 2 meq/ml, 2 meq/ml (20 ml), 20 meq/100ml

2 BvD; MO; GC

potassium chloride intravenous solution 40 meq/100ml

2 MO; GC

potassium chloride oral packet 20 meq 2 MO; GC

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

2 MO; GC

potassium citrate er oral tablet extended release

10 meq (1080mg), 15 meq (1620mg), 5 meq (540mg)

2 MO; GC

sodium chloride intravenous solution 0.45%, 0.9%, 3%, 5%

2 BvD; MO; GC

Electrolyte/Mineral/Metal Modifiers

CHEMET ORAL CAPSULE 100MG 4 MO

deferasirox oral tablet soluble 125mg, 250mg, 500mg

5 PA

FERRIPROX ORAL SOLUTION 100MG/ML 4 PA; LA; MO

FERRIPROX ORAL TABLET 500MG 5 PA; LA

IONOSOL-MB IN D5W INTRAVENOUS SOLUTION 4 MO

ISOLYTE-P IN D5W INTRAVENOUS SOLUTION 4 MO

KIONEX ORAL SUSPENSION 15 GM/60ML 2 MO; GC

LOKELMA ORAL PACKET 10 GM, 5 GM 4 MO

NORMOSOL-M IN D5W INTRAVENOUS SOLUTION 3 BvD; MO

NORMOSOL-R IN D5W INTRAVENOUS SOLUTION 3 BvD; MO

SAMSCA ORAL TABLET 15MG, 30MG 5 QL (60 EA per 30 days)

sodium chloride irrigation solution 0.9% 1 MO; GC

sodium polystyrene sulfonate oral powder 2 MO; GC

SPS ORAL SUSPENSION 15 GM/60ML 4 MO

trientine hcl oral capsule 250mg 5 PA

Nutrients


AMINOSYN II INTRAVENOUS SOLUTION 10% 4 BvD; MO

AMINOSYN-PF INTRAVENOUS SOLUTION 10%, 7%

4 BvD; MO

CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75%

3 BvD; MO


SOLUTION 4.25%

3 BvD; MO


SOLUTION 4.25%

3 BvD; MO

CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS

SOLUTION 5%

3 BvD; MO

CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS

SOLUTION 5%

3 BvD; MO


SOLUTION 4.25%

4 BvD; MO


SOLUTION 4.25%

4 BvD; MO


SOLUTION 5%

4 BvD; MO

CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5%

4 BvD; MO

dextrose intravenous solution 10%, 5% 2 BvD; MO; GC

FREAMINE HBC INTRAVENOUS SOLUTION 6.9% 4 BvD; MO

HEPATAMINE INTRAVENOUS SOLUTION 8% 4 BvD; MO

INTRALIPID INTRAVENOUS EMULSION 20%, 30% 4 BvD; MO

ISOLYTE-S INTRAVENOUS SOLUTION 4 BvD; MO

NEPHRAMINE INTRAVENOUS SOLUTION 5.4% 4 BvD; MO

NORMOSOL-R PH 7.4 INTRAVENOUS SOLUTION 4 BvD; MO

nutrilipid intravenous emulsion 20% 4 BvD; MO

PLASMA-LYTE 148 INTRAVENOUS SOLUTION 3 BvD; MO

PLASMA-LYTE A INTRAVENOUS SOLUTION 3 BvD; MO

PREMASOL INTRAVENOUS SOLUTION 10% 4 BvD; MO

PREMASOL INTRAVENOUS SOLUTION 6% 2 BvD; MO; GC


PROCALAMINE INTRAVENOUS SOLUTION 3% 4 BvD; MO

PROSOL INTRAVENOUS SOLUTION 20% 4 BvD; MO

TPN ELECTROLYTES INTRAVENOUS SOLUTION 2 BvD; MO; GC

TRAVASOL INTRAVENOUS SOLUTION 10% 4 BvD; MO

TROPHAMINE INTRAVENOUS SOLUTION 10% 4 BvD; MO

GASTROINTESTINAL AGENTS

Antispasmodics, Gastrointestinal

dicyclomine hcl oral capsule 10mg 1 MO; GC

dicyclomine hcl oral solution 10mg/5ml 2 MO; GC

dicyclomine hcl oral tablet 20mg 1 MO; GC

glycopyrrolate oral tablet 1mg 1 MO; GC

glycopyrrolate oral tablet 2mg 2 MO; GC

Gastrointestinal Agents, Other

CREON ORAL CAPSULE DELAYED RELEASE

PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

3 MO

cromolyn sodium oral concentrate 100mg/5ml 4 MO

diphenoxylate-atropine oral liquid 2.5-0.025mg/5ml

4 MO

diphenoxylate-atropine oral tablet 2.5-0.025mg 1 MO; GC

GATTEX SUBCUTANEOUS KIT 5MG 5 PA; LA

loperamide hcl oral capsule 2mg 1 MO; GC

metoclopramide hcl oral solution 5mg/5ml 1 MO; GC

metoclopramide hcl oral tablet 10mg, 5mg 1 MO; GC

MOVANTIK ORAL TABLET 12.5MG, 25MG 3 MO; QL (30 EA per 30 days)

MYTESI ORAL TABLET DELAYED RELEASE 125MG 4 PA; MO

ursodiol oral capsule 300mg 2 MO; GC

ursodiol oral tablet 250mg, 500mg 2 MO; GC


ZENPEP ORAL CAPSULE DELAYED RELEASE

PARTICLES 10000-32000 UNIT, 15000-47000

UNIT, 20000-63000 UNIT, 25000-79000 UNIT,

3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT

3 MO

Histamine2 (H2) Receptor Antagonists

famotidine oral suspension reconstituted 40mg/5ml

1 MO; GC

famotidine oral tablet 20mg, 40mg 1 MO; GC

ranitidine hcl oral capsule 150mg, 300mg 1 MO; GC

ranitidine hcl oral syrup 75mg/5ml 2 MO; GC

ranitidine hcl oral tablet 150mg, 300mg 1 MO; GC

Irritable Bowel Syndrome Agents

alosetron hcl oral tablet 0.5mg 4 MO; QL (60 EA per 30 days)

alosetron hcl oral tablet 1mg 5 QL (60 EA per 30 days)

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 3 MO; QL (60 EA per 30 days)

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72

MCG


Laxatives

CLENPIQ ORAL SOLUTION 10-3.5-12MG-GM -

GM/160ML

4 MO

constulose oral solution 10gm/15ml 2 MO; GC

enulose oral solution 10gm/15ml 1 MO; GC

GAVILYTE-C ORAL SOLUTION RECONSTITUTED

240 GM

1 MO; GC

GAVILYTE-G ORAL SOLUTION RECONSTITUTED

236 GM

1 MO; GC

GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION

RECONSTITUTED 420 GM

1 MO; GC

generlac oral solution 10gm/15ml 1 MO; GC

lactulose oral solution 10gm/15ml 1 MO; GC


peg 3350/electrolytes oral solution reconstituted

240gm

1 MO; GC

peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420gm

1 MO; GC

peg-3350/electrolytes oral solution reconstituted

236gm

1 MO; GC

SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-

3.13-1.6 GM/177ML

4 MO

TRILYTE ORAL SOLUTION RECONSTITUTED 420

GM

1 MO; GC

Protectants

CARAFATE ORAL SUSPENSION 1 GM/10ML 4 MO

misoprostol oral tablet 100mcg, 200mcg 1 MO; GC

sucralfate oral tablet 1gm 1 MO; GC

Proton Pump Inhibitors

DEXILANT ORAL CAPSULE DELAYED RELEASE

30MG, 60MG

3 ST; MO




2 MO; GC

esomeprazole strontium oral capsule delayed release 49.3mg

2 MO; GC

omeprazole oral capsule delayed release 10mg, 20mg, 40mg

2 MO; GC

pantoprazole sodium oral tablet delayed release

20mg, 40mg

2 MO; GC

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

Enzyme Replacement/Modifiers

CARBAGLU ORAL TABLET 200MG 5 PA; LA

CYSTADANE ORAL POWDER 5

ENDARI ORAL PACKET 5 GM 4 LA; MO


GALAFOLD ORAL CAPSULE 123MG 5 PA; LA; QL (14 EA per 28 days)

KUVAN ORAL PACKET 100MG, 500MG 5 PA; LA

KUVAN ORAL TABLET SOLUBLE 100MG 5 PA; LA

levocarnitine oral solution 1gm/10ml 1 BvD; MO; GC

levocarnitine oral tablet 330mg 2 BvD; MO; GC

miglustat oral capsule 100mg 5 PA; LA

ORFADIN ORAL CAPSULE 10MG, 2MG, 20MG, 5MG 5 PA; LA

RAVICTI ORAL LIQUID 1.1 GM/ML 5 PA; LA

sodium phenylbutyrate oral powder 3gm/tsp 5 PA

sodium phenylbutyrate oral tablet 500mg 4 PA; MO

XURIDEN ORAL PACKET 2 GM 5 PA

GENITOURINARY AGENTS

Antispasmodics, Urinary

darifenacin hydrobromide er oral tablet extended release 24hour 15mg, 7.5mg

2 MO; GC

MYRBETRIQ ORAL TABLET EXTENDED RELEASE

24 HOUR 25MG, 50MG

3 MO

oxybutynin chloride er oral tablet extended release 24hour 10mg, 15mg, 5mg


oxybutynin chloride oral syrup 5mg/5ml 1 MO; GC

oxybutynin chloride oral tablet 5mg 1 MO; GC

tolterodine tartrate er oral capsule extended release 24hour 2mg, 4mg


tolterodine tartrate oral tablet 1mg, 2mg 2 MO; GC; QL (60 EA per 30 days)

Benign Prostatic Hypertrophy Agents

alfuzosin hcl er oral tablet extended release 24hour 10mg


CARDURA XL ORAL TABLET EXTENDED RELEASE

24 HOUR 4MG, 8MG

3 MO

dutasteride oral capsule 0.5mg 2 MO; GC


dutasteride-tamsulosin hcl oral capsule 0.5-0.4mg


finasteride oral tablet 5mg 1 MO; GC; QL (30 EA per 30 days)

silodosin oral capsule 4mg, 8mg 4 MO; QL (30 EA per 30 days)

tamsulosin hcl oral capsule 0.4mg 2 MO; GC; QL (60 EA per 30 days)

Genitourinary Agents, Other

bethanechol chloride oral tablet 10mg, 50mg 2 MO; GC

bethanechol chloride oral tablet 25mg, 5mg 1 MO; GC

CYSTAGON ORAL CAPSULE 150MG, 50MG 4 PA; LA; MO

ELMIRON ORAL CAPSULE 100MG 4 MO

Phosphate Binders

AURYXIA ORAL TABLET 1 GM 210MG(FE) 4 PA; MO

calcium acetate (phos binder) oral capsule

667mg

2 MO; GC

calcium acetate (phos binder) oral tablet 667mg 1 MO; GC



sevelamer carbonate oral tablet 800mg 4 MO; QL (540 EA per 30 days)

VELPHORO ORAL TABLET CHEWABLE 500MG 4 MO

Vaginal Products

clindamycin phosphate vaginal cream 2% 2 MO; GC

estradiol vaginal cream 0.1mg/gm 4 MO

estradiol vaginal tablet 10mcg 4 MO

INTRAROSA VAGINAL INSERT 6.5MG 3 PA; MO

metronidazole vaginal gel 0.75% 2 MO; GC

OSPHENA ORAL TABLET 60MG 3 PA; MO

terconazole vaginal cream 0.4%, 0.8% 2 MO; GC

terconazole vaginal suppository 80mg 2 MO; GC

VANDAZOLE VAGINAL GEL 0.75% 4 MO

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)


Glucocorticoids/Mineralocorticoids

budesonide er oral tablet extended release 24hour 9mg

4 MO

budesonide oral capsule delayed release particles 3mg

4 MO

DEXAMETHASONE INTENSOL ORAL

CONCENTRATE 1MG/ML

1 MO; GC

dexamethasone oral elixir 0.5mg/5ml 2 MO; GC

dexamethasone oral tablet 0.5mg, 0.75mg, 1mg, 1.5mg, 2mg, 4mg

1 MO; GC

dexamethasone oral tablet 6mg 2 MO; GC

hydrocortisone oral tablet 10mg, 20mg, 5mg 1 MO; GC

methylprednisolone oral tablet 16mg, 32mg, 4mg, 8mg

2 MO; GC

methylprednisolone oral tablet therapy pack 4mg

2 MO; GC

prednisolone oral solution 15mg/5ml 2 MO; GC

prednisolone sodium phosphate oral solution


prednisolone sodium phosphate oral solution 25mg/5ml, 6.7 (5 base)mg/5ml

2 MO; GC

prednisolone sodium phosphate oral tablet dispersible 10mg, 15mg, 30mg

2 MO; GC

PREDNISONE INTENSOL ORAL CONCENTRATE 5MG/ML

1 MO; GC

prednisone oral solution 5mg/5ml 4 MO

prednisone oral tablet 1mg, 10mg, 2.5mg, 20mg, 5mg, 50mg

1 MO; GC

prednisone oral tablet therapy pack 10mg (21), 10mg (48), 5mg (21), 5mg (48)

1 MO; GC

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

cortisone acetate oral tablet 25mg 3 MO

DEMSER ORAL CAPSULE 250MG 5


fludrocortisone acetate oral tablet 0.1mg 1 MO; GC

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS)

Anabolic Steroids

ANADROL-50 ORAL TABLET 50MG 5

oxandrolone oral tablet 10mg 5 PA

oxandrolone oral tablet 2.5mg 4 PA; MO

Androgens

ANDRODERM TRANSDERMAL PATCH 24 HOUR 2MG/24HR, 4MG/24HR

3 PA2; MO

danazol oral capsule 100mg, 50mg 2 MO; GC

danazol oral capsule 200mg 4 MO

methyltestosterone oral capsule 10mg 5

testosterone cypionate intramuscular solution

100mg/ml, 200mg/ml, 200mg/ml (1 ml) 2 PA; MO; GC

testosterone enanthate intramuscular solution

200mg/ml 2 PA; MO; GC

testosterone transdermal gel 10mg/act (2%), 12.5mg/act (1%), 20.25mg/1.25gm (1.62%), 20.25mg/act (1.62%), 25mg/2.5gm (1%), 40.5mg/2.5gm (1.62%)

2 PA; MO; GC

testosterone transdermal gel 50mg/5gm (1%) 4 PA; MO

testosterone transdermal solution 30mg/act 2 PA; MO; GC

Contraceptives

ALTAVERA ORAL TABLET 0.15-30MG-MCG 2 MO; GC

alyacen 1/35 oral tablet 1-35mg-mcg 2 MO; GC

APRI ORAL TABLET 0.15-30MG-MCG 2 MO; GC

ARANELLE ORAL TABLET 0.5/1/0.5-35MG-MCG 2 MO; GC

AUBRA ORAL TABLET 0.1-20MG-MCG 2 MO; GC

AVIANE ORAL TABLET 0.1-20MG-MCG 2 MO; GC

BALZIVA ORAL TABLET 0.4-35MG-MCG 2 MO; GC

BLISOVI FE 1.5/30 ORAL TABLET 1.5-30MG-MCG 2 MO; GC


briellyn oral tablet 0.4-35mg-mcg 2 MO; GC

CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025MG 2 MO; GC

CRYSELLE-28 ORAL TABLET 0.3-30MG-MCG 2 MO; GC

CYCLAFEM 1/35 ORAL TABLET 1-35MG-MCG 2 MO; GC

CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35MG-

MCG

2 MO; GC

CYRED ORAL TABLET 0.15-30MG-MCG 2 MO; GC

DELYLA ORAL TABLET 0.1-20MG-MCG 2 MO; GC

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01mg (21/5), 0.15-30mg-mcg

2 MO; GC


4 MO


1 MO; GC

EMOQUETTE ORAL TABLET 0.15-30MG-MCG 2 MO; GC

ENPRESSE-28 ORAL TABLET 2 MO; GC

ENSKYCE ORAL TABLET 0.15-30MG-MCG 2 MO; GC

ESTARYLLA ORAL TABLET 0.25-35MG-MCG 2 MO; GC


1 MO; GC


2 MO; GC

FALMINA ORAL TABLET 0.1-20MG-MCG 2 MO; GC

FEMYNOR ORAL TABLET 0.25-35MG-MCG 2 MO; GC

GIANVI ORAL TABLET 3-0.02MG 4 MO

INTROVALE ORAL TABLET 0.15-0.03MG 2 MO; GC

ISIBLOOM ORAL TABLET 0.15-30MG-MCG 2 MO; GC

JASMIEL ORAL TABLET 3-0.02MG 4 MO

JULEBER ORAL TABLET 0.15-30MG-MCG 2 MO; GC

JUNEL 1.5/30 ORAL TABLET 1.5-30MG-MCG 2 MO; GC

JUNEL 1/20 ORAL TABLET 1-20MG-MCG 2 MO; GC


JUNEL FE 1.5/30 ORAL TABLET 1.5-30MG-MCG 2 MO; GC

JUNEL FE 1/20 ORAL TABLET 1-20MG-MCG 2 MO; GC

KARIVA ORAL TABLET 0.15-0.02/0.01MG (21/5) 2 MO; GC

KELNOR 1/35 ORAL TABLET 1-35MG-MCG 1 MO; GC

KELNOR 1/50 ORAL TABLET 1-50MG-MCG 2 MO; GC

KURVELO ORAL TABLET 0.15-30MG-MCG 2 MO; GC

LARIN 1.5/30 ORAL TABLET 1.5-30MG-MCG 4 MO

LARIN 1/20 ORAL TABLET 1-20MG-MCG 2 MO; GC

LARIN FE 1.5/30 ORAL TABLET 1.5-30MG-MCG 4 MO

LARIN FE 1/20 ORAL TABLET 1-20MG-MCG 4 MO

LARISSIA ORAL TABLET 0.1-20MG-MCG 2 MO; GC

LEENA ORAL TABLET 0.5/1/0.5-35MG-MCG 2 MO; GC

LESSINA ORAL TABLET 0.1-20MG-MCG 2 MO; GC

LEVONEST ORAL TABLET 2 MO; GC

levonorgest-eth estrad 91-day oral tablet 0.15-0.03mg

2 MO; GC

levonorgestrel-ethinyl estrad oral tablet 0.1-20mg-mcg, 0.15-30mg-mcg

2 MO; GC

levonorg-eth estrad triphasic oral tablet 2 MO; GC

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30MG-

MCG

2 MO; GC

LORYNA ORAL TABLET 3-0.02MG 4 MO

LOW-OGESTREL ORAL TABLET 0.3-30MG-MCG 2 MO; GC

LUTERA ORAL TABLET 0.1-20MG-MCG 2 MO; GC

marlissa oral tablet 0.15-30mg-mcg 2 MO; GC

medroxyprogesterone acetate intramuscular suspension 150mg/ml

4 MO

medroxyprogesterone acetate intramuscular suspension prefilled syringe 150mg/ml

4 MO

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30MG-MCG

2 MO; GC


MICROGESTIN 1/20 ORAL TABLET 1-20MG-MCG 2 MO; GC

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30MG-MCG

2 MO; GC

MICROGESTIN FE 1/20 ORAL TABLET 1-20MG-MCG

2 MO; GC

MILI ORAL TABLET 0.25-35MG-MCG 2 MO; GC

MONONESSA ORAL TABLET 0.25-35MG-MCG 2 MO; GC

NECON 0.5/35 (28) ORAL TABLET 0.5-35MG-MCG 2 MO; GC

NIKKI ORAL TABLET 3-0.02MG 4 MO

norethindrone acet-ethinyl est oral tablet 1-20mg-mcg

2 MO; GC

norgestimate-eth estradiol oral tablet 0.25-35mg-mcg

2 MO; GC

norgestim-eth estrad triphasic oral tablet

0.18/0.215/0.25mg-35mcg

1 MO; GC

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35MG-

MCG

2 MO; GC

NORTREL 1/35 (21) ORAL TABLET 1-35MG-MCG 2 MO; GC

NORTREL 1/35 (28) ORAL TABLET 1-35MG-MCG 2 MO; GC

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35MG-

MCG

2 MO; GC

NUVARING VAGINAL RING 0.12-0.015MG/24HR 4 MO

OCELLA ORAL TABLET 3-0.03MG 1 MO; GC

ORSYTHIA ORAL TABLET 0.1-20MG-MCG 2 MO; GC

PIMTREA ORAL TABLET 0.15-0.02/0.01MG (21/5) 2 MO; GC

PIRMELLA 1/35 ORAL TABLET 1-35MG-MCG 4 MO

PORTIA-28 ORAL TABLET 0.15-30MG-MCG 2 MO; GC

PREVIFEM ORAL TABLET 0.25-35MG-MCG 2 MO; GC

RECLIPSEN ORAL TABLET 0.15-30MG-MCG 2 MO; GC

SETLAKIN ORAL TABLET 0.15-0.03MG 2 MO; GC

SPRINTEC 28 ORAL TABLET 0.25-35MG-MCG 2 MO; GC

SRONYX ORAL TABLET 0.1-20MG-MCG 2 MO; GC


SYEDA ORAL TABLET 3-0.03MG 1 MO; GC

TARINA 24 FE ORAL TABLET 1-20MG-MCG(24) 4 MO

TARINA FE 1/20 ORAL TABLET 1-20MG-MCG 4 MO

TRI-ESTARYLLA ORAL TABLET

0.18/0.215/0.25MG-35 MCG

1 MO; GC

TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35MG-

MCG

2 MO; GC

TRI-MILI ORAL TABLET 0.18/0.215/0.25MG-35

MCG

1 MO; GC

TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25MG-

35 MCG

1 MO; GC

TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25MG-35 MCG

1 MO; GC

TRIVORA (28) ORAL TABLET 2 MO; GC

TRI-VYLIBRA ORAL TABLET 0.18/0.215/0.25MG-35 MCG

1 MO; GC

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025MG 2 MO; GC

VIENVA ORAL TABLET 0.1-20MG-MCG 2 MO; GC

VYFEMLA ORAL TABLET 0.4-35MG-MCG 2 MO; GC

VYLIBRA ORAL TABLET 0.25-35MG-MCG 2 MO; GC

ZOVIA 1/35E (28) ORAL TABLET 1-35MG-MCG 1 MO; GC

Estrogens

estradiol oral tablet 0.5mg, 1mg, 2mg 1 MO; GC

estradiol transdermal patch twice weekly

0.025mg/24hr, 0.0375mg/24hr, 0.05mg/24hr, 0.075mg/24hr, 0.1mg/24hr

2 MO; GC

estradiol transdermal patch weekly

0.025mg/24hr, 0.0375mg/24hr, 0.05mg/24hr, 0.06mg/24hr, 0.075mg/24hr, 0.1mg/24hr

2 MO; GC

MENEST ORAL TABLET 0.3MG, 0.625MG, 1.25MG 4 MO

norethindrone-eth estradiol oral tablet 1-5mg-mcg

2 MO; GC

Progestins


CAMILA ORAL TABLET 0.35MG 2 MO; GC

DEBLITANE ORAL TABLET 0.35MG 2 MO; GC

DEPO-PROVERA INTRAMUSCULAR SUSPENSION

400MG/ML

4 BvD; MO

ERRIN ORAL TABLET 0.35MG 2 MO; GC

INCASSIA ORAL TABLET 0.35MG 2 MO; GC

JOLIVETTE ORAL TABLET 0.35MG 2 MO; GC

LYZA ORAL TABLET 0.35MG 2 MO; GC

medroxyprogesterone acetate oral tablet 10mg, 2.5mg, 5mg

1 MO; GC

megestrol acetate oral suspension 40mg/ml 1 MO; GC

megestrol acetate oral suspension 625mg/5ml 4 MO

megestrol acetate oral tablet 20mg, 40mg 1 MO; GC

NORA-BE ORAL TABLET 0.35MG 2 MO; GC

norethindrone acetate oral tablet 5mg 2 MO; GC

norethindrone oral tablet 0.35mg 2 MO; GC

NORLYROC ORAL TABLET 0.35MG 2 MO; GC

PREMARIN ORAL TABLET 0.3MG, 0.45MG,

0.625MG, 0.9MG, 1.25MG

3 MO

PREMARIN VAGINAL CREAM 0.625MG/GM 3 MO

PREMPHASE ORAL TABLET 0.625-5MG 3 MO

PREMPRO ORAL TABLET 0.3-1.5MG, 0.45-1.5MG,

0.625-2.5MG, 0.625-5MG

3 MO

progesterone micronized oral capsule 100mg, 200mg

2 MO; GC

SHAROBEL ORAL TABLET 0.35MG 2 MO; GC

Selective Estrogen Receptor Modifying Agents

raloxifene hcl oral tablet 60mg 2 MO; GC; QL (30 EA per 30 days)

SOLTAMOX ORAL SOLUTION 10MG/5ML 4 PA2; MO

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)


cabergoline oral tablet 0.5mg 2 MO; GC

desmopressin ace spray refrig nasal solution 0.01%

2 MO; GC

desmopressin acetate oral tablet 0.1mg, 0.2mg 2 MO; GC

INCRELEX SUBCUTANEOUS SOLUTION 40MG/4ML

5 PA; LA

NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 55.3 MCG

4 MO

OMNITROPE SUBCUTANEOUS SOLUTION 10MG/1.5ML, 5MG/1.5ML

5 PA


RECONSTITUTED 5.8MG

5 PA

ORILISSA ORAL TABLET 150MG, 200MG 5 PA

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125

MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1 MO; GC

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

1 MO; GC

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125

MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

1 MO; GC

liothyronine sodium oral tablet 25mcg, 5mcg, 50mcg

1 MO; GC

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG,

25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

3 MO

UNITHROID ORAL TABLET 100 MCG, 112 MCG,

125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG,

300 MCG, 50 MCG, 75 MCG, 88 MCG

1 MO; GC

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

Hormonal Agents, Suppressant (Pituitary)


KORLYM ORAL TABLET 300MG 5 PA2; LA


2 PA; MO; GC


4 PA; MO

octreotide acetate injection solution 500mcg/ml 5 PA

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3MG/ML, 0.6MG/ML, 0.9MG/ML


SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120MG/0.5ML, 60MG/0.2ML,

90MG/0.3ML

5 PA2; QL (1ML per 28 days)

SOMAVERT SUBCUTANEOUS SOLUTION

RECONSTITUTED 10MG, 15MG, 20MG, 25MG,

30MG


SYNAREL NASAL SOLUTION 2MG/ML 5 PA

TRELSTAR MIXJECT INTRAMUSCULAR

SUSPENSION RECONSTITUTED 11.25MG, 22.5MG, 3.75MG

5 PA2

HORMONAL AGENTS, SUPPRESSANT (THYROID)

Antithyroid Agents

methimazole oral tablet 10mg, 5mg 1 MO; GC

propylthiouracil oral tablet 50mg 1 MO; GC

IMMUNOLOGICAL AGENTS

Immune Suppressants

AZASAN ORAL TABLET 100MG, 75MG 3 BvD; MO

azathioprine oral tablet 50mg 2 BvD; MO; GC

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 200MG/ML

5 PA

BENLYSTA SUBCUTANEOUS SOLUTION


5 PA

cyclosporine modified oral capsule 100mg, 25mg, 50mg

2 BvD; MO; GC

cyclosporine modified oral solution 100mg/ml 2 BvD; MO; GC


cyclosporine oral capsule 100mg, 25mg 2 BvD; MO; GC

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75MG, 1MG, 4MG

4 BvD; MO

GENGRAF ORAL CAPSULE 100MG 2 BvD; MO; GC

GENGRAF ORAL CAPSULE 25MG 1 BvD; MO; GC

GENGRAF ORAL SOLUTION 100MG/ML 2 BvD; MO; GC

methotrexate oral tablet 2.5mg 1 BvD; MO; GC

methotrexate sodium injection solution

50mg/2ml 1 BvD; MO; GC

mycophenolate mofetil oral capsule 250mg 4 BvD; MO

mycophenolate mofetil oral suspension reconstituted 200mg/ml

5 BvD

mycophenolate mofetil oral tablet 500mg 2 BvD; MO; GC

mycophenolate sodium oral tablet delayed release 180mg, 360mg

2 BvD; MO; GC

PROGRAF ORAL PACKET 0.2MG, 1MG 4 BvD; MO

SANDIMMUNE ORAL CAPSULE 100MG, 25MG 3 BvD; MO

SANDIMMUNE ORAL SOLUTION 100MG/ML 4 BvD; MO

sirolimus oral solution 1mg/ml 5 BvD

sirolimus oral tablet 0.5mg 2 BvD; MO; GC

sirolimus oral tablet 1mg, 2mg 4 BvD; MO

tacrolimus oral capsule 0.5mg 2 BvD; MO; GC

tacrolimus oral capsule 1mg, 5mg 4 BvD; MO

TREXALL ORAL TABLET 10MG, 15MG, 5MG, 7.5MG 4 BvD; MO

XATMEP ORAL SOLUTION 2.5MG/ML 4 BvD; MO

ZORTRESS ORAL TABLET 0.25MG 4 PA2; MO; QL (60 EA per 30 days)

ZORTRESS ORAL TABLET 0.5MG 5 PA2; QL (120 EA per 30 days)

ZORTRESS ORAL TABLET 0.75MG, 1MG 5 PA2; QL (60 EA per 30 days)

Immunomodulators

ACTIMMUNE SUBCUTANEOUS SOLUTION

2000000 UNIT/0.5ML

5 PA2; LA


ARCALYST SUBCUTANEOUS SOLUTION

RECONSTITUTED 220MG

5 PA; LA

COSENTYX (300MG DOSE) SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE 150MG/ML

5 PA

COSENTYX SENSOREADY (300MG)

SUBCUTANEOUS SOLUTION AUTO-INJECTOR

150MG/ML

5 PA

ENBREL SUBCUTANEOUS SOLUTION PREFILLED


5 PA

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25MG

5 PA

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50MG/ML

5 PA

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT

40MG/0.8ML, 40MG/0.8ML (6 PACK), 80MG/0.8ML,

80MG/0.8ML & 40MG/0.4ML

5 PA

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR

KIT 40MG/0.4ML, 40MG/0.8ML

5 PA

HUMIRA PEN-CD/UC/HS STARTER


40MG/0.8ML, 80MG/0.8ML

5 PA

HUMIRA PEN-PS/UV/ADOL HS START


40MG/0.8ML, 80MG/0.8ML & 40MG/0.4ML

5 PA

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE

KIT 10MG/0.1ML, 10MG/0.2ML, 20MG/0.2ML, 20MG/0.4ML, 40MG/0.4ML, 40MG/0.8ML

5 PA

leflunomide oral tablet 10mg 1 MO; GC

leflunomide oral tablet 20mg 2 MO; GC

OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML 3 BvD; MO

OCTAGAM INTRAVENOUS SOLUTION 2 GM/20ML 5 BvD

PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML,

10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30

GM/300ML, 5 GM/50ML

5 BvD


PRIVIGEN INTRAVENOUS SOLUTION 20

GM/200ML

5 BvD

STELARA SUBCUTANEOUS SOLUTION

45MG/0.5ML

5 PA

STELARA SUBCUTANEOUS SOLUTION PREFILLED


5 PA

XELJANZ ORAL TABLET 10MG, 5MG 5 PA

XELJANZ XR ORAL TABLET EXTENDED RELEASE

24 HOUR 11MG

5 PA

Vaccines

ACTHIB INTRAMUSCULAR SOLUTION

RECONSTITUTED

4 MO

ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5

(PREFILLED SYRINGE), 5-2-15.5 LF-MCG/0.5

4 MO

bcg vaccine injection injectable 4 MO

BEXSERO INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE

4 MO

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-

18.5 , 5-2.5-18.5 (0.5ML SYRINGE)

3 MO

DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-

5

4 MO

diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml

4 BvD; MO

ENGERIX-B INJECTION SUSPENSION 10

MCG/0.5ML, 20 MCG/ML

4 BvD; MO

GARDASIL 9 INTRAMUSCULAR SUSPENSION 4 MO

GARDASIL 9 INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE

4 MO

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL

U/ML, 1440 EL U/ML 1ML, 720 EL U/0.5ML, 720 EL U/0.5ML 0.5ML

4 MO

HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG

3 MO


IMOVAX RABIES INTRAMUSCULAR INJECTABLE

2.5 UNIT/ML

4 BvD; MO

INFANRIX INTRAMUSCULAR SUSPENSION 25-58-

10

4 MO

IPOL INJECTION INJECTABLE 3 MO

IXIARO INTRAMUSCULAR SUSPENSION 3 MO

KINRIX INTRAMUSCULAR SUSPENSION , INJECTION 0.5ML

4 MO

MENACTRA INTRAMUSCULAR INJECTABLE 4 MO

MENVEO INTRAMUSCULAR SOLUTION

RECONSTITUTED

4 MO

M-M-R II SUBCUTANEOUS INJECTABLE 3 MO

PEDIARIX INTRAMUSCULAR SUSPENSION 4 MO

PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5

MCG/0.5ML

4 MO

PROQUAD SUBCUTANEOUS SUSPENSION

RECONSTITUTED

4 MO

QUADRACEL INTRAMUSCULAR SUSPENSION 4 MO

RABAVERT INTRAMUSCULAR SUSPENSION

RECONSTITUTED

4 BvD; MO

RECOMBIVAX HB INJECTION SUSPENSION 10

MCG/ML, 10 MCG/ML (1ML SYRINGE), 40 MCG/ML, 5 MCG/0.5ML

4 BvD; MO

ROTARIX ORAL SUSPENSION RECONSTITUTED 4 MO

ROTATEQ ORAL SOLUTION 3 MO

SHINGRIX INTRAMUSCULAR SUSPENSION

RECONSTITUTED 50 MCG/0.5ML

3 MO

TDVAX INTRAMUSCULAR SUSPENSION 2-2

LF/0.5ML

3 BvD; MO

TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU 3 BvD; MO

TRUMENBA INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE

4 MO


TWINRIX INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 720-20 ELU-MCG/ML

4 BvD; MO

TYPHIM VI INTRAMUSCULAR SOLUTION 25

MCG/0.5ML, 25 MCG/0.5ML (0.5ML SYRINGE)

4 MO

VAQTA INTRAMUSCULAR SUSPENSION 25

UNIT/0.5ML, 25 UNIT/0.5ML 0.5ML, 50 UNIT/ML,

50 UNIT/ML 1ML

4 MO

VARIVAX SUBCUTANEOUS INJECTABLE 1350

PFU/0.5ML

4 MO

VARIZIG INTRAMUSCULAR SOLUTION 125 UNIT/1.2ML

4 MO

YF-VAX SUBCUTANEOUS INJECTABLE 4 MO

ZOSTAVAX SUBCUTANEOUS SUSPENSION

RECONSTITUTED 19400 UNT/0.65ML

4 MO

INFLAMMATORY BOWEL DISEASE AGENTS

Aminosalicylates

APRISO ORAL CAPSULE EXTENDED RELEASE 24

HOUR 0.375 GM

3 MO

balsalazide disodium oral capsule 750mg 2 MO; GC

LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM 3 MO

mesalamine rectal enema 4gm 4 MO

sulfasalazine oral tablet 500mg 1 MO; GC

sulfasalazine oral tablet delayed release 500mg 1 MO; GC

METABOLIC BONE DISEASE AGENTS

Metabolic Bone Disease Agents

alendronate sodium oral tablet 10mg, 40mg, 5mg


alendronate sodium oral tablet 35mg 1 MO; GC; QL (4 EA per 28 days)

alendronate sodium oral tablet 70mg 2 MO; GC; QL (4 EA per 28 days)

calcitonin (salmon) nasal solution 200 unit/act 2 BvD; MO; GC

calcitriol oral capsule 0.25mcg, 0.5mcg 1 BvD; MO; GC

calcitriol oral solution 1mcg/ml 2 BvD; MO; GC


cinacalcet hcl oral tablet 30mg 4 BvD; MO; QL (60 EA per 30 days)



doxercalciferol oral capsule 0.5mcg, 1mcg, 2.5mcg

2 BvD; MO; GC

FORTEO SUBCUTANEOUS SOLUTION 600

MCG/2.4ML

5 PA; QL (2.4ML per 28 days)

ibandronate sodium oral tablet 150mg 1 MO; GC; QL (1 EA per 30 days)

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG,

25 MCG, 50 MCG, 75 MCG

5 LA

paricalcitol oral capsule 1mcg, 2mcg, 4mcg 4 BvD; MO

PROLIA SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 60MG/ML

4 ST; MO; QL (1ML per 180 days)

risedronate sodium oral tablet 150mg 2 MO; GC; QL (1 EA per 28 days)

risedronate sodium oral tablet 30mg, 5mg 2 MO; GC; QL (30 EA per 30 days)

risedronate sodium oral tablet 35mg, 35mg (12 pack), 35mg (4 pack)


risedronate sodium oral tablet delayed release

35mg


TYMLOS SUBCUTANEOUS SOLUTION PEN-

INJECTOR 3120 MCG/1.56ML

5 PA

XGEVA SUBCUTANEOUS SOLUTION 120MG/1.7ML 5 PA; QL (2ML per 28 days)

MISCELLANEOUS

Miscellaneous

cvs gauze sterile pad 2"x2" 6 MO; GC

hydroxychloroquine sulfate oral tablet 200mg 1 MO; GC

OPHTHALMIC AGENTS

Ophthalmic Agents, Other

atropine sulfate ophthalmic solution 1% 2 MO; GC


CYSTARAN OPHTHALMIC SOLUTION 0.44% 5 PA

RESTASIS OPHTHALMIC EMULSION 0.05% 3 MO; QL (60 EA per 30 days)

Ophthalmic Anti-Allergy Agents

azelastine hcl ophthalmic solution 0.05% 2 MO; GC

BEPREVE OPHTHALMIC SOLUTION 1.5% 4 MO

cromolyn sodium ophthalmic solution 4% 1 MO; GC

olopatadine hcl ophthalmic solution 0.1% 2 MO; GC

olopatadine hcl ophthalmic solution 0.2% 3 MO

OXERVATE OPHTHALMIC SOLUTION 0.002% 5 PA

PAZEO OPHTHALMIC SOLUTION 0.7% 4 MO

Ophthalmic Antiglaucoma Agents

ALPHAGAN P OPHTHALMIC SOLUTION 0.1% 3 MO

apraclonidine hcl ophthalmic solution 0.5% 2 MO; GC

AZOPT OPHTHALMIC SUSPENSION 1% 3 MO

betaxolol hcl ophthalmic solution 0.5% 2 MO; GC

brimonidine tartrate ophthalmic solution 0.15%, 0.2%

2 MO; GC

carteolol hcl ophthalmic solution 1% 1 MO; GC

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5% 4 MO

dorzolamide hcl ophthalmic solution 2% 1 MO; GC

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8mg/ml

4 MO

dorzolamide hcl-timolol mal pf ophthalmic solution 22.3-6.8mg/ml

4 MO

levobunolol hcl ophthalmic solution 0.5% 1 MO; GC

pilocarpine hcl ophthalmic solution 1%, 2%, 4% 2 MO; GC

RHOPRESSA OPHTHALMIC SOLUTION 0.02% 4 MO

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2% 4 MO

timolol maleate ophthalmic gel forming solution

0.25%, 0.5%

2 MO; GC


timolol maleate ophthalmic solution 0.25%, 0.5%, 0.5% (daily)

1 MO; GC

Ophthalmic Anti-Infectives

AZASITE OPHTHALMIC SOLUTION 1% 4 MO

bacitracin ophthalmic ointment 500 unit/gm 2 MO; GC

bacitracin-polymyxin b ophthalmic ointment

500-10000 unit/gm

1 MO; GC

BESIVANCE OPHTHALMIC SUSPENSION 0.6% 4 MO

ciprofloxacin hcl ophthalmic solution 0.3% 1 MO; GC

erythromycin ophthalmic ointment 5mg/gm 1 MO; GC

gatifloxacin ophthalmic solution 0.5% 2 MO; GC

GENTAK OPHTHALMIC OINTMENT 0.3% 2 MO; GC

gentamicin sulfate ophthalmic solution 0.3% 1 MO; GC

MOXEZA OPHTHALMIC SOLUTION 0.5% 3 MO

moxifloxacin hcl ophthalmic solution 0.5% 2 MO; GC

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

2 MO; GC

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

2 MO; GC

ofloxacin ophthalmic solution 0.3% 2 MO; GC

polymyxin b-trimethoprim ophthalmic solution

10000-0.1 unit/ml-%

1 MO; GC

sulfacetamide sodium ophthalmic ointment 10% 4 MO

sulfacetamide sodium ophthalmic solution 10% 1 MO; GC

tobramycin ophthalmic solution 0.3% 1 MO; GC

trifluridine ophthalmic solution 1% 2 MO; GC

Ophthalmic Anti-Inflammatories

bacitra-neomycin-polymyxin-hc ophthalmic ointment 1%

2 MO; GC


BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-

0.2%

4 MO

bromfenac sodium (once-daily) ophthalmic solution 0.09%

2 MO; GC

BROMSITE OPHTHALMIC SOLUTION 0.075% 4 MO

dexamethasone sodium phosphate ophthalmic solution 0.1%

2 MO; GC

diclofenac sodium ophthalmic solution 0.1% 2 MO; GC

DUREZOL OPHTHALMIC EMULSION 0.05% 3 MO

fluorometholone ophthalmic suspension 0.1% 2 MO; GC

flurbiprofen sodium ophthalmic solution 0.03% 1 MO; GC

ILEVRO OPHTHALMIC SUSPENSION 0.3% 3 MO

ketorolac tromethamine ophthalmic solution

0.4%, 0.5%

2 MO; GC

LOTEMAX OPHTHALMIC GEL 0.5% 4 MO

LOTEMAX OPHTHALMIC OINTMENT 0.5% 4 MO

LOTEMAX SM OPHTHALMIC GEL 0.38% 4 MO

loteprednol etabonate ophthalmic suspension

0.5%

2 MO; GC

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

2 MO; GC

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1 MO; GC

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

2 MO; GC

prednisolone acetate ophthalmic suspension 1% 2 MO; GC

prednisolone sodium phosphate ophthalmic solution 1%

2 MO; GC

PROLENSA OPHTHALMIC SOLUTION 0.07% 4 MO

sulfacetamide-prednisolone ophthalmic solution 10-0.23%

2 MO; GC

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1%

2 MO; GC


ZYLET OPHTHALMIC SUSPENSION 0.5-0.3% 4 MO

Ophthalmic Prostaglandin And Prostamide Analogs

latanoprost ophthalmic solution 0.005% 2 MO; GC

LUMIGAN OPHTHALMIC SOLUTION 0.01% 3 MO

TRAVATAN Z OPHTHALMIC SOLUTION 0.004% 3 MO

VYZULTA OPHTHALMIC SOLUTION 0.024% 4 MO

ZIOPTAN OPHTHALMIC SOLUTION 0.0015% 4 MO

OTIC AGENTS

Otic Agents

acetic acid otic solution 2% 1 MO; GC

CIPRODEX OTIC SUSPENSION 0.3-0.1% 4 MO

ciprofloxacin hcl otic solution 0.2% 4 MO

fluocinolone acetonide otic oil 0.01% 2 MO; GC

neomycin-polymyxin-hc otic solution 1% 2 MO; GC

neomycin-polymyxin-hc otic suspension 3.5-10000-1

2 MO; GC

ofloxacin otic solution 0.3% 4 MO

RESPIRATORY TRACT AGENTS

Antihistamines

cetirizine hcl oral solution 1mg/ml 1 MO; GC

clemastine fumarate oral tablet 2.68mg 1 MO; GC

desloratadine oral tablet 5mg 2 MO; GC

levocetirizine dihydrochloride oral solution

2.5mg/5ml 2 MO; GC

levocetirizine dihydrochloride oral tablet 5mg 2 MO; GC

Anti-Inflammatories, Inhaled Corticosteroids

ARNUITY ELLIPTA INHALATION AEROSOL

POWDER BREATH ACTIVATED 100 MCG/ACT, 200

MCG/ACT, 50 MCG/ACT





MCG/INH



AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH


ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220

MCG/INH


ASMANEX HFA INHALATION AEROSOL 100



budesonide inhalation suspension 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml

4 BvD; MO

FLOVENT DISKUS INHALATION AEROSOL

POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST


FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT


FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT

3 MO; QL (21.2 GM per 30 days)

Antileukotrienes

montelukast sodium oral packet 4mg 2 MO; GC; QL (30 EA per 30 days)

montelukast sodium oral tablet 10mg 1 MO; GC; QL (30 EA per 30 days)

montelukast sodium oral tablet chewable 4mg, 5mg


zafirlukast oral tablet 10mg, 20mg 2 MO; GC; QL (60 EA per 30 days)

Bronchodilators, Anticholinergic

acetylcysteine inhalation solution 10%, 20% 2 BvD; MO; GC

ipratropium bromide inhalation solution 0.02% 1 BvD; MO; GC

SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG


SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT


Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)


DALIRESP ORAL TABLET 250 MCG, 500 MCG 3 MO; QL (30 EA per 30 days)

sildenafil citrate oral tablet 20mg 2 PA; MO; GC; QL (90 EA per 30 days)

theophylline er oral tablet extended release 12hour 100mg, 200mg, 300mg

1 MO; GC

theophylline er oral tablet extended release 24hour 400mg, 600mg

1 MO; GC

theophylline oral solution 80mg/15ml 4 MO

Bronchodilators, Sympathomimetic

albuterol sulfate hfa inhalation aerosol solution

108 (90 base)mcg/act (nda020983) 2 MO; GC; QL (36 GM per 30 days)

albuterol sulfate inhalation nebulization solution

(2.5mg/3ml) 0.083%, (5mg/ml) 0.5%, 0.63mg/3ml, 1.25mg/3ml

2 BvD; MO; GC

albuterol sulfate oral syrup 2mg/5ml 1 MO; GC

albuterol sulfate oral tablet 2mg, 4mg 2 MO; GC

COMBIVENT RESPIMAT INHALATION AEROSOL

SOLUTION 20-100 MCG/ACT


ipratropium-albuterol inhalation solution 0.5-2.5 (3)mg/3ml

2 BvD; MO; GC

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE


terbutaline sulfate oral tablet 2.5mg, 5mg 2 MO; GC

VENTOLIN HFA INHALATION AEROSOL SOLUTION

108 (90 BASE) MCG/ACT


Nasal Agents

azelastine hcl nasal solution 0.1%, 0.15% 2 MO; GC; QL (30ML per 25 days)

flunisolide nasal solution 25mcg/act (0.025%) 2 MO; GC; QL (50ML per 30 days)

fluticasone propionate nasal suspension

50mcg/act

1 MO; GC; QL (16 GM per 30 days)

ipratropium bromide nasal solution 0.03% 1 MO; GC; QL (60ML per 30 days)

ipratropium bromide nasal solution 0.06% 1 MO; GC; QL (30ML per 30 days)

mometasone furoate nasal suspension 50mcg/act

2 MO; GC; QL (34 GM per 30 days)


Pulmonary Antihypertensives

ADEMPAS ORAL TABLET 0.5MG, 1MG, 1.5MG, 2MG, 2.5MG


ambrisentan oral tablet 10mg, 5mg 5 PA; QL (30 EA per 30 days)

bosentan oral tablet 125mg, 62.5mg 5 PA; LA; QL (60 EA per 30 days)

OPSUMIT ORAL TABLET 10MG 5 PA; LA; QL (90 EA per 30 days)

TRACLEER ORAL TABLET SOLUBLE 32MG 5 PA; LA; QL (120 EA per 30 days)

UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG,

1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600

MCG, 800 MCG


UPTRAVI ORAL TABLET THERAPY PACK 200 & 800

MCG


Pulmonary Fibrosis Agents

ESBRIET ORAL CAPSULE 267MG 5 PA

ESBRIET ORAL TABLET 267MG, 801MG 5 PA

OFEV ORAL CAPSULE 100MG, 150MG 5 PA; LA

Respiratory Tract Agents, Other

ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50

MCG/DOSE, 500-50 MCG/DOSE


ADVAIR HFA INHALATION AEROSOL 115-21

MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT


ANORO ELLIPTA INHALATION AEROSOL POWDER

BREATH ACTIVATED 62.5-25 MCG/INH


BREO ELLIPTA INHALATION AEROSOL POWDER

BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH


cromolyn sodium inhalation nebulization solution 20mg/2ml

3 BvD; MO

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200MG/1.14ML, 300MG/2ML

5 PA

epinephrine injection solution auto-injector

0.15mg/0.3ml, 0.3mg/0.3ml 2 MO; GC


fluticasone-salmeterol inhalation aerosol powder breath activated 113-14mcg/act, 232-14mcg/act, 55-14mcg/act


KALYDECO ORAL PACKET 25MG, 50MG, 75MG 5 PA; LA

KALYDECO ORAL TABLET 150MG 5 PA; LA

ORKAMBI ORAL PACKET 100-125MG, 150-188MG 5 PA; LA

ORKAMBI ORAL TABLET 100-125MG, 200-125MG 5 PA; LA

PROLASTIN-C INTRAVENOUS SOLUTION

RECONSTITUTED 1000MG

5 PA; LA

PULMOZYME INHALATION SOLUTION 1MG/ML 5 PA

STIOLTO RESPIMAT INHALATION AEROSOL

SOLUTION 2.5-2.5 MCG/ACT


SYMDEKO ORAL TABLET THERAPY PACK 100-150

& 150MG

5 PA; LA

TOBI PODHALER INHALATION CAPSULE 28MG 5 PA

TRELEGY ELLIPTA INHALATION AEROSOL

POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH


XOLAIR SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 150MG/ML, 75MG/0.5ML

5 PA; LA

XOLAIR SUBCUTANEOUS SOLUTION

RECONSTITUTED 150MG

5 PA; LA

SKELETAL MUSCLE RELAXANTS

Skeletal Muscle Relaxants

baclofen oral tablet 10mg, 20mg, 5mg 1 MO; GC

carisoprodol oral tablet 250mg 4 MO

carisoprodol oral tablet 350mg 1 MO; GC

carisoprodol-aspirin oral tablet 200-325mg 4 MO

chlorzoxazone oral tablet 375mg, 750mg 2 MO; GC

chlorzoxazone oral tablet 500mg 1 MO; GC

cyclobenzaprine hcl oral tablet 10mg, 5mg 2 MO; GC

cyclobenzaprine hcl oral tablet 7.5mg 4 MO


metaxalone oral tablet 800mg 4 MO

methocarbamol oral tablet 500mg, 750mg 1 MO; GC

orphenadrine citrate er oral tablet extended release 12hour 100mg

2 MO; GC

tizanidine hcl oral tablet 2mg, 4mg 2 MO; GC

SLEEP DISORDER AGENTS

Benzodiazepines

oxazepam oral capsule 10mg, 15mg, 30mg 2 MO; GC; QL (120 EA per 30 days)

temazepam oral capsule 15mg, 30mg 1 MO; GC; QL (30 EA per 30 days)

temazepam oral capsule 22.5mg 4 MO; QL (30 EA per 30 days)

temazepam oral capsule 7.5mg 2 MO; GC; QL (120 EA per 30 days)

Gaba Receptor Modulators

zaleplon oral capsule 10mg, 5mg 2 MO; GC; QL (30 EA per 30 days)

zolpidem tartrate oral tablet 10mg 2 MO; GC; QL (30 EA per 30 days)

zolpidem tartrate oral tablet 5mg 2 MO; GC; QL (60 EA per 30 days)

Sleep Disorders, Other

armodafinil oral tablet 150mg, 200mg, 250mg 4 PA; MO

armodafinil oral tablet 50mg 3 PA; MO

BELSOMRA ORAL TABLET 10MG, 15MG, 20MG,

5MG


HETLIOZ ORAL CAPSULE 20MG 5 PA; QL (30 EA per 30 days)

modafinil oral tablet 100mg, 200mg 3 PA; MO

SILENOR ORAL TABLET 3MG, 6MG 4 MO; QL (30 EA per 30 days)

XYREM ORAL SOLUTION 500MG/ML 5 PA; LA; QL (540ML per 30 days)

Index of Drugs

A abacavir sulfate ............................. 51, 152

abacavir sulfate-lamivudine .......... 51, 152

abacavir-lamivudine-zidovudine .. 51, 152

ABELCET ......................................... 31, 132

ABILIFY MAINTENA ................... 46, 47, 147

abiraterone acetate ....................... 37, 138

acamprosate calcium .................... 15, 116

acarbose ......................................... 56, 156

acebutolol hcl ................................ 64, 165

acetaminophen-codeine ............... 13, 114

acetaminophen-codeine #3 .......... 13, 114

acetazolamide ............................... 67, 168

acetazolamide er ........................... 67, 168

acetic acid .................................... 102, 204

acetylcysteine .............................. 104, 205

acitretin .......................................... 72, 174

ACTHIB ........................................... 95, 197

ACTIMMUNE ................................... 94, 196

acyclovir ......................................... 50, 151

acyclovir sodium ............................ 50, 151

ADACEL ........................................... 96, 197

adefovir dipivoxil ........................... 49, 150

ADEMPAS ...................................... 105, 207

ADVAIR DISKUS ............................ 106, 207

ADVAIR HFA .................................. 106, 207

AFINITOR ........................................ 37, 138

AFINITOR DISPERZ ......................... 37, 138

albendazole ................................... 43, 144

albuterol sulfate .......................... 104, 206

albuterol sulfate hfa .................... 104, 206

alclometasone dipropionate ......... 72, 174

ALECENSA ...................................... 37, 138

alendronate sodium .............. 98, 199, 200

alfuzosin hcl er ............................... 83, 185

ALINIA ............................................. 43, 144

aliskiren fumarate .......................... 66, 167

allopurinol ...................................... 33, 134

alosetron hcl .................................. 81, 182

ALPHAGAN P .................................. 99, 201

alprazolam ..................................... 54, 155

ALPRAZOLAM INTENSOL ............... 54, 155

ALTAVERA ....................................... 86, 187

ALUNBRIG ................................ 37, 38, 138

alyacen 1/35 ................................... 86, 187

amantadine hcl .............................. 44, 145

AMBISOME ...................................... 31, 132

ambrisentan ................................. 105, 207

amcinonide .................................... 72, 174

amikacin sulfate ............................ 16, 117

amiloride hcl .................................. 67, 168

amiloride-hydrochlorothiazide ..... 62, 163

AMINOSYN II ................................... 78, 180

AMINOSYN-PF ................................ 78, 180

amiodarone hcl.............................. 62, 163

AMITIZA .......................................... 81, 182

amitriptyline hcl ............................ 30, 131

amlodipine besy-benazepril hcl .... 62, 163

amlodipine besylate ...................... 65, 166

amlodipine besylate-valsartan ..... 62, 163

amlodipine-atorvastatin ............... 66, 167

amlodipine-olmesartan ................ 62, 163

amlodipine-valsartan-hctz ............ 63, 164

ammonium lactate ........................ 72, 174

AMNESTEEM ................................... 72, 174

amoxapine ..................................... 30, 131

amoxicillin ..................................... 20, 121

amoxicillin-pot clavulanate .......... 20, 121

amoxicillin-pot clavulanate er ...... 20, 121

amphetamine-dextroamphetamine .... 70,

171

amphotericin b .............................. 32, 132

ampicillin ....................................... 20, 121

ampicillin sodium .......................... 20, 121

ampicillin-sulbactam sodium ....... 20, 121

ANADROL-50 .................................. 85, 187

anagrelide hcl ................................ 60, 161

anastrozole .................................... 43, 144

ANDRODERM .................................. 85, 187

ANORO ELLIPTA ........................... 106, 207

APOKYN .......................................... 45, 146

apraclonidine hcl ........................... 99, 201

aprepitant ...................................... 31, 132

APRI ................................................ 86, 187

APRISO ........................................... 98, 199

APTIOM .......................................... 26, 127

APTIVUS ................................. 53, 153, 154

ARANELLE ...................................... 86, 187

ARCALYST ....................................... 94, 196

ARIKAYCE ....................................... 16, 117

aripiprazole .................................... 47, 147

armodafinil .................................. 108, 209

ARNUITY ELLIPTA ......................... 103, 205

ASMANEX (120 METERED DOSES) 103, 205

ASMANEX (30 METERED DOSES) .. 103, 205

ASMANEX (60 METERED DOSES) .. 103, 205

ASMANEX HFA .............................. 103, 205

aspirin-dipyridamole er ................. 60, 161

ASSURE ID INSULIN SAFETY SYR ... 55, 156

atazanavir sulfate .......................... 53, 154

atenolol .......................................... 64, 165

atenolol-chlorthalidone ................ 63, 164

atomoxetine hcl ............................. 70, 172

atorvastatin calcium ..................... 68, 169

atovaquone ................................... 43, 144

atovaquone-proguanil hcl ............ 43, 144

ATRIPLA ......................................... 50, 151

atropine sulfate ............................. 99, 201

AUBRA ............................................ 86, 188

AURYXIA ......................................... 83, 185

AUSTEDO ....................................... 71, 172

AVIANE ........................................... 86, 188

AVONEX .......................................... 71, 173

AVONEX PEN .................................. 71, 173

AVONEX PREFILLED ....................... 71, 173

AZACTAM........................................ 19, 120

AZASAN .......................................... 93, 194

AZASITE........................................ 100, 202

azathioprine .................................. 93, 195

azelastine hcl .................. 99, 105, 201, 206

azithromycin .................................. 21, 122

AZOPT ............................................ 99, 201

aztreonam ..................................... 19, 120

B bacitracin ..................................... 100, 202

bacitracin-polymyxin b ............... 100, 202

bacitra-neomycin-polymyxin-hc 101, 203

baclofen ....................................... 107, 208

BACTOCILL IN DEXTROSE .............. 20, 121

balsalazide disodium .................... 98, 199

BALVERSA ...................................... 38, 138

BALZIVA .......................................... 86, 188

BANZEL .......................................... 26, 127

BARACLUDE ................................... 49, 150

bcg vaccine .................................... 96, 197

BELSOMRA ................................... 108, 209

benazepril hcl ................................ 61, 162

benazepril-hydrochlorothiazide ... 63, 164

BENLYSTA ...................................... 93, 195

benznidazole ................................. 43, 144

benzoyl peroxide-erythromycin .... 72, 174

benztropine mesylate ................... 44, 145

BEPREVE ........................................ 99, 201

BESIVANCE ................................... 100, 202

betamethasone dipropionate ....... 73, 174

betamethasone dipropionate aug 73, 174

betamethasone valerate ............... 73, 174

BETASERON ................................... 71, 173

betaxolol hcl ..................... 64, 99, 165, 201

bethanechol chloride .................... 83, 185

bexarotene .................................... 38, 138

BEXSERO ........................................ 96, 197

bicalutamide ................................. 38, 139

BICILLIN L-A .................................... 20, 121

BIKTARVY ........................................ 52, 153

bisoprolol fumarate ....................... 64, 165

bisoprolol-hydrochlorothiazide .... 63, 164

BLEPHAMIDE S.O.P. ..................... 101, 203

BLISOVI FE 1.5/30 ........................... 86, 188

BOOSTRIX ....................................... 96, 197

bosentan ...................................... 105, 207

BOSULIF ......................................... 38, 139

BRAFTOVI ....................................... 38, 139

BREO ELLIPTA .............................. 106, 207

briellyn ........................................... 86, 188

BRILINTA ........................................ 60, 161

brimonidine tartrate .................... 100, 201

BRIVIACT ........................................ 23, 124

bromfenac sodium (once-daily) .. 101, 203

bromocriptine mesylate ................ 45, 146

BROMSITE .................................... 101, 203

budesonide ..................... 84, 103, 186, 205

budesonide er ................................ 84, 186

bumetanide.................................... 67, 168

buprenorphine hcl ......................... 15, 116

buprenorphine hcl-naloxone hcl ... 16, 117

bupropion hcl ................................ 28, 129

bupropion hcl er (smoking det) ..... 16, 117

bupropion hcl er (sr) ...................... 28, 129

bupropion hcl er (xl) ...................... 28, 129

buspirone hcl ................................. 54, 155

butalbital-acetaminophen ............ 13, 114

butalbital-apap-caffeine ............... 13, 114

butalbital-asa-caff-codeine ........... 13, 114

butalbital-aspirin-caffeine............. 14, 115

BYSTOLIC ....................................... 64, 165

C cabergoline .................................... 91, 193

CABLIVI ........................................... 60, 161

CABOMETYX ................................... 38, 139

calcipotriene .................................. 73, 174

calcitonin (salmon) ........................ 98, 200

calcitriol ......................................... 98, 200

calcium acetate (phos binder)....... 83, 185

CALQUENCE ................................... 38, 139

CAMILA ........................................... 90, 192

candesartan cilexetil ..................... 61, 162

candesartan cilexetil-hctz ............. 63, 164

CAPRELSA....................................... 38, 139

captopril ......................................... 61, 162

captopril-hydrochlorothiazide ...... 63, 164

CARAFATE ....................................... 81, 183

CARBAGLU ...................................... 82, 184

carbamazepine .............................. 23, 124

carbamazepine er .......................... 23, 124

carbidopa-levodopa ...................... 44, 145

carbidopa-levodopa er .................. 44, 145

carbidopa-levodopa-entacapone . 44, 145

CARDURA XL ......................................... 185

carisoprodol ................................. 107, 208

carisoprodol-aspirin .................... 107, 209

carteolol hcl ................................. 100, 201

CARTIA XT ....................................... 65, 166

carvedilol ....................................... 64, 165

carvedilol phosphate er....................... 165

caspofungin acetate ...................... 32, 132

CAYSTON ........................................ 19, 120

CAZIANT ......................................... 86, 188

cefaclor .......................................... 18, 119

cefaclor er ...................................... 18, 119

cefadroxil ....................................... 18, 119

cefazolin sodium ........................... 18, 119

cefdinir ........................................... 18, 119

cefepime hcl................................... 18, 119

cefixime .......................................... 18, 119

cefotetan disodium ....................... 18, 119

cefoxitin sodium ............................ 18, 119

cefpodoxime proxetil .................... 19, 120

cefprozil ......................................... 19, 120

ceftazidime .................................... 19, 120

ceftriaxone sodium ........................ 19, 120

cefuroxime axetil ........................... 19, 120

cefuroxime sodium ........................ 19, 120

celecoxib ........................................ 33, 134

CELONTIN ...................................... 25, 126

cephalexin ...................................... 19, 120

cetirizine hcl ................................. 103, 204

CHANTIX ......................................... 16, 117

CHANTIX CONTINUING MONTH PAK .... 16,

117

CHANTIX STARTING MONTH PAK .. 16, 117

CHEMET.......................................... 78, 179

chlordiazepoxide hcl ..................... 54, 155

chlorhexidine gluconate ................ 72, 173

chloroquine phosphate ................. 43, 144

chlorothiazide ................................ 67, 169

chlorpromazine hcl........................ 45, 146

chlorthalidone ............................... 67, 169

chlorzoxazone.............................. 107, 209

cholestyramine .............................. 68, 170

cholestyramine light ...................... 68, 170

ciclopirox ............................... 32, 132, 133

ciclopirox olamine ......................... 32, 133

cilostazol ........................................ 60, 161

CIMDUO .......................................... 51, 152

cinacalcet hcl ................................. 98, 200

CINRYZE ......................................... 66, 167

CIPRODEX..................................... 102, 204

ciprofloxacin .................................. 22, 123

ciprofloxacin hcl .... 22, 100, 102, 123, 202,

204

ciprofloxacin in d5w ...................... 22, 123

citalopram hydrobromide ............. 29, 130

CLARAVIS ........................................ 73, 175

clarithromycin ............................... 21, 122

clarithromycin er ........................... 21, 122

clemastine fumarate ................... 103, 204

CLENPIQ ......................................... 81, 182

clindamycin hcl .............................. 16, 117

clindamycin palmitate hcl ............ 17, 118

clindamycin phos-benzoyl perox .. 73, 175

clindamycin phosphate..... 17, 73, 84, 118,

175, 185

clindamycin phosphate in d5w ..... 17, 118

CLINIMIX E/DEXTROSE (2.75/5) ..... 78, 180

CLINIMIX E/DEXTROSE (4.25/10) ... 78, 180

CLINIMIX E/DEXTROSE (4.25/5) ..... 78, 180

CLINIMIX E/DEXTROSE (5/15) ........ 78, 180

CLINIMIX E/DEXTROSE (5/20) ........ 79, 180

CLINIMIX/DEXTROSE (4.25/10) ...... 79, 180

CLINIMIX/DEXTROSE (4.25/5) ........ 79, 180

CLINIMIX/DEXTROSE (5/15) ........... 79, 180

CLINIMIX/DEXTROSE (5/20) ........... 79, 180

clobazam ....................................... 24, 125

clobetasol propionate ................... 73, 175

clobetasol propionate e ................ 73, 175

clomipramine hcl .......................... 30, 131

clonazepam .............................. 54, 55, 155

clonidine ........................................ 60, 161

clonidine hcl .................................. 60, 161

clopidogrel bisulfate ..................... 60, 161

clorazepate dipotassium .............. 55, 155

clotrimazole ................................... 32, 133

clotrimazole-betamethasone ....... 73, 175

clozapine .................................. 45, 46, 146

COARTEM ....................................... 43, 144

codeine sulfate .............................. 14, 115

colchicine ....................................... 33, 134

colchicine-probenecid .................. 33, 134

colesevelam hcl ............................. 68, 170

colestipol hcl ................................. 69, 170

colistimethate sodium (cba) ......... 17, 118

COLOCORT ..................................... 73, 175

COMBIGAN ................................... 100, 201

COMBIVENT RESPIMAT ................ 104, 206

COMETRIQ (100 MG DAILY DOSE) .. 38, 139

COMETRIQ (140 MG DAILY DOSE) .. 38, 139

COMETRIQ (60 MG DAILY DOSE) .... 38, 139

COMFORT ASSIST INSULIN SYRINGE ... 56,

156

COMPLERA ..................................... 50, 151

COMPRO ........................................ 31, 131

constulose ..................................... 81, 182

COPAXONE ..................................... 71, 173

COPIKTRA ...................................... 38, 139

CORLANOR ..................................... 66, 167

cortisone acetate ........................... 85, 187

COSENTYX (300 MG DOSE) ............ 94, 196

COSENTYX SENSOREADY (300 MG) 94, 196

COTELLIC ....................................... 38, 139

COUMADIN ........................................... 159

CREON............................................ 80, 181

CRIXIVAN ........................................ 53, 154

cromolyn sodium .... 80, 99, 106, 181, 201,

208

CRYSELLE-28 .................................. 86, 188

cvs gauze sterile ............................ 99, 200

CYCLAFEM 1/35 .............................. 86, 188

CYCLAFEM 7/7/7 ............................. 86, 188

cyclobenzaprine hcl ..................... 107, 209

cyclophosphamide ........................ 37, 137

cyclosporine ................................... 93, 195

cyclosporine modified ................... 93, 195

CYRED ............................................. 86, 188

CYSTADANE .................................... 82, 184

CYSTAGON ...................................... 83, 185

CYSTARAN ...................................... 99, 201

D dalfampridine er ............................ 72, 173

DALIRESP ..................................... 104, 206

danazol........................................... 85, 187

dapsone ......................................... 17, 118

DAPTACEL ...................................... 96, 197

daptomycin .................................... 17, 118

DARAPRIM ...................................... 43, 144

darifenacin hydrobromide er ........ 83, 184

DAURISMO ...................................... 38, 139

DEBLITANE ..................................... 90, 192

deferasirox ..................................... 78, 179

DELSTRIGO ..................................... 50, 151

DELYLA ........................................... 86, 188

DEMSER .......................................... 85, 187

DEPEN TITRATABS ......................... 37, 138

DEPO-PROVERA ............................. 90, 192

DESCOVY ........................................ 51, 152

desipramine hcl ............................. 30, 131

desloratadine ............................... 103, 204

desmopressin ace spray refrig....... 91, 193

desmopressin acetate ................... 91, 193

desogestrel-ethinyl estradiol ........ 86, 188

desonide................................... 73, 74, 175

desoximetasone ............................. 74, 175

desvenlafaxine er ........................... 29, 130

desvenlafaxine succinate er .......... 29, 130

dexamethasone ............................. 84, 186

DEXAMETHASONE INTENSOL ........ 84, 186

dexamethasone sodium phosphate .. 101,

203

DEXILANT ....................................... 82, 183

dexmethylphenidate hcl ................ 70, 172

dextroamphetamine sulfate .......... 70, 172

dextroamphetamine sulfate er ..... 70, 172

dextrose ......................................... 79, 180

dextrose-nacl ................................. 76, 178

DIASTAT ACUDIAL .......................... 24, 125

DIASTAT PEDIATRIC ....................... 24, 125

diazepam .......................... 25, 55, 126, 155

diclofenac potassium .................... 34, 134

diclofenac sodium .. 34, 101, 134, 135, 203

diclofenac sodium er ..................... 34, 134

dicloxacillin sodium ....................... 20, 121

dicyclomine hcl ........................ 79, 80, 181

didanosine ..................................... 51, 152

diflorasone diacetate ..................... 74, 175

diflunisal ........................................ 34, 135

DIGITEK .......................................... 66, 168

DIGOX ............................................. 66, 168

digoxin ........................................... 66, 168

dihydroergotamine mesylate ........ 35, 136

DILANTIN ........................................ 26, 127

diltiazem hcl .................................. 65, 166

diltiazem hcl er .............................. 65, 166

diltiazem hcl er beads ................... 65, 166

diltiazem hcl er coated beads ....... 65, 166

dilt-xr .............................................. 65, 166

diphenoxylate-atropine ................ 80, 181

diphtheria-tetanus toxoids dt ....... 96, 197

disopyramide phosphate .............. 62, 163

disulfiram ....................................... 15, 116

divalproex sodium ......................... 25, 126

divalproex sodium er ..................... 25, 126

dofetilide ........................................ 62, 163

donepezil hcl.................................. 27, 128

dorzolamide hcl ........................... 100, 201

dorzolamide hcl-timolol mal ....... 100, 201

dorzolamide hcl-timolol mal pf .. 100, 201

DOVATO .......................................... 52, 153

doxazosin mesylate ....................... 61, 162

doxepin hcl .................................... 30, 131

doxercalciferol ............................... 98, 200

DOXY 100 ........................................ 23, 124

doxycycline hyclate ....................... 23, 124

doxycycline monohydrate ............. 23, 124

dronabinol ..................................... 31, 132

drospirenone-ethinyl estradiol ..... 86, 188

DROXIA ........................................... 37, 138

duloxetine hcl ................................ 29, 130

DUPIXENT .................................... 106, 208

DUREZOL...................................... 101, 203

dutasteride .................................... 83, 185

dutasteride-tamsulosin hcl ........... 83, 185

E econazole nitrate ........................... 32, 133

EDARBI ................................................. 162

EDARBYCLOR ....................................... 162

EDURANT ....................................... 50, 151

efavirenz ........................................ 50, 151

ELIGARD ......................................... 38, 139

ELIQUIS .......................................... 59, 159

ELIQUIS STARTER PACK ................ 59, 160

ELMIRON ........................................ 83, 185

EMCYT ............................................ 38, 139

EMEND............................................ 31, 132

EMGALITY ....................................... 35, 136

EMGALITY (300 MG DOSE) .............. 35, 136

EMOQUETTE .................................. 86, 188

EMSAM ........................................... 28, 129

EMTRIVA ......................................... 51, 152

EMVERM ......................................... 43, 144

enalapril maleate .......................... 61, 162

enalapril-hydrochlorothiazide ...... 63, 164

ENBREL .......................................... 94, 196

ENBREL SURECLICK ...................... 94, 196

ENDARI ........................................... 82, 184

ENDOCET ....................................... 14, 115

ENGERIX-B ..................................... 96, 197

enoxaparin sodium ....................... 59, 160

ENPRESSE-28 ................................. 87, 188

ENSKYCE ........................................ 87, 188

entacapone .................................... 45, 145

entecavir ........................................ 49, 150

ENTRESTO ..................................... 63, 164

enulose .......................................... 81, 182

ENVARSUS XR ................................ 93, 195

EPIDIOLEX ...................................... 23, 124

epinephrine ................................. 106, 208

EPITOL ........................................... 24, 125

EPIVIR HBV ..................................... 49, 150

eplerenone .................................... 67, 168

eprosartan mesylate ..................... 61, 162

ERAXIS ............................................ 32, 133

ergotamine-caffeine ...................... 35, 136

ERIVEDGE ....................................... 38, 139

ERLEADA ........................................ 38, 139

erlotinib hcl ................................... 38, 139

ERRIN ............................................. 90, 192

ertapenem sodium ........................ 20, 121

ery 74, 175

ERY-TAB ......................................... 22, 123

ERYTHROCIN LACTOBIONATE ....... 22, 123

ERYTHROCIN STEARATE ................ 22, 123

erythromycin .................. 74, 100, 175, 202

erythromycin base ........................ 22, 123

erythromycin ethylsuccinate ........ 22, 123

ESBRIET ....................................... 105, 207

escitalopram oxalate..................... 29, 130

esomeprazole magnesium ............ 82, 183

esomeprazole strontium ............... 82, 183

ESTARYLLA ..................................... 87, 188

estradiol .................... 84, 90, 185, 191, 192

ethambutol hcl .............................. 36, 137

ethosuximide ................................. 25, 126

ethynodiol diac-eth estradiol........ 87, 188

etodolac ......................................... 34, 135

EUCRISA ......................................... 74, 175

EVOTAZ .......................................... 53, 154

EXEL COMFORT POINT PEN NEEDLE .... 56,

156

exemestane ................................... 43, 144

ezetimibe ....................................... 69, 170

ezetimibe-simvastatin ......................... 170

F FALMINA ......................................... 87, 188

famciclovir ..................................... 50, 151

famotidine ..................................... 80, 182

FANAPT .......................................... 47, 148

FANAPT TITRATION PACK.............. 47, 148

FARYDAK ........................................ 38, 139

felbamate ...................................... 24, 125

felodipine er ................................... 65, 166

FEMYNOR ....................................... 87, 188

fenofibrate ..................................... 68, 169

fenofibrate micronized .................. 68, 169

fenofibric acid ...................................... 169

fentanyl .......................................... 13, 114

fentanyl citrate............................... 14, 115

FERRIPROX ..................................... 78, 179

FETZIMA ......................................... 29, 130

FETZIMA TITRATION ....................... 29, 130

FIASP .............................................. 57, 158

FIASP FLEXTOUCH ......................... 57, 158

finasteride ...................................... 83, 185

FIRVANQ ......................................... 17, 118

flecainide acetate .......................... 62, 163

FLOVENT DISKUS ......................... 103, 205

FLOVENT HFA ............................... 103, 205

fluconazole..................................... 32, 133

fluconazole in sodium chloride ..... 32, 133

flucytosine ...................................... 32, 133

fludrocortisone acetate ................. 85, 187

flunisolide .................................... 105, 206

fluocinolone acetonide .. 74, 102, 175, 176,

204

fluocinonide ................................... 74, 176

fluocinonide emulsified base ........ 74, 176

fluorometholone .......................... 101, 203

fluorouracil .................................... 39, 139

fluoxetine hcl ................................. 29, 130

fluphenazine decanoate ................ 46, 146

fluphenazine hcl .................... 46, 146, 147

flurbiprofen .................................... 34, 135

flurbiprofen sodium ..................... 101, 203

flutamide ........................................ 39, 139

fluticasone propionate ... 74, 105, 176, 207

fluticasone-salmeterol ................ 106, 208

fluvastatin sodium ............................... 170

fluvastatin sodium er ........................... 169

fluvoxamine maleate ..................... 29, 130

fondaparinux sodium .................... 59, 160

FORTEO .......................................... 98, 200

fosamprenavir calcium .................. 53, 154

fosinopril sodium ........................... 61, 162

fosinopril sodium-hctz ................... 63, 164

FREAMINE HBC ............................... 79, 180

furosemide ..................................... 67, 168

FUZEON .......................................... 52, 153

FYCOMPA ........................... 24, 25, 125, 126

G gabapentin ..................................... 25, 126

GALAFOLD ...................................... 82, 184

galantamine hydrobromide .......... 27, 128

galantamine hydrobromide er ...... 27, 128

GARDASIL 9 ............................ 96, 197, 198

gatifloxacin .................................. 100, 202

GATTEX ........................................... 80, 181

GAVILYTE-C ..................................... 81, 182

GAVILYTE-G .................................... 81, 183

GAVILYTE-N WITH FLAVOR PACK ... 81, 183

gemfibrozil ..................................... 68, 169

generlac ......................................... 81, 183

GENGRAF ........................................ 93, 195

GENTAK ........................................ 100, 202

gentamicin in saline ...................... 16, 117

gentamicin sulfate ... 16, 74, 100, 117, 176,

202

GENVOYA ........................................ 50, 151

GEODON ......................................... 55, 156

GIANVI ............................................ 87, 188

GILENYA ......................................... 72, 173

GILOTRIF ........................................ 39, 139

glatiramer acetate ......................... 72, 173

GLEOSTINE ..................................... 37, 137

glimepiride ..................................... 56, 156

glipizide .......................................... 56, 156

glipizide er ..................................... 56, 156

glipizide-metformin hcl ................. 56, 157

global alcohol prep ease ............... 56, 156

GLUCAGEN HYPOKIT ...................... 57, 158

GLUCAGON EMERGENCY ............... 57, 158

glyburide .............................................. 157

glyburide micronized........................... 157

glyburide-metformin ..................... 56, 157

glycopyrrolate................................ 80, 181

GOCOVRI ........................................ 45, 145

granisetron hcl ............................... 31, 132

griseofulvin microsize.................... 32, 133

griseofulvin ultramicrosize ............ 32, 133

guanfacine hcl ............................... 61, 161

guanfacine hcl er ........................... 70, 172

guanidine hcl ................................. 36, 137

H halobetasol propionate ................. 74, 176

haloperidol .................................... 46, 147

haloperidol decanoate .................. 46, 147

haloperidol lactate ........................ 46, 147

HAVRIX ........................................... 96, 198

heparin sodium (porcine) .............. 59, 160

HEPATAMINE .................................. 79, 180

HETLIOZ ....................................... 108, 209

HIBERIX .......................................... 96, 198

HUMIRA .......................................... 95, 196

HUMIRA PEDIATRIC CROHNS START .... 95,

196

HUMIRA PEN .................................. 95, 196

HUMIRA PEN-CD/UC/HS STARTER 95, 196

HUMIRA PEN-PS/UV/ADOL HS START .. 95,

196

hydralazine hcl .............................. 70, 171

hydrochlorothiazide ...................... 67, 169

hydrocodone-acetaminophen ...... 14, 115

hydrocodone-ibuprofen ................ 14, 115

hydrocortisone ........... 74, 75, 84, 176, 186

hydrocortisone ace-pramoxine ..... 74, 176

hydrocortisone valerate ................ 75, 176

hydromorphone hcl ...................... 14, 115

hydromorphone hcl pf .................. 14, 115

hydroxychloroquine sulfate .......... 99, 200

hydroxyurea................................... 39, 139

hydroxyzine hcl.............................. 54, 155

hydroxyzine pamoate.................... 54, 155

I ibandronate sodium ...................... 98, 200

IBRANCE ......................................... 39, 140

IBU ................................................. 34, 135

ibuprofen ....................................... 34, 135

ICLUSIG .......................................... 39, 140

IDHIFA ............................................ 39, 140

ILEVRO ......................................... 101, 203

imatinib mesylate .......................... 39, 140

IMBRUVICA ..................................... 39, 140

imipenem-cilastatin ...................... 20, 121

imipramine hcl .............................. 30, 131

imiquimod ..................................... 75, 176

IMOVAX RABIES .............................. 96, 198

INCASSIA ........................................ 90, 192

INCRELEX ....................................... 91, 193

indapamide ................................... 68, 169

indomethacin ................................ 34, 135

INFANRIX ........................................ 96, 198

INLYTA ............................................ 39, 140

INTELENCE ..................................... 51, 151

INTRALIPID .................................... 79, 181

INTRAROSA .................................... 84, 185

INTRON A ....................................... 49, 150

INTROVALE..................................... 87, 188

INVEGA SUSTENNA ........................ 47, 148

INVEGA TRINZA .............................. 47, 148

INVIRASE ........................................ 53, 154

INVOKAMET .................................... 56, 157

INVOKAMET XR .............................. 56, 157

INVOKANA ...................................... 56, 157

IONOSOL-MB IN D5W ..................... 78, 179

IPOL ............................................... 96, 198

ipratropium bromide ... 104, 105, 205, 207

ipratropium-albuterol ................. 104, 206

irbesartan ...................................... 61, 162

irbesartan-hydrochlorothiazide ... 63, 164

IRESSA............................................ 39, 140

ISENTRESS ..................................... 52, 153

ISENTRESS HD ............................... 52, 153

ISIBLOOM ....................................... 87, 188

ISOLYTE-P IN D5W ......................... 78, 179

ISOLYTE-S ...................................... 79, 181

isoniazid ......................................... 36, 137

isosorbide dinitrate ....................... 69, 171

isosorbide dinitrate er ................... 69, 171

isosorbide mononitrate ................ 69, 171

isosorbide mononitrate er ............ 69, 171

isotretinoin .................................... 75, 176

isradipine ....................................... 65, 167

itraconazole ................................... 32, 133

ivermectin ...................................... 43, 144

IXIARO ............................................. 96, 198

J JAKAFI ............................................ 39, 140

JANTOVEN ...................................... 59, 160

JANUMET........................................ 56, 157

JANUMET XR .................................. 56, 157

JANUVIA ......................................... 56, 157

JARDIANCE ..................................... 56, 157

JASMIEL .......................................... 87, 189

JOLIVETTE ...................................... 90, 192

JUBLIA ............................................ 32, 133

JULEBER ......................................... 87, 189

JULUCA .......................................... 51, 152

JUNEL 1.5/30 .................................. 87, 189

JUNEL 1/20 ..................................... 87, 189

JUNEL FE 1.5/30 ............................. 87, 189

JUNEL FE 1/20 ................................ 87, 189

JUXTAPID ....................................... 69, 170

K KALETRA ......................................... 53, 154

KALYDECO .................................... 106, 208

KARIVA ............................................ 87, 189

kcl in dextrose-nacl ........................ 76, 178

kcl-lactated ringers-d5w ................ 76, 178

KELNOR 1/35 .................................. 87, 189

KELNOR 1/50 .................................. 87, 189

ketoconazole ........................... 32, 33, 133

ketoprofen ..................................... 34, 135

ketorolac tromethamine ............. 101, 203

KINRIX............................................. 96, 198

KIONEX ........................................... 78, 179

KISQALI (200 MG DOSE) ................. 39, 140

KISQALI (400 MG DOSE) ................. 39, 140

KISQALI (600 MG DOSE) ................. 39, 140

KISQALI FEMARA (400 MG DOSE) ... 39, 140

KISQALI FEMARA (600 MG DOSE) ... 39, 140

KISQALI FEMARA(200 MG DOSE) .... 40, 140

KLOR-CON ...................................... 77, 178

KLOR-CON 10 ................................. 76, 178

KLOR-CON M10 .............................. 77, 178

KLOR-CON M15 .............................. 77, 178

KLOR-CON M20 .............................. 77, 178

KLOR-CON SPRINKLE ..................... 77, 178

KORLYM .......................................... 92, 194

KURVELO ........................................ 87, 189

KUVAN ............................................ 82, 184

L labetalol hcl ................................... 64, 165

lactulose ......................................... 81, 183

lamivudine .................. 49, 51, 52, 150, 152

lamivudine-zidovudine .................. 52, 152

lamotrigine .................................... 26, 127

lamotrigine er ................................ 26, 127

lamotrigine starter kit-blue ........... 26, 127

lamotrigine starter kit-green ......... 26, 127

lamotrigine starter kit-orange ....... 26, 127

LANOXIN ............................................... 168

LANTUS .......................................... 58, 158

LANTUS SOLOSTAR ....................... 58, 158

LARIN 1.5/30 ................................... 87, 189

LARIN 1/20...................................... 87, 189

LARIN FE 1.5/30 .............................. 87, 189

LARIN FE 1/20 ................................. 87, 189

LARISSIA ......................................... 87, 189

latanoprost .................................. 102, 204

LATUDA .......................................... 47, 148

LEENA ............................................. 87, 189

leflunomide .................................... 95, 197

LENVIMA (10 MG DAILY DOSE) ....... 40, 140






LENVIMA (4 MG DAILY DOSE) ......... 40, 141

LENVIMA (8 MG DAILY DOSE) ......... 40, 141

LESSINA .......................................... 87, 189

letrozole ......................................... 43, 144

leucovorin calcium ........................ 40, 141

LEUKERAN ...................................... 37, 138

LEUKINE ......................................... 60, 160

leuprolide acetate ......................... 40, 141

LEVEMIR ......................................... 58, 159

LEVEMIR FLEXTOUCH .................... 58, 159

levetiracetam ................................. 24, 125

levetiracetam er ............................. 24, 125

levobunolol hcl ............................ 100, 201

levocarnitine .................................. 82, 184

levocetirizine dihydrochloride .... 103, 204

levofloxacin .................................... 22, 123

levofloxacin in d5w ........................ 22, 123

LEVONEST ...................................... 87, 189

levonorgest-eth estrad 91-day ...... 88, 189

levonorgestrel-ethinyl estrad ........ 88, 189

levonorg-eth estrad triphasic ........ 88, 189

LEVORA 0.15/30 (28) ...................... 88, 189

LEVO-T............................................ 92, 193

levothyroxine sodium .................... 92, 193

LEVOXYL ......................................... 92, 193

LEXIVA ............................................ 53, 154

LIALDA ............................................ 98, 199

lidocaine ........................................ 15, 116

lidocaine hcl ................................... 15, 116

lidocaine hcl urethral/mucosal ..... 15, 116

lidocaine viscous hcl...................... 72, 173

lidocaine-prilocaine ...................... 15, 116

linezolid ......................................... 17, 118

LINZESS .......................................... 81, 182

liothyronine sodium ...................... 92, 193

lisinopril ......................................... 61, 162

lisinopril-hydrochlorothiazide ...... 63, 164

lithium ........................................... 55, 156

lithium carbonate .......................... 55, 156

lithium carbonate er...................... 55, 156

LIVALO ............................................ 68, 170

LOKELMA ....................................... 78, 180

LONSURF ....................................... 40, 141

loperamide hcl .............................. 80, 182

lopinavir-ritonavir ......................... 53, 154

lorazepam ...................................... 55, 156

LORBRENA ..................................... 40, 141

LORCET .......................................... 14, 115

LORYNA .......................................... 88, 189

losartan potassium ....................... 61, 162

losartan potassium-hctz ............... 63, 164

LOTEMAX...................................... 101, 203

LOTEMAX SM ................................ 101, 203

loteprednol etabonate ................ 101, 203

lovastatin ....................................... 68, 170

LOW-OGESTREL ............................. 88, 189

loxapine succinate ........................ 46, 147

LUMIGAN ...................................... 102, 204

LUPRON DEPOT (1-MONTH) .......... 40, 141




LUTERA .......................................... 88, 189

LYNPARZA ...................................... 41, 141

LYRICA ............................... 25, 71, 126, 173

LYSODREN ..................................... 41, 141

LYZA ............................................... 90, 192

M magnesium sulfate ........................ 77, 178

malathion ...................................... 44, 145

maprotiline hcl .............................. 28, 129

marlissa ......................................... 88, 189

MARPLAN ....................................... 28, 129

MATULANE ..................................... 41, 141

MATZIM LA ........................................... 167

MAYZENT........................................ 72, 173

meclizine hcl .................................. 31, 131

medroxyprogesterone acetate88, 90, 189,

190, 192

mefloquine hcl ............................... 43, 144

megestrol acetate ......................... 90, 192

MEKINIST ....................................... 41, 141

MEKTOVI ........................................ 41, 142

meloxicam ..................................... 34, 135

memantine hcl .............................. 27, 128

memantine hcl er .......................... 27, 128

MENACTRA ..................................... 96, 198

MENEST.......................................... 90, 192

MENVEO ......................................... 96, 198

mercaptopurine ............................ 37, 138

meropenem ................................... 20, 121

mesalamine ................................... 98, 199

MESNEX .......................................... 41, 142

METADATE ER ................................. 70, 172

metaxalone .................................. 107, 209

metformin hcl ................................ 56, 157

metformin hcl er ............................ 56, 157

methadone hcl ............................... 13, 114

methazolamide .............................. 67, 168

methenamine hippurate ............... 17, 118

methimazole .................................. 93, 194

methocarbamol ........................... 107, 209

methotrexate ................................. 93, 195

methotrexate sodium .................... 93, 195

methotrexate sodium (pf) ............. 37, 138

methyclothiazide ........................... 68, 169

methyldopa .................................... 61, 161

methylphenidate hcl ..................... 71, 172

methylphenidate hcl er ................. 71, 172

methylprednisolone ...................... 84, 186

methyltestosterone ....................... 85, 187

metoclopramide hcl ...................... 80, 182

metolazone .................................... 68, 169

metoprolol succinate er ................ 64, 165

metoprolol tartrate ........................ 64, 165

metoprolol-hydrochlorothiazide .. 63, 164

metronidazole..... 17, 75, 84, 118, 176, 185

metronidazole in nacl .................... 17, 118

mexiletine hcl ................................. 62, 163

MICROGESTIN 1.5/30 ..................... 88, 190

MICROGESTIN 1/20 ........................ 88, 190

MICROGESTIN FE 1.5/30 ................ 88, 190

MICROGESTIN FE 1/20 ................... 88, 190

midodrine hcl ................................. 61, 161

MIGERGOT ...................................... 35, 136

miglitol ........................................... 56, 157

miglustat ........................................ 82, 184

MILI ................................................. 88, 190

MINITRAN ............................................. 171

minocycline hcl .............................. 23, 124

minoxidil ........................................ 70, 171

mirtazapine .................................... 28, 129

misoprostol .................................... 81, 183

MITIGARE ........................................ 33, 134

M-M-R II .......................................... 96, 198

modafinil ...................................... 108, 209

moexipril hcl .................................. 61, 162

molindone hcl ................................ 46, 147

mometasone furoate ...... 75, 105, 176, 207

MONONESSA .................................. 88, 190

montelukast sodium ............ 103, 104, 205

morphine sulfate ........................... 14, 115

morphine sulfate (concentrate) .... 14, 115

morphine sulfate er ....................... 13, 114

MOVANTIK ...................................... 80, 182

MOXEZA ........................................ 100, 202

moxifloxacin hcl .............. 22, 100, 123, 202

moxifloxacin hcl in nacl ................. 22, 123

MULTAQ.......................................... 62, 163

mupirocin ....................................... 75, 176

mycophenolate mofetil ................. 93, 195

mycophenolate sodium ................. 94, 195

MYORISAN ...................................... 75, 177

MYRBETRIQ .................................... 83, 184

MYTESI ........................................... 80, 182

N nabumetone .................................. 34, 135

nadolol ........................................... 64, 165

nafcillin sodium ............................. 21, 122

naloxone hcl .................................. 15, 116

naltrexone hcl ................................ 15, 116

NAMZARIC ................................ 27, 28, 128

naproxen ........................................ 34, 135

naproxen dr ................................... 34, 135

naproxen sodium ........................... 34, 135

naproxen sodium er ...................... 34, 135

naratriptan hcl ............................... 35, 136

NARCAN .......................................... 15, 116

NATACYN ........................................ 33, 133

nateglinide ..................................... 56, 157

NATPARA ........................................ 98, 200

NEBUPENT ..................................... 44, 144

NECON 0.5/35 (28) ......................... 88, 190

nefazodone hcl .............................. 28, 129

neomycin sulfate ........................... 16, 117

neomycin-bacitracin zn-polymyx 100, 202

neomycin-polymyxin-dexameth . 102, 203

neomycin-polymyxin-gramicidin 101, 202

neomycin-polymyxin-hc .......102, 203, 204

NEPHRAMINE ................................. 79, 181

NERLYNX ........................................ 41, 142

NEUPRO ......................................... 45, 146

nevirapine ...................................... 51, 151

nevirapine er .................................. 51, 151

NEXAVAR ........................................ 41, 142

niacin er (antihyperlipidemic) ....... 69, 170

nicardipine hcl ............................... 65, 167

NICOTROL ...................................... 16, 117

nifedipine ............................................. 167

nifedipine er ................................... 66, 167

nifedipine er osmotic release ........ 66, 167

NIKKI .............................................. 88, 190

nilutamide ..................................... 41, 142

NINLARO ........................................ 41, 142

NITRO-DUR .................................... 69, 171

nitrofurantoin ................................ 17, 118

nitrofurantoin macrocrystal .......... 17, 118

nitrofurantoin monohyd macro .... 17, 118

nitroglycerin ............................ 69, 70, 171

NOCDURNA .................................... 91, 193

NORA-BE ........................................ 91, 192

norethindrone ............................... 91, 192

norethindrone acetate .................. 91, 192

norethindrone acet-ethinyl est ..... 88, 190

norethindrone-eth estradiol ......... 90, 192

norgestimate-eth estradiol ........... 88, 190

norgestim-eth estrad triphasic ..... 88, 190

NORLYROC ..................................... 91, 192

NORMOSOL-M IN D5W ................... 78, 180

NORMOSOL-R IN D5W.................... 78, 180

NORMOSOL-R PH 7.4 ..................... 79, 181

NORPACE CR ........................................ 163

NORTHERA ..................................... 66, 168

NORTREL 0.5/35 (28) ..................... 89, 190

NORTREL 1/35 (21) ........................ 89, 190

NORTREL 1/35 (28) ........................ 89, 190

NORTREL 7/7/7 .............................. 89, 190

nortriptyline hcl ............................. 30, 131

NORVIR .......................................... 53, 154

NOVOLIN 70/30 .............................. 58, 159

NOVOLIN N ..................................... 58, 159

NOVOLIN R ..................................... 58, 159

NOVOLOG....................................... 58, 159

NOVOLOG FLEXPEN ....................... 58, 159

NOVOLOG MIX 70/30 ...................... 58, 159

NOVOLOG MIX 70/30 FLEXPEN ...... 58, 159

NOVOLOG PENFILL ........................ 58, 159

NOXAFIL ......................................... 33, 133

NUEDEXTA ..................................... 71, 172

NUPLAZID ...................................... 47, 148

nutrilipid ........................................ 79, 181

NUVARING ...................................... 89, 190

NYAMYC .......................................... 33, 133

nystatin .......................................... 33, 134

nystatin-triamcinolone ................. 75, 177

NYSTOP .......................................... 33, 134

O OCELLA .......................................... 89, 190

OCTAGAM ....................................... 95, 197

octreotide acetate ......................... 92, 194

ODEFSEY ........................................ 52, 153

ODOMZO ........................................ 41, 142

OFEV ............................................. 105, 207

ofloxacin .......... 22, 101, 102, 123, 202, 204

olanzapine ................................ 47, 48, 148

olanzapine-fluoxetine hcl ............. 55, 156

olmesartan medoxomil ................. 61, 162

olmesartan medoxomil-hctz ......... 63, 164

olmesartan-amlodipine-hctz ........ 63, 164

olopatadine hcl ............................. 99, 201

omega-3-acid ethyl esters ............. 69, 170

omeprazole .................................... 82, 183

OMNITROPE ................................... 91, 193

ondansetron .................................. 31, 132

ondansetron hcl ............................ 31, 132

OPSUMIT ...................................... 105, 207

ORFADIN ........................................ 82, 184

ORILISSA ........................................ 91, 193

ORKAMBI ...................................... 106, 208

orphenadrine citrate er ............... 107, 209

ORSYTHIA....................................... 89, 190

oseltamivir phosphate .................. 54, 154

OSPHENA ....................................... 84, 185

oxacillin sodium ............................ 21, 122

oxandrolone .................................. 85, 187

oxaprozin ....................................... 34, 135

oxazepam ..................................... 107, 209

oxcarbazepine................................ 26, 127

OXERVATE ...................................... 99, 201

oxybutynin chloride ....................... 83, 184

oxybutynin chloride er ................... 83, 184

oxycodone hcl ................... 13, 14, 114, 115

oxycodone hcl er ............................ 13, 114

oxycodone-acetaminophen .......... 15, 116

oxycodone-aspirin ......................... 15, 116

oxycodone-ibuprofen .................... 15, 116

OZEMPIC ........................................ 57, 157

P PACERONE ..................................... 62, 163

paliperidone er .............................. 48, 148

PANRETIN ....................................... 41, 142

pantoprazole sodium .................... 82, 183

PANZYGA ........................................ 95, 197

paricalcitol ..................................... 98, 200

paromomycin sulfate .................... 16, 117

paroxetine hcl ................................ 29, 130

PASER ............................................. 36, 137

PAXIL .............................................. 29, 130

PAZEO ............................................ 99, 201

PEDIARIX ........................................ 96, 198

PEDVAX HIB .................................... 97, 198

peg 3350/electrolytes .................... 81, 183

peg 3350-kcl-na bicarb-nacl .......... 81, 183

peg-3350/electrolytes .................... 81, 183

PEGANONE ..................................... 26, 127

PEGASYS ......................................... 50, 150

PEGASYS PROCLICK ....................... 50, 150

penicillin g pot in dextrose ............ 21, 122

penicillin g potassium .................... 21, 122

penicillin g procaine ...................... 21, 122

penicillin g sodium ......................... 21, 122

penicillin v potassium .................... 21, 122

PENTAM .......................................... 44, 144

pentoxifylline er ............................. 60, 161

perindopril erbumine .................... 62, 162

permethrin ..................................... 44, 145

perphenazine ................................. 46, 147

PERSERIS ....................................... 48, 148

phenelzine sulfate ......................... 29, 129

phenobarbital ................................ 24, 125

phenytoin ............................... 27, 127, 128

phenytoin sodium extended ......... 27, 128

PICATO ........................................... 75, 177

PIFELTRO ....................................... 51, 151

pilocarpine hcl ................ 72, 100, 174, 201

pimecrolimus ................................. 75, 177

pimozide ........................................ 46, 147

PIMTREA ......................................... 89, 190

pindolol .......................................... 64, 166

pioglitazone hcl ............................. 57, 157

pioglitazone hcl-glimepiride ......... 57, 157

pioglitazone hcl-metformin hcl ..... 57, 157

piperacillin sod-tazobactam so ..... 21, 122

PIQRAY (200 MG DAILY DOSE) ........ 41, 142



PIRMELLA 1/35 ............................... 89, 190

piroxicam ....................................... 34, 135

PLASMA-LYTE 148 .......................... 79, 181

PLASMA-LYTE A .............................. 79, 181

podofilox ........................................ 75, 177

polymyxin b-trimethoprim .......... 101, 202

POMALYST ...................................... 41, 142

PORTIA-28 ...................................... 89, 190

potassium chloride ........................ 77, 179

potassium chloride crys er ............ 77, 178

potassium chloride er .................... 77, 179

potassium chloride in dextrose ..... 77, 179

potassium chloride in nacl ............ 77, 179

potassium citrate er ...................... 77, 179

PRALUENT ...................................... 69, 170

pramipexole dihydrochloride ....... 45, 146

pramipexole dihydrochloride er ... 45, 146

prasugrel hcl .................................. 60, 161

pravastatin sodium ....................... 68, 170

prazosin hcl .................................... 61, 162

prednicarbate ................................ 75, 177

prednisolone .................................. 84, 186

prednisolone acetate .................. 102, 203

prednisolone sodium phosphate . 85, 102,

186, 203

prednisone ..................................... 85, 186

PREDNISONE INTENSOL ................ 85, 186

preferred plus insulin syringe ........ 56, 156

PREMARIN ...................................... 91, 192

PREMASOL ..................................... 79, 181

PREMPHASE ................................... 91, 192

PREMPRO ....................................... 91, 192

PREVALITE...................................... 69, 170

PREVIFEM ....................................... 89, 190

PREZCOBIX .................................... 53, 154

PREZISTA .......................... 52, 53, 153, 154

PRIFTIN .......................................... 36, 137

primaquine phosphate .................. 44, 144

primidone ...................................... 24, 125

PRIVIGEN ........................................ 95, 197

probenecid ..................................... 33, 134

PROCALAMINE ............................... 79, 181

prochlorperazine ........................... 31, 132

prochlorperazine maleate 31, 46, 132, 147

PROCTO-MED HC ........................... 75, 177

PROCTO-PAK ................................. 75, 177

PROCTOSOL HC ............................. 75, 177

PROCTOZONE-HC .......................... 75, 177

progesterone micronized .............. 91, 192

PROGLYCEM ................................... 57, 158

PROGRAF........................................ 94, 195

PROLASTIN-C ............................... 106, 208

PROLENSA.................................... 102, 203

PROLIA ........................................... 98, 200

PROMACTA ..................................... 60, 161

promethazine hcl ........................... 31, 132

propafenone hcl ............................ 62, 163

propafenone hcl er ........................ 62, 163

proparacaine hcl ........................... 15, 116

propranolol hcl ......................... 64, 65, 166

propranolol hcl er .......................... 64, 166

propranolol-hctz ........................... 63, 164

propylthiouracil ............................. 93, 194

PROQUAD ...................................... 97, 198

PROSOL ......................................... 79, 181

protriptyline hcl ............................. 30, 131

PULMOZYME ................................ 106, 208

PURIXAN ........................................ 37, 138

pyrazinamide ................................. 36, 137

pyridostigmine bromide ............... 36, 137

Q QUADRACEL ................................... 97, 198

quetiapine fumarate ..................... 48, 149

quetiapine fumarate er ................. 48, 149

quinapril hcl ................................... 62, 163

quinapril-hydrochlorothiazide...... 63, 164

quinidine sulfate............................ 62, 163

quinine sulfate ............................... 44, 144

R RABAVERT ...................................... 97, 198

raloxifene hcl ................................. 91, 193

ramipril .......................................... 62, 163

ranitidine hcl ................................. 80, 182

ranolazine er .................................. 67, 168

rasagiline mesylate ....................... 45, 146

RAVICTI .......................................... 82, 184

REBETOL ........................................ 49, 150

RECLIPSEN ..................................... 89, 191

RECOMBIVAX HB ............................ 97, 198

RECTIV............................................ 75, 177

REGRANEX ..................................... 75, 177

RELENZA DISKHALER .................... 54, 154

RELI-ON INSULIN SYRINGE ............ 56, 156

repaglinide..................................... 57, 157

repaglinide-metformin hcl ............ 57, 157

REPATHA ........................................ 69, 171

REPATHA PUSHTRONEX SYSTEM .. 69, 170

REPATHA SURECLICK .................... 69, 171

RESCRIPTOR .................................. 51, 151

RESTASIS ....................................... 99, 201

RETACRIT ....................................... 60, 161

REVLIMID ........................................ 37, 138

REXULTI ......................................... 48, 149

REYATAZ......................................... 54, 154

RHOPRESSA ................................. 100, 201

RIBASPHERE .................................. 50, 150

ribavirin .................................. 50, 150, 151

rifabutin ......................................... 36, 137

rifampin ......................................... 36, 137

RIFATER ......................................... 36, 137

riluzole ........................................... 71, 172

rimantadine hcl .............................. 54, 155

risedronate sodium ....................... 99, 200

RISPERDAL CONSTA ....................... 48, 149

risperidone ............................... 48, 49, 149

ritonavir .......................................... 54, 154

rivastigmine ................................... 27, 128

rivastigmine tartrate ...................... 27, 128

rizatriptan benzoate ...................... 35, 136

ropinirole hcl .................................. 45, 146

rosuvastatin calcium ..................... 68, 170

ROTARIX ......................................... 97, 198

ROTATEQ ........................................ 97, 198

ROWEEPRA ..................................... 24, 125

ROWEEPRA XR ................................ 24, 125

RUBRACA ........................................ 41, 142

RUCONEST ..................................... 67, 168

RYDAPT ........................................... 41, 142

RYTARY ........................................... 45, 145

S SAMSCA .......................................... 78, 180

SANDIMMUNE................................. 94, 195

SANTYL ........................................... 76, 177

SAPHRIS ......................................... 49, 149

SAVELLA ......................................... 71, 173

SAVELLA TITRATION PACK ............. 71, 173

scopolamine .................................. 31, 132

selegiline hcl .................................. 45, 146

selenium sulfide ............................. 76, 177

SELZENTRY ..................................... 53, 153

SEREVENT DISKUS ....................... 105, 206

sertraline hcl .......................... 30, 130, 131

SETLAKIN ....................................... 89, 191

sevelamer carbonate ..................... 84, 185

SHAROBEL ...................................... 91, 193

SHINGRIX ........................................ 97, 198

SIGNIFOR ........................................ 92, 194

sildenafil citrate ........................... 104, 206

SILENOR ....................................... 108, 209

silodosin ......................................... 83, 185

silver sulfadiazine .......................... 76, 177

SIMBRINZA ................................... 100, 202

simvastatin..................................... 68, 170

sirolimus......................................... 94, 195

SIRTURO ......................................... 36, 137

SIVEXTRO ....................................... 17, 118

sodium chloride ..................... 78, 179, 180

sodium phenylbutyrate ................. 82, 184

sodium polystyrene sulfonate ....... 78, 180

sofosbuvir-velpatasvir ................... 50, 150

SOLIQUA ......................................... 57, 158

SOLTAMOX ..................................... 91, 193

SOMATULINE DEPOT ..................... 92, 194

SOMAVERT ..................................... 92, 194

SORINE ........................................... 65, 166

sotalol hcl ....................................... 65, 166

sotalol hcl (af) ................................ 65, 166

SPIRIVA HANDIHALER .................. 104, 206

SPIRIVA RESPIMAT ....................... 104, 206

spironolactone .............................. 67, 169

spironolactone-hctz ...................... 64, 165

SPRINTEC 28 .................................. 89, 191

SPRITAM ......................................... 24, 125

SPRYCEL ......................................... 41, 142

SPS ................................................. 78, 180

SRONYX .......................................... 89, 191

SSD ................................................. 76, 177

stavudine ....................................... 52, 152

STELARA ......................................... 95, 197

STIOLTO RESPIMAT ..................... 106, 208

STIVARGA ....................................... 41, 142

STRIBILD ........................................ 52, 152

SUBOXONE ..................................... 16, 117

sucralfate ....................................... 82, 183

sulfacetamide sodium ................. 101, 202

sulfacetamide sodium (acne) ........ 22, 123

sulfacetamide-prednisolone ....... 102, 204

sulfadiazine .................................... 23, 124

sulfamethoxazole-trimethoprim ... 23, 124

sulfasalazine .................................. 98, 199

sulindac .......................................... 35, 135

sumatriptan ................................... 35, 136

sumatriptan succinate ............ 35, 36, 136

sumatriptan succinate refill .......... 35, 136

SUPRAX .......................................... 19, 120

SUPREP BOWEL PREP KIT ............. 81, 183

SUTENT .......................................... 41, 142

SYEDA ............................................. 89, 191

SYLATRON ...................................... 50, 151

SYMDEKO ..................................... 106, 208

SYMFI .............................................. 51, 152

SYMFI LO ........................................ 51, 152

SYMLINPEN 120 .................................... 158

SYMLINPEN 60...................................... 158

SYMPAZAN ..................................... 25, 126

SYMTUZA ........................................ 51, 152

SYNAREL......................................... 93, 194

SYNDROS........................................ 31, 132

SYNJARDY ...................................... 57, 158

SYNJARDY XR ................................. 57, 158

SYNRIBO ......................................... 42, 142

SYNTHROID .................................... 92, 194

T TABLOID ......................................... 37, 138

tacrolimus ......................... 76, 94, 177, 195

TAFINLAR ....................................... 42, 142

TAGRISSO ....................................... 42, 142

TAKHZYRO ..................................... 67, 168

TALZENNA ...................................... 42, 142

tamoxifen citrate ........................... 42, 143

tamsulosin hcl ............................... 83, 185

TARGRETIN .................................... 42, 143

TARINA 24 FE .................................. 89, 191

TARINA FE 1/20 .............................. 89, 191

TASIGNA ......................................... 42, 143

tazarotene ..................................... 76, 177

TAZORAC ........................................ 76, 177

TAZTIA XT ....................................... 66, 167

TDVAX ............................................. 97, 199

TECFIDERA ..................................... 72, 173

TEFLARO ........................................ 19, 120

TEGSEDI ......................................... 71, 172

TEKTURNA HCT ............................. 64, 165

telmisartan .................................... 61, 162

telmisartan-amlodipine ...................... 165

telmisartan-hctz ............................ 64, 165

temazepam .................................. 107, 209

TENIVAC ......................................... 97, 199

tenofovir disoproxil fumarate ....... 52, 152

terazosin hcl .................................. 61, 162

terbinafine hcl ............................... 33, 134

terbutaline sulfate ....................... 105, 206

terconazole .................................... 84, 186

testosterone .................................. 86, 187

testosterone cypionate ................. 85, 187

testosterone enanthate ................ 86, 187

tetrabenazine ................................ 71, 172

tetracycline hcl .............................. 23, 124

THALOMID ...................................... 37, 138

theophylline ................................ 104, 206

theophylline er ............................ 104, 206

thioridazine hcl .............................. 46, 147

thiothixene .................................... 46, 147

tiagabine hcl .................................. 25, 126

TIBSOVO ........................................ 42, 143

tigecycline...................................... 17, 118

TIGLUTIK ........................................ 71, 173

timolol maleate .............. 65, 100, 166, 202

tinidazole ....................................... 17, 118

TIVICAY ........................................... 53, 153

tizanidine hcl ............................... 107, 209

TOBI PODHALER .......................... 106, 208

tobramycin ..................... 16, 101, 117, 202

tobramycin sulfate ........................ 16, 117

tobramycin-dexamethasone ...... 102, 204

TOLAK ............................................ 42, 143

tolazamide ........................................... 158

tolbutamide ......................................... 158

tolmetin sodium ............................ 35, 135

tolterodine tartrate ....................... 83, 184

tolterodine tartrate er ................... 83, 184

topiramate ..................................... 26, 127

topiramate er ................................. 26, 127

toremifene citrate ......................... 42, 143

torsemide ...................................... 67, 168

TOUJEO MAX SOLOSTAR ............... 58, 159

TOUJEO SOLOSTAR ....................... 58, 159

TPN ELECTROLYTES ...................... 79, 181

TRACLEER .................................... 105, 207

tramadol hcl .................................. 15, 116

tramadol-acetaminophen ............. 15, 116

trandolapril.................................... 62, 163

trandolapril-verapamil hcl er .............. 165

tranexamic acid ............................. 60, 161

TRANSDERM-SCOP (1.5 MG) .......... 31, 132

tranylcypromine sulfate ................ 29, 129

TRAVASOL ...................................... 79, 181

TRAVATAN Z ................................. 102, 204

trazodone hcl ................................. 28, 129

TRECATOR ...................................... 36, 137

TRELEGY ELLIPTA ......................... 107, 208

TRELSTAR MIXJECT ........................ 93, 194

TRESIBA .......................................... 58, 159

TRESIBA FLEXTOUCH ..................... 58, 159

tretinoin ............................ 42, 76, 143, 177

TREXALL ......................................... 94, 195

triamcinolone acetonide . 72, 76, 174, 177,

178

triamterene-hctz ............................ 64, 165

TRIDERM ......................................... 76, 178

trientine hcl .................................... 78, 180

TRI-ESTARYLLA .............................. 89, 191

trifluoperazine hcl .......................... 46, 147

trifluridine .................................... 101, 202

trihexyphenidyl hcl ........................ 44, 145

TRI-LEGEST FE ............................... 89, 191

TRILYTE .......................................... 81, 183

trimethoprim ................................. 17, 118

TRI-MILI .......................................... 89, 191

trimipramine maleate.................... 30, 131

TRINTELLIX ..................................... 28, 129

TRI-PREVIFEM ................................ 89, 191

TRI-SPRINTEC ................................ 89, 191

TRIUMEQ ........................................ 52, 152

TRIVORA (28) .................................. 89, 191

TRI-VYLIBRA ................................... 90, 191

TROPHAMINE ................................. 79, 181

TRULICITY....................................... 57, 158

TRUMENBA ..................................... 97, 199

TRUVADA ........................................ 52, 152

TWINRIX .......................................... 97, 199

TYBOST ........................................... 53, 153

TYKERB ........................................... 42, 143

TYMLOS .......................................... 99, 200

TYPHIM VI ....................................... 97, 199

U UCERIS ........................................... 76, 178

ULORIC ........................................... 33, 134

UNITHROID..................................... 92, 194

UPTRAVI ....................................... 105, 207

ursodiol .......................................... 80, 182

V valacyclovir hcl .............................. 50, 151

VALCHLOR ...................................... 42, 143

valganciclovir hcl ........................... 49, 150

valproate sodium .................................. 25

valproic acid .................................. 25, 126

valsartan ........................................ 61, 162

valsartan-hydrochlorothiazide ..... 64, 165

vancomycin hcl .............................. 18, 119

VANDAZOLE ................................... 84, 186

VAQTA ............................................ 97, 199

VARIVAX .......................................... 97, 199

VARIZIG .......................................... 97, 199

VARUBI ........................................... 31, 132

VASCEPA ........................................ 69, 171

VELIVET .......................................... 90, 191

VELPHORO ..................................... 84, 185

VEMLIDY ......................................... 49, 150

VENCLEXTA .................................... 42, 143

VENCLEXTA STARTING PACK ......... 42, 143

venlafaxine hcl ............................... 30, 131

venlafaxine hcl er ........................... 30, 131

VENTOLIN HFA ............................. 105, 206

verapamil hcl ................................. 66, 167

verapamil hcl er ............................. 66, 167

VERSACLOZ .................................... 46, 147

VERZENIO ....................................... 42, 143

VICTOZA ......................................... 57, 158

VIDEX .............................................. 52, 153

VIDEX EC ......................................... 52, 153

VIENVA ............................................ 90, 191

vigabatrin ................................. 25, 26, 126

VIGADRONE .................................... 26, 127

VIIBRYD .......................................... 28, 129

VIIBRYD STARTER PACK ................. 28, 129

VIMPAT ........................................... 27, 128

VIRACEPT ....................................... 54, 154

VIRAMUNE ...................................... 51, 152

VIREAD............................................ 52, 153

VITRAKVI......................................... 42, 143

VIVITROL ........................................ 15, 116

VIZIMPRO ....................................... 42, 143

voriconazole .................................. 33, 134

VOSEVI ............................................ 50, 150

VOTRIENT ....................................... 42, 143

VRAYLAR ......................................... 49, 149

VYFEMLA ......................................... 90, 191

VYLIBRA .......................................... 90, 191

VYZULTA ....................................... 102, 204

W warfarin sodium ............................ 59, 160

X XALKORI ......................................... 42, 143

XARELTO ........................................ 59, 160

XARELTO STARTER PACK .............. 59, 160

XATMEP .......................................... 94, 196

XELJANZ ......................................... 95, 197

XELJANZ XR ................................... 95, 197

XGEVA ............................................. 99, 200

XIFAXAN ......................................... 18, 119

XOFLUZA ........................................ 54, 155

XOLAIR ......................................... 107, 208

XOSPATA ........................................ 42, 143

XTAMPZA ER .................................. 13, 114

XTANDI ........................................... 43, 143

XULTOPHY ..................................... 57, 158

XURIDEN ........................................ 82, 184

XYREM .......................................... 108, 209

Y YF-VAX ............................................ 97, 199

YONSA ............................................ 43, 143

YOSPRALA ...................................... 60, 161

Z zafirlukast .................................... 104, 205

zaleplon ....................................... 107, 209

ZARXIO ........................................... 60, 161

ZEJULA ........................................... 43, 143

ZELBORAF ...................................... 43, 143

ZENPEP .......................................... 80, 182

zidovudine ..................................... 52, 153

ZIOPTAN ...................................... 102, 204

ziprasidone hcl .............................. 49, 149

ZIRGAN ........................................... 49, 150

ZOHYDRO ER .................................. 13, 114

ZOLINZA ......................................... 43, 143

zolmitriptan ............................ 36, 136, 137

zolpidem tartrate ........................ 108, 209

zonisamide .................................... 25, 126

ZORTRESS ...................................... 94, 196

ZOSTAVAX ...................................... 97, 199

ZOVIA 1/35E (28) ............................ 90, 191

ZYDELIG ......................................... 43, 143

ZYKADIA .................................. 43, 143, 144

ZYLET ........................................... 102, 204

ZYPREXA RELPREVV ....................... 49, 149

ZYTIGA ............................................ 43, 144

To learn what the abbreviations on this table mean, see the beginning of the drug list table.


contact Imperial Health Plan of California at (800) 838-8271 October 1 – March 31: Monday –

Sunday, from 8:00 a.m. – 8:00 p.m. April 1 – September 30: Monday – Friday, from 8:00 a.m. –

8:00 p.m., or visit www.imperialhealthplan.com.

Imperial Health Plan of California (HMO) (HMO SNP) complies with applicable Federal civil rights

laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATTENTION: If you speak English, language assistance services, free of charge, are available to you.

Call 1-800-838-8271 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

Llame al 1-800-838-8271 (TTY: 711).

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

1-800-708-5976 (TTY：711).

Documents

2020 Drug Formulary - Imperial Health...2019/07/17 · on the front and back cover pages. In the event of non-maintenance changes to the formulary throughout the plan year, Imperial