6& - uaex.edu · MCG) (TABLET) 3 INOTROPIC DRUGS dobutamine hcl 1 dobutamine hcl in dextrose 5 % 1 milrinone lactate 1 CARDIOVASCULAR DISEASE - HYPERTENSION ACE INHIBITOR/CALCIUM

This document is the University of Arkansas System Formulary, a list of generic and brand name drugs covered by The Plan under your prescription drug benefit. Drugs on the formulary are chosen for their safety, effectiveness and value. This list is not all-inclusive and is not a guarantee of coverage. The formulary may change at any time. Plan Benefit design is the final determinate of coverage. If you have questions, please contact a MedImpact Healthcare customer service representative at 800-788-2949. How to Use the FormularyThe formulary is a list of preferred drugs available under the pharmacy plan benefit. All drugs on the formulary are listed by their generic names and most common brand name. The formulary may be accessed by using the index, either by generic or brand name (in capital letters) and by therapeutic drug category. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. Certain drugs may be subject to Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), or Reference Based Pricing (RBP) requirements according to Benefit Design. Unless noted, multisource brand drugs (brand drugs with generic equivalent) are covered at 100% copay. There are a number of drugs listed in the formulary that may require prior authorization to ensure appropriate use. For drugs that require Prior Authorization for coverage, providers must submit a request to MedImpact. Certain preventive care drug catagories have products that are covered with $0 member cost share. Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. Specific prescription benefit plan design may not cover certain catagories or certain dosages of drugs, regardless of their appearance in this document. Log in to www.medimpact.com to check coverage and cost share information for a specific medicine.

If you have questions about these requirements or other formulary questions, please contact MedImpact at 800-788- 2949. Symbol Guideline Description

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

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

PA Prior Authorization

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

QL Quantity Limit

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

RBP Reference Based Pricing

Plan will pay an amount per pill; remaining cost will be applied to member share

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

Pharmacy Benefit DesignThe formulary is a three tier benefit design. Tiers are the different cost levels you pay for a drug. Copayment, copay or coinsurance means the amount a plan participant is required to pay for a prescription in accordance with The Plan, which may be a deductible, a coinsurance, a fixed amount or other charge, with the balance, if any, paid by the Plan.

Prescription Drugs

Classic Plan Health Savings Plan

Premier Plan

Tier 1 $15 copay 10% after deductible is met

$10 copay


$50 copay


$80 copay

University of Arkansas Health Plan Page 1 of 57

University of ArkansasJanuary 2018

Drug Name Tier Requirements/Limits

ALLERGY2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS

DESLORATADINE/PSEUDOEPHEDRINE CLARINEX-D 12HOUR 3

fexofenadine/pseudoephedrine (180-240mg) (tab er24h) 1

PSEUDOEPHEDRINE HCL/ACRIVAS SEMPREX-D 2ALLERGENIC EXTRACTS, THERAPEUTICS

GR POL-ORC/SW VER/RYE/KENT/TIM ORALAIR (100-300IR) (TAB SUBL) 3

ANTIHISTAMINES - 1ST GENERATIONclemastine fumarate (2.68 mg) (tablet) 1cyproheptadine hcl 1hydroxyzine hcl 1hydroxyzine pamoate 1promethazine hcl 1

ANTIHISTAMINES - 2ND GENERATION

DESLORATADINE CLARINEX (2.5MG/5ML) (SYRUP) 3

desloratadine 1levocetirizine dihydrochloride (2.5 mg/5ml) (solution) 1

NASAL ANTIHISTAMINEazelastine hcl 1olopatadine hcl 1

NASAL ANTIHISTAMINE & ANTI-INFLAM. STEROID COMB.AZELASTINE/FLUTICASONE DYMISTA 3 RBP

NASAL ANTI-INFLAMMATORY STEROIDSBECLOMETHASONE DIPROPIONATE BECONASE AQ 3 RBPCICLESONIDE OMNARIS 3 RBPCICLESONIDE ZETONNA 3 RBPflunisolide 1 RBPfluticasone propionate (50 mcg) (spray susp) 1 RBPmometasone furoate 1 RBP

ANTIEMESIS/ANTIVERTIGOANTIEMETIC/ANTIVERTIGO AGENTS

aprepitant (125 mg) (capsule) 1 QL: 1 IN 21 DAYSdimenhydrinate (50 mg/ml) (vial) 1DOLASETRON MESYLATE ANZEMET 3 QL: 1 IN 1 DAYdronabinol 1 QL: 2 IN 1 DAYFOSAPREPITANT DIMEGLUMINE EMEND 3GRANISETRON SANCUSO 3 QL: 2 IN 1 DAYgranisetron hcl (1 mg/ml(1)) (vial) 1granisetron hcl (1 mg/ml) (vial) 1granisetron hcl/pf 1NABILONE CESAMET 3 PAondansetron 1 QL: 21 IN 5 DAYSondansetron hcl (2 mg/ml) (vial) 1PALONOSETRON HCL ALOXI 2prochlorperazine 1promethazine hcl 1scopolamine 1

TRIMETHOBENZAMIDE HCL TIGAN (100 MG/ML)(VIAL) 3

trimethobenzamide hcl 1 QL: 7 IN 10 DAYS

University of Arkansas Prescription Drug Formulary

Page 2 of 57University of Arkansas Health Plan Effective: January 1, 2018


ASTHMA AND COPDANTICHOLINERGIC, ORALLY INHALED SHORT ACTING

IPRATROPIUM BROMIDE ATROVENT HFA 2ipratropium bromide 1

ANTICHOLINERGICS, ORALLY INHALED LONG ACTING

ACLIDINIUM BROMIDE TUDORZAPRESSAIR 3

TIOTROPIUM BROMIDE SPIRIVA 2TIOTROPIUM BROMIDE SPIRIVA RESPIMAT 2UMECLIDINIUM BROMIDE INCRUSE ELLIPTA 3

BETA-ADRENERGIC AGENTSalbuterol sulfate 1metaproterenol sulfate 1terbutaline sulfate 1

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

BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTING

OLODATEROL HCL STRIVERDIRESPIMAT 3

BETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTINGARFORMOTEROL TARTRATE BROVANA 3FORMOTEROL FUMARATE PERFOROMIST 3SALMETEROL XINAFOATE SEREVENT DISKUS 2

BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS

IPRATROPIUM/ALBUTEROL SULFATE COMBIVENTRESPIMAT 2

ipratropium/albuterol sulfate 1UMECLIDINIUM BRM/VILANTEROL TR ANORO ELLIPTA 2

BETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONSBUDESONIDE/FORMOTEROL FUMARATE SYMBICORT 3FLUTICASONE/SALMETEROL ADVAIR DISKUS 2FLUTICASONE/SALMETEROL ADVAIR HFA 2FLUTICASONE/VILANTEROL BREO ELLIPTA 3MOMETASONE/FORMOTEROL DULERA 3

GLUCOCORTICOIDS, ORALLY INHALEDBECLOMETHASONE DIPROPIONATE QVAR 2budesonide 1

BUDESONIDE

PULMICORTFLEXHALER (180MCG) (AER POWBA)

2

BUDESONIDE

PULMICORTFLEXHALER (90MCG) (AER POWBA)

3

CICLESONIDE ALVESCO 3FLUTICASONE FUROATE ARNUITY ELLIPTA 3

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

2


2





3

FLUTICASONE PROPIONATE FLOVENT HFA 2MOMETASONE FUROATE ASMANEX 3MOMETASONE FUROATE ASMANEX HFA 2

LEUKOTRIENE RECEPTOR ANTAGONISTSmontelukast sodium 1

MAST CELL STABILIZERScromolyn sodium 1

MAST CELL STABILIZERS, ORALLY INHALEDcromolyn sodium 1

MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E(IGE)OMALIZUMAB XOLAIR 3 PA

PHOSPHODIESTERASE-4 (PDE4) INHIBITORSROFLUMILAST DALIRESP 3 PA

XANTHINESaminophylline 1caffeine citrate 1caffeine/sodium benzoate 1THEOPHYLLINE ANHYDROUS THEO-24 2theophylline anhydrous 1theophylline in dextrose 5 % 1

AUTONOMIC NERVOUS SYSTEM DISORDERSALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS

memantine hcl (10 mg) (tablet) 1 AGE: >= 50 YEARSALZHEIMER'S THX,NMDA RECEPT ANTAG & CHOLINES INHIB

MEMANTINE HCL/DONEPEZIL HCL NAMZARIC (21 MG-10MG) (CAP SPR 24) 3

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

3

CHOLINESTERASE INHIBITORSdonepezil hcl (10 mg) (tab rapdis) 1 AGE: >= 50 YEARSdonepezil hcl (10 mg) (tablet) 1donepezil hcl (23 mg) (tablet) 1 AGE: >= 50 YEARSdonepezil hcl (5 mg) (tab rapdis) 1donepezil hcl (5 mg) (tablet) 1edrophonium chloride 1EDROPHONIUM CHLORIDE/ATROPINE ENLON-PLUS 2galantamine hbr 1neostigmine methylsulfate (5 mg/5 ml) (syringe) 1physostigmine salicylate 1

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

pyridostigmine bromide 1PYRIDOSTIGMINE BROMIDE REGONOL 3rivastigmine 1rivastigmine tartrate 1

BEHAVIORAL HEALTH - ANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS

mirtazapine 1MAOIS - NON-SELECTIVE & IRREVERSIBLE

ISOCARBOXAZID MARPLAN 2phenelzine sulfate 1tranylcypromine sulfate 1



Drug Name Tier Requirements/LimitsNOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS)

BUPROPION HBR APLENZIN 3bupropion hcl (100 mg) (tab er 12h) 1BUPROPION HCL FORFIVO XL 3

SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)citalopram hydrobromide 1escitalopram oxalate 1fluvoxamine maleate 1paroxetine hcl 1

PAROXETINE HCL PAXIL (10 MG/5 ML)(ORAL SUSP) 3

sertraline hcl 1SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS)

nefazodone hcl 1trazodone hcl 1

SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)duloxetine hcl (20 mg) (capsule dr) 1 QL: 1 IN 1 DAYvenlafaxine hcl (100 mg) (tablet) 1

TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNSamitriptyline/chlordiazepoxide 1

TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNSperphenazine/amitriptyline hcl 1

TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIBamitriptyline hcl 1amoxapine 1clomipramine hcl 1desipramine hcl 1doxepin hcl 1imipramine hcl 1imipramine pamoate 1maprotiline hcl 1nortriptyline hcl 1protriptyline hcl 1trimipramine maleate 1

BEHAVIORAL HEALTH - OTHERADRENERGICS, AROMATIC, NON-CATECHOLAMINE

dextroamphetamine sulfate (10 mg) (capsule er) 1 AGE: >= 26 YEARS

DEXTROAMPHETAMINE SULFATE ZENZEDI (2.5 MG)(TABLET) 3

DEXTROAMPHETAMINE/AMPHETAMINE ADDERALL XR 1 AGE: >= 26 YEARSdextroamphetamine/amphetamine (10 mg) (tablet) 1

LISDEXAMFETAMINE DIMESYLATE VYVANSE (10 MG)(CAPSULE) 3 AGE: >= 26 YEARS, QL: 1 IN 1 DAY

methamphetamine hcl 1ANTI-ALCOHOLIC PREPARATIONS

acamprosate calcium 1disulfiram 1NALTREXONE MICROSPHERES VIVITROL 3

ANTI-ANXIETY DRUGSalprazolam 1ALPRAZOLAM INTENSOL 2buspirone hcl 1chlordiazepoxide hcl 1clorazepate dipotassium 1diazepam 1lorazepam 1



Drug Name Tier Requirements/Limitsmeprobamate 1oxazepam 1

ANTI-MANIA DRUGSCARBAMAZEPINE EQUETRO 3lithium carbonate 1lithium citrate 1

ANTI-NARCOLEPSY & ANTI-CATAPLEXY,SEDATIVE-TYPE AGTSODIUM OXYBATE XYREM 3 PA

ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINESpimozide 1

ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED

ARIPIPRAZOLEABILIFYMAINTENA (300MG) (SUSER VIAL)

3 PA

aripiprazole (10 mg) (tablet) 1 PAANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS

loxapine succinate 1ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG

clozapine (100 mg) (tablet) 1olanzapine 1

OLANZAPINE PAMOATE ZYPREXARELPREVV 3 PA

paliperidone 1quetiapine fumarate 1

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

3

risperidone 1

RISPERIDONE MICROSPHERES RISPERDALCONSTA 3 PA

ziprasidone hcl 1ZIPRASIDONE MESYLATE GEODON 2

ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENESthiothixene 1

ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONESdroperidol 1haloperidol 1haloperidol decanoate 1haloperidol lactate 1

ANTI-PSYCHOTICS,PHENOTHIAZINESchlorpromazine hcl 1fluphenazine decanoate 1fluphenazine hcl 1perphenazine 1thioridazine hcl 1trifluoperazine hcl 1

BARBITURATESamobarbital sodium 1BUTABARBITAL SODIUM BUTISOL SODIUM 2phenobarbital 1PHENOBARBITAL SODIUM LUMINAL SODIUM 3phenobarbital sodium 1phenobarbital/0.9 % sod chlor 1SECOBARBITAL SODIUM SECONAL SODIUM 2

BENZODIAZEPINE ANTAGONISTSflumazenil 1



Drug Name Tier Requirements/LimitsCENTRAL NERVOUS SYSTEM STIMULANTS

doxapram hcl 1HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTS

RAMELTEON ROZEREM 3 QL: 1 IN 1 DAY, RBPMONOAMINE OXIDASE(MAO) INHIBITORS

SELEGILINE EMSAM 3 QL: 1 IN 1 DAYNARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS

armodafinil (150 mg) (tablet) 1 PA, QL: 1 IN 1 DAYmodafinil 1 PA

NARCOTIC ANTAGONISTSnaloxone hcl 1NALOXONE HCL NARCAN 2naltrexone hcl 1

SEDATIVE-HYPNOTICS,NON-BARBITURATEdexmedetomidine hcl 1estazolam 1eszopiclone 1 QL: 1 IN 1 DAY, RBPflurazepam hcl 1lorazepam 1midazolam hcl 1quazepam 1SUVOREXANT BELSOMRA 3 RBPtemazepam 1triazolam 1zaleplon 1 QL: 1 IN 1 DAYzolpidem tartrate 1 QL: 1 IN 1 DAYZOLPIDEM TARTRATE ZOLPIMIST 3 QL: 1mL IN 1 DAY, RBP

SELECTIVE SEROTONIN 5-HT2A INVERSE AGONISTS (SSIA)PIMAVANSERIN TARTRATE NUPLAZID 3 PA

SSRI &ANTIPSYCH,ATYP,DOPAMINE&SEROTONIN ANTAG COMBolanzapine/fluoxetine hcl 1

TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSYdexmethylphenidate hcl (10 mg) (cpbp 50-50) 1 AGE: >= 26 YEARS, QL: 1 IN 1 DAYMETHYLPHENIDATE DAYTRANA 3 ST, AGE: >= 26 YEARSmethylphenidate hcl (10 mg) (cpbp 30-70) 1 AGE: >= 26 YEARS

METHYLPHENIDATE HCL RITALIN LA (10 MG)(CPBP 50-50) 3 AGE: >= 26 YEARS

TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPEatomoxetine hcl 1 QL: 1 IN 1 DAY

CARDIOVASCULAR DISEASE - ARRHYTHMIAANTIARRHYTHMICS

adenosine 1amiodarone hcl 1amiodarone hcl/d5w 1disopyramide phosphate 1DISOPYRAMIDE PHOSPHATE NORPACE CR 3dofetilide 1DRONEDARONE HCL MULTAQ 3flecainide acetate 1ibutilide fumarate 1lidocaine hcl/dextrose 5 %/pf 1lidocaine hcl/pf 1mexiletine hcl 1procainamide hcl (100 mg/ml) (vial) 1procainamide hcl (500 mg/ml) (vial) 1propafenone hcl 1



Drug Name Tier Requirements/Limitsquinidine gluconate 1quinidine sulfate 1

CARDIOVASCULAR DISEASE - CARDIAC STIMULANTADRENERGIC AGENTS,CATECHOLAMINES

dopamine hcl 1dopamine hcl in dextrose 5 % 1epinephrine 1

DIGITALIS GLYCOSIDESdigoxin (125 mcg) (tablet) 1digoxin (250 mcg/ml) (ampul) 1digoxin (250 mcg/ml) (syringe) 1

DIGOXIN LANOXIN (125MCG) (TABLET) 3

INOTROPIC DRUGSdobutamine hcl 1dobutamine hcl in dextrose 5 % 1milrinone lactate 1

CARDIOVASCULAR DISEASE - HYPERTENSIONACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION

amlodipine besylate/benazepril 1trandolapril/verapamil hcl 1

ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETICbenazepril/hydrochlorothiazide 1captopril/hydrochlorothiazide 1enalapril/hydrochlorothiazide 1fosinopril/hydrochlorothiazide 1lisinopril/hydrochlorothiazide 1moexipril/hydrochlorothiazide 1quinapril/hydrochlorothiazide 1

ALPHA/BETA-ADRENERGIC BLOCKING AGENTScarvedilol 1carvedilol phosphate 1 QL: 1 IN 1 DAYlabetalol hcl 1

ALPHA-ADRENERGIC BLOCKING AGENTSDOXAZOSIN MESYLATE CARDURA XL 3doxazosin mesylate 1phenoxybenzamine hcl 1phentolamine mesylate 1prazosin hcl 1terazosin hcl 1

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

ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMBcandesartan/hydrochlorothiazid 1 STirbesartan/hydrochlorothiazide 1 STlosartan/hydrochlorothiazide 1olmesartan/hydrochlorothiazide 1 STtelmisartan/hydrochlorothiazid 1 STvalsartan/hydrochlorothiazide 1

ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKRamlodipine bes/olmesartan med 1 STtelmisartan/amlodipine 1 ST

ANTIHYPERTENSIVES, ACE INHIBITORSbenazepril hcl 1



Drug Name Tier Requirements/Limitscaptopril 1enalapril maleate 1fosinopril sodium 1lisinopril 1moexipril hcl 1perindopril erbumine 1quinapril hcl 1ramipril 1trandolapril 1

ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONISTcandesartan cilexetil 1 STeprosartan mesylate 1 STirbesartan 1 STlosartan potassium 1olmesartan medoxomil 1 STtelmisartan 1 STvalsartan 1 ST

ANTIHYPERTENSIVES, MISCELLANEOUSMETYROSINE DEMSER 2

ANTIHYPERTENSIVES, SYMPATHOLYTICclonidine 1guanfacine hcl 1methyldopa 1

ANTIHYPERTENSIVES, VASODILATORSFENOLDOPAM MESYLATE CORLOPAM 3hydralazine hcl 1minoxidil 1

BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl 1atenolol 1betaxolol hcl 1bisoprolol fumarate 1esmolol hcl 1metoprolol succinate 1metoprolol tartrate (5 mg/5 ml) (ampul) 1metoprolol tartrate (5 mg/5 ml) (syringe) 1metoprolol tartrate (5 mg/5 ml) (vial) 1nadolol 1NEBIVOLOL HCL BYSTOLIC 3PENBUTOLOL SULFATE LEVATOL 2pindolol 1propranolol hcl 1sotalol hcl (120 mg) (tablet) 1SOTALOL HCL (150MG/10ML) (VIAL) 3

CALCIUM CHANNEL BLOCKING AGENTSamlodipine besylate 1CLEVIDIPINE BUTYRATE CLEVIPREX 3diltiazem hcl 1diltiazem hcl in 0.9% nacl (125 mg/125) (plast. bag) 1felodipine 1isradipine 1nicardipine hcl 1NICARDIPINE IN DEXTROSE,ISO-OS CARDENE I.V. 3NICARDIPINE IN NACL, ISO-OSM CARDENE I.V. 3nifedipine 1nimodipine 1nisoldipine 1



Drug Name Tier Requirements/Limitsverapamil hcl 1

LOOP DIURETICSbumetanide 1ethacrynate sodium 1ethacrynic acid 1furosemide 1furosemide in dextrose 5 % 1torsemide 1

OSMOTIC DIURETICSmannitol 1

MANNITOL OSMITROL (15 %)(IV SOLN) 3

POTASSIUM SPARING DIURETICSamiloride hcl 1eplerenone 1spironolactone 1

TRIAMTERENE DYRENIUM (100MG) (CAPSULE) 2

TRIAMTERENE DYRENIUM (50 MG)(CAPSULE) 3

PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATORRIOCIGUAT ADEMPAS 3 PA

PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIBsildenafil citrate (20 mg) (tablet) 1 PATADALAFIL ADCIRCA 3 PA

PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONISTAMBRISENTAN LETAIRIS 3

BOSENTAN TRACLEER (125MG) (TABLET) 3

PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPEEPOPROSTENOL SODIUM (ARGININE) VELETRI 3SELEXIPAG UPTRAVI 3TREPROSTINIL TYVASO 3TREPROSTINIL SODIUM REMODULIN 2

TREPROSTINIL/NEBULIZER/ACCESORTYVASOINSTITUTIONALSTART KIT

3

RENIN INHIBITOR, DIRECTALISKIREN HEMIFUMARATE TEKTURNA 3 ST

THIAZIDE AND RELATED DIURETICSchlorothiazide 1CHLOROTHIAZIDE DIURIL 2chlorthalidone 1hydrochlorothiazide 1indapamide 1methyclothiazide 1metolazone 1phenoxybenzamine hcl 1

VASODILATORS, COMBINATIONISOSORBIBE DINIT/HYDRALAZINE BIDIL 3

VASODILATORS,MISCELLANEOUSalprostadil 1

CARDIOVASCULAR DISEASE - LIPID IRREGULARITYANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS

atorvastatin calcium 1 RBPfluvastatin sodium 1 RBP



Drug Name Tier Requirements/LimitsLOVASTATIN ALTOPREV 2 RBPPITAVASTATIN CALCIUM LIVALO 3 RBPpravastatin sodium 1 RBProsuvastatin calcium 1 RBPsimvastatin 1 RBP

LIPOTROPICSFENOFIBRATE NANOCRYSTALLIZED TRIGLIDE 3fenofibrate,micronized (130 mg) (capsule) 1fenofibrate,micronized (43 mg) (capsule) 1gemfibrozil 1

ICOSAPENT ETHYL VASCEPA (0.5GRAM) (CAPSULE) 3

METHIONINE/INOSI/CHOL/FOLIC AC LIPOCHOL PLUS 2niacin (500 mg) (tablet) 1

CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTSADRENERGIC VASOPRESSOR AGENTS

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

SACUBITRIL/VALSARTAN ENTRESTO 3 PAANTIANGINAL & ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMIC

RANOLAZINE RANEXA 3 PAANTIANGINAL, HEART RATE REDUCING, I(F) INHIBITOR

IVABRADINE HCL CORLANOR (5 MG)(TABLET) 3 PA

ANTIHYPERLIP - HMG-COA&CALCIUM CHANNEL BLOCKER CBamlodipine/atorvastatin 1

CARDIOVASCULAR DISEASE - VASODILATIONVASODILATORS,CORONARY

amyl nitrite 1ISOSORBIDE DINITRATE DILATRATE-SR 2ISOSORBIDE DINITRATE ISORDIL 2isosorbide dinitrate 1nitroglycerin 1nitroglycerin in 5 % dextrose 1

VASODILATORS,PERIPHERALergoloid mesylates 1isoxsuprine hcl 1papaverine hcl 1

CONTRACEPTION/OXYTOCICSCONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC

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

ETONOGESTREL NEXPLANON 0CONTRACEPTIVES,INJECTABLE

medroxyprogesterone acetate 0CONTRACEPTIVES,ORAL

desogestrel-ethinyl estradiol 0 QL: 1 IN 1 DAYdrospir/eth estra/levomefol ca 0 QL: 1 IN 1 DAYESTRADIOL VALERATE/DIENOGEST NATAZIA 0 QL: 1 IN 1 DAYethinyl estradiol/drospirenone 0 QL: 1 IN 1 DAYethynodiol d-ethinyl estradiol 0 QL: 1 IN 1 DAYlevonorgestrel 0 QL: 1 IN 1 DAYnorethindrone 0 QL: 1 IN 1 DAYnorethindrone ac-eth estradiol 0 QL: 1 IN 1 DAYnorethindrone-e.estradiol-iron 0 QL: 1 IN 1 DAY



Drug Name Tier Requirements/Limitsnorethindrone-ethinyl estrad 0 QL: 1 IN 1 DAYnorgestimate-ethinyl estradiol 0 QL: 1 IN 1 DAYnorgestrel-ethinyl estradiol 0 QL: 1 IN 1 DAYULIPRISTAL ACETATE ELLA 0 QL: 1 IN 1 DAY

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

DERMATOLOGY - ACNEACNE AGENTS,TOPICAL

AZELAIC ACID AZELEX 2 AGE: <= 25 YEARSclindamycin phos/benzoyl perox 1dapsone 1sulfacetamide sodium 1

ROSACEA AGENTS, TOPICAL

AZELAIC ACID FINACEA (15 %)(FOAM) 3 QL: 50gm IN 30 DAYS

TOPICAL PREPARATIONS,ANTIBACTERIALSCADEXOMER IODINE IODOFLEX 2CLIOQUINOL/HYDROCORTISONE ALA-QUIN 2hydrocortisone/iodoquinol 1

VITAMIN A DERIVATIVESadapalene (0.1 %) (lotion) 1 QL: 59mL PER FILL

tretinoin 1 AGE: <= 25 YEARS, QL: 45gm PERFILL

DERMATOLOGY - ANTIINFECTIVETOPICAL ANTIBIOTICS

CLINDAMYCIN PHOSPHATE CLINDAGEL 3erythromycin base/ethanol 1mupirocin 1

TOPICAL ANTIFUNGALSciclopirox (1 %) (shampoo) 1econazole nitrate 1naftifine hcl 1oxiconazole nitrate 1SULCONAZOLE NITRATE EXELDERM 2

TOPICAL ANTIPARASITICSlindane 1malathion 1permethrin (5 %) (cream (g)) 1spinosad 1 PA

TOPICAL ANTIVIRALSacyclovir 1

TOPICAL PLEUROMUTILIN DERIVATIVESRETAPAMULIN ALTABAX 3

TOPICAL SULFONAMIDESmafenide acetate 1SULFACETAMIDE SODIUM/SULFUR ROSANIL 3

DERMATOLOGY - ANTIINFLAMMATORYTOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDAL

NEOMYC/BACIT/POLYMYX/HYDROCORT CORTISPORIN 2TOPICAL ANTI-INFLAMMATORY STEROIDAL

alclometasone dipropionate 1betamethasone dipropionate 1betamethasone valerate (0.1 %) (cream (g)) 1betamethasone/propylene glyc 1clobetasol propionate (0.05 %) (gel (gram)) 1



Drug Name Tier Requirements/Limitsdesoximetasone (0.25 %) (cream (g)) 1fluocinolone acetonide (0.01 %) (cream (g)) 1fluocinonide (0.05 %) (cream (g)) 1fluticasone propionate (0.05 %) (cream (g)) 1halobetasol propionate 1hydrocortisone (1 %) (crm/pe app) 1mometasone furoate 1prednicarbate 1triamcinolone acetonide (0.025 %) (cream (g)) 1

TOPICAL ANTI-INFLAMMATORY, NSAIDSdiclofenac sodium (1 %) (gel (gram)) 1DICLOFENAC SODIUM DICLOZOR 3DICLOFENAC SODIUM/CAPSAICIN NUDICLO 3

DICLOFENAC/CAPSICUM OLEORESIN DERMACINRXLEXITRAL 3

DERMATOLOGY - ANTIPRURITIC DRUGSANTIPRURITICS,TOPICAL

doxepin hcl 1

DERMATOLOGY - MISCELLANEOUSANTIPERSPIRANTS

ALUMINUM CHLORIDE DRYSOL 3KERATOLYTICS

benzoyl peroxide (4 %) (gel (gram)) 1podofilox 1podophyllum resin 1salicylic acid (26 %) (liquid) 1urea (39 %) (cream (g)) 1

TOPICAL ANTI-INFLAMMATORY STEROID-LOCAL ANESTHETICHYDROCORTISONE/PRAMOXINE EPIFOAM 2hydrocortisone/pramoxine 1

HYDROCORTISONE/PRAMOXINE PRAMOSONE (1 %-1%) (CREAM (G)) 2

TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTSALITRETINOIN PANRETIN 2BEXAROTENE TARGRETIN 2diclofenac sodium 1FLUOROURACIL FLUOROPLEX 2

DERMATOLOGY - PSORIASIS/ECZEMAANTIPSORIATIC AGENTS,SYSTEMIC

acitretin 1methoxsalen 1

SECUKINUMAB COSENTYX (2SYRINGES) 3 PA

SECUKINUMAB COSENTYX PEN 3 PA

SECUKINUMAB COSENTYXSYRINGE 3 PA

ANTIPSORIATICS AGENTSANTHRALIN DRITHOCREME HP 3ANTHRALIN MICRONIZED ZITHRANOL 3 QL: 85gm IN 30 DAYScalcipotriene 1calcitriol 1

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

TOPICAL IMMUNOSUPPRESSIVE AGENTSPIMECROLIMUS ELIDEL 2tacrolimus 1




DIABETESANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST)

LIRAGLUTIDE VICTOZA 2-PAK 3 PAANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIB

EMPAGLIFLOZIN JARDIANCE 3 PAANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S)

acarbose 1miglitol 1

ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPEPRAMLINTIDE ACETATE SYMLINPEN 120 3

ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPEchlorpropamide 1glimepiride 1glipizide 1glyburide 1glyburide,micronized 1nateglinide 1repaglinide 1tolazamide 1tolbutamide 1

ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S)pioglitazone hcl 1ROSIGLITAZONE MALEATE AVANDIA 3 PA

ANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA)metformin hcl (850 mg) (tablet) 1METFORMIN HCL RIOMET 2

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

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

ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR & BIGUANIDE COMBCANAGLIFLOZIN/METFORMIN HCL INVOKAMET 3CANAGLIFLOZIN/METFORMIN HCL INVOKAMET XR 3EMPAGLIFLOZIN/METFORMIN HCL SYNJARDY 3 PA

ANTIHYPERGLYCM,INSUL-RESP.ENHANCER & BIGUANIDE CMBPIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET XR 3pioglitazone hcl/metformin hcl 1ROSIGLITAZONE/METFORMIN HCL AVANDAMET 3 PA

DIABETIC ULCER PREPARATIONS,TOPICALBECAPLERMIN REGRANEX 2

HYPERGLYCEMICSDIAZOXIDE PROGLYCEM 2GLUCAGON,HUMAN RECOMBINANT GLUCAGEN 2 QL: 3 PER FILL

INSULINSINSULIN GLARGINE,HUM.REC.ANLOG LANTUS 2INSULIN GLARGINE,HUM.REC.ANLOG LANTUS SOLOSTAR 2INSULIN GLARGINE,HUM.REC.ANLOG TOUJEO SOLOSTAR 2INSULIN LISPRO HUMALOG 2

INSULIN LISPRO HUMALOGKWIKPEN U-100 2

INSULIN LISPRO HUMALOGKWIKPEN U-200 2




INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 50-50 2

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 50-50 KWIKPEN 2

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 75-25 2

INSULIN LISPRO PROTAMIN/LISPRO HUMALOG MIX 75-25 KWIKPEN 2

INSULIN NPH HUM/REG INSULIN HM HUMULIN 70/30KWIKPEN 2

INSULIN NPH HUM/REG INSULIN HM HUMULIN 70-30 2INSULIN NPH HUMAN ISOPHANE HUMULIN N 2

INSULIN NPH HUMAN ISOPHANE HUMULIN NKWIKPEN 2

INSULIN REGULAR, HUMAN HUMULIN R 2INSULIN REGULAR, HUMAN HUMULIN R U-500 2

INSULIN REGULAR, HUMAN HUMULIN R U-500KWIKPEN 2

EAR - GENERAL DISORDERSEAR PREPARATIONS ANTI-INFLAMMATORY

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

acetic acid 1hydrocortisone/acetic acid 1HYDROCORTISONE/PRAMOXINE/C-XYL CORTANE-B 3

EAR PREPARATIONS,ANTIBIOTICSNEOMYC/COLIST/HYDROCORT/THONZN COLY-MYCIN S 2neomycin/polymyxin b/hydrocort 1ofloxacin 1

OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICSCIPROFLOXACIN HCL/DEXAMETH CIPRODEX 2CIPROFLOXACIN/HYDROCORTISONE CIPRO HC 3

ENDOCRINE DISORDER - FERTILITYDRUGS TO TREAT IMPOTENCY

ALPROSTADIL EDEX 3 PAALPROSTADIL MUSE 2 PAsildenafil citrate 1 PAVARDENAFIL HCL LEVITRA 3 PAVARDENAFIL HCL STAXYN 3 PA

ENDOCRINE DISORDER - OTHERANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR.

LEUPROLIDE ACETATE LUPRON DEPOT (7.5MG) (SYRINGEKIT) 2

BONE FORMATION STIM. AGENTS - PARATHYROID HORMONETERIPARATIDE FORTEO 2 PA

BONE RESORPTION INHIBITOR & VITAMIN D COMBINATIONS

ALENDRONATE SODIUM/VITAMIN D3FOSAMAX PLUS D(70 MG-2800)(TABLET)

2

BONE RESORPTION INHIBITORSalendronate sodium (10 mg) (tablet) 1 RBPcalcitonin,salmon,synthetic 1CALCITONIN,SALMON,SYNTHETIC MIACALCIN 2 PAetidronate disodium 1ibandronate sodium (150 mg) (tablet) 1 QL: 1 IN 28 DAYS, RBPibandronate sodium (3 mg/3 ml) (vial) 1



Drug Name Tier Requirements/Limitspamidronate disodium 1raloxifene hcl 1risedronate sodium (5 mg) (tablet) 1 RBPzoledronic acid 1zoledronic acid/mannitol-water 1

CALCIMIMETIC,PARATHYROID CALCIUM ENHANCERCINACALCET HCL SENSIPAR 3

GROWTH HORMONE RECEPTOR ANTAGONISTSPEGVISOMANT SOMAVERT 3

GROWTH HORMONE RELEASING HORMONE (GHRH) & ANALOGS

TESAMORELIN ACETATE EGRIFTA (2 MG)(VIAL) 3 PA

GROWTH HORMONESSOMATROPIN GENOTROPIN 2 PA

SOMATROPIN HUMATROPE (12MG) (CARTRIDGE) 3 PA


SOMATROPIN HUMATROPE (5MG) (VIAL) 2 PA


SOMATROPIN

NORDITROPINFLEXPRO(10MG/1.5ML) (PENINJCTR)

2 PA

SOMATROPIN

NORDITROPINFLEXPRO(15MG/1.5ML) (PENINJCTR)

2 PA

SOMATROPINNORDITROPINFLEXPRO (30 MG/3ML) (PEN INJCTR)

3 PA

SOMATROPIN

NORDITROPINFLEXPRO (5MG/1.5ML) (PENINJCTR)

2 PA

SOMATROPINNUTROPIN AQNUSPIN (10 MG/2ML) (PEN INJCTR)

2 PA


3 PA


2 PA

SOMATROPIN OMNITROPE 2 PA

SOMATROPIN SAIZEN (5 MG)(VIAL) 2 PA

SOMATROPIN SAIZEN (8.8 MG)(VIAL) 3 PA

SOMATROPIN SEROSTIM (4 MG)(VIAL) 3 PA



SOMATROPIN ZOMACTON 2 PASOMATROPIN ZORBTIVE 3 PA



Drug Name Tier Requirements/LimitsHYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE

doxercalciferol 1

DOXERCALCIFEROLHECTOROL(2MCG/ML(1))(VIAL)

3

paricalcitol (1 mcg) (capsule) 1paricalcitol (2 mcg/ml) (vial) 1paricalcitol (5 mcg/ml) (vial) 1

INSULIN-LIKE GROWTH FACTOR-1 (IGF-1) HORMONESMECASERMIN INCRELEX 3 PA

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

LEUPROLIDE ACETATE LUPRON DEPOT(LUPANETA) 2

NAFARELIN ACETATE SYNAREL 2LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY

HISTRELIN ACETATE SUPPRELIN LA 2

LEUPROLIDE ACETATELUPRON DEPOT-PED (11.25 MG)(KIT)

2

LEUPROLIDE ACETATELUPRON DEPOT-PED (11.25 MG)(SYRINGEKIT)

2

LEUPROLIDE ACETATE LUPRON DEPOT-PED (15 MG) (KIT) 2

LEUPROLIDE ACETATE LUPRON DEPOT-PED (7.5 MG) (KIT) 2

PITUITARY SUPPRESSIVE AGENTScabergoline 1danazol 1

ENDOCRINE DISORDER - THYROIDANTITHYROID PREPARATIONS

methimazole 1propylthiouracil 1

IODINE CONTAINING AGENTSpotassium iodide (1 g/ml) (solution) 1potassium iodide/iodine 1sodium iodide 1

THYROID HORMONESLEVOTHYROXINE SODIUM LEVO-T 3levothyroxine sodium 1LEVOTHYROXINE SODIUM LEVOXYL 3LEVOTHYROXINE SODIUM SYNTHROID 3LEVOTHYROXINE SODIUM TIROSINT 3LEVOTHYROXINE SODIUM UNITHROID 3liothyronine sodium 1LIOTRIX THYROLAR-1 2LIOTRIX THYROLAR-1/2 2LIOTRIX THYROLAR-1/4 2LIOTRIX THYROLAR-2 2LIOTRIX THYROLAR-3 2THYROID,PORK ARMOUR THYROID 3thyroid,pork 1

EYE - GENERAL DISORDERSEYE ANTIBIOTIC-CORTICOID COMBINATIONS

GENTAMICIN SULF/PREDNISOLONE PRED-G 2



Drug Name Tier Requirements/Limitsneomycin/bacit/p-myx/hydrocort 1neomycin/polymyxin b/dexametha 1neomycin/polymyxin b/hydrocort 1

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

TOBRAMYCIN/DEXAMETHASONE TOBRADEX ST 3tobramycin/dexamethasone 1TOBRAMYCIN/LOTEPRED ETAB ZYLET 3

EYE ANTIHISTAMINESALCAFTADINE LASTACAFT 3azelastine hcl 1BEPOTASTINE BESILATE BEPREVE 3EMEDASTINE DIFUMARATE EMADINE 3epinastine hcl 1olopatadine hcl (0.1 %) (drops) 1

EYE ANTIINFLAMMATORY AGENTSbromfenac sodium 1BROMFENAC SODIUM BROMSITE 3BROMFENAC SODIUM PROLENSA 3DEXAMETHASONE MAXIDEX 2dexamethasone sod phosphate 1diclofenac sodium 1FLUOCINOLONE ACETONIDE RETISERT 3fluorometholone 1FLUOROMETHOLONE FML FORTE 2FLUOROMETHOLONE FML S.O.P. 2FLUOROMETHOLONE ACETATE FLAREX 2flurbiprofen sodium 1ketorolac tromethamine 1KETOROLAC TROMETHAMINE/PF ACUVAIL 3LOTEPREDNOL ETABONATE ALREX 3LOTEPREDNOL ETABONATE LOTEMAX 3NEPAFENAC ILEVRO 3NEPAFENAC NEVANAC 2PREDNISOLONE ACETATE PRED MILD 2prednisolone acetate 1prednisolone sod phosphate 1TRIAMCINOLONE ACETONIDE/PF TRIESENCE 3

EYE ANTIVIRALSGANCICLOVIR ZIRGAN 3trifluridine 1

EYE LOCAL ANESTHETICSbenoxinate hcl/fluorescein sod 1LIDOCAINE HCL/PF AKTEN 3proparacaine hcl 1proparacaine/fluorescein sod 1tetracaine hcl 1

TETRACAINE HCL TETRAVISC (0.5 %)(DROPR VISC) 3

TETRACAINE HCL TETRAVISC FORTE 3tetracaine hcl/pf 1

EYE SULFONAMIDESsulfacetamide sodium 1SULFACETAMIDE/PREDNISOLONE BLEPHAMIDE 2SULFACETAMIDE/PREDNISOLONE BLEPHAMIDE S.O.P. 2sulfacetamide/prednisolone sp 1



Drug Name Tier Requirements/LimitsEYE VASOCONSTRICTORS (RX ONLY)

phenylephrine hcl 1OPHTHALMIC ANTIBIOTICS

AZITHROMYCIN AZASITE 3bacitracin 1bacitracin/polymyxin b sulfate 1cefuroxime sodium/0.9% nacl/pf 1

CIPROFLOXACIN HCL CILOXAN (0.3 %)(OINT. (G)) 2

ciprofloxacin hcl 1erythromycin base 1gatifloxacin 1gentamicin sulfate 1levofloxacin 1MOXIFLOXACIN HCL MOXEZA 2moxifloxacin hcl 1moxifloxacin(pf)/bal.salt sol2 (1 mg/ml) (vial) 1NATAMYCIN NATACYN 2neomycin sulf/bacitracin/poly 1neomycin/polymyxn b/gramicidin 1ofloxacin 1polymyxin b sulf/trimethoprim 1tobramycin 1

TOBRAMYCIN TOBREX (0.3 %)(OINT. (G)) 3

OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPECYCLOSPORINE RESTASIS 2

CYCLOSPORINE RESTASISMULTIDOSE 3

OPHTHALMIC MAST CELL STABILIZERScromolyn sodium 1LODOXAMIDE TROMETHAMINE ALOMIDE 3NEDOCROMIL SODIUM ALOCRIL 3

OPHTHALMIC PREPARATIONS, MISCELLANEOUSCHONDR SULF A SOD/HYALURONATE DISCOVISC 3CHONDR SULF A SOD/HYALURONATE DUOVISC 3CHONDR SULF A SOD/HYALURONATE VISCOAT 3HYALURONATE SODIUM AMVISC 3 PAHYALURONATE SODIUM AMVISC PLUS 3 PAHYALURONATE SODIUM HEALON 3 PAHYALURONATE SODIUM HEALON5 3 PAHYALURONATE SODIUM PROVISC 3 PA

EYE - GLAUCOMACARBONIC ANHYDRASE INHIBITORS

acetazolamide 1acetazolamide sodium 1methazolamide 1

MIOTICS/OTHER INTRAOC. PRESSURE REDUCERSACETYLCHOLINE CHLORIDE MIOCHOL-E 3apraclonidine hcl 1

APRACLONIDINE HCL IOPIDINE (1 %)(DROPERETTE) 3

betaxolol hcl 1BETAXOLOL HCL BETOPTIC S 3bimatoprost 1BIMATOPROST LUMIGAN 3




BRIMONIDINE TARTRATE ALPHAGAN P (0.1%) (DROPS) 3

brimonidine tartrate 1BRIMONIDINE TARTRATE/TIMOLOL COMBIGAN 3BRINZOLAMIDE AZOPT 2CARBACHOL MIOSTAT 3carteolol hcl 1dorzolamide hcl 1dorzolamide hcl/timolol maleat 1DORZOLAMIDE/TIMOLOL/PF COSOPT PF 3

ECHOTHIOPHATE IODIDE PHOSPHOLINEIODIDE 2

latanoprost 1levobunolol hcl 1metipranolol 1pilocarpine hcl 1TIMOLOL BETIMOL 3timolol maleate 1

TIMOLOL MALEATE/PF TIMOPTICOCUDOSE 3

TRAVOPROST TRAVATAN Z 2MYDRIATICS

atropine sulfate 1atropine sulfate/0.9 %sod chlr 1cyclopentolat/tropic/phenyleph 1cyclopentolate hcl 1CYCLOPENTOLATE/PHENYLEPHRINE CYCLOMYDRIL 2homatropine hbr 1HYDROXYAMPHETAMINE/TROPICAMIDE PAREMYD 2tropicamide 1

EYE - MISCELLANEOUSARTIFICIAL TEARS

HYDROXYPROPYL CELLULOSE LACRISERT 2OCULAR PHOTOACTIVATED VESSEL-OCCLUDING AGENTS

VERTEPORFIN VISUDYNE 2OPHTH VASC. ENDOTHELIAL GROWTH FACTOR ANTAGONISTS

PEGAPTANIB SODIUM MACUGEN 3OPHTH. VEGF-A RECEPTOR ANTAG. RCMB MC ANTIBODY

bevacizumab (2.5 mg/0.1) (syringe) 1 PA

RANIBIZUMAB LUCENTIS(0.3MG/0.05) (VIAL) 3

OPHTHALMIC CYSTINE DEPLETING AGENTSCYSTEAMINE HCL CYSTARAN 3 PA

GOUT AND RELATED DISEASESCOLCHICINE

colchicine (0.6 mg) (tablet) 1probenecid/colchicine 1

HYPERURICEMIA TX - PURINE INHIBITORSallopurinol 1

HYPERURICEMIA TX - URATE-OXIDASE ENZYME-TYPE

RASBURICASE ELITEK (1.5 MG)(VIAL) 2

RASBURICASE ELITEK (7.5 MG)(VIAL) 3

URICOSURIC AGENTSprobenecid 1




HEMATOLOGICAL DISORDERSANTICOAGULANTS,COUMARIN TYPE

WARFARIN SODIUM COUMADIN 3warfarin sodium 1

ANTIFIBRINOLYTIC AGENTS

AMINOCAPROIC ACID AMICAR (1000 MG)(TABLET) 2

AMINOCAPROIC ACIDAMICAR (250MG/ML)(SOLUTION)

3

AMINOCAPROIC ACID AMICAR (500 MG)(TABLET) 3

aminocaproic acid 1tranexamic acid (1000 mg/10) (ampul) 1tranexamic acid (650 mg) (tablet) 1 PA, QL: 30 IN 5 DAYS

ANTIHEMOPHILIC FACTORS

ANTIHEMO.FVIII,FULL LENGTH PEG ADYNOVATE (1000(+/-)) (VIAL) 3 PA




ANTIHEMOPH.FVIII REC,FC FUSION ELOCTATE (1000UNIT) (VIAL) 3







ANTIHEMOPH.FVIII,B-DOMAIN DELXYNTHASOLOFUSE (250 (+/-)) (SYRINGE)

3

ANTIHEMOPH.FVIII,B-DOMAIN DELXYNTHASOLOFUSE (500 (+/-)) (SYRINGE)

3

ANTIHEMOPH.FVIII,FULL LENGTH ADVATE 2

ANTIHEMOPH.FVIII,FULL LENGTH HELIXATE FS (1000(+/-)) (VIAL) 2





ANTIHEMOPH.FVIII,FULL LENGTH KOGENATE FS 2

ANTIHEMOPH.FVIII,FULL LENGTH KOVALTRY (1000(+/-)) (VIAL) 2





ANTIHEMOPH.FVIII,FULL LENGTH KOVALTRY (250 (+/-)) (VIAL) 2


ANTIHEMOPH.FVIII,FULL LENGTH KOVALTRY (500 (+/-)) (VIAL) 2

ANTIHEMOPH.FVIII,HEK B-DELETE NUWIQ (1000 (+/-))(VIAL) 3 PA




ANTIHEMOPHILIC FACTOR, HUM REC RECOMBINATE(1000 (+/-)) (VIAL) 2



ANTIHEMOPHILIC FACTOR, HUM REC RECOMBINATE (250(+/-)) (VIAL) 2

ANTIHEMOPHILIC FACTOR, HUM REC RECOMBINATE (500(+/-)) (VIAL) 2

ANTIHEMOPHILIC FACTOR/VWF ALPHANATE 3ANTIHEMOPHILIC FACTOR/VWF HUMATE-P 2

ANTIHEMOPHILIC FACTOR/VWF WILATE (1K-1KUNIT) (VIAL) 3 PA

ANTIHEMOPHILIC FACTOR/VWF WILATE (500-500)(VIAL) 3 PA

ANTIHEMOPHILIC FVIII,REC PORC OBIZUR 3 PAANTI-INHIBITOR COAGULANT COMP. FEIBA NF 2COAGULATION FACTOR VIIA,RECOMB NOVOSEVEN RT 3

BLOOD FACTORS,MISCELLANEOUSVON WILLEBRAND FACTOR VONVENDI 3 PA

CITRATES AS ANTICOAGULANTScitrate phosphate dextros soln 1sodium citrate 1SODIUM CITRATE DIHYDRATE TRICITRASOL 2

COAGULANTSprotamine sulfate 1

DIRECT FACTOR XA INHIBITORS

APIXABAN ELIQUIS (2.5 MG)(TABLET) 2 QL: 2 IN 1 DAY

APIXABAN ELIQUIS (5 MG)(TABLET) 2 QL: 4 IN 1 DAY

EDOXABAN TOSYLATE SAVAYSA 2 QL: 1 IN 1 DAY

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



FACTOR IX COMPLEX (PCC) PREPARATIONSHUM PROTHROMBIN CPLX(PCC)4FACT KCENTRA 3



Drug Name Tier Requirements/LimitsFACTOR IX PREPARATIONS

FACTOR IX ALPHANINE SD(1000 (+/-)) (VIAL) 2



FACTOR IX MONONINE 2

FACTOR IX CPLX(PCC)NO4,3FACTOR PROFILNINE (1000(+/-)) (VIAL) 3



FACTOR IX CPLX(PCC)NO6,3FACTOR BEBULIN 2

FACTOR IX HUMAN RECOMB,THR 148 IXINITY (1000UNIT) (VIAL) 3 PA

FACTOR IX HUMAN RECOMB,THR 148 IXINITY (1500UNIT) (VIAL) 3 PA

FACTOR IX HUMAN RECOMB,THR 148 IXINITY (500 UNIT)(VIAL) 3 PA

FACTOR IX HUMAN RECOMBINANT BENEFIX (1000UNIT) (KIT) 2


FACTOR IX HUMAN RECOMBINANT BENEFIX (250 UNIT)(KIT) 2


FACTOR IX HUMAN RECOMBINANT BENEFIX (500 UNIT)(KIT) 2

FACTOR IX HUMAN RECOMBINANT RIXUBIS 3

FACTOR IX REC, FC FUSION PROTN ALPROLIX (250UNIT) (VIAL) 3 PA

FACTOR IX REC, FC FUSION PROTN ALPROLIX (4000UNIT) (VIAL) 3

FACTOR IX RECOM,ALBUMIN FUSION IDELVION 3 PAFACTOR X PREPARATIONS

COAGULATION FACTOR X COAGADEX 3 PAHEMATINICS,OTHER

DARBEPOETIN ALFA IN POLYSORBAT ARANESP (100MCG/ML) (VIAL) 2 PA

DARBEPOETIN ALFA IN POLYSORBATARANESP(100MCG/0.5)(SYRINGE)

2 PA

DARBEPOETIN ALFA IN POLYSORBAT ARANESP(150MCG/.75) (VIAL) 2 PA


2 PA



2 PA



2 PA






2 PA

DARBEPOETIN ALFA IN POLYSORBATARANESP (40MCG/0.4)(SYRINGE)

2 PA


DARBEPOETIN ALFA IN POLYSORBATARANESP (500MCG/ML)(SYRINGE)

2 PA

DARBEPOETIN ALFA IN POLYSORBATARANESP (60MCG/0.3)(SYRINGE)

2 PA

DARBEPOETIN ALFA IN POLYSORBAT ARANESP(60MCG/ML) (VIAL) 2 PA

EPOETIN ALFA EPOGEN 2 PAEPOETIN ALFA PROCRIT 2 PA

HEMORRHEOLOGIC AGENTSpentoxifylline 1

HEPARIN AND RELATED PREPARATIONSDALTEPARIN SODIUM,PORCINE FRAGMIN 2 PAenoxaparin sodium (100 mg/ml) (syringe) 1 QL: 2mL IN 1 DAYenoxaparin sodium (120mg/.8ml) (syringe) 1 QL: 8mL IN 5 DAYSenoxaparin sodium (150 mg/ml) (syringe) 1 QL: 2mL IN 1 DAYenoxaparin sodium (300mg/3ml) (vial) 1 QL: 6mL IN 1 DAYenoxaparin sodium (30mg/0.3ml) (syringe) 1 QL: 3mL IN 5 DAYSenoxaparin sodium (40mg/0.4ml) (syringe) 1 QL: 4mL IN 5 DAYSenoxaparin sodium (60mg/0.6ml) (syringe) 1 QL: 6mL IN 5 DAYSenoxaparin sodium (80mg/0.8ml) (syringe) 1 QL: 8mL IN 5 DAYSfondaparinux sodium 1 QL: 10mL IN 365 DAYS

HUMAN MONOCLONAL ANTIBODY COMPLEMENT(C5) INHIBITORECULIZUMAB SOLIRIS 2 PA

LEUKOCYTE (WBC) STIMULANTSFILGRASTIM NEUPOGEN 2 PAFILGRASTIM-SNDZ ZARXIO 3 PA

PEGFILGRASTIMNEULASTA(6MG/0.6ML) (SYRW/ INJ)

3 PA

PEGFILGRASTIMNEULASTA(6MG/0.6ML)(SYRINGE)

2 PA

SARGRAMOSTIM LEUKINE 2 PATBO-FILGRASTIM GRANIX 2 PA

PLATELET AGGREGATION INHIBITORSABCIXIMAB REOPRO 3aspirin/dipyridamole 1cilostazol 1clopidogrel bisulfate 1dipyridamole 1eptifibatide 1prasugrel hcl 1ticlopidine hcl 1TIROFIBAN HCL MONOHYDRATE AGGRASTAT 3

TIROFIBAN-0.9% SODIUM CHLORIDEAGGRASTAT(12.5MG/250)(PLAST. BAG)

3



Drug Name Tier Requirements/LimitsPLATELET REDUCING AGENTS

anagrelide hcl 1SICKLE CELL ANEMIA AGENTS

HYDROXYUREA DROXIA 2THROMBIN INHIBITORS,SEL.,DIRECT,&REV.-HIRUDIN TYPE

bivalirudin 1DESIRUDIN IPRIVASK 3 QL: 2 IN 1 DAY|20 PER LIFETIME

THROMBIN INHIBITORS,SELECTIVE,DIRECT, & REVERSIBLEDABIGATRAN ETEXILATE MESYLATE PRADAXA 2 QL: 2 IN 1 DAY

THROMBOLYTIC ENZYMESALTEPLASE ACTIVASE 3

ALTEPLASE CATHFLOACTIVASE 3

RETEPLASE RETAVASE 3TENECTEPLASE TNKASE 3

THROMBOPOIETIN RECEPTOR AGONISTSELTROMBOPAG OLAMINE PROMACTA 3 PA

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

HORMONAL DEFICIENCYANDROGENIC AGENTS

testosterone cypionate 1 PAtestosterone enanthate 1 PA

ESTROGEN & PROGESTIN WITH ANTIMINERALOCORTICOID CBDROSPIRENONE/ESTRADIOL ANGELIQ 3

ESTROGEN/ANDROGEN COMBINATIONSestrogen,ester/me-testosterone 1

ESTROGENIC AGENTSESTRADIOL ALORA 2ESTRADIOL DIVIGEL 3ESTRADIOL ELESTRIN 3estradiol 1ESTRADIOL ESTROGEL 3ESTRADIOL EVAMIST 3ESTRADIOL MENOSTAR 2ESTRADIOL MINIVELLE 2ESTRADIOL CYPIONATE DEPO-ESTRADIOL 2

ESTRADIOL VALERATE DELESTROGEN (10MG/ML) (VIAL) 3

estradiol valerate 1ESTRADIOL/LEVONORGESTREL CLIMARA PRO 2ESTRADIOL/NORETHINDRONE ACET COMBIPATCH 2estradiol/norethindrone acet 1ESTRADIOL/NORGESTIMATE PREFEST 2ESTROGEN,CON/M-PROGEST ACET PREMPHASE 2ESTROGEN,CON/M-PROGEST ACET PREMPRO 2ESTROGENS, CONJUGATED PREMARIN 2ESTROGENS,ESTERIFIED MENEST 2estropipate 1norethindrone ac-eth estradiol 0

PROGESTATIONAL AGENTShydroxyprogesterone caproate 1MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 2



Drug Name Tier Requirements/Limitsmedroxyprogesterone acetate 1norethindrone acetate 1progesterone 1PROGESTERONE, MICRONIZED CRINONE 2 PAprogesterone, micronized 1

IMMUNOSUPPRESSION/MODULATIONIMMUNOMODULATORS

ALDESLEUKIN PROLEUKIN 2imiquimod 1 QL: 48 IN 365 DAYS

IMIQUIMOD ZYCLARA (2.5 %)(CRM MD PMP) 3

IMIQUIMOD ZYCLARA (3.75 %)(CRM MD PMP) 3

INTERFERON ALFA-2B,RECOMB. INTRON A (10MMUNIT) (VIAL) 2 PA

INTERFERON ALFA-2B,RECOMB. INTRON A(10MM/ML) (VIAL) 2 PA



INTERFERON ALFA-2B,RECOMB.INTRON A(6MMUNIT/ML)(VIAL)

2 PA

INTERFERON ALFA-N3 ALFERON N 2INTERFERON GAMMA-1B,RECOMB. ACTIMMUNE 2 PA

IMMUNOSUPP - MONOCLONAL AB INHIBITING T LYMPH FXNBASILIXIMAB SIMULECT 2

IMMUNOSUPPRESSIVESAZATHIOPRINE AZASAN 3azathioprine 1azathioprine sodium 1BELATACEPT NULOJIX 3 PAcyclosporine 1

CYCLOSPORINESANDIMMUNE (100MG/ML)(SOLUTION)

3

cyclosporine, modified 1CYCLOSPORINE, MODIFIED NEORAL 3EVEROLIMUS ZORTRESS 3 PAMYCOPHENOLATE MOFETIL CELLCEPT 3mycophenolate mofetil 1mycophenolate sodium 1

SIROLIMUSRAPAMUNE (1MG/ML)(SOLUTION)

3

sirolimus 1TACROLIMUS PROGRAF 3tacrolimus 1

INFECTIOUS DISEASE - BACTERIALBETALACTAMS

aztreonam 1AZTREONAM LYSINE CAYSTON 3 PA

AZTREONAM/DEXTROSE-WATERAZACTAM-ISO-OSMOTICDEXTROSE

2



Drug Name Tier Requirements/LimitsCARBAPENEMS (THIENAMYCINS)

ERTAPENEM SODIUM INVANZ 2imipenem/cilastatin sodium 1meropenem 1

CEPHALOSPORINS - 1ST GENERATIONcefadroxil 1cephalexin 1

CEPHALOSPORINS - 2ND GENERATIONcefaclor 1cefprozil 1CEFUROXIME AXETIL CEFTIN 3

CEPHALOSPORINS - 3RD GENERATIONcefdinir 1

CEFIXIME SUPRAX (400 MG)(CAPSULE) 3 QL: 1 IN 30 DAYS

ceftazidime 1CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC.

FOSFOMYCIN TROMETHAMINE MONUROL 2meth/meblue/sod phos/psal/hyos 1METH/MEBLUE/SOD PHOS/PSAL/HYOS PHOSPHASAL 3METH/MEBLUE/SOD PHOS/PSAL/HYOS URETRON D-S 3METH/MEBLUE/SOD PHOS/PSAL/HYOS URIN D.S. 3methen/mblue/sal/sod phos/hyos 1methenam/sod phos/mblue/hyoscy (81.6-.12mg)(tablet) 1

methenamine hippurate 1methenamine mandelate 1TRIMETHOPRIM PRIMSOL 2trimethoprim 1TRIMETHOPRIM TRIMPEX 2

CYCLIC LIPOPEPTIDESdaptomycin 1

GLYCYLCYCLINEStigecycline 1

MACROLIDESazithromycin 1AZITHROMYCIN ZMAX 3clarithromycin 1ERYTHROMYCIN BASE ERY-TAB 2erythromycin ethylsuccinate 1erythromycin stearate 1FIDAXOMICIN DIFICID 3 PA

NITROFURAN DERIVATIVESnitrofurantoin 1

OXAZOLIDINONESlinezolid 1 PA

LINEZOLIDZYVOX(200MG/0.1L) (IVSOLN)

3 PA

PENICILLINSamoxicillin 1amoxicillin/potassium clav 1dicloxacillin sodium 1

QUINOLONESCIPROFLOXACIN CIPRO 2ciprofloxacin 1



Drug Name Tier Requirements/Limitsciprofloxacin hcl 1ciprofloxacin in 5 % dextrose 1ciprofloxacin lactate 1ciprofloxacin/ciprofloxa hcl 1GEMIFLOXACIN MESYLATE FACTIVE 2levofloxacin 1levofloxacin in dextrose 5 % 1moxifloxacin hcl 1moxifloxacin in nacl (iso-osm) 1ofloxacin 1

STREPTOGRAMINSQUINUPRISTIN/DALFOPRISTIN SYNERCID 2

TETRACYCLINESdemeclocycline hcl 1DOXYCYCLINE CALCIUM VIBRAMYCIN 2doxycycline hyclate (100 mg) (capsule) 1doxycycline hyclate (100 mg) (tablet) 1doxycycline hyclate (100 mg) (vial) 1doxycycline hyclate (50 mg) (capsule) 1doxycycline monohydrate (100 mg) (capsule) 1 QL: 2 IN 1 DAYdoxycycline monohydrate (25 mg/5 ml) (susp recon) 1doxycycline monohydrate (50 mg) (capsule) 1 QL: 2 IN 1 DAYdoxycycline monohydrate (75 mg) (capsule) 1

DOXYCYCLINE/SKIN CLEANSER NO19 MORGIDOX (100MG) (KIT) 3

MINOCYCLINE HCL MINOCIN (100 MG)(VIAL) 3

minocycline hcl (100 mg) (capsule) 1minocycline hcl (100 mg) (tablet) 1minocycline hcl (50 mg) (capsule) 1minocycline hcl (50 mg) (tablet) 1minocycline hcl (75 mg) (capsule) 1minocycline hcl (75 mg) (tablet) 1tetracycline hcl 1

INFECTIOUS DISEASE - FUNGALANTIFUNGAL AGENTS

clotrimazole 1fluconazole 1fluconazole in dextrose,iso-os 1fluconazole in nacl,iso-osm 1flucytosine 1itraconazole 1 PA, QL: 2 IN 1 DAYITRACONAZOLE ONMEL 3 PA

ITRACONAZOLESPORANOX (10MG/ML)(SOLUTION)

3 PA

ketoconazole 1

POSACONAZOLE NOXAFIL (100 MG)(TABLET DR) 3 QL: 93 PER FILL

POSACONAZOLENOXAFIL (200MG/5ML) (ORALSUSP)

3

terbinafine hcl 1voriconazole 1

ANTIFUNGAL ANTIBIOTICSamphotericin b 1AMPHOTERICIN B LIPID COMPLEX ABELCET 2AMPHOTERICIN B LIPOSOME AMBISOME 2



Drug Name Tier Requirements/Limitsgriseofulvin ultramicrosize 1griseofulvin, microsize 1

MICAFUNGIN SODIUM MYCAMINE (100MG) (VIAL) 3

MICAFUNGIN SODIUM MYCAMINE (50MG) (VIAL) 2

nystatin 1

INFECTIOUS DISEASE - MISCELLANEOUSAMINOGLYCOSIDES

amikacin sulfate 1gentamicin in nacl, iso-osm 1gentamicin sulfate 1gentamicin sulfate/pf 1neomycin sulfate 1streptomycin sulfate 1tobramycin in 0.225% sod chlor 1tobramycin sulfate 1tobramycin/sodium chloride 1

ANTIBACTERIAL AGENTS,MISCELLANEOUSglycine urologic solution 1

ANTILEPROTICSdapsone 1

THALIDOMIDE THALOMID (100MG) (CAPSULE) 2



THALIDOMIDE THALOMID (50 MG)(CAPSULE) 2

ANTI-MYCOBACTERIUM AGENTSAMINOSALICYLIC ACID PASER 2ethambutol hcl 1ETHIONAMIDE TRECATOR 2isoniazid 1pyrazinamide 1rifabutin 1

ANTITUBERCULAR ANTIBIOTICSBEDAQUILINE FUMARATE SIRTURO 3 PA

CAPREOMYCIN SULFATE CAPASTATSULFATE 2

cycloserine 1RIFAMP/ISONIAZID/PYRAZINAMIDE RIFATER 2rifampin 1RIFAMPIN/ISONIAZID RIFAMATE 2RIFAPENTINE PRIFTIN 2

CHLORAMPHENICOL AND DERIVATIVESchloramphenicol sod succinate 1

LINCOSAMIDESclindamycin hcl 1clindamycin palmitate hcl 1clindamycin phosphate 1clindamycin phosphate/d5w 1lincomycin hcl 1

POLYMYXIN AND DERIVATIVEScolistin (colistimethate na) 1polymyxin b sulfate 1



Drug Name Tier Requirements/LimitsRIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS

RIFAXIMIN XIFAXAN (200 MG)(TABLET) 3

RIFAXIMIN XIFAXAN (550 MG)(TABLET) 3 PA

VANCOMYCIN AND DERIVATIVESvancomycin hcl (125 mg) (capsule) 1 PAvancomycin hcl (250 mg) (capsule) 1 PA

INFECTIOUS DISEASE - PARASITIC2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL

tinidazole 1AMEBACIDES

paromomycin sulfate 1ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS

metronidazole 1metronidazole/sodium chloride 1

ANTHELMINTICSALBENDAZOLE ALBENZA 2ivermectin 1PRAZIQUANTEL BILTRICIDE 2

ANTIMALARIAL DRUGSARTEMETHER/LUMEFANTRINE COARTEM 3atovaquone/proguanil hcl 1chloroquine phosphate 1hydroxychloroquine sulfate 1mefloquine hcl 1PRIMAQUINE PHOSPHATE PRIMAQUINE 3PYRIMETHAMINE DARAPRIM 2quinine sulfate 1

ANTIPARASITICSNITAZOXANIDE ALINIA 2

ANTIPROTOZOAL DRUGS,MISCELLANEOUSatovaquone 1PENTAMIDINE ISETHIONATE NEBUPENT 2PENTAMIDINE ISETHIONATE PENTAM 300 3

INFECTIOUS DISEASE - VIRALANTIVIRAL MONOCLONAL ANTIBODIES

PALIVIZUMAB SYNAGIS 2 PAANTIVIRALS, GENERAL

acyclovir 1acyclovir sodium 1cidofovir 1famciclovir 1foscarnet sodium 1ganciclovir sodium 1oseltamivir phosphate 1rimantadine hcl 1valacyclovir hcl 1valganciclovir hcl (450 mg) (tablet) 1valganciclovir hcl (50 mg/ml) (soln recon) 1 AGE: <= 6 YEARSZANAMIVIR RELENZA 3 QL: 20 IN 365 DAYS

ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIBDARUNAVIR ETHANOLATE PREZISTA 3DARUNAVIR/COBICISTAT PREZCOBIX 3 QL: 1 IN 1 DAYTIPRANAVIR APTIVUS 3



Drug Name Tier Requirements/LimitsTIPRANAVIR/VITAMIN E TPGS APTIVUS 2

ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOGEMTRICITABINE/TENOFOV ALAFENAM DESCOVY 3

EMTRICITABINE/TENOFOVIR (TDF) TRUVADA (200-300MG) (TABLET) 2

ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMBabacavir sulfate/lamivudine 1abacavir/lamivudine/zidovudine 1lamivudine/zidovudine 1

ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG.

MARAVIROC SELZENTRY (150MG) (TABLET) 3 QL: 2 IN 1 DAY

MARAVIROC SELZENTRY (300MG) (TABLET) 3 QL: 2 IN 1 DAY

ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORSENFUVIRTIDE FUZEON 3 PA

ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTIDELAVIRDINE MESYLATE RESCRIPTOR 2efavirenz 1

EFAVIRENZ SUSTIVA (600 MG)(TABLET) 2

ETRAVIRINE INTELENCE (100MG) (TABLET) 2

ETRAVIRINE INTELENCE (200MG) (TABLET) 3

ETRAVIRINE INTELENCE (25 MG)(TABLET) 2

nevirapine 1RILPIVIRINE HCL EDURANT 3

ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTIabacavir sulfate 1didanosine 1DIDANOSINE VIDEX 2EMTRICITABINE EMTRIVA 2lamivudine 1stavudine 1

STAVUDINE ZERIT (1 MG/ML)(SOLN RECON) 2

ZIDOVUDINE RETROVIR (10MG/ML) (VIAL) 2

zidovudine 1ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI

tenofovir disoproxil fumarate 1

TENOFOVIR DISOPROXIL FUMARATE VIREAD (150 MG)(TABLET) 3



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

3

ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB

LOPINAVIR/RITONAVIR KALETRA (100MG-25MG) (TABLET) 3

LOPINAVIR/RITONAVIR KALETRA (200MG-50MG) (TABLET) 2

lopinavir/ritonavir 2



Drug Name Tier Requirements/LimitsANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS

ATAZANAVIR SULFATE REYATAZ (150 MG)(CAPSULE) 2



ATAZANAVIR SULFATE REYATAZ (50 MG)(POWD PACK) 3

ATAZANAVIR SULFATE/COBICISTAT EVOTAZ 3 QL: 1 IN 1 DAYfosamprenavir calcium 1

FOSAMPRENAVIR CALCIUM LEXIVA (50 MG/ML)(ORAL SUSP) 3

INDINAVIR SULFATE CRIXIVAN 2NELFINAVIR MESYLATE VIRACEPT 2RITONAVIR NORVIR 3SAQUINAVIR MESYLATE INVIRASE 2

ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR

DOLUTEGRAVIR SODIUM TIVICAY (50 MG)(TABLET) 2 ST

RALTEGRAVIR POTASSIUM ISENTRESS (100MG) (POWD PACK) 3

RALTEGRAVIR POTASSIUM ISENTRESS (100MG) (TAB CHEW) 3

RALTEGRAVIR POTASSIUM ISENTRESS (25 MG)(TAB CHEW) 3

RALTEGRAVIR POTASSIUM ISENTRESS (400MG) (TABLET) 2 QL: 4 IN 1 DAY

ARTV CMB NUCLEOSIDE,NUCLEOTIDE,&NON-NUCLEOSIDE RTIEFAVIRENZ/EMTRICITAB/TENOFOVIR ATRIPLA 2EMTRICITA/RILPIVIRINE/TENOF DF COMPLERA 3EMTRICITAB/RILPIVIRI/TENOF ALA ODEFSEY 3

ARV CMB-NRTI,N(T)RTI, INTEGRASE INHIBITORELVITEG/COB/EMTRI/TENOF ALAFEN GENVOYA 3ELVITEG/COB/EMTRI/TENOFO DISOP STRIBILD 3

ARV COMB-NRTIS & INTEGRASE INHIBITORABACAVIR/DOLUTEGRAVIR/LAMIVUDI TRIUMEQ 3

CYTOCHROME P450 INHIBITORSCOBICISTAT TYBOST 3 ST, QL: 1 IN 1 DAY

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

HEP C VIRUS - NS5A & NS5B POLYMERASE INHIB. COMBO.SOFOSBUVIR/VELPATASVIR EPCLUSA 3 PA

HEPATITIS B TREATMENT AGENTSadefovir dipivoxil 1

ENTECAVIRBARACLUDE (0.05MG/ML)(SOLUTION)

2

entecavir 1

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

2

lamivudine 1TENOFOVIR ALAFENAMIDE FUMARATE VEMLIDY 3 QL: 1 IN 1 DAY

HEPATITIS C TREATMENT AGENTSPEGINTERFERON ALFA-2A PEGASYS 2 PA




PEGINTERFERON ALFA-2A PEGASYSPROCLICK 2 PA

PEGINTERFERON ALFA-2B PEGINTRON 2 PARIBAVIRIN REBETOL 2ribavirin (200 mg) (capsule) 1ribavirin (200 mg) (tablet) 1ribavirin (400 mg) (tablet) 1ribavirin (600 mg) (tablet) 1

HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMBELBASVIR/GRAZOPREVIR ZEPATIER 3 PA

INFLAMMATORY DISEASEANTI-ARTHRITIC AND CHELATING AGENTS

PENICILLAMINE DEPEN 2ANTI-FLAM. INTERLEUKIN-1 RECEPTOR ANTAGONIST

ANAKINRA KINERET 2 PARILONACEPT ARCALYST 3 PA

ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR

ADALIMUMABHUMIRA(10MG/0.2ML)(SYRINGEKIT)

2 PA, QL: 1 IN 15 DAYS





ADALIMUMABHUMIRAPEDIATRICCROHN'S


ADALIMUMAB HUMIRA PEN 2 PA, QL: 1 IN 15 DAYS

ADALIMUMABHUMIRA PENCROHN-UC-HSSTARTER


ADALIMUMAB HUMIRA PENPSORIASIS-UVEITIS 2 PA, QL: 1 IN 15 DAYS

ETANERCEPT ENBREL 3 PA, QL: 4 IN 15 DAYS

ETANERCEPT ENBRELSURECLICK 3 PA, QL: 4mL IN 15 DAYS

GOLIMUMAB SIMPONI 3 PAANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR

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

APREMILAST OTEZLA 3 PAANTI-INFLAMMATORY/ANTIARTHRITICS AGENTS, MISC.

HYALURONATE SOD, CROSS-LINKED GEL-ONE 2 PAHYALURONATE SODIUM EUFLEXXA 2 PAHYALURONATE SODIUM GENVISC 850 2 PAHYALURONATE SODIUM HYALGAN 2 PAHYALURONATE SODIUM ORTHOVISC 2 PAHYALURONATE SODIUM SUPARTZ FX 2 PAHYALURONATE SODIUM VISCO-3 2 PAHYLAN G-F 20 SYNVISC 2 PAHYLAN G-F 20 SYNVISC-ONE 2 PA

ANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITOR

ABATACEPT ORENCIA (125MG/ML) (SYRINGE) 3 PA




ABATACEPT ORENCIACLICKJECT 3 PA

ABATACEPT/MALTOSE ORENCIA 3 PABRADYKININ B2 RECEPTOR ANTAGONISTS

ICATIBANT ACETATE FIRAZYR 2 PAGLUCOCORTICOIDS

BETAMETHASON/NORFLURAN/PENTFLU BETALOAN SUIK 3betamethasone acetate,sod phos 1budesonide 1BUDESONIDE UCERIS 3 STcortisone acetate 1dexamethasone 1DEXAMETHASONE INTENSOL 2DEXAMETHASONE DEXPAK 2

DEXAMETHASONE ZODEX (1.5MG (21))(TAB DS PK) 2

dexamethasone in 0.9 % sod chl 1dexamethasone sod phosphate 1dexamethasone sodium phosp/pf 1hydrocortisone 1hydrocortisone sod succinate 1HYDROCORTISONE SOD SUCCINATE SOLU-CORTEF 2HYDROCORTISONE SODIUM SUCC/PF SOLU-CORTEF 3

ME-PREDNIS/NORFLURAN/HFC 245FA MEDROLOAN IISUIK 3

ME-PREDNIS/NORFLURAN/HFC 245FA MEDROLOAN SUIK 3ME-PREDNIS/NORFLURAN/HFC 245FA P-CARE D40G 3ME-PREDNIS/NORFLURAN/HFC 245FA P-CARE D80G 3

METHYLPREDNISOLONE MEDROL (2 MG)(TABLET) 2

methylprednisolone 1

METHYLPREDNISOLONE ACETATE DEPO-MEDROL (20MG/ML) (VIAL) 2

methylprednisolone acetate 1methylprednisolone sod succ 1

METHYLPREDNISOLONE SOD SUCC SOLU-MEDROL (2G) (VIAL) 2

METHYLPREDNISOLONE SOD SUCC SOLU-MEDROL (500MG) (VIAL) 2

METHYLPREDNISOLONE SOD SUCC/PF SOLU-MEDROL 3PREDNISOLONE MILLIPRED 3PREDNISOLONE MILLIPRED DP 3prednisolone 1prednisolone sod phosphate (10 mg) (tab rapdis) 1prednisolone sod phosphate (15 mg/5 ml) (solution) 1prednisolone sod phosphate (25 mg/5 ml) (solution) 1prednisolone sod phosphate (30 mg) (tab rapdis) 1prednisolone sod phosphate (5 mg/5 ml) (solution) 1prednisone 1PREDNISONE INTENSOL 2PREDNISONE RAYOS 3TRIAMCIN/NORFLURANE/HFC 245FA P-CARE K40G 3TRIAMCIN/NORFLURANE/HFC 245FA P-CARE K80G 3TRIAMCIN/NORFLURANE/HFC 245FA POD-CARE 100KG 3TRIAMCIN/NORFLURANE/HFC 245FA TRILOAN II SUIK 3TRIAMCIN/NORFLURANE/HFC 245FA TRILOAN SUIK 3TRIAMCINOLONE ACETONIDE KENALOG-10 2triamcinolone acetonide 1



Drug Name Tier Requirements/LimitsTRIAMCINOLONE HEXACETONIDE ARISTOSPAN 2

GOLD SALTSAURANOFIN RIDAURA 2

INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORSTOCILIZUMAB ACTEMRA 3 PA

JANUS KINASE (JAK) INHIBITORSTOFACITINIB CITRATE XELJANZ 3 PA

MINERALOCORTICOIDSfludrocortisone acetate 1

MONOCLONAL ANTIBODY-HUMAN INTERLEUKIN 12/23 INHIB

USTEKINUMABSTELARA(130MG/26ML)(VIAL)

3

USTEKINUMABSTELARA(45MG/0.5ML)(SYRINGE)

3 PA

NSAID & TOPICAL IRRITANT COUNTER-IRRITANT COMB.DICLOFENAC SODIUM/CAPSAICIN NUDICLO 3

NSAIDS (COX NON-SPECIFIC INHIB)& PROSTAGLANDIN CMBdiclofenac sodium/misoprostol 1

NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPEdiclofenac sodium 1etodolac 1fenoprofen calcium (600 mg) (tablet) 1flurbiprofen 1meloxicam 1nabumetone 1naproxen 1

NAPROXEN SODIUM NAPRELAN (750MG) (TBMP 24HR) 3

naproxen sodium (275 mg) (tablet) 1naproxen sodium (550 mg) (tablet) 1oxaprozin 1piroxicam 1sulindac 1tolmetin sodium 1

LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATBOWEL ANTIINFLAMATORY AGENTS

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

MESALAMINE CANASA 3DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT

balsalazide disodium 1BALSALAZIDE DISODIUM GIAZO 3 STMESALAMINE APRISO 2 QL: 4 IN 1 DAYMESALAMINE DELZICOL 2MESALAMINE PENTASA 3sulfasalazine 1

DRUGS TO TX CHRONIC INFLAMM. DISEASE OF COLONCERTOLIZUMAB PEGOL CIMZIA 3 PAINFLIXIMAB REMICADE 3 PAINFLIXIMAB-DYYB INFLECTRA 3 PA

IRRITABLE BOWEL AGENTS,GUANYLATE CYLASE-C AGONIST

LINACLOTIDE LINZESS (145 MCG)(CAPSULE) 3 QL: 1 IN 1 DAY



Drug Name Tier Requirements/LimitsRECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR)

BUDESONIDE UCERIS 3

LOWER GASTROINTESTINAL DISORDERS - OTHERAMMONIA INHIBITORS

ACETOHYDROXAMIC ACID LITHOSTAT 2CARGLUMIC ACID CARBAGLU 3 PAsodium benzoate/sod phenylacet 1sodium phenylbutyrate 1

ANTIDIARRHEALSdiphenoxylate hcl/atropine 1opium tincture 1paregoric 1

LAXATIVES AND CATHARTICSLACTULOSE KRISTALOSE 2lactulose 1LUBIPROSTONE AMITIZA 3 QL: 2 IN 1 DAYPEG 3350/SOD CHLOR/POTASS CIT GIALAX 3polyethylene glycol 3350 (17g/dose) (powder) 1SOD PHOSPHATE MBAS/SOD PHOS,DI OSMOPREP 0SODIUM, POTASSIUM,MAG SULFATES SUPREP 0

NARCOTIC ANTAGONISTS, PERIPHERALLY-ACTINGALVIMOPAN ENTEREG 3NALOXEGOL OXALATE MOVANTIK 3 QL: 1 IN 1 DAY

MISCELLANEOUS AGENTSANAPHYLAXIS THERAPY AGENTS

epinephrine (0.15/0.15) (auto injct) 1 QL: 3 IN 30 DAYS

NEOPLASTIC DISEASEALKYLATING AGENTS

ALTRETAMINE HEXALEN 2 PR: RESTRICTED TOONCOLOGIST

BENDAMUSTINE HCL TREANDA 3 PR: RESTRICTED TOONCOLOGIST

BUSULFAN MYLERAN 2 PR: RESTRICTED TOONCOLOGIST

carboplatin 1 PR: RESTRICTED TOONCOLOGIST

CARMUSTINE BICNU 2 PR: RESTRICTED TOONCOLOGIST

CARMUSTINE IN POLIFEPROSAN 20 GLIADEL 3 PR: RESTRICTED TOONCOLOGIST

CHLORAMBUCIL LEUKERAN 2 PR: RESTRICTED TOONCOLOGIST

cisplatin 1 PR: RESTRICTED TOONCOLOGIST

CYCLOPHOSPHAMIDE (25 MG) (CAPSULE) 3 PR: RESTRICTED TOONCOLOGIST

CYCLOPHOSPHAMIDE (50 MG) (CAPSULE) 3 PR: RESTRICTED TOONCOLOGIST

hydroxyurea 1 PR: RESTRICTED TOONCOLOGIST

ifosfamide 1 PR: RESTRICTED TOONCOLOGIST

ifosfamide/mesna 1 PR: RESTRICTED TOONCOLOGIST

LOMUSTINE GLEOSTINE (10 MG)(CAPSULE) 2 PR: RESTRICTED TO

ONCOLOGIST




MECHLORETHAMINE HCL MUSTARGEN 2 PR: RESTRICTED TOONCOLOGIST

melphalan 1

melphalan hcl 1 PR: RESTRICTED TOONCOLOGIST

oxaliplatin 1 PR: RESTRICTED TOONCOLOGIST

TEMOZOLOMIDE TEMODAR (100 MG)(VIAL) 3 PA

temozolomide 1 PA

thiotepa 1 PR: RESTRICTED TOONCOLOGIST

ANTIANDROGENIC AGENTS

ABIRATERONE ACETATE ZYTIGA (250 MG)(TABLET) 3 PA

bicalutamide 1 PR: RESTRICTED TOONCOLOGIST

ENZALUTAMIDE XTANDI 3 PR: RESTRICTED TOONCOLOGIST

flutamide 1 PR: RESTRICTED TOONCOLOGIST

nilutamide 1 PR: RESTRICTED TOONCOLOGIST

ANTIBIOTIC ANTINEOPLASTICS

bleomycin sulfate 1 PR: RESTRICTED TOONCOLOGIST

dactinomycin 1 PR: RESTRICTED TOONCOLOGIST

daunorubicin hcl 1 PR: RESTRICTED TOONCOLOGIST

doxorubicin hcl 1 PR: RESTRICTED TOONCOLOGIST

epirubicin hcl 1 PR: RESTRICTED TOONCOLOGIST

idarubicin hcl 1 PR: RESTRICTED TOONCOLOGIST

mitomycin 1 PR: RESTRICTED TOONCOLOGIST

STREPTOZOCIN ZANOSAR 2 PR: RESTRICTED TOONCOLOGIST

VALRUBICIN VALSTAR 3 PR: RESTRICTED TOONCOLOGIST

ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODYRITUXIMAB RITUXAN 2 PA

ANTIMETABOLITES

azacitidine 1 PR: RESTRICTED TOONCOLOGIST

capecitabine 1 PR: RESTRICTED TOONCOLOGIST

cladribine 1 PR: RESTRICTED TOONCOLOGIST

cytarabine 1 PR: RESTRICTED TOONCOLOGIST

cytarabine/pf 1 PR: RESTRICTED TOONCOLOGIST

floxuridine 1 PR: RESTRICTED TOONCOLOGIST

fludarabine phosphate 1 PR: RESTRICTED TOONCOLOGIST




fluorouracil 1 PR: RESTRICTED TOONCOLOGIST

gemcitabine hcl 1 PR: RESTRICTED TOONCOLOGIST

mercaptopurine 1 PR: RESTRICTED TOONCOLOGIST

MERCAPTOPURINE PURIXAN 3 AGE: >= 7 YEARS, PR:RESTRICTED TO ONCOLOGIST

methotrexate sodium 1METHOTREXATE SODIUM TREXALL 2methotrexate sodium/pf 1

NELARABINE ARRANON 3 PR: RESTRICTED TOONCOLOGIST

PEMETREXED DISODIUM ALIMTA (100 MG)(VIAL) 3 PR: RESTRICTED TO

ONCOLOGIST

PEMETREXED DISODIUM ALIMTA (500 MG)(VIAL) 2 PR: RESTRICTED TO

ONCOLOGIST

PENTOSTATIN NIPENT 3 PR: RESTRICTED TOONCOLOGIST

THIOGUANINE TABLOID 2 PR: RESTRICTED TOONCOLOGIST

ANTINEOPLAST EGF RECEPTOR BLOCKER RCMB MC ANTIBODY

CETUXIMAB ERBITUX 2 PR: RESTRICTED TOONCOLOGIST

TRASTUZUMAB HERCEPTIN (440MG) (VIAL) 2 PR: RESTRICTED TO

ONCOLOGISTANTINEOPLAST HUM VEGF INHIBITOR RECOMB MC ANTIBODY

BEVACIZUMAB AVASTIN 2 PA, PR: RESTRICTED TOONCOLOGIST

ANTINEOPLASTIC AROMATASE INHIBITORS

anastrozole 1 PR: RESTRICTED TOONCOLOGIST

exemestane 1 PR: RESTRICTED TOONCOLOGIST

letrozole 1ANTINEOPLASTIC - EPOTHILONES AND ANALOGS

IXABEPILONE IXEMPRA 3 PR: RESTRICTED TOONCOLOGIST

ANTINEOPLASTIC - HALICHONDRIN B ANALOGSERIBULIN MESYLATE HALAVEN 3 PA

ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORSRUXOLITINIB PHOSPHATE JAKAFI 3 PA

ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORSCOBIMETINIB FUMARATE COTELLIC 3 PATRAMETINIB DIMETHYL SULFOXIDE MEKINIST 3 PA

ANTINEOPLASTIC - MTOR KINASE INHIBITORS

EVEROLIMUS AFINITOR (10 MG)(TABLET) 3 PR: RESTRICTED TO

ONCOLOGIST

EVEROLIMUS AFINITOR (2.5 MG)(TABLET) 3 PA, PR: RESTRICTED TO

ONCOLOGIST

EVEROLIMUS AFINITOR (5 MG)(TABLET) 3 PR: RESTRICTED TO

ONCOLOGIST

EVEROLIMUS AFINITOR (7.5 MG)(TABLET) 3 PR: RESTRICTED TO

ONCOLOGIST

EVEROLIMUS AFINITOR DISPERZ 3 PA, PR: RESTRICTED TOONCOLOGIST



Drug Name Tier Requirements/LimitsANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS

IRINOTECAN HCLCAMPTOSAR(300MG/15ML)(VIAL)

3 PR: RESTRICTED TOONCOLOGIST

irinotecan hcl 1 PR: RESTRICTED TOONCOLOGIST

TOPOTECAN HCL HYCAMTIN (0.25MG) (CAPSULE) 3 PR: RESTRICTED TO

ONCOLOGIST

TOPOTECAN HCL HYCAMTIN (1 MG)(CAPSULE) 3 PR: RESTRICTED TO

ONCOLOGISTANTINEOPLASTIC - VEGF-A,B & P1GF INHIBITOR

ZIV-AFLIBERCEPT ZALTRAP 3ANTINEOPLASTIC - VEGFR ANTAGONIST

RAMUCIRUMABCYRAMZA(500MG/50ML)(VIAL)

3

ANTINEOPLASTIC IMMUNOMODULATOR AGENTSLENALIDOMIDE REVLIMID 3 PA

POMALIDOMIDE POMALYST 3 PA, PR: RESTRICTED TOONCOLOGIST

ANTINEOPLASTIC LHRH(GNRH) ANTAGONIST,PITUIT.SUPPRSDEGARELIX ACETATE FIRMAGON 3

ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS

ACALABRUTINIB CALQUENCE 3 PR: RESTRICTED TOONCOLOGIST

AFATINIB DIMALEATE GILOTRIF 3 PA

BORTEZOMIB VELCADE 2 PR: RESTRICTED TOONCOLOGIST

BOSUTINIB BOSULIF (100 MG)(TABLET) 3 PR: RESTRICTED TO

ONCOLOGIST

BOSUTINIB BOSULIF (500 MG)(TABLET) 3 PR: RESTRICTED TO

ONCOLOGIST

CABOZANTINIB S-MALATE CABOMETYX 3 PA, PR: RESTRICTED TOONCOLOGIST

CABOZANTINIB S-MALATE COMETRIQ 3 PA, PR: RESTRICTED TOONCOLOGIST

CARFILZOMIB KYPROLIS (60 MG)(VIAL) 3 PR: RESTRICTED TO

ONCOLOGISTCRIZOTINIB XALKORI 3 PADASATINIB SPRYCEL 2 PAERLOTINIB HCL TARCEVA 3 PAIBRUTINIB IMBRUVICA 3 PAimatinib mesylate 1 PA

LAPATINIB DITOSYLATE TYKERB 3 PR: RESTRICTED TOONCOLOGIST

LENVATINIB MESYLATELENVIMA (18MG/DAY)(CAPSULE)

3 PA, PR: RESTRICTED TOONCOLOGIST

LENVATINIB MESYLATELENVIMA (8MG/DAY)(CAPSULE)

3 PA, PR: RESTRICTED TOONCOLOGIST

NILOTINIB HCL TASIGNA (150 MG)(CAPSULE) 3 PA, PR: RESTRICTED TO

ONCOLOGIST

NILOTINIB HCL TASIGNA (200 MG)(CAPSULE) 3 PR: RESTRICTED TO

ONCOLOGIST

PAZOPANIB HCL VOTRIENT 3 PA, PR: RESTRICTED TOONCOLOGIST

REGORAFENIB STIVARGA 3 PASORAFENIB TOSYLATE NEXAVAR 2 PA



Drug Name Tier Requirements/LimitsSUNITINIB MALATE SUTENT 2 PAVANDETANIB CAPRELSA 3 PAVEMURAFENIB ZELBORAF 3 PA, QL: 8 IN 1 DAY

ANTINEOPLASTIC,ANTI-PROGRAMMED DEATH-1 (PD-1) MABNIVOLUMAB OPDIVO 3 PAPEMBROLIZUMAB KEYTRUDA 3 PA

ANTINEOPLASTIC,HISTONE DEACETYLASE INHIBITORS,HDISVORINOSTAT ZOLINZA 3 PA

ANTINEOPLASTIC-INTERLEUKIN-6(IL-6)INHIB,ANTIBODYSILTUXIMAB SYLVANT 3

ANTINEOPLASTIC-ISOCITRATE DEHYDROGENASE INHIBITORS

ENASIDENIB MESYLATE IDHIFA (100 MG)(TABLET) 3

ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES

ALEMTUZUMAB CAMPATH 3 PR: RESTRICTED TOONCOLOGIST

DINUTUXIMAB UNITUXIN 3 PA, PR: RESTRICTED TOONCOLOGIST

KIT Y-90/IBRITUMOMAB/H.ALBUMIN ZEVALIN 3 PR: RESTRICTED TOONCOLOGIST

ANTINEOPLASTICS,MISCELLANEOUS

BCG LIVE BCG (TICE STRAIN) 0 PR: RESTRICTED TOONCOLOGIST

dacarbazine 1 PR: RESTRICTED TOONCOLOGIST

DOCETAXEL DOCEFREZ 3 PR: RESTRICTED TOONCOLOGIST

docetaxel (160mg/16ml) (vial) 1 PR: RESTRICTED TOONCOLOGIST

etoposide 1 PR: RESTRICTED TOONCOLOGIST

ETOPOSIDE PHOSPHATE ETOPOPHOS 2 PR: RESTRICTED TOONCOLOGIST

MITOTANE LYSODREN 2 PR: RESTRICTED TOONCOLOGIST

mitoxantrone hcl 1 PA, PR: RESTRICTED TOONCOLOGIST

paclitaxel 1 PR: RESTRICTED TOONCOLOGIST

PACLITAXEL PROTEIN-BOUND ABRAXANE 2 PR: RESTRICTED TOONCOLOGIST

PEGASPARGASE ONCASPAR 2 PR: RESTRICTED TOONCOLOGIST

PROCARBAZINE HCL MATULANE 2 PR: RESTRICTED TOONCOLOGIST

tretinoin 1INTRAPLEURAL SCLEROSING AGENTS, ANTINEOPLAST. ADJ.

TALC SCLEROSOL 3 PR: RESTRICTED TOONCOLOGIST

talc 1 PR: RESTRICTED TOONCOLOGIST

PHOTOACTIVATED, ANTINEOPLASTIC AGENTS (SYSTEMIC)

METHOXSALEN UVADEX 2 PR: RESTRICTED TOONCOLOGIST

PORFIMER SODIUM PHOTOFRIN 2 PR: RESTRICTED TOONCOLOGIST



Drug Name Tier Requirements/LimitsPHOTOACTIVATED, ANTINEOPLS. & PREMALIGNANT LESIONS

AMINOLEVULINIC ACID HCL AMELUZ 3 PR: RESTRICTED TOONCOLOGIST

AMINOLEVULINIC ACID HCL LEVULAN 2 PR: RESTRICTED TOONCOLOGIST

SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM)

FULVESTRANT FASLODEX 2 PR: RESTRICTED TOONCOLOGIST

TAMOXIFEN CITRATE SOLTAMOX 3tamoxifen citrate 1

TOREMIFENE CITRATE FARESTON 2 PR: RESTRICTED TOONCOLOGIST

SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR)

bexarotene 1 PR: RESTRICTED TOONCOLOGIST

STEROID ANTINEOPLASTICS

ESTRAMUSTINE PHOSPHATE SODIUM EMCYT 2 PR: RESTRICTED TOONCOLOGIST

megestrol acetate 1VINCA ALKALOIDS

vinblastine sulfate 1 PR: RESTRICTED TOONCOLOGIST

vincristine sulfate 1 PR: RESTRICTED TOONCOLOGIST

vinorelbine tartrate 1 PR: RESTRICTED TOONCOLOGIST

NEUROLOGICAL DISEASE - MISCELLANEOUSAGENTS TO TREAT MULTIPLE SCLEROSIS

ALEMTUZUMAB LEMTRADA 3 PADIMETHYL FUMARATE TECFIDERA 2 PAFINGOLIMOD HCL GILENYA 3 PA, QL: 1 IN 1 DAY

glatiramer acetate (20 mg/ml) (syringe) 1 PR: RESTRICTED TONEUROLOGIST

INTERFERON BETA-1A AVONEX 3 PR: RESTRICTED TONEUROLOGIST

INTERFERON BETA-1A AVONEX PEN 3 PR: RESTRICTED TONEUROLOGIST

INTERFERON BETA-1A/ALBUMIN AVONEX 3 PR: RESTRICTED TONEUROLOGIST

INTERFERON BETA-1A/ALBUMINREBIF(22MCG/.5ML)(SYRINGE)

2 PR: RESTRICTED TONEUROLOGIST

INTERFERON BETA-1A/ALBUMINREBIF(44MCG/.5ML)(SYRINGE)

2 PR: RESTRICTED TONEUROLOGIST

INTERFERON BETA-1A/ALBUMIN REBIF (8.8-22(6))(SYRINGE) 3 PR: RESTRICTED TO

NEUROLOGIST

INTERFERON BETA-1A/ALBUMIN REBIF REBIDOSE 2 PR: RESTRICTED TONEUROLOGIST

INTERFERON BETA-1B BETASERON 3 PR: RESTRICTED TONEUROLOGIST

INTERFERON BETA-1B EXTAVIA 3 PR: RESTRICTED TONEUROLOGIST

PEGINTERFERON BETA-1A PLEGRIDY 3 PAPEGINTERFERON BETA-1A PLEGRIDY PEN 3 PA

TERIFLUNOMIDE AUBAGIO (14 MG)(TABLET) 2



Drug Name Tier Requirements/LimitsAMYOTROPHIC LATERAL SCLEROSIS AGENTS

riluzole 1MOVEMENT DISORDERS(DRUG THERAPY)

tetrabenazine 1PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTS

DEXTROMETHORPHAN HBR/QUINIDINE NUEDEXTA 3 PA

PAIN MANAGEMENT - ANALGESICSANALGESIC, NON-SALICYLATE & BARBITURATE COMB.

butalbital/acetaminophen (50mg-325mg) (tablet) 1ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMB

BUTALB/ACETAMINOPHEN/CAFFEINE VANATOL LQ 3BUTALB/ACETAMINOPHEN/CAFFEINE VANATOL S 3

ANALGESIC/ANTIPYRETICS, SALICYLATEScholine salicyl/mag salicylate 1diflunisal 1salsalate 1

ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATIONhydrocodone/ibuprofen (7.5-200 mg) (tablet) 1 QL: 5 IN 3 DAYSibuprofen/oxycodone hcl 1

ANALGESICS, NON-NARCOTICSclonidine hcl/pf 1

ANALGESICS,NARCOTICSbuprenorphine (10 mcg/hr) (patch tdwk) 1 QL: 4 IN 28 DAYSBUPRENORPHINE HCL BUPRENEX 3buprenorphine hcl 1carisoprodol/aspirin/codeine 1fentanyl (75mcg/hr) (patch td72) 1 QL: 1 IN 3 DAYS

FENTANYL CITRATE ABSTRAL (100MCG) (TAB SUBL) 3 PA

fentanyl citrate 1 QL: 1 IN 5 DAYSFENTANYL CITRATE FENTORA 3 QL: 1 IN 5 DAYSfentanyl citrate/pf (100mcg/2ml) (syringe) 1hydrocodone/acetaminophen (10mg-300mg) (tablet) 1hydromorphone hcl (1 mg/ml) (ampul) 1levorphanol tartrate 1meperidine hcl 1MEPERIDINE HCL/PF DEMEROL 3meperidine hcl/pf 1methadone hcl (10 mg) (tablet) 1

MORPHINE SULFATE KADIAN (40 MG)(CAP ER PEL) 3

morphine sulfate (10 mg) (cap er pel) 1MORPHINE SULFATE/PF INFUMORPH 3morphine sulfate/pf 1nalbuphine hcl 1opium/belladonna alkaloids 1oxycodone hcl (10 mg) (tab er 12h) 1 QL: 3 IN 1 DAY

OXYCODONE HCL OXYCONTIN (15MG) (TAB ER 12H) 2 QL: 3 IN 1 DAY

oxycodone hcl/acetaminophen 1oxymorphone hcl (10 mg) (tab er 12h) 1pentazocine hcl/naloxone hcl 1PENTAZOCINE LACTATE TALWIN 2tramadol hcl (100 mg) (tab er 24h) 1 QL: 1 IN 1 DAY

ANTIMIGRAINE PREPARATIONSeletriptan hbr 1 ST, QL: 1 IN 5 DAYS



Drug Name Tier Requirements/LimitsERGOTAMINE TARTRATE ERGOMAR 2ergotamine tartrate/caffeine 1 QL: 10 IN 30 DAYSERGOTAMINE TARTRATE/CAFFEINE MIGERGOT 3isomethept/dichlphn/acetaminop 1naratriptan hcl 1 QL: 3 IN 10 DAYSrizatriptan benzoate 1 QL: 2 IN 5 DAYSsumatriptan 1 QL: 2 IN 5 DAYS

SUMATRIPTAN SUCC/NAPROXEN SOD TREXIMET (10 MG-60MG) (TABLET) 3

sumatriptan succinate (100 mg) (tablet) 1 QL: 3 IN 10 DAYSzolmitriptan 1 QL: 1 IN 5 DAYS

NARC.& NON-SAL.ANALGESIC,BARBITURATE &XANTHINE CMBbutalbit/acetamin/caff/codeine (50-325-30) (capsule) 1

NARCOTIC WITHDRAWAL THERAPY AGENTSbuprenorphine hcl (0.3 mg/ml) (syringe) 1buprenorphine hcl (2 mg) (tab subl) 1 PAbuprenorphine hcl (8 mg) (tab subl) 1 PAbuprenorphine hcl/naloxone hcl 1 PA

BUPRENORPHINE HCL/NALOXONE HCL SUBOXONE (8 MG-2MG) (FILM) 3 PA

BUPRENORPHINE HCL/NALOXONE HCLZUBSOLV (1.4-0.36MG) (TABSUBL)

3 PA

PARKINSONS DISEASEANTIPARKINSONISM DRUGS,ANTICHOLINERGIC

benztropine mesylate 1trihexyphenidyl hcl 1

ANTIPARKINSONISM DRUGS,OTHERamantadine hcl 1APOMORPHINE HCL APOKYN 3 PAbromocriptine mesylate 1carbidopa/levodopa 1entacapone 1pramipexole di-hcl (0.125 mg) (tablet) 1rasagiline mesylate 2ropinirole hcl 1selegiline hcl 1SELEGILINE HCL ZELAPAR 3tolcapone 1

DECARBOXYLASE INHIBITORScarbidopa 1

SEIZURE DISORDERANTICONVULSANTS

carbamazepine 1CARBAMAZEPINE TEGRETOL 3CARBAMAZEPINE TEGRETOL XR 3clonazepam 1diazepam 1DIVALPROEX SODIUM DEPAKOTE 3DIVALPROEX SODIUM DEPAKOTE ER 3ethosuximide 1ETHOTOIN PEGANONE 2felbamate 1fosphenytoin sodium 1gabapentin 1

LACOSAMIDE VIMPAT (100 MG)(TABLET) 3



Drug Name Tier Requirements/Limitslamotrigine (100 mg) (tablet) 1levetiracetam 1METHSUXIMIDE CELONTIN 2oxcarbazepine 1OXCARBAZEPINE OXTELLAR XR 3

PERAMPANEL FYCOMPA (10 MG)(TABLET) 3

PHENYTOIN DILANTIN-125 3phenytoin 1PHENYTOIN SODIUM EXTENDED DILANTIN 3phenytoin sodium extended 1PREGABALIN LYRICA 3 PAprimidone 1RUFINAMIDE BANZEL 3 PA

TIAGABINE HCL GABITRIL (12 MG)(TABLET) 2

tiagabine hcl 1topiramate (100 mg) (tablet) 1VALPROIC ACID DEPAKENE 3valproic acid 1

VIGABATRIN SABRIL (500 MG)(TABLET) 3

vigabatrin 1zonisamide 1

BENZODIAZEPINES

CLOBAZAM ONFI (10 MG)(TABLET) 3 PA

SKELETAL MUSCLE DISORDERSKELETAL MUSCLE RELAXANTS

baclofen 1BACLOFEN GABLOFEN 3

BACLOFEN LIORESALINTRATHECAL 3

carisoprodol 1 RBPchlorzoxazone 1CHLORZOXAZONE LORZONE 3 RBPcyclobenzaprine hcl (10 mg) (tablet) 1dantrolene sodium 1metaxalone 1 RBPmethocarbamol 1orphenadrine citrate 1 RBPtizanidine hcl 1

SMOKING CESSATIONSMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS)

nicotine 0NICOTINE NICOTROL NS 2

SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONISTVARENICLINE TARTRATE CHANTIX 0

SMOKING DETERRENTS, OTHERbupropion hcl 1

UPPER GASTROINTESTINAL DISORDERS - DIGESTIVEGASTRIC ENZYMES

SACROSIDASE SUCRAID 2PANCREATIC ENZYMES

LIPASE/PROTEASE/AMYLASE CREON 3LIPASE/PROTEASE/AMYLASE PANCREAZE 3




LIPASE/PROTEASE/AMYLASEPERTZYE (16K-57.5K) (CAPSULEDR)

3

LIPASE/PROTEASE/AMYLASEPERTZYE (4000-14375) (CAPSULEDR)

3

LIPASE/PROTEASE/AMYLASEPERTZYE (8K-28.75K) (CAPSULEDR)

3

LIPASE/PROTEASE/AMYLASE VIOKACE 3

LIPASE/PROTEASE/AMYLASE ZENPEP (10-34-55K)(CAPSULE DR) 3

LIPASE/PROTEASE/AMYLASE ZENPEP (15-51-82K)(CAPSULE DR) 3

LIPASE/PROTEASE/AMYLASEZENPEP (25-85-136K) (CAPSULEDR)

3

LIPASE/PROTEASE/AMYLASE ZENPEP (3K-10K-16K) (CAPSULE DR) 3

LIPASE/PROTEASE/AMYLASE ZENPEP (5K-17K-27K) (CAPSULE DR) 3

UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASEANTICHOLINERGICS/ANTISPASMODICS

DICYCLOMINE HCL BENTYL 3dicyclomine hcl 1

BELLADONNA ALKALOIDSatropine sulfate 1atropine sulfate/0.9 %sod chlr (0.8 mg/2ml) (syringe) 1atropine sulfate/0.9 %sod chlr (1 mg/2.5ml) (syringe) 1hyoscyamine sulfate 1

HYOSCYAMINE SULFATE LEVSIN (0.5MG/ML) (AMPUL) 2

HYOSCYAMINE SULFATE SYMAX DUOTAB 3methscopolamine bromide 1

UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASEANTICHOLINERGICS,QUATERNARY AMMONIUM

chlordiazepoxide/clidinium br 1GLYCOPYRROLATE CUVPOSA 3glycopyrrolate (0.2 mg/ml) (vial) 1glycopyrrolate (1 mg) (tablet) 1glycopyrrolate (1 mg/5 ml) (syringe) 1propantheline bromide 1

ANTI-ULCER PREPARATIONSmisoprostol 1sucralfate 1

ANTI-ULCER-H.PYLORI AGENTSBISMUTH/METRONID/TETRACYCLINE PYLERA 3lansoprazole/amoxiciln/clarith 1

HISTAMINE H2-RECEPTOR INHIBITORS

cimetidine hcl 1 AG: AGE >= 8 YEARS = 100%COPAY

nizatidine (150mg/10ml) (solution) 1 AG: AGE >= 8 YEARS = 100%COPAY

ranitidine hcl (15 mg/ml) (syrup) 1 AG: AGE >= 8 YEARS = 100%COPAY

INTESTINAL MOTILITY STIMULANTSmetoclopramide hcl (10 mg) (tablet) 1



Drug Name Tier Requirements/Limitsmetoclopramide hcl (10 mg/2 ml) (syringe) 1metoclopramide hcl (5 mg/ml) (vial) 1

URINARY TRACT - FUNCTIONAL DISORDERSBENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS

alfuzosin hcl 1dutasteride 1finasteride 1SILODOSIN RAPAFLO 3tamsulosin hcl 1

URINARY TRACT ANALGESIC AGENTSDIMETHYL SULFOXIDE RIMSO-50 3PENTOSAN POLYSULFATE SODIUM ELMIRON 2

URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE)phenazopyridine hcl (100 mg) (tablet) 1

URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG.darifenacin hydrobromide 1 RBPSOLIFENACIN SUCCINATE VESICARE 3 RBP

URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENTFESOTERODINE FUMARATE TOVIAZ 3 RBPflavoxate hcl 1 RBPOXYBUTYNIN OXYTROL 3 RBPoxybutynin chloride (10 mg) (tab er 24) 2 RBPtolterodine tartrate 1 RBPtrospium chloride 1 RBP

VAGINAL DISORDERSVAGINAL ANTIBIOTICS

CLINDAMYCIN PHOSPHATE CLEOCIN (100 MG)(SUPP.VAG) 2

clindamycin phosphate 1CLINDAMYCIN PHOSPHATE CLINDESSE 3metronidazole 1METRONIDAZOLE VANDAZOLE 3

VAGINAL ANTIFUNGALSBUTOCONAZOLE NITRATE GYNAZOLE 1 3miconazole nitrate (200 mg) (supp.vag) 1terconazole 1

VAGINAL ANTISEPTICSACETIC ACID/OXYQUINOLINE FEM PH 2ACETIC ACID/OXYQUINOLINE RELAGARD 2

VAGINAL ESTROGEN PREPARATIONSESTRADIOL ESTRACE 3estradiol 1ESTRADIOL ESTRING 3ESTRADIOL ACETATE FEMRING 3ESTROGENS, CONJUGATED PREMARIN 2



STEP THERAPY EDITS • AMLODIPINE BES/OLMESARTAN MEDPrior prescription for Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,

Captopril/hydrochlorothiazide, Enalapril Maleate, Enalapril/hydrochlorothiazide,Enalaprilat Dihydrate, Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, or Valsartan/hydrochlorothiazide in last 180 days

• AMLODIPINE/VALSARTAN/HCTHIAZID

Prior prescription for Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,Captopril/hydrochlorothiazide, Enalapril Maleate, Enalapril/hydrochlorothiazide,Enalaprilat Dihydrate, Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, or Valsartan/hydrochlorothiazide in last 180 days

• CANDESARTAN CILEXETIL Prior prescription for Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,Captopril/hydrochlorothiazide, Enalapril Maleate, Enalapril/hydrochlorothiazide,Enalaprilat Dihydrate, Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, or Valsartan/hydrochlorothiazide in last 180 days

• CANDESARTAN/HYDROCHLOROTHIAZID


• DAYTRANA Prior prescription for Aptensio XR, Armodafinil, Dexmethylphenidate HCL,Dextroamphetamine Sulfate, Dextroamphetamine/amphetamine, MethamphetamineHCL, Methylphenidate HCL, Modafinil, Mydayis, Quillichew ER, Quillivant XR,Ritalin LA, Vyvanse, or Zenzedi in last 180 days

• ELETRIPTAN HBR At least 2 prior prescriptions for Naratriptan HCL, Rizatriptan Benzoate, SumatriptanSuccinate, or Zolmitriptan in last 365 days

• EPROSARTAN MESYLATE Prior prescription for Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,Captopril/hydrochlorothiazide, Enalapril Maleate, Enalapril/hydrochlorothiazide,Enalaprilat Dihydrate, Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, or Valsartan/hydrochlorothiazide in last 180 days

• GIAZO Prior prescription for Balsalazide Disodium or Giazo in last 180 days• IRBESARTAN Prior prescription for Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,


• IRBESARTAN/HYDROCHLOROTHIAZIDE


• OLMESARTAN MEDOXOMIL Prior prescription for Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,Captopril/hydrochlorothiazide, Enalapril Maleate, Enalapril/hydrochlorothiazide,Enalaprilat Dihydrate, Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,

Medication Prescribing Limitations

47University of Arkansas Health Plan Effective: January 1, 2018

Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, or Valsartan/hydrochlorothiazide in last 180 days

• OLMESARTAN/AMLODIPIN/HCTHIAZID


• OLMESARTAN/HYDROCHLOROTHIAZIDE


• TEKTURNA Prior prescription for Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,Captopril/hydrochlorothiazide, Enalapril Maleate, Enalapril/hydrochlorothiazide,Enalaprilat Dihydrate, Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, or Valsartan/hydrochlorothiazide in last 180 days

• TELMISARTAN Prior prescription for Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,Captopril/hydrochlorothiazide, Enalapril Maleate, Enalapril/hydrochlorothiazide,Enalaprilat Dihydrate, Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, or Valsartan/hydrochlorothiazide in last 180 days

• TELMISARTAN/AMLODIPINE Prior prescription for Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,Captopril/hydrochlorothiazide, Enalapril Maleate, Enalapril/hydrochlorothiazide,Enalaprilat Dihydrate, Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazide,Lisinopril, Lisinopril/hydrochlorothiazide, Losartan Potassium,Losartan/hydrochlorothiazide, Moexipril HCL, Moexipril/hydrochlorothiazide,Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazide,Ramipril, Trandolapril, or Valsartan/hydrochlorothiazide in last 180 days

• TELMISARTAN/HYDROCHLOROTHIAZID


• TIVICAY (50 MG) (TABLET) Prior prescription for Isentress HCL or Isentress in last 120 days• TYBOST Prior prescription for Prezista or Reyataz in last 90 days• UCERIS Prior prescription for Apriso, Asacol, Delzicol, Mesalamine, or Pentasa in last 120

days• VALSARTAN Prior prescription for Benazepril HCL, Benazepril/hydrochlorothiazide, Captopril,


Medication Prescribing Limitations


- A -ABACAVIR SULFATE..................................................... 31ABACAVIR SULFATE/LAMIVUDINE...........................31ABACAVIR/DOLUTEGRAVIR/LAMIVUDI.................. 32ABACAVIR/LAMIVUDINE/ZIDOVUDINE...................31ABATACEPT...............................................................33, 34ABATACEPT/MALTOSE................................................. 34ABCIXIMAB.................................................................... 24ABELCET......................................................................... 28ABILIFY MAINTENA (300 MG) (SUSER VIAL)............6ABIRATERONE ACETATE............................................. 37ABRAXANE..................................................................... 40ABSTRAL (100 MCG) (TAB SUBL)...............................42ACALABRUTINIB........................................................... 39ACAMPROSATE CALCIUM.............................................5ACARBOSE...................................................................... 14ACEBUTOLOL HCL..........................................................9ACETAZOLAMIDE..........................................................19ACETAZOLAMIDE SODIUM.........................................19ACETIC ACID.................................................................. 15ACETIC ACID/OXYQUINOLINE...................................46ACETOHYDROXAMIC ACID........................................ 36ACETYLCHOLINE CHLORIDE.....................................19ACITRETIN...................................................................... 13ACLIDINIUM BROMIDE.................................................. 3ACTEMRA........................................................................35ACTIMMUNE...................................................................26ACTIVASE........................................................................ 25ACTOPLUS MET XR.......................................................14ACUVAIL.......................................................................... 18ACYCLOVIR.............................................................. 12, 30ACYCLOVIR SODIUM....................................................30ADALIMUMAB............................................................... 33ADAPALENE....................................................................12ADAPALENE (0.1 %) (LOTION)........................................ADCIRCA......................................................................... 10ADDERALL XR................................................................. 5ADEFOVIR DIPIVOXIL.................................................. 32ADEMPAS.........................................................................10ADENOSINE...................................................................... 7ADVAIR DISKUS............................................................... 3ADVAIR HFA......................................................................3ADVATE............................................................................ 21ADYNOVATE (1000 (+/-)) (VIAL).................................. 21ADYNOVATE (2000 (+/-)) (VIAL).................................. 21ADYNOVATE (250 (+/-)) (VIAL).................................... 21ADYNOVATE (500 (+/-)) (VIAL).................................... 21AFATINIB DIMALEATE................................................. 39AFINITOR (10 MG) (TABLET)....................................... 38AFINITOR (2.5 MG) (TABLET)...................................... 38AFINITOR (5 MG) (TABLET)......................................... 38AFINITOR (7.5 MG) (TABLET)...................................... 38AFINITOR DISPERZ....................................................... 38AGGRASTAT.................................................................... 24AGGRASTAT (12.5MG/250) (PLAST. BAG).................. 24AKTEN..............................................................................18ALA-QUIN........................................................................12ALBENDAZOLE.............................................................. 30ALBENZA.........................................................................30ALBUTEROL SULFATE....................................................3ALCAFTADINE................................................................18ALCLOMETASONE DIPROPIONATE........................... 12ALDESLEUKIN................................................................26ALEMTUZUMAB...................................................... 40, 41ALENDRONATE SODIUM............................................. 15ALENDRONATE SODIUM (10 MG) (TABLET)................ALENDRONATE SODIUM/VITAMIN D3......................15ALFERON N..................................................................... 26ALFUZOSIN HCL............................................................ 46ALIMTA (100 MG) (VIAL)..............................................38ALIMTA (500 MG) (VIAL)..............................................38ALINIA..............................................................................30ALISKIREN HEMIFUMARATE..................................... 10ALITRETINOIN............................................................... 13ALLOPURINOL............................................................... 20ALOCRIL.......................................................................... 19ALOMIDE.........................................................................19ALORA..............................................................................25ALOXI................................................................................. 2ALPHAGAN P (0.1 %) (DROPS).....................................20ALPHANATE....................................................................22ALPHANINE SD (1000 (+/-)) (VIAL)............................. 23ALPHANINE SD (1500 (+/-)) (VIAL)............................. 23ALPHANINE SD (500 (+/-)) (VIAL)............................... 23ALPRAZOLAM.................................................................. 5ALPRAZOLAM INTENSOL...............................................ALPROLIX (250 UNIT) (VIAL)...................................... 23ALPROLIX (4000 UNIT) (VIAL).................................... 23ALPROSTADIL...........................................................10, 15ALREX.............................................................................. 18ALTABAX......................................................................... 12

ALTEPLASE..................................................................... 25ALTOPREV.......................................................................11ALTRETAMINE................................................................36ALUMINUM CHLORIDE................................................13ALVESCO........................................................................... 3ALVIMOPAN.................................................................... 36AMANTADINE HCL........................................................43AMBISOME......................................................................28AMBRISENTAN...............................................................10AMELUZ...........................................................................41AMICAR (1000 MG) (TABLET)......................................21AMICAR (250 MG/ML) (SOLUTION)........................... 21AMICAR (500 MG) (TABLET)........................................21AMIKACIN SULFATE..................................................... 29AMILORIDE HCL............................................................10AMINOCAPROIC ACID.................................................. 21AMINOLEVULINIC ACID HCL.....................................41AMINOPHYLLINE............................................................ 4AMINOSALICYLIC ACID.............................................. 29AMIODARONE HCL......................................................... 7AMIODARONE HCL/D5W................................................7AMITIZA.......................................................................... 36AMITRIPTYLINE HCL..................................................... 5AMITRIPTYLINE/CHLORDIAZEPOXIDE..................... 5AMLODIPINE BES/OLMESARTAN MED................ 8, 47AMLODIPINE BESYLATE............................................... 9AMLODIPINE BESYLATE/BENAZEPRIL...................... 8AMLODIPINE/ATORVASTATIN.....................................11AMLODIPINE/VALSARTAN/HCTHIAZID............... 8, 47AMOBARBITAL SODIUM................................................6AMOXAPINE..................................................................... 5AMOXICILLIN.................................................................27AMOXICILLIN/POTASSIUM CLAV.............................. 27AMPHOTERICIN B..........................................................28AMPHOTERICIN B LIPID COMPLEX.......................... 28AMPHOTERICIN B LIPOSOME.....................................28AMVISC............................................................................19AMVISC PLUS................................................................. 19AMYL NITRITE............................................................... 11ANAGRELIDE HCL.........................................................25ANAKINRA...................................................................... 33ANASTROZOLE.............................................................. 38ANGELIQ..........................................................................25ANORO ELLIPTA.............................................................. 3ANTHRALIN.................................................................... 13ANTHRALIN MICRONIZED.......................................... 13ANTIHEMO.FVIII,FULL LENGTH PEG....................... 21ANTIHEMOPH.FVIII REC,FC FUSION.........................21ANTIHEMOPH.FVIII,B-DOMAIN DEL.........................21ANTIHEMOPH.FVIII,FULL LENGTH.....................21, 22ANTIHEMOPH.FVIII,HEK B-DELETE......................... 22ANTIHEMOPHILIC FACTOR, HUM REC.....................22ANTIHEMOPHILIC FACTOR/VWF...............................22ANTIHEMOPHILIC FVIII,REC PORC...........................22ANTI-INHIBITOR COAGULANT COMP.......................22ANZEMET.......................................................................... 2APIXABAN.......................................................................22APLENZIN..........................................................................5APOKYN...........................................................................43APOMORPHINE HCL..................................................... 43APRACLONIDINE HCL.................................................. 19APREMILAST.................................................................. 33APREPITANT..................................................................... 2APREPITANT (125 MG) (CAPSULE).................................APRISO............................................................................. 35APTIVUS.................................................................... 30, 31ARANESP (100 MCG/ML) (VIAL)................................. 23ARANESP (100MCG/0.5) (SYRINGE)........................... 23ARANESP (150MCG/.75) (VIAL)................................... 23ARANESP (150MCG/0.3) (SYRINGE)........................... 23ARANESP (200 MCG/ML) (VIAL)................................. 23ARANESP (200MCG/0.4) (SYRINGE)........................... 23ARANESP (25 MCG/ML) (VIAL)................................... 23ARANESP (25MCG/0.42) (SYRINGE)........................... 23ARANESP (300 MCG/ML) (VIAL)................................. 24ARANESP (300MCG/0.6) (SYRINGE)........................... 24ARANESP (40 MCG/0.4) (SYRINGE)............................ 24ARANESP (40 MCG/ML) (VIAL)................................... 24ARANESP (500 MCG/ML) (SYRINGE)......................... 24ARANESP (60 MCG/0.3) (SYRINGE)............................ 24ARANESP (60MCG/ML) (VIAL).................................... 24ARCALYST.......................................................................33ARFORMOTEROL TARTRATE........................................ 3ARIPIPRAZOLE.................................................................6ARIPIPRAZOLE (10 MG) (TABLET).................................ARISTOSPAN................................................................... 35ARMODAFINIL................................................................. 7ARMODAFINIL (150 MG) (TABLET)................................ARMOUR THYROID.......................................................17ARNUITY ELLIPTA.......................................................... 3ARRANON........................................................................38ARTEMETHER/LUMEFANTRINE.................................30

ASMANEX..........................................................................4ASMANEX HFA.................................................................4ASPIRIN/DIPYRIDAMOLE............................................ 24ATAZANAVIR SULFATE.................................................32ATAZANAVIR SULFATE/COBICISTAT.........................32ATENOLOL........................................................................ 9ATOMOXETINE HCL........................................................7ATORVASTATIN CALCIUM........................................... 10ATOVAQUONE.................................................................30ATOVAQUONE/PROGUANIL HCL................................30ATRIPLA...........................................................................32ATROPINE SULFATE................................................ 20, 45ATROPINE SULFATE/0.9 %SOD CHLR.................. 20, 45ATROPINE SULFATE/0.9 %SOD CHLR (0.8 MG/2ML)(SYRINGE)...........................................................................ATROPINE SULFATE/0.9 %SOD CHLR (1 MG/2.5ML)(SYRINGE)...........................................................................ATROVENT HFA................................................................3AUBAGIO (14 MG) (TABLET)........................................41AURANOFIN.................................................................... 35AVANDAMET...................................................................14AVANDIA..........................................................................14AVASTIN...........................................................................38AVONEX........................................................................... 41AVONEX PEN...................................................................41AZACITIDINE..................................................................37AZACTAM-ISO-OSMOTIC DEXTROSE....................... 26AZASAN........................................................................... 26AZASITE...........................................................................19AZATHIOPRINE.............................................................. 26AZATHIOPRINE SODIUM..............................................26AZELAIC ACID................................................................12AZELASTINE HCL......................................................2, 18AZELASTINE/FLUTICASONE........................................ 2AZELEX............................................................................12AZITHROMYCIN.......................................................19, 27AZOPT.............................................................................. 20AZTREONAM.................................................................. 26AZTREONAM LYSINE....................................................26AZTREONAM/DEXTROSE-WATER..............................26

- B -BACITRACIN................................................................... 19BACITRACIN/POLYMYXIN B SULFATE..................... 19BACLOFEN...................................................................... 44BALSALAZIDE DISODIUM...........................................35BANZEL............................................................................44BARACLUDE (0.05 MG/ML) (SOLUTION).................. 32BASILIXIMAB................................................................. 26BCG (TICE STRAIN)....................................................... 40BCG LIVE......................................................................... 40BEBULIN.......................................................................... 23BECAPLERMIN............................................................... 14BECLOMETHASONE DIPROPIONATE...................... 2, 3BECONASE AQ..................................................................2BEDAQUILINE FUMARATE.......................................... 29BELATACEPT...................................................................26BELSOMRA........................................................................7BENAZEPRIL HCL............................................................ 8BENAZEPRIL/HYDROCHLOROTHIAZIDE................... 8BENDAMUSTINE HCL...................................................36BENEFIX (1000 UNIT) (KIT)..........................................23BENEFIX (2000 UNIT) (KIT)..........................................23BENEFIX (250 UNIT) (KIT)............................................23BENEFIX (3000 UNIT) (KIT)..........................................23BENEFIX (500 UNIT) (KIT)............................................23BENOXINATE HCL/FLUORESCEIN SOD.................... 18BENTYL............................................................................45BENZOYL PEROXIDE.................................................... 13BENZOYL PEROXIDE (4 %) (GEL (GRAM))...................BENZTROPINE MESYLATE.......................................... 43BEPOTASTINE BESILATE..............................................18BEPREVE..........................................................................18BETALOAN SUIK............................................................34BETAMETHASON/NORFLURAN/PENTFLU...............34BETAMETHASONE ACETATE,SOD PHOS.................. 34BETAMETHASONE DIPROPIONATE........................... 12BETAMETHASONE VALERATE................................... 12BETAMETHASONE VALERATE (0.1 %) (CREAM (G))...............................................................................................BETAMETHASONE/PROPYLENE GLYC..................... 12BETASERON.................................................................... 41BETAXOLOL HCL.......................................................9, 19BETIMOL..........................................................................20BETOPTIC S..................................................................... 19BEVACIZUMAB.........................................................20, 38BEVACIZUMAB (2.5 MG/0.1) (SYRINGE).......................BEXAROTENE........................................................... 13, 41BICALUTAMIDE............................................................. 37BICNU...............................................................................36BIDIL.................................................................................10BILTRICIDE..................................................................... 30


Index

BIMATOPROST................................................................19BISMUTH/METRONID/TETRACYCLINE.................... 45BISOPROLOL FUMARATE.............................................. 9BIVALIRUDIN..................................................................25BLEOMYCIN SULFATE..................................................37BLEPHAMIDE..................................................................18BLEPHAMIDE S.O.P........................................................18BORTEZOMIB..................................................................39BOSENTAN...................................................................... 10BOSULIF (100 MG) (TABLET).......................................39BOSULIF (500 MG) (TABLET).......................................39BOSUTINIB...................................................................... 39BREO ELLIPTA..................................................................3BRIMONIDINE TARTRATE............................................20BRIMONIDINE TARTRATE/TIMOLOL........................ 20BRINZOLAMIDE.............................................................20BROMFENAC SODIUM.................................................. 18BROMOCRIPTINE MESYLATE.....................................43BROMSITE....................................................................... 18BROVANA...........................................................................3BUDESONIDE........................................................3, 34, 36BUDESONIDE/FORMOTEROL FUMARATE................. 3BUMETANIDE................................................................. 10BUPRENEX...................................................................... 42BUPRENORPHINE.......................................................... 42BUPRENORPHINE (10 MCG/HR) (PATCH TDWK).........BUPRENORPHINE HCL........................................... 42, 43BUPRENORPHINE HCL (0.3 MG/ML) (SYRINGE).........BUPRENORPHINE HCL (2 MG) (TAB SUBL)..................BUPRENORPHINE HCL (8 MG) (TAB SUBL)..................BUPRENORPHINE HCL/NALOXONE HCL................. 43BUPROPION HBR..............................................................5BUPROPION HCL........................................................5, 44BUPROPION HCL (100 MG) (TAB ER 12H).....................BUSPIRONE HCL.............................................................. 5BUSULFAN.......................................................................36BUTABARBITAL SODIUM...............................................6BUTALB/ACETAMINOPHEN/CAFFEINE.................... 42BUTALBIT/ACETAMIN/CAFF/CODEINE.................... 43BUTALBIT/ACETAMIN/CAFF/CODEINE (50-325-30)(CAPSULE)...........................................................................BUTALBITAL/ACETAMINOPHEN................................ 42BUTALBITAL/ACETAMINOPHEN (50MG-325MG)(TABLET)..............................................................................BUTISOL SODIUM............................................................6BUTOCONAZOLE NITRATE......................................... 46BYSTOLIC..........................................................................9

- C -CABERGOLINE............................................................... 17CABOMETYX.................................................................. 39CABOZANTINIB S-MALATE.........................................39CADEXOMER IODINE................................................... 12CAFFEINE CITRATE.........................................................4CAFFEINE/SODIUM BENZOATE....................................4CALCIPOTRIENE............................................................ 13CALCITONIN,SALMON,SYNTHETIC..........................15CALCITRIOL....................................................................13CALQUENCE................................................................... 39CAMPATH.........................................................................40CAMPTOSAR (300MG/15ML) (VIAL).......................... 39CANAGLIFLOZIN/METFORMIN HCL......................... 14CANASA........................................................................... 35CANDESARTAN CILEXETIL.....................................9, 47CANDESARTAN/HYDROCHLOROTHIAZID...........8, 47CAPASTAT SULFATE...................................................... 29CAPECITABINE...............................................................37CAPRELSA.......................................................................40CAPREOMYCIN SULFATE............................................ 29CAPTOPRIL........................................................................9CAPTOPRIL/HYDROCHLOROTHIAZIDE......................8CARBACHOL...................................................................20CARBAGLU......................................................................36CARBAMAZEPINE..................................................... 6, 43CARBIDOPA.....................................................................43CARBIDOPA/LEVODOPA.............................................. 43CARBOPLATIN................................................................36CARDENE I.V.....................................................................9CARDURA XL................................................................... 8CARFILZOMIB................................................................ 39CARGLUMIC ACID.........................................................36CARISOPRODOL.............................................................44CARISOPRODOL/ASPIRIN/CODEINE......................... 42CARMUSTINE................................................................. 36CARMUSTINE IN POLIFEPROSAN 20.........................36CARTEOLOL HCL...........................................................20CARVEDILOL.................................................................... 8CARVEDILOL PHOSPHATE............................................ 8CATHFLO ACTIVASE..................................................... 25CAYSTON.........................................................................26CEFACLOR.......................................................................27CEFADROXIL...................................................................27

CEFDINIR.........................................................................27CEFIXIME........................................................................ 27CEFPROZIL...................................................................... 27CEFTAZIDIME................................................................. 27CEFTIN............................................................................. 27CEFUROXIME AXETIL.................................................. 27CEFUROXIME SODIUM/0.9% NACL/PF...................... 19CELLCEPT........................................................................26CELONTIN....................................................................... 44CEPHALEXIN.................................................................. 27CERTOLIZUMAB PEGOL.............................................. 35CESAMET...........................................................................2CETUXIMAB....................................................................38CHANTIX......................................................................... 44CHLORAMBUCIL........................................................... 36CHLORAMPHENICOL SOD SUCCINATE....................29CHLORDIAZEPOXIDE HCL............................................ 5CHLORDIAZEPOXIDE/CLIDINIUM BR...................... 45CHLOROQUINE PHOSPHATE....................................... 30CHLOROTHIAZIDE.........................................................10CHLORPROMAZINE HCL................................................6CHLORPROPAMIDE....................................................... 14CHLORTHALIDONE.......................................................10CHLORZOXAZONE........................................................ 44CHOLINE SALICYL/MAG SALICYLATE.................... 42CHONDR SULF A SOD/HYALURONATE.....................19CICLESONIDE............................................................... 2, 3CICLOPIROX....................................................................12CICLOPIROX (1 %) (SHAMPOO)......................................CIDOFOVIR......................................................................30CILOSTAZOL................................................................... 24CILOXAN (0.3 %) (OINT. (G))........................................ 19CIMETIDINE HCL........................................................... 45CIMZIA............................................................................. 35CINACALCET HCL......................................................... 16CIPRO................................................................................27CIPRO HC......................................................................... 15CIPRODEX....................................................................... 15CIPROFLOXACIN............................................................27CIPROFLOXACIN HCL.............................................19, 28CIPROFLOXACIN HCL/DEXAMETH........................... 15CIPROFLOXACIN IN 5 % DEXTROSE..........................28CIPROFLOXACIN LACTATE..........................................28CIPROFLOXACIN/CIPROFLOXA HCL.........................28CIPROFLOXACIN/HYDROCORTISONE...................... 15CISPLATIN....................................................................... 36CITALOPRAM HYDROBROMIDE.................................. 5CITRATE PHOSPHATE DEXTROS SOLN.................... 22CLADRIBINE................................................................... 37CLARINEX (2.5 MG/5ML) (SYRUP)............................... 2CLARINEX-D 12 HOUR....................................................2CLARITHROMYCIN....................................................... 27CLEMASTINE FUMARATE............................................. 2CLEMASTINE FUMARATE (2.68 MG) (TABLET)...........CLEOCIN (100 MG) (SUPP.VAG)................................... 46CLEVIDIPINE BUTYRATE...............................................9CLEVIPREX....................................................................... 9CLIMARA PRO................................................................ 25CLINDAGEL.....................................................................12CLINDAMYCIN HCL...................................................... 29CLINDAMYCIN PALMITATE HCL................................29CLINDAMYCIN PHOS/BENZOYL PEROX.................. 12CLINDAMYCIN PHOSPHATE........................... 12, 29, 46CLINDAMYCIN PHOSPHATE/D5W..............................29CLINDESSE......................................................................46CLIOQUINOL/HYDROCORTISONE............................. 12CLOBAZAM..................................................................... 44CLOBETASOL PROPIONATE.........................................12CLOBETASOL PROPIONATE (0.05 %) (GEL (GRAM))...............................................................................................CLOMIPRAMINE HCL..................................................... 5CLONAZEPAM................................................................ 43CLONIDINE........................................................................9CLONIDINE HCL/PF....................................................... 42CLOPIDOGREL BISULFATE..........................................24CLORAZEPATE DIPOTASSIUM...................................... 5CLOTRIMAZOLE............................................................ 28CLOZAPINE....................................................................... 6CLOZAPINE (100 MG) (TABLET).....................................COAGADEX..................................................................... 23COAGULATION FACTOR VIIA,RECOMB................... 22COAGULATION FACTOR X...........................................23COARTEM........................................................................ 30COBICISTAT.....................................................................32COBIMETINIB FUMARATE...........................................38COLCHICINE................................................................... 20COLCHICINE (0.6 MG) (TABLET)....................................COLISTIN (COLISTIMETHATE NA).............................29COLY-MYCIN S............................................................... 15COMBIGAN......................................................................20COMBIPATCH..................................................................25COMBIVENT RESPIMAT................................................. 3

COMETRIQ...................................................................... 39COMPLERA......................................................................32CORLANOR (5 MG) (TABLET)......................................11CORLOPAM....................................................................... 9CORTANE-B..................................................................... 15CORTISONE ACETATE...................................................34CORTISPORIN................................................................. 12COSENTYX (2 SYRINGES)............................................13COSENTYX PEN............................................................. 13COSENTYX SYRINGE....................................................13COSOPT PF.......................................................................20COTELLIC........................................................................ 38COUMADIN..................................................................... 21CREON..............................................................................44CRINONE..........................................................................26CRIXIVAN........................................................................ 32CRIZOTINIB.....................................................................39CROMOLYN SODIUM................................................ 4, 19CUVPOSA.........................................................................45CYCLOBENZAPRINE HCL............................................44CYCLOBENZAPRINE HCL (10 MG) (TABLET)..............CYCLOMYDRIL.............................................................. 20CYCLOPENTOLAT/TROPIC/PHENYLEPH.................. 20CYCLOPENTOLATE HCL.............................................. 20CYCLOPENTOLATE/PHENYLEPHRINE..................... 20CYCLOPHOSPHAMIDE................................................. 36CYCLOPHOSPHAMIDE (25 MG) (CAPSULE).................CYCLOPHOSPHAMIDE (50 MG) (CAPSULE).................CYCLOSERINE................................................................29CYCLOSPORINE....................................................... 19, 26CYCLOSPORINE, MODIFIED........................................26CYPROHEPTADINE HCL................................................. 2CYRAMZA (500MG/50ML) (VIAL)...............................39CYSTARAN...................................................................... 20CYSTEAMINE HCL.........................................................20CYTARABINE..................................................................37CYTARABINE/PF............................................................ 37

- D -DABIGATRAN ETEXILATE MESYLATE..................... 25DACARBAZINE............................................................... 40DACTINOMYCIN............................................................ 37DALIRESP.......................................................................... 4DALTEPARIN SODIUM,PORCINE................................ 24DANAZOL........................................................................ 17DANTROLENE SODIUM................................................ 44DAPSONE................................................................... 12, 29DAPTOMYCIN.................................................................27DARAPRIM...................................................................... 30DARBEPOETIN ALFA IN POLYSORBAT............... 23, 24DARIFENACIN HYDROBROMIDE............................... 46DARUNAVIR ETHANOLATE......................................... 30DARUNAVIR/COBICISTAT............................................ 30DASATINIB...................................................................... 39DAUNORUBICIN HCL.................................................... 37DAYTRANA..................................................................7, 47DEGARELIX ACETATE.................................................. 39DELAVIRDINE MESYLATE...........................................31DELESTROGEN (10 MG/ML) (VIAL)........................... 25DELZICOL........................................................................35DEMECLOCYCLINE HCL..............................................28DEMEROL........................................................................ 42DEMSER............................................................................. 9DEPAKENE.......................................................................44DEPAKOTE.......................................................................43DEPAKOTE ER.................................................................43DEPEN.............................................................................. 33DEPO-ESTRADIOL......................................................... 25DEPO-MEDROL (20 MG/ML) (VIAL)........................... 34DEPO-PROVERA............................................................. 25DERMACINRX LEXITRAL............................................ 13DESCOVY.........................................................................31DESIPRAMINE HCL......................................................... 5DESIRUDIN......................................................................25DESLORATADINE.............................................................2DESLORATADINE/PSEUDOEPHEDRINE......................2DESOGESTREL-ETHINYL ESTRADIOL..................... 11DESOXIMETASONE....................................................... 13DESOXIMETASONE (0.25 %) (CREAM (G))....................DEXAMETHASONE..................................................18, 34DEXAMETHASONE IN 0.9 % SOD CHL...................... 34DEXAMETHASONE INTENSOL.......................................DEXAMETHASONE SOD PHOSPHATE.................18, 34DEXAMETHASONE SODIUM PHOSP/PF....................34DEXMEDETOMIDINE HCL............................................. 7DEXMETHYLPHENIDATE HCL......................................7DEXMETHYLPHENIDATE HCL (10 MG) (CPBP 50-50)...............................................................................................DEXPAK........................................................................... 34DEXTROAMPHETAMINE SULFATE.............................. 5DEXTROAMPHETAMINE SULFATE (10 MG)(CAPSULE ER).....................................................................


Index

DEXTROAMPHETAMINE/AMPHETAMINE..................5DEXTROAMPHETAMINE/AMPHETAMINE (10 MG)(TABLET)..............................................................................DEXTROMETHORPHAN HBR/QUINIDINE................ 42DIAZEPAM................................................................... 5, 43DIAZOXIDE..................................................................... 14DICLOFENAC SODIUM..................................... 13, 18, 35DICLOFENAC SODIUM (1 %) (GEL (GRAM))................DICLOFENAC SODIUM/CAPSAICIN..................... 13, 35DICLOFENAC SODIUM/MISOPROSTOL.....................35DICLOFENAC/CAPSICUM OLEORESIN..................... 13DICLOXACILLIN SODIUM............................................27DICLOZOR....................................................................... 13DICYCLOMINE HCL...................................................... 45DIDANOSINE...................................................................31DIFICID.............................................................................27DIFLUNISAL....................................................................42DIGOXIN............................................................................ 8DIGOXIN (125 MCG) (TABLET)........................................DIGOXIN (250 MCG/ML) (AMPUL)..................................DIGOXIN (250 MCG/ML) (SYRINGE)..............................DILANTIN........................................................................ 44DILANTIN-125.................................................................44DILATRATE-SR................................................................11DILTIAZEM HCL...............................................................9DILTIAZEM HCL IN 0.9% NACL.....................................9DILTIAZEM HCL IN 0.9% NACL (125 MG/125)(PLAST. BAG).......................................................................DIMENHYDRINATE......................................................... 2DIMENHYDRINATE (50 MG/ML) (VIAL)........................DIMETHYL FUMARATE................................................41DIMETHYL SULFOXIDE............................................... 46DINUTUXIMAB...............................................................40DIPHENOXYLATE HCL/ATROPINE............................. 36DIPYRIDAMOLE............................................................. 24DISCOVISC...................................................................... 19DISOPYRAMIDE PHOSPHATE....................................... 7DISULFIRAM.....................................................................5DIURIL..............................................................................10DIVALPROEX SODIUM..................................................43DIVIGEL........................................................................... 25DOBUTAMINE HCL..........................................................8DOBUTAMINE HCL IN DEXTROSE 5 %........................8DOCEFREZ.......................................................................40DOCETAXEL....................................................................40DOCETAXEL (160MG/16ML) (VIAL)...............................DOFETILIDE...................................................................... 7DOLASETRON MESYLATE.............................................2DOLUTEGRAVIR SODIUM............................................32DONEPEZIL HCL.............................................................. 4DONEPEZIL HCL (10 MG) (TAB RAPDIS).......................DONEPEZIL HCL (10 MG) (TABLET)...............................DONEPEZIL HCL (23 MG) (TABLET)...............................DONEPEZIL HCL (5 MG) (TAB RAPDIS).........................DONEPEZIL HCL (5 MG) (TABLET).................................DOPAMINE HCL................................................................8DOPAMINE HCL IN DEXTROSE 5 %............................. 8DORZOLAMIDE HCL..................................................... 20DORZOLAMIDE HCL/TIMOLOL MALEAT.................20DORZOLAMIDE/TIMOLOL/PF..................................... 20DOXAPRAM HCL..............................................................7DOXAZOSIN MESYLATE................................................ 8DOXEPIN HCL.............................................................5, 13DOXERCALCIFEROL..................................................... 17DOXORUBICIN HCL.......................................................37DOXYCYCLINE CALCIUM........................................... 28DOXYCYCLINE HYCLATE........................................... 28DOXYCYCLINE HYCLATE (100 MG) (CAPSULE).........DOXYCYCLINE HYCLATE (100 MG) (TABLET)............DOXYCYCLINE HYCLATE (100 MG) (VIAL).................DOXYCYCLINE HYCLATE (50 MG) (CAPSULE)...........DOXYCYCLINE MONOHYDRATE...............................28DOXYCYCLINE MONOHYDRATE (100 MG)(CAPSULE)...........................................................................DOXYCYCLINE MONOHYDRATE (25 MG/5 ML)(SUSP RECON).....................................................................DOXYCYCLINE MONOHYDRATE (50 MG)(CAPSULE)...........................................................................DOXYCYCLINE MONOHYDRATE (75 MG)(CAPSULE)...........................................................................DOXYCYCLINE/SKIN CLEANSER NO19....................28DRITHOCREME HP........................................................ 13DRONABINOL................................................................... 2DRONEDARONE HCL...................................................... 7DROPERIDOL.................................................................... 6DROSPIR/ETH ESTRA/LEVOMEFOL CA.................... 11DROSPIRENONE/ESTRADIOL......................................25DROXIA............................................................................ 25DRYSOL............................................................................13DULERA............................................................................. 3DULOXETINE HCL...........................................................5DULOXETINE HCL (20 MG) (CAPSULE DR)..................

DUOVISC..........................................................................19DUTASTERIDE................................................................ 46DYMISTA............................................................................2DYRENIUM (100 MG) (CAPSULE)............................... 10DYRENIUM (50 MG) (CAPSULE)................................. 10

- E -ECHOTHIOPHATE IODIDE............................................20ECONAZOLE NITRATE..................................................12ECULIZUMAB................................................................. 24EDEX.................................................................................15EDOXABAN TOSYLATE................................................ 22EDROPHONIUM CHLORIDE...........................................4EDROPHONIUM CHLORIDE/ATROPINE...................... 4EDURANT........................................................................ 31EFAVIRENZ......................................................................31EFAVIRENZ/EMTRICITAB/TENOFOVIR..................... 32EGRIFTA (2 MG) (VIAL)................................................ 16ELBASVIR/GRAZOPREVIR...........................................33ELESTRIN........................................................................ 25ELETRIPTAN HBR.................................................... 42, 47ELIDEL............................................................................. 13ELIQUIS (2.5 MG) (TABLET)......................................... 22ELIQUIS (5 MG) (TABLET)............................................ 22ELITEK (1.5 MG) (VIAL)................................................ 20ELITEK (7.5 MG) (VIAL)................................................ 20ELLA................................................................................. 12ELMIRON......................................................................... 46ELOCTATE (1000 UNIT) (VIAL).................................... 21ELOCTATE (1500 UNIT) (VIAL).................................... 21ELOCTATE (2000 UNIT) (VIAL).................................... 21ELOCTATE (250 UNIT) (VIAL)...................................... 21ELOCTATE (3000 UNIT) (VIAL).................................... 21ELOCTATE (500 UNIT) (VIAL)...................................... 21ELOCTATE (750 UNIT) (VIAL)...................................... 21ELTROMBOPAG OLAMINE...........................................25ELVITEG/COB/EMTRI/TENOF ALAFEN..................... 32ELVITEG/COB/EMTRI/TENOFO DISOP...................... 32EMADINE.........................................................................18EMCYT............................................................................. 41EMEDASTINE DIFUMARATE....................................... 18EMEND............................................................................... 2EMPAGLIFLOZIN............................................................14EMPAGLIFLOZIN/METFORMIN HCL..........................14EMSAM...............................................................................7EMTRICITA/RILPIVIRINE/TENOF DF......................... 32EMTRICITAB/RILPIVIRI/TENOF ALA.........................32EMTRICITABINE.............................................................31EMTRICITABINE/TENOFOV ALAFENAM..................31EMTRICITABINE/TENOFOVIR (TDF)..........................31EMTRIVA..........................................................................31ENALAPRIL MALEATE....................................................9ENALAPRIL/HYDROCHLOROTHIAZIDE..................... 8ENASIDENIB MESYLATE..............................................40ENBREL............................................................................33ENBREL SURECLICK.....................................................33ENFUVIRTIDE................................................................. 31ENLON-PLUS.....................................................................4ENOXAPARIN SODIUM................................................. 24ENOXAPARIN SODIUM (100 MG/ML) (SYRINGE)........ENOXAPARIN SODIUM (120MG/.8ML) (SYRINGE)...............................................................................................ENOXAPARIN SODIUM (150 MG/ML) (SYRINGE)........ENOXAPARIN SODIUM (300MG/3ML) (VIAL)...............ENOXAPARIN SODIUM (30MG/0.3ML) (SYRINGE)...............................................................................................ENOXAPARIN SODIUM (40MG/0.4ML) (SYRINGE)...............................................................................................ENOXAPARIN SODIUM (60MG/0.6ML) (SYRINGE)...............................................................................................ENOXAPARIN SODIUM (80MG/0.8ML) (SYRINGE)...............................................................................................ENTACAPONE................................................................. 43ENTECAVIR..................................................................... 32ENTEREG......................................................................... 36ENTRESTO.......................................................................11ENZALUTAMIDE............................................................ 37EPCLUSA..........................................................................32EPIFOAM..........................................................................13EPINASTINE HCL........................................................... 18EPINEPHRINE..............................................................8, 36EPINEPHRINE (0.15/0.15) (AUTO INJCT)........................EPIRUBICIN HCL............................................................ 37EPIVIR HBV (25 MG/5 ML) (SOLUTION).................... 32EPLERENONE..................................................................10EPOETIN ALFA............................................................... 24EPOGEN............................................................................24EPOPROSTENOL SODIUM (ARGININE)..................... 10EPROSARTAN MESYLATE........................................ 9, 47EPTIFIBATIDE................................................................. 24EQUETRO...........................................................................6ERBITUX.......................................................................... 38

ERGOLOID MESYLATES...............................................11ERGOMAR....................................................................... 43ERGOTAMINE TARTRATE.............................................43ERGOTAMINE TARTRATE/CAFFEINE........................ 43ERIBULIN MESYLATE...................................................38ERLOTINIB HCL............................................................. 39ERTAPENEM SODIUM................................................... 27ERY-TAB........................................................................... 27ERYTHROMYCIN BASE.......................................... 19, 27ERYTHROMYCIN BASE/ETHANOL............................ 12ERYTHROMYCIN ETHYLSUCCINATE........................27ERYTHROMYCIN STEARATE.......................................27ESCITALOPRAM OXALATE............................................5ESMOLOL HCL................................................................. 9ESTAZOLAM..................................................................... 7ESTRACE..........................................................................46ESTRADIOL............................................................... 25, 46ESTRADIOL ACETATE...................................................46ESTRADIOL CYPIONATE.............................................. 25ESTRADIOL VALERATE................................................ 25ESTRADIOL VALERATE/DIENOGEST........................ 11ESTRADIOL/LEVONORGESTREL............................... 25ESTRADIOL/NORETHINDRONE ACET.......................25ESTRADIOL/NORGESTIMATE..................................... 25ESTRAMUSTINE PHOSPHATE SODIUM.................... 41ESTRING.......................................................................... 46ESTROGEL....................................................................... 25ESTROGEN,CON/M-PROGEST ACET.......................... 25ESTROGEN,ESTER/ME-TESTOSTERONE...................25ESTROGENS, CONJUGATED.................................. 25, 46ESTROGENS,ESTERIFIED.............................................25ESTROPIPATE.................................................................. 25ESZOPICLONE.................................................................. 7ETANERCEPT.................................................................. 33ETHACRYNATE SODIUM.............................................. 10ETHACRYNIC ACID....................................................... 10ETHAMBUTOL HCL.......................................................29ETHINYL ESTRADIOL/DROSPIRENONE................... 11ETHIONAMIDE............................................................... 29ETHOSUXIMIDE............................................................. 43ETHOTOIN....................................................................... 43ETHYNODIOL D-ETHINYL ESTRADIOL....................11ETIDRONATE DISODIUM..............................................15ETODOLAC...................................................................... 35ETONOGESTREL............................................................ 11ETONOGESTREL/ETHINYL ESTRADIOL...................11ETOPOPHOS.................................................................... 40ETOPOSIDE......................................................................40ETOPOSIDE PHOSPHATE..............................................40ETRAVIRINE....................................................................31EUFLEXXA...................................................................... 33EVAMIST.......................................................................... 25EVEROLIMUS............................................................26, 38EVOTAZ............................................................................ 32EXELDERM......................................................................12EXEMESTANE................................................................. 38EXTAVIA.......................................................................... 41

- F -FACTIVE...........................................................................28FACTOR IX.......................................................................23FACTOR IX CPLX(PCC)NO4,3FACTOR....................... 23FACTOR IX CPLX(PCC)NO6,3FACTOR....................... 23FACTOR IX HUMAN RECOMB,THR 148.....................23FACTOR IX HUMAN RECOMBINANT.........................23FACTOR IX REC, FC FUSION PROTN..........................23FACTOR IX RECOM,ALBUMIN FUSION.....................23FAMCICLOVIR................................................................ 30FARESTON....................................................................... 41FASLODEX.......................................................................41FEIBA NF..........................................................................22FELBAMATE....................................................................43FELODIPINE...................................................................... 9FEM PH............................................................................. 46FEMRING......................................................................... 46FENOFIBRATE NANOCRYSTALLIZED....................... 11FENOFIBRATE,MICRONIZED.......................................11FENOFIBRATE,MICRONIZED (130 MG) (CAPSULE)...............................................................................................FENOFIBRATE,MICRONIZED (43 MG) (CAPSULE)...............................................................................................FENOLDOPAM MESYLATE............................................ 9FENOPROFEN CALCIUM.............................................. 35FENOPROFEN CALCIUM (600 MG) (TABLET)...............FENTANYL.......................................................................42FENTANYL (75MCG/HR) (PATCH TD72).........................FENTANYL CITRATE..................................................... 42FENTANYL CITRATE/PF................................................42FENTANYL CITRATE/PF (100MCG/2ML) (SYRINGE)...............................................................................................FENTORA.........................................................................42FESOTERODINE FUMARATE....................................... 46


Index

FEXOFENADINE/PSEUDOEPHEDRINE........................ 2FEXOFENADINE/PSEUDOEPHEDRINE (180-240MG)(TAB ER 24H).......................................................................FIDAXOMICIN.................................................................27FILGRASTIM................................................................... 24FILGRASTIM-SNDZ........................................................24FINACEA (15 %) (FOAM)............................................... 12FINASTERIDE..................................................................46FINGOLIMOD HCL......................................................... 41FIRAZYR.......................................................................... 34FIRMAGON...................................................................... 39FLAREX............................................................................18FLAVOXATE HCL............................................................46FLECAINIDE ACETATE....................................................7FLOVENT DISKUS (100 MCG) (BLST W/DEV).............3FLOVENT DISKUS (250 MCG) (BLST W/DEV).............3FLOVENT DISKUS (50 MCG) (BLST W/DEV)...............4FLOVENT HFA...................................................................4FLOXURIDINE.................................................................37FLUCONAZOLE.............................................................. 28FLUCONAZOLE IN DEXTROSE,ISO-OS..................... 28FLUCONAZOLE IN NACL,ISO-OSM............................ 28FLUCYTOSINE................................................................ 28FLUDARABINE PHOSPHATE........................................37FLUDROCORTISONE ACETATE................................... 35FLUMAZENIL....................................................................6FLUNISOLIDE................................................................... 2FLUOCINOLONE ACETONIDE...............................13, 18FLUOCINOLONE ACETONIDE (0.01 %) (CREAM (G))...............................................................................................FLUOCINOLONE ACETONIDE OIL............................. 15FLUOCINONIDE..............................................................13FLUOCINONIDE (0.05 %) (CREAM (G))..........................FLUOROMETHOLONE...................................................18FLUOROMETHOLONE ACETATE................................ 18FLUOROPLEX................................................................. 13FLUOROURACIL.......................................................13, 38FLUPHENAZINE DECANOATE.......................................6FLUPHENAZINE HCL...................................................... 6FLURAZEPAM HCL.......................................................... 7FLURBIPROFEN..............................................................35FLURBIPROFEN SODIUM............................................. 18FLUTAMIDE.....................................................................37FLUTICASONE FUROATE............................................... 3FLUTICASONE PROPIONATE............................... 2-4, 13FLUTICASONE PROPIONATE (0.05 %) (CREAM (G))...............................................................................................FLUTICASONE PROPIONATE (50 MCG) (SPRAYSUSP)....................................................................................FLUTICASONE/SALMETEROL.......................................3FLUTICASONE/VILANTEROL........................................3FLUVASTATIN SODIUM................................................ 10FLUVOXAMINE MALEATE.............................................5FML FORTE......................................................................18FML S.O.P......................................................................... 18FONDAPARINUX SODIUM............................................24FORFIVO XL...................................................................... 5FORMOTEROL FUMARATE............................................ 3FORTEO............................................................................ 15FOSAMAX PLUS D (70 MG-2800) (TABLET).............. 15FOSAMPRENAVIR CALCIUM.......................................32FOSAPREPITANT DIMEGLUMINE................................ 2FOSCARNET SODIUM................................................... 30FOSFOMYCIN TROMETHAMINE................................ 27FOSINOPRIL SODIUM..................................................... 9FOSINOPRIL/HYDROCHLOROTHIAZIDE.................... 8FOSPHENYTOIN SODIUM............................................ 43FRAGMIN......................................................................... 24FULVESTRANT............................................................... 41FUROSEMIDE..................................................................10FUROSEMIDE IN DEXTROSE 5 %................................10FUZEON............................................................................31FYCOMPA (10 MG) (TABLET).......................................44

- G -GABAPENTIN..................................................................43GABITRIL (12 MG) (TABLET).......................................44GABLOFEN...................................................................... 44GALANTAMINE HBR.......................................................4GANCICLOVIR................................................................18GANCICLOVIR SODIUM............................................... 30GATIFLOXACIN.............................................................. 19GEL-ONE.......................................................................... 33GEMCITABINE HCL....................................................... 38GEMFIBROZIL.................................................................11GEMIFLOXACIN MESYLATE....................................... 28GENOTROPIN.................................................................. 16GENTAMICIN IN NACL, ISO-OSM............................... 29GENTAMICIN SULF/PREDNISOLONE........................ 17GENTAMICIN SULFATE...........................................19, 29GENTAMICIN SULFATE/PF........................................... 29GENVISC 850................................................................... 33

GENVOYA........................................................................ 32GEODON............................................................................ 6GIALAX............................................................................ 36GIAZO.........................................................................35, 47GILENYA.......................................................................... 41GILOTRIF......................................................................... 39GLATIRAMER ACETATE............................................... 41GLATIRAMER ACETATE (20 MG/ML) (SYRINGE)........GLEOSTINE (10 MG) (CAPSULE).................................36GLIADEL.......................................................................... 36GLIMEPIRIDE..................................................................14GLIPIZIDE........................................................................ 14GLIPIZIDE/METFORMIN HCL......................................14GLUCAGEN..................................................................... 14GLUCAGON,HUMAN RECOMBINANT.......................14GLYBURIDE.....................................................................14GLYBURIDE,MICRONIZED...........................................14GLYBURIDE/METFORMIN HCL...................................14GLYCINE UROLOGIC SOLUTION................................29GLYCOPYRROLATE....................................................... 45GLYCOPYRROLATE (0.2 MG/ML) (VIAL).......................GLYCOPYRROLATE (1 MG) (TABLET)...........................GLYCOPYRROLATE (1 MG/5 ML) (SYRINGE)...............GOLIMUMAB.................................................................. 33GR POL-ORC/SW VER/RYE/KENT/TIM........................ 2GRANISETRON................................................................. 2GRANISETRON HCL........................................................ 2GRANISETRON HCL (1 MG/ML(1)) (VIAL)....................GRANISETRON HCL (1 MG/ML) (VIAL).........................GRANISETRON HCL/PF...................................................2GRANIX............................................................................24GRISEOFULVIN ULTRAMICROSIZE........................... 29GRISEOFULVIN, MICROSIZE....................................... 29GUANFACINE HCL...........................................................9GYNAZOLE 1...................................................................46

- H -HALAVEN.........................................................................38HALOBETASOL PROPIONATE..................................... 13HALOPERIDOL................................................................. 6HALOPERIDOL DECANOATE........................................ 6HALOPERIDOL LACTATE............................................... 6HEALON...........................................................................19HEALON5.........................................................................19HECTOROL (2MCG/ML(1)) (VIAL).............................. 17HELIXATE FS (1000 (+/-)) (VIAL)................................. 21HELIXATE FS (2000 (+/-)) (VIAL)................................. 21HELIXATE FS (250 (+/-)) (VIAL)................................... 21HELIXATE FS (3000 (+/-)) (VIAL)................................. 21HELIXATE FS (500 (+/-)) (VIAL)................................... 21HERCEPTIN (440 MG) (VIAL)....................................... 38HEXALEN........................................................................ 36HISTRELIN ACETATE.................................................... 17HOMATROPINE HBR......................................................20HUM PROTHROMBIN CPLX(PCC)4FACT................... 22HUMALOG.......................................................................14HUMALOG KWIKPEN U-100........................................ 14HUMALOG KWIKPEN U-200........................................ 14HUMALOG MIX 50-50....................................................15HUMALOG MIX 50-50 KWIKPEN................................ 15HUMALOG MIX 75-25....................................................15HUMALOG MIX 75-25 KWIKPEN................................ 15HUMATE-P....................................................................... 22HUMATROPE (12 MG) (CARTRIDGE)..........................16HUMATROPE (24 MG) (CARTRIDGE)..........................16HUMATROPE (5 MG) (VIAL).........................................16HUMATROPE (6 MG) (CARTRIDGE)............................16HUMIRA (10MG/0.2ML) (SYRINGEKIT)..................... 33HUMIRA (20MG/0.4ML) (SYRINGEKIT)..................... 33HUMIRA (40MG/0.8ML) (SYRINGEKIT)..................... 33HUMIRA PEDIATRIC CROHN'S....................................33HUMIRA PEN...................................................................33HUMIRA PEN CROHN-UC-HS STARTER.................... 33HUMIRA PEN PSORIASIS-UVEITIS.............................33HUMULIN 70/30 KWIKPEN...........................................15HUMULIN 70-30.............................................................. 15HUMULIN N.....................................................................15HUMULIN N KWIKPEN................................................. 15HUMULIN R.....................................................................15HUMULIN R U-500..........................................................15HUMULIN R U-500 KWIKPEN...................................... 15HYALGAN........................................................................ 33HYALURONATE SOD, CROSS-LINKED.......................33HYALURONATE SODIUM........................................19, 33HYCAMTIN (0.25 MG) (CAPSULE).............................. 39HYCAMTIN (1 MG) (CAPSULE)................................... 39HYDRALAZINE HCL........................................................9HYDROCHLOROTHIAZIDE.......................................... 10HYDROCODONE/ACETAMINOPHEN..........................42HYDROCODONE/ACETAMINOPHEN (10MG-300MG)(TABLET)..............................................................................HYDROCODONE/IBUPROFEN..................................... 42

HYDROCODONE/IBUPROFEN (7.5-200 MG)(TABLET)..............................................................................HYDROCORTISONE................................................. 13, 34HYDROCORTISONE (1 %) (CRM/PE APP)......................HYDROCORTISONE SOD SUCCINATE....................... 34HYDROCORTISONE SODIUM SUCC/PF..................... 34HYDROCORTISONE/ACETIC ACID............................. 15HYDROCORTISONE/IODOQUINOL.............................12HYDROCORTISONE/PRAMOXINE.............................. 13HYDROCORTISONE/PRAMOXINE/C-XYL................. 15HYDROMORPHONE HCL..............................................42HYDROMORPHONE HCL (1 MG/ML) (AMPUL)............HYDROXYAMPHETAMINE/TROPICAMIDE...............20HYDROXYCHLOROQUINE SULFATE......................... 30HYDROXYPROGESTERONE CAPROATE................... 25HYDROXYPROPYL CELLULOSE.................................20HYDROXYUREA.......................................................25, 36HYDROXYZINE HCL........................................................2HYDROXYZINE PAMOATE............................................. 2HYLAN G-F 20.................................................................33HYOSCYAMINE SULFATE.............................................45

- I -IBANDRONATE SODIUM...............................................15IBANDRONATE SODIUM (150 MG) (TABLET)...............IBANDRONATE SODIUM (3 MG/3 ML) (VIAL)..............IBRUTINIB....................................................................... 39IBUPROFEN/OXYCODONE HCL.................................. 42IBUTILIDE FUMARATE................................................... 7ICATIBANT ACETATE.................................................... 34ICOSAPENT ETHYL....................................................... 11IDARUBICIN HCL........................................................... 37IDELVION.........................................................................23IDHIFA (100 MG) (TABLET).......................................... 40IFOSFAMIDE....................................................................36IFOSFAMIDE/MESNA.....................................................36ILEVRO.............................................................................18IMATINIB MESYLATE................................................... 39IMBRUVICA.....................................................................39IMIPENEM/CILASTATIN SODIUM...............................27IMIPRAMINE HCL............................................................ 5IMIPRAMINE PAMOATE..................................................5IMIQUIMOD.....................................................................26INCRELEX........................................................................17INCRUSE ELLIPTA............................................................3INDAPAMIDE...................................................................10INDINAVIR SULFATE..................................................... 32INFLECTRA..................................................................... 35INFLIXIMAB....................................................................35INFLIXIMAB-DYYB....................................................... 35INFUMORPH....................................................................42INSULIN GLARGINE,HUM.REC.ANLOG....................14INSULIN LISPRO.............................................................14INSULIN LISPRO PROTAMIN/LISPRO.........................15INSULIN NPH HUM/REG INSULIN HM...................... 15INSULIN NPH HUMAN ISOPHANE............................. 15INSULIN REGULAR, HUMAN...................................... 15INTELENCE (100 MG) (TABLET)..................................31INTELENCE (200 MG) (TABLET)..................................31INTELENCE (25 MG) (TABLET)....................................31INTERFERON ALFA-2B,RECOMB................................26INTERFERON ALFA-N3................................................. 26INTERFERON BETA-1A................................................. 41INTERFERON BETA-1A/ALBUMIN..............................41INTERFERON BETA-1B..................................................41INTERFERON GAMMA-1B,RECOMB..........................26INTRON A (10MM UNIT) (VIAL)..................................26INTRON A (10MM/ML) (VIAL)..................................... 26INTRON A (18MM UNIT) (VIAL)..................................26INTRON A (50MM UNIT) (VIAL)..................................26INTRON A (6MMUNIT/ML) (VIAL)..............................26INVANZ.............................................................................27INVIRASE.........................................................................32INVOKAMET................................................................... 14INVOKAMET XR.............................................................14IODOFLEX....................................................................... 12IOPIDINE (1 %) (DROPERETTE)...................................19IPRATROPIUM BROMIDE................................................3IPRATROPIUM/ALBUTEROL SULFATE........................ 3IPRIVASK......................................................................... 25IRBESARTAN...............................................................9, 47IRBESARTAN/HYDROCHLOROTHIAZIDE.............8, 47IRINOTECAN HCL.......................................................... 39ISENTRESS (100 MG) (POWD PACK)...........................32ISENTRESS (100 MG) (TAB CHEW)............................. 32ISENTRESS (25 MG) (TAB CHEW)............................... 32ISENTRESS (400 MG) (TABLET)...................................32ISOCARBOXAZID.............................................................4ISOMETHEPT/DICHLPHN/ACETAMINOP.................. 43ISONIAZID....................................................................... 29ISORDIL............................................................................11ISOSORBIBE DINIT/HYDRALAZINE.......................... 10


Index

ISOSORBIDE DINITRATE..............................................11ISOXSUPRINE HCL........................................................ 11ISRADIPINE....................................................................... 9ITRACONAZOLE.............................................................28IVABRADINE HCL.......................................................... 11IVERMECTIN...................................................................30IXABEPILONE.................................................................38IXEMPRA......................................................................... 38IXINITY (1000 UNIT) (VIAL).........................................23IXINITY (1500 UNIT) (VIAL).........................................23IXINITY (500 UNIT) (VIAL)...........................................23

- J -JAKAFI..............................................................................38JARDIANCE..................................................................... 14

- K -KADIAN (40 MG) (CAP ER PEL)...................................42KALETRA (100MG-25MG) (TABLET).......................... 31KALETRA (200MG-50MG) (TABLET).......................... 31KCENTRA........................................................................ 22KENALOG-10...................................................................34KETOCONAZOLE........................................................... 28KETOROLAC TROMETHAMINE.................................. 18KETOROLAC TROMETHAMINE/PF.............................18KEYTRUDA......................................................................40KINERET.......................................................................... 33KIT Y-90/IBRITUMOMAB/H.ALBUMIN...................... 40KOGENATE FS.................................................................21KOVALTRY (1000 (+/-)) (VIAL)......................................21KOVALTRY (2000 (+/-)) (VIAL)......................................22KOVALTRY (250 (+/-)) (VIAL)........................................22KOVALTRY (3000 (+/-)) (VIAL)......................................22KOVALTRY (500 (+/-)) (VIAL)........................................22KRISTALOSE................................................................... 36KYPROLIS (60 MG) (VIAL)............................................39

- L -LABETALOL HCL............................................................. 8LACOSAMIDE................................................................. 43LACRISERT......................................................................20LACTULOSE.................................................................... 36LAMIVUDINE............................................................31, 32LAMIVUDINE/ZIDOVUDINE........................................ 31LAMOTRIGINE................................................................44LAMOTRIGINE (100 MG) (TABLET)................................LANOXIN (125 MCG) (TABLET).....................................8LANSOPRAZOLE/AMOXICILN/CLARITH..................45LANTUS............................................................................14LANTUS SOLOSTAR...................................................... 14LAPATINIB DITOSYLATE..............................................39LASTACAFT.....................................................................18LATANOPROST............................................................... 20LEFLUNOMIDE...............................................................33LEMTRADA..................................................................... 41LENALIDOMIDE............................................................. 39LENVATINIB MESYLATE.............................................. 39LENVIMA (18 MG/DAY) (CAPSULE)........................... 39LENVIMA (8 MG/DAY) (CAPSULE)............................. 39LETAIRIS..........................................................................10LETROZOLE.................................................................... 38LEUKERAN......................................................................36LEUKINE.......................................................................... 24LEUPROLIDE ACETATE...........................................15, 17LEVATOL............................................................................9LEVETIRACETAM.......................................................... 44LEVITRA.......................................................................... 15LEVOBUNOLOL HCL.....................................................20LEVOCETIRIZINE DIHYDROCHLORIDE..................... 2LEVOCETIRIZINE DIHYDROCHLORIDE (2.5MG/5ML) (SOLUTION).......................................................LEVOFLOXACIN.......................................................19, 28LEVOFLOXACIN IN DEXTROSE 5 %...........................28LEVONORGESTREL.......................................................11LEVORPHANOL TARTRATE......................................... 42LEVO-T............................................................................. 17LEVOTHYROXINE SODIUM......................................... 17LEVOXYL.........................................................................17LEVSIN (0.5 MG/ML) (AMPUL).................................... 45LEVULAN........................................................................ 41LEXIVA (50 MG/ML) (ORAL SUSP)..............................32LIDOCAINE HCL/DEXTROSE 5 %/PF............................7LIDOCAINE HCL/PF................................................... 7, 18LINACLOTIDE................................................................. 35LINCOMYCIN HCL.........................................................29LINDANE..........................................................................12LINEZOLID...................................................................... 27LINZESS (145 MCG) (CAPSULE).................................. 35LIORESAL INTRATHECAL........................................... 44LIOTHYRONINE SODIUM.............................................17LIOTRIX........................................................................... 17LIPASE/PROTEASE/AMYLASE...............................44, 45LIPOCHOL PLUS.............................................................11

LIRAGLUTIDE.................................................................14LISDEXAMFETAMINE DIMESYLATE...........................5LISINOPRIL........................................................................9LISINOPRIL/HYDROCHLOROTHIAZIDE......................8LITHIUM CARBONATE....................................................6LITHIUM CITRATE........................................................... 6LITHOSTAT...................................................................... 36LIVALO............................................................................. 11LODOXAMIDE TROMETHAMINE............................... 19LOMUSTINE.................................................................... 36LOPINAVIR/RITONAVIR................................................ 31LORAZEPAM................................................................. 5, 7LORZONE.........................................................................44LOSARTAN POTASSIUM................................................. 9LOSARTAN/HYDROCHLOROTHIAZIDE.......................8LOTEMAX........................................................................18LOTEPREDNOL ETABONATE.......................................18LOVASTATIN....................................................................11LOXAPINE SUCCINATE...................................................6LUBIPROSTONE..............................................................36LUCENTIS (0.3MG/0.05) (VIAL)....................................20LUMIGAN........................................................................ 19LUMINAL SODIUM.......................................................... 6LUPRON DEPOT..............................................................17LUPRON DEPOT (7.5 MG) (SYRINGEKIT).................. 15LUPRON DEPOT (LUPANETA)......................................17LUPRON DEPOT-PED (11.25 MG) (KIT).......................17LUPRON DEPOT-PED (11.25 MG) (SYRINGEKIT)......17LUPRON DEPOT-PED (15 MG) (KIT)............................17LUPRON DEPOT-PED (7.5 MG) (KIT)...........................17LYRICA.............................................................................44LYSODREN...................................................................... 40

- M -MACUGEN....................................................................... 20MAFENIDE ACETATE.................................................... 12MALATHION....................................................................12MANNITOL...................................................................... 10MAPROTILINE HCL..........................................................5MARAVIROC....................................................................31MARPLAN..........................................................................4MATULANE..................................................................... 40MAXIDEX........................................................................ 18MECASERMIN.................................................................17MECHLORETHAMINE HCL..........................................37MEDROL (2 MG) (TABLET)...........................................34MEDROLOAN II SUIK.................................................... 34MEDROLOAN SUIK........................................................34MEDROXYPROGESTERONE ACETATE.......... 11, 25, 26MEFLOQUINE HCL........................................................ 30MEGESTROL ACETATE................................................. 41MEKINIST........................................................................ 38MELOXICAM...................................................................35MELPHALAN...................................................................37MELPHALAN HCL..........................................................37MEMANTINE HCL............................................................4MEMANTINE HCL (10 MG) (TABLET)............................MEMANTINE HCL/DONEPEZIL HCL............................4MENEST........................................................................... 25MENOSTAR......................................................................25MEPERIDINE HCL.......................................................... 42MEPERIDINE HCL/PF.....................................................42MEPHYTON..................................................................... 25ME-PREDNIS/NORFLURAN/HFC 245FA..................... 34MEPROBAMATE............................................................... 6MERCAPTOPURINE....................................................... 38MEROPENEM.................................................................. 27MESALAMINE.................................................................35MESTINON (60 MG/5 ML) (SYRUP)............................... 4METAPROTERENOL SULFATE.......................................3METAXALONE................................................................44METFORMIN HCL.......................................................... 14METFORMIN HCL (850 MG) (TABLET)...........................METH/MEBLUE/SOD PHOS/PSAL/HYOS................... 27METHADONE HCL......................................................... 42METHADONE HCL (10 MG) (TABLET)...........................METHAMPHETAMINE HCL............................................5METHAZOLAMIDE........................................................ 19METHEN/MBLUE/SAL/SOD PHOS/HYOS...................27METHENAM/SOD PHOS/MBLUE/HYOSCY............... 27METHENAM/SOD PHOS/MBLUE/HYOSCY (81.6-.12MG) (TABLET)................................................................METHENAMINE HIPPURATE....................................... 27METHENAMINE MANDELATE.................................... 27METHIMAZOLE.............................................................. 17METHIONINE/INOSI/CHOL/FOLIC AC....................... 11METHOCARBAMOL.......................................................44METHOTREXATE SODIUM...........................................38METHOTREXATE SODIUM/PF..................................... 38METHOXSALEN....................................................... 13, 40METHSCOPOLAMINE BROMIDE................................ 45

METHSUXIMIDE............................................................ 44METHYCLOTHIAZIDE...................................................10METHYLDOPA.................................................................. 9METHYLPHENIDATE.......................................................7METHYLPHENIDATE HCL..............................................7METHYLPHENIDATE HCL (10 MG) (CPBP 30-70).........METHYLPREDNISOLONE............................................ 34METHYLPREDNISOLONE ACETATE.......................... 34METHYLPREDNISOLONE SOD SUCC........................ 34METHYLPREDNISOLONE SOD SUCC/PF.................. 34METIPRANOLOL............................................................ 20METOCLOPRAMIDE HCL....................................... 45, 46METOCLOPRAMIDE HCL (10 MG) (TABLET)...............METOCLOPRAMIDE HCL (10 MG/2 ML) (SYRINGE)...............................................................................................METOCLOPRAMIDE HCL (5 MG/ML) (VIAL)................METOLAZONE................................................................ 10METOPROLOL SUCCINATE............................................9METOPROLOL TARTRATE..............................................9METOPROLOL TARTRATE (5 MG/5 ML) (AMPUL).......METOPROLOL TARTRATE (5 MG/5 ML) (SYRINGE)...............................................................................................METOPROLOL TARTRATE (5 MG/5 ML) (VIAL)...........METRONIDAZOLE................................................... 30, 46METRONIDAZOLE/SODIUM CHLORIDE................... 30METYROSINE....................................................................9MEXILETINE HCL............................................................ 7MIACALCIN.....................................................................15MICAFUNGIN SODIUM................................................. 29MICONAZOLE NITRATE............................................... 46MICONAZOLE NITRATE (200 MG) (SUPP.VAG)............MIDAZOLAM HCL............................................................7MIDODRINE HCL........................................................... 11MIGERGOT...................................................................... 43MIGLITOL........................................................................ 14MILLIPRED...................................................................... 34MILLIPRED DP................................................................34MILRINONE LACTATE.....................................................8MINIVELLE......................................................................25MINOCIN (100 MG) (VIAL)........................................... 28MINOCYCLINE HCL...................................................... 28MINOCYCLINE HCL (100 MG) (CAPSULE)....................MINOCYCLINE HCL (100 MG) (TABLET).......................MINOCYCLINE HCL (50 MG) (CAPSULE)......................MINOCYCLINE HCL (50 MG) (TABLET).........................MINOCYCLINE HCL (75 MG) (CAPSULE)......................MINOCYCLINE HCL (75 MG) (TABLET).........................MINOXIDIL........................................................................9MIOCHOL-E.....................................................................19MIOSTAT.......................................................................... 20MIRTAZAPINE...................................................................4MISOPROSTOL................................................................45MITOMYCIN....................................................................37MITOTANE....................................................................... 40MITOXANTRONE HCL.................................................. 40MODAFINIL....................................................................... 7MOEXIPRIL HCL...............................................................9MOEXIPRIL/HYDROCHLOROTHIAZIDE......................8MOMETASONE FUROATE.....................................2, 4, 13MOMETASONE/FORMOTEROL......................................3MONONINE......................................................................23MONTELUKAST SODIUM...............................................4MONUROL....................................................................... 27MORGIDOX (100 MG) (KIT).......................................... 28MORPHINE SULFATE.....................................................42MORPHINE SULFATE (10 MG) (CAP ER PEL)................MORPHINE SULFATE/PF............................................... 42MOVANTIK...................................................................... 36MOXEZA.......................................................................... 19MOXIFLOXACIN HCL..............................................19, 28MOXIFLOXACIN IN NACL (ISO-OSM)........................ 28MOXIFLOXACIN(PF)/BAL.SALT SOL2........................19MOXIFLOXACIN(PF)/BAL.SALT SOL2 (1 MG/ML)(VIAL)...................................................................................MULTAQ............................................................................. 7MUPIROCIN..................................................................... 12MUSE................................................................................ 15MUSTARGEN...................................................................37MYCAMINE (100 MG) (VIAL).......................................29MYCAMINE (50 MG) (VIAL).........................................29MYCOPHENOLATE MOFETIL......................................26MYCOPHENOLATE SODIUM....................................... 26MYLERAN........................................................................36

- N -NABILONE......................................................................... 2NABUMETONE................................................................35NADOLOL.......................................................................... 9NAFARELIN ACETATE...................................................17NAFTIFINE HCL..............................................................12NALBUPHINE HCL.........................................................42NALOXEGOL OXALATE................................................36


Index

NALOXONE HCL.............................................................. 7NALTREXONE HCL..........................................................7NALTREXONE MICROSPHERES....................................5NAMZARIC (21 MG-10MG) (CAP SPR 24).....................4NAMZARIC (7-10/14-10) (CAP24 DSPK)........................ 4NAPRELAN (750 MG) (TBMP 24HR)............................35NAPROXEN...................................................................... 35NAPROXEN SODIUM..................................................... 35NAPROXEN SODIUM (275 MG) (TABLET).....................NAPROXEN SODIUM (550 MG) (TABLET).....................NARATRIPTAN HCL....................................................... 43NARCAN.............................................................................7NATACYN.........................................................................19NATAMYCIN....................................................................19NATAZIA.......................................................................... 11NATEGLINIDE................................................................. 14NEBIVOLOL HCL..............................................................9NEBUPENT...................................................................... 30NEDOCROMIL SODIUM................................................ 19NEFAZODONE HCL..........................................................5NELARABINE..................................................................38NELFINAVIR MESYLATE.............................................. 32NEOMYC/BACIT/POLYMYX/HYDROCORT............... 12NEOMYC/COLIST/HYDROCORT/THONZN................15NEOMYCIN SULF/BACITRACIN/POLY.......................19NEOMYCIN SULFATE....................................................29NEOMYCIN/BACIT/P-MYX/HYDROCORT................. 18NEOMYCIN/POLYMYXIN B/DEXAMETHA...............18NEOMYCIN/POLYMYXIN B/HYDROCORT..........15, 18NEOMYCIN/POLYMYXN B/GRAMICIDIN................. 19NEORAL........................................................................... 26NEOSTIGMINE METHYLSULFATE............................... 4NEOSTIGMINE METHYLSULFATE (5 MG/5 ML)(SYRINGE)...........................................................................NEPAFENAC.................................................................... 18NEULASTA (6MG/0.6ML) (SYR W/ INJ)...................... 24NEULASTA (6MG/0.6ML) (SYRINGE)......................... 24NEUPOGEN......................................................................24NEVANAC.........................................................................18NEVIRAPINE................................................................... 31NEXAVAR.........................................................................39NEXPLANON...................................................................11NIACIN............................................................................. 11NIACIN (500 MG) (TABLET)..............................................NICARDIPINE HCL...........................................................9NICARDIPINE IN DEXTROSE,ISO-OS...........................9NICARDIPINE IN NACL, ISO-OSM................................ 9NICOTINE.........................................................................44NICOTROL NS................................................................. 44NIFEDIPINE....................................................................... 9NILOTINIB HCL.............................................................. 39NILUTAMIDE...................................................................37NIMODIPINE......................................................................9NIPENT............................................................................. 38NISOLDIPINE.................................................................... 9NITAZOXANIDE..............................................................30NITROFURANTOIN........................................................ 27NITROGLYCERIN........................................................... 11NITROGLYCERIN IN 5 % DEXTROSE......................... 11NIVOLUMAB................................................................... 40NIZATIDINE.....................................................................45NIZATIDINE (150MG/10ML) (SOLUTION)......................NORDITROPIN FLEXPRO (10MG/1.5ML) (PENINJCTR)............................................................................ 16NORDITROPIN FLEXPRO (15MG/1.5ML) (PENINJCTR)............................................................................ 16NORDITROPIN FLEXPRO (30 MG/3 ML) (PENINJCTR)............................................................................ 16NORDITROPIN FLEXPRO (5 MG/1.5ML) (PENINJCTR)............................................................................ 16NORELGESTROMIN/ETHIN.ESTRADIOL.................. 12NORETHINDRONE......................................................... 11NORETHINDRONE ACETATE....................................... 26NORETHINDRONE AC-ETH ESTRADIOL.............11, 25NORETHINDRONE-E.ESTRADIOL-IRON................... 11NORETHINDRONE-ETHINYL ESTRAD...................... 12NORGESTIMATE-ETHINYL ESTRADIOL...................12NORGESTREL-ETHINYL ESTRADIOL....................... 12NORPACE CR.....................................................................7NORTRIPTYLINE HCL..................................................... 5NORVIR............................................................................ 32NOVOSEVEN RT............................................................. 22NOXAFIL (100 MG) (TABLET DR)................................28NOXAFIL (200 MG/5ML) (ORAL SUSP).......................28NUDICLO................................................................... 13, 35NUEDEXTA......................................................................42NULOJIX.......................................................................... 26NUPLAZID......................................................................... 7NUTROPIN AQ NUSPIN (10 MG/2 ML) (PEN INJCTR)........................................................................................... 16NUTROPIN AQ NUSPIN (20 MG/2 ML) (PEN INJCTR)........................................................................................... 16

NUTROPIN AQ NUSPIN (5 MG/2 ML) (PEN INJCTR)........................................................................................... 16NUVARING.......................................................................11NUWIQ (1000 (+/-)) (VIAL)............................................ 22NUWIQ (2000 (+/-)) (VIAL)............................................ 22NUWIQ (250 (+/-)) (VIAL).............................................. 22NUWIQ (500 (+/-)) (VIAL).............................................. 22NYSTATIN........................................................................ 29

- O -OBIZUR............................................................................ 22ODEFSEY......................................................................... 32OFLOXACIN.........................................................15, 19, 28OLANZAPINE.................................................................... 6OLANZAPINE PAMOATE.................................................6OLANZAPINE/FLUOXETINE HCL................................. 7OLMESARTAN MEDOXOMIL...................................9, 47OLMESARTAN/AMLODIPIN/HCTHIAZID.............. 8, 48OLMESARTAN/HYDROCHLOROTHIAZIDE...........8, 48OLODATEROL HCL.......................................................... 3OLOPATADINE HCL................................................... 2, 18OLOPATADINE HCL (0.1 %) (DROPS)..............................OMALIZUMAB..................................................................4OMNARIS........................................................................... 2OMNITROPE.................................................................... 16ONCASPAR...................................................................... 40ONDANSETRON................................................................2ONDANSETRON HCL.......................................................2ONDANSETRON HCL (2 MG/ML) (VIAL).......................ONFI (10 MG) (TABLET)................................................ 44ONMEL............................................................................. 28OPDIVO............................................................................ 40OPIUM TINCTURE..........................................................36OPIUM/BELLADONNA ALKALOIDS.......................... 42ORALAIR (100-300 IR) (TAB SUBL)............................... 2ORENCIA..........................................................................34ORENCIA (125 MG/ML) (SYRINGE)............................ 33ORENCIA CLICKJECT................................................... 34ORPHENADRINE CITRATE...........................................44ORTHOVISC.....................................................................33OSELTAMIVIR PHOSPHATE......................................... 30OSMITROL (15 %) (IV SOLN)........................................10OSMOPREP...................................................................... 36OTEZLA............................................................................33OXALIPLATIN................................................................. 37OXAPROZIN.....................................................................35OXAZEPAM........................................................................6OXCARBAZEPINE.......................................................... 44OXICONAZOLE NITRATE............................................. 12OXTELLAR XR................................................................44OXYBUTYNIN.................................................................46OXYBUTYNIN CHLORIDE............................................46OXYBUTYNIN CHLORIDE (10 MG) (TAB ER 24)..........OXYCODONE HCL......................................................... 42OXYCODONE HCL (10 MG) (TAB ER 12H).....................OXYCODONE HCL/ACETAMINOPHEN...................... 42OXYCONTIN (15 MG) (TAB ER 12H)........................... 42OXYMORPHONE HCL................................................... 42OXYMORPHONE HCL (10 MG) (TAB ER 12H)...............OXYTROL.........................................................................46

- P -PACLITAXEL....................................................................40PACLITAXEL PROTEIN-BOUND.................................. 40PALIPERIDONE................................................................. 6PALIVIZUMAB................................................................ 30PALONOSETRON HCL..................................................... 2PAMIDRONATE DISODIUM.......................................... 16PANCREAZE.................................................................... 44PANRETIN........................................................................13PAPAVERINE HCL...........................................................11PAREGORIC..................................................................... 36PAREMYD........................................................................ 20PARICALCITOL...............................................................17PARICALCITOL (1 MCG) (CAPSULE)..............................PARICALCITOL (2 MCG/ML) (VIAL)...............................PARICALCITOL (5 MCG/ML) (VIAL)...............................PAROMOMYCIN SULFATE............................................30PAROXETINE HCL............................................................5PASER............................................................................... 29PAXIL (10 MG/5 ML) (ORAL SUSP)................................5PAZOPANIB HCL.............................................................39P-CARE D40G.................................................................. 34P-CARE D80G.................................................................. 34P-CARE K40G.................................................................. 34P-CARE K80G.................................................................. 34PEG 3350/SOD CHLOR/POTASS CIT............................ 36PEGANONE......................................................................43PEGAPTANIB SODIUM.................................................. 20PEGASPARGASE.............................................................40PEGASYS..........................................................................32PEGASYS PROCLICK.....................................................33PEGFILGRASTIM............................................................24

PEGINTERFERON ALFA-2A....................................32, 33PEGINTERFERON ALFA-2B..........................................33PEGINTERFERON BETA-1A..........................................41PEGINTRON.....................................................................33PEGVISOMANT...............................................................16PEMBROLIZUMAB.........................................................40PEMETREXED DISODIUM............................................38PENBUTOLOL SULFATE................................................. 9PENICILLAMINE............................................................ 33PENTAM 300.................................................................... 30PENTAMIDINE ISETHIONATE......................................30PENTASA..........................................................................35PENTAZOCINE HCL/NALOXONE HCL....................... 42PENTAZOCINE LACTATE..............................................42PENTOSAN POLYSULFATE SODIUM..........................46PENTOSTATIN................................................................. 38PENTOXIFYLLINE..........................................................24PERAMPANEL................................................................. 44PERFOROMIST..................................................................3PERINDOPRIL ERBUMINE............................................. 9PERMETHRIN..................................................................12PERMETHRIN (5 %) (CREAM (G))...................................PERPHENAZINE................................................................6PERPHENAZINE/AMITRIPTYLINE HCL.......................5PERTZYE (16K-57.5K) (CAPSULE DR)........................ 45PERTZYE (4000-14375) (CAPSULE DR)....................... 45PERTZYE (8K-28.75K) (CAPSULE DR)........................ 45PHENAZOPYRIDINE HCL............................................. 46PHENAZOPYRIDINE HCL (100 MG) (TABLET).............PHENELZINE SULFATE................................................... 4PHENOBARBITAL............................................................ 6PHENOBARBITAL SODIUM............................................6PHENOBARBITAL/0.9 % SOD CHLOR.......................... 6PHENOXYBENZAMINE HCL....................................8, 10PHENTOLAMINE MESYLATE........................................ 8PHENYLEPHRINE HCL..................................................19PHENYTOIN.................................................................... 44PHENYTOIN SODIUM EXTENDED............................. 44PHOSPHASAL..................................................................27PHOSPHOLINE IODIDE................................................. 20PHOTOFRIN..................................................................... 40PHYSOSTIGMINE SALICYLATE....................................4PHYTONADIONE (VIT K1)............................................25PHYTONADIONE (VIT K1) (10 MG/ML) (AMPUL)........PHYTONADIONE (VIT K1) (1MG/0.5ML) (AMPUL)...............................................................................................PHYTONADIONE (VIT K1) (1MG/0.5ML) (SYRINGE)...............................................................................................PILOCARPINE HCL........................................................ 20PIMAVANSERIN TARTRATE........................................... 7PIMECROLIMUS............................................................. 13PIMOZIDE.......................................................................... 6PINDOLOL......................................................................... 9PIOGLITAZONE HCL......................................................14PIOGLITAZONE HCL/GLIMEPIRIDE...........................14PIOGLITAZONE HCL/METFORMIN HCL................... 14PIROXICAM..................................................................... 35PITAVASTATIN CALCIUM............................................. 11PLEGRIDY........................................................................41PLEGRIDY PEN............................................................... 41POD-CARE 100KG...........................................................34PODOFILOX.....................................................................13PODOPHYLLUM RESIN.................................................13POLYETHYLENE GLYCOL 3350...................................36POLYETHYLENE GLYCOL 3350 (17G/DOSE)(POWDER)............................................................................POLYMYXIN B SULF/TRIMETHOPRIM......................19POLYMYXIN B SULFATE.............................................. 29POMALIDOMIDE............................................................ 39POMALYST...................................................................... 39PORFIMER SODIUM.......................................................40POSACONAZOLE............................................................28POTASSIUM IODIDE...................................................... 17POTASSIUM IODIDE (1 G/ML) (SOLUTION)..................POTASSIUM IODIDE/IODINE........................................17PRADAXA........................................................................ 25PRAMIPEXOLE DI-HCL.................................................43PRAMIPEXOLE DI-HCL (0.125 MG) (TABLET)..............PRAMLINTIDE ACETATE.............................................. 14PRAMOSONE (1 %-1 %) (CREAM (G)).........................13PRASUGREL HCL........................................................... 24PRAVASTATIN SODIUM.................................................11PRAZIQUANTEL............................................................. 30PRAZOSIN HCL.................................................................8PRED MILD......................................................................18PRED-G.............................................................................17PREDNICARBATE...........................................................13PREDNISOLONE............................................................. 34PREDNISOLONE ACETATE...........................................18PREDNISOLONE SOD PHOSPHATE...................... 18, 34PREDNISOLONE SOD PHOSPHATE (10 MG) (TABRAPDIS)................................................................................


Index

PREDNISOLONE SOD PHOSPHATE (15 MG/5 ML)(SOLUTION).........................................................................PREDNISOLONE SOD PHOSPHATE (25 MG/5 ML)(SOLUTION).........................................................................PREDNISOLONE SOD PHOSPHATE (30 MG) (TABRAPDIS)................................................................................PREDNISOLONE SOD PHOSPHATE (5 MG/5 ML)(SOLUTION).........................................................................PREDNISONE.................................................................. 34PREDNISONE INTENSOL..................................................PREFEST...........................................................................25PREGABALIN.................................................................. 44PREMARIN.................................................................25, 46PREMPHASE....................................................................25PREMPRO.........................................................................25PREZCOBIX..................................................................... 30PREZISTA......................................................................... 30PRIFTIN............................................................................ 29PRIMAQUINE.................................................................. 30PRIMAQUINE PHOSPHATE...........................................30PRIMIDONE..................................................................... 44PRIMSOL.......................................................................... 27PROAIR HFA...................................................................... 3PROBENECID.................................................................. 20PROBENECID/COLCHICINE......................................... 20PROCAINAMIDE HCL......................................................7PROCAINAMIDE HCL (100 MG/ML) (VIAL)...................PROCAINAMIDE HCL (500 MG/ML) (VIAL)...................PROCARBAZINE HCL....................................................40PROCHLORPERAZINE.....................................................2PROCRIT...........................................................................24PROFILNINE (1000 (+/-)) (VIAL)...................................23PROFILNINE (1500 (+/-)) (VIAL)...................................23PROFILNINE (500 (+/-)) (VIAL).....................................23PROGESTERONE.............................................................26PROGESTERONE, MICRONIZED..................................26PROGLYCEM................................................................... 14PROGRAF......................................................................... 26PROLENSA.......................................................................18PROLEUKIN.....................................................................26PROMACTA......................................................................25PROMETHAZINE HCL..................................................... 2PROPAFENONE HCL........................................................ 7PROPANTHELINE BROMIDE........................................45PROPARACAINE HCL.................................................... 18PROPARACAINE/FLUORESCEIN SOD........................ 18PROPRANOLOL HCL....................................................... 9PROPYLTHIOURACIL.................................................... 17PROTAMINE SULFATE...................................................22PROTRIPTYLINE HCL......................................................5PROVENTIL HFA...............................................................3PROVISC...........................................................................19PSEUDOEPHEDRINE HCL/ACRIVAS.............................2PULMICORT FLEXHALER (180 MCG) (AER POW BA)............................................................................................. 3PULMICORT FLEXHALER (90 MCG) (AER POW BA)............................................................................................. 3PURIXAN..........................................................................38PYLERA............................................................................45PYRAZINAMIDE............................................................. 29PYRIDOSTIGMINE BROMIDE........................................ 4PYRIMETHAMINE..........................................................30

- Q -QUAZEPAM........................................................................7QUETIAPINE FUMARATE............................................... 6QUINAPRIL HCL...............................................................9QUINAPRIL/HYDROCHLOROTHIAZIDE...................... 8QUINIDINE GLUCONATE................................................8QUINIDINE SULFATE.......................................................8QUININE SULFATE.........................................................30QUINUPRISTIN/DALFOPRISTIN.................................. 28QVAR...................................................................................3

- R -RALOXIFENE HCL......................................................... 16RALTEGRAVIR POTASSIUM.........................................32RAMELTEON..................................................................... 7RAMIPRIL.......................................................................... 9RAMUCIRUMAB.............................................................39RANEXA...........................................................................11RANIBIZUMAB............................................................... 20RANITIDINE HCL........................................................... 45RANITIDINE HCL (15 MG/ML) (SYRUP).........................RANOLAZINE..................................................................11RAPAFLO......................................................................... 46RAPAMUNE (1 MG/ML) (SOLUTION)......................... 26RASAGILINE MESYLATE..............................................43RASBURICASE................................................................20RAYOS.............................................................................. 34REBETOL......................................................................... 33REBIF (22MCG/.5ML) (SYRINGE)................................ 41REBIF (44MCG/.5ML) (SYRINGE)................................ 41

REBIF (8.8-22(6)) (SYRINGE)........................................ 41REBIF REBIDOSE........................................................... 41RECOMBINATE (1000 (+/-)) (VIAL)..............................22RECOMBINATE (1500 (+/-)) (VIAL)..............................22RECOMBINATE (2000 (+/-)) (VIAL)..............................22RECOMBINATE (250 (+/-)) (VIAL)................................22RECOMBINATE (500 (+/-)) (VIAL)................................22REGONOL.......................................................................... 4REGORAFENIB............................................................... 39REGRANEX......................................................................14RELAGARD......................................................................46RELENZA......................................................................... 30REMICADE...................................................................... 35REMODULIN................................................................... 10REOPRO............................................................................24REPAGLINIDE................................................................. 14REPAGLINIDE/METFORMIN HCL............................... 14RESCRIPTOR................................................................... 31RESTASIS......................................................................... 19RESTASIS MULTIDOSE................................................. 19RETAPAMULIN............................................................... 12RETAVASE........................................................................25RETEPLASE..................................................................... 25RETISERT.........................................................................18RETROVIR (10 MG/ML) (VIAL).................................... 31REVLIMID........................................................................39REYATAZ (150 MG) (CAPSULE)................................... 32REYATAZ (200 MG) (CAPSULE)................................... 32REYATAZ (300 MG) (CAPSULE)................................... 32REYATAZ (50 MG) (POWD PACK)................................ 32RIBAVIRIN....................................................................... 33RIBAVIRIN (200 MG) (CAPSULE).....................................RIBAVIRIN (200 MG) (TABLET)........................................RIBAVIRIN (400 MG) (TABLET)........................................RIBAVIRIN (600 MG) (TABLET)........................................RIDAURA......................................................................... 35RIFABUTIN...................................................................... 29RIFAMATE........................................................................29RIFAMP/ISONIAZID/PYRAZINAMIDE........................ 29RIFAMPIN........................................................................ 29RIFAMPIN/ISONIAZID................................................... 29RIFAPENTINE..................................................................29RIFATER........................................................................... 29RIFAXIMIN...................................................................... 30RILONACEPT...................................................................33RILPIVIRINE HCL...........................................................31RILUZOLE........................................................................42RIMANTADINE HCL...................................................... 30RIMSO-50......................................................................... 46RIOCIGUAT......................................................................10RIOMET............................................................................ 14RISEDRONATE SODIUM............................................... 16RISEDRONATE SODIUM (5 MG) (TABLET)....................RISPERDAL CONSTA....................................................... 6RISPERIDONE................................................................... 6RISPERIDONE MICROSPHERES.................................... 6RITALIN LA (10 MG) (CPBP 50-50)................................ 7RITONAVIR...................................................................... 32RITUXAN......................................................................... 37RITUXIMAB.....................................................................37RIVAROXABAN...............................................................22RIVASTIGMINE................................................................. 4RIVASTIGMINE TARTRATE............................................ 4RIXUBIS........................................................................... 23RIZATRIPTAN BENZOATE............................................ 43ROFLUMILAST................................................................. 4ROPINIROLE HCL...........................................................43ROSANIL.......................................................................... 12ROSIGLITAZONE MALEATE........................................ 14ROSIGLITAZONE/METFORMIN HCL..........................14ROSUVASTATIN CALCIUM...........................................11ROZEREM.......................................................................... 7RUFINAMIDE.................................................................. 44RUXOLITINIB PHOSPHATE.......................................... 38

- S -SABRIL (500 MG) (TABLET)......................................... 44SACROSIDASE................................................................ 44SACUBITRIL/VALSARTAN............................................11SAIZEN (5 MG) (VIAL)...................................................16SAIZEN (8.8 MG) (VIAL)................................................16SALICYLIC ACID............................................................13SALICYLIC ACID (26 %) (LIQUID)..................................SALMETEROL XINAFOATE............................................3SALSALATE.....................................................................42SANCUSO...........................................................................2SANDIMMUNE (100 MG/ML) (SOLUTION)................26SAQUINAVIR MESYLATE............................................. 32SARGRAMOSTIM........................................................... 24SAVAYSA..........................................................................22SCLEROSOL.....................................................................40SCOPOLAMINE.................................................................2

SECOBARBITAL SODIUM...............................................6SECONAL SODIUM.......................................................... 6SECUKINUMAB.............................................................. 13SELEGILINE...................................................................... 7SELEGILINE HCL........................................................... 43SELEXIPAG...................................................................... 10SELZENTRY (150 MG) (TABLET).................................31SELZENTRY (300 MG) (TABLET).................................31SEMPREX-D.......................................................................2SENSIPAR.........................................................................16SEREVENT DISKUS......................................................... 3SEROQUEL XR (50-200-300) (TAB24HDSPK)............... 6SEROSTIM (4 MG) (VIAL)............................................. 16SEROSTIM (5 MG) (VIAL)............................................. 16SEROSTIM (6 MG) (VIAL)............................................. 16SERTRALINE HCL............................................................ 5SILDENAFIL CITRATE.............................................10, 15SILDENAFIL CITRATE (20 MG) (TABLET).....................SILODOSIN...................................................................... 46SILTUXIMAB................................................................... 40SIMPONI...........................................................................33SIMULECT....................................................................... 26SIMVASTATIN..................................................................11SIROLIMUS......................................................................26SIRTURO...........................................................................29SOD PHOSPHATE MBAS/SOD PHOS,DI......................36SODIUM BENZOATE/SOD PHENYLACET..................36SODIUM CITRATE.......................................................... 22SODIUM CITRATE DIHYDRATE.................................. 22SODIUM IODIDE.............................................................17SODIUM OXYBATE.......................................................... 6SODIUM PHENYLBUTYRATE......................................36SODIUM, POTASSIUM,MAG SULFATES..................... 36SOFOSBUVIR/VELPATAS/VOXILAPREV....................32SOFOSBUVIR/VELPATASVIR....................................... 32SOLIFENACIN SUCCINATE...........................................46SOLIRIS............................................................................ 24SOLTAMOX...................................................................... 41SOLU-CORTEF................................................................ 34SOLU-MEDROL...............................................................34SOLU-MEDROL (2 G) (VIAL)........................................ 34SOLU-MEDROL (500 MG) (VIAL)................................ 34SOMATROPIN..................................................................16SOMAVERT...................................................................... 16SORAFENIB TOSYLATE................................................39SOTALOL HCL...................................................................9SOTALOL HCL (120 MG) (TABLET).................................SOTALOL HCL (150MG/10ML) (VIAL)............................SPINOSAD........................................................................12SPIRIVA.............................................................................. 3SPIRIVA RESPIMAT.......................................................... 3SPIRONOLACTONE........................................................10SPORANOX (10 MG/ML) (SOLUTION)........................ 28SPRYCEL.......................................................................... 39STAVUDINE..................................................................... 31STAXYN........................................................................... 15STELARA (130MG/26ML) (VIAL).................................35STELARA (45MG/0.5ML) (SYRINGE).......................... 35STIVARGA........................................................................39STREPTOMYCIN SULFATE...........................................29STREPTOZOCIN..............................................................37STRIBILD......................................................................... 32STRIVERDI RESPIMAT.................................................... 3SUBOXONE (8 MG-2 MG) (FILM).................................43SUCRAID..........................................................................44SUCRALFATE.................................................................. 45SULCONAZOLE NITRATE.............................................12SULFACETAMIDE SODIUM.................................... 12, 18SULFACETAMIDE SODIUM/SULFUR..........................12SULFACETAMIDE/PREDNISOLONE........................... 18SULFACETAMIDE/PREDNISOLONE SP...................... 18SULFADIAZINE...............................................................35SULFASALAZINE........................................................... 35SULINDAC....................................................................... 35SUMATRIPTAN................................................................43SUMATRIPTAN SUCC/NAPROXEN SOD.....................43SUMATRIPTAN SUCCINATE.........................................43SUMATRIPTAN SUCCINATE (100 MG) (TABLET).........SUNITINIB MALATE...................................................... 40SUPARTZ FX.................................................................... 33SUPPRELIN LA................................................................17SUPRAX (400 MG) (CAPSULE)..................................... 27SUPREP.............................................................................36SUSTIVA (600 MG) (TABLET)....................................... 31SUTENT............................................................................ 40SUVOREXANT.................................................................. 7SYLVANT..........................................................................40SYMAX DUOTAB............................................................45SYMBICORT...................................................................... 3SYMLINPEN 120............................................................. 14SYNAGIS.......................................................................... 30SYNAREL......................................................................... 17


Index

SYNERCID....................................................................... 28SYNJARDY.......................................................................14SYNTHROID.................................................................... 17SYNVISC.......................................................................... 33SYNVISC-ONE.................................................................33

- T -TABLOID.......................................................................... 38TACROLIMUS............................................................ 13, 26TADALAFIL..................................................................... 10TALC................................................................................. 40TALWIN............................................................................ 42TAMOXIFEN CITRATE...................................................41TAMSULOSIN HCL.........................................................46TARCEVA......................................................................... 39TARGRETIN..................................................................... 13TASIGNA (150 MG) (CAPSULE)....................................39TASIGNA (200 MG) (CAPSULE)....................................39TAZAROTENE..................................................................13TAZORAC (0.05 %) (CREAM (G))..................................13TBO-FILGRASTIM.......................................................... 24TECFIDERA..................................................................... 41TEGRETOL.......................................................................43TEGRETOL XR................................................................ 43TEKTURNA................................................................10, 48TELMISARTAN............................................................9, 48TELMISARTAN/AMLODIPINE..................................8, 48TELMISARTAN/HYDROCHLOROTHIAZID............ 8, 48TEMAZEPAM.....................................................................7TEMODAR (100 MG) (VIAL)......................................... 37TEMOZOLOMIDE........................................................... 37TENECTEPLASE............................................................. 25TENOFOVIR ALAFENAMIDE FUMARATE.................32TENOFOVIR DISOPROXIL FUMARATE......................31TERAZOSIN HCL.............................................................. 8TERBINAFINE HCL........................................................ 28TERBUTALINE SULFATE................................................ 3TERCONAZOLE.............................................................. 46TERIFLUNOMIDE...........................................................41TERIPARATIDE............................................................... 15TESAMORELIN ACETATE.............................................16TESTOSTERONE CYPIONATE...................................... 25TESTOSTERONE ENANTHATE.................................... 25TETRABENAZINE...........................................................42TETRACAINE HCL......................................................... 18TETRACAINE HCL/PF....................................................18TETRACYCLINE HCL.................................................... 28TETRAVISC (0.5 %) (DROPR VISC)..............................18TETRAVISC FORTE........................................................ 18THALIDOMIDE............................................................... 29THALOMID (100 MG) (CAPSULE)............................... 29THALOMID (150 MG) (CAPSULE)............................... 29THALOMID (200 MG) (CAPSULE)............................... 29THALOMID (50 MG) (CAPSULE)................................. 29THEO-24............................................................................. 4THEOPHYLLINE ANHYDROUS..................................... 4THEOPHYLLINE IN DEXTROSE 5 %.............................4THIOGUANINE................................................................38THIORIDAZINE HCL........................................................ 6THIOTEPA........................................................................ 37THIOTHIXENE...................................................................6THYROID,PORK..............................................................17THYROLAR-1.................................................................. 17THYROLAR-1/2............................................................... 17THYROLAR-1/4............................................................... 17THYROLAR-2.................................................................. 17THYROLAR-3.................................................................. 17TIAGABINE HCL.............................................................44TICLOPIDINE HCL......................................................... 24TIGAN (100 MG/ML) (VIAL)........................................... 2TIGECYCLINE.................................................................27TIMOLOL......................................................................... 20TIMOLOL MALEATE......................................................20TIMOLOL MALEATE/PF................................................ 20TIMOPTIC OCUDOSE.....................................................20TINIDAZOLE................................................................... 30TIOTROPIUM BROMIDE..................................................3TIPRANAVIR....................................................................30TIPRANAVIR/VITAMIN E TPGS................................... 31TIROFIBAN HCL MONOHYDRATE............................. 24TIROFIBAN-0.9% SODIUM CHLORIDE.......................24TIROSINT......................................................................... 17TIVICAY (50 MG) (TABLET)....................................32, 48TIZANIDINE HCL........................................................... 44TNKASE............................................................................25TOBRADEX (0.3 %-0.1%) (OINT. (G)).......................... 18TOBRADEX ST................................................................18TOBRAMYCIN................................................................ 19TOBRAMYCIN IN 0.225% SOD CHLOR...................... 29TOBRAMYCIN SULFATE...............................................29TOBRAMYCIN/DEXAMETHASONE............................18TOBRAMYCIN/LOTEPRED ETAB................................ 18

TOBRAMYCIN/SODIUM CHLORIDE.......................... 29TOBREX (0.3 %) (OINT. (G))..........................................19TOCILIZUMAB................................................................35TOFACITINIB CITRATE................................................. 35TOLAZAMIDE................................................................. 14TOLBUTAMIDE...............................................................14TOLCAPONE....................................................................43TOLMETIN SODIUM...................................................... 35TOLTERODINE TARTRATE........................................... 46TOPIRAMATE.................................................................. 44TOPIRAMATE (100 MG) (TABLET)..................................TOPOTECAN HCL...........................................................39TOREMIFENE CITRATE.................................................41TORSEMIDE.................................................................... 10TOUJEO SOLOSTAR....................................................... 14TOVIAZ.............................................................................46TRACLEER (125 MG) (TABLET)................................... 10TRAMADOL HCL............................................................42TRAMADOL HCL (100 MG) (TAB ER 24H).....................TRAMETINIB DIMETHYL SULFOXIDE......................38TRANDOLAPRIL...............................................................9TRANDOLAPRIL/VERAPAMIL HCL..............................8TRANEXAMIC ACID...................................................... 21TRANEXAMIC ACID (1000 MG/10) (AMPUL)................TRANEXAMIC ACID (650 MG) (TABLET)......................TRANYLCYPROMINE SULFATE....................................4TRASTUZUMAB............................................................. 38TRAVATAN Z....................................................................20TRAVOPROST..................................................................20TRAZODONE HCL............................................................5TREANDA........................................................................ 36TRECATOR.......................................................................29TREPROSTINIL............................................................... 10TREPROSTINIL SODIUM...............................................10TREPROSTINIL/NEBULIZER/ACCESOR.....................10TRETINOIN................................................................ 12, 40TREXALL......................................................................... 38TREXIMET (10 MG-60MG) (TABLET)..........................43TRIAMCIN/NORFLURANE/HFC 245FA.......................34TRIAMCINOLONE ACETONIDE............................ 13, 34TRIAMCINOLONE ACETONIDE (0.025 %) (CREAM(G))........................................................................................TRIAMCINOLONE ACETONIDE/PF.............................18TRIAMCINOLONE HEXACETONIDE.......................... 35TRIAMTERENE............................................................... 10TRIAZOLAM......................................................................7TRICITRASOL................................................................. 22TRIESENCE......................................................................18TRIFLUOPERAZINE HCL................................................ 6TRIFLURIDINE................................................................18TRIGLIDE.........................................................................11TRIHEXYPHENIDYL HCL............................................. 43TRILOAN II SUIK............................................................34TRILOAN SUIK................................................................34TRIMETHOBENZAMIDE HCL........................................ 2TRIMETHOPRIM.............................................................27TRIMIPRAMINE MALEATE............................................ 5TRIMPEX..........................................................................27TRIUMEQ......................................................................... 32TROPICAMIDE................................................................ 20TROSPIUM CHLORIDE.................................................. 46TRUVADA (200-300 MG) (TABLET)..............................31TUDORZA PRESSAIR.......................................................3TYBOST......................................................................32, 48TYKERB........................................................................... 39TYVASO............................................................................10TYVASO INSTITUTIONAL START KIT........................10

- U -UCERIS................................................................. 34, 36, 48ULIPRISTAL ACETATE...................................................12UMECLIDINIUM BRM/VILANTEROL TR.....................3UMECLIDINIUM BROMIDE............................................3UNITHROID..................................................................... 17UNITUXIN........................................................................40UPTRAVI...........................................................................10UREA................................................................................ 13UREA (39 %) (CREAM (G))................................................URETRON D-S................................................................. 27URIN D.S.......................................................................... 27USTEKINUMAB.............................................................. 35UVADEX........................................................................... 40

- V -VALACYCLOVIR HCL....................................................30VALGANCICLOVIR HCL............................................... 30VALGANCICLOVIR HCL (450 MG) (TABLET)................VALGANCICLOVIR HCL (50 MG/ML) (SOLN RECON)...............................................................................................VALPROIC ACID............................................................. 44VALRUBICIN................................................................... 37VALSARTAN................................................................ 9, 48VALSARTAN/HYDROCHLOROTHIAZIDE.................... 8

VALSTAR..........................................................................37VANATOL LQ...................................................................42VANATOL S......................................................................42VANCOMYCIN HCL....................................................... 30VANCOMYCIN HCL (125 MG) (CAPSULE).....................VANCOMYCIN HCL (250 MG) (CAPSULE).....................VANDAZOLE................................................................... 46VANDETANIB.................................................................. 40VARDENAFIL HCL......................................................... 15VARENICLINE TARTRATE............................................ 44VASCEPA (0.5 GRAM) (CAPSULE)...............................11VELCADE.........................................................................39VELETRI...........................................................................10VEMLIDY......................................................................... 32VEMURAFENIB.............................................................. 40VENLAFAXINE HCL........................................................ 5VENLAFAXINE HCL (100 MG) (TABLET).......................VENTOLIN HFA................................................................ 3VERAPAMIL HCL........................................................... 10VERTEPORFIN................................................................ 20VESICARE........................................................................46VIBRAMYCIN..................................................................28VICTOZA 2-PAK..............................................................14VIDEX...............................................................................31VIGABATRIN................................................................... 44VIMPAT (100 MG) (TABLET)......................................... 43VINBLASTINE SULFATE............................................... 41VINCRISTINE SULFATE................................................ 41VINORELBINE TARTRATE............................................41VIOKACE......................................................................... 45VIRACEPT........................................................................32VIREAD (150 MG) (TABLET)........................................ 31VIREAD (200 MG) (TABLET)........................................ 31VIREAD (250 MG) (TABLET)........................................ 31VIREAD (40MG/SCOOP) (POWDER)............................31VISCO-3............................................................................ 33VISCOAT...........................................................................19VISUDYNE....................................................................... 20VIVITROL...........................................................................5VON WILLEBRAND FACTOR....................................... 22VONVENDI...................................................................... 22VORICONAZOLE............................................................ 28VORINOSTAT...................................................................40VOSEVI.............................................................................32VOTRIENT........................................................................39VYVANSE (10 MG) (CAPSULE)...................................... 5

- W -WARFARIN SODIUM...................................................... 21WILATE (1K-1K UNIT) (VIAL)......................................22WILATE (500-500) (VIAL).............................................. 22

- X -XALKORI......................................................................... 39XARELTO (10 MG) (TABLET)....................................... 22XARELTO (15 MG) (TABLET)....................................... 22XARELTO (20 MG) (TABLET)....................................... 22XELJANZ.......................................................................... 35XIFAXAN (200 MG) (TABLET)......................................30XIFAXAN (550 MG) (TABLET)......................................30XOLAIR.............................................................................. 4XTANDI............................................................................ 37XYNTHA SOLOFUSE (250 (+/-)) (SYRINGE).............. 21XYNTHA SOLOFUSE (500 (+/-)) (SYRINGE).............. 21XYREM...............................................................................6

- Z -ZALEPLON.........................................................................7ZALTRAP..........................................................................39ZANAMIVIR.....................................................................30ZANOSAR........................................................................ 37ZARXIO............................................................................ 24ZELAPAR..........................................................................43ZELBORAF.......................................................................40ZENPEP (10-34-55K) (CAPSULE DR)........................... 45ZENPEP (15-51-82K) (CAPSULE DR)........................... 45ZENPEP (25-85-136K) (CAPSULE DR)......................... 45ZENPEP (3K-10K-16K) (CAPSULE DR)........................45ZENPEP (5K-17K-27K) (CAPSULE DR)........................45ZENZEDI (2.5 MG) (TABLET)..........................................5ZEPATIER......................................................................... 33ZERIT (1 MG/ML) (SOLN RECON)............................... 31ZETONNA...........................................................................2ZEVALIN...........................................................................40ZIDOVUDINE...................................................................31ZIPRASIDONE HCL.......................................................... 6ZIPRASIDONE MESYLATE............................................. 6ZIRGAN............................................................................ 18ZITHRANOL.................................................................... 13ZIV-AFLIBERCEPT......................................................... 39ZMAX................................................................................27ZODEX (1.5MG (21)) (TAB DS PK)............................... 34ZOLEDRONIC ACID....................................................... 16


Index

ZOLEDRONIC ACID/MANNITOL-WATER.................. 16ZOLINZA.......................................................................... 40ZOLMITRIPTAN.............................................................. 43ZOLPIDEM TARTRATE.................................................... 7ZOLPIMIST........................................................................ 7ZOMACTON.....................................................................16ZONISAMIDE.................................................................. 44ZORBTIVE........................................................................16ZORTRESS........................................................................26ZUBSOLV (1.4-0.36MG) (TAB SUBL)........................... 43ZYCLARA (2.5 %) (CRM MD PMP).............................. 26ZYCLARA (3.75 %) (CRM MD PMP)............................ 26ZYLET...............................................................................18ZYPREXA RELPREVV..................................................... 6ZYTIGA (250 MG) (TABLET).........................................37ZYVOX (200MG/0.1L) (IV SOLN)..................................27


Index

Documents

6& - uaex.edu · MCG) (TABLET) 3 INOTROPIC DRUGS dobutamine hcl 1 dobutamine hcl in dextrose 5 % 1 milrinone lactate 1 CARDIOVASCULAR DISEASE - HYPERTENSION ACE INHIBITOR/CALCIUM