(List of Covered Drugs) Options 2020 Program CompForm...Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during

Pennsylvania Public School Employees’ Retirement System (PSERS)

Health Options Program

Comprehensive Gold5 Prescription Drug Formulary for the Value Medicare Rx Option (List of Covered Drugs)

2020PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

This Gold5 Prescription Drug Formulary for the Value Medicare Rx Option (PDP) is effective as of July 1, 2020. For more recent information or other questions, please call the HOP Administration Unit at 1-800-773-7725, or for TTY users, 1-800-498-5428, 8 a.m. to 8 p.m. EST, Monday - Friday, or visit www.HOPbenefits.com.

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means the Health Options Program, which is sponsored by the Pennsylvania Public School Employees’ Retirement System. When it refers to “plan” or “our plan,” it means the Value Medicare Rx Option.

This document includes a list of the drugs (formulary) for our plan, which is effective as of July 1, 2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or

copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

What is the Value Medicare Rx Option Comprehensive Formulary?A formulary is a list of covered drugs selected for the Value Medicare Rx Option in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The Value Medicare Rx Option will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an OptumRx network pharmacy, and other Plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Please note that this formulary covers the Value Medicare Rx Option only. If you are enrolled in the Enhanced or Basic Medicare Rx Option, please contact us for a copy of that formulary. Our contact information appears on the front and back cover pages. If you have coverage through a Medicare Advantage plan through the Health Options Program, you will have to contact the Medicare Advantage plan directly for a copy of the formulary for your prescription drug plan.

CMS CONTRACT NUMBER: E3014; FORMULARY ID: 20409

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Can the formulary (drug list) change?Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except when a new, less expensive drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We must follow Medicare rules in making these changes. Below are changes to the drug list that will also affect members currently taking a drug:

• New Generic Drugs. We may immediately remove a brand-name drug on our drug list if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand-name drug on our drug list, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand-name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.

If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section on page iv entitled “How do I request an exception to the Value Medicare Rx Option Formulary?”

• Drugs Removed From the Market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

• Other Changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand-name drug currently on the formulary or add new restrictions to the brand-name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.

If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section entitled “How do I request an exception to the Value Medicare Rx Option Formulary?”

The enclosed formulary is current as of July 1, 2020. To get updated information about the drugs covered by the Value Medicare Rx Option, please contact us. Our contact information appears on the front and back cover pages. In the event of midyear formulary changes, a revised Comprehensive Formulary will be posted to www.HOPbenefits.com.

How do I use the formulary?There are two ways to find your drug within the formulary:

• Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular Agents.” If you

http://www.HOPbenefits.com

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know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

• Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 57. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? The Value Medicare Rx Option covers both brand-name drugs and generic drugs. A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

Are there any restrictions on my coverage?Some covered drugs have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization (PA): The Value Medicare Rx Option requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from the Value Medicare Rx Option before you fill your prescriptions. If you don’t get approval, the Value Medicare Rx Option may not cover the drug.

• Quantity Limits (QL): For certain drugs, the Value Medicare Rx Option limits the amount of the drug that the Value Medicare Rx Option will cover. For example, the Value Medicare Rx Option covers 30 pills per 30 days for Crestor. If your prescription is for more, OptumRx will contact your doctor to determine whether more than one per day will be covered. This may be in addition to a standard one-month or three-month supply.

• Step Therapy (ST): In some cases, the Value Medicare Rx Option requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, the Value Medicare Rx Option may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask the Value Medicare Rx Option to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section “How do I request an exception to the Value Medicare Rx Option Formulary?” on page iv, for information about how to request an exception.

What if my drug is not on the formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact OptumRx and ask if your drug is covered. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you learn that the Value Medicare Rx Option does not cover your drug, you have two options:

• You can ask OptumRx for a list of similar drugs that are covered by the Value Medicare Rx Option. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan.

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• You can ask the plan to make an exception and cover your drug. See page iv or information about how to request an exception.

How do I request an exception to the Value Medicare Rx Option Formulary?You can ask the Value Medicare Rx Option to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you will not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level (if this drug is not on the Specialty tier). If approved, this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the Value Medicare Rx Option limits the amount of drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, the Value Medicare Rx Option will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your

prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum of a 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

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Emergency transitions and level of care changes

You may have a change in your treatment setting due to the level of care you require. Such transitions may include if you are:

• Admitted to a long-term care facility following an inpatient hospital stay.

• Discharged from a hospital or skilled nursing facility to a home setting.

• Admitted to a hospital or skilled nursing facility from a home setting.

• Transferred from one skilled nursing facility to another and that new facility is serviced by a different pharmacy.

• Discharged from a skilled nursing facility Medicare Part A stay, where payments include all pharmacy charges, and you now need to use your Part D plan benefit.

• Reverted back to standard Medicare Part A and B coverage after giving up hospice status.

This transition policy applies to drugs that are covered under the Value Medicare Rx Option and filled at a network pharmacy.

For More InformationFor more detailed information about the Value Medicare Rx Option’s prescription drug coverage, please review your Evidence

of Coverage for the Value Medicare Rx Option and other plan materials. If you have questions about the Value Medicare Rx Option, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or visit https://www.medicare.gov.

How to Read the Value Medicare Rx Option Prescription Drug FormularyThe formulary that begins on page 1 provides coverage information about the drugs covered by the Value Medicare Rx Option. If you have trouble finding your drug in the list, turn to the Index that begins on page 57.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIDODERM) and generic drugs are listed in lower-case italics (e.g., meloxicam).

The information in the Requirements/Limits column tells you if the Value Medicare Rx Option has any special requirements for coverage of your drug.

WHAT THE ABBREVIATIONS MEAN

B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

NDS: Non-Extended Day Supply. This prescription drug is not available for an extended day supply under the Value Medicare Rx Option.

PA: Prior Authorization. You or your physician need to get approval from the Value Medicare Rx Option before you fill this prescription. If you don’t get approval, the Value Medicare Rx Option may not cover the drug. See page iii for more information.

QL: Quantity Limit. The Value Medicare Rx Option limits the amount of this drug that will be covered. See page iii for more information.

ST: Step Therapy. The Value Medicare Rx Option requires you to first try another drug to treat your medical condition before we will cover this one for that condition. See page iii for more information.

https://www.medicare.gov

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2020 Comprehensive Gold5 Prescription Drug Formulary

DEDUCTIBLE• In general, you must pay the annual

deductible of $435 before the Value Medicare Rx Option pays any portion of your prescription drug costs.

PREFERRED GENERIC DRUGS (TIER 1)• In Initial Coverage, you’ll pay a maximum

of $2 for up to a 30-day supply (and a maximum of up to $6 for a 31- to 90-day supply) of preferred generic drugs without having to satisfy the annual deductible.

• In the Coverage Gap, you’ll pay 25% of the cost.

• In Catastrophic Coverage, you’ll pay the greater of $3.60 or 5%.

GENERIC DRUGS (TIER 2)• In Initial Coverage, you’ll pay 25% of

the cost after you satisfy the annual deductible.



PREFERRED BRAND-NAME DRUGS (TIER 3)• In Initial Coverage, you’ll pay 25% of




NON-PREFERRED BRAND-NAME DRUGS (TIER 4)• In Initial Coverage, you’ll pay 25% of




SPECIALTY DRUGS (TIER 5)• In Initial Coverage, you’ll pay 25% of



• In Catastrophic Coverage, you’ll pay the greater of $3.60 or 5% for a generic prescription; you’ll pay the greater of $8.95 or 5% for a brand prescription.

• Specialty drugs are limited to a 30-day supply.

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Drug Name Drug Tier Requirements/Limits

Analgesics Analgesics

butalbital/acetaminophen/caffeine caps 300mg; 50mg; 40mg, 325mg; 50mg; 40mg

4 PA

BUTALBITAL/ACETAMINOPHEN CAPS 300MG; 50MG 4 PA butalbital/acetaminophen tabs 300mg; 50mg, 325mg; 50mg 4 PA tencon tabs 325mg; 50mg 4 PA zebutal caps 325mg; 50mg; 40mg 4 PA

Nonsteroidal Anti-inflammatory Drugs celecoxib caps 2 QL (60 EA per 30 days) diclofenac potassium 4 diclofenac sodium dr 4 diclofenac sodium er 4 diclofenac sodium/misoprostol 4 diclofenac sodium gel 1% 2 QL (1000 GM per 30 days) diclofenac sodium gel 3% 4 diflunisal tabs 500mg 2 etodolac er 2 etodolac caps, tabs 2 FENOPROFEN CALCIUM CAPS 400MG 4 fenoprofen calcium tabs 4 flurbiprofen tabs 100mg 2 ibuprofen susp 2 ibuprofen tabs 400mg, 600mg, 800mg 1 ibu tabs 600mg, 800mg 1 indomethacin er 4 indomethacin caps 25mg, 50mg 4 ketoprofen er cp24 200mg 4 ketoprofen caps 2 ketorolac tromethamine nasal soln 15.75mg/spray 5 QL (5 EA per 30 days) ketorolac tromethamine tabs 10mg 4 QL (20 EA per 30 days) meclofenamate sodium caps 4 mefenamic acid caps 4 meloxicam tabs 1 nabumetone tabs 2 naproxen dr 2 naproxen sodium cr 2 naproxen sodium tabs 275mg, 550mg 2 naproxen susp 2 naproxen tabs 250mg, 375mg, 500mg 1 oxaprozin 2 piroxicam caps 2 SPRIX 5 QL (5 EA per 30 days) sulindac tabs 1 tolmetin sodium caps 4 tolmetin sodium tabs 600mg 4

Opioid Analgesics, Long-acting BUPRENORPHINE PTWK 10MCG/HR, 15MCG/HR, 20MCG/HR, 5MCG/HR

3 QL (4 EA per 28 days) NDS

2


BUPRENORPHINE PTWK 7.5MCG/HR 3 QL (8 EA per 28 days) NDS BUTRANS PTWK 7.5MCG/HR 3 QL (8 EA per 28 days) NDS fentanyl pt72 100mcg/hr, 12mcg/hr, 25mcg/hr, 37.5mcg/hr, 50mcg/hr, 75mcg/hr

4 NDS

fentanyl pt72 62.5mcg/hr, 87.5mcg/hr 5 NDS hydromorphone hcl er t24a 16mg 4 hydromorphone hcl er t24a 12mg, 8mg 4 NDS hydromorphone hydrochloride er 5 NDS LEVORPHANOL TARTRATE TABS 3MG 5 NDS levorphanol tartrate tabs 2mg 5 NDS methadone hcl soln, tabs 2 NDS morphine sulfate er cp24 40mg 4 morphine sulfate er cp24 10mg, 120mg, 20mg, 30mg, 45mg, 50mg, 60mg, 75mg, 80mg, 90mg

4 NDS

morphine sulfate er cp24 100mg 5 NDS morphine sulfate er tbcr 2 NDS oxymorphone hydrochloride er tb12 10mg, 15mg, 20mg, 30mg, 5mg, 7.5mg

4 NDS

oxymorphone hydrochlorideer 4 NDS tramadol hcl er tb24 4 NDS XTAMPZA ER 3 NDS

Opioid Analgesics, Short-acting acetaminophen/codeine soln 1 NDS acetaminophen/codeine tabs 2 NDS ascomp/codeine 4 PA NDS butalbital/acetaminophen/caffeine/codeine 4 PA NDS butalbital/aspirin/caffeine/codeine 4 PA NDS butorphanol tartrate soln 2 NDS codeine sulfate tabs 2 NDS duramorph 2 NDS endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg 2 NDS fentanyl citrate oral transmucosal 5 PA NDS fentanyl citrate tabs 5 PA hydrocodone bitartrate/acetaminophen soln 325mg/15ml; 7.5mg/15ml

2 NDS

hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg, 300mg; 7.5mg

2 NDS

hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg 4 NDS hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg

2 NDS

hydrocodone/ibuprofen tabs 10mg; 200mg, 5mg; 200mg, 7.5mg; 200mg

2 NDS

hydromorphone hcl liqd, tabs 2 NDS hydromorphone hcl inj 10mg/ml 2 NDS hydromorphone hydrochloride inj 50mg/5ml 2 NDS lorcet 2 NDS lorcet hd 2 NDS lorcet plus tabs 325mg; 7.5mg 2 NDS morphine sulfate soln, tabs 2 NDS

3


oxycodone hcl caps 2 NDS oxycodone hydrochloride soln, tabs 2 NDS oxycodone hydrochloride conc 4 NDS oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg

2 NDS

oxycodone/aspirin tabs 325mg; 4.835mg 2 NDS oxycodone/ibuprofen 2 NDS oxymorphone hydrochloride 2 NDS pentazocine/naloxone hcl 4 NDS PRIMLEV TABS 300MG; 5MG, 300MG; 7.5MG 4 NDS PRIMLEV TABS 300MG; 10MG 5 NDS PROLATE TABS 300MG; 5MG, 300MG; 7.5MG 4 PROLATE TABS 300MG; 10MG 5 tramadol hcl tabs 1 NDS tramadol hydrochloride/acetaminophen 2 NDS tramadol hydrochloride tabs 100mg 2

Anesthetics Local Anesthetics

lidocaine hcl jelly gel 2 QL (30 ML per 30 days) PA lidocaine hcl soln 2 QL (250 ML per 30 days) PA lidocaine/prilocaine crea 2 QL (30 GM per 30 days) PA lidocaine oint 4 QL (150 GM per 30 days) PA lidocaine ptch 5% 4 PA PLIAGLIS 4 QL (30 GM per 30 days) PA

Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving

acamprosate calcium dr 2 disulfiram tabs 2 VIVITROL 5

Opioid Dependence Treatments buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg 3 QL (360 EA per 30 days) buprenorphine hcl/naloxone hcl subl 8mg; 2mg 3 QL (90 EA per 30 days) buprenorphine hcl subl 2 buprenorphine hydrochloride/naloxone hydrochloride film 8mg; 2mg

2 QL (90 EA per 30 days)

buprenorphine hydrochloride/naloxone hydrochloride film 12mg; 3mg, 4mg; 1mg


buprenorphine hydrochloride/naloxone hydrochloride film 2mg; 0.5mg


LUCEMYRA 5 QL (224 EA per 14 days) naltrexone hcl tabs 2 SUBOXONE FILM 12MG; 3MG, 4MG; 1MG 4 QL (60 EA per 30 days) SUBOXONE FILM 2MG; 0.5MG 4 QL (90 EA per 30 days)

Opioid Reversal Agents naloxone hcl inj 0.4mg/ml, 2mg/2ml 2 naloxone hydrochloride inj 0.4mg/ml 2 NARCAN LIQD 3

Smoking Cessation Agents bupropion hydrochloride er (sr) tb12 150mg 2 QL (60 EA per 30 days)

4


CHANTIX CONTINUING MONTH PAK 3 QL (504 EA per 365 days) CHANTIX STARTING MONTH PAK 3 QL (504 EA per 365 days) CHANTIX TABS 0.5MG, 1MG 3 QL (504 EA per 365 days) NICOTROL INHALER 4 QL (2688 EA per 365 days) NICOTROL NS 3 QL (360 ML per 365 days)

Anti-inflammatory Agents Glucocorticoids

procto-med hc 2 procto-pak 2 proctosol hc 2 proctozone-hc 2 triamcinolone acetonide aers 0.147mg/gm 4

Antibacterials Aminoglycosides

amikacin sulfate inj 500mg/2ml 2 gentak oint 2 gentamicin sulfate/0.9% sodium chloride inj 1.2mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%

2

gentamicin sulfate ophthalmic soln 1 gentamicin sulfate crea, oint 2 gentamicin sulfate inj 40mg/ml 2 isotonic gentamicin inj 0.8mg/ml; 0.9% 2 neomycin sulfate 2 paromomycin sulfate 4 streptomycin sulfate inj 1gm 4 tobramycin sulfate ophthalmic soln 1 tobramycin sulfate inj 10mg/ml, 80mg/2ml 2 TOBREX OINT 4

Antibacterials, Other ALTABAX 4 bacitracin oint 2 CLEOCIN SUPP 4 clindacin-p 2 clindamycin hcl caps 300mg, 75mg 2 clindamycin hydrochloride caps 150mg 2 clindamycin palmitate hcl 2 clindamycin phosphate/dextrose 2 clindamycin phosphate crea, gel, lotn, external soln, swab 2 clindamycin phosphate foam 4 clindamycin phosphate inj 300mg/2ml, 600mg/4ml, 900mg/6ml

2

CLINDESSE 4 colistimethate sodium 4 CORTISPORIN CREA, OINT 4 DALVANCE 5 DAPTOMYCIN INJ 350MG 5 daptomycin inj 500mg 5 linezolid tabs 4 QL (56 EA per 28 days) linezolid susr 5 QL (1800 ML per 28 days)

5


linezolid inj 600mg/300ml 5 mafenide acetate pack 4 methenamine hippurate 2 metronidazole in nacl 0.79% 2 metronidazole vaginal 2 metronidazole caps 375mg 2 metronidazole tabs 250mg, 500mg 2 MONUROL 4 mupirocin oint 2 mupirocin crea 4 nitrofurantoin macrocrystals 4 nitrofurantoin monohydrate/macrocrystals 2 nitrofurantoin susp 4 polymyxin b sulfate inj 2 silver sulfadiazine crea 2 SIVEXTRO 5 QL (6 EA per 30 days) ssd 2 SULFAMYLON CREA 4 tigecycline 5 trimethoprim tabs 1 vancomycin hcl inj 10gm 2 VANCOMYCIN HYDROCHLORIDE ORAL SOLR 4 vancomycin hydrochloride caps 125mg 4 QL (120 EA per 30 days) vancomycin hydrochloride caps 250mg 5 QL (240 EA per 30 days) vancomycin hydrochloride inj 1gm, 250mg, 500mg, 750mg 2 vandazole 2 XENLETA TABS 5 XIFAXAN 5 PA

Beta-lactam, Cephalosporins AVYCAZ 5 cefaclor er tb12 500mg 4 cefaclor caps 4 cefaclor susr 125mg/5ml, 250mg/5ml, 375mg/5ml 4 cefadroxil 2 cefazolin sodium inj 10gm, 1gm, 500mg 2 cefdinir 2 cefepime inj 1gm, 2gm 2 cefixime caps 3 cefixime susr 4 cefotetan inj 1gm, 2gm 2 cefoxitin sodium inj 10gm, 1gm, 2gm 2 cefpodoxime proxetil 2 cefprozil 2 ceftazidime inj 1gm, 2gm, 6gm 2 ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg 2 cefuroxime axetil tabs 2 cefuroxime sodium inj 1.5gm, 7.5gm, 750mg 2 cephalexin caps 1 cephalexin susr, tabs 2

6


SUPRAX CAPS, CHEW 3 SUPRAX SUSR 500MG/5ML 5 tazicef inj 1gm, 2gm, 6gm 2 TEFLARO 5

Beta-lactam, Other AZACTAM INJ 1GM, 2GM 4 aztreonam inj 1gm 4 ertapenem 4 imipenem/cilastatin 2 meropenem 2 VABOMERE 4

Beta-lactam, Penicillins amoxicillin/clavulanate potassium er 4 amoxicillin/clavulanate potassium tabs 1 amoxicillin/clavulanate potassium chew, susr 2 amoxicillin chew 125mg, 250mg 1 amoxicillin caps, susr, tabs 1 ampicillin sodium inj 10gm, 125mg, 1gm 2 ampicillin-sulbactam 2 ampicillin caps 500mg 1 BICILLIN C-R INJ 300000UNIT/ML; 300000UNIT/ML, 900000UNIT/2ML; 300000UNIT/2ML

4

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

4

dicloxacillin sodium 2 nafcillin sodium inj 1gm, 2gm 4 nafcillin sodium inj 10gm 5 OXACILLIN SODIUM INJ 1.5GM/50ML; 1GM/50ML, 300MG/50ML; 2GM/50ML

4

oxacillin sodium inj 10gm, 1gm, 2gm 4 PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE INJ 0; 40000UNIT/ML, 0; 60000UNIT/ML

4

penicillin g potassium inj 20000000unit 2 penicillin g sodium 5 penicillin v potassium 1 piperacillin/tazobactam inj 2gm; 0.25gm, 36gm; 4.5gm, 3gm; 0.375gm, 4gm; 0.5gm

2

ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML

4

Macrolides azithromycin tabs 1 azithromycin pack, susr 2 azithromycin inj 500mg 2 clarithromycin er 2 clarithromycin susr, tabs 2 DIFICID 5 ery 2 ERY-TAB 3 ERYPED 400 5

7


erythrocin lactobionate inj 500mg 4 ERYTHROCIN STEARATE TABS 250MG 4 erythromycin base 4 erythromycin dr 2 erythromycin ethylsuccinate susr, tabs 4 erythromycin oint 1 erythromycin gel 2 erythromycin cpep 4 erythromycin soln 2% 2

Quinolones BAXDELA 5 BESIVANCE 4 CILOXAN OINT 4 ciprofloxacin hcl tabs 100mg, 750mg 1 ciprofloxacin hydrochloride 1 ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% 2 ciprofloxacin soln 2 gatifloxacin 2 levofloxacin in d5w inj 5%; 500mg/100ml, 5%; 750mg/150ml 2 levofloxacin ophthalmic soln, tabs 2 levofloxacin inj, oral soln 4 moxifloxacin hydrochloride/sodium hydrochloride 4 moxifloxacin hydrochloride soln 2 moxifloxacin hydrochloride tabs 4 ofloxacin ophthalmic soln, otic soln 2 ofloxacin tabs 300mg, 400mg 2

Sulfonamides sulfacetamide sodium oint, soln 2 sulfacetamide sodium lotn 4 sulfadiazine tabs 4 sulfamethoxazole/trimethoprim ds 1 sulfamethoxazole/trimethoprim tabs 1 sulfamethoxazole/trimethoprim susp 2

Tetracyclines demeclocycline hcl tabs 2 DORYX MPC 4 doxy 100 4 doxycycline hyclate dr tbec 100mg, 150mg, 200mg, 50mg, 75mg

4

doxycycline hyclate caps 2 doxycycline hyclate tabs 100mg, 20mg, 75mg 2 doxycycline hyclate tabs 150mg 4 doxycycline monohydrate caps, tabs 2 doxycycline susr 2 minocycline hcl caps 75mg 2 minocycline hcl tabs 2 MINOCYCLINE HYDROCHLORIDE ER TB24 55MG 5 minocycline hydrochloride er tb24 135mg, 45mg, 90mg 2

8


minocycline hydrochloride er tb24 105mg, 115mg, 65mg, 80mg

5

minocycline hydrochloride caps 100mg, 50mg 2 mondoxyne nl caps 100mg, 75mg 2 NUZYRA 5 SEYSARA 5 tetracycline hydrochloride caps 4 VIBRAMYCIN SYRP 4

Anticonvulsants Anticonvulsants, Other

APTIOM 5 BRIVIACT SOLN, TABS 5 PA EPIDIOLEX 5 PA FYCOMPA SUSP 4 FYCOMPA TABS 2MG, 8MG 4 FYCOMPA TABS 10MG, 12MG, 4MG, 6MG 5 levetiracetam er 2 levetiracetam tabs 1 levetiracetam soln 2 NAYZILAM 5 roweepra 1 roweepra xr 2 SPRITAM 4

Calcium Channel Modifying Agents CELONTIN CAPS 300MG 4 ethosuximide 2 LYRICA SOLN 3 QL (900 ML per 30 days) LYRICA CAPS 300MG 3 QL (60 EA per 30 days) LYRICA CAPS 100MG, 150MG, 200MG, 225MG, 25MG, 50MG, 75MG


pregabalin caps 300mg 2 QL (60 EA per 30 days) pregabalin caps 100mg, 150mg, 200mg, 225mg, 25mg, 50mg, 75mg


pregabalin soln 2 QL (900 ML per 30 days) zonisamide 2

Gamma-aminobutyric Acid (GABA) Augmenting Agents clobazam susp 5 clobazam tabs 10mg 4 clobazam tabs 20mg 5 clonazepam odt tbdp 2mg 2 QL (300 EA per 30 days) clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg 2 QL (90 EA per 30 days) clonazepam tabs 2mg 1 QL (300 EA per 30 days) clonazepam tabs 0.5mg, 1mg 1 QL (90 EA per 30 days) DIASTAT ACUDIAL 4 DIASTAT PEDIATRIC GEL 2.5MG 4 diazepam rectal gel 4 divalproex sodium dr 2 divalproex sodium er 2 divalproex sodium csdr 2

9


gabapentin caps 400mg 1 QL (270 EA per 30 days) gabapentin caps 100mg, 300mg 1 QL (360 EA per 30 days) gabapentin soln 4 QL (2160 ML per 30 days) gabapentin tabs 800mg 2 QL (150 EA per 30 days) gabapentin tabs 600mg 2 QL (180 EA per 30 days) phenobarbital elix 4 PA phenobarbital tabs 100mg, 15mg, 16.2mg, 30mg, 32.4mg, 60mg, 64.8mg, 97.2mg

4 PA

primidone tabs 2 SABRIL TABS 5 PA SYMPAZAN 5 tiagabine hydrochloride 4 valproic acid caps, soln 2 VALTOCO 5 QL (10 EA per 30 days) vigabatrin 5 PA vigadrone 5 PA

Glutamate Reducing Agents felbamate tabs 4 felbamate susp 5 lamotrigine er 4 lamotrigine odt 4 lamotrigine starter kit/blue 2 lamotrigine starter kit/green 4 lamotrigine starter kit/orange 2 lamotrigine tabs 1 lamotrigine chew 2 topiramate er 4 topiramate tabs 1 topiramate cpsp 2

Sodium Channel Agents BANZEL 5 carbamazepine er 2 carbamazepine chew 1 carbamazepine susp, tabs 2 CARBATROL 4 DILANTIN INFATABS 4 DILANTIN-125 4 DILANTIN CAPS 4 epitol 2 oxcarbazepine tabs 2 oxcarbazepine susp 4 PEGANONE TABS 250MG 4 PHENYTEK 4 phenytoin sodium extended 2 phenytoin chew, susp 2 TEGRETOL-XR 4 TEGRETOL SUSP, TABS 4 VIMPAT SOLN 4 VIMPAT TABS 50MG 4

10


VIMPAT TABS 100MG, 150MG, 200MG 5 Antidementia Agents

Antidementia Agents, Other ergoloid mesylates tabs 2

Cholinesterase Inhibitors donepezil hcl tbdp 1 donepezil hcl tabs 10mg 1 donepezil hcl tabs 23mg 4 donepezil hydrochloride tabs 5mg 1 galantamine hydrobromide er 2 galantamine hydrobromide tabs 2 galantamine hydrobromide soln 4 rivastigmine tartrate 2 rivastigmine transdermal system 4

N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl titration pak 4 memantine hydrochloride er 4 QL (30 EA per 30 days) memantine hydrochloride tabs 2 memantine hydrochloride soln 4

Antidepressants Antidepressants, Other

APLENZIN 5 QL (30 EA per 30 days) ST bupropion hcl tabs 100mg 2 bupropion hydrochloride er (sr) tb12 150mg, 200mg 1 QL (60 EA per 30 days) bupropion hydrochloride er (sr) tb12 100mg 1 QL (90 EA per 30 days) bupropion hydrochloride er (xl) tb24 300mg 2 QL (30 EA per 30 days) bupropion hydrochloride er (xl) tb24 150mg 2 QL (90 EA per 30 days) bupropion hydrochloride tabs 75mg 2 mirtazapine odt 2 mirtazapine tabs 2

Monoamine Oxidase Inhibitors EMSAM 5 QL (30 EA per 30 days) ST MARPLAN 4 phenelzine sulfate 2 tranylcypromine sulfate 4

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor

citalopram hydrobromide tabs 1 citalopram hydrobromide soln 2 DESVENLAFAXINE ER TB24 100MG 4 QL (120 EA per 30 days) ST DESVENLAFAXINE ER TB24 50MG 4 QL (30 EA per 30 days) ST desvenlafaxine er tb24 100mg 4 QL (120 EA per 30 days) desvenlafaxine er tb24 25mg, 50mg 4 QL (30 EA per 30 days) DRIZALMA SPRINKLE CSDR 20MG, 60MG 4 QL (60 EA per 30 days) DRIZALMA SPRINKLE CSDR 30MG, 40MG 4 QL (90 EA per 30 days) duloxetine hcl cpep 40mg 2 QL (90 EA per 30 days) duloxetine hydrochloride cpep 20mg, 60mg 2 QL (60 EA per 30 days) duloxetine hydrochloride cpep 30mg 2 QL (90 EA per 30 days) escitalopram oxalate 1

11


FETZIMA 4 QL (30 EA per 30 days) ST FETZIMA TITRATION PACK 4 QL (56 EA per 365 days) ST fluoxetine dr 2 QL (4 EA per 28 days) fluoxetine hcl caps 20mg 1 fluoxetine hydrochloride caps 10mg, 40mg 1 fluoxetine hydrochloride soln, tabs 2 fluvoxamine maleate 2 fluvoxamine maleate er 4 QL (60 EA per 30 days) maprotiline hcl 2 nefazodone hcl tabs 100mg, 150mg 4 nefazodone hydrochloride tabs 200mg, 250mg, 50mg 4 olanzapine/fluoxetine caps 25mg; 12mg, 50mg; 12mg, 50mg; 6mg


olanzapine/fluoxetine caps 25mg; 3mg, 25mg; 6mg 4 QL (90 EA per 30 days) paroxetine 4 QL (30 EA per 30 days) paroxetine hcl er 4 paroxetine hcl tabs 30mg, 40mg 4 paroxetine hydrochloride tabs 10mg, 20mg 4 PAXIL SUSP 4 PEXEVA TABS 10MG, 20MG, 40MG 4 QL (30 EA per 30 days) PEXEVA TABS 30MG 4 QL (60 EA per 30 days) sertraline hcl conc 2 sertraline hcl tabs 25mg, 50mg 1 sertraline hydrochloride tabs 100mg 1 trazodone hydrochloride 2 TRINTELLIX 4 QL (30 EA per 30 days) venlafaxine hcl 2 venlafaxine hcl er cp24 150mg, 37.5mg 2 venlafaxine hcl er tb24 37.5mg 4 venlafaxine hydrochloride er cp24 2 venlafaxine hydrochloride er tb24 150mg, 225mg, 75mg 4 VIIBRYD STARTER PACK 4 QL (60 EA per 365 days) VIIBRYD TABS 4 QL (30 EA per 30 days)

Tricyclics amitriptyline hcl tabs 100mg, 150mg, 25mg, 75mg 4 PA amitriptyline hydrochloride tabs 10mg, 50mg 4 PA amoxapine 4 chlordiazepoxide/amitriptyline 4 PA clomipramine hcl caps 4 desipramine hcl tabs 4 doxepin hcl caps 100mg, 10mg, 150mg, 50mg, 75mg 4 PA doxepin hcl conc 4 PA doxepin hydrochloride caps 25mg 4 PA imipramine hcl tabs 25mg, 50mg 4 imipramine hydrochloride tabs 10mg 4 imipramine pamoate 4 nortriptyline hcl caps 25mg, 75mg 2 nortriptyline hcl soln 2 nortriptyline hydrochloride caps 10mg, 50mg 2

12


perphenazine/amitriptyline 4 PA protriptyline hcl 2 trimipramine maleate caps 4

Antiemetics Antiemetics, Other

compro 2 doxylamine succinate/pyridoxine hydrochloride 4 QL (120 EA per 30 days) meclizine hcl tabs 4 phenadoz supp 12.5mg 4 PA prochlorperazine maleate tabs 1 prochlorperazine supp 25mg 2 promethazine hcl plain 3 PA promethazine hcl supp 12.5mg, 25mg 4 PA promethazine hcl tabs 12.5mg 4 PA promethazine hydrochloride tabs 25mg, 50mg 4 PA promethegan supp 25mg, 50mg 4 PA scopolamine 4 trimethobenzamide hydrochloride 4 B/D

Emetogenic Therapy Adjuncts aprepitant caps 40mg 4 QL (1 EA per 30 days) B/D aprepitant caps 125mg 4 QL (2 EA per 30 days) B/D aprepitant caps 0 4 QL (6 EA per 30 days) B/D aprepitant caps 80mg 4 QL (8 EA per 30 days) B/D DRONABINOL CAPS 10MG 4 QL (60 EA per 30 days) PA dronabinol caps 2.5mg, 5mg 4 QL (60 EA per 30 days) PA EMEND SUSR 4 QL (6 EA per 30 days) B/D granisetron hcl tabs 2 QL (30 EA per 30 days) B/D ondansetron hcl soln 4 QL (450 ML per 30 days) B/D ondansetron hcl tabs 24mg 2 QL (14 EA per 28 days) B/D ondansetron hydrochloride tabs 1 B/D ondansetron odt 1 B/D SANCUSO 5 QL (2 EA per 30 days) SYNDROS 5 QL (120 ML per 30 days) PA

Antifungals Antifungals

ABELCET 5 B/D AMBISOME 5 B/D amphotericin b inj 4 B/D caspofungin acetate 5 ciclopirox nail lacquer 2 PA ciclopirox olamine crea 2 ciclopirox gel, sham, susp 2 clotrimazole/betamethasone dipropionate crea 1 clotrimazole/betamethasone dipropionate lotn 2 clotrimazole crea 1 clotrimazole lozg, soln 2 CRESEMBA CAPS 5 econazole nitrate crea 2 ERAXIS INJ 50MG 4

13


ERAXIS INJ 100MG 5 fluconazole in nacl inj 200mg/100ml; 0.9% 2 fluconazole in sodium chloride inj 400mg/200ml; 0.9% 2 fluconazole susr, tabs 2 flucytosine caps 5 griseofulvin microsize susp 2 griseofulvin microsize tabs 4 griseofulvin ultramicrosize tabs 125mg, 250mg 4 GYNAZOLE-1 4 itraconazole caps 4 PA itraconazole soln 5 PA JUBLIA 4 ketoconazole sham 1 ketoconazole crea, tabs 2 ketoconazole foam 4 ketodan 4 MENTAX 4 miconazole 3 supp 2 MYCAMINE 5 NAFTIFINE HCL 4 naftifine hydrochloride crea 4 NAFTIN GEL 4 NATACYN 4 NOXAFIL SUSP, TBEC 5 nyamyc 2 nystatin/triamcinolone 2 nystatin crea, susp 1 nystatin oint, powd, tabs 2 nystop 2 oxiconazole nitrate 4 OXISTAT LOTN 4 posaconazole dr 5 terbinafine hcl tabs 1 QL (84 EA per 180 days) terconazole 2 TOLSURA 5 PA voriconazole inj, susr, tabs 5

Antigout Agents Antigout Agents

allopurinol tabs 1 COLCHICINE CAPS 3 COLCHICINE TABS 0.6MG 3 febuxostat 2 GLOPERBA 4 ST probenecid/colchicine 2 probenecid tabs 2 ULORIC 3 ST

Antimigraine Agents Antimigraine Agents

REYVOW 4 QL (4 EA per 30 days) PA

14


UBRELVY TABS 50MG 5 QL (10 EA per 30 days) PA Ergot Alkaloids

dihydroergotamine mesylate soln 5 QL (8 ML per 30 days) ergotamine tartrate/caffeine 2 MIGERGOT 5

Prophylactic AIMOVIG INJ 140MG/ML 4 QL (1 ML per 30 days) PA AIMOVIG INJ 70MG/ML 4 QL (2 ML per 30 days) PA EMGALITY INJ 120MG/ML 4 QL (1 ML per 30 days) PA EMGALITY INJ 100MG/ML 4 QL (3 ML per 30 days) PA NURTEC 5 QL (8 EA per 30 days) PA timolol maleate tabs 10mg, 20mg, 5mg 2 UBRELVY TABS 100MG 5 QL (10 EA per 30 days) PA

Serotonin (5-HT) 1b/1d Receptor Agonists almotriptan 4 QL (12 EA per 30 days) eletriptan hydrobromide 4 QL (12 EA per 30 days) frovatriptan succinate 4 QL (12 EA per 30 days) naratriptan hcl 2 QL (9 EA per 30 days) rizatriptan benzoate 2 QL (18 EA per 30 days) rizatriptan benzoate odt 2 QL (18 EA per 30 days) SUMATRIPTAN SUCCINATE REFILL INJ 4MG/0.5ML 4 QL (5 ML per 30 days) sumatriptan succinate tabs 1 QL (9 EA per 30 days) SUMATRIPTAN SUCCINATE INJ 6MG/0.5ML 4 QL (5 ML per 30 days) sumatriptan succinate inj 4mg/0.5ml, 6mg/0.5ml 4 QL (5 ML per 30 days) sumatriptan/naproxen sodium 4 QL (9 EA per 30 days) SUMATRIPTAN SOLN 4 QL (12 EA per 30 days) TOSYMRA 5 QL (12 EA per 30 days) zolmitriptan odt tbdp 2.5mg 2 QL (12 EA per 30 days) zolmitriptan odt tbdp 5mg 2 QL (9 EA per 30 days) zolmitriptan tabs 2 QL (12 EA per 30 days)

Antimyasthenic Agents Parasympathomimetics

GUANIDINE HCL 4 MESTINON SOLN 5 pyridostigmine bromide er 4 pyridostigmine bromide soln 5 pyridostigmine bromide tabs 60mg 2

Antimycobacterials Antimycobacterials, Other

dapsone tabs 100mg, 25mg 2 rifabutin 4

Antituberculars ethambutol hcl tabs 100mg 2 ethambutol hydrochloride 2 isoniazid tabs 1 isoniazid syrp 2 PASER 4 PRIFTIN 4 pyrazinamide tabs 2

15


rifampin caps 2 rifampin inj 4 RIFATER 4 SIRTURO 5 TRECATOR 4

Antineoplastics Alkylating Agents

CYCLOPHOSPHAMIDE CAPS 2 B/D GLEOSTINE CAPS 100MG, 10MG, 40MG 4 KISQALI FEMARA 200 DOSE 5 PA KISQALI FEMARA 400 DOSE 5 PA KISQALI FEMARA 600 DOSE 5 PA LEUKERAN 5 MATULANE 5 VALCHLOR 5 PA

Antiandrogens abiraterone acetate 5 PA bicalutamide 2 ERLEADA 5 PA flutamide 2 nilutamide 5 NUBEQA 5 PA XTANDI 5 PA YONSA 5 PA ZYTIGA TABS 500MG 5 PA

Antiangiogenic Agents POMALYST 5 PA REVLIMID 5 PA THALOMID 5 PA

Antiestrogens/Modifiers EMCYT 5 SOLTAMOX 5 tamoxifen citrate tabs 2 toremifene citrate 5

Antimetabolites DROXIA 4 FLUOROPLEX 5 fluorouracil crea 5% 2 fluorouracil crea 0.5% 5 fluorouracil soln 2 hydroxyurea caps 2 LONSURF 5 PA mercaptopurine tabs 2 PURIXAN 5 SIKLOS TABS 100MG 4 PA SIKLOS TABS 1000MG 5 PA TABLOID 4

Antineoplastics, Other BRAFTOVI CAPS 75MG 5 PA

16


COPIKTRA 5 PA COTELLIC 5 PA DAURISMO 5 PA FARYDAK CAPS 10MG, 20MG 5 PA IBRANCE 5 PA INREBIC 5 PA KISQALI 5 PA leucovorin calcium tabs 2 LORBRENA 5 PA LYNPARZA TABS 5 PA MEKTOVI 5 PA NERLYNX 5 QL (180 EA per 30 days) PA NINLARO 5 PA PEMAZYRE 5 QL (30 EA per 30 days) PA PIQRAY 200MG DAILY DOSE 5 PA PIQRAY 250MG DAILY DOSE 5 PA PIQRAY 300MG DAILY DOSE 5 PA ROZLYTREK 5 PA RYDAPT 5 PA SYLATRON INJ 200MCG, 300MCG 5 PA SYNRIBO 5 PA TALZENNA 5 PA TAZVERIK 5 PA VERZENIO 5 PA VITRAKVI 5 PA XPOVIO 100 MG ONCE WEEKLY 5 PA XPOVIO 60 MG ONCE WEEKLY 5 PA XPOVIO 80 MG ONCE WEEKLY 5 PA XPOVIO 80 MG TWICE WEEKLY 5 PA ZOLINZA 5 PA ZYKADIA TABS 5 PA

Aromatase Inhibitors, 3rd Generation anastrozole tabs 1 exemestane 4 letrozole 1

Enzyme Inhibitors BALVERSA 5 PA ZYDELIG 5 PA

Molecular Target Inhibitors AFINITOR 5 QL (30 EA per 30 days) PA AFINITOR DISPERZ 5 PA ALECENSA 5 PA ALUNBRIG TBPK 5 QL (60 EA per 365 days) PA ALUNBRIG TABS 30MG 5 QL (120 EA per 30 days) PA ALUNBRIG TABS 180MG, 90MG 5 QL (30 EA per 30 days) PA AYVAKIT 5 QL (30 EA per 30 days) PA BOSULIF 5 PA BRUKINSA 5 PA CABOMETYX 5 PA

17


CALQUENCE 5 PA CAPRELSA TABS 300MG 5 PA CAPRELSA TABS 100MG 5 QL (60 EA per 30 days) PA COMETRIQ 5 PA ERIVEDGE 5 PA erlotinib hydrochloride 5 PA everolimus tabs 2.5mg, 5mg, 7.5mg 5 QL (30 EA per 30 days) PA GILOTRIF 5 QL (30 EA per 30 days) PA ICLUSIG TABS 45MG 5 PA ICLUSIG TABS 15MG 5 QL (60 EA per 30 days) PA IDHIFA 5 QL (30 EA per 30 days) PA imatinib mesylate 5 PA IMBRUVICA 5 PA INLYTA 5 PA IRESSA 5 PA JAKAFI TABS 15MG, 20MG, 25MG, 5MG 5 PA JAKAFI TABS 10MG 5 QL (60 EA per 30 days) PA KOSELUGO 5 PA LENVIMA 10 MG DAILY DOSE 5 PA LENVIMA 12MG DAILY DOSE 5 PA LENVIMA 14 MG DAILY DOSE 5 PA LENVIMA 18 MG DAILY DOSE 5 PA LENVIMA 20 MG DAILY DOSE 5 PA LENVIMA 24 MG DAILY DOSE 5 PA LENVIMA 4 MG DAILY DOSE 5 PA LENVIMA 8 MG DAILY DOSE 5 PA MEKINIST 5 PA NEXAVAR 5 PA ODOMZO 5 PA RUBRACA 5 PA SPRYCEL 5 PA STIVARGA 5 PA SUTENT 5 PA TAFINLAR 5 PA TAGRISSO TABS 80MG 5 PA TAGRISSO TABS 40MG 5 QL (30 EA per 30 days) PA TASIGNA 5 PA TIBSOVO 5 PA TURALIO 5 PA TYKERB 5 PA VENCLEXTA STARTING PACK 5 PA VENCLEXTA TABS 10MG, 50MG 3 PA VENCLEXTA TABS 100MG 5 PA VIZIMPRO 5 PA VOTRIENT 5 PA XALKORI 5 PA XOSPATA 5 PA ZEJULA 5 PA ZELBORAF 5 PA

18


Retinoids bexarotene 5 PA PANRETIN 5 TARGRETIN GEL 5 PA tretinoin caps 10mg 5

Treatment Adjuncts MESNEX TABS 5

Antiparasitics Anthelmintics

albendazole tabs 5 BENZNIDAZOLE 3 ivermectin tabs 3mg 2 praziquantel tabs 4

Antiprotozoals ALINIA 5 atovaquone 5 atovaquone/proguanil hcl 2 chloroquine phosphate tabs 2 COARTEM 4 DARAPRIM 5 PA hydroxychloroquine sulfate tabs 2 mefloquine hcl 2 NEBUPENT 4 B/D PENTAM 300 4 pentamidine isethionate inj 2 pentamidine isethionate inhalation solr 2 B/D primaquine phosphate tabs 2 PYRIMETHAMINE TABS 5 PA quinine sulfate caps 324mg 2 PA tinidazole tabs 2

Pediculicides/Scabicides lindane sham 4 malathion 4 permethrin crea 2 SKLICE 4

Antiparkinson Agents Anticholinergics

benztropine mesylate tabs 2 trihexyphenidyl hcl soln 2 trihexyphenidyl hydrochloride 4

Antiparkinson Agents, Other entacapone 2 GOCOVRI 5 PA tolcapone 5

Dopamine Agonists APOKYN INJ 30MG/3ML 5 QL (90 ML per 30 days) PA bromocriptine mesylate caps, tabs 4 INBRIJA 5 PA NEUPRO 4 ST

19


pramipexole dihydrochloride 2 pramipexole dihydrochloride er 4 ropinirole er 2 ropinirole hcl tabs 0.5mg, 1mg, 2mg, 4mg, 5mg 2 ropinirole hydrochloride tabs 0.25mg, 3mg 2

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa/levodopa 2 carbidopa/levodopa er 2 carbidopa/levodopa odt 4 carbidopa/levodopa/entacapone 4 carbidopa tabs 5 RYTARY 4 ST

Monoamine Oxidase B (MAO-B) Inhibitors rasagiline mesylate tabs 4 selegiline hcl caps, tabs 2 ZELAPAR 5

Antipsychotics 1st Generation/Typical

chlorpromazine hcl tabs 4 fluphenazine decanoate inj 2 fluphenazine hcl tabs 1 fluphenazine hcl conc, inj 2 fluphenazine hydrochloride 2 haloperidol decanoate inj 2 haloperidol lactate 2 haloperidol conc 1 haloperidol tabs 2 loxapine succinate caps 25mg, 50mg, 5mg 2 loxapine caps 10mg 2 molindone hydrochloride 4 perphenazine tabs 2 pimozide 4 thioridazine hcl tabs 100mg, 10mg, 25mg, 50mg 4 PA thiothixene caps 10mg, 1mg, 2mg, 5mg 2 trifluoperazine hcl tabs 2

2nd Generation/Atypical ABILIFY MAINTENA 5 ABILIFY MYCITE 5 QL (30 EA per 30 days) ST aripiprazole odt 5 QL (60 EA per 30 days) aripiprazole tabs 4 QL (30 EA per 30 days) aripiprazole soln 4 QL (750 ML per 30 days) ARISTADA 5 ARISTADA INITIO 5 CAPLYTA 5 QL (30 EA per 30 days) ST FANAPT TITRATION PACK 4 QL (8 EA per 180 days) ST FANAPT TABS 1MG, 2MG, 4MG 4 QL (60 EA per 30 days) ST FANAPT TABS 10MG, 12MG, 6MG, 8MG 5 QL (60 EA per 30 days) ST GEODON INJ 4 QL (60 EA per 30 days) INVEGA SUSTENNA INJ 39MG/0.25ML 4

20


INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/ML, 234MG/1.5ML, 78MG/0.5ML

5

INVEGA TRINZA 5 LATUDA TABS 120MG, 20MG, 40MG, 60MG 5 QL (30 EA per 30 days) LATUDA TABS 80MG 5 QL (60 EA per 30 days) NUPLAZID CAPS 5 PA NUPLAZID TABS 10MG 5 PA olanzapine odt 2 QL (30 EA per 30 days) olanzapine tabs 1 QL (30 EA per 30 days) olanzapine inj 2 paliperidone er tb24 1.5mg, 3mg 4 QL (30 EA per 30 days) paliperidone er tb24 6mg 4 QL (60 EA per 30 days) paliperidone er tb24 9mg 5 QL (30 EA per 30 days) PERSERIS 5 quetiapine fumarate er tb24 150mg, 300mg, 400mg, 50mg 4 QL (60 EA per 30 days) quetiapine fumarate er tb24 200mg 4 QL (90 EA per 30 days) quetiapine fumarate tabs 300mg, 400mg 2 QL (60 EA per 30 days) quetiapine fumarate tabs 100mg, 200mg, 25mg, 50mg 2 QL (90 EA per 30 days) REXULTI 5 QL (30 EA per 30 days) RISPERDAL CONSTA INJ 12.5MG, 25MG 4 RISPERDAL CONSTA INJ 37.5MG, 50MG 5 risperidone odt 2 QL (60 EA per 30 days) risperidone tabs 1 QL (60 EA per 30 days) risperidone soln 2 QL (240 ML per 30 days) SAPHRIS 5 QL (60 EA per 30 days) SECUADO 5 QL (30 EA per 30 days) PA VRAYLAR CPPK 4 QL (14 EA per 365 days) ST VRAYLAR CAPS 5 QL (30 EA per 30 days) ST ziprasidone hcl 2 QL (60 EA per 30 days) ZYPREXA RELPREVV INJ 210MG 4

Treatment-Resistant clozapine odt tbdp 150mg 4 QL (180 EA per 30 days) clozapine odt tbdp 100mg, 25mg 4 QL (270 EA per 30 days) clozapine odt tbdp 12.5mg 4 QL (90 EA per 30 days) clozapine odt tbdp 200mg 5 QL (120 EA per 30 days) clozapine tabs 200mg 2 QL (120 EA per 30 days) clozapine tabs 50mg 2 QL (180 EA per 30 days) clozapine tabs 100mg, 25mg 2 QL (270 EA per 30 days) VERSACLOZ 5 QL (540 ML per 30 days)

Antispasticity Agents Antispasticity Agents

baclofen tabs 2 dantrolene sodium caps 2 tizanidine hcl caps 4 tizanidine hcl tabs 2mg 2 tizanidine hydrochloride tabs 4mg 2

Antivirals Anti-cytomegalovirus (CMV) Agents

PREVYMIS TABS 5

21


valganciclovir 5 valganciclovir hydrochlorde 5 ZIRGAN 4

Anti-hepatitis B (HBV) Agents adefovir dipivoxil 5 BARACLUDE SOLN 5 QL (600 ML per 30 days) entecavir 4 QL (30 EA per 30 days) EPIVIR HBV SOLN 4 INTRON A 5 PA lamivudine tabs 100mg 2 VEMLIDY 5

Anti-hepatitis C (HCV) Agents, Direct Acting Agents EPCLUSA 5 QL (84 EA per 365 days) PA HARVONI TABS 90MG; 400MG 5 QL (168 EA per 365 days) PA LEDIPASVIR/SOFOSBUVIR 5 QL (168 EA per 365 days) PA MAVYRET 5 QL (336 EA per 365 days) PA SOFOSBUVIR/VELPATASVIR 5 QL (84 EA per 365 days) PA VOSEVI 5 QL (84 EA per 365 days) PA

Anti-hepatitis C (HCV) Agents, Other PEGASYS 5 PA PEGASYS PROCLICK INJ 180MCG/0.5ML 5 PA ribavirin caps 2 ribavirin tabs 200mg 4

Anti-HIV Agents, Integrase Inhibitors (INSTI) BIKTARVY 5 QL (30 EA per 30 days) DELSTRIGO 5 QL (30 EA per 30 days) DOVATO 5 QL (30 EA per 30 days) GENVOYA 5 QL (30 EA per 30 days) ISENTRESS CHEW 25MG 3 ISENTRESS CHEW 100MG 5 ISENTRESS PACK 100MG 5 JULUCA 5 QL (30 EA per 30 days) STRIBILD 5 QL (30 EA per 30 days) TIVICAY TABS 10MG 4 TIVICAY TABS 25MG, 50MG 5 TRIUMEQ 5 QL (30 EA per 30 days)

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

ATRIPLA 5 QL (30 EA per 30 days) COMPLERA 5 QL (30 EA per 30 days) EDURANT 5 efavirenz caps 50mg 2 efavirenz caps 200mg 5 efavirenz tabs 5 INTELENCE TABS 25MG 4 INTELENCE TABS 100MG, 200MG 5 nevirapine 2 nevirapine er 4 ODEFSEY 5 QL (30 EA per 30 days)

22


PIFELTRO 5 SUSTIVA TABS 5 SUSTIVA CAPS 50MG 4 SUSTIVA CAPS 200MG 5 SYMFI 5 QL (30 EA per 30 days) SYMFI LO 5 QL (30 EA per 30 days)

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

abacavir 4 abacavir sulfate/lamivudine 4 QL (30 EA per 30 days) abacavir sulfate/lamivudine/zidovudine 5 QL (60 EA per 30 days) CIMDUO 5 QL (30 EA per 30 days) DESCOVY 5 QL (30 EA per 30 days) didanosine cpdr 200mg, 250mg, 400mg 2 EMTRIVA 4 lamivudine/zidovudine 4 QL (60 EA per 30 days) lamivudine soln 10mg/ml 2 lamivudine tabs 150mg, 300mg 4 stavudine caps 2 tenofovir disoproxil fumarate 4 TRUVADA 5 QL (30 EA per 30 days) VIREAD POWD 5 VIREAD TABS 150MG, 200MG, 250MG 5 zidovudine 2

Anti-HIV Agents, Other FUZEON 5 QL (60 EA per 30 days) ISENTRESS HD 5 ISENTRESS TABS 400MG 5 SELZENTRY SOLN 5 SELZENTRY TABS 25MG 4 SELZENTRY TABS 150MG, 300MG, 75MG 5 TYBOST 3

Anti-HIV Agents, Protease Inhibitors APTIVUS 5 atazanavir sulfate 5 CRIXIVAN CAPS 200MG, 400MG 3 EVOTAZ 5 QL (30 EA per 30 days) fosamprenavir calcium 5 INVIRASE TABS 5 KALETRA TABS 100MG; 25MG 4 KALETRA TABS 200MG; 50MG 5 LEXIVA SUSP 4 lopinavir/ritonavir 5 NORVIR PACK, SOLN, TABS 4 PREZCOBIX 5 QL (30 EA per 30 days) PREZISTA SUSP 5 PREZISTA TABS 150MG, 75MG 4 PREZISTA TABS 600MG, 800MG 5 REYATAZ 5

23


ritonavir 2 SYMTUZA 5 QL (30 EA per 30 days) VIRACEPT 5

Anti-influenza Agents amantadine hcl syrp 1 amantadine hcl caps, tabs 2 oseltamivir phosphate caps 75mg 2 QL (110 EA per 365 days) oseltamivir phosphate caps 30mg 2 QL (168 EA per 365 days) oseltamivir phosphate caps 45mg 2 QL (84 EA per 365 days) oseltamivir phosphate susr 2 QL (1080 ML per 365 days) RELENZA DISKHALER 4 QL (240 EA per 365 days) rimantadine hydrochloride 2 XOFLUZA 3 QL (4 EA per 365 days)

Antiherpetic Agents acyclovir sodium inj 50mg/ml 4 B/D acyclovir caps, tabs 1 acyclovir crea, oint, susp 4 DENAVIR 5 famciclovir tabs 2 trifluridine 2 valacyclovir hcl tabs 1gm 2 QL (120 EA per 30 days) valacyclovir hydrochloride tabs 500mg 2 QL (120 EA per 30 days)

Anxiolytics Anxiolytics, Other

buspirone hcl tabs 15mg, 30mg 1 buspirone hydrochloride tabs 10mg, 5mg, 7.5mg 1 meprobamate 4

Benzodiazepines alprazolam er tb24 2mg 2 QL (150 EA per 30 days) PA alprazolam er tb24 0.5mg, 1mg 2 QL (30 EA per 30 days) PA alprazolam er tb24 3mg 2 QL (90 EA per 30 days) PA alprazolam intensol 2 PA alprazolam odt tbdp 0.25mg, 0.5mg, 1mg 2 QL (120 EA per 30 days) PA alprazolam odt tbdp 2mg 2 QL (150 EA per 30 days) PA alprazolam tabs 0.25mg, 0.5mg, 1mg 1 QL (120 EA per 30 days) PA alprazolam tabs 2mg 1 QL (150 EA per 30 days) PA chlordiazepoxide hcl caps 5mg 1 QL (120 EA per 30 days) PA chlordiazepoxide hcl caps 10mg 1 QL (900 EA per 30 days) PA chlordiazepoxide hydrochloride 1 QL (360 EA per 30 days) PA clorazepate dipotassium tabs 15mg 2 QL (180 EA per 30 days) clorazepate dipotassium tabs 7.5mg 2 QL (360 EA per 30 days) clorazepate dipotassium tabs 3.75mg 2 QL (720 EA per 30 days) diazepam conc, soln 2 diazepam tabs 10mg 1 QL (120 EA per 30 days) diazepam tabs 5mg 1 QL (240 EA per 30 days) diazepam tabs 2mg 1 QL (300 EA per 30 days) estazolam 2 QL (30 EA per 30 days) PA lorazepam conc 2 PA lorazepam tabs 2mg 1 QL (150 EA per 30 days) PA

24


lorazepam tabs 0.5mg, 1mg 1 QL (90 EA per 30 days) PA oxazepam 2 QL (120 EA per 30 days) PA temazepam caps 15mg, 30mg 2 QL (30 EA per 30 days) PA temazepam caps 22.5mg, 7.5mg 4 QL (30 EA per 30 days) PA

Bipolar Agents Mood Stabilizers

EQUETRO 4 lithium 2 lithium carbonate er 1 lithium carbonate caps, tabs 1

Blood Glucose Regulators Antidiabetic Agents

acarbose tabs 2 CYCLOSET 4 glimepiride 1 glipizide er 1 glipizide/metformin hydrochloride 1 glipizide tabs 1 glyburide micronized tabs 3mg, 6mg 2 glyburide/metformin hydrochloride 2 glyburide tabs 2 GLYXAMBI 3 ST INVOKAMET 3 ST INVOKAMET XR 3 ST INVOKANA 3 ST JANUMET 3 ST JANUMET XR 3 ST JANUVIA 3 ST JARDIANCE 3 ST JENTADUETO 3 ST JENTADUETO XR 3 ST KOMBIGLYZE XR 4 ST metformin hydrochloride er tb24 500mg, 750mg 1 metformin hydrochloride tabs 1 metformin hydrochloride soln 2 miglitol 2 nateglinide 1 ONGLYZA 4 ST OZEMPIC INJ 2MG/1.5ML 3 QL (1.5 ML per 28 days) OZEMPIC INJ 2MG/1.5ML 3 QL (3 ML per 28 days) pioglitazone hcl-glimepiride 2 pioglitazone hcl/metformin hcl 1 pioglitazone hcl tabs 45mg 1 pioglitazone hydrochloride tabs 15mg, 30mg 1 repaglinide 1 RIOMET 4 RIOMET ER 4 RYBELSUS TABS 14MG, 7MG 3 QL (30 EA per 30 days) RYBELSUS TABS 3MG 3 QL (60 EA per 365 days)

25


SYMLINPEN 120 5 PA SYMLINPEN 60 5 PA SYNJARDY 3 ST SYNJARDY XR 3 ST TRADJENTA 3 ST TRIJARDY XR 3 ST TRULICITY 3 QL (2 ML per 28 days) VICTOZA 3 QL (9 ML per 30 days)

Glycemic Agents BAQSIMI TWO PACK 3 diazoxide susp 5 GLUCAGEN HYPOKIT 4 GLUCAGON EMERGENCY KIT 3 GVOKE PFS 3 PROGLYCEM 5

Insulins HUMALOG 3 HUMALOG JUNIOR KWIKPEN 3 HUMALOG KWIKPEN 3 HUMALOG MIX 50/50 3 HUMALOG MIX 50/50 KWIKPEN 3 HUMALOG MIX 75/25 3 HUMALOG MIX 75/25 KWIKPEN 3 HUMULIN 70/30 3 HUMULIN 70/30 KWIKPEN 3 HUMULIN N 3 HUMULIN N KWIKPEN 3 HUMULIN R 3 HUMULIN R U-500 (CONCENTRATED) 3 HUMULIN R U-500 KWIKPEN 3 INSULIN ASPART 3 INSULIN ASPART FLEXPEN 3 INSULIN ASPART PENFILL 3 INSULIN ASPART PROTAMINE/INSULIN ASPART 3 INSULIN ASPART PROTAMINE/INSULIN ASPART FLEXPEN

3

INSULIN LISPRO 3 INSULIN LISPRO JUNIOR KWIKPEN 3 INSULIN LISPRO KWIKPEN 3 INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN

3

LANTUS 3 LANTUS SOLOSTAR 3 LEVEMIR 3 LEVEMIR FLEXTOUCH 3 NOVOLIN 70/30 3 NOVOLIN 70/30 FLEXPEN 3 NOVOLIN N 3 NOVOLIN N FLEXPEN 3

26


NOVOLIN R 3 NOVOLIN R FLEXPEN 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 70/30 3 NOVOLOG MIX 70/30 PREFILLED FLEXPEN 3 NOVOLOG PENFILL 3 TOUJEO MAX SOLOSTAR 3 TOUJEO SOLOSTAR 3 TRESIBA 3 TRESIBA FLEXTOUCH 3

Blood Products/Modifiers/Volume Expanders Anticoagulants

COUMADIN TABS 4 ELIQUIS STARTER PACK 3 QL (148 EA per 365 days) ELIQUIS TABS 2.5MG 3 QL (60 EA per 30 days) ELIQUIS TABS 5MG 3 QL (90 EA per 30 days) enoxaparin sodium inj 30mg/0.3ml 4 QL (10.5 ML per 90 days) enoxaparin sodium inj 40mg/0.4ml 4 QL (14 ML per 90 days) enoxaparin sodium inj 60mg/0.6ml 4 QL (21 ML per 90 days) enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml 4 QL (28 ML per 90 days) enoxaparin sodium inj 100mg/ml, 150mg/ml 4 QL (35 ML per 90 days) fondaparinux sodium inj 2.5mg/0.5ml 4 QL (17.5 ML per 90 days) fondaparinux sodium inj 5mg/0.4ml 5 QL (14 ML per 90 days) fondaparinux sodium inj 7.5mg/0.6ml 5 QL (21 ML per 90 days) fondaparinux sodium inj 10mg/0.8ml 5 QL (28 ML per 90 days) FRAGMIN INJ 2500UNIT/0.2ML, 5000UNIT/0.2ML 4 QL (7 ML per 90 days) FRAGMIN INJ 7500UNIT/0.3ML 5 QL (10.5 ML per 90 days) FRAGMIN INJ 12500UNIT/0.5ML 5 QL (17.5 ML per 90 days) FRAGMIN INJ 15000UNIT/0.6ML 5 QL (21 ML per 90 days) FRAGMIN INJ 95000UNIT/3.8ML 5 QL (22.8 ML per 90 days) FRAGMIN INJ 18000UNT/0.72ML 5 QL (25.3 ML per 90 days) FRAGMIN INJ 10000UNIT/ML 5 QL (35 ML per 90 days) heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml

2

jantoven 1 PRADAXA 4 QL (60 EA per 30 days) warfarin sodium tabs 1 XARELTO STARTER PACK 3 QL (102 EA per 365 days) XARELTO TABS 10MG, 20MG 3 QL (30 EA per 30 days) XARELTO TABS 15MG, 2.5MG 3 QL (60 EA per 30 days)

Blood Formation Modifiers anagrelide hydrochloride 2 ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML

4 PA

27


ARANESP ALBUMIN FREE INJ 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML, 60MCG/ML

5 PA

FULPHILA 5 PA GRANIX 5 ST LEUKINE INJ 250MCG 5 PA MULPLETA 5 PA NEULASTA 5 PA NEUPOGEN 5 ST NIVESTYM 5 ST OXBRYTA 5 QL (90 EA per 30 days) PA PROMACTA 5 PA UDENYCA 5 PA ZARXIO 5 ZIEXTENZO 5 PA

Hemostasis Agents RETACRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

4 PA

RETACRIT INJ 40000UNIT/ML 5 PA TAVALISSE 5 PA tranexamic acid tabs 2

Platelet Modifying Agents aspirin/dipyridamole 4 BRILINTA 3 CABLIVI 5 QL (30 EA per 30 days) PA cilostazol 1 clopidogrel tabs 75mg 1 dipyridamole tabs 4 prasugrel 4

Cardiovascular Agents Alpha-adrenergic Agonists

clonidine hcl ptwk 2 clonidine hcl tabs 0.1mg, 0.3mg 1 clonidine hydrochloride tabs 0.2mg 1 guanfacine hcl 4 methyldopa/hydrochlorothiazide 4 methyldopa tabs 250mg, 500mg 4 midodrine hcl 2

Alpha-adrenergic Blocking Agents phenoxybenzamine hydrochloride 5 prazosin hcl caps 1mg, 5mg 2 prazosin hydrochloride caps 2mg 2

Angiotensin II Receptor Antagonists candesartan cilexetil 1 candesartan cilexetil/hydrochlorothiazide 1 EDARBI 4 EDARBYCLOR 4 irbesartan 1

28


irbesartan/hydrochlorothiazide 1 losartan potassium/hydrochlorothiazide 1 losartan potassium tabs 1 olmesartan medoxomil/hydrochlorothiazide 2 olmesartan medoxomil tabs 2 telmisartan 1 telmisartan/hydrochlorothiazide 1 valsartan 1 valsartan/hydrochlorothiazide 1

Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl/hydrochlorothiazide 1 benazepril hcl tabs 10mg, 40mg, 5mg 1 benazepril hydrochloride tabs 20mg 1 captopril/hydrochlorothiazide 1 captopril tabs 1 enalapril maleate/hydrochlorothiazide 1 enalapril maleate tabs 1 fosinopril sodium 1 fosinopril sodium/hydrochlorothiazide 1 lisinopril/hydrochlorothiazide 1 lisinopril tabs 1 moexipril hcl 1 perindopril erbumine 1 quinapril hcl tabs 20mg, 40mg, 5mg 1 quinapril hydrochloride tabs 10mg 1 quinapril/hydrochlorothiazide 1 ramipril 1 trandolapril 1 trandolapril/verapamil hcl er 1

Antiarrhythmics amiodarone hcl tabs 200mg 1 amiodarone hcl tabs 400mg 2 amiodarone hydrochloride tabs 100mg 2 disopyramide phosphate caps 4 dofetilide 4 flecainide acetate 2 mexiletine hcl 2 MULTAQ 3 NORPACE CR 4 pacerone tabs 200mg 1 pacerone tabs 100mg, 400mg 2 propafenone hcl 2 propafenone hydrochloride er 4 quinidine gluconate cr 4 quinidine sulfate tabs 2 sorine 2 sotalol hcl 2 sotalol hcl (af) tabs 120mg 2 sotalol hydrochloride (af) tabs 160mg, 80mg 2

29


Beta-adrenergic Blocking Agents acebutolol hcl caps 200mg 1 acebutolol hydrochloride caps 400mg 1 atenolol/chlorthalidone 1 atenolol tabs 1 betaxolol hcl tabs 10mg, 20mg 2 bisoprolol fumarate 2 bisoprolol fumarate/hydrochlorothiazide 1 BYSTOLIC 3 carvedilol 1 carvedilol phosphate 4 DUTOPROL 4 INNOPRAN XL 4 labetalol hydrochloride tabs 2 metoprolol succinate er 2 metoprolol tartrate tabs 100mg, 25mg, 50mg 1 metoprolol/hydrochlorothiazide 2 nadolol tabs 20mg, 40mg, 80mg 2 pindolol tabs 2 propranolol hcl er cp24 120mg, 160mg 2 propranolol hcl soln 2 propranolol hcl tabs 40mg, 80mg 2 propranolol hydrochloride er cp24 60mg, 80mg 2 propranolol hydrochloride tabs 10mg, 20mg, 60mg 2 propranolol/hydrochlorothiazide 2

Calcium Channel Blocking Agents amlodipine besylate/atorvastatin calcium 2 amlodipine besylate/benazepril hydrochloride 1 amlodipine besylate/valsartan 1 amlodipine besylate tabs 1 amlodipine/olmesartan medoxomil 2 amlodipine/valsartan/hctz tabs 10mg; 12.5mg; 160mg, 10mg; 25mg; 160mg, 10mg; 25mg; 320mg, 5mg; 25mg; 160mg

4

amlodipine/valsartan/hydrochlorothiazide tabs 5mg; 12.5mg; 160mg

2

CARDIZEM LA TB24 120MG 4 cartia xt 2 dilt-xr 2 diltiazem hcl er cp24 420mg 2 diltiazem hcl er cp12 2 diltiazem hcl tabs 1 diltiazem hydrochloride er 2 felodipine er 2 isradipine 4 matzim la 2 nicardipine hcl caps 4 nifedipine er 2 nifedipine caps 4 nimodipine caps 5

30


nisoldipine er 4 NYMALIZE SOLN 60MG/20ML 5 taztia xt 2 telmisartan/amlodipine 2 tiadylt er 2 verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg 2 verapamil hcl er tbcr 2 verapamil hcl sr cp24 360mg 2 verapamil hcl tabs 40mg, 80mg 1 verapamil hydrochloride er cp24 2 verapamil hydrochloride tabs 1

Cardiovascular Agents, Other aliskiren 2 CORLANOR SOLN 4 QL (450 ML per 30 days) PA CORLANOR TABS 4 QL (60 EA per 30 days) PA DEMSER 5 digitek tabs 0.125mg 2 digitek tabs 0.25mg 4 digoxin soln 2 digoxin tabs 125mcg 2 digoxin tabs 250mcg 4 digox tabs 125mcg 2 digox tabs 250mcg 4 ENTRESTO 3 QL (60 EA per 30 days) LANOXIN TABS 125MCG, 250MCG, 62.5MCG 4 NORTHERA 5 PA pentoxifylline er 4 ranolazine er 2 REPATHA 4 QL (3 ML per 28 days) PA REPATHA PUSHTRONEX SYSTEM 4 QL (3.5 ML per 28 days) PA REPATHA SURECLICK 4 QL (3 ML per 28 days) PA TAKHZYRO 5 PA VYNDAMAX 5 QL (30 EA per 30 days) PA VYNDAQEL 5 QL (120 EA per 30 days) PA

Diuretics, Loop bumetanide tabs 1 bumetanide inj 2 ethacrynic acid tabs 5 furosemide tabs 1 furosemide inj, oral soln 2 torsemide tabs 1

Diuretics, Potassium-sparing ALDACTAZIDE TABS 50MG; 50MG 4 amiloride hcl tabs 2 amiloride/hydrochlorothiazide 1 DYRENIUM 4 eplerenone 2 spironolactone/hydrochlorothiazide 2 spironolactone tabs 1

31


triamterene/hydrochlorothiazide caps 25mg; 37.5mg 2 triamterene/hydrochlorothiazide tabs 1 triamterene caps 2

Diuretics, Thiazide chlorthalidone tabs 25mg, 50mg 2 DIURIL SUSP 4 hydrochlorothiazide caps, tabs 1 indapamide tabs 1 metolazone 2

Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized 2 fenofibrate caps 130mg, 150mg, 43mg, 50mg 2 fenofibrate tabs 54mg 1 fenofibrate tabs 145mg, 160mg, 40mg, 48mg 2 fenofibrate tabs 120mg 4 fenofibric acid dr 2 gemfibrozil tabs 1

Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium 1 fluvastatin 1 fluvastatin sodium er 4 LIVALO 3 ST lovastatin 1 pravastatin sodium 1 rosuvastatin calcium 1 simvastatin tabs 1

Dyslipidemics, Other cholestyramine light powd 2 cholestyramine pack 2 colesevelam hydrochloride tabs 4 colestipol hcl pack, tabs 2 ezetimibe 2 ezetimibe/simvastatin 2 JUXTAPID 5 QL (30 EA per 30 days) PA niacin er 2 niacor 2 omega-3-acid ethyl esters 4 prevalite pack 2 VASCEPA 4

Vasodilators, Direct-acting Arterial/Venous BIDIL 3 ISORDIL TITRADOSE TABS 40MG 5 isosorbide dinitrate tabs 10mg, 20mg, 30mg, 5mg 2 isosorbide dinitrate tabs 40mg 5 isosorbide mononitrate 1 isosorbide mononitrate er 1 minitran 2 NITRO-BID 4 NITRO-DUR PT24 0.3MG/HR, 0.8MG/HR 4

32


nitroglycerin lingual soln 4 nitroglycerin transdermal 2 nitroglycerin subl 0.3mg, 0.4mg, 0.6mg 2

Vasodilators, Direct-acting Arterial hydralazine hcl tabs 10mg 1 hydralazine hydrochloride tabs 100mg, 25mg, 50mg 1 minoxidil tabs 4

Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines

amphetamine/dextroamphetamine cp24 2 QL (30 EA per 30 days) PA amphetamine/dextroamphetamine tabs 2 QL (90 EA per 30 days) PA dextroamphetamine sulfate er cp24 15mg 2 QL (120 EA per 30 days) PA dextroamphetamine sulfate er cp24 10mg 2 QL (180 EA per 30 days) PA dextroamphetamine sulfate er cp24 5mg 2 QL (60 EA per 30 days) PA dextroamphetamine sulfate soln 4 QL (1800 ML per 30 days) PA dextroamphetamine sulfate tabs 5mg 2 QL (90 EA per 30 days) PA dextroamphetamine sulfate tabs 10mg 4 QL (180 EA per 30 days) PA ZENZEDI TABS 10MG 4 QL (180 EA per 30 days) PA ZENZEDI TABS 30MG 4 QL (60 EA per 30 days) PA ZENZEDI TABS 15MG, 2.5MG, 20MG, 5MG, 7.5MG 4 QL (90 EA per 30 days) PA

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

atomoxetine caps 18mg, 25mg 2 QL (30 EA per 30 days) atomoxetine caps 10mg 2 QL (60 EA per 30 days) atomoxetine caps 100mg, 40mg, 60mg, 80mg 4 QL (30 EA per 30 days) clonidine hcl er 4 dexmethylphenidate hcl er 4 QL (30 EA per 30 days) PA dexmethylphenidate hcl tabs 10mg, 5mg 2 QL (60 EA per 30 days) PA dexmethylphenidate hydrochloride tabs 2.5mg 2 QL (60 EA per 30 days) PA guanfacine er 4 methylphenidate hydrochloride cd cpcr 10mg, 20mg, 50mg, 60mg

4 QL (30 EA per 30 days) PA

methylphenidate hydrochloride er (la) 4 QL (30 EA per 30 days) PA methylphenidate hydrochloride er cp24 10mg 2 QL (30 EA per 30 days) PA methylphenidate hydrochloride er cp24 20mg, 30mg, 40mg 4 QL (30 EA per 30 days) PA methylphenidate hydrochloride er cpcr 30mg, 40mg 4 QL (30 EA per 30 days) PA methylphenidate hydrochloride er tb24 18mg, 27mg, 54mg 4 QL (30 EA per 30 days) PA methylphenidate hydrochloride er tb24 36mg 4 QL (60 EA per 30 days) PA methylphenidate hydrochloride er tbcr 10mg 4 QL (180 EA per 30 days) PA methylphenidate hydrochloride er tbcr 18mg, 27mg, 54mg, 72mg

4 QL (30 EA per 30 days) PA

methylphenidate hydrochloride er tbcr 36mg 4 QL (60 EA per 30 days) PA methylphenidate hydrochloride er tbcr 20mg 4 QL (90 EA per 30 days) PA methylphenidate hydrochloride chew 10mg 2 QL (180 EA per 30 days) PA methylphenidate hydrochloride chew 2.5mg, 5mg 2 QL (90 EA per 30 days) PA methylphenidate hydrochloride tabs 2 QL (90 EA per 30 days) PA relexxii 4 QL (30 EA per 30 days) PA

Central Nervous System, Other AUSTEDO 5 QL (120 EA per 30 days) PA

33


butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg 4 PA BUTALBITAL/ACETAMINOPHEN TABS 325MG; 25MG 5 PA butalbital/aspirin/caffeine caps 4 PA INGREZZA CPPK 5 QL (56 EA per 365 days) PA INGREZZA CAPS 80MG 5 QL (30 EA per 30 days) PA INGREZZA CAPS 40MG 5 QL (60 EA per 30 days) PA NUEDEXTA 4 PA riluzole 2 PA tetrabenazine 5 PA TIGLUTIK 5 PA vanatol lq 5 PA

Fibromyalgia Agents SAVELLA 3 QL (60 EA per 30 days) SAVELLA TITRATION PACK 3 QL (110 EA per 365 days)

Multiple Sclerosis Agents AMPYRA 5 QL (60 EA per 30 days) PA AUBAGIO 5 QL (30 EA per 30 days) PA AVONEX PEN 5 QL (4 EA per 28 days) PA AVONEX INJ 30MCG/0.5ML 5 QL (4 EA per 28 days) PA BETASERON 5 QL (15 EA per 30 days) PA dalfampridine er 5 QL (60 EA per 30 days) PA EXTAVIA 5 QL (15 EA per 30 days) PA GILENYA CAPS 0.5MG 5 QL (30 EA per 30 days) PA glatiramer acetate inj 40mg/ml 5 QL (12 ML per 28 days) PA glatiramer acetate inj 20mg/ml 5 QL (30 ML per 30 days) PA glatopa inj 40mg/ml 5 QL (12 ML per 28 days) PA glatopa inj 20mg/ml 5 QL (30 ML per 30 days) PA MAVENCLAD 5 PA MAYZENT TABS 0.25MG 5 QL (120 EA per 30 days) PA MAYZENT TABS 2MG 5 QL (30 EA per 30 days) PA PLEGRIDY 5 QL (1 ML per 28 days) PA PLEGRIDY STARTER PACK INJ 0 5 QL (2 ML per 365 days) PA PLEGRIDY STARTER PACK INJ 0 5 QL (4 ML per 365 days) PA REBIF 5 QL (6 ML per 28 days) PA REBIF REBIDOSE 5 QL (6 ML per 28 days) PA REBIF REBIDOSE TITRATION PACK 5 QL (8.4 ML per 365 days) PA REBIF TITRATION PACK 5 QL (8.4 ML per 365 days) PA TECFIDERA 5 QL (60 EA per 30 days) PA TECFIDERA STARTER PACK 5 QL (120 EA per 365 days) PA VUMERITY 5 QL (120 EA per 30 days) PA

Dental and Oral Agents Dental and Oral Agents

cevimeline hydrochloride 4 chlorhexidine gluconate soln 1 lidocaine viscous 1 pilocarpine hydrochloride 2 triamcinolone acetonide dental paste 2

Dermatological Agents Dermatological Agents

34


acitretin caps 10mg, 25mg 4 acitretin caps 17.5mg 5 adapalene/benzoyl peroxide 4 adapalene crea, gel 4 ammonium lactate crea, lotn 2 amnesteem 4 PA avita 4 PA azelaic acid 2 CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE SUSP

5 QL (400 GM per 30 days)

calcipotriene/betamethasone dipropionate oint 5 QL (400 GM per 30 days) calcipotriene crea, oint 2 QL (120 GM per 30 days) calcipotriene soln 2 QL (60 ML per 30 days) CALCITRIOL OINT 3MCG/GM 4 claravis 4 PA clindamycin phosphate/benzoyl peroxide gel 5%; 1.2% 2 clindamycin phosphate/tretinoin 4 clindamycin/benzoyl peroxide 4 CONDYLOX GEL 4 COSENTYX 5 PA COSENTYX SENSOREADY PEN 5 PA dapsone gel 5%, 7.5% 4 diclofenac sodium transdermal soln 1.5% 4 PA doxepin hydrochloride crea 5% 4 QL (90 GM per 30 days) PA DUOBRII 5 PA DUPIXENT INJ 300MG/2ML 5 QL (8 ML per 28 days) PA EPIDUO FORTE 4 erythromycin/benzoyl peroxide 4 EUCRISA 4 FINACEA 3 hydrocortisone acetate/pramoxine crea 1%; 1% 4 ILUMYA 5 PA imiquimod pump 5 imiquimod crea 2 isotretinoin caps 4 PA ivermectin crea 1% 4 methoxsalen caps 5 metronidazole crea 0.75% 2 metronidazole gel 0.75% 2 metronidazole gel 1% 4 metronidazole lotn 0.75% 4 MIRVASO 4 PA myorisan 4 PA neuac 2 NORITATE 5 PENNSAID SOLN 2% 5 PA PICATO 5 pimecrolimus 4 podofilox soln 2

35


RECTIV 4 REGRANEX 5 PA SANTYL 4 selenium sulfide lotn 1 SILIQ 5 PA STELARA INJ 45MG/0.5ML, 90MG/ML 5 PA TACLONEX SUSP 5 QL (400 GM per 30 days) tacrolimus oint 0.03%, 0.1% 4 TALTZ 5 PA tazarotene crea 4 TAZORAC GEL 4 TAZORAC CREA 0.05% 4 TREMFYA 5 PA tretinoin microsphere 4 PA tretinoin crea 0.025%, 0.05%, 0.1% 2 PA tretinoin gel 0.01%, 0.025%, 0.05% 4 PA VEREGEN 5 zenatane 4 PA ZYCLARA PUMP 5

Electrolytes/Minerals/Metals/Vitamins Electrolyte/Mineral Replacement

CARBAGLU 5 CLINIMIX 4.25%/DEXTROSE 10% 4 B/D CLINIMIX 4.25%/DEXTROSE 5% 4 B/D CLINIMIX 5%/DEXTROSE 15% 4 B/D CLINIMIX 5%/DEXTROSE 20% 4 B/D CLINIMIX E 2.75%/DEXTROSE 5% 4 B/D CLINIMIX E 4.25%/DEXTROSE 10% 4 B/D CLINIMIX E 4.25%/DEXTROSE 5% 4 B/D CLINIMIX E 5%/DEXTROSE 15% 4 B/D CLINIMIX E 5%/DEXTROSE 20% 4 B/D dextrose 10%/nacl 0.45% 2 dextrose 10% 2 dextrose 10%/nacl 0.2% 2 dextrose 2.5%/nacl 0.45% 2 dextrose 5% 2 dextrose 5%/nacl 0.2% 2 dextrose 5%/nacl 0.225% 2 dextrose 5%/nacl 0.45% 2 dextrose 5%/nacl 0.9% 2 ISOLYTE-P/DEXTROSE 5% 4 ISOLYTE-S 4 kcl 0.075%/d5w/nacl 0.45% 2 kcl 0.15%/d5w/nacl 0.2% 2 kcl 0.15%/d5w/nacl 0.45% 2 kcl 0.15%/d5w/nacl 0.9% 2 kcl 0.3%/d5w/nacl 0.45% 2 kcl 0.3%/d5w/nacl 0.9% 2 klor-con 4

36


klor-con 10 2 klor-con 8 2 klor-con m10 2 klor-con m15 2 klor-con m20 2 magnesium sulfate inj 50% 2 NORMOSOL-M IN D5W 4 NORMOSOL-R 4 NORMOSOL-R IN D5W 4 PLASMA-LYTE A 4 PLASMA-LYTE-148 4 potassium chloride cr tbcr 10meq 2 potassium chloride er cpcr 2 potassium chloride er tbcr 10meq, 20meq, 8meq 2 potassium chloride/dextrose/lactated ringers inj 3meq/l; 149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l

2

potassium chloride/dextrose/sodium chloride inj 5%; 30meq/l; 0.45%

2

potassium chloride/dextrose inj 5%; 20meq/l, 5%; 40meq/l 2 potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9%

2

potassium chloride oral soln 2 potassium chloride pack 4 potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml

2

potassium citrate er 2 PROCALAMINE 4 B/D sodium chloride inj 0.45%, 0.9%, 3%, 5% 2 sodium fluoride tabs 1mg 2 tpn electrolytes 2

Electrolyte/Mineral/Metal Modifiers CLOVIQUE 5 PA deferasirox tbso 5 PA deferasirox tabs 360mg, 90mg 5 PA DEPEN TITRATABS 5 EXJADE 5 PA FERRIPROX 5 PA JADENU 5 PA JADENU SPRINKLE 5 PA JYNARQUE TABS 30MG 5 QL (30 EA per 30 days) JYNARQUE TABS 15MG 5 QL (60 EA per 30 days) JYNARQUE TBPK 0 5 QL (56 EA per 28 days) kionex susp 2 penicillamine tabs 5 sodium polystyrene sulfonate powd, susp 2 sps 2 trientine hydrochloride 5 PA veltassa 5

Phosphate Binders

37


AURYXIA 5 PA calcium acetate caps 2 calcium acetate tabs 667mg 2 lanthanum carbonate 5 sevelamer carbonate tabs 4 sevelamer carbonate pack 5 sevelamer hydrochloride 3 VELPHORO 5

Vitamins RAYALDEE 5 vp-pnv-dha 2

Gastrointestinal Agents Antispasmodics, Gastrointestinal

CUVPOSA 4 dicyclomine hcl soln 2 dicyclomine hydrochloride caps, tabs 2 glycopyrrolate tabs 1mg, 2mg 2 methscopolamine bromide tabs 4 propantheline bromide tabs 4

Gastrointestinal Agents, Other CHENODAL 5 CHOLBAM 5 PA cromolyn sodium conc 100mg/5ml 2 diphenoxylate/atropine tabs 2 diphenoxylate/atropine liqd 4 GATTEX 5 PA lansoprazole/amoxicillin/clarithromycin 4 loperamide hcl caps 2 metoclopramide hcl soln 1 metoclopramide hcl tabs 5mg 1 metoclopramide hydrochloride tabs 1 metoclopramide odt 4 OCALIVA 5 QL (30 EA per 30 days) PA RELISTOR TABS 5 QL (90 EA per 30 days) ST RELISTOR INJ 8MG/0.4ML 5 QL (12 ML per 30 days) ST RELISTOR INJ 12MG/0.6ML 5 QL (18 ML per 30 days) ST ursodiol tabs 2 XERMELO 5 QL (90 EA per 30 days) PA

Histamine2 (H2) Receptor Antagonists cimetidine hcl soln 2 cimetidine tabs 2 famotidine susr 2 famotidine tabs 20mg, 40mg 1 nizatidine caps 2 nizatidine soln 4

Irritable Bowel Syndrome Agents alosetron hydrochloride 5 PA AMITIZA 3 QL (60 EA per 30 days) LINZESS 3 QL (30 EA per 30 days)

38


Laxatives CLENPIQ 3 constulose 2 enulose 1 gavilyte-c 1 gavilyte-g 1 gavilyte-n/flavor pack 2 generlac 1 KRISTALOSE 4 lactulose pack, soln 2 peg-3350/electrolytes 1 peg-3350/nacl/na bicarbonate/kcl 2 SUPREP BOWEL PREP KIT 3 trilyte 2

Protectants CARAFATE SUSP 4 misoprostol 2 SUCRALFATE SUSP 4 sucralfate tabs 2

Proton Pump Inhibitors DEXILANT 4 QL (30 EA per 30 days) esomeprazole magnesium 2 QL (60 EA per 30 days) lansoprazole cpdr 2 QL (60 EA per 30 days) lansoprazole tbdd 4 QL (60 EA per 30 days) omeprazole/sodium bicarbonate caps 5 QL (30 EA per 30 days) omeprazole/sodium bicarbonate pack 5 QL (60 EA per 30 days) omeprazole cpdr 1 QL (60 EA per 30 days) pantoprazole sodium tbec 1 QL (60 EA per 30 days) rabeprazole sodium 2 QL (60 EA per 30 days)

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

CERDELGA 5 PA CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT, 15000UNIT; 3000UNIT; 9500UNIT, 180000UNIT; 36000UNIT; 114000UNIT, 30000UNIT; 6000UNIT; 19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT

3

CYSTADANE 5 CYSTAGON 4 GALAFOLD 5 QL (14 EA per 28 days) PA KUVAN 5 PA miglustat 5 PA NITYR 5 ORFADIN 5 PROCYSBI PACK 5 PA RAVICTI 5 PA sodium phenylbutyrate powd, tabs 5 SUCRAID 5 TEGSEDI 5 PA XURIDEN 5 QL (120 EA per 30 days) PA

39


ZENPEP CPEP 105000UNIT; 25000UNIT; 79000UNIT, 14000UNIT; 3000UNIT; 10000UNIT, 168000UNIT; 40000UNIT; 126000UNIT, 24000UNIT; 5000UNIT; 17000UNIT, 42000UNIT; 10000UNIT; 32000UNIT, 63000UNIT; 15000UNIT; 47000UNIT, 84000UNIT; 20000UNIT; 63000UNIT

3

Genitourinary Agents Antispasmodics, Urinary

darifenacin hydrobromide er 4 flavoxate hcl 2 GELNIQUE GEL 10% 4 MYRBETRIQ 3 oxybutynin chloride er 2 oxybutynin chloride syrp 1 oxybutynin chloride tabs 2 solifenacin succinate 2 tolterodine tartrate 2 tolterodine tartrate er 2 trospium chloride 2 trospium chloride er 2

Benign Prostatic Hypertrophy Agents alfuzosin hcl er 2 CARDURA XL 4 doxazosin mesylate 2 dutasteride/tamsulosin hydrochloride 4 dutasteride caps 4 finasteride tabs 5mg 1 silodosin 3 tadalafil tabs 2.5mg, 5mg 2 QL (30 EA per 30 days) PA tamsulosin hydrochloride 2 terazosin hcl caps 10mg, 1mg, 5mg 1 terazosin hydrochloride caps 2mg 1

Genitourinary Agents, Other bethanechol chloride tabs 2 ELMIRON 4 THIOLA EC 5

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

alclometasone dipropionate 2 amcinonide 4 apexicon e 5 augmented betamethasone dipropionate 2 beser lotn 2 betamethasone dipropionate crea, lotn, oint 2 betamethasone valerate crea, lotn, oint 2 betamethasone valerate foam 4 QL (100 GM per 30 days) CAPEX 4 clobetasol propionate emollient 4 clobetasol propionate soln 2

40


clobetasol propionate crea, foam, gel, liqd, lotn, oint, sham 4 clocortolone pivalate 4 clodan 4 CORDRAN TAPE 4 CORDRAN CREA 0.025% 4 cortisone acetate tabs 25mg 2 DESONATE 4 desonide crea, oint 2 desonide lotn 4 desoximetasone crea, gel, liqd 4 DESOXIMETASONE OINT 0.05% 4 desoximetasone oint 0.25% 4 dexamethasone 10-day dose pack 4 dexamethasone 13-day dose pack 4 dexamethasone 6-day dose pack 4 dexamethasone intensol 2 dexamethasone elix 2 dexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 1mg, 2mg, 4mg, 6mg

1

diflorasone diacetate crea 4 diflorasone diacetate oint 4 QL (60 GM per 30 days) EMFLAZA 5 PA fludrocortisone acetate tabs 2 fluocinolone acetonide scalp 2 fluocinolone acetonide crea 0.01%, 0.025% 2 fluocinolone acetonide oint 0.025% 2 fluocinolone acetonide soln 0.01% 2 fluocinonide emulsified base 2 fluocinonide crea 0.1% 5 QL (120 GM per 30 days) fluocinonide gel, oint, soln 2 flurandrenolide crea, oint 4 fluticasone propionate crea 0.05% 2 fluticasone propionate lotn 0.05% 2 fluticasone propionate oint 0.005% 2 halcinonide 4 HALOBETASOL PROPIONATE FOAM 5 halobetasol propionate oint 2 halobetasol propionate crea 4 hydrocortisone butyrate crea, lotn, oint 2 hydrocortisone butyrate soln 4 hydrocortisone valerate crea 2 QL (60 GM per 30 days) hydrocortisone valerate oint 4 hydrocortisone crea 2.5% 1 hydrocortisone lotn 2.5% 1 hydrocortisone oint 2.5% 1 hydrocortisone tabs 10mg, 20mg, 5mg 2 LEXETTE 5 MEDROL TABS 2MG 4 methylprednisolone dose pack tbpk 2

41


methylprednisolone tabs 2 MILLIPRED TABS 4 mometasone furoate crea 0.1% 1 mometasone furoate oint 0.1% 1 mometasone furoate soln 0.1% 1 nolix crea 4 PANDEL 5 prednicarbate 2 prednisolone sodium phosphate oral soln 10mg/5ml, 20mg/5ml, 25mg/5ml, 5mg/5ml

2

prednisolone soln 1 prednisone intensol 2 prednisone soln, tbpk 2 prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 50mg, 5mg 1 RAYOS 5 SYNALAR CREA 4 tovet 4 triamcinolone acetonide crea 0.025%, 0.1%, 0.5% 1 triamcinolone acetonide lotn 0.025%, 0.1% 1 triamcinolone acetonide oint 0.025%, 0.1%, 0.5% 1 triamcinolone acetonide oint 0.05% 4 trianex 4 triderm crea 0.1% 1 UCERIS 4

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

ACTHAR 5 PA desmopressin acetate tabs 2 desmopressin acetate soln 4 EGRIFTA INJ 1MG 5 QL (60 EA per 30 days) PA GENOTROPIN 5 PA GENOTROPIN MINIQUICK INJ 0.2MG 4 PA GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

5 PA

HUMATROPE COMBO PACK 5 PA HUMATROPE INJ 12MG, 24MG, 6MG 5 PA INCRELEX 5 PA NORDITROPIN FLEXPRO 5 PA NUTROPIN AQ NUSPIN 10 5 PA NUTROPIN AQ NUSPIN 20 5 PA NUTROPIN AQ NUSPIN 5 5 PA OMNITROPE INJ 10MG/1.5ML, 5MG/1.5ML 5 PA SAIZEN 5 PA SAIZENPREP RECONSTITUTIONKIT 5 PA SEROSTIM INJ 4MG, 5MG, 6MG 5 PA STIMATE SOLN 5 ZORBTIVE 5 PA

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

42


Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

KORLYM 5 QL (120 EA per 30 days) PA Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Anabolic Steroids ANADROL-50 5 PA oxandrolone tabs 2.5mg 2 QL (240 EA per 30 days) PA oxandrolone tabs 10mg 5 QL (60 EA per 30 days) PA

Androgens ANDRODERM PT24 2MG/24HR, 4MG/24HR 3 PA danazol caps 2 methitest 4 PA methyltestosterone caps 5 PA testosterone cypionate inj 100mg/ml, 200mg/ml 2 PA testosterone enanthate inj 2 PA TESTOSTERONE PUMP GEL 1% 3 PA TESTOSTERONE GEL 25MG/2.5GM, 50MG/5GM 3 PA testosterone gel 1.62%, 20.25mg/1.25gm, 40.5mg/2.5gm 3 PA testosterone soln 4 PA

Estrogens altavera 2 alyacen 1/35 2 amabelz 4 amethia 2 QL (91 EA per 91 days) amethia lo 2 QL (91 EA per 91 days) apri 2 aranelle 2 ashlyna 2 QL (91 EA per 91 days) aubra 2 aviane 2 balziva 2 blisovi 24 fe 2 blisovi fe 1.5/30 2 briellyn 2 camrese lo 2 QL (91 EA per 91 days) caziant 2 CLIMARA PRO 4 COMBIPATCH 4 cryselle-28 2 cyclafem 1/35 2 cyclafem 7/7/7 2 cyred 2 DEPO-ESTRADIOL INJ 5MG/ML 4 desogestrel/ethinyl estradiol 2 DIVIGEL GEL 1MG/GM 4 DOTTI 4 drospirenone/ethinyl estradiol 2

43


drospirenone/ethinyl estradiol/levomefolate calcium tabs 3mg; 0.02mg; 0.451mg

2

ELESTRIN 4 emoquette 2 enpresse-28 2 enskyce 2 estarylla 2 estradiol valerate inj 20mg/ml, 40mg/ml 2 estradiol/norethindrone acetate 4 estradiol crea 2 estradiol pttw, ptwk, vaginal tabs 4 estradiol oral tabs 0.5mg 2 estradiol oral tabs 1mg, 2mg 4 ESTRING 4 QL (1 EA per 90 days) ESTROGEL 4 ethynodiol diacetate/ethinyl estradiol 2 falmina 2 fayosim 2 QL (91 EA per 91 days) FEMRING 4 QL (1 EA per 90 days) femynor 2 FYAVOLV 4 gianvi 2 hailey 24 fe 2 introvale 2 QL (91 EA per 91 days) isibloom 2 jasmiel 2 jinteli 4 juleber 2 junel 1.5/30 2 junel 1/20 2 junel fe 1.5/30 2 junel fe 1/20 2 junel fe 24 2 kaitlib fe 2 kariva 2 kelnor 1/35 2 kelnor 1/50 2 kurvelo 2 larin 1.5/30 2 larin 1/20 2 larin fe 1.5/30 2 larin fe 1/20 2 larissia 2 layolis fe 2 leena 2 lessina 2 levonest 2 levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg 2 levonorgestrel and ethinyl estradiol tabs 0; 0 2 QL (91 EA per 91 days)

44


levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg

2

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 2 QL (91 EA per 91 days) levora 0.15/30-28 2 LO LOESTRIN FE 4 lopreeza tabs 1mg; 0.5mg 4 loryna 2 low-ogestrel 2 lutera 2 marlissa 2 melodetta 24 fe 2 MENEST TABS 0.3MG, 0.625MG, 1.25MG 4 mibelas 24 fe 2 microgestin 1.5/30 2 microgestin 1/20 2 microgestin fe 2 microgestin fe 1.5/30 2 mili 2 mimvey 4 necon 0.5/35-28 2 nikki 2 norethindrone & ethinyl estradiol ferrous fumarate 2 norethindrone acetate/ethinyl estradiol/ferrous fumarate chew 2 norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg 2 norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg, 5mcg; 1mg

4

norethindrone/ethinyl estradiol/ferrous fumarate 2 norgestimate/ethinyl estradiol 2 nortrel 0.5/35 (28) 2 nortrel 1/35 2 nortrel 7/7/7 2 ocella 2 ogestrel 2 orsythia 2 pimtrea 2 pirmella 1/35 2 portia-28 2 PREMARIN CREA 4 PREMARIN TABS 0.3MG 3 PREMARIN TABS 0.45MG, 0.625MG, 0.9MG, 1.25MG 4 PREMPHASE 4 PREMPRO 4 previfem 2 reclipsen 2 rivelsa 2 QL (91 EA per 91 days) setlakin 2 QL (91 EA per 91 days) sprintec 28 2 sronyx 2 syeda 2

45


tarina 24 fe 2 tarina fe 1/20 2 tri-estarylla 2 tri-legest fe 2 tri-lo-estarylla 2 tri-lo-sprintec 2 tri-mili 2 tri-previfem 2 tri-sprintec 2 tri-vylibra 2 tri-vylibra lo 2 trivora-28 2 tydemy 2 velivet 2 vienva 2 vyfemla 2 vylibra 2 wymzya fe 2 xulane 4 yuvafem 4 zarah 2 zovia 1/35e 2

Progestins camila 2 CRINONE 4 PA deblitane 2 DEPO-PROVERA INJ 400MG/ML 4 QL (10 ML per 28 days) DEPO-SUBQ PROVERA 104 4 QL (0.65 ML per 90 days) errin 2 incassia 2 lyza 2 medroxyprogesterone acetate tabs 1 medroxyprogesterone acetate inj 2 QL (1 ML per 90 days) megestrol acetate susp, tabs 4 PA nora-be 2 norethindrone acetate tabs 2 norethindrone tabs 2 progesterone caps 2 sharobel 2

Selective Estrogen Receptor Modifying Agents OSPHENA 3 QL (30 EA per 30 days) PA raloxifene hydrochloride 2

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

euthyrox tabs 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 25mcg, 50mcg, 75mcg, 88mcg

4

levo-t 4 levothyroxine sodium tabs 2

46


levoxyl tabs 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 25mcg, 50mcg, 75mcg, 88mcg

4

liothyronine sodium tabs 2 SYNTHROID TABS 4 TIROSINT 4 unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg

4

Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal)

LYSODREN 5 Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary) cabergoline 2 ELIGARD INJ 30MG 4 QL (1 EA per 112 days) PA ELIGARD INJ 45MG 4 QL (1 EA per 168 days) PA ELIGARD INJ 7.5MG 4 QL (1 EA per 28 days) PA ELIGARD INJ 22.5MG 4 QL (1 EA per 84 days) PA FIRMAGON INJ 80MG 4 QL (1 EA per 28 days) PA FIRMAGON INJ 120MG/VIAL 5 QL (4 EA per 365 days) PA leuprolide acetate inj 5 PA LUPANETA PACK KIT 3.75MG; 5MG 5 QL (1 EA per 28 days) PA LUPANETA PACK KIT 11.25MG; 5MG 5 QL (1 EA per 84 days) PA LUPRON DEPOT (1-MONTH) 5 QL (1 EA per 28 days) PA LUPRON DEPOT (3-MONTH) 5 QL (1 EA per 84 days) PA LUPRON DEPOT (4-MONTH) 5 QL (1 EA per 112 days) PA LUPRON DEPOT (6-MONTH) 5 QL (1 EA per 168 days) PA octreotide acetate inj 100mcg/ml, 200mcg/ml, 50mcg/ml 2 PA octreotide acetate inj 1000mcg/ml, 500mcg/ml 5 PA ORILISSA TABS 150MG 5 QL (30 EA per 30 days) PA ORILISSA TABS 200MG 5 QL (60 EA per 30 days) PA SIGNIFOR 5 QL (60 ML per 30 days) PA SOMATULINE DEPOT 5 PA SOMAVERT 5 PA SYNAREL 5 TRELSTAR MIXJECT INJ 22.5MG 5 QL (1 EA per 168 days) PA TRELSTAR MIXJECT INJ 3.75MG 5 QL (1 EA per 28 days) PA TRELSTAR MIXJECT INJ 11.25MG 5 QL (1 EA per 84 days) PA

Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents

methimazole tabs 10mg, 5mg 1 propylthiouracil tabs 2

Immunological Agents Angioedema Agents

BERINERT 5 PA FIRAZYR 5 PA icatibant acetate 5 PA RUCONEST 5 PA

Immune Suppressants ASTAGRAF XL CP24 0.5MG, 1MG 4 B/D

47


ASTAGRAF XL CP24 5MG 5 B/D AZASAN 4 B/D azathioprine tabs 2 B/D BENLYSTA INJ 200MG/ML 5 PA CIMZIA 5 PA cyclosporine modified 4 B/D cyclosporine caps 4 B/D ENBREL 5 PA ENBREL MINI 5 PA ENBREL SURECLICK 5 PA ENVARSUS XR TB24 0.75MG, 1MG 4 B/D ENVARSUS XR TB24 4MG 5 B/D everolimus tabs 0.25mg, 0.5mg, 0.75mg 5 PA gengraf caps 100mg, 25mg 4 B/D gengraf soln 4 B/D HUMIRA 5 PA HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK INJ 0, 80MG/0.8ML

5 PA

HUMIRA PEN 5 PA HUMIRA PEN-CD/UC/HS STARTER 5 PA HUMIRA PEN-PS/UV STARTER 5 PA KINERET 5 PA methotrexate sodium inj 50mg/2ml 2 methotrexate tabs 2 methotrexate inj 50mg/2ml 2 mycophenolate mofetil caps, tabs 4 B/D mycophenolate mofetil susr 5 B/D mycophenolic acid dr 4 B/D ORENCIA CLICKJECT 5 QL (4 ML per 28 days) PA ORENCIA INJ 125MG/ML, 50MG/0.4ML, 87.5MG/0.7ML 5 PA PROGRAF PACK 5 B/D RAPAMUNE SOLN 5 B/D RASUVO INJ 7.5MG/0.15ML 4 QL (0.6 ML per 28 days) PA RASUVO INJ 10MG/0.2ML 4 QL (0.8 ML per 28 days) PA RASUVO INJ 12.5MG/0.25ML 4 QL (1 ML per 28 days) PA RASUVO INJ 15MG/0.3ML 4 QL (1.2 ML per 28 days) PA RASUVO INJ 17.5MG/0.35ML 4 QL (1.4 ML per 28 days) PA RASUVO INJ 20MG/0.4ML 4 QL (1.6 ML per 28 days) PA RASUVO INJ 22.5MG/0.45ML 4 QL (1.8 ML per 28 days) PA RASUVO INJ 25MG/0.5ML 4 QL (2 ML per 28 days) PA RASUVO INJ 30MG/0.6ML 4 QL (2.4 ML per 28 days) PA SANDIMMUNE SOLN 4 B/D SIMPONI 5 PA sirolimus soln 5 B/D sirolimus tabs 0.5mg, 1mg 4 B/D sirolimus tabs 2mg 5 B/D SKYRIZI 5 PA tacrolimus caps 0.5mg, 1mg, 5mg 4 B/D TREXALL 4

48


XATMEP 4 ZORTRESS 5 PA

Immunizing Agents, Passive BIVIGAM INJ 5GM/50ML 5 PA FLEBOGAMMA DIF INJ 5GM/50ML 5 PA gammagard liquid inj 2.5gm/25ml 5 PA GAMMAGARD S/D IGA LESS THAN 1MCG/ML 5 PA GAMMAKED INJ 1GM/10ML 5 PA GAMMAPLEX INJ 10GM/100ML, 10GM/200ML, 20GM/200ML, 5GM/50ML

5 PA

GAMUNEX-C INJ 1GM/10ML 5 PA OCTAGAM INJ 1GM/20ML, 2GM/20ML 5 PA PANZYGA 5 PA PRIVIGEN INJ 20GM/200ML 5 PA

Immunomodulators ACTEMRA ACTPEN 5 PA ACTEMRA INJ 162MG/0.9ML 5 QL (3.6 ML per 28 days) PA ACTIMMUNE 5 PA ARCALYST 5 PA KEVZARA 5 PA leflunomide tabs 2 OLUMIANT 5 PA OTEZLA 5 PA RIDAURA 5 RINVOQ 5 PA XELJANZ 5 PA XELJANZ XR 5 PA

Vaccines ACTHIB INJ 0 3 ADACEL 3 BCG VACCINE 3 BEXSERO 3 BOOSTRIX 3 DAPTACEL INJ 23MCG/0.5ML; 15LF/0.5ML; 5LF/0.5ML 3 diphtheria/tetanus toxoids adsorbed pediatric 2 ENGERIX-B 3 B/D GARDASIL 9 3 HAVRIX INJ 1440ELU/ML, 720ELU/0.5ML 3 HIBERIX 3 IMOVAX RABIES (H.D.C.V.) 3 B/D INFANRIX 3 IPOL INACTIVATED IPV 3 IXIARO 3 KINRIX 3 M-M-R II 3 MENACTRA 3 MENVEO 3 PEDIARIX 3 PEDVAX HIB INJ 7.5MCG/0.5ML 3

49


PROQUAD 3 QUADRACEL 3 RABAVERT 3 B/D RECOMBIVAX HB 3 B/D ROTARIX 3 ROTATEQ SOLN 3 SHINGRIX 3 TDVAX 3 TENIVAC 3 TRUMENBA 3 TWINRIX 3 TYPHIM VI 3 VAQTA 3 VARIVAX 3 VARIZIG 3 PA YF-VAX 3 ZOSTAVAX 3

Inflammatory Bowel Disease Agents Aminosalicylates

APRISO 3 balsalazide disodium 4 DIPENTUM 5 MESALAMINE DR TBEC 800MG 3 mesalamine dr tbec 1.2gm 3 mesalamine er 2 mesalamine enem 4 mesalamine supp 5

Glucocorticoids budesonide er 5 budesonide cpep 3mg 4 hydrocortisone enem 100mg/60ml 2

Sulfonamides sulfasalazine tabs, tbec 2

Metabolic Bone Disease Agents Metabolic Bone Disease Agents

alendronate sodium soln 2 alendronate sodium tabs 10mg, 35mg 1 alendronate sodium tabs 70mg 1 QL (4 EA per 28 days) BINOSTO 4 QL (4 EA per 28 days) calcitonin-salmon soln 2 QL (3.7 ML per 30 days) calcitriol caps 0.25mcg, 0.5mcg 2 calcitriol soln 1mcg/ml 2 cinacalcet hydrochloride tabs 30mg 4 cinacalcet hydrochloride tabs 60mg, 90mg 5 doxercalciferol caps 4 EVENITY 5 QL (2.34 ML per 28 days) PA FORTEO INJ 600MCG/2.4ML 5 PA FOSAMAX PLUS D 4 QL (4 EA per 28 days) ST ibandronate sodium tabs 2 QL (1 EA per 28 days)

50


NATPARA 5 QL (2 EA per 28 days) PA paricalcitol caps 2 PROLIA 4 QL (2 ML per 365 days) risedronate sodium dr 2 QL (4 EA per 28 days) risedronate sodium tabs 150mg 2 QL (1 EA per 28 days) risedronate sodium tabs 30mg, 5mg 4 risedronate sodium tabs 35mg 4 QL (4 EA per 28 days) TYMLOS 5 PA XGEVA 5 PA

Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents

ALCOHOL PREP PADS 3 AMINOSYN II INJ 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 38MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML

4 B/D

AMINOSYN-PF 7% 4 B/D AMINOSYN-PF INJ 46MEQ/L; 698MG/100ML; 1227MG/100ML; 527MG/100ML; 820MG/100ML; 385MG/100ML; 312MG/100ML; 760MG/100ML; 1200MG/100ML; 677MG/100ML; 180MG/100ML; 427MG/100ML; 812MG/100ML; 495MG/100ML; 3.4MEQ/L; 70MG/100ML; 512MG/100ML; 180MG/100ML; 44MG/100ML; 673MG/100ML

4 B/D

B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X 5/16"


BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" 3 QL (200 EA per 30 days) BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 12.7MM


BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 8MM 3 QL (200 EA per 30 days) BD PEN NEEDLE/ORIGINAL/ULTRA-FINE/29G X 12.7MM


CINRYZE 5 PA clinisol sf 15% 4 B/D CURITY GAUZE PADS 2"X2" 3 ENDARI 5 PA FIRDAPSE 5 QL (240 EA per 30 days) PA FREAMINE HBC 6.9% 4 B/D HAEGARDA 5 PA HEPATAMINE 4 B/D intralipid inj 20gm/100ml 2 B/D KEVEYIS 5 QL (120 EA per 30 days) PA levocarnitine soln, tabs 2 MYALEPT 5 PA NEPHRAMINE 4 B/D nutrilipid 2 B/D

51


plenamine 4 B/D PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

4 B/D

PROSOL 4 B/D RUZURGI 5 QL (300 EA per 30 days) PA sodium chloride 0.9% 1 TRAVASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 500MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

4 B/D

TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML

4 B/D

Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs

bimatoprost 2 QL (5 ML per 30 days) COMBIGAN 3 latanoprost soln 1 LUMIGAN 3 QL (2.5 ML per 25 days) VYZULTA 4 QL (5 ML per 25 days)

Ophthalmic Agents, Other atropine sulfate soln 2 bacitracin/polymyxin b 2 CYSTARAN 5 QL (60 ML per 28 days) PA LACRISERT 4 neomycin/bacitracin/polymyxin 2 neomycin/polymyxin/gramicidin 2 OXERVATE 5 QL (56 ML per 28 days) PA polymyxin b sulfate/trimethoprim sulfate 1 proparacaine hcl 1 RESTASIS 3 RHOPRESSA 3 QL (2.5 ML per 25 days) ST XIIDRA 4 QL (60 EA per 30 days)

Ophthalmic Anti-allergy Agents ALOCRIL 4 azelastine hcl ophthalmic soln 0.05% 2 BEPREVE 4 cromolyn sodium soln 4% 1 epinastine hcl 2

52


olopatadine hcl ophthalmic soln 0.1% 2 olopatadine hydrochloride soln 0.2% 2 PAZEO 3

Ophthalmic Anti-inflammatories ALOMIDE 4 ALREX 4 BLEPHAMIDE 4 BLEPHAMIDE S.O.P. 4 bromfenac 2 dexamethasone sodium phosphate soln 2 diclofenac sodium ophthalmic soln 0.1% 1 DUREZOL 3 FLAREX 3 fluorometholone 2 flurbiprofen sodium 1 FML 3 FML FORTE 3 ILEVRO 3 QL (6 ML per 30 days) ketorolac tromethamine ophthalmic soln 0.4%, 0.5% 2 LOTEMAX SM 4 QL (20 GM per 365 days) LOTEMAX OINT 4 QL (14 GM per 365 days) LOTEMAX GEL 4 QL (20 GM per 365 days) loteprednol etabonate 2 MAXIDEX SUSP 3 neomycin/polymyxin/bacitracin/hydrocortisone 2 neomycin/polymyxin/dexamethasone 2 neomycin/polymyxin/hydrocortisone ophthalmic susp 1%; 3.5mg/ml; 10000unit/ml

2

PRED MILD 3 PRED-G 4 PRED-G S.O.P. 4 prednisolone acetate 2 prednisolone sodium phosphate ophthalmic soln 1% 2 PROLENSA 4 QL (12 ML per 365 days) sulfacetamide sodium/prednisolone sodium phosphate 2 TOBRADEX ST 4 TOBRADEX OINT 4 tobramycin/dexamethasone 2 ZYLET 4

Ophthalmic Antiglaucoma Agents acetazolamide er 2 acetazolamide tabs 2 ALPHAGAN P SOLN 0.1% 3 apraclonidine 2 AZOPT 3 betaxolol hcl soln 0.5% 2 BETIMOL 4 BETOPTIC-S 4 brimonidine tartrate 1

53


carteolol hcl 2 dorzolamide hcl 2 dorzolamide hcl/timolol maleate 2 dorzolamide hydrochloride/timolol maleate pf 2 IOPIDINE SOLN 1% 4 levobunolol hcl soln 0.5% 2 methazolamide tabs 4 PHOSPHOLINE IODIDE SOLR 0.125% 4 pilocarpine hcl soln 1%, 2%, 4% 2 ROCKLATAN 3 QL (2.5 ML per 25 days) SIMBRINZA 3 timolol maleate ophthalmic gel forming 2 timolol maleate soln 0.25%, 0.5% 1 timolol maleate soln 0.5% 2

Otic Agents Otic Agents

acetic acid 2 CIPRO HC 4 CIPRODEX 3 flac 4 fluocinolone acetonide oil 0.01% 4 hydrocortisone/acetic acid 2 neomycin/polymyxin/hc 2 neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml; 10000unit/ml

2

Respiratory Tract/Pulmonary Agents Anti-inflammatories, Inhaled Corticosteroids

ASMANEX HFA AERO 50MCG/ACT 4 QL (13 GM per 30 days) ASMANEX HFA AERO 100MCG/ACT, 200MCG/ACT 4 QL (26 GM per 30 days) ASMANEX TWISTHALER 120 METERED DOSES 4 QL (1 EA per 30 days) ASMANEX TWISTHALER 30 METERED DOSES 4 QL (1 EA per 30 days) ASMANEX TWISTHALER 60 METERED DOSES 4 QL (1 EA per 30 days) azelastine hydrochloride/fluticasone propionate 4 QL (23 GM per 30 days) BREO ELLIPTA 3 QL (60 EA per 30 days) budesonide susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml 4 QL (120 ML per 30 days) B/D DULERA AERO 5MCG/ACT; 50MCG/ACT 4 QL (13 GM per 30 days) FLOVENT DISKUS AEPB 250MCG/BLIST 3 QL (240 EA per 30 days) FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST 3 QL (60 EA per 30 days) FLOVENT HFA AERO 44MCG/ACT 3 QL (21.2 GM per 30 days) FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT 3 QL (24 GM per 30 days) flunisolide soln 0.025% 2 QL (50 ML per 30 days) fluticasone propionate susp 50mcg/act 1 mometasone furoate susp 50mcg/act 4 QL (34 GM per 30 days) NUCALA INJ 100MG 5 QL (3 EA per 28 days) PA QVAR REDIHALER 3 QL (21.2 GM per 30 days)

Antihistamines azelastine hcl nasal soln 0.15% 2 QL (60 ML per 30 days) azelastine hydrochloride soln 0.1% 2 QL (60 ML per 30 days) cetirizine hydrochloride soln 1mg/ml 1

54


cyproheptadine hcl syrp 4 PA cyproheptadine hydrochloride tabs 4 PA desloratadine 2 dexchlorpheniramine maleate soln 2 PA DYMISTA 4 QL (23 GM per 30 days) hydroxyzine hcl syrp 4 PA hydroxyzine hcl tabs 50mg 4 PA hydroxyzine hydrochloride tabs 10mg, 25mg 4 PA hydroxyzine pamoate caps 4 PA levocetirizine dihydrochloride soln, tabs 2 olopatadine hcl nasal soln 0.6% 4 QL (30.5 GM per 30 days) SEMPREX-D 4

Antileukotrienes montelukast sodium chew, tabs 1 montelukast sodium pack 4 zafirlukast 2 zileuton er 5 ST ZYFLO 5 ST

Bronchodilators, Anticholinergic ATROVENT HFA 4 QL (25.8 GM per 30 days) COMBIVENT RESPIMAT 3 QL (8 GM per 30 days) INCRUSE ELLIPTA 3 QL (30 EA per 30 days) ipratropium bromide/albuterol sulfate 2 QL (540 ML per 30 days) B/D ipratropium bromide inhalation soln 1 QL (312.5 ML per 30 days) B/D ipratropium bromide nasal soln 2 LONHALA MAGNAIR REFILL KIT 5 QL (60 ML per 30 days) SPIRIVA HANDIHALER 3 QL (30 EA per 30 days) SPIRIVA RESPIMAT AERS 2.5MCG/ACT 3 QL (8 GM per 28 days) SPIRIVA RESPIMAT AERS 1.25MCG/ACT 3 QL (8 GM per 30 days) TUDORZA PRESSAIR 4 QL (60 EA per 30 days) ST YUPELRI 5 QL (90 ML per 30 days) B/D

Bronchodilators, Sympathomimetic albuterol sulfate er 4 albuterol sulfate hfa aers 108mcg/act 2 QL (13.4 GM per 30 days) albuterol sulfate hfa aers 108mcg/act 2 QL (17 GM per 30 days) albuterol sulfate hfa aers 108mcg/act 2 QL (48 GM per 30 days) albuterol sulfate syrp, tabs 4 albuterol sulfate nebu 2.5mg/0.5ml 2 QL (100 EA per 30 days) B/D albuterol sulfate nebu 0.63mg/3ml, 1.25mg/3ml 2 QL (375 ML per 30 days) B/D albuterol sulfate nebu 0.083% 2 QL (525 ML per 30 days) B/D EPINEPHRINE INJ 0.15MG/0.3ML, 0.3MG/0.3ML 3 EPINEPHRINE INJ 0.15MG/0.15ML, 0.3MG/0.3ML 4 ST EPIPEN 2-PAK 3 EPIPEN-JR 2-PAK 3 levalbuterol hydrochloride nebu 1.25mg/3ml 4 QL (270 ML per 30 days) B/D levalbuterol hydrochloride nebu 0.31mg/3ml, 0.63mg/3ml 4 QL (540 ML per 30 days) B/D levalbuterol tartrate hfa 2 QL (30 GM per 30 days) levalbuterol nebu 4 QL (90 EA per 30 days) B/D metaproterenol sulfate syrp 4

55


PERFOROMIST 5 QL (120 ML per 30 days) B/D PROAIR HFA 3 QL (17 GM per 30 days) PROAIR RESPICLICK 3 QL (2 EA per 30 days) PROVENTIL HFA 4 QL (13.4 GM per 30 days) SEREVENT DISKUS 3 QL (60 EA per 30 days) STRIVERDI RESPIMAT 4 QL (4 GM per 30 days) terbutaline sulfate tabs 4 VENTOLIN HFA 3 QL (48 GM per 30 days) XOPENEX CONCENTRATE 4 QL (90 EA per 30 days) B/D XOPENEX HFA 4 QL (30 GM per 30 days) XOPENEX NEBU 1.25MG/3ML 4 QL (270 ML per 30 days) B/D XOPENEX NEBU 0.31MG/3ML, 0.63MG/3ML 4 QL (540 ML per 30 days) B/D

Cystic Fibrosis Agents BETHKIS 5 B/D CAYSTON 5 PA KALYDECO 5 PA ORKAMBI TABS 5 QL (112 EA per 28 days) PA ORKAMBI PACK 5 QL (56 EA per 28 days) PA PULMOZYME 5 PA SYMDEKO 5 QL (56 EA per 28 days) PA TOBI PODHALER 5 QL (224 EA per 56 days) tobramycin 5 B/D TRIKAFTA 5 QL (84 EA per 28 days) PA

Mast Cell Stabilizers cromolyn sodium nebu 20mg/2ml 2 B/D

Phosphodiesterase Inhibitors, Airways Disease DALIRESP 4 PA theophylline er tb24 2 theophylline er tb12 300mg 2 theophylline soln 2

Pulmonary Antihypertensives ADEMPAS 5 QL (90 EA per 30 days) PA alyq 5 QL (60 EA per 30 days) PA AMBRISENTAN 5 QL (30 EA per 30 days) PA bosentan 5 QL (60 EA per 30 days) PA LETAIRIS 5 QL (30 EA per 30 days) PA OPSUMIT 5 QL (30 EA per 30 days) PA ORENITRAM TBCR 0.125MG 4 PA ORENITRAM TBCR 0.25MG, 1MG, 2.5MG, 5MG 5 PA sildenafil citrate tabs 2 QL (90 EA per 30 days) PA sildenafil citrate susr 5 PA tadalafil tabs 20mg 5 QL (60 EA per 30 days) PA UPTRAVI TBPK 5 QL (400 EA per 365 days) PA UPTRAVI TABS 5 QL (60 EA per 30 days) PA VENTAVIS 5 QL (270 ML per 30 days) PA

Pulmonary Fibrosis Agents ESBRIET TABS 267MG, 801MG 5 PA

Respiratory Tract Agents, Other acetylcysteine soln 2 B/D

56


ADVAIR DISKUS 3 QL (60 EA per 30 days) ADVAIR HFA 3 QL (24 GM per 30 days) ANORO ELLIPTA 3 QL (60 EA per 30 days) ARALAST NP INJ 1000MG 5 PA DULERA AERO 5MCG/ACT; 100MCG/ACT, 5MCG/ACT; 200MCG/ACT

4 QL (17.6 GM per 30 days)

DUPIXENT INJ 200MG/1.14ML 5 QL (4.56 ML per 28 days) PA ESBRIET CAPS 267MG 5 PA FASENRA 5 PA FASENRA PEN 5 PA fluticasone propionate/salmeterol diskus 3 QL (60 EA per 30 days) GLASSIA 5 PA NUCALA INJ 100MG/ML 5 QL (3 ML per 28 days) PA OFEV 5 PA PROLASTIN-C INJ 1000MG 5 PA promethazine/phenylephrine 4 PA STIOLTO RESPIMAT 3 QL (24 GM per 30 days) SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT 3 QL (12 GM per 30 days) SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT 3 QL (13.8 GM per 30 days) TRELEGY ELLIPTA 3 QL (60 EA per 30 days) wixela inhub 3 QL (60 EA per 30 days) XOLAIR 5 PA ZEMAIRA 5 PA

Skeletal Muscle Relaxants Skeletal Muscle Relaxants

carisoprodol tabs 4 PA chlorzoxazone tabs 500mg 4 PA cyclobenzaprine hydrochloride tabs 4 PA methocarbamol tabs 4 PA orphenadrine citrate er 4 PA

Sleep Disorder Agents GABA Receptor Modulators

eszopiclone 4 QL (30 EA per 30 days) zaleplon caps 5mg 4 QL (30 EA per 30 days) zaleplon caps 10mg 4 QL (60 EA per 30 days) zolpidem tartrate er 4 QL (30 EA per 30 days) zolpidem tartrate tabs 3 QL (30 EA per 30 days) zolpidem tartrate subl 4 QL (30 EA per 30 days)

Sleep Disorders, Other armodafinil tabs 150mg, 200mg, 250mg 4 QL (30 EA per 30 days) PA armodafinil tabs 50mg 4 QL (60 EA per 30 days) PA BELSOMRA 3 QL (30 EA per 30 days) doxepin hydrochloride tabs 3mg, 6mg 2 QL (30 EA per 30 days) HETLIOZ 5 QL (30 EA per 30 days) PA modafinil 4 QL (30 EA per 30 days) PA ramelteon 2 QL (30 EA per 30 days) SILENOR 4 QL (30 EA per 30 days) WAKIX 5 QL (60 EA per 30 days) PA XYREM 5 QL (540 ML per 30 days) PA

57

Index Drug Name Page #

abacavir 22 abacavir sulfate/lamivudine 22

abacavir sulfate/lamivudine/zidovudine 22 ABELCET 12

ABILIFY MAINTENA 19 ABILIFY MYCITE 19 abiraterone acetate 15

acamprosate calcium dr 3 acarbose 24

acebutolol hcl 29 acebutolol hydrochloride 29

acetaminophen/codeine 2 acetazolamide 52

acetazolamide er 52 acetic acid 53

acetylcysteine 55 acitretin 34

ACTEMRA 48 ACTEMRA ACTPEN 48

ACTHAR 41 ACTHIB 48

ACTIMMUNE 48 acyclovir 23

acyclovir sodium 23 ADACEL 48 adapalene 34

adapalene/benzoyl peroxide 34 adefovir dipivoxil 21

ADEMPAS 55 ADVAIR DISKUS 56

ADVAIR HFA 56 AFINITOR 16

AFINITOR DISPERZ 16 AIMOVIG 14

albendazole 18 albuterol sulfate 54

albuterol sulfate er 54 albuterol sulfate hfa 54

alclometasone dipropionate 39 ALCOHOL PREP PADS 50

ALDACTAZIDE 30 ALECENSA 16

alendronate sodium 49 alfuzosin hcl er 39

ALINIA 18 aliskiren 30

Drug Name Page # allopurinol 13 almotriptan 14 ALOCRIL 51

ALOMIDE 52 alosetron hydrochloride 37

ALPHAGAN P 52 alprazolam 23

alprazolam er 23 alprazolam intensol 23

alprazolam odt 23 ALREX 52

ALTABAX 4 altavera 42

ALUNBRIG 16 alyacen 1/35 42

alyq 55 amabelz 42

amantadine hcl 23 AMBISOME 12

AMBRISENTAN 55 amcinonide 39

amethia 42 amethia lo 42

amikacin sulfate 4 amiloride hcl 30

amiloride/hydrochlorothiazide 30 AMINOSYN II 50

AMINOSYN-PF 50 AMINOSYN-PF 7% 50

amiodarone hcl 28 amiodarone hydrochloride 28

AMITIZA 37 amitriptyline hcl 11

amitriptyline hydrochloride 11 amlodipine besylate 29

amlodipine besylate/atorvastatin calcium 29 amlodipine besylate/benazepril

hydrochloride 29

amlodipine besylate/valsartan 29 amlodipine/olmesartan medoxomil 29

amlodipine/valsartan/hctz 29 amlodipine/valsartan/hydrochlorothiazide 29

ammonium lactate 34 amnesteem 34 amoxapine 11 amoxicillin 6

amoxicillin/clavulanate potassium 6 amoxicillin/clavulanate potassium er 6

amphetamine/dextroamphetamine 32 amphotericin b 12

58

Drug Name Page # ampicillin 6

ampicillin sodium 6 ampicillin-sulbactam 6

AMPYRA 33 ANADROL-50 42

anagrelide hydrochloride 26 anastrozole 16

ANDRODERM 42 ANORO ELLIPTA 56

apexicon e 39 APLENZIN 10

APOKYN 18 apraclonidine 52

aprepitant 12 apri 42

APRISO 49 APTIOM 8

APTIVUS 22 ARALAST NP 56

aranelle 42 ARANESP ALBUMIN FREE 26

ARCALYST 48 aripiprazole 19

aripiprazole odt 19 ARISTADA 19

ARISTADA INITIO 19 armodafinil 56

ascomp/codeine 2 ashlyna 42

ASMANEX HFA 53 ASMANEX TWISTHALER 120

METERED DOSES 53

ASMANEX TWISTHALER 30 METERED DOSES

53

ASMANEX TWISTHALER 60 METERED DOSES

53

aspirin/dipyridamole 27 ASTAGRAF XL 46

atazanavir sulfate 22 atenolol 29

atenolol/chlorthalidone 29 atomoxetine 32

atorvastatin calcium 31 atovaquone 18

atovaquone/proguanil hcl 18 ATRIPLA 21

atropine sulfate 51 ATROVENT HFA 54

AUBAGIO 33 aubra 42

Drug Name Page # augmented betamethasone dipropionate 39

AURYXIA 37 AUSTEDO 32

aviane 42 avita 34

AVONEX 33 AVONEX PEN 33

AVYCAZ 5 AYVAKIT 16

AZACTAM 6 AZASAN 47

azathioprine 47 azelaic acid 34

azelastine hcl 51 azelastine hcl 53

azelastine hydrochloride 53 azelastine hydrochloride/fluticasone

propionate 53

azithromycin 6 AZOPT 52

aztreonam 6 bacitracin 4

bacitracin/polymyxin b 51 baclofen 20

balsalazide disodium 49 BALVERSA 16

balziva 42 BANZEL 9

BAQSIMI TWO PACK 25 BARACLUDE 21

BAXDELA 7 BCG VACCINE 48

BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"

50

B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X 5/16"

50

BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 12.7MM

50

BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 8MM

50

BD PEN NEEDLE/ORIGINAL/ULTRA-FINE/29G X 12.7MM

50

BELSOMRA 56 benazepril hcl 28

benazepril hcl/hydrochlorothiazide 28 benazepril hydrochloride 28

BENLYSTA 47 BENZNIDAZOLE 18

benztropine mesylate 18 BEPREVE 51

59

Drug Name Page # BERINERT 46

beser 39 BESIVANCE 7

betamethasone dipropionate 39 betamethasone valerate 39

BETASERON 33 betaxolol hcl 29 betaxolol hcl 52

bethanechol chloride 39 BETHKIS 55 BETIMOL 52

BETOPTIC-S 52 bexarotene 18 BEXSERO 48

bicalutamide 15 BICILLIN C-R 6 BICILLIN L-A 6

BIDIL 31 BIKTARVY 21 bimatoprost 51 BINOSTO 49

bisoprolol fumarate 29 bisoprolol fumarate/hydrochlorothiazide 29

BIVIGAM 48 BLEPHAMIDE 52

BLEPHAMIDE S.O.P. 52 blisovi 24 fe 42

blisovi fe 1.5/30 42 BOOSTRIX 48

bosentan 55 BOSULIF 16

BRAFTOVI 15 BREO ELLIPTA 53

briellyn 42 BRILINTA 27

brimonidine tartrate 52 BRIVIACT 8 bromfenac 52

bromocriptine mesylate 18 BRUKINSA 16

budesonide 49 budesonide 53

budesonide er 49 bumetanide 30

BUPRENORPHINE 1 buprenorphine hcl 3

buprenorphine hcl/naloxone hcl 3 buprenorphine hydrochloride/naloxone

hydrochloride 3

bupropion hcl 10

Drug Name Page # bupropion hydrochloride 10

bupropion hydrochloride er (sr) 3 bupropion hydrochloride er (sr) 10 bupropion hydrochloride er (xl) 10

buspirone hcl 23 buspirone hydrochloride 23

BUTALBITAL/ACETAMINOPHEN 1 BUTALBITAL/ACETAMINOPHEN 33

butalbital/acetaminophen/caffeine 1 butalbital/acetaminophen/caffeine 33

butalbital/acetaminophen/caffeine/codeine 2 butalbital/aspirin/caffeine 33

butalbital/aspirin/caffeine/codeine 2 butorphanol tartrate 2

BUTRANS 2 BYSTOLIC 29 cabergoline 46

CABLIVI 27 CABOMETYX 16

calcipotriene 34 CALCIPOTRIENE/BETAMETHASONE

DIPROPIONATE 34

calcitonin-salmon 49 CALCITRIOL 34

calcitriol 49 calcium acetate 37 CALQUENCE 17

camila 45 camrese lo 42

candesartan cilexetil 27 candesartan cilexetil/hydrochlorothiazide 27

CAPEX 39 CAPLYTA 19

CAPRELSA 17 captopril 28

captopril/hydrochlorothiazide 28 CARAFATE 38 CARBAGLU 35

carbamazepine 9 carbamazepine er 9

CARBATROL 9 carbidopa 19

carbidopa/levodopa 19 carbidopa/levodopa er 19

carbidopa/levodopa odt 19 carbidopa/levodopa/entacapone 19

CARDIZEM LA 29 CARDURA XL 39

carisoprodol 56 carteolol hcl 53

60

Drug Name Page # cartia xt 29

carvedilol 29 carvedilol phosphate 29 caspofungin acetate 12

CAYSTON 55 caziant 42

cefaclor 5 cefaclor er 5 cefadroxil 5

cefazolin sodium 5 cefdinir 5

cefepime 5 cefixime 5

cefotetan 5 cefoxitin sodium 5

cefpodoxime proxetil 5 cefprozil 5

ceftazidime 5 ceftriaxone sodium 5

cefuroxime axetil 5 cefuroxime sodium 5

celecoxib 1 CELONTIN 8

cephalexin 5 CERDELGA 38

cetirizine hydrochloride 53 cevimeline hydrochloride 33

CHANTIX 4 CHANTIX CONTINUING MONTH PAK 4

CHANTIX STARTING MONTH PAK 4 CHENODAL 37

chlordiazepoxide hcl 23 chlordiazepoxide hydrochloride 23 chlordiazepoxide/amitriptyline 11

chlorhexidine gluconate 33 chloroquine phosphate 18

chlorpromazine hcl 19 chlorthalidone 31 chlorzoxazone 56

CHOLBAM 37 cholestyramine 31

cholestyramine light 31 ciclopirox 12

ciclopirox nail lacquer 12 ciclopirox olamine 12

cilostazol 27 CILOXAN 7 CIMDUO 22 cimetidine 37

cimetidine hcl 37

Drug Name Page # CIMZIA 47

cinacalcet hydrochloride 49 CINRYZE 50 CIPRO HC 53

CIPRODEX 53 ciprofloxacin 7

ciprofloxacin hcl 7 ciprofloxacin hydrochloride 7

ciprofloxacin i.v.-in d5w 7 citalopram hydrobromide 10

claravis 34 clarithromycin 6

clarithromycin er 6 CLENPIQ 38 CLEOCIN 4

CLIMARA PRO 42 clindacin-p 4

clindamycin hcl 4 clindamycin hydrochloride 4 clindamycin palmitate hcl 4

clindamycin phosphate 4 clindamycin phosphate/benzoyl peroxide 34

clindamycin phosphate/dextrose 4 clindamycin phosphate/tretinoin 34

clindamycin/benzoyl peroxide 34 CLINDESSE 4

CLINIMIX 4.25%/DEXTROSE 10% 35 CLINIMIX 4.25%/DEXTROSE 5% 35

CLINIMIX 5%/DEXTROSE 15% 35 CLINIMIX 5%/DEXTROSE 20% 35

CLINIMIX E 2.75%/DEXTROSE 5% 35 CLINIMIX E 4.25%/DEXTROSE 10% 35 CLINIMIX E 4.25%/DEXTROSE 5% 35

CLINIMIX E 5%/DEXTROSE 15% 35 CLINIMIX E 5%/DEXTROSE 20% 35

clinisol sf 15% 50 clobazam 8

clobetasol propionate 39 clobetasol propionate emollient 39

clocortolone pivalate 40 clodan 40

clomipramine hcl 11 clonazepam 8

clonazepam odt 8 clonidine hcl 27

clonidine hcl er 32 clonidine hydrochloride 27

clopidogrel 27 clorazepate dipotassium 23

clotrimazole 12

61

Drug Name Page # clotrimazole/betamethasone dipropionate 12

CLOVIQUE 36 clozapine 20

clozapine odt 20 COARTEM 18

codeine sulfate 2 COLCHICINE 13

colesevelam hydrochloride 31 colestipol hcl 31

colistimethate sodium 4 COMBIGAN 51

COMBIPATCH 42 COMBIVENT RESPIMAT 54

COMETRIQ 17 COMPLERA 21

compro 12 CONDYLOX 34

constulose 38 COPIKTRA 16 CORDRAN 40

CORLANOR 30 cortisone acetate 40 CORTISPORIN 4

COSENTYX 34 COSENTYX SENSOREADY PEN 34

COTELLIC 16 COUMADIN 26

CREON 38 CRESEMBA 12

CRINONE 45 CRIXIVAN 22

cromolyn sodium 37 cromolyn sodium 51 cromolyn sodium 55

cryselle-28 42 CURITY GAUZE PADS 2"X2" 50

CUVPOSA 37 cyclafem 1/35 42

cyclafem 7/7/7 42 cyclobenzaprine hydrochloride 56

CYCLOPHOSPHAMIDE 15 CYCLOSET 24 cyclosporine 47

cyclosporine modified 47 cyproheptadine hcl 54

cyproheptadine hydrochloride 54 cyred 42

CYSTADANE 38 CYSTAGON 38 CYSTARAN 51

Drug Name Page # dalfampridine er 33

DALIRESP 55 DALVANCE 4

danazol 42 dantrolene sodium 20

dapsone 14 dapsone 34

DAPTACEL 48 DAPTOMYCIN 4

DARAPRIM 18 darifenacin hydrobromide er 39

DAURISMO 16 deblitane 45

deferasirox 36 DELSTRIGO 21

demeclocycline hcl 7 DEMSER 30

DENAVIR 23 DEPEN TITRATABS 36 DEPO-ESTRADIOL 42

DEPO-PROVERA 45 DEPO-SUBQ PROVERA 104 45

DESCOVY 22 desipramine hcl 11

desloratadine 54 desmopressin acetate 41

desogestrel/ethinyl estradiol 42 DESONATE 40

desonide 40 desoximetasone 40

DESVENLAFAXINE ER 10 dexamethasone 40

dexamethasone 10-day dose pack 40 dexamethasone 13-day dose pack 40 dexamethasone 6-day dose pack 40

dexamethasone intensol 40 dexamethasone sodium phosphate 52

dexchlorpheniramine maleate 54 DEXILANT 38

dexmethylphenidate hcl 32 dexmethylphenidate hcl er 32

dexmethylphenidate hydrochloride 32 dextroamphetamine sulfate 32

dextroamphetamine sulfate er 32 dextrose 10%/nacl 0.45% 35

dextrose 10% 35 dextrose 10%/nacl 0.2% 35

dextrose 2.5%/nacl 0.45% 35 dextrose 5% 35

dextrose 5%/nacl 0.2% 35

62

Drug Name Page # dextrose 5%/nacl 0.225% 35 dextrose 5%/nacl 0.45% 35 dextrose 5%/nacl 0.9% 35 DIASTAT ACUDIAL 8

DIASTAT PEDIATRIC 8 diazepam 23

diazepam rectal gel 8 diazoxide 25

diclofenac potassium 1 diclofenac sodium 1 diclofenac sodium 34 diclofenac sodium 52

diclofenac sodium dr 1 diclofenac sodium er 1

diclofenac sodium/misoprostol 1 dicloxacillin sodium 6

dicyclomine hcl 37 dicyclomine hydrochloride 37

didanosine 22 DIFICID 6

diflorasone diacetate 40 diflunisal 1

digitek 30 digox 30

digoxin 30 dihydroergotamine mesylate 14

DILANTIN 9 DILANTIN INFATABS 9

DILANTIN-125 9 diltiazem hcl 29

diltiazem hcl er 29 diltiazem hydrochloride er 29

dilt-xr 29 DIPENTUM 49

diphenoxylate/atropine 37 diphtheria/tetanus toxoids adsorbed

pediatric 48

dipyridamole 27 disopyramide phosphate 28

disulfiram 3 DIURIL 31

divalproex sodium 8 divalproex sodium dr 8 divalproex sodium er 8

DIVIGEL 42 dofetilide 28

donepezil hcl 10 donepezil hydrochloride 10

DORYX MPC 7 dorzolamide hcl 53

Drug Name Page # dorzolamide hcl/timolol maleate 53

dorzolamide hydrochloride/timolol maleate pf

53

DOTTI 42 DOVATO 21

doxazosin mesylate 39 doxepin hcl 11

doxepin hydrochloride 11 doxepin hydrochloride 34 doxepin hydrochloride 56

doxercalciferol 49 doxy 100 7

doxycycline 7 doxycycline hyclate 7

doxycycline hyclate dr 7 doxycycline monohydrate 7

doxylamine succinate/pyridoxine hydrochloride

12

DRIZALMA SPRINKLE 10 DRONABINOL 12

drospirenone/ethinyl estradiol 42 drospirenone/ethinyl estradiol/levomefolate

calcium 43

DROXIA 15 DULERA 53 DULERA 56

duloxetine hcl 10 duloxetine hydrochloride 10

DUOBRII 34 DUPIXENT 34 DUPIXENT 56 duramorph 2 DUREZOL 52 dutasteride 39

dutasteride/tamsulosin hydrochloride 39 DUTOPROL 29

DYMISTA 54 DYRENIUM 30

econazole nitrate 12 EDARBI 27

EDARBYCLOR 27 EDURANT 21

efavirenz 21 EGRIFTA 41

ELESTRIN 43 eletriptan hydrobromide 14

ELIGARD 46 ELIQUIS 26

ELIQUIS STARTER PACK 26 ELMIRON 39

63

Drug Name Page # EMCYT 15 EMEND 12

EMFLAZA 40 EMGALITY 14

emoquette 43 EMSAM 10

EMTRIVA 22 enalapril maleate 28

enalapril maleate/hydrochlorothiazide 28 ENBREL 47

ENBREL MINI 47 ENBREL SURECLICK 47

ENDARI 50 endocet 2

ENGERIX-B 48 enoxaparin sodium 26

enpresse-28 43 enskyce 43

entacapone 18 entecavir 21

ENTRESTO 30 enulose 38

ENVARSUS XR 47 EPCLUSA 21

EPIDIOLEX 8 EPIDUO FORTE 34

epinastine hcl 51 EPINEPHRINE 54 EPIPEN 2-PAK 54

EPIPEN-JR 2-PAK 54 epitol 9

EPIVIR HBV 21 eplerenone 30 EQUETRO 24

ERAXIS 12 ergoloid mesylates 10

ergotamine tartrate/caffeine 14 ERIVEDGE 17 ERLEADA 15

erlotinib hydrochloride 17 errin 45

ertapenem 6 ery 6

ERYPED 400 6 ERY-TAB 6

erythrocin lactobionate 7 ERYTHROCIN STEARATE 7

erythromycin 7 erythromycin base 7

erythromycin dr 7

Drug Name Page # erythromycin ethylsuccinate 7

erythromycin/benzoyl peroxide 34 ESBRIET 55 ESBRIET 56

escitalopram oxalate 10 esomeprazole magnesium 38

estarylla 43 estazolam 23 estradiol 43

estradiol valerate 43 estradiol/norethindrone acetate 43

ESTRING 43 ESTROGEL 43 eszopiclone 56

ethacrynic acid 30 ethambutol hcl 14

ethambutol hydrochloride 14 ethosuximide 8

ethynodiol diacetate/ethinyl estradiol 43 etodolac 1

etodolac er 1 EUCRISA 34

euthyrox 45 EVENITY 49 everolimus 17 everolimus 47 EVOTAZ 22

exemestane 16 EXJADE 36

EXTAVIA 33 ezetimibe 31

ezetimibe/simvastatin 31 falmina 43

famciclovir 23 famotidine 37 FANAPT 19

FANAPT TITRATION PACK 19 FARYDAK 16 FASENRA 56

FASENRA PEN 56 fayosim 43

febuxostat 13 felbamate 9

felodipine er 29 FEMRING 43

femynor 43 fenofibrate 31

fenofibrate micronized 31 fenofibric acid dr 31

FENOPROFEN CALCIUM 1

64

Drug Name Page # fentanyl 2

fentanyl citrate 2 fentanyl citrate oral transmucosal 2

FERRIPROX 36 FETZIMA 11

FETZIMA TITRATION PACK 11 FINACEA 34 finasteride 39 FIRAZYR 46

FIRDAPSE 50 FIRMAGON 46

flac 53 FLAREX 52

flavoxate hcl 39 FLEBOGAMMA DIF 48

flecainide acetate 28 FLOVENT DISKUS 53

FLOVENT HFA 53 fluconazole 13

fluconazole in nacl 13 fluconazole in sodium chloride 13

flucytosine 13 fludrocortisone acetate 40

flunisolide 53 fluocinolone acetonide 40 fluocinolone acetonide 53

fluocinolone acetonide scalp 40 fluocinonide 40

fluocinonide emulsified base 40 fluorometholone 52 FLUOROPLEX 15

fluorouracil 15 fluoxetine dr 11

fluoxetine hcl 11 fluoxetine hydrochloride 11 fluphenazine decanoate 19

fluphenazine hcl 19 fluphenazine hydrochloride 19

flurandrenolide 40 flurbiprofen 1

flurbiprofen sodium 52 flutamide 15

fluticasone propionate 40 fluticasone propionate 53

fluticasone propionate/salmeterol diskus 56 fluvastatin 31

fluvastatin sodium er 31 fluvoxamine maleate 11

fluvoxamine maleate er 11 FML 52

Drug Name Page # FML FORTE 52

fondaparinux sodium 26 FORTEO 49

FOSAMAX PLUS D 49 fosamprenavir calcium 22

fosinopril sodium 28 fosinopril sodium/hydrochlorothiazide 28

FRAGMIN 26 FREAMINE HBC 6.9% 50

frovatriptan succinate 14 FULPHILA 27 furosemide 30 FUZEON 22

FYAVOLV 43 FYCOMPA 8 gabapentin 9

GALAFOLD 38 galantamine hydrobromide 10

galantamine hydrobromide er 10 gammagard liquid 48

GAMMAGARD S/D IGA LESS THAN 1MCG/ML

48

GAMMAKED 48 GAMMAPLEX 48 GAMUNEX-C 48 GARDASIL 9 48

gatifloxacin 7 GATTEX 37 gavilyte-c 38 gavilyte-g 38

gavilyte-n/flavor pack 38 GELNIQUE 39 gemfibrozil 31

generlac 38 gengraf 47

GENOTROPIN 41 GENOTROPIN MINIQUICK 41

gentak 4 gentamicin sulfate 4

gentamicin sulfate/0.9% sodium chloride 4 GENVOYA 21

GEODON 19 gianvi 43

GILENYA 33 GILOTRIF 17 GLASSIA 56

glatiramer acetate 33 glatopa 33

GLEOSTINE 15 glimepiride 24

65

Drug Name Page # glipizide 24

glipizide er 24 glipizide/metformin hydrochloride 24

GLOPERBA 13 GLUCAGEN HYPOKIT 25

GLUCAGON EMERGENCY KIT 25 glyburide 24

glyburide micronized 24 glyburide/metformin hydrochloride 24

glycopyrrolate 37 GLYXAMBI 24

GOCOVRI 18 granisetron hcl 12

GRANIX 27 griseofulvin microsize 13

griseofulvin ultramicrosize 13 guanfacine er 32

guanfacine hcl 27 GUANIDINE HCL 14

GVOKE PFS 25 GYNAZOLE-1 13

HAEGARDA 50 hailey 24 fe 43 halcinonide 40

HALOBETASOL PROPIONATE 40 haloperidol 19

haloperidol decanoate 19 haloperidol lactate 19

HARVONI 21 HAVRIX 48

heparin sodium 26 HEPATAMINE 50

HETLIOZ 56 HIBERIX 48

HUMALOG 25 HUMALOG JUNIOR KWIKPEN 25

HUMALOG KWIKPEN 25 HUMALOG MIX 50/50 25

HUMALOG MIX 50/50 KWIKPEN 25 HUMALOG MIX 75/25 25

HUMALOG MIX 75/25 KWIKPEN 25 HUMATROPE 41

HUMATROPE COMBO PACK 41 HUMIRA 47

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK

47

HUMIRA PEN 47 HUMIRA PEN-CD/UC/HS STARTER 47

HUMIRA PEN-PS/UV STARTER 47 HUMULIN 70/30 25

Drug Name Page # HUMULIN 70/30 KWIKPEN 25

HUMULIN N 25 HUMULIN N KWIKPEN 25

HUMULIN R 25 HUMULIN R U-500 (CONCENTRATED) 25

HUMULIN R U-500 KWIKPEN 25 hydralazine hcl 32

hydralazine hydrochloride 32 hydrochlorothiazide 31

hydrocodone bitartrate/acetaminophen 2 hydrocodone/acetaminophen 2

hydrocodone/ibuprofen 2 hydrocortisone 40 hydrocortisone 49

hydrocortisone acetate/pramoxine 34 hydrocortisone butyrate 40 hydrocortisone valerate 40

hydrocortisone/acetic acid 53 hydromorphone hcl 2

hydromorphone hcl er 2 hydromorphone hydrochloride 2

hydromorphone hydrochloride er 2 hydroxychloroquine sulfate 18

hydroxyurea 15 hydroxyzine hcl 54

hydroxyzine hydrochloride 54 hydroxyzine pamoate 54 ibandronate sodium 49

IBRANCE 16 ibu 1

ibuprofen 1 icatibant acetate 46

ICLUSIG 17 IDHIFA 17

ILEVRO 52 ILUMYA 34

imatinib mesylate 17 IMBRUVICA 17

imipenem/cilastatin 6 imipramine hcl 11

imipramine hydrochloride 11 imipramine pamoate 11

imiquimod 34 imiquimod pump 34

IMOVAX RABIES (H.D.C.V.) 48 INBRIJA 18

incassia 45 INCRELEX 41

INCRUSE ELLIPTA 54 indapamide 31

66

Drug Name Page # indomethacin 1

indomethacin er 1 INFANRIX 48 INGREZZA 33

INLYTA 17 INNOPRAN XL 29

INREBIC 16 INSULIN ASPART 25

INSULIN ASPART FLEXPEN 25 INSULIN ASPART PENFILL 25

INSULIN ASPART PROTAMINE/INSULIN ASPART

25

INSULIN ASPART PROTAMINE/INSULIN ASPART

FLEXPEN

25

INSULIN LISPRO 25 INSULIN LISPRO JUNIOR KWIKPEN 25

INSULIN LISPRO KWIKPEN 25 INSULIN LISPRO

PROTAMINE/INSULIN LISPRO KWIKPEN

25

INTELENCE 21 intralipid 50

INTRON A 21 introvale 43

INVEGA SUSTENNA 19 INVEGA TRINZA 20

INVIRASE 22 INVOKAMET 24

INVOKAMET XR 24 INVOKANA 24

IOPIDINE 53 IPOL INACTIVATED IPV 48

ipratropium bromide 54 ipratropium bromide/albuterol sulfate 54

irbesartan 27 irbesartan/hydrochlorothiazide 28

IRESSA 17 ISENTRESS 21 ISENTRESS 22

ISENTRESS HD 22 isibloom 43

ISOLYTE-P/DEXTROSE 5% 35 ISOLYTE-S 35

isoniazid 14 ISORDIL TITRADOSE 31

isosorbide dinitrate 31 isosorbide mononitrate 31

isosorbide mononitrate er 31 isotonic gentamicin 4

Drug Name Page # isotretinoin 34

isradipine 29 itraconazole 13

ivermectin 18 ivermectin 34

IXIARO 48 JADENU 36

JADENU SPRINKLE 36 JAKAFI 17 jantoven 26

JANUMET 24 JANUMET XR 24

JANUVIA 24 JARDIANCE 24

jasmiel 43 JENTADUETO 24

JENTADUETO XR 24 jinteli 43

JUBLIA 13 juleber 43

JULUCA 21 junel 1.5/30 43

junel 1/20 43 junel fe 1.5/30 43

junel fe 1/20 43 junel fe 24 43

JUXTAPID 31 JYNARQUE 36

kaitlib fe 43 KALETRA 22

KALYDECO 55 kariva 43

kcl 0.075%/d5w/nacl 0.45% 35 kcl 0.15%/d5w/nacl 0.2% 35

kcl 0.15%/d5w/nacl 0.45% 35 kcl 0.15%/d5w/nacl 0.9% 35 kcl 0.3%/d5w/nacl 0.45% 35 kcl 0.3%/d5w/nacl 0.9% 35

kelnor 1/35 43 kelnor 1/50 43

ketoconazole 13 ketodan 13

ketoprofen 1 ketoprofen er 1

ketorolac tromethamine 1 ketorolac tromethamine 52

KEVEYIS 50 KEVZARA 48 KINERET 47

KINRIX 48

67

Drug Name Page # kionex 36

KISQALI 16 KISQALI FEMARA 200 DOSE 15 KISQALI FEMARA 400 DOSE 15 KISQALI FEMARA 600 DOSE 15

klor-con 35 klor-con 10 36 klor-con 8 36

klor-con m10 36 klor-con m15 36 klor-con m20 36

KOMBIGLYZE XR 24 KORLYM 42

KOSELUGO 17 KRISTALOSE 38

kurvelo 43 KUVAN 38

labetalol hydrochloride 29 LACRISERT 51

lactulose 38 lamivudine 21 lamivudine 22

lamivudine/zidovudine 22 lamotrigine 9

lamotrigine er 9 lamotrigine odt 9

lamotrigine starter kit/blue 9 lamotrigine starter kit/green 9

lamotrigine starter kit/orange 9 LANOXIN 30

lansoprazole 38 lansoprazole/amoxicillin/clarithromycin 37

lanthanum carbonate 37 LANTUS 25

LANTUS SOLOSTAR 25 larin 1.5/30 43

larin 1/20 43 larin fe 1.5/30 43

larin fe 1/20 43 larissia 43

latanoprost 51 LATUDA 20 layolis fe 43

LEDIPASVIR/SOFOSBUVIR 21 leena 43

leflunomide 48 LENVIMA 10 MG DAILY DOSE 17 LENVIMA 12MG DAILY DOSE 17 LENVIMA 14 MG DAILY DOSE 17 LENVIMA 18 MG DAILY DOSE 17

Drug Name Page # LENVIMA 20 MG DAILY DOSE 17 LENVIMA 24 MG DAILY DOSE 17 LENVIMA 4 MG DAILY DOSE 17 LENVIMA 8 MG DAILY DOSE 17

lessina 43 LETAIRIS 55

letrozole 16 leucovorin calcium 16

LEUKERAN 15 LEUKINE 27

leuprolide acetate 46 levalbuterol 54

levalbuterol hydrochloride 54 levalbuterol tartrate hfa 54

LEVEMIR 25 LEVEMIR FLEXTOUCH 25

levetiracetam 8 levetiracetam er 8 levobunolol hcl 53

levocarnitine 50 levocetirizine dihydrochloride 54

levofloxacin 7 levofloxacin in d5w 7

levonest 43 levonorgestrel and ethinyl estradiol 43

levonorgestrel/ethinyl estradiol 44 levora 0.15/30-28 44

LEVORPHANOL TARTRATE 2 levo-t 45

levothyroxine sodium 45 levoxyl 46

LEXETTE 40 LEXIVA 22 lidocaine 3

lidocaine hcl 3 lidocaine hcl jelly 3 lidocaine viscous 33

lidocaine/prilocaine 3 lindane 18

linezolid 4 LINZESS 37

liothyronine sodium 46 lisinopril 28

lisinopril/hydrochlorothiazide 28 lithium 24

lithium carbonate 24 lithium carbonate er 24

LIVALO 31 LO LOESTRIN FE 44

LONHALA MAGNAIR REFILL KIT 54

68

Drug Name Page # LONSURF 15

loperamide hcl 37 lopinavir/ritonavir 22

lopreeza 44 lorazepam 23

LORBRENA 16 lorcet 2

lorcet hd 2 lorcet plus 2

loryna 44 losartan potassium 28

losartan potassium/hydrochlorothiazide 28 LOTEMAX 52

LOTEMAX SM 52 loteprednol etabonate 52

lovastatin 31 low-ogestrel 44

loxapine 19 loxapine succinate 19

LUCEMYRA 3 LUMIGAN 51

LUPANETA PACK 46 LUPRON DEPOT (1-MONTH) 46 LUPRON DEPOT (3-MONTH) 46 LUPRON DEPOT (4-MONTH) 46 LUPRON DEPOT (6-MONTH) 46

lutera 44 LYNPARZA 16

LYRICA 8 LYSODREN 46

lyza 45 mafenide acetate 5

magnesium sulfate 36 malathion 18

maprotiline hcl 11 marlissa 44

MARPLAN 10 MATULANE 15

matzim la 29 MAVENCLAD 33

MAVYRET 21 MAXIDEX 52 MAYZENT 33

meclizine hcl 12 meclofenamate sodium 1

MEDROL 40 medroxyprogesterone acetate 45

mefenamic acid 1 mefloquine hcl 18

megestrol acetate 45

Drug Name Page # MEKINIST 17 MEKTOVI 16

melodetta 24 fe 44 meloxicam 1

memantine hcl titration pak 10 memantine hydrochloride 10

memantine hydrochloride er 10 MENACTRA 48

MENEST 44 MENTAX 13 MENVEO 48

meprobamate 23 mercaptopurine 15

meropenem 6 mesalamine 49

MESALAMINE DR 49 mesalamine er 49

MESNEX 18 MESTINON 14

metaproterenol sulfate 54 metformin hydrochloride 24

metformin hydrochloride er 24 methadone hcl 2 methazolamide 53

methenamine hippurate 5 methimazole 46

methitest 42 methocarbamol 56

methotrexate 47 methotrexate sodium 47

methoxsalen 34 methscopolamine bromide 37

methyldopa 27 methyldopa/hydrochlorothiazide 27

methylphenidate hydrochloride 32 methylphenidate hydrochloride cd 32 methylphenidate hydrochloride er 32

methylphenidate hydrochloride er (la) 32 methylprednisolone 41

methylprednisolone dose pack 40 methyltestosterone 42

metoclopramide hcl 37 metoclopramide hydrochloride 37

metoclopramide odt 37 metolazone 31

metoprolol succinate er 29 metoprolol tartrate 29

metoprolol/hydrochlorothiazide 29 metronidazole 5 metronidazole 34

69

Drug Name Page # metronidazole in nacl 0.79% 5

metronidazole vaginal 5 mexiletine hcl 28 mibelas 24 fe 44 miconazole 3 13

microgestin 1.5/30 44 microgestin 1/20 44

microgestin fe 44 microgestin fe 1.5/30 44

midodrine hcl 27 MIGERGOT 14

miglitol 24 miglustat 38

mili 44 MILLIPRED 41

mimvey 44 minitran 31

minocycline hcl 7 minocycline hydrochloride 8

MINOCYCLINE HYDROCHLORIDE ER 7 minoxidil 32

mirtazapine 10 mirtazapine odt 10

MIRVASO 34 misoprostol 38

M-M-R II 48 modafinil 56

moexipril hcl 28 molindone hydrochloride 19

mometasone furoate 41 mometasone furoate 53

mondoxyne nl 8 montelukast sodium 54

MONUROL 5 morphine sulfate 2

morphine sulfate er 2 moxifloxacin hydrochloride/sodium

hydrochloride 7

moxifloxacin hydrochloride 7 MULPLETA 27

MULTAQ 28 mupirocin 5

MYALEPT 50 MYCAMINE 13

mycophenolate mofetil 47 mycophenolic acid dr 47

myorisan 34 MYRBETRIQ 39

nabumetone 1 nadolol 29

Drug Name Page # nafcillin sodium 6

NAFTIFINE HCL 13 naftifine hydrochloride 13

NAFTIN 13 naloxone hcl 3

naloxone hydrochloride 3 naltrexone hcl 3

naproxen 1 naproxen dr 1

naproxen sodium 1 naproxen sodium cr 1

naratriptan hcl 14 NARCAN 3

NATACYN 13 nateglinide 24 NATPARA 50

NAYZILAM 8 NEBUPENT 18

necon 0.5/35-28 44 nefazodone hcl 11

nefazodone hydrochloride 11 neomycin sulfate 4

neomycin/bacitracin/polymyxin 51 neomycin/polymyxin/bacitracin/hydrocortis

one 52

neomycin/polymyxin/dexamethasone 52 neomycin/polymyxin/gramicidin 51

neomycin/polymyxin/hc 53 neomycin/polymyxin/hydrocortisone 52 neomycin/polymyxin/hydrocortisone 53

NEPHRAMINE 50 NERLYNX 16

neuac 34 NEULASTA 27 NEUPOGEN 27

NEUPRO 18 nevirapine 21

nevirapine er 21 NEXAVAR 17

niacin er 31 niacor 31

nicardipine hcl 29 NICOTROL INHALER 4

NICOTROL NS 4 nifedipine 29

nifedipine er 29 nikki 44

nilutamide 15 nimodipine 29 NINLARO 16

70

Drug Name Page # nisoldipine er 30 NITRO-BID 31

NITRO-DUR 31 nitrofurantoin 5

nitrofurantoin macrocrystals 5 nitrofurantoin monohydrate/macrocrystals 5

nitroglycerin 32 nitroglycerin lingual 32

nitroglycerin transdermal 32 NITYR 38

NIVESTYM 27 nizatidine 37

nolix 41 nora-be 45

NORDITROPIN FLEXPRO 41 norethindrone 45

norethindrone & ethinyl estradiol ferrous fumarate

44

norethindrone acetate 45 norethindrone acetate/ethinyl estradiol 44

norethindrone acetate/ethinyl estradiol/ferrous fumarate

44

norethindrone/ethinyl estradiol/ferrous fumarate

44

norgestimate/ethinyl estradiol 44 NORITATE 34

NORMOSOL-M IN D5W 36 NORMOSOL-R 36

NORMOSOL-R IN D5W 36 NORPACE CR 28

NORTHERA 30 nortrel 0.5/35 (28) 44

nortrel 1/35 44 nortrel 7/7/7 44

nortriptyline hcl 11 nortriptyline hydrochloride 11

NORVIR 22 NOVOLIN 70/30 25

NOVOLIN 70/30 FLEXPEN 25 NOVOLIN N 25

NOVOLIN N FLEXPEN 25 NOVOLIN R 26

NOVOLIN R FLEXPEN 26 NOVOLOG 26

NOVOLOG FLEXPEN 26 NOVOLOG MIX 70/30 26

NOVOLOG MIX 70/30 PREFILLED FLEXPEN

26

NOVOLOG PENFILL 26 NOXAFIL 13

Drug Name Page # NUBEQA 15 NUCALA 53 NUCALA 56

NUEDEXTA 33 NUPLAZID 20

NURTEC 14 nutrilipid 50

NUTROPIN AQ NUSPIN 10 41 NUTROPIN AQ NUSPIN 20 41 NUTROPIN AQ NUSPIN 5 41

NUZYRA 8 nyamyc 13

NYMALIZE 30 nystatin 13

nystatin/triamcinolone 13 nystop 13

OCALIVA 37 ocella 44

OCTAGAM 48 octreotide acetate 46

ODEFSEY 21 ODOMZO 17

OFEV 56 ofloxacin 7 ogestrel 44

olanzapine 20 olanzapine odt 20

olanzapine/fluoxetine 11 olmesartan medoxomil 28

olmesartan medoxomil/hydrochlorothiazide 28 olopatadine hcl 52 olopatadine hcl 54

olopatadine hydrochloride 52 OLUMIANT 48

omega-3-acid ethyl esters 31 omeprazole 38

omeprazole/sodium bicarbonate 38 OMNITROPE 41

ondansetron hcl 12 ondansetron hydrochloride 12

ondansetron odt 12 ONGLYZA 24 OPSUMIT 55 ORENCIA 47

ORENCIA CLICKJECT 47 ORENITRAM 55

ORFADIN 38 ORILISSA 46 ORKAMBI 55

orphenadrine citrate er 56

71

Drug Name Page # orsythia 44

oseltamivir phosphate 23 OSPHENA 45

OTEZLA 48 OXACILLIN SODIUM 6

oxandrolone 42 oxaprozin 1 oxazepam 24

OXBRYTA 27 oxcarbazepine 9 OXERVATE 51

oxiconazole nitrate 13 OXISTAT 13

oxybutynin chloride 39 oxybutynin chloride er 39

oxycodone hcl 3 oxycodone hydrochloride 3

oxycodone/acetaminophen 3 oxycodone/aspirin 3

oxycodone/ibuprofen 3 oxymorphone hydrochloride 3

oxymorphone hydrochloride er 2 oxymorphone hydrochlorideer 2

OZEMPIC 24 pacerone 28

paliperidone er 20 PANDEL 41

PANRETIN 18 pantoprazole sodium 38

PANZYGA 48 paricalcitol 50

paromomycin sulfate 4 paroxetine 11

paroxetine hcl 11 paroxetine hcl er 11

paroxetine hydrochloride 11 PASER 14 PAXIL 11

PAZEO 52 PEDIARIX 48

PEDVAX HIB 48 peg-3350/electrolytes 38

peg-3350/nacl/na bicarbonate/kcl 38 PEGANONE 9

PEGASYS 21 PEGASYS PROCLICK 21

PEMAZYRE 16 penicillamine 36

penicillin g potassium 6

Drug Name Page # PENICILLIN G POTASSIUM IN ISO-

OSMOTIC DEXTROSE 6

penicillin g sodium 6 penicillin v potassium 6

PENNSAID 34 PENTAM 300 18

pentamidine isethionate 18 pentazocine/naloxone hcl 3

pentoxifylline er 30 PERFOROMIST 55

perindopril erbumine 28 permethrin 18

perphenazine 19 perphenazine/amitriptyline 12

PERSERIS 20 PEXEVA 11 phenadoz 12

phenelzine sulfate 10 phenobarbital 9

phenoxybenzamine hydrochloride 27 PHENYTEK 9

phenytoin 9 phenytoin sodium extended 9 PHOSPHOLINE IODIDE 53

PICATO 34 PIFELTRO 22

pilocarpine hcl 53 pilocarpine hydrochloride 33

pimecrolimus 34 pimozide 19 pimtrea 44 pindolol 29

pioglitazone hcl 24 pioglitazone hcl/metformin hcl 24

pioglitazone hcl-glimepiride 24 pioglitazone hydrochloride 24

piperacillin/tazobactam 6 PIQRAY 200MG DAILY DOSE 16 PIQRAY 250MG DAILY DOSE 16 PIQRAY 300MG DAILY DOSE 16

pirmella 1/35 44 piroxicam 1

PLASMA-LYTE A 36 PLASMA-LYTE-148 36

PLEGRIDY 33 PLEGRIDY STARTER PACK 33

plenamine 51 PLIAGLIS 3

podofilox 34 polymyxin b sulfate 5

72

Drug Name Page # polymyxin b sulfate/trimethoprim sulfate 51

POMALYST 15 portia-28 44

posaconazole dr 13 potassium chloride 36

potassium chloride cr 36 potassium chloride er 36

potassium chloride/dextrose 36 potassium chloride/dextrose/lactated

ringers 36

potassium chloride/dextrose/sodium chloride

36

potassium chloride/sodium chloride 36 potassium citrate er 36

PRADAXA 26 pramipexole dihydrochloride 19

pramipexole dihydrochloride er 19 prasugrel 27

pravastatin sodium 31 praziquantel 18 prazosin hcl 27

prazosin hydrochloride 27 PRED MILD 52

PRED-G 52 PRED-G S.O.P. 52

prednicarbate 41 prednisolone 41

prednisolone acetate 52 prednisolone sodium phosphate 41 prednisolone sodium phosphate 52

prednisone 41 prednisone intensol 41

pregabalin 8 PREMARIN 44 PREMASOL 51

PREMPHASE 44 PREMPRO 44

prevalite 31 previfem 44

PREVYMIS 20 PREZCOBIX 22

PREZISTA 22 PRIFTIN 14

primaquine phosphate 18 primidone 9

PRIMLEV 3 PRIVIGEN 48

PROAIR HFA 55 PROAIR RESPICLICK 55

probenecid 13

Drug Name Page # probenecid/colchicine 13

PROCALAMINE 36 prochlorperazine 12

prochlorperazine maleate 12 procto-med hc 4

procto-pak 4 proctosol hc 4

proctozone-hc 4 PROCYSBI 38

progesterone 45 PROGLYCEM 25

PROGRAF 47 PROLASTIN-C 56

PROLATE 3 PROLENSA 52

PROLIA 50 PROMACTA 27

promethazine hcl 12 promethazine hcl plain 12

promethazine hydrochloride 12 promethazine/phenylephrine 56

promethegan 12 propafenone hcl 28

propafenone hydrochloride er 28 propantheline bromide 37

proparacaine hcl 51 propranolol hcl 29

propranolol hcl er 29 propranolol hydrochloride 29

propranolol hydrochloride er 29 propranolol/hydrochlorothiazide 29

propylthiouracil 46 PROQUAD 49

PROSOL 51 protriptyline hcl 12

PROVENTIL HFA 55 PULMOZYME 55

PURIXAN 15 pyrazinamide 14

pyridostigmine bromide 14 pyridostigmine bromide er 14

PYRIMETHAMINE 18 QUADRACEL 49

quetiapine fumarate 20 quetiapine fumarate er 20

quinapril hcl 28 quinapril hydrochloride 28

quinapril/hydrochlorothiazide 28 quinidine gluconate cr 28

quinidine sulfate 28

73

Drug Name Page # quinine sulfate 18

QVAR REDIHALER 53 RABAVERT 49

rabeprazole sodium 38 raloxifene hydrochloride 45

ramelteon 56 ramipril 28

ranolazine er 30 RAPAMUNE 47

rasagiline mesylate 19 RASUVO 47 RAVICTI 38

RAYALDEE 37 RAYOS 41

REBIF 33 REBIF REBIDOSE 33

REBIF REBIDOSE TITRATION PACK 33 REBIF TITRATION PACK 33

reclipsen 44 RECOMBIVAX HB 49

RECTIV 35 REGRANEX 35

RELENZA DISKHALER 23 relexxii 32

RELISTOR 37 repaglinide 24 REPATHA 30

REPATHA PUSHTRONEX SYSTEM 30 REPATHA SURECLICK 30

RESTASIS 51 RETACRIT 27 REVLIMID 15

REXULTI 20 REYATAZ 22 REYVOW 13

RHOPRESSA 51 ribavirin 21

RIDAURA 48 rifabutin 14 rifampin 15

RIFATER 15 riluzole 33

rimantadine hydrochloride 23 RINVOQ 48 RIOMET 24

RIOMET ER 24 risedronate sodium 50

risedronate sodium dr 50 RISPERDAL CONSTA 20

risperidone 20

Drug Name Page # risperidone odt 20

ritonavir 23 rivastigmine tartrate 10

rivastigmine transdermal system 10 rivelsa 44

rizatriptan benzoate 14 rizatriptan benzoate odt 14

ROCKLATAN 53 ropinirole er 19

ropinirole hcl 19 ropinirole hydrochloride 19

rosuvastatin calcium 31 ROTARIX 49 ROTATEQ 49

roweepra 8 roweepra xr 8

ROZLYTREK 16 RUBRACA 17

RUCONEST 46 RUZURGI 51

RYBELSUS 24 RYDAPT 16 RYTARY 19

SABRIL 9 SAIZEN 41

SAIZENPREP RECONSTITUTIONKIT 41 SANCUSO 12

SANDIMMUNE 47 SANTYL 35 SAPHRIS 20

SAVELLA 33 SAVELLA TITRATION PACK 33

scopolamine 12 SECUADO 20

selegiline hcl 19 selenium sulfide 35

SELZENTRY 22 SEMPREX-D 54

SEREVENT DISKUS 55 SEROSTIM 41

sertraline hcl 11 sertraline hydrochloride 11

setlakin 44 sevelamer carbonate 37

sevelamer hydrochloride 37 SEYSARA 8

sharobel 45 SHINGRIX 49 SIGNIFOR 46

SIKLOS 15

74

Drug Name Page # sildenafil citrate 55

SILENOR 56 SILIQ 35

silodosin 39 silver sulfadiazine 5

SIMBRINZA 53 SIMPONI 47

simvastatin 31 sirolimus 47

SIRTURO 15 SIVEXTRO 5

SKLICE 18 SKYRIZI 47

sodium chloride 36 sodium chloride 0.9% 51

sodium fluoride 36 sodium phenylbutyrate 38

sodium polystyrene sulfonate 36 SOFOSBUVIR/VELPATASVIR 21

solifenacin succinate 39 SOLTAMOX 15

SOMATULINE DEPOT 46 SOMAVERT 46

sorine 28 sotalol hcl 28

sotalol hcl (af) 28 sotalol hydrochloride (af) 28

SPIRIVA HANDIHALER 54 SPIRIVA RESPIMAT 54

spironolactone 30 spironolactone/hydrochlorothiazide 30

sprintec 28 44 SPRITAM 8

SPRIX 1 SPRYCEL 17

sps 36 sronyx 44

ssd 5 stavudine 22

STELARA 35 STIMATE 41

STIOLTO RESPIMAT 56 STIVARGA 17

streptomycin sulfate 4 STRIBILD 21

STRIVERDI RESPIMAT 55 SUBOXONE 3

SUCRAID 38 SUCRALFATE 38

sulfacetamide sodium 7

Drug Name Page # sulfacetamide sodium/prednisolone sodium

phosphate 52

sulfadiazine 7 sulfamethoxazole/trimethoprim 7

sulfamethoxazole/trimethoprim ds 7 SULFAMYLON 5

sulfasalazine 49 sulindac 1

SUMATRIPTAN 14 sumatriptan succinate 14

SUMATRIPTAN SUCCINATE REFILL 14 sumatriptan/naproxen sodium 14

SUPRAX 6 SUPREP BOWEL PREP KIT 38

SUSTIVA 22 SUTENT 17

syeda 44 SYLATRON 16

SYMBICORT 56 SYMDEKO 55

SYMFI 22 SYMFI LO 22

SYMLINPEN 120 25 SYMLINPEN 60 25

SYMPAZAN 9 SYMTUZA 23 SYNALAR 41 SYNAREL 46 SYNDROS 12

SYNJARDY 25 SYNJARDY XR 25

SYNRIBO 16 SYNTHROID 46

TABLOID 15 TACLONEX 35

tacrolimus 35 tacrolimus 47

tadalafil 39 tadalafil 55

TAFINLAR 17 TAGRISSO 17

TAKHZYRO 30 TALTZ 35

TALZENNA 16 tamoxifen citrate 15

tamsulosin hydrochloride 39 TARGRETIN 18

tarina 24 fe 45 tarina fe 1/20 45

TASIGNA 17

75

Drug Name Page # TAVALISSE 27

tazarotene 35 tazicef 6

TAZORAC 35 taztia xt 30

TAZVERIK 16 TDVAX 49

TECFIDERA 33 TECFIDERA STARTER PACK 33

TEFLARO 6 TEGRETOL 9

TEGRETOL-XR 9 TEGSEDI 38

telmisartan 28 telmisartan/amlodipine 30

telmisartan/hydrochlorothiazide 28 temazepam 24

tencon 1 TENIVAC 49

tenofovir disoproxil fumarate 22 terazosin hcl 39

terazosin hydrochloride 39 terbinafine hcl 13

terbutaline sulfate 55 terconazole 13

TESTOSTERONE 42 testosterone cypionate 42 testosterone enanthate 42

TESTOSTERONE PUMP 42 tetrabenazine 33

tetracycline hydrochloride 8 THALOMID 15 theophylline 55

theophylline er 55 THIOLA EC 39

thioridazine hcl 19 thiothixene 19

tiadylt er 30 tiagabine hydrochloride 9

TIBSOVO 17 tigecycline 5

TIGLUTIK 33 timolol maleate 14 timolol maleate 53

timolol maleate ophthalmic gel forming 53 tinidazole 18

TIROSINT 46 TIVICAY 21

tizanidine hcl 20 tizanidine hydrochloride 20

Drug Name Page # TOBI PODHALER 55

TOBRADEX 52 TOBRADEX ST 52

tobramycin 55 tobramycin sulfate 4

tobramycin/dexamethasone 52 TOBREX 4 tolcapone 18

tolmetin sodium 1 TOLSURA 13

tolterodine tartrate 39 tolterodine tartrate er 39

topiramate 9 topiramate er 9

toremifene citrate 15 torsemide 30

TOSYMRA 14 TOUJEO MAX SOLOSTAR 26

TOUJEO SOLOSTAR 26 tovet 41

tpn electrolytes 36 TRADJENTA 25

tramadol hcl 3 tramadol hcl er 2

tramadol hydrochloride 3 tramadol hydrochloride/acetaminophen 3

trandolapril 28 trandolapril/verapamil hcl er 28

tranexamic acid 27 tranylcypromine sulfate 10

TRAVASOL 51 trazodone hydrochloride 11

TRECATOR 15 TRELEGY ELLIPTA 56

TRELSTAR MIXJECT 46 TREMFYA 35

TRESIBA 26 TRESIBA FLEXTOUCH 26

tretinoin 18 tretinoin 35

tretinoin microsphere 35 TREXALL 47

triamcinolone acetonide 4 triamcinolone acetonide 41

triamcinolone acetonide dental paste 33 triamterene 31

triamterene/hydrochlorothiazide 31 trianex 41 triderm 41

trientine hydrochloride 36

76

Drug Name Page # tri-estarylla 45

trifluoperazine hcl 19 trifluridine 23

trihexyphenidyl hcl 18 trihexyphenidyl hydrochloride 18

TRIJARDY XR 25 TRIKAFTA 55 tri-legest fe 45

tri-lo-estarylla 45 tri-lo-sprintec 45

trilyte 38 trimethobenzamide hydrochloride 12

trimethoprim 5 tri-mili 45

trimipramine maleate 12 TRINTELLIX 11

tri-previfem 45 tri-sprintec 45 TRIUMEQ 21 trivora-28 45 tri-vylibra 45

tri-vylibra lo 45 TROPHAMINE 51

trospium chloride 39 trospium chloride er 39

TRULICITY 25 TRUMENBA 49

TRUVADA 22 TUDORZA PRESSAIR 54

TURALIO 17 TWINRIX 49 TYBOST 22

tydemy 45 TYKERB 17 TYMLOS 50

TYPHIM VI 49 UBRELVY 14 UBRELVY 14

UCERIS 41 UDENYCA 27

ULORIC 13 unithroid 46

UPTRAVI 55 ursodiol 37

VABOMERE 6 valacyclovir hcl 23

valacyclovir hydrochloride 23 VALCHLOR 15

valganciclovir 21 valganciclovir hydrochlorde 21

Drug Name Page # valproic acid 9

valsartan 28 valsartan/hydrochlorothiazide 28

VALTOCO 9 vanatol lq 33

vancomycin hcl 5 VANCOMYCIN HYDROCHLORIDE 5

vandazole 5 VAQTA 49

VARIVAX 49 VARIZIG 49

VASCEPA 31 velivet 45

VELPHORO 37 veltassa 36

VEMLIDY 21 VENCLEXTA 17

VENCLEXTA STARTING PACK 17 venlafaxine hcl 11

venlafaxine hcl er 11 venlafaxine hydrochloride er 11

VENTAVIS 55 VENTOLIN HFA 55

verapamil hcl 30 verapamil hcl er 30 verapamil hcl sr 30

verapamil hydrochloride 30 verapamil hydrochloride er 30

VEREGEN 35 VERSACLOZ 20

VERZENIO 16 VIBRAMYCIN 8

VICTOZA 25 vienva 45

vigabatrin 9 vigadrone 9 VIIBRYD 11

VIIBRYD STARTER PACK 11 VIMPAT 9

VIRACEPT 23 VIREAD 22

VITRAKVI 16 VIVITROL 3 VIZIMPRO 17

voriconazole 13 VOSEVI 21

VOTRIENT 17 vp-pnv-dha 37

VRAYLAR 20 VUMERITY 33

77

Drug Name Page # vyfemla 45 vylibra 45

VYNDAMAX 30 VYNDAQEL 30

VYZULTA 51 WAKIX 56

warfarin sodium 26 wixela inhub 56

wymzya fe 45 XALKORI 17 XARELTO 26

XARELTO STARTER PACK 26 XATMEP 48

XELJANZ 48 XELJANZ XR 48

XENLETA 5 XERMELO 37

XGEVA 50 XIFAXAN 5

XIIDRA 51 XOFLUZA 23

XOLAIR 56 XOPENEX 55

XOPENEX CONCENTRATE 55 XOPENEX HFA 55

XOSPATA 17 XPOVIO 100 MG ONCE WEEKLY 16 XPOVIO 60 MG ONCE WEEKLY 16 XPOVIO 80 MG ONCE WEEKLY 16

XPOVIO 80 MG TWICE WEEKLY 16 XTAMPZA ER 2

XTANDI 15 xulane 45

XURIDEN 38 XYREM 56 YF-VAX 49 YONSA 15

YUPELRI 54 yuvafem 45

zafirlukast 54 zaleplon 56

zarah 45 ZARXIO 27

zebutal 1 ZEJULA 17

ZELAPAR 19 ZELBORAF 17

ZEMAIRA 56 zenatane 35 ZENPEP 39

Drug Name Page # ZENZEDI 32 zidovudine 22

ZIEXTENZO 27 zileuton er 54

ziprasidone hcl 20 ZIRGAN 21

ZOLINZA 16 zolmitriptan 14

zolmitriptan odt 14 zolpidem tartrate 56

zolpidem tartrate er 56 zonisamide 8

ZORBTIVE 41 ZORTRESS 48

ZOSTAVAX 49 ZOSYN 6

zovia 1/35e 45 ZYCLARA PUMP 35

ZYDELIG 16 ZYFLO 54

ZYKADIA 16 ZYLET 52

ZYPREXA RELPREVV 20 ZYTIGA 15

Pennsylvania Public School Employees’ Retirement System (PSERS) Notice of Nondiscrimination

The Pennsylvania Public School Employees’ Retirement System (PSERS) Health Options Program complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Pennsylvania Public School Employees’ Retirement System (PSERS) Health Options Program does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

The PSERS Health Options Program:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

– Qualified sign language interpreters

– Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

– Qualified interpreters

– Information written in other languages

If you need these services, contact Peter Camacci, Director, Health Insurance Office.

If you believe that the PSERS Health Options Program has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Peter Camacci, Director, Health Insurance Office Public School Employees’ Retirement System 5 N 5th Street Harrisburg, PA 17101-1905 Phone: 1-888-773-7748; TTY use: 711; Fax: 717-772-3860; Email: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Peter Camacci is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW, Room 509F, HHH Building Washington, DC 20201 1-800-368-1019, 1-800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:pcamacci%40pa.gov?subject=

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

Attention: Free Language Assistance

This chart displays, in various languages, the phone number to call for free language assistance services for individuals with limited English proficiency.

Language Message About Language AssistanceSpanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia

lingüística. Llame al 1-800-773-7725; TTY: 711.Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電

1-800-773-7725; TTY: 711 。French ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont

proposés gratuitement. Appelez le 1-800-773-7725; TTY: 711.Italian ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza

linguistica gratuiti. Chiamare il numero 1-800-773-7725; TTY: 711.German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche

Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-773-7725; TTY: 711.Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.

Gọi số 1-800-773-7725; TTY: 711.Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng

tulong sa wika nang walang bayad. Tumawag sa 1-800-773-7725; TTY: 711.Arabic ملحوظة: إذا كنت تتحدث العربية اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

.TTY: 711; 1-800-773-7725Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수

있습니다. 1-800-773-7725; TTY: 711 번으로 전화해 주십시오.

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-773-7725; TTY: 711.

Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-773-7725; TTY: 711.

Serbo-Croatian OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-800-773-7725; TTY: 711.

Gujarati સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-800-773-7725; TTY: 711.

Ukrainian УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-800-773-7725; TTY: 711.

Cambodian ប្រយ័ត្ន៖ បើសិនជាអ្នកនិយាយ ភាសាខ្ម្ររ, ស្រវាជំនួយផ្ន្រកភាសា ដ្រយមិនគិតឈ្នួល គឺអាចមានសំរាប់បំរើអ្នក។ ចូរ ទូរស័ព្ទ 1-800-773-7725; TTY: 711។

French Creole (Haitian)

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-773-7725; TTY: 711.

Portuguese ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-773-7725; TTY: 711.

Greek ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-773-7725; TTY: 711.

Pennsylvania Dutch

Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-800-773-7725; TTY: 711.

THE VALUE MEDICARE Rx OPTION (PDP) IS A STAND-ALONE PRESCRIPTION DRUG PLAN WITH A MEDICARE CONTRACT. ENROLLMENT IN THE

VALUE MEDICARE Rx OPTION (PDP) DEPENDS ON CONTRACT RENEWAL. CMS CONTRACT NUMBER: E3014; FORMULARY ID: 20409

Doc. Number: 115

This formulary is effective as of July 1, 2020. For more recent information or other questions, please

contact the HOP Administration Unit at 1-800-773-7725, or for TTY users, 1-800-498-5428, 8 a.m. to 8 p.m. EST,

Monday - Friday, or visit www.HOPbenefits.com.

http://www.HOPbenefits.com

Documents

(List of Covered Drugs) Options 2020 Program CompForm...Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during