Get More Than Original Medicare 2020 · 2020-05-26 · Get More Than Original Medicare 2020....

Get More Than Original Medicare

2020 Community Health Plan of Washington Medicare Advantage Prescription Drug Formulary (Tier 5)

This formulary was updated on 05/01/2020. For more recent information or other questions, please contact Community Health Plan of Washington Medicare Advantage Customer Service at 1-800-942-0247 (TTY: Dial 711), from 8 a.m. to 8 p.m., 7 days a week. Or, visit our website at medicare.chpw.org.

H5826_RX_296_2020_Formulary_Tier5_May_C

Community Health Plan of Washington

Medicare Advantage

2020 Formulary List of Covered Drugs

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

HPMS Approved Formulary File Submission ID 00020071, Version Number 12

This formulary was updated on 05/01/2020. For more recent information or other questions, please contact Community Health Plan of Washington Medicare Advantage Customer Service at 1-800-942-0247 (TTY: Dial 711), from 8 a.m. to 8 p.m., 7 days a week. Or, visit our website atmedicare.chpw.org.

This information is available for free in alternative formats such as Braille, large print, and audio. Please call our customer service number at 1-800-942-0247 (TTY Relay: Dial 711), from 8:00 a.m. to 8:00 p.m., 7 days a week.

H5826_RX_296_2020_Formulary_Tier5_May_C

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

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Community Health Plan of Washington. When it refers to “plan” or “our plan,” it means Community Health Plan of Washington Medicare Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of 05/01/2020. For updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.

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

Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

• Drugs removed from the market. If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturer removes the drug from the market, we willimmediately remove the drug from our formulary and provide notice to members who take thedrug.

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

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o If we make these other changes, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can also find information in thesection below entitled “How do I request an exception to the Community Health Plan ofWashington Medicare Advantage Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year.

The enclosed formulary is current as of 05/01/2020. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages.

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

Medical Condition

The formulary begins on page 18. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular, Hypertension/Lipids.” If you know what your drug is used for, look for the category name in the list that begins on page 18. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 98. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

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

• Prior Authorization: Our plan requires you or your physician to get prior authorization for certaindrugs. This means that you will need to get approval from our plan before you fill your prescriptions.If you don’t get approval, our plan may not cover the drug.

• Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover.For example, our plan provides 30 tablets per prescription for simvastatin. This may be in additionto a standard one-month or three-month supply.

• Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If DrugA does not work for you, our plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 18. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Community Health Plan of Washington Medicare Advantage formulary?” on page V for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that our plan does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by our plan. When youreceive the list, show it to your doctor and ask him or her to prescribe a similar drug that is coveredby our plan.

• You can ask our plan to make an exception and cover your drug. See below for information abouthow to request an exception.

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How do I request an exception to the Community Health Plan of Washington Medicare Advantage Formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

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

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

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

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

You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

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

Our Policy Regarding Changes in Level of Care You may have a change in your treatment setting due to the level of care you require. Such transitions include:

1. Being discharged from a hospital to a home;2. Ending your skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges)

and now needing to use your Part D plan;3. Giving up Hospice Status and reverting back to standard Medicare Part A and B coverage;4. Being discharged from chronic psychiatric hospitals with highly individualized drug regimens;

For these unplanned transitions, you may need to request an exception or an appeal for continued coverage of your drug. In addition, we will review requests for continuation of therapy on a case-by-case basis if you have had a change in your level of care and are stabilized on drug regimens that if altered, are known to have risks.

Please see the Community Health Plan of Washington Transition Policy (https://medicare.chpw.org/member-center/member-resources/prescription-drug-coverage/) for more information.

Admission or discharge from a long-term care facility should not affect access to your Part D benefits.

For more information For more detailed information about your Community Health Plan of Washington Medicare Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

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

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Community Health Plan of Washington Medicare Advantage Special Needs Plan Formulary The formulary that begins on page 18 provides coverage information about the drugs covered by our plan.. If you have trouble finding your drug in the list, turn to the Index that begins on page 98.

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

The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.

List of Abbreviations

o BvD PA: This prescription may be covered under Medicare Part B or Medicare Part D dependingupon the circumstances. Information may need to be submitted describing the use and setting ofthe drug to make the determination.

o LA: Limited Availability. This prescription may be available only at certain pharmacies. For moreinformation consult your Pharmacy Directory or call Customer Service at 1-800-942-0247, 7 days aweek, 8 a.m. to 8 p.m. TTY users should 711.

o MO: Mail-Order Drug. This prescription is available through our mail-order service, as well as ourretail network pharmacies. Consider using mail-order for your long-term (maintenance) medications(such as high blood pressure medications). Retail network pharmacies may be more appropriate forshort-term prescriptions, such as antibiotics.

o PA: Prior Authorization. The plan requires you or your physician to get prior authorization for certaindrugs. This means that you will need to get approval before you fill your prescriptions. If you don’tget approval, we may not cover the drug.

o ST: Step Therapy. In some cases, the plan requires you to first try certain drugs to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug Adoes not work for you, we will then cover Drug B.

o QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover.

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Drug Payment Stages and Drug Tiers

The amount you pay for a covered drug will depend on:

• Drug payment stage. There are different stages of drug coverage in your plan. Theamount you pay will depend on the coverage stage you’re in.

• Drug tier. There are five drug tiers. Each tier has a copay and/or co-insurance amount.The table below shows the differences between the tiers.

Please reference your Evidence of Coverage for more information about drug coverage and copay or co-insurance amounts for each tier.

Drug Tier Includes Tier 1 - Preferred Generic Tier 1 is the lowest tier and includes preferred generic drugs Tier 2 - Generic Tier 2 includes generic drugs Tier 3 - Preferred Brand Tier 3 includes preferred brand drugs and non-preferred

generic drugs. Tier 4 - Non-Preferred Drugs

Tier 4 includes non-preferred brand drugs and non-preferred generic drugs.

Tier 5 - Specialty Tier 5 is the highest tier. It contains very high-cost brand and generic drugs, which may require special handling and/or close monitoring.

Extra Help

Members who qualify will receive Extra Help for prescription drug, copays and co-insurance. Please read the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider), to learn about your costs. You may also call customer service. Our contact information appears on the front and back cover pages.

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Medicare Advantage de Community

Health Plan of Washington

Formulario de la lista de medicamentos cubiertos 2020

LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE SE CUBREN EN ESTE PLAN

Formulario aprobado por la HPMS; Ident. de presentación del formulario: 00020071, versión 12

Este formulario fue actualizado el 01/05/2020. Para obtener información reciente o por otras consultas, contacte a Servicios al Cliente del Plan Community Health of Washington de Medicare Advantage al 1-800-942-0247 o, para usuarios de TTY, marque 711, los 7 días de la semana, de 8:00 a. m. a 8:00 p. m. o visite medicare.chpw.org.

Esta información está disponible de forma gratuita en formatos alternativos, como braille, tamaño de letra grande y audio. Llame a nuestro Servicio al cliente al 1-800-942-0247 (servicio de retransmisión TTY: 711) de 8:00 a. m. a 8:00 p. m., los 7 días de la semana.

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Nota a los miembros existentes: Este formulario ha cambiado desde el año pasado. Revise este documento para asegurarse de que todavía incluye los medicamentos que usted toma.

Cuando esta lista de medicamentos (formulario) dice “nosotros” “nos” o “nuestro”, hace referencia a Community Health Plan of Washington. Cuando menciona “plan” o “nuestro plan”, se refiere a Medicare Advantage de Community Health Plan of Washington.

Este documento incluye una lista de los medicamentos (formulario) para nuestro plan que rige a partir del 1.° de septiembre de 2019. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en la portada y la contraportada.

En general, usted debe utilizar farmacias de nuestra red para aprovechar sus beneficios de medicamentos con receta. Los beneficios, el formulario, la red de farmacias o los copagos/coseguros pueden cambiar el 1 de enero de 2020, u ocasionalmente durante el año.

¿Qué es el formulario del plan de Medicare Advantage de Community Health Plan of Washington? Un formulario es una lista de medicamentos cubiertos seleccionados por nuestro plan, en colaboración con un equipo de proveedores de atención médica, que representa las terapias con receta que se consideran una parte necesaria de un programa de tratamiento de calidad. Generalmente nuestro plan cubre los medicamentos que se mencionan en nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la receta se presente en una farmacia de la red del plan y se cumpla con otras normas del plan. Para obtener más información sobre cómo surtir sus recetas, revise su Evidencia de cobertura.

¿El formulario (lista de medicamentos) puede cambiar? La mayoría de los cambios en la cobertura de los medicamentos ocurrieron el 1 de enero, pero podremos agregar o quitar medicamentos de la Lista de medicamentos durante el año, moverlos a niveles de costo compartido diferentes o agregar restricciones nuevas.

Los cambios que pueden afectarlo este año: En los siguientes casos, usted se verá afectado por el cambio de cobertura durante el año:

• Medicamentos sacados del mercado. Si la Administración de Drogas y Alimentos (FDA)considera que un medicamento de nuestro formulario no es seguro, o si el fabricante delmedicamento lo quita del mercado, eliminaremos inmediatamente dicho medicamento denuestro formulario y enviaremos un aviso a los miembros que toman ese medicamento.

• Otros cambios. Podremos realizar otros cambios que afecten a los miembros que estén tomandoeste medicamento. Por ejemplo, podremos agregar un medicamento genérico nuevo parareemplazar un medicamento de marca que se encuentra actualmente en el formulario o agregarrestricciones nuevas al medicamento de marca o moverlo a un nivel de costos compartidos

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diferente. Podremos agregar un medicamento genérico que no sea nuevo en el mercado para reemplazar un medicamento de marca que se encuentra actualmente en el formulario o agregar restricciones nuevas al medicamento de marca o moverlo a un nivel de costo compartido diferente. También podremos hacer cambios basándonos en las normas clínicas nuevas. Si eliminamos medicamentos de nuestro formulario, agregamos la autorización previa, restricciones de tratamiento escalonado con un medicamento o si movemos un medicamento a un nivel de costo compartido mayor, debemos notificar a aquellos miembros afectados por el cambio al menos 30 días antes de que el cambio entre en vigencia, o en el momento en que el miembro solicite un resurtido del medicamento, momento en el que el miembro recibirá un suministro por 30 días de dicho medicamento.

o Si realizamos estos cambios, usted y su proveedor pueden solicitar al plan que haga unaexcepción y siga cubriendo el medicamento de marca para usted. La notificación que lebrindamos también incluirá información sobre cómo solicitar una excepción, ademáspuede encontrar información en la sección a continuación titulada “¿Cómo solicito unaexcepción al formulario del plan de necesidades especiales Medicare Advantage deCommunity Health Plan of Washington?”

Cambios que no lo afectarán si está tomando el medicamento. Por lo general, si está tomando un medicamento en nuestro formulario 2020 que tenía cobertura al comienzo del año, no discontinuaremos ni reduciremos la cobertura del medicamento durante el año 2020 con excepción de lo descrito arriba. Esto significa que esos medicamentos seguirán disponibles con el mismo costo compartido y sin restricciones nuevas para los miembros que lo utilicen durante el resto del año de cobertura.

El formulario adjunto rige a partir del 01/05/2020. Para obtener información actualizada sobre los medicamentos cubiertos por el plan, comuníquese con nosotros. Nuestra información de contacto figura en la portada y la contraportada.

¿Cómo utilizo el formulario? Existen dos maneras de encontrar su medicamento dentro del formulario:

Afección médica

El formulario comienza en la página 18. Los medicamentos en este formulario están agrupados en dos categorías según el tipo de afecciones médicas que tratan. Por ejemplo, los medicamentos que se utilizan para tratar una afección cardíaca se enumeran bajo la categoría: “Cardiovascular, hipertensión/lípidos”. Si usted sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página 18. Luego busque su medicamento bajo el nombre de la categoría.

Lista por orden alfabético

Si usted no está seguro en qué categoría debe buscar, busque su medicamento en el índice que comienza en la página 98. El índice ofrece una lista por orden alfabético de todos los medicamentos incluidos en este documento. En el índice se enumeran los medicamentos de marca y los

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medicamentos genéricos. Busque en el índice y encuentre su medicamento. Al lado del nombre de su medicamento, verá el número de página donde puede encontrar información de cobertura. Diríjase a la página que figura en el índice y encuentre el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos? Nuestro plan cubre medicamentos de marca y medicamentos genéricos. Un medicamento genérico está aprobado por la FDA y tiene el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan menos que los medicamentos de marca.

¿Existe alguna restricción en mi cobertura? Algunos medicamentos cubiertos tienen requisitos adicionales o límites en la cobertura. Estos requisitos pueden incluir lo siguiente:

• Autorización previa: Nuestro plan requiere que usted o su médico obtengan autorización previapara ciertos medicamentos. Esto significa que deberá obtener nuestra aprobación antes de surtirsus recetas. Si usted no obtiene la aprobación, puede que nuestro plan no cubra el medicamento.

• Límites de cantidades: Para ciertos medicamentos, nuestro plan limita la cantidad demedicamento que cubriremos. Por ejemplo, nuestro plan ofrece 30 comprimidos por receta desimvastatina. Esto puede ser adicional a un suministro estándar de uno o tres meses.

• Tratamiento escalonado: en algunos casos, nuestro plan requiere que primero pruebe ciertosmedicamentos para tratar su afección médica antes de que cubramos otro medicamento para suafección. Por ejemplo, si el medicamento A y el medicamento B tratan la misma afección médica,es posible que no cubramos el medicamento B a menos que pruebe el medicamento A primero. Siel medicamento A no funciona para usted, entonces nuestro plan cubrirá el medicamento B.

Puede averiguar si su medicamento tiene límites o requisitos adicionales al consultar el formulario que comienza en la página 18. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos si visita nuestro sitio web. Hemos publicado documentos en línea que explican nuestras restricciones de autorización previa y tratamiento escalonado. También puede solicitar que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en la portada y la contraportada.

Puede solicitar que hagamos una excepción a estos límites o restricciones, o que le demos una lista de medicamentos similares que puedan utilizarse para tratar su afección médica. Consulte la sección “¿Cómo solicito una excepción al formulario del plan de Medicare Advantage de Community Health Plan of Washington?” en la página XII para obtener más información sobre cómo solicitar una excepción.

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¿Qué pasa si mi medicamento no está en el formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero debe comunicarse con Servicio al cliente y preguntar si su medicamento está cubierto.

Si se le comunica que el plan no cubre su medicamento, tiene dos opciones:

• Puede solicitar a Servicio al cliente una lista de medicamentos similares cubiertos por el plan.Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar quecubra nuestro plan.

• Puede solicitar que hagamos una excepción y cubramos su medicamento. Consulte la siguienteinformación sobre cómo solicitar una excepción.

¿Cómo solicito una excepción al formulario del Plan Community of Washington de Medicare Advantage? Puede solicitar que hagamos una excepción a nuestras normas de cobertura. Hay varios tipos de excepciones que puede solicitarnos.

• Puede pedirnos que cubramos un medicamento incluso si no se encuentra en nuestro formulario.Si se aprueba, este medicamento se cubrirá a un nivel de costo compartido predeterminado, yusted no podrá solicitarnos que proporcionemos el medicamento a un nivel de costo compartidomenor.

• Puede solicitar que cubramos un medicamento del formulario a un menor nivel de costocompartido si dicho medicamento no está en el nivel de especialidad. Si se aprueba, estosería menos del monto que debería pagar por el medicamento.

• Puede pedirnos que no apliquemos los límites o restricciones de cobertura de su medicamento.Por ejemplo, para ciertos medicamentos, nuestro plan limita la cantidad de medicamento quecubriremos. Si su medicamento tiene un límite de cantidad, nos puede solicitar que renunciemos allímite y que cubramos una cantidad mayor.

En general, solo aprobaremos su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan, el medicamento de menor costo compartido o las restricciones de uso adicionales no son tan efectivos para el tratamiento de su afección o si estos pueden causarle efectos médicos adversos.

Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial sobre una excepción a nuestro formulario o a las restricciones de uso. Cuando solicita una excepción a nuestro formulario o a las restricciones de uso, debe presentar una declaración de su médico o una persona autorizada a emitir recetas que respalde su solicitud. En general, debemos tomar nuestra decisión dentro de las 72 horas de haber recibido la declaración de respaldo de la persona autorizada a emitir recetas. Puede solicitar una

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apelación acelerada (rápida) si usted o su médico creen que su salud podría verse gravemente perjudicada si espera hasta 72 horas para que se tome una decisión. Si se le otorga la apelación acelerada, debemos comunicarle una decisión antes de las 24 horas después de haber recibido la declaración de respaldo de su médico u otra persona autorizada a emitir recetas.

¿Qué debo hacer antes de que pueda hablar con mi médico sobre cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo o existente de nuestro plan, es posible que tome medicamentos que no están en nuestro formulario. O tal vez está tomando un medicamento que se encuentra en nuestro formulario, pero tiene acceso limitado para obtenerlo. Por ejemplo, tal vez necesite nuestra autorización previa antes de surtir su receta. Debe consultar con su médico para decidir si debe cambiar a un medicamento apropiado que cubramos o solicitar una excepción a nuestro formulario para que cubramos el medicamento que toma. Mientras consulta con su médico para determinar la acción correcta para usted, es posible que en ciertos casos cubramos su medicamento durante los primeros 90 días de su membresía en nuestro plan. Para cada uno de los medicamentos que no estén en nuestro formulario, o si su acceso a estos medicamentos es limitado, cubriremos un suministro temporal de 30 días. Si su receta está indicada para menos días, permitiremos obtener varias veces los medicamentos hasta llegar a un máximo de un suministro para 30 días del medicamento. Luego de su primer suministro de 30 días, no pagaremos por estos medicamentos, incluso si usted ha sido miembro del plan durante menos de 90 días.

Si es un residente de un centro de atención a largo plazo y necesita un medicamento que no está en nuestro formulario, o si su acceso a estos medicamentos es limitado, pero ya ha superado los primeros 90 días como miembro de nuestro plan, cubriremos un suministro de emergencia de 31 días de ese medicamento mientras usted intenta obtener una excepción al formulario.

Nuestra política con respecto a los cambios en el nivel de atención Puede haber cambios en el entorno de su tratamiento debido al nivel de atención que requiere. Dichas transiciones incluyen las siguientes:

1. ser dado de alta de un hospital a su casa;2. finalizar su estadía en un establecimiento de enfermería especializada de la Parte A (en la que los pagos

incluyen todos los cargos farmacéuticos) a raíz de una necesidad de usar su plan de la Parte D;3. renunciar al Estado de necesidad de cuidados paliativos y volver a la cobertura de la Parte A y B estándar

de Medicare;4. ser dado de alta de hospitales psiquiátricos con regímenes altos de medicamentos individualizados.

Para estas transiciones no planificadas, es posible que necesite solicitar una excepción o apelación para una cobertura continua de su medicamento. Además, revisaremos las solicitudes de continuación del tratamiento sobre una base de caso por caso si ha tenido un cambio en el nivel de atención y si está estable en un régimen de medicamento que, si es alterado, tiene riesgos conocidos.

14

Lea la política de transición del Plan Community Health of Washington (https://medicare.chpw.org/member-center/member-resources/prescription-drug-coverage/) para obtener más información.

La admisión o el alta de un establecimiento de cuidados a largo plazo no debería afectar sus beneficios de la Parte D.

Para más información Para obtener información más detallada sobre la cobertura de medicamentos con receta del Plan Community Health of Washington de Medicare Advantage, revise su Evidencia de cobertura y otros materiales del plan.

Si tiene alguna pregunta sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en la portada y la contraportada.

Si tiene preguntas generales sobre la cobertura de medicamentos con receta de Medicare, llame al 1-800-MEDICARE (1-800-633-4227), durante las 24 horas, los 7 días de la semana. Los usuarios de TTYdeben llamar al 1-877-486-2048. O visite http://www.medicare.gov.

Formulario de Medicare Advantage de Community Health Plan of Washington

El formulario que comienza en la página 18 ofrece información de cobertura sobre los medicamentos cubiertos en nuestro plan. Si tiene problemas para encontrar su medicamento en la lista, diríjase al índice que comienza en la página 98. La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca están escritos en mayúscula (por ejemplo, RISPERDAL) y los medicamentos genéricos están escritos en minúscula cursiva (por ejemplo, risperidona). La información en la columna de Requisitos/límites indica si su plan tiene algún requisito especial para la cobertura de su medicamento.

15

Etapas de pago y niveles de medicamentos

El monto que usted paga por los medicamentos cubiertos dependerá de lo siguiente:

• Etapa de pago del medicamento: Su plan distingue distintas etapas de cobertura demedicamentos. El monto que usted pague dependerá de la etapa de cobertura en la que seencuentre.

• Nivel del medicamento: Hay cinco niveles de medicamentos. Cada nivel tiene un monto decopago y/o coseguro determinados. La tabla a continuación muestra las diferencias entreniveles.

Consulte su Evidencia de cobertura para obtener más información sobre la cobertura de medicamentos y los montos de copago o coseguro de cada nivel.

Los niveles de medicamentos incluyen lo siguiente: Nivel 1: medicamentos genéricos preferidos

El Nivel 1 es el nivel más bajo, e incluye medicamentos genéricos preferidos.

Nivel 2 medicamentos genéricos

El Nivel 2 incluye medicamentos genéricos.

Nivel 3: medicamentos de marca preferidos

El Nivel 3 incluye medicamentos de marca preferidos y medicamentos genéricos no preferidos.

Nivel 4: medicamentos no preferidos

El Nivel 4 incluye medicamentos de marca no preferidos y medicamentos genéricos no preferidos.

Nivel 5: medicamentos de especialidad

El Nivel 5 es el nivel más alto, e incluye los medicamentos de marca y genéricos de costo alto que pueden requerir un manejo o una supervisión especiales.

Ayuda adicional

Los miembros elegibles recibirán Ayuda adicional para pagar sus medicamentos recetados cubiertos, así como para cubrir sus gastos de copago y coseguro. Lea la Cláusula adicional a la Evidencia de cobertura para las personas que reciben ayuda adicional para pagar los medicamentos con receta (Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs, LIS Rider) para obtener más información sobre sus costos. También puede comunicarse con el Departamento de Servicio al Cliente. Nuestra información de contacto figura en la portada y la contraportada.

16

Índice de medicamentos

A continuación, presentamos una lista de abreviaturas que pueden aparecer en la columna de Requisitos/límites que indica si existe algún requisito especial para la cobertura de su medicamento.

Lista de abreviaturas

B/D PA: este medicamento con receta puede estar cubierto por la Parte B o D de Medicare según las circunstancias. Es posible que se deba presentar información que describa el uso y la administración de un medicamento para tomar una determinación.

LA (Limited Availability): disponibilidad limitada. Es posible que este medicamento solo esté disponible en determinadas farmacias. Para obtener más información, comuníquese con Servicio al cliente.

MO (Mail-Order): medicamento de venta por correo. Este medicamento con receta está disponible a través de nuestro servicio de pedido por correo, así como a través de nuestras farmacias minoristas de la red. Considere utilizar el servicio de pedido por correo para sus medicamentos a largo plazo (medicamentos de mantenimiento), como los medicamentos para la presión arterial alta. Las farmacias minoristas de la red pueden ser más adecuadas para medicamentos a corto plazo (como los antibióticos).

PA (Prior Authorization): autorización previa. El Plan requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que usted deberá obtener aprobación antes de surtir sus recetas. Si usted no obtiene la aprobación, puede que no cubramos el medicamento.

QL (Quantity Limit): límite de cantidades. Para ciertos medicamentos, el Plan limita la cantidad del medicamento que cubriremos.

ST (Step Therapy): tratamiento escalonado. En algunos casos, el Plan requiere que usted pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para su afección. Por ejemplo, si el medicamento A y el medicamento B tratan la misma afección médica, es posible que no cubramos el medicamento B a menos que pruebe el medicamento A primero. Si el medicamento A no funciona para usted, entonces cubriremos el medicamento B.

17

COMMUNITY HEALTH PLAN OF WASHINGTON

2020 PRESCRIPTION DRUG FORMULARY (TIER 1)

CURRENT AS OF 5/1/2020

Drug Name Drug Tier Requirements/Limits

ANALGESICSANALGESICSacetaminophen-codeine oral solution 120-12 mg/5 ml

2QL (4500 ML per 30 days)

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg

2QL (360 EA per 30 days)

acetaminophen-codeine oral tablet 300-60 mg


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


hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml


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


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


hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg


LORCET (HYDROCODONE)


LORCET HD 2QL (360 EA per 30 days)

LORCET PLUS ORAL TABLET 7.5-325 MG



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


oxycodone-aspirin 2QL (360 EA per 30 days)

tramadol-acetaminophen


NONSTEROIDAL ANTI-INFLAMMATORY DRUGScelecoxib 2

diclofenac potassium 2

diclofenac sodium oral 2

diclofenac sodium topical drops


diclofenac sodium topical gel 3 %

2PA; QL (100 GM per 28 days)

diclofenac-misoprostol 2

diflunisal 2

etodolac 2

fenoprofen oral tablet 2

flurbiprofen oral tablet100 mg

2

IBU ORAL TABLET 600 MG, 800 MG

1

ibuprofen oral suspension

2

ibuprofen oral tablet400 mg, 600 mg, 800 mg

1

ibuprofen-oxycodone 2QL (28 EA per 30 days)

ketoprofen oral capsule25 mg

2

ketoprofen oral capsule50 mg, 75 mg

5

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

2

18


meclofenamate 2

mefenamic acid 2

meloxicam oral tablet15 mg

1

meloxicam oral tablet7.5 mg


nabumetone 2

naproxen oral suspension

2

naproxen oral tablet 1

naproxen oral tablet,delayed release (dr/ec)

2

naproxen sodium oral tablet 275 mg, 550 mg

2

naproxen sodium oral tablet, er multiphase 24 hr

2

oxaprozin 2

piroxicam 2

sulindac 1

tolmetin oral capsule 2

tolmetin oral tablet 600 mg

2

OPIOID ANALGESICS, LONG-ACTINGbuprenorphine hcl sublingual

2

buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour

2PA; QL (4 EA per 28 days)

DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML


DURAMORPH (PF) INJECTION SOLUTION 1 MG/ML



fentanyl citrate buccal lozenge on a handle


fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr


fentanyl transdermal patch 72 hour 87.5 mcg/hour


hydrocodone bitartrate 2PA; QL (90 EA per 30 days)

hydromorphone (pf) injection solution 10 mg/ml


hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 8 mg


hydromorphone oral tablet extended release 24 hr 32 mg


levorphanol tartrate oral tablet 2 mg


methadone oral solution10 mg/5 ml

2PA; QL (600 ML per 30 days)

methadone oral solution5 mg/5 ml


methadone oral tablet10 mg


methadone oral tablet 5 mg


morphine concentrate oral solution


morphine oral capsule, er multiphase 24 hr


morphine oral capsule,extend.release pellets


19


morphine oral solution 2QL (900 ML per 30 days)

morphine oral tablet 2QL (180 EA per 30 days)

morphine oral tablet extended release


OPIOID ANALGESICS, SHORT-ACTINGbutorphanol tartrate nasal


fentanyl citrate buccal lozenge on a handle


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




hydromorphone oral liquid


hydromorphone oral tablet


morphine concentrate oral solution


morphine oral solution 2QL (900 ML per 30 days)

morphine oral tablet 2QL (180 EA per 30 days)

oxycodone oral capsule 2QL (360 EA per 30 days)

oxycodone oral concentrate


oxycodone oral solution 2QL (1200 ML per 30 days)

oxycodone oral tablet10 mg, 15 mg, 20 mg, 30 mg


oxycodone oral tablet 5 mg



oxymorphone oral tablet10 mg


oxymorphone oral tablet5 mg


tramadol oral tablet 50 mg


ANESTHETICSLOCAL ANESTHETICSlidocaine hcl mucous membrane jelly


lidocaine hcl mucous membrane solution 4 % (40 mg/ml)

2

lidocaine topical adhesive patch,medicated 5 %


lidocaine topical ointment

4QL (36 GM per 30 days)

LIDOCAINE VISCOUS

2

lidocaine-prilocaine topical cream


ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTSALCOHOL DETERRENTS/ANTI-CRAVINGacamprosate 4

disulfiram 2

naltrexone 2

VIVITROL 5

OPIOID DEPENDENCE TREATMENTSbuprenorphine hcl sublingual

2

20


buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour


buprenorphine-naloxone sublingual film 12-3 mg


buprenorphine-naloxone sublingual film 2-0.5 mg


buprenorphine-naloxone sublingual film 4-1 mg, 8-2 mg


buprenorphine-naloxone sublingual tablet 2-0.5 mg


buprenorphine-naloxone sublingual tablet 8-2 mg


naltrexone 2

SUBOXONE SUBLINGUAL FILM 12-3 MG


SUBOXONE SUBLINGUAL FILM 2-0.5 MG


SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG


VIVITROL 5

OPIOID REVERSAL AGENTSnaloxone injection solution

2

naloxone injection syringe

2

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

3


SMOKING CESSATION AGENTSbupropion hcl (smoking deter)

2

CHANTIX 3

CHANTIX CONTINUING MONTH BOX

3

CHANTIX STARTING MONTH BOX

3

NICOTROL 4

NICOTROL NS 4

ANTIBACTERIALSAMINOGLYCOSIDES

amikacin injection solution 500 mg/2 ml

2

ARIKAYCE 5 PA

BETHKIS 5BvD; QL (224 ML per 28 days)

GENTAK OPHTHALMIC (EYE) OINTMENT

2

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml

2

gentamicin injection solution 40 mg/ml

2

gentamicin ophthalmic (eye) drops

2

gentamicin topical 2

neomycin 2

paromomycin 4

streptomycin 3

tobramycin 2

21


tobramycin in 0.225 % nacl

5BvD; QL (280 ML per 28 days)

tobramycin sulfate injection solution

2

ANTIBACTERIALS, OTHERacetic acid otic (ear) 2

ALCOHOL PADS 3

bacitracin ophthalmic (eye)

2

clindamycin hcl 2

clindamycin in 5 % dextrose

2

CLINDAMYCIN PEDIATRIC

2

clindamycin phosphate injection solution 150 mg/ml

2

clindamycin phosphate topical gel


clindamycin phosphate topical lotion


clindamycin phosphate topical solution


clindamycin phosphate vaginal

2

colistin (colistimethate na)

2

daptomycin intravenous recon soln 350 mg

3

daptomycin intravenous recon soln 500 mg

5

linezolid in dextrose 5% 5

linezolid oral suspension for reconstitution

5

linezolid oral tablet 2

methenamine hippurate 2

metronidazole in nacl (iso-os)

2

metronidazole oral 2


metronidazole topical cream

2

metronidazole topical gel

2

metronidazole topical lotion

2

metronidazole vaginal 2

mupirocin 2QL (30 GM per 30 days)

mupirocin calcium 2QL (30 GM per 30 days)

nitrofurantoin 2

nitrofurantoin macrocrystal

2

nitrofurantoin monohyd/m-cryst

2

polymyxin b sulfate 2

SULFAMYLON TOPICAL CREAM

3

tigecycline 5

tinidazole 2

trimethoprim 2

vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg, 750 mg

2

vancomycin oral capsule 125 mg

2

vancomycin oral capsule 250 mg

5

VANDAZOLE 2

XIFAXAN ORAL TABLET 200 MG




ANTIBACTERIALScolistin (colistimethate na)

2

BETA-LACTAM, CEPHALOSPORINScefaclor oral capsule 2

22


cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

2

cefaclor oral tablet extended release 12 hr

2

cefadroxil oral capsule 2

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

2

cefadroxil oral tablet 2

cefazolin injection recon soln 1 gram, 10 gram, 500 mg

2

cefdinir 2

cefepime injection 2

cefixime 2

cefotetan injection 2

cefoxitin 2

cefpodoxime 2

cefprozil 2

ceftazidime 2

ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg

2

cefuroxime axetil oral tablet

2

cefuroxime sodium injection recon soln 750 mg

2

cefuroxime sodium intravenous

2

cephalexin 2

SUPRAX ORAL CAPSULE

4

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML

4

SUPRAX ORAL TABLET,CHEWABLE

4


TAZICEF INJECTION 2

TEFLARO 5

BETA-LACTAM, OTHERaztreonam injection recon soln 1 gram

2

CAYSTON 5PA; QL (84 ML per 28 days)

ertapenem 2

imipenem-cilastatin 2

meropenem 2

BETA-LACTAM, PENICILLINS

amoxicillin oral capsule 2

amoxicillin oral suspension for reconstitution

2

amoxicillin oral tablet 2

amoxicillin oral tablet,chewable 125 mg, 250 mg

2

amoxicillin-pot clavulanate

2

ampicillin oral capsule500 mg

2

ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg

2

ampicillin-sulbactam injection

2

BICILLIN C-R 3

BICILLIN L-A 3

dicloxacillin 2

nafcillin injection recon soln 1 gram, 2 gram

2

nafcillin injection recon soln 10 gram

5

oxacillin in dextrose(iso-osm)

2

oxacillin injection recon soln 1 gram, 2 gram

2

23


oxacillin injection recon soln 10 gram

5

penicillin g potassium injection recon soln 20 million unit

2

penicillin g procaine intramuscular syringe1.2 million unit/2 ml

2

penicillin g sodium 2

penicillin v potassium 2

piperacillin-tazobactam intravenous recon soln2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

2

MACROLIDESazithromycin intravenous

2

azithromycin oral packet

2

azithromycin oral suspension for reconstitution

2

azithromycin oral tablet250 mg, 500 mg, 600 mg

2

clarithromycin 2

E.E.S. 400 ORAL TABLET

2

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG

2

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

3

ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG

2

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

3

erythromycin 2


erythromycin ethylsuccinate oral suspension for reconstitution

2

erythromycin ethylsuccinate oral tablet

2

erythromycin with ethanol topical solution

2

QUINOLONESciprofloxacin hcl 2

ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml

2

gatifloxacin 2

levofloxacin 2

levofloxacin in d5w intravenous piggyback500 mg/100 ml, 750 mg/150 ml

2

moxifloxacin ophthalmic (eye) drops

2

moxifloxacin oral 2

moxifloxacin-sod.chloride(iso)

2

ofloxacin ophthalmic (eye)

2

ofloxacin oral tablet400 mg

2

ofloxacin otic (ear) 2

SULFONAMIDESsilver sulfadiazine 2

SSD 2

sulfacetamide sodium (acne)

2

sulfacetamide sodium ophthalmic (eye)

2

sulfadiazine 4

sulfamethoxazole-trimethoprim oral

2

24


TETRACYCLINESdemeclocycline 4

DOXY-100 2

doxycycline hyclate oral capsule

2

doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 75 mg

2

doxycycline monohydrate oral capsule

2

doxycycline monohydrate oral suspension for reconstitution

2

doxycycline monohydrate oral tablet

2

minocycline oral capsule

2

minocycline oral tablet 2

MONDOXYNE NL ORAL CAPSULE 100 MG, 75 MG

2

tetracycline 2

ANTICONVULSANTSANTICONVULSANTS, OTHERBRIVIACT ORAL 5

DIASTAT 4

DIASTAT ACUDIAL 4

diazepam oral concentrate

2PAns; QL (240 ML per 30 days)

diazepam oral solution5 mg/5 ml (1 mg/ml)


diazepam oral tablet 2PAns; QL (120 EA per 30 days)

diazepam rectal 2


levetiracetam oral solution 100 mg/ml

2

levetiracetam oral tablet 2

levetiracetam oral tablet extended release 24 hr

2

ROWEEPRA 2

ROWEEPRA XR 2

SPRITAM 4

CALCIUM CHANNEL MODIFYING AGENTSCELONTIN ORAL CAPSULE 300 MG

3

ethosuximide 2

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG


LYRICA ORAL CAPSULE 225 MG, 300 MG


LYRICA ORAL SOLUTION


pregabalin oral capsule100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg


pregabalin oral capsule225 mg, 300 mg


pregabalin oral solution 2QL (900 ML per 30 days)

zonisamide 2 PAns

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS

clobazam oral suspension


25


clobazam oral tablet 10 mg

2PAns; QL (60 EA per 30 days)

clobazam oral tablet 20 mg


clonazepam oral tablet0.5 mg, 1 mg


clonazepam oral tablet2 mg


clonazepam oral tablet,disintegrating0.125 mg, 0.25 mg, 0.5 mg, 1 mg


clonazepam oral tablet,disintegrating 2 mg


clorazepate dipotassium oral tablet 15 mg


clorazepate dipotassium oral tablet 3.75 mg




DIASTAT 4

DIASTAT ACUDIAL 4






diazepam rectal 2

divalproex oral capsule, delayed rel sprinkle

2

divalproex oral tablet extended release 24 hr

2


divalproex oral tablet,delayed release (dr/ec)

1

EPIDIOLEX 5 PAns

gabapentin oral capsule100 mg, 400 mg


gabapentin oral capsule300 mg


gabapentin oral solution250 mg/5 ml


gabapentin oral tablet600 mg


gabapentin oral tablet800 mg


lamotrigine oral tablet,disintegrating

4

lorazepam oral concentrate


lorazepam oral tablet0.5 mg, 1 mg


lorazepam oral tablet 2 mg


NAYZILAM 5PAns; QL (10 EA per 30 days)

phenobarbital 2 PAns

primidone 2

SYMPAZAN ORAL FILM 10 MG, 20 MG


SYMPAZAN ORAL FILM 5 MG


tiagabine 4

valproic acid 2

valproic acid (as sodium salt) oral solution 250 mg/5 ml

2

VALTOCO 5PAns; QL (10 EA per 30 days)

26


vigabatrin 5

VIGADRONE 5

GLUTAMATE REDUCING AGENTSfelbamate oral suspension

5

felbamate oral tablet 2

FYCOMPA ORAL SUSPENSION

5

FYCOMPA ORAL TABLET

3

lamotrigine oral tablet 1

lamotrigine oral tablet extended release 24hr

4

lamotrigine oral tablet, chewable dispersible

2

lamotrigine oral tablets,dose pack

2

topiramate oral capsule, sprinkle

2 PAns

topiramate oral tablet 1 PAns

SODIUM CHANNEL AGENTSAPTIOM ORAL TABLET 200 MG, 400 MG, 800 MG

4

APTIOM ORAL TABLET 600 MG

5

BANZEL 5

carbamazepine oral suspension 100 mg/5 ml

2

carbamazepine oral tablet

1

carbamazepine oral tablet extended release 12 hr

2

carbamazepine oral tablet,chewable

1

DILANTIN 3

EPITOL 2


oxcarbazepine 2

PEGANONE 3

phenytoin oral suspension 125 mg/5 ml

2

phenytoin oral tablet,chewable

2

phenytoin sodium extended

2

VIMPAT ORAL SOLUTION

3

VIMPAT ORAL TABLET

3

ANTIDEMENTIA AGENTSANTIDEMENTIA AGENTS, OTHER

ergoloid 4

CHOLINESTERASE INHIBITORSdonepezil oral tablet 10 mg, 5 mg

1

donepezil oral tablet 23 mg

4

donepezil oral tablet,disintegrating

1

galantamine 2

rivastigmine 2

rivastigmine tartrate 2

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTmemantine oral capsule,sprinkle,er 24hr

2 PA

memantine oral solution 2 PA

memantine oral tablet 2 PA

NAMZARIC 3 PA

27


ANTIDEPRESSANTSANTIDEPRESSANTS, OTHERABILIFY MAINTENA 5

aripiprazole oral solution

5

aripiprazole oral tablet 2QL (30 EA per 30 days)

aripiprazole oral tablet,disintegrating


bupropion hcl oral tablet

1

bupropion hcl oral tablet extended release 24 hr 150 mg


bupropion hcl oral tablet extended release 24 hr 300 mg


bupropion hcl oral tablet sustained-release 12 hr


maprotiline 2

mirtazapine oral tablet 1

mirtazapine oral tablet,disintegrating

2

nefazodone 2

quetiapine oral tablet100 mg, 200 mg, 25 mg, 50 mg


quetiapine oral tablet300 mg, 400 mg


quetiapine oral tablet extended release 24 hr150 mg, 200 mg


quetiapine oral tablet extended release 24 hr300 mg, 400 mg, 50 mg


trazodone 1


ANTIDEPRESSANTSfluoxetine oral tablet 60 mg

2

olanzapine-fluoxetine 2

MONOAMINE OXIDASE INHIBITORSEMSAM 5

MARPLAN 3

phenelzine 2

tranylcypromine 4

SSRIS/ SNRIS

citalopram oral solution 2

citalopram oral tablet 1QL (30 EA per 30 days)

desvenlafaxine succinate


DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG, 30 MG, 60 MG


DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 40 MG


duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg


duloxetine oral capsule,delayed release(dr/ec) 40 mg


escitalopram oxalate oral solution

2

escitalopram oxalate oral tablet


FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK


28


FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR


fluoxetine oral capsule10 mg



1



fluoxetine oral capsule,delayed release(dr/ec)


fluoxetine oral solution 2

fluoxetine oral tablet 10 mg


fluoxetine oral tablet 20 mg

2

fluvoxamine oral capsule,extended release 24hr


fluvoxamine oral tablet100 mg






paroxetine hcl oral tablet 10 mg, 20 mg, 40 mg


paroxetine hcl oral tablet 30 mg


paroxetine hcl oral tablet extended release 24 hr


paroxetine mesylate(menop.sym)


PAXIL ORAL SUSPENSION

4

sertraline oral concentrate

2

sertraline oral tablet100 mg, 50 mg



sertraline oral tablet 25 mg


TRINTELLIX 3QL (30 EA per 30 days)

venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg


venlafaxine oral capsule,extended release 24hr 75 mg


venlafaxine oral tablet 2QL (90 EA per 30 days)

venlafaxine oral tablet extended release 24hr


VIIBRYD ORAL TABLET


VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)


TRICYCLICS

amitriptyline 2

amoxapine 2

clomipramine 4

desipramine 2

doxepin oral capsule 4

doxepin oral concentrate

4

doxepin oral tablet 2QL (30 EA per 30 days)

imipramine hcl 4

imipramine pamoate 4

nortriptyline 2

protriptyline 2

PRUDOXIN 2QL (45 GM per 30 days)

trimipramine 4

29


ANTIEMETICSANTIEMETICS, OTHERchlorpromazine oral 2

COMPRO 2

doxylamine-pyridoxine (vit b6)

2

hydroxyzine hcl oral tablet

2 PA

meclizine oral tablet12.5 mg, 25 mg

2

metoclopramide hcl oral solution

2

metoclopramide hcl oral tablet

1

metoclopramide hcl oral tablet,disintegrating

2

perphenazine 2

prochlorperazine 2

prochlorperazine maleate

1

promethazine oral 4 PA

scopolamine base 2

EMETOGENIC THERAPY ADJUNCTSaprepitant 2 BvD

dronabinol oral capsule10 mg

2 BvD

dronabinol oral capsule2.5 mg, 5 mg

4 BvD

EMEND ORAL SUSPENSION FOR RECONSTITUTION

3 BvD

granisetron hcl oral 2 BvD

ondansetron 2 BvD

ondansetron hcl oral 2 BvD

VARUBI ORAL 3 BvD


ANTIFUNGALSANTIFUNGALSABELCET 5 BvD

AMBISOME 5 BvD

amphotericin b 4 BvD

caspofungin 5 BvD

ciclopirox topical cream 2QL (90 GM per 28 days)

ciclopirox topical gel 2QL (45 GM per 28 days)

ciclopirox topical shampoo


ciclopirox topical solution

2

ciclopirox topical suspension


clotrimazole mucous membrane

2

clotrimazole topical cream


clotrimazole topical solution


CRESEMBA ORAL 5

econazole 2QL (85 GM per 28 days)

fluconazole 2

fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

2 PA

flucytosine 5

griseofulvin microsize 2

griseofulvin ultramicrosize

2

itraconazole 2

ketoconazole oral 2

ketoconazole topical cream


ketoconazole topical foam


30


ketoconazole topical shampoo


ketodan 2QL (100 GM per 28 days)

MICONAZOLE-3 VAGINAL SUPPOSITORY

2

MYCAMINE 5

naftifine topical cream 2QL (60 GM per 28 days)

NATACYN 3

NOXAFIL ORAL 5

NYAMYC 2

nystatin oral suspension 2

nystatin oral tablet 2

nystatin topical cream 2QL (30 GM per 28 days)

nystatin topical ointment


nystatin topical powder 2

NYSTOP 2

posaconazole oral tablet,delayed release (dr/ec)

5

terbinafine hcl oral 2

terconazole 2

voriconazole intravenous

2 PA

voriconazole oral 5

ZOLINZA 5

ANTIGOUT AGENTSANTIGOUT AGENTSallopurinol 1

COLCRYS 4 ST

febuxostat 2

MITIGARE 3 ST

probenecid 2

probenecid-colchicine 2


ULORIC 3

ANTI-INFLAMMATORY AGENTSGLUCOCORTICOIDSbetamethasone dipropionate

2

betamethasone valerate 2

betamethasone, augmented

2

BLEPHAMIDE 4

BLEPHAMIDE S.O.P. 4

cortisone 2

DEXAMETHASONE INTENSOL

2

dexamethasone oral elixir

2

dexamethasone oral tablet

1

dexamethasone oral tablets,dose pack

2

hydrocortisone oral tablet 20 mg, 5 mg

2

hydrocortisone-pramoxine rectal cream1-1 %

2

methylprednisolone oral tablet

2 BvD

MILLIPRED ORAL TABLET

4 BvD

prednisolone acetate 2

prednisolone oral solution 15 mg/5 ml

2

prednisolone sodium phosphate ophthalmic (eye)

2

prednisolone sodium phosphate oral solution25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

2

31


PREDNISONE INTENSOL

2 BvD

prednisone oral solution 2

prednisone oral tablet 1 BvD

prednisone oral tablets,dose pack 10 mg, 5 mg

1

sulfacetamide-prednisolone

2

triamcinolone acetonide topical aerosol


NONSTEROIDAL ANTI-INFLAMMATORY DRUGScelecoxib 2

diclofenac potassium 2

diclofenac sodium oral 2

diflunisal 2

etodolac oral capsule200 mg

2

etodolac oral tablet 2

etodolac oral tablet extended release 24 hr

2

fenoprofen oral tablet 2

flurbiprofen oral tablet100 mg

2

IBU ORAL TABLET 600 MG, 800 MG

1

ibuprofen oral suspension

2

ibuprofen oral tablet400 mg, 600 mg, 800 mg

1

ibuprofen-oxycodone 2QL (28 EA per 30 days)

ketoprofen oral capsule50 mg, 75 mg

5

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

2

meclofenamate 2

mefenamic acid 2


meloxicam oral tablet15 mg

1

meloxicam oral tablet7.5 mg


nabumetone 2

naproxen oral suspension

2

naproxen oral tablet 1

naproxen oral tablet,delayed release (dr/ec)

2

naproxen sodium oral tablet 275 mg, 550 mg

2

naproxen sodium oral tablet, er multiphase 24 hr

2

oxaprozin 2

piroxicam 2

sulindac 1

tolmetin oral capsule 2


2

ANTIMIGRAINE AGENTSANTIMIGRAINE AGENTS

sumatriptan-naproxen 2QL (18 EA per 28 days)

ERGOT ALKALOIDSdihydroergotamine nasal


ergotamine-caffeine 2

MIGERGOT 2

PROPHYLACTICdivalproex oral capsule, delayed rel sprinkle

2


2

32



1

timolol maleate oral 2

topiramate oral capsule, sprinkle

2 PAns

topiramate oral tablet 1 PAns

valproic acid 2


2

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS

eletriptan 2QL (18 EA per 28 days)

naratriptan 2QL (18 EA per 28 days)

rizatriptan 2QL (36 EA per 28 days)

sumatriptan nasal spray,non-aerosol 20 mg/actuation


sumatriptan nasal spray,non-aerosol 5 mg/actuation


sumatriptan succinate oral


sumatriptan succinate subcutaneous cartridge4 mg/0.5 ml


sumatriptan succinate subcutaneous cartridge6 mg/0.5 ml


sumatriptan succinate subcutaneous pen injector


sumatriptan succinate subcutaneous solution


sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml



sumatriptan-naproxen 2QL (18 EA per 28 days)

zolmitriptan 2QL (18 EA per 28 days)

ANTIMYASTHENIC AGENTSPARASYMPATHOMIMETICSguanidine 2

pyridostigmine bromide oral syrup

5

pyridostigmine bromide oral tablet 60 mg

2

pyridostigmine bromide oral tablet extended release

2

ANTIMYCOBACTERIALSANTIMYCOBACTERIALS, OTHER

dapsone oral 2

PRIFTIN 3

rifabutin 2

ANTITUBERCULARSethambutol 2

isoniazid oral 2

PASER 3

pyrazinamide 2

rifampin 2

SIRTURO 5

TRECATOR 3

ANTINEOPLASTICSALKYLATING AGENTScyclophosphamide oral capsule

2 BvD

LEUKERAN 3

33


MATULANE 5

VALCHLOR 5

ANTIANDROGENS

abiraterone 5PAns; QL (120 EA per 30 days)

bicalutamide 2

ERLEADA 5 PAns

flutamide 2

nilutamide 5

NUBEQA 5 PAns

XTANDI 5PAns; QL (120 EA per 30 days)

YONSA 5PAns; QL (120 EA per 30 days)

ZYTIGA ORAL TABLET 500 MG


ANTIANGIOGENIC AGENTSPOMALYST 5 PAns

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG


THALOMID 5 PAns

ANTIESTROGENS/MODIFIERSEMCYT 5

SOLTAMOX 3

tamoxifen 2

toremifene 5

ANTIMETABOLITESDROXIA 3

hydroxyurea 2

LONSURF 5 PAns

PURIXAN 5

SIKLOS 5


TABLOID 4

ANTINEOPLASTICS, OTHERleucovorin calcium oral 2

REVLIMID ORAL CAPSULE 2.5 MG, 20 MG


SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG

5

SYNRIBO 5 BvD

XPOVIO 5 PAns

ANTINEOPLASTICSGLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

3

LYNPARZA ORAL TABLET


MESNEX ORAL 5

NINLARO 5PAns; QL (3 EA per 28 days)

RUBRACA 5PAns; QL (120 EA per 30 days)

TALZENNA ORAL CAPSULE 0.25 MG


TALZENNA ORAL CAPSULE 1 MG


VENCLEXTA ORAL TABLET 10 MG, 50 MG

3 PAns

VENCLEXTA ORAL TABLET 100 MG

5 PAns

VENCLEXTA STARTING PACK


34


ZEJULA 5PAns; QL (90 EA per 30 days)

AROMATASE INHIBITORS, 3RD GENERATIONanastrozole 2

exemestane 2

letrozole 2

ENZYME INHIBITORS

COPIKTRA 5PAns; QL (60 EA per 30 days)

FARYDAK ORAL CAPSULE 10 MG, 20 MG


IBRANCE ORAL CAPSULE


IDHIFA 5PAns; QL (30 EA per 30 days)

KISQALI 5 PAns

KISQALI FEMARA CO-PACK

5 PAns

PIQRAY 5 PAns

TIBSOVO 5 PAns

VERZENIO 5PAns; QL (60 EA per 30 days)

VITRAKVI ORAL CAPSULE 100 MG


VITRAKVI ORAL CAPSULE 25 MG


VITRAKVI ORAL SOLUTION


XOSPATA 5 PAns

ZOLINZA 5


ZYDELIG 5PAns; QL (60 EA per 30 days)

MOLECULAR TARGET INHIBITORS

AFINITOR 5PAns; QL (30 EA per 30 days)

ALECENSA 5PAns; QL (240 EA per 30 days)

ALUNBRIG ORAL TABLET 180 MG, 90 MG


ALUNBRIG ORAL TABLET 30 MG


ALUNBRIG ORAL TABLETS,DOSE PACK


AYVAKIT 5 PAns; LA

BALVERSA 5 PAns

BOSULIF ORAL TABLET 100 MG


BOSULIF ORAL TABLET 400 MG, 500 MG


BRAFTOVI ORAL CAPSULE 75 MG


BRUKINSA 5 PAns; LA

CABOMETYX 5 PAns

CALQUENCE 5PAns; QL (60 EA per 30 days)

CAPRELSA ORAL TABLET 100 MG


CAPRELSA ORAL TABLET 300 MG


COMETRIQ 5 PAns

35


COTELLIC 5PAns; QL (63 EA per 28 days)

DAURISMO ORAL TABLET 100 MG


DAURISMO ORAL TABLET 25 MG


ERIVEDGE 5PAns; QL (30 EA per 30 days)

erlotinib oral tablet 100 mg, 150 mg


erlotinib oral tablet 25 mg


everolimus (antineoplastic)


GILOTRIF 5PAns; QL (30 EA per 30 days)

ICLUSIG ORAL TABLET 15 MG


ICLUSIG ORAL TABLET 45 MG


imatinib oral tablet 100 mg


imatinib oral tablet 400 mg


IMBRUVICA ORAL CAPSULE 140 MG


IMBRUVICA ORAL CAPSULE 70 MG


IMBRUVICA ORAL TABLET



INLYTA ORAL TABLET 1 MG


INLYTA ORAL TABLET 5 MG


INREBIC 5PAns; QL (120 EA per 30 days)

IRESSA 5PAns; QL (30 EA per 30 days)

JAKAFI 5PAns; QL (60 EA per 30 days)

LENVIMA 5 PAns

LORBRENA ORAL TABLET 100 MG


LORBRENA ORAL TABLET 25 MG


MEKINIST ORAL TABLET 0.5 MG


MEKINIST ORAL TABLET 2 MG


MEKTOVI 5PAns; QL (180 EA per 30 days)

NERLYNX 5 PAns

NEXAVAR 5PAns; QL (120 EA per 30 days)

ODOMZO 5PAns; QL (30 EA per 30 days)

OFEV 5PA; QL (60 EA per 30 days)

ROZLYTREK ORAL CAPSULE 100 MG


36


ROZLYTREK ORAL CAPSULE 200 MG


RYDAPT 5 PAns

SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG


SPRYCEL ORAL TABLET 20 MG, 70 MG


STIVARGA 5PAns; QL (84 EA per 28 days)

SUTENT 5PAns; QL (30 EA per 30 days)

TAFINLAR 5PAns; QL (120 EA per 30 days)

TAGRISSO 5PAns; QL (30 EA per 30 days)

TASIGNA ORAL CAPSULE 150 MG, 200 MG


TASIGNA ORAL CAPSULE 50 MG


TAZVERIK 5 PAns; LA

TYKERB 5PAns; QL (180 EA per 30 days)

VIZIMPRO 5PAns; QL (30 EA per 30 days)

VOTRIENT 5PAns; QL (120 EA per 30 days)

XALKORI 5PAns; QL (60 EA per 30 days)

ZELBORAF 5PAns; QL (240 EA per 30 days)


ZYKADIA ORAL TABLET


RETINOIDSbexarotene 5 PAns

PANRETIN 5

TARGRETIN TOPICAL

5 PAns

tretinoin (antineoplastic)

5

tretinoin topical cream 2 PA

tretinoin topical gel0.01 %, 0.025 %

2 PA

TREATMENT ADJUNCTS

leucovorin calcium oral 2

ANTIPARASITICSANTHELMINTICSalbendazole 5

EMVERM 5

ivermectin oral 2

praziquantel 2

ANTIPROTOZOALSALINIA ORAL SUSPENSION FOR RECONSTITUTION

3

ALINIA ORAL TABLET

5

atovaquone 5

atovaquone-proguanil 2

benznidazole 3

chloroquine phosphate 2

COARTEM 3

DARAPRIM 5 PA

hydroxychloroquine 2

mefloquine 2

NEBUPENT 3BvD; QL (1 EA per 28 days)

37


PENTAM 4

pentamidine inhalation 2BvD; QL (1 EA per 28 days)

pentamidine injection 2

primaquine 3

quinine sulfate 2

PEDICULICIDES/SCABICIDESlindane topical shampoo 2

malathion 2

permethrin topical cream

2

ANTIPARKINSON AGENTSANTICHOLINERGICSbenztropine oral 2 PA

ANTIPARKINSON AGENTS, OTHERamantadine hcl 2

carbidopa-levodopa-entacapone

4

entacapone 2

tolcapone 5

ANTIPARKINSON AGENTScarbidopa 2

carbidopa-levodopa-entacapone

4

DOPAMINE AGONISTSAPOKYN 5

bromocriptine 4

NEUPRO 4

pramipexole 2

ropinirole 2


DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORScarbidopa 2

carbidopa-levodopa 2

MONOAMINE OXIDASE B (MAO-B) INHIBITORSrasagiline 2

selegiline hcl 2

ANTIPSYCHOTICS1ST GENERATION/TYPICALchlorpromazine oral 2

fluphenazine decanoate 2

fluphenazine hcl 2

haloperidol 1

haloperidol decanoate intramuscular solution100 mg/ml, 50 mg/ml

2

haloperidol lactate injection

2

haloperidol lactate oral 2

loxapine succinate 2

molindone 2

perphenazine 2

pimozide 2

prochlorperazine maleate

1

thioridazine 4

thiothixene 1

trifluoperazine 2

2ND GENERATION/ATYPICALABILIFY MAINTENA 5

38


aripiprazole oral solution

5

aripiprazole oral tablet 2QL (30 EA per 30 days)

aripiprazole oral tablet,disintegrating


ARISTADA 5

ARISTADA INITIO 5

FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG


FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG


FANAPT ORAL TABLETS,DOSE PACK


GEODON INTRAMUSCULAR

4

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

5

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML

4

INVEGA TRINZA 5

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG


LATUDA ORAL TABLET 80 MG


NUPLAZID ORAL CAPSULE


NUPLAZID ORAL TABLET 10 MG


olanzapine intramuscular

2


olanzapine oral 2QL (30 EA per 30 days)

paliperidone oral tablet extended release 24hr1.5 mg, 3 mg


paliperidone oral tablet extended release 24hr 6 mg


paliperidone oral tablet extended release 24hr 9 mg


PERSERIS 5









REXULTI 5QL (30 EA per 30 days)

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML

3


5

risperidone oral solution

2

risperidone oral tablet0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg


risperidone oral tablet 4 mg


39


risperidone oral tablet,disintegrating0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg


risperidone oral tablet,disintegrating 4 mg


SAPHRIS 5QL (60 EA per 30 days)

SECUADO 5QL (30 EA per 30 days)

VRAYLAR ORAL CAPSULE


VRAYLAR ORAL CAPSULE,DOSE PACK


ziprasidone hcl 2QL (60 EA per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG

4

TREATMENT-RESISTANT

clozapine oral tablet 2

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

2

clozapine oral tablet,disintegrating 150 mg, 200 mg

4

VERSACLOZ 5

ANTISPASTICITY AGENTSANTISPASTICITY AGENTSbaclofen oral tablet 10 mg, 20 mg

2

dantrolene oral 2

tizanidine 2


ANTIVIRALSANTI-CYTOMEGALOVIRUS (CMV) AGENTS

PREVYMIS ORAL 5QL (30 EA per 30 days)

valganciclovir 5

ZIRGAN 4

ANTI-HEPATITIS B (HBV) AGENTSadefovir 5

BARACLUDE ORAL SOLUTION

5

entecavir 2

EPIVIR HBV ORAL SOLUTION

3

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML)

5 BvD

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML

3 BvD


5 BvD

lamivudine 2

ribavirin oral capsule 2

ribavirin oral tablet 200 mg

2

tenofovir disoproxil fumarate

2

VEMLIDY 5

VIREAD ORAL POWDER

5

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

5

40


ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING

EPCLUSA 5PA; QL (28 EA per 28 days)

HARVONI ORAL TABLET 90-400 MG


ANTI-HEPATITIS C (HCV) AGENTS, OTHERS

EPCLUSA 5PA; QL (28 EA per 28 days)



INTRON A INJECTION RECON SOLN

5 BvD


5 BvD

PEGASYS SUBCUTANEOUS SOLUTION


PEGASYS SUBCUTANEOUS SYRINGE


ribavirin oral capsule 2

ribavirin oral tablet 200 mg

2

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG

5

ANTIHERPETIC AGENTSacyclovir oral capsule 2

acyclovir oral suspension 200 mg/5 ml

2

acyclovir oral tablet 2

acyclovir sodium intravenous solution

4 BvD

acyclovir topical cream 2PA; QL (5 GM per 30 days)


acyclovir topical ointment


DENAVIR 3

famciclovir 2

trifluridine 2

valacyclovir oral tablet1 gram


valacyclovir oral tablet500 mg


ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)BIKTARVY 5

GENVOYA 5

ISENTRESS HD 5

ISENTRESS ORAL POWDER IN PACKET

5

ISENTRESS ORAL TABLET

5

ISENTRESS ORAL TABLET,CHEWABLE 100 MG

5

ISENTRESS ORAL TABLET,CHEWABLE 25 MG

3

STRIBILD 5

SYMTUZA 5

TIVICAY ORAL TABLET 10 MG

3

TIVICAY ORAL TABLET 25 MG, 50 MG

5

41


ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)COMPLERA 5

EDURANT 5

efavirenz oral capsule200 mg

5

efavirenz oral capsule50 mg

2

efavirenz oral tablet 5

INTELENCE ORAL TABLET 100 MG, 200 MG

5

INTELENCE ORAL TABLET 25 MG

3

nevirapine 2

PIFELTRO 5

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)abacavir 2

abacavir-lamivudine 2

abacavir-lamivudine-zidovudine

5

ATRIPLA 5

CIMDUO 5

DELSTRIGO 5

DESCOVY 5

didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg

2

DOVATO 5


EMTRIVA 3

JULUCA 5

lamivudine 2

lamivudine-zidovudine 2

ODEFSEY 5

stavudine oral capsule 2

SYMFI 5

SYMFI LO 5

tenofovir disoproxil fumarate

2

TRUVADA 5

VIREAD ORAL POWDER

5

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

5

zidovudine 2

ANTI-HIV AGENTS, OTHERFUZEON SUBCUTANEOUS RECON SOLN

5

SELZENTRY ORAL SOLUTION

3

SELZENTRY ORAL TABLET 150 MG, 300 MG

5

SELZENTRY ORAL TABLET 25 MG, 75 MG

3

TRIUMEQ 5

ANTI-HIV AGENTS, PROTEASE INHIBITORS

APTIVUS 5

APTIVUS (WITH VITAMIN E)

5

atazanavir oral capsule150 mg, 200 mg

2

atazanavir oral capsule300 mg

5

42


CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

3

EVOTAZ 5

fosamprenavir 5

INVIRASE ORAL TABLET

5

KALETRA ORAL TABLET 100-25 MG

3

KALETRA ORAL TABLET 200-50 MG

5

LEXIVA ORAL SUSPENSION

3

lopinavir-ritonavir 2

NORVIR ORAL POWDER IN PACKET

3

NORVIR ORAL SOLUTION

3

PREZCOBIX 5

PREZISTA ORAL SUSPENSION

5

PREZISTA ORAL TABLET 150 MG, 75 MG

3

PREZISTA ORAL TABLET 600 MG, 800 MG

5

REYATAZ ORAL POWDER IN PACKET

5

ritonavir 2

VIRACEPT ORAL TABLET

5

ANTI-INFLUENZA AGENTSamantadine hcl 2

oseltamivir 2

RELENZA DISKHALER

3

rimantadine 2

XOFLUZA 3


ANXIOLYTICSANXIOLYTICS, OTHERbuspirone 2

doxepin oral capsule 4


4



2 PA

BENZODIAZEPINESclonazepam oral tablet0.5 mg, 1 mg


clonazepam oral tablet2 mg


clonazepam oral tablet,disintegrating0.125 mg, 0.25 mg, 0.5 mg, 1 mg


clonazepam oral tablet,disintegrating 2 mg


clorazepate dipotassium oral tablet 15 mg






DIASTAT 4

DIASTAT ACUDIAL 4





43



diazepam rectal 2

lorazepam oral concentrate


lorazepam oral tablet0.5 mg, 1 mg


lorazepam oral tablet 2 mg


NAYZILAM 5PAns; QL (10 EA per 30 days)

VALTOCO 5PAns; QL (10 EA per 30 days)

SSRIS/ SNRISDRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG, 30 MG, 60 MG


DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 40 MG


duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg




escitalopram oxalate oral solution

2

escitalopram oxalate oral tablet


paroxetine hcl oral tablet 10 mg, 20 mg, 40 mg


paroxetine hcl oral tablet 30 mg



paroxetine hcl oral tablet extended release 24 hr


PAXIL ORAL SUSPENSION

4

sertraline oral concentrate

2

sertraline oral tablet100 mg, 50 mg


sertraline oral tablet 25 mg


venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg


venlafaxine oral capsule,extended release 24hr 75 mg


venlafaxine oral tablet 2QL (90 EA per 30 days)

venlafaxine oral tablet extended release 24hr


BIPOLAR AGENTSBIPOLAR AGENTS, OTHERGEODON INTRAMUSCULAR

4

olanzapine intramuscular

2

olanzapine oral 2QL (30 EA per 30 days)

PERSERIS 5







44





3


5

risperidone oral solution

2

risperidone oral tablet0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg


risperidone oral tablet 4 mg


risperidone oral tablet,disintegrating0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg


risperidone oral tablet,disintegrating 4 mg


SAPHRIS 5QL (60 EA per 30 days)

SECUADO 5QL (30 EA per 30 days)

VRAYLAR ORAL CAPSULE


VRAYLAR ORAL CAPSULE,DOSE PACK


ziprasidone hcl 2QL (60 EA per 30 days)


ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG

4

MOOD STABILIZERScarbamazepine oral capsule, er multiphase 12 hr

2

carbamazepine oral suspension 100 mg/5 ml

2

carbamazepine oral tablet

1

carbamazepine oral tablet extended release 12 hr 100 mg

2

carbamazepine oral tablet,chewable

1

divalproex oral capsule, delayed rel sprinkle

2


2


1

EPITOL 2

lamotrigine oral tablet 1

lamotrigine oral tablet extended release 24hr50 mg

4

lamotrigine oral tablet, chewable dispersible

2

lamotrigine oral tablet,disintegrating

4

lamotrigine oral tablets,dose pack

2

lithium carbonate 1

lithium citrate oral solution 8 meq/5 ml

2

valproic acid 2

45



2

BLOOD GLUCOSE REGULATORSANTIDIABETIC AGENTSacarbose oral tablet 100 mg


acarbose oral tablet 25 mg


acarbose oral tablet 50 mg


BYDUREON BCISE 3PA; QL (4 ML per 28 days)

BYDUREON SUBCUTANEOUS PEN INJECTOR


BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML

3PA; QL (2.4 ML per 30 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML


colesevelam 2

CYCLOSET 4QL (180 EA per 30 days)

FARXIGA ORAL TABLET 10 MG


FARXIGA ORAL TABLET 5 MG


glimepiride oral tablet 1 mg







glipizide oral tablet 10 mg


glipizide oral tablet 5 mg


glipizide oral tablet extended release 24hr10 mg


glipizide oral tablet extended release 24hr2.5 mg


glipizide oral tablet extended release 24hr 5 mg


INVOKAMET 3QL (60 EA per 30 days)

INVOKAMET XR 3QL (60 EA per 30 days)

INVOKANA 3QL (30 EA per 30 days)

JANUVIA 3QL (30 EA per 30 days)

metformin oral tablet1,000 mg


metformin oral tablet500 mg


metformin oral tablet850 mg


metformin oral tablet extended release 24 hr500 mg


metformin oral tablet extended release 24 hr750 mg


miglitol oral tablet 100 mg






nateglinide oral tablet120 mg


nateglinide oral tablet60 mg


46


ONGLYZA 3QL (30 EA per 30 days)

pioglitazone 1QL (30 EA per 30 days)

repaglinide oral tablet0.5 mg


repaglinide oral tablet 1 mg


repaglinide oral tablet 2 mg


RIOMET 3QL (765 ML per 30 days)

SYMLINPEN 120 5PA; QL (10.8 ML per 30 days)

SYMLINPEN 60 5PA; QL (6 ML per 30 days)

TRULICITY 3PA; QL (2 ML per 28 days)

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG


XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG


BLOOD GLUCOSE REGULATORSglipizide-metformin oral tablet 2.5-250 mg


glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg


JANUMET 3QL (60 EA per 30 days)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG



JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG


KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG


KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG


pioglitazone-glimepiride 2QL (30 EA per 30 days)

pioglitazone-metformin 2QL (90 EA per 30 days)

GLYCEMIC AGENTSBAQSIMI 3

GLUCAGEN HYPOKIT

3

GLUCAGON EMERGENCY KIT (HUMAN)

3

KORLYM 5 PA

PROGLYCEM 3

INSULINSASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2"

3

GAUZE PAD TOPICAL BANDAGE 2 X 2 "

3

HUMALOG JUNIOR KWIKPEN U-100

3

HUMALOG KWIKPEN INSULIN

3

HUMALOG MIX 50-50 INSULN U-100

3

HUMALOG MIX 50-50 KWIKPEN

3

47


HUMALOG MIX 75-25 KWIKPEN

3

HUMALOG MIX 75-25(U-100)INSULN

3

HUMALOG U-100 INSULIN

3

HUMULIN 70/30 U-100 INSULIN

3

HUMULIN 70/30 U-100 KWIKPEN

3

HUMULIN N NPH INSULIN KWIKPEN

3

HUMULIN N NPH U-100 INSULIN

3

HUMULIN R REGULAR U-100 INSULN

3

HUMULIN R U-500 (CONC) INSULIN

3

HUMULIN R U-500 (CONC) KWIKPEN

3

insulin syringe-needle u-100 syringe 0.3 ml 29 gauge, 1 ml 29 gauge x 1/2", 1/2 ml 28 gauge

3

LANTUS SOLOSTAR U-100 INSULIN

3

LANTUS U-100 INSULIN

3

pen needle, diabetic needle 29 gauge x 1/2"

3

TOUJEO MAX U-300 SOLOSTAR

3

TOUJEO SOLOSTAR U-300 INSULIN

3


BLOOD PRODUCTS/ MODIFIERS/ VOLUME EXPANDERSANTICOAGULANTSELIQUIS 3

ELIQUIS DVT-PE TREAT 30D START

3

enoxaparin subcutaneous syringe

2

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

5

fondaparinux subcutaneous syringe2.5 mg/0.5 ml

2

heparin (porcine) injection solution

2

JANTOVEN 1

PRADAXA 4

warfarin 1

XARELTO 3

BLOOD FORMATION MODIFIERSanagrelide 2

CABLIVI INJECTION KIT

5 PA

DOPTELET (10 TAB PACK)

5 PA


5 PA


5 PA

FULPHILA 5 PA

GRANIX 5 PA

LEUKINE INJECTION RECON SOLN

5 PA

48


MULPLETA 5 PA

NEULASTA SUBCUTANEOUS SYRINGE

5 PA

NEUPOGEN 5 PA

PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

3 PA

PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML

5 PA

PROMACTA ORAL POWDER IN PACKET 12.5 MG

5 PA

PROMACTA ORAL TABLET

5 PA

RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

3 PA

RETACRIT INJECTION SOLUTION 40,000 UNIT/ML

5 PA

ZARXIO 5 PA

ZIEXTENZO 5 PA

HEMOSTASIS AGENTStranexamic acid oral 2

PLATELET MODIFYING AGENTSaspirin-dipyridamole 2

BRILINTA 3

cilostazol 2

clopidogrel oral tablet75 mg



dipyridamole oral 2

prasugrel 2

CARDIOVASCULAR AGENTSALPHA-ADRENERGIC AGONISTS

clonidine 4QL (4 EA per 28 days)

clonidine hcl oral tablet 1

methyldopa 2

midodrine 2

NORTHERA 5 PA

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin oral tablet 1 mg, 2 mg, 4 mg


doxazosin oral tablet 8 mg


phenoxybenzamine 5 PA

prazosin 2

terazosin oral capsule 1 mg, 2 mg, 5 mg


terazosin oral capsule10 mg


ANGIOTENSIN II RECEPTOR ANTAGONISTScandesartan 2

ENTRESTO 3QL (60 EA per 30 days)

irbesartan 1

losartan 1

olmesartan 1

olmesartan-hydrochlorothiazide

1

telmisartan 2

valsartan 1

49


ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORSbenazepril 1

captopril 2

enalapril maleate 1

fosinopril 1

lisinopril 1

moexipril 1

perindopril erbumine 1

quinapril 1

ramipril 1

trandolapril 1

ANTIARRHYTHMICSamiodarone oral 2

dofetilide 2

flecainide 2

mexiletine 2

PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG

2

propafenone 2

quinidine gluconate oral 2

quinidine sulfate oral tablet

2

SORINE 2

SOTALOL AF ORAL TABLET 120 MG

2

SOTALOL AF ORAL TABLET 160 MG, 80 MG

5

sotalol oral 2

SOTYLIZE 3

BETA-ADRENERGIC BLOCKING AGENTSacebutolol 2


atenolol 1

betaxolol oral 2

bisoprolol fumarate 2

carvedilol 1

carvedilol phosphate 2

labetalol oral 2

metoprolol succinate 1

metoprolol tartrate oral 1

nadolol 2

pindolol 2

propranolol oral capsule,extended release 24 hr

2

propranolol oral solution

2

propranolol oral tablet 1

timolol maleate oral 2

CALCIUM CHANNEL BLOCKING AGENTSamlodipine 1

CARTIA XT 2

diltiazem hcl oral capsule,extended release 12 hr

2

diltiazem hcl oral capsule,extended release 24 hr 360 mg, 420 mg

2

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

2

diltiazem hcl oral tablet 1

DILT-XR 2

felodipine 2

isradipine 2

MATZIM LA 2

nicardipine oral 2

50


nifedipine oral tablet extended release

2

nifedipine oral tablet extended release 24hr

2

nimodipine 2

nisoldipine 2

TAZTIA XT 2

TIADYLT ER ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 420 MG

2

tiadylt er oral capsule,extended release 24 hr 360 mg

2

verapamil oral capsule, 24 hr er pellet ct

2

verapamil oral capsule,ext rel. pellets 24 hr

2

verapamil oral tablet 1

verapamil oral tablet extended release

2

CARDIOVASCULAR AGENTS, OTHERaliskiren 2

CORLANOR 3 PA

DIGITEK 2

DIGOX 2

digoxin oral solution 50 mcg/ml (0.05 mg/ml)

2

digoxin oral tablet 2

LANOXIN ORAL TABLET 62.5 MCG (0.0625 MG)

3

pentoxifylline 2

ranolazine 2

UPTRAVI 5 PA

CARDIOVASCULAR AGENTSaliskiren 2


amiloride-hydrochlorothiazide

2

amlodipine-atorvastatin 2QL (30 EA per 30 days)

amlodipine-benazepril 1

amlodipine-olmesartan 2

amlodipine-valsartan 2

amlodipine-valsartan-hcthiazid

2

atenolol-chlorthalidone 2

benazepril-hydrochlorothiazide

2

bisoprolol-hydrochlorothiazide

1

candesartan-hydrochlorothiazid

2

captopril-hydrochlorothiazide

2

DEMSER 5 PA

enalapril-hydrochlorothiazide

1

ezetimibe-simvastatin 2QL (30 EA per 30 days)

fosinopril-hydrochlorothiazide

2

irbesartan-hydrochlorothiazide

1

lisinopril-hydrochlorothiazide

1

losartan-hydrochlorothiazide

1

metoprolol ta-hydrochlorothiaz

2

olmesartan-amlodipin-hcthiazid

2

olmesartan-hydrochlorothiazide

1

propranolol-hydrochlorothiazid

2

quinapril-hydrochlorothiazide

2

51


spironolacton-hydrochlorothiaz

2

TEKTURNA HCT 3

telmisartan-amlodipine 2

telmisartan-hydrochlorothiazid

2

trandolapril-verapamil 2

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

1

triamterene-hydrochlorothiazid oral tablet

1

valsartan-hydrochlorothiazide

1

DIURETICS, CARBONIC ANHYDRASE INHIBITORS

acetazolamide 2

methazolamide 2

DIURETICS, LOOPbumetanide 2

ethacrynic acid 5

furosemide injection 2

furosemide oral solution10 mg/ml, 40 mg/5 ml (8 mg/ml)

2

furosemide oral tablet 1

torsemide oral 2

DIURETICS, POTASSIUM-SPARING

amiloride 2

eplerenone 2

spironolactone 1

triamterene 2

DIURETICS, THIAZIDEchlorthalidone oral tablet 25 mg, 50 mg

1


hydrochlorothiazide 1

indapamide 2

irbesartan-hydrochlorothiazide

1

metolazone 2

DYSLIPIDEMICS, FIBRIC ACID DERIVATIVESfenofibrate micronized 2

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

2

fenofibrate oral tablet 2

fenofibric acid (choline) 2

gemfibrozil 1

DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS

atorvastatin 1QL (30 EA per 30 days)

fluvastatin oral capsule20 mg


fluvastatin oral capsule40 mg


fluvastatin oral tablet extended release 24 hr


lovastatin oral tablet 10 mg


lovastatin oral tablet 20 mg, 40 mg


pravastatin 1QL (30 EA per 30 days)

rosuvastatin 1QL (30 EA per 30 days)

simvastatin oral tablet 1QL (30 EA per 30 days)

DYSLIPIDEMICS, OTHERcholestyramine (with sugar) oral powder in packet

2

52


CHOLESTYRAMINE LIGHT ORAL POWDER

2

colesevelam 2

colestipol oral packet 2

colestipol oral tablet 2

ezetimibe 2

JUXTAPID 5 PA

niacin oral tablet extended release 24 hr

2

PRALUENT PEN 3PA; QL (2 ML per 28 days)

PREVALITE ORAL POWDER IN PACKET

2

REPATHA PUSHTRONEX


REPATHA SURECLICK


REPATHA SYRINGE 3PA; QL (3 ML per 28 days)

VASCEPA 3

VASODILATORS, DIRECT-ACTING ARTERIAL/ VENOUSisosorbide dinitrate oral tablet

2

isosorbide mononitrate 1

NITRO-BID 2

nitroglycerin sublingual 2

nitroglycerin transdermal patch 24 hour

2

nitroglycerin translingual spray,non-aerosol

2

RECTIV 3

VASODILATORS, DIRECT-ACTING ARTERIALhydralazine oral 2


minoxidil oral 2

CENTRAL NERVOUS SYSTEM AGENTSATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINESdextroamphetamine oral solution

2

dextroamphetamine-amphetamine

2

PROCENTRA 2

ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINESatomoxetine 2

clonidine hcl oral tablet extended release 12 hr

2

METADATE ER 2

methylphenidate hcl oral capsule,er biphasic 50-50

2

methylphenidate hcl oral solution

2

methylphenidate hcl oral tablet

2

methylphenidate hcl oral tablet extended release

2

methylphenidate hcl oral tablet,chewable

2

CENTRAL NERVOUS SYSTEM, OTHERNUEDEXTA 5 PA

53


riluzole 2

tetrabenazine oral tablet12.5 mg


tetrabenazine oral tablet25 mg


VECAMYL 5

FIBROMYALGIA AGENTSduloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg




LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG


LYRICA ORAL CAPSULE 225 MG, 300 MG


LYRICA ORAL SOLUTION


pregabalin oral capsule100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg


pregabalin oral capsule225 mg, 300 mg


pregabalin oral solution 2QL (900 ML per 30 days)

MULTIPLE SCLEROSIS AGENTSAVONEX INTRAMUSCULAR PEN INJECTOR KIT


AVONEX INTRAMUSCULAR SYRINGE KIT


dalfampridine 5 PA


FIRDAPSE 5 PA

GILENYA ORAL CAPSULE 0.5 MG

5 PA

glatiramer subcutaneous syringe 20 mg/ml


glatiramer subcutaneous syringe 40 mg/ml


GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML


GLATOPA SUBCUTANEOUS SYRINGE 40 MG/ML


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML


PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML


PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML


PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML


REBIF (WITH ALBUMIN)


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML


REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)


54


REBIF TITRATION PACK


TECFIDERA 5 PA

DENTAL AND ORAL AGENTSDENTAL AND ORAL AGENTScevimeline 2

chlorhexidine gluconate mucous membrane

2

doxycycline hyclate oral capsule

2

doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 75 mg

2

doxycycline monohydrate oral tablet150 mg, 75 mg

2

minocycline oral capsule

2

minocycline oral tablet 2


2

pilocarpine hcl oral 2

triamcinolone acetonide dental

2

DERMATOLOGICAL AGENTSDERMATOLOGICAL AGENTSacitretin oral capsule 10 mg, 25 mg

2

acitretin oral capsule17.5 mg

5

ammonium lactate 2

AMNESTEEM 2

azelaic acid 2


betamethasone dipropionate topical lotion

2

calcipotriene scalp 2QL (120 ML per 30 days)

calcipotriene topical cream


calcipotriene topical ointment


calcipotriene-betamethasone topical ointment


calcitriol topical 4

CLARAVIS 4

clobetasol topical spray,non-aerosol


clotrimazole-betamethasone topical cream


clotrimazole-betamethasone topical lotion


dapsone topical gel 2





doxepin topical 5QL (45 GM per 30 days)

doxycycline hyclate oral capsule 50 mg

2

doxycycline monohydrate oral capsule 100 mg, 50 mg

2

doxycycline monohydrate oral tablet100 mg, 50 mg

2

DUPIXENT 5 PA

fluocinonide topical cream 0.1 %


fluorouracil topical cream 5 %

2

55


fluorouracil topical solution

2

hydrocortisone butyrate topical lotion

2

imiquimod topical cream in packet

2

isotretinoin 2

ivermectin topical 2

mafenide acetate 2

methoxsalen 5


2

MYORISAN 2

NOLIX TOPICAL CREAM


nystatin-triamcinolone 2QL (60 GM per 28 days)

oxiconazole 2

pimecrolimus 2PA; QL (100 GM per 30 days)

podofilox 2

prednicarbate topical cream

2

PRUDOXIN 2QL (45 GM per 30 days)

REGRANEX 5

SANTYL 3

selenium sulfide topical lotion

2

SKYRIZI SUBCUTANEOUS SYRINGE KIT


STELARA SUBCUTANEOUS

5 PA

tacrolimus topical 2PA; QL (100 GM per 30 days)

tazarotene 2 PA

TAZORAC TOPICAL CREAM 0.05 %

3 PA


TAZORAC TOPICAL GEL

3 PA

tretinoin 2 PA

triamcinolone acetonide topical ointment 0.05 %

2

TRIANEX 2

VALCHLOR 5

ZENATANE 4

ELECTROLYTES/MINERALS/METALS/VITAMINSELECTROLYTE/ MINERAL REPLACEMENTCARBAGLU 5 PA

ISOLYTE-S 3

KLOR-CON 10 2

KLOR-CON 8 2

KLOR-CON M10 2

KLOR-CON M15 2

KLOR-CON M20 2

K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ

2

magnesium sulfate injection

2

NORMOSOL-R PH 7.4 3

PLASMA-LYTE 148 3

PLASMA-LYTE A 3

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

2

potassium chloride in water intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml

2

56


potassium chloride intravenous solution 2 meq/ml

2

potassium chloride oral capsule, extended release

1

potassium chloride oral liquid

2

potassium chloride oral packet

2

potassium chloride oral tablet extended release

1

potassium chloride oral tablet,er particles/crystals

1

potassium chloride-0.45 % nacl

2

sodium chloride 0.45 % intravenous parenteral solution

5

sodium chloride 0.9 % intravenous parenteral solution

2

sodium chloride 3 % 2

sodium chloride 5 % 2

sodium chloride irrigation

2

ELECTROLYTE/MINERAL/METAL MODIFIERSCHEMET 3 PA

CLOVIQUE 5

deferasirox oral tablet360 mg, 90 mg

5 PA

deferasirox oral tablet, dispersible

5 PA

DEPEN TITRATABS 5

FERRIPROX 5 PA

KIONEX (WITH SORBITOL)

2

KLOR-CON 2

LOKELMA 3


penicillamine 5

PLENAMINE 2 BvD

SAMSCA 5 PA

sodium polystyrene sulfonate oral powder

2

SPS (WITH SORBITOL) ORAL

2

trientine 5 PA

VELTASSA 3

ELECTROLYTES/MINERALS/METALS/VITAMINSAMINOSYN II 10 % 3 BvD

AMINOSYN II 15 % 3 BvD

AMINOSYN-PF 10 % 3 BvD

AMINOSYN-PF 7 % (SULFITE-FREE)

3 BvD

CLINIMIX 5%/D15W SULFITE FREE

3 BvD

CLINIMIX 4.25%/D10W SULF FREE

3 BvD

CLINIMIX 4.25%/D5W SULFIT FREE

3 BvD

CLINIMIX 5%-D20W(SULFITE-FREE)

3 BvD

d10 %-0.45 % sodium chloride

2

d2.5 %-0.45 % sodium chloride

2

d5 % and 0.9 % sodium chloride

2

d5 %-0.45 % sodium chloride

2

dextrose 10 % and 0.2 % nacl

2

dextrose 10 % in water (d10w)

2

dextrose 5 % in water (d5w) intravenous parenteral solution

2

57


dextrose 5%-0.2 % sod chloride

2

HEPATAMINE 8% 3 BvD

INTRALIPID INTRAVENOUS EMULSION 20 %

2 BvD

ISOLYTE-P IN 5 % DEXTROSE

3

levocarnitine (with sugar)

2

levocarnitine oral tablet 2

NEPHRAMINE 5.4 % 3 BvD

NORMOSOL-R IN 5 % DEXTROSE

3

PLENAMINE 2 BvD

potassium chlorid-d5-0.45%nacl

2

potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l

2

potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l

2

potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l

2

potassium chloride-d5-0.9%nacl

2

PREMASOL 10 % 2 BvD

PRENATAL VITAMIN PLUS LOW IRON

2

TRAVASOL 10 % 4 BvD

TROPHAMINE 10 % 3 BvD

TROPHAMINE 6% 3 BvD

VITAMINSdoxercalciferol oral 2

KLOR-CON 10 2

KLOR-CON 8 2

KLOR-CON M10 2


KLOR-CON M15 2

KLOR-CON M20 2

GASTROINTESTINAL AGENTSANTISPASMODICS, GASTROINTESTINALdicyclomine oral capsule

2

dicyclomine oral solution

2

dicyclomine oral tablet 2

glycopyrrolate oral tablet 1 mg, 2 mg

2

scopolamine base 2

GASTROINTESTINAL AGENTS, OTHER

CHENODAL 5 PA

CHOLBAM ORAL CAPSULE 250 MG

5 PA

CHOLBAM ORAL CAPSULE 50 MG


diphenoxylate-atropine 2

GATTEX 30-VIAL 5 PA

loperamide oral capsule 2

metoclopramide hcl oral solution

2

metoclopramide hcl oral tablet

1

metoclopramide hcl oral tablet,disintegrating

2

MOVANTIK 3

OCALIVA 5PA; QL (30 EA per 30 days)

PROCTOZONE-HC 2

RELISTOR SUBCUTANEOUS SOLUTION

5

58


RELISTOR SUBCUTANEOUS SYRINGE

5

ursodiol 2

XERMELO 5PA; QL (90 EA per 30 days)



GASTROINTESTINAL AGENTSamoxicil-clarithromy-lansopraz


HISTAMINE2 (H2) RECEPTOR ANTAGONISTScimetidine 2

cimetidine hcl oral 2

famotidine oral suspension

2

famotidine oral tablet20 mg, 40 mg

1

nizatidine 2

IRRITABLE BOWEL SYNDROME AGENTSalosetron 5

budesonide oral capsule,delayed,extend.release

2

budesonide oral tablet,delayed and ext.release

5

mesalamine oral capsule (with del rel tablets)

2

TRULANCE 3

VIBERZI 5

LAXATIVES

CONSTULOSE 2

ENULOSE 2

GAVILYTE-C 2


GAVILYTE-G 2

GAVILYTE-N 2

GENERLAC 2

lactulose oral solution10 gram/15 ml

2

peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram

2

peg-electrolyte soln 2

TRILYTE WITH FLAVOR PACKETS

2

PROTECTANTSmisoprostol 2

sucralfate 2

PROTON PUMP INHIBITORSesomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg


esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg

2

lansoprazole oral capsule,delayed release(dr/ec) 15 mg


lansoprazole oral capsule,delayed release(dr/ec) 30 mg

2

omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg


omeprazole oral capsule,delayed release(dr/ec) 40 mg

1

pantoprazole oral tablet,delayed release (dr/ec) 20 mg


pantoprazole oral tablet,delayed release (dr/ec) 40 mg

1

59


GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENTGENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENTCERDELGA 5

CREON 3

CYSTADANE 5

CYSTAGON 3 PA

FIRDAPSE 5 PA

KUVAN 5 PA

miglustat 5

ORFADIN 5 PA

PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG/0.5 ML


PALYNZIQ SUBCUTANEOUS SYRINGE 2.5 MG/0.5 ML


PALYNZIQ SUBCUTANEOUS SYRINGE 20 MG/ML


RAVICTI 5 PA

sodium phenylbutyrate oral tablet

5 PA

SUCRAID 5 PA

VIOKACE 3

XURIDEN 5


GENITOURINARY AGENTSANTISPASMODICS, URINARYflavoxate 2

MYRBETRIQ 3

oxybutynin chloride 2

solifenacin 2

tolterodine 2

trospium 2

BENIGN PROSTATIC HYPERTROPHY AGENTS

alfuzosin 2

doxazosin oral tablet 1 mg, 2 mg, 4 mg


doxazosin oral tablet 8 mg


dutasteride 2

dutasteride-tamsulosin 2

finasteride oral tablet 5 mg

2

phenoxybenzamine 5 PA

prazosin 2

silodosin 2

tadalafil oral tablet 2.5 mg, 5 mg


tamsulosin 1

terazosin oral capsule 1 mg, 2 mg, 5 mg


terazosin oral capsule10 mg


GENITOURINARY AGENTS, OTHERbethanechol chloride 2

CLOVIQUE 5

DEPEN TITRATABS 5

ELMIRON 3

penicillamine 5

60


potassium citrate 2

sodium phenylbutyrate oral powder

5 PA

THIOLA 5

THIOLA EC 5

PHOSPHATE BINDERScalcium acetate(phosphat bind)

2

lanthanum 2

sevelamer carbonate oral powder in packet

5

sevelamer carbonate oral tablet

2

sevelamer hcl 2

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)ALA-CORT TOPICAL CREAM 1 %

2

alclometasone 2

betamethasone dipropionate topical cream

2

betamethasone dipropionate topical ointment

2

betamethasone valerate 2

betamethasone, augmented

2

clobetasol scalp 2QL (100 ML per 28 days)


clobetasol topical cream 2QL (120 GM per 28 days)

clobetasol topical foam 2QL (100 GM per 28 days)

clobetasol topical gel 2QL (120 GM per 28 days)

clobetasol topical lotion 2QL (118 ML per 28 days)

clobetasol topical ointment


clobetasol topical shampoo


clobetasol-emollient topical cream


clobetasol-emollient topical foam


cortisone 2

desonide 4


2


2


1


2

fludrocortisone 2

fluocinolone acetonide oil

2

fluocinolone and shower cap

2

fluocinolone topical cream

2

fluocinolone topical ointment

2

fluocinolone topical solution

2



fluocinonide topical gel 2QL (120 GM per 30 days)

61


fluocinonide topical ointment


fluocinonide topical solution


FLUOCINONIDE-E 2QL (120 GM per 30 days)

halobetasol propionate topical cream

2

halobetasol propionate topical ointment

2

hydrocortisone oral 2

hydrocortisone topical cream 1 %, 2.5 %

2

hydrocortisone topical lotion 2.5 %

2

hydrocortisone topical ointment 1 %, 2.5 %

2


2 BvD

methylprednisolone oral tablets,dose pack

2


4 BvD

mometasone topical 2

prednicarbate topical ointment

2


2

prednisolone sodium phosphate oral solution10 mg/5 ml, 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

2

prednisolone sodium phosphate oral tablet,disintegrating

2 BvD

PREDNISONE INTENSOL

2 BvD




prednisone oral tablets,dose pack 10 mg, 5 mg

1

PROCTO-PAK 2

PROCTOZONE-HC 2

triamcinolone acetonide topical aerosol


triamcinolone acetonide topical cream

2

triamcinolone acetonide topical lotion

2

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

2

TRIDERM TOPICAL CREAM 0.1 %

2

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)

DDAVP NASAL SOLUTION

3

desmopressin nasal spray,non-aerosol

2

desmopressin oral 2

INCRELEX 5

MYALEPT 5 PA

OMNITROPE 5 PA

STIMATE 3

VYNDAMAX 5 PA

VYNDAQEL 5 PA

62


HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PROSTAGLANDINS)HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PROSTAGLANDINS)misoprostol oral tablet200 mcg

2

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS)ANABOLIC STEROIDSoxandrolone oral tablet10 mg

5 PA

oxandrolone oral tablet2.5 mg

2 PA

ANDROGENSdanazol 4

methyltestosterone oral capsule

5

testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml

2 PA

testosterone enanthate 2 PAns


testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation


testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)


testosterone transdermal gel in metered-dose pump20.25 mg/1.25 gram (1.62 %)


testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)


testosterone transdermal gel in packet 1.62 % (20.25 mg/1.25 gram)

2PA; QL (37.5 GM per 30 days)

testosterone transdermal gel in packet 1.62 % (40.5 mg/2.5 gram)


testosterone transdermal solution in metered pump w/app


ESTROGENS

DOTTI 2PA; QL (8 EA per 28 days)

estradiol oral 4 PA

estradiol transdermal patch semiweekly


estradiol transdermal patch weekly


estradiol vaginal 2

estradiol valerate intramuscular oil 20 mg/ml

2

MARLISSA (28) 2

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

3 PA

63


YUVAFEM 2

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS)ALTAVERA (28) 2

ALYACEN 1/35 (28) 2

APRI 2

ARANELLE (28) 2

AUBRA 2

AVIANE 2

budesonide oral capsule,delayed,extend.release

2


5

CAZIANT (28) 2

CRYSELLE (28) 2

CYCLAFEM 1/35 (28) 2

CYCLAFEM 7/7/7 (28) 2

CYRED 2

DEBLITANE 2

desog-e.estradiol/e.estradiol

2

desogestrel-ethinyl estradiol

2

drospirenone-ethinyl estradiol

2

ELURYNG 2

EMOQUETTE 2

ENPRESSE 2

ENSKYCE 2

ESTARYLLA 2

estradiol valerate intramuscular oil 40 mg/ml

2


estradiol-norethindrone acet

2 PA

ethynodiol diac-eth estradiol

2

etonogestrel-ethinyl estradiol

2

FALMINA (28) 2

FAYOSIM 2

FEMYNOR 2

GIANVI (28) 2

INCASSIA 2

INTROVALE 2

ISIBLOOM 2

JASMIEL (28) 2

JULEBER 2

KARIVA (28) 2

KELNOR 1/35 (28) 2

KELNOR 1-50 2

KURVELO (28) 2

l norgest/e.estradiol-e.estrad

2

LARIN 1.5/30 (21) 2

LARIN 1/20 (21) 2

LARIN FE 1.5/30 (28) 2

LARIN FE 1/20 (28) 2

LARISSIA 2

LESSINA 2

LEVONEST (28) 2

levonorgestrel-ethinyl estrad

2

levonorg-eth estrad triphasic

2

LEVORA-28 2

LORYNA (28) 2

LOW-OGESTREL (28) 2

LUTERA (28) 2

MARLISSA (28) 2

MICROGESTIN 1.5/30 (21)

2

64


MICROGESTIN 1/20 (21)

2

MICROGESTIN FE 1.5/30 (28)

2

MICROGESTIN FE 1/20 (28)

2

MILI 2

NIKKI (28) 2

NORA-BE 2

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

4 PA

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

2

norgestimate-ethinyl estradiol

2

NORTREL 0.5/35 (28) 2

NORTREL 1/35 (21) 2

NORTREL 1/35 (28) 2

NORTREL 7/7/7 (28) 2

ORSYTHIA 2

PIMTREA (28) 2

PIRMELLA ORAL TABLET 1-35 MG-MCG

2

PORTIA 28 2

PREVIFEM 2

RECLIPSEN (28) 2

SETLAKIN 2

SHAROBEL 2

SPRINTEC (28) 2

SRONYX 2

SYEDA 2

TARINA 24 FE 2

TARINA FE 1/20 (28) 2

TRI-ESTARYLLA 2

TRI-LEGEST FE 2

TRI-LO-ESTARYLLA 2


TRI-LO-SPRINTEC 2

TRI-PREVIFEM (28) 2

TRI-SPRINTEC (28) 2

TRIVORA (28) 2

VELIVET TRIPHASIC REGIMEN (28)

2

VIENVA 2

XULANE 2

ZARAH 2

ZOVIA 1/35E (28) 2

PROGESTINS

CAMILA 2

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

3

ERRIN 2

LYZA 2

MARLISSA (28) 2

medroxyprogesterone 2

megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml (125 mg/ml)

2 PA

megestrol oral tablet 2 PAns

norethindrone (contraceptive)

2

norethindrone acetate 2

progesterone micronized

2

SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTSraloxifene 2

65


HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID)HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID)levothyroxine oral 1

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

1

liothyronine oral 2

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1

HORMONAL AGENTS, SUPPRESSANT (ADRENAL)HORMONAL AGENTS, SUPPRESSANT (ADRENAL)LYSODREN 3


HORMONAL AGENTS, SUPPRESSANT (PITUITARY)HORMONAL AGENTS, SUPPRESSANT (PITUITARY)bromocriptine 4

cabergoline 2

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG

5 BvD

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG

3 BvD

leuprolide subcutaneous kit

5 PAns

LUPRON DEPOT 5 PAns

LUPRON DEPOT (3 MONTH)

5 PAns


5 PAns


5 PAns

octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml

5

octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml

2

SIGNIFOR 5

SOMATULINE DEPOT

5

SOMAVERT 5

SYNAREL 5

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

5 BvD

66


HORMONAL AGENTS, SUPPRESSANT (THYROID)ANTITHYROID AGENTSmethimazole oral tablet10 mg, 5 mg

2

propylthiouracil 2

IMMUNOLOGICAL AGENTSANGIOEDEMA AGENTSCINRYZE 5 PA

FIRAZYR 5 PA

HAEGARDA 5 PA

icatibant 5 PA

IMMUNE SUPPRESSANTS

ACTEMRA ACTPEN 5PA; QL (4 ML per 28 days)

ACTEMRA SUBCUTANEOUS

5 PA

AFINITOR DISPERZ 5 PAns

AFINITOR ORAL TABLET 2.5 MG


azathioprine 2 BvD

BENLYSTA SUBCUTANEOUS

5 PA

cyclosporine modified 2 BvD

cyclosporine oral capsule

2 BvD

DEPEN TITRATABS 5

ENBREL MINI 5PA; QL (8 ML per 28 days)

ENBREL SUBCUTANEOUS RECON SOLN



ENBREL SUBCUTANEOUS SYRINGE


ENBREL SURECLICK 5PA; QL (8 ML per 28 days)

everolimus (antineoplastic)


GENGRAF ORAL CAPSULE 100 MG, 25 MG

2 BvD

GENGRAF ORAL SOLUTION

2 BvD

HUMIRA PEN 5PA; QL (4 EA per 28 days)

HUMIRA PEN CROHNS-UC-HS START


HUMIRA PEN PSOR-UVEITS-ADOL HS


HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML


HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML


HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML


HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML


HUMIRA(CF) PEN CROHNS-UC-HS


HUMIRA(CF) PEN PSOR-UV-ADOL HS


67


HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML


HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML


HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML


mercaptopurine 2

methotrexate sodium 2 BvD

methotrexate sodium (pf) injection solution

2 BvD

mycophenolate mofetil oral capsule

2 BvD

mycophenolate mofetil oral suspension for reconstitution

5 BvD

mycophenolate mofetil oral tablet

2 BvD

mycophenolate sodium 2 BvD

ORENCIA 5 PA

ORENCIA CLICKJECT

5 PA

OTEZLA 5 PA

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)

5 PA

penicillamine oral capsule

5

pimecrolimus 2PA; QL (100 GM per 30 days)

PROGRAF ORAL GRANULES IN PACKET

3 BvD

RINVOQ 5PA; QL (30 EA per 30 days)


SANDIMMUNE ORAL SOLUTION

3 BvD

sirolimus oral solution 5 BvD

sirolimus oral tablet 0.5 mg, 1 mg

2 BvD

sirolimus oral tablet 2 mg

5 BvD

tacrolimus oral 2 BvD

XATMEP 4 BvD

XELJANZ 5PA; QL (60 EA per 30 days)

XELJANZ XR 5PA; QL (30 EA per 30 days)

ZORTRESS 5 BvD

IMMUNIZING AGENTS, PASSIVE

PRIVIGEN 5 PA

IMMUNOLOGICAL AGENTS

leflunomide 2QL (30 EA per 30 days)

IMMUNOMODULATORSACTIMMUNE 5 BvD

ARCALYST 5 PA

leflunomide 2QL (30 EA per 30 days)

RIDAURA 5

VACCINES

ACTHIB (PF) 3

ADACEL(TDAP ADOLESN/ADULT)(PF)

3

bcg vaccine, live (pf) 3

BEXSERO 3

BOOSTRIX TDAP 3

DAPTACEL (DTAP PEDIATRIC) (PF)

3

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

3 BvD

68


ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

3 BvD

GARDASIL 9 (PF) 3

HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML

3

HAVRIX (PF) INTRAMUSCULAR SYRINGE

3

HIBERIX (PF) 3

IMOVAX RABIES VACCINE (PF)

3

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

3

IPOL 3

IXIARO (PF) 3

KINRIX (PF) 3

MENACTRA (PF) INTRAMUSCULAR SOLUTION

3

MENVEO A-C-Y-W-135-DIP (PF)

3

M-M-R II (PF) 3

PEDIARIX (PF) 3

PEDVAX HIB (PF) 3

PROQUAD (PF) 3

QUADRACEL (PF) 3

RABAVERT (PF) 3

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML

3 BvD

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

3 BvD

ROTARIX 3


ROTATEQ VACCINE 3

SHINGRIX (PF) 3

TDVAX 3

TENIVAC (PF) INTRAMUSCULAR SYRINGE

3

tetanus,diphtheria tox ped(pf)

3

TRUMENBA 3

TWINRIX (PF) INTRAMUSCULAR SYRINGE

3

TYPHIM VI 3

VAQTA (PF) 3

VARIVAX (PF) 3

VARIZIG INTRAMUSCULAR SOLUTION

3

YF-VAX (PF) 3

ZOSTAVAX (PF) 3

INFLAMMATORY BOWEL DISEASE AGENTSAMINOSALICYLATESbalsalazide 2

DIPENTUM 5

mesalamine 2

PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG

3

PENTASA ORAL CAPSULE, EXTENDED RELEASE 500 MG

5

69


GLUCOCORTICOIDSbudesonide oral capsule,delayed,extend.release

2


5

cortisone 2


2


2


1


2

hydrocortisone oral 2

hydrocortisone rectal 2


2 BvD

methylprednisolone oral tablets,dose pack

2


4 BvD



2

prednisolone sodium phosphate oral solution10 mg/5 ml, 20 mg/5 ml (4 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

2

prednisolone sodium phosphate oral tablet,disintegrating

2 BvD

PREDNISONE INTENSOL

2 BvD



PROCTO-MED HC 2

PROCTOSOL HC TOPICAL

2


SULFONAMIDESsulfasalazine 2

METABOLIC BONE DISEASE AGENTSMETABOLIC BONE DISEASE AGENTSalendronate oral solution


alendronate oral tablet10 mg


alendronate oral tablet35 mg, 70 mg


calcitonin (salmon) 2

calcitriol oral 2

cinacalcet oral tablet 30 mg

2

cinacalcet oral tablet 60 mg, 90 mg

5

doxercalciferol oral 2

FORTEO 5PA; QL (2.4 ML per 28 days)

ibandronate oral 2QL (1 EA per 30 days)

NATPARA 5 PA

paricalcitol oral 4

PROLIA 3 PA

risedronate oral tablet150 mg


risedronate oral tablet30 mg, 5 mg


risedronate oral tablet35 mg


risedronate oral tablet,delayed release (dr/ec)


TYMLOS 5PA; QL (1.56 ML per 30 days)

70


XGEVA 5 BvD

NON-FRFNON-FRF1ST TIER UNIFINE PENTIPS

5

1ST TIER UNIFINE PENTIPS PLUS

5

ABRAXANE 5

acetaminophen-caff-dihydrocod oral capsule


acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml


acetazolamide sodium 5

acetic acid irrigation 5

acetylcysteine intravenous

5

ACTEMRA INTRAVENOUS

5

ADASUVE 5

adenosine 5

ADRENALIN INJECTION

5

ADRIAMYCIN INTRAVENOUS RECON SOLN 10 MG

5

ADRIAMYCIN INTRAVENOUS SOLUTION

5

ADRUCIL INTRAVENOUS SOLUTION 2.5 GRAM/50 ML, 500 MG/10 ML

5

ADVOCATE PEN NEEDLE

5

ADVOCATE SYRINGES

5

AK-POLY-BAC 5

albumin, human 25 % 5

albumin, human 5 % 5


ALBUMINAR 25 % 5

ALBURX (HUMAN) 25 %

5

ALBURX (HUMAN) 5 %

5

ALBUTEIN 25 % 5

ALBUTEIN 5 % 5

albuterol sulfate inhalation solution for nebulization 5 mg/ml

5

ALCOHOL PREP PADS

5

alcohol swabs 5

ALCOHOL WIPES 5

ALDURAZYME 5

alendronate oral tablet5 mg


ALIMTA 5

ALIQOPA 5

allopurinol sodium 5

ALOPRIM 5

alprostadil 5

ALYACEN 7/7/7 (28) 5

AMETHYST (28) 5

AMICAR 5

amikacin injection solution 1,000 mg/4 ml

5

aminocaproic acid intravenous

5

aminocaproic acid oral tablet

5

AMINOSYN 10 % 5

AMINOSYN 7 % WITH ELECTROLYTES

5

AMINOSYN 8.5 % 5

AMINOSYN 8.5 %-ELECTROLYTES

5

AMINOSYN II 8.5 % 5

AMINOSYN II 8.5 %-ELECTROLYTES

5

71


AMINOSYN M 3.5 % 5

AMINOSYN-HBC 7% 5

AMINOSYN-RF 5.2 % 5

amiodarone intravenous 5

ampicillin oral capsule250 mg

5

ampicillin sodium injection recon soln 2 gram, 250 mg, 500 mg

5

ampicillin sodium intravenous

5

ampicillin-sulbactam intravenous

5

ARALAST NP INTRAVENOUS RECON SOLN 500 MG

5

ARRANON 5

arsenic trioxide 5

ARZERRA 5

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG/ ACTUATION (14)


ASSURE ID INSULIN SAFETY SYRINGE 0.5 ML 29 GAUGE X 1/2"

5

ASSURE ID PEN NEEDLE

5

atropine injection solution 0.4 mg/ml

5

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml

5

AUBRA EQ 5

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML

3


AUTOPEN 1 TO 21 UNITS

5

AUTOPEN 2 TO 42 UNITS

5

AVASTIN 5

azacitidine 5

azathioprine sodium 5

aztreonam injection recon soln 2 gram

5

AZURETTE (28) 5

bacitracin intramuscular

5

BALANCED SALT 5

BAL-CARE DHA 5

BAND-AID GAUZE PADS TOPICAL BANDAGE 2 X 2 "

5

BAVENCIO 5

BD ALCOHOL SWABS

5

BD AUTOSHIELD DUO PEN NEEDLE

5

BD ECLIPSE LUER-LOK SYRINGE 1 ML 30 GAUGE X 1/2"

5

BD INSULIN SYRINGE HALF UNIT SYRINGE 0.3 ML 31 GAUGE X 5/16"

5

BD INSULIN SYRINGE MICRO-FINE SYRINGE 1 ML 28 GAUGE X 1/2"

5

BD INSULIN SYRINGE SLIP TIP

5

72


BD INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.5 ML 29 GAUGE X 1/2", 1 ML 25 X 1", 1 ML 26 X 1/2", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"

5

BD INSULIN SYRINGE U-500

5

BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16

5

BD LO-DOSE MICRO-FINE IV SYRINGE 1/2 ML 28 GAUGE X 1/2"

5

BD LO-DOSE ULTRA-FINE SYRINGE 0.5 ML 29 GAUGE X 1/2"

5

BD NANO 2ND GEN PEN NEEDLE

5

BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 1 ML 29 GAUGE X 1/2", 1 ML 31 GAUGE X 15/64"

5

BD SAFETYGLIDE SYRINGE SYRINGE 1 ML 27 GAUGE X 5/8"

5


BD ULTRA-FINE MICRO PEN NEEDLE

5

BD ULTRA-FINE MINI PEN NEEDLE

5

BD ULTRA-FINE NANO PEN NEEDLE

5

BD ULTRA-FINE ORIG PEN NEEDLE

5

BD ULTRA-FINE SHORT PEN NEEDLE

5

BD VEO INSULIN SYR HALF UNIT

5

BD VEO INSULIN SYRINGE UF

5

BEKYREE (28) 5

BELEODAQ 5

BENDEKA 5

BENLYSTA INTRAVENOUS

5

benztropine injection 5

BESPONSA 5

betamethasone acet,sod phos

5

BICNU 5

bleomycin 5

BLINCYTO INTRAVENOUS KIT

5

BORDERED GAUZE TOPICAL BANDAGE 2 X 2 "

5

bortezomib 5

BOTOX 5

BRAFTOVI ORAL CAPSULE 50 MG


BRIVIACT INTRAVENOUS

5

BSS 5

budesonide nasal 5QL (17.2 ML per 30 days)

BUMINATE 25 % 5

BUMINATE 5 % 5

73


buprenorphine hcl injection

5

busulfan 5

butorphanol tartrate injection solution 1 mg/ml


butorphanol tartrate injection solution 2 mg/ml


caffeine citrate 5

calcitriol intravenous solution 1 mcg/ml

5

calcium chloride 5

calcium gluconate intravenous

5

CAMRESE 5

CAPASTAT 5

CARBOCAINE (PF) INJECTION SOLUTION 15 MG/ML (1.5 %)

5

carboplatin intravenous solution

5

cardioplegic soln 5

CAREFINE PEN NEEDLE

5

CARETOUCH ALCOHOL PREP PAD

5

CARETOUCH INSULIN SYRINGE SYRINGE 1 ML 28 X 5/16", 1 ML 29 GAUGE X 5/16

5

CARETOUCH PEN NEEDLE

5

carmustine 5

cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

5

cefazolin injection recon soln 100 gram, 20 gram, 300 g

5


cefazolin intravenous 5

cefepime in dextrose,iso-osm

5

cefotaxime injection recon soln 1 gram

5

cefotetan intravenous 5

cefoxitin in dextrose, iso-osm

5

ceftriaxone in dextrose,iso-os

5

ceftriaxone intravenous 5

CEPROTIN (BLUE BAR)

5

CEPROTIN (GREEN BAR)

5

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5

chloramphenicol sod succinate

5

chloroprocaine (pf) 5

chlorothiazide oral tablet 500 mg

2

chlorothiazide sodium 5

chlorpromazine injection

5

cholestyramine (with sugar) oral powder

5

CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET

5

CICLODAN TOPICAL SOLUTION

5

cidofovir 5

CINVANTI 5

ciprofloxacin in 5 % dextrose intravenous piggyback 400 mg/200 ml

5

ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml

5

74


ciprofloxacin oral suspension,microcapsule recon 500 mg/5 ml

2

cisplatin intravenous solution

5

cladribine 5

CLICKFINE PEN NEEDLE

5

clindamycin palmitate hcl

5

CLINIMIX 5%/D25W SULFITE-FREE

5

CLINIMIX 4.25%-D25W SULF-FREE

5

clofarabine 5

clomiphene citrate 5

clonidine (pf) 5

clopidogrel oral tablet300 mg

5

C-NATE DHA 5

colestipol oral granules 5

COLOCORT 2

COMFORT EZ INSULIN SYRINGE

5

COMFORT EZ PEN NEEDLES

5

COMPLETE NATAL DHA

5

CORTIFOAM 5

COSMEGEN 5

CRESEMBA INTRAVENOUS

5

CROTAN 5

CRYSVITA 5

CURITY ALCOHOL SWABS

5

CURITY GAUZE TOPICAL BANDAGE 2 X 2 "

5

CURITY GAUZE TOPICAL SPONGE 2 X 2 "

5


cyclophosphamide intravenous

5

cyclosporine intravenous

5

CYRAMZA 5

CYRED EQ 5

cytarabine 5

cytarabine (pf) injection solution

5

dacarbazine 5

dactinomycin 5

dantrolene intravenous 5

DARZALEX 5

DASETTA 1/35 (28) 5

DASETTA 7/7/7 (28) 5

daunorubicin intravenous solution

5

DAYSEE 5

DECADRON ORAL TABLET

5

decitabine 5

deferoxamine 5

DENTA 5000 PLUS 5

DENTAGEL 5

DERMACEA NON-WOVEN TOPICAL SPONGE 2 X 2 "

5

DERMACEA TOPICAL BANDAGE 2 X 2 "

5

DERMACEA TOPICAL SPONGE 2 X 2 "

5

desmopressin injection 5

desmopressin nasal spray with pump

5

dexamethasone oral solution

5

dexamethasone sodium phos (pf) injection solution

5

75


dexamethasone sodium phosphate injection

5

dexrazoxane hcl 5


5


5


5


5

dextrose 5 % in water (d5w) intravenous piggyback

5

dextrose 5 %-lactated ringers

5

dextrose 5%-0.3 % sod.chloride

2


5


5

diazepam injection 5

DIAZEPAM INTENSOL


dicyclomine intramuscular

5

dihydroergotamine injection

5

diltiazem hcl intravenous

5

diltiazem hcl oral capsule,ext.rel 24h degradable 180 mg, 240 mg

5

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg

5

diltiazem hcl oral capsule,extended release 24hr 360 mg

5


diltiazem hcl oral tablet extended release 24 hr

5

dimenhydrinate injection solution

5

diphenhydramine hcl injection solution 50 mg/ml

5

diphenhydramine hcl injection syringe

5

diphenhydramine hcl oral elixir

5

dipyridamole intravenous

5

dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml)

5

dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml)

5

docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml, 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

5

dopamine in 5 % dextrose

5

dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/10 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml)

5

doxercalciferol intravenous

5

doxorubicin intravenous recon soln 50 mg

5

doxorubicin intravenous solution

5

76


doxorubicin, peg-liposomal

5

doxycycline hyclate intravenous

5

doxycycline hyclate oral tablet 50 mg

5

droperidol injection solution

5

DROPLET INSULIN SYR HALF UNIT

5

DROPLET INSULIN SYRINGE

5

DROPLET PEN NEEDLE

5

DROPSAFE PEN NEEDLE

5

drospirenone-e.estradiol-lm.fa oral tablet 3-0.03-0.451 mg (21) (7)

5

EASY COMFORT ALCOHOL PAD

5

EASY COMFORT INSULIN SYRINGE

5

EASY COMFORT PEN NEEDLES

5

EASY GLIDE INSULIN SYRINGE

5

EASY GLIDE PEN NEEDLE

5

EASY TOUCH ALCOHOL PREP PADS

5

EASY TOUCH FLIPLOCK INSULIN

5

EASY TOUCH INSULIN SAFETY SYR

5

EASY TOUCH INSULIN SYRINGE

5

EASY TOUCH LUER LOCK INSULIN

5


EASY TOUCH NEEDLE

5

EASY TOUCH PEN NEEDLE

5

EASY TOUCH SHEATHLOCK INSULIN

5

EASY TOUCH UNI-SLIP SYRINGE 1 ML

5

EC-NAPROXEN 5

EFFER-K ORAL TABLET, EFFERVESCENT 25 MEQ

5

ELAPRASE 5

electrolyte-48 in d5w 5

ELINEST 5

ELITEK 5

ELITE-OB 5

EMPLICITI 5

enalaprilat intravenous solution

5

ENDOCET ORAL TABLET 2.5-325 MG


ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

5

enoxaparin subcutaneous solution

5

ENTYVIO 5

EPIPEN 5QL (4 EA per 30 days)

EPIPEN JR 5QL (4 EA per 30 days)

epirubicin intravenous solution

5

epoprostenol (glycine) 5

eprosartan 2

ERBITUX 5

ERWINAZE 5

esmolol intravenous solution

5

77


esomeprazole sodium 5

ethacrynate sodium 5

ETOPOPHOS 5

etoposide intravenous 5

EXEL INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2"

5

EYLEA INTRAVITREAL SOLUTION

5

FABRAZYME 5

famotidine (pf) 5

famotidine (pf)-nacl (iso-os)

5

famotidine intravenous solution

5

FARYDAK ORAL CAPSULE 15 MG


FASLODEX 5

fenofibric acid 2

fentanyl citrate (pf) injection solution

5

fentanyl citrate (pf) intravenous syringe 100 mcg/2 ml (50 mcg/ml)

5

floxuridine 5

fludarabine 5

flumazenil 5

fluocinolone topical oil 5



fluocinonide-emollient 5QL (120 GM per 30 days)

fluoride (sodium) dental cream

5

fluoride (sodium) dental gel

5


fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

5

FLUORITAB ORAL TABLET,CHEWABLE 1 MG (2.2 MG SOD. FLUORIDE)

5

fluorouracil intravenous 5

FOLIVANE-OB 5

FOLOTYN 5

fomepizole 5

fosaprepitant 5

fosphenytoin 5

FREAMINE III 10 % 5

FREESTYLE CONTROL

5

FREESTYLE FLASH SYSTEM

5

FREESTYLE FREEDOM

5

FREESTYLE FREEDOM LITE

5

FREESTYLE INSULINX

5

FREESTYLE INSULINX TEST STRIPS

5

FREESTYLE LITE METER

5

FREESTYLE LITE STRIPS

5

FREESTYLE NAVIGATOR GLUC SENS

5

FREESTYLE PRECISION

5

FREESTYLE PRECISION NEO METER

5

FREESTYLE PRECISION NEO STRIPS

5

78


FREESTYLE SIDEKICK II

5

FREESTYLE SYSTEM KIT

5

FREESTYLE TEST 5

fulvestrant 5

gabapentin oral solution300 mg/6 ml (6 ml)


GAMASTAN 5

GAMASTAN S/D 5

ganciclovir sodium 5

GATTEX ONE-VIAL 5

gauze bandage topical bandage 2 x 2 "

5

GAZYVA 5

gemcitabine 5

gentamicin injection solution 20 mg/2 ml

5

gentamicin sulfate (ped) (pf)

5

GLUCOSE KETONE CONTROL SOLN

5

GLYCINE UROLOGIC 5

glycine urologic solution

5

glycopyrrolate (pf) in water intravenous syringe 0.4 mg/2 ml (0.2 mg/ml)

5

glycopyrrolate injection 5

glycopyrrolate oral tablet 1.5 mg

5

GLYDO 5QL (60 ML per 30 days)

granisetron (pf) 5

granisetron hcl intravenous

5

HALAVEN 5

haloperidol lactate intramuscular

5



5

HEALTHWISE INSULIN SYRINGE

5

HEALTHWISE PEN NEEDLE

5

HEALTHY ACCENTS UNIFINE PENTIP

5

HEATHER 5

heparin (porcine) in 5 % dex intravenous parenteral solution20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

5

heparin (porcine) in nacl (pf)

5

heparin (porcine) injection cartridge

5

heparin (porcine) injection syringe 5,000 unit/ml

5

heparin(porcine) in 0.45% nacl intravenous parenteral solution12,500 unit/250 ml, 25,000 unit/250 ml, 25,000 unit/500 ml

5

heparin, porcine (pf) injection

5

heparin, porcine (pf) subcutaneous

5

HERCEPTIN HYLECTA

5

HERCEPTIN INTRAVENOUS RECON SOLN 150 MG

5

HIZENTRA SUBCUTANEOUS SOLUTION

5

hydralazine injection 5

79


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


hydrocodone-acetaminophen oral tablet 2.5-325 mg


hydrocortisone topical cream with perineal applicator

5


5

hydromorphone injection solution

5

hydromorphone injection syringe 1 mg/ml, 4 mg/ml

5

hydromorphone injection syringe 2 mg/ml


hydroxyprogesterone caproate

5

HYPERHEP B S/D 5

HYPERHEP B S-D NEONATAL

5

HYQVIA 5

ibandronate intravenous 5

IBU ORAL TABLET 400 MG

5

ibutilide fumarate 5

idarubicin 5

ifosfamide 5

ILARIS (PF) SUBCUTANEOUS SOLUTION

5

IMFINZI 5

IMPAVIDO 5

INCONTROL ALCOHOL PADS

5

INCONTROL PEN NEEDLE

5


INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

5

INFUGEM 5

insulin syr/ndl u100 half mark

5

INSULIN SYRINGE MICROFINE SYRINGE 1 ML 27 GAUGE X 5/8"

5

insulin syringe needleless

5

INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"

5

insulin syringe-needle u-100 syringe 0.3 ml 29 gauge x 1/2", 0.3 ml 30, 0.3 ml 30 gauge x 1/2", 0.3 ml 30 gauge x 5/16", 0.3 ml 31 gauge x 1/4", 0.3 ml 31 gauge x 15/64", 0.3 ml 31 gauge x 5/16", 0.5 ml 29 gauge x 1/2", 0.5 ml 30 gauge x 1/2", 0.5 ml 30 gauge x 5/16", 0.5 ml 31 gauge x 5/16", 1 ml 27 gauge x 1/2", 1 ml 28 gauge, 1 ml 28 gauge x 1/2", 1 ml 29 gauge x 7/16", 1 ml 30 gauge x 1/2", 1 ml 30 gauge x 3/8", 1 ml 30 gauge x 5/16, 1 ml 30 gauge x 7/16", 1 ml 31 gauge x 1/4", 1 ml 31 gauge x 15/64", 1 ml 31 gauge x 5/16, 1/2 ml 27 gauge x 1/2", 1/2 ml 28 gauge x 1/2", 1/2 ml 29 , 1/2 ml 30 gauge, 1/2 ml 31 gauge x 1/4", 1/2 ml 31 gauge x 15/64"

5

INSUPEN 5

80


IONOSOL-MB IN D5W

3

irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml, 500 mg/25 ml

5

ISOLYTE S PH 7.4 5

isoniazid injection 5

isosorbide dinitrate oral tablet extended release

2

ISTODAX 5

IV PREP WIPES 5

IXEMPRA 5

JENCYCLA 5

JETREA (PF) INTRAVITREAL SOLUTION 0.125 MG/0.1 ML (1.25 MG/ML)

5

JEVTANA 5

JOLESSA 5

KADCYLA 5

KALLIGA 5

KANJINTI 5

KANUMA 5

KEPIVANCE 5

KEYTRUDA INTRAVENOUS SOLUTION

5

KHAPZORY 5

KLOR-CON/EF 5

K-PHOS NO 2 5

K-PHOS ORIGINAL 5

KRYSTEXXA 5

KYPROLIS 5

labetalol intravenous solution

5

labetalol intravenous syringe 20 mg/4 ml (5 mg/ml)

5

lactated ringers 5


lactulose oral solution20 gram/30 ml

5

LANOXIN ORAL TABLET 187.5 MCG (0.1875 MG)

5

LARIN 24 FE 5

LEMTRADA 5

leucovorin calcium injection recon soln

5

levetiracetam in nacl (iso-os)

5

levetiracetam intravenous

5

levetiracetam oral solution 500 mg/5 ml (5 ml)

5

levocarnitine oral solution 100 mg/ml

5

levofloxacin in d5w intravenous piggyback250 mg/50 ml

5

levoleucovorin calcium intravenous recon soln50 mg

5

levoleucovorin calcium intravenous solution

5

levothyroxine intravenous recon soln

5

LIBTAYO 5

lidocaine (pf) in d7.5w 5

lidocaine (pf) injection solution

5

lidocaine (pf) intravenous

5

lidocaine hcl injection solution

5

lidocaine hcl laryngotracheal

5

lidocaine hcl mucous membrane jelly in applicator


81


lidocaine in 5 % dextrose (pf) intravenous parenteral solution 4 mg/ml (0.4 %), 8 mg/ml (0.8 %)

5

lidocaine-epinephrine 5

LILLOW (28) 5

lincomycin 5

linezolid-0.9% sodium chloride

5

LIORESAL 5

liothyronine intravenous 5

LISCO TOPICAL SPONGE 2 X 2 "

5

LITE TOUCH INSULIN PEN NEEDLES

5

LITE TOUCH INSULIN SYRINGE

5

lorazepam injection 5

LORAZEPAM INTENSOL


LO-ZUMANDIMINE (28)

5

LUCENTIS 5

LUDENT FLUORIDE ORAL TABLET,CHEWABLE 1 MG (2.2 MG SOD. FLUORIDE)

5

LUMIZYME 5

LUMOXITI 5

LUPRON DEPOT-PED 5

LUPRON DEPOT-PED (3 MONTH)

5

MAGELLAN INSULIN SAFETY SYRNG

5

MAGELLAN SYRINGE SYRINGE 0.3 ML 30 X 5/16", 0.5 ML 30 GAUGE X 5/16"

5

magnesium chloride injection

5


magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml

5

magnesium sulfate in water

5

mannitol 20 % 5

mannitol 25 % intravenous solution

5

MARQIBO 5

MAXICOMFORT II PEN NEEDLE

5

MAXICOMFORT INSULIN SYRINGE

5

MAXI-COMFORT INSULIN SYRINGE

5

MAXICOMFORT SAFETY PEN NEEDLE

5

MEDISENSE 5

MEDISENSE GLUCOSE KETONE

5

MEDISENSE MID CONTROL

5

megestrol oral suspension 400 mg/10 ml (10 ml)

5

melphalan 5

melphalan hcl 5

MENEST ORAL TABLET 2.5 MG

5

MEPSEVII 5

mesalamine with cleansing wipe

5

mesna 5

methadone injection solution

5

METHADONE INTENSOL

5

methadone oral concentrate

5

82


METHADOSE ORAL CONCENTRATE


methenamine mandelate 5

METHERGINE 5

methotrexate sodium (pf) injection recon soln

5

methylergonovine 5

methylprednisolone acetate

5

methylprednisolone sodium succ injection recon soln 125 mg, 40 mg

5

methylprednisolone sodium succ intravenous

5

metipranolol 5

metoclopramide hcl injection

5

metoprolol tartrate intravenous

5

METRO I.V. 5

metronidazole topical gel with pump

5

MIACALCIN INJECTION

5

mifepristone 5

MILLIPRED DP 5

milrinone 5

milrinone in 5 % dextrose

5

MINI ULTRA-THIN II 5

MIOSTAT 5

MIRENA 5

mitomycin intravenous 5

mitoxantrone 5

M-NATAL PLUS 5

MONOJECT INSULIN SAFETY SYRING

5


MONOJECT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16", 1 ML , 1 ML 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2"

5

MONOJECT SYRINGE SYRINGE 1/2 ML 28 GAUGE

5

MONOJECT ULTRA COMFORT INSULIN

5

MONO-LINYAH 5

MORGIDOX ORAL CAPSULE 100 MG

5

MORGIDOX ORAL CAPSULE 50 MG

2

morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml

5

morphine (pf) intravenous patient control.analgesia soln

5

morphine injection solution 8 mg/ml

5

morphine injection syringe 10 mg/ml


morphine injection syringe 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml

5

morphine intravenous solution 10 mg/ml

5

morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml

5

83


MOZOBIL 5

MVASI 5

mycophenolate mofetil (hcl)

5

MYLOTARG 5

nadolol-bendroflumethiazide oral tablet 80-5 mg

5

nafcillin in dextrose iso-osm

5

nafcillin intravenous 5

naftifine topical gel 5QL (60 GM per 28 days)

NAGLAZYME 5

nalbuphine 5

neomycin-polymyxin b gu

5

NEO-POLYCIN 5

NEO-POLYCIN HC 5

neostigmine methylsulfate intravenous solution

5

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR

5

NEXPLANON 5

niacin oral tablet 500 mg

5

nicardipine intravenous solution

5

nitisinone 5

nitroglycerin in 5 % dextrose intravenous solution 100 mg/250 ml (400 mcg/ml), 25 mg/250 ml (100 mcg/ml), 50 mg/250 ml (200 mcg/ml)

5

nitroglycerin intravenous

5


norepinephrine bitartrate

5

norethindrone ac-eth estradiol oral tablet 1.5-30 mg-mcg

5

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7)

5

NORLYDA 5

NORMOSOL-R 5

NOVOFINE 32 5

NOVOFINE AUTOCOVER

5

NOVOFINE PLUS 5

NOVOPEN ECHO 5

NOVOTWIST NEEDLE 32 GAUGE X 1/5"

5

NPLATE 5

NULOJIX 5

OCREVUS 5

octreotide acetate injection syringe

5

OKEBO ORAL CAPSULE 75 MG

5

OMNIPOD DASH 5 PACK POD

5

OMNIPOD INSULIN MANAGEMENT

5

OMNIPOD INSULIN REFILL

5

ONCASPAR 5

ondansetron hcl (pf) 5

ondansetron hcl intravenous

5

ONETOUCH ULTRA BLUE TEST STRIP

5

ONETOUCH ULTRA CONTROL

5

ONETOUCH ULTRA2 METER

5

84


ONETOUCH ULTRAMINI

5

ONETOUCH VERIO FLEX METER

5

ONETOUCH VERIO HIGH CONTROL

5

ONETOUCH VERIO IQ METER

5

ONETOUCH VERIO METER

5

ONETOUCH VERIO MID CONTROL

5

ONETOUCH VERIO TEST STRIPS

5

ONIVYDE 5

OPDIVO 5

opium tincture 5

OPTIUM EZ 5

OPTIUM TEST 5

ORALONE 5

ORENCIA (WITH MALTOSE)

5

OSMITROL 15 % 5

OSMITROL 20 % 5

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG(19)

5

oxacillin intravenous 5

oxaliplatin 5

oxytocin injection solution

5

OZURDEX 5

paclitaxel 5

palonosetron intravenous solution0.25 mg/5 ml

5

palonosetron intravenous syringe

5

pamidronate 5


pantoprazole intravenous

5

paricalcitol intravenous 5

PAROEX ORAL RINSE

5

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML


PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32"

5

pen needle, diabetic needle 31 gauge x 1/3", 31 gauge x 1/4", 31 gauge x 1/6", 31 gauge x 3/16", 31 gauge x 5/16", 32 gauge x 1/4", 32 gauge x 3/16", 32 gauge x 5/32"

5

penicillin g potassium injection recon soln 5 million unit

5

penicillin g procaine intramuscular syringe600,000 unit/ml

5

PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML

5

PENTIPS 5

PERIOGARD 5

PERJETA 5

PFIZERPEN-G 5

phenobarbital sodium injection solution

5

phentolamine injection recon soln

5

phenytoin oral suspension 100 mg/4 ml

5

85


phenytoin sodium intravenous solution

5

PHILITH 5

piperacillin-tazobactam intravenous recon soln13.5 gram

5

PIRMELLA ORAL TABLET 0.5/0.75/1 MG- 35 MCG

5

PLASBUMIN 25 % 5

PLASBUMIN 5 % 5

PLASMANATE 5

PNV 29-1 5

PNV-DHA 5

PNV-DHA + DOCUSATE

5

PNV-OMEGA 5

PNV-SELECT 5

POLIVY 5

POLOCAINE INJECTION SOLUTION 1 % (10 MG/ML)

5

POLOCAINE-MPF 5

POLYCIN 5

polyethylene glycol 3350

5

PORTRAZZA 5

potassium acetate intravenous solution 2 meq/ml

5

potassium chloride in 5 % dex intravenous parenteral solution 30 meq/l

5

potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l

5


potassium chloride in water intravenous piggyback 10 meq/50 ml, 20 meq/50 ml, 30 meq/100 ml

5

potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l

5

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l

2

potassium phosphate m-/d-basic intravenous solution 3 mmol/ml

5

POTELIGEO 5

PR NATAL 400 5

PR NATAL 400 EC 5

PR NATAL 430 5

PR NATAL 430 EC 5

PRECISION PCX PLUS TEST

5

PRECISION PCX TEST

5

PRECISION POINT OF CARE TEST

5

PRECISION Q-I-D TEST

5

PRECISION XTRA MONITOR

5

PRECISION XTRA TEST

5

prednisolone sodium phosphate oral solution15 mg/5 ml (3 mg/ml)

5

PRENAISSANCE 5

PRENAISSANCE PLUS

5

PRENATAL PLUS 5

PRENATAL PLUS (CALCIUM CARB)

5

PREPLUS 5

86


PRETAB 5

PREVALITE ORAL POWDER

5

PREVYMIS INTRAVENOUS

5

PRO COMFORT ALCOHOL PADS

5

PRO COMFORT INSULIN SYRINGE

5

PRO COMFORT PEN NEEDLE

5

procainamide injection 5

prochlorperazine edisylate

5

PROCRIT INJECTION SOLUTION 20,000 UNIT/2 ML

5

PRODIGY INSULIN SYRINGE

5

progesterone 5

PROGRAF INTRAVENOUS

5

PROLASTIN-C INTRAVENOUS SOLUTION

5

PROLEUKIN 5

promethazine injection solution

5

propranolol intravenous 5

protamine 5

RADICAVA 5

RAGWITEK 5

ranitidine hcl oral syrup 2

ranitidine hcl oral tablet150 mg, 300 mg

1

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML

5

REGONOL 5

RELION NEEDLES 5


RELION PEN NEEDLES

5

RELION ULTIMA 5

REMICADE 5

REMODULIN 5

RENACIDIN IRRIGATION SOLUTION 1980.6 MG-59.4 MG-980.4MG/30ML

5

repaglinide-metformin 2QL (150 EA per 30 days)

RETROVIR INTRAVENOUS

5

REVCOVI 5

REVONTO 5

ringer's 5

RITUXAN 5

RITUXAN HYCELA 5

romidepsin intravenous recon soln

5

ROSADAN TOPICAL CREAM

5

ROSADAN TOPICAL GEL

5

SAFESNAP INSULIN SYRINGE

5

SAFETY PEN NEEDLE

5

salsalate 5

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

5

SE-NATAL 19 CHEWABLE

5

SE-NATAL-19 5

SF 5

SF 5000 PLUS 5

87


sildenafil (pulm.hypertension) intravenous

5

SIMULECT 5

sodium acetate 5

sodium benzoate-sod phenylacet

5

sodium bicarbonate intravenous solution 1 meq/ml (8.4 %)

5

sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4 %), 7.5 % (0.9 meq/ml), 8.4 % (1 meq/ml)

5

sodium chloride 0.9 % intravenous piggyback

5

sodium chloride intravenous

5

SODIUM FLUORIDE 5000 PLUS

5

sodium nitroprusside 5

sodium phosphate 5

SOLIRIS 5

SPS (WITH SORBITOL) RECTAL

5

STAMARIL (PF) 5

STELARA INTRAVENOUS

5

STERILE PADS TOPICAL BANDAGE 2 X 2 "

5

STRENSIQ 5

SUBVENITE 5

SUBVENITE STARTER (BLUE) KIT

5

SUBVENITE STARTER (GREEN) KIT

5

SUBVENITE STARTER (ORANGE) KIT

5


sulfamethoxazole-trimethoprim intravenous

5

SULFATRIM 5

SURE COMFORT ALCOHOL PREP PADS

5

SURE COMFORT INS. SYR. U-100

5

SURE COMFORT INSULIN SYRINGE

5

SURE COMFORT PEN NEEDLE

5

SURE-FINE PEN NEEDLES

5

SURE-JECT INSULIN SYRINGE

5

SURE-PREP ALCOHOL PREP PADS

5

SYLVANT 5

SYNAGIS 5

SYNERCID 5

TARINA FE 1-20 EQ (28)

5

TARON-C DHA 5

TARON-PREX PRENATAL-DHA

5

TAZICEF INTRAVENOUS

5

TECENTRIQ 5

TECHLITE INSULIN SYR HALF UNIT

5

TECHLITE INSULIN SYRINGE

5

TECHLITE PEN NEEDLE

5

TEMIXYS 5

TEMODAR INTRAVENOUS

5

temsirolimus 5

88


TENIVAC (PF) INTRAMUSCULAR SUSPENSION

5

terbutaline subcutaneous

5

TERUMO INSULIN SYRINGE

5

testosterone transdermal gel


theophylline in dextrose 5 % intravenous parenteral solution 400 mg/500 ml

5

theophylline oral elixir 5

theophylline oral tablet extended release 12 hr100 mg, 200 mg, 450 mg

5

THINPRO INSULIN SYRINGE

5

thiotepa injection recon soln 15 mg

5

TICE BCG 5

TILIA FE 5

tobramycin sulfate injection recon soln

5


5

TOPCARE CLICKFINE

5

TOPCARE ULTRA COMFORT

5

TOPOSAR 5

topotecan 5

TORISEL 5

TREANDA INTRAVENOUS RECON SOLN

5

treprostinil sodium 5

TRI FEMYNOR 5

triamcinolone acetonide injection

5


TRIDERM TOPICAL CREAM 0.5 %

5

TRI-LINYAH 5

TRI-LO-MARZIA 5

TRINATAL RX 1 5

TRISENOX INTRAVENOUS SOLUTION 2 MG/ML

5

TRIVEEN-DUO DHA 5

TROGARZO 5

TRUE COMFORT ALCOHOL PADS

5

TRUE COMFORT INSULIN SYRINGE

5

TRUE COMFORT PEN NEEDLE

5

TRUEPLUS INSULIN 5

TRUEPLUS PEN NEEDLE

5

TULANA 5

TYSABRI 5

TYVASO 5

TYVASO INSTITUTIONAL START KIT

5

TYVASO REFILL KIT 5

TYVASO STARTER KIT

5

ULTICARE INSULIN SYR HALF UNIT

5

ULTICARE INSULIN SYRINGE

5

ULTICARE PEN NEEDLE

5

ULTICARE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16

5

89


ULTILET ALCOHOL SWAB

5

ULTILET INSULIN SYRINGE

5

ULTILET PEN NEEDLE

5

ULTIMA MONITOR 5

ULTRA CMFT INS SYR HALF UNIT

5

ULTRA COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30, 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 GAUGE X 7/16", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE

5

ULTRA THIN PEN NEEDLE

5

ULTRACARE INSULIN SYRINGE

5

ULTRACARE PEN NEEDLE

5

ULTRA-THIN II (SHORT) INS SYR

5

ULTRA-THIN II (SHORT) PEN NDL

5

ULTRA-THIN II INS PEN NEEDLES

5


ULTRA-THIN II INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"

5

UNIFINE PENTIPS NEEDLE 29 GAUGE, 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32", 33 GAUGE X 5/32"

5

UNIFINE PENTIPS PLUS

5

UNITHROID ORAL TABLET 137 MCG

5

UNITUXIN 5

UVADEX 5

valproate sodium 5

valproic acid (as sodium salt) oral solution 500 mg/10 ml (10 ml)

5

valrubicin 5

VALSTAR 5

vancomycin in 0.9 % sodium chl intravenous piggyback

5

vancomycin intravenous recon soln 5 gram

5

VANISHPOINT SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"

5

VANTAS 5

VARUBI INTRAVENOUS

5

VECTIBIX 5

VELCADE 5

VELETRI 5

verapamil intravenous 5

90


VERIPRED 20 5

VERSALON TOPICAL SPONGE 2 X 2 "

5

V-GO 20 5

V-GO 30 5

V-GO 40 5

VICODIN HP 5QL (390 EA per 30 days)

VIMIZIM 5

VIMPAT INTRAVENOUS

5

vinblastine intravenous solution

5

vincristine 5

vinorelbine 5

VIORELE (28) 5

VIRT-C DHA 5

VIRT-NATE DHA 5

VIRT-PN DHA 5

VIRT-PN PLUS 5

VISTOGARD 5

VYXEOS 5

water for irrigation, sterile

5

WEBCOL 5

WERA (28) 5

XIAFLEX 5

YERVOY 5

YONDELIS 5

ZALTRAP 5

ZANOSAR 5

ZATEAN-PN DHA 5

ZATEAN-PN PLUS 5

ZINGIBER 5

ZOLADEX 5

zoledronic acid intravenous solution

5

zoledronic acid-mannitol-water

5


ZUMANDIMINE (28) 5

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG, 405 MG

5

OPHTHALMIC AGENTSOPHTHALMIC AGENTS, OTHERatropine ophthalmic (eye) drops

2

CYSTARAN 5 PA

OXERVATE 5 PA

sulfacetamide sodium ophthalmic (eye) ointment

2

OPHTHALMIC AGENTS

bacitracin-polymyxin b ophthalmic (eye)

2

BLEPHAMIDE 4

BLEPHAMIDE S.O.P. 4

neomycin-bacitracin-poly-hc

2

neomycin-bacitracin-polymyxin

2

neomycin-polymyxin b-dexameth

2

neomycin-polymyxin-gramicidin

2

neomycin-polymyxin-hc ophthalmic (eye)

2

OXERVATE 5 PA

polymyxin b sulf-trimethoprim

2

sulfacetamide sodium ophthalmic (eye) ointment

2

sulfacetamide-prednisolone

2

91


tobramycin-dexamethasone

2

OPHTHALMIC ANTI-ALLERGY AGENTSazelastine ophthalmic (eye)

2

cromolyn ophthalmic (eye)

2

epinastine 2

olopatadine ophthalmic (eye)

2

OPHTHALMIC ANTIGLAUCOMA AGENTSacetazolamide oral tablet

2

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

3

apraclonidine 2

betaxolol ophthalmic (eye)

2

bimatoprost ophthalmic (eye)

2

brimonidine 2

carteolol 2

dorzolamide 2

dorzolamide-timolol 2

dorzolamide-timolol (pf) ophthalmic (eye) dropperette

2

levobunolol ophthalmic (eye) drops 0.5 %

2

methazolamide 2

PHOSPHOLINE IODIDE

4

pilocarpine hcl ophthalmic (eye) drops1 %, 2 %, 4 %

2

timolol maleate ophthalmic (eye) drops

1


timolol maleate ophthalmic (eye) drops, once daily

2

timolol maleate ophthalmic (eye) gel forming solution

2

OPHTHALMIC ANTI-INFLAMMATORIESbromfenac 2

dexamethasone sodium phosphate ophthalmic (eye)

2

diclofenac sodium ophthalmic (eye)

2

fluorometholone 2

flurbiprofen sodium 2

ketorolac ophthalmic (eye)

2

loteprednol etabonate 2


prednisolone sodium phosphate ophthalmic (eye)

2

XIIDRA 3QL (60 EA per 30 days)

OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGSbimatoprost ophthalmic (eye)

2

latanoprost 2

travoprost 2

OTIC AGENTSOTIC AGENTS

CIPRODEX 3

hydrocortisone-acetic acid

2

92


neomycin-polymyxin-hc otic (ear)

2

ofloxacin oral tablet300 mg

2

RESPIRATORY TRACT/ PULMONARY AGENTSANTIHISTAMINES

azelastine nasal 2QL (60 ML per 30 days)

cetirizine oral solution 1 mg/ml

2


2 PA

levocetirizine oral solution

2

levocetirizine oral tablet 2QL (30 EA per 30 days)

olopatadine nasal 2QL (30.5 GM per 30 days)

promethazine oral 4 PA

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

ADVAIR DISKUS 3QL (60 EA per 30 days)

ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION



ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60)


ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG/ ACTUATION (120)


budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml


budesonide inhalation suspension for nebulization 1 mg/2 ml


flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)


fluticasone propionate nasal


mometasone nasal 2QL (34 GM per 30 days)

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION

3QL (10.6 GM per 30 days)

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 80 MCG/ACTUATION

3QL (21.2 GM per 30 days)

ANTILEUKOTRIENES

montelukast 2

93


zafirlukast 2

BRONCHODILATORS, ANTICHOLINERGIC

ATROVENT HFA 3QL (25.8 GM per 30 days)

INCRUSE ELLIPTA 3QL (30 EA per 30 days)

ipratropium bromide inhalation

2 BvD

ipratropium bromide nasal


SPIRIVA RESPIMAT 3QL (4 GM per 30 days)

SPIRIVA WITH HANDIHALER


BRONCHODILATORS, SYMPATHOMIMETIC


albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation


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

2 BvD

albuterol sulfate oral syrup

2

albuterol sulfate oral tablet

4

albuterol sulfate oral tablet extended release 12 hr

4


DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION


epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml


EPIPEN 2-PAK 3QL (2 EA per 30 days)

EPIPEN JR 2-PAK 3QL (2 EA per 30 days)

levalbuterol hcl 2 BvD

metaproterenol oral syrup

2

PERFOROMIST 3 BvD

PROAIR HFA 3QL (17 GM per 30 days)

PROAIR RESPICLICK 3QL (2 EA per 30 days)

SEREVENT DISKUS 3QL (60 EA per 30 days)

STRIVERDI RESPIMAT


SYMJEPI 4QL (2 EA per 30 days)

terbutaline oral 2

CYSTIC FIBROSIS AGENTS

CAYSTON 5PA; QL (84 ML per 28 days)

KALYDECO ORAL GRANULES IN PACKET


KALYDECO ORAL TABLET


ORKAMBI ORAL GRANULES IN PACKET


94


ORKAMBI ORAL TABLET


PULMOZYME 5 BvD

SYMDEKO 5PA; QL (56 EA per 28 days)

TRIKAFTA 5 PA

MAST CELL STABILIZERScromolyn inhalation 2 BvD

cromolyn oral 2

PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASEDALIRESP ORAL TABLET 250 MCG


DALIRESP ORAL TABLET 500 MCG

4 PA

THEO-24 3

theophylline oral solution

2

theophylline oral tablet extended release 12 hr300 mg

2

theophylline oral tablet extended release 24 hr

2

PULMONARY ANTIHYPERTENSIVESADEMPAS 5 PA

ALYQ 5PA; QL (60 EA per 30 days)

ambrisentan 5 PA

bosentan 5 PA

OPSUMIT 5 PA

sildenafil (pulm.hypertension) oral suspension for reconstitution



sildenafil (pulm.hypertension) oral tablet


tadalafil (pulm. hypertension)


PULMONARY FIBROSIS AGENTS

ESBRIET ORAL CAPSULE


ESBRIET ORAL TABLET 267 MG





RESPIRATORY TRACT AGENTS, OTHERacetylcysteine 2 BvD

ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG

5

GRASTEK 3 PA

INCRUSE ELLIPTA 3QL (30 EA per 30 days)

ODACTRA 3 PA

PROLASTIN-C INTRAVENOUS RECON SOLN

5

STIOLTO RESPIMAT 3QL (4 GM per 30 days)

RESPIRATORY TRACT/ PULMONARY AGENTS


COMBIVENT RESPIMAT


95


ESBRIET ORAL CAPSULE






FASENRA 5 PA

FASENRA PEN 5 PA

ipratropium-albuterol 2 BvD


PULMOZYME 5 BvD

SYMBICORT 3QL (10.2 GM per 30 days)

XOLAIR SUBCUTANEOUS RECON SOLN


XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML


XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML


SKELETAL MUSCLE RELAXANTSSKELETAL MUSCLE RELAXANTScyclobenzaprine oral tablet

4 PA

tizanidine 2

SLEEP DISORDER AGENTSGABA RECEPTOR MODULATORS

eszopiclone 4QL (30 EA per 30 days)


zaleplon oral capsule 10 mg


zaleplon oral capsule 5 mg


zolpidem oral tablet 2QL (30 EA per 30 days)

SLEEP DISORDERS, OTHERarmodafinil 4 PA

doxepin oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg

4


4


HETLIOZ 5PA; QL (30 EA per 30 days)

modafinil 2 PA

ramelteon 2QL (30 EA per 30 days)

ROZEREM 3QL (30 EA per 30 days)

XYREM 5PA; QL (540 ML per 30 days)

96

Index1ST TIER UNIFINE PENTIPS.. 711ST TIER UNIFINE PENTIPS PLUS...........................................71abacavir ...................................... 42abacavir-lamivudine ................... 42abacavir-lamivudine-zidovudine 42ABELCET.................................. 30ABILIFY MAINTENA........ 28, 38abiraterone ................................. 34ABRAXANE.............................. 71acamprosate ................................20acarbose ......................................46acebutolol ................................... 50acetaminophen-caff-dihydrocod . 71acetaminophen-codeine ........ 18, 71acetazolamide ....................... 52, 92acetazolamide sodium .................71acetic acid .............................22, 71acetylcysteine ........................ 71, 95acitretin .......................................55ACTEMRA...........................67, 71ACTEMRA ACTPEN................ 67ACTHIB (PF)............................. 68ACTIMMUNE............................68acyclovir ......................................41acyclovir sodium .........................41ADACEL(TDAP ADOLESN/ADULT)(PF)...........68ADASUVE................................. 71adefovir ....................................... 40ADEMPAS................................. 95adenosine .................................... 71ADRENALIN............................. 71ADRIAMYCIN.......................... 71ADRUCIL...................................71ADVAIR DISKUS......... 93, 94, 95ADVOCATE PEN NEEDLE..... 71ADVOCATE SYRINGES..........71AFINITOR............................35, 67AFINITOR DISPERZ................ 67AK-POLY-BAC......................... 71ALA-CORT................................ 61albendazole ................................. 37albumin, human 25 % ................. 71albumin, human 5 % ................... 71ALBUMINAR 25 %...................71ALBURX (HUMAN) 25 %........71ALBURX (HUMAN) 5 %..........71ALBUTEIN 25 %....................... 71ALBUTEIN 5 %......................... 71albuterol sulfate .................... 71, 94

alclometasone ............................. 61ALCOHOL PADS...................... 22ALCOHOL PREP PADS........... 71alcohol swabs ..............................71ALCOHOL WIPES.................... 71ALDURAZYME........................ 71ALECENSA............................... 35alendronate ........................... 70, 71alfuzosin ......................................60ALIMTA.....................................71ALINIA.......................................37ALIQOPA...................................71aliskiren ...................................... 51allopurinol .................................. 31allopurinol sodium ......................71ALOPRIM.................................. 71alosetron ..................................... 59ALPHAGAN P........................... 92alprostadil ...................................71ALTAVERA (28)....................... 64ALUNBRIG................................35ALYACEN 1/35 (28)..................64ALYACEN 7/7/7 (28)................ 71ALYQ......................................... 95amantadine hcl ......................38, 43AMBISOME...............................30ambrisentan ................................ 95AMETHYST (28).......................71AMICAR.................................... 71amikacin ................................21, 71amiloride .....................................52amiloride-hydrochlorothiazide ... 51aminocaproic acid ...................... 71AMINOSYN 10 %......................71AMINOSYN 7 % WITH ELECTROLYTES......................71AMINOSYN 8.5 %.....................71AMINOSYN 8.5 %-ELECTROLYTES......................71AMINOSYN II 10 %..................57AMINOSYN II 15 %..................57AMINOSYN II 8.5 %.................71AMINOSYN II 8.5 %-ELECTROLYTES......................71AMINOSYN M 3.5 %................72AMINOSYN-HBC 7%...............72AMINOSYN-PF 10 %................57AMINOSYN-PF 7 % (SULFITE-FREE).......................57AMINOSYN-RF 5.2 %.............. 72amiodarone ........................... 50, 72

amitriptyline ................................29amlodipine .................................. 50amlodipine-atorvastatin ..............51amlodipine-benazepril ................ 51amlodipine-olmesartan ............... 51amlodipine-valsartan ..................51amlodipine-valsartan-hcthiazid ..51ammonium lactate .......................55AMNESTEEM........................... 55amoxapine ...................................29amoxicil-clarithromy-lansopraz . 59amoxicillin .................................. 23amoxicillin-pot clavulanate ........ 23amphotericin b ............................ 30ampicillin .............................. 23, 72ampicillin sodium ..................23, 72ampicillin-sulbactam ............ 23, 72anagrelide ................................... 48anastrozole ..................................35APOKYN....................................38apraclonidine ..............................92aprepitant ....................................30APRI........................................... 64APTIOM..................................... 27APTIVUS................................... 42APTIVUS (WITH VITAMIN E).................................................42ARALAST NP......................72, 95ARANELLE (28)........................64ARCALYST............................... 68ARIKAYCE................................21aripiprazole ...........................28, 39ARISTADA................................ 39ARISTADA INITIO................... 39armodafinil ................................. 96ARRANON.................................72arsenic trioxide ........................... 72ARZERRA..................................72ASMANEX HFA........................93ASMANEX TWISTHALER 72, 93aspirin-dipyridamole .................. 49ASSURE ID INSULIN SAFETY............................... 47, 72ASSURE ID PEN NEEDLE.......72atazanavir ................................... 42atenolol ....................................... 50atenolol-chlorthalidone .............. 51atomoxetine .................................53atorvastatin ................................. 52atovaquone ..................................37atovaquone-proguanil .................37

98

ATRIPLA................................... 42atropine .................................72, 91ATROVENT HFA......................94AUBRA...................................... 64AUBRA EQ................................ 72AUGMENTIN............................ 72AUTOPEN 1 TO 21 UNITS.......72AUTOPEN 2 TO 42 UNITS.......72AVASTIN...................................72AVIANE..................................... 64AVONEX....................................54AYVAKIT.................................. 35azacitidine ...................................72azathioprine ................................ 67azathioprine sodium ....................72azelaic acid ................................. 55azelastine .............................. 92, 93azithromycin ............................... 24aztreonam ............................. 23, 72AZURETTE (28)........................ 72bacitracin ..............................22, 72bacitracin-polymyxin b ............... 91baclofen .......................................40BALANCED SALT....................72BAL-CARE DHA.......................72balsalazide .................................. 69BALVERSA............................... 35BAND-AID GAUZE PADS.......72BANZEL.....................................27BAQSIMI................................... 47BARACLUDE............................40BAVENCIO................................72bcg vaccine, live (pf) ...................68BD ALCOHOL SWABS............72BD AUTOSHIELD DUO PEN NEEDLE.....................................72BD ECLIPSE LUER-LOK......... 72BD INSULIN SYRINGE............73BD INSULIN SYRINGE HALF UNIT............................... 72BD INSULIN SYRINGE MICRO-FINE............................. 72BD INSULIN SYRINGE SLIP TIP.............................................. 72BD INSULIN SYRINGE U-500 73BD INSULIN SYRINGE ULTRA-FINE.............................73BD LO-DOSE MICRO-FINE IV................................................ 73BD LO-DOSE ULTRA-FINE.... 73BD NANO 2ND GEN PEN NEEDLE.....................................73

BD SAFETYGLIDE INSULIN SYRINGE................................... 73BD SAFETYGLIDE SYRINGE 73BD ULTRA-FINE MICRO PEN NEEDLE............................ 73BD ULTRA-FINE MINI PEN NEEDLE.....................................73BD ULTRA-FINE NANO PEN NEEDLE.....................................73BD ULTRA-FINE ORIG PEN NEEDLE.....................................73BD ULTRA-FINE SHORT PEN NEEDLE............................ 73BD VEO INSULIN SYR HALF UNIT...........................................73BD VEO INSULIN SYRINGE UF............................................... 73BEKYREE (28).......................... 73BELEODAQ...............................73benazepril ................................... 50benazepril-hydrochlorothiazide ..51BENDEKA................................. 73BENLYSTA......................... 67, 73benznidazole ............................... 37benztropine ........................... 38, 73BESPONSA................................73betamethasone acet,sod phos ......73betamethasone dipropionate.........................................31, 55, 61betamethasone valerate ........ 31, 61betamethasone, augmented ...31, 61betaxolol ............................... 50, 92bethanechol chloride ...................60BETHKIS................................... 21bexarotene ...................................37BEXSERO.................................. 68bicalutamide ............................... 34BICILLIN C-R............................23BICILLIN L-A............................23BICNU........................................73BIKTARVY................................41bimatoprost ................................. 92bisoprolol fumarate .................... 50bisoprolol-hydrochlorothiazide .. 51bleomycin ....................................73BLEPHAMIDE.....................31, 91BLEPHAMIDE S.O.P.......... 31, 91BLINCYTO................................ 73BOOSTRIX TDAP.....................68BORDERED GAUZE................ 73bortezomib .................................. 73bosentan ......................................95

BOSULIF....................................35BOTOX.......................................73BRAFTOVI.......................... 35, 73BRILINTA..................................49brimonidine .................................92BRIVIACT........................... 25, 73bromfenac ................................... 92bromocriptine ....................... 38, 66BRUKINSA................................35BSS............................................. 73budesonide .......... 59, 64, 70, 73, 93bumetanide ..................................52BUMINATE 25 %......................73BUMINATE 5 %........................73buprenorphine .......................19, 21buprenorphine hcl ...........19, 20, 74buprenorphine-naloxone .............21bupropion hcl ..............................28bupropion hcl (smoking deter) ....21buspirone .................................... 43busulfan .......................................74butorphanol tartrate ............. 20, 74BYDUREON.............................. 46BYDUREON BCISE..................46BYETTA.....................................46cabergoline ................................. 66CABLIVI.................................... 48CABOMETYX........................... 35caffeine citrate ............................ 74calcipotriene ............................... 55calcipotriene-betamethasone ......55calcitonin (salmon) ..................... 70calcitriol ..........................55, 70, 74calcium acetate(phosphat bind) ..61calcium chloride ......................... 74calcium gluconate .......................74CALQUENCE............................ 35CAMILA.....................................65CAMRESE................................. 74candesartan .................................49candesartan-hydrochlorothiazid .51CAPASTAT................................74CAPRELSA................................35captopril ......................................50captopril-hydrochlorothiazide ....51CARBAGLU.............................. 56carbamazepine ......................27, 45carbidopa ....................................38carbidopa-levodopa ....................38carbidopa-levodopa-entacapone 38CARBOCAINE (PF).................. 74carboplatin ..................................74

99

cardioplegic soln ........................ 74CAREFINE PEN NEEDLE........74CARETOUCH ALCOHOL PREP PAD..................................74CARETOUCH INSULIN SYRINGE................................... 74CARETOUCH PEN NEEDLE...74carmustine ...................................74carteolol ......................................92CARTIA XT............................... 50carvedilol .................................... 50carvedilol phosphate ...................50caspofungin .................................30CAYSTON........................... 23, 94CAZIANT (28)........................... 64cefaclor ................................. 22, 23cefadroxil .................................... 23cefazolin ................................23, 74cefazolin in dextrose (iso-os) ...... 74cefdinir ........................................23cefepime ...................................... 23cefepime in dextrose,iso-osm ...... 74cefixime ....................................... 23cefotaxime ................................... 74cefotetan ................................23, 74cefoxitin .......................................23cefoxitin in dextrose, iso-osm ......74cefpodoxime ................................ 23cefprozil ...................................... 23ceftazidime .................................. 23ceftriaxone ............................ 23, 74ceftriaxone in dextrose,iso-os ..... 74cefuroxime axetil .........................23cefuroxime sodium ...................... 23celecoxib ............................... 18, 32CELONTIN................................ 25cephalexin ................................... 23CEPROTIN (BLUE BAR)......... 74CEPROTIN (GREEN BAR).......74CERDELGA............................... 60CEREZYME...............................74cetirizine ..................................... 93cevimeline ................................... 55CHANTIX.................................. 21CHANTIX CONTINUING MONTH BOX............................ 21CHANTIX STARTING MONTH BOX............................ 21CHEMET....................................57CHENODAL.............................. 58chloramphenicol sod succinate ...74chlorhexidine gluconate ..............55

chloroprocaine (pf) .....................74chloroquine phosphate ................37chlorothiazide ............................. 74chlorothiazide sodium .................74chlorpromazine ............... 30, 38, 74chlorthalidone .............................52CHOLBAM................................ 58cholestyramine (with sugar) . 52, 74CHOLESTYRAMINE LIGHT...............................................53, 74CICLODAN................................74ciclopirox .................................... 30cidofovir ......................................74cilostazol ..................................... 49CIMDUO.................................... 42cimetidine ....................................59cimetidine hcl ..............................59cinacalcet ....................................70CINRYZE................................... 67CINVANTI................................. 74CIPRODEX................................ 92ciprofloxacin ......................... 74, 75ciprofloxacin hcl ......................... 24ciprofloxacin in 5 % dextrose...............................................24, 74cisplatin .......................................75citalopram ...................................28cladribine ....................................75CLARAVIS................................ 55clarithromycin .............................24CLICKFINE PEN NEEDLE...... 75clindamycin hcl ...........................22clindamycin in 5 % dextrose .......22clindamycin palmitate hcl ...........75CLINDAMYCIN PEDIATRIC.. 22clindamycin phosphate ............... 22CLINIMIX 5%/D15W SULFITE FREE..........................57CLINIMIX 5%/D25W SULFITE-FREE......................... 75CLINIMIX 4.25%/D10W SULF FREE................................57CLINIMIX 4.25%/D5W SULFIT FREE............................ 57CLINIMIX 4.25%-D25W SULF-FREE............................... 75CLINIMIX 5%-D20W(SULFITE-FREE)............57clobazam ............................... 25, 26clobetasol ..............................55, 61clobetasol-emollient ....................61clofarabine ..................................75

clomiphene citrate .......................75clomipramine .............................. 29clonazepam ........................... 26, 43clonidine ..................................... 49clonidine (pf) ...............................75clonidine hcl ..........................49, 53clopidogrel ............................49, 75clorazepate dipotassium ....... 26, 43clotrimazole ................................ 30clotrimazole-betamethasone ....... 55CLOVIQUE..........................57, 60clozapine ..................................... 40C-NATE DHA............................ 75COARTEM.................................37COLCRYS..................................31colesevelam ...........................46, 53colestipol ...............................53, 75colistin (colistimethate na) ......... 22COLOCORT...............................75COMBIVENT RESPIMAT........95COMETRIQ............................... 35COMFORT EZ INSULIN SYRINGE................................... 75COMFORT EZ PEN NEEDLES...................................75COMPLERA...............................42COMPLETE NATAL DHA....... 75COMPRO................................... 30CONSTULOSE.......................... 59COPIKTRA................................ 35CORLANOR.............................. 51CORTIFOAM.............................75cortisone ......................... 31, 61, 70COSMEGEN.............................. 75COTELLIC................................. 36CREON.......................................60CRESEMBA.........................30, 75CRIXIVAN.................................43cromolyn ............................... 92, 95CROTAN....................................75CRYSELLE (28)........................ 64CRYSVITA................................ 75CURITY ALCOHOL SWABS...75CURITY GAUZE.......................75CYCLAFEM 1/35 (28)...............64CYCLAFEM 7/7/7 (28)..............64cyclobenzaprine .......................... 96cyclophosphamide .................33, 75CYCLOSET................................46cyclosporine ..........................67, 75cyclosporine modified .................67CYRAMZA................................ 75

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CYRED.......................................64CYRED EQ................................ 75CYSTADANE............................ 60CYSTAGON...............................60CYSTARAN...............................91cytarabine ................................... 75cytarabine (pf) .............................75d10 %-0.45 % sodium chloride ...57d2.5 %-0.45 % sodium chloride ..57d5 % and 0.9 % sodium chloride ....................................... 57d5 %-0.45 % sodium chloride .....57dacarbazine .................................75dactinomycin ...............................75dalfampridine ..............................54DALIRESP................................. 95danazol ........................................63dantrolene ............................. 40, 75dapsone ................................. 33, 55DAPTACEL (DTAP PEDIATRIC) (PF)...................... 68daptomycin ..................................22DARAPRIM............................... 37DARZALEX...............................75DASETTA 1/35 (28).................. 75DASETTA 7/7/7 (28)................. 75daunorubicin ...............................75DAURISMO............................... 36DAYSEE.....................................75DDAVP.......................................62DEBLITANE..............................64DECADRON.............................. 75decitabine ....................................75deferasirox .................................. 57deferoxamine ...............................75DELSTRIGO.............................. 42demeclocycline ............................25DEMSER.................................... 51DENAVIR.................................. 41DENTA 5000 PLUS................... 75DENTAGEL............................... 75DEPEN TITRATABS.... 57, 60, 67DEPO-PROVERA......................65DERMACEA..............................75DERMACEA NON-WOVEN.... 75DESCOVY................................. 42desipramine .................................29desmopressin .........................62, 75desog-e.estradiol/e.estradiol .......64desogestrel-ethinyl estradiol .......64desonide ...................................... 61desvenlafaxine succinate .............28

dexamethasone ..........31, 61, 70, 75DEXAMETHASONE INTENSOL.....................31, 61, 70dexamethasone sodium phos (pf) ...............................................75dexamethasone sodium phosphate ..............................76, 92dexrazoxane hcl .......................... 76dextroamphetamine .....................53dextroamphetamine-amphetamine ...............................53dextrose 10 % and 0.2 % nacl .... 57dextrose 10 % in water (d10w) ...57dextrose 20 % in water (d20w) ...76dextrose 25 % in water (d25w) ...76dextrose 30 % in water (d30w) ...76dextrose 40 % in water (d40w) ...76dextrose 5 % in water (d5w) .57, 76dextrose 5 %-lactated ringers .....76dextrose 5%-0.2 % sod chloride . 58dextrose 5%-0.3 % sod.chloride . 76dextrose 50 % in water (d50w) ...76dextrose 70 % in water (d70w) ...76DIASTAT....................... 25, 26, 43DIASTAT ACUDIAL.... 25, 26, 43diazepam ............. 25, 26, 43, 44, 76DIAZEPAM INTENSOL........... 76diclofenac potassium ............ 18, 32diclofenac sodium ..... 18, 32, 55, 92diclofenac-misoprostol ............... 18dicloxacillin ................................ 23dicyclomine ........................... 58, 76didanosine ...................................42diflunisal ............................... 18, 32DIGITEK.................................... 51DIGOX........................................51digoxin ........................................ 51dihydroergotamine ................32, 76DILANTIN................................. 27diltiazem hcl ..........................50, 76DILT-XR.................................... 50dimenhydrinate ........................... 76DIPENTUM................................69diphenhydramine hcl ...................76diphenoxylate-atropine ............... 58dipyridamole ......................... 49, 76disulfiram ....................................20divalproex ................. 26, 32, 33, 45dobutamine ................................. 76dobutamine in d5w ......................76docetaxel ..................................... 76dofetilide ..................................... 50

donepezil ..................................... 27dopamine .....................................76dopamine in 5 % dextrose ...........76DOPTELET (10 TAB PACK)....48DOPTELET (15 TAB PACK)....48DOPTELET (30 TAB PACK)....48dorzolamide ................................ 92dorzolamide-timolol ....................92dorzolamide-timolol (pf) .............92DOTTI........................................ 63DOVATO....................................42doxazosin .............................. 49, 60doxepin ......................29, 43, 55, 96doxercalciferol ................58, 70, 76doxorubicin ................................. 76doxorubicin, peg-liposomal ........ 77DOXY-100..................................25doxycycline hyclate ......... 25, 55, 77doxycycline monohydrate ..... 25, 55doxylamine-pyridoxine (vit b6) ...30DRIZALMA SPRINKLE..... 28, 44dronabinol ...................................30droperidol ................................... 77DROPLET INSULIN SYR HALF UNIT............................... 77DROPLET INSULIN SYRINGE................................... 77DROPLET PEN NEEDLE......... 77DROPSAFE PEN NEEDLE.......77drospirenone-e.estradiol-lm.fa ... 77drospirenone-ethinyl estradiol ....64DROXIA.....................................34DULERA.................................... 94duloxetine ........................28, 44, 54DUPIXENT................................ 55DURAMORPH (PF)...................19dutasteride .................................. 60dutasteride-tamsulosin ................60E.E.S. 400................................... 24EASY COMFORT ALCOHOL PAD............................................ 77EASY COMFORT INSULIN SYRINGE................................... 77EASY COMFORT PEN NEEDLES...................................77EASY GLIDE INSULIN SYRINGE................................... 77EASY GLIDE PEN NEEDLE....77EASY TOUCH........................... 77EASY TOUCH ALCOHOL PREP PADS................................77

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EASY TOUCH FLIPLOCK INSULIN.................................... 77EASY TOUCH INSULIN SAFETY SYR............................ 77EASY TOUCH INSULIN SYRINGE................................... 77EASY TOUCH LUER LOCK INSULIN.................................... 77EASY TOUCH PEN NEEDLE.. 77EASY TOUCH SHEATHLOCK INSULIN.........77EASY TOUCH UNI-SLIP..........77EC-NAPROXEN........................ 77econazole .................................... 30EDURANT................................. 42efavirenz ......................................42EFFER-K.................................... 77ELAPRASE................................ 77electrolyte-48 in d5w .................. 77eletriptan .....................................33ELINEST.................................... 77ELIQUIS.....................................48ELIQUIS DVT-PE TREAT 30D START................................48ELITEK...................................... 77ELITE-OB.................................. 77ELMIRON.................................. 60ELURYNG................................. 64EMCYT...................................... 34EMEND...................................... 30EMOQUETTE............................64EMPLICITI.................................77EMSAM......................................28EMTRIVA.................................. 42EMVERM...................................37enalapril maleate ........................ 50enalaprilat ...................................77enalapril-hydrochlorothiazide ....51ENBREL.....................................67ENBREL MINI...........................67ENBREL SURECLICK..............67ENDOCET............................18, 77ENGERIX-B (PF).................68, 77ENGERIX-B PEDIATRIC (PF).69enoxaparin ............................ 48, 77ENPRESSE.................................64ENSKYCE..................................64entacapone ..................................38entecavir ......................................40ENTRESTO................................49ENTYVIO...................................77ENULOSE.................................. 59

EPCLUSA...................................41EPIDIOLEX................................26epinastine ....................................92epinephrine ................................. 94EPIPEN.......................................77EPIPEN 2-PAK.......................... 94EPIPEN JR..................................77EPIPEN JR 2-PAK..................... 94epirubicin ....................................77EPITOL.................................27, 45EPIVIR HBV.............................. 40eplerenone ...................................52epoprostenol (glycine) ................ 77eprosartan ...................................77ERBITUX................................... 77ergoloid .......................................27ergotamine-caffeine .................... 32ERIVEDGE................................ 36ERLEADA..................................34erlotinib .......................................36ERRIN........................................ 65ertapenem ....................................23ERWINAZE................................77ERY-TAB................................... 24ERYTHROCIN...........................24ERYTHROCIN (AS STEARATE)...............................24erythromycin ............................... 24erythromycin ethylsuccinate ....... 24erythromycin with ethanol .......... 24ESBRIET.............................. 95, 96escitalopram oxalate .............28, 44esmolol ........................................77esomeprazole magnesium ........... 59esomeprazole sodium ..................78ESTARYLLA............................. 64estradiol ...................................... 63estradiol valerate .................. 63, 64estradiol-norethindrone acet ...... 64eszopiclone ..................................96ethacrynate sodium .....................78ethacrynic acid ............................52ethambutol .................................. 33ethosuximide ............................... 25ethynodiol diac-eth estradiol ...... 64etodolac .................................18, 32etonogestrel-ethinyl estradiol ..... 64ETOPOPHOS............................. 78etoposide ..................................... 78everolimus (antineoplastic) ...36, 67EVOTAZ.................................... 43EXEL INSULIN......................... 78

exemestane ..................................35EYLEA....................................... 78ezetimibe ..................................... 53ezetimibe-simvastatin ..................51FABRAZYME............................78FALMINA (28)...........................64famciclovir .................................. 41famotidine ............................. 59, 78famotidine (pf) ............................ 78famotidine (pf)-nacl (iso-os) ...... 78FANAPT.....................................39FARXIGA...................................46FARYDAK........................... 35, 78FASENRA.................................. 96FASENRA PEN..........................96FASLODEX............................... 78FAYOSIM.................................. 64febuxostat ....................................31felbamate .....................................27felodipine .................................... 50FEMYNOR.................................64fenofibrate ...................................52fenofibrate micronized ................ 52fenofibrate nanocrystallized ....... 52fenofibric acid .............................78fenofibric acid (choline) ..............52fenoprofen ............................. 18, 32fentanyl ................................. 19, 20fentanyl citrate ...................... 19, 20fentanyl citrate (pf) ..................... 78FERRIPROX.............................. 57FETZIMA............................. 28, 29finasteride ................................... 60FIRAZYR................................... 67FIRDAPSE........................... 54, 60FIRMAGON KIT W DILUENT SYRINGE................................... 66flavoxate ......................................60flecainide .....................................50floxuridine ...................................78fluconazole ..................................30fluconazole in nacl (iso-osm) ......30flucytosine ................................... 30fludarabine ..................................78fludrocortisone ............................61flumazenil ....................................78flunisolide ................................... 93fluocinolone .......................... 61, 78fluocinolone acetonide oil ...........61fluocinolone and shower cap ...... 61fluocinonide .............. 55, 61, 62, 78FLUOCINONIDE-E...................62

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fluocinonide-emollient ................ 78fluoride (sodium) ........................ 78FLUORITAB..............................78fluorometholone ..........................92fluorouracil ..................... 55, 56, 78fluoxetine ...............................28, 29fluphenazine decanoate ...............38fluphenazine hcl .......................... 38flurbiprofen ........................... 18, 32flurbiprofen sodium .................... 92flutamide ..................................... 34fluticasone propionate ................ 93fluvastatin ................................... 52fluvoxamine .................................29FOLIVANE-OB..........................78FOLOTYN..................................78fomepizole ................................... 78fondaparinux ...............................48FORTEO.....................................70fosamprenavir ............................. 43fosaprepitant ............................... 78fosinopril .....................................50fosinopril-hydrochlorothiazide ... 51fosphenytoin ................................78FREAMINE III 10 %..................78FREESTYLE CONTROL.......... 78FREESTYLE FLASH SYSTEM.....................................78FREESTYLE FREEDOM.......... 78FREESTYLE FREEDOM LITE 78FREESTYLE INSULINX.......... 78FREESTYLE INSULINX TEST STRIPS.............................78FREESTYLE LITE METER......78FREESTYLE LITE STRIPS...... 78FREESTYLE NAVIGATOR GLUC SENS...............................78FREESTYLE PRECISION........ 78FREESTYLE PRECISION NEO METER..............................78FREESTYLE PRECISION NEO STRIPS.............................. 78FREESTYLE SIDEKICK II.......79FREESTYLE SYSTEM KIT......79FREESTYLE TEST....................79FULPHILA................................. 48fulvestrant ................................... 79furosemide ...................................52FUZEON.....................................42FYCOMPA................................. 27gabapentin ............................ 26, 79galantamine ................................ 27

GAMASTAN..............................79GAMASTAN S/D...................... 79ganciclovir sodium ......................79GARDASIL 9 (PF)..................... 69gatifloxacin ................................. 24GATTEX 30-VIAL.....................58GATTEX ONE-VIAL................ 79gauze bandage ............................ 79GAUZE PAD..............................47GAVILYTE-C............................ 59GAVILYTE-G............................ 59GAVILYTE-N............................ 59GAZYVA....................................79gemcitabine .................................79gemfibrozil .................................. 52GENERLAC............................... 59GENGRAF................................. 67GENTAK....................................21gentamicin .............................21, 79gentamicin in nacl (iso-osm) .......21gentamicin sulfate (ped) (pf) .......79GENVOYA.................................41GEODON..............................39, 44GIANVI (28)...............................64GILENYA...................................54GILOTRIF.................................. 36glatiramer ................................... 54GLATOPA..................................54GLEOSTINE.............................. 34glimepiride ..................................46glipizide .......................................46glipizide-metformin .....................47GLUCAGEN HYPOKIT............47GLUCAGON EMERGENCY KIT (HUMAN)........................... 47GLUCOSE KETONE CONTROL SOLN...................... 79GLYCINE UROLOGIC............. 79glycine urologic solution ............ 79glycopyrrolate .......................58, 79glycopyrrolate (pf) in water ........79GLYDO...................................... 79granisetron (pf) ...........................79granisetron hcl ......................30, 79GRANIX.....................................48GRASTEK..................................95griseofulvin microsize .................30griseofulvin ultramicrosize ......... 30guanidine .................................... 33HAEGARDA..............................67HALAVEN................................. 79halobetasol propionate ............... 62

haloperidol ..................................38haloperidol decanoate ................ 38haloperidol lactate ................38, 79HARVONI............................41, 79HAVRIX (PF).............................69HEALTHWISE INSULIN SYRINGE................................... 79HEALTHWISE PEN NEEDLE..79HEALTHY ACCENTS UNIFINE PENTIP......................79HEATHER..................................79heparin (porcine) .................. 48, 79heparin (porcine) in 5 % dex ...... 79heparin (porcine) in nacl (pf) ..... 79heparin(porcine) in 0.45% nacl ..79heparin, porcine (pf) ...................79HEPATAMINE 8%.................... 58HERCEPTIN.............................. 79HERCEPTIN HYLECTA...........79HETLIOZ....................................96HIBERIX (PF)............................ 69HIZENTRA................................ 79HUMALOG JUNIOR KWIKPEN U-100.......................47HUMALOG KWIKPEN INSULIN.................................... 47HUMALOG MIX 50-50 INSULN U-100...........................47HUMALOG MIX 50-50 KWIKPEN..................................47HUMALOG MIX 75-25 KWIKPEN..................................48HUMALOG MIX 75-25(U-100)INSULN.............................. 48HUMALOG U-100 INSULIN....48HUMIRA.................................... 67HUMIRA PEN............................67HUMIRA PEN CROHNS-UC-HS START..................................67HUMIRA PEN PSOR-UVEITS-ADOL HS....................67HUMIRA(CF).............................68HUMIRA(CF) PEDI CROHNS STARTER...................................67HUMIRA(CF) PEN.................... 68HUMIRA(CF) PEN CROHNS-UC-HS........................................ 67HUMIRA(CF) PEN PSOR-UV-ADOL HS................................... 67HUMULIN 70/30 U-100 INSULIN.................................... 48

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HUMULIN 70/30 U-100 KWIKPEN..................................48HUMULIN N NPH INSULIN KWIKPEN..................................48HUMULIN N NPH U-100 INSULIN.................................... 48HUMULIN R REGULAR U-100 INSULN...............................48HUMULIN R U-500 (CONC) INSULIN.................................... 48HUMULIN R U-500 (CONC) KWIKPEN..................................48hydralazine ........................... 53, 79hydrochlorothiazide ....................52hydrocodone bitartrate ............... 19hydrocodone-acetaminophen 18, 80hydrocodone-ibuprofen ...............18hydrocortisone .......... 31, 62, 70, 80hydrocortisone butyrate ..............56hydrocortisone-acetic acid ......... 92hydrocortisone-pramoxine ..........31hydromorphone ...............19, 20, 80hydromorphone (pf) ........ 19, 20, 80hydroxychloroquine .................... 37hydroxyprogesterone caproate ... 80hydroxyurea ................................ 34hydroxyzine hcl ............... 30, 43, 93HYPERHEP B S/D.....................80HYPERHEP B S-D NEONATAL...............................80HYQVIA.....................................80ibandronate ...........................70, 80IBRANCE...................................35IBU................................. 18, 32, 80ibuprofen ...............................18, 32ibuprofen-oxycodone ............ 18, 32ibutilide fumarate ........................80icatibant ...................................... 67ICLUSIG.....................................36idarubicin ....................................80IDHIFA.......................................35ifosfamide ....................................80ILARIS (PF)............................... 80imatinib ....................................... 36IMBRUVICA............................. 36IMFINZI..................................... 80imipenem-cilastatin .....................23imipramine hcl ............................ 29imipramine pamoate ................... 29imiquimod ................................... 56IMOVAX RABIES VACCINE (PF)............................................. 69

IMPAVIDO................................ 80INCASSIA..................................64INCONTROL ALCOHOL PADS.......................................... 80INCONTROL PEN NEEDLE.... 80INCRELEX.................................62INCRUSE ELLIPTA............ 94, 95indapamide ................................. 52INFANRIX (DTAP) (PF)..... 69, 80INFUGEM.................................. 80INLYTA......................................36INREBIC.................................... 36insulin syr/ndl u100 half mark ....80INSULIN SYRINGE.................. 80INSULIN SYRINGE MICROFINE.............................. 80insulin syringe needleless ........... 80insulin syringe-needle u-100 .48, 80INSUPEN................................... 80INTELENCE.............................. 42INTRALIPID..............................58INTRON A........................... 40, 41INTROVALE..............................64INVEGA SUSTENNA............... 39INVEGA TRINZA..................... 39INVIRASE..................................43INVOKAMET............................ 46INVOKAMET XR......................46INVOKANA...............................46IONOSOL-MB IN D5W............ 81IPOL........................................... 69ipratropium bromide ...................94ipratropium-albuterol ................. 96irbesartan ....................................49irbesartan-hydrochlorothiazide...............................................51, 52IRESSA.......................................36irinotecan ....................................81ISENTRESS............................... 41ISENTRESS HD.........................41ISIBLOOM................................. 64ISOLYTE S PH 7.4.................... 81ISOLYTE-P IN 5 % DEXTROSE............................... 58ISOLYTE-S................................ 56isoniazid ................................33, 81isosorbide dinitrate ...............53, 81isosorbide mononitrate ............... 53isotretinoin ..................................56isradipine .................................... 50ISTODAX...................................81itraconazole ................................ 30

IV PREP WIPES.........................81ivermectin ..............................37, 56IXEMPRA.................................. 81IXIARO (PF).............................. 69JAKAFI.......................................36JANTOVEN................................48JANUMET..................................47JANUMET XR........................... 47JANUVIA................................... 46JASMIEL (28)............................ 64JENCYCLA................................81JETREA (PF)..............................81JEVTANA.................................. 81JOLESSA....................................81JULEBER................................... 64JULUCA..................................... 42JUXTAPID................................. 53KADCYLA.................................81KALETRA..................................43KALLIGA...................................81KALYDECO.............................. 94KANJINTI.................................. 81KANUMA.................................. 81KARIVA (28)............................. 64KELNOR 1/35 (28).................... 64KELNOR 1-50............................64KEPIVANCE..............................81ketoconazole ..........................30, 31ketodan ........................................31ketoprofen ............................. 18, 32ketorolac ..................................... 92KEYTRUDA.............................. 81KHAPZORY...............................81KINRIX (PF).............................. 69KIONEX (WITH SORBITOL).. 57KISQALI.................................... 35KISQALI FEMARA CO-PACK 35KLOR-CON................................57KLOR-CON 10.....................56, 58KLOR-CON 8.......................56, 58KLOR-CON M10................. 56, 58KLOR-CON M15................. 56, 58KLOR-CON M20................. 56, 58KLOR-CON/EF..........................81KOMBIGLYZE XR................... 47KORLYM................................... 47K-PHOS NO 2............................ 81K-PHOS ORIGINAL..................81KRYSTEXXA............................ 81K-TAB........................................ 56KURVELO (28)..........................64KUVAN......................................60

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KYPROLIS.................................81l norgest/e.estradiol-e.estrad ...... 64labetalol ................................ 50, 81lactated ringers ...........................81lactulose ................................59, 81lamivudine .............................40, 42lamivudine-zidovudine ................42lamotrigine ......................26, 27, 45LANOXIN............................ 51, 81lansoprazole ................................59lanthanum ................................... 61LANTUS SOLOSTAR U-100 INSULIN.................................... 48LANTUS U-100 INSULIN........ 48LARIN 1.5/30 (21)..................... 64LARIN 1/20 (21)........................ 64LARIN 24 FE............................. 81LARIN FE 1.5/30 (28)................64LARIN FE 1/20 (28)...................64LARISSIA.................................. 64latanoprost ..................................92LATUDA....................................39leflunomide ................................. 68LEMTRADA.............................. 81LENVIMA..................................36LESSINA....................................64letrozole ...................................... 35leucovorin calcium ..........34, 37, 81LEUKERAN...............................33LEUKINE................................... 48leuprolide ....................................66levalbuterol hcl ........................... 94levetiracetam .........................25, 81levetiracetam in nacl (iso-os) ..... 81levobunolol ................................. 92levocarnitine ......................... 58, 81levocarnitine (with sugar) ...........58levocetirizine ...............................93levofloxacin .................................24levofloxacin in d5w ............... 24, 81levoleucovorin calcium ............... 81LEVONEST (28)........................ 64levonorgestrel-ethinyl estrad ...... 64levonorg-eth estrad triphasic ......64LEVORA-28...............................64levorphanol tartrate ....................19levothyroxine .........................66, 81LEVOXYL..................................66LEXIVA......................................43LIBTAYO...................................81lidocaine ..................................... 20lidocaine (pf) in d7.5w ...............81

lidocaine (pf) ...............................81lidocaine hcl ..........................20, 81lidocaine in 5 % dextrose (pf) .....82LIDOCAINE VISCOUS.............20lidocaine-epinephrine ................. 82lidocaine-prilocaine ....................20LILLOW (28)............................. 82lincomycin ...................................82lindane ........................................ 38linezolid .......................................22linezolid in dextrose 5% ..............22linezolid-0.9% sodium chloride .. 82LIORESAL................................. 82liothyronine ...........................66, 82LISCO.........................................82lisinopril ......................................50lisinopril-hydrochlorothiazide ....51LITE TOUCH INSULIN PEN NEEDLES...................................82LITE TOUCH INSULIN SYRINGE................................... 82lithium carbonate ........................45lithium citrate ..............................45LOKELMA.................................57LONSURF.................................. 34loperamide .................................. 58lopinavir-ritonavir ...................... 43lorazepam ....................... 26, 44, 82LORAZEPAM INTENSOL....... 82LORBRENA...............................36LORCET (HYDROCODONE).. 18LORCET HD.............................. 18LORCET PLUS.......................... 18LORYNA (28)............................ 64losartan ....................................... 49losartan-hydrochlorothiazide ..... 51loteprednol etabonate ................. 92lovastatin .....................................52LOW-OGESTREL (28)..............64loxapine succinate .......................38LO-ZUMANDIMINE (28)......... 82LUCENTIS................................. 82LUDENT FLUORIDE................82LUMIZYME...............................82LUMOXITI.................................82LUPRON DEPOT...................... 66LUPRON DEPOT (3 MONTH). 66LUPRON DEPOT (4 MONTH). 66LUPRON DEPOT (6 MONTH). 66LUPRON DEPOT-PED..............82LUPRON DEPOT-PED (3 MONTH).................................... 82

LUTERA (28).............................64LYNPARZA............................... 34LYRICA............................... 25, 54LYSODREN............................... 66LYZA..........................................65mafenide acetate ......................... 56MAGELLAN INSULIN SAFETY SYRNG.......................82MAGELLAN SYRINGE............82magnesium chloride ....................82magnesium sulfate ...................... 56magnesium sulfate in d5w ...........82magnesium sulfate in water ........ 82malathion .................................... 38mannitol 20 % .............................82mannitol 25 % .............................82maprotiline ..................................28MARLISSA (28)............ 63, 64, 65MARPLAN.................................28MARQIBO................................. 82MATULANE..............................34MATZIM LA..............................50MAXICOMFORT II PEN NEEDLE.....................................82MAXICOMFORT INSULIN SYRINGE................................... 82MAXI-COMFORT INSULIN SYRINGE................................... 82MAXICOMFORT SAFETY PEN NEEDLE............................ 82meclizine ..................................... 30meclofenamate ...................... 19, 32MEDISENSE..............................82MEDISENSE GLUCOSE KETONE.................................... 82MEDISENSE MID CONTROL. 82medroxyprogesterone ..................65mefenamic acid ..................... 19, 32mefloquine ...................................37megestrol ...............................65, 82MEKINIST................................. 36MEKTOVI..................................36meloxicam ............................. 19, 32melphalan ................................... 82melphalan hcl ..............................82memantine ...................................27MENACTRA (PF)......................69MENEST.............................. 63, 82MENVEO A-C-Y-W-135-DIP (PF)............................................. 69MEPSEVII..................................82mercaptopurine ...........................68

105

meropenem ..................................23mesalamine ........................... 59, 69mesalamine with cleansing wipe 82mesna .......................................... 82MESNEX....................................34METADATE ER........................ 53metaproterenol ............................94metformin ....................................46methadone .............................19, 82METHADONE INTENSOL.......82METHADOSE............................83methazolamide ...................... 52, 92methenamine hippurate ...............22methenamine mandelate ............. 83METHERGINE.......................... 83methimazole ................................ 67methotrexate sodium ...................68methotrexate sodium (pf) ...... 68, 83methoxsalen ................................ 56methyldopa ..................................49methylergonovine ........................83methylphenidate hcl .................... 53methylprednisolone .........31, 62, 70methylprednisolone acetate ........ 83methylprednisolone sodium succ 83methyltestosterone ...................... 63metipranolol ................................83metoclopramide hcl .........30, 58, 83metolazone .................................. 52metoprolol succinate ...................50metoprolol ta-hydrochlorothiaz ..51metoprolol tartrate ................50, 83METRO I.V................................ 83metronidazole ....................... 22, 83metronidazole in nacl (iso-os) .... 22mexiletine ....................................50MIACALCIN..............................83MICONAZOLE-3.......................31MICROGESTIN 1.5/30 (21)...... 64MICROGESTIN 1/20 (21)......... 65MICROGESTIN FE 1.5/30 (28).65MICROGESTIN FE 1/20 (28)....65midodrine ....................................49mifepristone ................................ 83MIGERGOT............................... 32miglitol ........................................46miglustat ..................................... 60MILI............................................65MILLIPRED................... 31, 62, 70MILLIPRED DP.........................83milrinone .....................................83milrinone in 5 % dextrose ...........83

MINI ULTRA-THIN II.............. 83minocycline ........................... 25, 55minoxidil ..................................... 53MIOSTAT...................................83MIRENA.....................................83mirtazapine ................................. 28misoprostol ........................... 59, 63MITIGARE.................................31mitomycin ....................................83mitoxantrone ............................... 83M-M-R II (PF)............................ 69M-NATAL PLUS....................... 83modafinil ..................................... 96moexipril ..................................... 50molindone ................................... 38mometasone .......................... 62, 93MONDOXYNE NL........25, 55, 56MONOJECT INSULIN SAFETY SYRING..................... 83MONOJECT INSULIN SYRINGE................................... 83MONOJECT SYRINGE.............83MONOJECT ULTRA COMFORT INSULIN................ 83MONO-LINYAH........................83montelukast ................................. 93MORGIDOX.............................. 83morphine ......................... 19, 20, 83morphine (pf) .............................. 83morphine concentrate ........... 19, 20MOVANTIK...............................58moxifloxacin ................................24moxifloxacin-sod.chloride(iso) ... 24MOZOBIL.................................. 84MULPLETA............................... 49mupirocin ....................................22mupirocin calcium ...................... 22MVASI....................................... 84MYALEPT................................. 62MYCAMINE.............................. 31mycophenolate mofetil ................ 68mycophenolate mofetil (hcl) ........84mycophenolate sodium ................68MYLOTARG..............................84MYORISAN............................... 56MYRBETRIQ.............................60nabumetone ...........................19, 32nadolol ........................................ 50nadolol-bendroflumethiazide ......84nafcillin ................................. 23, 84nafcillin in dextrose iso-osm .......84naftifine ................................. 31, 84

NAGLAZYME........................... 84nalbuphine .................................. 84naloxone ......................................21naltrexone ............................. 20, 21NAMZARIC............................... 27naproxen ............................... 19, 32naproxen sodium ...................19, 32naratriptan ..................................33NARCAN................................... 21NATACYN.................................31nateglinide .................................. 46NATPARA................................. 70NAYZILAM......................... 26, 44NEBUPENT............................... 37nefazodone .................................. 28neomycin ..................................... 21neomycin-bacitracin-poly-hc ...... 91neomycin-bacitracin-polymyxin ..91neomycin-polymyxin b gu ........... 84neomycin-polymyxin b-dexameth ..................................... 91neomycin-polymyxin-gramicidin 91neomycin-polymyxin-hc ........ 91, 93NEO-POLYCIN..........................84NEO-POLYCIN HC...................84neostigmine methylsulfate ...........84NEPHRAMINE 5.4 %................58NERLYNX................................. 36NEULASTA......................... 49, 84NEUPOGEN...............................49NEUPRO.................................... 38nevirapine ................................... 42NEXAVAR.................................36NEXPLANON............................84niacin .................................... 53, 84nicardipine ............................50, 84NICOTROL................................ 21NICOTROL NS.......................... 21nifedipine .................................... 51NIKKI (28)................................. 65nilutamide ................................... 34nimodipine .................................. 51NINLARO.................................. 34nisoldipine ...................................51nitisinone .....................................84NITRO-BID................................53nitrofurantoin ..............................22nitrofurantoin macrocrystal ........22nitrofurantoin monohyd/m-cryst .22nitroglycerin ......................... 53, 84nitroglycerin in 5 % dextrose ......84nizatidine .....................................59

106

NOLIX........................................56NORA-BE...................................65norepinephrine bitartrate ........... 84norethindrone (contraceptive) .... 65norethindrone acetate .................65norethindrone ac-eth estradiol...............................................65, 84norethindrone-e.estradiol-iron ... 84norgestimate-ethinyl estradiol .... 65NORLYDA.................................84NORMOSOL-R..........................84NORMOSOL-R IN 5 % DEXTROSE............................... 58NORMOSOL-R PH 7.4..............56NORTHERA...............................49NORTREL 0.5/35 (28)............... 65NORTREL 1/35 (21).................. 65NORTREL 1/35 (28).................. 65NORTREL 7/7/7 (28)................. 65nortriptyline ................................ 29NORVIR..................................... 43NOVOFINE 32...........................84NOVOFINE AUTOCOVER...... 84NOVOFINE PLUS..................... 84NOVOPEN ECHO..................... 84NOVOTWIST.............................84NOXAFIL...................................31NPLATE..................................... 84NUBEQA....................................34NUEDEXTA...............................53NULOJIX....................................84NUPLAZID................................ 39NYAMYC...................................31nystatin ........................................31nystatin-triamcinolone ................56NYSTOP.....................................31OCALIVA.................................. 58OCREVUS..................................84octreotide acetate ..................66, 84ODACTRA................................. 95ODEFSEY.................................. 42ODOMZO...................................36OFEV..............................36, 95, 96ofloxacin ............................... 24, 93OKEBO.......................................84olanzapine .............................39, 44olanzapine-fluoxetine ..................28olmesartan .................................. 49olmesartan-amlodipin-hcthiazid .51olmesartan-hydrochlorothiazide...............................................49, 51olopatadine ........................... 92, 93

omeprazole ..................................59OMNIPOD DASH 5 PACK POD............................................ 84OMNIPOD INSULIN MANAGEMENT........................84OMNIPOD INSULIN REFILL.. 84OMNITROPE............................. 62ONCASPAR............................... 84ondansetron ................................ 30ondansetron hcl .................... 30, 84ondansetron hcl (pf) ....................84ONETOUCH ULTRA BLUE TEST STRIP...............................84ONETOUCH ULTRA CONTROL................................. 84ONETOUCH ULTRA2 METER.......................................84ONETOUCH ULTRAMINI....... 85ONETOUCH VERIO FLEX METER.......................................85ONETOUCH VERIO HIGH CONTROL................................. 85ONETOUCH VERIO IQ METER.......................................85ONETOUCH VERIO METER...85ONETOUCH VERIO MID CONTROL................................. 85ONETOUCH VERIO TEST STRIPS....................................... 85ONGLYZA................................. 47ONIVYDE.................................. 85OPDIVO..................................... 85opium tincture .............................85OPSUMIT...................................95OPTIUM EZ............................... 85OPTIUM TEST.......................... 85ORALONE................................. 85ORENCIA...................................68ORENCIA (WITH MALTOSE).85ORENCIA CLICKJECT............ 68ORFADIN...................................60ORKAMBI........................... 94, 95ORSYTHIA................................ 65oseltamivir .................................. 43OSMITROL 15 %.......................85OSMITROL 20 %.......................85OTEZLA.....................................68OTEZLA STARTER............ 68, 85oxacillin .......................... 23, 24, 85oxacillin in dextrose(iso-osm) .....23oxaliplatin ................................... 85oxandrolone ................................ 63

oxaprozin .............................. 19, 32oxcarbazepine ............................. 27OXERVATE...............................91oxiconazole ................................. 56oxybutynin chloride .....................60oxycodone ................................... 20oxycodone-acetaminophen ..........18oxycodone-aspirin .......................18oxymorphone ...............................20oxytocin .......................................85OZURDEX................................. 85PACERONE............................... 50paclitaxel .....................................85paliperidone ................................39palonosetron ............................... 85PALYNZIQ................................ 60pamidronate ................................85PANRETIN.................................37pantoprazole ......................... 59, 85paricalcitol ............................70, 85PAROEX ORAL RINSE............85paromomycin .............................. 21paroxetine hcl ....................... 29, 44paroxetine mesylate(menop.sym) ..................29PASER........................................33PAXIL...................................29, 44PEDIARIX (PF)..........................69PEDVAX HIB (PF).................... 69peg 3350-electrolytes ..................59PEGANONE...............................27PEGASYS...................................41peg-electrolyte soln .....................59PEGINTRON..............................85PEN NEEDLE............................ 85pen needle, diabetic .............. 48, 85penicillamine ...................57, 60, 68penicillin g potassium ........... 24, 85penicillin g procaine ............. 24, 85penicillin g sodium ......................24penicillin v potassium ................. 24PENTACEL (PF)........................85PENTAM....................................38pentamidine .................................38PENTASA.................................. 69PENTIPS.....................................85pentoxifylline ...............................51PERFOROMIST.........................94perindopril erbumine .................. 50PERIOGARD............................. 85PERJETA....................................85permethrin ...................................38

107

perphenazine .........................30, 38PERSERIS............................ 39, 44PFIZERPEN-G........................... 85phenelzine ................................... 28phenobarbital ..............................26phenobarbital sodium ................. 85phenoxybenzamine ................ 49, 60phentolamine ...............................85phenytoin ...............................27, 85phenytoin sodium ........................ 86phenytoin sodium extended .........27PHILITH.....................................86PHOSPHOLINE IODIDE.......... 92PIFELTRO..................................42pilocarpine hcl ...................... 55, 92pimecrolimus .........................56, 68pimozide ......................................38PIMTREA (28)........................... 65pindolol ....................................... 50pioglitazone .................................47pioglitazone-glimepiride .............47pioglitazone-metformin ...............47piperacillin-tazobactam ........24, 86PIQRAY..................................... 35PIRMELLA.......................... 65, 86piroxicam .............................. 19, 32PLASBUMIN 25 %....................86PLASBUMIN 5 %......................86PLASMA-LYTE 148..................56PLASMA-LYTE A.....................56PLASMANATE......................... 86PLEGRIDY.................................54PLENAMINE....................... 57, 58PNV 29-1.................................... 86PNV-DHA.................................. 86PNV-DHA + DOCUSATE.........86PNV-OMEGA............................ 86PNV-SELECT............................ 86podofilox ..................................... 56POLIVY......................................86POLOCAINE..............................86POLOCAINE-MPF.................... 86POLYCIN................................... 86polyethylene glycol 3350 ............ 86polymyxin b sulfate ..................... 22polymyxin b sulf-trimethoprim ....91POMALYST...............................34PORTIA 28.................................65PORTRAZZA.............................86posaconazole ...............................31potassium acetate ........................86

potassium chlorid-d5-0.45%nacl ................................... 58potassium chloride ......................57potassium chloride in 0.9%nacl . 56potassium chloride in 5 % dex...............................................58, 86potassium chloride in lr-d5 ...58, 86potassium chloride in water ..56, 86potassium chloride-0.45 % nacl . 57potassium chloride-d5-0.2%nacl ............................... 58, 86potassium chloride-d5-0.3%nacl ..................................... 86potassium chloride-d5-0.9%nacl ..................................... 58potassium citrate .........................61potassium phosphate m-/d-basic .86POTELIGEO.............................. 86PR NATAL 400..........................86PR NATAL 400 EC....................86PR NATAL 430..........................86PR NATAL 430 EC....................86PRADAXA................................. 48PRALUENT PEN.......................53pramipexole ................................ 38prasugrel .....................................49pravastatin .................................. 52praziquantel ................................ 37prazosin .................................49, 60PRECISION PCX PLUS TEST..86PRECISION PCX TEST............ 86PRECISION POINT OF CARE TEST...........................................86PRECISION Q-I-D TEST.......... 86PRECISION XTRA MONITOR 86PRECISION XTRA TEST......... 86prednicarbate ........................56, 62prednisolone ................... 31, 62, 70prednisolone acetate .......31, 70, 92prednisolone sodium phosphate.............................31, 62, 70, 86, 92prednisone .......................32, 62, 70PREDNISONE INTENSOL.........................................32, 62, 70pregabalin .............................25, 54PREMASOL 10 %......................58PRENAISSANCE.......................86PRENAISSANCE PLUS............86PRENATAL PLUS.....................86PRENATAL PLUS (CALCIUM CARB)................... 86

PRENATAL VITAMIN PLUS LOW IRON.................................58PREPLUS................................... 86PRETAB..................................... 87PREVALITE.........................53, 87PREVIFEM.................................65PREVYMIS.......................... 40, 87PREZCOBIX.............................. 43PREZISTA..................................43PRIFTIN..................................... 33primaquine ..................................38primidone ....................................26PRIVIGEN..................................68PRO COMFORT ALCOHOL PADS.......................................... 87PRO COMFORT INSULIN SYRINGE................................... 87PRO COMFORT PEN NEEDLE.....................................87PROAIR HFA.............................94PROAIR RESPICLICK..............94probenecid .................................. 31probenecid-colchicine .................31procainamide .............................. 87PROCENTRA.............................53prochlorperazine .........................30prochlorperazine edisylate ......... 87prochlorperazine maleate .....30, 38PROCRIT............................. 49, 87PROCTO-MED HC....................70PROCTO-PAK........................... 62PROCTOSOL HC...................... 70PROCTOZONE-HC............. 58, 62PRODIGY INSULIN SYRINGE................................... 87progesterone ............................... 87progesterone micronized .............65PROGLYCEM............................47PROGRAF............................68, 87PROLASTIN-C.................... 87, 95PROLEUKIN..............................87PROLIA......................................70PROMACTA.............................. 49promethazine ...................30, 87, 93propafenone ................................ 50propranolol ........................... 50, 87propranolol-hydrochlorothiazid . 51propylthiouracil .......................... 67PROQUAD (PF).........................69protamine ....................................87protriptyline ................................ 29PRUDOXIN..........................29, 56

108

PULMOZYME..................... 95, 96PURIXAN...................................34pyrazinamide ...............................33pyridostigmine bromide .............. 33QUADRACEL (PF)....................69quetiapine ................. 28, 39, 44, 45quinapril ..................................... 50quinapril-hydrochlorothiazide ....51quinidine gluconate .................... 50quinidine sulfate ..........................50quinine sulfate .............................38QVAR REDIHALER................. 93RABAVERT (PF).......................69RADICAVA............................... 87RAGWITEK............................... 87raloxifene .................................... 65ramelteon .................................... 96ramipril ....................................... 50ranitidine hcl ...............................87ranolazine ................................... 51rasagiline .................................... 38RAVICTI.................................... 60REBIF (WITH ALBUMIN)....... 54REBIF REBIDOSE.................... 54REBIF TITRATION PACK....... 55RECLIPSEN (28)....................... 65RECOMBIVAX HB (PF).....69, 87RECTIV......................................53REGONOL................................. 87REGRANEX...............................56RELENZA DISKHALER...........43RELION NEEDLES...................87RELION PEN NEEDLES.......... 87RELION ULTIMA..................... 87RELISTOR........................... 58, 59REMICADE............................... 87REMODULIN............................ 87RENACIDIN.............................. 87repaglinide ..................................47repaglinide-metformin ................ 87REPATHA PUSHTRONEX...... 53REPATHA SURECLICK...........53REPATHA SYRINGE................53RETACRIT.................................49RETROVIR................................ 87REVCOVI...................................87REVLIMID.................................34REVONTO................................. 87REXULTI................................... 39REYATAZ..................................43ribavirin ................................ 40, 41RIDAURA.................................. 68

rifabutin ...................................... 33rifampin .......................................33riluzole ........................................ 54rimantadine .................................43ringer's ........................................ 87RINVOQ.....................................68RIOMET..................................... 47risedronate ..................................70RISPERDAL CONSTA........39, 45risperidone ......................39, 40, 45ritonavir ...................................... 43RITUXAN.................................. 87RITUXAN HYCELA................. 87rivastigmine ................................ 27rivastigmine tartrate ................... 27rizatriptan ................................... 33romidepsin .................................. 87ropinirole .................................... 38ROSADAN................................. 87rosuvastatin .................................52ROTARIX...................................69ROTATEQ VACCINE...............69ROWEEPRA.............................. 25ROWEEPRA XR........................25ROZEREM................................. 96ROZLYTREK.......................36, 37RUBRACA................................. 34RYDAPT.................................... 37SAFESNAP INSULIN SYRINGE................................... 87SAFETY PEN NEEDLE............ 87salsalate ...................................... 87SAMSCA....................................57SANDIMMUNE.........................68SANDOSTATIN LAR DEPOT..87SANTYL.....................................56SAPHRIS..............................40, 45scopolamine base ..................30, 58SECUADO........................... 40, 45selegiline hcl ............................... 38selenium sulfide .......................... 56SELZENTRY............................. 42SE-NATAL 19 CHEWABLE.....87SE-NATAL-19............................87SEREVENT DISKUS................ 94sertraline ...............................29, 44SETLAKIN.................................65sevelamer carbonate ................... 61sevelamer hcl .............................. 61SF................................................87SF 5000 PLUS............................ 87SHAROBEL............................... 65

SHINGRIX (PF)......................... 69SIGNIFOR..................................66SIKLOS...................................... 34sildenafil (pulm.hypertension)...............................................88, 95silodosin ......................................60silver sulfadiazine ....................... 24SIMULECT................................ 88simvastatin .................................. 52sirolimus ..................................... 68SIRTURO................................... 33SKYRIZI.....................................56sodium acetate ............................ 88sodium benzoate-sod phenylacet 88sodium bicarbonate .................... 88sodium chloride .................... 57, 88sodium chloride 0.45 % .............. 57sodium chloride 0.9 % .......... 57, 88sodium chloride 3 % ................... 57sodium chloride 5 % ................... 57SODIUM FLUORIDE 5000 PLUS...........................................88sodium nitroprusside .................. 88sodium phenylbutyrate ..........60, 61sodium phosphate ....................... 88sodium polystyrene sulfonate ......57solifenacin ...................................60SOLIRIS..................................... 88SOLTAMOX.............................. 34SOMATULINE DEPOT.............66SOMAVERT.............................. 66SORINE......................................50sotalol ......................................... 50SOTALOL AF............................ 50SOTYLIZE................................. 50SPIRIVA RESPIMAT................ 94SPIRIVA WITH HANDIHALER.......................... 94spironolactone ............................ 52spironolacton-hydrochlorothiaz . 52SPRINTEC (28)..........................65SPRITAM................................... 25SPRYCEL...................................37SPS (WITH SORBITOL)..... 57, 88SRONYX....................................65SSD............................................. 24STAMARIL (PF)........................88stavudine ..................................... 42STELARA............................ 56, 88STERILE PADS......................... 88STIMATE................................... 62STIOLTO RESPIMAT...............95

109

STIVARGA................................ 37STRENSIQ................................. 88streptomycin ................................21STRIBILD.................................. 41STRIVERDI RESPIMAT...........94SUBOXONE...............................21SUBVENITE.............................. 88SUBVENITE STARTER (BLUE) KIT................................88SUBVENITE STARTER (GREEN) KIT.............................88SUBVENITE STARTER (ORANGE) KIT......................... 88SUCRAID...................................60sucralfate .................................... 59sulfacetamide sodium ............24, 91sulfacetamide sodium (acne) ...... 24sulfacetamide-prednisolone ..32, 91sulfadiazine ................................. 24sulfamethoxazole-trimethoprim...............................................24, 88SULFAMYLON......................... 22sulfasalazine ............................... 70SULFATRIM..............................88sulindac .................................19, 32sumatriptan ................................. 33sumatriptan succinate .................33sumatriptan-naproxen ...........32, 33SUPRAX.....................................23SURE COMFORT ALCOHOL PREP PADS................................88SURE COMFORT INS. SYR. U-100.......................................... 88SURE COMFORT INSULIN SYRINGE................................... 88SURE COMFORT PEN NEEDLE.....................................88SURE-FINE PEN NEEDLES.....88SURE-JECT INSULIN SYRINGE................................... 88SURE-PREP ALCOHOL PREP PADS.......................................... 88SUTENT..................................... 37SYEDA....................................... 65SYLATRON......................... 34, 41SYLVANT..................................88SYMBICORT............................. 96SYMDEKO.................................95SYMFI........................................ 42SYMFI LO..................................42SYMJEPI.................................... 94SYMLINPEN 120...................... 47

SYMLINPEN 60........................ 47SYMPAZAN.............................. 26SYMTUZA................................. 41SYNAGIS................................... 88SYNAREL..................................66SYNERCID................................ 88SYNRIBO...................................34TABLOID...................................34tacrolimus ............................. 56, 68tadalafil .......................................60tadalafil (pulm. hypertension) .... 95TAFINLAR.................................37TAGRISSO.................................37TALZENNA............................... 34tamoxifen .....................................34tamsulosin ................................... 60TARGRETIN..............................37TARINA 24 FE...........................65TARINA FE 1/20 (28)................65TARINA FE 1-20 EQ (28)......... 88TARON-C DHA.........................88TARON-PREX PRENATAL-DHA............................................88TASIGNA...................................37tazarotene ................................... 56TAZICEF..............................23, 88TAZORAC................................. 56TAZTIA XT................................51TAZVERIK................................ 37TDVAX...................................... 69TECENTRIQ.............................. 88TECFIDERA.............................. 55TECHLITE INSULIN SYR HALF UNIT............................... 88TECHLITE INSULIN SYRINGE................................... 88TECHLITE PEN NEEDLE........ 88TEFLARO.................................. 23TEKTURNA HCT......................52telmisartan .................................. 49telmisartan-amlodipine ...............52telmisartan-hydrochlorothiazid .. 52TEMIXYS...................................88TEMODAR.................................88temsirolimus ................................88TENIVAC (PF).....................69, 89tenofovir disoproxil fumarate40, 42terazosin ................................49, 60terbinafine hcl .............................31terbutaline .............................89, 94terconazole ..................................31TERUMO INSULIN SYRINGE 89

testosterone ........................... 63, 89testosterone cypionate .................63testosterone enanthate ................ 63tetanus,diphtheria tox ped(pf) .....69tetrabenazine ...............................54tetracycline ..................................25THALOMID............................... 34THEO-24.................................... 95theophylline ...........................89, 95theophylline in dextrose 5 % .......89THINPRO INSULIN SYRINGE................................... 89THIOLA......................................61THIOLA EC............................... 61thioridazine ................................. 38thiotepa ....................................... 89thiothixene ...................................38TIADYLT ER.............................51tiadylt er ......................................51tiagabine ..................................... 26TIBSOVO................................... 35TICE BCG.................................. 89tigecycline ................................... 22TILIA FE.................................... 89timolol maleate ............... 33, 50, 92tinidazole .....................................22TIVICAY....................................41tizanidine ...............................40, 96tobramycin .................................. 21tobramycin in 0.225 % nacl ........22tobramycin sulfate ................ 22, 89tobramycin-dexamethasone ........ 92tolcapone .....................................38tolmetin ........................... 19, 32, 89tolterodine ...................................60TOPCARE CLICKFINE............ 89TOPCARE ULTRA COMFORT................................. 89topiramate .............................27, 33TOPOSAR.................................. 89topotecan .....................................89toremifene ................................... 34TORISEL....................................89torsemide .....................................52TOUJEO MAX U-300 SOLOSTAR................................48TOUJEO SOLOSTAR U-300 INSULIN.................................... 48tramadol ......................................20tramadol-acetaminophen ............18trandolapril .................................50trandolapril-verapamil ............... 52

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tranexamic acid ...........................49tranylcypromine ..........................28TRAVASOL 10 %......................58travoprost ....................................92trazodone .................................... 28TREANDA................................. 89TRECATOR............................... 33TRELSTAR................................ 66treprostinil sodium ......................89tretinoin .................................37, 56tretinoin (antineoplastic) ............ 37TRI FEMYNOR......................... 89triamcinolone acetonide.............................32, 55, 56, 62, 89triamterene ..................................52triamterene-hydrochlorothiazid ..52TRIANEX...................................56TRIDERM............................ 62, 89trientine .......................................57TRI-ESTARYLLA..................... 65trifluoperazine .............................38trifluridine ...................................41TRIKAFTA.................................95TRI-LEGEST FE........................ 65TRI-LINYAH............................. 89TRI-LO-ESTARYLLA...............65TRI-LO-MARZIA...................... 89TRI-LO-SPRINTEC................... 65TRILYTE WITH FLAVOR PACKETS...................................59trimethoprim ............................... 22trimipramine ............................... 29TRINATAL RX 1.......................89TRINTELLIX............................. 29TRI-PREVIFEM (28)................. 65TRISENOX.................................89TRI-SPRINTEC (28).................. 65TRIUMEQ.................................. 42TRIVEEN-DUO DHA................89TRIVORA (28)...........................65TROGARZO...............................89TROPHAMINE 10 %.................58TROPHAMINE 6%....................58trospium ...................................... 60TRUE COMFORT ALCOHOL PADS.......................................... 89TRUE COMFORT INSULIN SYRINGE................................... 89TRUE COMFORT PEN NEEDLE.....................................89TRUEPLUS INSULIN............... 89TRUEPLUS PEN NEEDLE....... 89

TRULANCE............................... 59TRULICITY............................... 47TRUMENBA..............................69TRUVADA.................................42TULANA....................................89TWINRIX (PF)...........................69TYKERB.................................... 37TYMLOS....................................70TYPHIM VI................................69TYSABRI................................... 89TYVASO.................................... 89TYVASO INSTITUTIONAL START KIT................................ 89TYVASO REFILL KIT..............89TYVASO STARTER KIT..........89ULORIC..................................... 31ULTICARE.................................89ULTICARE INSULIN SYR HALF UNIT............................... 89ULTICARE INSULIN SYRINGE................................... 89ULTICARE PEN NEEDLE........89ULTILET ALCOHOL SWAB... 90ULTILET INSULIN SYRINGE.90ULTILET PEN NEEDLE...........90ULTIMA MONITOR................. 90ULTRA CMFT INS SYR HALF UNIT............................... 90ULTRA COMFORT INSULIN SYRINGE................................... 90ULTRA THIN PEN NEEDLE... 90ULTRACARE INSULIN SYRINGE................................... 90ULTRACARE PEN NEEDLE... 90ULTRA-THIN II (SHORT) INS SYR.............................................90ULTRA-THIN II (SHORT) PEN NDL....................................90ULTRA-THIN II INS PEN NEEDLES...................................90ULTRA-THIN II INSULIN SYRINGE................................... 90UNIFINE PENTIPS....................90UNIFINE PENTIPS PLUS.........90UNITHROID........................ 66, 90UNITUXIN.................................90UPTRAVI................................... 51ursodiol ....................................... 59UVADEX....................................90valacyclovir .................................41VALCHLOR.........................34, 56valganciclovir ............................. 40

valproate sodium ........................ 90valproic acid ................... 26, 33, 45valproic acid (as sodium salt)...................................26, 33, 46, 90valrubicin ....................................90valsartan ..................................... 49valsartan-hydrochlorothiazide ... 52VALSTAR..................................90VALTOCO........................... 26, 44vancomycin ........................... 22, 90vancomycin in 0.9 % sodium chl 90VANDAZOLE............................22VANISHPOINT SYRINGE....... 90VANTAS.................................... 90VAQTA (PF).............................. 69VARIVAX (PF)..........................69VARIZIG....................................69VARUBI............................... 30, 90VASCEPA.................................. 53VECAMYL.................................54VECTIBIX..................................90VELCADE..................................90VELETRI....................................90VELIVET TRIPHASIC REGIMEN (28)...........................65VELTASSA................................57VEMLIDY..................................40VENCLEXTA............................ 34VENCLEXTA STARTING PACK..........................................34venlafaxine ............................29, 44verapamil .............................. 51, 90VERIPRED 20............................91VERSACLOZ.............................40VERSALON............................... 91VERZENIO................................ 35V-GO 20..................................... 91V-GO 30..................................... 91V-GO 40..................................... 91VIBERZI.....................................59VICODIN HP............................. 91VIENVA..................................... 65vigabatrin ....................................27VIGADRONE.............................27VIIBRYD....................................29VIMIZIM....................................91VIMPAT............................... 27, 91vinblastine ...................................91vincristine ................................... 91vinorelbine .................................. 91VIOKACE.................................. 60VIORELE (28)............................91

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VIRACEPT.................................43VIREAD............................... 40, 42VIRT-C DHA............................. 91VIRT-NATE DHA..................... 91VIRT-PN DHA...........................91VIRT-PN PLUS..........................91VISTOGARD............................. 91VITRAKVI................................. 35VIVITROL............................20, 21VIZIMPRO................................. 37voriconazole ................................31VOTRIENT................................ 37VRAYLAR........................... 40, 45VYNDAMAX.............................62VYNDAQEL.............................. 62VYXEOS.................................... 91warfarin ...................................... 48water for irrigation, sterile ......... 91WEBCOL................................... 91WERA (28).................................91XALKORI.................................. 37XARELTO..................................48XATMEP....................................68XELJANZ...................................68XELJANZ XR............................ 68XERMELO................................. 59XGEVA...................................... 71XIAFLEX................................... 91XIFAXAN............................ 22, 59XIGDUO XR.............................. 47XIIDRA...................................... 92XOFLUZA..................................43XOLAIR..................................... 96XOSPATA..................................35XPOVIO..................................... 34XTANDI..................................... 34XULANE....................................65XURIDEN.................................. 60XYREM......................................96YERVOY....................................91YF-VAX (PF)............................. 69YONDELIS................................ 91YONSA.......................................34YUVAFEM.................................64zafirlukast ................................... 94zaleplon .......................................96ZALTRAP.................................. 91ZANOSAR................................. 91ZARAH.......................................65ZARXIO..................................... 49ZATEAN-PN DHA.................... 91ZATEAN-PN PLUS................... 91

ZEJULA......................................35ZELBORAF................................37ZENATANE............................... 56zidovudine ................................... 42ZIEXTENZO.............................. 49ZINGIBER..................................91ziprasidone hcl ......................40, 45ZIRGAN..................................... 40ZOLADEX..................................91zoledronic acid ............................91zoledronic acid-mannitol-water ..91ZOLINZA............................. 31, 35zolmitriptan .................................33zolpidem ......................................96zonisamide .................................. 25ZORTRESS................................ 68ZOSTAVAX (PF).......................69ZOVIA 1/35E (28)......................65ZUMANDIMINE (28)................91ZYDELIG................................... 35ZYKADIA.................................. 37ZYPREXA RELPREVV 40, 45, 91ZYTIGA......................................34

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MEDICARE ADVANTAGE COMMUNITY HEALTH PLAN of WashingtonTM

The power of community

This formulary was updated on 05/01/2020. For more recent information or other questions, please contact Community Health Plan of Washington Medicare Advantage Customer Service at 1-800-942-0247 or for TTY users, dial 711, 7 days a week, 8 a.m. to 8 p.m. or visit our website atmedicare.chpw.org.

Changes to our formulary may occur during the benefit year. An updated formulary is located on our website at medicare.chpw.org. You may also call Customer Service for updated information.

Contact us Prospective Members TTY Relay: Dial 711 1111 3rd Ave, Suite 400 1-800-944-1247

8:00 a.m. to 8:00 p.m. Seattle, WA 98101-3207

Current Members 7 days a week medicare.chpw.org 1-800-942-0247

Get More Than Original Medicare 2020 · 2020-05-26 · Get More Than Original Medicare 2020....

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