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Formulary 2020

© EpiphanyRx, LLC. All Rights Reserved 3/4/2020

2020 EpiphanyRx Formulary

Welcome to EpiphanyRx! We are excited to serve you and manage your prescription drug benefits. This drug list,

or formulary, contains important information about drug coverage. Our team of pharmacists, nurses, doctors,

statisticians and healthcare economists review drugs approved by the U.S. Food and Drug Administration (FDA)

to determine coverage for you and your employer. This drug list is regularly updated and subject to change at

any time.

About the list

You can use this list to find information about drug coverage and therapeutic options. You can search for a drug

name by clicking on Edit and then selecting Find/Search or by using the Control and F keys on your keyboard.

After typing in the drug name, click Search to find your drug. It is always an option to bring this list with you to

your next doctor’s appointment. You can use the information from this list to talk with your doctor about

potential lower-cost drug options.

On the list, each drug is identified with a tier value based on the drug’s cost to the plan. Tier 1 drugs are the lowest cost drugs to the plan and Tier 3 are the highest cost drugs to the plan. Your plan may cover specialty drugs in Tier 4. Tiers are important because the amount you pay is based on the drug tier. You can receive up to a 30-day supply of most medications on the formulary. Some drugs, like diabetes and drugs to help with heart conditions, may be covered for up to a 90-day supply. If you are interested in which drugs may qualify, please reference the Maintenance Drug list

located at https://epiphanyrx.com/resources/members/.

While this drug list is a good guide, it is good idea to check your Summary Plan Description to confirm the amount you will pay and what coverage your plan allows.

Some FDA-approved drugs may not be covered by the plan if they have over-the-counter (OTC) equivalents or provide

low-value as compared to other drugs available on the plan’s formulary. Not all FDA-approved indications or uses may

be covered for a drug if multiple uses exist. Your prescription drug benefit plan may not cover certain products or drug

categories regardless of the appearance in this document. Your Summary Plan Document is a good place to go to better

understand exclusions. You can always call us if you have questions, by dialing 844-820-3260

Under the Affordable Care Act, certain preventative medications may be covered at a $0 copay. Please refer to the

Affordable Care Act Preventative drug list located at https://epiphanyrx.com/resources/members/for these drugs.

https://epiphanyrx.com/resources/members/

https://epiphanyrx.com/resources/members/


Legend

Prior Authorization (PA) – The Plan requires a review to determine if the drug qualifies for coverage under the

benefit. If your physician prescribes a drug that requires a prior authorization, the PBM will work with your

prescriber to complete the prior authorization review. Either you or the pharmacy can ask your doctor to call

844-820-3260 to initiate the prior authorization or appeal process.

Step Therapy (ST) – In some cases, you are required to first try certain drugs to treat your medical condition before the

Plan will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition,

the Plan may not cover Drug B unless you try Drug A first.

Quantity Limits (QL) - For certain drugs, the amount of the drug that will be covered by the plan is limited based on national standards and current scientific literature. These limits ensure the quantity of units supplied for each prescription remain consistent with clinical dosing guidelines and benefit plan design.

Tier (T#)– The value that determines the copayment in which you pay for the medication. Every drug will be given a tier value. Refer to your Summary Plan Design document for the specific copayment.

Specialty Drugs – Specialty medications are drugs that are used to treat complex conditions, such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis and rheumatoid arthritis. Specialty drugs must be obtained from a select pharmacy and are limited to 30 days supply.

Essential Health Benefit Drugs - The amount you pay for drugs designated as Essential Health Benefits count toward your deductible and/or out of pocket maximum. Your plan may cover select Non-Essential Health Benefits (Non-EHB) Drugs at the tiers outlined below. Any amount you pay for Non-Essential Health Benefits Drugs will NOT count toward your deductible and/or out of pocket maximum.


Route Tier PA ST QL Specialty Non-EHB

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

Adderall Oral 3

Adderall XR Oral 2

Adipex-P Oral 3

Adzenys ER Oral 3

Adzenys XR-ODT Oral 3

Amphetamine Sulfate Oral 1

Amphetamine-Dextroamphet ER Oral 1

Amphetamine-Dextroamphetamine Oral 1

Aptensio XR Oral 3

Armodafinil Oral 1

Atomoxetine HCl Oral 1

Belviq Oral 3

Belviq XR Oral 3

Benzphetamine HCl Oral 1

Caffeine Citrate Oral 1

cloNIDine HCl ER Oral 1

Concerta Oral 2

Contrave Oral 3

Cotempla XR-ODT Oral 3

Daytrana Transdermal 3

Desoxyn Oral 3

Dexedrine Oral 3

Dexmethylphenidate HCl Oral 1

Dexmethylphenidate HCl ER Oral 1

Dextroamphetamine Sulfate Oral 1

Dextroamphetamine Sulfate ER Oral 1

Diethylpropion HCl Oral 1

Diethylpropion HCl ER Oral 1

Dyanavel XR Oral 3

Evekeo Oral 3

Focalin Oral 3

Focalin XR Oral 3

guanFACINE HCl ER Oral 1

Intuniv Oral 3

Kapvay Oral 3

Metadate ER Oral 1

Methamphetamine HCl Oral 1



Methylin Oral 3

Methylphenidate HCl Oral 1

Methylphenidate HCl ER Oral 1

Methylphenidate HCl ER (CD) Oral 1

Methylphenidate HCl ER (LA) Oral 1

Modafinil Oral 1

Mydayis Oral 3

Nuvigil Oral 3

Phendimetrazine Tartrate Oral 1

Phendimetrazine Tartrate ER Oral 1

Phentermine HCl Oral 1

ProCentra Oral 3

Provigil Oral 3

Qsymia Oral 3 Y

QuilliChew ER Oral 3

Quillivant XR Oral 3

Regimex Oral 3

Ritalin Oral 3

Ritalin LA Oral 3

Saxenda Subcutaneous 3

Strattera Oral 2

Sunosi Oral 3 Y

Vyvanse Oral 2

Xenical Oral 3

Zenzedi 10 mg Oral 1


Zenzedi 2.5 mg Oral 3

Zenzedi 7.5 mg Oral 3

Zenzedi 5 mg Oral 1


Zenzedi30 mg Oral 3

ALLERGENIC EXTRACTS/BIOLOGICALS MISC

Adagen Intramuscular 3 Y Y

Grastek Sublingual 3 Y

Oralair Sublingual 3 Y

Oralair Adult Sample Kit Sublingual 3 Y

Oralair Adult Starter Pack Sublingual 3 Y

Oralair Childrens Sample Kit Sublingual 3 Y



Oralair Childrens Starter Pack Sublingual 3 Y

Ragwitek Sublingual 3 Y

AMINOGLYCOSIDES

Bethkis Inhalation 3 Y Y Y

Kitabis Pak Inhalation 3 Y Y Y

Neomycin Sulfate Oral 1

Paromomycin Sulfate Oral 1

Tobi Inhalation 3 Y Y Y

Tobi Podhaler Inhalation 3 Y Y Y

Tobramycin Inhalation 1 Y Y Y

ANALGESICS - ANTI-INFLAMMATORY

Actemra Intravenous 3 Y Y

Actemra Subcutaneous 3 Y Y

Actemra ACTPen Subcutaneous 3 Y Y

Anaprox DS Oral 3

Arava Oral 3

Arcalyst Subcutaneous 3 Y Y

Arthrotec Oral 3

CeleBREX Oral 3

Celecoxib Oral 1

Daypro Oral 3

Diclofenac Potassium Oral 1 Y

Diclofenac Sodium Oral 1 Y

Diclofenac Sodium ER Oral 1 Y

Diclofenac-miSOPROStol Oral 1

EC-Naprosyn Oral 3

Enbrel Subcutaneous 2 Y Y Y

Enbrel Mini Subcutaneous 3 Y Y

Enbrel SureClick Subcutaneous 2 Y Y Y

Etodolac Oral 1

Etodolac ER Oral 1

Feldene Oral 3

Fenoprofen Calcium Oral 1

Fenortho Oral 3

Flurbiprofen Oral 1 Y

Humira Subcutaneous 2 Y Y Y

Humira Pediatric Crohns Start Subcutaneous 2 Y Y Y

Humira Pen Subcutaneous 2 Y Y Y



Humira Pen-CD/UC/HS Starter Subcutaneous 2 Y Y Y

Humira Pen-Ps/UV/Adol HS Start Subcutaneous 2 Y Y Y

IBU Oral 1

Ibuprofen Oral 1

Ilaris Subcutaneous 2 Y Y

Indocin Oral 3

Indocin Rectal 3

Indomethacin Oral 1

Indomethacin ER Oral 1

Ketoprofen Oral 1 Y

Ketoprofen ER Oral 1 Y

Ketorolac Tromethamine Oral 1

Kevzara Subcutaneous 3 Y Y

Kineret Subcutaneous 3 Y Y Y

Leflunomide Oral 1

Lodine Oral 3

Meclofenamate Sodium Oral 1

Mefenamic Acid Oral 1

Meloxicam Oral 1 Y

Mobic Oral 3 Y

Nabumetone Oral 1

Nalfon Oral 3

Naprosyn Oral 3

Naproxen Oral 1

Naproxen DR Oral 1

Naproxen Sodium Oral 1

Naproxen Sodium ER Oral 1

Olumiant Oral 3 Y Y

Orencia Subcutaneous 3 Y Y

Orencia ClickJect Subcutaneous 3 Y Y

Otezla Oral 2 Y Y

Otrexup Subcutaneous 3 Y Y

Oxaprozin Oral 1

Piroxicam Oral 1

Ponstel Oral 3

ProFeno Oral 3

Rasuvo Subcutaneous 3 Y Y

Ridaura Oral 3



Simponi Subcutaneous 2 Y Y Y

Sulindac Oral 1

Tivorbex Oral 3

Tolmetin Sodium Oral 1

Xeljanz Oral 3 Y Y Y

Xeljanz XR Oral 3 Y Y Y

Zorvolex Oral 3 Y

ANALGESICS - NonNarcotic

Adult Aspirin EC Low Strength Oral 1

Adult Aspirin Regimen Oral 1

Aspirin Oral 1

Aspirin 81 Oral 1

Aspirin Adult Oral 1

Aspirin Adult Low Dose Oral 1

Aspirin Adult Low Strength Oral 1

Aspirin Childrens Oral 1

Aspirin EC Oral 1

Aspirin EC Low Dose Oral 1

Aspirin EC Low Strength Oral 1

Aspirin Low Dose Oral 1

Aspirin Low Strength Oral 1

Aspir-Low Oral 1

Bayer Advanced Aspirin Reg St Oral 1

Bayer Aspirin Oral 1

Bayer Aspirin EC Low Dose Oral 1

Bayer Low Dose Oral 1

Bupap Oral 1

Butalbital-Acetaminophen Oral 1

Butalbital-APAP Oral 1

Butalbital-APAP-Caffeine Oral 1

Butalbital-ASA-Caffeine Oral 1

Butalbital-Aspirin-Caffeine Oral 1

Capacet Oral 1 Y

Childrens Aspirin Oral 1

Childrens Aspirin Low Strength Oral 1

CVS Aspirin Oral 1

CVS Aspirin Adult Low Dose Oral 1

CVS Aspirin Adult Low Strength Oral 1



CVS Aspirin Child Oral 1

CVS Aspirin EC Oral 1

CVS Aspirin Low Dose Oral 1

CVS Childrens Aspirin Oral 1

Diflunisal Oral 1

EC-81 Aspirin Oral 1

Ecotrin Oral 3

Ecotrin Low Strength Oral 1

EcPirin Oral 1

EQ Adult Aspirin Low Strength Oral 1

EQ Aspirin Oral 1

EQ Aspirin Adult Low Dose Oral 1

EQ Aspirin Low Dose Oral 1

EQ Childrens Aspirin Oral 1

EQL Adult Aspirin Low Strength Oral 1

EQL Aspirin Oral 1

EQL Aspirin EC Oral 1

EQL Aspirin Low Dose Oral 1

EQL Childrens Aspirin Oral 1

Esgic Oral 3

Fioricet Oral 3 Y

GNP Adult Aspirin Low Strength Oral 1

GNP Aspirin Oral 1

GNP Aspirin Low Dose Oral 1

GoodSense Aspirin Oral 1

GoodSense Aspirin Adult Low St Oral 1

GoodSense Aspirin Low Dose Oral 1

H-E-B Aspirin Oral 1

HM Aspirin Oral 1

HM Aspirin EC Oral 1

HM Aspirin EC Low Dose Oral 1

KLS Aspirin EC Oral 1

KLS Aspirin Low Dose Oral 1

KP Aspirin Oral 1

Levacet Oral 3

Margesic Oral 1 Y

Marten-Tab Oral 1 Y

Meijer Aspirin EC Oral 1



Miniprin Low Dose Oral 1

MM Aspirin Oral 1

Norwich Aspirin Oral 1

Phrenilin Forte Oral 1

PX Aspirin Oral 1

PX Enteric Aspirin Oral 1

QC Aspirin Oral 1

QC Aspirin Low Dose Oral 1

QC Childrens Aspirin Oral 1

QC Enteric Aspirin Oral 1

RA Aspirin Oral 1

RA Aspirin Adult Low Dose Oral 1

RA Aspirin Adult Low Strength Oral 1

RA Aspirin Childrens Oral 1

RA Aspirin EC Oral 1

RA Aspirin EC Adult Low St Oral 1

RA Childrens Aspirin Oral 1

Salsalate Oral 1

SB Aspirin Oral 1

SB Aspirin Adult Low Strength Oral 1

SB Aspirin EC Oral 1

SB Childrens Aspirin Oral 1

SB Low Dose ASA EC Oral 1

SM Aspirin Oral 1

SM Aspirin Adult Low Strength Oral 1

SM Aspirin EC Oral 1

SM Aspirin EC Low Strength Oral 1

SM Aspirin Low Dose Oral 1

SM Childrens Aspirin Oral 1

St Joseph Aspirin Oral 1

St Joseph Low Dose Oral 1

Tencon Oral 2 Y

TGT Aspirin Oral 1

TGT Aspirin EC Oral 1

TGT Aspirin Low Dose Oral 1

TGT Childrens Aspirin Oral 1

Vanatol LQ Oral 3

Vanatol S Oral 3



Zebutal Oral 1 Y

ANALGESICS - OPIOID

Abstral Sublingual 3 Y Y

Acetaminophen-Codeine Oral 1 Y

Acetaminophen-Codeine #2 Oral 1 Y



Actiq Buccal 3 Y Y

APAP-Caff-Dihydrocodeine Oral 1 Y

Ascomp-Codeine Oral 1 Y

Aspirin-Caff-Dihydrocodeine Oral 1 Y

Bunavail Buccal 3 Y

Buprenorphine Transdermal 1 Y

Buprenorphine HCl Sublingual 1 Y

Buprenorphine HCl-Naloxone HCl Sublingual 1 Y

Butalbital-APAP-Caff-Cod Oral 1 Y

Butalbital-ASA-Caff-Codeine Oral 1 Y

Butorphanol Tartrate Nasal 1 Y

Butrans Transdermal 3 Y

Codeine Sulfate Oral 1 Y

Demerol Oral 3 Y

Dilaudid Oral 3 Y

Dolophine Oral 3

Duragesic-100 Transdermal 3





Dvorah Oral 3 Y

Embeda Oral 3

Endocet Oral 1 Y

Exalgo Oral 3

fentaNYL Transdermal 1 Y

fentaNYL Citrate Buccal 1 Y Y

Fentora Buccal 3 Y Y

Fioricet/Codeine Oral 3 Y

Fiorinal/Codeine #3 Oral 3 Y

Hycet Oral 3 Y



HYDROcodone-Acetaminophen Oral 1 Y

HYDROcodone-Ibuprofen Oral 1 Y

HYDROmorphone HCl Oral 1 Y

HYDROmorphone HCl Rectal 1 Y

HYDROmorphone HCl ER Oral 1

Hysingla ER Oral 3 Y

Ibudone Oral 3 Y

Ionsys Transdermal 3

Levorphanol Tartrate Oral 1

Lorcet Oral 1 Y

Lorcet HD Oral 1 Y

Lorcet Plus Oral 1 Y

Lortab Oral 1 Y

Meperidine HCl Oral 1 Y

Meperidine-Promethazine Oral 1

Methadone HCl Oral 1

Methadone HCl Intensol Oral 1

Methadose Oral 1

Methadose Sugar-Free Oral 3

MorphaBond ER Oral 3

Morphine Sulfate Oral 1

Morphine Sulfate Rectal 1

Morphine Sulfate (Concentrate) Oral 1

Morphine Sulfate ER Oral 1

Morphine Sulfate ER Beads Oral 1

MS Contin Oral 3

Nalbuphine HCl Injection 1

Norco Oral 3 Y

Nucynta Oral 3 Y

Nucynta ER Oral 3 Y

Opana Oral 3 Y

Opana ER Oral 3 Y

Oxaydo Oral 3 Y

oxyCODONE HCl Oral 1 Y

oxyCODONE HCl ER Oral 1 Y

oxyCODONE-Acetaminophen Oral 1 Y

oxyCODONE-Aspirin Oral 1 Y

oxyCODONE-Ibuprofen Oral 1 Y



OxyCONTIN Oral 3 Y

oxyMORphone HCl Oral 1 Y

oxyMORphone HCl ER Oral 1 Y

Panlor Oral 3 Y

Pentazocine-Naloxone HCl Oral 1 Y

Percocet Oral 3 Y

Primlev Oral 3 Y

Reprexain Oral 1 Y

Roxicodone Oral 3 Y

Suboxone Sublingual 2 Y

Synalgos-DC Oral 3 Y

traMADol HCl Oral 1 Y

traMADol HCl ER Oral 1 Y

traMADol HCl ER (Biphasic) Oral 1 Y

traMADol-Acetaminophen Oral 1 Y

Trezix Oral 3 Y

Tylenol with Codeine #3 Oral 3 Y

Tylenol with Codeine #4 Oral 3 Y

Ultracet Oral 3 Y

Ultram Oral 3 Y

Verdrocet Oral 3 Y

Vicodin Oral 1 Y

Vicodin ES Oral 1 Y

Vicodin HP Oral 1 Y

Xodol Oral 3 Y

Xtampza ER Oral 3 Y

Xylon Oral 1 Y

Zamicet Oral 3 Y

Zohydro ER Oral 3 Y

Zubsolv Sublingual 3 Y

Lortab Elixer Oral 3 Y

Methadose Concentrate Oral 3

ANDROGENS-ANABOLIC

Anadrol-50 Oral 3 Y

Androderm Transdermal 3 Y

AndroGel Transdermal 3 Y

AndroGel Pump Transdermal 2 Y

Android Oral 3 Y



Androxy Oral 2 Y

Axiron Transdermal 2 Y

Danazol Oral 1

Depo-Testosterone Intramuscular 3 Y

Fortesta Transdermal 3 Y

Methitest Oral 3 Y

Natesto Nasal 3 Y

Oxandrin Oral 3 Y

Oxandrolone Oral 1 Y

Striant Buccal 3 Y

Testim Transdermal 3 Y

Testone CIK Intramuscular 3 Y

Testosterone Transdermal 1 Y

Testosterone Cypionate Injection 1

Testosterone Cypionate Intramuscular 1

Testosterone Cypionate & Prop Injection 1

Testosterone Enanthate Injection 1

Testosterone Enanthate Intramuscular 1

Testosterone Propionate Injection 1

Testred Oral 3 Y

Vogelxo Transdermal 3 Y

Vogelxo Pump Transdermal 3 Y

ANORECTAL AGENTS

Ana-Lex Rectal 1

Analpram HC Rectal 3

Analpram HC Singles Rectal 3

Analpram-HC Rectal 3

Colocort Rectal 1

Cortenema Rectal 3

Cortifoam Rectal 2

Hemmorex-HC Rectal 1

Hydrocortisone Rectal 1

Hydrocortisone Ace-Pramoxine Rectal 1

Hydrocortisone Acetate Rectal 1

Lidocaine-Hydrocortisone Ace Rectal 1

PramCort Rectal 1

ProCort Rectal 3

Proctocort Rectal 3



Proctofoam HC Rectal 3

ANTHELMINTICS

Albendazole Oral 1

Albenza Oral 2

Benznidazole Oral 1

Biltricide Oral 2

Emverm Oral 3

Ivermectin Oral 1

Praziquantel Oral 1

Stromectol Oral 3

ANTIANGINAL AGENTS

Dilatrate-SR Oral 3

GoNitro Sublingual 3

Isordil Titradose Oral 3

Isosorbide Dinitrate Oral 1

Isosorbide Dinitrate ER Oral 1

Isosorbide Mononitrate Oral 1

Isosorbide Mononitrate ER Oral 1

Minitran Transdermal 1

Nitro-Bid Transdermal 2

Nitro-Dur Transdermal 3

Nitroglycerin Sublingual 1

Nitroglycerin Transdermal 1

Nitroglycerin Translingual 1

Nitroglycerin ER Oral 1

Nitrolingual Translingual 3

NitroMist Translingual 3

Nitrostat Sublingual 3

Nitro-Time Oral 2

Ranexa Oral 3

Ranolazine ER Oral 1

ANTIANXIETY AGENTS

ALPRAZolam Oral 1

ALPRAZolam ER Oral 1

ALPRAZolam Intensol Oral 3

ALPRAZolam XR Oral 1

Ativan Injection 3

Ativan Oral 3



busPIRone HCl Oral 1

chlordiazePOXIDE HCl Oral 1

Clorazepate Dipotassium Oral 1

diazePAM Oral 1

diazePAM Intensol Oral 1

hydrOXYzine HCl Oral 1

hydrOXYzine Pamoate Oral 1

LORazepam Injection 1

LORazepam Oral 1

LORazepam Intensol Oral 1

Meprobamate Oral 1

Oxazepam Oral 1

Tranxene-T Oral 3

Valium Oral 3

Vistaril Oral 3

Xanax Oral 3

Xanax XR Oral 3

ANTIARRHYTHMICS

Amiodarone HCl Oral 1

Disopyramide Phosphate Oral 1

Dofetilide Oral 1

Flecainide Acetate Oral 1

Mexiletine HCl Oral 1

Multaq Oral 2

Norpace Oral 3

Norpace CR Oral 3

Pacerone Oral 1

Propafenone HCl Oral 1

Propafenone HCl ER Oral 1

quiNIDine Gluconate Injection 1

quiNIDine Gluconate ER Oral 1

quiNIDine Sulfate Oral 1

quiNIDine Sulfate ER Oral 1

Rythmol SR Oral 3

Tikosyn Oral 3

ANTIASTHMATIC AND BRONCHODILATOR AGENTS

Accolate Oral 3

Advair Diskus Inhalation 2



Advair HFA Inhalation 2

Aerospan Inhalation 3

AirDuo RespiClick 113/14 Inhalation 3



Albuterol Sulfate Inhalation 1

Albuterol Sulfate Oral 1

Albuterol Sulfate ER Oral 1

Albuterol Sulfate HFA Inhalation 1

Alvesco Inhalation 3

Anoro Ellipta Inhalation 2

Arcapta Neohaler Inhalation 3

ArmonAir RespiClick 113 Inhalation 3



Arnuity Ellipta Inhalation 2

Asmanex (120 Metered Doses) Inhalation 2





Asmanex HFA Inhalation 2

Atrovent HFA Inhalation 2

Bevespi Aerosphere Inhalation 3

Breo Ellipta Inhalation 2

Brovana Inhalation 3

Budesonide Inhalation 1

Cinqair Intravenous 3 Y Y

Combivent Respimat Inhalation 2

Cromolyn Sodium Inhalation 1

Daliresp Oral 3

Dulera Inhalation 2

Elixophyllin Oral 3

Fasenra Subcutaneous 3 Y Y

Flovent Diskus Inhalation 2

Flovent HFA Inhalation 2

Fluticasone-Salmeterol Inhalation 1

Foradil Aerolizer Inhalation 2



Incruse Ellipta Inhalation 2

Ipratropium Bromide Inhalation 1

Ipratropium-Albuterol Inhalation 1

Levalbuterol HCl Inhalation 1

Levalbuterol Tartrate Inhalation 1

Lonhala Magnair Refill Kit Inhalation 3 Y

Lonhala Magnair Starter Kit Inhalation 3 Y

Metaproterenol Sulfate Oral 1

Montelukast Sodium Oral 1

Nucala Subcutaneous 3 Y Y

Perforomist Inhalation 3

ProAir Digihaler Inhalation 3

ProAir HFA Inhalation 3

ProAir RespiClick Inhalation 2

Proventil HFA Inhalation 3

Pulmicort Inhalation 3

Pulmicort Flexhaler Inhalation 3

Qvar Inhalation 2

Qvar RediHaler Inhalation 2

Seebri Neohaler Inhalation 3

Serevent Diskus Inhalation 2

Singulair Oral 3

Spiriva HandiHaler Inhalation 2

Spiriva Respimat Inhalation 2

Stiolto Respimat Inhalation 2

Striverdi Respimat Inhalation 3

Symbicort Inhalation 2

Terbutaline Sulfate Oral 1

Theo-24 Oral 3

Theochron Oral 3

Theophylline Oral 1

Theophylline ER Oral 1

Trelegy Ellipta Inhalation 3

Tudorza Pressair Inhalation 3

Utibron Neohaler Inhalation 3

Ventolin HFA Inhalation 3

VoSpire ER Oral 3

Wixela Inhub Inhalation 1



Xolair Subcutaneous 3 Y Y

Xopenex Inhalation 3

Xopenex Concentrate Inhalation 3

Xopenex HFA Inhalation 3

Zafirlukast Oral 1

Zileuton ER Oral 1

Zyflo Oral 3

Zyflo CR Oral 3

ANTICOAGULANTS

Arixtra Subcutaneous 3 Y

Bevyxxa Oral 3

Coumadin Oral 3

Eliquis Oral 2

Eliquis Starter Pack Oral 2

Enoxaparin Sodium Injection 1 Y

Enoxaparin Sodium Subcutaneous 1 Y

Fondaparinux Sodium Subcutaneous 1 Y

Fragmin Subcutaneous 3 Y

Heparin Lock Flush Intravenous 1

Heparin Sodium (Porcine) Injection 1

Heparin Sodium (Porcine) PF Injection 1

Heparin Sodium Flush Intravenous 1

Heparin Sodium Lock Flush Intravenous 1

Iprivask Subcutaneous 3 Y

Jantoven Oral 1

Lovenox Injection 3 Y

Lovenox Subcutaneous 3 Y

Pradaxa Oral 3

Savaysa Oral 3

Warfarin Sodium Oral 1

Xarelto Oral 2

Xarelto Starter Pack Oral 2

ANTICONVULSANTS

Aptiom Oral 3

Briviact Oral 3

carBAMazepine Oral 1

carBAMazepine ER Oral 1

Carbatrol Oral 3



Celontin Oral 2

Cerebyx Injection 3

cloBAZam Oral 1

clonazePAM Oral 1

Depakene Oral 3

Depakote Oral 3

Depakote ER Oral 3

Depakote Sprinkles Oral 3

Diacomit Oral 3 Y Y

Diastat AcuDial Rectal 2

Diastat Pediatric Rectal 2

diazePAM Rectal 1

Dilantin Oral 2

Dilantin Infatabs Oral 3

Divalproex Sodium Oral 1

Divalproex Sodium ER Oral 1

Epidiolex Oral 3 Y Y

Epitol Oral 1

Ethosuximide Oral 1

Fanatrex FusePaq Oral 3 Y

Felbamate Oral 1

Felbatol Oral 3

Fycompa Oral 3

Gabapentin Oral 1 Y

Gabitril Oral 3

Keppra Oral 3

Keppra XR Oral 3

KlonoPIN Oral 3

LaMICtal Oral 3

LaMICtal ODT Oral 3

LaMICtal Starter Oral 3

LaMICtal XR Oral 3

lamoTRIgine Oral 1

lamoTRIgine ER Oral 1

lamoTRIgine Starter Kit-Blue Oral 1

lamoTRIgine Starter Kit-Green Oral 1

lamoTRIgine Starter Kit-Orange Oral 1

levETIRAcetam Oral 1



levETIRAcetam ER Oral 1

Lyrica Oral 2

Mysoline Oral 3

Neurontin Oral 3 Y

Onfi Oral 3

OXcarbazepine Oral 1

Peganone Oral 3

Phenytek Oral 3

Phenytoin Oral 1

Phenytoin Infatabs Oral 1

Phenytoin Sodium Extended Oral 1

Pregabalin Oral 1

Primidone Oral 1

Qudexy XR Oral 3

Roweepra Oral 1

Roweepra XR Oral 3

Sabril Oral 2 Y Y

Subvenite Oral 1

Subvenite Starter Kit-Blue Oral 3

Subvenite Starter Kit-Green Oral 3

Subvenite Starter Kit-Orange Oral 3

Sympazan Oral 3

TEGretol Oral 3

TEGretol-XR Oral 3

tiaGABine HCl Oral 1

Topamax Oral 3

Topamax Sprinkle Oral 3

Topiramate Oral 1

Topiramate ER Oral 1

Trileptal Oral 3

Trokendi XR Oral 3 Y

Valproate Sodium Oral 1

Valproic Acid Oral 1

Vigabatrin Oral 1 Y Y

Vigadrone Oral 2 Y Y

Vimpat Oral 3

Zarontin Oral 3

Zonegran Oral 3



Zonisamide Oral 1

Banzel Tablet Oral 2 Y

Banzel Suspension Oral 2 Y

ANTIDEPRESSANTS

Amitriptyline HCl Oral 1

Amoxapine Oral 1

Anafranil Oral 3

buPROPion HCl Oral 1

buPROPion HCl ER (SR) Oral 1

buPROPion HCl ER (XL) Oral 1

CeleXA Oral 3

Citalopram Hydrobromide Oral 1

clomiPRAMINE HCl Oral 1

Cymbalta Oral 3

Desipramine HCl Oral 1

Desvenlafaxine ER Oral 1

Desvenlafaxine Succinate ER Oral 1

Doxepin HCl Oral 1

DULoxetine HCl Oral 1

Effexor XR Oral 3

Elavil Oral 3

Emsam Transdermal 3

Escitalopram Oxalate Oral 1

Fetzima Oral 3

Fetzima Titration Oral 3

FLUoxetine HCl Oral 1

fluvoxaMINE Maleate Oral 1

fluvoxaMINE Maleate ER Oral 1

Forfivo XL Oral 3

Imipramine HCl Oral 1

Imipramine Pamoate Oral 1

Khedezla Oral 3

Lexapro Oral 3

Maprotiline HCl Oral 1

Marplan Oral 3

Mirtazapine Oral 1

Nardil Oral 3

Nefazodone HCl Oral 1



Norpramin Oral 3

Nortriptyline HCl Oral 1

Pamelor Oral 3

Parnate Oral 3

PARoxetine HCl Oral 1

PARoxetine HCl ER Oral 1

Paxil Oral 3

Paxil CR Oral 3

Pexeva Oral 3

Phenelzine Sulfate Oral 1

Pristiq Oral 3

Protriptyline HCl Oral 1

PROzac Oral 3

Remeron Oral 3

Remeron SolTab Oral 3

Sertraline HCl Oral 1

Surmontil Oral 3

Tofranil Oral 3

Tranylcypromine Sulfate Oral 1

traZODone HCl Oral 1

Trimipramine Maleate Oral 1

Trintellix Oral 3

Venlafaxine HCl Oral 1

Venlafaxine HCl ER Oral 1

Viibryd Oral 3

Viibryd Starter Pack Oral 3

Zoloft Oral 3

ANTIDIABETICS

Acarbose Oral 1

Actoplus Met Oral 3

Actoplus met XR Oral 3

Actos Oral 3

Adlyxin Subcutaneous 3

Adlyxin Starter Pack Subcutaneous 3

Admelog Subcutaneous 3 Y

Admelog SoloStar Subcutaneous 3 Y

Afrezza Inhalation 3 Y

Alogliptin Benzoate Oral 1



Alogliptin-metFORMIN HCl Oral 1

Alogliptin-Pioglitazone Oral 1

Amaryl Oral 3

Apidra Injection 3 Y

Apidra SoloStar Subcutaneous 3 Y

Avandia Oral 3

Basaglar KwikPen Subcutaneous 3

Bydureon Subcutaneous 3

Bydureon BCise Subcutaneous 3

Byetta 10 MCG Pen Subcutaneous 3

Byetta 5 MCG Pen Subcutaneous 3

chlorproPAMIDE Oral 1

Cycloset Oral 3

Duetact Oral 3

Farxiga Oral 3

Fiasp Subcutaneous 2

Fiasp FlexTouch Subcutaneous 2

Fiasp PenFill Subcutaneous 3

Fortamet Oral 3

Glimepiride Oral 1

glipiZIDE Oral 1

glipiZIDE ER Oral 1

glipiZIDE XL Oral 1

glipiZIDE-metFORMIN HCl Oral 1

GlucaGen HypoKit Injection 3

Glucagon Emergency Injection 2

Glucophage Oral 3

Glucophage XR Oral 3

Glucotrol Oral 3

Glucotrol XL Oral 3

Glucovance Oral 3

glyBURIDE Oral 1

glyBURIDE Micronized Oral 1

glyBURIDE-metFORMIN Oral 1

Glynase Oral 3

Glyset Oral 3

Glyxambi Oral 2

HumaLOG Subcutaneous 3 Y



HumaLOG Junior KwikPen Subcutaneous 3 Y

HumaLOG KwikPen Subcutaneous 3 Y

HumaLOG Mix 50/50 Subcutaneous 3 Y

HumaLOG Mix 50/50 KwikPen Subcutaneous 3 Y

HumaLOG Mix 75/25 Subcutaneous 3 Y

HumaLOG Mix 75/25 KwikPen Subcutaneous 3 Y

HumuLIN 70/30 Subcutaneous 3 Y

HumuLIN 70/30 KwikPen Subcutaneous 3 Y

HumuLIN N Subcutaneous 3 Y

HumuLIN N KwikPen Subcutaneous 3 Y

HumuLIN R Injection 3 Y

HumuLIN R U-500 (CONCENTRATED) Subcutaneous 2 Y

HumuLIN R U-500 KwikPen Subcutaneous 2 Y

Insulin Lispro Subcutaneous 3 Y

Insulin Lispro (1 Unit Dial) Subcutaneous 3 Y

Invokamet Oral 2

Invokamet XR Oral 2

Invokana Oral 2

Janumet Oral 2

Janumet XR Oral 2

Januvia Oral 2

Jardiance Oral 2

Jentadueto Oral 3

Jentadueto XR Oral 3

Kazano Oral 3

Kombiglyze XR Oral 2

Korlym Oral 3 Y Y Y Y

Lantus Subcutaneous 2

Lantus SoloStar Subcutaneous 2

Levemir Subcutaneous 2

Levemir FlexTouch Subcutaneous 2

metFORMIN HCl Oral 1

metFORMIN HCl ER Oral 1

Miglitol Oral 1

Nateglinide Oral 1

Nesina Oral 3

NovoLIN 70/30 Subcutaneous 2

NovoLIN 70/30 FlexPen Subcutaneous 2



NovoLIN 70/30 FlexPen Relion Subcutaneous 2

NovoLIN 70/30 ReliOn Subcutaneous 2

NovoLIN N Subcutaneous 2

NovoLIN N ReliOn Subcutaneous 2

NovoLIN R Injection 2

NovoLIN R ReliOn Injection 2

NovoLOG Subcutaneous 2

NovoLOG FlexPen Subcutaneous 2

NovoLOG Mix 70/30 Subcutaneous 2

NovoLOG Mix 70/30 FlexPen Subcutaneous 2

NovoLOG PenFill Subcutaneous 2

Onglyza Oral 2

Oseni Oral 3

Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous 2

Ozempic (1 MG/DOSE) Subcutaneous 2

Pioglitazone HCl Oral 1

Pioglitazone HCl-Glimepiride Oral 1

Pioglitazone HCl-metFORMIN HCl Oral 1

Prandin Oral 3

Precose Oral 3

Qtern Oral 3

Repaglinide Oral 1

Repaglinide-metFORMIN HCl Oral 1

Riomet Oral 3

Segluromet Oral 3

Soliqua Subcutaneous 3

Starlix Oral 3

Steglatro Oral 3

Steglujan Oral 3

SymlinPen 120 Subcutaneous 3

SymlinPen 60 Subcutaneous 3

Synjardy Oral 2

Synjardy XR Oral 2

Tanzeum Subcutaneous 3

TOLAZamide Oral 1

TOLBUTamide Oral 1

Toujeo Max SoloStar Subcutaneous 2

Toujeo SoloStar Subcutaneous 2



Tradjenta Oral 3

Tresiba Subcutaneous 2

Tresiba FlexTouch Subcutaneous 2

Trulicity Subcutaneous 2

Victoza Subcutaneous 2

Xigduo XR Oral 3

Xultophy Subcutaneous 3

metFORMIN HCl Solution Oral 3

ANTIDIARRHEAL/PROBIOTIC AGENTS

Diphenoxylate-Atropine Oral 1

Lomotil Oral 3

Loperamide HCl Oral 1

Opium Oral 1

Paregoric Oral 1

ANTIDOTES AND SPECIFIC ANTAGONISTS

Cetylev Oral 3

Chemet Oral 2

Deferasirox Oral 1 Y

Deferoxamine Mesylate Injection 1 Y Y

Desferal Injection 3 Y

Exjade Oral 3 Y

Ferriprox Oral 3 Y

Jadenu Oral 3 Y

Jadenu Sprinkle Oral 3 Y

Naloxone HCl Injection 1 Y

Naltrexone HCl Oral 1

Narcan Nasal 2 Y

ANTIEMETICS

Akynzeo Oral 3 Y Y

Aloxi Intravenous 3 Y Y

Anzemet Oral 3

Aprepitant Oral 1 Y

Bonine Oral 1

Cesamet Oral 3

Dronabinol Oral 1

Granisetron HCl Oral 1

Marinol Oral 3

Meclizine HCl Oral 1



Ondansetron Oral 1

Ondansetron HCl Oral 1

Palonosetron HCl Intravenous 1 Y Y

Sancuso Transdermal 3 Y Y

Scopolamine Transdermal 1

Sustol Subcutaneous 3 Y Y

Syndros Oral 3

Tigan Intramuscular 3

Tigan Oral 3

Transderm Scop (1.5 MG) Transdermal 3

Transderm-Scop (1.5 MG) Transdermal 2

Trimethobenzamide HCl Oral 1

Varubi Oral 3 Y Y

Zofran Oral 3

Zofran ODT Oral 3

Zuplenz Oral 3

ANTIFUNGALS

Ancobon Oral 3

Bio-Statin Oral 3

Cresemba Oral 3 Y

Diflucan Oral 3

Fluconazole Oral 1

Griseofulvin Microsize Oral 1

Griseofulvin Ultramicrosize Oral 1

Gris-PEG Oral 3

Itraconazole Oral 1

Ketoconazole Oral 1

Nystatin Oral 1

Posaconazole Oral 2

Sporanox Oral 3

Sporanox Pulsepak Oral 3

Terbinafine HCl Oral 1

Vfend Oral 3

Voriconazole Oral 1

Flucytosine 250 mg Oral 1

Flucytosine 500 mg Oral 1 Y

Flucytosine250 mg Oral 1

LamISIL Packet Oral 2



LamISIL Tablet Oral 3

Noxafil Suspension Oral 3

Noxafil Packet Oral 2 Y

ANTIHISTAMINES

Brompheniramine Tannate Oral 1

Carbinoxamine Maleate Oral 1

Cetirizine HCl Oral 1

Clarinex Oral 3

Clemastine Fumarate Oral 1

Cyproheptadine HCl Oral 1

Desloratadine Oral 1

Diphen Oral 1

diphenhydrAMINE HCl Oral 1

Karbinal ER Oral 3

Levocetirizine Dihydrochloride Oral 1

Phenadoz Rectal 1

Phenergan Rectal 1

Promethazine HCl Injection 1

Promethazine HCl Oral 1

Promethazine HCl Rectal 1

Promethegan Rectal 1

RyVent Oral 3

ANTIHYPERLIPIDEMICS

Altoprev Oral 3

Atorvastatin Calcium Oral 1

Cholestyramine Oral 1

Cholestyramine Light Oral 1

Colesevelam HCl Oral 1

Colestid Oral 3

Colestipol HCl Oral 1

Crestor Oral 3

Ezetimibe Oral 1

Ezetimibe-Simvastatin Oral 1

Fenofibrate Oral 1

Fenofibrate Micronized Oral 1

Fenofibric Acid Oral 1

Fenoglide Oral 3

Fibricor Oral 3



FloLipid Oral 3

Fluvastatin Sodium Oral 1

Fluvastatin Sodium ER Oral 1

Gemfibrozil Oral 1

Juxtapid Oral 3 Y Y Y

Kynamro Subcutaneous 3 Y Y

Lescol XL Oral 3

Lipitor Oral 3

Lipofen Oral 3

Livalo Oral 3

Lofibra Oral 3

Lopid Oral 3

Lovastatin Oral 1

Niacin (Antihyperlipidemic) Oral 3

Niacin ER (Antihyperlipidemic) Oral 1

Niacor Oral 3

Niaspan Oral 3

Praluent Subcutaneous 2 Y

Pravachol Oral 3

Pravastatin Sodium Oral 1

Prevalite Oral 1

Questran Oral 3

Questran Light Oral 3

Repatha Subcutaneous 2 Y

Repatha Pushtronex System Subcutaneous 2 Y

Repatha SureClick Subcutaneous 2 Y

Rosuvastatin Calcium Oral 1

Simvastatin Oral 1

Tricor Oral 3

Triglide Oral 3

Triklo Oral 1

Trilipix Oral 3

Vascepa Oral 3

Vytorin Oral 3

Welchol Oral 2

Zetia Oral 2

Zocor Oral 3

Zypitamag Oral 3



ANTIHYPERTENSIVES

Accupril Oral 3

Accuretic Oral 3

Aceon Oral 3

Aliskiren Fumarate Oral 1

Altace Oral 3

amLODIPine Besy-Benazepril HCl Oral 1

amLODIPine Besylate-Valsartan Oral 1

amLODIPine-Olmesartan Oral 1

amLODIPine-Valsartan-HCTZ Oral 1

Atacand Oral 3

Atacand HCT Oral 3

Atenolol-Chlorthalidone Oral 1

Avalide Oral 3

Avapro Oral 3

Azor Oral 3

Benazepril HCl Oral 1

Benazepril-hydroCHLOROthiazide Oral 1

Benicar Oral 3

Benicar HCT Oral 3

Bisoprolol-hydroCHLOROthiazide Oral 1

Candesartan Cilexetil Oral 1

Candesartan Cilexetil-HCTZ Oral 1

Captopril Oral 1

Captopril-hydroCHLOROthiazide Oral 1

Cardura Oral 3

Catapres Oral 3

Catapres-TTS-1 Transdermal 3



cloNIDine Transdermal 1

cloNIDine HCl Oral 1

Clorpres Oral 3

Corzide Oral 3

Cozaar Oral 3

Demser Oral 3

Dibenzyline Oral 3 Y

Diovan Oral 3



Diovan HCT Oral 3

Doxazosin Mesylate Oral 1

Dutoprol Oral 3

Edarbi Oral 3

Edarbyclor Oral 3

Enalapril Maleate Oral 1

Enalapril-hydroCHLOROthiazide Oral 1

Epaned Oral 3

Eplerenone Oral 1

Eprosartan Mesylate Oral 1

Exforge Oral 3

Exforge HCT Oral 3

Fosinopril Sodium Oral 1

Fosinopril Sodium-HCTZ Oral 1

guanFACINE HCl Oral 1

hydrALAZINE HCl Oral 1

Hyzaar Oral 3

Inspra Oral 3

Irbesartan Oral 1

Irbesartan-hydroCHLOROthiazide Oral 1

Lisinopril Oral 1

Lisinopril-hydroCHLOROthiazide Oral 1

Lopressor HCT Oral 3

Losartan Potassium Oral 1

Losartan Potassium-HCTZ Oral 1

Lotensin Oral 3

Lotensin HCT Oral 3

Lotrel Oral 3

Methyldopa Oral 1

Methyldopa-hydroCHLOROthiazide Oral 1

Metoprolol-HCTZ ER Oral 1

Metoprolol-hydroCHLOROthiazide Oral 1

Micardis Oral 3

Micardis HCT Oral 3

Minipress Oral 3

Minoxidil Oral 1

Moexipril HCl Oral 1

Moexipril-hydroCHLOROthiazide Oral 1



Nadolol-Bendroflumethiazide Oral 1

Olmesartan Medoxomil Oral 1

Olmesartan Medoxomil-HCTZ Oral 1

Olmesartan-amLODIPine-HCTZ Oral 1

Perindopril Erbumine Oral 1

Phenoxybenzamine HCl Oral 1

Prazosin HCl Oral 1

Prestalia Oral 3

Prinivil Oral 3

Propranolol-HCTZ Oral 1

Qbrelis Oral 3

Quinapril HCl Oral 1

Quinapril-hydroCHLOROthiazide Oral 1

Ramipril Oral 1

Tarka Oral 3

Tekturna Oral 3

Tekturna HCT Oral 3

Telmisartan Oral 1

Telmisartan-amLODIPine Oral 1

Telmisartan-HCTZ Oral 1

Tenoretic 100 Oral 3

Tenoretic 50 Oral 3

Terazosin HCl Oral 1

Trandolapril Oral 1

Trandolapril-Verapamil HCl ER Oral 1

Tribenzor Oral 3

Twynsta Oral 3

Valsartan Oral 1

Valsartan-hydroCHLOROthiazide Oral 1

Vaseretic Oral 3

Vasotec Oral 3

Vecamyl Oral 3

Zestoretic Oral 3

Zestril Oral 3

Ziac Oral 3

ANTI-INFECTIVE AGENTS - MISC.

Aemcolo Oral 3

Alinia Oral 3 Y



Atovaquone Oral 1

Bactrim Oral 3

Bactrim DS Oral 3

Cayston Inhalation 3 Y Y Y

Cleocin Oral 3

Clindamycin HCl Oral 1

Clindamycin Palmitate HCl Oral 1

Clindamycin Phosphate Injection 1

Dapsone Oral 1

Firvanq Oral 3

Flagyl Oral 3

Impavido Oral 3 Y

Linezolid Oral 1

Mepron Oral 3

metroNIDAZOLE Oral 1

Nebupent Inhalation 2

Pentamidine Isethionate Injection 1

Primsol Oral 3

Sivextro Oral 2 Y

Sulfamethoxazole-Trimethoprim Oral 1

Sulfatrim Pediatric Oral 1

Tindamax Oral 3

Tinidazole Oral 1

Trimethoprim Oral 1

Trimpex Oral 3

Vancocin Oral 3

Vancocin HCl Oral 3

Vancomycin HCl Oral 1

Xifaxan Oral 2

Zyvox Oral 3

ANTIMALARIALS

Arakoda Oral 3

Atovaquone-Proguanil HCl Oral 1

Chloroquine Phosphate Oral 1

Coartem Oral 2

Daraprim Oral 2 Y Y

Hydroxychloroquine Sulfate Oral 1

Krintafel Oral 3



Malarone Oral 3

Mefloquine HCl Oral 1

Plaquenil Oral 3

Primaquine Phosphate Oral 1

Qualaquin Oral 3

quiNINE Sulfate Oral 1

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Guanidine HCl Oral 1

Mestinon Oral 3

Pyridostigmine Bromide 60 mg Oral 1

Pyridostigmine Bromide 30 mg Oral 3

Pyridostigmine Bromide ER Oral 1

Pyridostigmine Bromide Solution Oral 1

ANTIMYCOBACTERIAL AGENTS

cycloSERINE Oral 1

Ethambutol HCl Oral 1

Isoniazid Oral 1

Myambutol Oral 3

Mycobutin Oral 3

Paser Oral 3

Priftin Oral 2

Pyrazinamide Oral 1

Rifabutin Oral 1

Rifadin Oral 3

Rifamate Oral 3

rifAMPin Oral 1

Rifater Oral 3

Sirturo Oral 3

Trecator Oral 3

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

Abiraterone Acetate Oral 1 Y Y Y

Actimmune Subcutaneous 2 Y Y Y

Afinitor Oral 2 Y Y Y

Afinitor Disperz Oral 2 Y Y Y

Alecensa Oral 2 Y Y Y

Alferon N Injection 3 Y Y

Alkeran Oral 3 Y

Alunbrig Oral 3 Y Y Y



Anastrozole Oral 1

Arimidex Oral 3

Aromasin Oral 3

Bexarotene Oral 1 Y Y Y

Bicalutamide Oral 1 Y

Bosulif Oral 2 Y Y Y

Braftovi Oral 3 Y Y

Cabometyx Oral 3 Y Y Y

Calquence Oral 3 Y Y Y

Capecitabine Oral 1 Y Y Y

Caprelsa Oral 2 Y Y Y

Casodex Oral 3 Y

Cometriq (100 MG Daily Dose) Oral 2 Y Y Y



Copiktra Oral 3 Y Y

Cotellic Oral 2 Y Y Y

Cyclophosphamide Oral 1

Depo-Provera Intramuscular 3

Eligard Subcutaneous 3 Y Y

Emcyt Oral 2 Y

Erivedge Oral 2 Y Y Y

Erleada Oral 3 Y Y Y

Erlotinib HCl Oral 1 Y Y Y

Erwinaze Injection 3 Y Y Y

Etoposide Oral 1

Exemestane Oral 1

Fareston Oral 3 Y

Farydak Oral 2 Y Y Y

Faslodex Intramuscular 3 Y Y

Femara Oral 3

Firmagon Subcutaneous 3 Y Y

Flutamide Oral 1 Y

Fulvestrant Intramuscular 1 Y Y

Gilotrif Oral 2 Y Y Y

Gleevec Oral 3 Y Y Y

Gleostine Oral 3 Y Y

Hexalen Oral 2 Y Y



Hycamtin Oral 2 Y Y

Hydrea Oral 3

Hydroxyurea Oral 1

Ibrance Oral 2 Y Y Y

Iclusig Oral 2 Y Y Y

IDHIFA Oral 3 Y Y Y

Imatinib Mesylate Oral 1 Y Y Y

Imbruvica Oral 2 Y Y Y

Inlyta Oral 2 Y Y Y

Intron A Injection 2 Y Y

Iressa Oral 2 Y Y Y

Jakafi Oral 2 Y Y Y

Kisqali (200 MG Dose) Oral 2 Y Y



Kisqali Femara (400 MG Dose) Oral 3 Y Y

Kisqali Femara (600 MG Dose) Oral 3 Y Y

Kisqali Femara(200 MG Dose) Oral 3 Y Y

Lenvima (10 MG Daily Dose) Oral 2 Y Y Y








Letrozole Oral 1

Leucovorin Calcium Oral 1

Leukeran Oral 2 Y

Leuprolide Acetate Injection 1 Y Y

Lomustine Oral 1 Y

Lonsurf Oral 2 Y Y

Lupron Depot (1-Month) Intramuscular 2 Y Y




Lynparza Oral 3 Y Y Y

Lysodren Oral 2 Y



Matulane Oral 2 Y Y

Megestrol Acetate Oral 1

Mekinist Oral 2 Y Y Y

Mektovi Oral 3 Y Y

Melphalan Oral 1 Y

Mercaptopurine Oral 1

Mesnex Oral 3 Y

Methotrexate Oral 1

Methotrexate Sodium Injection 1

Methotrexate Sodium Oral 1

Methotrexate Sodium (PF) Injection 1

Myleran Oral 2

Nerlynx Oral 3 Y Y Y

NexAVAR Oral 2 Y Y Y

Nilandron Oral 3 Y Y

Nilutamide Oral 1 Y Y

Ninlaro Oral 2 Y Y Y

Odomzo Oral 2 Y Y Y

Pomalyst Oral 2 Y Y Y

Purixan Oral 2 Y

Rituxan Intravenous 3 Y Y Y

Rituxan Hycela Subcutaneous 3 Y Y

Rubraca Oral 3 Y Y Y

Rydapt Oral 3 Y Y

Soltamox Oral 2

Sprycel Oral 2 Y Y Y

Stivarga Oral 2 Y Y Y

Sutent Oral 2 Y Y Y

Sylatron Subcutaneous 2 Y Y

Synribo Subcutaneous 2 Y Y Y

Tabloid Oral 2 Y

Tafinlar Oral 2 Y Y Y

Tagrisso Oral 2 Y Y Y

Tamoxifen Citrate Oral 1

Tarceva Oral 2 Y Y Y

Targretin Oral 3 Y Y Y

Tasigna Oral 2 Y Y Y

Temodar Oral 3 Y Y Y



Temozolomide Oral 1 Y Y Y

Tibsovo Oral 3 Y Y

Trelstar Intramuscular 2 Y Y

Trelstar Mixject Intramuscular 2 Y Y

Tretinoin Oral 1 Y Y

Trexall Oral 3

Tykerb Oral 2 Y Y Y

Vantas Subcutaneous 3 Y Y

Venclexta Oral 3 Y Y Y

Venclexta Starting Pack Oral 3 Y Y Y

Verzenio Oral 3 Y Y Y

Vizimpro Oral 3 Y Y

Votrient Oral 2 Y Y Y

Xalkori Oral 2 Y Y Y

Xatmep Oral 3

Xeloda Oral 3 Y Y Y

Xtandi Oral 2 Y Y Y

Yonsa Oral 3 Y Y

Zejula Oral 3 Y Y

Zelboraf Oral 2 Y Y Y

Zolinza Oral 2 Y Y Y

Zydelig Oral 2 Y Y Y

Zytiga Oral 2 Y Y Y

Zykadia Capsule Oral 3 Y Y Y

Zykadia Tablet Oral 3 Y Y

ANTIPARKINSON AND RELATED THERAPY AGENTS

Amantadine HCl Oral 1

Apokyn Subcutaneous 3 Y Y Y

Azilect Oral 3

Benztropine Mesylate Injection 1

Benztropine Mesylate Oral 1

Bromocriptine Mesylate Oral 1

Carbidopa Oral 1

Carbidopa-Levodopa Oral 1

Carbidopa-Levodopa ER Oral 1

Carbidopa-Levodopa-Entacapone Oral 1

Cogentin Injection 3

Comtan Oral 3



Duopa Enteral 3

Eldepryl Oral 3

Entacapone Oral 1

Gocovri Oral 3 Y

Inbrija Inhalation 3 Y Y

Lodosyn Oral 3

Mirapex Oral 3

Mirapex ER Oral 3

Neupro Transdermal 3

Parlodel Oral 3

Pramipexole Dihydrochloride Oral 1

Pramipexole Dihydrochloride ER Oral 1

Rasagiline Mesylate Oral 1

Requip Oral 3

Requip XL Oral 3

rOPINIRole HCl Oral 1

rOPINIRole HCl ER Oral 1

Selegiline HCl Oral 1

Sinemet Oral 3

Sinemet CR Oral 3

Stalevo 100 Oral 3

Stalevo 125 Oral 3

Stalevo 150 Oral 3

Stalevo 200 Oral 3

Stalevo 50 Oral 3

Stalevo 75 Oral 3

Tasmar Oral 3

Tolcapone Oral 1

Trihexyphenidyl HCl Oral 1

Xadago Oral 3

Zelapar Oral 3

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Abilify Oral 3

Abilify Maintena Intramuscular 3

Adasuve Inhalation 3

ARIPiprazole Oral 1

Aristada Intramuscular 3

chlorproMAZINE HCl Injection 1



chlorproMAZINE HCl Oral 1

cloZAPine Oral 1

Clozaril Oral 3

Compro Rectal 1

Equetro Oral 3

Fanapt Oral 3 Y

Fanapt Titration Pack Oral 3 Y

FazaClo Oral 3

fluPHENAZine Decanoate Injection 1

fluPHENAZine HCl Injection 1

fluPHENAZine HCl Oral 1

Geodon Intramuscular 3

Geodon Oral 3

Haloperidol Oral 1

Haloperidol Lactate Oral 1

Invega Oral 3

Invega Sustenna Intramuscular 3

Invega Trinza Intramuscular 3 Y

Latuda Oral 3

Lithium Oral 1

Lithium Carbonate Oral 1

Lithium Carbonate ER Oral 1

Lithobid Oral 3

Loxapine Succinate Oral 1

Molindone HCl Oral 1

Nuplazid Oral 3 Y Y

OLANZapine Intramuscular 1

OLANZapine Oral 1

Paliperidone ER Oral 1

Perphenazine Oral 1

Perseris Subcutaneous 3 Y

Prochlorperazine Rectal 1

Prochlorperazine Maleate Oral 1

QUEtiapine Fumarate Oral 1

QUEtiapine Fumarate ER Oral 1

Rexulti Oral 3 Y

RisperDAL Oral 3

RisperDAL Consta Intramuscular 3



RisperDAL M-TAB Oral 3

risperiDONE Oral 1

risperiDONE M-TAB Oral 1

Saphris Sublingual 3

SEROquel Oral 3

SEROquel XR Oral 2

Thioridazine HCl Oral 1

Thiothixene Oral 1

Trifluoperazine HCl Oral 1

Vraylar Oral 3

Ziprasidone HCl Oral 1

ZyPREXA Intramuscular 3

ZyPREXA Oral 3

ZyPREXA Relprevv Intramuscular 3

ZyPREXA Zydis Oral 3

ANTIVIRALS

Abacavir Sulfate Oral 1

Abacavir Sulfate-lamiVUDine Oral 1

Abacavir-lamiVUDine-Zidovudine Oral 1

Acyclovir Oral 1

Adefovir Dipivoxil Oral 1 Y Y Y

Aptivus Oral 3

Atazanavir Sulfate Oral 1

Atripla Oral 2

Baraclude Oral 3 Y Y Y

Biktarvy Oral 3 Y

Cimduo Oral 3

Combivir Oral 3

Complera Oral 2

Copegus Oral 3 Y

Crixivan Oral 3

Daklinza Oral 3 Y Y Y

Delstrigo Oral 3 Y

Descovy Oral 3 Y

Didanosine Oral 1

Edurant Oral 3

Efavirenz Oral 1

Emtriva Oral 3



Entecavir Oral 1 Y Y Y

Epclusa Oral 2 Y Y Y

Epivir Oral 3

Epivir HBV Oral 3 Y

Epzicom Oral 3

Evotaz Oral 2

Famciclovir Oral 1

Flumadine Oral 3

Fosamprenavir Calcium Oral 1

Fuzeon Subcutaneous 3

Genvoya Oral 2

Harvoni Oral 2 Y Y Y

Hepsera Oral 3 Y Y Y

Intelence Oral 2

Invirase Oral 3

Isentress Oral 2

Isentress HD Oral 2

Juluca Oral 3

lamiVUDine Oral 1

lamiVUDine-Zidovudine Oral 1

Ledipasvir-Sofosbuvir Oral 1 Y Y

Lexiva Oral 3

Lopinavir-Ritonavir Oral 1

Mavyret Oral 3 Y Y Y

Moderiba Oral 3 Y

Moderiba (1000 MG Pack) Oral 3 Y

Moderiba (1200 MG Pack) Oral 3 Y Y

Moderiba (600 MG Pack) Oral 3 Y

Moderiba (800 MG Pack) Oral 3 Y Y

Nevirapine Oral 1

Nevirapine ER Oral 1

Odefsey Oral 2

Olysio Oral 3 Y Y Y

Oseltamivir Phosphate Oral 1 Y

Pegasys Subcutaneous 2 Y Y Y

Pegasys ProClick Subcutaneous 2 Y Y Y

PegIntron Subcutaneous 3 Y

Peg-Intron Subcutaneous 3 Y



Peg-Intron Redipen Subcutaneous 3 Y

Peg-Intron Redipen Pak 4 Subcutaneous 3 Y

Pifeltro Oral 3 Y

Prevymis Oral 3

Prezcobix Oral 2

Prezista Oral 2

Relenza Diskhaler Inhalation 3 Y

Rescriptor Oral 3

Retrovir Oral 3

Ribasphere RibaPak (1000 Pack) Oral 3 Y

Ribasphere Ribapak (1200 Pack) Oral 3 Y



RibaTab (1000 MG Pack) Oral 3 Y



Ribavirin Inhalation 1 Y

Ribavirin Oral 1 Y

riMANTAdine HCl Oral 1

Ritonavir Oral 1

Selzentry Oral 3

Sofosbuvir-Velpatasvir Oral 1 Y Y

Sovaldi Oral 2 Y Y Y

Stavudine Oral 1

Stribild Oral 2

Sustiva Oral 2

Symfi Oral 3

Symfi Lo Oral 3

Symtuza Oral 3 Y

Tamiflu Oral 3 Y

Technivie Oral 3 Y Y Y

Temixys Oral 3

Tenofovir Disoproxil Fumarate Oral 1

Tivicay Oral 2

Triumeq Oral 2

Trizivir Oral 3

Truvada Oral 3 Y

Tybost Oral 3



Tyzeka Oral 3

valACYclovir HCl Oral 1

Valcyte Oral 3 Y Y

valGANciclovir HCl Oral 1 Y Y

Valtrex Oral 3

Vemlidy Oral 3 Y Y Y

Victrelis Oral 3 Y

Videx Oral 2

Videx EC Oral 3

Viekira Pak Oral 3 Y Y

Viekira XR Oral 3 Y Y

Viracept Oral 3

Viramune Oral 3

Viramune XR Oral 3

Virazole Inhalation 3 Y

Viread Oral 2

Vosevi Oral 3 Y Y Y

Xofluza Oral 3 Y

Zepatier Oral 3 Y Y

Zerit Oral 3

Ziagen Oral 3

Zidovudine Oral 1

Zovirax Oral 3

Kaletra Tablet Oral 2

Kaletra Solution Oral 3

Norvir So Oral 3

Norvir Capsule Oral 3

Norvir Tablet Oral 2

Norvir Packet Oral 3

Rebetol Capsule Oral 3 Y

Rebetol Solution Oral 3 Y Y

Reyataz Capsule Oral 2

Reyataz Packet Oral 3

Ribasphere Tablet 20 mg Oral 1 Y



Ribasphere Capsule Oral 1 Y

BETA BLOCKERS



Acebutolol HCl Oral 1

Atenolol Oral 1

Betapace Oral 3

Betapace AF Oral 3

Betaxolol HCl Oral 1

Bisoprolol Fumarate Oral 1

Bystolic Oral 3

Carvedilol Oral 1

Carvedilol Phosphate ER Oral 1

Coreg Oral 3

Coreg CR Oral 3

Corgard Oral 3

Hemangeol Oral 3

Inderal LA Oral 3

Inderal XL Oral 3

InnoPran XL Oral 3

Kapspargo Sprinkle Oral 3

Labetalol HCl Oral 1

Lopressor Oral 3

Metoprolol Succinate ER Oral 1

Metoprolol Tartrate Oral 1

Nadolol Oral 1

Pindolol Oral 1

Propranolol HCl Oral 1

Propranolol HCl ER Oral 1

Sorine Oral 1

Sotalol HCl Oral 1

Sotalol HCl (AF) Oral 1

Sotalol Hydrochloride Oral 1

Sotylize Oral 3

Tenormin Oral 3

Timolol Maleate Oral 1

Toprol XL Oral 3

CALCIUM CHANNEL BLOCKERS

Adalat CC Oral 3

Afeditab CR Oral 1

amLODIPine Besylate Oral 1

Calan Oral 3



Calan SR Oral 3

Cardizem Oral 3

Cardizem CD Oral 3

Cardizem LA Oral 3

Cartia XT Oral 1

dilTIAZem CD Oral 1

dilTIAZem HCl Oral 1

dilTIAZem HCl ER Oral 1

dilTIAZem HCl ER Beads Oral 1

dilTIAZem HCl ER Coated Beads Oral 1

Dilt-XR Oral 1

Felodipine ER Oral 1

Isradipine Oral 1

Matzim LA Oral 1

niCARdipine HCl Oral 1

Nifedical XL Oral 1

NIFEdipine Oral 1

NIFEdipine ER Oral 1

NIFEdipine ER Osmotic Release Oral 1

niMODipine Oral 1

Nisoldipine ER Oral 1

Norvasc Oral 3

Nymalize Oral 3

Procardia Oral 3

Procardia XL Oral 3

Sular Oral 3

Taztia XT Oral 1

Tiazac Oral 3

Verapamil HCl Oral 1

Verapamil HCl ER Oral 1

Verelan Oral 3

Verelan PM Oral 3

CARDIOTONICS

Digitek Oral 1

Digox Oral 1

Digoxin Oral 1

Lanoxin Oral 3

CARDIOVASCULAR AGENTS - MISC.



Adcirca Oral 2 Y Y Y

Adempas Oral 3 Y Y Y

Alyq Oral 1 Y Y Y

Ambrisentan Oral 1 Y Y Y

amLODIPine-Atorvastatin Oral 1

BiDil Oral 3

Bosentan Oral 1 Y Y Y

Caduet Oral 3

Caverject Intracavernosal 3 Y

Caverject Impulse Intracavernosal 3 Y

Cialis Oral 3 Y

Edex Intracavernosal 3 Y

Entresto Oral 2

Epoprostenol Sodium Intravenous 1 Y Y

Flolan Intravenous 3 Y Y

Isoxsuprine HCl Oral 1

Letairis Oral 2 Y Y Y

Levitra Oral 3 Y

Muse Urethral 3 Y

Opsumit Oral 2 Y Y Y

Orenitram Oral 3 Y Y Y

Remodulin Injection 3 Y Y

Revatio Oral 3 Y Y Y

Sildenafil Citrate Oral 1 Y Y Y

Staxyn Oral 3 Y

Stendra Oral 3 Y

Tadalafil (PAH) Oral 1 Y Y Y

Tracleer Oral 2 Y Y Y

Treprostinil Injection 1 Y Y

Tyvaso Inhalation 3 Y Y

Tyvaso Refill Inhalation 3 Y Y

Tyvaso Starter Inhalation 3 Y Y

Uptravi Oral 2 Y Y

Vardenafil HCl Oral 1 Y

Veletri Intravenous 3 Y Y

Ventavis Inhalation 3 Y Y Y

Viagra Oral 3 Y

Vyndamax Oral 3 Y Y



Corlanor Tablet Oral 3

Corlanor Solution Oral 3 Y

Sildenafil Citrate Suspension Oral 1 Y Y

Tracleer Soluble Tablet Oral 3 Y Y

CEPHALOSPORINS

Cedax Oral 3

Cefaclor Oral 1

Cefaclor ER Oral 1

Cefadroxil Oral 1

Cefdinir Oral 1

Cefditoren Pivoxil Oral 1

Cefixime Oral 1

Cefpodoxime Proxetil Oral 1

Cefprozil Oral 1

Ceftibuten Oral 1

Ceftin Oral 3

Cefuroxime Axetil Oral 1

Cephalexin Oral 1

Daxbia Oral 3

Keflex Oral 3

Spectracef Oral 3

Suprax Suspension 100 mg Oral 3



Suprax Tablet Oral 2

Suprax Capsule Oral 3

CONTRACEPTIVES

Afirmelle Oral 1

Aftera Oral 3

Altavera Oral 1

Alyacen 1/35 Oral 1

Alyacen 7/7/7 Oral 1

Amethia Oral 1

Amethia Lo Oral 1

Amethyst Oral 3

Apri Oral 1

Aranelle Oral 1

Ashlyna Oral 1



Aubra Oral 1

Aubra EQ Oral 1

Aurovela 1.5/30 Oral 1

Aurovela 1/20 Oral 1

Aurovela 24 FE Oral 1

Aurovela Fe 1.5/30 Oral 1

Aurovela FE 1/20 Oral 1

Aviane Oral 1

Ayuna Oral 1

Azurette Oral 1

Balcoltra Oral 3

Balziva Oral 1

Bekyree Oral 1

Beyaz Oral 3

Blisovi 24 Fe Oral 1

Blisovi Fe 1.5/30 Oral 1

Blisovi FE 1/20 Oral 1

Brevicon (28) Oral 3

Briellyn Oral 1

Camila Oral 1

Camrese Oral 1

Camrese Lo Oral 1

Caziant Oral 1

Chateal Oral 1

Chateal EQ Oral 1

Cryselle-28 Oral 1

Cyclafem 1/35 Oral 1

Cyclafem 7/7/7 Oral 1

Cyclessa Oral 3

Cyred Oral 1

Cyred EQ Oral 1

Dasetta 1/35 Oral 1

Dasetta 7/7/7 Oral 1

Daysee Oral 1

Deblitane Oral 1

Delyla Oral 1

Depo-Provera Intramuscular 3 Y

Depo-SubQ Provera 104 Subcutaneous 3



Desogen Oral 3

Desogestrel-Ethinyl Estradiol Oral 1

Drospiren-Eth Estrad-Levomefol Oral 1

Drospirenone-Ethinyl Estradiol Oral 1

EContra EZ Oral 1

EContra One-Step Oral 3

Elinest Oral 1

Ella Oral 2

Emoquette Oral 1

Enpresse-28 Oral 1

Enskyce Oral 1

Errin Oral 1

Estarylla Oral 1

Estrostep Fe Oral 3

Ethynodiol Diac-Eth Estradiol Oral 1

FaLessa Oral 3

Fallback Solo Oral 1

Falmina Oral 1

Fayosim Oral 1

Femynor Oral 1

Generess FE Oral 3

Gianvi Oral 1

Gildagia Oral 1

Gildess 1.5/30 Oral 1

Gildess 1/20 Oral 1

Gildess FE 1.5/30 Oral 1

Gildess FE 1/20 Oral 1

Hailey 1.5/30 Oral 1

Hailey 24 Fe Oral 1

Heather Oral 1

Incassia Oral 1

Introvale Oral 1 Y

Isibloom Oral 1

Jasmiel Oral 1

Jencycla Oral 1

Jolessa Oral 1

Jolivette Oral 1

Juleber Oral 1



Junel 1.5/30 Oral 1

Junel 1/20 Oral 1

Junel FE 1.5/30 Oral 1

Junel FE 1/20 Oral 1

Junel Fe 24 Oral 1

Kaitlib Fe Oral 1

Kalliga Oral 1

Kariva Oral 1

Kelnor 1/35 Oral 1

Kelnor 1/50 Oral 1

Kimidess Oral 1

Kurvelo Oral 1

Kyleena Intrauterine 3

Larin 1.5/30 Oral 1

Larin 1/20 Oral 1

Larin 24 FE Oral 1

Larin Fe 1.5/30 Oral 1

Larin Fe 1/20 Oral 1

Larissia Oral 1

Layolis FE Oral 1

Leena Oral 1

Lessina Oral 1

Levonest Oral 1

Levonorgest-Eth Est & Eth Est Oral 1

Levonorgest-Eth Estrad 91-Day Oral 1

Levonorgestrel Oral 1

Levonorgestrel-Ethinyl Estrad Oral 1

Levonorg-Eth Estrad Triphasic Oral 1

Levora 0.15/30 (28) Oral 1

Liletta (52 MG) Intrauterine 3

Lillow Oral 2

Lo Loestrin Fe Oral 3

Loestrin 1.5/30 (21) Oral 3

Loestrin 1/20 (21) Oral 3

Loestrin Fe 1.5/30 Oral 3

Loestrin Fe 1/20 Oral 3

Lomedia 24 FE Oral 1

Loryna Oral 1



LoSeasonique Oral 3

Low-Ogestrel Oral 1

Lo-Zumandimine Oral 1

Lutera Oral 1

Lyza Oral 1

Marlissa Oral 1

medroxyPROGESTERone Acetate Intramuscular 1

Melodetta 24 Fe Oral 1

Mibelas 24 Fe Oral 1

Microgestin 1.5/30 Oral 1

Microgestin 1/20 Oral 1

Microgestin 24 Fe Oral 1

Microgestin FE 1.5/30 Oral 1

Microgestin FE 1/20 Oral 1

Mili Oral 1

Minastrin 24 Fe Oral 3

Mircette Oral 3

Mirena (52 MG) Intrauterine 3

Mono-Linyah Oral 1

MonoNessa Oral 1

My Way Oral 1

Myzilra Oral 1

Natazia Oral 3

Necon 0.5/35 (28) Oral 1

Necon 1/35 (28) Oral 1

Necon 1/50 (28) Oral 2

Necon 10/11 (28) Oral 2

Necon 7/7/7 Oral 1

New Day Oral 1

Nexplanon Subcutaneous 3

Next Choice One Dose Oral 1

Nikki Oral 1

Nora-BE Oral 1

Norethin Ace-Eth Estrad-FE Oral 1

Norethindrone Oral 1

Norethindrone Acet-Ethinyl Est Oral 1

Norethin-Eth Estradiol-Fe Oral 1

Norgestimate-Eth Estradiol Oral 1



Norgestim-Eth Estrad Triphasic Oral 1

Norlyda Oral 1

Norlyroc Oral 1

Nortrel 0.5/35 (28) Oral 1

Nortrel 1/35 (21) Oral 1

Nortrel 1/35 (28) Oral 1

Nortrel 7/7/7 Oral 1

NuvaRing Vaginal 2

Ocella Oral 3

Ogestrel Oral 2

Opcicon One-Step Oral 1

Option 2 Oral 1

Orsythia Oral 1

Ortho Micronor Oral 3

Ortho Tri-Cyclen (28) Oral 3

Ortho Tri-Cyclen Lo Oral 3

Ortho-Cyclen (28) Oral 3

Ortho-Novum 1/35 (28) Oral 3

Ortho-Novum 7/7/7 (28) Oral 3

Ovcon-35 (28) Oral 3

Paragard Intrauterine Copper Intrauterine 3

Philith Oral 1

Pimtrea Oral 1

Pirmella 1/35 Oral 1

Pirmella 7/7/7 Oral 1

Plan B One-Step Oral 3

Portia-28 Oral 1

Previfem Oral 1

Quartette Oral 3

Quasense Oral 1

Rajani Oral 1

React Oral 1

Reclipsen Oral 1

Rivelsa Oral 1

Safyral Oral 3

Seasonique Oral 3

Setlakin Oral 1

Sharobel Oral 1



Simliya Oral 1

Simpesse Oral 1

Skyla Intrauterine 3

Sprintec 28 Oral 1

Sronyx Oral 1

Syeda Oral 1

Take Action Oral 3

Tarina 24 Fe Oral 1

Tarina FE 1/20 Oral 1

Tarina FE 1/20 EQ Oral 1

Taytulla Oral 3

Tilia Fe Oral 1

Tri Femynor Oral 1

Tri-Estarylla Oral 1

Tri-Legest Fe Oral 1

Tri-Linyah Oral 1

Tri-Lo-Estarylla Oral 1

Tri-Lo-Marzia Oral 1

Tri-Lo-Mili Oral 1

Tri-Lo-Sprintec Oral 1

Tri-Mili Oral 1

TriNessa (28) Oral 1

TriNessa Lo Oral 1

Tri-Norinyl (28) Oral 3

Tri-Previfem Oral 1

Tri-Sprintec Oral 1

Trivora (28) Oral 1

Tri-VyLibra Oral 1

Tri-VyLibra Lo Oral 1

Tulana Oral 1

Tydemy Oral 3

Velivet Oral 1

Vestura Oral 1

Vienva Oral 1

Viorele Oral 1

Vyfemla Oral 1

VyLibra Oral 1

Wera Oral 1



Wymzya Fe Oral 1

Xulane Transdermal 2

Yasmin 28 Oral 3

YAZ Oral 3

Zarah Oral 1

Zenchent Oral 1

Zenchent FE Oral 1

Zovia 1/35E (28) Oral 1

Zovia 1/50E (28) Oral 1

Zumandimine Oral 1

CORTICOSTEROIDS

Budesonide Oral 1

Budesonide ER Oral 1

Cortef Oral 3

Cortisone Acetate Oral 1

Decadron Oral 3

Deltasone Oral 1

Dexamethasone Oral 1

Dexamethasone Intensol Oral 2

Dexamethasone Sod Phos-Bupiv Injection 3 Y

Emflaza Oral 3 Y Y

Entocort EC Oral 3

Fludrocortisone Acetate Oral 1

Hydrocortisone Oral 1

Medrol Oral 3

methylPREDNISolone Oral 1

Millipred Oral 3

Millipred DP Oral 3

Millipred DP 12-Day Oral 3

Orapred ODT Oral 3

Pediapred Oral 3

prednisoLONE Oral 1

prednisoLONE Sodium Phosphate Oral 1

predniSONE Oral 1

predniSONE Intensol Oral 3

COUGH/COLD/ALLERGY

Acetylcysteine Inhalation 1

Benzonatate Oral 1



Biotuss Oral 1

Biotuss Pediatric Oral 1

Bromfed DM Oral 1

Carbaphen 12 Oral 3

Carbaphen 12 Ped Oral 3

Codar AR Oral 3

Decon-G Oral 3

Exactuss Oral 3

Gilphex TR Oral 3

Giltuss Oral 3

Giltuss Pediatric Oral 1

Giltuss TR Oral 3

guaiFENesin-Codeine Oral 1

Hycofenix Oral 3

HYDROcodone-Homatropine Oral 1

Hydromet Oral 1

Lexuss 210 Oral 3

NeoTuss Plus Oral 3

Nortuss-DE Oral 1

Nortuss-Ex Oral 3

Phenylephrine-guaiFENesin Oral 1

Promethazine VC Plain Oral 1

Promethazine VC/Codeine Oral 1

Promethazine-Codeine Oral 1

Promethazine-DM Oral 1

Promethazine-Phenyleph-Codeine Oral 1

Promethazine-Phenylephrine Oral 1

Pseudoeph-Bromphen-DM Oral 1

SSKI Oral 2

Tessalon Perles Oral 3

TGQ 15DM/5PEH/2CPM Oral 3

TGQ 30PSE/150GFN/15DM Oral 3

TGQ 30PSE/3BRM/15DM Oral 3

Tussigon Oral 1

Vituz Oral 3

DERMATOLOGICALS

Absorica Oral 3

Acitretin Oral 1 Y Y



Acyclovir External 1

Aczone External 3

Adapalene External 1

Ala Scalp External 3

Ala-Cort External 1

Alclometasone Dipropionate External 1

Aldara External 3

AlphaTrex External 1

Altabax External 3

Amcinonide External 1

Amnesteem Oral 1

Avita External 1

Azelaic Acid External 1

Bactroban External 3

Benzoyl Peroxide External 1

Benzoyl Peroxide-Erythromycin External 1

Beser External 1

Betamethasone Dipropionate External 1

Betamethasone Dipropionate Aug External 1

Betamethasone Valerate External 1

BP Foaming Wash External 1

Calcipotriene External 1

Calcipotriene-Betameth Diprop External 1

Calcitrene External 1

Calcitriol External 1

Capex External 3

Carac External 2 Y

Centany External 3

Cerovel External 1

Ciclodan External 1

Ciclodan Solution External 3

Ciclopirox External 1

Ciclopirox Olamine External 1

Ciclopirox Treatment External 1

Claravis Oral 1

Cleocin-T External 3

Clindamycin Phos-Benzoyl Perox External 1

Clindamycin Phosphate External 1



Clobetasol Prop Emollient Base External 1

Clobetasol Propionate External 1

Clobetasol Propionate E External 1

Clobetasol Propionate Emulsion External 1

Clobex External 3

Clocortolone Pivalate External 1

Clocortolone Pivalate Pump External 1

Cloderm External 3

Cloderm Pump External 3

Clotrimazole External 1

Clotrimazole-Betamethasone External 1

Condylox External 3

Cordran External 3

Cormax Scalp Application External 1

Cortane-B External 3

Cortisporin External 3

Cosentyx Subcutaneous 3 Y Y Y

Cosentyx (300 MG Dose) Subcutaneous 3 Y Y Y

Cosentyx Sensoready (300 MG) Subcutaneous 3 Y Y Y

Cosentyx Sensoready Pen Subcutaneous 3 Y Y Y

Crotan External 3

Cutivate External 3

Denavir External 3

Derma-Smoothe/FS Body External 3

Derma-Smoothe/FS Scalp External 3

Dermatop External 3

Desonate External 3

Desonide External 1

DesOwen External 3

Desoximetasone External 1

Diclofenac Epolamine Transdermal 3

Diclofenac Sodium External 1 Y

Diclofenac Sodium Transdermal 1 Y

Diclofono Transdermal 3 Y

Diprolene External 3

Diprolene AF External 3

Dovonex External 3

Drysol External 2



Dupixent Subcutaneous 3 Y Y

Econazole Nitrate External 1

Efudex External 3

Elidel External 2

Elimite External 3

Elocon External 3

Epifoam External 3

Ertaczo External 3

Ery External 1

Erythromycin External 1

Eucrisa External 3

Eurax External 3

Exoderm External 3

Finacea External 2

Flector Transdermal 3

Fluocinolone Acetonide External 1

Fluocinolone Acetonide Body External 1

Fluocinolone Acetonide Scalp External 1

Fluocinonide External 1

Fluocinonide Emulsified Base External 1

Fluoroplex External 2

Fluorouracil External 1 Y

Flurandrenolide External 1

Fluticasone Propionate External 1

Frotek External 3 Y

Gentamicin Sulfate External 1

Halcinonide External 1

Halobetasol Propionate External 1

Halog External 3

Halotin External 3

Hydrocortisone External 1

Hydrocortisone Ace-Pramoxine External 1

Hydrocortisone Butyr Lipo Base External 1

Hydrocortisone Butyrate External 1

Hydrocortisone Valerate External 1

Hydrocortisone-Iodoquinol External 1

Ilumya Subcutaneous 3 Y Y

Imiquimod External 1



Imiquimod Pump External 3

Impoyz External 3

ISOtretinoin Oral 1

Kenalog External 3

Ketoconazole External 1

Ketorolac Tromethamine External 1

Lac-Hydrin External 3

Lactic Acid E External 1

Latrix External 1

Latrix XM External 3

Lidocaine External 1 Y

Lidocaine HCl Urethral/Mucosal External 1 Y

Lidoderm External 3 Y

LidoRx External 3 Y

Lindane External 1

LoKara External 1

Loprox External 3

Lotrisone External 3

Malathion External 1

Mentax External 3

Methoxsalen Rapid Oral 1

metroNIDAZOLE External 1

Mometasone Furoate External 1

Mupirocin External 1

Mupirocin Calcium External 1

Myorisan Oral 1

Naftifine HCl External 1

Naftin External 3

Natroba External 3

Neo-Synalar External 3

Nizoral External 3

Nyamyc External 1

Nyata External 1

Nystatin External 1

Nystatin-Triamcinolone External 1

Nystop External 1

Ovace Plus External 3

Ovace Plus Wash External 3



Ovide External 3

Oxiconazole Nitrate External 1

Oxistat External 3

Oxsoralen Ultra Oral 3

Panretin External 3 Y

Permethrin External 1

Pimecrolimus External 1

Podocon External 3

Podofilox External 1

Pramosone External 3

Pramosone E External 3

Prednicarbate External 1

Protopic External 3

Pyrogallic Acid External 1

Rea Lo 40 External 1

Remeven External 1

Retin-A External 3

Riax External 3

Salacyn External 1

Salicylic Acid External 1

Santyl External 3

Scalacort External 1

Seb-Prev Wash External 1

Selenium Sulfide External 1

Siliq Subcutaneous 3 Y Y

Silvadene External 3

Silver sulfADIAZINE External 1

Sklice External 3

Skyrizi (150 MG Dose) Subcutaneous 2 Y Y

Sodium Sulfacetamide External 1

Solaraze Transdermal 3 Y

Soriatane Oral 3 Y Y

Spinosad External 1

SSD External 1

Stelara Subcutaneous 2 Y Y Y

Sulfacetamide Sodium External 1

Sulfamylon External 3

Sulfurated Lime External 1



Synalar External 3

Taclonex External 3

Tacrolimus External 1

Taltz Subcutaneous 3 Y Y

Targretin External 3 Y Y

Tazarotene External 1

Tazorac External 2

TBC External 3

Temovate External 3

Texacort External 3

Tolak External 3

Topicort External 3

Topicort Spray External 3

Tremfya Subcutaneous 3 Y Y Y

Tretinoin External 1 Y

Triamcinolone Acetonide External 1

Triderm External 1

Tridesilon External 3

Ultravate External 3

Umecta Mousse External 1

Uramaxin External 3

Urea External 1

Urea-C40 External 1

Valchlor External 2 Y Y

Vanos External 3

Verdeso External 3

Veregen External 3 Y

Voltaren Transdermal 3 Y

Westcort External 3

Xolegel External 3

Xurea External 1

Zenatane Oral 1

Zovirax External 3

Zyclara External 3 Y

Zyclara Pump External 3 Y

Clodan Shampoo External 1

Clodan Kit External 3

Differin Lotion External 2



Differin Gel External 3

Rosadan Gel External 1

Rosadan Kit External 3

Tovet Kit External 3

Tovet Foam External 1

DIAGNOSTIC PRODUCTS

Breeze 2 Test In Vitro 2 Y

Contour Next Test In Vitro 2 Y

Contour Test In Vitro 2 Y

DIGESTIVE AIDS

Creon Oral 2

Pancreaze Oral 3

Pertzye Oral 3

Sucraid Oral 3 Y Y

Viokace Oral 3

Zenpep Oral 2

DIURETICS

acetaZOLAMIDE Oral 1

acetaZOLAMIDE ER Oral 1

Aldactazide Oral 3

Aldactone Oral 3

aMILoride HCl Oral 1

aMILoride-hydroCHLOROthiazide Oral 1

Bumetanide Oral 1

Bumex Oral 3

Chlorothiazide Oral 1

Chlorthalidone Oral 1

Demadex Oral 3

Diamox Sequels Oral 3

Diuril Oral 3

Dyazide Oral 3

Dyrenium Oral 3

Edecrin Oral 3

Furosemide Oral 1

hydroCHLOROthiazide Oral 1

Indapamide Oral 1

Keveyis Oral 3 Y Y Y

Lasix Oral 3



Maxzide Oral 3

Maxzide-25 Oral 3

methazolAMIDE Oral 1

Methyclothiazide Oral 1

metOLazone Oral 1

Microzide Oral 3

Neptazane Oral 3

Spironolactone Oral 1

Spironolactone-HCTZ Oral 1

Torsemide Oral 1

Triamterene Oral 1

Triamterene-HCTZ Oral 1

ENDOCRINE AND METABOLIC AGENTS - MISC.

Acthar Injection 3 Y Y Y

Actonel Oral 3

Aldurazyme Intravenous 3 Y Y

Alendronate Sodium Oral 1

Atelvia Oral 3

Binosto Oral 3

Boniva Oral 3

Bravelle Injection 3 Y

Buphenyl Oral 3 Y Y

Cabergoline Oral 1

Calcitonin (Salmon) Nasal 1

Calcitriol Oral 1

Carbaglu Oral 3 Y Y

Carnitor Oral 3

Carnitor SF Oral 3

Cetrotide Subcutaneous 2 Y

Chorionic Gonadotropin Intramuscular 1 Y

Cinacalcet HCl Oral 1 Y Y Y

clomiPHENE Citrate Oral 1

Crysvita Subcutaneous 3 Y Y

Cystadane Oral 3 Y Y

DDAVP Nasal 3

DDAVP Oral 3

DDAVP Rhinal Tube Nasal 3

Desmopressin Ace Rhinal Tube Nasal 1



Desmopressin Ace Spray Refrig Nasal 1

Desmopressin Acetate Injection 1 Y

Desmopressin Acetate Oral 1

Desmopressin Acetate Spray Nasal 1

Doxercalciferol Oral 1

Egrifta Subcutaneous 3 Y Y Y

Elaprase Intravenous 3 Y Y

Evista Oral 3

Follistim AQ Injection 2 Y

Follistim AQ Subcutaneous 2 Y

Forteo Subcutaneous 2 Y Y Y

Fosamax Oral 3

Fosamax Plus D Oral 3

Galafold Oral 3 Y Y

Ganirelix Acetate Subcutaneous 1 Y

Genotropin Subcutaneous 3 Y Y

Genotropin MiniQuick Subcutaneous 3 Y Y

Gonal-f Injection 2 Y

Gonal-f RFF Subcutaneous 2 Y

Gonal-f RFF Rediject Subcutaneous 2 Y

HCG Injection 3 Y

Hectorol Oral 3

Humatrope Injection 3 Y Y

Ibandronate Sodium Oral 1

Increlex Subcutaneous 2 Y Y

Kuvan Oral 3 Y Y Y

levOCARNitine Oral 1

levOCARNitine SF Oral 1

Lupaneta Pack Combination 3 Y Y

Lupron Depot-Ped (1-Month) Intramuscular 2 Y Y

Lupron Depot-Ped (3-Month) Intramuscular 2 Y Y

Menopur Subcutaneous 3 Y

Miacalcin Injection 3

Mifeprex Oral 3

miFEPRIStone Oral 1

Myalept Subcutaneous 3 Y Y

Naglazyme Intravenous 3 Y Y

Natpara Subcutaneous 3 Y Y



Nitisinone Oral 3 Y Y

Nityr Oral 3 Y Y

Nocdurna Sublingual 3

Norditropin FlexPro Subcutaneous 2 Y Y

Novarel Intramuscular 2 Y

Nutropin AQ NuSpin 10 Subcutaneous 3 Y Y



Nutropin AQ Pen Subcutaneous 3 Y Y

Octreotide Acetate Injection 1 Y Y

Omnitrope Subcutaneous 3 Y Y

Orfadin Oral 3 Y Y

Orilissa Oral 3 Y Y

Osphena Oral 3

Ovidrel Subcutaneous 2 Y

Palynziq Subcutaneous 3 Y Y

Paricalcitol Oral 1

Pregnyl Intramuscular 2 Y

Prolia Subcutaneous 2 Y Y

Raloxifene HCl Oral 1

Ravicti Oral 3 Y Y

Risedronate Sodium Oral 1

Rocaltrol Oral 3

Saizen Injection 3 Y Y

Saizen Click.Easy Injection 3 Y Y

Saizenprep Injection 3 Y Y

Samsca Oral 3 Y Y Y

SandoSTATIN Injection 3 Y Y

SandoSTATIN LAR Depot Intramuscular 2 Y Y

Sensipar Oral 3 Y Y Y

Serostim Subcutaneous 3 Y Y

Signifor Subcutaneous 3 Y Y Y

Signifor LAR Intramuscular 3 Y Y

Sodium Phenylbutyrate Oral 1 Y Y

Somatuline Depot Subcutaneous 3 Y Y

Somavert Subcutaneous 3 Y Y Y

Stimate Nasal 3

Strensiq Subcutaneous 2 Y Y Y



Supprelin LA Subcutaneous 3 Y Y

Synarel Nasal 3 Y Y

Triptodur Intramuscular 3 Y Y

Tymlos Subcutaneous 3 Y Y

Xgeva Subcutaneous 3 Y Y

Xuriden Oral 3 Y Y

Zemplar Oral 3 Y

Zomacton Subcutaneous 3 Y Y

Zorbtive Subcutaneous 3 Y Y

Etidronate Disodium 200 mg Oral 1

Etidronate Disodium 400 mg Oral 1 Y

Jynarque 90 & 30 mg Oral 3 Y Y


Jynarque 30 mg Oral 3 Y Y Y


Jynarque 15 mg Oral 3 Y Y Y

ESTROGENS

Activella Oral 3

Alora Transdermal 3

Amabelz Oral 1

Angeliq Oral 3

Biest/Progesterone Transdermal 3

Bijuva Oral 3

Climara Transdermal 3

Climara Pro Transdermal 2

CombiPatch Transdermal 3

Covaryx Oral 1

Covaryx HS Oral 1

Delestrogen Intramuscular 3

Depo-Estradiol Intramuscular 3

Divigel Transdermal 2

Dotti Transdermal 1

Duavee Oral 3

EEMT Oral 1

EEMT HS Oral 1

Elestrin Transdermal 3

Est Estrogens-Methyltest Oral 1

Est Estrogens-Methyltest DS Oral 1



Est Estrogens-Methyltest HS Oral 1

Estrace Oral 3

Estradiol Oral 1

Estradiol Transdermal 1

Estradiol-Norethindrone Acet Oral 1

Estrogel Transdermal 2

Estropipate Oral 1

Evamist Transdermal 3

Femhrt Low Dose Oral 3

Fyavolv Oral 1

Jevantique Lo Oral 1

Jinteli Oral 1

Lopreeza Oral 1

Menest Oral 3

Menostar Transdermal 3

Mimvey Oral 1

Mimvey Lo Oral 1

Minivelle Transdermal 3

Norethindrone-Eth Estradiol Oral 1

Prefest Oral 3

Premarin Oral 2

Premphase Oral 2

Prempro Oral 2

Vivelle-Dot Transdermal 3

FLUOROQUINOLONES

Avelox Oral 3

Baxdela Oral 3

Cipro Oral 3

Cipro XR Oral 3

Ciprofloxacin Oral 1

Ciprofloxacin HCl Oral 1

Ciprofloxacin-Ciproflox HCl ER Oral 1

Factive Oral 3

Levaquin Oral 3

levoFLOXacin Oral 1

Moxifloxacin HCl Oral 1

Moxifloxacin HCl in NaCl Intravenous 1

Ofloxacin Oral 1



GASTROINTESTINAL AGENTS - MISC.

Actigall Oral 3

Alosetron HCl Oral 1

Amitiza Oral 3

Apriso Oral 1

Asacol HD Oral 2

Auryxia Oral 3

Azulfidine Oral 3

Azulfidine EN-tabs Oral 3

Balsalazide Disodium Oral 1

Calcium Acetate (Phos Binder) Oral 1

Canasa Rectal 2

Chenodal Oral 2 Y Y Y

Cholbam Oral 3 Y Y

Cimzia Subcutaneous 3 Y Y Y

Cimzia Prefilled Subcutaneous 3 Y Y Y

Cimzia Starter Kit Subcutaneous 3 Y Y Y

Colazal Oral 3

Cromolyn Sodium Oral 1

Delzicol Oral 2

Dipentum Oral 3

Eliphos Oral 3

Enulose Oral 1

Fosrenol Oral 3

Gastrocrom Oral 3

Gattex Subcutaneous 3 Y Y Y

Generlac Oral 1

Giazo Oral 3

Inflectra Intravenous 1 Y Y

Lactulose Encephalopathy Oral 1

Lanthanum Carbonate Oral 1

Lialda Oral 2

Linzess Oral 2

Lotronex Oral 3

Mesalamine Oral 1

Mesalamine Rectal 1

Metoclopramide HCl Oral 1

Movantik Oral 3



Ocaliva Oral 3 Y Y Y

Pentasa Oral 2

Phoslyra Oral 3

Reglan Oral 3

Remicade Intravenous 3 Y Y

Renagel Oral 3

Renflexis Intravenous 3 Y Y

Sevelamer Carbonate Oral 1

Sevelamer HCl Oral 1

SfRowasa Rectal 3

Stelara Intravenous 2 Y Y Y

sulfaSALAzine Oral 1

Symproic Oral 3 Y Y

Trulance Oral 3

Urso 250 Oral 3

Urso Forte Oral 3

Ursodiol Oral 1

Viberzi Oral 3

Xermelo Oral 3 Y Y

GENITOURINARY AGENTS - MISCELLANEOUS

Alfuzosin HCl ER Oral 1

Avodart Oral 3

Cardura XL Oral 3

Cystagon Oral 2 Y Y

Cytra K Crystals Oral 1

Dutasteride Oral 1

Dutasteride-Tamsulosin HCl Oral 1

Elmiron Oral 3

Finasteride Oral 1

Flomax Oral 3

Jalyn Oral 3

K-Phos No 2 Oral 2

Lithostat Oral 3

Oracit Oral 3

Phenazo Oral 1

Phenazopyridine HCl Oral 1

Pot & Sod Cit-Cit Ac Oral 1

Potassium Citrate ER Oral 1



Potassium Citrate-Citric Acid Oral 1

Proscar Oral 3

Pyridium Oral 3

Rapaflo Oral 3

Shohls Modified Oral 3

Silodosin Oral 1

Sod Citrate-Citric Acid Oral 1

Tamsulosin HCl Oral 1

Taron-Crystals Oral 1

Thiola Oral 3 Y

Tricitrates Oral 1

Urocit-K 10 Oral 3

Urocit-K 15 Oral 3

Urocit-K 5 Oral 3

Uroxatral Oral 3

Virtrate-2 Oral 1

Virtrate-3 Oral 1

Virtrate-K Oral 1

GOUT AGENTS

Allopurinol Oral 1

Colchicine Oral 1

Colchicine-Probenecid Oral 1

Colcrys Oral 2

Duzallo Oral 3

Febuxostat Oral 1

Krystexxa Intravenous 3 Y Y Y

Mitigare Oral 3

Probenecid Oral 1

Uloric Oral 3

Zurampic Oral 3

Zyloprim Oral 3

HEMATOLOGICAL AGENTS - MISC.

Advate Intravenous 3 Y Y

Adynovate Intravenous 3 Y Y

Afstyla Intravenous 3 Y Y

Aggrenox Oral 3

Agrylin Oral 3

Alphanate/VWF Complex/Human Intravenous 3 Y Y



AlphaNine SD Intravenous 3 Y Y

Alprolix Intravenous 3 Y Y

Anagrelide HCl Oral 1

Aspirin-Dipyridamole ER Oral 1

Bebulin Intravenous 3 Y Y

BeneFIX Intravenous 3 Y Y

Berinert Intravenous 3 Y Y Y

Brilinta Oral 2

Cilostazol Oral 1

Clopidogrel Bisulfate Oral 1

Coagadex Intravenous 3 Y Y

Corifact Intravenous 3 Y Y

Dipyridamole Oral 1

Effient Oral 3

Eloctate Intravenous 3 Y Y

Feiba Intravenous 3 Y Y

Feiba NF Intravenous 3 Y Y

Fibryga Intravenous 3 Y Y

Firazyr Subcutaneous 2 Y Y Y

Haegarda Subcutaneous 3 Y Y Y

Helixate FS Intravenous 3 Y Y

Hemlibra Subcutaneous 3 Y Y

Hemofil M Intravenous 3 Y Y

Humate-P Intravenous 3 Y Y

Icatibant Acetate Subcutaneous 1 Y Y Y

Idelvion Intravenous 3 Y Y

Ixinity Intravenous 3 Y Y

Jivi Intravenous 3 Y Y

Kalbitor Subcutaneous 3 Y Y Y

Kcentra Intravenous 3 Y Y

Koate Intravenous 3 Y Y

Koate-DVI Intravenous 3 Y Y

Kogenate FS Intravenous 3 Y Y

Kogenate FS Bio-Set Intravenous 3 Y Y

Kovaltry Intravenous 3 Y Y

Monoclate-P Intravenous 3 Y Y

Mononine Intravenous 3 Y Y

Novoeight Intravenous 3 Y Y



NovoSeven RT Intravenous 3 Y Y

Nuwiq Intravenous 3 Y Y

Obizur Intravenous 3 Y Y

Pentoxifylline ER Oral 1

Plavix Oral 3

Prasugrel HCl Oral 1

Profilnine Intravenous 3 Y Y

Profilnine SD Intravenous 3 Y Y

Rebinyn Intravenous 3 Y Y

Recombinate Intravenous 3 Y Y

RiaSTAP Intravenous 3 Y Y

Rixubis Intravenous 3 Y Y

Ruconest Intravenous 3 Y Y Y

Takhzyro Subcutaneous 3 Y Y

Tavalisse Oral 3 Y Y

Tretten Intravenous 3 Y Y

Vonvendi Intravenous 3 Y Y

Wilate Intravenous 3 Y Y

Xyntha Intravenous 3 Y Y

Xyntha Solofuse Intravenous 3 Y Y

Zontivity Oral 3

HEMATOPOIETIC AGENTS

Aranesp (Albumin Free) Injection 2 Y Y

Cerdelga Oral 3 Y Y Y

Cerezyme Intravenous 3 Y Y

CVS Folic Acid Oral 1

Doptelet Oral 3 Y Y

Droxia Oral 3 Y

Elelyso Intravenous 3 Y Y Y

Endari Oral 3 Y Y

Epogen Injection 3 Y Y

EQL Folic Acid Oral 1

FA-8 Oral 1

Folate Oral 1

Folic Acid Oral 1

Fulphila Subcutaneous 2 Y Y

GNP Folic Acid Oral 1

Granix Subcutaneous 2 Y Y Y



HM Folic Acid Oral 1

Infed Injection 3

KP Folic Acid Oral 1

Miglustat Oral 1 Y Y

Mircera Injection 3 Y Y

Mozobil Subcutaneous 3 Y Y Y

Mulpleta Oral 3 Y Y

Neulasta Subcutaneous 2 Y Y Y

Neulasta Onpro Subcutaneous 2 Y Y Y

Neupogen Injection 3 Y Y Y

Nivestym Injection 2 Y Y

Nplate Subcutaneous 3 Y Y

Procrit Injection 2 Y Y

Promacta Oral 3 Y Y Y

PX Folic Acid Oral 1

QC Folic Acid Oral 1

RA Folic Acid Oral 1

Retacrit Injection 2 Y Y

SM Folic Acid Oral 1

YL Folic Acid Oral 1

Zarxio Injection 2 Y Y Y

Zavesca Oral 3 Y Y Y

HEMOSTATICS

Amicar Oral 3

Aminocaproic Acid Oral 1

Lysteda Oral 3

Tranexamic Acid Oral 1

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

Ambien Oral 3

Ambien CR Oral 3

Belsomra Oral 3

Butisol Sodium Oral 3

Doral Oral 3

Edluar Sublingual 3

Estazolam Oral 1

Eszopiclone Oral 1

Flurazepam HCl Oral 1

Halcion Oral 3



Hetlioz Oral 3 Y Y Y

Intermezzo Sublingual 3

Lunesta Oral 3

Midazolam HCl Oral 1

PHENobarbital Oral 1

Quazepam Oral 1

Restoril Oral 3

Rozerem Oral 3

Seconal Oral 3

Silenor Oral 3

Sonata Oral 3

Temazepam Oral 1

Triazolam Oral 1

Zaleplon Oral 1

Zolpidem Tartrate Oral 1

Zolpidem Tartrate Sublingual 1

Zolpidem Tartrate ER Oral 1

Zolpimist Oral 3

LAXATIVES

Alophen Oral 1

Bisac-Evac Rectal 1

Bisacodyl Rectal 1

Bisacodyl EC Oral 1

Bisacodyl Laxative Oral 1

Bisacodyl Laxative Rectal 1

Biscolax Rectal 1

Carters Little Pills Oral 1

Citrate of Magnesia Oral 1

Citroma Oral 1

Clenpiq Oral 3

Complete Ready-To-Use Enema Rectal 1

Constulose Oral 1

Correct Oral 1

Correctol Oral 1

CVS Bisacodyl Oral 1

CVS Bisacodyl Rectal 1

CVS Citrate of Magnesia Oral 1

CVS Enema Disposable Rectal 1



CVS Gentle Laxative Oral 1

CVS Gentle Laxative Rectal 1

CVS Gentle Laxative Womens Oral 1

CVS Magnesium Citrate Oral 1

CVS Milk of Magnesia Oral 1

CVS Phosphate Saline Laxative Oral 1

CVS Senna Oral 1

Ducodyl Oral 1

Dulcolax Oral 3

Dulcolax Rectal 3

Dulcolax Bowel Prep Kit Combination 3

Dulcolax Milk of Magnesia Oral 1

Enema Rectal 1

Enema Disposable Rectal 1

Enema Pediatric Rectal 1

Enema Ready-To-Use Rectal 1

EQ ClearLax Oral 1

EQ Enema Rectal 1

EQ Gentle Laxative Oral 1

EQ Magnesium Citrate Oral 1

EQ Milk of Magnesia Oral 1

EQ Womans Laxative Oral 1

EQ Womens Laxative Oral 1

EQL Gentle Laxative Oral 1

EQL Laxative Oral 1

EQL Laxative Rectal 1

EQL Magnesium Citrate Oral 1

EQL Milk of Magnesia Oral 1

EQL Ready-to-Use Enema Rectal 1

EQL Womans Laxative Oral 1

Ex-Lax Ultra Oral 1

Feenamint Oral 1

Fleet Bisacodyl Rectal 3

Fleet Enema Rectal 3

Fleet Laxative Oral 1

Fleet Pediatric Rectal 3

GaviLyte-C Oral 1

GaviLyte-G Oral 1



GaviLyte-H Oral 1

Gentle Laxative Oral 1

Gentle Laxative Rectal 1

Gentle Laxative For Women Oral 1

Gialax Oral 3

GNP Bisa-Lax Oral 1

GNP Enema Rectal 1

GNP Gentle Laxative Rectal 1

GNP Laxative Oral 1

GNP Laxative Rectal 1

GNP Magnesium Citrate Oral 1

GNP Milk of Magnesia Oral 1

GNP Senna Lax Oral 3

GNP Womens Laxative Oral 1

Golytely Oral 3

GoodSense ClearLax Oral 1

GoodSense Enema Rectal 1

GoodSense Magnesium Citrate Oral 1

GoodSense Womens Laxative Oral 1

HealthyLax Oral 3

HM ClearLax Oral 1

HM Enema Rectal 1

HM Laxative Oral 1

HM Laxative Rectal 1

HM Magnesium Citrate Oral 1

HM Milk of Magnesia Oral 1

HM Senna Oral 1

KP Bisacodyl Oral 1

Kristalose Oral 3

Lactulose Oral 1

Laxative Oral 1

Laxative Rectal 1

Laxative Feminine Oral 1

Magnesium Citrate Oral 1

Milk of Magnesia Oral 1

Milk of Magnesia Concentrate Oral 1

MoviPrep Oral 3

OsmoPrep Oral 3



PCP 100 Combination 3

Pedia-Lax Oral 3

PEG 3350 Oral 1

PEG 3350/Electrolytes Oral 1

PEG 3350-KCl-Na Bicarb-NaCl Oral 1

PEG-3350/Electrolytes Oral 1

PEG-Prep Oral 1

PEGyLAX Oral 1

Phillips Oral 1

Phillips Milk of Magnesia Oral 1

Phosphate Laxative Oral 3

Plenvu Oral 3

Polyethylene Glycol 3350 Oral 1

Poly-Prep Combination 3

Pure & Gentle Enema Rectal 1

PX Laxative Oral 1

PX Milk of Magnesia Oral 1

QC Enema Rectal 1

QC Gentle Laxative Oral 1

QC Gentle Laxative Rectal 1

QC Magnesium Citrate Oral 1

QC Milk of Magnesia Oral 1

QC Natura-LAX Oral 1

RA Enema Rectal 1

RA Fast Relief Laxative Rectal 1

RA Laxative Oral 1

RA Magnesium Citrate Oral 1

RA Milk of Magnesia Oral 1

RA Oral Saline Laxative Oral 1

RA Saline Enema Rectal 1

RA Saline Laxative Oral 1

RA Stimulant Laxative Rectal 1

RA Womens Laxative Oral 1

Saline Laxative Oral 3

SB Bisacodyl Laxative EC Oral 1

SB Gentle Laxative Womens Oral 1

SB Gentle Lax-Women Oral 1

SB Laxative Rectal 1



SB Magnesium Citrate Oral 1

SB Milk of Magnesia Oral 1

Senna Oral 1

SM Enema Rectal 1

SM Gentle Laxative Oral 1

SM Laxative Rectal 1

SM Magnesium Citrate Oral 1

SM Milk of Magnesia Oral 1

SM Oral Saline Laxative Oral 1

SM Senna Laxative Oral 1

SM Womans Laxative Oral 1

Stimulant Laxative Oral 1

Suprep Bowel Prep Kit Oral 3

TGT Gentle Laxative Oral 1

TGT Powderlax Oral 1

TGT Saline Laxative Rectal 1

TGT Womens Laxative Oral 1

The Magic Bullet Rectal 1

TriLyte Oral 1

Veracolate Oral 1

Womans Laxative Oral 1

Womens Gentle Laxative Oral 1

Womens Laxative Oral 1

Lactulose Packet Oral 3

MACROLIDES

Azithromycin Oral 1

Clarithromycin Oral 1

Clarithromycin ER Oral 1

Dificid Oral 3 Y Y

E.E.S. 400 Oral 2

E.E.S. Granules Oral 3

EryPed 200 Oral 3

EryPed 400 Oral 3

Ery-Tab Oral 3

Erythrocin Stearate Oral 2

Erythromycin Base Oral 1

Erythromycin Ethylsuccinate Oral 1

PCE Oral 3



Zithromax Oral 3

Zithromax Tri-Pak Oral 3

Zithromax Z-Pak Oral 3

Zmax Oral 3

MEDICAL DEVICES AND SUPPLIES

1st Choice Lancets Super Thin Miscellaneous 1

1st Choice Lancets Thin Miscellaneous 1

1st Choice Lancets Ultra Thin Miscellaneous 1

1st Tier Unifine Pentips Miscellaneous 3 Y

1st Tier Unifine Pentips Plus Miscellaneous 3 Y

1st Tier Unilet ComforTouch Miscellaneous 1

Accu-Chek FastClix Lancet Miscellaneous 1

Accu-Chek FastClix Lancets Miscellaneous 1

Accu-Chek Multiclix Lancet Dev Miscellaneous 1

Accu-Chek Multiclix Lancets Miscellaneous 1

Accu-Chek Safe-T Pro Lancets Miscellaneous 1

Accu-Chek Soft Touch Lancets Miscellaneous 1

Accu-Chek Softclix Lancet Dev Miscellaneous 1

Accu-Chek Softclix Lancets Miscellaneous 1

Acti-Lance Lite Lancets 28G Miscellaneous 1

Acti-Lance Special Lancets 17G Miscellaneous 1

Acti-Lance Universal 23G Miscellaneous 1

AgaMatrix Ultra-Thin Lancets Miscellaneous 1

Aimsco Twist Lancets 32G Miscellaneous 1

Aimsco Twist Lancets 33G Miscellaneous 1

Anti-Stick Insulin Syringe Miscellaneous 1 Y

AquaLance Lancets 30G Miscellaneous 1

Assure Comfort Lancets 28G Miscellaneous 1

Assure Haemolance Plus High Miscellaneous 1

Assure Haemolance Plus Low Miscellaneous 1

Assure Haemolance Plus Micro Miscellaneous 1

Assure Haemolance Plus Normal Miscellaneous 1

Assure Haemolance Plus Ped Miscellaneous 1

Assure ID Insulin Safety Syr Miscellaneous 1 Y

Assure Lance Lancets Miscellaneous 1

Assure Lance Lancets 21G Miscellaneous 1

Assure Lance Plus Safety 25G Miscellaneous 1

Assure Lance Plus Safety 30G Miscellaneous 1



At Last Lancets Miscellaneous 1

Aurora Lancet Super Thin 30G Miscellaneous 1

Aurora Lancet Thin 23G Miscellaneous 1

Aurora Pen Needles Miscellaneous 3 Y

Aurora Unifine Pentips Miscellaneous 3 Y

Autolet II Clinisafe Miscellaneous 1

Autolet Lite Clinisafe Miscellaneous 1

Autolet Lite Starter Pack Miscellaneous 1

Autolet Platforms Miscellaneous 1

Bayer Breeze 2 System Miscellaneous 3 Y

Bayer Contour Link Monitor Miscellaneous 2 Y Y

Bayer Microlet Lancets Miscellaneous 1

BD AutoShield Miscellaneous 3 Y

BD AutoShield Duo Miscellaneous 3 Y

BD Insulin Syr Ultrafine II Miscellaneous 1 Y

BD Insulin Syringe Miscellaneous 1 Y

BD Insulin Syringe Half-Unit Miscellaneous 1 Y

BD Insulin Syringe MicroFine Miscellaneous 1 Y

BD Insulin Syringe U/F Miscellaneous 1 Y

BD Insulin Syringe U/F 1/2Unit Miscellaneous 1 Y

BD Insulin Syringe U-40 Miscellaneous 1 Y

BD Insulin Syringe U-500 Miscellaneous 1 Y

BD Insulin Syringe Ultrafine Miscellaneous 1 Y

BD Integra Insulin Syringe Miscellaneous 1 Y

BD Integra Syringe Miscellaneous 1 Y

BD Lancet Ultrafine 30G Miscellaneous 1

BD Lancet Ultrafine 33G Miscellaneous 1

BD Microtainer Lancets Miscellaneous 1

BD Pen Needle Mini U/F Miscellaneous 3 Y

BD Pen Needle Nano 2nd Gen Miscellaneous 3 Y

BD Pen Needle Nano U/F Miscellaneous 3 Y

BD Pen Needle Original U/F Miscellaneous 3 Y

BD Pen Needle Short U/F Miscellaneous 3 Y

BD SafetyGlide Insulin Syringe Miscellaneous 1 Y

BD Safety-Lok Insulin Syringe Miscellaneous 1 Y

BD Veo Insulin Syringe U/F Miscellaneous 1 Y

CareFine Pen Needles Miscellaneous 3 Y

CareOne Insulin Syringe Miscellaneous 1 Y



CareOne Lancet Thin 23G Miscellaneous 1

CareOne Lancet Ultra Thin 28G Miscellaneous 1

CareOne Unifine Pentips Miscellaneous 3 Y

CareOne Unifine Pentips Plus Miscellaneous 3 Y

CareTouch Pen Needles Miscellaneous 3 Y

CareTouch Twist Lancets 28G Miscellaneous 1



Caya Vaginal 3

Clickfine Pen Needles Miscellaneous 3 Y

CoaguChek Lancets Miscellaneous 1

Comfort Assist Insulin Syringe Miscellaneous 1 Y

Comfort EZ Insulin Syringe Miscellaneous 1 Y

Comfort EZ Micro Pen Needles Miscellaneous 3 Y

Comfort EZ Pen Needles Miscellaneous 3 Y

Comfort EZ Short Pen Needles Miscellaneous 3 Y

Comfort Lancets Miscellaneous 1

Contour Monitor Miscellaneous 2 Y Y

Contour Next EZ Miscellaneous 2 Y Y

Contour Next Link Miscellaneous 2 Y Y

Contour Next Monitor Miscellaneous 2 Y Y

Contour Next One Miscellaneous 2 Y Y

Contour Next USB Monitor Miscellaneous 2 Y Y

CVS Lancets Original Miscellaneous 1

CVS Lancets Thin 26G Miscellaneous 1

CVS Ultra Thin Lancets Miscellaneous 1

Diastar Easy Test II Lancets Miscellaneous 1

Diastar Easy Test Lancets Miscellaneous 1

Diathrive Lancet Ultra Thin 30 Miscellaneous 1

Diathrive Lancets Miscellaneous 1

Droplet Lancets Ultra Thin 30G Miscellaneous 1

Droplet Pen Needles Miscellaneous 3 Y

Drug Mart On-The-Go Lancet 30G Miscellaneous 1

Drug Mart Unifine Pentips Miscellaneous 3 Y

Drug Mart Unifine Pentips Plus Miscellaneous 3 Y

Drug Mart Unilet Lancets 28G Miscellaneous 1

Drug Mart Unilet Lancets 30G Miscellaneous 1

Duane Reade Lancet Altern Site Miscellaneous 1



Duane Reade Lancet Super Thin Miscellaneous 1

Duane Reade Lancet Ultra Thin Miscellaneous 1

Duane Reade Unifine Pentips Miscellaneous 3 Y

Easy Glide Luer Lock Syringe Miscellaneous 3 Y

Easy Touch FlipLock Insulin Sy Miscellaneous 1 Y

Easy Touch Insulin Safety Syr Miscellaneous 1 Y

Easy Touch Insulin Syringe Miscellaneous 1 Y

Easy Touch Lancets 21G Miscellaneous 1



Easy Touch Lancets 26G/Twist Miscellaneous 1








Easy Touch Pen Needles Miscellaneous 3 Y

Easy Touch Safety Lancets 21G Miscellaneous 1




Easy Touch SheathLock Syringe Miscellaneous 1 Y

EasyTest II Lancets Miscellaneous 1

EasyTest Lancets Miscellaneous 1

Elite-Thin Insulin Syringe Miscellaneous 1 Y

EQL Insulin Syringe Miscellaneous 1 Y

EQL Short Pen Needle Miscellaneous 3 Y

EQL Ultra Comfort Insulin Syr Miscellaneous 1 Y

EQL Ultra Short Pen Needle Miscellaneous 3 Y

Exel Comfort Point Insulin Syr Miscellaneous 1 Y

Exel Comfort Point Pen Needle Miscellaneous 3 Y

FemCap Vaginal 3

Fifty50 Pen Needles Miscellaneous 3 Y

Fifty50 Safety Seal Lancets Miscellaneous 1

Fifty50 Superior Comfort Syr Miscellaneous 1 Y

Fifty50 Unilet Lancets 33G Miscellaneous 1



Fine 30 Miscellaneous 1

Fingerstix Lancets Miscellaneous 1

Freds Pharmacy Unifine Pentip+ Miscellaneous 3 Y

Freds Pharmacy Unifine Pentips Miscellaneous 3 Y

Freds Pharmacy Unilet Lanc 28G Miscellaneous 1

Freds Pharmacy Unilet Lanc 30G Miscellaneous 1

FreeStyle Unistick II Lancets Miscellaneous 1

Gentle-Let GP Lancets Miscellaneous 1

Gentle-Let Lancets Miscellaneous 1

Gentle-Let Platforms Miscellaneous 1

Global Easy Glide Insulin Syr Miscellaneous 1 Y

GlucoCom Lancets 28G Miscellaneous 1



GlucoPro Insulin Syringe Miscellaneous 1 Y

Glucosource Lancets Miscellaneous 1

GoodSense Clickfine Pen Needle Miscellaneous 3 Y

GoodSense Pen Needle Penfine Miscellaneous 3 Y

Haemolance Miscellaneous 1

Haemolance Low Flow Lancets Miscellaneous 1

Haemolance Plus Miscellaneous 1

Haemolance Plus High Flow Miscellaneous 1

Haemolance Plus Low Flow Miscellaneous 1

Haemolance Plus Max Flow Miscellaneous 1

Haemolance Plus Pediatric Flow Miscellaneous 1

HealthWise Insulin Syr/Needle Miscellaneous 1 Y

HealthWise Micron Pen Needles Miscellaneous 3 Y

HealthWise Mini Pen Needles Miscellaneous 3 Y

HealthWise Pen Needles Miscellaneous 3 Y

HealthWise Short Pen Needles Miscellaneous 3 Y

HealthWise Unifine Pentips Miscellaneous 3 Y

Healthy Accents Unifine Pentip Miscellaneous 3 Y

Healthy Accents Unilet Lancets Miscellaneous 1

H-E-B inControl Lancets 28G Miscellaneous 1



H-E-B inControl Pen Needles Miscellaneous 3 Y

H-E-B inControl Unifine Pentip Miscellaneous 3 Y



HumaPen LUXURA HD Miscellaneous 3

Hypolance AST Lancing Miscellaneous 1

InPen 100-Blue-Lilly Miscellaneous 3

InPen 100-Blue-Novo Miscellaneous 3

InPen 100-Gray-Lilly Miscellaneous 3

InPen 100-Grey-Novo Miscellaneous 3

InPen 100-Pink-Lilly Miscellaneous 3

InPen 100-Pink-Novo Miscellaneous 3

Insulin Syringe Miscellaneous 1 Y

Insulin Syringe/Needle Miscellaneous 1 Y

Insupen Pen Needles Miscellaneous 3 Y

Insupen Sensitive Miscellaneous 3 Y

Insupen Ultrafin Miscellaneous 3 Y

Kinney Lancets Miscellaneous 1

Kinney Thin Lancets Miscellaneous 1

Kinray Insulin Syringe Miscellaneous 1 Y

Kroger Pen Needles Miscellaneous 3 Y

Lancets Miscellaneous 1

Lancets 28G Miscellaneous 1

Lancets 30G Miscellaneous 1

Lancets Micro Thin 33G Miscellaneous 1

Lancets Thin Miscellaneous 1

Lancets Ultra Thin Miscellaneous 1

Leader Unifine Pentips Miscellaneous 3 Y

Leader Unifine Pentips Plus Miscellaneous 3 Y

Liberty Medical Lancets Miscellaneous 1

LifeScan Unistik 2 Miscellaneous 1

LifeScan Unistik II Lancets Miscellaneous 1

Litetouch Insulin Syringe Miscellaneous 1 Y

Live Better Lancet Super Thin Miscellaneous 1

Live Better Lancet Ultra Thin Miscellaneous 1

Live Better Pen Needles Miscellaneous 3 Y

Magellan Insulin Safety Syr Miscellaneous 1 Y

Marathon Medical Pentips Miscellaneous 3 Y

Maxi-Comfort Insulin Syringe Miscellaneous 1 Y

Maxi-Comfort Safety Pen Needle Miscellaneous 3 Y

Maxicomfort syr 27G x 1/2" Miscellaneous 1 Y

Medic Insulin Syringe Miscellaneous 1 Y



MediChoice Safety Lancet Miscellaneous 1

MediChoice Safety Lancet Extra Miscellaneous 1

MediChoice Safety Lancet Norm Miscellaneous 1

Medicine Shoppe Pen Needles Miscellaneous 3 Y

MediSense Thin Lancets Miscellaneous 1

Medlance Extra 21G Miscellaneous 1

Medlance Lite 25G Miscellaneous 1

Medlance Plus Extra 21G Miscellaneous 1

Medlance Plus Lancets Miscellaneous 1

Medlance Plus Lite 25G Miscellaneous 1

Medlance Plus Special 0.8mm Miscellaneous 1

Medlance Plus SuperLite 30G Miscellaneous 1

Medlance Plus Universal 21G Miscellaneous 1

Medlance Universal 21G Miscellaneous 1

Meijer Lancets Universal 21G Miscellaneous 1

Meijer Lancets Universal 30G Miscellaneous 1

Meijer Pen Needles Miscellaneous 3 Y

Microlet Lancets Miscellaneous 1

Microtainer Safety Flow Lancet Miscellaneous 1

Monoject Insulin Syringe Miscellaneous 1 Y

Monoject Ultra Comfort Syringe Miscellaneous 1 Y

Monojector End Caps Miscellaneous 1

Monojector OPD End Caps Miscellaneous 1

Monolet Lancets Miscellaneous 1

Monolet OPD Lancets Miscellaneous 1

Monolettor Safety Lancets Miscellaneous 1

Moore Mono Insulin Syringe Miscellaneous 1 Y

Multi-Lancet Device 2 Miscellaneous 1

NetGroup Lancets Miscellaneous 1

Nova Safety Lancets 23G Miscellaneous 1

Nova Safety Lancets 28G Miscellaneous 1

Nova Sureflex Lancets Miscellaneous 1

NovoFine Miscellaneous 3 Y

NovoFine Autocover Miscellaneous 3 Y

NovoFine Plus Miscellaneous 3 Y

NovoPen Echo Miscellaneous 3

NovoTwist Miscellaneous 3 Y

Omniflex Diaphragm Vaginal 3



On Call Lancets Miscellaneous 1

On Call Plus Lancets Miscellaneous 1

OneTouch Club Lancets Fine Pt Miscellaneous 1

OneTouch Combo Pack Miscellaneous 1

OneTouch Delica Lancets 30G Miscellaneous 1

OneTouch Delica Lancets 33G Miscellaneous 1

OneTouch Delica Plus Lancet30G Miscellaneous 1

OneTouch Delica Plus Lancet33G Miscellaneous 1

OneTouch FinePoint Lancets Miscellaneous 1

OneTouch Lancets Miscellaneous 1

OneTouch SureSoft Lancing Dev Miscellaneous 1

OneTouch UltraSoft Lancets Miscellaneous 1

PC Lancets Super Thin 30G Miscellaneous 1

PC Unifine Pentips Miscellaneous 3 Y

Pen Needles Miscellaneous 3 Y

Pen Needles 1/2" Miscellaneous 3 Y

Pen Needles 5/16" Miscellaneous 3 Y

Penlet II Blood Sampler Miscellaneous 1

Penlet II Replacement Cap Miscellaneous 1

PenTips Miscellaneous 2 Y

Perfect Lancets 28G Miscellaneous 1

Perfect Lancets 30G Miscellaneous 1

Precision SureDose Plus Syr Miscellaneous 1 Y

Precision Sure-Dose Syringe Miscellaneous 1 Y

Precision Thin Lancets Miscellaneous 1

Precision Thins GP Lancets Miscellaneous 1

Precision Ultra Lancet Miscellaneous 1

Preferred Plus Unifine Pentips Miscellaneous 3 Y

Pressure Activat Safety Lancet Miscellaneous 1

Prevent Safety Pen Needles Miscellaneous 3

Pro Comfort Pen Needles Miscellaneous 3 Y

Prodigy Insulin Syringe Miscellaneous 1 Y

Prodigy Lancets 28G Miscellaneous 1

Prodigy Safety Lancets 26G Miscellaneous 1

Prodigy Twist Top Lancets 28G Miscellaneous 1

PSS Select GP Lancets Miscellaneous 1

PSS Select Platforms Miscellaneous 1

PSS Select Safety Lancets Miscellaneous 1



Push Button Safety Lancets Miscellaneous 1

PX Lancets Ultra Thin Miscellaneous 1

PX Lancets Ultra Thin 28G Miscellaneous 1

PX Mini Pen Needles Miscellaneous 3 Y

QC Lancets Super Thin 30G Miscellaneous 1

QC Lancets Ultra Thin Miscellaneous 1

QC Pen Needles Miscellaneous 3 Y

QC Unifine Pentips Miscellaneous 3 Y

QC Unilet Lancets 28G Miscellaneous 1

QC Unilet Lancets Micro Thin Miscellaneous 1

RA E-Zject Color Lancets 33G Miscellaneous 1

RA Insulin Syringe Miscellaneous 1 Y

RA Pen Needles Miscellaneous 3 Y

ReliOn Insulin Syringe Miscellaneous 1 Y

ReliOn Lancing Device Miscellaneous 1

ReliOn Mini Pen Needles Miscellaneous 3 Y

ReliOn Pen Needles Miscellaneous 3 Y

ReliOn Short Pen Needles Miscellaneous 3 Y

Rightest Alternate Site Adapt Miscellaneous 1

Rightest GL300 Lancets Miscellaneous 1

SafeSnap Insulin Syringe Miscellaneous 1 Y

Safe-T-Lance Miscellaneous 1

Safe-T-Lance Plus Miscellaneous 1

Safety Lancet 21G/Pressure Act Miscellaneous 1

Safety Lancet 28G/Pressure Act Miscellaneous 1

Safety Lancets Miscellaneous 1

Safety Lancets 21G Miscellaneous 1

Safety Lancets 28G Miscellaneous 1

SAPS Twist Top Lancets Miscellaneous 1

SB Insulin Syringe Miscellaneous 1 Y

Schnucks Insulin Syringe Miscellaneous 1 Y

Select-Lite Device/Lancets Miscellaneous 1

Shopko On-the-Go Lancets 30G Miscellaneous 1

Shopko Unifine Pentips Miscellaneous 3 Y

Shopko Unifine Pentips Plus Miscellaneous 3 Y

Shopko Unilet Lancets 28G Miscellaneous 1

Shopko Unilet Lancets 30G Miscellaneous 1

Side Button Safety Lancet Miscellaneous 1



Single-Let Miscellaneous 1

Smartest Lancets 28G Miscellaneous 1

Solus V2 Lancets 28G Miscellaneous 1

Solus V2 Twist Lancets 30G Miscellaneous 1

SteriLance PA Miscellaneous 1

SteriLance TL Miscellaneous 1

TechLite AST Lancets Miscellaneous 1

TechLite Lancets Miscellaneous 1

TechLite Lancets 30G Miscellaneous 1

TechLite Pen Needles Miscellaneous 3 Y

TGT Lancet Alternate Site Miscellaneous 1

TGT Lancet Super Thin 30G Miscellaneous 1

TGT Lancet Thin 23G Miscellaneous 1

TGT Lancet Ultra Thin 28G Miscellaneous 1

Thinlets GP Lancets Miscellaneous 1

Thinlets Lancet Miscellaneous 1

Todays Health Mini Pen Needles Miscellaneous 3 Y

Todays Health Pen Needles Miscellaneous 3 Y

Todays Health Short Pen Needle Miscellaneous 3 Y

Todays Health Thin Lancets 28G Miscellaneous 1

Todays Health Thin Lancets 30G Miscellaneous 1

Topco Insulin Syringe Miscellaneous 1 Y

Travel Lancets Miscellaneous 1

TRUEplus 5-Bevel Pen Needles Miscellaneous 2 Y

TRUEplus Insulin Syringe Miscellaneous 1 Y

TRUEplus Lancets 26G Miscellaneous 1




TRUEplus Pen Needles Miscellaneous 3 Y

TRUEplus Safety Lancets 28G Miscellaneous 1

UltiCare Insulin Safety Syr Miscellaneous 1 Y

UltiCare Insulin Syringe Miscellaneous 1 Y

UltiCare Micro Pen Needles Miscellaneous 3 Y

UltiCare Mini Pen Needles Miscellaneous 3 Y

UltiCare Pen Needles Miscellaneous 3 Y

UltiCare Short Pen Needles Miscellaneous 3 Y

UltiCare Thin Lancets 30G Miscellaneous 1



Ultilet Classic Lancets Miscellaneous 1

Ultilet Insulin Syringe Miscellaneous 1 Y

Ultilet Insulin Syringe Short Miscellaneous 1 Y

Ultilet Lancets Miscellaneous 1

Ultilet Pen Needle Miscellaneous 3 Y

Ultilet Safety Lancets Miscellaneous 1

Ultilet Safety Lancets 23G Miscellaneous 1

Ultra Thin Lancets 28G Miscellaneous 1

Ultra-Comfort Insulin Syringe Miscellaneous 1 Y

UltraLance Miscellaneous 1

Ultra-Thin II Auto Lancet Miscellaneous 1

Ultra-Thin II Ins Syr Short Miscellaneous 1 Y

Ultra-Thin II Insulin Syringe Miscellaneous 1 Y

Ultra-Thin II Lancets Miscellaneous 1

Ultra-Thin II Mini Pen Needle Miscellaneous 3 Y

Ultra-Thin II Pen Needle Short Miscellaneous 3 Y

Ultra-Thin II Pen Needles Miscellaneous 3 Y

Unifine Pentips Miscellaneous 3 Y

Unifine Pentips Plus Miscellaneous 3 Y

Unilet ComforTouch Lancet Miscellaneous 1

Unilet ExceLite Miscellaneous 1

Unilet ExceLite II Miscellaneous 1

Unilet G.P. Lancet Miscellaneous 1

Unilet G.P. Superlite Lancet Miscellaneous 1

Unilet GP 28 Ultra Thin Miscellaneous 1

Unilet Lancet Miscellaneous 1

Unilet Superlite Lancet Miscellaneous 1

Unilet Super-Thin 30G Miscellaneous 1

Unilet Ultra-Thin 28G Miscellaneous 1

Unistik 1 Miscellaneous 1


Unistik 2 Comfort Miscellaneous 1

Unistik 2 Extra Miscellaneous 1

Unistik 2 Neonatal Miscellaneous 1

Unistik 2 Normal Miscellaneous 1

Unistik 2 Super Miscellaneous 1


Unistik 3 Comfort Miscellaneous 1



Unistik 3 Extra Miscellaneous 1

Unistik 3 Gentle Miscellaneous 1

Unistik 3 Neonatal Miscellaneous 1

Unistik 3 Normal Miscellaneous 1

Unistik CZT Comfort Miscellaneous 1

Unistik CZT Normal Miscellaneous 1

Unistik Safety Lancets 28G Miscellaneous 1

Unistik Safety Lancets 30G Miscellaneous 1

Unistik Touch Safety Lanc 21G Miscellaneous 1




ValuMark Lancet Super Thin 30G Miscellaneous 1

ValuMark Lancet Ultra Thin 28G Miscellaneous 1

ValuMark Pen Needles Miscellaneous 3 Y

Vida Mia Unifine Pentips Miscellaneous 3 Y

Vida Mia Unilet Lancets 28G Miscellaneous 1

Vida Mia Unilet Lancets 30G Miscellaneous 1

V-R Mono Insulin Syringe Miscellaneous 1 Y

W&F Lancets 26G Miscellaneous 1

W&F Lancets Colored 21G Miscellaneous 1

Walgreens Adv Travel Lancets Miscellaneous 1

Wegmans Unifine Pentips Plus Miscellaneous 3 Y

Wide-Seal Diaphragm 60 Vaginal 3








MIGRAINE PRODUCTS

Aimovig Subcutaneous 2 Y

Aimovig (140 MG Dose) Subcutaneous 2 Y

Almotriptan Malate Oral 1 Y

Amerge Oral 3 Y

Axert Oral 3 Y

Cafergot Oral 3



D.H.E. 45 Injection 3

Dihydroergotamine Mesylate Injection 1

Dihydroergotamine Mesylate Nasal 1 Y Y

Eletriptan Hydrobromide Oral 1 Y

Emgality Subcutaneous 2 Y

Emgality (300 MG Dose) Subcutaneous 2 Y

Ergomar Sublingual 3

Ergotamine-Caffeine Oral 1

Frova Oral 3 Y

Frovatriptan Succinate Oral 1 Y

Imitrex Nasal 3 Y

Imitrex Oral 3 Y

Imitrex Subcutaneous 3 Y

Imitrex STATdose Refill Subcutaneous 3 Y

Imitrex STATdose System Subcutaneous 3 Y

Isometheptene-Caffeine-APAP Oral 1

Isometheptene-Dichloral-APAP Oral 1

Maxalt Oral 3 Y

Maxalt-MLT Oral 3 Y

Migergot Rectal 3

Migranal Nasal 2

Naratriptan HCl Oral 1 Y

Nodolor Oral 1

Onzetra Xsail Nasal 3 Y Y

Prodrin Oral 3

Relpax Oral 2 Y

Rizatriptan Benzoate Oral 1 Y

SUMAtriptan Nasal 1 Y

SUMAtriptan Succinate Oral 1 Y

SUMAtriptan Succinate Subcutaneous 1 Y

SUMAtriptan Succinate Refill Subcutaneous 1 Y

Sumavel DosePro Subcutaneous 3 Y Y

Zecuity Transdermal 3 Y

Zembrace SymTouch Subcutaneous 3 Y

ZOLMitriptan Oral 1 Y

Zomig Nasal 3 Y

Zomig Oral 3 Y

Zomig ZMT Oral 3 Y



MINERALS & ELECTROLYTES

Floriva Oral 3

Fluorabon Oral 3

Fluor-a-day Solution Oral 1

Fluor-a-day Chewable Tablet Oral 2

Fluoritab Oral 1

Flura-Drops Oral 1

Galzin Oral 3

Karidium Oral 1

K-Effervescent Oral 1

Klor-Con Oral 1

Klor-Con 10 Oral 1

Klor-Con M10 Oral 1

Klor-Con M15 Oral 3

Klor-Con M20 Oral 1

Klor-Con Sprinkle Oral 1

Klor-Con/EF Oral 1

K-Phos Oral 2

K-Phos-Neutral Oral 3

K-Prime Oral 1

K-Sol Oral 1

K-Tab Oral 3

K-Vescent Oral 1

Lozi-Flur Mouth/Throat 3

Ludent Oral 1

Micro-K Oral 3

NaFrinse Oral 1

NaFrinse Drops Oral 1

Phospha 250 Neutral Oral 1

Phospho-Trin 250 Neutral Oral 1

Potassium Bicarbonate Oral 1

Potassium Chloride Oral 1

Potassium Chloride Crys ER Oral 1

Potassium Chloride ER Oral 1

Sodium Fluoride Oral 1

Virt-Phos 250 Neutral Oral 1

Effer-K 10 MEQ Oral 3





Fluor-a-day Solution Oral 2

MISCELLANEOUS THERAPEUTIC CLASSES

Astagraf XL Oral 3

Azasan Oral 3

azaTHIOprine Oral 1

Benlysta Subcutaneous 3 Y Y Y

CellCept Oral 3

Clovique Oral 1 Y Y

Cuprimine Oral 3 Y Y

cycloSPORINE Oral 1

cycloSPORINE Modified Oral 1

Depen Titratabs Oral 2 Y

D-Penamine Oral 3

Envarsus XR Oral 3

Gengraf Oral 1

Imuran Oral 3

Kionex Oral 1

Lokelma Oral 3

Mycophenolate Mofetil Oral 1

Mycophenolate Sodium Oral 1

Myfortic Oral 3

Neoral Oral 3

penicillAMINE Oral 1 Y

Prograf Oral 3

Rapamune Oral 3

Revlimid Oral 2 Y Y Y

SandIMMUNE Oral 3

Sirolimus Oral 1

Sodium Polystyrene Sulfonate Oral 1

Sodium Polystyrene Sulfonate Rectal 1

SPS Oral 1

Syprine Oral 3 Y Y

Tacrolimus Oral 1

Thalomid Oral 2 Y Y Y

Trientine HCl Oral 1 Y Y

Veltassa Oral 3

Zortress Oral 3 Y Y Y



MOUTH/THROAT/DENTAL AGENTS

Cevimeline HCl Oral 1

Chlorhexidine Gluconate Mouth/Throat 1

Clotrimazole Mouth/Throat 1

Evoxac Oral 3

Lidocaine HCl Mouth/Throat 1

Lidocaine Viscous HCl Mouth/Throat 1

Nystatin Mouth/Throat 1

Oralone Mouth/Throat 1

Paroex Mouth/Throat 1

Peridex Mouth/Throat 3

Pilocarpine HCl Oral 1

Salagen Oral 3

Triamcinolone Acetonide Mouth/Throat 1

MULTIVITAMINS

Floriva Oral 3

Multi Vitamin/Fluoride Oral 1

Multi-Vit/Fluoride Oral 1

Multi-Vit/Fluoride/Iron Oral 1

Multi-Vit/Iron/Fluoride Oral 1

Multivitamin/Fluoride Oral 1

Multi-Vitamin/Fluoride Oral 1

Multivitamin/Fluoride/Iron Oral 1

Multi-Vitamin/Fluoride/Iron Oral 1

Multivitamins/Fluoride Oral 1

MVC-Fluoride Oral 1

Nicomide Oral 3

Poly-Vi-Flor Oral 3

Prenate DHA Oral 3

Prenate Elite Oral 3

Prenate Essential Oral 3

Prenate Mini Oral 3

Strovite Forte Oral 3

Multivitamin/Fluoride Solution Oral 1

Multivitamin/Fluoride Chewable Tablet Oral 3

Multivitamin/Fluoride Solution Oral 1

MUSCULOSKELETAL THERAPY AGENTS

Baclofen Oral 1 Y



Carisoprodol Oral 1

Carisoprodol-Aspirin Oral 1

Carisoprodol-Aspirin-Codeine Oral 1

Chlorzoxazone Oral 1 Y

Cyclo/Gaba 10/300 Oral 3

Cyclobenzaprine HCl Oral 1

Dantrium Oral 3

Dantrolene Sodium Oral 1

Fexmid Oral 3

Metaxall Oral 1

Metaxalone Oral 1

Methocarbamol Oral 1

Orphenadrine Citrate ER Oral 1

Parafon Forte DSC Oral 3

Robaxin Oral 3

Robaxin-750 Oral 3

Skelaxin Oral 3

Soma Oral 3

Tabradol FusePaq Oral 3

Tabradol RapidPaq Oral 3

Zanaflex Oral 3 Y

tiZANidine HCl Tablet Oral 1 Y

tiZANidine HCl Capsule Oral 1 Y

NASAL AGENTS - SYSTEMIC AND TOPICAL

Astepro Nasal 3

Azelastine HCl Nasal 1

Bactroban Nasal Nasal 2

Beconase AQ Nasal 3

Budesonide Nasal 1

Dymista Nasal 3

GNP Budesonide Nasal Spray Nasal 1

Goprelto Nasal 3

Ipratropium Bromide Nasal 1

Nasonex Nasal 2

Olopatadine HCl Nasal 1

Omnaris Nasal 3

Patanase Nasal 3

Qnasl Nasal 3



Qnasl Childrens Nasal 3

Triamcinolone Acetonide Nasal 1

Zetonna Nasal 3

NEUROMUSCULAR AGENTS

Rilutek Oral 3 Y Y

Riluzole Oral 1 Y Y

Tiglutik Oral 3 Y Y

OPHTHALMIC AGENTS

Acular Ophthalmic 3

Acular LS Ophthalmic 3

Acuvail Ophthalmic 3

AK-Poly-Bac Ophthalmic 1

Akten Ophthalmic 3

Alocril Ophthalmic 3

Alomide Ophthalmic 3

Alphagan P Ophthalmic 2

Alrex Ophthalmic 2

Altacaine Ophthalmic 1

Altafrin Ophthalmic 1

Apraclonidine HCl Ophthalmic 1

Atropine Sulfate Ophthalmic 1

Atropine Sulfate-NaCl Ophthalmic 1

AzaSite Ophthalmic 3

Azelastine HCl Ophthalmic 1

Azopt Ophthalmic 2

Bacitracin Ophthalmic 1

Bacitracin-Polymyxin B Ophthalmic 1

Bacitra-Neomycin-Polymyxin-HC Ophthalmic 1

Bepreve Ophthalmic 3

Besivance Ophthalmic 3

Betadine Ophthalmic Prep Ophthalmic 3

Betagan Ophthalmic 3

Betaxolol HCl Ophthalmic 1

Betoptic-S Ophthalmic 3

Bimatoprost Ophthalmic 1

Bleph-10 Ophthalmic 3

Blephamide Ophthalmic 3

Blephamide S.O.P. Ophthalmic 3



Brimonidine Tartrate Ophthalmic 1

Brimonidine-Dorzolamide Ophthalmic 1

Bromfenac Sodium Ophthalmic 1

Bromfenac Sodium (Once-Daily) Ophthalmic 1

BromSite Ophthalmic 3

Carteolol HCl Ophthalmic 1

Ciloxan Ophthalmic 2

Ciprofloxacin HCl Ophthalmic 1

Combigan Ophthalmic 3

Cosopt Ophthalmic 3

Cosopt PF Ophthalmic 3

Cromolyn Sodium Ophthalmic 1

Cyclogyl Ophthalmic 3

Cyclomydril Ophthalmic 3

Cyclopentolate HCl Ophthalmic 1

cycloSPORINE in Klarity Ophthalmic 3

Cystaran Ophthalmic 3 Y Y Y

Dexamethasone Sodium Phosphate Ophthalmic 1

Dexamethasone-Moxifloxacin Intraocular 1

Dexameth-Moxiflox-Ketorolac Intraocular 1

Diclofenac Sodium Ophthalmic 1

Dorzolamide HCl Ophthalmic 1

Dorzolamide HCl-Timolol Mal Ophthalmic 1

Dorzolamide HCl-Timolol Mal PF Ophthalmic 1

Double PM Ophthalmic 3

Durezol Ophthalmic 3

Elestat Ophthalmic 3

Emadine Ophthalmic 3

Epinastine HCl Ophthalmic 1

Erythromycin Ophthalmic 1

Flarex Ophthalmic 3

Fluorometholone Ophthalmic 1

Flurbiprofen Sodium Ophthalmic 1

FML Ophthalmic 3

FML Forte Ophthalmic 3

FML Liquifilm Ophthalmic 3

Gatifloxacin Ophthalmic 1

Gentak Ophthalmic 1



Gentamicin Sulfate Ophthalmic 1

Homatropaire Ophthalmic 1

Homatropine HBr Ophthalmic 1

Ilevro Ophthalmic 3

Ilotycin Ophthalmic 1

Inveltys Ophthalmic 3

Iopidine Ophthalmic 3

Isopto Atropine Ophthalmic 2

Isopto Carpine Ophthalmic 3

Istalol Ophthalmic 3

Ketorolac Tromethamine Ophthalmic 1

Klarity-A Ophthalmic 3

Lacrisert Ophthalmic 3

Lastacaft Ophthalmic 3

Latanoprost Ophthalmic 1

Latanoprost-Timolol Maleate Ophthalmic 1

Levobunolol HCl Ophthalmic 1

levoFLOXacin Ophthalmic 1

Lotemax Ophthalmic 2

Lotemax SM Ophthalmic 3

Loteprednol Etabonate Ophthalmic 1

Lumigan Ophthalmic 2

Maxidex Ophthalmic 3

Maxitrol Ophthalmic 3

Metipranolol Ophthalmic 1

Miochol-E Intraocular 3

Miostat Intraocular 3

Moxeza Ophthalmic 3

Moxifloxacin HCl Ophthalmic 1

Mydriacyl Ophthalmic 3

Natacyn Ophthalmic 2

Neomycin-Bacitracin Zn-Polymyx Ophthalmic 1

Neomycin-Polymyxin-Dexameth Ophthalmic 1

Neomycin-Polymyxin-Gramicidin Ophthalmic 1

Neomycin-Polymyxin-HC Ophthalmic 1

Neo-Polycin Ophthalmic 1

Neo-Polycin HC Ophthalmic 1

Neosporin Ophthalmic 3



Nevanac Ophthalmic 3

Ocufen Ophthalmic 3

Ocuflox Ophthalmic 3

Ofloxacin Ophthalmic 1

Olopatadine HCl Ophthalmic 1

Omnipred Ophthalmic 3

Oxervate Ophthalmic 3 Y Y

Pataday Ophthalmic 2

Patanol Ophthalmic 3

Pazeo Ophthalmic 2

Phenylephrine HCl Ophthalmic 1

Phospholine Iodide Ophthalmic 3

Pilocarpine HCl Ophthalmic 1

Polycin Ophthalmic 1

Polymyxin B-Trimethoprim Ophthalmic 1

Polytrim Ophthalmic 3

Povidone-Iodine Ophthalmic 3

Pred Forte Ophthalmic 3

Pred Mild Ophthalmic 3

Pred-G Ophthalmic 3

Pred-G S.O.P. Ophthalmic 3

prednisoLONE Acetate Ophthalmic 1

prednisoLONE Acetate P-F Ophthalmic 3

prednisoLONE Sodium Phosphate Ophthalmic 1

prednisoLONE-Bromfenac Ophthalmic 1

prednisoLONE-Gatifloxacin Ophthalmic 1

prednisoLONE-Moxifloxacin Ophthalmic 1

Prednisolon-Gatiflox-Bromfenac Ophthalmic 1

Prednisolon-Moxiflox-Bromfenac Ophthalmic 1

Prolensa Ophthalmic 3

Proparacaine HCl Ophthalmic 1

Rescula Ophthalmic 3

Restasis Ophthalmic 3

Restasis MultiDose Ophthalmic 3

Rhopressa Ophthalmic 3

Simbrinza Ophthalmic 2

Sulfacetamide Sodium Ophthalmic 1

Sulfacetamide-prednisoLONE Ophthalmic 1



Tetcaine Ophthalmic 1

Tetracaine HCl Ophthalmic 1

TetraVisc Ophthalmic 1

TetraVisc Forte Ophthalmic 1

Timolol Maleate Ophthalmic 1

Timolol-Brimon-Dorzol-Latanopr Ophthalmic 1

Timolol-Brimonidine-Dorzolamid Ophthalmic 1

Timolol-Dorzolamid-Latanoprost Ophthalmic 1

Timoptic Ophthalmic 3

Timoptic Ocudose Ophthalmic 3

Timoptic-XE Ophthalmic 3

TobraDex Ophthalmic 3

TobraDex ST Ophthalmic 3

Tobramycin Ophthalmic 1 Y

Tobramycin-Dexamethasone Ophthalmic 1

Travatan Z Ophthalmic 2

Triamcinolone-Moxifloxacin Intraocular 1

Triesence Intraocular 3

Trifluridine Ophthalmic 1

Triple PMB Ophthalmic 3

Triple PMK Ophthalmic 3

Tropicamide Ophthalmic 1

Tropicamide-Cyclopentolate-PE Ophthalmic 1

Tropic-Proparaca-PE-Ketorolac Ophthalmic 1

Trusopt Ophthalmic 3

Vigamox Ophthalmic 2

Viroptic Ophthalmic 3

Vyzulta Ophthalmic 3

Xalatan Ophthalmic 3

Xelpros Ophthalmic 3

Xiidra Ophthalmic 3

Zioptan Ophthalmic 3

Zirgan Ophthalmic 3

Zylet Ophthalmic 2

Zymaxid Ophthalmic 3

Tobrex Solution Ophthalmic 3

Tobrex Ointment Ophthalmic 2

OTIC AGENTS



Acetasol HC Otic 1

Cetraxal Otic 3

Cipro HC Otic 2

Ciprodex Otic 2

Ciprofloxacin HCl Otic 1

Coly-Mycin S Otic 3

Cortane-B Otic 3

Cortane-B Aqueous Otic 3

Cortic-ND Otic 1

Cyotic Otic 1

DermOtic Otic 3

Exotic-HC Otic 1

Flac Otic 3

Floxin Otic Otic 3

Fluocinolone Acetonide Otic 1

Hydrocortisone-Acetic Acid Otic 1

Neomycin-Polymyxin-HC Otic 1

Ofloxacin Otic 1

Oticin HC NR Otic 3

Otomax-HC Otic 1

Otovel Otic 3

PramOtic Otic 3

OXYTOCICS

Methergine Oral 2

Methylergonovine Maleate Oral 1

PASSIVE IMMUNIZING AND TREATMENT AGENTS

Bivigam Intravenous 3 Y Y

Carimune NF Intravenous 3 Y Y

Cuvitru Subcutaneous 3 Y Y

Flebogamma DIF Intravenous 3 Y Y

GamaSTAN Intramuscular 3 Y Y

GamaSTAN S/D Intramuscular 3 Y Y

Gammagard Injection 3 Y Y

Gammagard S/D Less IgA Intravenous 3 Y Y

Gammaked Injection 3 Y Y

Gammaplex Intravenous 3 Y Y

Gamunex-C Injection 3 Y Y

Hizentra Subcutaneous 3 Y Y



Hyqvia Subcutaneous 3 Y Y

Octagam Intravenous 3 Y Y

Privigen Intravenous 3 Y Y

Synagis Intramuscular 2 Y Y

PENICILLINS

Amoxicillin Oral 1

Amoxicillin Trihydrate Miscillaneous 1

Amoxicillin-Pot Clavulanate Oral 1

Amoxicillin-Pot Clavulanate ER Oral 1

Ampicillin Oral 1

Augmentin Oral 3

Augmentin ES-600 Oral 3

Augmentin XR Oral 3

Dicloxacillin Sodium Oral 1

Penicillin V Potassium Oral 1

PHARMACEUTICAL ADJUVANTS

1st Base External 3

ADA External 3

Advanced Base Plus External 3

Alba-Derm External 3

Alcohol Base Gel Miscillaneous 3

AlpaWash External 3

Altaderm External 3

Anhydrous Base Miscillaneous 3

Anhydrous Cream Base Miscillaneous 3

Apothederm External 3

Apothesar External 3

Apothesar 2 External 3

Apothesar Plus External 3

Apothesil External 3

ATREVIS HYDROGEL External 3

Auxipro Vanishing External 3

Base W301 External 3

Blended Suspending Compound Oral 3

BraVura All-In-One External 3

Capsule Coni-Snap #1 Pink Miscillaneous 3

Capsule 0 Clear DR Miscillaneous 3

Capsule 0 Clear Veggie Miscillaneous 3





Capsule Coni-Snap #0 Blu/White Miscillaneous 3

Capsule Coni-Snap #0 Clear Miscillaneous 3

Capsule Coni-Snap #0 Dark Blue Miscillaneous 3

Capsule Coni-Snap #0 Green/Clr Miscillaneous 3

Capsule Coni-Snap #0 Pink Miscillaneous 3

Capsule Coni-Snap #0 Purple Miscillaneous 3

Capsule Coni-Snap #0 Red/White Miscillaneous 3

Capsule Coni-Snap #0 White Miscillaneous 3




Capsule Coni-Snap #1 Aqua Blue Miscillaneous 3

Capsule Coni-Snap #1 Blue Miscillaneous 3

Capsule Coni-Snap #1 Blue/Pink Miscillaneous 3

Capsule Coni-Snap #1 Blue/Wht Miscillaneous 3

Capsule Coni-Snap #1 Brown Miscillaneous 3

Capsule Coni-Snap #1 Brwn/Ivry Miscillaneous 3


Capsule Coni-Snap #1 Dk Grn/Or Miscillaneous 3

Capsule Coni-Snap #1 Drk Green Miscillaneous 3

Capsule Coni-Snap #1 Grey/Pink Miscillaneous 3

Capsule Coni-Snap #1 Grn/Ylw Miscillaneous 3

Capsule Coni-Snap #1 Orange Miscillaneous 3

Capsule Coni-Snap #1 Pink/Blue Miscillaneous 3

Capsule Coni-Snap #1 Pink/Clr Miscillaneous 3

Capsule Coni-Snap #1 Pink/Whit Miscillaneous 3

Capsule Coni-Snap #1 Pink/Yllw Miscillaneous 3

Capsule Coni-Snap #1 Purple Miscillaneous 3

Capsule Coni-Snap #1 Red/Blue Miscillaneous 3

Capsule Coni-Snap #1 Red/White Miscillaneous 3

Capsule Coni-Snap #1 Veggie Miscillaneous 3


Capsule Coni-Snap #1 White/Grn Miscillaneous 3

Capsule Coni-Snap #1 Wht/Clr Miscillaneous 3

Capsule Coni-Snap #1 Yellow Miscillaneous 3

Capsule Coni-Snap #1 Yellow/Gr Miscillaneous 3





Capsule Coni-Snap #3 Blu/Clear Miscillaneous 3

Capsule Coni-Snap #3 Brn/Blue Miscillaneous 3


Capsule Coni-Snap #3 Gray/Ylw Miscillaneous 3

Capsule Coni-Snap #3 Green/Blu Miscillaneous 3

Capsule Coni-Snap #3 Grey/Pink Miscillaneous 3

Capsule Coni-Snap #3 Maron/Blu Miscillaneous 3

Capsule Coni-Snap #3 Mint Grn Miscillaneous 3

Capsule Coni-Snap #3 Olive/Clr Miscillaneous 3

Capsule Coni-Snap #3 Orange Miscillaneous 3

Capsule Coni-Snap #3 Pink/Pink Miscillaneous 3

Capsule Coni-Snap #3 Pnk/Clear Miscillaneous 3

Capsule Coni-Snap #3 Red/Clear Miscillaneous 3

Capsule Coni-Snap #3 Red/Red Miscillaneous 3


Capsule Coni-Snap #3 Wht/Clr Miscillaneous 3

Capsule Coni-Snap #3 Yellow Miscillaneous 3

Capsule Coni-Snap #4 Black/Grn Miscillaneous 3



Carbogel 940 Miscillaneous 3

Carbohol 940 Miscillaneous 3

Carbomer Aqueous Miscillaneous 3

Carbomer Hydroalcoholic Miscillaneous 3

Cela Base External 3

Cherry Oral 3

Chrysaderm Day External 3

Chrysaderm Night External 3

Collodion Flexible External 3

Corn (Syrup) Oral 3

Cream Base External 3

Cream Base Liposomic External 3

Cream Base with Liposome External 3

Cream Concentrate External 3

Cutis Plus External 3

CVS Petroleum Jelly External 3



Delivra External 3

DermacinRx Topical Base External 3

DRcaps Size 0 Miscillaneous 3



Durabase External 3

Durabase Advanced External 3

Emolivan External 3

Emollient Base External 3

Empty Capsule Size 0 Clear Miscillaneous 3

Empty Capsule Size 0 Pink Miscillaneous 3

Empty Capsule Size 0 Purp/Wht Miscillaneous 3

Empty Capsule Size 0 Purple Miscillaneous 3

Empty Capsule Size 0 White Miscillaneous 3

Empty Capsule Size 0 White/Clr Miscillaneous 3

Empty Capsule Size 0 White/Opa Miscillaneous 3

Empty Capsule Size 00 Blue Opq Miscillaneous 3



Empty Capsule Size 1 Brn/Ivory Miscillaneous 3


Empty Capsule Size 1 Drk Green Miscillaneous 3

Empty Capsule Size 1 Grey/Pink Miscillaneous 3

Empty Capsule Size 1 Grn/Ornge Miscillaneous 3

Empty Capsule Size 1 Grn/White Miscillaneous 3

Empty Capsule Size 1 Grn/Yllw Miscillaneous 3

Empty Capsule Size 1 Ivory Miscillaneous 3

Empty Capsule Size 1 Maroon/Cl Miscillaneous 3

Empty Capsule Size 1 Mint Grn Miscillaneous 3

Empty Capsule Size 1 Orange Miscillaneous 3

Empty Capsule Size 1 Orge/Clr Miscillaneous 3

Empty Capsule Size 1 Orge/Yllw Miscillaneous 3

Empty Capsule Size 1 Ornge/Grn Miscillaneous 3


Empty Capsule Size 1 Pink/Clr Miscillaneous 3

Empty Capsule Size 1 Pink/Yllw Miscillaneous 3

Empty Capsule Size 1 Pnk/White Miscillaneous 3

Empty Capsule Size 1 Pwdr Blue Miscillaneous 3



Empty Capsule Size 1 Red Miscillaneous 3

Empty Capsule Size 1 Red/Blue Miscillaneous 3

Empty Capsule Size 1 Red/White Miscillaneous 3

Empty Capsule Size 1 Veg Clear Miscillaneous 3



Empty Capsule Size 1 Wht/Clear Miscillaneous 3

Empty Capsule Size 1 Yellow Miscillaneous 3



Empty Capsule Size 3 Black/Grn Miscillaneous 3

Empty Capsule Size 3 Blue Opq Miscillaneous 3

Empty Capsule Size 3 Blue/Clr Miscillaneous 3

Empty Capsule Size 3 Blue/Marn Miscillaneous 3

Empty Capsule Size 3 Blue/Wht Miscillaneous 3


Empty Capsule Size 3 Dark Grn Miscillaneous 3

Empty Capsule Size 3 Dark Orng Miscillaneous 3

Empty Capsule Size 3 Grey/Pink Miscillaneous 3

Empty Capsule Size 3 Grey/Yllw Miscillaneous 3

Empty Capsule Size 3 Grn/Blue Miscillaneous 3

Empty Capsule Size 3 Marn/Blue Miscillaneous 3

Empty Capsule Size 3 Marn/Clr Miscillaneous 3

Empty Capsule Size 3 Mint Grn Miscillaneous 3

Empty Capsule Size 3 Olive/Clr Miscillaneous 3

Empty Capsule Size 3 Orange Miscillaneous 3

Empty Capsule Size 3 Orange/Wh Miscillaneous 3


Empty Capsule Size 3 Pink/Blue Miscillaneous 3

Empty Capsule Size 3 Pink/Wh Miscillaneous 3

Empty Capsule Size 3 Pink/Yllw Miscillaneous 3

Empty Capsule Size 3 Pnk/Clear Miscillaneous 3

Empty Capsule Size 3 Prple/Clr Miscillaneous 3


Empty Capsule Size 3 Pwdr Blue Miscillaneous 3

Empty Capsule Size 3 Red Miscillaneous 3

Empty Capsule Size 3 Red/Clear Miscillaneous 3








Empty Capsule Size 3 Yellw/Clr Miscillaneous 3









Espumil Miscillaneous 3

Exquisite HRT Miscillaneous 3

Fagron LS Plus External 3

Fagron Natural External 3

Fagron Supreme External 3

Fitalite External 3

Freedom AdaptaDerm External 3

Freedom Derma Serum External 3

Freedom Derma-D External 3

Freedom Derma-N External 3

GRX White Petrolatum External 3

HRT Botanical Miscillaneous 3

HRT Cream Miscillaneous 3

HRT Cream Base Miscillaneous 3

HRT Heavy Miscillaneous 3

Hydrogel Miscillaneous 3

Krisgel 100 External 3

Lanolin Miscillaneous 3

Lanolin External 1

Lanolin Anhydrous External 3

Lecithin Organogel External 3

Liopen Absorption Enhancing External 3

Lipo Cream Base External 3

Lipofoam RX Miscillaneous 3

Lipopen Ultra Base External 3



Liposomal Heavy External 3

Liposomal Regular External 3

Lipozyme External 3

Lozibase S Miscillaneous 3

Mediderm External 3

Medihol Base Miscillaneous 3

Mouth Wash-GP Oral 3

Mouthwash-AF Oral 3

Mouthwash-OM Oral 3

MultiBase External 3

Nourilite External 3

Nourivan Antiox Base External 3

Noxi-K External 3

Occluvan External 3

Omnibase External 3

Ora-Blend Oral 3

Ora-Blend SF Oral 3

Oral Mix Dry Alka SF Oral 3

Oral Mix Dry Alka/Cherry Oral 3

Oral Suspending Compound Plus Oral 3

Ora-Plus Oral 3

Ora-Sweet Oral 3

Ora-Sweet SF Oral 3

PCCA Acacia Syrup Base Oral 3

PCCA Aladerm Base External 3

PCCA Anhydrous Base Miscillaneous 3

PCCA Anhydrous Lipoderm Base External 3

PCCA Biopeptide Base External 3

PCCA CoBase #1 External 3

PCCA Cosmetic HRT Base External 3

PCCA Custom Lipo-Max External 3

PCCA Custom Troche Base Miscillaneous 3

PCCA Lipoderm Base External 3

PCCA Liposomic Base Dry External 3

PCCA Liposomic Base Normal External 3

PCCA Liposomic Base Oily External 3

PCCA Liposomic Base Sensitive External 3

PCCA MVC Base External 3



PCCA NataCream External 3

PCCA Natatroche Base Miscillaneous 3

PCCA Perme8 Anhydrous Miscillaneous 3

PCCA Polypeg Base External 3

PCCA Pracasil TM-Plus Base External 3

PCCA Sweet-SF Oral 3

PCCA Syrup Vehicle Oral 3

PCCA Vanishing Cream Base External 3

PCCA Vanishing Cream Light External 3

PCCA Vanpen Base External 3

PCCA W06 Anhydrous Topical Miscillaneous 3

PCCA-Plus Oral 3

PEG Ointment Base External 3

PEG Troche Base Miscillaneous 3

PENcream External 3

PenDerm External 3

PenSomal External 3

Pentaphene Base External 3

Performax Salt Supportive Base External 3

Petrolatum External 3

Petrolatum White External 3

Pharmabase Heavy External 3

PhytoBase External 3

Placebo #00 Oral 3

PLO Gel - Mediflo External 3

PLO Gel - Mediflo Pre-Mixed External 3

PLO Transdermal External 3

PLO20 Base External 3

PLO20 Flowable External 3

Polyethylene Glycol 300 Miscillaneous 3

Polyethylene Glycol 8000 External 3

P-Siloxan DS External 3

Purified Water Oral 3

Raspberry Syrup Oral 3

Rejuvacare Plus External 3

Rheospray External 3

SA3 Derm External 3

Salt Durable Cream External 3



Salt Stable LS Advanced External 3

Saltstable LO External 3

Sedanare External 3

Seraqua External 3

Silosome Transdermal External 3

Silprotex Plus External 3

Simple Syrup Oral 3

Skyy Derm External 3

Solvatech Plus Oral 3

Solvatech Sweet SF Oral 3

Solydra External 3

Stera Base External 3

Suspension Vehicle Oral 3

Sweetening Suspending Compound Oral 3

Syrpalta Oral 3

Syrpalta (Red) Oral 3

SyrSpend SF Oral 3

SyrSpend SF PH4 Oral 3

Syrup Vehicle Oral 3

Syrup Vehicle SF Oral 3

TDC Max External 3

TDM Solution External 3

Techna 20 SF Troche Base Miscillaneous 3

TeroDerm External 3

TeroDerm-Plus External 3

Tightening Base External 3

Transdermal Pain Base External 3

Ultraderm External 3

U-Mild External 3

Universal Water Miscillaneous 3

Vanishing External 3

Vanishing Cream Botanical Base External 3

Vanish-Pen External 3

Vegetable Capsule #0 Green Miscillaneous 3

Vegetable Capsule #0 White Miscillaneous 3








VersaFree Oral 3

VersaPlus Oral 3

VersaPro External 3

Versatile Cream Base External 3

Versatile Rich Base External 3

VitaTroche Plus Base SF Miscillaneous 3

Water Base Gel Miscillaneous 3

White Petrolatum External 3

Xematop Base External 3

Yellow Petrolatum External 3

Zoe Scripts IdealBase External 3

PROGESTINS

Aygestin Oral 3

medroxyPROGESTERone Acetate Oral 1

Megace ES Oral 3

Megestrol Acetate Oral 1

Norethindrone Acetate Oral 1

Progesterone Intramuscular 1

Progesterone Micronized Oral 1

Progesterone Micronized Transdermal 1

Prometrium Oral 3

Provera Oral 3

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.

Acamprosate Calcium Oral 1

Ampyra Oral 3 Y Y Y

Antabuse Oral 3

Aricept Oral 3

Aubagio Oral 2 Y Y Y

Austedo Oral 3 Y Y

Avonex Intramuscular 2 Y Y Y

Avonex Pen Intramuscular 2 Y Y Y

Avonex Prefilled Intramuscular 2 Y Y Y

Betaseron Subcutaneous 2 Y Y Y

Buproban Oral 1

buPROPion HCl ER (Smoking Det) Oral 1

Chantix Oral 2



Chantix Continuing Month Pak Oral 2

Chantix Starting Month Pak Oral 2

chlordiazePOXIDE-Amitriptyline Oral 1

Copaxone Subcutaneous 2 Y Y Y

CVS Nicotine Mouth/Throat 1

CVS Nicotine Transdermal 1

CVS Nicotine Polacrilex Mouth/Throat 1

CVS NTS Step 1 Transdermal 1

Disulfiram Oral 1

Donepezil HCl Oral 1

EQ Nicotine Mouth/Throat 1

EQ Nicotine Transdermal 1

EQ Nicotine Polacrilex Mouth/Throat 1

EQ Nicotine Step 3 Transdermal 1

EQL Nicotine Mouth/Throat 1

EQL Nicotine Transdermal 1

EQL Nicotine Polacrilex Mouth/Throat 1

Ergoloid Mesylates Oral 1

Exelon Transdermal 3

Extavia Subcutaneous 3 Y Y Y

FLUoxetine HCl (PMDD) Oral 1

Galantamine Hydrobromide Oral 1

Galantamine Hydrobromide ER Oral 1

Gilenya Oral 2 Y Y Y

Glatiramer Acetate Subcutaneous 1 Y Y

GNP Nicotine Transdermal 1

GNP Nicotine Mini Mouth/Throat 1

GNP Nicotine Polacrilex Mouth/Throat 1

GoodSense Nicotine Mouth/Throat 1

HM Nicotine Transdermal 1

HM Nicotine Polacrilex Mouth/Throat 1

Ingrezza Oral 3 Y Y

KLS Quit2 Mouth/Throat 1

KLS Quit4 Mouth/Throat 1

Lyrica CR Oral 3 Y

Memantine HCl Oral 1

Memantine HCl ER Oral 1

Namenda Oral 3



Namenda Titration Pak Oral 3

Namenda XR Oral 3

Namenda XR Titration Pack Oral 3

Namzaric Oral 3

Nicoderm CQ Transdermal 3

Nicorelief Mouth/Throat 1

Nicorette Mouth/Throat 3

Nicorette Mini Mouth/Throat 3

Nicorette Starter Kit Mouth/Throat 3

Nicotine Transdermal 1

Nicotine Mini Mouth/Throat 1

Nicotine Polacrilex Mouth/Throat 1

Nicotine Step 1 Transdermal 1



Nicotrol Inhalation 2

Nicotrol NS Nasal 2

Nuedexta Oral 2 Y

OLANZapine-FLUoxetine HCl Oral 1

Orap Oral 3

Perphenazine-Amitriptyline Oral 1

Pimozide Oral 1

Plegridy Subcutaneous 2 Y Y

Plegridy Starter Pack Subcutaneous 2 Y Y

PX Stop Smoking Aid Mouth/Throat 1

QC Nicotine Polacrilex Mouth/Throat 1

RA Mini Nicotine Mouth/Throat 1

RA Nicotine Mouth/Throat 1

RA Nicotine Transdermal 1

RA Nicotine Gum Mouth/Throat 1

RA Nicotine Polacrilex Mouth/Throat 1

Razadyne Oral 3

Razadyne ER Oral 3

Rebif Subcutaneous 2 Y Y Y

Rebif Rebidose Subcutaneous 2 Y Y Y

Rebif Rebidose Titration Pack Subcutaneous 2 Y Y Y

Rebif Titration Pack Subcutaneous 2 Y Y Y

Rivastigmine Transdermal 1



Rivastigmine Tartrate Oral 1

Sarafem Oral 3

Savella Oral 3

Savella Titration Pack Oral 3

SM Nicotine Mouth/Throat 1

SM Nicotine Transdermal 1

SM Nicotine Polacrilex Mouth/Throat 1

SR Nicotine Mouth/Throat 1

SW Nicotine Polacrilex Mouth/Throat 1

Symbyax Oral 3

Tecfidera Oral 2 Y Y Y

Tetrabenazine Oral 1 Y Y

TGT Nicotine Mouth/Throat 1

TGT Nicotine Polacrilex Mouth/Throat 1

TGT Nicotine Step One Transdermal 1

TGT Nicotine Step Three Transdermal 1

TGT Nicotine Step Two Transdermal 1

Thrive Mouth/Throat 1

Xenazine Oral 3 Y Y Y

Zinbryta Subcutaneous 3 Y Y

Zyban Oral 3

RESPIRATORY AGENTS - MISC.

Aralast NP Intravenous 3 Y Y

Esbriet Oral 3 Y Y Y

Glassia Intravenous 3 Y Y

Kalydeco Oral 2 Y Y Y Y

Ofev Oral 3 Y Y Y

Orkambi Oral 3 Y Y Y Y

Prolastin-C Intravenous 3 Y Y

Pulmozyme Inhalation 2 Y Y Y

Symdeko Oral 3 Y Y Y Y

Trikafta Oral 2 Y Y Y

Zemaira Intravenous 3 Y Y

SULFONAMIDES

sulfADIAZINE Oral 1

TETRACYCLINES

Avidoxy Oral 1

CoreMino Oral 1



Demeclocycline HCl Oral 1

Doryx Oral 3

Doxycycline Hyclate Oral 1

Doxycycline Monohydrate Oral 1

Minocin Oral 3

Minocycline HCl Oral 1

Minocycline HCl ER Oral 1

Mondoxyne NL Oral 1

Monodox Oral 3

Morgidox Oral 1

Okebo Oral 1

Tetracycline HCl Oral 1

Vibramycin Oral 3

Ximino Oral 3

THYROID AGENTS

Armour Thyroid Oral 3

Cytomel Oral 3

Euthyrox Oral 1

Levo-T Oral 1

Levothyroxine Sodium Oral 1

Levoxyl Oral 1

Liothyronine Sodium Oral 1

methIMAzole Oral 1

Nature-Throid Oral 3

NP Thyroid Oral 1

Propylthiouracil Oral 1

Synthroid Oral 3

Tapazole Oral 3

Thyroid Oral 1

Thyrolar-1 Oral 3

Thyrolar-1/2 Oral 3

Thyrolar-1/4 Oral 3

Thyrolar-2 Oral 3

Thyrolar-3 Oral 3

Tirosint Oral 3

Tirosint-SOL Oral 3

Unithroid Oral 1

Unithroid Direct Oral 1



Westhroid Oral 3

WP Thyroid Oral 3

TOXOIDS

Adacel Intramuscular 3

Boostrix Intramuscular 3

TDVAX Intramuscular 3

Tenivac Intramuscular 3

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS

Aciphex Oral 3

AcipHex Sprinkle Oral 3

Anaspaz Oral 3

Bentyl Intramuscular 3

Bentyl Oral 3

Carafate Oral 2

chlordiazePOXIDE-Clidinium Oral 1

Cimetidine Oral 1

Cimetidine HCl Oral 1

Cuvposa Oral 3 Y

Cytotec Oral 3

Dicyclomine HCl Oral 1

Donnatal Oral 3

Ed-Spaz Oral 1

Esomeprazole Magnesium Oral 1

Famotidine Oral 1

Glycopyrrolate Oral 1

Hyoscyamine Sulfate Injection 1

Hyoscyamine Sulfate Oral 1

Hyoscyamine Sulfate Sublingual 1

Hyoscyamine Sulfate ER Oral 1

Hyoscyamine Sulfate SL Sublingual 1

Hyosyne Oral 1

Lansoprazole Oral 1

Levbid Oral 3

Levsin Injection 3

Levsin Oral 3

Levsin/SL Sublingual 3

Librax Oral 3

Methscopolamine Bromide Oral 1



miSOPROStol Oral 1

Nizatidine Oral 1

NuLev Oral 1

Omeprazole Oral 1

Omeprazole+Syrspend SF Alka Oral 3

Omeprazole-Sodium Bicarbonate Oral 1

Oscimin Oral 1

Oscimin Sublingual 1

Oscimin SR Oral 1

Pamine Oral 3

Pamine Forte Oral 3

Pantoprazole Sodium Oral 1

PB-Hyoscy-Atropine-Scopolamine Oral 1

Pepcid Oral 3

PHENobarbital-Belladonna Alk Oral 1

Phenohytro Oral 1

PriLOSEC Oral 3

Propantheline Bromide Oral 1

Protonix Oral 3

Pylera Oral 3

RABEprazole Sodium Oral 1

raNITIdine 150 Max Strength Oral 1

raNITIdine HCl Oral 1

Robinul Oral 3

Robinul-Forte Oral 3

Sucralfate Oral 1

Symax Duotab Oral 3

Symax-SL Sublingual 1

Symax-SR Oral 1

Zantac Oral 3

Zegerid Oral 3

URINARY ANTI-INFECTIVES

Azuphen MB Oral 1

Furadantin Oral 3

Hiprex Oral 3

Hyolev MB Oral 1

Hyophen Oral 3

Indiomin MB Oral 1



Macrobid Oral 3

Macrodantin Oral 3

ME/NaPhos/MB/Hyo1 Oral 1

Methenamine Hippurate Oral 1

Methenamine Mandelate Oral 1

Monurol Oral 3

Nitrofurantoin Oral 1

Nitrofurantoin Macrocrystal Oral 1

Nitrofurantoin Monohyd Macro Oral 1

Phosphasal Oral 1

Ur N-C Oral 1

Uramit MB Oral 1

Urelle Oral 1

Uretron D/S Oral 1

Uribel Oral 1

Urimar-T Oral 3

Urin DS Oral 1

Uro-458 Oral 1

Urogesic-Blue Oral 3

Uro-MP Oral 1

Urophen MB Oral 1

Uryl Oral 1

Ustell Oral 1

UTA Oral 3

Uticap Oral 1

Utira-C Oral 1

Utrona-C Oral 1

Vilamit MB Oral 1

Vilevev MB Oral 1

URINARY ANTISPASMODICS

Bethanechol Chloride Oral 1

Darifenacin Hydrobromide ER Oral 1

Detrol Oral 3

Detrol LA Oral 3

Ditropan XL Oral 3

Enablex Oral 3

flavoxATE HCl Oral 1

Gelnique Transdermal 3



Gelnique Pump Transdermal 3

Myrbetriq Oral 3

Oxybutynin Chloride Oral 1

Oxybutynin Chloride ER Oral 1

Solifenacin Succinate Oral 1

Tolterodine Tartrate Oral 1

Tolterodine Tartrate ER Oral 1

Toviaz Oral 3

Trospium Chloride Oral 1

Trospium Chloride ER Oral 1

Urecholine Oral 3

VESIcare Oral 2

VACCINES

Afluria Intramuscular 3

Afluria Preservative Free Intramuscular 3

Afluria Quadrivalent Intramuscular 3

Bexsero Intramuscular 3

Fluad Intramuscular 3

Fluarix Quadrivalent Intramuscular 3

Flublok Intramuscular 3

Flublok Quadrivalent Intramuscular 3

Flucelvax Quadrivalent Intramuscular 3

Flulaval Quadrivalent Intramuscular 3

FluMist Quadrivalent Nasal 3

Fluvirin Intramuscular 3

Fluzone High-Dose Intramuscular 3

Fluzone Quadrivalent Intradermal 3

Fluzone Quadrivalent Intramuscular 3

Gardasil Intramuscular 3

Gardasil 9 Intramuscular 3

Havrix Intramuscular 3

Heplisav-B Intramuscular 3

Ipol Injection 3

Menactra Intramuscular 3

Menveo Intramuscular 3

M-M-R II Injection 3

Pneumovax 23 Injection 3

Prevnar 13 Intramuscular 3



Recombivax HB Injection 3

Rotarix Oral 3

RotaTeq Oral 3

Shingrix Intramuscular 3

Trumenba Intramuscular 3

Twinrix Intramuscular 3

Varivax Subcutaneous 3

Vaxchora Oral 3

Vivotif Oral 3

Zostavax Subcutaneous 3

VAGINAL PRODUCTS

AVC Vaginal Vaginal 3

Cleocin Suppository Vaginal 2

Cleocin Cream Vaginal 3

Clindamycin Phosphate Vaginal 1

Clindesse Vaginal 3

Crinone Vaginal 3

Encare Vaginal 3

Endometrin Vaginal 3

Estrace Vaginal 2

Estradiol Vaginal 1

Estring Vaginal 3

Fem pH Vaginal 3

Femring Vaginal 3

Gynazole-1 Vaginal 3

Imvexxy Maintenance Pack Vaginal 3

Imvexxy Starter Pack Vaginal 3

Intrarosa Vaginal 3

MetroGel-Vaginal Vaginal 3

metroNIDAZOLE Vaginal 1

Miconazole 3 Vaginal 3

Nuvessa Vaginal 3

Options Conceptrol Vaginal 3

Premarin Vaginal 3

Relagard Vaginal 3

Shur-Seal Contraceptive Vaginal 3

Terazol 7 Vaginal 3

Terconazole Vaginal 1



Today Sponge Vaginal 3

Vagifem Vaginal 2

Vandazole Vaginal 1

Yuvafem Vaginal 1

Zazole Vaginal 1

VCF Vaginal Contraceptive Gel Vaginal 1

VCF Vaginal Contraceptive Film Vaginal 3

VCF Vaginal Contraceptive Foam Vaginal 3

VASOPRESSORS

Adrenalin Injection 3 Y

Adyphren Injection 3 Y

Adyphren Amp Injection 3 Y

Adyphren Amp II Injection 3 Y

Adyphren II Injection 3 Y

EPINEPHrine Injection 1 Y

EPINEPHrine PF Injection 1

Epinephrine Professional Injection 3 Y

EpinephrineSnap-EMS Injection 3 Y

Epinephrinesnap-v Injection 3 Y

EpiPen 2-Pak Injection 2 Y

EpiPen Jr 2-Pak Injection 2 Y

EPIsnap Injection 3 Y

Midodrine HCl Oral 1

Northera Oral 3 Y Y

VITAMINS

Aqueous Vitamin D Oral 1

Baby Ddrops Oral 3

Baby Super Daily D3 Oral 1

Baby Vitamin D3 Oral 1

Bio-D-Mulsion Oral 1

BProtected Pedia D-Vite Oral 1

Cholecalciferol Oral 1

CVS D3 Oral 1

CVS Vitamin D Child Gummies Oral 1

CVS Vitamin D3 Oral 1

CVS Vitamin D3 Drops/Infant Oral 1

D 1000 Oral 1

D 10000 Oral 1



D 400 Oral 1

D-1000 Oral 1

D-1000 Extra Strength Oral 1

D3 Adult Oral 1

D3 High Potency Oral 1

D3 Kids Oral 1

D3-1000 Oral 1

D-400 Oral 1

Ddrops Oral 3

Ddrops Booster Oral 3

Delta D3 Oral 1

D-Vi-Sol Oral 3

D-Vita Oral 1

EQL Vitamin D Gummies Child Oral 1

EQL Vitamin D3 Oral 1

EQL Vitamin D-3 Oral 1

EQL Vitamin D3 Gummies Oral 1

Ergocalciferol Oral 1

GNP D 1000 Oral 1

GNP D 2000 Oral 1

GNP Vitamin D Oral 1

GNP Vitamin D3 Extra Strength Oral 1

Healthy Kids Vitamin D3 Oral 1

HM Vitamin D Oral 1

Just D Oral 1

KP Vitamin D Oral 1

KP Vitamin D3 Oral 1

Maximum D3 Oral 3

Mephyton Oral 2

Nat-Rul Vitamin D Oral 1

PA Vitamin D-3 Oral 1

PA Vitamin D-3 Gummy Oral 1

Phytonadione Oral 1

Pronutrients Vitamin D3 Oral 1

SM Vitamin D Oral 1

SM Vitamin D3 Oral 1

Super Daily D3 Oral 3

UpSpring Baby Vit D Oral 3



VitaJoy Daily D Gummies Oral 1

VitaMelts Vitamin D Oral 3

Vitamin D Oral 1

Vitamin D (Cholecalciferol) Oral 1

Vitamin D (Ergocalciferol) Oral 1

Vitamin D High Potency Oral 1

Vitamin D-1000 Max St Oral 1

Vitamin D2 Oral 1

Vitamin D3 Oral 1

Vitamin D-3 Oral 1

Vitamin D3 Adult Gummies Oral 1

Vitamin D3 High Potency Oral 1

Vitamin D3 Immune Health Oral 3

Vitamin D-400 Oral 1

Formulary 2020 - EpiphanyRx › wp-content › uploads › 2020 › 03 › CY...2020 EpiphanyRx...

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Transcript of Formulary 2020 - EpiphanyRx › wp-content › uploads › 2020 › 03 › CY...2020 EpiphanyRx...