HMO Formulary

Clear Spring Health Enhanced Plan 2019 5-Tier (List of Covered Drugs)
List of Drugs by Medical Condition
ANALGESICS .................................................................................................................................................... 4
ANESTHETICS ................................................................................................................................................. 5
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS........................................................ 6
ANTIBACTERIALS .......................................................................................................................................... 7
ANTICONVULSANTS.................................................................................................................................... 13
ANTIDEMENTIA AGENTS .......................................................................................................................... 17
ANTIDEPRESSANTS ..................................................................................................................................... 17
ANTIEMETICS ............................................................................................................................................... 20
ANTIFUNGALS ............................................................................................................................................... 21
ANTIGOUT AGENTS..................................................................................................................................... 22
ANTI-INFLAMMATORY AGENTS............................................................................................................. 23
ANTIMIGRAINE AGENTS ........................................................................................................................... 24
ANTIMYASTHENIC AGENTS ..................................................................................................................... 24
ANTIMYCOBACTERIALS ........................................................................................................................... 25
ANTINEOPLASTICS...................................................................................................................................... 25
ANTIPARASITICS.......................................................................................................................................... 31
ANTIPARKINSON AGENTS ........................................................................................................................ 32
ANTIPSYCHOTICS ........................................................................................................................................ 33
ANTIVIRALS ................................................................................................................................................... 37
ANXIOLYTICS................................................................................................................................................ 41
BIPOLAR AGENTS ........................................................................................................................................ 42
BLOOD GLUCOSE REGULATORS ............................................................................................................ 43
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS .................................................................. 46
CARDIOVASCULAR AGENTS .................................................................................................................... 48
CENTRAL NERVOUS SYSTEM AGENTS ................................................................................................. 57
DENTAL AND ORAL AGENTS.................................................................................................................... 59
DERMATOLOGICAL AGENTS................................................................................................................... 59
ELECTROLYTES/MINERALS/METALS/VITAMINS ............................................................................. 62
EXCLUDED DRUG......................................................................................................................................... 66
GASTROINTESTINAL AGENTS ................................................................................................................. 66
GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT ................... 68
GENITOURINARY AGENTS........................................................................................................................ 69
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) ..................... 70
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/
MODIFIERS) ................................................................................................................................................... 71
1
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) .................... 77
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) ....................... 77
HORMONAL AGENTS, SUPPRESSANT (PITUITARY) ......................................................................... 78
HORMONAL AGENTS, SUPPRESSANT (THYROID) ............................................................................. 78
IMMUNOLOGICAL AGENTS...................................................................................................................... 79
INFLAMMATORY BOWEL DISEASE AGENTS ...................................................................................... 83
METABOLIC BONE DISEASE AGENTS ................................................................................................... 83
MISCELLANEOUS ......................................................................................................................................... 84
OPHTHALMIC AGENTS .............................................................................................................................. 84
OTIC AGENTS ................................................................................................................................................ 87
RESPIRATORY TRACT AGENTS .............................................................................................................. 88
SKELETAL MUSCLE RELAXANTS........................................................................................................... 91
SLEEP DISORDER AGENTS........................................................................................................................ 92
2
Legend
1: Preferred Generics
2: Generics
3: Preferred Brands
4: Non-Preferred Drugs
5: Specialty
BvD: Part B vs. Part D-This prescription drug may be covered under Medicare Part B or D depending upon
the circumstances.
HRM: HighRisk Medication (PA required for ages 65 or over)
LA: This prescription drug is limited to certain pharmacies.
MO: Mail Order Eligible-This prescription may also be available via mail.
PA1: Prior Authorization-You (or your physician) are required to get prior authorization before you fill your
prescription for this drug. Without prior approval, we may not cover this drug.
PA2: Prior Authorization (New Starts Only)-You (or your physician) are required to get prior authorization
before you fill your prescription for this drug unless you are a previous user of the drug. If you have a history
of using this medication, you will not need prior authorization.
QL: There is a limit on the amount of this drug that is covered per prescription, or within a specific time
frame.
ST1: Step Therapy-In some cases, you may be required to first try certain drugs to treat your medical
condition before we will cover another drug for that condition.
ST2: Step Therapy (New Starts Only)-In some cases, you may be required to first try certain drugs to treat
your medical condition before we will cover another drug for that condition unless you are a previous user of
the drug. If you have a history of using this medication, you will not need to try other medications first.
3
Clear Spring Health Enhanced Plan 2019 5-Tier (List of Covered Drugs)
Drug Name Drug Tier Requirements/Limits

ANALGESICS
OPIOID ANALGESICS, LONG-ACTING
fentanyl transdermal patch 72 hour 100 mcg/hr, 3 MO; QL (10 per 30 days)
25 mcg/hr
fentanyl transdermal patch 72 hour 12 mcg/hr, 50 2 MO; QL (10 per 30 days)
mcg/hr, 75 mcg/hr
fentanyl transdermal patch 72 hour 37.5 mcg/hr, 4 MO; QL (10 per 30 days)
62.5 mcg/hr, 87.5 mcg/hr
methadone hcl oral tablet 10 mg, 5 mg 3 MO; QL (240 per 30 days)
morphine sulfate er oral tablet extended release 4 MO; QL (90 per 30 days)
100 mg, 60 mg
morphine sulfate er oral tablet extended release 15 2 MO; QL (90 per 30 days)
mg, 200 mg, 30 mg
oxycodone hcl er oral tablet er 12 hour abuse- 4 QL (90 per 30 days)
deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg
oxycodone hcl er oral tablet er 12 hour abuse- 4 QL (60 per 30 days)
deterrent 60 mg, 80 mg
OPIOID ANALGESICS, SHORT-ACTING
acetaminophen-codeine #3 oral tablet 300-30 mg 1 QL (400 per 30 days)
acetaminophen-codeine oral solution 120-12 1 QL (5000 per 30 days)
mg/5ml
acetaminophen-codeine oral tablet 300-15 mg, 2 QL (400 per 30 days)
300-60 mg
butalbital-acetaminophen oral tablet 50-325 mg 2 PA2; HRM; QL (180 per 30 days)
butalbital-apap-caffeine oral capsule 50-325-40 4 PA2; HRM; QL (180 per 30 days)
mg
butalbital-apap-caffeine oral tablet 50-325-40 mg 4 PA2; HRM; QL (180 per 30 days)
butalbital-asa-caff-codeine oral capsule 50-325- 4 PA2; HRM; QL (370 per 30 days)
40-30 mg
butalbital-aspirin-caffeine oral capsule 50-325-40 4 PA2; HRM; QL (180 per 30 days)
mg
codeine sulfate oral tablet 30 mg 2 QL (360 per 30 days)
codeine sulfate oral tablet 60 mg 4 QL (360 per 30 days)
ENDOCET ORAL TABLET 10-325 MG, 7.5-325 4 QL (370 per 30 days)
MG
You can find information on what the symbols and abbreviations on this table mean by going to page X of the
introduction. Clear Spring 2019 Formulary ID 19512, information last updated XX/XX/20XX Version XX
Effective 08/01/2019
4
ENDOCET ORAL TABLET 5-325 MG 3 QL (370 per 30 days)
fentanyl citrate buccal lozenge on a handle 1200 5 PA1; QL (180 per 30 days)
mcg, 1600 mcg, 600 mcg, 800 mcg
fentanyl citrate buccal lozenge on a handle 200 4 PA1; QL (180 per 30 days)
mcg, 400 mcg
hydrocodone-acetaminophen oral solution 7.5-325 3 QL (5500 per 30 days)
mg/15ml
hydrocodone-acetaminophen oral tablet 10-325 3 QL (370 per 30 days)
mg, 5-325 mg, 7.5-325 mg
hydrocodone-ibuprofen oral tablet 10-200 mg, 5- 3 QL (150 per 30 days)
200 mg
hydrocodone-ibuprofen oral tablet 7.5-200 mg 3 QL (180 per 30 days)
hydromorphone hcl oral liquid 1 mg/ml 4 QL (1920 per 30 days)
hydromorphone hcl oral tablet 2 mg, 4 mg 2 QL (360 per 30 days)
hydromorphone hcl oral tablet 8 mg 2 QL (240 per 30 days)
hydromorphone hcl pf injection solution 10 mg/ml, 4 BvD; QL (240 per 30 days)
50 mg/5ml
LORCET ORAL TABLET 5-325 MG 3 QL (370 per 30 days)
morphine sulfate (concentrate) oral solution 100 2 MO; QL (600 per 30 days)
mg/5ml
morphine sulfate oral solution 10 mg/5ml 2 MO; QL (3600 per 30 days)
morphine sulfate oral solution 20 mg/5ml 2 MO; QL (2700 per 30 days)
morphine sulfate oral tablet 15 mg, 30 mg 2 QL (180 per 30 days)
oxycodone hcl oral capsule 5 mg 2 QL (180 per 30 days)
oxycodone hcl oral concentrate 100 mg/5ml 4 QL (180 per 30 days)
oxycodone hcl oral solution 5 mg/5ml 4 QL (1080 per 30 days)
oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 2 QL (180 per 30 days)
mg, 5 mg
oxycodone-acetaminophen oral tablet 10-325 mg, 2 QL (370 per 30 days)
2.5-325 mg, 5-325 mg, 7.5-325 mg
oxycodone-aspirin oral tablet 4.8355-325 mg 2 QL (360 per 30 days)
oxycodone-ibuprofen oral tablet 5-400 mg 2 QL (360 per 30 days)
tramadol hcl oral tablet 50 mg 1 QL (240 per 30 days)
tramadol-acetaminophen oral tablet 37.5-325 mg 2 QL (370 per 30 days)
ANESTHETICS
5
LOCAL ANESTHETICS
lidocaine external patch 5 % 4 PA1; QL (90 per 30 days)
lidocaine hcl external solution 4 % 4 QL (50 per 30 days)
lidocaine hcl urethral/mucosal external gel 2 % 2 QL (30 per 30 days)
lidocaine-prilocaine external cream 2.5-2.5 % 4 QL (30 per 30 days)
proparacaine hcl ophthalmic solution 0.5 % 1
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium oral tablet delayed release 2 MO
333 mg
disulfiram oral tablet 250 mg, 500 mg 2 MO
OPIOID ANTAGONISTS
naloxone hcl injection solution cartridge 0.4 3
mg/ml
naloxone hcl injection solution prefilled syringe 2 2
mg/2ml
naltrexone hcl oral tablet 50 mg 2
NARCAN NASAL LIQUID 4 MG/0.1ML 3 MO
OPIOID DEPENDENCE TREATMENTS
buprenorphine hcl sublingual tablet sublingual 2 3 QL (240 per 30 days)
mg
buprenorphine hcl sublingual tablet sublingual 8 3 QL (80 per 30 days)
mg
buprenorphine hcl-naloxone hcl sublingual tablet 3 QL (90 per 30 days)
sublingual 2-0.5 mg, 8-2 mg
SUBOXONE SUBLINGUAL FILM 12-3 MG 4 QL (60 per 30 days)
SUBOXONE SUBLINGUAL FILM 2-0.5 MG 4 QL (360 per 30 days)
SMOKING CESSATION AGENTS
bupropion hcl er (smoking det) oral tablet 2 QL (60 per 30 days)
extended release 12 hour 150 mg
CHANTIX ORAL TABLET 0.5 MG, 1 MG 3 QL (56 per 28 days)
NICOTROL INHALATION INHALER 10 MG 4
6
ANTIBACTERIALS
AMINOGLYCOSIDES
amikacin sulfate injection solution 500 mg/2ml 4 BvD
ARIKAYCE INHALATION SUSPENSION 590 4 PA1
MG/8.4ML
gentamicin in saline intravenous solution 0.8-0.9 2
mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-
0.9 mg/ml-%
gentamicin sulfate injection solution 40 mg/ml 2 BvD
neomycin sulfate oral tablet 500 mg 1
paromomycin sulfate oral capsule 250 mg 4
tobramycin inhalation nebulization solution 300 5 BvD
mg/5ml
tobramycin sulfate injection solution 10 mg/ml 4 BvD
tobramycin sulfate injection solution 80 mg/2ml 2 BvD
ANTIBACTERIALS, OTHER
clindamycin hcl oral capsule 150 mg, 75 mg 1
clindamycin hcl oral capsule 300 mg 2
clindamycin palmitate hcl oral solution 4
reconstituted 75 mg/5ml
clindamycin phosphate in d5w intravenous 4
solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml
clindamycin phosphate injection solution 300 4 BvD
mg/2ml, 600 mg/4ml, 900 mg/6ml
colistimethate sodium (cba) injection solution 4 BvD
reconstituted 150 mg
dapsone oral tablet 100 mg, 25 mg 2 MO
daptomycin intravenous solution reconstituted 350 4 BvD
mg, 500 mg
FIRVANQ ORAL SOLUTION 4 MO
RECONSTITUTED 25 MG/ML, 50 MG/ML
linezolid intravenous solution 600 mg/300ml 5 PA1
linezolid oral suspension reconstituted 100 mg/5ml 5 PA1
linezolid oral tablet 600 mg 5 PA1
methenamine hippurate oral tablet 1 gm 1
7
metronidazole in nacl intravenous solution 500- 2 BvD
0.79 mg/100ml-%
metronidazole oral tablet 250 mg, 500 mg 1
nitrofurantoin macrocrystal oral capsule 100 mg 2 PA1; HRM; QL (30 per 30 days)
nitrofurantoin macrocrystal oral capsule 25 mg 2 PA1; HRM
nitrofurantoin macrocrystal oral capsule 50 mg 2 QL (30 per 30 days)
nitrofurantoin monohyd macro oral capsule 100 2 PA1; HRM
mg
nitrofurantoin oral suspension 25 mg/5ml 4 PA1; HRM; QL (7590 per 120 days)
SIVEXTRO INTRAVENOUS SOLUTION 5
RECONSTITUTED 200 MG
SIVEXTRO ORAL TABLET 200 MG 5
tigecycline intravenous solution reconstituted 50 4 BvD
mg
trimethoprim oral tablet 100 mg 1
vancomycin hcl intravenous solution reconstituted 4 BvD
1 gm, 10 gm, 250 mg, 500 mg, 750 mg
vancomycin hcl oral capsule 125 mg 4
vancomycin hcl oral capsule 250 mg 5
XIFAXAN ORAL TABLET 200 MG 4
XIFAXAN ORAL TABLET 550 MG 4 MO
BETA-LACTAM, CEPHALOSPORINS
cefaclor er oral tablet extended release 12 hour 4
500 mg
cefaclor oral capsule 250 mg, 500 mg 2
cefaclor oral suspension reconstituted 125 4
mg/5ml, 250 mg/5ml, 375 mg/5ml
cefadroxil oral capsule 500 mg 2
cefadroxil oral suspension reconstituted 250 2
mg/5ml, 500 mg/5ml
cefadroxil oral tablet 1 gm 2
cefazolin sodium injection solution reconstituted 1 4 BvD
gm, 10 gm, 500 mg
cefdinir oral capsule 300 mg 2
cefdinir oral suspension reconstituted 125 mg/5ml, 2
250 mg/5ml
8
cefepime hcl injection solution reconstituted 1 gm, 4 BvD
2 gm
cefixime oral suspension reconstituted 100 4
mg/5ml, 200 mg/5ml
cefotaxime sodium injection solution reconstituted 4
1 gm
cefotaxime sodium injection solution reconstituted 2
500 mg
cefotetan disodium injection solution reconstituted 4
1 gm, 2 gm
cefoxitin sodium injection solution reconstituted 4 BvD
10 gm
cefoxitin sodium intravenous solution reconstituted 4 BvD
1 gm, 2 gm
cefpodoxime proxetil oral suspension reconstituted 4
100 mg/5ml, 50 mg/5ml
cefpodoxime proxetil oral tablet 100 mg, 200 mg 4
cefprozil oral suspension reconstituted 125 2
mg/5ml, 250 mg/5ml
cefprozil oral tablet 250 mg, 500 mg 2
ceftazidime injection solution reconstituted 1 gm, 2 4
gm, 6 gm
ceftriaxone sodium injection solution reconstituted 4 BvD
1 gm, 2 gm, 250 mg, 500 mg
ceftriaxone sodium intravenous solution 4 BvD
reconstituted 10 gm
cefuroxime axetil oral tablet 250 mg, 500 mg 2
cefuroxime sodium injection solution reconstituted 4 BvD
7.5 gm, 750 mg
cefuroxime sodium intravenous solution 4 BvD
reconstituted 1.5 gm
cephalexin oral capsule 250 mg, 500 mg 1
cephalexin oral capsule 750 mg 4
cephalexin oral suspension reconstituted 125 2
mg/5ml, 250 mg/5ml
cephalexin oral tablet 250 mg, 500 mg 4
SUPRAX ORAL CAPSULE 400 MG 4
9
TEFLARO INTRAVENOUS SOLUTION 5 BvD
RECONSTITUTED 400 MG, 600 MG
BETA-LACTAM, OTHER
AZACTAM INJECTION SOLUTION 4 BvD
RECONSTITUTED 2 GM
aztreonam injection solution reconstituted 1 gm 2
doripenem intravenous solution reconstituted 500 4 BvD
mg
ertapenem sodium injection solution reconstituted 4 BvD
1 gm
imipenem-cilastatin intravenous solution 4 BvD
reconstituted 250 mg, 500 mg
meropenem intravenous solution reconstituted 1 4 BvD
gm, 500 mg
BETA-LACTAM, PENICILLINS
amoxicillin oral capsule 250 mg, 500 mg 1
amoxicillin oral suspension reconstituted 125 1
mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml
amoxicillin oral tablet 500 mg, 875 mg 1
amoxicillin oral tablet chewable 125 mg, 250 mg 1
amoxicillin-pot clavulanate er oral tablet extended 4
release 12 hour 1000-62.5 mg
amoxicillin-pot clavulanate oral suspension 2
reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml,
400-57 mg/5ml, 600-42.9 mg/5ml
amoxicillin-pot clavulanate oral tablet 250-125 2
mg, 500-125 mg, 875-125 mg
amoxicillin-pot clavulanate oral tablet chewable 2
200-28.5 mg, 400-57 mg
ampicillin oral capsule 500 mg 1
ampicillin sodium injection solution reconstituted 4 BvD
1 gm, 125 mg
ampicillin sodium intravenous solution 4 BvD
reconstituted 10 gm
ampicillin-sulbactam sodium injection solution 4 BvD
reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1)
gm
10
BACTOCILL IN DEXTROSE INTRAVENOUS 4
SOLUTION 1 GM/50ML, 2 GM/50ML
BICILLIN L-A INTRAMUSCULAR 4
SUSPENSION 1200000 UNIT/2ML, 2400000
UNIT/4ML, 600000 UNIT/ML
dicloxacillin sodium oral capsule 250 mg, 500 mg 2
nafcillin sodium injection solution reconstituted 1 4 BvD
gm, 2 gm
nafcillin sodium intravenous solution reconstituted 4 BvD
10 gm
oxacillin sodium injection solution reconstituted 1 4
gm, 10 gm, 2 gm
penicillin g pot in dextrose intravenous solution 4
40000 unit/ml, 60000 unit/ml
penicillin g potassium injection solution 4 BvD
reconstituted 20000000 unit
penicillin g procaine intramuscular suspension 4
600000 unit/ml
penicillin g sodium injection solution reconstituted 4 BvD
5000000 unit
penicillin v potassium oral solution reconstituted 1
125 mg/5ml, 250 mg/5ml
penicillin v potassium oral tablet 250 mg, 500 mg 1
piperacillin sod-tazobactam so intravenous 4 BvD
solution reconstituted 2.25 (2-0.25) gm, 3.375 (3-
0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm
MACROLIDES
azithromycin intravenous solution reconstituted 2 BvD
500 mg
azithromycin oral packet 1 gm 4
azithromycin oral suspension reconstituted 100 2
mg/5ml, 200 mg/5ml
azithromycin oral tablet 250 mg, 250 mg (6 pack) 1
azithromycin oral tablet 500 mg, 500 mg (3 pack), 2
600 mg
clarithromycin er oral tablet extended release 24 2
hour 500 mg
11
clarithromycin oral suspension reconstituted 125 2
mg/5ml, 250 mg/5ml
clarithromycin oral tablet 250 mg, 500 mg 2
E.E.S. 400 ORAL TABLET 400 MG 4
ERY-TAB ORAL TABLET DELAYED 4
RELEASE 250 MG, 333 MG, 500 MG
ERYTHROCIN LACTOBIONATE 4 BvD
INTRAVENOUS SOLUTION
ERYTHROCIN STEARATE ORAL TABLET 4
250 MG
erythromycin base oral capsule delayed release 2
particles 250 mg
erythromycin base oral tablet 250 mg 2
erythromycin base oral tablet 500 mg 4
erythromycin ethylsuccinate oral tablet 400 mg 4
QUINOLONES
ciprofloxacin hcl oral tablet 100 mg 4
ciprofloxacin hcl oral tablet 250 mg, 500 mg 1
ciprofloxacin hcl oral tablet 750 mg 2
ciprofloxacin in d5w intravenous solution 200 4 BvD
mg/100ml
ciprofloxacin oral suspension reconstituted 500 4
mg/5ml (10%)
levofloxacin in d5w intravenous solution 500 4 BvD
mg/100ml, 750 mg/150ml
levofloxacin intravenous solution 25 mg/ml 4 BvD
levofloxacin oral solution 25 mg/ml 4
levofloxacin oral tablet 250 mg 2
levofloxacin oral tablet 500 mg, 750 mg 4
moxifloxacin hcl in nacl intravenous solution 400 4 BvD
mg/250ml
moxifloxacin hcl oral tablet 400 mg 4
ofloxacin oral tablet 300 mg, 400 mg 2
SULFONAMIDES
12
sulfadiazine oral tablet 500 mg 4
sulfamethoxazole-trimethoprim oral suspension 2
200-40 mg/5ml
sulfamethoxazole-trimethoprim oral tablet 400-80 1
mg, 800-160 mg
sulfasalazine oral tablet 500 mg 1 MO
sulfasalazine oral tablet delayed release 500 mg 1 MO
TETRACYCLINES
DOXY 100 INTRAVENOUS SOLUTION 4 BvD
doxycycline hyclate oral capsule 100 mg, 50 mg 1
doxycycline hyclate oral tablet 100 mg, 20 mg 1
doxycycline monohydrate oral capsule 100 mg 2
doxycycline monohydrate oral capsule 50 mg 1
doxycycline monohydrate oral tablet 100 mg, 50 2
mg
minocycline hcl oral capsule 100 mg, 75 mg 2
minocycline hcl oral capsule 50 mg 1
minocycline hcl oral tablet 100 mg, 50 mg, 75 mg 2
tetracycline hcl oral capsule 250 mg, 500 mg 2
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
BRIVIACT ORAL SOLUTION 10 MG/ML 5 PA2; ST2
BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 5 PA2; ST2
MG, 50 MG, 75 MG
carbamazepine er oral capsule extended release 2 MO
12 hour 100 mg, 200 mg, 300 mg
carbamazepine er oral tablet extended release 12 2 MO
hour 100 mg, 200 mg, 400 mg
carbamazepine oral suspension 100 mg/5ml 2 MO
carbamazepine oral tablet 200 mg 2 MO
carbamazepine oral tablet chewable 100 mg 1 MO
EPIDIOLEX ORAL SOLUTION 100 MG/ML 4 PA2; MO
EPITOL ORAL TABLET 200 MG 2 MO
13
felbamate oral suspension 600 mg/5ml 5
felbamate oral tablet 400 mg, 600 mg 4 MO
FYCOMPA ORAL SUSPENSION 0.5 MG/ML 4 ST2; MO
levetiracetam er oral tablet extended release 24 3 MO
hour 500 mg, 750 mg
levetiracetam oral solution 100 mg/ml 2 MO
levetiracetam oral tablet 1000 mg, 250 mg, 500 1 MO
mg, 750 mg
ROWEEPRA ORAL TABLET 1000 MG, 750 4 MO
MG
ROWEEPRA XR ORAL TABLET EXTENDED 4 MO
RELEASE 24 HOUR 500 MG, 750 MG
SPRITAM ORAL TABLET DISINTEGRATING 4 ST2; MO
SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG
TEGRETOL-XR ORAL TABLET EXTENDED 4 MO
RELEASE 12 HOUR 100 MG
BARBITURATES
phenobarbital oral elixir 20 mg/5ml 1 PA2; MO; HRM; QL (1500 per 30
days)
phenobarbital oral tablet 100 mg, 16.2 mg, 32.4 1 PA2; MO; HRM; QL (90 per 30 days)
mg, 64.8 mg, 97.2 mg
phenobarbital oral tablet 15 mg, 60 mg 1 PA2; MO; HRM; QL (120 per 30
days)
phenobarbital oral tablet 30 mg 1 PA2; MO; HRM; QL (300 per 30
days)
primidone oral tablet 250 mg, 50 mg 1 MO
BENZODIAZEPINES
clobazam oral suspension 2.5 mg/ml 5 QL (480 per 30 days)
clobazam oral tablet 10 mg 4 MO; QL (60 per 30 days)
clobazam oral tablet 20 mg 5 QL (60 per 30 days)
DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 4
MG
DIASTAT PEDIATRIC RECTAL GEL 2.5 MG 4
diazepam rectal gel 10 mg, 2.5 mg, 20 mg 4
SYMPAZAN ORAL FILM 10 MG, 20 MG 5 ST2; QL (60 per 30 days)
SYMPAZAN ORAL FILM 5 MG 4 ST2; MO; QL (60 per 30 days)
14
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN ORAL CAPSULE 300 MG 4 ST2; MO
ethosuximide oral capsule 250 mg 2 MO
ethosuximide oral solution 250 mg/5ml 2 MO
zonisamide oral capsule 100 mg, 25 mg, 50 mg 2 MO
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
divalproex sodium er oral tablet extended release 2 MO
24 hour 250 mg, 500 mg
divalproex sodium oral capsule delayed release 2 MO
sprinkle 125 mg
divalproex sodium oral tablet delayed release 125 1 MO
mg
divalproex sodium oral tablet delayed release 250 2 MO
mg, 500 mg
FYCOMPA ORAL TABLET 10 MG, 12 MG, 4 5 ST2; QL (30 per 30 days)
MG, 6 MG
FYCOMPA ORAL TABLET 2 MG, 8 MG 4 ST2; MO; QL (30 per 30 days)
gabapentin oral capsule 100 mg 1 MO; QL (270 per 30 days)
gabapentin oral capsule 300 mg, 400 mg 2 MO; QL (270 per 30 days)
gabapentin oral solution 250 mg/5ml 2 MO
gabapentin oral tablet 600 mg, 800 mg 2 MO; QL (180 per 30 days)
LYRICA ORAL CAPSULE 100 MG, 25 MG, 50 3 MO; QL (90 per 30 days)
MG
LYRICA ORAL CAPSULE 200 MG, 225 MG, 3 MO; QL (60 per 30 days)
300 MG
LYRICA ORAL SOLUTION 20 MG/ML 3 MO; QL (900 per 30 days)
tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg 4 MO
valproic acid oral capsule 250 mg 2 MO
valproic acid oral solution 250 mg/5ml 2 MO
vigabatrin oral packet 500 mg 5 PA2; QL (180 per 30 days)
vigabatrin oral tablet 500 mg 5 PA2; QL (180 per 30 days)
VIGADRONE ORAL PACKET 500 MG 5 PA2; QL (180 per 30 days)
GLUTAMATE REDUCING AGENTS
15
lamotrigine er oral tablet extended release 24 4 MO
hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50
mg
lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 1 MO
25 mg
lamotrigine oral tablet chewable 25 mg, 5 mg 1 MO
lamotrigine oral tablet dispersible 100 mg, 200 mg 4 MO
lamotrigine starter kit-blue oral kit 35 x 25 mg 2
lamotrigine starter kit-green oral kit 84 x 25 mg & 2
14x100 mg
lamotrigine starter kit-orange oral kit 42 x 25 mg 2
& 7 x 100 mg
topiramate oral capsule sprinkle 15 mg, 25 mg 2 MO
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 2 MO
mg
SODIUM CHANNEL AGENTS
APTIOM ORAL TABLET 200 MG, 400 MG, 800 5 ST2; QL (30 per 30 days)
MG
APTIOM ORAL TABLET 600 MG 5 ST2; QL (60 per 30 days)
BANZEL ORAL SUSPENSION 40 MG/ML 5 ST2; QL (2760 per 30 days)
BANZEL ORAL TABLET 200 MG 5 ST2; QL (480 per 30 days)
BANZEL ORAL TABLET 400 MG 5 ST2; QL (240 per 30 days)
DILANTIN ORAL CAPSULE 30 MG 4 MO
oxcarbazepine oral suspension 300 mg/5ml 4 MO
oxcarbazepine oral tablet 150 mg, 600 mg 2 MO
oxcarbazepine oral tablet 300 mg 1 MO
PEGANONE ORAL TABLET 250 MG 4 ST2; MO
phenytoin oral suspension 125 mg/5ml 1 MO
phenytoin oral tablet chewable 50 mg 1 MO
phenytoin sodium extended oral capsule 100 mg, 1 MO
200 mg, 300 mg
VIMPAT ORAL SOLUTION 10 MG/ML 5 ST2; QL (1395 per 30 days)
VIMPAT ORAL TABLET 100 MG, 150 MG, 200 5 ST2; QL (60 per 30 days)
MG
VIMPAT ORAL TABLET 50 MG 4 ST2; MO
16
ANTIDEMENTIA AGENTS
CHOLINESTERASE INHIBITORS
donepezil hcl oral tablet 10 mg 1 MO; QL (60 per 30 days)
donepezil hcl oral tablet dispersible 10 mg 2 MO; QL (60 per 30 days)
donepezil hcl oral tablet dispersible 5 mg 2 MO; QL (30 per 30 days)
galantamine hydrobromide er oral capsule 2 MO; QL (30 per 30 days)
extended release 24 hour 16 mg, 24 mg, 8 mg
galantamine hydrobromide oral solution 4 mg/ml 2 MO; QL (180 per 30 days)
galantamine hydrobromide oral tablet 12 mg, 4 2 MO; QL (60 per 30 days)
mg, 8 mg
rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 2 MO; QL (60 per 30 days)
4.5 mg, 6 mg
rivastigmine transdermal patch 24 hour 13.3 2 MO; QL (30 per 30 days)
mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine hcl er oral capsule extended release 24 2 MO
hour 14 mg, 21 mg, 28 mg, 7 mg
memantine hcl oral solution 2 mg/ml 2 MO; QL (360 per 30 days)
memantine hcl oral tablet 10 mg, 5 mg 2 MO; QL (60 per 30 days)
memantine hcl oral tablet 5 (28)-10 (21) mg 2
NAMZARIC ORAL CAPSULE ER 24 HOUR 3
THERAPY PACK 7 & 14 & 21 &28 -10 MG
NAMZARIC ORAL CAPSULE EXTENDED 3 MO
RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-
10 MG, 7-10 MG
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
bupropion hcl er (sr) oral tablet extended release 1 MO; QL (120 per 30 days)
12 hour 100 mg
12 hour 150 mg
12 hour 200 mg
17
bupropion hcl er (xl) oral tablet extended release 2 MO; QL (90 per 30 days)
24 hour 150 mg, 300 mg
bupropion hcl er (xl) oral tablet extended release 2 MO; QL (30 per 30 days)
24 hour 450 mg
bupropion hcl oral tablet 100 mg 1 MO; QL (180 per 30 days)
bupropion hcl oral tablet 75 mg 1 MO; QL (120 per 30 days)
maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg 2 MO
mirtazapine oral tablet 15 mg, 30 mg, 45 mg 1 MO; QL (30 per 30 days)
mirtazapine oral tablet 7.5 mg 1 MO; QL (45 per 30 days)
mirtazapine oral tablet dispersible 15 mg, 30 mg, 2 MO; QL (30 per 30 days)
45 mg
nefazodone hcl oral tablet 100 mg, 150 mg, 200 2 MO
mg, 250 mg, 50 mg
trazodone hcl oral tablet 100 mg, 150 mg, 50 mg 1 MO
trazodone hcl oral tablet 300 mg 2 MO
TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 4 MO; QL (30 per 30 days)
MG
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 3 ST2; MO; QL (30 per 30 days)
MG
VIIBRYD STARTER PACK ORAL KIT 10 & 20 3 ST2; QL (30 per 30 days)
MG
MONOAMINE OXIDASE INHIBITORS
EMSAM TRANSDERMAL PATCH 24 HOUR 5 ST2; QL (30 per 30 days)
12 MG/24HR, 6 MG/24HR, 9 MG/24HR
MARPLAN ORAL TABLET 10 MG 4 ST2; MO; QL (180 per 30 days)
phenelzine sulfate oral tablet 15 mg 1 MO
tranylcypromine sulfate oral tablet 10 mg 4 MO
SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS
citalopram hydrobromide oral solution 10 mg/5ml 2 ST2; MO
citalopram hydrobromide oral tablet 10 mg, 40 mg 1 ST2; MO; QL (30 per 30 days)
citalopram hydrobromide oral tablet 20 mg 1 ST2; MO; QL (60 per 30 days)
desvenlafaxine er oral tablet extended release 24 4 MO; QL (30 per 30 days)
hour 100 mg, 50 mg
desvenlafaxine succinate er oral tablet extended 4 MO; QL (30 per 30 days)
release 24 hour 100 mg, 25 mg, 50 mg
18
duloxetine hcl oral capsule delayed release 2 MO; QL (60 per 30 days)
particles 20 mg, 30 mg, 60 mg
escitalopram oxalate oral solution 5 mg/5ml 2 MO; QL (600 per 30 days)
escitalopram oxalate oral tablet 10 mg 2 MO; QL (45 per 30 days)
FETZIMA ORAL CAPSULE EXTENDED 3 MO; QL (30 per 30 days)
RELEASE 24 HOUR 120 MG, 20 MG, 40 MG,
80 MG
FETZIMA TITRATION ORAL CAPSULE ER 24 3 QL (56 per 365 days)
HOUR THERAPY PACK 20 & 40 MG
fluoxetine hcl oral capsule 10 mg 1 MO; QL (60 per 30 days)
fluoxetine hcl oral solution 20 mg/5ml 2 MO; QL (600 per 30 days)
fluoxetine hcl oral tablet 10 mg 2 MO; QL (60 per 30 days)
fluoxetine hcl oral tablet 20 mg 2 MO; QL (120 per 30 days)
fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 1 MO; QL (90 per 30 days)
mg
KHEDEZLA ORAL TABLET EXTENDED 4 MO; QL (30 per 30 days)
paroxetine hcl oral tablet 10 mg, 20 mg 1 MO; QL (30 per 30 days)
paroxetine hcl oral tablet 30 mg 2 MO; QL (60 per 30 days)
paroxetine hcl oral tablet 40 mg 1 MO; QL (60 per 30 days)
PAXIL ORAL SUSPENSION 10 MG/5ML 4 MO; QL (900 per 30 days)
sertraline hcl oral concentrate 20 mg/ml 1 MO; QL (300 per 30 days)
sertraline hcl oral tablet 100 mg 1 MO; QL (60 per 30 days)
sertraline hcl oral tablet 25 mg, 50 mg 1 MO; QL (90 per 30 days)
venlafaxine hcl er oral capsule extended release 1 MO; QL (60 per 30 days)
24 hour 150 mg, 37.5 mg, 75 mg
venlafaxine hcl er oral tablet extended release 24 3 MO; QL (30 per 30 days)
hour 150 mg, 37.5 mg
hour 225 mg
hour 75 mg
19
venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 1 MO
mg, 50 mg, 75 mg
TRICYCLICS
amitriptyline hcl oral tablet 10 mg, 25 mg, 50 mg 2 PA2; MO; HRM
amitriptyline hcl oral tablet 100 mg, 150 mg, 75 1 PA2; MO; HRM
mg
amoxapine oral tablet 100 mg, 150 mg 2 ST2; MO
amoxapine oral tablet 25 mg, 50 mg 1 ST2; MO
clomipramine hcl oral capsule 25 mg, 50 mg, 75 4 PA2; MO; HRM
mg
desipramine hcl oral tablet 10 mg, 25 mg 1 MO
desipramine hcl oral tablet 100 mg, 150 mg, 50 2 MO
mg, 75 mg
doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 2 PA2; MO; HRM
25 mg, 50 mg, 75 mg
doxepin hcl oral concentrate 10 mg/ml 2 PA2; MO; HRM
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 2 PA2; MO; HRM
nortriptyline hcl oral capsule 10 mg, 25 mg, 50 1 MO
mg, 75 mg
nortriptyline hcl oral solution 10 mg/5ml 2 MO
protriptyline hcl oral tablet 10 mg, 5 mg 4 MO
trimipramine maleate oral capsule 100 mg, 25 mg, 2 MO
50 mg
ANTIEMETICS
ANTIEMETICS, OTHER
COMPRO RECTAL SUPPOSITORY 25 MG 4
meclizine hcl oral tablet 12.5 mg, 25 mg 1
prochlorperazine maleate oral tablet 5 mg 1 BvD; MO
prochlorperazine rectal suppository 25 mg 4
promethazine hcl oral tablet 12.5 mg, 25 mg, 50 1 PA1; HRM
mg
scopolamine transdermal patch 72 hour 1 4 QL (4 per 12 days)
mg/3days
EMETOGENIC THERAPY ADJUNCTS
aprepitant oral capsule 125 mg, 40 mg, 80 mg 4 BvD; QL (30 per 30 days)
20
aprepitant oral capsule 80 & 125 mg 4 BvD; QL (12 per 30 days)
dronabinol oral capsule 10 mg 5 BvD; QL (60 per 30 days)
dronabinol oral capsule 2.5 mg 2 BvD; QL (60 per 30 days)
dronabinol oral capsule 5 mg 4 BvD; QL (60 per 30 days)
EMEND ORAL SUSPENSION 4 BvD
granisetron hcl oral tablet 1 mg 4 BvD; QL (60 per 30 days)
ondansetron hcl oral solution 4 mg/5ml 2 BvD; QL (450 per 30 days)
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 2 BvD
ondansetron oral tablet dispersible 4 mg, 8 mg 2 BvD
SYNDROS ORAL SOLUTION 5 MG/ML 4 BvD; QL (120 per 30 days)
VARUBI ORAL TABLET 90 MG 3 BvD
ANTIFUNGALS
ANTIFUNGALS
ABELCET INTRAVENOUS SUSPENSION 5 5 BvD
MG/ML
AMBISOME INTRAVENOUS SUSPENSION 5 BvD
RECONSTITUTED 50 MG
amphotericin b intravenous solution reconstituted 4 BvD
50 mg
caspofungin acetate intravenous solution 5 BvD
reconstituted 50 mg, 70 mg
ciclopirox external solution 8 % 1
ciclopirox olamine external cream 0.77 % 2
ciclopirox olamine external suspension 0.77 % 2
clotrimazole external cream 1 % 1
clotrimazole external solution 1 % 1
econazole nitrate external cream 1 % 2
ERAXIS INTRAVENOUS SOLUTION 5 BvD
RECONSTITUTED 50 MG
fluconazole in sodium chloride intravenous 2 BvD
solution 200-0.9 mg/100ml-%, 400-0.9 mg/200ml-
%
fluconazole oral suspension reconstituted 10 2
mg/ml, 40 mg/ml
21
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 2
50 mg
flucytosine oral capsule 250 mg, 500 mg 5
griseofulvin microsize oral suspension 125 mg/5ml 4
griseofulvin microsize oral tablet 500 mg 4
griseofulvin ultramicrosize oral tablet 125 mg, 250 4
mg
itraconazole oral capsule 100 mg 4 PA1
JUBLIA EXTERNAL SOLUTION 10 % 4
ketoconazole external cream 2 % 2
ketoconazole external shampoo 2 % 1
ketoconazole oral tablet 200 mg 2
NATACYN OPHTHALMIC SUSPENSION 5 % 4
NOXAFIL ORAL SUSPENSION 40 MG/ML 4 PA1; MO; QL (840 per 28 days)
NOXAFIL ORAL TABLET DELAYED 5 PA1
RELEASE 100 MG
NYAMYC EXTERNAL POWDER 100000 2
UNIT/GM
nystatin external cream 100000 unit/gm 1
nystatin external ointment 100000 unit/gm 1
nystatin external powder 100000 unit/gm 2
nystatin oral tablet 500000 unit 1
NYSTOP EXTERNAL POWDER 100000 2
UNIT/GM
terbinafine hcl oral tablet 250 mg 4 QL (90 per 365 days)
voriconazole intravenous solution reconstituted 5 BvD
200 mg
voriconazole oral suspension reconstituted 40 4 PA1
mg/ml
voriconazole oral tablet 200 mg, 50 mg 5 PA1; QL (120 per 30 days)
ANTIGOUT AGENTS
ANTIGOUT AGENTS
allopurinol oral tablet 100 mg, 300 mg 1 MO
colchicine oral tablet 0.6 mg 2
22
colchicine-probenecid oral tablet 0.5-500 mg 1 MO
probenecid oral tablet 500 mg 1 MO
ULORIC ORAL TABLET 40 MG, 80 MG 3 ST1; MO
ANTI-INFLAMMATORY AGENTS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
celecoxib oral capsule 100 mg, 200 mg, 400 mg, 2 ST1; MO
50 mg
diclofenac potassium oral tablet 50 mg 2 MO
diclofenac sodium er oral tablet extended release 1 MO
24 hour 100 mg
diclofenac sodium oral tablet delayed release 25 2 MO
mg
diclofenac sodium oral tablet delayed release 50 1 MO
mg, 75 mg
diclofenac sodium transdermal gel 1 % 2 PA1
diclofenac sodium transdermal solution 1.5 % 4
diflunisal oral tablet 500 mg 2 MO
flurbiprofen oral tablet 100 mg 1 MO
flurbiprofen oral tablet 50 mg 2 MO
IBU ORAL TABLET 600 MG, 800 MG 1 MO
ibuprofen oral suspension 100 mg/5ml 1
ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MO
indomethacin oral capsule 25 mg 1 MO
meloxicam oral tablet 15 mg, 7.5 mg 1 MO
nabumetone oral tablet 500 mg, 750 mg 1 MO
naproxen dr oral tablet delayed release 375 mg, 2 MO
500 mg
naproxen oral suspension 125 mg/5ml 1 MO
naproxen oral tablet 250 mg, 375 mg, 500 mg 1 MO
naproxen sodium er oral tablet extended release 4 MO
24 hour 500 mg
naproxen sodium oral tablet 275 mg, 550 mg 2 MO
oxaprozin oral tablet 600 mg 2 MO
piroxicam oral capsule 10 mg, 20 mg 2 MO
23
sulindac oral tablet 150 mg, 200 mg 1 MO
tolmetin sodium oral capsule 400 mg 2 MO
tolmetin sodium oral tablet 600 mg 2 MO
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
dihydroergotamine mesylate nasal solution 4 5
mg/ml
ergotamine-caffeine oral tablet 1-100 mg 4 QL (40 per 28 days)
MIGERGOT RECTAL SUPPOSITORY 2-100 4
MG
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
naratriptan hcl oral tablet 2.5 mg 2 QL (9 per 30 days)
rizatriptan benzoate oral tablet 10 mg 2 QL (12 per 30 days)
rizatriptan benzoate oral tablet 5 mg 2 QL (24 per 30 days)
rizatriptan benzoate oral tablet dispersible 10 mg 2 QL (12 per 30 days)
rizatriptan benzoate oral tablet dispersible 5 mg 2 QL (24 per 30 days)
sumatriptan nasal solution 20 mg/act, 5 mg/act 4 QL (18 per 30 days)
sumatriptan succinate oral tablet 100 mg, 25 mg, 2 QL (9 per 30 days)
50 mg
sumatriptan succinate subcutaneous solution 6 2 QL (8 per 30 days)
mg/0.5ml
sumatriptan succinate subcutaneous solution auto- 2 QL (4.5 per 30 days)
injector 4 mg/0.5ml
sumatriptan succinate subcutaneous solution 2 MO; QL (8 per 30 days)
prefilled syringe 6 mg/0.5ml
zolmitriptan oral tablet 2.5 mg 2 QL (12 per 30 days)
zolmitriptan oral tablet 5 mg 2 QL (6 per 30 days)
zolmitriptan oral tablet dispersible 2.5 mg 2 QL (12 per 30 days)
zolmitriptan oral tablet dispersible 5 mg 2 QL (6 per 30 days)
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
guanidine hcl oral tablet 125 mg 2
pyridostigmine bromide oral solution 60 mg/5ml 2
pyridostigmine bromide oral tablet 60 mg 1
24
ANTIMYCOBACTERIALS
ANTITUBERCULARS
ethambutol hcl oral tablet 100 mg 2
ethambutol hcl oral tablet 400 mg 1
isoniazid oral syrup 50 mg/5ml 1 MO
isoniazid oral tablet 100 mg, 300 mg 1 MO
PASER ORAL PACKET 4 GM 4
PRIFTIN ORAL TABLET 150 MG 4
pyrazinamide oral tablet 500 mg 2
rifabutin oral capsule 150 mg 4
rifampin intravenous solution reconstituted 600 4 BvD
mg
rifampin oral capsule 150 mg, 300 mg 2
RIFATER ORAL TABLET 50-120-300 MG 4
SIRTURO ORAL TABLET 100 MG 5 PA1
TRECATOR ORAL TABLET 250 MG 4
ANTINEOPLASTICS
ALKYLATING AGENTS
cyclophosphamide oral capsule 25 mg, 50 mg 3 BvD
GLEOSTINE ORAL CAPSULE 10 MG 4
LEUKERAN ORAL TABLET 2 MG 4
ANTIANGIOGENIC AGENTS
REVLIMID ORAL CAPSULE 10 MG, 15 MG, 5 PA2; LA; QL (28 per 28 days)
2.5 MG, 20 MG, 25 MG, 5 MG
THALOMID ORAL CAPSULE 100 MG, 200 5 PA2; QL (30 per 30 days)
MG, 50 MG
THALOMID ORAL CAPSULE 150 MG 5 PA2; QL (60 per 30 days)
ANTIMETABOLITES
DROXIA ORAL CAPSULE 200 MG, 300 MG, 4 MO
400 MG
mercaptopurine oral tablet 50 mg 2
methotrexate sodium (pf) injection solution 50 1 BvD
mg/2ml
25
PURIXAN ORAL SUSPENSION 2000 4 LA
MG/100ML
TABLOID ORAL TABLET 40 MG 4 PA2
ANTINEOPLASTICS
BALVERSA ORAL TABLET 3 MG 5 PA2; LA; QL (90 per 30 days)
bexarotene oral capsule 75 mg 5 PA2; QL (300 per 30 days)
bicalutamide oral tablet 50 mg 2
CALQUENCE ORAL CAPSULE 100 MG 5 PA2; LA; QL (60 per 30 days)
COPIKTRA ORAL CAPSULE 15 MG, 25 MG 5 PA2; QL (60 per 30 days)
DAURISMO ORAL TABLET 100 MG, 25 MG 5 PA2
EMCYT ORAL CAPSULE 140 MG 3
ERIVEDGE ORAL CAPSULE 150 MG 5 PA2; QL (28 per 28 days)
ERLEADA ORAL TABLET 60 MG 5 PA2; LA
fluorouracil external cream 5 % 2
fluorouracil external solution 2 %, 5 % 2
flutamide oral capsule 125 mg 2
hydroxyurea oral capsule 500 mg 1
IDHIFA ORAL TABLET 100 MG 5 PA2; LA; QL (30 per 30 days)
IDHIFA ORAL TABLET 50 MG 5 PA2; LA; QL (60 per 30 days)
KISQALI FEMARA 200 DOSE ORAL TABLET 5 PA2
THERAPY PACK 200 & 2.5 MG
leucovorin calcium oral tablet 10 mg, 5 mg 1
leucovorin calcium oral tablet 15 mg 2
leucovorin calcium oral tablet 25 mg 4
leuprolide acetate injection kit 1 mg/0.2ml 3 PA2
LONSURF ORAL TABLET 15-6.14 MG 5 PA2; LA; QL (150 per 28 days)
LONSURF ORAL TABLET 20-8.19 MG 5 PA2; LA
26
LUPRON DEPOT (1-MONTH) 5 PA2; QL (1 per 30 days)
INTRAMUSCULAR KIT 3.75 MG
LUPRON DEPOT (1-MONTH) 5 PA2
LUPRON DEPOT (3-MONTH) 5 PA2; QL (1 per 28 days)
INTRAMUSCULAR KIT 30 MG
INTRAMUSCULAR KIT 45 MG
LYNPARZA ORAL TABLET 100 MG 5 PA2; LA; QL (180 per 30 days)
LYNPARZA ORAL TABLET 150 MG 5 PA2; LA; QL (120 per 30 days)
LYSODREN ORAL TABLET 500 MG 3
MATULANE ORAL CAPSULE 50 MG 5 PA2; LA
MESNEX ORAL TABLET 400 MG 5
NERLYNX ORAL TABLET 40 MG 5 PA2; LA; QL (180 per 30 days)
nilutamide oral tablet 150 mg 5 QL (60 per 30 days)
ODOMZO ORAL CAPSULE 200 MG 5 PA2
PANRETIN EXTERNAL GEL 0.1 % 5
SYNRIBO SUBCUTANEOUS SOLUTION 5 PA2
RECONSTITUTED 3.5 MG
tamoxifen citrate oral tablet 10 mg 1 MO
tamoxifen citrate oral tablet 20 mg 2 MO
TARGRETIN EXTERNAL GEL 1 % 5 PA2
TIBSOVO ORAL TABLET 250 MG 5 PA2; LA; QL (60 per 30 days)
TOLAK EXTERNAL CREAM 4 % 4
toremifene citrate oral tablet 60 mg 5 PA2; QL (30 per 30 days)
tretinoin oral capsule 10 mg 5
VALCHLOR EXTERNAL GEL 0.016 % 5 PA2; QL (60 per 14 days)
VERZENIO ORAL TABLET 100 MG, 150 MG, 5 PA2; LA; QL (60 per 30 days)
50 MG
VERZENIO ORAL TABLET 200 MG 5 PA2; LA; QL (30 per 30 days)
XTANDI ORAL CAPSULE 40 MG 5 PA2; LA; QL (120 per 30 days)
27
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole oral tablet 1 mg 2 MO
exemestane oral tablet 25 mg 4 MO; QL (60 per 30 days)
letrozole oral tablet 2.5 mg 2 MO; QL (30 per 30 days)
MOLECULAR TARGET INHIBITORS
abiraterone acetate oral tablet 250 mg 5 PA2; QL (120 per 30 days)
AFINITOR DISPERZ ORAL TABLET 5 PA2; QL (30 per 30 days)
SOLUBLE 2 MG, 3 MG
AFINITOR DISPERZ ORAL TABLET 5 PA2; QL (60 per 30 days)
SOLUBLE 5 MG
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 5 PA2; QL (30 per 30 days)
MG, 7.5 MG
ALECENSA ORAL CAPSULE 150 MG 5 PA2
ALUNBRIG ORAL TABLET 180 MG 5 PA2; LA; QL (30 per 30 days)
ALUNBRIG ORAL TABLET THERAPY PACK 5 PA2; LA; QL (30 per 30 days)
90 & 180 MG
BOSULIF ORAL TABLET 100 MG 5 PA2; QL (120 per 30 days)
BOSULIF ORAL TABLET 400 MG, 500 MG 5 PA2; QL (30 per 30 days)
BRAFTOVI ORAL CAPSULE 50 MG 5 PA2; LA; QL (270 per 30 days)
BRAFTOVI ORAL CAPSULE 75 MG 5 PA2; LA; QL (180 per 30 days)
CABOMETYX ORAL TABLET 20 MG, 40 MG, 5 PA2; LA
60 MG
CAPRELSA ORAL TABLET 100 MG 5 PA2; LA; QL (60 per 30 days)
CAPRELSA ORAL TABLET 300 MG 5 PA2; LA; QL (30 per 30 days)
COMETRIQ (100 MG DAILY DOSE) ORAL 5 PA2; LA; QL (56 per 28 days)
KIT 1 X 80 & 1 X 20 MG
COMETRIQ (140 MG DAILY DOSE) ORAL 5 PA2; LA; QL (112 per 28 days)
KIT 1 X 80 & 3 X 20 MG
COMETRIQ (60 MG DAILY DOSE) ORAL KIT 5 PA2; LA; QL (84 per 28 days)
20 MG
COTELLIC ORAL TABLET 20 MG 5 PA2; QL (63 per 28 days)
erlotinib hcl oral tablet 100 mg, 150 mg 5 PA2; QL (30 per 30 days)
erlotinib hcl oral tablet 25 mg 5 PA2; QL (90 per 30 days)
28
FARYDAK ORAL CAPSULE 10 MG 5 PA2; QL (60 per 30 days)
FARYDAK ORAL CAPSULE 15 MG, 20 MG 5 PA2; QL (30 per 30 days)
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 5 PA2; LA; QL (30 per 30 days)
MG
IBRANCE ORAL CAPSULE 100 MG, 125 MG, 5 PA2
75 MG
ICLUSIG ORAL TABLET 15 MG 5 PA2; LA; QL (60 per 30 days)
ICLUSIG ORAL TABLET 45 MG 5 PA2; LA; QL (30 per 30 days)
imatinib mesylate oral tablet 100 mg 5 PA2; QL (180 per 30 days)
imatinib mesylate oral tablet 400 mg 5 PA2; QL (60 per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG, 70 MG 5 PA2; LA; QL (120 per 30 days)
IMBRUVICA ORAL TABLET 140 MG 5 PA2; LA; QL (120 per 30 days)
IMBRUVICA ORAL TABLET 280 MG 5 PA2; LA; QL (60 per 30 days)
IMBRUVICA ORAL TABLET 420 MG, 560 MG 5 PA2; LA; QL (30 per 30 days)
INLYTA ORAL TABLET 1 MG 5 PA2; QL (180 per 30 days)
INLYTA ORAL TABLET 5 MG 5 PA2; QL (60 per 30 days)
IRESSA ORAL TABLET 250 MG 5 PA2; LA
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 5 PA2; LA; QL (60 per 30 days)
MG, 25 MG, 5 MG
KISQALI 200 DOSE ORAL TABLET 5 PA2; QL (30 per 30 days)
THERAPY PACK 200 MG
KISQALI 400 DOSE ORAL TABLET 5 PA2
THERAPY PACK 200 MG
KISQALI 600 DOSE ORAL TABLET 5 PA2
THERAPY PACK 200 MG
LENVIMA 10 MG DAILY DOSE ORAL 5 PA2
CAPSULE THERAPY PACK 10 MG
CAPSULE THERAPY PACK 3 X 4 MG
CAPSULE THERAPY PACK 10 & 4 MG
CAPSULE THERAPY PACK 10 MG & 2 X 4
MG
29
CAPSULE THERAPY PACK 2 X 10 MG & 4
MG
CAPSULE THERAPY PACK 4 MG
LORBRENA ORAL TABLET 100 MG 5 PA2; QL (30 per 30 days)
LORBRENA ORAL TABLET 25 MG 5 PA2; QL (90 per 30 days)
MEKINIST ORAL TABLET 0.5 MG 5 PA2; QL (120 per 30 days)
MEKINIST ORAL TABLET 2 MG 5 PA2; QL (30 per 30 days)
MEKTOVI ORAL TABLET 15 MG 5 PA2; LA; QL (180 per 30 days)
NEXAVAR ORAL TABLET 200 MG 5 PA2; LA; QL (120 per 30 days)
NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 5 PA2
MG
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 5 PA2; LA; QL (21 per 28 days)
MG, 4 MG
RUBRACA ORAL TABLET 200 MG, 250 MG, 5 PA2; LA
300 MG
RYDAPT ORAL CAPSULE 25 MG 5 PA2; QL (240 per 30 days)
SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 5 PA2; QL (60 per 30 days)
MG, 80 MG
SPRYCEL ORAL TABLET 140 MG 5 PA2; QL (30 per 30 days)
SPRYCEL ORAL TABLET 20 MG 5 PA2; QL (90 per 30 days)
STIVARGA ORAL TABLET 40 MG 5 PA2; LA; QL (84 per 28 days)
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 5 PA2; QL (28 per 28 days)
37.5 MG, 50 MG
TAFINLAR ORAL CAPSULE 50 MG 5 PA2; QL (180 per 30 days)
TAFINLAR ORAL CAPSULE 75 MG 5 PA2; QL (120 per 30 days)
TAGRISSO ORAL TABLET 40 MG, 80 MG 5 PA2; LA
TALZENNA ORAL CAPSULE 0.25 MG 5 PA2; QL (90 per 30 days)
TALZENNA ORAL CAPSULE 1 MG 5 PA2; QL (30 per 30 days)
TARCEVA ORAL TABLET 100 MG, 150 MG 5 PA2; QL (30 per 30 days)
TARCEVA ORAL TABLET 25 MG 5 PA2; QL (90 per 30 days)
TASIGNA ORAL CAPSULE 150 MG, 200 MG, 5 PA2; QL (120 per 30 days)
50 MG
30
TYKERB ORAL TABLET 250 MG 5 PA2; QL (180 per 30 days)
VENCLEXTA ORAL TABLET 10 MG, 50 MG 4 PA2; LA
VENCLEXTA ORAL TABLET 100 MG 5 PA2; LA
VENCLEXTA STARTING PACK ORAL 5 PA2; LA
TABLET THERAPY PACK 10 & 50 & 100 MG
VITRAKVI ORAL CAPSULE 100 MG 5 PA2; QL (60 per 30 days)
VITRAKVI ORAL CAPSULE 25 MG 5 PA2; QL (180 per 30 days)
VITRAKVI ORAL SOLUTION 20 MG/ML 5 PA2
VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 5 PA2; QL (30 per 30 days)
MG
VOTRIENT ORAL TABLET 200 MG 5 PA2; QL (120 per 30 days)
XALKORI ORAL CAPSULE 200 MG, 250 MG 5 PA2; QL (60 per 30 days)
XOSPATA ORAL TABLET 40 MG 5 PA2
YONSA ORAL TABLET 125 MG 5 PA2; QL (120 per 30 days)
ZEJULA ORAL CAPSULE 100 MG 5 PA2; LA; QL (90 per 30 days)
ZELBORAF ORAL TABLET 240 MG 5 PA2; QL (240 per 30 days)
ZOLINZA ORAL CAPSULE 100 MG 5 PA2; QL (120 per 30 days)
ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA2; LA; QL (60 per 30 days)
ZYKADIA ORAL CAPSULE 150 MG 5 PA2; QL (150 per 30 days)
ZYKADIA ORAL TABLET 150 MG 5 PA2; QL (150 per 30 days)
ZYTIGA ORAL TABLET 500 MG 5 PA2; QL (120 per 30 days)
ANTIPARASITICS
ANTHELMINTICS
albendazole oral tablet 200 mg 4
EMVERM ORAL TABLET CHEWABLE 100 3
MG
ivermectin oral tablet 3 mg 3
ANTIPROTOZOALS
ALINIA ORAL SUSPENSION 4 QL (150 per 30 days)
RECONSTITUTED 100 MG/5ML
ALINIA ORAL TABLET 500 MG 4 QL (40 per 30 days)
atovaquone oral suspension 750 mg/5ml 5
atovaquone-proguanil hcl oral tablet 250-100 mg 2
31
atovaquone-proguanil hcl oral tablet 62.5-25 mg 3
benznidazole oral tablet 100 mg, 12.5 mg 2
chloroquine phosphate oral tablet 250 mg, 500 mg 2 MO
COARTEM ORAL TABLET 20-120 MG 4
DARAPRIM ORAL TABLET 25 MG 5
mefloquine hcl oral tablet 250 mg 2 MO
NEBUPENT INHALATION SOLUTION 4 BvD
PENTAM INJECTION SOLUTION 4 BvD
primaquine phosphate oral tablet 26.3 mg 4
quinine sulfate oral capsule 324 mg 2 PA1
tinidazole oral tablet 250 mg, 500 mg 3
PEDICULICIDES/SCABICIDES
malathion external lotion 0.5 % 4
permethrin external cream 5 % 2
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 1 PA1; MO; HRM
mg
trihexyphenidyl hcl oral elixir 0.4 mg/ml 1 PA1; MO; HRM
trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 PA1; MO; HRM
ANTIPARKINSON AGENTS, OTHER
amantadine hcl oral capsule 100 mg 2 MO
amantadine hcl oral syrup 50 mg/5ml 2 MO
amantadine hcl oral tablet 100 mg 2 MO
carbidopa-levodopa er oral tablet extended 2 MO
release 25-100 mg, 50-200 mg
carbidopa-levodopa oral tablet 10-100 mg 1 MO
carbidopa-levodopa oral tablet 25-100 mg, 25-250 2 MO
mg
carbidopa-levodopa oral tablet dispersible 10-100 1 MO
mg, 25-100 mg
32
carbidopa-levodopa oral tablet dispersible 25-250 2 MO
mg
carbidopa-levodopa-entacapone oral tablet 12.5- 2 MO
50-200 mg, 18.75-75-200 mg, 31.25-125-200 mg
carbidopa-levodopa-entacapone oral tablet 25- 4 MO
100-200 mg, 37.5-150-200 mg, 50-200-200 mg
entacapone oral tablet 200 mg 2 MO
GOCOVRI ORAL CAPSULE EXTENDED 5 PA1; LA
RELEASE 24 HOUR 137 MG, 68.5 MG
RYTARY ORAL CAPSULE EXTENDED 4 ST1; MO
RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-
195 MG, 61.25-245 MG
DOPAMINE AGONISTS
APOKYN SUBCUTANEOUS SOLUTION 5 PA1; LA; QL (60 per 28 days)
CARTRIDGE 30 MG/3ML
bromocriptine mesylate oral capsule 5 mg 2 MO
bromocriptine mesylate oral tablet 2.5 mg 2 MO
NEUPRO TRANSDERMAL PATCH 24 HOUR 1 4 MO
MG/24HR, 2 MG/24HR, 3 MG/24HR, 4
MG/24HR, 6 MG/24HR, 8 MG/24HR
pramipexole dihydrochloride er oral tablet 2 MO
extended release 24 hour 3.75 mg
pramipexole dihydrochloride oral tablet 0.125 mg, 2 MO
0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg
ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 2 MO
mg, 3 mg, 4 mg, 5 mg
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
rasagiline mesylate oral tablet 0.5 mg, 1 mg 4 MO
selegiline hcl oral capsule 5 mg 2 MO
selegiline hcl oral tablet 5 mg 2 MO
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
chlorpromazine hcl oral tablet 10 mg, 100 mg, 25 2 BvD; MO
mg
chlorpromazine hcl oral tablet 200 mg, 50 mg 4 BvD; MO
clozapine oral tablet 100 mg, 200 mg 2 ST2; QL (120 per 30 days)
33
clozapine oral tablet 25 mg, 50 mg 2 QL (120 per 30 days)
clozapine oral tablet dispersible 100 mg, 12.5 mg, 4 ST2; QL (120 per 30 days)
150 mg, 25 mg
clozapine oral tablet dispersible 200 mg 5 ST2; QL (120 per 30 days)
FAZACLO ORAL TABLET DISPERSIBLE 100 4 ST2; QL (120 per 30 days)
MG, 12.5 MG, 150 MG, 25 MG
FAZACLO ORAL TABLET DISPERSIBLE 200 5 ST2; QL (120 per 30 days)
MG
fluphenazine decanoate injection solution 25 4
mg/ml
fluphenazine hcl injection solution 2.5 mg/ml 4
fluphenazine hcl oral concentrate 5 mg/ml 2 MO
fluphenazine hcl oral elixir 2.5 mg/5ml 2 MO
fluphenazine hcl oral tablet 1 mg, 2.5 mg 1 MO
fluphenazine hcl oral tablet 10 mg, 5 mg 2 MO
haloperidol decanoate intramuscular solution 100 2
mg/ml, 100 mg/ml 1 ml, 50 mg/ml
haloperidol lactate injection solution 5 mg/ml, 5 4
mg/ml(1 ml prefilled syringe)
haloperidol lactate oral concentrate 2 mg/ml 1 MO
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 1 MO
20 mg, 5 mg
loxapine succinate oral capsule 10 mg, 25 mg, 5 1 MO
mg, 50 mg
molindone hcl oral tablet 10 mg, 25 mg, 5 mg 2 MO
perphenazine oral tablet 16 mg, 2 mg 2 MO
perphenazine oral tablet 4 mg, 8 mg 2 BvD; MO
pimozide oral tablet 1 mg, 2 mg 2 MO
prochlorperazine maleate oral tablet 10 mg 1 BvD; MO
thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 1 PA2; MO; HRM
50 mg
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 MO
trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 1 MO
5 mg
VERSACLOZ ORAL SUSPENSION 50 MG/ML 5 ST2; QL (540 per 30 days)
2ND GENERATION/ATYPICAL
34
ABILIFY MAINTENA INTRAMUSCULAR 5
PREFILLED SYRINGE 300 MG, 400 MG
ABILIFY MAINTENA INTRAMUSCULAR 5
SUSPENSION RECONSTITUTED ER 300 MG,
400 MG
aripiprazole oral solution 1 mg/ml 4 MO; QL (750 per 30 days)
aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 4 MO; QL (30 per 30 days)
mg, 30 mg, 5 mg
aripiprazole oral tablet dispersible 10 mg 5 QL (90 per 30 days)
aripiprazole oral tablet dispersible 15 mg 5 QL (60 per 30 days)
FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG 4 ST2; QL (60 per 30 days)
FANAPT ORAL TABLET 10 MG, 12 MG, 6 5 ST2; QL (60 per 30 days)
MG, 8 MG
FANAPT TITRATION PACK ORAL TABLET 1 4 ST2; QL (60 per 30 days)
& 2 & 4 & 6 MG
INVEGA SUSTENNA INTRAMUSCULAR 5
SUSPENSION PREFILLED SYRINGE 117
MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 78
MG/0.5ML
INVEGA SUSTENNA INTRAMUSCULAR 4
MG/0.25ML
INVEGA TRINZA INTRAMUSCULAR 5
MG/0.875ML, 410 MG/1.315ML, 546
MG/1.75ML, 819 MG/2.625ML
LATUDA ORAL TABLET 120 MG 3 MO; QL (30 per 30 days)
LATUDA ORAL TABLET 20 MG, 40 MG, 60 3 MO; QL (60 per 30 days)
MG, 80 MG
NUPLAZID ORAL CAPSULE 34 MG 5 LA
NUPLAZID ORAL TABLET 10 MG 5 LA
olanzapine intramuscular solution reconstituted 10 4 QL (60 per 30 days)
mg
olanzapine oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg 4 MO; QL (30 per 30 days)
olanzapine oral tablet 2.5 mg 1 MO; QL (30 per 30 days)
olanzapine oral tablet 20 mg 4 MO; QL (60 per 30 days)
olanzapine oral tablet dispersible 10 mg, 5 mg 4 MO; QL (60 per 30 days)
35
olanzapine oral tablet dispersible 15 mg, 20 mg 4 MO; QL (30 per 30 days)
paliperidone er oral tablet extended release 24 4 MO; QL (30 per 30 days)
hour 1.5 mg, 3 mg
paliperidone er oral tablet extended release 24 4 MO; QL (60 per 30 days)
hour 6 mg
paliperidone er oral tablet extended release 24 5 QL (30 per 30 days)
hour 9 mg
PERSERIS SUBCUTANEOUS PREFILLED 4 MO; QL (1 per 30 days)
SYRINGE 120 MG, 90 MG
quetiapine fumarate oral tablet 100 mg, 25 mg, 1 MO; QL (60 per 30 days)
300 mg, 400 mg, 50 mg
quetiapine fumarate oral tablet 200 mg 1 MO; QL (30 per 30 days)
REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 5
MG, 2 MG, 3 MG, 4 MG
RISPERDAL CONSTA INTRAMUSCULAR 4 QL (2 per 28 days)
SUSPENSION RECONSTITUTED 12.5 MG
RISPERDAL CONSTA INTRAMUSCULAR 5 QL (2 per 28 days)
SUSPENSION RECONSTITUTED 25 MG, 37.5
MG, 50 MG
risperidone oral solution 1 mg/ml 2 MO; QL (480 per 30 days)
risperidone oral tablet 0.25 mg, 1 mg, 2 mg, 3 mg, 2 MO; QL (60 per 30 days)
4 mg
risperidone oral tablet 0.5 mg 2 MO; QL (120 per 30 days)
risperidone oral tablet dispersible 0.25 mg, 1 mg, 2 MO; QL (60 per 30 days)
2 mg
risperidone oral tablet dispersible 0.5 mg 2 MO; QL (120 per 30 days)
risperidone oral tablet dispersible 3 mg, 4 mg 4 MO; QL (60 per 30 days)
SAPHRIS SUBLINGUAL TABLET 4 PA2; ST2; MO; HRM; QL (60 per 30
SUBLINGUAL 10 MG, 2.5 MG, 5 MG days)
VRAYLAR ORAL CAPSULE 1.5 MG 5 ST2; QL (60 per 30 days)
VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG, 6 5 ST2; QL (30 per 30 days)
MG
VRAYLAR ORAL CAPSULE THERAPY PACK 4 ST2
1.5 & 3 MG
ziprasidone hcl oral capsule 20 mg, 40 mg 2 MO; QL (60 per 30 days)
ziprasidone hcl oral capsule 60 mg, 80 mg 4 MO; QL (60 per 30 days)
36
ZYPREXA RELPREVV INTRAMUSCULAR 4 PA2; ST2; HRM; QL (2 per 28 days)
SUSPENSION RECONSTITUTED 210 MG
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
valganciclovir hcl oral solution reconstituted 50 4 MO
mg/ml
valganciclovir hcl oral tablet 450 mg 5
ZIRGAN OPHTHALMIC GEL 0.15 % 3
ANTIHEPATITIS AGENTS
entecavir oral tablet 0.5 mg 4 PA1; MO; QL (30 per 30 days)
entecavir oral tablet 1 mg 5 PA1; QL (30 per 30 days)
EPIVIR HBV ORAL SOLUTION 5 MG/ML 3 MO
lamivudine oral tablet 100 mg 3 MO; QL (90 per 30 days)
VEMLIDY ORAL TABLET 25 MG 5 PA1; QL (30 per 30 days)
ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil oral tablet 10 mg 4 PA1; MO; QL (30 per 30 days)
INTRON A INJECTION SOLUTION 10000000 5 PA2
UNIT/ML, 6000000 UNIT/ML
INTRON A INJECTION SOLUTION 5 PA2
RECONSTITUTED 10000000 UNIT, 18000000
UNIT, 50000000 UNIT
ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING
MAVYRET ORAL TABLET 100-40 MG 5 PA1
sofosbuvir-velpatasvir oral tablet 400-100 mg 5 PA1
VOSEVI ORAL TABLET 400-100-100 MG 5 PA1
ANTI-HEPATITIS C (HCV) AGENTS, OTHER
PEGASYS PROCLICK SUBCUTANEOUS 5 PA1
SOLUTION 180 MCG/0.5ML
PEGASYS SUBCUTANEOUS SOLUTION 180 5 PA1
MCG/0.5ML, 180 MCG/ML
RIBASPHERE ORAL CAPSULE 200 MG 3
ribavirin oral capsule 200 mg 4
ribavirin oral tablet 200 mg 4
37
SYLATRON SUBCUTANEOUS KIT 200 MCG, 5 PA2; QL (4 per 28 days)
300 MCG, 600 MCG
ANTIHERPETIC AGENTS
acyclovir oral capsule 200 mg 1
acyclovir oral suspension 200 mg/5ml 2
acyclovir oral tablet 400 mg, 800 mg 1
acyclovir sodium intravenous solution 50 mg/ml 2 BvD
famciclovir oral tablet 125 mg, 250 mg, 500 mg 2
valacyclovir hcl oral tablet 1 gm, 500 mg 2
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE
INHIBITORS
ATRIPLA ORAL TABLET 600-200-300 MG 5 QL (30 per 30 days)
COMPLERA ORAL TABLET 200-25-300 MG 5 QL (30 per 30 days)
EDURANT ORAL TABLET 25 MG 5 QL (30 per 30 days)
efavirenz oral capsule 200 mg 3 MO; QL (120 per 30 days)
efavirenz oral capsule 50 mg 4 MO; QL (480 per 30 days)
efavirenz oral tablet 600 mg 5 QL (30 per 30 days)
INTELENCE ORAL TABLET 100 MG 5 QL (120 per 30 days)
INTELENCE ORAL TABLET 200 MG 5 QL (60 per 30 days)
INTELENCE ORAL TABLET 25 MG 4 MO; QL (120 per 30 days)
nevirapine er oral tablet extended release 24 hour 2 MO; QL (90 per 30 days)
100 mg
nevirapine er oral tablet extended release 24 hour 4 MO; QL (30 per 30 days)
400 mg
nevirapine oral suspension 50 mg/5ml 4 MO; QL (1200 per 30 days)
nevirapine oral tablet 200 mg 2 MO; QL (60 per 30 days)
PIFELTRO ORAL TABLET 100 MG 5 QL (30 per 30 days)
RESCRIPTOR ORAL TABLET 200 MG 4 MO; QL (180 per 30 days)
SYMFI LO ORAL TABLET 400-300-300 MG 5 QL (30 per 30 days)
SYMFI ORAL TABLET 600-300-300 MG 5 QL (30 per 30 days)
SYMTUZA ORAL TABLET 800-150-200-10 MG 5 QL (30 per 30 days)
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE
TRANSCRIPTASE INHIBITORS
38
abacavir sulfate oral solution 20 mg/ml 4 MO; QL (960 per 30 days)
abacavir sulfate oral tablet 300 mg 4 MO; QL (60 per 30 days)
abacavir sulfate-lamivudine oral tablet 600-300 5 QL (30 per 30 days)
mg
abacavir-lamivudine-zidovudine oral tablet 300- 5 QL (60 per 30 days)
150-300 mg
CIMDUO ORAL TABLET 300-300 MG 5 QL (30 per 30 days)
DESCOVY ORAL TABLET 200-25 MG 5 QL (30 per 30 days)
didanosine oral capsule delayed release 200 mg 2 MO; QL (60 per 30 days)
EMTRIVA ORAL CAPSULE 200 MG 4 MO; QL (30 per 30 days)
EMTRIVA ORAL SOLUTION 10 MG/ML 4 MO; QL (680 per 28 days)
JULUCA ORAL TABLET 50-25 MG 5 QL (30 per 30 days)
lamivudine oral solution 10 mg/ml 4 MO; QL (900 per 30 days)
lamivudine-zidovudine oral tablet 150-300 mg 4 MO; QL (60 per 30 days)
stavudine oral capsule 15 mg, 20 mg 2 MO; QL (120 per 30 days)
stavudine oral capsule 30 mg, 40 mg 2 MO; QL (60 per 30 days)
tenofovir disoproxil fumarate oral tablet 300 mg 4 MO; QL (30 per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG 5 QL (30 per 30 days)
TRUVADA ORAL TABLET 100-150 MG, 133- 5 QL (30 per 30 days)
200 MG, 167-250 MG, 200-300 MG
VIDEX EC ORAL CAPSULE DELAYED 4 MO; QL (90 per 30 days)
RELEASE 125 MG
VIDEX ORAL SOLUTION RECONSTITUTED 4 4 MO; QL (1200 per 30 days)
GM
VIREAD ORAL POWDER 40 MG/GM 5 QL (240 per 30 days)
VIREAD ORAL TABLET 150 MG, 200 MG, 250 5 QL (30 per 30 days)
MG
zidovudine oral capsule 100 mg 2 MO; QL (180 per 30 days)
zidovudine oral syrup 50 mg/5ml 2 MO; QL (1680 per 28 days)
zidovudine oral tablet 300 mg 2 MO; QL (60 per 30 days)
39
ANTI-HIV AGENTS, OTHER
FUZEON SUBCUTANEOUS SOLUTION 5 QL (60 per 30 days)
RECONSTITUTED 90 MG
ISENTRESS HD ORAL TABLET 600 MG 5 QL (60 per 30 days)
ISENTRESS ORAL PACKET 100 MG 4 MO; QL (60 per 30 days)
ISENTRESS ORAL TABLET 400 MG 5 QL (120 per 30 days)
ISENTRESS ORAL TABLET CHEWABLE 100 4 MO; QL (180 per 30 days)
MG, 25 MG
SELZENTRY ORAL SOLUTION 20 MG/ML 4 MO; QL (1800 per 30 days)
SELZENTRY ORAL TABLET 150 MG 5 QL (240 per 30 days)
SELZENTRY ORAL TABLET 25 MG 4 MO; QL (120 per 30 days)
SELZENTRY ORAL TABLET 300 MG 5 QL (120 per 30 days)
SELZENTRY ORAL TABLET 75 MG 4 MO; QL (60 per 30 days)
TIVICAY ORAL TABLET 10 MG 4 MO; QL (60 per 30 days)
TIVICAY ORAL TABLET 25 MG 5 QL (45 per 30 days)
TIVICAY ORAL TABLET 50 MG 5 QL (60 per 30 days)
TYBOST ORAL TABLET 150 MG 3 MO; QL (30 per 30 days)
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS ORAL CAPSULE 250 MG 4 MO; QL (120 per 30 days)
APTIVUS ORAL SOLUTION 100 MG/ML 4 MO; QL (285 per 28 days)
atazanavir sulfate oral capsule 150 mg, 200 mg 4 MO; QL (60 per 30 days)
atazanavir sulfate oral capsule 300 mg 5 QL (60 per 30 days)
CRIXIVAN ORAL CAPSULE 200 MG 3 MO; QL (450 per 30 days)
CRIXIVAN ORAL CAPSULE 400 MG 4 MO; QL (270 per 30 days)
DOVATO ORAL TABLET 50-300 MG 5 QL (30 per 30 days)
EVOTAZ ORAL TABLET 300-150 MG 5 QL (30 per 30 days)
fosamprenavir calcium oral tablet 700 mg 5 QL (120 per 30 days)
INVIRASE ORAL TABLET 500 MG 5 QL (120 per 30 days)
KALETRA ORAL TABLET 100-25 MG 4 MO; QL (300 per 30 days)
KALETRA ORAL TABLET 200-50 MG 5 QL (150 per 30 days)
LEXIVA ORAL SUSPENSION 50 MG/ML 4 MO; QL (1575 per 28 days)
lopinavir-ritonavir oral solution 400-100 mg/5ml 4 MO; QL (400 per 30 days)
NORVIR ORAL PACKET 100 MG 4 MO; QL (360 per 30 days)
40
NORVIR ORAL SOLUTION 80 MG/ML 4 MO; QL (480 per 30 days)
PREZCOBIX ORAL TABLET 800-150 MG 5 QL (30 per 30 days)
PREZISTA ORAL SUSPENSION 100 MG/ML 5 QL (360 per 30 days)
PREZISTA ORAL TABLET 150 MG 4 MO; QL (240 per 30 days)
PREZISTA ORAL TABLET 600 MG 5 QL (60 per 30 days)
PREZISTA ORAL TABLET 75 MG 4 MO; QL (480 per 30 days)
PREZISTA ORAL TABLET 800 MG 5 QL (30 per 30 days)
REYATAZ ORAL PACKET 50 MG 4 MO; QL (180 per 30 days)
ritonavir oral tablet 100 mg 4 MO; QL (360 per 30 days)
VIRACEPT ORAL TABLET 250 MG 4 MO; QL (300 per 30 days)
VIRACEPT ORAL TABLET 625 MG 5 QL (120 per 30 days)
ANTI-INFLUENZA AGENTS
oseltamivir phosphate oral capsule 30 mg, 45 mg, 2
75 mg
oseltamivir phosphate oral suspension 3
reconstituted 6 mg/ml
RELENZA DISKHALER INHALATION 4
AEROSOL POWDER BREATH ACTIVATED 5
MG/BLISTER
rimantadine hcl oral tablet 100 mg 2
XOFLUZA ORAL TABLET THERAPY PACK 2 3
X 20 MG, 2 X 40 MG
ANTIRETROVIRAL COMBINATIONS
BIKTARVY ORAL TABLET 50-200-25 MG 5 QL (30 per 30 days)
DELSTRIGO ORAL TABLET 100-300-300 MG 5 QL (30 per 30 days)
ODEFSEY ORAL TABLET 200-25-25 MG 5 QL (30 per 30 days)
STRIBILD ORAL TABLET 150-150-200-300 5 QL (30 per 30 days)
MG
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 1
mg, 7.5 mg
hydroxyzine hcl oral syrup 10 mg/5ml 4
hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA1; HRM
41
hydroxyzine pamoate oral capsule 100 mg, 25 mg, 2
50 mg
BENZODIAZEPINES
ALPRAZOLAM INTENSOL ORAL 2 QL (300 per 30 days)
CONCENTRATE 1 MG/ML
alprazolam oral tablet 0.25 mg, 0.5 mg 2 QL (120 per 30 days)
alprazolam oral tablet 1 mg 2 QL (240 per 30 days)
alprazolam oral tablet 2 mg 2 QL (150 per 30 days)
chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 2 QL (120 per 30 days)
mg
clonazepam oral tablet 0.5 mg, 1 mg 2 MO; QL (90 per 30 days)
clonazepam oral tablet 2 mg 2 MO; QL (300 per 30 days)
clonazepam oral tablet dispersible 0.125 mg, 0.25 2 MO; QL (90 per 30 days)
mg, 0.5 mg, 1 mg
clonazepam oral tablet dispersible 2 mg 2 MO; QL (300 per 30 days)
clorazepate dipotassium oral tablet 15 mg, 3.75 2 QL (180 per 30 days)
mg, 7.5 mg
DIAZEPAM INTENSOL ORAL 2 QL (240 per 30 days)
CONCENTRATE 5 MG/ML
diazepam oral solution 5 mg/5ml 4 QL (1200 per 30 days)
diazepam oral tablet 10 mg 1 QL (120 per 30 days)
lorazepam oral concentrate 2 mg/ml 2 QL (240 per 30 days)
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 2 QL (150 per 30 days)
BIPOLAR AGENTS
MOOD STABILIZERS
GEODON INTRAMUSCULAR SOLUTION 4 ST2; QL (18 per 30 days)
RECONSTITUTED 20 MG
lithium carbonate er oral tablet extended release 1 MO
300 mg, 450 mg
lithium carbonate oral capsule 150 mg, 300 mg, 1 MO
600 mg
lithium carbonate oral tablet 300 mg 1 MO
lithium oral solution 8 meq/5ml 1 MO
42
olanzapine-fluoxetine hcl oral capsule 12-25 mg, 4 MO; QL (30 per 30 days)
12-50 mg, 6-50 mg
olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6- 4 MO; QL (90 per 30 days)
25 mg
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS, SUPPLY
ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 3
1 ML
COMFORT ASSIST INSULIN SYRINGE 29G X 3
1/2" 1 ML
EXEL COMFORT POINT PEN NEEDLE 29G X 3
12MM
global alcohol prep ease pad 70 % 3
preferred plus insulin syringe 28g x 1/2" 0.5 ml 3
RELI-ON INSULIN SYRINGE 29G 0.3 ML 3
ANTIDIABETIC AGENTS
acarbose oral tablet 100 mg, 25 mg, 50 mg 2 MO
glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 MO
glipizide er oral tablet extended release 24 hour 1 MO
10 mg, 2.5 mg, 5 mg
glipizide oral tablet 10 mg, 5 mg 1 MO
glipizide-metformin hcl oral tablet 2.5-250 mg, 1 MO
2.5-500 mg, 5-500 mg
glyburide-metformin oral tablet 1.25-250 mg, 2.5- 2 MO
500 mg, 5-500 mg
INVOKAMET ORAL TABLET 150-1000 MG, 3 MO
150-500 MG, 50-1000 MG, 50-500 MG
INVOKAMET XR ORAL TABLET EXTENDED 3 MO
RELEASE 24 HOUR 150-1000 MG, 150-500
MG, 50-1000 MG, 50-500 MG
INVOKANA ORAL TABLET 100 MG, 300 MG 3 MO
JANUMET ORAL TABLET 50-1000 MG, 50-500 3 MO
MG
JANUMET XR ORAL TABLET EXTENDED 3 MO
RELEASE 24 HOUR 100-1000 MG, 50-1000
MG, 50-500 MG
43
JANUVIA ORAL TABLET 100 MG, 25 MG, 50 3 MO
MG
JARDIANCE ORAL TABLET 10 MG, 25 MG 3 MO
metformin hcl er oral tablet extended release 24 1 MO
hour 500 mg, 750 mg
metformin hcl oral tablet 1000 mg, 500 mg, 850 1 MO
mg
miglitol oral tablet 100 mg, 25 mg, 50 mg 2 MO
nateglinide oral tablet 120 mg, 60 mg 2 MO
OZEMPIC SUBCUTANEOUS SOLUTION PEN- 3 MO
INJECTOR 0.25 OR 0.5 MG/DOSE, 1 MG/DOSE
pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg 1 MO
pioglitazone hcl-glimepiride oral tablet 30-2 mg, 2 MO
30-4 mg
pioglitazone hcl-metformin hcl oral tablet 15-500 2 MO
mg, 15-850 mg
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 2 MO
repaglinide-metformin hcl oral tablet 1-500 mg, 2- 3 MO
500 mg
SOLIQUA SUBCUTANEOUS SOLUTION PEN- 3 MO
INJECTOR 100-33 UNT-MCG/ML
SYNJARDY ORAL TABLET 12.5-1000 MG, 3 MO
12.5-500 MG, 5-1000 MG, 5-500 MG
SYNJARDY XR ORAL TABLET EXTENDED 3 MO
RELEASE 24 HOUR 10-1000 MG, 12.5-1000
MG, 25-1000 MG, 5-1000 MG
TRULICITY SUBCUTANEOUS SOLUTION 3 MO
PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML
VICTOZA SUBCUTANEOUS SOLUTION PEN- 3 MO
INJECTOR 18 MG/3ML
XULTOPHY SUBCUTANEOUS SOLUTION 3 MO
PEN-INJECTOR 100-3.6 UNIT-MG/ML
GLYCEMIC AGENTS
GLUCAGEN HYPOKIT INJECTION 3
SOLUTION RECONSTITUTED 1 MG
GLUCAGON EMERGENCY INJECTION KIT 1 3
MG
44
PROGLYCEM ORAL SUSPENSION 50 MG/ML 5
INSULINS
FIASP FLEXTOUCH SUBCUTANEOUS 3 MO
SOLUTION PEN-INJECTOR 100 UNIT/ML
FIASP SUBCUTANEOUS SOLUTION 100 3 MO
UNIT/ML
HUMULIN R U-500 (CONCENTRATED) 3 MO
SUBCUTANEOUS SOLUTION 500 UNIT/ML
HUMULIN R U-500 KWIKPEN 3 MO
SUBCUTANEOUS SOLUTION PEN-INJECTOR
500 UNIT/ML
LANTUS SOLOSTAR SUBCUTANEOUS 3 MO
LANTUS SUBCUTANEOUS SOLUTION 100 3 MO
UNIT/ML
LEVEMIR FLEXTOUCH SUBCUTANEOUS 3 MO
LEVEMIR SUBCUTANEOUS SOLUTION 100 3 MO
UNIT/ML
NOVOLIN 70/30 SUBCUTANEOUS 3 MO
SUSPENSION (70-30) 100 UNIT/ML
NOVOLIN N SUBCUTANEOUS SUSPENSION 3 MO
100 UNIT/ML
NOVOLIN R INJECTION SOLUTION 100 3 MO
UNIT/ML
NOVOLOG FLEXPEN SUBCUTANEOUS 3 MO
NOVOLOG MIX 70/30 FLEXPEN 3 MO
SUBCUTANEOUS SUSPENSION PEN-
INJECTOR (70-30) 100 UNIT/ML
NOVOLOG MIX 70/30 SUBCUTANEOUS 3 MO
SUSPENSION (70-30) 100 UNIT/ML
NOVOLOG PENFILL SUBCUTANEOUS 3 MO
SOLUTION CARTRIDGE 100 UNIT/ML
NOVOLOG SUBCUTANEOUS SOLUTION 100 3 MO
UNIT/ML
TOUJEO MAX SOLOSTAR SUBCUTANEOUS 3 MO
45
TOUJEO SOLOSTAR SUBCUTANEOUS 3 MO
TRESIBA FLEXTOUCH SUBCUTANEOUS 3 MO
SOLUTION PEN-INJECTOR 100 UNIT/ML, 200
UNIT/ML
TRESIBA SUBCUTANEOUS SOLUTION 100 3 MO
UNIT/ML
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
ELIQUIS ORAL TABLET 2.5 MG, 5 MG 3 MO
ELIQUIS STARTER PACK ORAL TABLET 5 3 MO
MG
enoxaparin sodium subcutaneous solution 100 4 QL (30 per 30 days)
mg/ml, 150 mg/ml
mg/0.8ml, 80 mg/0.8ml
mg/0.3ml
mg/0.4ml
mg/0.6ml
fondaparinux sodium subcutaneous solution 10 5 QL (11.2 per 30 days)
mg/0.8ml
fondaparinux sodium subcutaneous solution 2.5 4 QL (7 per 30 days)
mg/0.5ml
fondaparinux sodium subcutaneous solution 5 5 QL (5.6 per 30 days)
mg/0.4ml
fondaparinux sodium subcutaneous solution 7.5 5 QL (8.4 per 30 days)
mg/0.6ml
heparin sodium (porcine) injection solution 1000 2 BvD
unit/ml, 10000 unit/ml, 20000 unit/ml
heparin sodium (porcine) injection solution 5000 1 BvD
unit/ml
JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 1 MO
MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG
warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 1 MO
mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
46
XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 3 MO
MG, 20 MG
XARELTO STARTER PACK ORAL TABLET 3
THERAPY PACK 15 & 20 MG
BLOOD FORMATION MODIFIERS
LEUKINE INJECTION SOLUTION 5 PA1
RECONSTITUTED 250 MCG
LEUKINE INTRAVENOUS SOLUTION 5 PA1
RECONSTITUTED 250 MCG
NEUPOGEN INJECTION SOLUTION 300 5 PA1; QL (14 per 30 days)
MCG/ML, 480 MCG/1.6ML
NEUPOGEN INJECTION SOLUTION 5 PA1; QL (14 per 30 days)
PREFILLED SYRINGE 300 MCG/0.5ML, 480
MCG/0.8ML
pentoxifylline er oral tablet extended release 400 1 MO
mg
PROCRIT INJECTION SOLUTION 10000 4 PA1; QL (12 per 28 days)
UNIT/ML, 4000 UNIT/ML
UNIT/ML
UNIT/ML
UNIT/ML
UNIT/ML
PROMACTA ORAL PACKET 12.5 MG 5 PA1; QL (360 per 30 days)
PROMACTA ORAL TABLET 12.5 MG 5 PA1; QL (60 per 30 days)
PROMACTA ORAL TABLET 50 MG, 75 MG 5 PA1; QL (30 per 30 days)
RETACRIT INJECTION SOLUTION 10000 4 PA1; MO; QL (12 per 28 days)
UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML
UNIT/ML
UNIT/ML
tranexamic acid oral tablet 650 mg 2
PLATELET MODIFYING AGENTS
47
anagrelide hcl oral capsule 0.5 mg, 1 mg 2 MO
aspirin-dipyridamole er oral capsule extended 2 MO
release 12 hour 25-200 mg
BRILINTA ORAL TABLET 60 MG 3 MO
BRILINTA ORAL TABLET 90 MG 3 MO; QL (60 per 30 days)
CABLIVI INJECTION KIT 11 MG 5 PA1; LA
cilostazol oral tablet 100 mg, 50 mg 2 MO
clopidogrel bisulfate oral tablet 75 mg 2 MO
prasugrel hcl oral tablet 10 mg, 5 mg 3 MO
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 MO
clonidine transdermal patch weekly 0.1 mg/24hr, 2 MO
0.2 mg/24hr, 0.3 mg/24hr
guanfacine hcl oral tablet 1 mg, 2 mg 1 MO
methyldopa oral tablet 250 mg, 500 mg 1 PA1; MO; HRM
midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 2
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg 1 MO; QL (45 per 30 days)
doxazosin mesylate oral tablet 8 mg 1 MO; QL (60 per 30 days)
prazosin hcl oral capsule 1 mg, 2 mg 1 MO
prazosin hcl oral capsule 5 mg 2 MO
terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 MO
ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesartan cilexetil oral tablet 16 mg, 4 mg, 8 mg 1 MO; QL (60 per 30 days)
candesartan cilexetil oral tablet 32 mg 1 MO; QL (30 per 30 days)
eprosartan mesylate oral tablet 600 mg 3 MO; QL (30 per 30 days)
irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 MO; QL (30 per 30 days)
losartan potassium oral tablet 100 mg, 25 mg 1 MO; QL (30 per 30 days)
losartan potassium oral tablet 50 mg 1 MO; QL (60 per 30 days)
olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 1 MO
mg
telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 MO; QL (30 per 30 days)
48
valsartan oral tablet 160 mg, 320 mg 1 MO; QL (30 per 30 days)
valsartan oral tablet 40 mg, 80 mg 1 MO; QL (90 per 30 days)
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 1 MO
mg
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 1 MO
mg
enalapril maleate oral tablet 10 mg, 2.5 mg, 20 1 MO
mg, 5 mg
fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1 MO
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 1 MO
40 mg, 5 mg
moexipril hcl oral tablet 15 mg, 7.5 mg 1 MO
perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 MO
quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 1 MO
mg
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 1 MO
mg
trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 MO
ANTIARRHYTHMICS
amiodarone hcl oral tablet 100 mg, 200 mg, 400 2 MO
mg
disopyramide phosphate oral capsule 100 mg, 150 2 PA1; MO; HRM
mg
dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 4 MO
flecainide acetate oral tablet 100 mg, 150 mg, 50 2 MO
mg
mexiletine hcl oral capsule 150 mg, 200 mg, 250 2 MO
mg
PACERONE ORAL TABLET 100 MG, 200 MG, 4 MO
400 MG
propafenone hcl er oral capsule extended release 4 MO
12 hour 225 mg, 325 mg, 425 mg
propafenone hcl oral tablet 150 mg, 225 mg, 300 2 MO
mg
quinidine sulfate oral tablet 200 mg, 300 mg 1 MO
49
SORINE ORAL TABLET 120 MG, 160 MG, 240 2 MO
MG, 80 MG
sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 2 MO
sotalol hcl oral tablet 160 mg, 240 mg, 80 mg 2 MO
ANTIHYPERTENSIVE COMBINATIONS
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 MO
amlodipine besy-benazepril hcl oral capsule 10-20 2 MO; QL (30 per 30 days)
mg
amlodipine besy-benazepril hcl oral capsule 10-40 1 MO; QL (30 per 30 days)
mg, 5-40 mg
amlodipine besy-benazepril hcl oral capsule 2.5- 1 MO; QL (45 per 30 days)
10 mg, 5-10 mg, 5-20 mg
amlodipine besylate-valsartan oral tablet 10-160 2 MO; QL (30 per 30 days)
mg, 10-320 mg, 5-160 mg, 5-320 mg
amlodipine-olmesartan oral tablet 10-20 mg, 10- 2 MO; QL (30 per 30 days)
40 mg, 5-20 mg, 5-40 mg
amlodipine-valsartan-hctz oral tablet 10-160-12.5 2 MO; QL (30 per 30 days)
mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg,
5-160-25 mg
atenolol-chlorthalidone oral tablet 100-25 mg, 50- 1 MO
25 mg
benazepril-hydrochlorothiazide oral tablet 10-12.5 2 MO
mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg
bisoprolol-hydrochlorothiazide oral tablet 10-6.25 1 MO
mg, 2.5-6.25 mg, 5-6.25 mg
candesartan cilexetil-hctz oral tablet 16-12.5 mg, 2 MO; QL (30 per 30 days)
32-12.5 mg, 32-25 mg
captopril-hydrochlorothiazide oral tablet 25-15 2 MO
mg, 25-25 mg, 50-15 mg, 50-25 mg
enalapril-hydrochlorothiazide oral tablet 10-25 1 MO
mg, 5-12.5 mg
ENTRESTO ORAL TABLET 24-26 MG, 49-51 3 PA1; MO
MG, 97-103 MG
fosinopril sodium-hctz oral tablet 10-12.5 mg, 20- 1 MO
12.5 mg
irbesartan-hydrochlorothiazide oral tablet 150- 1 MO; QL (30 per 30 days)
12.5 mg, 300-12.5 mg
50
lisinopril-hydrochlorothiazide oral tablet 10-12.5 1 MO
mg, 20-12.5 mg, 20-25 mg
losartan potassium-hctz oral tablet 100-12.5 mg, 1 MO; QL (30 per 30 days)
100-25 mg, 50-12.5 mg
metoprolol-hydrochlorothiazide oral tablet 100-25 1 MO
mg, 100-50 mg, 50-25 mg
olmesartan medoxomil-hctz oral tablet 20-12.5 2 MO; QL (30 per 30 days)
mg, 40-12.5 mg, 40-25 mg
olmesartan-amlodipine-hctz oral tablet 20-5-12.5 2 MO; QL (30 per 30 days)
mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg,
40-5-25 mg
propranolol-hctz oral tablet 40-25 mg, 80-25 mg 1 MO
quinapril-hydrochlorothiazide oral tablet 10-12.5 1 MO
mg, 20-12.5 mg, 20-25 mg
spironolactone-hctz oral tablet 25-25 mg 1 MO
TEKTURNA HCT ORAL TABLET 150-12.5 3 MO; QL (30 per 30 days)
MG, 150-25 MG, 300-12.5 MG, 300-25 MG
telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 2 MO; QL (30 per 30 days)
mg, 80-25 mg
triamterene-hctz oral capsule 37.5-25 mg 1 MO
triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 MO
valsartan-hydrochlorothiazide oral tablet 160-12.5 1 MO; QL (30 per 30 days)
mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5
mg
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl oral capsule 200 mg, 400 mg 1 MO
atenolol oral tablet 100 mg, 25 mg, 50 mg 1 MO
betaxolol hcl oral tablet 10 mg, 20 mg 1 MO
bisoprolol fumarate oral tablet 10 mg, 5 mg 1 MO
BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 4 MO
MG, 5 MG
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 1 MO
6.25 mg
labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 MO
metoprolol succinate er oral tablet extended 1 MO
release 24 hour 100 mg, 25 mg, 50 mg
51
metoprolol succinate er oral tablet extended 2 MO
release 24 hour 200 mg
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 1 MO
mg
nadolol oral tablet 20 mg, 40 mg, 80 mg 2 MO
pindolol oral tablet 10 mg, 5 mg 2 MO
propranolol hcl er oral capsule extended release 2 MO
24 hour 120 mg, 160 mg, 60 mg, 80 mg
propranolol hcl oral solution 20 mg/5ml, 40 2 MO
mg/5ml
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 1 MO
60 mg, 80 mg
sotalol hcl oral tablet 120 mg 2 MO
timolol maleate oral tablet 10 mg, 5 mg 1 MO
timolol maleate oral tablet 20 mg 2 MO
CALCIUM CHANNEL BLOCKING AGENTS
amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 1 MO
mg
CARTIA XT ORAL CAPSULE EXTENDED 4 MO; QL (60 per 30 days)
RELEASE 24 HOUR 120 MG, 180 MG, 240 MG
CARTIA XT ORAL CAPSULE EXTENDED 4 MO; QL (30 per 30 days)
diltiazem hcl er beads oral capsule extended 2 MO; QL (30 per 30 days)
release 24 hour 360 mg, 420 mg
diltiazem hcl er coated beads oral capsule 1 MO; QL (60 per 30 days)
extended release 24 hour 120 mg, 180 mg, 240 mg
diltiazem hcl er coated beads oral capsule 1 MO; QL (30 per 30 days)
diltiazem hcl er oral capsule extended release 12 2 MO
hour 120 mg, 60 mg, 90 mg
diltiazem hcl oral tablet 120 mg, 90 mg 2 MO
diltiazem hcl oral tablet 30 mg, 60 mg 1 MO
dilt-xr oral capsule extended release 24 hour 120 4 MO; QL (60 per 30 days)
mg, 180 mg, 240 mg
felodipine er oral tablet extended release 24 hour 1 MO; QL (30 per 30 days)
10 mg, 2.5 mg, 5 mg
isradipine oral capsule 2.5 mg 1 MO
52
isradipine oral capsule 5 mg 2 MO
nicardipine hcl oral capsule 20 mg, 30 mg 2 MO
nifedipine er oral tablet extended release 24 hour 1 MO; QL (60 per 30 days)
30 mg, 60 mg
nifedipine er oral tablet extended release 24 hour 1 MO; QL (30 per 30 days)
90 mg
nifedipine er osmotic release oral tablet extended 1 MO; QL (60 per 30 days)
nifedipine er osmotic release oral tablet extended 1 MO; QL (30 per 30 days)
TAZTIA XT ORAL CAPSULE EXTENDED 4 MO; QL (60 per 30 days)
RELEASE 24 HOUR 120 MG, 180 MG, 240 MG
TAZTIA XT ORAL CAPSULE EXTENDED 4 MO; QL (30 per 30 days)
verapamil hcl er oral capsule extended release 24 2 MO; QL (30 per 30 days)
hour 100 mg, 300 mg
verapamil hcl er oral capsule extended release 24 2 MO; QL (60 per 30 days)
hour 120 mg, 180 mg, 200 mg, 240 mg, 360 mg
verapamil hcl er oral tablet extended release 120 1 MO
mg, 180 mg, 240 mg
verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 MO
CARDIOVASCULAR AGENTS, OTHER
aliskiren fumarate oral tablet 150 mg, 300 mg 3 MO; QL (30 per 30 days)
amlodipine-atorvastatin oral tablet 10-10 mg, 10- 2 MO
20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg,
2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
CINRYZE INTRAVENOUS SOLUTION 5 PA1; LA
RECONSTITUTED 500 UNIT
CORLANOR ORAL TABLET 5 MG, 7.5 MG 4 MO
DIGITEK ORAL TABLET 125 MCG 2 MO; QL (30 per 30 days)
DIGITEK ORAL TABLET 250 MCG 2 PA1; MO; HRM; QL (30 per 30 days)
DIGOX ORAL TABLET 125 MCG 2 MO; QL (30 per 30 days)
DIGOX ORAL TABLET 250 MCG 2 PA1; MO; HRM; QL (30 per 30 days)
digoxin oral solution 0.05 mg/ml 2 PA1; MO; HRM; QL (255 per 30
days)
digoxin oral tablet 125 mcg 2 MO; QL (30 per 30 days)
53
digoxin oral tablet 250 mcg 2 PA1; MO; HRM; QL (30 per 30 days)
FIRAZYR SUBCUTANEOUS SOLUTION 30 5 PA1
MG/3ML
NORTHERA ORAL CAPSULE 100 MG, 200 5 PA1; LA; QL (180 per 30 days)
MG, 300 MG
ranolazine er oral tablet extended release 12 hour 3 ST1; MO
1000 mg, 500 mg
TAKHZYRO SUBCUTANEOUS SOLUTION 5 PA1; LA; QL (4 per 28 days)
300 MG/2ML
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide er oral capsule extended release 12 2 MO
hour 500 mg
acetazolamide oral tablet 125 mg, 250 mg 2 MO
methazolamide oral tablet 25 mg, 50 mg 4 MO
DIURETICS, LOOP
bumetanide injection solution 0.25 mg/ml 2
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 2 MO
furosemide injection solution 10 mg/ml, 10 mg/ml 2 BvD
(4ml syringe)
furosemide oral solution 10 mg/ml, 8 mg/ml 1 MO
furosemide oral tablet 20 mg, 40 mg, 80 mg 1 MO
torsemide oral tablet 10 mg, 20 mg, 5 mg 1 MO
torsemide oral tablet 100 mg 2 MO
DIURETICS, POTASSIUM-SPARING
amiloride hcl oral tablet 5 mg 1 MO
eplerenone oral tablet 25 mg, 50 mg 2 MO
spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 MO
DIURETICS, THIAZIDE
chlorothiazide oral tablet 250 mg 1 MO
chlorothiazide oral tablet 500 mg 2 MO
chlorthalidone oral tablet 25 mg, 50 mg 1 MO
hydrochlorothiazide oral capsule 12.5 mg 1 MO
hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 1 MO
mg
54
indapamide oral tablet 1.25 mg, 2.5 mg 1 MO
metolazone oral tablet 10 mg 2 MO
metolazone oral tablet 2.5 mg, 5 mg 1 MO
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
fenofibrate micronized oral capsule 130 mg, 134 2 MO; QL (30 per 30 days)
mg, 200 mg, 67 mg
fenofibrate micronized oral capsule 43 mg 2 MO; QL (60 per 30 days)
fenofibrate oral capsule 150 mg 2 MO; QL (30 per 30 days)
fenofibrate oral capsule 50 mg 2 MO; QL (60 per 30 days)
fenofibrate oral tablet 145 mg, 160 mg 2 MO; QL (30 per 30 days)
fenofibrate oral tablet 40 mg, 48 mg, 54 mg 2 MO; QL (60 per 30 days)
gemfibrozil oral tablet 600 mg 2 MO
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
atorvastatin calcium oral tablet 10 mg, 20 mg, 40 1 MO; QL (30 per 30 days)
mg, 80 mg
LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG 3 MO
lovastatin oral tablet 10 mg 1 MO; QL (45 per 30 days)
pravastatin sodium oral tablet 10 mg, 20 mg, 40 1 MO; QL (30 per 30 days)
mg, 80 mg
rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 2 MO
mg, 5 mg
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 1 MO; QL (30 per 30 days)
80 mg
DYSLIPIDEMICS, OTHER
cholestyramine light oral powder 4 gm/dose 2 MO
cholestyramine oral packet 4 gm 2 MO
colesevelam hcl oral packet 3.75 gm 2 MO
colesevelam hcl oral tablet 625 mg 2 MO
colestipol hcl oral packet 5 gm 2 MO
colestipol hcl oral tablet 1 gm 2 MO
ezetimibe oral tablet 10 mg 3 MO
55
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 5 PA1
MG, 40 MG, 5 MG
KYNAMRO SUBCUTANEOUS SOLUTION 5 PA1; LA
PREFILLED SYRINGE 200 MG/ML
niacin er (antihyperlipidemic) oral tablet extended 2 MO
release 1000 mg, 500 mg, 750 mg
omega-3-acid ethyl esters oral capsule 1 gm 2 MO
PRALUENT SUBCUTANEOUS SOLUTION 5 PA1
PEN-INJECTOR 150 MG/ML, 75 MG/ML
PREVALITE ORAL PACKET 4 GM 4 MO
REPATHA PUSHTRONEX SYSTEM 5 PA1
SUBCUTANEOUS SOLUTION CARTRIDGE
420 MG/3.5ML
REPATHA SUBCUTANEOUS SOLUTION 5 PA1
REPATHA SURECLICK SUBCUTANEOUS 5 PA1
SOLUTION AUTO-INJECTOR 140 MG/ML
VASCEPA ORAL CAPSULE 0.5 GM, 1 GM 4 MO
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
isosorbide dinitrate er oral tablet extended release 2 MO
40 mg
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 1 MO
mg, 5 mg
isosorbide mononitrate er oral tablet extended 2 MO
isosorbide mononitrate er oral tablet extended 1 MO
isosorbide mononitrate oral tablet 10 mg, 20 mg 1 MO
MINITRAN TRANSDERMAL PATCH 24 3 MO; QL (30 per 30 days)
HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6
MG/HR
NITRO-DUR TRANSDERMAL PATCH 24 3 MO
HOUR 0.3 MG/HR, 0.8 MG/HR
nitroglycerin sublingual tablet sublingual 0.3 mg, 1 MO
0.4 mg, 0.6 mg
nitroglycerin transdermal patch 24 hour 0.1 1 MO; QL (30 per 30 days)
mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr
nitroglycerin translingual solution 0.4 mg/spray 2 MO
56
NITROSTAT SUBLINGUAL TABLET 1 MO
SUBLINGUAL 0.4 MG
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 1 MO
50 mg
minoxidil oral tablet 10 mg, 2.5 mg 1 MO
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
amphetamine-dextroamphetamine oral tablet 10 2 MO; QL (90 per 30 days)
mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
amphetamine-dextroamphetamine oral tablet 30 2 MO; QL (60 per 30 days)
mg
dextroamphetamine sulfate er oral capsule 4 MO; QL (180 per 30 days)
dextroamphetamine sulfate oral tablet 10 mg 4 MO; QL (180 per 30 days)
dextroamphetamine sulfate oral tablet 5 mg 4 MO; QL (150 per 30 days)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-
AMPHETAMINES
atomoxetine hcl oral capsule 10 mg, 100 mg, 18 4 ST1; MO; QL (30 per 30 days)
mg, 25 mg, 40 mg, 60 mg, 80 mg
dexmethylphenidate hcl oral tablet 2.5 mg 1 MO; QL (240 per 30 days)
dexmethylphenidate hcl oral tablet 5 mg 1 MO; QL (120 per 30 days)
guanfacine hcl er oral tablet extended release 24 4 MO
hour 1 mg, 2 mg, 3 mg, 4 mg
METADATE ER ORAL TABLET EXTENDED 4 MO; QL (90 per 30 days)
RELEASE 20 MG
methylphenidate hcl er oral tablet extended 4 MO; QL (90 per 30 days)
release 10 mg, 20 mg
methylphenidate hcl oral solution 10 mg/5ml 4 MO; QL (900 per 30 days)
methylphenidate hcl oral solution 5 mg/5ml 4 MO; QL (1800 per 30 days)
methylphenidate hcl oral tablet 10 mg, 5 mg 1 MO; QL (90 per 30 days)
methylphenidate hcl oral tablet 20 mg 2 MO; QL (90 per 30 days)
57
CENTRAL NERVOUS SYSTEM, OTHER
NUEDEXTA ORAL CAPSULE 20-10 MG 3 PA1; MO
riluzole oral tablet 50 mg 4 MO
TEGSEDI SUBCUTANEOUS SOLUTION 5 PA1
PREFILLED SYRINGE 284 MG/1.5ML
tetrabenazine oral tablet 12.5 mg 5 PA1; QL (240 per 30 days)
tetrabenazine oral tablet 25 mg 5 PA1; QL (120 per 30 days)
TIGLUTIK ORAL SUSPENSION 50 MG/10ML 5
FIBROMYALGIA AGENTS
LYRICA ORAL CAPSULE 150 MG 3 MO; QL (90 per 30 days)
LYRICA ORAL CAPSULE 75 MG 3 MO; QL (120 per 30 days)
SAVELLA ORAL TABLET 100 MG, 12.5 MG, 3 MO; QL (60 per 30 days)
25 MG, 50 MG
SAVELLA TITRATION PACK ORAL 12.5 & 25 3 QL (110 per 365 days)
& 50 MG
MULTIPLE SCLEROSIS AGENTS
AUBAGIO ORAL TABLET 14 MG, 7 MG 5 PA1; QL (30 per 30 days)
AVONEX INTRAMUSCULAR KIT 30 MCG 5 PA1
AVONEX PEN INTRAMUSCULAR AUTO- 5 PA1
INJECTOR KIT 30 MCG/0.5ML
AVONEX PREFILLED INTRAMUSCULAR 5 PA1
PREFILLED SYRINGE KIT 30 MCG/0.5ML
BETASERON SUBCUTANEOUS KIT 0.3 MG 5 PA1; QL (15 per 30 days)
COPAXONE SUBCUTANEOUS SOLUTION 5 PA1
PREFILLED SYRINGE 20 MG/ML, 40 MG/ML
dalfampridine er oral tablet extended release 12 5 PA1; QL (60 per 30 days)
hour 10 mg
GILENYA ORAL CAPSULE 0.5 MG 5 PA1; QL (28 per 28 days)
glatiramer acetate subcutaneous solution prefilled 5 PA1; QL (30 per 30 days)
syringe 20 mg/ml
glatiramer acetate subcutaneous solution prefilled 5 PA1; QL (12 per 28 days)
syringe 40 mg/ml
MAYZENT ORAL TABLET 0.25 MG 5 PA1; QL (210 per 30 days)
MAYZENT ORAL TABLET 2 MG 5 PA1; QL (30 per 30 days)
58
PLEGRIDY STARTER PACK 5 PA1
SUBCUTANEOUS SOLUTION PEN-INJECTOR
63 & 94 MCG/0.5ML
PLEGRIDY SUBCUTANEOUS SOLUTION 5 PA1
PEN-INJECTOR 125 MCG/0.5ML
PLEGRIDY SUBCUTANEOUS SOLUTION 5 PA1
PREFILLED SYRINGE 125 MCG/0.5ML
TECFIDERA ORAL 120 & 240 MG 5 PA1
TECFIDERA ORAL CAPSULE DELAYED 5 PA1; QL (60 per 30 days)
RELEASE 120 MG, 240 MG
DENTAL AND ORAL AGENTS
DENTAL AND ORAL AGENTS
chlorhexidine gluconate mouth/throat solution 1
0.12 %
clotrimazole mouth/throat lozenge 10 mg 1
lidocaine viscous hcl mouth/throat solution 2 % 4
lidocaine viscous mouth/throat solution 2 % 4
nystatin mouth/throat suspension 100000 unit/ml 2
pilocarpine hcl oral tablet 5 mg, 7.5 mg 2 MO
triamcinolone acetonide mouth/throat paste 0.1 % 2
DERMATOLOGICAL AGENTS
DERMATOLOGICAL AGENTS
acitretin oral capsule 10 mg 4 PA1
acitretin oral capsule 17.5 mg, 25 mg 5 PA1
amcinonide external cream 0.1 % 4
amcinonide external ointment 0.1 % 4
ammonium lactate external lotion 12 % 1
AMNESTEEM ORAL CAPSULE 10 MG, 20 4
MG, 40 MG
benzoyl peroxide-erythromycin external gel 5-3 % 2
betamethasone dipropionate aug external lotion 2
0.05 %
betamethasone dipropionate external cream 0.05 2
%
59
betamethasone dipropionate external lotion 0.05 1
%
betamethasone dipropionate external ointment 2
0.05 %
betamethasone valerate external cream 0.1 % 1
betamethasone valerate external lotion 0.1 % 1
betamethasone valerate external ointment 0.1 % 1
calcipotriene external solution 0.005 % 4
CLARAVIS ORAL CAPSULE 20 MG, 30 MG, 4
40 MG
clindamycin phos-benzoyl perox external gel 1-5 2
%
clindamycin phosphate external gel 1 % 2
clindamycin phosphate external lotion 1 % 2
clindamycin phosphate external solution 1 % 2
clobetasol prop emollient base external cream 4
0.05 %
clobetasol propionate external cream 0.05 % 4
clobetasol propionate external gel 0.05 % 4
clobetasol propionate external ointment 0.05 % 4
clobetasol propionate external solution 0.05 % 2
clotrimazole-betamethasone external cream 1-0.05 2
%
clotrimazole-betamethasone external lotion 1-0.05 2
%
COLOCORT RECTAL ENEMA 100 MG/60ML 2
desonide external cream 0.05 % 4
desonide external lotion 0.05 % 4
desonide external ointment 0.05 % 2
desoximetasone external cream 0.05 % 4
desoximetasone external cream 0.25 % 2
desoximetasone external gel 0.05 % 4
desoximetasone external ointment 0.25 % 3
diflorasone diacetate external cream 0.05 % 4
ery external pad 2 % 2
60
erythromycin external gel 2 % 2
erythromycin external solution 2 % 1
EUCRISA EXTERNAL OINTMENT 2 % 4
fluocinolone acetonide external cream 0.01 %, 2
0.025 %
fluocinolone acetonide external solution 0.01 % 2
fluocinonide emulsified base external cream 0.05 2
%
fluocinonide external gel 0.05 % 2
fluocinonide external ointment 0.05 % 2
fluocinonide external solution 0.05 % 2
fluticasone propionate external cream 0.05 % 2
fluticasone propionate external ointment 0.005 % 2
gentamicin sulfate external cream 0.1 % 2
gentamicin sulfate external ointment 0.1 % 2
halobetasol propionate external cream 0.05 % 4
halobetasol propionate external ointment 0.05 % 2
hydrocortisone ace-pramoxine rectal cream 1-1 % 1
hydrocortisone external cream 2.5 % 1
hydrocortisone external lotion 2.5 % 1
hydrocortisone external ointment 1 % 2
hydrocortisone external ointment 2.5 % 1
hydrocortisone rectal enema 100 mg/60ml 4
hydrocortisone valerate external cream 0.2 % 2
hydrocortisone valerate external ointment 0.2 % 2
imiquimod external cream 5 % 2
isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 4
mg
metronidazole external cream 0.75 % 2
metronidazole external gel 0.75 %, 1 % 2
metronidazole external lotion 0.75 % 2
mometasone furoate external cream 0.1 % 1
mometasone furoate external ointment 0.1 % 1
61
mupirocin external ointment 2 % 2
MYORISAN ORAL CAPSULE 30 MG 4
nystatin-triamcinolone external cream 100000-0.1 2
unit/gm-%
nystatin-triamcinolone external ointment 100000- 2
0.1 unit/gm-%
PICATO EXTERNAL GEL 0.015 %, 0.05 % 4
pimecrolimus external cream 1 % 4 ST1
podofilox external solution 0.5 % 2
prednicarbate external cream 0.1 % 4
prednicarbate external ointment 0.1 % 4
PROCTO-PAK RECTAL CREAM 1 % 4
PROCTOSOL HC RECTAL CREAM 2.5 % 4
PROCTOZONE-HC RECTAL CREAM 2.5 % 1
psorcon external cream 0.05 % 4
RECTIV RECTAL OINTMENT 0.4 % 4
REGRANEX EXTERNAL GEL 0.01 % 5 PA1
SANTYL EXTERNAL OINTMENT 250 4
UNIT/GM
selenium sulfide external lotion 2.5 % 2
silver sulfadiazine external cream 1 % 2
SSD EXTERNAL CREAM 1 % 2
sulfacetamide sodium (acne) external lotion 10 % 2
tazarotene external cream 0.1 % 4
tretinoin external cream 0.025 %, 0.05 %, 0.1 % 2
tretinoin external gel 0.01 %, 0.025 %, 0.05 % 2
triamcinolone acetonide external cream 0.025 %, 1
0.1 %, 0.5 %
triamcinolone acetonide external lotion 0.025 % 1
triamcinolone acetonide external lotion 0.1 % 2
triamcinolone acetonide external ointment 0.025 1
%, 0.1 %, 0.5 %
TRIDERM EXTERNAL CREAM 0.1 % 2
ELECTROLYTES/MINERALS/METALS/VITAMINS
62
ELECTROLYTE/MINERAL REPLACEMENT
dextrose-nacl intravenous solution 10-0.2 % 4 BvD
dextrose-nacl intravenous solution 10-0.45 %, 2.5- 2 BvD
0.45 %, 5-0.2 %, 5-0.225 %, 5-0.33 %, 5-0.45 %,
5-0.9 %
kcl in dextrose-nacl intravenous solution 10-5-0.45 2 BvD
meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.33 meq/l-
%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%,
30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-
5-0.9 meq/l-%-%
KLOR-CON 10 ORAL TABLET EXTENDED 2 MO
RELEASE 10 MEQ
KLOR-CON M10 ORAL TABLET EXTENDED 1 MO
RELEASE 10 MEQ
RELEASE 15 MEQ
RELEASE 20 MEQ
KLOR-CON ORAL PACKET 20 MEQ 2 MO
KLOR-CON ORAL TABLET EXTENDED 2 MO
RELEASE 8 MEQ
magnesium sulfate injection solution 50 %, 50 % 1 BvD
(10ml syringe)
potassium chloride crys er oral tablet extended 1 MO
release 10 meq, 20 meq
potassium chloride er oral capsule extended 2 MO
release 10 meq, 8 meq
potassium chloride er oral tablet extended release 1 MO
10 meq, 20 meq, 8 meq
potassium chloride in dextrose intravenous 2 BvD
solution 20-5 meq/l-%
potassium chloride in dextrose intravenous 4 BvD
solution 40-5 meq/l-%
potassium chloride in nacl intravenous solution 2 BvD
20-0.45 meq/l-%, 20-0.9 meq/l-%
potassium chloride in nacl intravenous solution 4 BvD
40-0.9 meq/l-%
potassium chloride intravenous solution 2 meq/ml, 2 BvD
2 meq/ml (20 ml), 20 meq/100ml
63
potassium chloride oral packet 20 meq 2 MO
potassium chloride oral solution 20 meq/15ml 2 MO
(10%), 40 meq/15ml (20%)
potassium citrate er oral tablet extended release 2
10 meq (1080 mg), 5 meq (540 mg)
sodium chloride intravenous solution 0.45 %, 0.9 2 BvD
%, 3 %, 5 %
ELECTROLYTE/MINERAL/METAL MODIFIERS
CHEMET ORAL CAPSULE 100 MG 4
deferasirox oral tablet soluble 125 mg, 250 mg, 5 PA1
500 mg
FERRIPROX ORAL SOLUTION 100 MG/ML 4 PA1; LA
FERRIPROX ORAL TABLET 500 MG 5 PA1; LA
IONOSOL-MB IN D5W INTRAVENOUS 4
SOLUTION
ISOLYTE-P IN D5W INTRAVENOUS 4
SOLUTION
KIONEX ORAL SUSPENSION 15 GM/60ML 2
LOKELMA ORAL PACKET 10 GM, 5 GM 4 MO
NORMOSOL-M IN D5W INTRAVENOUS 3 BvD
SOLUTION
NORMOSOL-R IN D5W INTRAVENOUS 3 BvD
SOLUTION
SAMSCA ORAL TABLET 15 MG, 30 MG 5 QL (60 per 30 days)
sodium chloride irrigation solution 0.9 % 1
sodium polystyrene sulfonate oral powder 2
SPS ORAL SUSPENSION 15 GM/60ML 4
trientine hcl oral capsule 250 mg 5 PA1
NUTRIENTS
AMINOSYN II INTRAVENOUS SOLUTION 10 4 BvD
%
AMINOSYN-PF INTRAVENOUS SOLUTION 4 BvD
10 %, 7 %
CLINIMIX E/DEXTROSE (2.75/5) 3 BvD
INTRAVENOUS SOLUTION 2.75 %
64
CLINIMIX E/DEXTROSE (5/15) 3 BvD
INTRAVENOUS SOLUTION 5 %
CLINIMIX E/DEXTROSE (5/20) 3 BvD
INTRAVENOUS SOLUTION 5 %
CLINIMIX/DEXTROSE (4.25/10) 4 BvD
CLINIMIX/DEXTROSE (5/15) INTRAVENOUS 4 BvD
SOLUTION 5 %
SOLUTION 5 %
SOLUTION 5 %
dextrose intravenous solution 10 %, 5 % 2 BvD
FREAMINE HBC INTRAVENOUS SOLUTION 4 BvD
6.9 %
HEPATAMINE INTRAVENOUS SOLUTION 8 4 BvD
%
INTRALIPID INTRAVENOUS EMULSION 20 4 BvD
%, 30 %
ISOLYTE-S INTRAVENOUS SOLUTION 4 BvD
NEPHRAMINE INTRAVENOUS SOLUTION 4 BvD
5.4 %
NORMOSOL-R PH 7.4 INTRAVENOUS 4 BvD
SOLUTION
nutrilipid intravenous emulsion 20 % 4 BvD
PLASMA-LYTE 148 INTRAVENOUS 3 BvD
SOLUTION
PLASMA-LYTE A INTRAVENOUS 3 BvD
SOLUTION
PREMASOL INTRAVENOUS SOLUTION 10 % 4 BvD
65
PREMASOL INTRAVENOUS SOLUTION 6 % 2 BvD
PROCALAMINE INTRAVENOUS SOLUTION 4 BvD
3%
PROSOL INTRAVENOUS SOLUTION 20 % 4 BvD
TPN ELECTROLYTES INTRAVENOUS 2 BvD
SOLUTION
TRAVASOL INTRAVENOUS SOLUTION 10 % 4 BvD
TROPHAMINE INTRAVENOUS SOLUTION 10 4 BvD
%
EXCLUDED DRUG
EXCLUDED DRUG
sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg 2 QL (6 per 30 days)
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
dicyclomine hcl oral capsule 10 mg 1
dicyclomine hcl oral solution 10 mg/5ml 2
dicyclomine hcl oral tablet 20 mg 1
glycopyrrolate oral tablet 1 mg 1
glycopyrrolate oral tablet 2 mg 2
GASTROINTESTINAL AGENTS, OTHER
CREON ORAL CAPSULE DELAYED 3 MO
RELEASE PARTICLES 12000 UNIT, 24000-
76000 UNIT, 3000-9500 UNIT, 36000 UNIT,
6000 UNIT
diphenoxylate-atropine oral liquid 2.5-0.025 4
mg/5ml
diphenoxylate-atropine oral tablet 2.5-0.025 mg 1
GATTEX SUBCUTANEOUS KIT 5 MG 5 PA1; LA
loperamide hcl oral capsule 2 mg 1
metoclopramide hcl oral solution 5 mg/5ml 1
metoclopramide hcl oral tablet 10 mg, 5 mg 1 MO
MOVANTIK ORAL TABLET 12.5 MG, 25 MG 3 QL (30 per 30 days)
MYTESI ORAL TABLET DELAYED RELEASE 4 PA1; MO
125 MG
66
ursodiol oral capsule 300 mg 2 MO
ursodiol oral tablet 250 mg, 500 mg 2 MO
ZENPEP ORAL CAPSULE DELAYED 3 MO
RELEASE PARTICLES 10000-32000 UNIT,
15000-47000 UNIT, 20000-63000 UNIT, 25000-
79000 UNIT, 3000-14000 UNIT, 40000-126000
UNIT, 5000-24000 UNIT
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
famotidine oral tablet 20 mg, 40 mg 1 MO
ranitidine hcl oral capsule 150 mg, 300 mg 1 MO
ranitidine hcl oral syrup 75 mg/5ml 2 MO
ranitidine hcl oral tablet 150 mg, 300 mg 1 MO
IRRITABLE BOWEL SYNDROME AGENTS
alosetron hcl oral tablet 0.5 mg 4 MO; QL (60 per 30 days)
alosetron hcl oral tablet 1 mg 5 QL (60 per 30 days)
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 3 MO
LINZESS ORAL CAPSULE 145 MCG, 290 3 MO; QL (30 per 30 days)
MCG, 72 MCG
LAXATIVES
CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM 4
-GM/160ML
constulose oral solution 10 gm/15ml 2 MO
enulose oral solution 10 gm/15ml 1 MO
GAVILYTE-C ORAL SOLUTION 1
RECONSTITUTED 240 GM
GAVILYTE-G ORAL SOLUTION 1
GAVILYTE-N WITH FLAVOR PACK ORAL 1
SOLUTION RECONSTITUTED 420 GM
generlac oral solution 10 gm/15ml 1 MO
lactulose oral solution 10 gm/15ml 1 MO
peg 3350/electrolytes oral solution reconstituted 1
240 gm
peg-3350/electrolytes oral solution reconstituted 1
236 gm
67
PREPOPIK ORAL PACKET 10-3.5-12 MG-GM- 4
GM
SUPREP BOWEL PREP KIT ORAL SOLUTION 4
17.5-3.13-1.6 GM/177ML
TRILYTE ORAL SOLUTION 1
PROTECTANTS
CARAFATE ORAL SUSPENSION 1 GM/10ML 4 MO
misoprostol oral tablet 100 mcg, 200 mcg 1 MO
sucralfate oral tablet 1 gm 1 MO
PROTON PUMP INHIBITORS
DEXILANT ORAL CAPSULE DELAYED 3 ST1; MO
RELEASE 30 MG, 60 MG
esomeprazole magnesium oral capsule delayed 2 MO
release 40 mg
esomeprazole strontium oral capsule delayed 2 MO
release 49.3 mg
omeprazole oral capsule delayed release 10 mg 2 MO; QL (30 per 30 days)
omeprazole oral capsule delayed release 20 mg 2 MO
omeprazole oral capsule delayed release 40 mg 2 MO; QL (120 per 30 days)
pantoprazole sodium oral tablet delayed release 2 MO; QL (30 per 30 days)
20 mg
pantoprazole sodium oral tablet delayed release 2 MO; QL (90 per 30 days)
40 mg
GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS,
TREATMENT
ENZYME REPLACEMENT/MODIFIERS
CARBAGLU ORAL TABLET 200 MG 5 PA1; LA
CYSTADANE ORAL POWDER 5
ENDARI ORAL PACKET 5 GM 4 LA
GALAFOLD ORAL CAPSULE 123 MG 5 PA1; LA; QL (14 per 28 days)
KUVAN ORAL PACKET 100 MG, 500 MG 5 PA1; LA
KUVAN ORAL TABLET SOLUBLE 100 MG 5 PA1; LA
levocarnitine oral solution 1 gm/10ml 1 BvD; MO
levocarnitine oral tablet 330 mg 2 BvD; MO
68
miglustat oral capsule 100 mg 5 PA1; LA
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 5 PA1; LA
MG, 5 MG
RAVICTI ORAL LIQUID 1.1 GM/ML 5 PA1; LA
sodium phenylbutyrate oral powder 3 gm/tsp 5 PA1
sodium phenylbutyrate oral tablet 500 mg 4 PA1; MO
XURIDEN ORAL PACKET 2 GM 5 PA1
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
darifenacin hydrobromide er oral tablet extended 2 MO
release 24 hour 15 mg, 7.5 mg
MYRBETRIQ ORAL TABLET EXTENDED 3 MO
oxybutynin chloride er oral tablet extended release 2 MO; QL (60 per 30 days)
24 hour 10 mg, 15 mg, 5 mg
oxybutynin chloride oral syrup 5 mg/5ml 1 MO
oxybutynin chloride oral tablet 5 mg 1 MO
tolterodine tartrate er oral capsule extended 2 MO; QL (30 per 30 days)
tolterodine tartrate oral tablet 1 mg, 2 mg 2 MO; QL (60 per 30 days)
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl er oral tablet extended release 24 2 MO; QL (30 per 30 days)
hour 10 mg
dutasteride oral capsule 0.5 mg 2 MO
dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg 2 MO; QL (30 per 30 days)
finasteride oral tablet 5 mg 1 MO; QL (30 per 30 days)
silodosin oral capsule 4 mg, 8 mg 4 MO; QL (30 per 30 days)
tamsulosin hcl oral capsule 0.4 mg 2 MO; QL (60 per 30 days)
GENITOURINARY AGENTS, OTHER
bethanechol chloride oral tablet 10 mg, 50 mg 2
bethanechol chloride oral tablet 25 mg, 5 mg 1
CYSTAGON ORAL CAPSULE 150 MG, 50 MG 4 PA1; LA
DEPEN TITRATABS ORAL TABLET 250 MG 5
ELMIRON ORAL CAPSULE 100 MG 4
69
PHOSPHATE BINDERS
AURYXIA ORAL TABLET 1 GM 210 MG(FE) 4 PA1; MO
calcium acetate (phos binder) oral capsule 667 mg 2 MO
calcium acetate (phos binder) oral tablet 667 mg 1 MO
sevelamer carbonate oral packet 0.8 gm 5 QL (540 per 30 days)
sevelamer carbonate oral packet 2.4 gm 5 QL (180 per 30 days)
sevelamer carbonate oral tablet 800 mg 3 MO; QL (540 per 30 days)
VELPHORO ORAL TABLET CHEWABLE 500 4 MO
MG
VAGINAL PRODUCTS
clindamycin phosphate vaginal cream 2 % 2
estradiol vaginal cream 0.1 mg/gm 4 MO
estradiol vaginal tablet 10 mcg 4 MO
INTRAROSA VAGINAL INSERT 6.5 MG 3 PA1; MO
metronidazole vaginal gel 0.75 % 2
OSPHENA ORAL TABLET 60 MG 3 PA1; MO
terconazole vaginal cream 0.4 %, 0.8 % 2
terconazole vaginal suppository 80 mg 2
VANDAZOLE VAGINAL GEL 0.75 % 4
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)
GLUCOCORTICOIDS/MINERALOCORTICOIDS
budesonide er oral tablet extended release 24 hour 4
9 mg
budesonide oral capsule delayed release particles 4
3 mg
DEXAMETHASONE INTENSOL ORAL 1
CONCENTRATE 1 MG/ML
dexamethasone oral elixir 0.5 mg/5ml 2
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1
1.5 mg, 2 mg, 4 mg
dexamethasone oral tablet 6 mg 2
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1
methylprednisolone oral tablet 16 mg, 32 mg, 4 2
mg, 8 mg
70
methylprednisolone oral tablet therapy pack 4 mg 2
prednisolone oral solution 15 mg/5ml 2
prednisolone sodium phosphate oral solution 10 4
mg/5ml, 20 mg/5ml
prednisolone sodium phosphate oral solution 25 2
mg/5ml, 6.7 (5 base) mg/5ml
prednisolone sodium phosphate oral tablet 2
dispersible 10 mg, 15 mg, 30 mg
PREDNISONE INTENSOL ORAL 1
CONCENTRATE 5 MG/ML
prednisone oral solution 5 mg/5ml 4
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 1
mg, 5 mg, 50 mg
prednisone oral tablet therapy pack 10 mg (21), 10 1
mg (48), 5 mg (21), 5 mg (48)
UCERIS RECTAL FOAM 2 MG/ACT 4
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
cortisone acetate oral tablet 25 mg 3
DEMSER ORAL CAPSULE 250 MG 5
fludrocortisone acetate oral tablet 0.1 mg 1 MO
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX
HORMONES/ MODIFIERS)
ANABOLIC STEROIDS
ANADROL-50 ORAL TABLET 50 MG 5
oxandrolone oral tablet 10 mg 5 PA1
oxandrolone oral tablet 2.5 mg 4 PA1
ANDROGENS
danazol oral capsule 100 mg, 50 mg 2
danazol oral capsule 200 mg 4
methyltestosterone oral capsule 10 mg 5
testosterone cypionate intramuscular solution 100 2 PA1
mg/ml, 200 mg/ml
testosterone enanthate intramuscular solution 200 2 PA1
mg/ml
71
testosterone transdermal gel 10 mg/act (2%), 25 3 PA1; MO
mg/2.5gm (1%)
testosterone transdermal gel 12.5 mg/act (1%), 2 PA1; MO
20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%),
40.5 mg/2.5gm (1.62%)
testosterone transdermal gel 50 mg/5gm (1%) 4 PA1; MO
testosterone transdermal solution 30 mg/act 3 PA1; MO
CONTRACEPTIVES
ALTAVERA ORAL TABLET 0.15-30 MG-MCG 2 MO
alyacen 1/35 oral tablet 1-35 mg-mcg 2 MO
APRI ORAL TABLET 0.15-30 MG-MCG 2 MO
ARANELLE ORAL TABLET 0.5/1/0.5-35 MG- 2 MO
MCG
AUBRA ORAL TABLET 0.1-20 MG-MCG 2 MO
AVIANE ORAL TABLET 0.1-20 MG-MCG 2 MO
BALZIVA ORAL TABLET 0.4-35 MG-MCG 2 MO
BLISOVI FE 1.5/30 ORAL TABLET 1.5-30 MG- 2 MO
MCG
briellyn oral tablet 0.4-35 mg-mcg 2 MO
CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 2 MO
MG
CRYSELLE-28 ORAL TABLET 0.3-30 MG- 2
MCG
CYCLAFEM 1/35 ORAL TABLET 1-35 MG- 2 MO
MCG
CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 2 MO
MG-MCG
CYRED EQ ORAL TABLET 0.15-30 MG-MCG 2 MO
DELYLA ORAL TABLET 0.1-20 MG-MCG 2 MO
desogestrel-ethinyl estradiol oral tablet 0.15- 2 MO
0.02/0.01 mg (21/5), 0.15-30 mg-mcg
drospirenone-ethinyl estradiol oral tablet 3-0.02 4 MO
mg
drospirenone-ethinyl estradiol oral tablet 3-0.03 1 MO
mg
72
EMOQUETTE ORAL TABLET 0.15-30 MG- 2 MO
MCG
ENPRESSE-28 ORAL TABLET 2 MO
ENSKYCE ORAL TABLET 0.15-30 MG-MCG 2 MO
ESTARYLLA ORAL TABLET 0.25-35 MG- 2 MO
MCG
ethynodiol diac-eth estradiol oral tablet 1-35 mg- 1 MO
mcg
ethynodiol diac-eth estradiol oral tablet 1-50 mg- 2 MO
mcg
FALMINA ORAL TABLET 0.1-20 MG-MCG 2 MO
FEMYNOR ORAL TABLET 0.25-35 MG-MCG 2 MO
GIANVI ORAL TABLET 3-0.02 MG 4 MO
INTROVALE ORAL TABLET 0.15-0.03 MG 2 MO
ISIBLOOM ORAL TABLET 0.15-30 MG-MCG 2 MO
JASMIEL ORAL TABLET 3-0.02 MG 4 MO
JULEBER ORAL TABLET 0.15-30 MG-MCG 2 MO
JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG 2 MO
JUNEL 1/20 ORAL TABLET 1-20 MG-MCG 2 MO
JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG- 2 MO
MCG
JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG 2 MO
KARIVA ORAL TABLET 0.15-0.02/0.01 MG 2
(21/5)
KELNOR 1/35 ORAL TABLET 1-35 MG-MCG 1 MO
KELNOR 1/50 ORAL TABLET 1-50 MG-MCG 2 MO
KURVELO ORAL TABLET 0.15-30 MG-MCG 2 MO
LARIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG 4 MO
LARIN 1/20 ORAL TABLET 1-20 MG-MCG 2 MO
LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG- 4 MO
MCG
LARIN FE 1/20 ORAL TABLET 1-20 MG-MCG 4 MO
LARISSIA ORAL TABLET 0.1-20 MG-MCG 2 MO
LEENA ORAL TABLET 0.5/1/0.5-35 MG-MCG 2 MO
LESSINA ORAL TABLET 0.1-20 MG-MCG 2 MO
73
LEVONEST ORAL TABLET 2 MO
levonorgest-eth estrad 91-day oral tablet 0.15- 2 MO
0.03 mg
levonorgestrel-ethinyl estrad oral tablet 0.1-20 2 MO
mg-mcg, 0.15-30 mg-mcg
levonorg-eth estrad triphasic oral tablet 2 MO
LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 2 MO
MG-MCG
LORYNA ORAL TABLET 3-0.02 MG 4 MO
LOW-OGESTREL ORAL TABLET 0.3-30 MG- 2
MCG
LUTERA ORAL TABLET 0.1-20 MG-MCG 2 MO
marlissa oral tablet 0.15-30 mg-mcg 2 MO
medroxyprogesterone acetate intramuscular 4
suspension 150 mg/ml
medroxyprogesterone acetate intramuscular 4
suspension prefilled syringe 150 mg/ml
MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 2 MO
MG-MCG
MICROGESTIN 1/20 ORAL TABLET 1-20 MG- 2 MO
MCG
MICROGESTIN FE 1.5/30 ORAL TABLET 1.5- 2 MO
30 MG-MCG
MICROGESTIN FE 1/20 ORAL TABLET 1-20 2 MO
MG-MCG
MILI ORAL TABLET 0.25-35 MG-MCG 2 MO
MONONESSA ORAL TABLET 0.25-35 MG- 2 MO
MCG
NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG- 2 MO
MCG
NIKKI ORAL TABLET 3-0.02 MG 4 MO
norethindrone acet-ethinyl est oral tablet 1-20 mg- 2 MO
mcg
norgestimate-eth estradiol oral tablet 0.25-35 mg- 2 MO
mcg
norgestim-eth estrad triphasic oral tablet 1 MO
0.18/0.215/0.25 mg-35 mcg
74
NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 2 MO
MG-MCG
NORTREL 1/35 (21) ORAL TABLET 1-35 MG- 2 MO
MCG
NORTREL 1/35 (28) ORAL TABLET 1-35 MG- 2 MO
MCG
NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 2 MO
MG-MCG
NUVARING VAGINAL RING 0.12-0.015 4 MO
MG/24HR
OCELLA ORAL TABLET 3-0.03 MG 1 MO
ORSYTHIA ORAL TABLET 0.1-20 MG-MCG 2 MO
PIMTREA ORAL TABLET 0.15-0.02/0.01 MG 2 MO
(21/5)
PIRMELLA 1/35 ORAL TABLET 1-35 MG- 4 MO
MCG
PORTIA-28 ORAL TABLET 0.15-30 MG-MCG 2 MO
PREVIFEM ORAL TABLET 0.25-35 MG-MCG 2 MO
RECLIPSEN ORAL TABLET 0.15-30 MG-MCG 2 MO
SETLAKIN ORAL TABLET 0.15-0.03 MG 2 MO
SPRINTEC 28 ORAL TABLET 0.25-35 MG- 2 MO
MCG
SRONYX ORAL TABLET 0.1-20 MG-MCG 2 MO
SYEDA ORAL TABLET 3-0.03 MG 1 MO
TARINA FE 1/20 ORAL TABLET 1-20 MG- 4 MO
MCG
TRI-ESTARYLLA ORAL TABLET 1 MO
0.18/0.215/0.25 MG-35 MCG
TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 2 MO
MG-MCG
TRI-MILI ORAL TABLET 0.18/0.215/0.25 MG- 1 MO
35 MCG
TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 1 MO
MG-35 MCG
TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 1
MG-35 MCG
TRIVORA (28) ORAL TABLET 2 MO
75
TRI-VYLIBRA ORAL TABLET 0.18/0.215/0.25 1 MO
MG-35 MCG
VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 2 MO
MG
VIENVA ORAL TABLET 0.1-20 MG-MCG 2 MO
VYFEMLA ORAL TABLET 0.4-35 MG-MCG 2 MO
VYLIBRA ORAL TABLET 0.25-35 MG-MCG 2 MO
ZOVIA 1/35E (28) ORAL TABLET 1-35 MG- 1 MO
MCG
ESTROGENS
BIJUVA ORAL CAPSULE 1-100 MG 3 PA1; MO; HRM
estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 PA1; MO; HRM
estradiol transdermal patch twice weekly 0.025 2 PA1; MO; HRM
mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr
estradiol transdermal patch weekly 0.025 3 PA1; MO; HRM
mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06
mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr
MENEST ORAL TABLET 0.3 MG, 0.625 MG, 4 PA1; MO; HRM
1.25 MG
PREMPHASE ORAL TABLET 0.625-5 MG 3 PA1; MO; HRM
PROGESTINS
CAMILA ORAL TABLET 0.35 MG 2 MO
DEBLITANE ORAL TABLET 0.35 MG 2 MO
DEPO-PROVERA INTRAMUSCULAR 4 BvD
SUSPENSION 400 MG/ML
ERRIN ORAL TABLET 0.35 MG 2
INCASSIA ORAL TABLET 0.35 MG 2 MO
JOLIVETTE ORAL TABLET 0.35 MG 2 MO
LYZA ORAL TABLET 0.35 MG 2 MO
medroxyprogesterone acetate oral tablet 10 mg, 1 MO
2.5 mg, 5 mg
megestrol acetate oral suspension 40 mg/ml 1 PA2; HRM
megestrol acetate oral suspension 625 mg/5ml 4 PA2; MO; HRM
megestrol acetate oral tablet 20 mg, 40 mg 1 PA2; HRM
76
NORA-BE ORAL TABLET 0.35 MG 2 MO
norethindrone acetate oral tablet 5 mg 2 MO
norethindrone oral tablet 0.35 mg 2 MO
NORLYROC ORAL TABLET 0.35 MG 2 MO
progesterone micronized oral capsule 100 mg, 200 2 MO
mg
SHAROBEL ORAL TABLET 0.35 MG 2 MO
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene hcl oral tablet 60 mg 2 MO; QL (30 per 30 days)
SOLTAMOX ORAL SOLUTION 10 MG/5ML 4 PA2; MO
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
cabergoline oral tablet 0.5 mg 2
desmopressin ace spray refrig nasal solution 0.01 2 MO
%
desmopressin acetate oral tablet 0.1 mg, 0.2 mg 2 MO
INCRELEX SUBCUTANEOUS SOLUTION 40 5 PA1; LA
MG/4ML
NOCDURNA SUBLINGUAL TABLET 4 MO
SUBLINGUAL 27.7 MCG, 55.3 MCG
NORDITROPIN FLEXPRO SUBCUTANEOUS 5 PA1
SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30
MG/3ML, 5 MG/1.5ML
ORILISSA ORAL TABLET 150 MG, 200 MG 5 PA1
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
LEVO-T ORAL TABLET 100 MCG, 112 MCG, 1 MO
125 MCG, 137 MCG, 150 MCG, 175 MCG, 200
MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88
MCG
levothyroxine sodium oral tablet 100 mcg, 112 1 MO
mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200
mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
77
LEVOXYL ORAL TABLET 100 MCG, 112 1 MO
MCG, 125 MCG, 137 MCG, 150 MCG, 175
MCG
liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 1 MO
mcg
SYNTHROID ORAL TABLET 100 MCG, 112 3 MO
MCG, 125 MCG, 137 MCG, 150 MCG, 175
MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG,
75 MCG, 88 MCG
UNITHROID ORAL TABLET 100 MCG, 112 1 MO
MCG, 125 MCG, 150 MCG, 175 MCG, 200
MCG
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
KORLYM ORAL TABLET 300 MG 5 PA2
octreotide acetate injection solution 100 mcg/ml, 2 PA1; MO
50 mcg/ml
octreotide acetate injection solution 1000 mcg/ml, 4 PA1; MO
200 mcg/ml
octreotide acetate injection solution 500 mcg/ml 5 PA1
SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 5 PA1; LA; QL (60 per 30 days)
MG/ML, 0.6 MG/ML, 0.9 MG/ML
SOMATULINE DEPOT SUBCUTANEOUS 5 PA2; QL (1 per 28 days)
SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90
MG/0.3ML
SOMAVERT SUBCUTANEOUS SOLUTION 5 PA1; LA; QL (60 per 30 days)
RECONSTITUTED 10 MG, 15 MG, 20 MG, 25
MG, 30 MG
SYNAREL NASAL SOLUTION 2 MG/ML 5 PA1
TRELSTAR MIXJECT INTRAMUSCULAR 5 PA2
SUSPENSION RECONSTITUTED 11.25 MG,
3.75 MG
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole oral tablet 10 mg, 5 mg 1 MO
propylthiouracil oral tablet 50 mg 1 MO
78
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
ASTAGRAF XL ORAL CAPSULE EXTENDED 4 BvD; MO
RELEASE 24 HOUR 0.5 MG, 1 MG
ASTAGRAF XL ORAL CAPSULE EXTENDED 5 BvD
AZASAN ORAL TABLET 100 MG, 75 MG 3 BvD; MO
azathioprine oral tablet 50 mg 2 BvD; MO
BENLYSTA SUBCUTANEOUS SOLUTION 5 PA1
AUTO-INJECTOR 200 MG/ML
BENLYSTA SUBCUTANEOUS SOLUTION 5 PA1
cyclosporine modified oral capsule 100 mg, 25 2 BvD; MO
mg, 50 mg
cyclosporine modified oral solution 100 mg/ml 2 BvD; MO
cyclosporine oral capsule 100 mg, 25 mg 2 BvD; MO
GENGRAF ORAL CAPSULE 100 MG 2 BvD; MO
GENGRAF ORAL CAPSULE 25 MG 1 BvD; MO
GENGRAF ORAL SOLUTION 100 MG/ML 2 BvD; MO
methotrexate oral tablet 2.5 mg 1 BvD
methotrexate sodium injection solution 250 1 BvD
mg/10ml
mycophenolate mofetil oral capsule 250 mg 4 BvD; MO
mycophenolate mofetil oral suspension 5 BvD
reconstituted 200 mg/ml
mycophenolate mofetil oral tablet 500 mg 2 BvD; MO
mycophenolate sodium oral tablet delayed release 2 BvD; MO
180 mg, 360 mg
PROGRAF ORAL PACKET 0.2 MG, 1 MG 4 BvD; MO
SANDIMMUNE ORAL CAPSULE 100 MG, 25 3 BvD; MO
MG
SANDIMMUNE ORAL SOLUTION 100 MG/ML 4 BvD; MO
sirolimus oral solution 1 mg/ml 5 BvD
sirolimus oral tablet 0.5 mg 2 BvD; MO
sirolimus oral tablet 1 mg, 2 mg 4 BvD; MO
79
tacrolimus oral capsule 0.5 mg 2 BvD; MO
tacrolimus oral capsule 1 mg, 5 mg 4 BvD; MO
XATMEP ORAL SOLUTION 2.5 MG/ML 4 BvD
ZORTRESS ORAL TABLET 0.25 MG 4 PA2; MO; QL (60 per 30 days)
ZORTRESS ORAL TABLET 0.5 MG 5 PA2; QL (120 per 30 days)
ZORTRESS ORAL TABLET 1 MG 5 PA2; QL (60 per 30 days)
IMMUNOMODULATORS
ACTIMMUNE SUBCUTANEOUS SOLUTION 5 PA2; LA
2000000 UNIT/0.5ML
ARCALYST SUBCUTANEOUS SOLUTION 5 PA1; LA
ENBREL MINI SUBCUTANEOUS SOLUTION 5 PA1
CARTRIDGE 50 MG/ML
ENBREL SUBCUTANEOUS SOLUTION 5 PA1
PREFILLED SYRINGE 25 MG/0.5ML, 50
MG/ML
ENBREL SUBCUTANEOUS SOLUTION 5 PA1
RECONSTITUTED 25 MG
ENBREL SURECLICK SUBCUTANEOUS 5 PA1
HUMIRA PEDIATRIC CROHNS START 5 PA1
SUBCUTANEOUS PREFILLED SYRINGE KIT
40 MG/0.8ML, 40 MG/0.8ML (6 PACK), 80
MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
HUMIRA PEN SUBCUTANEOUS PEN- 5 PA1
INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML
HUMIRA PEN-CD/UC/HS STARTER 5 PA1
SUBCUTANEOUS PEN-INJECTOR KIT 40
MG/0.8ML, 80 MG/0.8ML
HUMIRA PEN-PS/UV/ADOL HS START 5 PA1
SUBCUTANEOUS PEN-INJECTOR KIT 40
MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML
HUMIRA SUBCUTANEOUS PREFILLED 5 PA1
SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20
MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40
MG/0.8ML
leflunomide oral tablet 10 mg 1 MO
leflunomide oral tablet 20 mg 2 MO
80
OCTAGAM INTRAVENOUS SOLUTION 1 3 BvD
GM/20ML
OCTAGAM INTRAVENOUS SOLUTION 2 5 BvD
GM/20ML
ORENCIA CLICKJECT SUBCUTANEOUS 5 PA1
ORENCIA SUBCUTANEOUS SOLUTION 5 PA1
PREFILLED SYRINGE 125 MG/ML, 50
MG/0.4ML, 87.5 MG/0.7ML
PANZYGA INTRAVENOUS SOLUTION 1 5 BvD
GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20
GM/200ML, 30 GM/300ML, 5 GM/50ML
PRIVIGEN INTRAVENOUS SOLUTION 20 5 BvD
GM/200ML
VACCINES
ACTHIB INTRAMUSCULAR SOLUTION 4
RECONSTITUTED
ADACEL INTRAMUSCULAR SUSPENSION 5- 4
2-15.5 (PREFILLED SYRINGE), 5-2-15.5 LF-
MCG/0.5
bcg vaccine injection injectable 4
BEXSERO INTRAMUSCULAR SUSPENSION 4
PREFILLED SYRINGE
BOOSTRIX INTRAMUSCULAR SUSPENSION 3
5-2.5-18.5 , 5-2.5-18.5 (0.5ML SYRINGE)
DAPTACEL INTRAMUSCULAR SUSPENSION 4
23-15-5
diphtheria-tetanus toxoids dt intramuscular 4 BvD
suspension 25-5 lfu/0.5ml
ENGERIX-B INJECTION SUSPENSION 10 4 BvD
MCG/0.5ML, 20 MCG/ML
GARDASIL 9 INTRAMUSCULAR 4
SUSPENSION
GARDASIL 9 INTRAMUSCULAR 4
SUSPENSION PREFILLED SYRINGE
HAVRIX INTRAMUSCULAR SUSPENSION 4
1440 EL U/ML, 1440 EL U/ML 1 ML, 720 EL
U/0.5ML, 720 EL U/0.5ML 0.5 ML
81
IMOVAX RABIES INTRAMUSCULAR 4 BvD
INJECTABLE 2.5 UNIT/ML
INFANRIX INTRAMUSCULAR SUSPENSION 4
25-58-10
IPOL INJECTION INJECTABLE 3
IXIARO INTRAMUSCULAR SUSPENSION 3
KINRIX INTRAMUSCULAR SUSPENSION , 4
INJECTION 0.5 ML
MENACTRA INTRAMUSCULAR 4
INJECTABLE
MENVEO INTRAMUSCULAR SOLUTION 4
RECONSTITUTED
M-M-R II SUBCUTANEOUS INJECTABLE 3
PEDIARIX INTRAMUSCULAR SUSPENSION 4
PEDVAX HIB INTRAMUSCULAR 4
SUSPENSION 7.5 MCG/0.5ML
PROQUAD SUBCUTANEOUS SUSPENSION 4
RECONSTITUTED
QUADRACEL INTRAMUSCULAR 4
SUSPENSION
RABAVERT INTRAMUSCULAR 4 BvD
SUSPENSION RECONSTITUTED
RECOMBIVAX HB INJECTION SUSPENSION 4 BvD
10 MCG/ML, 10 MCG/ML (1ML SYRINGE), 40
MCG/ML, 5 MCG/0.5ML
ROTARIX ORAL SUSPENSION 4
RECONSTITUTED
ROTATEQ ORAL SOLUTION 3
SHINGRIX INTRAMUSCULAR SUSPENSION 3
RECONSTITUTED 50 MCG/0.5ML
TDVAX INTRAMUSCULAR SUSPENSION 2-2 3 BvD
LF/0.5ML
TENIVAC INTRAMUSCULAR INJECTABLE 3 BvD
5-2 LFU
TRUMENBA INTRAMUSCULAR 4
SUSPENSION PREFILLED SYRINGE
TWINRIX INTRAMUSCULAR SUSPENSION 4 BvD
PREFILLED SYRINGE 720-20 ELU-MCG/ML
82
TYPHIM VI INTRAMUSCULAR SOLUTION 25 4
MCG/0.5ML, 25 MCG/0.5ML (0.5ML
SYRINGE)
VAQTA INTRAMUSCULAR SUSPENSION 25 4
UNIT/0.5ML, 25 UNIT/0.5ML 0.5 ML, 50
UNIT/ML, 50 UNIT/ML 1 ML
VARIVAX SUBCUTANEOUS INJECTABLE 4
1350 PFU/0.5ML
VARIZIG INTRAMUSCULAR SOLUTION 125 4
UNIT/1.2ML
YF-VAX SUBCUTANEOUS INJECTABLE 4
ZOSTAVAX SUBCUTANEOUS SUSPENSION 4 QL (1 per 365 days)
RECONSTITUTED 19400 UNT/0.65ML
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
APRISO ORAL CAPSULE EXTENDED 3 MO; QL (120 per 30 days)
RELEASE 24 HOUR 0.375 GM
balsalazide disodium oral capsule 750 mg 2
LIALDA ORAL TABLET DELAYED RELEASE 3
1.2 GM
METABOLIC BONE DISEASE AGENTS
METABOLIC BONE DISEASE AGENTS
alendronate sodium oral tablet 10 mg, 5 mg 1 MO; QL (30 per 30 days)
alendronate sodium oral tablet 35 mg 1 MO; QL (4 per 28 days)
alendronate sodium oral tablet 40 mg 1 QL (30 per 30 days)
alendronate sodium oral tablet 70 mg 2 MO; QL (4 per 28 days)
calcitonin (salmon) nasal solution 200 unit/act 2 BvD; MO
calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 BvD; MO
calcitriol oral solution 1 mcg/ml 2 BvD; MO
cinacalcet hcl oral tablet 30 mg 4 BvD; MO; QL (60 per 30 days)
cinacalcet hcl oral tablet 60 mg 5 BvD; QL (60 per 30 days)
cinacalcet hcl oral tablet 90 mg 5 BvD; QL (120 per 30 days)
doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 2 BvD; MO
mcg
83
FORTEO SUBCUTANEOUS SOLUTION 600 5 PA1; QL (2.4 per 28 days)
MCG/2.4ML
ibandronate sodium oral tablet 150 mg 1 MO; QL (1 per 30 days)
NATPARA SUBCUTANEOUS CARTRIDGE 5 PA1; LA; HRM
100 MCG, 25 MCG, 50 MCG, 75 MCG
paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 4 BvD; MO
PROLIA SUBCUTANEOUS SOLUTION 60 4 ST1; QL (1 per 180 days)
MG/ML
PROLIA SUBCUTANEOUS SOLUTION 4 ST1; QL (1 per 180 days)
risedronate sodium oral tablet 150 mg 2 MO; QL (1 per 28 days)
risedronate sodium oral tablet 30 mg 2 QL (30 per 30 days)
risedronate sodium oral tablet 35 mg, 35 mg (12 2 MO; QL (4 per 28 days)
pack), 35 mg (4 pack)
risedronate sodium oral tablet 5 mg 2 MO; QL (30 per 30 days)
SENSIPAR ORAL TABLET 30 MG, 60 MG 5 BvD; QL (60 per 30 days)
SENSIPAR ORAL TABLET 90 MG 5 BvD; QL (120 per 30 days)
TYMLOS SUBCUTANEOUS SOLUTION PEN- 5 PA1
INJECTOR 3120 MCG/1.56ML
XGEVA SUBCUTANEOUS SOLUTION 120 5 PA1; QL (2 per 28 days)
MG/1.7ML
MISCELLANEOUS
MISCELLANEOUS
cvs gauze sterile pad 2"x2" 3
hydroxychloroquine sulfate oral tablet 200 mg 1 MO
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
atropine sulfate ophthalmic solution 1 % 2 MO
OXERVATE OPHTHALMIC SOLUTION 0.002 5 PA1
%
RESTASIS OPHTHALMIC EMULSION 0.05 % 3 MO; QL (60 per 30 days)
OPHTHALMIC ANTI-ALLERGY AGENTS
azelastine hcl ophthalmic solution 0.05 % 2
BEPREVE OPHTHALMIC SOLUTION 1.5 % 4
84
cromolyn sodium ophthalmic solution 4 % 1
olopatadine hcl ophthalmic solution 0.2 % 3
PAZEO OPHTHALMIC SOLUTION 0.7 % 4
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 3 MO
%
AZOPT OPHTHALMIC SUSPENSION 1 % 3 MO
betaxolol hcl ophthalmic solution 0.5 % 2 MO
brimonidine tartrate ophthalmic solution 0.15 %, 2 MO
0.2 %
carteolol hcl ophthalmic solution 1 % 1 MO
COMBIGAN OPHTHALMIC SOLUTION 0.2- 4 MO
0.5 %
dorzolamide hcl ophthalmic solution 2 % 1 MO
dorzolamide hcl-timolol mal ophthalmic solution 4 MO
22.3-6.8 mg/ml
dorzolamide hcl-timolol mal pf ophthalmic 4 MO
solution 22.3-6.8 mg/ml
levobunolol hcl ophthalmic solution 0.5 % 1 MO
pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 2 MO
SIMBRINZA OPHTHALMIC SUSPENSION 1- 4 MO
0.2 %
timolol maleate ophthalmic gel forming solution 2 MO
0.25 %, 0.5 %
timolol maleate ophthalmic solution 0.25 %, 0.5 1 MO
%, 0.5 % (daily)
OPHTHALMIC ANTI-INFECTIVES
bacitracin ophthalmic ointment 500 unit/gm 2
bacitracin-polymyxin b ophthalmic ointment 500- 1
10000 unit/gm
BESIVANCE OPHTHALMIC SUSPENSION 0.6 4
%
ciprofloxacin hcl ophthalmic solution 0.3 % 1
erythromycin ophthalmic ointment 5 mg/gm 1
gatifloxacin ophthalmic solution 0.5 % 2
85
GENTAK OPHTHALMIC OINTMENT 0.3 % 2
gentamicin sulfate ophthalmic solution 0.3 % 1
MOXEZA OPHTHALMIC SOLUTION 0.5 % 3
moxifloxacin hcl ophthalmic solution 0.5 % 3
neomycin-bacitracin zn-polymyx ophthalmic 2
ointment 5-400-10000
neomycin-polymyxin-gramicidin ophthalmic 2
solution 1.75-10000-.025
ofloxacin ophthalmic solution 0.3 % 2
polymyxin b-trimethoprim ophthalmic solution 1
10000-0.1 unit/ml-%
sulfacetamide sodium ophthalmic ointment 10 % 4
sulfacetamide sodium ophthalmic solution 10 % 1
tobramycin ophthalmic solution 0.3 % 1
trifluridine ophthalmic solution 1 % 3
OPHTHALMIC ANTI-INFLAMMATORIES
bacitra-neomycin-polymyxin-hc ophthalmic 2
ointment 1 %
BLEPHAMIDE S.O.P. OPHTHALMIC 4
OINTMENT 10-0.2 %
bromfenac sodium (once-daily) ophthalmic 2
solution 0.09 %
BROMSITE OPHTHALMIC SOLUTION 0.075 4
%
dexamethasone sodium phosphate ophthalmic 2
solution 0.1 %
diclofenac sodium ophthalmic solution 0.1 % 2
DUREZOL OPHTHALMIC EMULSION 0.05 % 3
fluorometholone ophthalmic suspension 0.1 % 2
flurbiprofen sodium ophthalmic solution 0.03 % 1
ILEVRO OPHTHALMIC SUSPENSION 0.3 % 3
ketorolac tromethamine ophthalmic solution 0.4 2
%, 0.5 %
LOTEMAX OPHTHALMIC GEL 0.5 % 4
LOTEMAX OPHTHALMIC OINTMENT 0.5 % 4
86
LOTEMAX OPHTHALMIC SUSPENSION 0.5 4
%
LOTEMAX SM OPHTHALMIC GEL 0.38 % 4
loteprednol etabonate ophthalmic suspension 0.5 2 MO
%
neomycin-polymyxin-dexameth ophthalmic 2
ointment 3.5-10000-0.1
neomycin-polymyxin-dexameth ophthalmic 1
suspension 3.5-10000-0.1
neomycin-polymyxin-hc ophthalmic suspension 2
3.5-10000-1
prednisolone acetate ophthalmic suspension 1 % 2
prednisolone sodium phosphate ophthalmic 2
solution 1 %
PROLENSA OPHTHALMIC SOLUTION 0.07 % 4
sulfacetamide-prednisolone ophthalmic solution 2
10-0.23 %
tobramycin-dexamethasone ophthalmic suspension 2
0.3-0.1 %
ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % 4
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
latanoprost ophthalmic solution 0.005 % 2 MO
LUMIGAN OPHTHALMIC SOLUTION 0.01 % 3 MO
TRAVATAN Z OPHTHALMIC SOLUTION 3 MO
0.004 %
VYZULTA OPHTHALMIC SOLUTION 0.024 % 4 MO
OTIC AGENTS
OTIC AGENTS
acetic acid otic solution 2 % 1
CIPRODEX OTIC SUSPENSION 0.3-0.1 % 4
ciprofloxacin hcl otic solution 0.2 % 4
fluocinolone acetonide otic oil 0.01 % 2
neomycin-polymyxin-hc otic solution 1 % 2
neomycin-polymyxin-hc otic suspension 3.5- 2
10000-1
87
ofloxacin otic solution 0.3 % 4
RESPIRATORY TRACT AGENTS
ANTIHISTAMINES
cetirizine hcl oral solution 1 mg/ml 1
clemastine fumarate oral tablet 2.68 mg 1
desloratadine oral tablet 5 mg 2
levocetirizine dihydrochloride oral solution 2.5 2
mg/5ml
levocetirizine dihydrochloride oral tablet 5 mg 2
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
ARNUITY ELLIPTA INHALATION AEROSOL 3 MO
POWDER BREATH ACTIVATED 100
MCG/ACT, 200 MCG/ACT, 50 MCG/ACT
ASMANEX 120 METERED DOSES 3 MO
INHALATION AEROSOL POWDER BREATH
ACTIVATED 220 MCG/INH
ACTIVATED 110 MCG/INH, 220 MCG/INH
ACTIVATED 220 MCG/INH
ASMANEX HFA INHALATION AEROSOL 100 3 MO
MCG/ACT, 200 MCG/ACT
FLOVENT DISKUS INHALATION AEROSOL 3 MO
MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST
FLOVENT HFA INHALATION AEROSOL 110 3 MO
MCG/ACT, 220 MCG/ACT, 44 MCG/ACT
ANTILEUKOTRIENES
montelukast sodium oral packet 4 mg 2 MO; QL (30 per 30 days)
montelukast sodium oral tablet 10 mg 1 MO; QL (30 per 30 days)
montelukast sodium oral tablet chewable 4 mg, 5 2 MO; QL (30 per 30 days)
mg
zafirlukast oral tablet 10 mg, 20 mg 2 MO; QL (60 per 30 days)
BRONCHODILATORS, ANTICHOLINERGIC
88
ipratropium bromide inhalation solution 0.02 % 1 BvD; MO
SPIRIVA HANDIHALER INHALATION 3 MO; QL (30 per 30 days)
CAPSULE 18 MCG
SPIRIVA RESPIMAT INHALATION AEROSOL 3 MO; QL (4 per 30 days)
SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT
BRONCHODILATORS, PHOSPHODIESTERASE INHIBITORS (XANTHINES)
DALIRESP ORAL TABLET 250 MCG, 500 3 MO; QL (30 per 30 days)
MCG
sildenafil citrate oral tablet 20 mg 2 PA1; MO; QL (90 per 30 days)
theophylline er oral tablet extended release 12 1 MO
hour 100 mg, 200 mg, 300 mg
theophylline er oral tablet extended release 24 1 MO
hour 400 mg, 600 mg
theophylline oral solution 80 mg/15ml 4 MO
BRONCHODILATORS, SYMPATHOMIMETIC
albuterol sulfate hfa inhalation aerosol solution 2 MO; QL (36 per 30 days)
108 (90 base) mcg/act (nda020983)
albuterol sulfate inhalation nebulization solution 2 BvD; MO
(2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63
mg/3ml, 1.25 mg/3ml
albuterol sulfate oral syrup 2 mg/5ml 1 MO
albuterol sulfate oral tablet 2 mg, 4 mg 2 MO
COMBIVENT RESPIMAT INHALATION 4 MO
AEROSOL SOLUTION 20-100 MCG/ACT
ipratropium-albuterol inhalation solution 0.5-2.5 2 BvD; MO
(3) mg/3ml
SEREVENT DISKUS INHALATION AEROSOL 3 MO; QL (60 per 30 days)
MCG/DOSE
terbutaline sulfate oral tablet 2.5 mg, 5 mg 3 MO
VENTOLIN HFA INHALATION AEROSOL 3 MO; QL (36 per 30 days)
SOLUTION 108 (90 BASE) MCG/ACT
CYSTIC FIBROSIS AGENTS
CAYSTON INHALATION SOLUTION 5 PA1; LA
RECONSTITUTED 75 MG
KALYDECO ORAL PACKET 25 MG, 50 MG, 5 PA1
75 MG
89
KALYDECO ORAL TABLET 150 MG 5 PA1; LA
ORKAMBI ORAL PACKET 100-125 MG, 150- 5 PA1; LA
188 MG
ORKAMBI ORAL TABLET 100-125 MG 5 PA1; LA
ORKAMBI ORAL TABLET 200-125 MG 5 PA1; LA; QL (120 per 30 days)
PULMOZYME INHALATION SOLUTION 1 5 PA1
MG/ML
SYMDEKO ORAL TABLET THERAPY PACK 5 PA1; LA
100-150 & 150 MG
TOBI PODHALER INHALATION CAPSULE 28 5
MG
NASAL AGENTS
ASTEPRO NASAL SOLUTION 0.15 % 3 QL (30 per 25 days)
azelastine hcl nasal solution 0.1 %, 0.15 % 2 QL (30 per 25 days)
DYMISTA NASAL SUSPENSION 137-50 4 QL (30 per 25 days)
MCG/ACT
flunisolide nasal solution 25 mcg/act (0.025%) 2 QL (50 per 30 days)
fluticasone propionate nasal suspension 50 1 QL (16 per 30 days)
mcg/act
ipratropium bromide nasal solution 0.03 % 1 MO; QL (60 per 30 days)
ipratropium bromide nasal solution 0.06 % 1 MO; QL (30 per 30 days)
mometasone furoate nasal suspension 50 mcg/act 2 QL (34 per 30 days)
PULMONARY ANTIHYPERTENSIVES
ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 5 PA1; LA; QL (90 per 30 days)
MG, 2 MG, 2.5 MG
ambrisentan oral tablet 10 mg, 5 mg 5 PA1; QL (30 per 30 days)
bosentan oral tablet 125 mg, 62.5 mg 5 PA1; LA; QL (60 per 30 days)
OPSUMIT ORAL TABLET 10 MG 5 PA1; LA; QL (90 per 30 days)
TRACLEER ORAL TABLET 125 MG, 62.5 MG 5 PA1; LA; QL (60 per 30 days)
TRACLEER ORAL TABLET SOLUBLE 32 MG 5 PA1; LA; QL (120 per 30 days)
UPTRAVI ORAL TABLET 1000 MCG, 1200 5 PA1; LA
MCG, 1400 MCG, 1600 MCG, 200 MCG, 400
MCG, 600 MCG, 800 MCG
UPTRAVI ORAL TABLET THERAPY PACK 5 PA1; LA
200 & 800 MCG
90
PULMONARY FIBROSIS AGENTS
ESBRIET ORAL TABLET 267 MG, 801 MG 5 PA1
OFEV ORAL CAPSULE 100 MG, 150 MG 5 PA1; LA
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine inhalation solution 10 %, 20 % 2 BvD
ADVAIR DISKUS INHALATION AEROSOL 3 MO; QL (60 per 30 days)
POWDER BREATH ACTIVATED 100-50
MCG/DOSE, 250-50 MCG/DOSE, 500-50
MCG/DOSE
ADVAIR HFA INHALATION AEROSOL 115- 3 MO; QL (12 per 30 days)
21 MCG/ACT, 230-21 MCG/ACT, 45-21
MCG/ACT
ANORO ELLIPTA INHALATION AEROSOL 3 MO; QL (60 per 30 days)
POWDER BREATH ACTIVATED 62.5-25
MCG/INH
BREO ELLIPTA INHALATION AEROSOL 3 MO
POWDER BREATH ACTIVATED 100-25
MCG/INH, 200-25 MCG/INH
cromolyn sodium inhalation nebulization solution 3 BvD; MO
20 mg/2ml
epinephrine injection solution auto-injector 0.15 2
mg/0.3ml, 0.3 mg/0.3ml
fluticasone-salmeterol inhalation aerosol powder 3 MO; QL (1 per 30 days)
breath activated 113-14 mcg/act, 232-14 mcg/act,
55-14 mcg/act
PROLASTIN-C INTRAVENOUS SOLUTION 5 PA1; LA
STIOLTO RESPIMAT INHALATION 3 MO; QL (4 per 30 days)
AEROSOL SOLUTION 2.5-2.5 MCG/ACT
TRELEGY ELLIPTA INHALATION AEROSOL 3 ST1; MO; QL (60 per 30 days)
POWDER BREATH ACTIVATED 100-62.5-25
MCG/INH
XOLAIR SUBCUTANEOUS SOLUTION 5 PA1
PREFILLED SYRINGE 150 MG/ML, 75
MG/0.5ML
XOLAIR SUBCUTANEOUS SOLUTION 5 PA1
SKELETAL MUSCLE RELAXANTS
91
SKELETAL MUSCLE RELAXANTS
baclofen oral tablet 10 mg, 20 mg, 5 mg 1 MO
carisoprodol oral tablet 250 mg 4 QL (120 per 30 days)
carisoprodol oral tablet 350 mg 1 PA1; HRM
carisoprodol-aspirin oral tablet 200-325 mg 4 PA1; HRM
chlorzoxazone oral tablet 375 mg, 750 mg 2
chlorzoxazone oral tablet 500 mg 1
cyclobenzaprine hcl oral tablet 10 mg, 5 mg 2 PA1; HRM
cyclobenzaprine hcl oral tablet 7.5 mg 4 PA1; HRM
metaxalone oral tablet 800 mg 4 PA1; HRM
methocarbamol oral tablet 500 mg, 750 mg 1 PA1; HRM
orphenadrine citrate er oral tablet extended 2 PA1; HRM
tizanidine hcl oral tablet 2 mg, 4 mg 2 MO
SLEEP DISORDER AGENTS
BENZODIAZEPINES
oxazepam oral capsule 10 mg, 15 mg, 30 mg 2 QL (120 per 30 days)
temazepam oral capsule 15 mg, 30 mg 1 QL (30 per 30 days)
temazepam oral capsule 22.5 mg 4 QL (30 per 30 days)
temazepam oral capsule 7.5 mg 2 QL (120 per 30 days)
GABA RECEPTOR MODULATORS
zaleplon oral capsule 10 mg 3 PA1; HRM; QL (90 per 365 days)
zaleplon oral capsule 5 mg 3 QL (90 per 365 days)
zolpidem tartrate oral tablet 10 mg 3 PA1; HRM; QL (30 per 30 days)
zolpidem tartrate oral tablet 5 mg 3 PA1; HRM; QL (60 per 30 days)
SLEEP DISORDERS, OTHER
BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 4 QL (30 per 30 days)
MG, 5 MG
BUTISOL SODIUM ORAL TABLET 30 MG 3 PA2; HRM
HETLIOZ ORAL CAPSULE 20 MG 5 PA1; QL (30 per 30 days)
NUVIGIL ORAL TABLET 200 MG 3 PA1; MO
SILENOR ORAL TABLET 3 MG, 6 MG 4 MO
XYREM ORAL SOLUTION 500 MG/ML 5 PA1; LA; QL (540 per 30 days)
92
Index of Drugs/Alphabetical Listing
A ambrisentan .......................... 90 ASMANEX 120 METERED

abacavir sulfate ..................... 39 amcinonide ........................... 59 DOSES .............................88
abacavir sulfate-lamivudine . 39 amikacin sulfate ...................... 7 ASMANEX 30 METERED
abacavir-lamivudine- amiloride hcl ......................... 54 DOSES .............................88
zidovudine ........................ 39 amiloride-hydrochlorothiazide ASMANEX 60 METERED
ABELCET ............................ 21 .......................................... 50 DOSES .............................88
ABILIFY MAINTENA ........ 35 AMINOSYN II ..................... 64 ASMANEX HFA .................88
abiraterone acetate ................ 28 AMINOSYN-PF................... 64 aspirin-dipyridamole er ........48
acamprosate calcium .............. 6 amiodarone hcl ..................... 49 ASSURE ID INSULIN
acarbose ................................ 43 AMITIZA ............................. 67 SAFETY SYR ..................43
acebutolol hcl ....................... 51 amitriptyline hcl ................... 20 ASTAGRAF XL ...................79
acetaminophen-codeine .......... 4 amlodipine besy-benazepril hcl ASTEPRO ............................90
acetaminophen-codeine #3 ..... 4 .......................................... 50 atazanavir sulfate ..................40
acetazolamide ....................... 54 amlodipine besylate .............. 52 atenolol .................................51
acetazolamide er ................... 54 amlodipine besylate-valsartan atenolol-chlorthalidone .........50
acetic acid ............................. 87 .......................................... 50 atomoxetine hcl ....................57
acetylcysteine ....................... 91 amlodipine-atorvastatin ........ 53 atorvastatin calcium ..............55
acitretin ................................. 59 amlodipine-olmesartan ......... 50 atovaquone ............................31
ACTHIB ............................... 81 amlodipine-valsartan-hctz .... 50 atovaquone-proguanil hcl ....31,
ACTIMMUNE ..................... 80 ammonium lactate ................ 59 32
acyclovir ............................... 38 AMNESTEEM ..................... 59 ATRIPLA .............................38
acyclovir sodium .................. 38 amoxapine ............................ 20 atropine sulfate .....................84
ADACEL .............................. 81 amoxicillin ............................ 10 AUBAGIO ............................58
adefovir dipivoxil ................. 37 amoxicillin-pot clavulanate .. 10 AUBRA ................................72
ADEMPAS ........................... 90 amoxicillin-pot clavulanate er AURYXIA ............................70
ADVAIR DISKUS ............... 91 .......................................... 10 AVIANE ...............................72
ADVAIR HFA ..................... 91 amphetamine- AVONEX .............................58
AFINITOR ........................... 28 dextroamphetamine .......... 57 AVONEX PEN .....................58
AFINITOR DISPERZ .......... 28 amphotericin b ...................... 21 AVONEX PREFILLED .......58
albendazole ........................... 31 ampicillin .............................. 10 AZACTAM ..........................10
albuterol sulfate .................... 89 ampicillin sodium ................. 10 AZASAN ..............................79
albuterol sulfate hfa .............. 89 ampicillin-sulbactam sodium 10 azathioprine ..........................79
ALECENSA ......................... 28 ANADROL-50 ..................... 71 azelastine hcl ..................84, 90
alendronate sodium .............. 83 anagrelide hcl ....................... 48 azithromycin .........................11
alfuzosin hcl er ..................... 69 anastrozole ............................ 28 AZOPT .................................85
ALINIA ................................ 31 ANORO ELLIPTA............... 91 aztreonam .............................10
aliskiren fumarate ................. 53 APOKYN ............................. 33 B
allopurinol ............................ 22 aprepitant ........................ 20, 21 bacitracin ..............................85
alosetron hcl ......................... 67 APRI ..................................... 72 bacitracin-polymyxin b .........85
ALPHAGAN P ..................... 85 APRISO ................................ 83 bacitra-neomycin-polymyxin-
alprazolam ............................ 42 APTIOM ............................... 16 hc ......................................86
ALPRAZOLAM INTENSOL APTIVUS ............................. 40 baclofen ................................92
.......................................... 42 ARANELLE ......................... 72 BACTOCILL IN DEXTROSE
ALTAVERA ........................ 72 ARCALYST ......................... 80 ..........................................11
ALUNBRIG ......................... 28 ARIKAYCE ........................... 7 balsalazide disodium ............83
alyacen 1/35.......................... 72 aripiprazole ........................... 35 BALVERSA .........................26
amantadine hcl...................... 32 ARNUITY ELLIPTA ........... 88 BALZIVA.............................72
AMBISOME ........................ 21 BANZEL ..............................16
93
bcg vaccine ........................... 81 bupropion hcl er (smoking det) cefotaxime sodium..................9
BELSOMRA ........................ 92 ............................................ 6 cefotetan disodium..................9
benazepril hcl ....................... 49 bupropion hcl er (sr) ............. 17 cefoxitin sodium .....................9
benazepril-hydrochlorothiazide bupropion hcl er (xl) ............. 18 cefpodoxime proxetil ..............9
.......................................... 50 buspirone hcl ........................ 41 cefprozil ..................................9
BENLYSTA ......................... 79 butalbital-acetaminophen ....... 4 ceftazidime .............................9
benznidazole ......................... 32 butalbital-apap-caffeine .......... 4 ceftriaxone sodium .................9
benzoyl peroxide-erythromycin butalbital-asa-caff-codeine ..... 4 cefuroxime axetil ....................9
.......................................... 59 butalbital-aspirin-caffeine ...... 4 cefuroxime sodium .................9
benztropine mesylate ............ 32 BUTISOL SODIUM ............ 92 celecoxib ...............................23
BEPREVE ............................ 84 BYSTOLIC .......................... 51 CELONTIN ..........................15
BESIVANCE ....................... 85 C cephalexin ...............................9
betamethasone dipropionate 59, cabergoline ........................... 77 cetirizine hcl .........................88
60 CABLIVI .............................. 48 CHANTIX ..............................6
betamethasone dipropionate CABOMETYX ..................... 28 CHEMET ..............................64
aug .................................... 59 calcipotriene ......................... 60 chlordiazepoxide hcl .............42
betamethasone valerate ........ 60 calcitonin (salmon) ............... 83 chlorhexidine gluconate ........59
BETASERON ...................... 58 calcitriol ................................ 83 chloroquine phosphate ..........32
betaxolol hcl ................... 51, 85 calcium acetate (phos binder) chlorothiazide .......................54
bethanechol chloride ............ 69 .......................................... 70 chlorpromazine hcl ...............33
bexarotene ............................ 26 CALQUENCE ...................... 26 chlorthalidone .......................54
BEXSERO ............................ 81 CAMILA .............................. 76 chlorzoxazone .......................92
bicalutamide ......................... 26 candesartan cilexetil ............. 48 cholestyramine ......................55
BICILLIN L-A ..................... 11 candesartan cilexetil-hctz ..... 50 cholestyramine light .............55
BIJUVA ................................ 76 CAPRELSA.......................... 28 ciclopirox ..............................21
BIKTARVY ......................... 41 captopril ................................ 49 ciclopirox olamine ................21
bisoprolol fumarate .............. 51 captopril-hydrochlorothiazide cilostazol ...............................48
bisoprolol-hydrochlorothiazide .......................................... 50 CIMDUO ..............................39
.......................................... 50 CARAFATE ......................... 68 cinacalcet hcl ........................83
BLEPHAMIDE S.O.P. ......... 86 CARBAGLU ........................ 68 CINRYZE .............................53
BLISOVI FE 1.5/30 ............. 72 carbamazepine ...................... 13 CIPRODEX ..........................87
BOOSTRIX .......................... 81 carbamazepine er .................. 13 ciprofloxacin .........................12
bosentan................................ 90 carbidopa-levodopa ........ 32, 33 ciprofloxacin hcl .......12, 85, 87
BOSULIF ............................. 28 carbidopa-levodopa er .......... 32 ciprofloxacin in d5w .............12
BRAFTOVI .......................... 28 carbidopa-levodopa- citalopram hydrobromide .....18
BREO ELLIPTA .................. 91 entacapone ........................ 33 CLARAVIS ..........................60
briellyn ................................. 72 carisoprodol .......................... 92 clarithromycin.......................12
BRILINTA ........................... 48 carisoprodol-aspirin .............. 92 clarithromycin er ..................11
brimonidine tartrate .............. 85 carteolol hcl .......................... 85 clemastine fumarate ..............88
BRIVIACT ........................... 13 CARTIA XT ......................... 52 CLENPIQ .............................67
bromfenac sodium (once-daily) carvedilol .............................. 51 clindamycin hcl ......................7
.......................................... 86 caspofungin acetate .............. 21 clindamycin palmitate hcl.......7
bromocriptine mesylate ........ 33 CAYSTON ........................... 89 clindamycin phos-benzoyl
BROMSITE .......................... 86 CAZIANT ............................ 72 perox .................................60
budesonide ............................ 70 cefaclor ................................... 8 clindamycin phosphate ....7, 60,
budesonide er........................ 70 cefaclor er ............................... 8 70
bumetanide ........................... 54 cefadroxil ................................ 8 clindamycin phosphate in d5w
buprenorphine hcl ................... 6 cefazolin sodium..................... 8 ............................................7
buprenorphine hcl-naloxone cefdinir.................................... 8 CLINIMIX E/DEXTROSE
hcl ....................................... 6 cefepime hcl ........................... 9 (2.75/5) .............................64
bupropion hcl........................ 18 cefixime .................................. 9
94
CLINIMIX E/DEXTROSE COMPLERA ........................ 38 DEXAMETHASONE
(4.25/10) ........................... 65 COMPRO ............................. 20 INTENSOL.......................70
CLINIMIX E/DEXTROSE constulose ............................. 67 dexamethasone sodium
(4.25/5) ............................. 65 COPAXONE ........................ 58 phosphate ..........................86
CLINIMIX E/DEXTROSE COPIKTRA .......................... 26 DEXILANT ..........................68
(5/15) ................................ 65 CORLANOR ........................ 53 dexmethylphenidate hcl ........57
CLINIMIX E/DEXTROSE cortisone acetate ................... 71 dextroamphetamine sulfate ...57
(5/20) ................................ 65 COTELLIC ........................... 28 dextroamphetamine sulfate er
CLINIMIX/DEXTROSE CREON ................................ 66 ..........................................57
(4.25/10) ........................... 65 CRIXIVAN .......................... 40 dextrose.................................65
CLINIMIX/DEXTROSE cromolyn sodium ............ 85, 91 dextrose-nacl.........................63
(4.25/25) ........................... 65 CRYSELLE-28 .................... 72 DIASTAT ACUDIAL ..........14
CLINIMIX/DEXTROSE cvs gauze sterile.................... 84 DIASTAT PEDIATRIC .......14
(4.25/5) ............................. 65 CYCLAFEM 1/35 ................ 72 diazepam .........................14, 42
CLINIMIX/DEXTROSE CYCLAFEM 7/7/7 ............... 72 DIAZEPAM INTENSOL .....42
(5/15) ................................ 65 cyclobenzaprine hcl .............. 92 diclofenac potassium ............23
CLINIMIX/DEXTROSE cyclophosphamide ................ 25 diclofenac sodium ...........23, 86
(5/20) ................................ 65 cyclosporine.......................... 79 diclofenac sodium er.............23
CLINIMIX/DEXTROSE cyclosporine modified .......... 79 dicloxacillin sodium .............11
(5/25) ................................ 65 CYRED EQ .......................... 72 dicyclomine hcl ....................66
clobazam............................... 14 CYSTADANE ...................... 68 didanosine .............................39
clobetasol prop emollient base CYSTAGON ........................ 69 diflorasone diacetate .............60
.......................................... 60 D diflunisal ...............................23
clobetasol propionate............ 60 dalfampridine er ................... 58 DIGITEK ..............................53
clomipramine hcl .................. 20 DALIRESP ........................... 89 DIGOX .................................53
clonazepam ........................... 42 danazol.................................. 71 digoxin ............................53, 54
clonidine ............................... 48 dapsone ................................... 7 dihydroergotamine mesylate 24
clonidine hcl ......................... 48 DAPTACEL ......................... 81 DILANTIN ...........................16
clopidogrel bisulfate ............. 48 daptomycin ............................. 7 diltiazem hcl .........................52
clorazepate dipotassium ....... 42 DARAPRIM ......................... 32 diltiazem hcl er .....................52
clotrimazole .................... 21, 59 darifenacin hydrobromide er 69 diltiazem hcl er beads ...........52
clotrimazole-betamethasone . 60 DAURISMO ......................... 26 diltiazem hcl er coated beads 52
clozapine......................... 33, 34 DEBLITANE........................ 76 dilt-xr ....................................52
COARTEM .......................... 32 deferasirox ............................ 64 diphenoxylate-atropine .........66
codeine sulfate ........................ 4 DELSTRIGO ........................ 41 diphtheria-tetanus toxoids dt 81
colchicine ............................. 22 DELYLA .............................. 72 disopyramide phosphate .......49
colchicine-probenecid .......... 23 DEMSER .............................. 71 disulfiram ................................6
colesevelam hcl .................... 55 DEPEN TITRATABS .......... 69 divalproex sodium ................15
colestipol hcl ........................ 55 DEPO-PROVERA................ 76 divalproex sodium er ............15
colistimethate sodium (cba) ... 7 DESCOVY ........................... 39 dofetilide ...............................49
COLOCORT ........................ 60 desipramine hcl..................... 20 donepezil hcl .........................17
COMBIGAN ........................ 85 desloratadine ......................... 88 doripenem .............................10
COMBIVENT RESPIMAT . 89 desmopressin ace spray refrig dorzolamide hcl ....................85
COMETRIQ (100 MG DAILY .......................................... 77 dorzolamide hcl-timolol mal 85
DOSE) .............................. 28 desmopressin acetate ............ 77 dorzolamide hcl-timolol mal pf
COMETRIQ (140 MG DAILY desogestrel-ethinyl estradiol . 72 ..........................................85
DOSE) .............................. 28 desonide ................................ 60 DOVATO .............................40
COMETRIQ (60 MG DAILY desoximetasone .................... 60 doxazosin mesylate ...............48
DOSE) .............................. 28 desvenlafaxine er .................. 18 doxepin hcl ...........................20
COMFORT ASSIST INSULIN desvenlafaxine succinate er .. 18 doxercalciferol ......................83
SYRINGE......................... 43 dexamethasone ..................... 70 DOXY 100............................13
95
doxycycline hyclate .............. 13 erlotinib hcl........................... 28 flecainide acetate ..................49
doxycycline monohydrate .... 13 ERRIN .................................. 76 FLOVENT DISKUS ............88
dronabinol............................. 21 ertapenem sodium................. 10 FLOVENT HFA ...................88
drospirenone-ethinyl estradiol ery ......................................... 60 fluconazole .....................21, 22
.......................................... 72 ERY-TAB ............................. 12 fluconazole in sodium chloride
DROXIA .............................. 25 ERYTHROCIN ..........................................21
duloxetine hcl ....................... 19 LACTOBIONATE ........... 12 flucytosine ............................22
DUREZOL ........................... 86 ERYTHROCIN STEARATE fludrocortisone acetate ..........71
dutasteride ............................ 69 .......................................... 12 flunisolide .............................90
dutasteride-tamsulosin hcl .... 69 erythromycin .................. 61, 85 fluocinolone acetonide ....61, 87
DYMISTA ............................ 90 erythromycin base ................ 12 fluocinonide ..........................61
E erythromycin ethylsuccinate. 12 fluocinonide emulsified base 61
E.E.S. 400 ............................. 12 ESBRIET .............................. 91 fluorometholone ...................86
econazole nitrate ................... 21 escitalopram oxalate ............. 19 fluorouracil ...........................26
EDURANT ........................... 38 esomeprazole magnesium..... 68 fluoxetine hcl ........................19
efavirenz ............................... 38 esomeprazole strontium ........ 68 fluphenazine decanoate ........34
ELIQUIS .............................. 46 ESTARYLLA ....................... 73 fluphenazine hcl....................34
ELIQUIS STARTER PACK 46 estradiol .......................... 70, 76 flurbiprofen ...........................23
ELMIRON ............................ 69 ethambutol hcl ...................... 25 flurbiprofen sodium ..............86
EMCYT ................................ 26 ethosuximide ........................ 15 flutamide ...............................26
EMEND ................................ 21 ethynodiol diac-eth estradiol 73 fluticasone propionate ....61, 90
EMOQUETTE ..................... 73 EUCRISA ............................. 61 fluticasone-salmeterol...........91
EMSAM ............................... 18 EVOTAZ .............................. 40 fluvoxamine maleate ............19
EMTRIVA ............................ 39 EXEL COMFORT POINT fondaparinux sodium ............46
EMVERM ............................ 31 PEN NEEDLE .................. 43 FORTEO...............................84
enalapril maleate .................. 49 exemestane ........................... 28 fosamprenavir calcium .........40
enalapril-hydrochlorothiazide ezetimibe .............................. 55 fosinopril sodium ..................49
.......................................... 50 F fosinopril sodium-hctz ..........50
ENBREL .............................. 80 FALMINA ............................ 73 FREAMINE HBC ................65
ENBREL MINI .................... 80 famciclovir............................ 38 furosemide ............................54
ENBREL SURECLICK ....... 80 famotidine ............................. 67 FUZEON ..............................40
ENDARI ............................... 68 FANAPT .............................. 35 FYCOMPA .....................14, 15
ENDOCET ......................... 4, 5 FANAPT TITRATION PACK G
ENGERIX-B ........................ 81 .......................................... 35 gabapentin.............................15
enoxaparin sodium ............... 46 FARYDAK ........................... 29 GALAFOLD.........................68
ENPRESSE-28 ..................... 73 FAZACLO............................ 34 galantamine hydrobromide ...17
ENSKYCE ........................... 73 felbamate .............................. 14 galantamine hydrobromide er
entacapone ............................ 33 felodipine er .......................... 52 ..........................................17
entecavir ............................... 37 FEMYNOR .......................... 73 GARDASIL 9 .......................81
ENTRESTO ......................... 50 fenofibrate ............................ 55 gatifloxacin ...........................85
enulose .................................. 67 fenofibrate micronized ......... 55 GATTEX ..............................66
EPIDIOLEX ......................... 13 fentanyl ................................... 4 GAVILYTE-C ......................67
epinephrine ........................... 91 fentanyl citrate ........................ 5 GAVILYTE-G ......................67
EPITOL ................................ 13 FERRIPROX ........................ 64 GAVILYTE-N WITH
EPIVIR HBV........................ 37 FETZIMA ............................. 19 FLAVOR PACK ..............67
eplerenone ............................ 54 FETZIMA TITRATION ...... 19 gemfibrozil ...........................55
eprosartan mesylate .............. 48 FIASP ................................... 45 generlac.................................67
ERAXIS ............................... 21 FIASP FLEXTOUCH .......... 45 GENGRAF ...........................79
ergotamine-caffeine .............. 24 finasteride ............................. 69 GENTAK ..............................86
ERIVEDGE .......................... 26 FIRAZYR ............................. 54 gentamicin in saline ................7
ERLEADA ........................... 26 FIRVANQ .............................. 7 gentamicin sulfate .......7, 61, 86
96
GEODON ............................. 42 hydrocortisone valerate ........ 61 isoniazid ................................25
GIANVI................................ 73 hydromorphone hcl................. 5 isosorbide dinitrate ...............56
GILENYA ............................ 58 hydromorphone hcl pf ............ 5 isosorbide dinitrate er ...........56
GILOTRIF ............................ 29 hydroxychloroquine sulfate .. 84 isosorbide mononitrate .........56
glatiramer acetate ................. 58 hydroxyurea .......................... 26 isosorbide mononitrate er .....56
GLEOSTINE ........................ 25 hydroxyzine hcl .................... 41 isotretinoin ............................61
glimepiride ........................... 43 hydroxyzine pamoate ........... 42 isradipine ........................52, 53
glipizide ................................ 43 I itraconazole...........................22
glipizide er ............................ 43 ibandronate sodium .............. 84 ivermectin .............................31
glipizide-metformin hcl ........ 43 IBRANCE ............................ 29 IXIARO ................................82
global alcohol prep ease ....... 43 IBU ....................................... 23 J
GLUCAGEN HYPOKIT ..... 44 ibuprofen .............................. 23 JAKAFI ................................29
GLUCAGON EMERGENCY ICLUSIG .............................. 29 JANTOVEN .........................46
.......................................... 44 IDHIFA ................................ 26 JANUMET ...........................43
glyburide-metformin ............ 43 ILEVRO ............................... 86 JANUMET XR .....................43
glycopyrrolate....................... 66 imatinib mesylate ................. 29 JANUVIA .............................44
GOCOVRI............................ 33 IMBRUVICA ....................... 29 JARDIANCE ........................44
granisetron hcl ...................... 21 imipenem-cilastatin .............. 10 JASMIEL ..............................73
griseofulvin microsize .......... 22 imipramine hcl...................... 20 JOLIVETTE .........................76
griseofulvin ultramicrosize ... 22 imiquimod ............................ 61 JUBLIA ................................22
guanfacine hcl ...................... 48 IMOVAX RABIES .............. 82 JULEBER .............................73
guanfacine hcl er .................. 57 INCASSIA............................ 76 JULUCA ...............................39
guanidine hcl ........................ 24 INCRELEX .......................... 77 JUNEL 1.5/30 .......................73
H indapamide ........................... 55 JUNEL 1/20 ..........................73
halobetasol propionate.......... 61 indomethacin ........................ 23 JUNEL FE 1.5/30 .................73
haloperidol ............................ 34 INFANRIX ........................... 82 JUNEL FE 1/20 ....................73
haloperidol decanoate ........... 34 INLYTA ............................... 29 JUXTAPID ...........................56
haloperidol lactate ................ 34 INTELENCE ........................ 38 K
HAVRIX .............................. 81 INTRALIPID........................ 65 KALETRA ...........................40
heparin sodium (porcine) ..... 46 INTRAROSA ....................... 70 KALYDECO ..................89, 90
HEPATAMINE .................... 65 INTRON A ........................... 37 KARIVA...............................73
HETLIOZ ............................. 92 INTROVALE ....................... 73 kcl in dextrose-nacl...............63
HUMIRA .............................. 80 INVEGA SUSTENNA ......... 35 KELNOR 1/35 ......................73
HUMIRA PEDIATRIC INVEGA TRINZA ............... 35 KELNOR 1/50 ......................73
CROHNS START ............ 80 INVIRASE ........................... 40 ketoconazole .........................22
HUMIRA PEN ..................... 80 INVOKAMET ...................... 43 ketorolac tromethamine ........86
HUMIRA PEN-CD/UC/HS INVOKAMET XR ............... 43 KHEDEZLA .........................19
STARTER ........................ 80 INVOKANA ........................ 43 KINRIX ................................82
HUMIRA PEN-PS/UV/ADOL IONOSOL-MB IN D5W ...... 64 KIONEX ...............................64
HS START ....................... 80 IPOL ..................................... 82 KISQALI 200 DOSE ............29
HUMULIN R U-500 ipratropium bromide ....... 89, 90 KISQALI 400 DOSE ............29
(CONCENTRATED) ....... 45 ipratropium-albuterol............ 89 KISQALI 600 DOSE ............29
HUMULIN R U-500 irbesartan .............................. 48 KISQALI FEMARA 200
KWIKPEN ....................... 45 irbesartan-hydrochlorothiazide DOSE................................26
hydralazine hcl ..................... 57 .......................................... 50 KISQALI FEMARA 400
hydrochlorothiazide .............. 54 IRESSA ................................ 29 DOSE................................26
hydrocodone-acetaminophen . 5 ISENTRESS ......................... 40 KISQALI FEMARA 600
hydrocodone-ibuprofen .......... 5 ISENTRESS HD .................. 40 DOSE................................26
hydrocortisone ................ 61, 70 ISIBLOOM ........................... 73 KLOR-CON .........................63
hydrocortisone ace-pramoxine ISOLYTE-P IN D5W ........... 64 KLOR-CON 10 ....................63
.......................................... 61 ISOLYTE-S .......................... 65 KLOR-CON M10 .................63
97
KLOR-CON M15................. 63 LEVEMIR FLEXTOUCH ... 45 loxapine succinate ................34
KLOR-CON M20................. 63 levetiracetam ........................ 14 LUMIGAN ...........................87
KORLYM............................. 78 levetiracetam er .................... 14 LUPRON DEPOT (1-
KURVELO ........................... 73 levobunolol hcl ..................... 85 MONTH) ..........................27
KUVAN ............................... 68 levocarnitine ......................... 68 LUPRON DEPOT (3-
KYNAMRO ......................... 56 levocetirizine dihydrochloride MONTH) ..........................27
L .......................................... 88 LUPRON DEPOT (4-
labetalol hcl .......................... 51 levofloxacin .......................... 12 MONTH) ..........................27
lactulose ................................ 67 levofloxacin in d5w .............. 12 LUPRON DEPOT (6-
lamivudine ...................... 37, 39 LEVONEST ......................... 74 MONTH) ..........................27
lamivudine-zidovudine ......... 39 levonorgest-eth estrad 91-day LUTERA ..............................74
lamotrigine ........................... 16 .......................................... 74 LYNPARZA .........................27
lamotrigine er ....................... 16 levonorgestrel-ethinyl estrad 74 LYRICA .........................15, 58
lamotrigine starter kit-blue ... 16 levonorg-eth estrad triphasic 74 LYSODREN .........................27
lamotrigine starter kit-green . 16 LEVORA 0.15/30 (28) ......... 74 LYZA ...................................76
lamotrigine starter kit-orange LEVO-T................................ 77 M
.......................................... 16 levothyroxine sodium ........... 77 magnesium sulfate ................63
LANTUS .............................. 45 LEVOXYL ........................... 78 malathion ..............................32
LANTUS SOLOSTAR ........ 45 LEXIVA ............................... 40 maprotiline hcl ......................18
LARIN 1.5/30....................... 73 LIALDA ............................... 83 marlissa .................................74
LARIN 1/20.......................... 73 lidocaine ................................. 6 MARPLAN...........................18
LARIN FE 1.5/30 ................. 73 lidocaine hcl ........................... 6 MATULANE ........................27
LARIN FE 1/20 .................... 73 lidocaine hcl urethral/mucosal 6 MAVYRET ..........................37
LARISSIA ............................ 73 lidocaine viscous .................. 59 MAYZENT...........................58
latanoprost ............................ 87 lidocaine viscous hcl ............ 59 meclizine hcl .........................20
LATUDA ............................. 35 lidocaine-prilocaine ................ 6 medroxyprogesterone acetate
LEENA ................................. 73 linezolid .................................. 7 ....................................74, 76
leflunomide........................... 80 LINZESS .............................. 67 mefloquine hcl ......................32
LENVIMA 10 MG DAILY liothyronine sodium .............. 78 megestrol acetate ..................76
DOSE ............................... 29 lisinopril................................ 49 MEKINIST ...........................30
LENVIMA 12 MG DAILY lisinopril-hydrochlorothiazide MEKTOVI............................30
DOSE ............................... 29 .......................................... 51 meloxicam ............................23
LENVIMA 14 MG DAILY lithium .................................. 42 memantine hcl ......................17
DOSE ............................... 29 lithium carbonate .................. 42 memantine hcl er ..................17
LENVIMA 18 MG DAILY lithium carbonate er .............. 42 MENACTRA ........................82
DOSE ............................... 29 LIVALO ............................... 55 MENEST ..............................76
LENVIMA 20 MG DAILY LOKELMA .......................... 64 MENVEO .............................82
DOSE ............................... 29 LONSURF ............................ 26 mercaptopurine .....................25
LENVIMA 24 MG DAILY loperamide hcl ...................... 66 meropenem ...........................10
DOSE ............................... 30 lopinavir-ritonavir ................ 40 MESNEX ..............................27
LENVIMA 4 MG DAILY lorazepam ............................. 42 METADATE ER ..................57
DOSE ............................... 30 LORBRENA ........................ 30 metaxalone ............................92
LENVIMA 8 MG DAILY LORCET ................................ 5 metformin hcl .......................44
DOSE ............................... 30 LORYNA ............................. 74 metformin hcl er ...................44
LESSINA ............................. 73 losartan potassium ................ 48 methadone hcl .........................4
letrozole ................................ 28 losartan potassium-hctz ........ 51 methazolamide ......................54
leucovorin calcium ............... 26 LOTEMAX .................... 86, 87 methenamine hippurate ..........7
LEUKERAN ........................ 25 LOTEMAX SM .................... 87 methimazole .........................78
LEUKINE............................. 47 loteprednol etabonate ........... 87 methocarbamol .....................92
leuprolide acetate.................. 26 lovastatin .............................. 55 methotrexate .........................79
LEVEMIR ............................ 45 LOW-OGESTREL ............... 74 methotrexate sodium ............79
98
methotrexate sodium (pf) ..... 25 nadolol .................................. 52 norethindrone ........................77
methyldopa ........................... 48 nafcillin sodium .................... 11 norethindrone acetate ............77
methylphenidate hcl ............. 57 naloxone hcl ........................... 6 norethindrone acet-ethinyl est
methylphenidate hcl er ......... 57 naltrexone hcl ......................... 6 ..........................................74
methylprednisolone ........ 70, 71 NAMZARIC ......................... 17 norgestimate-eth estradiol ....74
methyltestosterone ................ 71 naproxen ............................... 23 norgestim-eth estrad triphasic
metoclopramide hcl .............. 66 naproxen dr ........................... 23 ..........................................74
metolazone ........................... 55 naproxen sodium .................. 23 NORLYROC ........................77
metoprolol succinate er .. 51, 52 naproxen sodium er .............. 23 NORMOSOL-M IN D5W ....64
metoprolol tartrate ................ 52 naratriptan hcl ....................... 24 NORMOSOL-R IN D5W .....64
metoprolol- NARCAN ............................... 6 NORMOSOL-R PH 7.4........65
hydrochlorothiazide .......... 51 NATACYN .......................... 22 NORTHERA ........................54
metronidazole ............. 8, 61, 70 nateglinide ............................ 44 NORTREL 0.5/35 (28) .........75
metronidazole in nacl ............. 8 NATPARA ........................... 84 NORTREL 1/35 (21) ............75
mexiletine hcl ....................... 49 NEBUPENT ......................... 32 NORTREL 1/35 (28) ............75
MICROGESTIN 1.5/30 ....... 74 NECON 0.5/35 (28) ............. 74 NORTREL 7/7/7 ..................75
MICROGESTIN 1/20 .......... 74 nefazodone hcl...................... 18 nortriptyline hcl ....................20
MICROGESTIN FE 1.5/30 .. 74 neomycin sulfate..................... 7 NORVIR .........................40, 41
MICROGESTIN FE 1/20 ..... 74 neomycin-bacitracin zn- NOVOLIN 70/30 ..................45
midodrine hcl........................ 48 polymyx ............................ 86 NOVOLIN N ........................45
MIGERGOT ......................... 24 neomycin-polymyxin- NOVOLIN R ........................45
miglitol ................................. 44 dexameth .......................... 87 NOVOLOG ..........................45
miglustat ............................... 69 neomycin-polymyxin- NOVOLOG FLEXPEN ........45
MILI ..................................... 74 gramicidin......................... 86 NOVOLOG MIX 70/30 .......45
MINITRAN .......................... 56 neomycin-polymyxin-hc ...... 87 NOVOLOG MIX 70/30
minocycline hcl .................... 13 NEPHRAMINE .................... 65 FLEXPEN.........................45
minoxidil .............................. 57 NERLYNX ........................... 27 NOVOLOG PENFILL .........45
mirtazapine ........................... 18 NEUPOGEN ........................ 47 NOXAFIL.............................22
misoprostol ........................... 68 NEUPRO .............................. 33 NUEDEXTA ........................58
M-M-R II .............................. 82 nevirapine ............................. 38 NUPLAZID ..........................35
moexipril hcl ........................ 49 nevirapine er ......................... 38 nutrilipid ...............................65
molindone hcl ....................... 34 NEXAVAR .......................... 30 NUVARING .........................75
mometasone furoate ....... 61, 90 niacin er (antihyperlipidemic) NUVIGIL .............................92
MONONESSA ..................... 74 .......................................... 56 NYAMYC ............................22
montelukast sodium.............. 88 nicardipine hcl ...................... 53 nystatin ...........................22, 59
morphine sulfate ..................... 5 NICOTROL ............................ 6 nystatin-triamcinolone ..........62
morphine sulfate (concentrate) nifedipine er .......................... 53 NYSTOP...............................22
............................................ 5 nifedipine er osmotic release 53 O
morphine sulfate er ................. 4 NIKKI................................... 74 OCELLA ..............................75
MOVANTIK ........................ 66 nilutamide ............................. 27 OCTAGAM ..........................81
MOXEZA ............................. 86 NINLARO ............................ 30 octreotide acetate ..................78
moxifloxacin hcl ............. 12, 86 NITRO-DUR ........................ 56 ODEFSEY ............................41
moxifloxacin hcl in nacl ....... 12 nitrofurantoin .......................... 8 ODOMZO.............................27
mupirocin ............................. 62 nitrofurantoin macrocrystal .... 8 OFEV....................................91
mycophenolate mofetil ......... 79 nitrofurantoin monohyd macro ofloxacin ...................12, 86, 88
mycophenolate sodium ......... 79 ............................................ 8 olanzapine .......................35, 36
MYORISAN......................... 62 nitroglycerin ......................... 56 olanzapine-fluoxetine hcl .....43
MYRBETRIQ ...................... 69 NITROSTAT ........................ 57 olmesartan medoxomil .........48
MYTESI ............................... 66 NOCDURNA ....................... 77 olmesartan medoxomil-hctz .51
N NORA-BE ............................ 77 olmesartan-amlodipine-hctz .51
nabumetone .......................... 23 NORDITROPIN FLEXPRO 77 olopatadine hcl......................85
99
omega-3-acid ethyl esters ..... 56 penicillin v potassium ........... 11 prednisolone acetate .............87
omeprazole ........................... 68 PENTAM.............................. 32 prednisolone sodium phosphate
ondansetron .......................... 21 pentoxifylline er ................... 47 ....................................71, 87
ondansetron hcl .................... 21 perindopril erbumine ............ 49 prednisone.............................71
OPSUMIT ............................ 90 permethrin ............................ 32 PREDNISONE INTENSOL .71
ORENCIA ............................ 81 perphenazine ......................... 34 preferred plus insulin syringe
ORENCIA CLICKJECT ...... 81 PERSERIS ............................ 36 ..........................................43
ORFADIN ............................ 69 phenelzine sulfate ................. 18 PREMASOL ...................65, 66
ORILISSA ............................ 77 phenobarbital ........................ 14 PREMPHASE.......................76
ORKAMBI ........................... 90 phenytoin .............................. 16 PREPOPIK ...........................68
orphenadrine citrate er .......... 92 phenytoin sodium extended .. 16 PREVALITE ........................56
ORSYTHIA .......................... 75 PICATO................................ 62 PREVIFEM ..........................75
oseltamivir phosphate ........... 41 PIFELTRO ........................... 38 PREZCOBIX ........................41
OSPHENA ........................... 70 pilocarpine hcl ................ 59, 85 PREZISTA ...........................41
oxacillin sodium ................... 11 pimecrolimus ........................ 62 PRIFTIN ...............................25
oxandrolone .......................... 71 pimozide ............................... 34 primaquine phosphate ...........32
oxaprozin .............................. 23 PIMTREA ............................ 75 primidone ..............................14
oxazepam .............................. 92 pindolol ................................. 52 PRIVIGEN ...........................81
oxcarbazepine ....................... 16 pioglitazone hcl .................... 44 probenecid ............................23
OXERVATE ........................ 84 pioglitazone hcl-glimepiride. 44 PROCALAMINE .................66
oxybutynin chloride.............. 69 pioglitazone hcl-metformin hcl prochlorperazine ...................20
oxybutynin chloride er ......... 69 .......................................... 44 prochlorperazine maleate 20, 34
oxycodone hcl ........................ 5 piperacillin sod-tazobactam so PROCRIT .............................47
oxycodone hcl er .................... 4 .......................................... 11 PROCTO-PAK .....................62
oxycodone-acetaminophen ..... 5 PIRMELLA 1/35 .................. 75 PROCTOSOL HC ................62
oxycodone-aspirin .................. 5 piroxicam .............................. 23 PROCTOZONE-HC .............62
oxycodone-ibuprofen ............. 5 PLASMA-LYTE 148 ........... 65 progesterone micronized ......77
OZEMPIC ............................ 44 PLASMA-LYTE A .............. 65 PROGLYCEM .....................45
P PLEGRIDY .......................... 59 PROGRAF ............................79
PACERONE ......................... 49 PLEGRIDY STARTER PACK PROLASTIN-C ....................91
paliperidone er ...................... 36 .......................................... 59 PROLENSA .........................87
PANRETIN .......................... 27 podofilox .............................. 62 PROLIA ................................84
pantoprazole sodium ............ 68 polymyxin b-trimethoprim ... 86 PROMACTA ........................47
PANZYGA ........................... 81 POMALYST ........................ 30 promethazine hcl ..................20
paricalcitol ............................ 84 PORTIA-28 .......................... 75 propafenone hcl ....................49
paromomycin sulfate .............. 7 potassium chloride .......... 63, 64 propafenone hcl er ................49
paroxetine hcl ....................... 19 potassium chloride crys er .... 63 proparacaine hcl......................6
PASER ................................. 25 potassium chloride er............ 63 propranolol hcl......................52
PAXIL .................................. 19 potassium chloride in dextrose propranolol hcl er .................52
PAZEO ................................. 85 .......................................... 63 propranolol-hctz ...................51
PEDIARIX ........................... 82 potassium chloride in nacl .... 63 propylthiouracil ....................78
PEDVAX HIB ...................... 82 potassium citrate er ............... 64 PROQUAD ...........................82
peg 3350/electrolytes............ 67 PRALUENT ......................... 56 PROSOL ...............................66
peg-3350/electrolytes ........... 67 pramipexole dihydrochloride 33 protriptyline hcl ....................20
PEGANONE ........................ 16 pramipexole dihydrochloride er psorcon .................................62
PEGASYS ............................ 37 .......................................... 33 PULMOZYME .....................90
PEGASYS PROCLICK ....... 37 prasugrel hcl ......................... 48 PURIXAN ............................26
penicillin g pot in dextrose ... 11 pravastatin sodium ................ 55 pyrazinamide ........................25
penicillin g potassium........... 11 prazosin hcl........................... 48 pyridostigmine bromide........24
penicillin g procaine ............. 11 prednicarbate ........................ 62 Q
penicillin g sodium ............... 11 prednisolone ......................... 71 QUADRACEL .....................82
100
quetiapine fumarate .............. 36 ROWEEPRA ........................ 14 SPRITAM .............................14
quinapril hcl.......................... 49 ROWEEPRA XR ................. 14 SPRYCEL.............................30
quinapril-hydrochlorothiazide RUBRACA ........................... 30 SPS .......................................64
.......................................... 51 RYDAPT .............................. 30 SRONYX ..............................75
quinidine sulfate ................... 49 RYTARY.............................. 33 SSD .......................................62
quinine sulfate ...................... 32 S stavudine ...............................39
R SAMSCA.............................. 64 STIOLTO RESPIMAT .........91
RABAVERT ........................ 82 SANDIMMUNE .................. 79 STIVARGA ..........................30
raloxifene hcl ........................ 77 SANTYL .............................. 62 STRIBILD ............................41
ramipril ................................. 49 SAPHRIS.............................. 36 SUBOXONE ..........................6
ranitidine hcl ......................... 67 SAVELLA ............................ 58 sucralfate...............................68
ranolazine er ......................... 54 SAVELLA TITRATION sulfacetamide sodium ...........86
rasagiline mesylate ............... 33 PACK ............................... 58 sulfacetamide sodium (acne) 62
RAVICTI.............................. 69 scopolamine .......................... 20 sulfacetamide-prednisolone ..87
RECLIPSEN......................... 75 selegiline hcl ......................... 33 sulfadiazine ...........................13
RECOMBIVAX HB ............ 82 selenium sulfide .................... 62 sulfamethoxazole-trimethoprim
RECTIV ............................... 62 SELZENTRY ....................... 40 ..........................................13
REGRANEX ........................ 62 SENSIPAR ........................... 84 sulfasalazine .........................13
RELENZA DISKHALER .... 41 SEREVENT DISKUS .......... 89 sulindac .................................24
RELI-ON INSULIN sertraline hcl ......................... 19 sumatriptan ...........................24
SYRINGE......................... 43 SETLAKIN .......................... 75 sumatriptan succinate ...........24
repaglinide ............................ 44 sevelamer carbonate ............. 70 SUPRAX ................................9
repaglinide-metformin hcl .... 44 SHAROBEL ......................... 77 SUPREP BOWEL PREP KIT
REPATHA ........................... 56 SHINGRIX ........................... 82 ..........................................68
REPATHA PUSHTRONEX SIGNIFOR............................ 78 SUTENT ...............................30
SYSTEM .......................... 56 sildenafil citrate .............. 66, 89 SYEDA .................................75
REPATHA SURECLICK .... 56 SILENOR ............................. 92 SYLATRON .........................38
RESCRIPTOR ...................... 38 silodosin................................ 69 SYMDEKO ..........................90
RESTASIS ........................... 84 silver sulfadiazine ................. 62 SYMFI ..................................38
RETACRIT .......................... 47 SIMBRINZA ........................ 85 SYMFI LO............................38
REVLIMID .......................... 25 simvastatin ............................ 55 SYMPAZAN ........................14
REXULTI ............................. 36 sirolimus ............................... 79 SYMTUZA ...........................38
REYATAZ ........................... 41 SIRTURO ............................. 25 SYNAREL ............................78
RIBASPHERE ..................... 37 SIVEXTRO ............................ 8 SYNDROS ...........................21
ribavirin ................................ 37 sodium chloride .................... 64 SYNJARDY .........................44
rifabutin ................................ 25 sodium phenylbutyrate ......... 69 SYNJARDY XR ...................44
rifampin ................................ 25 sodium polystyrene sulfonate SYNRIBO.............................27
RIFATER ............................. 25 .......................................... 64 SYNTHROID .......................78
riluzole .................................. 58 sofosbuvir-velpatasvir .......... 37 T
rimantadine hcl ..................... 41 SOLIQUA ............................ 44 TABLOID.............................26
risedronate sodium ............... 84 SOLTAMOX ........................ 77 tacrolimus .............................80
RISPERDAL CONSTA ....... 36 SOMATULINE DEPOT ...... 78 TAFINLAR ..........................30
risperidone ............................ 36 SOMAVERT ........................ 78 TAGRISSO...........................30
ritonavir ................................ 41 SORINE................................ 50 TAKHZYRO ........................54
rivastigmine .......................... 17 sotalol hcl ....................... 50, 52 TALZENNA .........................30
rivastigmine tartrate.............. 17 sotalol hcl (af) ....................... 50 tamoxifen citrate ...................27
rizatriptan benzoate .............. 24 SPIRIVA HANDIHALER ... 89 tamsulosin hcl .......................69
ropinirole hcl ........................ 33 SPIRIVA RESPIMAT .......... 89 TARCEVA ...........................30
rosuvastatin calcium ............. 55 spironolactone ...................... 54 TARGRETIN .......................27
ROTARIX ............................ 82 spironolactone-hctz .............. 51 TARINA FE 1/20 .................75
ROTATEQ ........................... 82 SPRINTEC 28 ...................... 75 TASIGNA.............................30
101
tazarotene ............................. 62 TRACLEER ......................... 90 VALCHLOR ........................27
TAZTIA XT ......................... 53 tramadol hcl ............................ 5 valganciclovir hcl .................37
TDVAX ................................ 82 tramadol-acetaminophen ........ 5 valproic acid .........................15
TECFIDERA ........................ 59 trandolapril ........................... 49 valsartan ................................49
TEFLARO ............................ 10 tranexamic acid..................... 47 valsartan-hydrochlorothiazide
TEGRETOL-XR .................. 14 tranylcypromine sulfate ........ 18 ..........................................51
TEGSEDI ............................. 58 TRAVASOL ......................... 66 vancomycin hcl .......................8
TEKTURNA HCT ............... 51 TRAVATAN Z..................... 87 VANDAZOLE .....................70
telmisartan ............................ 48 trazodone hcl ........................ 18 VAQTA ................................83
telmisartan-hctz .................... 51 TRECATOR ......................... 25 VARIVAX ............................83
temazepam ............................ 92 TRELEGY ELLIPTA........... 91 VARIZIG ..............................83
TENIVAC ............................ 82 TRELSTAR MIXJECT ........ 78 VARUBI ...............................21
tenofovir disoproxil fumarate TRESIBA ............................. 46 VASCEPA ............................56
.......................................... 39 TRESIBA FLEXTOUCH..... 46 VELIVET .............................76
terazosin hcl.......................... 48 tretinoin .......................... 27, 62 VELPHORO .........................70
terbinafine hcl ....................... 22 triamcinolone acetonide . 59, 62 VEMLIDY ............................37
terbutaline sulfate ................. 89 triamterene-hctz .................... 51 VENCLEXTA ......................31
terconazole ........................... 70 TRIDERM ............................ 62 VENCLEXTA STARTING
testosterone ........................... 72 trientine hcl ........................... 64 PACK ...............................31
testosterone cypionate .......... 71 TRI-ESTARYLLA ............... 75 venlafaxine hcl......................20
testosterone enanthate .......... 71 trifluoperazine hcl................. 34 venlafaxine hcl er .................19
tetrabenazine......................... 58 trifluridine ............................. 86 VENTOLIN HFA .................89
tetracycline hcl ..................... 13 trihexyphenidyl hcl ............... 32 verapamil hcl ........................53
THALOMID......................... 25 TRI-LEGEST FE .................. 75 verapamil hcl er ....................53
theophylline .......................... 89 TRILYTE ............................. 68 VERSACLOZ.......................34
theophylline er ...................... 89 trimethoprim ........................... 8 VERZENIO ..........................27
thioridazine hcl ..................... 34 TRI-MILI.............................. 75 VICTOZA.............................44
thiothixene ............................ 34 trimipramine maleate ............ 20 VIDEX ..................................39
tiagabine hcl ......................... 15 TRINTELLIX ....................... 18 VIDEX EC............................39
TIBSOVO............................. 27 TRI-PREVIFEM .................. 75 VIENVA ...............................76
tigecycline .............................. 8 TRI-SPRINTEC ................... 75 vigabatrin ..............................15
TIGLUTIK ........................... 58 TRIUMEQ ............................ 39 VIGADRONE ......................15
timolol maleate ............... 52, 85 TRIVORA (28)..................... 75 VIIBRYD .............................18
tinidazole .............................. 32 TRI-VYLIBRA .................... 76 VIIBRYD STARTER PACK
TIVICAY ............................. 40 TROPHAMINE .................... 66 ..........................................18
tizanidine hcl ........................ 92 TRULICITY ......................... 44 VIMPAT ...............................16
TOBI PODHALER .............. 90 TRUMENBA........................ 82 VIRACEPT...........................41
tobramycin ........................ 7, 86 TRUVADA .......................... 39 VIREAD ...............................39
tobramycin sulfate .................. 7 TWINRIX ............................. 82 VITRAKVI ...........................31
tobramycin-dexamethasone .. 87 TYBOST .............................. 40 VIZIMPRO ...........................31
TOLAK ................................ 27 TYKERB .............................. 31 voriconazole .........................22
tolmetin sodium .................... 24 TYMLOS.............................. 84 VOSEVI ...............................37
tolterodine tartrate ................ 69 TYPHIM VI ......................... 83 VOTRIENT ..........................31
tolterodine tartrate er ............ 69 U VRAYLAR ...........................36
topiramate ............................. 16 UCERIS ................................ 71 VYFEMLA ...........................76
toremifene citrate.................. 27 ULORIC ............................... 23 VYLIBRA ............................76
torsemide .............................. 54 UNITHROID ........................ 78 VYZULTA ...........................87
TOUJEO MAX SOLOSTAR UPTRAVI............................. 90 W
.......................................... 45 ursodiol ................................. 67 warfarin sodium ....................46
TOUJEO SOLOSTAR ......... 46 V X
TPN ELECTROLYTES ....... 66 valacyclovir hcl .................... 38 XALKORI ............................31
102
XARELTO ........................... 47 Y zolmitriptan...........................24
XARELTO STARTER PACK YF-VAX ............................... 83 zolpidem tartrate ...................92
.......................................... 47 YONSA ................................ 31 zonisamide ............................15
XATMEP ............................. 80 Z ZORTRESS ..........................80
XGEVA ................................ 84 zafirlukast ............................. 88 ZOSTAVAX.........................83
XIFAXAN .............................. 8 zaleplon ................................ 92 ZOVIA 1/35E (28) ...............76
XOFLUZA ........................... 41 ZEJULA ............................... 31 ZYDELIG .............................31
XOLAIR ............................... 91 ZELBORAF ......................... 31 ZYKADIA ............................31
XOSPATA ........................... 31 ZENPEP ............................... 67 ZYLET .................................87
XTANDI............................... 27 zidovudine ............................ 39 ZYPREXA RELPREVV ......37
XULTOPHY ........................ 44 ziprasidone hcl...................... 36 ZYTIGA ...............................31
XURIDEN ............................ 69 ZIRGAN ............................... 37
XYREM ............................... 92 ZOLINZA ............................. 31
103

HMO Formulary

Hochgeladen von

Dokumentinformationen

Originalbeschreibung:

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

HMO Formulary

Hochgeladen von

Copyright:

Verfügbare Formate

Clear Spring Health Enhanced Plan 2019 5-Tier (List of Covered Drugs)

List of Drugs by Medical Condition

HRM: HighRisk Medication (PA required for ages 65 or over)

LA: This prescription drug is limited to certain pharmacies.

Drug Name Drug Tier Requirements/Limits

A ambrisentan .......................... 90 ASMANEX 120 METERED

Das könnte Ihnen auch gefallen