2020 Drug Formulary | Kaiser Permanente Washington...Cardiovascular Agents - Drugs for Heart and Circulation Conditions..... 31 Central Nervous System Agents - Drugs for Attention

XB0001338-50-17

All plans offered and underwritten by Kaiser Foundation Health Plan of Washington

or Kaiser Foundation Health Plan of Washington Options, Inc.

February 1

1 4

Drug Formulary INTRODUCTION

What is a formulary? A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners to identify drugs that offer the best overall value, considering effectiveness, safety, and cost.

How is the drug formulary developed? The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is composed of physicians from various medical specialties, pharmacists, and a consumer member. The P&T Committee reviews and selects the most appropriate drugs in each class for the formulary based on safety, effectiveness, and cost. The P&T Committee meets quarterly to review new and existing drugs to ensure that the formulary remains responsive to the needs of members and providers.

How do I search the formulary? Drugs on the formulary are listed by therapeutic class. An alphabetical index is included at the end of this document to assist in locating specific drugs.

Drugs are listed by generic name if a generic is available. If there is no generic available, drugs are listed by the brand name. Drugs are organized by class and drug formulary tier. Drugs administered in a provider’s office or in a clinic (e.g., drugs given intravenously) may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet.

How do I use the formulary to understand my drug coverage? Drug coverage is based on an individual’s contracted benefit. Coverage for a specific drug is subject to each member’s medical coverage agreement. Please consult your Benefit Booklet or call Member Service if you have questions about your drug coverage.

Kaiser Permanente will only cover FDA-approved drugs used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions.

Medications not listed in this document are not on the formulary at the time of publication. The most current information is online at www.kp.org/wa/formulary. Non-formulary drugs are not covered unless approved by the health plan as a coverage exception. The prescriber must contact Kaiser Permanente to determine the medical necessity of the non-formulary medication. An alternative formulary medication will be recommended when clinically appropriate. If a coverage exception is not approved, the patient is responsible for the full price of the drug.

Prior authorization, step therapy and nonformulary requests are considered based on coverage criteria requirements approved by the P&T Committee. To request review of an

http://www.ghc.org/

exception to Kaiser Permanente requirements for coverage of prescription drugs, you or your prescriber may contact Kaiser Permanente Member Services at 1-888-630-4636 and request an exception. If the evidence your prescriber provides meets medical necessity, an exception may be approved. Exceptions to required therapy that may be approved include: contraindications, clinical factors associated with adverse reactions, clinical factors reducing effect, other risks of clinical harm, and barriers to compliance with clinical care. Your prescriber may also request temporary coverage while the exception request is being processed.

Generic drugs are substituted when available and allowed by your prescriber. When a generic is available, the brand-name drug is generally considered non-formulary and subject to a higher cost share.

The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the member website at least 60 days prior to the effective date.

What are the methods that Kaiser Permanente uses to ensure appropriate and safe use of formulary drugs?

Prior Authorization (PA) The P&T Committee determines that certain drugs should require prior authorization before they will be covered. These drugs most often have alternatives on the formulary, safety concerns, or a high potential for inappropriate use. To request coverage for prior authorization drugs, you or your prescriber must contact Kaiser Permanente. Drugs requiring prior authorization are indicated with a “PA” superscript next to the drug name.

Step Therapy (ST) Step therapy requires you to try certain preferred drugs before receiving coverage for the drug you were prescribed. Step therapy is added by the P&T Committee. Step therapy automatically looks at your prescription history when you fill the drug you were prescribed. If you have tried the preferred drugs required by step therapy, the drug you were prescribed will automatically be covered. To request step therapy exceptions, you or your prescriber must contact Kaiser Permanente. Drugs requiring step therapy are indicated with a “ST” superscript next to the drug name.

Quantity Limit (QL) A quantity limit defines how much of a particular drug you can get during a specific time period or the maximum days supply that you can get at once. The P&T Committee determines if a drug should have a quantity limit. To request exceptions to quantity limits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits are indicated with “QL” superscript next to the drug name.

High Dose Pain Medicine Prescriber Review Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy.

Drugs Limited to Select Pharmacies Some drugs are required to be dispensed from a preferred specialty pharmacy vendor. Members with an out-of-network benefit may use other pharmacies; however, they may pay

a higher cost share. Please consult your Benefit Booklet for limitations and exclusions. Drugs limited to select pharmacies are listed on the www.kp.org/wa/formulary webpage.

Covered Diabetic Supplies Some diabetic supplies may be covered at a Tier 1 cost share if they are filled as a prescription. These items are:

Preferred blood glucose strips: o One Touch Verio o One Touch Ultra o Prodigy – prior authorization required o Contour Next – prior authorization required o Freestyle – prior authorization required

Disposable insulin syringes and needles Lancing devices and lancets

Preferred blood glucose meters are covered only when filled through mail order pharmacy.

Mail Order Pharmacy Service Mail order is convenient and efficiently utilizes Kaiser Permanente’s resources. This service works best for drugs that must be taken on regular basis, such as birth control pills and drugs for high blood pressure, high cholesterol, or other chronic conditions.

To begin using mail order, ask your prescriber to send your prescription directly to the Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy, contact the Mail Order Pharmacy.

Address: Kaiser Permanente Mail Order Pharmacy

PO Box 34383

Seattle, WA 98124-1383

Phone: 800-245-RXRX (1-800-245-7979)

Fax: 206-630-7950, or toll-free 1-800-350-1683 Specialty Drugs Specialty drugs are high-cost drugs prescribed by a physician for the treatment of complex conditions. Some specialty products are dispensed from a preferred specialty pharmacy vendor.

Over-the-Counter (OTC) Drugs A few plans offer coverage for OTC drugs. For these plans, a list of covered OTC drugs can be found in Appendix A. You may contact Member Service at 1-888-630-4636 to find if you have OTC drug coverage.

Preventative Medications and Preferred Contraceptives In accordance with the Affordable Care Act (ACA) requirements for preventive services, most plans cover preventative care medicines and contraceptives in full. If your plan offers ACA

benefits, all prescribed FDA approved contraceptive methods from the Kaiser Permanente formulary list will be covered in full when obtained in-network. For plans with out-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. The list of the preventative medications covered in full is available on the www.kp.org/wa/formulary webpage.

Please consult your Benefit Booklet under “Preventive Services” or call Member Service if you have questions about your coverage for these drugs.

If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend a preferred generic or therapeutically equivalent product. If you and your provider determine that the preferred contraceptive(s) would be medically inappropriate, your provider must request a contraceptive waiver. If waiver is completed, the requested non-preferred contraceptive will be covered in full. Excluded Prescription Products for Medications that have Over-The- Counter (OTC) Alternatives There are certain prescription products that have the same or similar products available over-the- counter (OTC) without a prescription. In certain cases, Kaiser Permanente will not cover the prescription product. The following prescription drug products are excluded from coverage: esomeprazole magnesium (Nexium), omeprazole/sodium bicarbonate (Zegerid), budesonide nasal spray (Rhinocort Aqua), triamcinolone nasal spray (Nasacort), and fluticasone propionate nasal spray (Flonase). Medical Benefit Injectable Drugs Some drugs are given in a non-hospital setting such as home infusion, a medical office, a physician's office, or an infusion suite. These drugs are covered under the medical benefit but may require prior authorization or a non-hospital setting. The list of medical benefit injectable drugs is available on the www.kp.org/wa/formulary webpage.

How do I get additional information? Please contact Member Service at 1-888-630-4636 with any questions or concerns regarding the information contained in this document.

The most current drug formulary is available at www.kp.org/wa/formulary.

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Table of Contents

Analgesics - Drugs for Pain and Inflammation ........................................................................ 11

Analgesics - Drugs for Pain .......................................................................................................... 12

Anesthetics ....................................................................................................................................... 15

Anti-Addiction / Substance Abuse Treatment Agents........................................................... 16

Antibacterials .................................................................................................................................... 17

Anticoagulants ................................................................................................................................. 20

Anticonvulsants - Drugs for Seizures ........................................................................................ 20

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia .............................. 22

Antidepressants ............................................................................................................................... 22

Antiemetics - Drugs for Nausea and Vomiting ........................................................................ 24

Antifungals ........................................................................................................................................ 24

Antigout Agents ............................................................................................................................... 25

Antimigraine Agents ....................................................................................................................... 26

Antimyasthenic Agents .................................................................................................................. 26

Antimycobacterials ......................................................................................................................... 26

Antineoplastics - Drugs for Cancer ............................................................................................ 27

Antiparasitics .................................................................................................................................... 29

Antiparkinson Agents ..................................................................................................................... 30

Antiplatelets ...................................................................................................................................... 30

Antipsychotics - Drugs for Mood Disorders ............................................................................ 31

Antivirals ............................................................................................................................................ 32

Anxiolytics - Drugs for Anxiety .................................................................................................... 34

Bipolar Agents - Drugs for Mood Disorders ............................................................................. 35

Blood Products and Modifiers - Drugs for Blood Disorders ............................................... 35

Cardiovascular Agents - Drugs for Heart and Circulation Conditions ............................. 35

Central Nervous System Agents - Drugs for Attention Deficit Disorder .......................... 40

Central Nervous System Agents - Drugs for Multiple Sclerosis......................................... 41

Central Nervous System Agents - Miscellaneous .................................................................. 42

Dental and Oral Agents - Drugs for Mouth and Throat Conditions ................................... 42

Dermatological Agents - Drugs for Skin Conditions ............................................................. 42

Diabetes - Antidiabetic Agents .................................................................................................... 50

Diabetes - Glucose Monitoring .................................................................................................... 51

Diabetes - Glycemic Agents ......................................................................................................... 52

Diabetes - Insulins ........................................................................................................................... 52

Electrolytes / Minerals / Metals / Vitamins ................................................................................ 54

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ................................................. 55

10

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions ............ 56

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment .......... 58

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions ................... 58

Genitourinary Agents - Drugs for Prostate Conditions ......................................................... 59

Hormonal Agents - Adrenal .......................................................................................................... 59

Hormonal Agents - Men's Health ................................................................................................. 61

Hormonal Agents - Osteoporosis ............................................................................................... 61

Hormonal Agents - Pituitary ......................................................................................................... 61

Hormonal Agents - Sex Hormones and Birth Control ........................................................... 62

Hormonal Agents - Thyroid ........................................................................................................... 67

Immunological Agents - Drugs for Immune System Stimulation or Suppression ........ 67

Immunological Agents - Drugs for Vaccination ...................................................................... 68

Inflammatory Bowel Disease Agents ......................................................................................... 70

Metabolic Bone Disease Agents - Drugs for Osteoporosis ................................................. 70

Metabolic Bone Disease Agents - Other ................................................................................... 71

Miscellaneous Therapeutic Agents ............................................................................................ 71

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation ........................ 73

Ophthalmic Agents - Drugs for Glaucoma ............................................................................... 75

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions ......................................... 76

Otic Agents - Drugs for Ear Conditions ..................................................................................... 77

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ..................... 77

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions .............................................................................................................................................................. 79

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ................................... 81

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ................ 81

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm ........................................ 81

Sleep Disorder Agents ................................................................................................................... 82

Index of Drugs .................................................................................................................................. 84

Effective Date: 02/01/2021 11

Drug Name Drug Tier

Notes

Analgesics - Drugs for Pain and Inflammation

ARTHROTEC 3

CAMBIA 3 PA

CELEBREX 3

celecoxib oral 1

DAYPRO 3

DICLOFENAC 3 PA

DICLOFENAC EPOLAMINE

3

diclofenac potassium 1

diclofenac sodium er 1

diclofenac sodium external gel 1 %

3

diclofenac sodium external solution

3

diclofenac sodium oral 1

diclofenac-misoprostol 3

DICLOFONO 3

diflunisal oral 1

EC-NAPROSYN 3

ec-naproxen 3

etodolac 1

etodolac er 3

FELDENE 3

fenoprofen calcium oral 3

fenortho 3

FLECTOR 3

flurbiprofen oral 1

GABAPENTIN-NAPROXEN CMPD KIT

3

ibuprofen 1

ibuprofen oral suspension 3

INDOCIN 3

indomethacin er 1

indomethacin oral capsule 25 mg, 50 mg

1

ketoprofen er 3

Drug Name Drug Tier

Notes

ketoprofen oral 3

ketorolac tromethamine injection solution 15 mg/ml

1

KETOROLAC TROMETHAMINE NASAL

3

ketorolac tromethamine oral

3

ketorolac tromethamine solution 30 mg/ml injection

1

KETOROLAC TROMETHAMINE SOLUTION 30 MG/ML INJECTION

3

KETOROLAC TROMETHAMINE SOLUTION 60 MG/2ML INTRAMUSCULAR

3

ketorolac tromethamine solution 60 mg/2ml intramuscular

1

klofensaid ii external solution 1.5 %

3

LICART 3

LODINE 3

meclofenamate sodium oral

1

mefenamic acid oral 3

meloxicam oral capsule 3

meloxicam oral tablet 1

MOBIC 3

nabumetone oral 1

NALFON 3

NAPRELAN 3

NAPROSYN 3

naproxen oral suspension 1

naproxen oral tablet 1

naproxen oral tablet delayed release

3


Drug Name Drug Tier

Notes

naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg

3

naproxen sodium oral tablet 275 mg, 550 mg

1

oxaprozin 3

PENNSAID 3 PA

piroxicam oral 1

QMIIZ ODT 3

RELAFEN 3

RELAFEN DS 3 PA

REXAPHENAC 3

salsalate oral 1

SPRIX 3

sulindac oral 1

TIVORBEX 3

tolmetin sodium oral capsule

1

tolmetin sodium oral tablet 200 mg

1

tolmetin sodium oral tablet 600 mg

3

VIVLODEX 3

VOLTAREN 3

ZIPSOR 3 PA

ZORVOLEX 3 PA

Analgesics - Drugs for Pain

7T GUMMY ES ORAL TABLET CHEWABLE 500 MG

3

acetaminophen-codeine 1 QL

acetaminophen-codeine #2

1 QL


1 QL


1 QL

ALLZITAL 3

APADAZ 3 QL

apap-caff-dihydrocodeine 3 QL

Drug Name Drug Tier

Notes

ARYMO ER 3 ST; QL

ascomp-codeine 3 QL

bac 1

BELBUCA 3 PA; QL

BENZHYDROCODONE-ACETAMINOPHEN

3 QL

BUPAP 3

buprenorphine transdermal

3 PA; QL

butalbital-acetaminophen capsule 50-300 mg oral

3

BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL

3

butalbital-acetaminophen oral tablet

3

butalbital-apap oral tablet 50-325 mg

3

butalbital-apap-caff-cod 3 QL

butalbital-apap-caffeine oral capsule

3

butalbital-apap-caffeine oral tablet

1

butalbital-asa-caff-codeine

3 QL

butalbital-aspirin-caffeine 1

butorphanol tartrate nasal 3 QL

BUTRANS 3 PA; QL

carisoprodol-aspirin-codeine

3 PA

codeine sulfate 1 QL

CONZIP 3 ST; QL

DILAUDID ORAL 3 QL

DOLOPHINE 3 ST; QL

DURAGESIC-100 3 PA; QL





duraxin oral capsule 300-200-20 mg

3


Drug Name Drug Tier

Notes

dvorah oral tablet 325-30-16 mg

3 QL

EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 MG, 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG

3 PA; QL

endocet 1 QL

ESGIC 3

EXALGO ORAL TABLET EXTENDED RELEASE 24 HOUR 12 MG, 16 MG, 32 MG, 8 MG

3 ST; QL

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

1 PA; QL

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

3 PA; QL

FIORICET 3

FIORICET/CODEINE 3 QL

FIORINAL ORAL CAPSULE 50-325-40 MG

3

FIORINAL/CODEINE #3 ORAL CAPSULE 50-325-40-30 MG

3 QL

hydrocodone bitartrate er 3 PA; QL

hydrocodone-acetaminophen oral solution 10-325 mg/15ml

3 QL

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

1 QL

hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg

3 QL

Drug Name Drug Tier

Notes

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

1 QL

hydrocodone-ibuprofen 3 QL

hydromorphone hcl er 3 ST; QL

hydromorphone hcl oral 1 QL

hydromorphone hcl rectal 1 QL

HYSINGLA ER 3 PA; QL

IBUDONE ORAL TABLET 10-200 MG

3 QL

IONSYS TRANSDERMAL PATCH 40 MCG/ACT

3 QL

KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG

3 PA; QL

levorphanol tartrate oral 1 PA; QL

lorcet hd oral tablet 10-325 mg

1 QL

lorcet oral tablet 5-325 mg 1 QL

lorcet plus oral tablet 7.5-325 mg

1 QL

LORTAB 3 QL

meperidine hcl oral tablet 3 QL

methadone hcl concentrate 10 mg/ml oral

3 ST; QL

methadone hcl concentrate 10 mg/ml oral

1 ST; QL

methadone hcl intensol 1 ST; QL

methadone hcl oral solution

1 ST; QL

methadone hcl oral tablet 1 ST; QL

methadone hcl oral tablet soluble

1 ST; QL

methadose oral concentrate 10 mg/ml

3 ST; QL

methadose oral tablet soluble

1 ST; QL

methadose sugar-free 3 ST; QL


Drug Name Drug Tier

Notes

MORPHABOND ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 100 MG, 15 MG, 30 MG, 60 MG

3 ST; QL

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

1 QL

morphine sulfate er beads 3 ST; QL

morphine sulfate er oral capsule extended release 24 hour

3 PA; QL

morphine sulfate er oral tablet extended release

1 ST; QL

morphine sulfate oral 1 QL

morphine sulfate rectal 1 QL

MS CONTIN 3 ST; QL

NALOCET 3 QL

NORCO ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG

3 QL

NUCYNTA 3 PA; QL

NUCYNTA ER 3 ST; QL

OPANA 3 QL

OXAYDO 3 QL

OXYCODONE HCL ER 2 ST; QL

oxycodone hcl oral capsule

3 QL

oxycodone hcl oral concentrate 100 mg/5ml

1 QL

oxycodone hcl oral solution

1 QL

oxycodone hcl oral tablet 1 QL

OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 2.5-300 MG, 5-300 MG

3 QL

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

1 QL

oxycodone-aspirin 1 QL

Drug Name Drug Tier

Notes

oxycodone-ibuprofen oral tablet 5-400 mg

3 QL

OXYCONTIN 2 ST; QL

oxymorphone hcl 3 QL

oxymorphone hcl er 3 ST; QL

pentazocine-naloxone hcl 3 QL

PERCOCET 3 QL

phrenilin forte oral capsule 50-300-40 mg

3

PRIMLEV ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG

3 QL

PROLATE ORAL TABLET

3 QL

ROXICODONE 3 QL

tencon 3

tramadol hcl er (biphasic) 3 ST; QL

TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

3 ST; QL

tramadol hcl er oral capsule extended release 24 hour 150 mg

3 ST; QL

tramadol hcl er oral tablet extended release 24 hour

3 ST; QL

tramadol hcl ir 1 QL

tramadol-acetaminophen 1 QL

TREZIX 3 QL

TYLENOL WITH CODEINE #3 ORAL TABLET 300-30 MG

3 QL

TYLENOL WITH CODEINE #4 ORAL TABLET 300-60 MG

3 QL

ULTRACET 3 QL

ULTRAM 3 QL

VANATOL LQ ORAL SOLUTION 50-325-40 MG/15ML

3

VANATOL S ORAL SOLUTION 50-325-40 MG/15ML

3


Drug Name Drug Tier

Notes

VTOL LQ 3

ZEBUTAL 3

ZOHYDRO ER 3 PA; QL

Anesthetics

1ST MEDX-PATCH/ LIDOCAINE EXTERNAL PATCH 4-0.0375-5-20 %

3

7T LIDO 3

AGONEAZE 3

ANASTIA EXTERNAL LOTION 2.75 %

3

ANODYNE LPT 3

ASTERO 3

BUPIVACAINE HCL-NACL INJECTION SOLUTION 0.2-0.9 %

3

BUPIVACAINE HCL-NACL INJECTION SOLUTION PREFILLED SYRINGE 0.1-0.9 % (50 ML)

3

COCAINE HCL NASAL 3

C-TOPICAL EXTERNAL SOLUTION 4 %

3

DERMACINRX EMPRICAINE

3

DERMACINRX PRIZOPAK

3

EHA 3

ethyl chloride 3

FLEXIN 3

GEBAUERS PAIN EASE 3

GEBAUERS SPRAY AND STRETCH

3

GEN7T 3

glydo 1

GOPRELTO 3

LDO PLUS 3

LEVATIO 3

LIDO BDK 3

Drug Name Drug Tier

Notes

lidocaine external ointment

3

lidocaine external patch 5 %

1

lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 %

3

lidocaine hcl external cream 3 %, 3.88 %

3

LIDOCAINE HCL EXTERNAL CREAM 4.12 %

3

lidocaine hcl external lotion

3 PA

lidocaine hcl external solution

3

lidocaine hcl injection solution 0.5 %

1

LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE

3

LIDOCAINE HCL SOLUTION 1 % INJECTION

3

lidocaine hcl solution 1 % injection

1

LIDOCAINE HCL SOLUTION 2 % INJECTION

3

lidocaine hcl solution 2 % injection

1

lidocaine hcl urethral/mucosal

1

lidocaine pak external ointment 5 %

3

lidocaine-epinephrine injection solution 1 %-1:100000

3

lidocaine-prilocaine 1

LIDOCANNA 3

LIDODERM 3

LIDO-K EXTERNAL LOTION 3 %

3 PA

LIDOMAR 3


Drug Name Drug Tier

Notes

lidopin external cream 3 %

3

LIDOPRIL 3

LIDOPRIL XR 3

LIDO-PRILO CAINE PACK

3

LIDORX 3 PA

LIDO-SORB 3 PA

LIDOTHOL EXTERNAL PATCH

3

LIDOTRAL 3

LIDOZION EXTERNAL LOTION 3 %

3 PA

LIVIXIL PAK 3

LYDEXA 3

MEDI-PATCH RX 3

NUMBONEX EXTERNAL LOTION 2.75 %

3

NUMBRINO 3

NUVAKAAN 3

PORT-PREP EXTERNAL KIT 2.5-2.5 %

3

premium lidocaine 3

PRIKAAN EXTERNAL KIT 2.5-2.5 %

3

PRIKAAN LITE EXTERNAL KIT 2.5-2.5 %

3

PRILOLID 3

PRILOVIX 3

PRILOVIX LITE 3

PRILOVIX LITE PLUS 3

PRILOVIX PLUS 3

prilovix ultralite 1

prilovix ultralite plus 1

PRILOXX LP EXTERNAL KIT 2.5-2.5 %

3

RELADOR PAK 3

RELADOR PAK PLUS 3

RENOVO 3

Drug Name Drug Tier

Notes

ROPIVACAINE HCL INJECTION SOLUTION 5 MG/ML

3

SOLULINE EXTERNAL KIT 2.5-2.5 %

3

SOLUPICC EXTERNAL KIT 2.5-2.5 %

3

SOOTHEE 3

SYNERA 3

VEXATROL 3

XYLOCAINE 3

XYLOCAINE/EPINEPHRINE INJECTION SOLUTION 1 %-1:100000

3

XYLOCAINE-MPF 3

ZERUVIA 3

ZIONODIL 3 PA

ZIONODIL 100 3 PA

ZTLIDO 3

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium 1

ANTABUSE ORAL TABLET 250 MG, 500 MG

3

BUNAVAIL 3 QL

buprenorphine hcl sublingual

1 QL

buprenorphine hcl-naloxone hcl sublingual film

3 QL

buprenorphine hcl-naloxone hcl sublingual tablet sublingual

1 QL

bupropion hcl er (smoking det)

1

CHANTIX 2

CHANTIX CONTINUING MONTH PAK

2

CHANTIX STARTING MONTH PAK

2

disulfiram oral 1


Drug Name Drug Tier

Notes

EVZIO INJECTION SOLUTION AUTO-INJECTOR 2 MG/0.4ML

3

naloxone hcl injection solution

1

NALOXONE HCL INJECTION SOLUTION AUTO-INJECTOR 2 MG/0.4ML

3

naloxone hcl injection solution cartridge

1

naloxone hcl injection solution prefilled syringe

1

naltrexone hcl oral 1

NARCAN 1

NICORETTE MOUTH/THROAT GUM 2 MG

2 PA

nicotine polacrilex mouth/throat

2 PA

nicotine step 1 1 PA



SUBOXONE 3 QL

VIVITROL 4 QL

ZUBSOLV 3 QL

ZYBAN ORAL TABLET EXTENDED RELEASE 12 HOUR 150 MG

3

Antibacterials

ACTICLATE 3

AEMCOLO 3 PA

ALTABAX 3

amoxicillin 1

amoxicillin-potassium clavulanate er

3

amoxicillin-potassium clavulanate oral

1

ampicillin 1

ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 250 mg, 500 mg

1

Drug Name Drug Tier

Notes

ARIKAYCE 3

AUGMENTIN 3

AUGMENTIN ES-600 3

AVELOX ORAL TABLET 400 MG

3

avidoxy 1

azithromycin oral 1

BACTRIM 3

BACTRIM DS 3

BACTROBAN EXTERNAL CREAM 2 %

3

BACTROBAN NASAL NASAL OINTMENT 2 %

3

BICILLIN L-A 2

cefaclor 3

cefaclor er 3

cefadroxil 1

cefazolin sodium injection solution reconstituted 1 gm

1

cefdinir 1

cefditoren pivoxil oral tablet 200 mg, 400 mg

3

cefepime hcl injection solution reconstituted 1 gm

3

cefixime 1

cefpodoxime proxetil 3

cefprozil 1

ceftazidime injection solution reconstituted 1 gm

1

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

1

cefuroxime axetil 1

CENTANY 3

cephalexin oral capsule 250 mg, 500 mg

1


Drug Name Drug Tier

Notes

cephalexin oral capsule 750 mg

3

cephalexin oral suspension reconstituted

1

cephalexin oral tablet 3

CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%)

2

CIPRO ORAL SUSPENSION RECONSTITUTED 500 MG/5ML (10%)

3

CIPRO ORAL TABLET 3

ciprofloxacin hcl oral 1

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

1

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg, 500 mg

3

clarithromycin er 3

clarithromycin oral 1

CLEOCIN 3

CLEOCIN PHOSPHATE INJECTION SOLUTION 300 MG/2ML

3

clindamycin hcl oral 1

clindamycin palmitate hcl 1

clindamycin phosphate injection solution 300 mg/2ml

1

clindamycin phosphate vaginal

1

CLINDESSE 3

colistimethate sodium (cba)

3

COLY-MYCIN M 3

coremino 3 PA

demeclocycline hcl 3

dicloxacillin sodium 1

DORYX 3

Drug Name Drug Tier

Notes

DORYX MPC 3

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg, 150 mg, 50 mg, 75 mg

1

doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg

3

DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG

3

doxycycline monohydrate oral capsule

1

doxycycline monohydrate oral suspension reconstituted

3

doxycycline monohydrate oral tablet

1

E.E.S. 400 3

E.E.S. GRANULES 3

ERYPED 200 3

ERYPED 400 3

ERY-TAB 3

ERYTHROCIN STEARATE

3

erythromycin base 3

erythromycin ethylsuccinate oral

3

erythromycin oral 3

FIRST-VANCOMYCIN ORAL SOLUTION 25 MG/ML, 50 MG/ML

3

FIRVANQ 2

FLAGYL 3

FORTAZ INJECTION SOLUTION RECONSTITUTED 1 GM

3

fosfomycin tromethamine 3


Drug Name Drug Tier

Notes

FURADANTIN ORAL SUSPENSION 25 MG/5ML

3

gentamicin sulfate external

1

gentamicin sulfate injection solution 40 mg/ml

1

HIPREX 3

KEFLEX 3

LEVAQUIN ORAL TABLET 500 MG, 750 MG

3

levofloxacin oral 1

LINCOCIN 3

lincomycin hcl injection 3

linezolid oral suspension reconstituted

1 QL

linezolid oral tablet 1

MACROBID 3

MACRODANTIN 3

mafenide acetate external 3

MAXIPIME INJECTION SOLUTION RECONSTITUTED 1 GM

3

methenamine hippurate 1

methenamine mandelate oral

3

METROGEL-VAGINAL VAGINAL GEL 0.75 %

3

metronidazole oral capsule

3

metronidazole oral tablet 1

metronidazole vaginal 1

MINOCIN ORAL CAPSULE 50 MG

3

minocycline hcl er oral tablet extended release 24 hour

3 PA

minocycline hcl oral capsule

1

minocycline hcl oral tablet 3

Drug Name Drug Tier

Notes

MINOLIRA 3 PA

mondoxyne nl 1

MONUROL 3

morgidox oral 1

moxifloxacin hcl oral 1

mupirocin calcium 1

mupirocin external 1

neomycin sulfate oral 1

neomycin-polymyxin b gu 3

nitrofurantoin 1

nitrofurantoin macrocrystal oral

1

nitrofurantoin monohydrate macrocrystals

1

NUVESSA 3

ofloxacin oral 3

okebo oral capsule 75 mg 1

paromomycin sulfate oral 3

penicillin v potassium 1

PRIMSOL 2

SILVADENE 3

silver nitrate external 3

silver sulfadiazine external

1

SIVEXTRO ORAL 4 QL

SOLODYN 3 PA

SOLOSEC 3

ssd 1

streptomycin sulfate intramuscular

3

sulfadiazine oral 3

sulfamethoxazole-trimethoprim oral

1

SULFAMYLON 3

sulfatrim pediatric 1

SUPRAX ORAL CAPSULE

3


Drug Name Drug Tier

Notes

SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML

3

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

2

SUPRAX ORAL TABLET CHEWABLE

3

TARGADOX 3

tazicef injection solution reconstituted 1 gm

1

tetracycline hcl oral 3

tinidazole oral 3

trimethoprim oral 1

vancomycin hcl oral capsule

1 QL

vancomycin hcl oral solution reconstituted

1

vandazole 1

VIBRAMYCIN 3

XENLETA ORAL 3

XEPI 3

XIMINO 3 PA

ZITHROMAX ORAL 3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

Anticoagulants

COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

3

ELIQUIS 3 PA

ELIQUIS DVT/PE STARTER PACK

3 PA

enoxaparin sodium 1 QL

fondaparinux sodium 4 QL

Drug Name Drug Tier

Notes

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML

3

FRAGMIN SUBCUTANEOUS SOLUTION 95000 UNIT/3.8ML

3 PA

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 5000 unit/ml

1

heparin sodium (porcine) pf

1

jantoven 1

LOVENOX 1 QL

PRADAXA 2

SAVAYSA 3 PA

warfarin sodium oral 1

XARELTO 2 PA

XARELTO STARTER PACK

2 PA

Anticonvulsants - Drugs for Seizures

carbamazepine er 1

carbamazepine oral 1

CARBATROL 3

CELONTIN 2

DEPAKENE ORAL CAPSULE 250 MG

3

DEPAKENE ORAL SOLUTION 250 MG/5ML

3

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES 3

DIASTAT ACUDIAL 3 QL

DIASTAT PEDIATRIC 1 QL

diazepam rectal 1 QL


Drug Name Drug Tier

Notes

DILANTIN INFATABS 3

DILANTIN ORAL CAPSULE 100 MG

3

DILANTIN ORAL CAPSULE 30 MG

2

DILANTIN ORAL SUSPENSION

3

divalproex sodium er 1

divalproex sodium oral 1

epitol 1

ethosuximide oral 1

felbamate oral suspension

3

felbamate oral tablet 3 QL

FYCOMPA 3 ST; QL

gabapentin oral 1

GABITRIL 3

KEPPRA ORAL 3

KEPPRA XR 3

LAMICTAL 3

LAMICTAL ODT 3

LAMICTAL STARTER 3

LAMICTAL XR 3

lamotrigine er 3

lamotrigine oral kit 3

lamotrigine oral tablet 1

lamotrigine oral tablet chewable

1

lamotrigine oral tablet dispersible

3

lamotrigine starter kit-blue 3

lamotrigine starter kit-green

3

lamotrigine starter kit-orange

3

levetiracetam er 1

levetiracetam oral 1

NEMBUTAL 3

NEURONTIN 3

Drug Name Drug Tier

Notes

oxcarbazepine 1

OXTELLAR XR 3

PEGANONE ORAL TABLET 250 MG

3

pentobarbital sodium injection

3

phenobarbital oral 1

phenobarbital oral solution 20 mg/5ml

1

phenobarbital sodium injection solution 130 mg/ml

1

PHENYTEK 3

phenytoin infatabs 1

phenytoin oral 1

phenytoin sodium extended oral capsule 100 mg

1

phenytoin sodium extended oral capsule 200 mg, 300 mg

3

phenytoin sodium injection

1

primidone oral 1 QL

QUDEXY XR 3 PA

roweepra 1

roweepra xr oral tablet extended release 24 hour 500 mg, 750 mg

1

SPRITAM 3

subvenite 1

subvenite starter kit-blue 3

subvenite starter kit-green 3

subvenite starter kit-orange

3

TEGRETOL 3

TEGRETOL-XR 3

tiagabine hcl 3

TOPAMAX 3

TOPAMAX SPRINKLE 3

topiramate er 3 PA


Drug Name Drug Tier

Notes

topiramate oral 1

TRILEPTAL 3

TROKENDI XR 3 PA

valproic acid oral 1

VALTOCO 10 MG DOSE 2 QL




VIMPAT ORAL 3

ZARONTIN 3

ZONEGRAN 3

zonisamide oral 1

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

ARICEPT 3

donepezil hcl oral tablet 10 mg, 5 mg

1

donepezil hcl oral tablet 23 mg

3

donepezil hcl oral tablet dispersible

3

EXELON 3

galantamine hydrobromide

1

galantamine hydrobromide er

1

memantine hcl er 3 PA

memantine hcl oral solution

3

memantine hcl oral tablet 10 mg, 5 mg

1

memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg

3

NAMENDA 3

NAMENDA TITRATION PAK

3

NAMENDA XR 3 PA

NAMENDA XR TITRATION PACK

3 PA

NAMZARIC 3

Drug Name Drug Tier

Notes

RAZADYNE ER 3

RAZADYNE ORAL TABLET 12 MG, 4 MG, 8 MG

3

rivastigmine 3

rivastigmine tartrate 1

Antidepressants

amitriptyline hcl oral 1

amoxapine 1

ANAFRANIL 3

APLENZIN 3

BRISDELLE 3

bupropion hcl er (sr) 1

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

1

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

3 ST

bupropion hcl oral 1

CELEXA 3

chlordiazepoxide-amitriptyline

3 QL

citalopram hydrobromide 1

clomipramine hcl oral 1

CYMBALTA 3

desipramine hcl oral 1

DESVENLAFAXINE ER 3 PA

desvenlafaxine succinate er

3

doxepin hcl oral capsule 1

doxepin hcl oral concentrate

1

DRIZALMA SPRINKLE 3

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

1


Drug Name Drug Tier

Notes

duloxetine hcl oral capsule delayed release particles 40 mg

3

EFFEXOR XR 3

escitalopram oxalate 1

FETZIMA 3 ST

FETZIMA TITRATION 3 PA

fluoxetine hcl (pmdd) oral capsule 10 mg, 20 mg

1

fluoxetine hcl (pmdd) oral tablet

3

fluoxetine hcl oral capsule 1

fluoxetine hcl oral capsule delayed release

3

fluoxetine hcl oral solution 1

fluoxetine hcl oral tablet 3

fluvoxamine maleate 1

fluvoxamine maleate er 3

FORFIVO XL 3 ST

imipramine hcl oral 1

imipramine pamoate 3

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 50 MG

3 PA

LEXAPRO 3

maprotiline hcl 1

MARPLAN 3

mirtazapine oral 1

NARDIL 3

nefazodone hcl 3

NORPRAMIN 3

nortriptyline hcl oral 1

olanzapine-fluoxetine hcl 3

PAMELOR 3

PARNATE 3

paroxetine hcl 1

paroxetine hcl er 3

paroxetine mesylate 3

Drug Name Drug Tier

Notes

PAXIL CR 3

PAXIL ORAL SUSPENSION

2

PAXIL ORAL TABLET 3

perphenazine-amitriptyline

1

PEXEVA 3

phenelzine sulfate oral 1

PRISTIQ 3 PA

protriptyline hcl 1

PROZAC 3

REMERON 3

REMERON SOLTAB 3

SARAFEM ORAL TABLET 10 MG, 20 MG

3

sertraline hcl oral 1

SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG

3

SYMBYAX 3

TOFRANIL ORAL TABLET 10 MG, 25 MG, 50 MG

3

tranylcypromine sulfate 1

trazodone hcl oral 1

trimipramine maleate oral 3

TRINTELLIX 3 ST

venlafaxine hcl 1

venlafaxine hcl er oral capsule extended release 24 hour

1

venlafaxine hcl er oral tablet extended release 24 hour

3

VIIBRYD 3 ST

VIIBRYD STARTER PACK

3 ST

WELLBUTRIN SR 3

WELLBUTRIN XL 3

ZOLOFT 3


Drug Name Drug Tier

Notes

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO ORAL 3

ANZEMET 3

aprepitant oral capsule 125 mg, 80 & 125 mg, 80 mg

1

aprepitant oral capsule 40 mg

3

BONJESTA 3 PA

CESAMET ORAL CAPSULE 1 MG

3

compro 1

DICLEGIS 3 PA

dimenhydrinate injection 1

doxylamine-pyridoxine 3 PA

dronabinol 1

EMEND ORAL 3

EMEND TRI-PACK 3

granisetron hcl oral 3 PA

MARINOL 3

meclizine hcl oral tablet 12.5 mg, 25 mg

3

metoclopramide hcl injection

1

metoclopramide hcl oral solution

1

metoclopramide hcl oral tablet

1

metoclopramide hcl oral tablet dispersible

3

ondansetron hcl injection solution 40 mg/20ml

1

ondansetron hcl oral 1

ONDANSETRON HCL SOLUTION 4 MG/2ML INJECTION

3

ondansetron hcl solution 4 mg/2ml injection

1

ondansetron odt 1

perphenazine oral 1

Drug Name Drug Tier

Notes

prochlorperazine 1

prochlorperazine edisylate injection

1

prochlorperazine maleate oral

1

REGLAN 3

SANCUSO 3 PA

scopolamine 3

SYNDROS 3

TIGAN 3

TRANSDERM SCOP (1.5 MG)

3

TRANSDERM-SCOP (1.5 MG)

3

trimethobenzamide hcl oral

3

VARUBI (180 MG DOSE) 3 PA

ZOFRAN 3

ZOFRAN ORAL SOLUTION 4 MG/5ML

3

ZUPLENZ 3

Antifungals

AVC VAGINAL VAGINAL CREAM 15 %

3

BIO-STATIN ORAL CAPSULE

3

bio-statin oral powder 3

ciclodan 1

ciclopirox external gel 1

ciclopirox external shampoo

3

ciclopirox external solution

1

ciclopirox olamine external

1

clotrimazole external 3

clotrimazole mouth/throat 1

clotrimazole-betamethasone

1

CRESEMBA ORAL 4 PA; QL

DIFLUCAN 3


Drug Name Drug Tier

Notes

econazole nitrate external 3

ECOZA 3

ERTACZO 3

EXELDERM 3

exoderm external lotion 3

EXTINA 3

fluconazole oral 1

flucytosine oral 4 QL

griseofulvin microsize oral 1

griseofulvin ultramicrosize 1

GYNAZOLE-1 3

itraconazole oral 1 PA

JUBLIA 3 PA

KERYDIN 3 PA

ketoconazole external cream

1

ketoconazole external foam

3

ketoconazole external shampoo

1

ketoconazole oral 1

ketodan external foam 3

LOPROX EXTERNAL CREAM

3

LOPROX EXTERNAL KIT 0.77 % (SUSP)

3

LOPROX EXTERNAL SHAMPOO

3

LOPROX EXTERNAL SUSPENSION

3

LOTRISONE EXTERNAL CREAM 1-0.05 %

3

LULICONAZOLE 3

LUZU 3

miconazole 3 vaginal suppository

3

MICONAZOLE-ZINC OXIDE-PETROLAT

3

naftifine hcl 3

NAFTIN 3

Drug Name Drug Tier

Notes

NIZORAL EXTERNAL SHAMPOO 2 %

3

nyamyc 1

nystatin external 1

nystatin mouth/throat 1

nystatin oral 1

nystatin-triamcinolone 1

nystop 1

ORAVIG 3

oxiconazole nitrate 3

OXISTAT 3

PENLAC EXTERNAL SOLUTION 8 %

3

SPORANOX 3 PA

SPORANOX PULSEPAK 3 PA

tavaborole 3 PA

terbinafine hcl oral 1

terconazole 3

voriconazole oral 1 PA

VUSION 3

XOLEGEL 3

Antigout Agents

allopurinol oral 1

COLCHICINE ORAL CAPSULE

1

colchicine tablet 0.6 mg oral

1

COLCHICINE TABLET 0.6 MG ORAL

3

colchicine-probenecid 1

COLCRYS 2

DUZALLO ORAL TABLET 200-200 MG, 200-300 MG

3 PA

febuxostat 3 PA

GLOPERBA 3

MITIGARE 3

probenecid 1

ULORIC 3 PA


Drug Name Drug Tier

Notes

ZURAMPIC ORAL TABLET 200 MG

3 PA

ZYLOPRIM 3

Antimigraine Agents

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML, 70 MG/ML

3 PA

AJOVY 3 PA

almotriptan malate 3 ST

AMERGE 3

CAFERGOT 3

dihydroergotamine mesylate injection

1 QL

dihydroergotamine mesylate nasal

4

eletriptan hydrobromide 3

EMGALITY 3 PA

EMGALITY (300 MG DOSE)

3 PA

ERGOMAR 2

ergotamine-caffeine 1

FROVA 3 ST

frovatriptan succinate 3 ST

IMITREX 3

IMITREX STATDOSE REFILL

3

IMITREX STATDOSE SYSTEM

3

MAXALT 3

MAXALT-MLT 3

MIGERGOT 2

naratriptan hcl 1

NURTEC 3 PA; QL

RELPAX 3

REYVOW 3 PA; QL

rizatriptan benzoate 1

sumatriptan nasal 1

Drug Name Drug Tier

Notes

sumatriptan succinate oral

1

sumatriptan succinate refill

1

sumatriptan succinate subcutaneous

1

sumatriptan-naproxen sodium

3 ST

TOSYMRA 3

TREXIMET 3 ST

UBRELVY 3 PA; QL

ZEMBRACE SYMTOUCH 3

zolmitriptan oral 1

ZOMIG 3

ZOMIG ZMT 3

Antimyasthenic Agents

GUANIDINE HCL 3

MESTINON ORAL SOLUTION

2

MESTINON ORAL TABLET

3

MESTINON ORAL TABLET EXTENDED RELEASE

3

pyridostigmine bromide er 1

pyridostigmine bromide oral

1

Antimycobacterials

cycloserine oral 3

dapsone oral 1

ethambutol hcl oral 1

isoniazid oral 1

MYAMBUTOL 3

MYCOBUTIN 3

PASER 3

PRIFTIN 2

pyrazinamide oral 1

rifabutin 1


Drug Name Drug Tier

Notes

RIFADIN ORAL CAPSULE 150 MG, 300 MG

3

RIFAMATE ORAL CAPSULE 150-300 MG

3

rifampin oral 1

RIFATER ORAL TABLET 50-120-300 MG

3

TRECATOR 3

Antineoplastics - Drugs for Cancer

abiraterone acetate oral tablet 250 mg

1 QL

abiraterone acetate oral tablet 500 mg

2 QL

AFINITOR DISPERZ 2 PA; QL

AFINITOR ORAL TABLET 10 MG

2 PA; QL

AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG

3 PA; QL

ALECENSA 3 PA; QL

ALKERAN ORAL 3 QL

ALUNBRIG 3 PA; QL

anastrozole oral 1

ARIMIDEX 3

AROMASIN 3

AYVAKIT 3 PA; QL

BALVERSA 3 PA; QL

bexarotene 3 PA; QL

bicalutamide 1

BOSULIF 3 PA; QL

BRAFTOVI 3 PA; QL

BRUKINSA 3 PA; QL

CABOMETYX 3 PA

CALQUENCE 3 PA; QL

capecitabine 1 QL

CAPRELSA 3 PA; QL

CASODEX 3

COMETRIQ (100 MG DAILY DOSE)

3 PA; QL

Drug Name Drug Tier

Notes


3 PA; QL


3 PA; QL

COPIKTRA 3 PA; QL

COTELLIC 2 PA; QL

cyclophosphamide oral 1

DAURISMO 3 PA; QL

DROXIA 2

EMCYT 3 QL

ERIVEDGE 3 PA

ERLEADA 3 PA; QL

erlotinib hcl 1 PA

etoposide oral 1 QL

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg

1 PA; QL

exemestane 1

FARESTON 3 PA

FARYDAK 3 PA; QL

FEMARA 3

flutamide 1

GAVRETO 3 PA; QL

GILOTRIF 2 PA; QL

GLEEVEC 3 QL

GLEOSTINE 2

HYCAMTIN ORAL 3 QL

HYDREA 3

hydroxyurea oral 1

IBRANCE 3 PA; QL

ICLUSIG 3 PA; QL

IDHIFA 3 PA; QL

imatinib mesylate 1 QL

IMBRUVICA ORAL CAPSULE

2 PA; QL

IMBRUVICA ORAL TABLET 140 MG, 420 MG, 560 MG

2 PA; QL

IMBRUVICA ORAL TABLET 280 MG

3 PA; QL

INLYTA 3 PA; QL


Drug Name Drug Tier

Notes

INQOVI 3 PA; QL

INREBIC 3 PA; QL

IRESSA 2 PA; QL

JAKAFI 3 PA

KISQALI (200 MG DOSE) 3 PA; QL



KISQALI FEMARA (400 MG DOSE)

3 PA; QL

KISQALI FEMARA (600 MG DOSE)

3 PA; QL

KISQALI FEMARA(200 MG DOSE)

3 PA; QL

lapatinib ditosylate 1 PA; QL

LENVIMA (10 MG DAILY DOSE)

3 PA; QL


3 PA; QL


3 PA; QL


3 PA


3 PA; QL


3 PA; QL


3 PA; QL


3 PA

letrozole oral 1

leucovorin calcium injection solution 100 mg/10ml

3

leucovorin calcium oral 1

LEUKERAN 2

LONSURF 3 PA; QL

LORBRENA 3 PA; QL

LYNPARZA 3 PA; QL

LYSODREN 3 PA

MATULANE 2 QL

MEKINIST 2 PA; QL

Drug Name Drug Tier

Notes

MEKTOVI 3 PA; QL

melphalan 1 QL

mercaptopurine oral 1

mesna 1

MESNEX ORAL 2

MYLERAN 2 QL

NERLYNX 3 PA; QL

NEXAVAR 2 PA

NILANDRON 3 PA

nilutamide 3 PA

NINLARO 3 PA; QL

NUBEQA 3 PA; QL

ODOMZO 3 PA; QL

ONUREG 3 PA; QL

ORGOVYX 3

PANRETIN 3 PA; QL

PEMAZYRE 3 PA; QL

PIQRAY (200 MG DAILY DOSE)

3 PA; QL


3 PA; QL


3 PA; QL

POMALYST 3 PA; QL

PURIXAN 3 PA

QINLOCK 3 PA; QL

RETEVMO 3 PA; QL

REVLIMID 2 PA; QL

ROZLYTREK 2 PA; QL

RUBRACA 3 PA; QL

RYDAPT 2 PA; QL

SOLTAMOX 3

SPRYCEL 2 PA; QL

STIVARGA 2 PA

SUTENT 2 PA; QL

TABLOID 2

TABRECTA 3 PA; QL

TAFINLAR 2 PA; QL

TAGRISSO 2 PA; QL


Drug Name Drug Tier

Notes

TALZENNA 3 PA; QL

tamoxifen citrate oral 1

TARCEVA 3 PA

TARGRETIN 3 PA; QL

TASIGNA 3 PA; QL

TAZVERIK 3 PA; QL

TEMODAR ORAL 3 QL

temozolomide 1 QL

THALOMID 2 PA; QL

TIBSOVO 3 PA; QL

toremifene citrate 3 PA

tretinoin oral 1 QL

TUKYSA 3 PA; QL

TURALIO 3 PA; QL

TYKERB 2 PA; QL

VENCLEXTA 2 PA; QL

VENCLEXTA STARTING PACK

2 PA; QL

VERZENIO 3 PA; QL

VITRAKVI 3 PA; QL

VIZIMPRO 3 PA; QL

VOTRIENT 2 PA; QL

XALKORI 3 PA; QL

XELODA 3 QL

XOSPATA 3 PA; QL

XPOVIO (100 MG ONCE WEEKLY)

3 PA; QL


3 PA; QL

XPOVIO (40 MG TWICE WEEKLY)

3 PA; QL


3 PA; QL


3 PA; QL


3 PA; QL


3 PA; QL

XTANDI 2 PA; QL

Drug Name Drug Tier

Notes

YONSA 3 QL

ZEJULA 3 PA; QL

ZELBORAF 2 PA

ZOLINZA 3 PA; QL

ZYDELIG 2 PA; QL

ZYKADIA ORAL CAPSULE 150 MG

3 PA; QL

ZYTIGA ORAL TABLET 250 MG

3 QL

ZYTIGA ORAL TABLET 500 MG

2 QL

Antiparasitics

albendazole oral 1

ALBENZA 3

ALINIA 2

atovaquone oral 4

BENZNIDAZOLE 3 QL

BILTRICIDE 3

chloroquine phosphate oral

1

COARTEM 3

crotan 2

DARAPRIM 3 PA; QL

ELIMITE 3

EMVERM 3

EURAX EXTERNAL CREAM 10 %

2

EURAX EXTERNAL LOTION 10 %

2

hydroxychloroquine sulfate oral

1

ivermectin external 3

ivermectin oral 3

KRINTAFEL 2

LAMPIT 3

lindane 3

malathion 3

NATROBA 3

NEBUPENT 3


Drug Name Drug Tier

Notes

nitazoxanide 2

OVIDE 3

PENTAM 3

pentamidine isethionate 3

permethrin external 1

PLAQUENIL 3

praziquantel oral 1

primaquine phosphate 1

pyrimethamine oral 4 PA; QL

QUALAQUIN 3

quinine sulfate oral 3

SKLICE 3

spinosad 3

STROMECTOL 3

ULESFIA EXTERNAL LOTION 5 %

2

Antiparkinson Agents

amantadine hcl oral 1

AZILECT 3 PA

benztropine mesylate 1

bromocriptine mesylate oral

1

carbidopa oral 1

carbidopa-levodopa er 1

carbidopa-levodopa oral tablet

1

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

1

carbidopa-levodopa oral tablet dispersible 25-250 mg

3

carbidopa-levodopa-entacapone

1

COGENTIN 3

COMTAN 3

DUOPA 4 PA

entacapone 1

LODOSYN 3

Drug Name Drug Tier

Notes

MIRAPEX 3

MIRAPEX ER 3

NEUPRO 3

ONGENTYS 3 PA

OSMOLEX ER 3 PA

PARLODEL 3

pramipexole dihydrochloride

1

pramipexole dihydrochloride er

3

rasagiline mesylate oral 1 PA

REQUIP ORAL TABLET 1 MG, 4 MG, 5 MG

3

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HOUR 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

3

ropinirole hcl 1

ropinirole hcl er 3

RYTARY 3 PA

selegiline hcl oral 1

SINEMET 3

SINEMET CR ORAL TABLET EXTENDED RELEASE 25-100 MG, 50-200 MG

3

STALEVO 100 3

STALEVO 125 3

STALEVO 150 3

STALEVO 200 3

STALEVO 50 3

STALEVO 75 3

trihexyphenidyl hcl 1

XADAGO 3 PA

Antiplatelets

AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG

3

aspirin-dipyridamole er 1


Drug Name Drug Tier

Notes

BRILINTA 2

cilostazol 1

clopidogrel bisulfate oral 1

dipyridamole oral 1

DURLAZA 3

EFFIENT 3

PLAVIX 3

prasugrel hcl 1

YOSPRALA 3

ZONTIVITY 3

Antipsychotics - Drugs for Mood Disorders

ABILIFY 3

ABILIFY MAINTENA 4 QL

ABILIFY MYCITE 3

aripiprazole oral solution 1

aripiprazole oral tablet 1

aripiprazole oral tablet dispersible

3

ARISTADA 4 QL

ARISTADA INITIO 4 QL

asenapine maleate 3 ST

chlorpromazine hcl injection

1

chlorpromazine hcl oral 1

clozapine oral tablet 1

clozapine oral tablet dispersible

3

CLOZARIL 3

FANAPT 3 ST

FANAPT TITRATION PACK

3 ST

FAZACLO ORAL TABLET DISPERSIBLE 100 MG, 12.5 MG, 150 MG, 200 MG, 25 MG

3

fluphenazine decanoate injection

1

fluphenazine hcl 1

GEODON 3

Drug Name Drug Tier

Notes

HALDOL 3

HALDOL DECANOATE 3

haloperidol decanoate intramuscular

1

haloperidol lactate 1

haloperidol oral 1

INVEGA 3 ST

INVEGA SUSTENNA 4

INVEGA TRINZA 4 QL

loxapine succinate 1

molindone hcl 3

olanzapine 1

paliperidone er 3 ST

PERSERIS 4

pimozide 1

quetiapine fumarate 1

quetiapine fumarate er 1

REXULTI 3 PA

RISPERDAL 3

RISPERDAL CONSTA 2

risperidone m-tab oral tablet dispersible 0.5 mg, 1 mg, 2 mg

3

risperidone oral solution 1

risperidone oral tablet 1

risperidone oral tablet dispersible

3

SAPHRIS 3 ST

SECUADO 3 ST

SEROQUEL 3

SEROQUEL XR 3

thioridazine hcl oral 3

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ 3

ziprasidone hcl 1

ziprasidone mesylate 3

ZYPREXA 3


Drug Name Drug Tier

Notes

ZYPREXA RELPREVV 2

ZYPREXA ZYDIS 3

Antivirals

abacavir sulfate 1

abacavir sulfate-lamivudine

1 QL

abacavir-lamivudine-zidovudine

4 QL

acyclovir external 3

acyclovir oral 1

adefovir dipivoxil 1 QL

APTIVUS ORAL CAPSULE

4 QL

atazanavir sulfate 1 QL

BARACLUDE ORAL SOLUTION

4 QL

BIKTARVY 4 QL

CIMDUO 4 QL

COMBIVIR ORAL TABLET 150-300 MG

3

COMPLERA 4 PA; QL

CRIXIVAN 2

DENAVIR 3

DESCOVY 4 QL

didanosine 1

DOVATO 4 QL

EDURANT 2

efavirenz 1

efavirenz-emtricitab-tenofovir

4 QL

efavirenz-lamivudine-tenofovir

1

emtricitabine 1

emtricitabine-tenofovir df 4 QL

EMTRIVA ORAL CAPSULE

3

EMTRIVA ORAL SOLUTION

2

entecavir 1 QL

EPCLUSA 4 PA; QL

Drug Name Drug Tier

Notes

EPIVIR HBV ORAL SOLUTION

2

EPIVIR HBV ORAL TABLET

3

EPIVIR ORAL SOLUTION 10 MG/ML

3

EPIVIR ORAL TABLET 150 MG, 300 MG

3

famciclovir oral 3

FLUMADINE ORAL TABLET 100 MG

3

fosamprenavir calcium 4 QL

GENVOYA 4

HARVONI 4 PA; QL

INTELENCE 2

INTRON A 2 QL

INVIRASE 2

ISENTRESS HD 2

ISENTRESS ORAL PACKET

3

ISENTRESS ORAL TABLET

2

ISENTRESS ORAL TABLET CHEWABLE

2

JULUCA 4 QL

KALETRA ORAL SOLUTION

3

KALETRA ORAL TABLET 2

lamivudine 1

lamivudine-zidovudine 1

LEDIPASVIR-SOFOSBUVIR

4 PA; QL

LEXIVA ORAL SUSPENSION

4 QL

lopinavir-ritonavir 1

MODERIBA (1200 MG PACK) ORAL TABLET THERAPY PACK 600 MG

3 QL

moderiba oral tablet 200 mg

1 QL

nevirapine er 1


Drug Name Drug Tier

Notes

nevirapine oral suspension

3

nevirapine oral tablet 1

NORVIR ORAL PACKET 2

NORVIR ORAL SOLUTION

2

NORVIR ORAL TABLET 3

ODEFSEY 4 QL

oseltamivir phosphate oral

1

PEGASYS 4 QL

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/0.5ML

4 QL

PEGINTRON 4 QL

PREVYMIS ORAL 4 PA; QL

PREZCOBIX 2 QL

PREZISTA 2

REBETOL ORAL SOLUTION 40 MG/ML

2 QL

RELENZA DISKHALER 2

RESCRIPTOR ORAL TABLET 200 MG

2

RETROVIR ORAL 3

REYATAZ ORAL PACKET

2

ribasphere oral capsule 200 mg

1 QL

ribasphere oral tablet 200 mg

1 QL

RIBASPHERE ORAL TABLET 400 MG

3

RIBASPHERE ORAL TABLET 600 MG

3 QL

RIBASPHERE RIBAPAK (1000 PACK) ORAL TABLET THERAPY PACK 400 & 600 MG

3 QL

RIBASPHERE RIBAPAK (1200 PACK) ORAL TABLET THERAPY PACK 600 MG

3 QL

Drug Name Drug Tier

Notes

RIBASPHERE RIBAPAK (600 PACK) ORAL TABLET THERAPY PACK 200 & 400 MG

3 QL

RIBASPHERE RIBAPAK (800 PACK) ORAL TABLET THERAPY PACK 400 MG

3

ribavirin inhalation 3

ribavirin oral 1 QL

rimantadine hcl 1

ritonavir 1

SELZENTRY ORAL SOLUTION

4 QL

SELZENTRY ORAL TABLET 150 MG, 300 MG

4 QL

SELZENTRY ORAL TABLET 25 MG, 75 MG

4

SITAVIG 3

SOFOSBUVIR-VELPATASVIR

4 PA; QL

stavudine 1

STRIBILD 4 PA; QL

SUSTIVA 3

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

3 QL

SYMFI 1

SYMFI LO 1

SYMTUZA 4 QL

TAMIFLU 2

TEMIXYS 4 QL

tenofovir disoproxil fumarate

1

TIVICAY 2

TIVICAY PD 2

TRIUMEQ 4 QL

TRUVADA 4 QL

TYBOST 2 PA

valacyclovir hcl oral 1


Drug Name Drug Tier

Notes

valganciclovir hcl 4 QL

VALTREX 3

VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG, 200 MG, 250 MG, 400 MG

3

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM

2

VIRACEPT 2

VIRAMUNE 3

VIRAMUNE ORAL TABLET 200 MG

3

VIRAMUNE XR 3

VIRAZOLE 3

VIREAD ORAL POWDER 2

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

2

VIREAD ORAL TABLET 300 MG

3

VOSEVI 4 PA; QL

XERESE 3

XOFLUZA (40 MG DOSE)

3

XOFLUZA (80 MG DOSE)

3

ZIAGEN ORAL SOLUTION 20 MG/ML

3

ZIAGEN ORAL TABLET 300 MG

3

zidovudine 1

ZOVIRAX 3

ZOVIRAX ORAL CAPSULE 200 MG

3

ZOVIRAX ORAL TABLET 400 MG, 800 MG

3

Anxiolytics - Drugs for Anxiety

alprazolam er 1 QL

alprazolam intensol 3 QL

alprazolam oral tablet 1 QL

Drug Name Drug Tier

Notes

alprazolam oral tablet dispersible

3 QL

alprazolam xr 1 QL

ATIVAN INJECTION SOLUTION 2 MG/ML

3 QL

ATIVAN ORAL 3 QL

buspirone hcl oral 1

chlordiazepoxide hcl 1 QL

clonazepam oral 1 QL

clorazepate dipotassium 1 QL

diazepam intensol 3 QL

diazepam intramuscular 1 QL

diazepam oral concentrate

3 QL

diazepam oral solution 1 QL

diazepam oral tablet 1 QL

diazepam solution 5 mg/ml injection

1 QL

DIAZEPAM SOLUTION 5 MG/ML INJECTION

3 QL

DORAL 3 QL

estazolam 3 QL

HALCION 3 QL

hydroxyzine hcl oral 1

hydroxyzine pamoate oral 1

KLONOPIN 3 QL

lorazepam injection solution 2 mg/ml

1 QL

lorazepam intensol 1 QL

lorazepam oral concentrate 2 mg/ml

1 QL

lorazepam oral tablet 1 QL

meprobamate 3

midazolam hcl (pf) injection solution 10 mg/2ml, 5 mg/ml

1 QL

midazolam hcl injection solution 10 mg/2ml, 5 mg/ml

1 QL

midazolam hcl oral 3 QL

oxazepam 1 QL


Drug Name Drug Tier

Notes

quazepam 3 QL

TRANXENE-T 3 QL

triazolam 1 QL

VALIUM 3 QL

VISTARIL 3

XANAX 3 QL

XANAX XR 3 QL

Bipolar Agents - Drugs for Mood Disorders

EQUETRO 3

lithium 1

lithium carbonate er 1

lithium carbonate oral 1

LITHOBID 3

Blood Products and Modifiers - Drugs for Blood Disorders

AGRYLIN 3

AMICAR 3

aminocaproic acid oral 3

anagrelide hcl 1

ARANESP (ALBUMIN FREE)

3 PA

EPOGEN 2 PA

HEMLIBRA 4 PA; QL

LEUKINE 2

LYSTEDA 3 QL

MIRCERA 3 PA

NEUPOGEN 4 QL

PROCRIT 2 PA

RETACRIT 3 PA

tranexamic acid oral 1 QL

ZARXIO 4 QL

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL 3

ACCURETIC 3

acebutolol hcl oral 1

acetazolamide sodium 3

Drug Name Drug Tier

Notes

ADALAT CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG, 90 MG

3

ALDACTAZIDE ORAL TABLET 25-25 MG

3

ALDACTAZIDE ORAL TABLET 50-50 MG

2

ALDACTONE 3

aliskiren fumarate 3 ST

alprostadil injection 1

ALTACE 3

ALTOPREV 3

amiloride hcl oral 1

amiloride-hydrochlorothiazide

1

amiodarone hcl oral tablet 100 mg, 400 mg

3

amiodarone hcl oral tablet 200 mg

1

amlodipine besylate oral 1

amlodipine besylate-benazepril hcl

1

amlodipine besylate-valsartan

3 ST

amlodipine-atorvastatin 3

amlodipine-olmesartan 1

amlodipine-valsartan-hctz 3

ANTARA 3

ATACAND 3

ATACAND HCT 3

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral 1

AVALIDE 3

AVAPRO 3

AZOR 3

benazepril hcl oral 1

benazepril-hydrochlorothiazide

1


Drug Name Drug Tier

Notes

BENICAR 3

BENICAR HCT 3

BETAPACE 3

BETAPACE AF 3

betaxolol hcl oral 1

BIDIL 3

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide

1

BRETYLIUM TOSYLATE 3

bumetanide oral 1

BUMEX 3

BYSTOLIC 3

BYVALSON ORAL TABLET 5-80 MG

3

CADUET 3

CALAN ORAL TABLET 120 MG

3

CALAN SR 3

candesartan cilexetil 3

candesartan cilexetil-hctz 3

captopril oral 1

captopril-hydrochlorothiazide

1

CARDIZEM 3

CARDIZEM CD 3

CARDIZEM LA 3

CARDURA 3

CAROSPIR 3

cartia xt 1

carvedilol 1

carvedilol phosphate er 3

CATAPRES 3

CATAPRES-TTS-1 3

CATAPRES-TTS-2 3

CATAPRES-TTS-3 3

chlorothiazide oral tablet 250 mg, 500 mg

1

Drug Name Drug Tier

Notes

chlorthalidone 1

cholestyramine light 1

cholestyramine oral 1

clonidine 1

clonidine hcl oral 1

colesevelam hcl 3

COLESTID 3

COLESTID FLAVORED 3

colestipol hcl 1

CONJUPRI 3 PA

COREG 3

COREG CR 3

CORGARD 3

CORLANOR 3 PA

CORZIDE ORAL TABLET 40-5 MG, 80-5 MG

3

COZAAR 3

CRESTOR 3

DEMADEX ORAL TABLET 10 MG

3

DEMSER 3

digitek 1

digox 1

digoxin injection 1

digoxin oral 1

DILATRATE-SR 3

diltiazem hcl er 1

diltiazem hcl er beads 3

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

1

diltiazem hcl er coated beads oral capsule extended release 24 hour 360 mg

3

diltiazem hcl er coated beads oral tablet extended release 24 hour

3


Drug Name Drug Tier

Notes

diltiazem hcl oral 1

dilt-xr 1

DIOVAN 3

DIOVAN HCT 3

disopyramide phosphate 1

DIURIL 2

dofetilide 3 PA

doxazosin mesylate oral 1

DUTOPROL 3

DYAZIDE ORAL CAPSULE 37.5-25 MG

3

DYRENIUM 3

EDARBI 3 ST

EDARBYCLOR 3 ST

EDECRIN 3 PA

enalapril maleate oral 1

enalapril-hydrochlorothiazide

1

ENTRESTO 2 PA

EPANED 3

epinephrine injection solution 30 mg/30ml

1

epinephrine pf 1

eplerenone 1

eprosartan mesylate oral tablet 600 mg

3 ST

ethacrynic acid 1 PA

EXFORGE 3 ST

EXFORGE HCT 3

EZALLOR SPRINKLE 3

ezetimibe 1

ezetimibe-simvastatin 1

felodipine er 1

fenofibrate micronized 1

fenofibrate oral capsule 134 mg, 200 mg, 67 mg

1

fenofibrate oral capsule 150 mg, 50 mg

3

Drug Name Drug Tier

Notes

fenofibrate oral tablet 120 mg, 145 mg, 40 mg, 48 mg

3

fenofibrate oral tablet 160 mg, 54 mg

1

fenofibric acid oral capsule delayed release

3

fenofibric acid oral tablet 1

FENOGLIDE 3

FIBRICOR 3

flecainide acetate 1

FLOLIPID 3

fluvastatin sodium 3

fluvastatin sodium er 3

fosinopril sodium 1

fosinopril sodium-hctz 1

furosemide injection 1

furosemide oral 1

gemfibrozil oral 1

GONITRO 3

guanfacine hcl 1

HEMANGEOL 3 PA

hydralazine hcl oral 1

hydrochlorothiazide oral 1

HYZAAR 3

icosapent ethyl 3 PA

indapamide 1

INDERAL LA 3

INDERAL XL 3

INNOPRAN XL 3

INSPRA 3

irbesartan 1

irbesartan-hydrochlorothiazide

1

isoproterenol hcl injection 3

ISORDIL TITRADOSE 3

isosorbide dinitrate 1


Drug Name Drug Tier

Notes

isosorbide dinitrate er oral tablet extended release 40 mg

3

isosorbide mononitrate 1

isosorbide mononitrate er 1

isradipine 1

ISUPREL 3

KAPSPARGO SPRINKLE 3

KATERZIA 3

labetalol hcl oral 1

LANOXIN 3

LANOXIN PEDIATRIC 3

LASIX 3

LESCOL XL 3

LIPITOR 3

LIPOFEN 3

lisinopril oral 1

lisinopril-hydrochlorothiazide

1

LIVALO 3

LOPID 3

LOPRESSOR 3

LOPRESSOR HCT ORAL TABLET 50-25 MG

3

losartan potassium oral 1

losartan potassium-hctz 1

LOTENSIN 3

LOTENSIN HCT 3

LOTREL 3

lovastatin 1

LOVAZA 3

matzim la 3

MAXZIDE 3

MAXZIDE-25 3

methyclothiazide oral tablet 5 mg

1

methyldopa 1

Drug Name Drug Tier

Notes

methyldopa-hydrochlorothiazide

3

metolazone 1

metoprolol succinate er 1

metoprolol tartrate oral 1

METOPROLOL-HCTZ ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG

3

metoprolol-hydrochlorothiazide

1

metyrosine 3

mexiletine hcl oral 1

MICARDIS 3

MICARDIS HCT 3

midodrine hcl 1

MINIPRESS 3

minitran 1

minoxidil oral 1

moexipril hcl 1

MULTAQ 3

nadolol oral 1

nadolol-bendroflumethiazide oral tablet 40-5 mg

3

NEXLETOL 3 PA

NEXLIZET 3 PA

niacin (antihyperlipidemic) 3

niacin er (antihyperlipidemic)

3

niacor 3

NIASPAN 3

nicardipine hcl oral 1

nifedipine er 1

nifedipine er osmotic release

1

nifedipine oral 1

nimodipine oral 1

nisoldipine er 3


Drug Name Drug Tier

Notes

NITRO-BID 2

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

3

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

2

nitroglycerin er oral capsule extended release 9 mg

1

nitroglycerin sublingual 1

nitroglycerin transdermal 1

nitroglycerin translingual 3

NITROLINGUAL 3

NITROMIST 3

NITROSTAT 3

nitro-time oral capsule extended release 9 mg

1

NORPACE 3

NORPACE CR 2

NORVASC 3

olmesartan medoxomil oral

1

olmesartan medoxomil-hctz

1

olmesartan-amlodipine-hctz

3

omega-3-acid ethyl esters 3

pacerone oral tablet 100 mg

3

pacerone oral tablet 200 mg

1

PACERONE TABLET 400 MG ORAL

3

pacerone tablet 400 mg oral

3

papaverine hcl injection 1

pentoxifylline er 1

perindopril erbumine 1

Drug Name Drug Tier

Notes

phenoxybenzamine hcl oral

4

phentolamine mesylate injection

1

pindolol 1

PRAVACHOL 3

pravastatin sodium 1

prazosin hcl oral 1

PRESTALIA 3

prevalite 1

PRINIVIL 3

procainamide hcl injection 1

PROCARDIA 3

PROCARDIA XL 3

propafenone hcl 1

propafenone hcl er 3

propranolol hcl er 1

propranolol hcl oral 1

propranolol-hctz 1

PROSTIN VR 3

QBRELIS 3

QUESTRAN 3

QUESTRAN LIGHT 3

quinapril hcl 1

quinapril-hydrochlorothiazide

1

quinidine gluconate er 1

QUINIDINE GLUCONATE INJECTION SOLUTION 80 MG/ML

3

quinidine sulfate 1

ramipril 1

RANEXA 3 PA

ranolazine er 3 PA

RECTIV 2

REPATHA 3 PA

REPATHA PUSHTRONEX SYSTEM

3 PA


Drug Name Drug Tier

Notes

REPATHA SURECLICK 3 PA

rosuvastatin calcium 1

RYTHMOL SR 3

SIMVASTATIN ORAL SUSPENSION 20 MG/5ML

3

simvastatin oral tablet 1

sorine 1

sotalol hcl (af) 1

sotalol hcl oral 1

SOTYLIZE 3

spironolactone oral 1

spironolactone-hctz 1

SULAR 3

TARKA 3

taztia xt 3

TEKTURNA 3 ST

TEKTURNA HCT 3 ST

telmisartan 3

telmisartan-amlodipine 3

telmisartan-hctz 3

TENORETIC 100 3

TENORETIC 50 3

TENORMIN 3

tiadylt er 3

TIAZAC 3

TIKOSYN 3 PA

timolol maleate oral 1

TOPROL XL 3

torsemide 1

trandolapril 1

trandolapril-verapamil hcl er

3

triamterene oral 1

triamterene-hctz 1

TRIBENZOR 3

TRICOR 3

Drug Name Drug Tier

Notes

TRIGLIDE ORAL TABLET 160 MG

3

TRILIPIX 3

TWYNSTA 3

valsartan 1

valsartan-hydrochlorothiazide

1

VASCEPA 3 PA

VASERETIC 3

VASOTEC 3

verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg

3

verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg

1

verapamil hcl er oral tablet extended release

1

verapamil hcl oral 1

VERELAN 3

VERELAN PM 3

VYTORIN 3

WELCHOL 3

ZESTORETIC 3

ZESTRIL 3

ZETIA 3

ZIAC 3

ZOCOR 3

ZYPITAMAG 3

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL 3

ADDERALL XR 3 QL

ADHANSIA XR 3 ST; QL

ADZENYS ER 3 PA

ADZENYS XR-ODT 3 PA

AMPHETAMINE ER 3 PA

amphetamine sulfate 3 PA


Drug Name Drug Tier

Notes

amphetamine-dextroamphetamine

1

amphetamine-dextroamphetamine er

1 QL

APTENSIO XR 3 ST; QL

atomoxetine hcl 1

clonidine hcl er 3

CONCERTA 3 QL

COTEMPLA XR-ODT 3 PA; QL

DAYTRANA 3 ST; QL

DESOXYN 3

DEXEDRINE 3 QL

dexmethylphenidate hcl 1

dexmethylphenidate hcl er

3 ST; QL

dextroamphetamine sulfate er

1 QL

dextroamphetamine sulfate oral solution

3

dextroamphetamine sulfate oral tablet

1

DYANAVEL XR 3 ST

EVEKEO 3 PA

EVEKEO ODT 3 PA

FOCALIN 3

FOCALIN XR 3 ST; QL

guanfacine hcl er 1

INTUNIV 3

JORNAY PM 3 ST; QL

KAPVAY 3

metadate er 1 QL

methamphetamine hcl 3

METHYLIN 3

methylphenidate hcl er 1 QL

methylphenidate hcl er (cd)

1 QL

methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg

3 ST; QL

Drug Name Drug Tier

Notes

methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg, 60 mg

1 ST; QL

methylphenidate hcl er (xr)

3 ST; QL

methylphenidate hcl oral solution

3

methylphenidate hcl oral tablet

1

methylphenidate hcl oral tablet chewable

3

MYDAYIS 3 PA; QL

PROCENTRA 3

QUILLICHEW ER 3 PA

QUILLIVANT XR 3 ST; QL

relexxii 1 QL

RITALIN 3

RITALIN LA 3 ST; QL

STRATTERA 3

VYVANSE 3 PA; QL

zenzedi oral tablet 10 mg, 5 mg

1

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

3

Central Nervous System Agents - Drugs for Multiple Sclerosis

AVONEX PEN 4 PA; QL

AVONEX PREFILLED 4 PA; QL

dimethyl fumarate oral 1 QL

dimethyl fumarate starter pack

1 QL

EXTAVIA 4 QL

GILENYA 4 PA; QL

glatiramer acetate 4 QL

glatopa 4 QL

REBIF 4 PA; QL

REBIF REBIDOSE 4 PA; QL

REBIF REBIDOSE TITRATION PACK

4 PA; QL

REBIF TITRATION PACK 4 PA; QL


Drug Name Drug Tier

Notes

Central Nervous System Agents - Miscellaneous

caffeine citrate oral 1

CAFFEINE-SODIUM BENZOATE

3

GRALISE 3

HORIZANT 3

LYRICA 3 QL

LYRICA CR 3 PA

NUEDEXTA 3 PA

pregabalin oral 1 QL

riluzole 1 QL

SAVELLA 3 ST

SAVELLA TITRATION PACK

3 ST

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

BOCASAL 3

cevimeline hcl 3

chlorhexidine gluconate mouth/throat

1

DEBACTEROL 3

EVOXAC 3

FIRST-MOUTHWASH BLM

3

lidocaine hcl mouth/throat 3

lidocaine viscous hcl 1

MUCOSITISRX 3

NEUTRASAL 3

NUMOISYN MOUTH/THROAT LOZENGE

3

oralone 1

paroex 1

periogard 1

pilocarpine hcl oral tablet 5 mg

1

pilocarpine hcl oral tablet 7.5 mg

3

SALAGEN 3

Drug Name Drug Tier

Notes

SALIVAMAX 3

triamcinolone acetonide mouth/throat

1

XEROSTOMIA RELIEF SPRAY

3

Dermatological Agents - Drugs for Skin Conditions

ABSORICA 3

ABSORICA LD 3

ACANYA 3

acitretin 1 QL

ACZONE 3

adapalene external cream 1

adapalene external gel 1

ADAPALENE EXTERNAL LOTION 0.1 %

2

ADAPALENE EXTERNAL PAD

3

ADAPALENE EXTERNAL SOLUTION

3

adapalene-benzoyl peroxide

3

ADVANCED ALLERGY COLLECTION

3

AKLIEF 3 PA

ALA SCALP 3

ala-cort external cream 1 %

3

ala-cort external cream 2.5 %

1

alclometasone dipropionate

1

ALDARA 3

ALTRENO 3

amcinonide 3

AMELUZ 2 QL

ammonium lactate external

3

amnesteem 1

AMZEEQ 3

ANACAINE 3


Drug Name Drug Tier

Notes

APEXICON E 3

ARAZLO 3

arzol silver nit applicators 3

ATOPADERM 3

ATOPICLAIR 3

ATRALIN 3

avar cleanser 1

AVAR EXTERNAL FOAM 9.5-5 %

3

AVAR LS CLEANSER 3

AVAR LS EXTERNAL FOAM 10-2 %

3

AVAR-E EMOLLIENT 3

AVAR-E GREEN 3

AVAR-E LS 3

avita 1

azelaic acid external 1

AZELEX 2

BENSAL HP 3

BENZACLIN 3

BENZACLIN WITH PUMP 3

BENZAMYCIN 3

benzepro foaming cloths 3

BENZOYL PEROX-HYDROCORTISONE

3

BENZOYL PEROXIDE EXTERNAL GEL 6.5 %, 8 %

3

BENZOYL PEROXIDE FORTE- HC

3

benzoyl peroxide-erythromycin

1

beser external lotion 3

betamethasone dipropionate aug

1

betamethasone dipropionate external

1

betamethasone valerate external

1

bp 10-1 3

Drug Name Drug Tier

Notes

bp cleansing wash 3

bpo 3

BRYHALI 3

calcipotriene external cream

1

CALCIPOTRIENE EXTERNAL FOAM

3

calcipotriene external ointment

1

calcipotriene external solution

1

calcipotriene-betameth diprop

3

calcitrene 1

calcitriol external 1

CAPEX 2

CARAC 2

cem-urea 3

CERACADE 3

ceramax external cream 3

claravis 1

CLEOCIN-T EXTERNAL GEL 1 %

3

CLEOCIN-T EXTERNAL SOLUTION 1 %

3

CLEOCIN-T EXTERNAL SWAB 1 %

3

clindacin etz external swab

1

clindacin-p 1

CLINDAGEL 3

clindamycin phos-benzoyl perox external gel 1.2-2.5 %

3

clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-5 %

1

clindamycin phosphate external foam

3

clindamycin phosphate external lotion

1


Drug Name Drug Tier

Notes

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL

3

clindamycin phosphate gel 1 % external

1

clindamycin-tretinoin 3

clobetasol prop emollient base

1

clobetasol propionate e 1

clobetasol propionate emulsion

3

clobetasol propionate external cream

1

clobetasol propionate external foam

3

clobetasol propionate external gel

1

clobetasol propionate external liquid

3

clobetasol propionate external lotion

1

clobetasol propionate external ointment

1

clobetasol propionate external shampoo

3

clobetasol propionate external solution

1

CLOBEX 3

CLOBEX SPRAY 3

clocortolone pivalate 3

clocortolone pivalate pump external cream 0.1 %

3

clodan external shampoo 3

CLODERM 3

CLODERM PUMP EXTERNAL CREAM 0.1 %

3

CONDYLOX 2

Drug Name Drug Tier

Notes

CORDRAN EXTERNAL CREAM

3

CORDRAN EXTERNAL LOTION

3

CORDRAN EXTERNAL OINTMENT

3

CORDRAN EXTERNAL TAPE

2

CORTISPORIN EXTERNAL CREAM

3

CORTISPORIN EXTERNAL OINTMENT

2

CUTIVATE 3

dapsone external gel 5 % 3

DAPSONE EXTERNAL GEL 7.5 %

3

DERMA-SMOOTHE/FS BODY

3

DERMA-SMOOTHE/FS SCALP

3

DERMASORB HC EXTERNAL KIT 2 %

3

DESONATE 3

desonide external cream 1

desonide external gel 3

desonide external lotion 1

desonide external ointment

1

DESOWEN 3

desoximetasone external cream

1

desoximetasone external gel

1

desoximetasone external liquid

3

desoximetasone external ointment

1

DEXERYL 3

diclofenac sodium external gel 3 %

3

DIFFERIN EXTERNAL CREAM

1


Drug Name Drug Tier

Notes

DIFFERIN EXTERNAL GEL

3

DIFFERIN EXTERNAL LOTION

2

diflorasone diacetate 3

DIPROLENE 3

DIPROLENE AF 3

DOVONEX 3

doxepin hcl external 3

doxycycline 3

DRITHO-CREME HP 3

DRYSOL 2

DUAC EXTERNAL GEL 1.2-5 %

3

EFUDEX 3

ELETONE 3

ELETONE TWINPACK EXTERNAL CREAM

3

ELIDEL 1

ELOCON EXTERNAL CREAM 0.1 %

3

EMULSION SB 3

ENSTILAR 3

ENTTY SPRAY 3

EPICERAM 3

EPIDUO 3

EPIDUO FORTE 3

EPIFOAM 3

ery 3

ERYGEL 3

erythromycin external gel 1

erythromycin external pad 2 %

3

erythromycin external solution

1

EUCRISA 3 PA; QL

EVOCLIN 3

FABIOR 3

Drug Name Drug Tier

Notes

FINACEA EXTERNAL FOAM

2

FINACEA EXTERNAL GEL

3

fluocinolone acetonide body

1

fluocinolone acetonide external

1

fluocinolone acetonide scalp

1

fluocinonide emulsified base

1

fluocinonide external cream 0.05 %

1

fluocinonide external cream 0.1 %

3

fluocinonide external gel 1

fluocinonide external ointment

1

fluocinonide external solution

1

FLUOROPLEX 2

FLUOROURACIL EXTERNAL CREAM 0.5 %

2

fluorouracil external cream 5 %

1

fluorouracil external solution

1

flurandrenolide 3

fluticasone propionate external cream

1

fluticasone propionate external lotion

3

fluticasone propionate external ointment

1

grafco silver nit applicator external 75-25 %

3

halcinonide 3

halobetasol propionate external cream

1

HALOBETASOL PROPIONATE EXTERNAL FOAM

3


Drug Name Drug Tier

Notes

halobetasol propionate external ointment

1

HALOG 3

HPR EXTERNAL FOAM 3

HPR PLUS 3

HYDRO 35 EXTERNAL FOAM 35 %

3

HYDRO 40 3

hydrocortisone ace-pramoxine external cream 2.5-1 %

1

hydrocortisone butyr lipo base

3

hydrocortisone butyrate external cream

1

hydrocortisone butyrate external lotion

3

hydrocortisone butyrate external ointment

1

hydrocortisone butyrate external solution

1

hydrocortisone external cream 1 %

3

hydrocortisone external cream 2.5 %

1

hydrocortisone external lotion 2.5 %

1

hydrocortisone external ointment 1 %, 2.5 %

1

hydrocortisone in absorbase external ointment 1 %

1

hydrocortisone valerate 1

HYLAGUARD 3

HYLAMIX EXTERNAL CREAM

3

HYLATOPIC PLUS EXTERNAL CREAM

3

HYLATOPIC PLUS EXTERNAL FOAM

3

HYLINATE EXTERNAL LOTION 0.1 %

3

ILIDERM 3

Drug Name Drug Tier

Notes

imiquimod external 1

IMIQUIMOD PUMP 3

IMPEKLO 3 PA

IMPOYZ 3 PA

isotretinoin oral 1

ivermectin cream 1 % external

3

IVERMECTIN CREAM 1 % EXTERNAL

3

KAMDOY 3

KENALOG EXTERNAL 3

KERALAC 3

KERALYT EXTERNAL GEL 6 %

3

KIVIK 3

KLARON 3

LAC-HYDRIN EXTERNAL CREAM 12 %

3

lactic acid e 3

lactic acid external 3

LEVULAN KERASTICK 2 QL

LEXETTE 3

LIDOCAINE-HYDROCORTISONE ACE EXTERNAL

3

LOCOID EXTERNAL CREAM 0.1 %

3

LOCOID EXTERNAL SOLUTION 0.1 %

3

LOCOID LIPOCREAM 3

LUXIQ 3

methoxsalen rapid 4 QL

metopic external cream 41 %

3

METROCREAM 3

METROGEL 3

METROLOTION 3

metronidazole external cream

1


Drug Name Drug Tier

Notes

metronidazole external gel 0.75 %

1

metronidazole external gel 1 %

3

metronidazole external lotion

3

MICORT-HC EXTERNAL CREAM 2.5 %

3

MIMYX 3

MIRVASO 3

mometasone furoate external

1

myorisan 1

NEOCERA 3

NEOSALUS CP 3

NEOSALUS EXTERNAL CREAM

3

NEOSALUS EXTERNAL FOAM

3

NEO-SYNALAR EXTERNAL CREAM

3

neuac external gel 1

NIVATOPIC PLUS EXTERNAL CREAM

3

nolix 3

NORITATE 3

NOVACORT 3

NUCORT 3

OLUX 3

OLUX-E 3

ONEXTON 3

ORACEA 3 PA

OVACE PLUS EXTERNAL CREAM

3

OVACE PLUS EXTERNAL FOAM

3

OVACE PLUS EXTERNAL SHAMPOO

3

OVACE PLUS WASH 3

OVACE WASH 3

Drug Name Drug Tier

Notes

PANDEL 3

PENLEN 3

PHLAG SPRAY 3

PICATO 2 QL

pimecrolimus cream 1 % external

1

PIMECROLIMUS CREAM 1 % EXTERNAL

1

PLEXION 3

PLEXION CLEANSER 3

PLEXION CLEANSING CLOTH

3

podocon 3

podofilox external 1

PRAMOSONE EXTERNAL CREAM 1-1 %

2

PRAMOSONE EXTERNAL CREAM 1-2.5 %

3

PRAMOSONE EXTERNAL LOTION

2

pramox 3

prednicarbate 3

PRESERA 3

PROSILK EXTERNAL 3

PROTEXA 3

PROTOPIC 3

PRUCLAIR 3

PRUDOXIN 3

PRUMYX 3

PSORCON 3

PYROGALLIC ACID 3

QBREXZA 3 PA

RESORCINOL-SULFUR 3

RETIN-A 1

RETIN-A MICRO GEL 0.04 %, 0.1 %

1


Drug Name Drug Tier

Notes

RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 %

1

RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %

3

RHOFADE 3

rosadan external cream 1

rosadan external gel 1

ROSADAN EXTERNAL KIT

3

RYNODERM EXTERNAL CREAM 37.5 %

3

SALEX 3

salicylic acid external 3

salicylic acid external cream 6 %

3

salicylic acid external liquid 27.5 %

3

salicylic acid external lotion 6 %

3

salicylic acid wart remover

3

salimez 3

SALIMEZ FORTE 3

salisol forte external solution 26 %

3

SALITECH EXTERNAL LOTION 5 %

3

salitech forte external lotion 6 %

3

SALVAX 3

SANTYL 2

selenium sulfide external lotion

1

selenium sulfide external shampoo 2.25 %

3

SERNIVO 3

sodium hyaluronate external

3

sodium sulfacetamide 1

Drug Name Drug Tier

Notes

sodium sulfacetamide wash

3

SODIUM SULFACETAMIDE-BAKUCHIOL

3

SOOLANTRA 3

SORILUX 3

sss 10-5 3

sulfacetamide sodium (acne)

1

sulfacetamide sodium external

3

sulfacetamide sodium-sulfur external cream

3

sulfacetamide sodium-sulfur external emulsion

1

sulfacetamide sodium-sulfur external liquid

3

sulfacetamide sodium-sulfur external lotion 10-5 %

1

sulfacetamide sodium-sulfur external lotion 9.8-4.8 %

3

sulfacetamide sodium-sulfur external pad

3

sulfacetamide sodium-sulfur external suspension

3

sulfacetamide sod-sulfur wash external liquid

3

sulfacetamide-sulfur in urea

1

sulfacleanse 8/4 3

sulfamez wash 3

SUMADAN WASH 3

SUMAXIN 3

SUMAXIN WASH 3

SUVICORT 3

synalar external cream 1

synalar external ointment 1

SYNALAR EXTERNAL SOLUTION

3


Drug Name Drug Tier

Notes

SYNERDERM 3

TACLONEX 3

tacrolimus external ointment

1

tazarotene external 1

TAZORAC EXTERNAL CREAM 0.05 %

2

TAZORAC EXTERNAL CREAM 0.1 %

3

TAZORAC EXTERNAL GEL

2

TEMOVATE 3

TETRIX 3

TEXACORT 3

TOLAK EXTERNAL CREAM 4 %

3

TOPICORT 3

TOPICORT SPRAY 3

tovet external foam 3

tretinoin external cream 1

tretinoin external gel 0.01 %, 0.025 %

1

tretinoin external gel 0.05 %

3

tretinoin microsphere 1

tretinoin microsphere pump

1

triamcinolone acetonide external aerosol solution

3

triamcinolone acetonide external cream

1

triamcinolone acetonide external lotion

1

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

1

triamcinolone acetonide external ointment 0.05 %

3

trianex 3

triderm 1

TRIDESILON 3

Drug Name Drug Tier

Notes

ULTRAVATE EXTERNAL CREAM 0.05 %

3

ULTRAVATE EXTERNAL OINTMENT 0.05 %

3

UMECTA MOUSSE 3

URALISS EXTERNAL CREAM 35 %

3

URAMAXIN 3

urea external cream 39 %, 41 %, 45 %, 47 %

3

urea external cream 40 % 1

UREA EXTERNAL FOAM 3

urea external suspension 3

urea hydrating 3

urea nail 3

uredeb 3

ure-k external cream 50 %

3

uremez-40 1

URESOL 3

UTOPIC 3

VANOS 3

VANOXIDE-HC 3

VECTICAL 1

VELTIN 3

VERDESO 3

VEREGEN 3

VIRASAL 3

WINLEVI 3 PA

XALIX 3

XERALUX 3

xurea 3

zaclir cleansing 3

zenatane 1

ZIANA 3

ZITHRANOL 3

ZONALON 3

ZYCLARA 3


Drug Name Drug Tier

Notes

ZYCLARA PUMP 3

Diabetes - Antidiabetic Agents

acarbose oral 1

ACTOPLUS MET 3

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 15-1000 MG, 30-1000 MG

3

ACTOS 3

ADLYXIN 3 PA; QL

ADLYXIN STARTER PACK

3 PA; QL

ALOGLIPTIN BENZOATE 3 PA

ALOGLIPTIN-METFORMIN HCL

3 PA

ALOGLIPTIN-PIOGLITAZONE

3 PA

AMARYL 3

AVANDIA 3

BYDUREON 3 PA; QL

BYDUREON BCISE AUTOINJECTOR

3 PA; QL

BYETTA 10 MCG PEN 3 PA; QL

BYETTA 5 MCG PEN 3 PA; QL

chlorpropamide oral tablet 100 mg, 250 mg

3

CYCLOSET 3 ST

DUETACT 3

FARXIGA 3 PA; QL

FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG

3 PA

FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG

3

glimepiride 1

glipizide er 1

glipizide ir 1

glipizide xl 1

Drug Name Drug Tier

Notes

glipizide-metformin hcl 3

GLUCOTROL 3

GLUCOTROL XL 3

GLUMETZA 3 PA

glyburide micronized 3

glyburide oral 1

glyburide-metformin 3

GLYNASE 3

GLYSET ORAL TABLET 100 MG, 25 MG, 50 MG

3

GLYXAMBI 3 ST

INVOKAMET 3 PA; QL

INVOKAMET XR 3 PA; QL

INVOKANA 3 PA; QL

JANUMET 3 PA

JANUMET XR 3 PA

JANUVIA 3 PA

JARDIANCE 2 PA; QL

JENTADUETO 3 ST

JENTADUETO XR 3 ST

KAZANO 3 PA

KOMBIGLYZE XR 3 PA

metformin hcl er 1

metformin hcl er (mod) 3 PA

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg

3 PA

metformin hcl er (osm) oral tablet extended release 24 hour 500 mg

3

metformin hcl ir 1

miglitol 3

nateglinide 3

NESINA 3 PA

ONGLYZA 3 PA

OSENI 3 PA

OZEMPIC 3 PA; QL

pioglitazone hcl 3


Drug Name Drug Tier

Notes

pioglitazone hcl-glimepiride

3

pioglitazone hcl-metformin hcl

3

PRANDIN ORAL TABLET 1 MG, 2 MG

3

PRECOSE 3

QTERN 3 PA; QL

repaglinide 3

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

3

RIOMET 3

RIOMET ER 3 PA

RYBELSUS 3 PA

SEGLUROMET 3 PA; QL

SOLIQUA 3 PA; QL

STARLIX 3

STEGLATRO 3 PA; QL

STEGLUJAN 3 PA; QL

SYMLINPEN 120 3

SYMLINPEN 60 3

SYNJARDY 3 PA; QL

SYNJARDY XR 3 PA; QL

tolazamide oral tablet 250 mg, 500 mg

1

tolbutamide 1

TRADJENTA 3 ST

TRIJARDY XR 3 PA; QL

TRULICITY 3 PA; QL

VICTOZA 3 PA; QL

XIGDUO XR 3 PA; QL

XULTOPHY 3 PA

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA IN VITRO

1

ACCU-CHEK COMPACT PLUS CONTROL

1

ACCU-CHEK FASTCLIX LANCET KIT

1

Drug Name Drug Tier

Notes

ACCU-CHEK GUIDE CONTROL

1

ACCU-CHEK MULTICLIX LANCET DEVICE KIT

1

ACCU-CHEK SMARTVIEW CONTROL

1

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

1

AGAMATRIX CONTROL LEVEL 2

1

AGAMATRIX CONTROL LEVEL 4

1

AUTOLET LANCING DEVICE

1

CARETOUCH CONTROL SOL LEVEL 2

1

CARETOUCH LANCING/EJECTOR

1

CONTOUR CONTROL 1

CONTOUR NEXT CONTROL

1

CONTOUR NEXT TEST 1 PA; QL

DIATHRIVE GLUCOSE CONTROL SOLN

1

DIATHRIVE LANCING DEVICE

1

EASY TRAK II CONTROL 1

EASYMAX 15 LEVEL 2-3 CONTROL

1

EASYMAX CONTROL 1

EASYMAX CONTROL NORMAL/HIGH

1

EMBRACE LANCING DEVICE/EJECTOR

1

EMBRACE TALK GLUCOSE CONTROL

1

FORTISCARE CONTROL 1

FREESTYLE TEST 1 PA; QL

GENTEEL LANCING KIT (BLUE)

1

GOJJI CONTROL 1

GOJJI LANCING DEVICE/CLEAR CAP

1


Drug Name Drug Tier

Notes

LANCETS 1

LANCETS KIT 1

MICROLET NEXT LANCING DEVICE

1

OMNIPOD DASH SYSTEM

3 PA

OMNIPOD STARTER 3 PA

ONETOUCH DELICA LANCING DEV

1

ONETOUCH DELICA PLUS LANCING

1

ONETOUCH ULTRA 1 QL

ONETOUCH VERIO IN VITRO SOLUTION HIGH

1

ONETOUCH VERIO TEST STRIPS

1 QL

SURESTEP PRO HIGH GLUCOSE

1

SURESTEP PRO LOW GLUCOSE

1

SURESTEP PRO NORMAL GLUCOSE

1

TRUE METRIX LEVEL 1 IN VITRO SOLUTION LOW

1

TRUE METRIX LEVEL 2 IN VITRO SOLUTION NORMAL

1

TRUE METRIX LEVEL 3 IN VITRO SOLUTION HIGH

1

UNISTRIP CONTROL IN VITRO SOLUTION LOW

1

V-GO 20 3 PA

V-GO 30 3 PA

V-GO 40 3 PA

VIVAGUARD INO CONTROL SOLUTION

1

VIVAGUARD LANCING DEVICE

1

Diabetes - Glycemic Agents

BAQSIMI ONE PACK 2

BAQSIMI TWO PACK 2

Drug Name Drug Tier

Notes

diazoxide oral 2

GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

GLUCAGON EMERGENCY KIT

3

PROGLYCEM 3

Diabetes - Insulins

ADMELOG 3

ADMELOG SOLOSTAR 3

AFREZZA 3 PA

APIDRA SOLOSTAR 3

APIDRA VIAL 3

BASAGLAR KWIKPEN 3 PA

BD AUTOSHIELD DUO PEN NEEDLES

1

BD ULTRA-FINE INSULIN SYRINGES

1

BD ULTRA-FINE PEN NEEDLES

1

BD VEO INSULIN SYR U/F 1/2UNIT

1

FIASP 3

FIASP FLEXTOUCH 3

FIASP PENFILL 3

HUMALOG KWIKPEN 2

HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 50/50 VIAL

3

HUMALOG MIX 75/25 KWIKPEN

3

HUMALOG MIX 75/25 VIAL

3

HUMALOG U-100 JUNIOR KWIKPEN

2

HUMALOG VIAL 2

HUMULIN 70/30 KWIKPEN

1

HUMULIN 70/30 VIAL 1

HUMULIN N KWIKPEN 1


Drug Name Drug Tier

Notes

HUMULIN N VIAL 1

HUMULIN R U-500 KWIKPEN

1

HUMULIN R U-500 VIAL 1

HUMULIN R VIAL 1

INSULIN ASP PROT & ASP FLEXPEN

3

INSULIN ASPART 3

INSULIN ASPART FLEXPEN

3

INSULIN ASPART PENFILL

3

INSULIN ASPART PROT & ASPART

3

INSULIN LISPRO (1 UNIT DIAL) SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS

2

INSULIN LISPRO (1 UNIT DIAL) SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS

3

INSULIN LISPRO JUNIOR KWIKPEN

3

INSULIN LISPRO PROT & LISPRO

3

INSULIN LISPRO SOLUTION 100 UNIT/ML SUBCUTANEOUS

2

INSULIN LISPRO SOLUTION 100 UNIT/ML SUBCUTANEOUS

3

INSULIN PEN NEEDLES 1

Drug Name Drug Tier

Notes

INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G 0.3 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

1

LANTUS SOLOSTAR 2 PA

LANTUS U-100 VIAL 2 PA

LEVEMIR U-100 FLEXTOUCH

2 PA

LEVEMIR U-100 VIAL 2 PA

LYUMJEV 3 PA

LYUMJEV KWIKPEN 3 PA

MAXICOMFORT SYR 27G X 1/2"

1

NOVOFINE AUTOCOVER PEN NEEDLE

1

NOVOFINE PEN NEEDLE

1

NOVOFINE PLUS PEN NEEDLE

1

NOVOLIN 70/30 FLEXPEN

3 ST

NOVOLIN 70/30 FLEXPEN RELION

3 ST

NOVOLIN 70/30 RELION 3 ST

NOVOLIN 70/30 VIAL 3 ST

NOVOLIN N FLEXPEN 3 ST

NOVOLIN N FLEXPEN RELION

3 ST

NOVOLIN N RELION 3 ST

NOVOLIN N VIAL 3 ST

NOVOLIN R FLEXPEN 3 ST

NOVOLIN R FLEXPEN RELION

3 ST


Drug Name Drug Tier

Notes

NOVOLIN R RELION 3 ST

NOVOLIN R VIAL 3 ST

NOVOLOG FLEXPEN 3

NOVOLOG MIX 70/30 FLEXPEN

3

NOVOLOG MIX 70/30 VIAL

3

NOVOLOG PENFILL 3

NOVOLOG U-100 VIAL 3

NOVOTWIST PEN NEEDLE

1

SEMGLEE 3 PA

TOUJEO MAX SOLOSTAR

3 PA

TOUJEO SOLOSTAR 3 PA

TRESIBA 3 PA

TRESIBA FLEXTOUCH 3 PA

Electrolytes / Minerals / Metals / Vitamins

alcohol injection solution 98 %

3

argyle sterile saline 1

argyle sterile water 3

CARNITOR ORAL 1

CARNITOR SF 1

CHEMET 3

curity sterile saline 1

cyanocobalamin injection solution 1000 mcg/ml

1

cytra k crystals 1

dehydrated alcohol 3

DEXPANTHENOL INJECTION

3

DRISDOL 3

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ

3

effer-k oral tablet effervescent 25 meq

3

effervescent pot chloride oral tablet effervescent 25 meq

3

Drug Name Drug Tier

Notes

ergocalciferol oral capsule 1

FERRIPROX ORAL SOLUTION

3 PA

FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML

3

fluoritab oral solution 3

fluoritab oral tablet chewable 0.55 (0.25 f) mg, 2.2 (1 f) mg

1

fluoritab oral tablet chewable 1.1 (0.5 f) mg

3

FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) MG/DROP

2

folic acid injection 1

folic acid oral tablet 1 mg 1

FOLVIK-D ORAL TABLET 1-3775 MG-UNIT

3

FOLVITE-D 3

GENICIN VITA-D 3

iodine strong oral 3

k-effervescent oral tablet effervescent 25 meq

3

kionex oral suspension 15 gm/60ml

1

klor-con 1

klor-con 10 1

klor-con m10 1

KLOR-CON M15 TABLET EXTENDED RELEASE 15 MEQ ORAL

1

KLOR-CON M15 TABLET EXTENDED RELEASE 15 MEQ ORAL

2

klor-con m20 1

klor-con sprinkle oral capsule extended release 10 meq, 8 meq

1

klor-con/ef 3

K-PHOS 3


Drug Name Drug Tier

Notes

K-PHOS NO 2 3

K-PHOS-NEUTRAL 3

k-prime 3

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ

1

K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ, 8 MEQ

2

levocarnitine oral solution 1

levocarnitine oral tablet 1

levocarnitine sf 1

MAGNESIUM SULFATE INJECTION

3

MEPHYTON 1

MIFEPREX 3

mifepristone 3

nafrinse 1

nafrinse drops 3

ORACIT 2

phospha 250 neutral 1

phosphorous 1

phospho-trin 250 neutral 1

phytonadione injection 1

phytonadione oral 1

potassium chloride crys er 1

potassium chloride er 1

potassium chloride oral 1

potassium citrate er 1

potassium citrate-citric acid

1

sod citrate-citric acid 1

SODIUM BICARBONATE INJECTION SOLUTION 8.4 %

3

sodium chloride (pf) 1

SODIUM CHLORIDE INJECTION SOLUTION 0.9 %

3

Drug Name Drug Tier

Notes

sodium chloride irrigation 1

sodium fluoride oral solution

1

sodium fluoride oral tablet 1.1 (0.5 f) mg

1

sodium fluoride oral tablet 2.2 (1 f) mg

3

sodium fluoride oral tablet chewable

1

sodium polystyrene sulfonate oral

1

sodium polystyrene sulfonate rectal

3

sps 1

sterile water for irrigation 3

TANDEM F ORAL CAPSULE 162-115.2-1 MG

3

taron-crystals oral packet 3300-1002 mg

1

tricitrates 1

UROCIT-K 10 3

UROCIT-K 15 3

UROCIT-K 5 3

VELTASSA 3 PA

virt-phos 250 neutral 1

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1

vitamin k1 injection 1

water for irrigation, sterile 3

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

ACIPHEX 3 ST

ACIPHEX SPRINKLE 3 PA

CARAFATE 3

cimetidine hcl 1

cimetidine oral 1

CYTOTEC 3

DEXILANT 3 PA


Drug Name Drug Tier

Notes

esomeprazole magnesium oral packet

3 PA

ESOMEPRAZOLE STRONTIUM

3 PA

famotidine oral suspension reconstituted

1

famotidine oral tablet 20 mg, 40 mg

1

FIRST-LANSOPRAZOLE 3

FIRST-OMEPRAZOLE 3

lansoprazole oral capsule delayed release

1

lansoprazole oral tablet delayed release dispersible

3 PA

misoprostol oral 1

NEXIUM ORAL PACKET 3 PA

nizatidine 3

omeprazole oral capsule delayed release

1

OMEPRAZOLE+SYRSPEND SF ALKA

3

omeprazole-sodium bicarbonate oral packet

3 PA

pantoprazole sodium oral packet

3

pantoprazole sodium oral tablet delayed release

1

PEPCID 3

PREVACID 3

PREVACID SOLUTAB 3 PA

PRILOSEC 3

PROTONIX ORAL 3

rabeprazole sodium oral tablet delayed release

1 ST

sucralfate oral 1

ZEGERID ORAL PACKET

3 PA

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

ACTIGALL 3

alvimopan 3

Drug Name Drug Tier

Notes

AMITIZA 3 PA; QL

amoxicill-clarithro-lansopraz

3

ANASPAZ 3

belladonna alkaloids-opium

1 QL

BENTYL 3

chlordiazepoxide-clidinium

1 QL

CLENPIQ 3

COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 240 GM

3

constulose 1

cromolyn sodium oral 3

CUVPOSA 3

dicyclomine hcl intramuscular

3

dicyclomine hcl oral 1

diphenoxylate-atropine 1

ed-spaz 3

ENTEREG 3

enulose 1

GASTROCROM 3

gavilyte-c 1

gavilyte-g 1

gavilyte-h 3

gavilyte-n with flavor pack 1

generlac 1

GLYCATE 3

glycopyrrolate injection solution

1

glycopyrrolate oral tablet 1 mg, 2 mg

1

GLYCOPYRROLATE ORAL TABLET 1.5 MG

3

GLYRX-PF INJECTION SOLUTION PREFILLED SYRINGE 0.6 MG/3ML

3


Drug Name Drug Tier

Notes

GOLYTELY 2

HELIDAC THERAPY 2

hyoscyamine sulfate er 3

hyoscyamine sulfate injection

3

hyoscyamine sulfate oral 3

hyoscyamine sulfate sl 3

hyoscyamine sulfate sublingual

3

hyosyne 3

KRISTALOSE 3

lactulose encephalopathy 1

lactulose oral packet 3

lactulose oral solution 1

LEVBID 3

LEVSIN 3

LEVSIN/SL 3

LIBRAX 3 QL

LINZESS ORAL CAPSULE 145 MCG, 290 MCG

3 PA; QL

LINZESS ORAL CAPSULE 72 MCG

3 PA

LOMOTIL 3

loperamide hcl oral capsule

1

methscopolamine bromide oral

3

MOTEGRITY 3 PA

MOTOFEN 3

MOVANTIK 3 PA; QL

MOVIPREP 3

MYTESI 3

nulev 3

NULYTELY LEMON-LIME

3

NULYTELY WITH FLAVOR PACKS

3

OMECLAMOX-PAK 3

Drug Name Drug Tier

Notes

opium 1 QL

oscimin 3

oscimin oral tablet dispersible 0.125 mg

3

oscimin sr 3

OSMOPREP 3

paregoric oral tincture 2 mg/5ml

3

peg 3350/electrolytes oral solution reconstituted 240 gm

1

peg 3350-kcl-na bicarb-nacl

1

peg-3350/electrolytes 1

peg-3350/electrolytes/ascorbat

3

peg-kcl-nacl-nasulf-na asc-c

3

peg-prep 3

PLENVU 3

PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM

3

PROBICHEW 3

propantheline bromide oral

1

PYLERA 2

RELISTOR ORAL 3 PA; QL

RELISTOR SUBCUTANEOUS

2 PA

SUPREP BOWEL PREP KIT

3

SUTAB 3

SYMAX DUOTAB 3

symax-sl 3

symax-sr 3

SYMPROIC 3 PA; QL

TALICIA 3

trilyte 1

TRULANCE 3 PA


Drug Name Drug Tier

Notes

URSO 250 3

URSO FORTE 3

ursodiol oral 1

VIBERZI 3 PA

ZELNORM 3 PA

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

CERDELGA 4 PA; QL

CREON 2

CYSTADANE 3

CYSTAGON 2 PA

PANCREAZE 3

PERTZYE 3

VIOKACE 3

ZENPEP 2

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

acetic acid irrigation 1

AURYXIA 3 PA; QL

bethanechol chloride oral 1

calcium acetate (phos binder)

1

calcium acetate oral tablet 667 mg

1

CERVIDIL 2

darifenacin hydrobromide er

1

DETROL 3

DETROL LA 3

DITROPAN XL 3

D-PENAMINE ORAL TABLET 125 MG

4 PA; QL

ELMIRON 2

ENABLEX 3

FEM PH 3

flavoxate hcl 1

FOSRENOL ORAL PACKET

3

GELNIQUE 3 ST

Drug Name Drug Tier

Notes

GELNIQUE PUMP TRANSDERMAL GEL 10 %

3 ST

hyophen 3

INTRAROSA 3 PA; QL

LITHOSTAT 3

me/naphos/mb/hyo1 3

MYRBETRIQ 3 ST

oxybutynin chloride er 1

oxybutynin chloride oral 1

OXYTROL 3 ST

penicillamine oral tablet 4 PA; QL

PENTOSAN POLYSULFATE SODIUM ORAL

2

phenazo oral tablet 200 mg

1

phenazopyridine hcl oral tablet 100 mg, 200 mg

1

PHOSLYRA 3

phosphasal 3

PREPIDIL 2

PROSTIN E2 2

PYRIDIUM 3

RELAGARD VAGINAL GEL 0.9-0.025 %

3

RENACIDIN 3

RENAGEL 3

RENVELA 3

RIMSO-50 3

sevelamer carbonate 1

sevelamer hcl 1

solifenacin succinate 1

tolterodine tartrate 1

tolterodine tartrate er 1

TOVIAZ 3 ST

trospium chloride 1

trospium chloride er 1


Drug Name Drug Tier

Notes

URECHOLINE ORAL TABLET 10 MG, 25 MG, 5 MG, 50 MG

3

urelle 3

uretron d/s 3

uribel 3

URIMAR-T 3

urin ds 3

URO-458 3

UROGESIC-BLUE 3

uro-mp 3

URYL ORAL TABLET 81.6 MG

3

ustell 3

uticap 3

utira-c 3

utrona-c 3

VESICARE 3

vilamit mb 3

VILEVEV MB 3

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er 1

AVODART 3

CARDURA XL 3

dutasteride oral 1

dutasteride-tamsulosin hcl 3

finasteride oral tablet 5 mg

1

FLOMAX 3

JALYN 3

PROSCAR 3

RAPAFLO 3

silodosin 3

tamsulosin hcl 1

terazosin hcl 1

UROXATRAL 3

Hormonal Agents - Adrenal

Drug Name Drug Tier

Notes

BETAMETHASONE SODIUM PHOSPHATE INJECTION

3

CORTEF ORAL TABLET 10 MG, 20 MG

3

CORTEF ORAL TABLET 5 MG

2

cortisone acetate oral 1

DECADRON ORAL ELIXIR 0.5 MG/5ML

3

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML

2

DEPO-MEDROL INJECTION SUSPENSION 40 MG/ML, 80 MG/ML

3

DEXABLISS 3

DEXAMETHASONE (LA) 3

dexamethasone intensol 2

dexamethasone oral elixir 1

dexamethasone oral solution

1

dexamethasone oral tablet

1

dexamethasone oral tablet therapy pack

3

dexamethasone sod phosphate pf injection solution

1

dexamethasone sodium phosphate injection solution 100 mg/10ml, 120 mg/30ml, 20 mg/5ml

1

dexamethasone sodium phosphate solution 10 mg/ml injection

1

DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 10 MG/ML INJECTION

3

DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 4 MG/ML INJECTION

3


Drug Name Drug Tier

Notes

dexamethasone sodium phosphate solution 4 mg/ml injection

1

DEXONTO 0.4% 3

DEXPAK 10 DAY ORAL TABLET THERAPY PACK 1.5 MG (35)

3


3


3

DXEVO 11-DAY 3

fludrocortisone acetate oral

1

HEMADY 3 PA

HIDEX 6-DAY 3

hydrocortisone oral 1

KENALOG INJECTION 3

MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG

3

MEDROL ORAL TABLET 2 MG

2

MEDROL ORAL TABLET THERAPY PACK

3

METHYLPREDNISOLONE ACE-LIDO

3

METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 40 MG/ML, 80 MG/ML

3

methylprednisolone oral 1

methylprednisolone sodium succ injection solution reconstituted 125 mg

1

MILLIPRED DP 12-DAY 3

MILLIPRED DP ORAL TABLET THERAPY PACK 5 MG (21), 5 MG (48)

3

Drug Name Drug Tier

Notes

MILLIPRED ORAL SOLUTION 10 MG/5ML

3

ORAPRED ODT 3

PEDIAPRED 3

prednisolone oral solution 1

prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml

3

prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

1

prednisolone sodium phosphate oral tablet dispersible

3

prednisone intensol 3

prednisone oral 1

RAYOS 3 PA

SOLU-CORTEF 2

SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 125 MG

3

TAPERDEX 12-DAY 3

TAPERDEX 6-DAY 3

TAPERDEX 7-DAY 3

TRIAMCINOLONE ACETONIDE INJECTION SUSPENSION 50 MG/ML

3

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML INJECTION

3

triamcinolone acetonide suspension 40 mg/ml injection

3

TRIAMCINOLONE DIACETATE INJECTION

3

TRIAMCINOLONE DIACETATE PF INJECTION SUSPENSION 80 MG/2ML

3


Drug Name Drug Tier

Notes

VERIPRED 20 ORAL SOLUTION 20 MG/5ML

3

ZCORT 7-DAY 3

Hormonal Agents - Men's Health

ANDRODERM 3 PA; QL

ANDROGEL 3 PA; QL

ANDROGEL PUMP 3 PA; QL

danazol oral 1

DEPO-TESTOSTERONE (brand testosterone cypionate intramuscular)

1 PA

FORTESTA 3 PA; QL

JATENZO 3 PA

METHITEST 3 PA

methyltestosterone oral 3 PA

NATESTO 3 PA; QL

oxandrolone oral 3

STRIANT BUCCAL 30 MG

3 PA; QL

TESTIM 3 PA; QL

TESTONE CIK 3

TESTOSTERONE CYPIONATE & PROP INJECTION SOLUTION 160-40 MG/ML

3 PA

TESTOSTERONE CYPIONATE INJECTION SOLUTION 100 MG/ML, 150 MG/ML, 50 MG/ML

3 PA

TESTOSTERONE CYPIONATE INJECTION SOLUTION 200 MG/ML

1 PA

testosterone cypionate intramuscular

1 PA

TESTOSTERONE ENANTHATE INJECTION SOLUTION 200 MG/ML

3 PA

testosterone enanthate intramuscular

1 PA

TESTOSTERONE PROPIONATE INJECTION SOLUTION 100 MG/ML

3 PA

Drug Name Drug Tier

Notes

testosterone transdermal gel 1.62 %, 12.5 mg/act (1%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

1 PA; QL

testosterone transdermal gel 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 40.5 mg/2.5gm (1.62%)

3 PA; QL

testosterone transdermal solution

3 PA; QL

VOGELXO 3 PA; QL

VOGELXO PUMP 3 PA; QL

XYOSTED 3 PA

Hormonal Agents - Osteoporosis

EVISTA 3

OSPHENA 3 PA

raloxifene hcl 1

Hormonal Agents - Pituitary

ACTHAR 4 PA; QL

cabergoline 1

DDAVP 3

DDAVP NASAL SOLUTION 0.01 %

3

DDAVP RHINAL TUBE 3

desmopressin ace spray refrig

1

desmopressin acetate injection

1

desmopressin acetate oral

1

desmopressin acetate spray

1

ELIGARD 3

leuprolide acetate injection

1

LUPRON DEPOT (1-MONTH)

2

LUPRON DEPOT (3-MONTH)

2


Drug Name Drug Tier

Notes

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

2

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

2

LUPRON DEPOT-PED (1-MONTH)

2

LUPRON DEPOT-PED (3-MONTH)

2

NOCDURNA 3 PA

NOCTIVA NASAL EMULSION 0.83 MCG/0.1ML, 1.66 MCG/0.1ML

2

octreotide acetate 1

OMNITROPE 4 PA; QL

SANDOSTATIN 3

SANDOSTATIN LAR DEPOT

2 QL

STIMATE 2

SYNAREL 3 QL

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA 3

afirmelle 1

ALORA 3

altavera 1

alyacen 1/35 1

alyacen 7/7/7 1

amabelz 3

amethia 3

amethia lo 3

amethyst 3

ANGELIQ 3

ANNOVERA 3

apri 1

aranelle 1

ashlyna 3

Drug Name Drug Tier

Notes

aubra 1

aubra eq 1

aurovela 1.5/30 1

aurovela 1/20 1

aurovela 24 fe 3

aurovela fe 1.5/30 1

aurovela fe 1/20 1

aviane 1

AYGESTIN 3

ayuna 1

azurette 3

BALCOLTRA 3

balziva 1

bekyree 3

BEYAZ 3

BIJUVA 3

blisovi 24 fe 3

blisovi fe 1.5/30 1

blisovi fe 1/20 1

briellyn 1

camila 1

camrese 3

camrese lo 3

caziant 1

charlotte 24 fe 3

chateal 1

chateal eq 1

CLIMARA 1

CLIMARA PRO 3

COMBIPATCH 3

covaryx 3

covaryx hs 3

CRINONE 3

cryselle-28 1

cyclafem 1/35 1

cyclafem 7/7/7 1


Drug Name Drug Tier

Notes

cyred 1

cyred eq 1

dasetta 1/35 1

dasetta 7/7/7 1

daysee 3

deblitane 1

DELESTROGEN 2

delyla 1

DEPO-ESTRADIOL 2

DEPO-PROVERA 3

DEPO-SUBQ PROVERA 104

3

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

3

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

1

DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 1 MG/GM, 1.25 MG/1.25GM

3

DIVIGEL TRANSDERMAL GEL 0.75 MG/0.75GM

3 PA

dotti 3

drospiren-eth estrad-levomefol

3

drospirenone-ethinyl estradiol oral tablet 3-0.02 mg

3

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

1

DUAVEE 3

eemt 3

eemt hs 3

ELESTRIN 3

elinest 1

ELLA 2

Drug Name Drug Tier

Notes

eluryng 1

emoquette 1

ENDOMETRIN 3

enpresse-28 1

enskyce 1

errin 1

est estrogens-methyltest 3

est estrogens-methyltest ds

3

est estrogens-methyltest hs

3

estarylla 1

ESTRACE 3

estradiol oral 1

estradiol transdermal patch twice weekly

3

estradiol transdermal patch weekly

1

estradiol vaginal 1

estradiol valerate intramuscular

1

estradiol-norethindrone acet

3

ESTRING 2

ESTROGEL 3

ESTROSTEP FE 3

ethynodiol diac-eth estradiol

1

etonogestrel-ethinyl estradiol

1

EVAMIST 3

falmina 1

fayosim 3

FEMHRT LOW DOSE 3

FEMRING 2

femynor 1

FIRST-PROGESTERONE VGS

3

fyavolv 3


Drug Name Drug Tier

Notes

gemmily 3

GENERESS FE 3

gianvi 3

hailey 1.5/30 1

hailey 24 fe 3

hailey fe 1.5/30 1

hailey fe 1/20 1

heather 1

hydroxyprogesterone caproate intramuscular oil

4

iclevia 3

IMVEXXY MAINTENANCE PACK

3

IMVEXXY STARTER PACK

3

incassia 1

introvale 3

isibloom 1

jaimiess 3

jasmiel 3

jencycla 1

jinteli 3

jolessa 3

jolivette oral tablet 0.35 mg

1

juleber 1

junel 1.5/30 1

junel 1/20 1

junel fe 1.5/30 1

junel fe 1/20 1

junel fe 24 3

kaitlib fe 3

kalliga 1

kariva 3

kelnor 1/35 1

kelnor 1/50 1

kurvelo 1

Drug Name Drug Tier

Notes

larin 1.5/30 1

larin 1/20 1

larin 24 fe 3

larin fe 1.5/30 1

larin fe 1/20 1

larissia 1

layolis fe 3

leena 1

lessina 1

levonest 1

levonorgest-eth est & eth est

3

levonorgest-eth estrad 91-day

3

levonorgestrel 1

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

1

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

3

levonorg-eth estrad triphasic

1

levora 0.15/30 (28) 1

LILETTA (52 MG) 3

lillow 1

LO LOESTRIN FE 3

LOESTRIN 1.5/30 (21) 3

LOESTRIN 1/20 (21) 3

LOESTRIN FE 1.5/30 3

LOESTRIN FE 1/20 3

lojaimiess 3

lopreeza oral tablet 0.5-0.1 mg, 1-0.5 mg

3

loryna 3

LOSEASONIQUE 3

low-ogestrel 1

lo-zumandimine 3

lutera 1


Drug Name Drug Tier

Notes

lyllana 3

lyza 1

MAKENA SUBCUTANEOUS

4 QL

marlissa 1

medroxyprogesterone acetate intramuscular

1

medroxyprogesterone acetate oral

1

MEGACE ES ORAL SUSPENSION 625 MG/5ML

3

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml

1

megestrol acetate oral suspension 625 mg/5ml

3

megestrol acetate oral tablet

1

melodetta 24 fe 3

MENEST 3

MENOSTAR 3

mibelas 24 fe 3

microgestin 1.5/30 1

microgestin 1/20 1

microgestin fe 1.5/30 1

microgestin fe 1/20 1

mili 1

mimvey 3

mimvey lo oral tablet 0.5-0.1 mg

3

MINASTRIN 24 FE 3

MINIVELLE 3

MIRCETTE 3

MIRENA (52 MG) 2

mono-linyah 1

mononessa oral tablet 0.25-35 mg-mcg

1

myzilra oral tablet 50-30/75-40/ 125-30 mcg

1

Drug Name Drug Tier

Notes

NATAZIA 3

necon 0.5/35 (28) 1

nikki 3

nora-be 1

norethin ace-eth estrad-fe oral capsule

3

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg(24)

3

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

1

norethin ace-eth estrad-fe oral tablet chewable

3

norethindrone acetate oral

1

norethindrone acet-ethinyl est oral tablet

1

norethindrone acet-ethinyl est oral tablet chewable 1-20 mg-mcg(24)

3

norethindrone oral 1

norethindrone-eth estradiol

3

norethin-eth estradiol-fe 3

norgestimate-eth estradiol 1

norgestimate-ethinyl estradiol triphasic

1

norlyda 1

norlyroc 1

nortrel 0.5/35 (28) 1

nortrel 1/35 (21) 1

nortrel 1/35 (28) 1

nortrel 7/7/7 1

NUVARING 3

nylia 7/7/7 1

nymyo 1

ocella 1

ogestrel oral tablet 0.5-50 mg-mcg

1

orsythia 1


Drug Name Drug Tier

Notes

ORTHO MICRONOR 3

ORTHO TRI-CYCLEN (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

3

ORTHO TRI-CYCLEN LO 3

ORTHO-CYCLEN (28) ORAL TABLET 0.25-35 MG-MCG

3

ORTHO-NOVUM 1/35 (28) ORAL TABLET 1-35 MG-MCG

3

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET 0.5/0.75/1-35 MG-MCG

3

PARAGARD INTRAUTERINE COPPER

2

philith 1

pimtrea 3

pirmella 1/35 1

pirmella 7/7/7 1

PLAN B ONE-STEP 3

portia-28 1

PREFEST 3

PREMARIN ORAL 3 ST

PREMARIN VAGINAL 2

PREMPHASE 3

PREMPRO 3

preventeza 1

previfem 1

progesterone intramuscular

1

progesterone micronized oral

1

PROMETRIUM 3

PROVERA 3

QUARTETTE 3

reclipsen 1

rivelsa 3

Drug Name Drug Tier

Notes

SAFYRAL 3

SEASONIQUE 3

setlakin 3

sharobel 1

simliya 3

simpesse 3

SKYLA 2

SLYND 3

sprintec 28 1

sronyx 1

syeda 1

tarina 24 fe 3

tarina fe 1/20 1

tarina fe 1/20 eq 1

TAYTULLA CAPSULE 1-20 MG-MCG(24) ORAL

3

TAYTULLA CAPSULE 1-20 MG-MCG(24) ORAL

3 PA

tilia fe 3

tri femynor 1

tri-estarylla 1

tri-legest fe 3

tri-linyah 1

tri-lo-estarylla 1

tri-lo-marzia 1

tri-lo-mili 1

tri-lo-sprintec 1

tri-mili 1

TRI-NORINYL (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG

3

tri-previfem 1

tri-sprintec 1

trivora (28) 1

tri-vylibra 1

tri-vylibra lo 1

tulana 1


Drug Name Drug Tier

Notes

TWIRLA 3

tyblume 1

tydemy 3

VAGIFEM 3

velivet 1

vienva 1

viorele 3

VIVELLE-DOT 3

volnea 3

vyfemla 1

vylibra 1

wera 1

wymzya fe 3

xulane 1

YASMIN 28 3

YAZ 3

yuvafem 1

zarah 1

zovia 1/35 (28) 1

zovia 1/35e (28) 1

zumandimine 1

Hormonal Agents - Thyroid

ARMOUR THYROID 3

CYTOMEL 3

euthyrox 3

levo-t 3

levothyroxine sodium oral tablet

1

levoxyl 3

liothyronine sodium oral 1

methimazole oral 1

NATURE-THROID 3

np thyroid 3

propylthiouracil oral 1

SYNTHROID 3

TAPAZOLE 3

Drug Name Drug Tier

Notes

thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

3

TIROSINT 3

TIROSINT-SOL 3

unithroid 3

WESTHROID 3

WP THYROID 3

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ALFERON N 3

ARAVA 3

ASTAGRAF XL 3

AZASAN 3

azathioprine oral 1

BERINERT 4 PA; QL

CELLCEPT 3

COSENTYX (300 MG DOSE)

4 PA; QL

COSENTYX 150 MG/ML 4 PA; QL

COSENTYX SENSOREADY (300 MG)

4 PA; QL

COSENTYX SENSOREADY PEN

4 PA; QL

CUVITRU 4 PA; QL

cyclosporine modified 1

cyclosporine oral 1

ENBREL 4 PA; QL

ENBREL MINI 4 PA; QL

ENBREL SURECLICK 4 PA; QL

ENVARSUS XR 3

gengraf 1

HEPAGAM B 3

HIZENTRA 4 PA; QL

HUMIRA PEDIATRIC CROHNS START

4 PA; QL

HUMIRA PEN 4 PA; QL

HUMIRA PEN-CD/UC/HS STARTER

4 PA; QL


Drug Name Drug Tier

Notes

HUMIRA PEN-PS/UV/ADOL HS START

4 PA; QL

HUMIRA PEN-PSOR/UVEIT STARTER

4 PA; QL

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT

4 PA; QL

HYPERHEP B S/D 2

HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 300 UNIT/ML

3

HYPERRAB INJECTION SOLUTION 900 UNIT/3ML

3 PA

HYPERRAB S/D 3

HYPERTET S/D 3

HYQVIA 4 PA; QL

icatibant acetate 4 QL

IMOGAM RABIES-HT 3

IMURAN 3

KEDRAB 3

leflunomide oral 1

methotrexate oral 1

methotrexate sodium 1

methotrexate sodium (pf) 1

mycophenolate mofetil oral

1

mycophenolate sodium 1

MYFORTIC 3

NABI-HB 2

NEORAL 3

ORENCIA CLICKJECT 4 PA; QL

ORENCIA SUBCUTANEOUS

4 PA; QL

OTEZLA 4 PA; QL

Drug Name Drug Tier

Notes

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML

3 PA

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 20 MG/0.4ML

3

PROGRAF ORAL 3

RAPAMUNE 3

RASUVO 2

REDITREX 3 PA

RHOPHYLAC 3

RIDAURA 4 QL

SANDIMMUNE ORAL 3

sirolimus oral 1

STELARA SUBCUTANEOUS

4 PA; QL

tacrolimus oral 1

TREMFYA 4 PA; QL

TREXALL 3

VARIZIG 3

XATMEP 3 QL

XELJANZ 4 PA; QL

XELJANZ XR 4 PA; QL

Immunological Agents - Drugs for Vaccination

ACTHIB 2

ADACEL 2

AFLURIA INTRAMUSCULAR SUSPENSION

1

AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

1


Drug Name Drug Tier

Notes

AFLURIA QUADRIVALENT

1

BEXSERO 2

BIOTHRAX 3

BOOSTRIX 2

DAPTACEL 2

DIPHTHERIA-TETANUS TOXOIDS DT

2

ENGERIX-B INTRAMUSCULAR INJECTABLE 10 MCG/0.5ML, 20 MCG/ML

2

EZ FLU SHOT-FLUCELVAX QUAD INTRAMUSCULAR PREFILLED SYRINGE KIT 0.5 ML

1

FLUAD 1

FLUAD QUADRIVALENT 3

FLUARIX QUADRIVALENT

1

FLUBLOK QUADRIVALENT

1

FLUCELVAX QUADRIVALENT

1

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION

1

FLUMIST QUADRIVALENT

1

FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

1

FLUZONE HIGH-DOSE QUADRIVALENT

1

FLUZONE QUADRIVALENT

1

GARDASIL 9 2

HAVRIX 2

Drug Name Drug Tier

Notes

HEPLISAV-B INTRAMUSCULAR SOLUTION 20 MCG/0.5ML

2

HIBERIX 2

INFANRIX 2

IPOL 2

KINRIX 2

MENACTRA 2

MENQUADFI 2

MENVEO 2

M-M-R II 2

PEDIARIX 2

PEDVAX HIB 2

PENTACEL 2

PNEUMOVAX 23 2

PREVNAR 13 2

PROQUAD 2

QUADRACEL 2

RECOMBIVAX HB 2

ROTARIX 2

ROTATEQ 2

SHINGRIX 2

TDVAX 2

TENIVAC 2

TETANUS-DIPHTHERIA TOXOIDS TD

2

TRUMENBA 2

TWINRIX 3

VAQTA INTRAMUSCULAR SUSPENSION 50 UNIT/ML

2

VARIVAX 2

VAXELIS 2

ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 19400 UNT/0.65ML

2


Drug Name Drug Tier

Notes

Inflammatory Bowel Disease Agents

ANALPRAM-HC 3

anucort-hc 3

ANUSOL-HC EXTERNAL 3

anusol-hc rectal 3

APRISO 1 ST

ASACOL HD 3 PA

AZULFIDINE 3

AZULFIDINE EN-TABS 3

balsalazide disodium 1

budesonide oral (generic Entocort)

3 PA

CANASA 3

COLAZAL 3

colocort rectal enema 100 mg/60ml

1

CORTENEMA 3

CORTIFOAM 2

DELZICOL 1 ST

hemmorex-hc 3

hydrocortisone (perianal) external cream 1 %

3

hydrocortisone (perianal) external cream 2.5 %

1

hydrocortisone ace-pramoxine external cream 1-1 %

3

hydrocortisone acetate rectal

3

hydrocortisone rectal 1

LIALDA TABLET DELAYED RELEASE 1.2 GM ORAL

3

LIALDA TABLET DELAYED RELEASE 1.2 GM ORAL

1

lidocaine-hydrocort (perianal)

3

LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL

3

Drug Name Drug Tier

Notes

lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 %

3

LIDOCORT 3

mesalamine er 1 ST

mesalamine oral capsule delayed release

1 ST

mesalamine oral tablet delayed release 1.2 gm

1

mesalamine oral tablet delayed release 800 mg

3 PA

mesalamine rectal 1

mesalamine-cleanser 3

PENTASA 2 ST

PROCORT 3

PROCTOCORT 3

PROCTOFOAM HC 2

procto-med hc 1

procto-pak 3

proctosol hc external cream 2.5 %

1

proctozone-hc 1

ROWASA 3

SFROWASA 3

sulfasalazine oral 1

UCERIS RECTAL 3

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL 3 ST

alendronate sodium 1

ATELVIA 3 ST

BINOSTO 3

BONIVA ORAL 3

calcitonin (salmon) 3

FOSAMAX 3

FOSAMAX PLUS D 3

ibandronate sodium oral 1

MIACALCIN INJECTION 3

RAYALDEE 3 PA


Drug Name Drug Tier

Notes

risedronate sodium oral tablet

1 ST

risedronate sodium oral tablet delayed release

3 ST

Metabolic Bone Disease Agents - Other

calcitriol oral 1

cinacalcet hcl 1 PA

doxercalciferol oral 3

etidronate disodium oral tablet 200 mg, 400 mg

1

paricalcitol oral 3

ROCALTROL 3

SENSIPAR 3 PA

ZEMPLAR ORAL 3

Miscellaneous Therapeutic Agents

ACACIA SUBCUTANEOUS

3

ACREMONIUM 3

ALCOHOL PREP PADS PAD

1

ALCOHOL PREP PADS PAD 70 %

1

ALDER 3

AMERICAN BEECH 3

ANTIVENIN LATRODECTUS MACTANS

3

ARIZONA CYPRESS 3

AUREOBASIDIUM 3

AUSTRALIAN PINE 3

BALD CYPRESS 3

BOTRYTIS SUBCUTANEOUS

3

BREATHE EASE LARGE 2

BREATHE EASE MEDIUM

2

BREATHE EASE SMALL 2

BREATHERITE 2

BROME 3

Drug Name Drug Tier

Notes

CALCIUM DISODIUM VERSENATE

3

CALIFORNIA PEPPER TREE

3

CANDIDA ALBICANS EXTRACT

3

CATTLE EPITHELIUM 3

CAYA 2

CEDAR ELM 3

CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS

3

CLADOSPORIUM SPHAEROSPERMUM

3

CLEVER CHOICE HOLDING CHAMBER

2

COMPACT SPACE CHAMBER/LG MASK

2

COMPACT SPACE CHAMBER/MED MASK

2

COMPACT SPACE CHAMBER/SM MASK

2

CURVULARIA 3

CYTOTINE ORAL POWDER

3

deferoxamine mesylate injection solution reconstituted 500 mg

1

DESFERAL 3

DOG EPITHELIUM SUBCUTANEOUS SOLUTION 1:20

3

DRECHSLERA 3

DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS

3

EASIVENT 2

EPICOCCUM 3

ergoloid mesylates oral 3

FEMCAP 2

FIRE ANT 3


Drug Name Drug Tier

Notes

FLEXICHAMBER ADULT MASK/SMALL

2

FLEXICHAMBER CHILD MASK/LARGE

2

FLEXICHAMBER CHILD MASK/SMALL

2

FORMADON EXTERNAL SOLUTION 10 %

3

FORMA-RAY EXTERNAL SOLUTION 20 %

3

FUSARIUM 3

GERMAN COCKROACH 3

GLUCAGEN DIAGNOSTIC

2

GLUCAGON HCL (DIAGNOSTIC)

2

GRASTEK 3 PA

HACKBERRY 3

HONEY BEE VENOM 3

HONEY BEE VENOM PROTEIN

3

HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:10

3

JUNE GRASS POLLEN STANDARDIZED

3

KAPOK 3

MASK VORTEX 2

MELALEUCA 3

methergine 1

methylergonovine maleate

1

MICROCHAMBER DEVICE

2

MIXED ASPERGILLUS 3

MIXED FEATHERS 3

MIXED VESPID VENOM PROTEIN INJECTION

3

mixed vespid venom protein subcutaneous solution reconstituted 1100-1100-1100 mcg

3

Drug Name Drug Tier

Notes

MIXED VESPID VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 120-120-120 MCG

3

MUCOR SUBCUTANEOUS

3

NOZIN NASAL SANITIZER POPSWAB

1

ODACTRA 3 PA

OLIVE TREE 3

OMNIPOD 5 PACK 3 PA

OMNIPOD DASH 5 PACK PODS

3 PA

ORALAIR 3 PA

ORALAIR ADULT SAMPLE KIT SUBLINGUAL TABLET SUBLINGUAL 300 IR

3 PA

ORALAIR ADULT STARTER PACK

3 PA

ORALAIR CHILDRENS SAMPLE KIT SUBLINGUAL THERAPY PACK 3 X 100 IR & 6 X 300 IR

3 PA

ORALAIR CHILDRENS STARTER PACK

3 PA

OXBRYTA 3 PA; QL

PANDA MASK LARGE 2

PANDA MASK MEDIUM 2

PANDA MASK SMALL 2

PEDIATRIC PANDA MASK

2

PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 20000 PNU/ML

3

PERENNIAL RYE GRASS POLLEN SUBCUTANEOUS SOLUTION 100000 BAU/ML

3

PHEXXI 3


Drug Name Drug Tier

Notes

PHYSOSTIGMINE SALICYLATE

3

pocket spacer 2

PRO COMFORT SPACER ADULT

2

PRO COMFORT SPACER CHILD

2

PRO COMFORT SPACER INFANT

2

PROCARE SPACER/ADULT MASK

2

PROCARE SPACER/CHILD MASK

2

QUEEN PALM 3

RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 1:10

3

RAGWITEK 3 PA

RED MAPLE 3

RHIZOPUS 3

SACCHAROMYCES CEREVISIAE SUBCUTANEOUS

3

SPINY PIGWEED 3

STEMPHYLIUM 3

SWEET GUM 3

SWEET VERNAL GRASS POLLEN

3

TACHOSIL 3

TALL RAGWEED 3

TRICHOPHYTON 3

VENOMIL HONEY BEE VENOM

3

VENOMIL MIXED VESPID VENOM

3

VENOMIL WASP VENOM

3

VENOMIL WHITE FACED HORNET

3

VENOMIL YELLOW HORNET VENOM

3

Drug Name Drug Tier

Notes

VENOMIL YELLOW JACKET VENOM

3

WASP VENOM PROTEIN 3

WESTERN JUNIPER 3

WHITE BIRCH 3

WHITE FACED HORNET VENOM

3

WHITE MULBERRY 3

WHITE-FACED HORNET VENOM

3

WIDE-SEAL DIAPHRAGM 60

2


2


2


2


2


2


2


2

YELLOW HORNET VENOM PROTEIN

3

YELLOW JACKET VENOM PROTEIN

3

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

ACULAR 2

ACULAR LS 3

ACUVAIL OPHTHALMIC SOLUTION 0.45 %

3

ALOCRIL 3

ALOMIDE 2

ALREX 3

AZASITE 3

azelastine hcl ophthalmic 1

bacitracin ophthalmic 1


Drug Name Drug Tier

Notes

BEPREVE 3

BESIVANCE 3

BETADINE OPHTHALMIC PREP

3

BLEPH-10 3

bromfenac sodium (once-daily)

3

BROMSITE 3

CILOXAN OPHTHALMIC OINTMENT

2

CILOXAN OPHTHALMIC SOLUTION

3

ciprofloxacin hcl ophthalmic

1

cromolyn sodium ophthalmic

1

dexamethasone sodium phosphate ophthalmic

1

diclofenac sodium ophthalmic

1

DUREZOL 2

ELESTAT OPHTHALMIC SOLUTION 0.05 %

3

EMADINE OPHTHALMIC SOLUTION 0.05 %

3

epinastine hcl 3

erythromycin ophthalmic 1

EYSUVIS 3 PA

FLAREX 3

fluorometholone 1

flurbiprofen sodium 1

FML 2

FML FORTE 2

FML LIQUIFILM 3

gatifloxacin ophthalmic 1

gentak 1

gentamicin sulfate ophthalmic

1

ILEVRO 3

INVELTYS 3

Drug Name Drug Tier

Notes

ketorolac tromethamine ophthalmic

1

KLARITY-A 3

KLARITY-B OPHTHALMIC SOLUTION 0.1 %

3

KLARITY-L 3

levofloxacin ophthalmic 3

LOTEMAX 3

LOTEMAX SM 3

loteprednol etabonate 3

MAXIDEX 3

MOXEZA 3

moxifloxacin hcl (2x day) 1

moxifloxacin hcl ophthalmic solution

1

NATACYN 2

NEVANAC 3

OCUFLOX 3

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic solution 0.1 %

1

olopatadine hcl ophthalmic solution 0.2 %

3

OMNIPRED OPHTHALMIC SUSPENSION 1 %

3

PATADAY OPHTHALMIC SOLUTION 0.2 %

3

PATANOL OPHTHALMIC SOLUTION 0.1 %

3

PAZEO OPHTHALMIC SOLUTION 0.7 %

3

POVIDONE-IODINE OPHTHALMIC

3

PRED FORTE 3

PRED MILD 2

PREDNISOL ACE-MOXIFLOX-BROMFEN

3

prednisolone acetate ophthalmic

1


Drug Name Drug Tier

Notes

prednisolone acetate p-f 1

prednisolone sodium phosphate ophthalmic

3

PREDNISOLON-MOXIFLOX-NEPAFENAC

3

PROLENSA 3

sulfacetamide sodium ophthalmic

1

tobramycin ophthalmic 1

TOBREX OPHTHALMIC OINTMENT

2

TOBREX OPHTHALMIC SOLUTION

3

trifluridine 1

UPNEEQ 3 PA

VIGAMOX 2

VIROPTIC OPHTHALMIC SOLUTION 1 %

3

ZERVIATE 3

ZIRGAN 3

ZYMAXID 3

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er 1

acetazolamide oral 1

ALPHAGAN P 3

apraclonidine hcl 3

AZOPT 2

BETAGAN OPHTHALMIC SOLUTION 0.5 %

3

betaxolol hcl ophthalmic 1

BETIMOL 3

BETOPTIC-S 2

bimatoprost ophthalmic 1

brimonidine tartrate ophthalmic solution 0.15 %

3

brimonidine tartrate ophthalmic solution 0.2 %

1

BRIMONIDINE-DORZOLAMIDE

3

Drug Name Drug Tier

Notes

carteolol hcl 1

COMBIGAN 3

COSOPT 3

COSOPT PF 3

DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC

3

dorzolamide hcl solution 2 % ophthalmic

1

dorzolamide hcl-timolol mal

1

dorzolamide hcl-timolol mal pf

3

IOPIDINE 3

ISOPTO CARPINE 3

ISTALOL 3

latanoprost ophthalmic 1

LATANOPROST-TIMOLOL MALEATE

3

levobunolol hcl 1

LUMIGAN 2

methazolamide oral 1

PHOSPHOLINE IODIDE 3

pilocarpine hcl ophthalmic 1

RHOPRESSA 3 PA

ROCKLATAN 3 PA

SIMBRINZA 3

timolol maleate ophthalmic gel forming solution

1

timolol maleate ophthalmic solution 0.25 %, 0.5 %

1

timolol maleate ophthalmic solution 0.5 % (daily)

3

timolol maleate pf 3

TIMOLOL-BRIMON-DORZOL-LATANOPR

3


Drug Name Drug Tier

Notes

TIMOLOL-BRIMONIDINE-DORZOLAMID

3

TIMOLOL-DORZOLAMID-LATANOPROST

3

TIMOPTIC 3

TIMOPTIC OCUDOSE 3

TIMOPTIC-XE 3

TRAVATAN Z 3

travoprost (bak free) 1

TRUSOPT 3

VYZULTA 3 PA

XALATAN 3

XELPROS 3

ZIOPTAN 3

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ACUICYN 3

ak-poly-bac 1

AKTEN 3

ALCAINE 3

altacaine 3

altafrin 1

atropine sulfate ophthalmic ointment

1

ATROPINE SULFATE OPHTHALMIC SOLUTION 0.01 %

1

atropine sulfate ophthalmic solution 1 %

1

AVENOVA 3

bacitracin-polymyxin b ophthalmic

1

bacitra-neomycin-polymyxin-hc

1

BLEPHAMIDE 2

BLEPHAMIDE S.O.P. 2

CEQUA 2 PA

CYCLOGYL 3

Drug Name Drug Tier

Notes

CYCLOMYDRIL 3

cyclopentolate hcl ophthalmic

1

CYCLOSPORINE IN KLARITY

2 PA

GATIFLOXACIN-DEXAMETHASONE OPHTHALMIC SOLUTION 0.5-0.1 %

3

GELFILM OPHTHALMIC 3

homatropaire 1

homatropine hbr ophthalmic solution 5 %

1

HYPOCYN 3

ISOPTO ATROPINE 2

LACRISERT 2

LASTACAFT 3

MAXITROL 3

neomycin-bacitracin zn-polymyx

3

neomycin-polymyxin-dexameth ophthalmic ointment

1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

neomycin-polymyxin-gramicidin

1

neomycin-polymyxin-hc ophthalmic

3

neo-polycin 3

neo-polycin hc 1

phenylephrine hcl ophthalmic

1

polycin 1

polymyxin b-trimethoprim 1

POLYTRIM 3

PRED-G 2

PRED-G S.O.P. 2

PREDNISOLONE ACETATE-NEPAFENAC

3


Drug Name Drug Tier

Notes

PREDNISOLONE ACET-MOXIFLOXACIN

3

PREDNISOLONE-BROMFENAC

3

PREDNISOLONE-GATIFLOXACIN

3

PREDNISOLONE-GATIFLOXACIN OPHTHALMIC SOLUTION 1-0.5 %

3

PREDNISOLONE-MOXIFLOXACIN

3

PREDNISOLON-GATIFLOX-BROMFENAC

3

PREDNISOLON-MOXIFLOX-BROMFENAC

3

proparacaine hcl ophthalmic

3

RESTASIS 2 PA

RESTASIS MULTIDOSE 2 PA

sulfacetamide-prednisolone ophthalmic solution

1

tetcaine ophthalmic solution 0.5 %

3

tetracaine hcl ophthalmic 3

tetravisc forte ophthalmic solution 0.5 %

3

tetravisc ophthalmic solution 0.5 %

3

TOBRADEX OPHTHALMIC OINTMENT

2

TOBRADEX OPHTHALMIC SUSPENSION

3

TOBRADEX ST 3

tobramycin-dexamethasone

1

TROPICAMIDE-CYCLOPENTOLATE-PE

3

TROPICAMIDE-PHENYLEPHRINE

3

Drug Name Drug Tier

Notes

TROPIC-PROPARACA-PE-KETOROLAC

3

XIIDRA 2 PA

ZYLET 3

Otic Agents - Drugs for Ear Conditions

acetic acid otic 1

CETRAXAL 3

CIPRO HC 2

CIPRODEX 3

ciprofloxacin hcl otic 3

ciprofloxacin-dexamethasone

1

COLY-MYCIN S OTIC SUSPENSION 3.3-3-10-0.5 MG/ML

3

DERMOTIC 3

flac 3

FLOXIN OTIC OTIC SOLUTION 0.3 %

3

fluocinolone acetonide otic

3

hydrocortisone-acetic acid 3

neomycin-polymyxin-hc otic

1

ofloxacin otic 1

OTOVEL 3

PRAMOTIC 3

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

ADRENALIN NASAL 3

azelastine hcl nasal 1

azelastine-fluticasone 3

BECONASE AQ 3 PA

benzonatate oral capsule 100 mg, 200 mg

1

benzonatate oral capsule 150 mg

3

bromfed dm 3


Drug Name Drug Tier

Notes

BROMPHENIRAMINE MALEATE INTRAMUSCULAR

3

carbinoxamine maleate 1

cetirizine hcl oral solution 3

CLARINEX 3

CLARINEX ORAL SYRUP 0.5 MG/ML

3

CLARINEX-D 12 HOUR 3

clemastine fumarate oral tablet 2.68 mg

1

CUROSURF 3

cyproheptadine hcl oral 1

DERMACINRX AZENASE PAK

3

desloratadine 1

dexchlorpheniramine maleate oral

3

diphen oral elixir 3

diphenhydramine hcl injection

1

diphenhydramine hcl oral elixir

3

DYMISTA 3

epinephrine hcl (nasal) 3

flunisolide nasal 1

HYCODAN 3

hydrocodone polst-chlorphen polst er susp

3

HYDROCODONE-GUAIFENESIN ORAL SOLUTION 2.5-200 MG/5ML

3

hydrocodone-homatropine

1

hydromet 1

HYPERSAL 3

INFASURF 3

ipratropium bromide nasal 1

KARBINAL ER 3

Drug Name Drug Tier

Notes

levocetirizine dihydrochloride oral

1

MICLARA LQ 3

mometasone furoate nasal

3 PA

NASONEX 3 PA

nebusal inhalation nebulization solution 3 %

1

NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %

3

olopatadine hcl nasal 3

OMNARIS 3 PA

PATANASE 3

phenadoz rectal suppository 12.5 mg, 25 mg

1

PHENERGAN 3

promethazine hcl injection 3

promethazine hcl oral 1

promethazine hcl rectal 1

promethazine-codeine 3 PA

promethazine-dm 1

promethazine-dm oral solution 6.25-15 mg/5ml

1

promethazine-phenyleph-codeine

3 PA

promethazine-phenylephrine

1

promethegan 1

pseudoeph-chlorphen-hydrocod oral solution 60-4-5 mg/5ml

3

pseudoephedrine-bromphen-dm

3

pulmosal inhalation nebulization solution 7 %

1

QNASL 3 PA

QNASL CHILDRENS 3 PA

RYCLORA 3

ryvent 1


Drug Name Drug Tier

Notes

SEMPREX-D ORAL CAPSULE 8-60 MG

3

sodium chloride inhalation nebulization solution 0.9 %, 3 %, 7 %

1

sodium chloride inhalation nebulization solution 10 %

3

SSKI 2

SURVANTA 2

TESSALON PERLES 3

TICALAST NASAL KIT 137-50 & 0.9 MCG/ACT-%

3

TUSSICAPS 3

TUSSIONEX PENNKINETIC ER ORAL SUSPENSION EXTENDED RELEASE 10-8 MG/5ML

3

TUXARIN ER 3 PA; QL

TUZISTRA XR 3 PA

XHANCE 3 PA

ZETONNA 3 PA

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE 3

acetylcysteine inhalation 1

ADVAIR DISKUS 3

ADVAIR HFA 2

ADYPHREN 3

ADYPHREN AMP 3

ADYPHREN AMP II 3

ADYPHREN II 3

AIRDUO DIGIHALER 3 PA

AIRDUO RESPICLICK 113/14

3 PA


3 PA


3 PA

Drug Name Drug Tier

Notes

albuterol sulfate er 3

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

1 QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

1 QL

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml

1

ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5% INHALATION

3

albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation

1

albuterol sulfate oral 1

ALVESCO 2

ANORO ELLIPTA 3 PA

ARCAPTA NEOHALER 3

ARMONAIR DIGIHALER 3 PA

ARNUITY ELLIPTA 3 PA

ASMANEX (120 METERED DOSES)

2 ST


2 ST


2 ST


2 ST


2 ST

ASMANEX HFA 2 ST

ATROVENT HFA 2

AUVI-Q 3 PA

BEVESPI AEROSPHERE 3 PA

BREO ELLIPTA 3 PA

BREZTRI AEROSPHERE 3 PA


Drug Name Drug Tier

Notes

BROVANA 3 PA

budesonide inhalation 1

BUDESONIDE-FORMOTEROL FUMARATE

3 PA

COMBIVENT RESPIMAT 2

cromolyn sodium inhalation

1

DALIRESP 3

difil-g forte oral liquid 100-100 mg/5ml

3

DUAKLIR PRESSAIR 3 PA

DULERA 3 PA

ELIXOPHYLLIN 3

epinephrine injection solution auto-injector

1

EPINEPHRINE PROFESSIONAL

3

EPINEPHRINESNAP-EMS

3

EPINEPHRINESNAP-V 3

EPIPEN 2-PAK 3

EPIPEN JR 2-PAK 3

EPISNAP 3

ESBRIET 4 PA; QL

FLOVENT DISKUS 2 PA

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT

2 PA

FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT

2

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1

Drug Name Drug Tier

Notes

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

3 PA

INCRUSE ELLIPTA 3 PA

ipratropium bromide inhalation

1

ipratropium-albuterol 1

levalbuterol hcl inhalation 3

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

3 QL

LONHALA MAGNAIR REFILL KIT

3 PA

LONHALA MAGNAIR STARTER KIT

3 PA

metaproterenol sulfate oral tablet 10 mg, 20 mg

1

montelukast sodium oral 1

OFEV 4 PA; QL

PERFOROMIST 3

PROAIR DIGIHALER 3 QL

PROAIR HFA 3 QL

PROAIR RESPICLICK 3 QL

PROVENTIL HFA 3 QL

PULMICORT FLEXHALER

3 PA

PULMICORT SUSPENSION

3

QVAR REDIHALER 3 PA

SEEBRI NEOHALER 3 PA

SEREVENT DISKUS 2 ST

SINGULAIR 3

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT

2 ST


Drug Name Drug Tier

Notes

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT

2

STIOLTO RESPIMAT 2

STRIVERDI RESPIMAT 2 PA

SYMBICORT 3 PA

SYMJEPI 3

terbutaline sulfate injection

3

terbutaline sulfate oral 1

THEO-24 3

theophylline 1

theophylline er 1

TRELEGY ELLIPTA 3 PA

TUDORZA PRESSAIR 3

UTIBRON NEOHALER 3 PA

VENTOLIN HFA 3 QL

wixela inhub 1

XOPENEX NEB 3

XOPENEX CONCENTRATE

3

XOPENEX HFA 3 QL

YUPELRI 3 PA

zafirlukast 3

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

PULMOZYME 2

tobramycin nebulization solution 300 mg/5ml inhalation

4 PA; QL

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ambrisentan 1 PA; QL

bosentan 1 PA; QL

OPSUMIT 4 PA; QL

sildenafil citrate oral tablet 20 mg

4 PA

TRACLEER 62.5 MG, 125 MG

3 PA; QL

TYVASO 2 PA; QL

Drug Name Drug Tier

Notes

TYVASO REFILL 2 PA; QL

TYVASO STARTER 2 PA; QL

UPTRAVI 4 PA; QL

VENTAVIS 4 PA; QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

AMRIX 3 PA; QL

baclofen oral 1

carisoprodol oral 3 PA; QL

carisoprodol-aspirin oral tablet 200-325 mg

3 PA

chlorzoxazone oral tablet 250 mg

3

chlorzoxazone oral tablet 375 mg, 500 mg, 750 mg

3 QL

cyclobenzaprine hcl er 3 PA; QL

cyclobenzaprine hcl oral tablet 10 mg, 5 mg

1 QL

cyclobenzaprine hcl oral tablet 7.5 mg

3 QL

DANTRIUM ORAL 3

dantrolene sodium oral 1

FEXMID 3 QL

FIRST-BACLOFEN 3

LORZONE 3 QL

metaxall oral tablet 800 mg

3 QL

metaxalone 3 QL

methocarbamol injection 1

methocarbamol oral 1 QL

NORGESIC FORTE 3 QL

orphenadrine citrate er 1 QL

orphenadrine citrate injection

3

orphenadrine-asa-caffeine

3 QL

orphenadrine-aspirin-caffeine oral tablet 50-770-60 mg

3 QL

ORPHENGESIC FORTE 3 QL

OZOBAX 3


Drug Name Drug Tier

Notes

ROBAXIN INJECTION 3

ROBAXIN ORAL TABLET 500 MG

3 QL

ROBAXIN-750 3 QL

SKELAXIN 3 QL

SOMA 3 PA; QL

tizanidine hcl oral capsule 3

tizanidine hcl oral tablet 1

VANADOM 3 PA; QL

ZANAFLEX 3

Sleep Disorder Agents

AMBIEN 3 QL

AMBIEN CR 3 QL

AMYTAL SODIUM 3

armodafinil 3 PA

BELSOMRA 3 PA

BUTISOL SODIUM ORAL TABLET 30 MG

3

DAYVIGO 3 PA

doxepin hcl oral tablet 3

EDLUAR 3 QL

eszopiclone 1 QL

flurazepam hcl 1 QL

INTERMEZZO SUBLINGUAL TABLET SUBLINGUAL 1.75 MG

3 QL

LUNESTA 3 QL

modafinil 1

NUVIGIL 3 PA

PROVIGIL 3

ramelteon 3

RESTORIL 3 QL

ROZEREM 3

SECONAL ORAL CAPSULE 100 MG

2

SILENOR 3

temazepam oral capsule 15 mg, 30 mg, 7.5 mg

1 QL

Drug Name Drug Tier

Notes

temazepam oral capsule 22.5 mg

3 QL

zaleplon 1 QL

zolpidem tartrate er 3 QL

zolpidem tartrate oral 1 QL

zolpidem tartrate sublingual

3 QL

ZOLPIMIST 3 QL


84

Index of Drugs

1 1ST MEDX-PATCH/

LIDOCAINE ................. 15 7 7T GUMMY ES ................ 12 7T LIDO ........................... 15 A abacavir sulfate ............... 32 abacavir sulfate-lamivudine

.................................... 32 abacavir-lamivudine-

zidovudine ................... 32 ABILIFY ........................... 31 ABILIFY MAINTENA ........ 31 ABILIFY MYCITE ............ 31 abiraterone acetate.......... 27 ABSORICA ...................... 42 ABSORICA LD ................ 42 ACACIA ........................... 71 acamprosate calcium ....... 16 ACANYA ......................... 42 acarbose ......................... 50 ACCOLATE ..................... 79 ACCU-CHEK AVIVA

DEVICE ....................... 51 ACCU-CHEK COMPACT

PLUS CONTROL ......... 51 ACCU-CHEK FASTCLIX

LANCET KIT ................ 51 ACCU-CHEK GUIDE

CONTROL ................... 51 ACCU-CHEK MULTICLIX

LANCET DEVICE KIT .. 51 ACCU-CHEK SMARTVIEW

CONTROL ................... 51 ACCU-CHEK SOFTCLIX

LANCET DEVICE KIT .. 51 ACCUPRIL ...................... 35 ACCURETIC ................... 35 acebutolol hcl .................. 35 acetaminophen-codeine .. 12 acetaminophen-codeine #2

.................................... 12 acetaminophen-codeine #3

.................................... 12 acetaminophen-codeine #4

.................................... 12 acetazolamide ................. 75 acetazolamide er ............. 75 acetazolamide sodium ..... 35 acetic acid ................. 58, 77 acetylcysteine .................. 79 ACIPHEX ........................ 55

ACIPHEX SPRINKLE ...... 55 acitretin ........................... 42 ACREMONIUM ............... 71 ACTHAR ......................... 61 ACTHIB ........................... 68 ACTICLATE .................... 17 ACTIGALL ....................... 56 ACTIVELLA ..................... 62 ACTONEL ....................... 70 ACTOPLUS MET ............ 50 ACTOPLUS MET XR ...... 50 ACTOS ............................ 50 ACUICYN ........................ 76 ACULAR ......................... 73 ACULAR LS .................... 73 ACUVAIL ......................... 73 acyclovir .......................... 32 ACZONE ......................... 42 ADACEL .......................... 68 ADALAT CC .................... 35 adapalene ....................... 42 ADAPALENE ................... 42 adapalene-benzoyl peroxide

.................................... 42 ADDERALL ..................... 40 ADDERALL XR ............... 40 adefovir dipivoxil .............. 32 ADHANSIA XR ................ 40 ADLYXIN ......................... 50 ADLYXIN STARTER PACK

.................................... 50 ADMELOG ...................... 52 ADMELOG SOLOSTAR .. 52 ADRENALIN .................... 77 ADVAIR DISKUS............. 79 ADVAIR HFA ................... 79 ADVANCED ALLERGY

COLLECTION ............. 42 ADYPHREN .................... 79 ADYPHREN AMP............ 79 ADYPHREN AMP II ......... 79 ADYPHREN II ................. 79 ADZENYS ER ................. 40 ADZENYS XR-ODT ......... 40 AEMCOLO ...................... 17 AFINITOR ....................... 27 AFINITOR DISPERZ ....... 27 afirmelle .......................... 62 AFLURIA ......................... 68 AFLURIA PRESERVATIVE

FREE........................... 68 AFLURIA QUADRIVALENT

.................................... 69

AFREZZA........................ 52 AGAMATRIX CONTROL

LEVEL 2 ...................... 51 AGAMATRIX CONTROL

LEVEL 4 ...................... 51 AGGRENOX ................... 30 AGONEAZE .................... 15 AGRYLIN ........................ 35 AIMOVIG......................... 26 AIRDUO DIGIHALER ...... 79 AIRDUO RESPICLICK

113/14 ......................... 79 AIRDUO RESPICLICK

232/14 ......................... 79 AIRDUO RESPICLICK

55/14 ........................... 79 AJOVY ............................ 26 AKLIEF ........................... 42 ak-poly-bac ..................... 76 AKTEN ............................ 76 AKYNZEO ....................... 24 ALA SCALP .................... 42 ala-cort ............................ 42 albendazole ..................... 29 ALBENZA........................ 29 albuterol sulfate ............... 79 ALBUTEROL SULFATE .. 79 albuterol sulfate er ........... 79 albuterol sulfate hfa ......... 79 ALBUTEROL SULFATE

HFA ............................. 79 ALCAINE......................... 76 alclometasone dipropionate

.................................... 42 alcohol ............................ 54 ALCOHOL PREP PADS .. 71 ALDACTAZIDE ............... 35 ALDACTONE .................. 35 ALDARA ......................... 42 ALDER ............................ 71 ALECENSA ..................... 27 alendronate sodium ......... 70 ALFERON N ................... 67 alfuzosin hcl er ................ 59 ALINIA ............................ 29 aliskiren fumarate ............ 35 ALKERAN ....................... 27 allopurinol........................ 25 ALLZITAL ........................ 12 almotriptan malate ........... 26 ALOCRIL......................... 73 ALOGLIPTIN BENZOATE

.................................... 50

85

ALOGLIPTIN-METFORMIN HCL ............................. 50

ALOGLIPTIN-PIOGLITAZONE .......... 50

ALOMIDE ........................ 73 ALORA ............................ 62 ALPHAGAN P ................. 75 alprazolam ....................... 34 alprazolam er ................... 34 alprazolam intensol.......... 34 alprazolam xr ................... 34 alprostadil ........................ 35 ALREX ............................ 73 ALTABAX ........................ 17 altacaine .......................... 76 ALTACE .......................... 35 altafrin ............................. 76 altavera ........................... 62 ALTOPREV ..................... 35 ALTRENO ....................... 42 ALUNBRIG ...................... 27 ALVESCO ....................... 79 alvimopan ........................ 56 alyacen 1/35 .................... 62 alyacen 7/7/7 ................... 62 amabelz ........................... 62 amantadine hcl ................ 30 AMARYL ......................... 50 AMBIEN .......................... 82 AMBIEN CR .................... 82 ambrisentan..................... 81 amcinonide ...................... 42 AMELUZ .......................... 42 AMERGE ......................... 26 AMERICAN BEECH ........ 71 amethia ........................... 62 amethia lo ........................ 62 amethyst .......................... 62 AMICAR .......................... 35 amiloride hcl .................... 35 amiloride-

hydrochlorothiazide ..... 35 aminocaproic acid ........... 35 amiodarone hcl ................ 35 AMITIZA .......................... 56 amitriptyline hcl ................ 22 amlodipine besylate ......... 35 amlodipine besylate-

benazepril hcl .............. 35 amlodipine besylate-

valsartan ...................... 35 amlodipine-atorvastatin ... 35 amlodipine-olmesartan .... 35 amlodipine-valsartan-hctz 35 ammonium lactate ........... 42

amnesteem ..................... 42 amoxapine....................... 22 amoxicill-clarithro-lansopraz

.................................... 56 amoxicillin ....................... 17 amoxicillin-potassium

clavulanate .................. 17 amoxicillin-potassium

clavulanate er .............. 17 AMPHETAMINE ER ........ 40 amphetamine sulfate ....... 40 amphetamine-

dextroamphetamine ..... 41 amphetamine-

dextroamphetamine er . 41 ampicillin ......................... 17 ampicillin sodium ............. 17 AMRIX ............................. 81 AMYTAL SODIUM ........... 82 AMZEEQ ......................... 42 ANACAINE ...................... 42 ANAFRANIL .................... 22 anagrelide hcl .................. 35 ANALPRAM-HC .............. 70 ANASPAZ ....................... 56 ANASTIA ......................... 15 anastrozole...................... 27 ANDRODERM ................. 61 ANDROGEL .................... 61 ANDROGEL PUMP ......... 61 ANGELIQ ........................ 62 ANNOVERA .................... 62 ANODYNE LPT ............... 15 ANORO ELLIPTA ............ 79 ANTABUSE ..................... 16 ANTARA ......................... 35 ANTIVENIN

LATRODECTUS MACTANS ................... 71

anucort-hc ....................... 70 anusol-hc ........................ 70 ANUSOL-HC ................... 70 ANZEMET ....................... 24 APADAZ .......................... 12 apap-caff-dihydrocodeine 12 APEXICON E .................. 43 APIDRA SOLOSTAR ...... 52 APIDRA VIAL .................. 52 APLENZIN....................... 22 apraclonidine hcl ............. 75 aprepitant ........................ 24 apri .................................. 62 APRISO .......................... 70 APTENSIO XR ................ 41 APTIVUS ......................... 32

aranelle ........................... 62 ARANESP (ALBUMIN

FREE) ......................... 35 ARAVA ............................ 67 ARAZLO ......................... 43 ARCAPTA NEOHALER ... 79 argyle sterile saline ......... 54 argyle sterile water .......... 54 ARICEPT ........................ 22 ARIKAYCE ...................... 17 ARIMIDEX ....................... 27 aripiprazole ..................... 31 ARISTADA ...................... 31 ARISTADA INITIO ........... 31 ARIZONA CYPRESS ...... 71 armodafinil ...................... 82 ARMONAIR DIGIHALER . 79 ARMOUR THYROID ....... 67 ARNUITY ELLIPTA ......... 79 AROMASIN ..................... 27 ARTHROTEC .................. 11 ARYMO ER ..................... 12 arzol silver nit applicators 43 ASACOL HD ................... 70 ascomp-codeine .............. 12 asenapine maleate .......... 31 ashlyna ........................... 62 ASMANEX (120 METERED

DOSES) ...................... 79 ASMANEX (14 METERED




DOSES) ...................... 79 ASMANEX HFA .............. 79 aspirin-dipyridamole er .... 30 ASTAGRAF XL ............... 67 ASTERO ......................... 15 ATACAND ....................... 35 ATACAND HCT............... 35 atazanavir sulfate ............ 32 ATELVIA ......................... 70 atenolol ........................... 35 atenolol-chlorthalidone .... 35 ATIVAN ........................... 34 atomoxetine hcl ............... 41 ATOPADERM ................. 43 ATOPICLAIR ................... 43 atorvastatin calcium ........ 35 atovaquone ..................... 29 ATRALIN ......................... 43 atropine sulfate ............... 76

86

ATROPINE SULFATE ..... 76 ATROVENT HFA ............. 79 aubra ............................... 62 aubra eq .......................... 62 AUGMENTIN ................... 17 AUGMENTIN ES-600 ...... 17 AUREOBASIDIUM .......... 71 aurovela 1.5/30 ................ 62 aurovela 1/20................... 62 aurovela 24 fe .................. 62 aurovela fe 1.5/30 ............ 62 aurovela fe 1/20 ............... 62 AURYXIA ........................ 58 AUSTRALIAN PINE ......... 71 AUTOLET LANCING

DEVICE ....................... 51 AUVI-Q ............................ 79 AVALIDE ......................... 35 AVANDIA ........................ 50 AVAPRO ......................... 35 AVAR .............................. 43 avar cleanser ................... 43 AVAR LS ......................... 43 AVAR LS CLEANSER ..... 43 AVAR-E EMOLLIENT ...... 43 AVAR-E GREEN ............. 43 AVAR-E LS ..................... 43 AVC VAGINAL ................ 24 AVELOX .......................... 17 AVENOVA ....................... 76 aviane.............................. 62 avidoxy ............................ 17 avita ................................ 43 AVODART ....................... 59 AVONEX PEN ................. 41 AVONEX PREFILLED ..... 41 AYGESTIN ...................... 62 ayuna .............................. 62 AYVAKIT ......................... 27 AZASAN .......................... 67 AZASITE ......................... 73 azathioprine ..................... 67 azelaic acid ..................... 43 azelastine hcl ............. 73, 77 azelastine-fluticasone ...... 77 AZELEX .......................... 43 AZILECT ......................... 30 azithromycin .................... 17 AZOPT ............................ 75 AZOR .............................. 35 AZULFIDINE ................... 70 AZULFIDINE EN-TABS ... 70 azurette ........................... 62 B bac .................................. 12

bacitracin ......................... 73 bacitracin-polymyxin b ..... 76 bacitra-neomycin-

polymyxin-hc ............... 76 baclofen .......................... 81 BACTRIM ........................ 17 BACTRIM DS .................. 17 BACTROBAN .................. 17 BACTROBAN NASAL ..... 17 BALCOLTRA ................... 62 BALD CYPRESS ............. 71 balsalazide disodium ....... 70 BALVERSA ..................... 27 balziva ............................. 62 BAQSIMI ONE PACK ...... 52 BAQSIMI TWO PACK ..... 52 BARACLUDE .................. 32 BASAGLAR KWIKPEN.... 52 BD AUTOSHIELD DUO

PEN NEEDLES ........... 52 BD ULTRA-FINE INSULIN

SYRINGES .................. 52 BD ULTRA-FINE PEN

NEEDLES ................... 52 BD VEO INSULIN SYR U/F

1/2UNIT ....................... 52 BECONASE AQ .............. 77 bekyree ........................... 62 BELBUCA ....................... 12 belladonna alkaloids-opium

.................................... 56 BELSOMRA .................... 82 benazepril hcl .................. 35 benazepril-

hydrochlorothiazide ..... 35 BENICAR ........................ 36 BENICAR HCT ................ 36 BENSAL HP .................... 43 BENTYL .......................... 56 BENZACLIN .................... 43 BENZACLIN WITH PUMP

.................................... 43 BENZAMYCIN ................. 43 benzepro foaming cloths . 43 BENZHYDROCODONE-

ACETAMINOPHEN ..... 12 BENZNIDAZOLE ............. 29 benzonatate .................... 77 BENZOYL PEROX-

HYDROCORTISONE .. 43 BENZOYL PEROXIDE .... 43 BENZOYL PEROXIDE

FORTE- HC ................. 43 benzoyl peroxide-

erythromycin ................ 43

benztropine mesylate ...... 30 BEPREVE ....................... 74 BERINERT ...................... 67 beser ............................... 43 BESIVANCE ................... 74 BETADINE OPHTHALMIC

PREP .......................... 74 BETAGAN ....................... 75 betamethasone

dipropionate ................ 43 betamethasone

dipropionate aug ......... 43 BETAMETHASONE

SODIUM PHOSPHATE59 betamethasone valerate .. 43 BETAPACE ..................... 36 BETAPACE AF ............... 36 betaxolol hcl .............. 36, 75 bethanechol chloride ....... 58 BETIMOL ........................ 75 BETOPTIC-S .................. 75 BEVESPI AEROSPHERE79 bexarotene ...................... 27 BEXSERO ....................... 69 BEYAZ ............................ 62 bicalutamide .................... 27 BICILLIN L-A ................... 17 BIDIL ............................... 36 BIJUVA ........................... 62 BIKTARVY ...................... 32 BILTRICIDE .................... 29 bimatoprost ..................... 75 BINOSTO ........................ 70 bio-statin ......................... 24 BIO-STATIN .................... 24 BIOTHRAX ...................... 69 bisoprolol fumarate .......... 36 bisoprolol-

hydrochlorothiazide ..... 36 BLEPH-10 ....................... 74 BLEPHAMIDE ................. 76 BLEPHAMIDE S.O.P....... 76 blisovi 24 fe ..................... 62 blisovi fe 1.5/30 ............... 62 blisovi fe 1/20 .................. 62 BOCASAL ....................... 42 BONIVA .......................... 70 BONJESTA ..................... 24 BOOSTRIX ..................... 69 bosentan ......................... 81 BOSULIF......................... 27 BOTRYTIS ...................... 71 bp 10-1 ............................ 43 bp cleansing wash ........... 43 bpo .................................. 43

87

BRAFTOVI ...................... 27 BREATHE EASE LARGE 71 BREATHE EASE MEDIUM

.................................... 71 BREATHE EASE SMALL 71 BREATHERITE ............... 71 BREO ELLIPTA ............... 79 BRETYLIUM TOSYLATE 36 BREZTRI AEROSPHERE79 briellyn ............................. 62 BRILINTA ........................ 31 brimonidine tartrate.......... 75 BRIMONIDINE-

DORZOLAMIDE .......... 75 BRISDELLE..................... 22 BROME ........................... 71 bromfed dm ..................... 77 bromfenac sodium (once-

daily) ............................ 74 bromocriptine mesylate ... 30 BROMPHENIRAMINE

MALEATE .................... 78 BROMSITE ..................... 74 BROVANA ....................... 80 BRUKINSA ...................... 27 BRYHALI ......................... 43 budesonide ................ 70, 80 BUDESONIDE-

FORMOTEROL FUMARATE ................. 80

bumetanide ..................... 36 BUMEX ........................... 36 BUNAVAIL ...................... 16 BUPAP ............................ 12 BUPIVACAINE HCL-NACL

.................................... 15 buprenorphine ................. 12 buprenorphine hcl ............ 16 buprenorphine hcl-naloxone

hcl ................................ 16 bupropion hcl ................... 22 bupropion hcl er (smoking

det) .............................. 16 bupropion hcl er (sr) ........ 22 bupropion hcl er (xl) ......... 22 BUPROPION HCL ER (XL)

.................................... 22 buspirone hcl ................... 34 butalbital-acetaminophen. 12 BUTALBITAL-

ACETAMINOPHEN ..... 12 butalbital-apap ................. 12 butalbital-apap-caff-cod ... 12 butalbital-apap-caffeine ... 12

butalbital-asa-caff-codeine .................................... 12

butalbital-aspirin-caffeine . 12 BUTISOL SODIUM .......... 82 butorphanol tartrate ......... 12 BUTRANS ....................... 12 BYDUREON .................... 50 BYDUREON BCISE

AUTOINJECTOR ........ 50 BYETTA 10 MCG PEN .... 50 BYETTA 5 MCG PEN ...... 50 BYSTOLIC ...................... 36 BYVALSON ..................... 36 C cabergoline...................... 61 CABOMETYX .................. 27 CADUET ......................... 36 CAFERGOT .................... 26 caffeine citrate ................. 42 CAFFEINE-SODIUM

BENZOATE ................. 42 CALAN ............................ 36 CALAN SR ...................... 36 calcipotriene .................... 43 CALCIPOTRIENE ........... 43 calcipotriene-betameth

diprop .......................... 43 calcitonin (salmon) .......... 70 calcitrene ......................... 43 calcitriol ..................... 43, 71 calcium acetate ............... 58 calcium acetate (phos

binder) ......................... 58 CALCIUM DISODIUM

VERSENATE ............... 71 CALIFORNIA PEPPER

TREE........................... 71 CALQUENCE .................. 27 CAMBIA .......................... 11 camila .............................. 62 camrese .......................... 62 camrese lo....................... 62 CANASA ......................... 70 candesartan cilexetil ........ 36 candesartan cilexetil-hctz 36 CANDIDA ALBICANS

EXTRACT ................... 71 capecitabine .................... 27 CAPEX ............................ 43 CAPRELSA ..................... 27 captopril .......................... 36 captopril-

hydrochlorothiazide ..... 36 CARAC ........................... 43 CARAFATE ..................... 55

carbamazepine ............... 20 carbamazepine er ........... 20 CARBATROL .................. 20 carbidopa ........................ 30 carbidopa-levodopa ......... 30 carbidopa-levodopa er..... 30 carbidopa-levodopa-

entacapone ................. 30 carbinoxamine maleate ... 78 CARDIZEM ..................... 36 CARDIZEM CD ............... 36 CARDIZEM LA ................ 36 CARDURA ...................... 36 CARDURA XL ................. 59 CARETOUCH CONTROL

SOL LEVEL 2 .............. 51 CARETOUCH

LANCING/EJECTOR ... 51 carisoprodol .................... 81 carisoprodol-aspirin ......... 81 carisoprodol-aspirin-codeine

.................................... 12 CARNITOR ..................... 54 CARNITOR SF ................ 54 CAROSPIR ..................... 36 carteolol hcl ..................... 75 cartia xt ........................... 36 carvedilol ......................... 36 carvedilol phosphate er ... 36 CASODEX ...................... 27 CATAPRES ..................... 36 CATAPRES-TTS-1 .......... 36 CATAPRES-TTS-2 .......... 36 CATAPRES-TTS-3 .......... 36 CATTLE EPITHELIUM .... 71 CAYA .............................. 71 caziant ............................ 62 CEDAR ELM ................... 71 cefaclor ........................... 17 cefaclor er ....................... 17 cefadroxil......................... 17 cefazolin sodium ............. 17 cefdinir ............................ 17 cefditoren pivoxil ............. 17 cefepime hcl .................... 17 cefixime ........................... 17 cefpodoxime proxetil ....... 17 cefprozil .......................... 17 ceftazidime ...................... 17 ceftriaxone sodium .......... 17 cefuroxime axetil ............. 17 CELEBREX ..................... 11 celecoxib ......................... 11 CELEXA .......................... 22 CELLCEPT ..................... 67

88

CELONTIN ...................... 20 cem-urea ......................... 43 CENTANY ....................... 17 cephalexin ................. 17, 18 CEQUA ........................... 76 CERACADE .................... 43 ceramax .......................... 43 CERDELGA..................... 58 CERVIDIL ........................ 58 CESAMET ....................... 24 cetirizine hcl..................... 78 CETRAXAL ..................... 77 cevimeline hcl .................. 42 CHANTIX ........................ 16 CHANTIX CONTINUING

MONTH PAK ............... 16 CHANTIX STARTING

MONTH PAK ............... 16 charlotte 24 fe .................. 62 chateal............................. 62 chateal eq ........................ 62 CHEMET ......................... 54 chlordiazepoxide hcl ........ 34 chlordiazepoxide-

amitriptyline ................. 22 chlordiazepoxide-clidinium

.................................... 56 chlorhexidine gluconate ... 42 chloroquine phosphate .... 29 chlorothiazide .................. 36 chlorpromazine hcl .......... 31 chlorpropamide ................ 50 chlorthalidone .................. 36 chlorzoxazone ................. 81 cholestyramine ................ 36 cholestyramine light ......... 36 ciclodan ........................... 24 ciclopirox ......................... 24 ciclopirox olamine ............ 24 cilostazol ......................... 31 CILOXAN ........................ 74 CIMDUO .......................... 32 cimetidine ........................ 55 cimetidine hcl ................... 55 cinacalcet hcl ................... 71 CIPRO ............................. 18 CIPRO HC ....................... 77 CIPRODEX ..................... 77 ciprofloxacin .................... 18 ciprofloxacin hcl ... 18, 74, 77 ciprofloxacin-ciproflox hcl er

.................................... 18 ciprofloxacin-

dexamethasone ........... 77 citalopram hydrobromide . 22

CLADOSPORIUM CLADOSPORIOIDES .. 71

CLADOSPORIUM SPHAEROSPERMUM . 71

claravis ............................ 43 CLARINEX ...................... 78 CLARINEX-D 12 HOUR .. 78 clarithromycin .................. 18 clarithromycin er .............. 18 clemastine fumarate ........ 78 CLENPIQ ........................ 56 CLEOCIN ........................ 18 CLEOCIN PHOSPHATE . 18 CLEOCIN-T ..................... 43 CLEVER CHOICE

HOLDING CHAMBER . 71 CLIMARA ........................ 62 CLIMARA PRO ............... 62 clindacin etz .................... 43 clindacin-p ....................... 43 CLINDAGEL .................... 43 clindamycin hcl ................ 18 clindamycin palmitate hcl . 18 clindamycin phosphate ... 18,

43, 44 CLINDAMYCIN

PHOSPHATE .............. 44 clindamycin phosphate-

benzoyl peroxide ......... 43 clindamycin-tretinoin ........ 44 CLINDESSE .................... 18 clobetasol prop emollient

base ............................ 44 clobetasol propionate ...... 44 clobetasol propionate e ... 44 clobetasol propionate

emulsion ...................... 44 CLOBEX ......................... 44 CLOBEX SPRAY............. 44 clocortolone pivalate ........ 44 clocortolone pivalate pump

.................................... 44 clodan ............................. 44 CLODERM ...................... 44 CLODERM PUMP ........... 44 clomipramine hcl ............. 22 clonazepam ..................... 34 clonidine .......................... 36 clonidine hcl .................... 36 clonidine hcl er ................ 41 clopidogrel bisulfate ......... 31 clorazepate dipotassium .. 34 clotrimazole ..................... 24 clotrimazole-betamethasone

.................................... 24

clozapine ......................... 31 CLOZARIL ...................... 31 COARTEM ...................... 29 COCAINE HCL ............... 15 codeine sulfate ................ 12 COGENTIN ..................... 30 COLAZAL........................ 70 colchicine ........................ 25 COLCHICINE .................. 25 colchicine-probenecid ..... 25 COLCRYS ....................... 25 colesevelam hcl............... 36 COLESTID ...................... 36 COLESTID FLAVORED .. 36 colestipol hcl ................... 36 colistimethate sodium (cba)

.................................... 18 colocort ........................... 70 COLY-MYCIN M .............. 18 COLY-MYCIN S .............. 77 COLYTE WITH FLAVOR

PACKS ........................ 56 COMBIGAN .................... 75 COMBIPATCH ................ 62 COMBIVENT RESPIMAT 80 COMBIVIR ...................... 32 COMETRIQ (100 MG

DAILY DOSE) ............. 27 COMETRIQ (140 MG

DAILY DOSE) ............. 27 COMETRIQ (60 MG DAILY

DOSE) ......................... 27 COMPACT SPACE

CHAMBER/LG MASK . 71 COMPACT SPACE

CHAMBER/MED MASK .................................... 71

COMPACT SPACE CHAMBER/SM MASK . 71

COMPLERA .................... 32 compro ............................ 24 COMTAN ........................ 30 CONCERTA .................... 41 CONDYLOX .................... 44 CONJUPRI ...................... 36 constulose ....................... 56 CONTOUR CONTROL .... 51 CONTOUR NEXT

CONTROL................... 51 CONTOUR NEXT TEST . 51 CONZIP .......................... 12 COPIKTRA ...................... 27 CORDRAN ...................... 44 COREG ........................... 36 COREG CR ..................... 36

89

coremino ......................... 18 CORGARD ...................... 36 CORLANOR .................... 36 CORTEF ......................... 59 CORTENEMA ................. 70 CORTIFOAM ................... 70 cortisone acetate ............. 59 CORTISPORIN ............... 44 CORZIDE ........................ 36 COSENTYX (300 MG

DOSE) ......................... 67 COSENTYX 150 MG/ML . 67 COSENTYX

SENSOREADY (300 MG) .................................... 67

COSENTYX SENSOREADY PEN ... 67

COSOPT ......................... 75 COSOPT PF.................... 75 COTELLIC ....................... 27 COTEMPLA XR-ODT ...... 41 COUMADIN ..................... 20 covaryx ............................ 62 covaryx hs ....................... 62 COZAAR ......................... 36 CREON ........................... 58 CRESEMBA .................... 24 CRESTOR ....................... 36 CRINONE ........................ 62 CRIXIVAN ....................... 32 cromolyn sodium . 56, 74, 80 crotan .............................. 29 cryselle-28 ....................... 62 C-TOPICAL ..................... 15 curity sterile saline ........... 54 CUROSURF .................... 78 CURVULARIA ................. 71 CUTIVATE ...................... 44 CUVITRU ........................ 67 CUVPOSA ....................... 56 cyanocobalamin .............. 54 cyclafem 1/35 .................. 62 cyclafem 7/7/7 ................. 62 cyclobenzaprine hcl ......... 81 cyclobenzaprine hcl er ..... 81 CYCLOGYL ..................... 76 CYCLOMYDRIL .............. 76 cyclopentolate hcl ............ 76 cyclophosphamide ........... 27 cycloserine ...................... 26 CYCLOSET ..................... 50 cyclosporine .................... 67 CYCLOSPORINE IN

KLARITY ..................... 76 cyclosporine modified ...... 67

CYMBALTA ..................... 22 cyproheptadine hcl .......... 78 cyred ............................... 63 cyred eq .......................... 63 CYSTADANE .................. 58 CYSTAGON .................... 58 CYTOMEL ....................... 67 CYTOTEC ....................... 55 CYTOTINE ...................... 71 cytra k crystals ................ 54 D DALIRESP ...................... 80 danazol ........................... 61 DANTRIUM ..................... 81 dantrolene sodium ........... 81 dapsone .................... 26, 44 DAPSONE....................... 44 DAPTACEL ..................... 69 DARAPRIM ..................... 29 darifenacin hydrobromide er

.................................... 58 dasetta 1/35 .................... 63 dasetta 7/7/7 ................... 63 DAURISMO ..................... 27 DAYPRO ......................... 11 daysee ............................ 63 DAYTRANA ..................... 41 DAYVIGO ........................ 82 DDAVP ............................ 61 DDAVP RHINAL TUBE ... 61 DEBACTEROL ................ 42 deblitane ......................... 63 DECADRON .................... 59 deferoxamine mesylate ... 71 dehydrated alcohol .......... 54 DELESTROGEN ............. 63 delyla............................... 63 DELZICOL....................... 70 DEMADEX ...................... 36 demeclocycline hcl .......... 18 DEMSER ......................... 36 DENAVIR ........................ 32 DEPAKENE ..................... 20 DEPAKOTE ..................... 20 DEPAKOTE ER ............... 20 DEPAKOTE SPRINKLES 20 DEPO-ESTRADIOL ......... 63 DEPO-MEDROL ............. 59 DEPO-PROVERA ........... 63 DEPO-SUBQ PROVERA

104 .............................. 63 DEPO-TESTOSTERONE 61 DERMACINRX AZENASE

PAK ............................. 78

DERMACINRX EMPRICAINE .............. 15

DERMACINRX PRIZOPAK .................................... 15

DERMA-SMOOTHE/FS BODY .......................... 44

DERMA-SMOOTHE/FS SCALP ........................ 44

DERMASORB HC ........... 44 DERMOTIC ..................... 77 DESCOVY ...................... 32 DESFERAL ..................... 71 desipramine hcl ............... 22 desloratadine .................. 78 desmopressin ace spray

refrig ............................ 61 desmopressin acetate ..... 61 desmopressin acetate spray

.................................... 61 desogestrel-ethinyl estradiol

.................................... 63 DESONATE .................... 44 desonide ......................... 44 DESOWEN ..................... 44 desoximetasone .............. 44 DESOXYN ...................... 41 DESVENLAFAXINE ER .. 22 desvenlafaxine succinate er

.................................... 22 DETROL ......................... 58 DETROL LA .................... 58 DEXABLISS .................... 59 dexamethasone............... 59 DEXAMETHASONE (LA) 59 dexamethasone intensol . 59 dexamethasone sod

phosphate pf ............... 59 dexamethasone sodium

phosphate ....... 59, 60, 74 DEXAMETHASONE

SODIUM PHOSPHATE59 dexchlorpheniramine

maleate ....................... 78 DEXEDRINE ................... 41 DEXERYL ....................... 44 DEXILANT ...................... 55 dexmethylphenidate hcl ... 41 dexmethylphenidate hcl er

.................................... 41 DEXONTO 0.4% ............. 60 DEXPAK 10 DAY ............ 60 DEXPAK 13 DAY ............ 60 DEXPAK 6 DAY .............. 60 DEXPANTHENOL ........... 54

90

dextroamphetamine sulfate .................................... 41

dextroamphetamine sulfate er ................................. 41

DIASTAT ACUDIAL ......... 20 DIASTAT PEDIATRIC ..... 20 DIATHRIVE GLUCOSE

CONTROL SOLN ........ 51 DIATHRIVE LANCING

DEVICE ....................... 51 diazepam ................... 20, 34 DIAZEPAM ...................... 34 diazepam intensol ........... 34 diazoxide ......................... 52 DICLEGIS ....................... 24 DICLOFENAC ................. 11 DICLOFENAC EPOLAMINE

.................................... 11 diclofenac potassium ....... 11 diclofenac sodium 11, 44, 74 diclofenac sodium er ........ 11 diclofenac-misoprostol ..... 11 DICLOFONO ................... 11 dicloxacillin sodium .......... 18 dicyclomine hcl ................ 56 didanosine ....................... 32 DIFFERIN .................. 44, 45 difil-g forte ....................... 80 diflorasone diacetate ....... 45 DIFLUCAN ...................... 24 diflunisal .......................... 11 digitek .............................. 36 digox ............................... 36 digoxin ............................. 36 dihydroergotamine mesylate

.................................... 26 DILANTIN ........................ 21 DILANTIN INFATABS ...... 21 DILATRATE-SR .............. 36 DILAUDID ....................... 12 diltiazem hcl..................... 37 diltiazem hcl er ................ 36 diltiazem hcl er beads ...... 36 diltiazem hcl er coated

beads .......................... 36 dilt-xr ............................... 37 dimenhydrinate ................ 24 dimethyl fumarate ............ 41 dimethyl fumarate starter

pack ............................. 41 DIOVAN .......................... 37 DIOVAN HCT .................. 37 diphen ............................. 78 diphenhydramine hcl ....... 78 diphenoxylate-atropine .... 56

DIPHTHERIA-TETANUS TOXOIDS DT .............. 69

DIPROLENE ................... 45 DIPROLENE AF .............. 45 dipyridamole .................... 31 disopyramide phosphate . 37 disulfiram ......................... 16 DITROPAN XL ................ 58 DIURIL ............................ 37 divalproex sodium ........... 21 divalproex sodium er ....... 21 DIVIGEL .......................... 63 dofetilide .......................... 37 DOG EPITHELIUM .......... 71 DOLOPHINE ................... 12 donepezil hcl ................... 22 DORAL ............................ 34 DORYX ........................... 18 DORYX MPC .................. 18 dorzolamide hcl ............... 75 DORZOLAMIDE HCL ...... 75 dorzolamide hcl-timolol mal

.................................... 75 dorzolamide hcl-timolol mal

pf ................................. 75 dotti ................................. 63 DOVATO ......................... 32 DOVONEX ...................... 45 doxazosin mesylate ......... 37 doxepin hcl .......... 22, 45, 82 doxercalciferol ................. 71 doxycycline...................... 45 doxycycline hyclate ......... 18 DOXYCYCLINE HYCLATE

.................................... 18 doxycycline monohydrate 18 doxylamine-pyridoxine ..... 24 D-PENAMINE .................. 58 DRECHSLERA ................ 71 DRISDOL ........................ 54 DRITHO-CREME HP ...... 45 DRIZALMA SPRINKLE.... 22 dronabinol ....................... 24 drospiren-eth estrad-

levomefol ..................... 63 drospirenone-ethinyl

estradiol ....................... 63 DROXIA .......................... 27 DRYSOL ......................... 45 DUAC .............................. 45 DUAKLIR PRESSAIR ...... 80 DUAVEE ......................... 63 DUETACT ....................... 50 DULERA ......................... 80 duloxetine hcl ............ 22, 23

DUOPA ........................... 30 DURAGESIC-100 ............ 12 DURAGESIC-12.............. 12 DURAGESIC-25.............. 12 DURAGESIC-50.............. 12 DURAGESIC-75.............. 12 duraxin ............................ 12 DUREZOL ....................... 74 DURLAZA ....................... 31 DUST MITE MIXED

ALLERGEN EXT ......... 71 dutasteride ...................... 59 dutasteride-tamsulosin hcl

.................................... 59 DUTOPROL .................... 37 DUZALLO ....................... 25 dvorah ............................. 13 DXEVO 11-DAY .............. 60 DYANAVEL XR ............... 41 DYAZIDE ........................ 37 DYMISTA ........................ 78 DYRENIUM ..................... 37 E E.E.S. 400 ....................... 18 E.E.S. GRANULES ......... 18 EASIVENT ...................... 71 EASY TRAK II CONTROL

.................................... 51 EASYMAX 15 LEVEL 2-3

CONTROL................... 51 EASYMAX CONTROL .... 51 EASYMAX CONTROL

NORMAL/HIGH ........... 51 EC-NAPROSYN .............. 11 ec-naproxen .................... 11 econazole nitrate ............. 25 ECOZA ........................... 25 EDARBI .......................... 37 EDARBYCLOR ............... 37 EDECRIN ........................ 37 EDLUAR ......................... 82 ed-spaz ........................... 56 EDURANT ....................... 32 eemt ................................ 63 eemt hs ........................... 63 efavirenz ......................... 32 efavirenz-emtricitab-

tenofovir ...................... 32 efavirenz-lamivudine-

tenofovir ...................... 32 effer-k .............................. 54 EFFER-K......................... 54 effervescent pot chloride . 54 EFFEXOR XR ................. 23 EFFIENT ......................... 31

91

EFUDEX .......................... 45 EHA ................................. 15 ELESTAT ........................ 74 ELESTRIN ....................... 63 ELETONE ....................... 45 ELETONE TWINPACK .... 45 eletriptan hydrobromide ... 26 ELIDEL ............................ 45 ELIGARD ........................ 61 ELIMITE .......................... 29 elinest .............................. 63 ELIQUIS .......................... 20 ELIQUIS DVT/PE

STARTER PACK ......... 20 ELIXOPHYLLIN ............... 80 ELLA ............................... 63 ELMIRON ........................ 58 ELOCON ......................... 45 eluryng ............................ 63 EMADINE ........................ 74 EMBEDA ......................... 13 EMBRACE LANCING

DEVICE/EJECTOR ..... 51 EMBRACE TALK

GLUCOSE CONTROL . 51 EMCYT ............................ 27 EMEND ........................... 24 EMEND TRI-PACK .......... 24 EMGALITY ...................... 26 EMGALITY (300 MG

DOSE) ......................... 26 emoquette ....................... 63 emtricitabine .................... 32 emtricitabine-tenofovir df . 32 EMTRIVA ........................ 32 EMULSION SB ................ 45 EMVERM ........................ 29 ENABLEX ........................ 58 enalapril maleate ............. 37 enalapril-

hydrochlorothiazide ..... 37 ENBREL .......................... 67 ENBREL MINI ................. 67 ENBREL SURECLICK ..... 67 endocet ........................... 13 ENDOMETRIN ................ 63 ENGERIX-B..................... 69 enoxaparin sodium .......... 20 enpresse-28 .................... 63 enskyce ........................... 63 ENSTILAR ....................... 45 entacapone ..................... 30 entecavir .......................... 32 ENTEREG ....................... 56 ENTRESTO ..................... 37

ENTTY SPRAY ............... 45 enulose ........................... 56 ENVARSUS XR .............. 67 EPANED ......................... 37 EPCLUSA ....................... 32 EPICERAM ..................... 45 EPICOCCUM .................. 71 EPIDUO .......................... 45 EPIDUO FORTE ............. 45 EPIFOAM ........................ 45 epinastine hcl .................. 74 epinephrine ............... 37, 80 epinephrine hcl (nasal) .... 78 epinephrine pf ................. 37 EPINEPHRINE

PROFESSIONAL ........ 80 EPINEPHRINESNAP-EMS

.................................... 80 EPINEPHRINESNAP-V ... 80 EPIPEN 2-PAK ................ 80 EPIPEN JR 2-PAK .......... 80 EPISNAP ........................ 80 epitol ............................... 21 EPIVIR ............................ 32 EPIVIR HBV .................... 32 eplerenone ...................... 37 EPOGEN ......................... 35 eprosartan mesylate ........ 37 EQUETRO ...................... 35 ergocalciferol ................... 54 ergoloid mesylates .......... 71 ERGOMAR...................... 26 ergotamine-caffeine ......... 26 ERIVEDGE...................... 27 ERLEADA ....................... 27 erlotinib hcl ...................... 27 errin ................................. 63 ERTACZO ....................... 25 ery ................................... 45 ERYGEL ......................... 45 ERYPED 200 .................. 18 ERYPED 400 .................. 18 ERY-TAB ........................ 18 ERYTHROCIN STEARATE

.................................... 18 erythromycin ........ 18, 45, 74 erythromycin base ........... 18 erythromycin ethylsuccinate

.................................... 18 ESBRIET ......................... 80 escitalopram oxalate ....... 23 ESGIC ............................. 13 esomeprazole magnesium

.................................... 56

ESOMEPRAZOLE STRONTIUM ............... 56

est estrogens-methyltest . 63 est estrogens-methyltest ds

.................................... 63 est estrogens-methyltest hs

.................................... 63 estarylla .......................... 63 estazolam........................ 34 ESTRACE ....................... 63 estradiol .......................... 63 estradiol valerate ............. 63 estradiol-norethindrone acet

.................................... 63 ESTRING ........................ 63 ESTROGEL .................... 63 ESTROSTEP FE ............. 63 eszopiclone ..................... 82 ethacrynic acid ................ 37 ethambutol hcl ................. 26 ethosuximide ................... 21 ethyl chloride ................... 15 ethynodiol diac-eth estradiol

.................................... 63 etidronate disodium ......... 71 etodolac .......................... 11 etodolac er ...................... 11 etonogestrel-ethinyl

estradiol ...................... 63 etoposide ........................ 27 EUCRISA ........................ 45 EURAX ........................... 29 euthyrox .......................... 67 EVAMIST ........................ 63 EVEKEO ......................... 41 EVEKEO ODT ................. 41 everolimus ....................... 27 EVISTA ........................... 61 EVOCLIN ........................ 45 EVOXAC ......................... 42 EVZIO ............................. 17 EXALGO ......................... 13 EXELDERM .................... 25 EXELON ......................... 22 exemestane .................... 27 EXFORGE ...................... 37 EXFORGE HCT .............. 37 exoderm .......................... 25 EXTAVIA ......................... 41 EXTINA ........................... 25 EYSUVIS ........................ 74 EZ FLU SHOT-

FLUCELVAX QUAD .... 69 EZALLOR SPRINKLE ..... 37 ezetimibe......................... 37

92

ezetimibe-simvastatin ...... 37 F FABIOR ........................... 45 falmina............................. 63 famciclovir ....................... 32 famotidine ........................ 56 FANAPT .......................... 31 FANAPT TITRATION PACK

.................................... 31 FARESTON ..................... 27 FARXIGA ........................ 50 FARYDAK ....................... 27 fayosim ............................ 63 FAZACLO ........................ 31 febuxostat ........................ 25 felbamate ........................ 21 FELDENE ........................ 11 felodipine er ..................... 37 FEM PH ........................... 58 FEMARA ......................... 27 FEMCAP ......................... 71 FEMHRT LOW DOSE ..... 63 FEMRING ........................ 63 femynor ........................... 63 fenofibrate ....................... 37 fenofibrate micronized ..... 37 fenofibric acid .................. 37 FENOGLIDE.................... 37 fenoprofen calcium .......... 11 fenortho ........................... 11 fentanyl ............................ 13 FERRIPROX ................... 54 FETZIMA ......................... 23 FETZIMA TITRATION ..... 23 FEXMID ........................... 81 FIASP .............................. 52 FIASP FLEXTOUCH ....... 52 FIASP PENFILL .............. 52 FIBRICOR ....................... 37 FINACEA ......................... 45 finasteride ........................ 59 FIORICET ....................... 13 FIORICET/CODEINE ...... 13 FIORINAL ........................ 13 FIORINAL/CODEINE #3 .. 13 FIRE ANT ........................ 71 FIRST-BACLOFEN .......... 81 FIRST-LANSOPRAZOLE 56 FIRST-MOUTHWASH BLM

.................................... 42 FIRST-OMEPRAZOLE .... 56 FIRST-PROGESTERONE

VGS ............................. 63 FIRST-VANCOMYCIN ..... 18 FIRVANQ ........................ 18

flac .................................. 77 FLAGYL .......................... 18 FLAREX .......................... 74 flavoxate hcl .................... 58 flecainide acetate ............ 37 FLECTOR ....................... 11 FLEXICHAMBER ADULT

MASK/SMALL ............. 72 FLEXICHAMBER CHILD

MASK/LARGE ............. 72 FLEXICHAMBER CHILD

MASK/SMALL ............. 72 FLEXIN ........................... 15 FLOLIPID ........................ 37 FLOMAX ......................... 59 FLOVENT DISKUS ......... 80 FLOVENT HFA ............... 80 FLOXIN OTIC .................. 77 FLUAD ............................ 69 FLUAD QUADRIVALENT 69 FLUARIX QUADRIVALENT

.................................... 69 FLUBLOK QUADRIVALENT

.................................... 69 FLUCELVAX

QUADRIVALENT ........ 69 fluconazole ...................... 25 flucytosine ....................... 25 fludrocortisone acetate .... 60 FLULAVAL

QUADRIVALENT ........ 69 FLUMADINE ................... 32 FLUMIST QUADRIVALENT

.................................... 69 flunisolide ........................ 78 fluocinolone acetonide .... 45,

77 fluocinolone acetonide body

.................................... 45 fluocinolone acetonide scalp

.................................... 45 fluocinonide ..................... 45 fluocinonide emulsified base

.................................... 45 FLUORABON .................. 54 fluoritab ........................... 54 fluorometholone .............. 74 FLUOROPLEX ................ 45 fluorouracil....................... 45 FLUOROURACIL ............ 45 fluoxetine hcl ................... 23 fluoxetine hcl (pmdd) ....... 23 fluphenazine decanoate .. 31 fluphenazine hcl .............. 31 FLURA-DROPS .............. 54

flurandrenolide ................ 45 flurazepam hcl ................. 82 flurbiprofen ...................... 11 flurbiprofen sodium .......... 74 flutamide ......................... 27 fluticasone propionate ..... 45 fluticasone-salmeterol ..... 80 FLUTICASONE-

SALMETEROL ............ 80 fluvastatin sodium ........... 37 fluvastatin sodium er ....... 37 fluvoxamine maleate ....... 23 fluvoxamine maleate er ... 23 FLUZONE HIGH-DOSE .. 69 FLUZONE HIGH-DOSE

QUADRIVALENT ........ 69 FLUZONE

QUADRIVALENT ........ 69 FML ................................. 74 FML FORTE .................... 74 FML LIQUIFILM .............. 74 FOCALIN ........................ 41 FOCALIN XR .................. 41 folic acid .......................... 54 FOLVIK-D ....................... 54 FOLVITE-D ..................... 54 fondaparinux sodium ....... 20 FORFIVO XL ................... 23 FORMADON ................... 72 FORMA-RAY .................. 72 FORTAMET .................... 50 FORTAZ ......................... 18 FORTESTA ..................... 61 FORTISCARE CONTROL

.................................... 51 FOSAMAX ...................... 70 FOSAMAX PLUS D ......... 70 fosamprenavir calcium .... 32 fosfomycin tromethamine 18 fosinopril sodium ............. 37 fosinopril sodium-hctz ..... 37 FOSRENOL .................... 58 FRAGMIN ....................... 20 FREESTYLE TEST ......... 51 FROVA ........................... 26 frovatriptan succinate ...... 26 FURADANTIN ................. 19 furosemide ...................... 37 FUSARIUM ..................... 72 fyavolv ............................. 63 FYCOMPA ...................... 21 G gabapentin ...................... 21 GABAPENTIN-NAPROXEN

CMPD KIT ................... 11

93

GABITRIL ........................ 21 galantamine hydrobromide

.................................... 22 galantamine hydrobromide

er ................................. 22 GARDASIL 9 ................... 69 GASTROCROM .............. 56 gatifloxacin ...................... 74 GATIFLOXACIN-

DEXAMETHASONE .... 76 gavilyte-c ......................... 56 gavilyte-g ......................... 56 gavilyte-h ......................... 56 gavilyte-n with flavor pack 56 GAVRETO ....................... 27 GEBAUERS PAIN EASE . 15 GEBAUERS SPRAY AND

STRETCH ................... 15 GELFILM ......................... 76 GELNIQUE ...................... 58 GELNIQUE PUMP........... 58 gemfibrozil ....................... 37 gemmily ........................... 64 GEN7T ............................ 15 GENERESS FE ............... 64 generlac .......................... 56 gengraf ............................ 67 GENICIN VITA-D ............. 54 gentak ............................. 74 gentamicin sulfate ..... 19, 74 GENTEEL LANCING KIT

(BLUE) ........................ 51 GENVOYA ...................... 32 GEODON ........................ 31 GERMAN COCKROACH. 72 gianvi ............................... 64 GILENYA ......................... 41 GILOTRIF ........................ 27 glatiramer acetate ............ 41 glatopa ............................ 41 GLEEVEC ....................... 27 GLEOSTINE .................... 27 glimepiride ....................... 50 glipizide er ....................... 50 glipizide ir ........................ 50 glipizide xl ........................ 50 glipizide-metformin hcl ..... 50 GLOPERBA..................... 25 GLUCAGEN DIAGNOSTIC

.................................... 72 GLUCAGEN HYPOKIT .... 52 GLUCAGON EMERGENCY

KIT ............................... 52 GLUCAGON HCL

(DIAGNOSTIC) ............ 72

GLUCOTROL .................. 50 GLUCOTROL XL............. 50 GLUMETZA ..................... 50 glyburide ......................... 50 glyburide micronized ....... 50 glyburide-metformin ......... 50 GLYCATE ....................... 56 glycopyrrolate .................. 56 GLYCOPYRROLATE ...... 56 glydo ............................... 15 GLYNASE ....................... 50 GLYRX-PF ...................... 56 GLYSET .......................... 50 GLYXAMBI ...................... 50 GOJJI CONTROL ............ 51 GOJJI LANCING

DEVICE/CLEAR CAP .. 51 GOLYTELY ..................... 57 GONITRO ....................... 37 GOPRELTO .................... 15 grafco silver nit applicator 45 GRALISE ........................ 42 granisetron hcl ................. 24 GRASTEK ....................... 72 griseofulvin microsize ...... 25 griseofulvin ultramicrosize25 guanfacine hcl ................. 37 guanfacine hcl er ............. 41 GUANIDINE HCL ............ 26 GYNAZOLE-1 ................. 25 H HACKBERRY .................. 72 hailey 1.5/30 .................... 64 hailey 24 fe ...................... 64 hailey fe 1.5/30 ................ 64 hailey fe 1/20 ................... 64 halcinonide ...................... 45 HALCION ........................ 34 HALDOL .......................... 31 HALDOL DECANOATE ... 31 halobetasol propionate ... 45,

46 HALOBETASOL

PROPIONATE ............. 45 HALOG ........................... 46 haloperidol ...................... 31 haloperidol decanoate ..... 31 haloperidol lactate ........... 31 HARVONI ........................ 32 HAVRIX ........................... 69 heather ............................ 64 HELIDAC THERAPY ....... 57 HEMADY ......................... 60 HEMANGEOL ................. 37 HEMLIBRA ...................... 35

hemmorex-hc .................. 70 HEPAGAM B ................... 67 heparin sodium (porcine) . 20 heparin sodium (porcine) pf

.................................... 20 HEPLISAV-B ................... 69 HIBERIX ......................... 69 HIDEX 6-DAY ................. 60 HIPREX .......................... 19 HIZENTRA ...................... 67 homatropaire ................... 76 homatropine hbr .............. 76 HONEY BEE VENOM ..... 72 HONEY BEE VENOM

PROTEIN .................... 72 HORIZANT ...................... 42 HORSE EPITHELIUM ..... 72 HPR ................................ 46 HPR PLUS ...................... 46 HUMALOG KWIKPEN..... 52 HUMALOG MIX 50/50

KWIKPEN ................... 52 HUMALOG MIX 50/50 VIAL

.................................... 52 HUMALOG MIX 75/25

KWIKPEN ................... 52 HUMALOG MIX 75/25 VIAL

.................................... 52 HUMALOG U-100 JUNIOR

KWIKPEN ................... 52 HUMALOG VIAL ............. 52 HUMIRA .......................... 68 HUMIRA PEDIATRIC

CROHNS START ........ 67 HUMIRA PEN ................. 67 HUMIRA PEN-CD/UC/HS

STARTER ................... 67 HUMIRA PEN-PS/UV/ADOL

HS START .................. 68 HUMIRA PEN-

PSOR/UVEIT STARTER .................................... 68

HUMULIN 70/30 KWIKPEN .................................... 52

HUMULIN 70/30 VIAL ..... 52 HUMULIN N KWIKPEN ... 52 HUMULIN N VIAL ........... 53 HUMULIN R U-500

KWIKPEN ................... 53 HUMULIN R U-500 VIAL . 53 HUMULIN R VIAL ........... 53 HYCAMTIN ..................... 27 HYCODAN ...................... 78 hydralazine hcl ................ 37 HYDREA ......................... 27

94

HYDRO 35 ...................... 46 HYDRO 40 ...................... 46 hydrochlorothiazide ......... 37 hydrocodone bitartrate er 13 hydrocodone polst-

chlorphen polst er susp 78 hydrocodone-

acetaminophen ............ 13 HYDROCODONE-

GUAIFENESIN ............ 78 hydrocodone-homatropine

.................................... 78 hydrocodone-ibuprofen .... 13 hydrocortisone ..... 46, 60, 70 hydrocortisone (perianal) . 70 hydrocortisone ace-

pramoxine .............. 46, 70 hydrocortisone acetate .... 70 hydrocortisone butyr lipo

base ............................ 46 hydrocortisone butyrate ... 46 hydrocortisone in absorbase

.................................... 46 hydrocortisone valerate ... 46 hydrocortisone-acetic acid

.................................... 77 hydromet ......................... 78 hydromorphone hcl .......... 13 hydromorphone hcl er ...... 13 hydroxychloroquine sulfate

.................................... 29 hydroxyprogesterone

caproate ...................... 64 hydroxyurea..................... 27 hydroxyzine hcl ................ 34 hydroxyzine pamoate ...... 34 HYLAGUARD .................. 46 HYLAMIX ........................ 46 HYLATOPIC PLUS .......... 46 HYLINATE ....................... 46 hyophen .......................... 58 hyoscyamine sulfate ........ 57 hyoscyamine sulfate er .... 57 hyoscyamine sulfate sl .... 57 hyosyne ........................... 57 HYPERHEP B S/D .......... 68 HYPERRAB..................... 68 HYPERRAB S/D .............. 68 HYPERSAL ..................... 78 HYPERTET S/D .............. 68 HYPOCYN ...................... 76 HYQVIA ........................... 68 HYSINGLA ER ................ 13 HYZAAR .......................... 37

I ibandronate sodium ......... 70 IBRANCE ........................ 27 IBUDONE ........................ 13 ibuprofen ......................... 11 icatibant acetate .............. 68 iclevia .............................. 64 ICLUSIG .......................... 27 icosapent ethyl ................ 37 IDHIFA ............................ 27 ILEVRO ........................... 74 ILIDERM ......................... 46 imatinib mesylate............. 27 IMBRUVICA .................... 27 imipramine hcl ................. 23 imipramine pamoate ........ 23 imiquimod ........................ 46 IMIQUIMOD PUMP ......... 46 IMITREX ......................... 26 IMITREX STATDOSE

REFILL ........................ 26 IMITREX STATDOSE

SYSTEM ..................... 26 IMOGAM RABIES-HT ..... 68 IMPEKLO ........................ 46 IMPOYZ .......................... 46 IMURAN .......................... 68 IMVEXXY MAINTENANCE

PACK .......................... 64 IMVEXXY STARTER PACK

.................................... 64 incassia ........................... 64 INCRUSE ELLIPTA ......... 80 indapamide...................... 37 INDERAL LA ................... 37 INDERAL XL ................... 37 INDOCIN ......................... 11 indomethacin ................... 11 indomethacin er ............... 11 INFANRIX ....................... 69 INFASURF ...................... 78 INLYTA ........................... 27 INNOPRAN XL ................ 37 INQOVI ........................... 28 INREBIC ......................... 28 INSPRA ........................... 37 INSULIN ASP PROT & ASP

FLEXPEN .................... 53 INSULIN ASPART ........... 53 INSULIN ASPART

FLEXPEN .................... 53 INSULIN ASPART PENFILL

.................................... 53 INSULIN ASPART PROT &

ASPART ...................... 53

INSULIN LISPRO ............ 53 INSULIN LISPRO (1 UNIT

DIAL) ........................... 53 INSULIN LISPRO JUNIOR

KWIKPEN ................... 53 INSULIN LISPRO PROT &

LISPRO ....................... 53 INSULIN PEN NEEDLES 53 INSULIN SYRINGES ...... 53 INTELENCE .................... 32 INTERMEZZO ................. 82 INTRAROSA ................... 58 INTRON A ....................... 32 introvale .......................... 64 INTUNIV ......................... 41 INVEGA .......................... 31 INVEGA SUSTENNA ...... 31 INVEGA TRINZA ............. 31 INVELTYS ....................... 74 INVIRASE ....................... 32 INVOKAMET ................... 50 INVOKAMET XR ............. 50 INVOKANA ..................... 50 iodine strong ................... 54 IONSYS .......................... 13 IOPIDINE ........................ 75 IPOL ................................ 69 ipratropium bromide .. 78, 80 ipratropium-albuterol ....... 80 irbesartan ........................ 37 irbesartan-

hydrochlorothiazide ..... 37 IRESSA ........................... 28 ISENTRESS .................... 32 ISENTRESS HD .............. 32 isibloom ........................... 64 isoniazid .......................... 26 isoproterenol hcl .............. 37 ISOPTO ATROPINE ....... 76 ISOPTO CARPINE .......... 75 ISORDIL TITRADOSE .... 37 isosorbide dinitrate .......... 37 isosorbide dinitrate er ...... 38 isosorbide mononitrate .... 38 isosorbide mononitrate er 38 isotretinoin ....................... 46 isradipine......................... 38 ISTALOL ......................... 75 ISUPREL......................... 38 itraconazole ..................... 25 ivermectin.................. 29, 46 IVERMECTIN .................. 46 J jaimiess ........................... 64 JAKAFI ............................ 28

95

JALYN ............................. 59 jantoven ........................... 20 JANUMET ....................... 50 JANUMET XR ................. 50 JANUVIA ......................... 50 JARDIANCE .................... 50 jasmiel ............................. 64 JATENZO ........................ 61 jencycla ........................... 64 JENTADUETO ................ 50 JENTADUETO XR........... 50 jinteli ................................ 64 jolessa ............................. 64 jolivette ............................ 64 JORNAY PM ................... 41 JUBLIA ............................ 25 juleber ............................. 64 JULUCA .......................... 32 JUNE GRASS POLLEN

STANDARDIZED ......... 72 junel 1.5/30 ...................... 64 junel 1/20 ......................... 64 junel fe 1.5/30 .................. 64 junel fe 1/20 ..................... 64 junel fe 24 ........................ 64 K KADIAN ........................... 13 kaitlib fe ........................... 64 KALETRA ........................ 32 kalliga .............................. 64 KAMDOY ......................... 46 KAPOK ............................ 72 KAPSPARGO SPRINKLE38 KAPVAY .......................... 41 KARBINAL ER ................. 78 kariva .............................. 64 KATERZIA ....................... 38 KAZANO ......................... 50 KEDRAB ......................... 68 k-effervescent .................. 54 KEFLEX .......................... 19 kelnor 1/35 ...................... 64 kelnor 1/50 ...................... 64 KENALOG ................. 46, 60 KEPPRA .......................... 21 KEPPRA XR .................... 21 KERALAC ....................... 46 KERALYT ........................ 46 KERYDIN ........................ 25 ketoconazole ................... 25 ketodan ........................... 25 ketoprofen ....................... 11 ketoprofen er ................... 11 ketorolac tromethamine .. 11,

74

KETOROLAC TROMETHAMINE ....... 11

KHEDEZLA ..................... 23 KINRIX ............................ 69 kionex .............................. 54 KISQALI (200 MG DOSE)28 KISQALI (400 MG DOSE)28 KISQALI (600 MG DOSE)28 KISQALI FEMARA (400 MG

DOSE) ......................... 28 KISQALI FEMARA (600 MG

DOSE) ......................... 28 KISQALI FEMARA(200 MG

DOSE) ......................... 28 KIVIK ............................... 46 KLARITY-A...................... 74 KLARITY-B...................... 74 KLARITY-L ...................... 74 KLARON ......................... 46 klofensaid ii ..................... 11 KLONOPIN...................... 34 klor-con ........................... 54 klor-con 10 ...................... 54 klor-con m10 ................... 54 KLOR-CON M15 ............. 54 klor-con m20 ................... 54 klor-con sprinkle .............. 54 klor-con/ef ....................... 54 KOMBIGLYZE XR ........... 50 K-PHOS .......................... 54 K-PHOS NO 2 ................. 55 K-PHOS-NEUTRAL ......... 55 k-prime ............................ 55 KRINTAFEL .................... 29 KRISTALOSE .................. 57 K-TAB ............................. 55 kurvelo ............................ 64 L labetalol hcl ..................... 38 LAC-HYDRIN .................. 46 LACRISERT .................... 76 lactic acid ........................ 46 lactic acid e ..................... 46 lactulose .......................... 57 lactulose encephalopathy 57 LAMICTAL....................... 21 LAMICTAL ODT .............. 21 LAMICTAL STARTER ..... 21 LAMICTAL XR ................. 21 lamivudine ....................... 32 lamivudine-zidovudine ..... 32 lamotrigine....................... 21 lamotrigine er .................. 21 lamotrigine starter kit-blue21

lamotrigine starter kit-green .................................... 21

lamotrigine starter kit-orange ......................... 21

LAMPIT ........................... 29 LANCETS ....................... 52 LANOXIN ........................ 38 LANOXIN PEDIATRIC .... 38 lansoprazole .................... 56 LANTUS SOLOSTAR...... 53 LANTUS U-100 VIAL ...... 53 lapatinib ditosylate ........... 28 larin 1.5/30 ...................... 64 larin 1/20 ......................... 64 larin 24 fe ........................ 64 larin fe 1.5/30 .................. 64 larin fe 1/20 ..................... 64 larissia ............................. 64 LASIX .............................. 38 LASTACAFT ................... 76 latanoprost ...................... 75 LATANOPROST-TIMOLOL

MALEATE ................... 75 layolis fe .......................... 64 LDO PLUS ...................... 15 LEDIPASVIR-

SOFOSBUVIR ............. 32 leena ............................... 64 leflunomide ...................... 68 LENVIMA (10 MG DAILY

DOSE) ......................... 28 LENVIMA (12 MG DAILY







DOSE) ......................... 28 LESCOL XL .................... 38 lessina ............................. 64 letrozole .......................... 28 leucovorin calcium ........... 28 LEUKERAN ..................... 28 LEUKINE......................... 35 leuprolide acetate ............ 61 levalbuterol hcl ................ 80 LEVALBUTEROL HFA .... 80 LEVAQUIN ...................... 19

96

LEVATIO ......................... 15 LEVBID ........................... 57 LEVEMIR U-100

FLEXTOUCH ............... 53 LEVEMIR U-100 VIAL ..... 53 levetiracetam ................... 21 levetiracetam er ............... 21 levobunolol hcl ................. 75 levocarnitine .................... 55 levocarnitine sf ................ 55 levocetirizine

dihydrochloride ............ 78 levofloxacin ............... 19, 74 levonest ........................... 64 levonorgest-eth est & eth

est ............................... 64 levonorgest-eth estrad 91-

day .............................. 64 levonorgestrel .................. 64 levonorgestrel-ethinyl estrad

.................................... 64 levonorg-eth estrad triphasic

.................................... 64 levora 0.15/30 (28) .......... 64 levorphanol tartrate.......... 13 levo-t ............................... 67 levothyroxine sodium ....... 67 levoxyl ............................. 67 LEVSIN ........................... 57 LEVSIN/SL ...................... 57 LEVULAN KERASTICK ... 46 LEXAPRO ....................... 23 LEXETTE ........................ 46 LEXIVA ............................ 32 LIALDA ............................ 70 LIBRAX ........................... 57 LICART ........................... 11 LIDO BDK ....................... 15 lidocaine .......................... 15 lidocaine hcl .............. 15, 42 LIDOCAINE HCL ............. 15 lidocaine hcl (pf) .............. 15 lidocaine hcl

urethral/mucosal .......... 15 lidocaine pak ................... 15 lidocaine viscous hcl ........ 42 lidocaine-epinephrine ...... 15 lidocaine-hydrocort

(perianal) ..................... 70 lidocaine-hydrocortisone

ace .............................. 70 LIDOCAINE-

HYDROCORTISONE ACE ....................... 46, 70

lidocaine-prilocaine .......... 15

LIDOCANNA ................... 15 LIDOCORT...................... 70 LIDODERM ..................... 15 LIDO-K ............................ 15 LIDOMAR ........................ 15 lidopin .............................. 16 LIDOPRIL ........................ 16 LIDOPRIL XR .................. 16 LIDO-PRILO CAINE PACK

.................................... 16 LIDORX ........................... 16 LIDO-SORB .................... 16 LIDOTHOL ...................... 16 LIDOTRAL....................... 16 LIDOZION ....................... 16 LILETTA (52 MG) ............ 64 lillow ................................ 64 LINCOCIN ....................... 19 lincomycin hcl .................. 19 lindane ............................ 29 linezolid ........................... 19 LINZESS ......................... 57 liothyronine sodium ......... 67 LIPITOR .......................... 38 LIPOFEN ......................... 38 lisinopril ........................... 38 lisinopril-hydrochlorothiazide

.................................... 38 lithium .............................. 35 lithium carbonate ............. 35 lithium carbonate er ......... 35 LITHOBID ....................... 35 LITHOSTAT .................... 58 LIVALO ........................... 38 LIVIXIL PAK .................... 16 LO LOESTRIN FE ........... 64 LOCOID .......................... 46 LOCOID LIPOCREAM .... 46 LODINE ........................... 11 LODOSYN....................... 30 LOESTRIN 1.5/30 (21) .... 64 LOESTRIN 1/20 (21) ....... 64 LOESTRIN FE 1.5/30 ...... 64 LOESTRIN FE 1/20 ......... 64 lojaimiess ........................ 64 LOMOTIL ........................ 57 LONHALA MAGNAIR

REFILL KIT ................. 80 LONHALA MAGNAIR

STARTER KIT ............. 80 LONSURF ....................... 28 loperamide hcl ................. 57 LOPID ............................. 38 lopinavir-ritonavir ............. 32 lopreeza .......................... 64

LOPRESSOR .................. 38 LOPRESSOR HCT ......... 38 LOPROX ......................... 25 lorazepam ....................... 34 lorazepam intensol .......... 34 LORBRENA .................... 28 lorcet ............................... 13 lorcet hd .......................... 13 lorcet plus........................ 13 LORTAB ......................... 13 loryna .............................. 64 LORZONE ....................... 81 losartan potassium .......... 38 losartan potassium-hctz .. 38 LOSEASONIQUE ............ 64 LOTEMAX ....................... 74 LOTEMAX SM ................ 74 LOTENSIN ...................... 38 LOTENSIN HCT .............. 38 loteprednol etabonate ..... 74 LOTREL .......................... 38 LOTRISONE ................... 25 lovastatin ......................... 38 LOVAZA .......................... 38 LOVENOX ....................... 20 low-ogestrel ..................... 64 loxapine succinate ........... 31 lo-zumandimine ............... 64 LULICONAZOLE ............. 25 LUMIGAN........................ 75 LUNESTA ....................... 82 LUPRON DEPOT (1-

MONTH) ...................... 61 LUPRON DEPOT (3-

MONTH) ...................... 61 LUPRON DEPOT (4-

MONTH) INTRAMUSCULAR KIT 30MG .......................... 62

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG .......................... 62

LUPRON DEPOT-PED (1-MONTH) ...................... 62

LUPRON DEPOT-PED (3-MONTH) ...................... 62

lutera ............................... 64 LUXIQ ............................. 46 LUZU .............................. 25 LYDEXA .......................... 16 lyllana .............................. 65 LYNPARZA ..................... 28 LYRICA ........................... 42 LYRICA CR ..................... 42

97

LYSODREN..................... 28 LYSTEDA ........................ 35 LYUMJEV ........................ 53 LYUMJEV KWIKPEN ...... 53 lyza .................................. 65 M MACROBID ..................... 19 MACRODANTIN .............. 19 mafenide acetate ............. 19 MAGNESIUM SULFATE . 55 MAKENA ......................... 65 malathion ......................... 29 maprotiline hcl ................. 23 MARINOL ........................ 24 marlissa ........................... 65 MARPLAN ....................... 23 MASK VORTEX .............. 72 MATULANE ..................... 28 matzim la ......................... 38 MAXALT .......................... 26 MAXALT-MLT .................. 26 MAXICOMFORT SYR 27G

X 1/2 ............................ 53 MAXIDEX ........................ 74 MAXIPIME ....................... 19 MAXITROL ...................... 76 MAXZIDE ........................ 38 MAXZIDE-25 ................... 38 me/naphos/mb/hyo1 ........ 58 meclizine hcl .................... 24 meclofenamate sodium ... 11 MEDI-PATCH RX ............ 16 MEDROL ......................... 60 medroxyprogesterone

acetate ........................ 65 mefenamic acid ............... 11 MEGACE ES ................... 65 megestrol acetate ............ 65 MEKINIST ....................... 28 MEKTOVI ........................ 28 MELALEUCA ................... 72 melodetta 24 fe ................ 65 meloxicam ....................... 11 melphalan ........................ 28 memantine hcl ................. 22 memantine hcl er ............. 22 MENACTRA .................... 69 MENEST ......................... 65 MENOSTAR .................... 65 MENQUADFI ................... 69 MENVEO ......................... 69 meperidine hcl ................. 13 MEPHYTON .................... 55 meprobamate .................. 34 mercaptopurine ............... 28

mesalamine ..................... 70 mesalamine er ................. 70 mesalamine-cleanser ...... 70 mesna ............................. 28 MESNEX ......................... 28 MESTINON ..................... 26 metadate er ..................... 41 metaproterenol sulfate ..... 80 metaxall ........................... 81 metaxalone...................... 81 metformin hcl er .............. 50 metformin hcl er (mod) .... 50 metformin hcl er (osm) .... 50 metformin hcl ir ................ 50 methadone hcl ................. 13 methadone hcl intensol ... 13 methadose ...................... 13 methadose sugar-free ..... 13 methamphetamine hcl ..... 41 methazolamide ................ 75 methenamine hippurate ... 19 methenamine mandelate . 19 methergine ...................... 72 methimazole .................... 67 METHITEST .................... 61 methocarbamol ............... 81 methotrexate ................... 68 methotrexate sodium ....... 68 methotrexate sodium (pf) . 68 methoxsalen rapid ........... 46 methscopolamine bromide

.................................... 57 methyclothiazide ............. 38 methyldopa...................... 38 methyldopa-

hydrochlorothiazide ..... 38 methylergonovine maleate

.................................... 72 METHYLIN ...................... 41 methylphenidate hcl ........ 41 methylphenidate hcl er .... 41 methylphenidate hcl er (cd)

.................................... 41 methylphenidate hcl er (la)

.................................... 41 methylphenidate hcl er (xr)

.................................... 41 methylprednisolone ......... 60 METHYLPREDNISOLONE

ACE-LIDO ................... 60 METHYLPREDNISOLONE

ACETATE .................... 60 methylprednisolone sodium

succ ............................. 60 methyltestosterone .......... 61

metoclopramide hcl ......... 24 metolazone ..................... 38 metopic ........................... 46 metoprolol succinate er ... 38 metoprolol tartrate ........... 38 METOPROLOL-HCTZ ER

.................................... 38 metoprolol-

hydrochlorothiazide ..... 38 METROCREAM .............. 46 METROGEL .................... 46 METROGEL-VAGINAL ... 19 METROLOTION .............. 46 metronidazole ..... 19, 46, 47 metyrosine ...................... 38 mexiletine hcl .................. 38 MIACALCIN .................... 70 mibelas 24 fe ................... 65 MICARDIS ...................... 38 MICARDIS HCT .............. 38 MICLARA LQ .................. 78 miconazole 3 ................... 25 MICONAZOLE-ZINC

OXIDE-PETROLAT ..... 25 MICORT-HC ................... 47 MICROCHAMBER .......... 72 microgestin 1.5/30 ........... 65 microgestin 1/20 .............. 65 microgestin fe 1.5/30 ....... 65 microgestin fe 1/20 .......... 65 MICROLET NEXT

LANCING DEVICE ...... 52 midazolam hcl ................. 34 midazolam hcl (pf) ........... 34 midodrine hcl ................... 38 MIFEPREX ...................... 55 mifepristone .................... 55 MIGERGOT .................... 26 miglitol ............................. 50 mili .................................. 65 MILLIPRED ..................... 60 MILLIPRED DP ............... 60 MILLIPRED DP 12-DAY .. 60 mimvey ........................... 65 mimvey lo ........................ 65 MIMYX ............................ 47 MINASTRIN 24 FE .......... 65 MINIPRESS .................... 38 minitran ........................... 38 MINIVELLE ..................... 65 MINOCIN ........................ 19 minocycline hcl ................ 19 minocycline hcl er ............ 19 MINOLIRA ....................... 19 minoxidil .......................... 38

98

MIRAPEX ........................ 30 MIRAPEX ER .................. 30 MIRCERA ........................ 35 MIRCETTE ...................... 65 MIRENA (52 MG) ............ 65 mirtazapine ...................... 23 MIRVASO ........................ 47 misoprostol ...................... 56 MITIGARE ....................... 25 MIXED ASPERGILLUS ... 72 MIXED FEATHERS ......... 72 mixed vespid venom protein

.................................... 72 MIXED VESPID VENOM

PROTEIN .................... 72 M-M-R II .......................... 69 MOBIC ............................ 11 modafinil .......................... 82 moderiba ......................... 32 MODERIBA (1200 MG

PACK) ......................... 32 moexipril hcl .................... 38 molindone hcl .................. 31 mometasone furoate .. 47, 78 mondoxyne nl .................. 19 mono-linyah ..................... 65 mononessa ...................... 65 montelukast sodium ......... 80 MONUROL ...................... 19 morgidox ......................... 19 MORPHABOND ER ........ 14 morphine sulfate .............. 14 morphine sulfate

(concentrate) ............... 14 morphine sulfate er .......... 14 morphine sulfate er beads

.................................... 14 MOTEGRITY ................... 57 MOTOFEN ...................... 57 MOVANTIK ..................... 57 MOVIPREP ..................... 57 MOXEZA ......................... 74 moxifloxacin hcl ......... 19, 74 moxifloxacin hcl (2x day) . 74 MS CONTIN .................... 14 MUCOR ........................... 72 MUCOSITISRX ............... 42 MULTAQ ......................... 38 mupirocin ......................... 19 mupirocin calcium ............ 19 MYAMBUTOL .................. 26 MYCOBUTIN ................... 26 mycophenolate mofetil ..... 68 mycophenolate sodium .... 68 MYDAYIS ........................ 41

MYFORTIC ..................... 68 MYLERAN ....................... 28 myorisan ......................... 47 MYRBETRIQ ................... 58 MYTESI ........................... 57 myzilra ............................. 65 N NABI-HB ......................... 68 nabumetone .................... 11 nadolol ............................ 38 nadolol-bendroflumethiazide

.................................... 38 nafrinse ........................... 55 nafrinse drops ................. 55 naftifine hcl ...................... 25 NAFTIN ........................... 25 NALFON ......................... 11 NALOCET ....................... 14 naloxone hcl .................... 17 NALOXONE HCL ............ 17 naltrexone hcl .................. 17 NAMENDA ...................... 22 NAMENDA TITRATION

PAK ............................. 22 NAMENDA XR ................ 22 NAMENDA XR TITRATION

PACK .......................... 22 NAMZARIC ..................... 22 NAPRELAN ..................... 11 NAPROSYN .................... 11 naproxen ......................... 11 naproxen sodium ............. 12 naproxen sodium er ......... 12 naratriptan hcl ................. 26 NARCAN ......................... 17 NARDIL ........................... 23 NASONEX....................... 78 NATACYN ....................... 74 NATAZIA ......................... 65 nateglinide ....................... 50 NATESTO ....................... 61 NATROBA ....................... 29 NATURE-THROID ........... 67 NEBUPENT ..................... 29 nebusal ........................... 78 NEBUSAL ....................... 78 necon 0.5/35 (28) ............ 65 nefazodone hcl ................ 23 NEMBUTAL ..................... 21 NEOCERA ...................... 47 neomycin sulfate ............. 19 neomycin-bacitracin zn-

polymyx ....................... 76 neomycin-polymyxin b gu 19

neomycin-polymyxin-dexameth .................... 76

neomycin-polymyxin-gramicidin .................... 76

neomycin-polymyxin-hc .. 76, 77

neo-polycin ...................... 76 neo-polycin hc ................. 76 NEORAL ......................... 68 NEOSALUS .................... 47 NEOSALUS CP............... 47 NEO-SYNALAR .............. 47 NERLYNX ....................... 28 NESINA .......................... 50 neuac .............................. 47 NEUPOGEN ................... 35 NEUPRO......................... 30 NEURONTIN ................... 21 NEUTRASAL .................. 42 NEVANAC ....................... 74 nevirapine ....................... 33 nevirapine er ................... 32 NEXAVAR ....................... 28 NEXIUM .......................... 56 NEXLETOL ..................... 38 NEXLIZET ....................... 38 niacin (antihyperlipidemic)

.................................... 38 niacin er

(antihyperlipidemic) ..... 38 niacor .............................. 38 NIASPAN ........................ 38 nicardipine hcl ................. 38 NICORETTE ................... 17 nicotine polacrilex ............ 17 nicotine step 1 ................. 17 nicotine step 2 ................. 17 nicotine step 3 ................. 17 nifedipine......................... 38 nifedipine er .................... 38 nifedipine er osmotic

release ........................ 38 nikki ................................. 65 NILANDRON ................... 28 nilutamide........................ 28 nimodipine ....................... 38 NINLARO ........................ 28 nisoldipine er ................... 38 nitazoxanide .................... 30 NITRO-BID ...................... 39 NITRO-DUR .................... 39 nitrofurantoin ................... 19 nitrofurantoin macrocrystal

.................................... 19

99

nitrofurantoin monohydrate macrocrystals .............. 19

nitroglycerin ..................... 39 nitroglycerin er ................. 39 NITROLINGUAL .............. 39 NITROMIST..................... 39 NITROSTAT .................... 39 nitro-time ......................... 39 NIVATOPIC PLUS ........... 47 nizatidine ......................... 56 NIZORAL ......................... 25 NOCDURNA.................... 62 NOCTIVA ........................ 62 nolix ................................. 47 nora-be ............................ 65 NORCO ........................... 14 norethin ace-eth estrad-fe 65 norethindrone .................. 65 norethindrone acetate ...... 65 norethindrone acet-ethinyl

est ............................... 65 norethindrone-eth estradiol

.................................... 65 norethin-eth estradiol-fe ... 65 NORGESIC FORTE ........ 81 norgestimate-eth estradiol

.................................... 65 norgestimate-ethinyl

estradiol triphasic ......... 65 NORITATE ...................... 47 norlyda ............................ 65 norlyroc ........................... 65 NORPACE ...................... 39 NORPACE CR ................ 39 NORPRAMIN .................. 23 nortrel 0.5/35 (28) ............ 65 nortrel 1/35 (21) ............... 65 nortrel 1/35 (28) ............... 65 nortrel 7/7/7 ..................... 65 nortriptyline hcl ................ 23 NORVASC ...................... 39 NORVIR .......................... 33 NOVACORT .................... 47 NOVOFINE AUTOCOVER

PEN NEEDLE .............. 53 NOVOFINE PEN NEEDLE

.................................... 53 NOVOFINE PLUS PEN

NEEDLE ...................... 53 NOVOLIN 70/30 FLEXPEN

.................................... 53 NOVOLIN 70/30 FLEXPEN

RELION ....................... 53 NOVOLIN 70/30 RELION 53 NOVOLIN 70/30 VIAL ...... 53

NOVOLIN N FLEXPEN ... 53 NOVOLIN N FLEXPEN

RELION ....................... 53 NOVOLIN N RELION ...... 53 NOVOLIN N VIAL ............ 53 NOVOLIN R FLEXPEN ... 53 NOVOLIN R FLEXPEN

RELION ....................... 53 NOVOLIN R RELION ...... 54 NOVOLIN R VIAL ............ 54 NOVOLOG FLEXPEN ..... 54 NOVOLOG MIX 70/30

FLEXPEN .................... 54 NOVOLOG MIX 70/30 VIAL

.................................... 54 NOVOLOG PENFILL ....... 54 NOVOLOG U-100 VIAL ... 54 NOVOTWIST PEN

NEEDLE ...................... 54 NOZIN NASAL SANITIZER

POPSWAB .................. 72 np thyroid ........................ 67 NUBEQA ......................... 28 NUCORT ......................... 47 NUCYNTA ....................... 14 NUCYNTA ER ................. 14 NUEDEXTA ..................... 42 nulev ............................... 57 NULYTELY LEMON-LIME

.................................... 57 NULYTELY WITH FLAVOR

PACKS ........................ 57 NUMBONEX ................... 16 NUMBRINO ..................... 16 NUMOISYN ..................... 42 NURTEC ......................... 26 NUVAKAAN .................... 16 NUVARING ..................... 65 NUVESSA ....................... 19 NUVIGIL .......................... 82 nyamyc ............................ 25 nylia 7/7/7 ........................ 65 nymyo ............................. 65 nystatin ............................ 25 nystatin-triamcinolone ..... 25 nystop ............................. 25 O ocella............................... 65 octreotide acetate ............ 62 OCUFLOX ....................... 74 ODACTRA....................... 72 ODEFSEY ....................... 33 ODOMZO ........................ 28 OFEV .............................. 80 ofloxacin .............. 19, 74, 77

ogestrel ........................... 65 okebo .............................. 19 olanzapine ....................... 31 olanzapine-fluoxetine hcl . 23 OLIVE TREE ................... 72 olmesartan medoxomil .... 39 olmesartan medoxomil-hctz

.................................... 39 olmesartan-amlodipine-hctz

.................................... 39 olopatadine hcl .......... 74, 78 OLUX .............................. 47 OLUX-E .......................... 47 OMECLAMOX-PAK ........ 57 omega-3-acid ethyl esters39 omeprazole ..................... 56 OMEPRAZOLE+SYRSPEN

D SF ALKA .................. 56 omeprazole-sodium

bicarbonate ................. 56 OMNARIS ....................... 78 OMNIPOD 5 PACK ......... 72 OMNIPOD DASH 5 PACK

PODS .......................... 72 OMNIPOD DASH SYSTEM

.................................... 52 OMNIPOD STARTER ..... 52 OMNIPRED ..................... 74 OMNITROPE .................. 62 ondansetron hcl............... 24 ONDANSETRON HCL .... 24 ondansetron odt .............. 24 ONETOUCH DELICA

LANCING DEV ............ 52 ONETOUCH DELICA PLUS

LANCING .................... 52 ONETOUCH ULTRA ....... 52 ONETOUCH VERIO KIT

W/DEVICE .................. 52 ONEXTON ...................... 47 ONGENTYS .................... 30 ONGLYZA ....................... 50 ONUREG ........................ 28 OPANA ........................... 14 opium .............................. 57 OPSUMIT........................ 81 ORACEA ......................... 47 ORACIT .......................... 55 ORALAIR ........................ 72 ORALAIR ADULT SAMPLE

KIT .............................. 72 ORALAIR ADULT

STARTER PACK ......... 72 ORALAIR CHILDRENS

SAMPLE KIT ............... 72

100

ORALAIR CHILDRENS STARTER PACK ......... 72

oralone ............................ 42 ORAPRED ODT .............. 60 ORAVIG .......................... 25 ORENCIA ........................ 68 ORENCIA CLICKJECT .... 68 ORGOVYX ...................... 28 orphenadrine citrate ......... 81 orphenadrine citrate er .... 81 orphenadrine-asa-caffeine

.................................... 81 orphenadrine-aspirin-

caffeine ........................ 81 ORPHENGESIC FORTE . 81 orsythia ............................ 65 ORTHO MICRONOR ....... 66 ORTHO TRI-CYCLEN (28)

.................................... 66 ORTHO TRI-CYCLEN LO66 ORTHO-CYCLEN (28) .... 66 ORTHO-NOVUM 1/35 (28)

.................................... 66 ORTHO-NOVUM 7/7/7 (28)

.................................... 66 oscimin ............................ 57 oscimin sr ........................ 57 oseltamivir phosphate ...... 33 OSENI ............................. 50 OSMOLEX ER ................. 30 OSMOPREP.................... 57 OSPHENA ....................... 61 OTEZLA .......................... 68 OTOVEL .......................... 77 OTREXUP ....................... 68 OVACE PLUS ................. 47 OVACE PLUS WASH ...... 47 OVACE WASH ................ 47 OVIDE ............................. 30 oxandrolone .................... 61 oxaprozin ......................... 12 OXAYDO ......................... 14 oxazepam ........................ 34 OXBRYTA ....................... 72 oxcarbazepine ................. 21 oxiconazole nitrate........... 25 OXISTAT ......................... 25 OXTELLAR XR ................ 21 oxybutynin chloride .......... 58 oxybutynin chloride er ...... 58 oxycodone hcl ................. 14 OXYCODONE HCL ER ... 14 oxycodone-acetaminophen

.................................... 14

OXYCODONE-ACETAMINOPHEN ..... 14

oxycodone-aspirin ........... 14 oxycodone-ibuprofen ....... 14 OXYCONTIN ................... 14 oxymorphone hcl ............. 14 oxymorphone hcl er ......... 14 OXYTROL ....................... 58 OZEMPIC ........................ 50 OZOBAX ......................... 81 P pacerone ......................... 39 PACERONE .................... 39 paliperidone er ................ 31 PAMELOR....................... 23 PANCREAZE .................. 58 PANDA MASK LARGE .... 72 PANDA MASK MEDIUM . 72 PANDA MASK SMALL .... 72 PANDEL .......................... 47 PANRETIN ...................... 28 pantoprazole sodium ....... 56 papaverine hcl ................. 39 PARAGARD

INTRAUTERINE COPPER ..................... 66

paregoric ......................... 57 paricalcitol ....................... 71 PARLODEL ..................... 30 PARNATE ....................... 23 paroex ............................. 42 paromomycin sulfate ....... 19 paroxetine hcl .................. 23 paroxetine hcl er .............. 23 paroxetine mesylate ........ 23 PASER ............................ 26 PATADAY ....................... 74 PATANASE ..................... 78 PATANOL ....................... 74 PAXIL .............................. 23 PAXIL CR ........................ 23 PAZEO ............................ 74 PEDIAPRED ................... 60 PEDIARIX ....................... 69 PEDIATRIC PANDA MASK

.................................... 72 PEDVAX HIB ................... 69 peg 3350/electrolytes ...... 57 peg 3350-kcl-na bicarb-nacl

.................................... 57 peg-3350/electrolytes ...... 57 peg-

3350/electrolytes/ascorbat ................................... 57

PEGANONE .................... 21

PEGASYS ....................... 33 PEGASYS PROCLICK .... 33 PEGINTRON ................... 33 peg-kcl-nacl-nasulf-na asc-c

.................................... 57 peg-prep ......................... 57 PEMAZYRE .................... 28 penicillamine ................... 58 penicillin v potassium ...... 19 PENICILLIUM NOTATUM72 PENLAC ......................... 25 PENLEN ......................... 47 PENNSAID ...................... 12 PENTACEL ..................... 69 PENTAM ......................... 30 pentamidine isethionate .. 30 PENTASA ....................... 70 pentazocine-naloxone hcl 14 pentobarbital sodium ....... 21 PENTOSAN

POLYSULFATE SODIUM .................................... 58

pentoxifylline er ............... 39 PEPCID .......................... 56 PERCOCET .................... 14 PERENNIAL RYE GRASS

POLLEN ...................... 72 PERFOROMIST .............. 80 perindopril erbumine ....... 39 periogard ......................... 42 permethrin ....................... 30 perphenazine .................. 24 perphenazine-amitriptyline

.................................... 23 PERSERIS ...................... 31 PERTZYE ....................... 58 PEXEVA ......................... 23 phenadoz ........................ 78 phenazo .......................... 58 phenazopyridine hcl ........ 58 phenelzine sulfate ........... 23 PHENERGAN ................. 78 phenobarbital .................. 21 phenobarbital sodium ...... 21 phenoxybenzamine hcl.... 39 phentolamine mesylate ... 39 phenylephrine hcl ............ 76 PHENYTEK ..................... 21 phenytoin ........................ 21 phenytoin infatabs ........... 21 phenytoin sodium ............ 21 phenytoin sodium extended

.................................... 21 PHEXXI ........................... 72 philith .............................. 66

101

PHLAG SPRAY ............... 47 PHOSLYRA ..................... 58 phospha 250 neutral ........ 55 phosphasal ...................... 58 PHOSPHOLINE IODIDE . 75 phosphorous.................... 55 phospho-trin 250 neutral .. 55 phrenilin forte ................... 14 PHYSOSTIGMINE

SALICYLATE ............... 73 phytonadione ................... 55 PICATO ........................... 47 pilocarpine hcl ........... 42, 75 pimecrolimus ................... 47 PIMECROLIMUS ............. 47 pimozide .......................... 31 pimtrea ............................ 66 pindolol ............................ 39 pioglitazone hcl ................ 50 pioglitazone hcl-glimepiride

.................................... 51 pioglitazone hcl-metformin

hcl ................................ 51 PIQRAY (200 MG DAILY

DOSE) ......................... 28 PIQRAY (250 MG DAILY

DOSE) ......................... 28 PIQRAY (300 MG DAILY

DOSE) ......................... 28 pirmella 1/35 .................... 66 pirmella 7/7/7 ................... 66 piroxicam ......................... 12 PLAN B ONE-STEP ........ 66 PLAQUENIL .................... 30 PLAVIX ............................ 31 PLENVU .......................... 57 PLEXION ......................... 47 PLEXION CLEANSER ..... 47 PLEXION CLEANSING

CLOTH ........................ 47 PNEUMOVAX 23 ............ 69 pocket spacer .................. 73 podocon .......................... 47 podofilox .......................... 47 polycin ............................. 76 polymyxin b-trimethoprim. 76 POLYTRIM ...................... 76 POMALYST ..................... 28 portia-28 .......................... 66 PORT-PREP ................... 16 potassium chloride........... 55 potassium chloride crys er

.................................... 55 potassium chloride er ...... 55 potassium citrate er ......... 55

potassium citrate-citric acid .................................... 55

POVIDONE-IODINE ........ 74 PRADAXA ....................... 20 pramipexole dihydrochloride

.................................... 30 pramipexole dihydrochloride

er ................................. 30 PRAMOSONE ................. 47 PRAMOTIC ..................... 77 pramox ............................ 47 PRANDIN ........................ 51 prasugrel hcl .................... 31 PRAVACHOL .................. 39 pravastatin sodium .......... 39 praziquantel ..................... 30 prazosin hcl ..................... 39 PRECOSE....................... 51 PRED FORTE ................. 74 PRED MILD ..................... 74 PRED-G .......................... 76 PRED-G S.O.P. ............... 76 prednicarbate .................. 47 PREDNISOL ACE-

MOXIFLOX-BROMFEN .................................... 74

prednisolone .................... 60 prednisolone acetate ....... 74 prednisolone acetate p-f .. 75 PREDNISOLONE

ACETATE-NEPAFENAC .................................... 76

PREDNISOLONE ACET-MOXIFLOXACIN ......... 77

prednisolone sodium phosphate ............. 60, 75

PREDNISOLONE-BROMFENAC ............. 77

PREDNISOLONE-GATIFLOXACIN .......... 77

PREDNISOLONE-MOXIFLOXACIN ......... 77

PREDNISOLON-GATIFLOX-BROMFENAC ............. 77

PREDNISOLON-MOXIFLOX-BROMFENAC ............. 77

PREDNISOLON-MOXIFLOX-NEPAFENAC .............. 75

prednisone ...................... 60 prednisone intensol ......... 60 PREFEST ....................... 66 pregabalin ....................... 42

PREMARIN ..................... 66 premium lidocaine ........... 16 PREMPHASE ................. 66 PREMPRO ...................... 66 PREPIDIL........................ 58 PREPOPIK ...................... 57 PRESERA ....................... 47 PRESTALIA .................... 39 PREVACID ...................... 56 PREVACID SOLUTAB .... 56 prevalite .......................... 39 preventeza ...................... 66 previfem .......................... 66 PREVNAR 13 .................. 69 PREVYMIS ..................... 33 PREZCOBIX ................... 33 PREZISTA ...................... 33 PRIFTIN .......................... 26 PRIKAAN ........................ 16 PRIKAAN LITE ................ 16 PRILOLID........................ 16 PRILOSEC ...................... 56 PRILOVIX ....................... 16 PRILOVIX LITE ............... 16 PRILOVIX LITE PLUS ..... 16 PRILOVIX PLUS ............. 16 prilovix ultralite ................ 16 prilovix ultralite plus ......... 16 PRILOXX LP ................... 16 primaquine phosphate ..... 30 primidone ........................ 21 PRIMLEV ........................ 14 PRIMSOL ........................ 19 PRINIVIL ......................... 39 PRISTIQ ......................... 23 PRO COMFORT SPACER

ADULT ........................ 73 PRO COMFORT SPACER

CHILD ......................... 73 PRO COMFORT SPACER

INFANT ....................... 73 PROAIR DIGIHALER ...... 80 PROAIR HFA .................. 80 PROAIR RESPICLICK .... 80 probenecid ...................... 25 PROBICHEW .................. 57 procainamide hcl ............. 39 PROCARDIA ................... 39 PROCARDIA XL ............. 39 PROCARE

SPACER/ADULT MASK .................................... 73

PROCARE SPACER/CHILD MASK .......................... 73

PROCENTRA ................. 41

102

prochlorperazine .............. 24 prochlorperazine edisylate

.................................... 24 prochlorperazine maleate 24 PROCORT ...................... 70 PROCRIT ........................ 35 PROCTOCORT ............... 70 PROCTOFOAM HC ......... 70 procto-med hc ................. 70 procto-pak ....................... 70 proctosol hc ..................... 70 proctozone-hc .................. 70 progesterone ................... 66 progesterone micronized . 66 PROGLYCEM ................. 52 PROGRAF ...................... 68 PROLATE ....................... 14 PROLENSA ..................... 75 promethazine hcl ............. 78 promethazine-codeine ..... 78 promethazine-dm ............ 78 promethazine-phenyleph-

codeine ........................ 78 promethazine-

phenylephrine .............. 78 promethegan ................... 78 PROMETRIUM ................ 66 propafenone hcl ............... 39 propafenone hcl er .......... 39 propantheline bromide ..... 57 proparacaine hcl .............. 77 propranolol hcl ................. 39 propranolol hcl er ............. 39 propranolol-hctz ............... 39 propylthiouracil ................ 67 PROQUAD ...................... 69 PROSCAR ...................... 59 PROSILK ......................... 47 PROSTIN E2 ................... 58 PROSTIN VR .................. 39 PROTEXA ....................... 47 PROTONIX ..................... 56 PROTOPIC ..................... 47 protriptyline hcl ................ 23 PROVENTIL HFA ............ 80 PROVERA ....................... 66 PROVIGIL ....................... 82 PROZAC ......................... 23 PRUCLAIR ...................... 47 PRUDOXIN ..................... 47 PRUMYX ......................... 47 pseudoeph-chlorphen-

hydrocod ...................... 78 pseudoephedrine-

bromphen-dm .............. 78

PSORCON ...................... 47 PULMICORT FLEXHALER

.................................... 80 PULMICORT

SUSPENSION ............. 80 pulmosal .......................... 78 PULMOZYME ................. 81 PURIXAN ........................ 28 PYLERA .......................... 57 pyrazinamide ................... 26 PYRIDIUM....................... 58 pyridostigmine bromide ... 26 pyridostigmine bromide er26 pyrimethamine ................. 30 PYROGALLIC ACID ........ 47 Q QBRELIS ........................ 39 QBREXZA ....................... 47 QINLOCK ........................ 28 QMIIZ ODT...................... 12 QNASL ............................ 78 QNASL CHILDRENS ...... 78 QTERN ........................... 51 QUADRACEL .................. 69 QUALAQUIN ................... 30 QUARTETTE .................. 66 quazepam ....................... 35 QUDEXY XR ................... 21 QUEEN PALM ................. 73 QUESTRAN .................... 39 QUESTRAN LIGHT ......... 39 quetiapine fumarate ......... 31 quetiapine fumarate er .... 31 QUILLICHEW ER ............ 41 QUILLIVANT XR ............. 41 quinapril hcl ..................... 39 quinapril-

hydrochlorothiazide ..... 39 QUINIDINE GLUCONATE

.................................... 39 quinidine gluconate er ..... 39 quinidine sulfate .............. 39 quinine sulfate ................. 30 QVAR REDIHALER ......... 80 R RABBIT EPITHELIUM ..... 73 rabeprazole sodium ......... 56 RAGWITEK ..................... 73 raloxifene hcl ................... 61 ramelteon ........................ 82 ramipril ............................ 39 RANEXA ......................... 39 ranolazine er ................... 39 RAPAFLO ....................... 59 RAPAMUNE .................... 68

rasagiline mesylate ......... 30 RASUVO ......................... 68 RAYALDEE ..................... 70 RAYOS ........................... 60 RAZADYNE .................... 22 RAZADYNE ER............... 22 REBETOL ....................... 33 REBIF ............................. 41 REBIF REBIDOSE .......... 41 REBIF REBIDOSE

TITRATION PACK ....... 41 REBIF TITRATION PACK41 reclipsen ......................... 66 RECOMBIVAX HB .......... 69 RECTIV ........................... 39 RED MAPLE ................... 73 REDITREX ...................... 68 REGLAN ......................... 24 RELADOR PAK............... 16 RELADOR PAK PLUS .... 16 RELAFEN ....................... 12 RELAFEN DS ................. 12 RELAGARD .................... 58 RELENZA DISKHALER .. 33 relexxii ............................. 41 RELISTOR ...................... 57 RELPAX .......................... 26 REMERON ...................... 23 REMERON SOLTAB ....... 23 RENACIDIN .................... 58 RENAGEL ....................... 58 RENOVO ........................ 16 RENVELA ....................... 58 repaglinide ...................... 51 repaglinide-metformin hcl 51 REPATHA ....................... 39 REPATHA PUSHTRONEX

SYSTEM ..................... 39 REPATHA SURECLICK .. 40 REQUIP .......................... 30 REQUIP XL ..................... 30 RESCRIPTOR ................ 33 RESORCINOL-SULFUR . 47 RESTASIS ...................... 77 RESTASIS MULTIDOSE . 77 RESTORIL ...................... 82 RETACRIT ...................... 35 RETEVMO ...................... 28 RETIN-A ......................... 47 RETIN-A MICRO GEL 0.04

%, 0.1 % ...................... 47 RETIN-A MICRO PUMP .. 48 RETROVIR ..................... 33 REVLIMID ....................... 28 REXAPHENAC ............... 12

103

REXULTI ......................... 31 REYATAZ ........................ 33 REYVOW ........................ 26 RHIZOPUS ...................... 73 RHOFADE ....................... 48 RHOPHYLAC .................. 68 RHOPRESSA .................. 75 ribasphere ....................... 33 RIBASPHERE ................. 33 RIBASPHERE RIBAPAK

(1000 PACK) ............... 33 RIBASPHERE RIBAPAK

(1200 PACK) ............... 33 RIBASPHERE RIBAPAK

(600 PACK) ................. 33 RIBASPHERE RIBAPAK

(800 PACK) ................. 33 ribavirin ............................ 33 RIDAURA ........................ 68 rifabutin ........................... 26 RIFADIN .......................... 27 RIFAMATE ...................... 27 rifampin ........................... 27 RIFATER ......................... 27 riluzole ............................. 42 rimantadine hcl ................ 33 RIMSO-50 ....................... 58 RIOMET .......................... 51 RIOMET ER .................... 51 risedronate sodium .......... 71 RISPERDAL .................... 31 RISPERDAL CONSTA .... 31 risperidone ...................... 31 risperidone m-tab ............ 31 RITALIN .......................... 41 RITALIN LA ..................... 41 ritonavir ........................... 33 rivastigmine ..................... 22 rivastigmine tartrate ......... 22 rivelsa .............................. 66 rizatriptan benzoate ......... 26 ROBAXIN ........................ 82 ROBAXIN-750 ................. 82 ROCALTROL .................. 71 ROCKLATAN .................. 75 ropinirole hcl .................... 30 ropinirole hcl er ................ 30 ROPIVACAINE HCL ........ 16 rosadan ........................... 48 ROSADAN ...................... 48 rosuvastatin calcium ........ 40 ROTARIX ........................ 69 ROTATEQ ....................... 69 ROWASA ........................ 70 roweepra ......................... 21

roweepra xr ..................... 21 ROXICODONE ................ 14 ROZEREM ...................... 82 ROZLYTREK ................... 28 RUBRACA....................... 28 RYBELSUS ..................... 51 RYCLORA ....................... 78 RYDAPT ......................... 28 RYNODERM ................... 48 RYTARY ......................... 30 RYTHMOL SR ................. 40 ryvent .............................. 78 S SACCHAROMYCES

CEREVISIAE ............... 73 SAFYRAL ........................ 66 SALAGEN ....................... 42 SALEX ............................ 48 salicylic acid .................... 48 salicylic acid wart remover

.................................... 48 salimez ............................ 48 SALIMEZ FORTE ............ 48 salisol forte ...................... 48 SALITECH....................... 48 salitech forte .................... 48 SALIVAMAX .................... 42 salsalate .......................... 12 SALVAX .......................... 48 SANCUSO ...................... 24 SANDIMMUNE ................ 68 SANDOSTATIN ............... 62 SANDOSTATIN LAR

DEPOT ........................ 62 SANTYL .......................... 48 SAPHRIS ........................ 31 SARAFEM ....................... 23 SAVAYSA ....................... 20 SAVELLA ........................ 42 SAVELLA TITRATION

PACK .......................... 42 scopolamine .................... 24 SEASONIQUE ................ 66 SECONAL ....................... 82 SECUADO ...................... 31 SEEBRI NEOHALER ...... 80 SEGLUROMET ............... 51 selegiline hcl .................... 30 selenium sulfide .............. 48 SELZENTRY ................... 33 SEMGLEE ....................... 54 SEMPREX-D ................... 79 SENSIPAR ...................... 71 SEREVENT DISKUS ....... 80 SERNIVO ........................ 48

SEROQUEL .................... 31 SEROQUEL XR .............. 31 sertraline hcl .................... 23 setlakin ............................ 66 sevelamer carbonate ....... 58 sevelamer hcl .................. 58 SFROWASA ................... 70 sharobel .......................... 66 SHINGRIX ....................... 69 sildenafil citrate ............... 81 SILENOR ........................ 82 silodosin .......................... 59 SILVADENE .................... 19 silver nitrate ..................... 19 silver sulfadiazine ............ 19 SIMBRINZA .................... 75 simliya ............................. 66 simpesse ......................... 66 simvastatin ...................... 40 SIMVASTATIN ................ 40 SINEMET ........................ 30 SINEMET CR .................. 30 SINGULAIR ..................... 80 sirolimus .......................... 68 SITAVIG .......................... 33 SIVEXTRO ...................... 19 SKELAXIN ...................... 82 SKLICE ........................... 30 SKYLA ............................ 66 SLYND ............................ 66 sod citrate-citric acid ....... 55 SODIUM BICARBONATE 55 sodium chloride ......... 55, 79 SODIUM CHLORIDE ...... 55 sodium chloride (pf) ......... 55 sodium fluoride ................ 55 sodium hyaluronate ......... 48 sodium polystyrene

sulfonate ..................... 55 sodium sulfacetamide ..... 48 sodium sulfacetamide wash

.................................... 48 SODIUM

SULFACETAMIDE-BAKUCHIOL ............... 48

SOFOSBUVIR-VELPATASVIR ............ 33

solifenacin succinate ....... 58 SOLIQUA ........................ 51 SOLODYN ...................... 19 SOLOSEC ....................... 19 SOLTAMOX .................... 28 SOLU-CORTEF .............. 60 SOLULINE ...................... 16 SOLU-MEDROL .............. 60

104

SOLUPICC ...................... 16 SOMA.............................. 82 SOOLANTRA .................. 48 SOOTHEE ....................... 16 SORILUX ........................ 48 sorine .............................. 40 sotalol hcl ........................ 40 sotalol hcl (af) .................. 40 SOTYLIZE ....................... 40 spinosad .......................... 30 SPINY PIGWEED ............ 73 SPIRIVA HANDIHALER .. 80 SPIRIVA RESPIMAT . 80, 81 spironolactone ................. 40 spironolactone-hctz ......... 40 SPORANOX .................... 25 SPORANOX PULSEPAK 25 sprintec 28 ....................... 66 SPRITAM ........................ 21 SPRIX ............................. 12 SPRYCEL ....................... 28 sps .................................. 55 sronyx.............................. 66 ssd .................................. 19 SSKI ................................ 79 sss 10-5 ........................... 48 STALEVO 100 ................. 30 STALEVO 125 ................. 30 STALEVO 150 ................. 30 STALEVO 200 ................. 30 STALEVO 50 ................... 30 STALEVO 75 ................... 30 STARLIX ......................... 51 stavudine ......................... 33 STEGLATRO ................... 51 STEGLUJAN ................... 51 STELARA ........................ 68 STEMPHYLIUM .............. 73 sterile water for irrigation . 55 STIMATE ......................... 62 STIOLTO RESPIMAT ...... 81 STIVARGA ...................... 28 STRATTERA ................... 41 streptomycin sulfate ......... 19 STRIANT ......................... 61 STRIBILD ........................ 33 STRIVERDI RESPIMAT .. 81 STROMECTOL ............... 30 SUBOXONE .................... 17 subvenite ......................... 21 subvenite starter kit-blue . 21 subvenite starter kit-green

.................................... 21 subvenite starter kit-orange

.................................... 21

sucralfate ........................ 56 SULAR ............................ 40 sulfacetamide sodium 48, 75 sulfacetamide sodium

(acne) .......................... 48 sulfacetamide sodium-sulfur

.................................... 48 sulfacetamide sod-sulfur

wash ............................ 48 sulfacetamide-prednisolone

.................................... 77 sulfacetamide-sulfur in urea

.................................... 48 sulfacleanse 8/4 .............. 48 sulfadiazine ..................... 19 sulfamethoxazole-

trimethoprim ................ 19 sulfamez wash ................ 48 SULFAMYLON ................ 19 sulfasalazine ................... 70 sulfatrim pediatric ............ 19 sulindac ........................... 12 SUMADAN WASH ........... 48 sumatriptan ..................... 26 sumatriptan succinate ..... 26 sumatriptan succinate refill

.................................... 26 sumatriptan-naproxen

sodium......................... 26 SUMAXIN ........................ 48 SUMAXIN WASH ............ 48 SUPRAX ................... 19, 20 SUPREP BOWEL PREP

KIT .............................. 57 SURESTEP PRO HIGH

GLUCOSE ................... 52 SURESTEP PRO LOW

GLUCOSE ................... 52 SURESTEP PRO NORMAL

GLUCOSE ................... 52 SURMONTIL ................... 23 SURVANTA ..................... 79 SUSTIVA ......................... 33 SUTAB ............................ 57 SUTENT .......................... 28 SUVICORT...................... 48 SWEET GUM .................. 73 SWEET VERNAL GRASS

POLLEN ...................... 73 syeda .............................. 66 SYLATRON ..................... 33 SYMAX DUOTAB ............ 57 symax-sl .......................... 57 symax-sr ......................... 57 SYMBICORT ................... 81

SYMBYAX ....................... 23 SYMFI ............................. 33 SYMFI LO ....................... 33 SYMJEPI......................... 81 SYMLINPEN 120 ............ 51 SYMLINPEN 60 .............. 51 SYMPROIC ..................... 57 SYMTUZA ....................... 33 synalar ............................ 48 SYNALAR ....................... 48 SYNAREL ....................... 62 SYNDROS ...................... 24 SYNERA ......................... 16 SYNERDERM ................. 49 SYNJARDY ..................... 51 SYNJARDY XR ............... 51 SYNTHROID ................... 67 T TABLOID......................... 28 TABRECTA ..................... 28 TACHOSIL ...................... 73 TACLONEX ..................... 49 tacrolimus.................. 49, 68 TAFINLAR ....................... 28 TAGRISSO ..................... 28 TALICIA .......................... 57 TALL RAGWEED ............ 73 TALZENNA ..................... 29 TAMIFLU......................... 33 tamoxifen citrate .............. 29 tamsulosin hcl ................. 59 TANDEM F ...................... 55 TAPAZOLE ..................... 67 TAPERDEX 12-DAY ....... 60 TAPERDEX 6-DAY ......... 60 TAPERDEX 7-DAY ......... 60 TARCEVA ....................... 29 TARGADOX .................... 20 TARGRETIN ................... 29 tarina 24 fe ...................... 66 tarina fe 1/20 ................... 66 tarina fe 1/20 eq .............. 66 TARKA ............................ 40 taron-crystals .................. 55 TASIGNA ........................ 29 tavaborole ....................... 25 TAYTULLA ...................... 66 tazarotene ....................... 49 tazicef ............................. 20 TAZORAC ....................... 49 taztia xt ........................... 40 TAZVERIK ...................... 29 TDVAX ............................ 69 TEGRETOL ..................... 21 TEGRETOL-XR............... 21

105

TEKTURNA ..................... 40 TEKTURNA HCT ............. 40 telmisartan ....................... 40 telmisartan-amlodipine .... 40 telmisartan-hctz ............... 40 temazepam ..................... 82 TEMIXYS ........................ 33 TEMODAR ...................... 29 TEMOVATE..................... 49 temozolomide .................. 29 tencon ............................. 14 TENIVAC ......................... 69 tenofovir disoproxil fumarate

.................................... 33 TENORETIC 100 ............. 40 TENORETIC 50 ............... 40 TENORMIN ..................... 40 terazosin hcl .................... 59 terbinafine hcl .................. 25 terbutaline sulfate ............ 81 terconazole ...................... 25 TESSALON PERLES ...... 79 TESTIM ........................... 61 TESTONE CIK ................ 61 testosterone .................... 61 testosterone cypionate .... 61 TESTOSTERONE

CYPIONATE ................ 61 TESTOSTERONE

CYPIONATE & PROP . 61 testosterone enanthate .... 61 TESTOSTERONE

ENANTHATE ............... 61 TESTOSTERONE

PROPIONATE ............. 61 TETANUS-DIPHTHERIA

TOXOIDS TD............... 69 tetcaine ............................ 77 tetracaine hcl ................... 77 tetracycline hcl ................. 20 tetravisc ........................... 77 tetravisc forte ................... 77 TETRIX ........................... 49 TEXACORT ..................... 49 THALOMID ...................... 29 THEO-24 ......................... 81 theophylline ..................... 81 theophylline er ................. 81 thioridazine hcl ................ 31 thiothixene ....................... 31 thyroid ............................. 67 tiadylt er ........................... 40 tiagabine hcl .................... 21 TIAZAC ........................... 40 TIBSOVO ........................ 29

TICALAST ....................... 79 TIGAN ............................. 24 TIKOSYN ........................ 40 tilia fe ............................... 66 timolol maleate .......... 40, 75 timolol maleate pf ............ 75 TIMOLOL-BRIMON-

DORZOL-LATANOPR . 75 TIMOLOL-BRIMONIDINE-

DORZOLAMID ............ 76 TIMOLOL-DORZOLAMID-

LATANOPROST .......... 76 TIMOPTIC ....................... 76 TIMOPTIC OCUDOSE .... 76 TIMOPTIC-XE ................. 76 tinidazole ......................... 20 TIROSINT ....................... 67 TIROSINT-SOL ............... 67 TIVICAY .......................... 33 TIVICAY PD .................... 33 TIVORBEX ...................... 12 tizanidine hcl ................... 82 TOBRADEX .................... 77 TOBRADEX ST ............... 77 tobramycin................. 75, 81 tobramycin-dexamethasone

.................................... 77 TOBREX ......................... 75 TOFRANIL ...................... 23 TOLAK ............................ 49 tolazamide ....................... 51 tolbutamide...................... 51 tolmetin sodium ............... 12 tolterodine tartrate ........... 58 tolterodine tartrate er ....... 58 TOPAMAX....................... 21 TOPAMAX SPRINKLE .... 21 TOPICORT...................... 49 TOPICORT SPRAY ......... 49 topiramate ....................... 22 topiramate er ................... 21 TOPROL XL .................... 40 toremifene citrate............. 29 torsemide ........................ 40 TOSYMRA ...................... 26 TOUJEO MAX SOLOSTAR

.................................... 54 TOUJEO SOLOSTAR ..... 54 tovet ................................ 49 TOVIAZ ........................... 58 TRACLEER ..................... 81 TRADJENTA ................... 51 tramadol hcl er ................ 14 TRAMADOL HCL ER ...... 14 tramadol hcl er (biphasic) 14

tramadol hcl ir ................. 14 tramadol-acetaminophen . 14 trandolapril ...................... 40 trandolapril-verapamil hcl er

.................................... 40 tranexamic acid ............... 35 TRANSDERM SCOP (1.5

MG) ............................. 24 TRANSDERM-SCOP (1.5

MG) ............................. 24 TRANXENE-T ................. 35 tranylcypromine sulfate ... 23 TRAVATAN Z .................. 76 travoprost (bak free) ........ 76 trazodone hcl .................. 23 TRECATOR .................... 27 TRELEGY ELLIPTA ........ 81 TREMFYA ....................... 68 TRESIBA......................... 54 TRESIBA FLEXTOUCH .. 54 tretinoin ..................... 29, 49 tretinoin microsphere ....... 49 tretinoin microsphere pump

.................................... 49 TREXALL ........................ 68 TREXIMET ...................... 26 TREZIX ........................... 14 tri femynor ....................... 66 triamcinolone acetonide . 42,

49, 60 TRIAMCINOLONE

ACETONIDE ............... 60 TRIAMCINOLONE

DIACETATE ................ 60 TRIAMCINOLONE

DIACETATE PF .......... 60 triamterene ...................... 40 triamterene-hctz .............. 40 trianex ............................. 49 triazolam ......................... 35 TRIBENZOR ................... 40 TRICHOPHYTON ........... 73 tricitrates ......................... 55 TRICOR .......................... 40 triderm ............................. 49 TRIDESILON .................. 49 tri-estarylla ...................... 66 trifluoperazine hcl ............ 31 trifluridine ........................ 75 TRIGLIDE ....................... 40 trihexyphenidyl hcl ........... 30 TRIJARDY XR ................ 51 tri-legest fe ...................... 66 TRILEPTAL ..................... 22 tri-linyah .......................... 66

106

TRILIPIX .......................... 40 tri-lo-estarylla ................... 66 tri-lo-marzia ..................... 66 tri-lo-mili ........................... 66 tri-lo-sprintec.................... 66 trilyte ............................... 57 trimethobenzamide hcl .... 24 trimethoprim .................... 20 tri-mili............................... 66 trimipramine maleate ....... 23 TRI-NORINYL (28) .......... 66 TRINTELLIX .................... 23 tri-previfem ...................... 66 tri-sprintec ....................... 66 TRIUMEQ ........................ 33 trivora (28) ....................... 66 tri-vylibra .......................... 66 tri-vylibra lo ...................... 66 TROKENDI XR ................ 22 TROPICAMIDE-

CYCLOPENTOLATE-PE .................................... 77

TROPICAMIDE-PHENYLEPHRINE ...... 77

TROPIC-PROPARACA-PE-KETOROLAC .............. 77

trospium chloride ............. 58 trospium chloride er ......... 58 TRUE METRIX LEVEL 1 . 52 TRUE METRIX LEVEL 2 . 52 TRUE METRIX LEVEL 3 . 52 TRULANCE ..................... 57 TRULICITY ...................... 51 TRUMENBA .................... 69 TRUSOPT ....................... 76 TRUVADA ....................... 33 TUDORZA PRESSAIR .... 81 TUKYSA .......................... 29 tulana .............................. 66 TURALIO ......................... 29 TUSSICAPS .................... 79 TUSSIONEX

PENNKINETIC ER ...... 79 TUXARIN ER ................... 79 TUZISTRA XR ................. 79 TWINRIX ......................... 69 TWIRLA ........................... 67 TWYNSTA ....................... 40 tyblume ............................ 67 TYBOST .......................... 33 tydemy ............................. 67 TYKERB .......................... 29 TYLENOL WITH CODEINE

#3 ................................ 14

TYLENOL WITH CODEINE #4 ................................ 14

TYVASO ......................... 81 TYVASO REFILL............. 81 TYVASO STARTER ........ 81 U UBRELVY ....................... 26 UCERIS .......................... 70 ULESFIA ......................... 30 ULORIC .......................... 25 ULTRACET ..................... 14 ULTRAM ......................... 14 ULTRAVATE ................... 49 UMECTA MOUSSE ......... 49 UNISTRIP CONTROL ..... 52 unithroid .......................... 67 UPNEEQ ......................... 75 UPTRAVI ........................ 81 URALISS ......................... 49 URAMAXIN ..................... 49 urea ................................. 49 UREA .............................. 49 urea hydrating ................. 49 urea nail .......................... 49 URECHOLINE ................. 59 uredeb ............................. 49 ure-k ................................ 49 urelle ............................... 59 uremez-40 ....................... 49 URESOL ......................... 49 uretron d/s ....................... 59 uribel ............................... 59 URIMAR-T....................... 59 urin ds ............................. 59 URO-458 ......................... 59 UROCIT-K 10 .................. 55 UROCIT-K 15 .................. 55 UROCIT-K 5 .................... 55 UROGESIC-BLUE ........... 59 uro-mp ............................. 59 UROXATRAL .................. 59 URSO 250 ....................... 58 URSO FORTE ................. 58 ursodiol ........................... 58 URYL .............................. 59 ustell................................ 59 UTIBRON NEOHALER.... 81 uticap .............................. 59 utira-c .............................. 59 UTOPIC .......................... 49 utrona-c ........................... 59 V VAGIFEM ........................ 67 valacyclovir hcl ................ 33 valganciclovir hcl ............. 34

VALIUM .......................... 35 valproic acid .................... 22 valsartan ......................... 40 valsartan-

hydrochlorothiazide ..... 40 VALTOCO 10 MG DOSE 22 VALTOCO 15 MG DOSE 22 VALTOCO 20 MG DOSE 22 VALTOCO 5 MG DOSE .. 22 VALTREX........................ 34 VANADOM ...................... 82 VANATOL LQ ................. 14 VANATOL S .................... 14 vancomycin hcl ............... 20 vandazole........................ 20 VANOS ........................... 49 VANOXIDE-HC ............... 49 VAQTA ............................ 69 VARIVAX ........................ 69 VARIZIG ......................... 68 VARUBI (180 MG DOSE) 24 VASCEPA ....................... 40 VASERETIC .................... 40 VASOTEC ....................... 40 VAXELIS ......................... 69 VECTICAL ...................... 49 velivet .............................. 67 VELTASSA ..................... 55 VELTIN ........................... 49 VENCLEXTA ................... 29 VENCLEXTA STARTING

PACK .......................... 29 venlafaxine hcl ................ 23 venlafaxine hcl er ............ 23 VENOMIL HONEY BEE

VENOM ....................... 73 VENOMIL MIXED VESPID

VENOM ....................... 73 VENOMIL WASP VENOM

.................................... 73 VENOMIL WHITE FACED

HORNET ..................... 73 VENOMIL YELLOW

HORNET VENOM ....... 73 VENOMIL YELLOW

JACKET VENOM ........ 73 VENTAVIS ...................... 81 VENTOLIN HFA .............. 81 verapamil hcl ................... 40 verapamil hcl er ............... 40 VERDESO ...................... 49 VEREGEN ...................... 49 VERELAN ....................... 40 VERELAN PM ................. 40 VERIPRED 20 ................. 61

107

VERSACLOZ ................... 31 VERZENIO ...................... 29 VESICARE ...................... 59 VEXATROL ..................... 16 V-GO 20 .......................... 52 V-GO 30 .......................... 52 V-GO 40 .......................... 52 VIBERZI .......................... 58 VIBRAMYCIN .................. 20 VICTOZA ......................... 51 VIDEX ............................. 34 VIDEX EC ....................... 34 vienva .............................. 67 VIGAMOX ....................... 75 VIIBRYD .......................... 23 VIIBRYD STARTER PACK

.................................... 23 vilamit mb ........................ 59 VILEVEV MB ................... 59 VIMPAT ........................... 22 VIOKACE ........................ 58 viorele.............................. 67 VIRACEPT ...................... 34 VIRAMUNE ..................... 34 VIRAMUNE XR ............... 34 VIRASAL ......................... 49 VIRAZOLE ...................... 34 VIREAD ........................... 34 VIROPTIC ....................... 75 virt-phos 250 neutral ........ 55 VISTARIL ........................ 35 vitamin d (ergocalciferol) . 55 vitamin k1 ........................ 55 VITRAKVI ........................ 29 VIVAGUARD INO

CONTROL SOLUTION 52 VIVAGUARD LANCING

DEVICE ....................... 52 VIVELLE-DOT ................. 67 VIVITROL ........................ 17 VIVLODEX ...................... 12 VIZIMPRO ....................... 29 VOGELXO ....................... 61 VOGELXO PUMP ........... 61 volnea.............................. 67 VOLTAREN ..................... 12 voriconazole .................... 25 VOSEVI ........................... 34 VOTRIENT ...................... 29 VTOL LQ ......................... 15 VUSION .......................... 25 vyfemla ............................ 67 vylibra .............................. 67 VYTORIN ........................ 40 VYVANSE ....................... 41

VYZULTA ........................ 76 W warfarin sodium ............... 20 WASP VENOM PROTEIN

.................................... 73 water for irrigation, sterile 55 WELCHOL ...................... 40 WELLBUTRIN SR ........... 23 WELLBUTRIN XL ............ 23 wera ................................ 67 WESTERN JUNIPER ...... 73 WESTHROID .................. 67 WHITE BIRCH ................ 73 WHITE FACED HORNET

VENOM ....................... 73 WHITE MULBERRY ........ 73 WHITE-FACED HORNET

VENOM ....................... 73 WIDE-SEAL DIAPHRAGM

60 ................................ 73 WIDE-SEAL DIAPHRAGM







95 ................................ 73 WINLEVI ......................... 49 wixela inhub .................... 81 WP THYROID ................. 67 wymzya fe ....................... 67 X XADAGO ......................... 30 XALATAN ........................ 76 XALIX .............................. 49 XALKORI ........................ 29 XANAX ............................ 35 XANAX XR ...................... 35 XARELTO ....................... 20 XARELTO STARTER PACK

.................................... 20 XATMEP ......................... 68 XELJANZ ........................ 68 XELJANZ XR .................. 68 XELODA ......................... 29 XELPROS ....................... 76 XENLETA ........................ 20 XEPI ................................ 20

XERALUX ....................... 49 XERESE ......................... 34 XEROSTOMIA RELIEF

SPRAY ........................ 42 XHANCE ......................... 79 XIGDUO XR .................... 51 XIIDRA ............................ 77 XIMINO ........................... 20 XOFLUZA (40 MG DOSE)

.................................... 34 XOFLUZA (80 MG DOSE)

.................................... 34 XOLEGEL ....................... 25 XOPENEX

CONCENTRATE ......... 81 XOPENEX HFA............... 81 XOPENEX NEB .............. 81 XOSPATA ....................... 29 XPOVIO (100 MG ONCE

WEEKLY) .................... 29 XPOVIO (40 MG ONCE

WEEKLY) .................... 29 XPOVIO (40 MG TWICE





WEEKLY) .................... 29 XTANDI ........................... 29 xulane ............................. 67 XULTOPHY ..................... 51 xurea ............................... 49 XYLOCAINE ................... 16 XYLOCAINE/EPINEPHRIN

E ................................. 16 XYLOCAINE-MPF ........... 16 XYOSTED ....................... 61 Y YASMIN 28 ..................... 67 YAZ ................................. 67 YELLOW HORNET VENOM

PROTEIN .................... 73 YELLOW JACKET VENOM

PROTEIN .................... 73 YONSA ........................... 29 YOSPRALA ..................... 31 YUPELRI......................... 81 yuvafem .......................... 67 Z zaclir cleansing ............... 49 zafirlukast ........................ 81

108

zaleplon ........................... 82 ZANAFLEX ...................... 82 zarah ............................... 67 ZARONTIN ...................... 22 ZARXIO ........................... 35 ZCORT 7-DAY ................ 61 ZEBUTAL ........................ 15 ZEGERID ........................ 56 ZEJULA ........................... 29 ZELBORAF ..................... 29 ZELNORM ....................... 58 ZEMBRACE SYMTOUCH

.................................... 26 ZEMPLAR ....................... 71 zenatane ......................... 49 ZENPEP .......................... 58 zenzedi ............................ 41 ZENZEDI ......................... 41 ZERUVIA ......................... 16 ZERVIATE ....................... 75 ZESTORETIC .................. 40 ZESTRIL ......................... 40 ZETIA .............................. 40 ZETONNA ....................... 79 ZIAC ................................ 40 ZIAGEN ........................... 34

ZIANA ............................. 49 zidovudine ....................... 34 ZIONODIL ....................... 16 ZIONODIL 100 ................ 16 ZIOPTAN ........................ 76 ziprasidone hcl ................ 31 ziprasidone mesylate ....... 31 ZIPSOR ........................... 12 ZIRGAN .......................... 75 ZITHRANOL .................... 49 ZITHROMAX ................... 20 ZITHROMAX TRI-PAK .... 20 ZITHROMAX Z-PAK ........ 20 ZOCOR ........................... 40 ZOFRAN ......................... 24 ZOHYDRO ER ................ 15 ZOLINZA ......................... 29 zolmitriptan ...................... 26 ZOLOFT .......................... 23 zolpidem tartrate ............. 82 zolpidem tartrate er ......... 82 ZOLPIMIST ..................... 82 ZOMIG ............................ 26 ZOMIG ZMT .................... 26 ZONALON ....................... 49 ZONEGRAN .................... 22

zonisamide ...................... 22 ZONTIVITY ..................... 31 ZORVOLEX .................... 12 ZOSTAVAX ..................... 69 zovia 1/35 (28) ................ 67 zovia 1/35e (28) .............. 67 ZOVIRAX ........................ 34 ZTLIDO ........................... 16 ZUBSOLV ....................... 17 zumandimine ................... 67 ZUPLENZ........................ 24 ZURAMPIC ..................... 26 ZYBAN ............................ 17 ZYCLARA ....................... 49 ZYCLARA PUMP ............ 50 ZYDELIG......................... 29 ZYKADIA......................... 29 ZYLET ............................. 77 ZYLOPRIM ...................... 26 ZYMAXID ........................ 75 ZYPITAMAG ................... 40 ZYPREXA ....................... 31 ZYPREXA RELPREVV ... 32 ZYPREXA ZYDIS ............ 32 ZYTIGA ........................... 29

Appendix A: OVER-THE-COUNTER (OTC) MEDICATION

BENEFIT LIST The medications listed below are covered only for members who have

purchased a special benefit offered through Kaiser Permanente Washington called the Over-the-Counter Pharmacy Benefit.

***Typically, if a generic product is available for a drug, the Brand Name product may not be covered.***

Generic Product Name ***Brand Name*** Forms ALLERGY COUGH AND COLD

Antihistamines CHLORPHENIRAMINE CHLOR-TRIMETON® Tab, Liquid CLEMASTINE TAVIST® Tab, Liquid DIPHENHYDRAMINE BENADRYL® Cap, Liquid LORATADINE CLARITIN® Tab, Liquid

Decongestants OXYMETAZOLINE NASAL SPRAY AFRIN® Spray PHENYLEPHRINE NASAL SPRAY NEO-SYNEPHRINE® Spray PSEUDOEPHEDRINE SUDAFED® Tablet

Antihistamine/Decongestant Combinations TRIPROLIDINE/PSEUDOEPHEDRINE ACTIFED® Tablet BROMPHENIRAMINE/PSEUDOEPHEDRINE DIMETAPP® Liquid

Expectorants/Cough Agents GUAIFENESIN ROBITUSSIN® Liquid GUAIFENESIN/DEXTROMETHORPHAN ROBITUSSIN-DM® Liquid DEXTROMETHORPHAN ROBITUSSIN COUGH® Liquid DEXTROMETHORPHAN EXTEND RELEASE DELSYM® Liquid

AUTONOMICS AND CNS Analgesics, Miscellaneous

ACETAMINOPHEN TYLENOL® Tab, Chew, Supp, Liquid

Non-Steroidal Anti-Inflammatories IBUPROFEN MOTRIN®, ADVIL® Tab, Liquid

Salicylates ASPIRIN BAYER®, ASCRIPTIN® Tab, Supp

DERMATOLOGICAL/ TOPICAL AGENTS Acne/Psoriasis, Topical

BENZOYL PEROXIDE 5%, 10% BENZAC® Gel, Wash, Lotion COAL TAR Solution

Anesthetic Agents, Topical BENZOCAINE HURRICAINE® Gel PRAMOXINE ANUSOL® Ointment

Antifungals, Topical

CLOTRIMAZOLE 1% LOTRIMIN® Cream, Solution MICONAZOLE 2% MICATIN®, DESENEX® Cream, Powder

Anti-Infectives, Topical BACITRACIN BACIGUENT® Ointment BACITRACIN, POLYMIXIN B POLYSPORIN® Ointment BACITRACIN, NEOMYCIN, POLYMYXIN B NEOSPORIN® Ointment OATMEAL, COLLOIDAL AVEENO® BATH POWDER Powder

Anti-Itch, Topical CALAMINE CALAMINE Lotion CAMPHOR/ MENTHOL SARNA® Lotion CAPSAICIN ZOSTRIX®, ZOSTRIX-HP® Cream

Anti-Virals, Topical DOCOSANOL 10% ABREVA® Cream

Corticosteroids, Topical, Low Potency HYDROCORTISONE 0.5%, 1% CORTIZONE® Cream, Oint,

Lotion Keratolytics

SALICYLIC ACID 17% DUOFILM® Liquid SALICYLIC ACID 40% MEDIPLAST® Plaster UREA 10%, 20% UREACIN®, CARMOL® 20 Cream, Lotion

Dermatologics, Miscellaneous ALUMINUM ACETATE BUROWS® Liquid AMMONIUM LACTATE 12% AMLACTIN® Cream, Lotion HYDROGEN PEROXIDE HYDROGEN PEROXIDE Liquid VITAMIN A&D A AND D® OINTMENT Ointment WITCH HAZEL TUCKS® Solution, Pads ZINC OXIDE, COD LIVER OIL & LANOLIN DESITIN® Oint, Paste ZINC OXIDE 20% BALMEX® Ointment

Scabicides PERMETHRIN NIX® Rinse PYRETHRINS, PIPERONYL BUTOXIDE RID®, R & C® Shampoo

Skin Protectants LANOLIN, HYDROUS LANOLIN Ointment PETROLATUM, GLYCERIN,BENZYL ALC MOISTUREL® Lotion PETROLATUM, MINERAL OIL/WAX, ETC. AQUAPHOR®, EUCERIN® Ointment

EYE, EAR, NOSE AND THROAT Otics

CARBAMIDE DEBROX® Solution

Nasal Agents CROMOLYN NASALCROM® Spray

Ophthalmics ARTIFICIAL TEARS HYOPTEARS®, PURALUBE® Drops, Ointment CARBOXYMETHYLCELLULOSE CELLUVISC®, REFRESH PLUS® Drops HYDROXYPROPYL METHYLCELLULOSE TEARS NATURALE II® Drops KETOTIFEN FUMARATE 0.025% ZADITOR® Drops NAPHAZOLINE/ PHENIRAMINE OPCON-A® Drops POLYVINYL ALCOHOL, POVIDONE REFRESH® PF Drops SODIUM CHLORIDE 5% MURO®-128 Drops, Ointment

Throat and Mouth Agents

CETYLPYRIDINIUM CL, BENZYL ALCOHOL CEPACOL® Lozenge

GASTROINTESTINAL AGENTS Antacids/Adsorbents

CHARCOAL, ACTIVATED W/O SORBITOL ACTIDOSE Liquid

ALUMINUM/ MAGNESIUM MAALOX® Tablet, Liquid

ALUMINUM/ MAGNESIUM/ SIMETHICONE MINTOX® PLUS, MI-ACID Tablet, Liquid

ALUM/ MAGN/TRISILIS/ALG AC/SOD BICAR GAVISCON®, GENATON Tablet

ALUMINUM HYDROXIDE ALTERNAGEL®, AMPHOGEL® Liquid

MAGNESIUM OXIDE MAG-OX® Tablet

Antidiarrheals BISMUTH SUBSALICYLATE PEPTO BISMOL® Tablet, Liquid LOPERAMIDE IMMODIUM® Tablet, Liquid

Antinauseants DIMENHYDRINATE DRAMAMINE® Tablet, Liquid MECLIZINE BONINE®, ANTIVERT® Tablet

Laxatives/Cathartics BISACODYL DULCOLAX® Tablet, Supp DOCUSATE SODIUM COLACE® Tablet, Liquid GLYCERIN GLYCERIN Liquid, Supp MAGNESIUM CITRATE CITRO-MAG® Liquid MILK OF MAGNESIA MILK OF MAGNESIA Liquid MINERAL OIL FLEET® MINERAL OIL Liquid PSYLLIUM METAMUCIL® Powder POLYETHYLENE GLYCOL MIRALAX® Powder SENNA SENOKOT® Tablet, Liquid

Histamine H2 Blockers RANITIDINE ZANTAC® Tablet

Gastrointestinal, Miscellaneous SIMETHICONE MYLICON® Tablet LACTOBACILLUS BACID® Capsule SHARK LIVER OIL, COCOA BUTTER, PHENYLEPHRINE

HEMORRHOIDAL SUPPOSITORIES

Supp

Proton Pump Inhibitors OMEPRAZOLE PRILOSEC OTC Tablet

GENITOURINARY Overactive bladder treatment

OXYBUTYNIN OXYTROL® PATCH Patch

HORMONES Contraceptive

LEVONORGESTROL PLAN B ONE STEP Tablet

LIPID LOWERING AGENTS Non-Prescription Agents

NIACIN NIACIN Tablet NIACIN EXTENDED-RELEASE SLO-NIACIN® Tablet FISH OILS SEA-OMEGA®-50 Capsule

NUTRITIONALS AND SUPPLEMENTS Vitamins/Dietary Supplements

ACETYLCYSTEINE NAC® Capsule

ASCORBIC ACID (VIT C) Tablet CYANOCOBALAMIN (VIT B12) Tablet CHOLECALCIFEROL (VIT D) Tablet FOLIC ACID Tablet NIACINAMIDE (VIT B3) Tablet PRENATAL VITAMINS W/ FOLIC ACID Tablet PYRIDOXINE (VIT B6) Tablet THIAMINE (VIT B1) Tablet VITAMIN A Capsule VITAMIN B COMPLEX Tablet VITAMIN B COMPLEX W/C Tablet VITAMIN E Capsule

Electrolytes, Iron, & Minerals CALCIUM CARBONATE TUMS® Chew tabs, Liquid CALCIUM CITRATE CAL-CITRATE® Tablet CALCIUM CITRATE w/VITAMIN D CITRACAL® Tablet ELECTROLYTE ORAL PEDIALYTE® Liquid FERROUS GLUCONATE FERGON® Tablet FERROUS SULFATE FER-IN-SOL® Tablet, Liquid MAGNESIUM OXIDE URO-MAG® Capsule SODIUM BICARBONATE Tablet ZINC SULFATE ZINCATE® Capsule

VAGINAL PREPARATIONS Vaginal Anti-Infectives

POVIDONE-IODINE BETADINE® Douche

Vaginal Antifungals CLOTRIMAZOLE MYCELEX®-7, GYNE-LOTRIMIN®-

3 Cream, Vag tabs

MICONAZOLE MONISTAT® Cream

Miscellaneous LUBRICATING JELLY K-Y JELLY® JELLY

Kaiser Permanente Nondiscrimination Notice and Language Access Services

KAISER PERMANENTE NONDISCRIMINATION NOTICE

Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (“Kaiser Permanente”) comply with applicable federal civil rights laws and do not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or any other basis protected by applicable federal, state, or local law. We also:

Provide free aids and services to people with disabilities to help ensure effective communication, such as:

• Qualified sign language interpreters• Written information in other formats (large print, audio, and accessible electronic formats)• Assistive devices (magnifiers, Pocket Talkers, and other aids)

Provide free language services to people whose primary language is not English, such as:

• Qualified interpreters• Information written in other languages

If you need these services, contact Kaiser Permanente.

If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance. Please call us if you need help submitting a grievance. The Civil Rights Coordinator will be notified of all grievances related to discrimination.

Kaiser Permanente Phone: 206-630-4636 Toll-free: 1-888-901-4636

TTY Washington Relay Service: 1-800-833-6388 or 711 TTY Idaho Relay Service: 1-800-377-3529 or 711

Electronically: kp.org/wa/feedback

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F HHH Building Washington, DC 20201 1-800-368-1019, 800-537-7697 (TDD)

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

For Medicare Advantage Plans Only: Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.

© 2018 Kaiser Foundation Health Plan of Washington H5050_XB0001444_56_18 accepted2018-XB-7_ACA_Notice_Taglines

http://www.hhs.gov/ocr/office/file/index.html

LANGUAGE ACCESS SERVICES

English: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-888-901-4636 (TTY: 1-800-833-6388 or 711).

Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

中文 (Chinese)：注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-901-4636 (TTY: 1-800-833-6388 / 711)。

Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

한국어(Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-901-4636 (TTY: 1-800-833-6388 / 711) 번으로 전화해 주십시오.

Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).

Filipino (Tagalog): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).

ភាសាខ្មែរ (Khmer)៖ របយ័ត៖ េ េបើសិនអកនិខ្យមរ, េ សជំនួខ្យផក េ យមិនគិតល គឺចនសំប់បំេ រអក។ ចូរទូ រស័ព 1-888-901-4636 (TTY: 1-800-833-6388 / 711)។日本語 (Japanese): 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-888-901-4636 (TTY: 1-800-833-6388 / 711) まで、お電話にてご連絡ください。

አማርኛ (Amharic) ፥ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-901-4636 (መስማት ለተሳናቸው: 1-800-833-6388 / 711).

Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

ਪੰਜਾਬੀ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿ ੇਹੋ, ਤਾਂ ਭਾਸਾ ਧ ਿੱ ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ।1-888-901-4636 (TTY: 1-800-833-6388 / 711) ‘ਤੇ ਕਾਲ ਕਰੋ।

تتوافر اللغوية المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا :ملحوظة في ومعلومات مساعدة على الحصول حق لديكم :(Arabic) العربية: (6388-833-800-1 / 711) .والبكم الصم هاتف رقم 4636-901-888-1 برقم اتصل .بالمجان لك

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

ພາສາລາວ (Lao): ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ,ແມ່ນມີ ພ້ອມ ໃຫ້ທ່ານ. ໂທຣ 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Srpsko-hrvatski (Serbo-Croatian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-888-901-4636 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-833-6388 / 711).

Français (French): ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-888-901-4636 (ATS: 1-800-833-6388 / 711).

Română (Romanian): ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Adamawa (Fulfulde): MAANDO: To a waawi Adamawa, e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

می فراهم شما برای رايگان بصورت زبانی تسهيالت کنيد، می گفتگو فارسی زبان به اگر :توجه :(Farsi) فارسی.بگيريد تماس (TTY: 1-800-833-6388 / 711) 4636-901-888-1 با .باشد

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Documents

2020 Drug Formulary | Kaiser Permanente Washington...Cardiovascular Agents - Drugs for Heart and Circulation Conditions..... 31 Central Nervous System Agents - Drugs for Attention